RHEUMATISM: WHAT IT IS, AND PARTICULARLY WHAT IT ISN’T

What’s in a name? All the aches and pains that came out of Pandora’s box, if the name happens to be rheumatism. It is a term of wondrous elasticity. It will cover every imaginable twinge in any and every region of the body-and explain none of them. It is a name that means just nothing, and yet it is in every man’s vocabulary, from proudest prince to dullest peasant. Its derivative meaning is little short of an absurdity in its inappropriateness, from the Greek reúma (a flowing), hence, a cold or catarrh. It is still preserved for us in the familiar “salt rheum” (eczema) and “rheum of the eyes” of our rural districts. But this very indefiniteness, absurdity if you will, is a comfort both to the sufferer and to the physician. Moreover, incidentally, to paraphrase Portia’s famous plea,-

It blesseth him that has and him that treats;
’T is mightier than the mightiest.
It doth fit the throned monarch closer than his crown.

To the patient it is a satisfying diagnosis and satisfactory explanation in one; to the doctor, a great saving of brain-fag. When we call a disease rheumatism, we know what to give for it-even if we don’t know what it is. As the old German distich runs,-

Was man kann nicht erkennen,
Muss er Rheumatismus nennen.

However, in spite of the confusion produced by this wholesale and indiscriminate application of the term to a host of widely different, painful conditions, many of which have little else in common save that they hurt and can be covered by this charitable name-blanket, a few definite facts are crystallizing here and there out of the chaos. The first is, that out of this swarm of different conditions there can be isolated one large and important central group which has the characters of a well-defined and constant disease-entity. This is the disease known popularly as rheumatic fever, and technically as acute rheumatism or acute articular rheumatism. In fact, the commonest division is to separate the “rheumatisms” into two great groups: acute, covering the “fever” form, and chronic, containing all the others. From a purely scientific point of view, this classification has rather an undesirable degree of resemblance to General Grant’s famous division of all music into two tunes: one of which was Old Hundred, and the other wasn’t. But for practical purposes it has certain merits and may pass.

Every one has seen, or known, or had, the acute articular form of rheumatism, and when once seen there is no difficulty in recognizing it again. It is one of the most striking and most abominable of disease-pictures, beginning with high fever and headache, then tenderness, quickly increasing to extreme sensitiveness in one or more of the larger joints, followed by drenching sweats of penetrating acid odor. The joint attacked becomes red, swollen, and glossy, so tender that merely pointing a finger at it will send a twinge of agony through the entire body, and the patient lies rigid and cramped for fear of the agony caused by the slightest movement. The tongue becomes coated and foul, the blood-cells are rapidly broken down, and the victim becomes ashy pale. He is worn out with pain and fever, yet afraid to fall asleep for fear of unconsciously moving the inflamed joint and waking in tortures; and altogether is about as acutely uncomfortable and completely miserable as any human being can well be made in so short a time.

Fortunately, as with its twin brother, the grip, the bark of rheumatism is far worse than its bite; and a striking feature of the disease is its low fatality, especially when contrasted with the fury of its onslaught and the profoundness of the prostration which it produces. Though it will torture its victim almost to the limits of his endurance for days and even weeks at a stretch, it seldom kills directly. Its chief danger lies in the legacies which it bequeaths. Though, like nearly all fevers, it is self-limited, tends to run its course and subside when the body has manufactured an antitoxin in sufficient amounts, it is unique in another respect, and that is in the extraordinary variability of the length of its “course.” This may range anywhere from ten days to as many weeks, the “average expectation of life” being about six weeks. The agonizing intensity of the pain and acute edge of the discomfort usually subside in from five to fifteen days, especially under competent care. When the temperature falls, the drenching sweats cease, the joints become less exquisitely painful, and the patient gradually begins to pull himself together and to feel as if life were once more worth living. He is not yet out of the woods, however, for while the pain is subsiding in the joints which have been first attacked, another joint may suddenly flare up within ten or twelve hours, and the whole distressing process be repeated, though usually on a somewhat milder and shorter scale. This uncertainty as to how many joints in the body may be attacked, is, in fact, one of the chief elements in making the duration of the disease so irregular and incalculable.

Even when the frank and open progress of the disease through the joints of the body has come to an end, the enemy is still lying in wait and reserving his most deadly assault. Distressing and crippling as are the effects of rheumatism upon the joints and tendons, its most deadly and permanent damage is wrought upon the heart. Fortunately, this vital organ is not attacked in more than about half the cases of acute rheumatism, and in probably not more than one-third of these are the changes produced either serious or permanent, especially if the case be carefully watched and managed. But it is not too much to say that, of all cases of serious or “organic” heart disease, rheumatism is probably responsible for from fifty to seventy per cent. The same germ or toxin which produces the striking inflammatory changes in the joints may be carried in the blood to the heart, and there attack either the lining and valves of the heart (endocardium), which is commonest, or the covering of the heart (pericardium), or the heart-muscle. So intense is the inflammation, that parts of the valves may be literally eaten away by ulceration, and when these ulcers heal with formation of scar-tissue as everywhere else in the body, the flaps of the valves may be either tied together or pulled out of shape, so that they can no longer properly close the openings of the heart-pump. This condition, or some modification of it, is what we usually mean when we speak of “heart disease,” or “organic heart disease.” The effect upon the heart-pump is similar to that which would be produced by cutting or twisting the valve in the “bucket” of a pump or in a bulb syringe.

In severe cases of rheumatism the heart may be attacked within the first few days of the disease, but usually it is not involved until after the trouble in the joints has begun to subside; and no patient should be considered safe from this danger until at least six weeks have elapsed from the beginning of the fever. The few cases (not to exceed one or two per cent) of rheumatic fever which go rapidly on to a fatal termination, usually die from this inflammation of the heart, technically known as endocarditis. The best way of preventing this serious complication and of keeping it within moderate limits, if it occurs, is absolute rest in bed, until the danger period is completely passed.

Now comes another redeeming feature of this troublesome disease, and that is the comparatively small permanent effects which it produces upon the joints in the way of crippling, or even stiffening. To gaze upon a rheumatic knee-joint, for instance, in the height of the attack,-swollen to the size of a hornet’s nest, hot, red, throbbing with agony, and looking as if it were on the point of bursting,-one would almost despair of saving the joint, and the best one would feel entitled to expect would be a roughening of its surfaces and a permanent stiffening of its movements.

On the contrary, when once the fury of the attack has passed its climax, especially if another joint should become involved, the whole picture changes as if by magic. The pain fades away to one-fifth of its former intensity within twenty-four, or even within twelve hours; three-fourths of the swelling follows suit in forty-eight hours; and within three or four days’ time the patient is moving the joint with comparative ease and comfort. After he gets up at the end of his six weeks, the knee, though still weak and stiff and sore, within a few weeks’ time “limbers up” completely, and usually becomes practically as good as ever. In short, the violence and swiftness of the onset are only matched by the rapidity and completeness of the retreat. It would probably be safe to say that not more than one joint in fifty, attacked by rheumatism, is left in any way permanently the worse.

But, alas! to counterbalance this mercifulness in the matter of permanent damage, unlike most other infections, one attack of rheumatic fever, so far from protecting against another, renders both the individual and the joint more liable to other attacks. The historic motto of the British in the War of 1812 might be paraphrased into, “Once rheumatic, always rheumatic.” The disease appears to be lost to all sense of decency and reason; and to such unprincipled lengths may it go, that I have actually known one luckless individual who had the unenviable record of seventeen separate and successive attacks of rheumatic fever. As he expressed it, he had “had rheumatism every spring but two for nineteen years past.” Yet only one ankle-joint was appreciably the worse for this terrific experience.

Obviously, the picture of acute rheumatism carries upon its face a strong suggestion of its real nature and causation. The high temperature, the headache, the sweats, the fierce attack and rapid decline, the self-limited course, the tendency to spread from one joint to another, from the joints to the heart, from the heart to the lungs and the kidneys, all stamp it unmistakably as an infection, a fever. On the other hand, there are two rather important elements lacking in the infection-picture: one, that, although it does at times occur in epidemics, it is very seldom transmitted to others; the other, that one attack does not produce immunity or protect against another. The majority of experts are now practically agreed that acute rheumatism, or rheumatic fever, is probably due to the invasion of the system by some microoerganism or germ. When, however, we come to fixing upon the particular bacillus, or micrococcus, there is a wide divergence of opinion, some six or seven different eminent investigators having each his favorite candidate for the doubtful honor. In fact, it is our inability as yet positively to identify and agree upon the causal germ that makes our knowledge of the entire subject still so regrettably vague, and renders either a definite classification or successful treatment so difficult.

The attitude of the most careful and experienced physicians and broad-minded bacteriologists may be roughly summed up in the statement that acute rheumatism is probably due to some germ or germs, but that the question is still open which particular germ is at fault, and even whether the group of symptoms which we call rheumatism may not possibly be produced by a number of different organisms, acting upon a particular type of constitution or susceptibility. There is no difficulty in finding germs of all sorts, principally micrococci, in the blood, in the tissues about the joints, and on the heart-valves of patients with rheumatism, and these germs, when injected into animals, will not infrequently produce fever and inflammatory changes in the joints, roughly resembling rheumatism. But the difficulty so far has been, first, that these organisms are of several different kinds and distinct species; and second, and even more important, that almost any of the organisms of the common infectious diseases are capable at times of producing inflammation of the joints and tendons. For instance, the third commonest point of attack of the tubercle bacillus, after the lungs and the glands, is the bones and joints, as illustrated in the sadly familiar “white-swelling of the knee” and hip-joint disease. All the so-called septic organisms, which produce suppuration and blood-poisoning in wounds and surgery, may, and very frequently do, attack the joints; while nearly all the common infections, such as typhoid, scarlet fever, pneumonia, and even measles, influenza, and tonsillitis, may be followed by severe joint symptoms.

In fact, we are coming to recognize that diseases of the joints, like diseases of the nervous system, are among the frequent results of any and all of the acute infectious diseases or fevers; and we now trace from fifty to seventy-five per cent of both joint troubles and degenerations of the nervous system to this cause. Two-thirds, for instance, of our cases of hip-joint disease and of spinal disease (caries) are due to tuberculosis.

The puzzling problem now before pathologists is the sorting out of these innumerable forms of joint inflammations and the splitting off of those which are clearly due to certain specific diseases, from the great, central group of true rheumatism. Most of these joint inflammations which are due to recognized germs, such as the pus-organisms of surgical fevers, tuberculosis, and typhoid, differ from true rheumatism in that they go on to suppuration (formation of “matter”) and permanently cripple the joint to a greater or less degree. So that there is probably a germ or group of germs which produces the swift attack and rapid subsidence and other characteristic features of true rheumatism, even though we have not yet succeeded in sorting them out of the swarm. So confident do we feel of this, that although, as will be shown, there are probably other factors involved, such as exposure, housing, occupation, food, and heredity, yet the best thought of the profession is practically agreed that none of these would alone produce the disease, but that they are only accessory causes plus the micrococcus. In practically all our modern textbooks of medicine, rheumatism is included under the head of infections.

This theory of causation, confessedly provisional and imperfect as it is, helps us to harmonize the other known facts about the disease; it has already greatly improved our treatment and given us a foothold for attacking the problem of prevention. For instance, it has long been known that rheumatism was very apt to follow tonsillitis or other forms of sore throat; indeed, many of the earlier authorities put down tonsillitis as one of the great group of “rheumatic” disturbances, and persons of rheumatic family tendency were supposed to have tonsillitis in childhood and rheumatism in later life. Not more than ten or fifteen per cent of all cases gave a history of tonsillitis; but since we have broadened our conception of infection and begun to inquire, not merely for symptoms of tonsillitis, but also for those of influenza, “common colds,” measles, whooping-cough, and the like, we reach the most significant result of finding that forty to sixty per cent of our cases of rheumatism have been preceded, anywhere from one to three weeks before, by an attack of some sort of “cold,” sore throat, catarrhal fever, cough, bronchitis, or other group of disturbances due to a mild infection. Further, it has long been notorious that when a rheumatic individual “catches cold” it is exceedingly apt to “settle in the joints,” and, if these cases happen to come under the eye of a physician, they are recognized as secondary attacks of true rheumatism. In other words, the “cold” may simply be a second dose of the same germ which caused the primary attack of rheumatism.

This brings us to the widespread article of popular belief that rheumatism is most commonly due to cold, exposure, chill, or damp. Much of this is found on investigation to be due to the well-known historic confusion between “cold,” in the sense of exposure to cold air, and “cold,” in the sense of a catarrh or influenza, with running at the nose, coughing, sore throat, and fever, a group of symptoms now clearly recognized to be due to an infection. In short, the vast majority of common colds are unmistakably infections, and spread from one victim to another, and this is the type of “cold” which causes the majority of rheumatic attacks.

The chill, which any one who is “coming down” with a cold experiences, and usually refers to a draft or a cold room, is, in nine cases out of ten, the rigor which precedes the fever, and has nothing whatever to do with the external temperature. The large majority of our cases of rheumatism can give no clear or convincing history of exposure to wet, cold, or damp. But popular impression is seldom entirely mistaken, and there can be no question that, given the presence of the infectious germ, a prolonged exposure to cold, and particularly to wet, will often prove to be the last straw which will break down the patient’s power of resistance, and determine an attack of rheumatism.

This climatic influence, however, is probably not responsible for more than fifteen or twenty per cent of all cases, and, popular impression to the contrary notwithstanding, the liability of outdoor workers who are subject to severe exposure, such as lumbermen, fishermen, and sailors, is only slightly greater than that of indoor workers. The highest susceptibility, in fact, not merely to the disease, but also to the development of serious heart involvements, is found among domestic servants, particularly servant girls, agricultural laborers and their families (in districts where wages are low and cottages bad), and slum-dwellers; in fact, those classes which are underfed, overworked, badly housed, and crowded together. Diet has exceeding little to do with the disease, and, so far from meat or high living of any sort predisposing to it, it is most common and most serious in precisely those classes which get least meat or luxuries of any sort, and are from stern necessity compelled to live upon a diet of cereals, potatoes, cheap fats, and coarse vegetables.

Even its relations to the weather and seasons support the infection theory. Its seasonal occurrence is very similar to that of pneumonia,-rarest in summer, commonest in winter, the highest percentage of cases occurring in the late fall and in the early spring; in other words, just at those times when people are first beginning to shut themselves up for the winter, light fires, and close windows, and at the end of their long period of winter imprisonment, when both their resisting power has been reduced to the lowest ebb in the year and infections of all sorts have had their most favorable conditions of growth for months.

The epidemics of rheumatism, which occasionally occur, probably follow epidemics of influenza, tonsillitis, or other mild infections, and instances of two or more cases of rheumatism in one family or household are most rationally explained as due to the spread of the precedent infection from one member of the family to the other. Instances of the direct transmission of the disease from one patient to another are exceedingly rare.

Our view of the infectious causation of rheumatism, vague as it is, has given us already our first intelligent prospect of prevention. Whatever may be the character of a germ or germs, the vast majority of them agree in making the nose and throat their first point of attack and of entry into the system. Hence, vigorous antiseptic and other rational treatment of all acute disturbances of the nose and throat, however slight, will prove a valuable preventive and diminisher of the percentage of rheumatism. This simply emphasizes again the truth and importance of the dictum of modern medicine, “Never neglect a cold,” since we are already able to trace, not merely rheumatism, but from two-thirds to three-fourths of our cases of heart disease, of kidney trouble, and of inflammations of the nervous system, to those mild infections which we term “colds,” or to other definite infectious diseases.

Not only is this good a priori reasoning, but it has been demonstrated in practice. One of our largest United States army posts had acquired an unenviable reputation from the amount of rheumatism occurring in the troops stationed there. A new surgeon coming to take charge of the post set about investigating the cause of this state of affairs, and came to the conclusion that the disease began as, or closely followed, tonsillitis and other forms of sore throat. He accordingly saw to it that every case of tonsillitis, of cold in the head, or sore throat was vigorously treated with local germicides and with intestinal antiseptics and laxatives, until it was completely cured; with the result that in less than a year he succeeded in lowering the percentage of cases of rheumatism per company nearly sixty per cent.

At some of our large health-resorts, where great numbers of cases of rheumatism are treated, it has been discovered that if a case of common cold, or tonsillitis, happens to come into the establishment, and runs through the inmates, nearly half of the rheumatic patients attacked will have a relapse or new seizure of their rheumatism. Accordingly, a rigorous and hawk-like watch is kept for every possible case of cold, tonsillitis, or sore throat entering the house; the patient is promptly isolated and treated on rigidly antiseptic principles, with the result that epidemics of relapses of rheumatism in the inmates have greatly diminished in frequency.

If every case of cold or sore throat were promptly and thoroughly treated with antiseptic sprays and washes such as any competent physician can direct his patients to keep in the house, in readiness for such an emergency, combined with laxatives and intestinal antiseptic treatment, and, above all, with rest in bed as long as any rise of temperature is present, there would be a marked diminution in both the frequency and the severity of rheumatism. If to this were added an abundant and nutritious dietary, good ventilation and pure air, an avoidance of overwork and overstrain, we should soon begin to get the better of this distressing disease. In fact, while positive data are lacking, on account of the small fatality of rheumatism and its consequent infrequent appearance among the causes of death in our vital statistics, yet it is the almost unanimous opinion of physicians of experience that the disease is distinctly diminishing, as a result of the marked improvement in food, housing, wages, and living conditions generally, which modern civilization has already brought about.

So much for acute rheumatism. Vague and unsatisfactory as is our knowledge of it, it is, unfortunately, clearness and precision itself when contrasted with the welter of confusion and fog which covers our ideas about the chronic variety. The catholicity of the term is something incredible. Every chronic pain and twinge, from corns to locomotor ataxia, and from stone-in-the-kidney to tic-douloureux, has been put down as “rheumatism.” It is little better than a diagnostic garbage-dump or dust-heap, where can be shot down all kinds of vague and wandering pains in joints, bones, muscles, and nerves, which have no visible or readily ascertainable cause. Probably at least half of all the discomforts which are put down as “rheumatism” of the ankle, the elbow, the shoulder, are not rheumatism at all, in any true or reasonable sense of the term, but merely painful symptoms due to other perfectly definite disease conditions of every imaginable sort. The remaining half may be divided into two great groups of nearly equal size. One of these, like acute rheumatism, is closely related to, and probably caused by, the attack of acute infections of milder character, falling upon less favorable soil. The other is of a vaguer type and is due, probably, to the accumulation of poisonous waste-products in the tissues, setting up irritative and even inflammatory changes in nerve, muscle, and joint. Either of these may be made worse by exposure to cold or changes in the weather. In fact, this is the type of rheumatism which has such a wide reputation as a barometer and weather prophet, second only to that of the United States Signal Service. When you “feel it in your bones,” you know it is going to snow, or to rain, or to clear up, or become cloudy, or whatever else may happen to follow the sensation, merely because all poisoned and irritated nerves are more sensitive to changes in temperature, wind-direction, moisture, and electric tension, than sound and normal ones. The change in the weather does not cause the rheumatism. It is the rheumatism that enables us to predict the change in the weather, though we have no clear idea what that change will be.

Probably the only statement of wide application that can be made in regard to the nature of chronic rheumatism is that a very considerable percentage of it is due to the accumulation of poisons (toxins) in the nerves supplying joints and muscles, setting up an irritation (neurotoxis), or, in extreme cases, an inflammation of the nerve (neuritis), which may even go on to partial paralysis, with wasting of the muscles supplied. The same broad principles of causation and prevention, therefore, apply here as in acute rheumatism.

The most important single fact for rheumatics of all sorts, whether acute or chronic, to remember is that they must avoid exposure to colds, in the sense of infections of all sorts, as they would a pestilence; that they must eat plenty of rich, sound, nourishing food; live in well-ventilated rooms; take plenty of exercise in the open air, to burn up any waste poisons that may be accumulating in the tissues; dress lightly but warmly (there is no special virtue in flannels), and treat every cold or mild infection which they may be unfortunate enough to catch, according to the strictest rigor of the antiseptic law.

The influence of diet in chronic rheumatism is almost as slight as in the acute form. Persons past middle age who can afford to indulge their appetites and are inclined to eat and drink more than is good for them, and, what is far more important, to exercise much less, may so embarrass their liver and kidneys as to create accumulations of waste products in the blood sufficient to cause rheumatic twinges. The vast majority, however, of the sufferers from chronic rheumatism, like those from the acute form, are underfed rather than overfed, and a liberal and abundant dietary, including plenty of red meats, eggs, fresh butter, green vegetables, and fresh fruits, will improve their nutrition and diminish their tendency to the attacks.

There appears to be absolutely no rational foundation for the popular belief that red meats cause rheumatism, either from the point of view of practical experience, or from that of chemical composition. We now know that white meats of all sorts are quite as rich in those elements known as the purin bodies, or uric-acid group, as red meats, and many of them much richer. It may be said in passing, that this last-mentioned bugbear of our diet-reformers is now believed to have nothing whatever to do with rheumatism, and probably very little with gout, and that the ravings of Haig and the Uric-Acid School generally are now thoroughly discredited. Certainly, whenever you see any remedy or any method of treatment vaunted as a cure for rheumatism, by neutralizing or washing out uric acid, you may safely set it down as a fraud.

One rather curious and unexpected fact should, however, be mentioned in regard to the relation of diet to rheumatism, and that is that many rheumatic patients have a peculiar susceptibility to some one article of food. This may be a perfectly harmless and wholesome thing for the vast majority of the species, but to this individual it acts as a poison and will promptly produce pains in the joints, redness, and even swelling, sometimes accompanied by a rash and severe disturbances of the digestive tract. The commonest offenders form a curious group in their apparent harmlessness, headed as they are by strawberries, followed by raspberries, cherries, bananas, oranges; then clams, crabs, and oysters; then cheese, especially overripe kinds; and finally, but very rarely, certain meats, like mutton and beef. What is the cause of this curious susceptibility we do not know, but it not infrequently occurs with this group of foods in rheumatics and also in asthmatics.

Both rheumatics and asthmatics are also subject to attacks of urticaria or “hives” (nettle-rash), from these and other special articles of diet.

As to principles of treatment in a disease of so varied and indefinite a character, due to such a multitude of causes, obviously nothing can be said except in the broadest and sketchiest of outline. The prevailing tendency is, for the acute form, rest in bed, the first and most important, also the second, the third, and the last element in the treatment. This will do more to diminish the severity of the attack and prevent the occurrence of heart and other complications than any other single procedure.

After this has been secured, the usual plan is to assist nature in the elimination of the toxins by alkalies, alkaline mineral waters, and other laxatives; to relieve the pain, promote the comfort, and improve the rest of the patient by a variety of harmless nerve-deadeners or pain-relievers, chief among which are the salicylates, aspirin, and the milder coal-tar products. By a judicious use of these in competent hands the pain and distress of the disease can be very greatly relieved, but it has not been found that its duration is much shortened thereby, or even that the danger of heart and other complication is greatly lessened. The agony of the inflamed joints may be much diminished by swathing in cotton-wool and flannel bandages, or in cloths wrung out of hot alkalies covered with oiled silk, or by light bandages kept saturated with some evaporating lotion containing alcohol. As soon as the fever has subsided, then hot baths and gentle massage of the affected joints give great relief and hasten the cure. But, when all is said and done, the most important curative element, as has already been intimated, is six weeks in bed.

In the chronic form the same remedies to relieve the pain are sometimes useful, but very much less effective, and often of little or no value. Dry heat, moist heat, gentle massage, and prolonged baking in special metal ovens, will often give much relief. Liniments of all sorts, from spavin cures to skunk oil, are chiefly of value in proportion to the amount of friction and massage administered when they are rubbed in.

In short, there is no disease under heaven in which so much depends upon a careful study of each individual case and adaptation of treatment to it personally, according to its cause and the patient in whom it occurs. Rheumatism, unfortunately, does tend to “run in families.” Apparently some peculiar susceptibility of the nervous system to influences which would be comparatively harmless to normal nerves and cells is capable of being inherited. But this inheritance is almost invariably “recessive,” in Mendelian terms, and a majority of the children of even the most rheumatic parent may entirely escape the disease, especially if they live rationally and vigorously, feed themselves abundantly, and avoid overwork and overcrowding.