Painful Joint Conditions Pseudo-rheumatism





[Footnote 33: The position here taken, that acute articular

rheumatism never leaves a mark after it, is entirely due to the

observation that whenever cases were seen in which sequelae were

noted, there always seems to the writer to be question of something

else besides simple acute articular rheumatism--a complication.

Subsequent pathological investigation may show that occasionally

acute articular rheumatism does to some extent disorganize joint

tissues. Personally, however, I have the feeling that there are a

number of different kinds of acute arthritis, probably three or

four, and that most of them leave no pathological condition in the

tissues. Perhaps we shall be able to differentiate the severer forms

and recognize them from the beginning, as we have already done with

regard to scarlatinal, gonorrheal, influenzal and other so-called

rheumatisms. For practical purposes it certainly seems better to

emphasize the fact that chronic rheumatism following an attack of

simple acute arthritis is so rare as to be negligible.]



Many painful conditions in connection with joints give rise to more or

less continuous or frequently repeated discomfort, which often leads

patients to think that there are serious pathological factors at work,

or that some progressive disease condition has obtained a hold of

them. Many of these painful conditions are due entirely to local

causes: to over-exertion, to the wrong use of muscles, to the exercise

of joints under unfortunate mechanical conditions and the like. Just

so long as people are assured that an ailment is local, is not likely

to be followed by serious impairment of function, that the discomfort

of it is only temporary, and, above all, just as soon as they get rid

of the notion of a progressive constitutional malady, they are content

to bear even annoying pain without much complaint, and, what is more

important, without such discouragement and worry as may impair the

general health. Unfortunately, it is the custom to call most of these

vague painful conditions "rheumatism," unless there is some other

patent cause for them. Especially is this done if the symptoms happen

to be worse in rainy weather, or in damp seasons. Rheumatism is always

thought of as a progressive constitutional disease, and the very idea

of it produces an unfortunate sense of depression.





Exaggeration of Significance.--Toothache, for instance, unless it is

allowed to nag for a long time, awakens no dreads and consequently

fails to produce the corresponding depression and discouragement, seen

so often in connections with conditions much less painful, but

associated with the thought of the possibility of serious

developments. "Omne ignotum pro magnifico," what is not well

understood is always exaggerated, was Cicero's summing up of the

tendency of the human mind to make the significance of misunderstood

things greater than they really are. It is particularly true of

painful conditions of the body, and the tendency must be

combated if patients are to be relieved. This must be done not alone

because along this way lies relief of suffering, since not a little of

the discomfort is due to the mental concentration consequent upon the

dread, but because, also, the discouraged state of mind interferes

with the trophic influences that go down from the central nervous

system to the periphery to keep it in good health and to restore

function when there is anything out of order. In a word, the

exaggeration of significance so likely to influence such patients for

ill must, as far as possible, be removed for their immediate relief as

well as ultimate cure.





Rheumatism, Gout, Catarrh.--There are three words in popular medical

language which can be made to include more diseases and explain more

symptoms than any others. Their meaning has become so indefinite that

they now convey very little information, though they are much

used--and abused. They are: rheumatism, gout and catarrh. Curiously

enough all three of them when their etymology is studied mean the same

thing as far as their derivation goes. Catarrh from [Greek text] the

Greek word to flow down and rheumatism from [Greek text] the Greek

verb to flow are terms that correspond exactly in etymology to gout,

which is probably derived from gutta, the Latin word for

drop--referring to the excess of secretion that is supposed to occur

in the disease. All of these have for their basic idea, in etymology

at least, an increase of secretion. A generation or two ago, the word

rheumatism included a host of disparate painful affections, and was

even more sadly abused than now, though its abuse has not ceased. The

word catarrh is now at its acme of abuse. Gout has been pushed

somewhat into the background by the other two. Any one of these three

terms carries with it, in the popular mind, a connotation of

progressive constitutional involvement which is not justified by

anything that physicians know with regard to these diseases.





The Uric Acid Diathesis.--The usual supposedly scientific explanation

of a decade ago for many of these vague pains and aches classed as

chronic rheumatism was that they developed on the basis of an excess

of uric acid in the system. Advance in chemistry has completely

obliterated the significance of the observation on which the theory of

a uric acid diathesis, as it was so learnedly called, as an

explanation for these conditions was founded. After uric acid there

came for a time the theory of an excess of lithic acid, the so-called

lithemia or American disease of a few years ago. These are, however,

merely pseudo-scientific hypotheses and the more physicians know of

chemistry the less they talk about them. Many practitioners, however,

continue to accept this universal explanation which makes diagnosis so

easy and which is supposed to be so suggestive for treatment. There

are various remedies that are claimed to reduce the uric acid content

of the blood or the system, and then there are various changes of diet

that are supposed to do the same thing. These two systems of treatment

and the combination of them have constituted the main therapeutic

resource of many physicians for these so-called rheumatic cases,

though their success has been anything but what they hoped for.





Diet Tinkering.--Tinkering with diet has been particularly harmful in

these cases. Over and over again I have seen patients who had lost

considerably in weight because they had had all the supposed

acid-forming elements removed from their diet. In many physicians'

minds this seems to include most of the starches, as well as the

fruits and many meats. Without any potatoes, with only a limited

amount of bread, with a warning as to red meats, and occasionally even

some distrustful remarks with regard to butter, it is not surprising

that the patients lost weight, that muscles became weaker, that

painful conditions became severer, and that, above all, the patients'

minds became less capable of bearing whatever discomfort is present.

Besides, constipation intervenes with its train of consequences and

patients become miserable, lose sleep often because of insufficient

nutrition and actual clamoring on the part of their gastrointestinal

tract for food. I have seen a man who was not much over normal weight

to begin with lose twenty-five pounds, nearly one-sixth of his weight,

while being dieted for vague pains (worse on rainy days) that were

really due to his occupation, but that had been diagnosed as

"rheumatic," consequent upon the uric acid diathesis, for which coal

tar products were prescribed over a long period and his diet

strenuously regulated. This has become as much of an abuse as the

old-time purgings and bleedings.





Irregular Treatment.--As we have said, this group of cases constitutes

the most frequent and abundant source of profit for quacks and

charlatans and irregular practitioners generally. The naturapath, the

osteopath, whom we have already mentioned, for to these cases he owes

most of his success in appealing to legislatures for recognition, the

irregular electropath, many supposed diet specialists, and even the

special shoemaker, have reaped a rich harvest from these patients. The

reason why they have done so is that, as a rule, they have at once

reassured the patients that their condition was not seriously

progressive and have promised them certain relief from their ailment.

Usually various local measures, such as St. John Long's liniment of

one hundred years ago and many of its successors, or the

mechanotherapy and the massage and the manipulation of the osteopaths

of the present day, have been employed with consequent restoration of

circulatory disturbances to normal conditions and, in general, the

setting up of better mechanical employment of muscles than was

possible before. If so-called chronic rheumatism is to be treated

successfully and this opprobrium of medicine, as it has been called,

is to be removed, it can only be done by a careful analysis of the

ills of each individual patient and a definite determination as to

just what local pathological condition is at work and not by a

slip-shod diagnosis of rheumatism with immediate recourse to a

supposed or assumed theoretic diathesis for the explanation of its

etiology.





Differentiation of Joint Conditions.--The local conditions that give

rise to painful conditions of joints are most diverse in character.

There was a time when all of the infectious joint affections had the

term rheumatism applied to them. Even at present it is not unusual to

hear of scarlatinal or gonorrheal or influenzal rheumatism. What is

meant, of course, is that the microbes of these specific diseases have

for some reason found a lowered resistive vitality in one of the

joints, or perhaps several of them, and have set up an inflammatory

disturbance. These specific arthritises are now definitely separated

from the rheumatism group and it seems clear that in the near future

we shall have rheumatism itself divided up into a series of diseases.

By this I mean that even where there is the redness, the swelling and

the fever of true inflammation of joints, it is not always due to one

microbe, but to various microbic agents, and so we shall have various

forms of rheumatism. At present we are prone to speak of many of the

neuritises as rheumatic, but it is probable that here a series

of varying microbic infections will be found, some of them much more

serious than others, most of them capable of complete cure, though

some of them will tend to leave pathological conditions in nerves that

are more or less crippling.





Painful Joint Affections.--These pains and aches occur particularly in

the old and those who have been hard muscle workers, in those who have

been exposed much to the elements and especially in the subjects of

old injuries. All of these conditions, one way or another, have left

their mark upon tissues so that the nerves do not receive proper

nutrition, especially when there is considerable exertion or in rainy

weather.



There are a number of reasons why rainy weather produces this effect.

The humidity of the atmosphere lessens evaporation. This disturbs heat

conditions in the tissues, for evaporation is the most important

element in heat dissipation. This leads to the accumulation of heat in

the parts and conduces to congestion. Any tissue of lowered vitality

will be affected by this and nerves become oversensitive. Besides, it

seems probable that the fall in the barometer with the lessened

pressure from without makes a difference in the circulation. There is

a general feeling of depression in wet weather and apparently the

circulation is not so active. It is particularly slow at the surface

of the body and in the terminal portions, so that the hands and feet

are likely to be cold. Just as soon as the barometer goes up somewhat

these conditions cease to be active and there is restoration of the

circulation to its previous condition. Besides, it seems not unlikely

that dampness produces some relaxation of muscles, so that it is more

difficult to make them contract, and consequently they are used at a

greater mechanical disadvantage and painful tiredness more readily

ensues. All sensitive tissues become more sensitive in rainy weather,

though in the case of toothache or neuralgia, for instance, we do not

think of connecting this with the word rheumatism.





Classes of Sufferers.--In persons who are over-thin or over-stout

complaints of joint discomfort are not uncommon. In the first case

they are due to the fact that muscles working around joints are not

strong enough to accomplish their normal purposes. In the other cases,

owing to the weight of the body, the muscles are overstrained. In a

number of stout people the muscles do not increase proportionately to

the size of the frame, much of the extra weight being in the shape of

adipose tissue that constitutes a grievous burden. In people who run

rapidly to either of these conditions of disturbed nutrition--thinness

or stoutness--complaints are particularly likely to be heard. Familiar

examples are often seen in the tuberculous who have lost weight

rapidly or in convalescents from typhoid fever who are much thinner

than they were before they took to their beds. On the other hand,

those who gain in weight rapidly after typhoid fever or some other

such pathological incident, or who, as the result of careful

sanatorium treatment, put on twenty pounds in the initial stage of

tuberculosis, may have similar discomforts to complain of in and

around their joints.





Heredity of Rheumatism.--The strongest unfavorable suggestion which

most patients have is that their ailment, whatever it is, is

hereditary and therefore not amenable to treatment. Nothing is more

amusing to one who knows the present-day status of opinion in biology

with regard to heredity than the frequent declaration that rheumatism

is hereditary. Probably nothing is commoner than to have a

patient who is suffering from some vague, painful condition in muscles

or joints, especially if that condition is worse on rainy days,

declare that it must be rheumatism because father or mother suffered

from rheumatism. I took the trouble to analyze in more than a dozen

cases the rheumatism that was supposed to exist in the preceding

generation, and found that it consisted of everything from pains due

to old injuries and especially dislocations or fractures, through the

various deformities connected with flatfoot, up to and including the

worst manifestations of arthritis deformans. The condition in the

parents supposed to be hereditary is never genuinely rheumatic.



There is just as much sense in talking of hereditary pneumonia as of

hereditary rheumatism. Perhaps there is an hereditary lack of

resistance in the pulmonary tissues of some people that predisposes

them to pneumonia. It must not be forgotten that a century ago, or

even less, it was not uncommon to hear that certain people had

hereditary tendencies to lung fever. We know now that these were

tendencies to tuberculosis and not to true pneumonia. We know,

besides, that tuberculosis itself is not hereditary and that probably

even the predisposition to it is not specifically hereditary.



As can be readily understood, the question of heredity in rheumatism

is extremely important for psychotherapy, since the persuasion that

their affection is inherited always produces an unfavorable effect

upon patients' minds. In the old days, when tuberculosis was

universally considered to be hereditary, a patient was likely to think

himself the victim of an hereditary condition which could not be cured

and which inevitably led to a fatal termination. Something of the same

idea, though the immediate outlook is not so gloomy, is likely to

follow the persuasion that rheumatism is hereditary. The question of

heredity, of course, is bound up with that of rheumatism being a

constitutional disease dependent on hyperacidity or some other

pathological condition of the blood. Acute rheumatism, that is, acute

arthritis, is an acute, infectious disease due to a microbe. This

ought to dispose of any question of heredity in it. Chronic rheumatism

is supposed to be related to acute rheumatism and to represent, as it

were, a low-grade enduring condition such as in sudden accessions

gives rise to acute rheumatism.





So-called Chronic Rheumatism.--In these cases it is always a question

whether the condition which causes the pain and discomfort is genuine

chronic rheumatism or not. I am one of those who doubt whether we have

any genuine, definite symptom-complex that should be termed chronic

rheumatism. I have seen many ailments called chronic rheumatism. Any

painful condition in the neighborhood of the joint that is worse on

rainy days is likely to be labeled rheumatism and, because the

salicylates are supposed to be a specific for rheumatism, treated with

large doses of these drugs. These relieve the pain, as do any other

coal tar products, but it is hard to understand how they are ever

supposed to do any good for the underlying pathological conditions.

The most noteworthy characteristic of acute rheumatic arthritis is

that it leaves no mark upon the joints that were affected by it. These

get completely better and the patient has no disability, no deformity,

and there usually remains not even the slightest sign of there having

been a serious inflammatory condition within the joints.



In this it resembles pneumonia rather strikingly. True lobar pneumonia

clears up completely and the man has no symptoms once he has

come through the convalescence. There are certain diseases affecting

the joints, especially the arthritises in connection with various

infectious diseases and the arthritis which accompanies acute

arthritis deformans, in which there are serious sequelae and sometimes

even complete disorganization of the joint. It is by these

after-effects alone that we are sometimes able to differentiate

genuine rheumatic arthritis from these other very different affections

which resemble it so closely. Just the same thing is true of

pneumonia. There are pneumonias that run a course at the beginning

strikingly like true lobar pneumonia but which do not have a frank

crisis and in which the lungs are seriously affected afterwards. We

know now that in these cases it is not an uncomplicated pneumococcus

pneumonia that has been at work, but either some other infection or

else true pneumonia with a complication. Very often a dormant

tuberculosis causes true pneumonia to run a different course from that

which it ordinarily follows, and this, as a complication, leaves its

serious mark upon the lungs.



Recurrence.--In some cases there seems to be a tendency for the

"rheumatic" disease to recur. This also is true of pneumonia. This

does not so much indicate, however, any loss of special tissue

vitality as a certain loss of vital resistance to a particular

microbe. Certainly this tendency is not sufficient to make us think of

chronic rheumatism or use that term any more than we would, under

similar conditions, talk of chronic pneumonia or of chronic

diphtheria, though both of these affections have a tendency to leave a

lack of resistive vitality. In a number of cases, subacute rheumatism

runs a course that is very bothersome and annoying and that is quite

intractable, with relapses and sequelae, but even this is entirely

different from the ordinary idea of chronic rheumatism. It is probable

that these cases, like the pneumonias that do not end by crises, are

complicated by some other condition in the joint that leads to

reinfection.





Unclassified Forms.--It is possible that in a certain number of cases

for which as yet we have no name but rheumatism, there is a virulence

of the microbic factor that brings about some joint disorganization.

This, however--and the cases are very rare--is probably an affection

to which the name of rheumatic arthritis will not be given when we

know more of the disease and its cause. There are probably many forms

of acute rheumatic arthritis due to varying microbes which will

eventually be divided into groups, as we have made groups in the

typhoid series of diseases and in the scarlet fever group and hope to

do with other diseases.





The Individual Case and Reassurance.--The main role of psychotherapy

in these affections is to set patients' minds at rest as far as

possible, by pointing out exactly what is the matter with them and

keeping them from worry, discomfort, and even interference with their

physical condition by over-solicitude. It is important to know every

detail of the patient's occupation, of his habits, of his environment,

of his exercise, and, above all, of his individual peculiarities of

structure in the neighborhood of joints, so as to decide exactly what

is the matter with him, and not be satisfied with the easy but

unscientific diagnosis of rheumatism, which may mean much but usually

means nothing.



Unless such reassurance is given, and especially if the ordinary drug

treatment for so-called chronic rheumatism is persisted in, after a

time these patients, unimproved by salicylate treatment, wander

off to all sorts of irregular practitioners and form the greater part

of the lucrative clientele of quacks and advertising specialists in

the cure of chronic diseases. More probably than any other class of

cases do they support the irregulars. Osteopathy has particularly

appealed to a great many of these patients. It has done it in two

ways. The first and most important probably by its effect upon the

mind of the patients. Osteopaths immediately proceed to reassure the

sufferers that their affection is not rheumatism, but some local

condition dependent upon either a subluxation of the vertebra which,

according to the founder of osteopathy, constitutes the basis of

ninety-five per cent. of all the ills to which human nature is heir or

upon some joint or muscle condition which can be corrected by

manipulation or massage. These patients have, as a rule, been

suffering a good deal before this from the thought that they were

afflicted with a progressive constitutional condition which would

almost inevitably cripple them. Often they have seen patients who were

suffering from arthritis deformans in its worst forms and advanced

stages; they have heard this called rheumatism and they have concluded

that it was only a question of time when they would be in the same

condition. There is no good reason to speak of such conditions as

rheumatic. They are entirely local, the hope of relief between attacks

is by properly applied massage and passive movements which facilitate

the blood supply in the neighborhood, and the best applications at the

time of discomfort are the various rubefacients which stimulate the

circulation in the parts, call the blood to the surface, and prevent

that congestion in the neighborhood of small nerves which is the cause

of the aches or pains. These affections take on a much more serious

character in the minds of patients as soon as the word rheumatism is

mentioned. To tell them that the condition is entirely local, has no

tendency to spread, has nothing to do with any constitutional

condition, and can be relieved by local measures and the improvement

of the general health, will often bring the patient a good measure of

relief.





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