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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

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

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

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

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