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RHEUMATISM: WHAT IT INVOLVES
A Classified Account of Rheumatic Affections
While acute rheumatism is described under the earlier heading of Rheumatic Fever the other types are grouped here. It will be seen, however, that the term covers a wide field of ills, many of which are dealt with at greater length under their own headings. Many local rheumatic affection, not immediately dangerous, may give rise to serious disablement.
This term is often loosely used to cover a great variety of conditions associated with pain in the skeletal and supporting structures of the body but conveys no exact meaning in a pathological sense. The so-called rheumatic affections constitute the most frequent cause of bodily pain and disability. The changes in joints and fibrous structures are of various kinds, and there are probably many kinds of causative agents. It would probably be better to abolish the term altogether. In popular usage the tendency is to label all painful conditions affecting the framework of the body as "rheumatic."
 
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Rheumatism in the widest sense is among the oldest known diseases, even skeletons of mummies showed corresponding pathological changes. In an old-Egyptian papyrus even different suggestions for the treatment of aches and pains were found. The term "rheumatism" which was coined by Hippocrates means "flowing of pain" and describes many diseases which are all accompanied by problems in the locomotor system. The famous Greek physician (circa 460 - 370 BC) worked intensively on rheumatism and influenced the following centuries with his popular theory on body fluids.
Hippocrates recommended absinthe for juandice and rheumatism. Ancient absinthe was different from the liquor that Verlaine and Picasso imbibed, generally being wormwood leaves soaked in wine or spirits. Most likely the word absinthe derives from the Greek word apsinthion, which means " undrinkable " presumably because of its bitter taste.
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RHEUMATISM: STRUCTURE OF A JOINT
Bones forming a joint are covered with cartilage where they come into contact, the joint cavity is lined with synovial membrane, and outside this are ligaments and tendons; various affections of these are named.
Doctors in the past have been too ready to classify a host of disorders under this heading, whereas now these are proving to be of varying natures and etiologies. Disease of the joints leading to severe disability and associated with inflammatory destruction of the joint and its surrounding structures occurs in many pathological conditions. Such are as Arthritis due to (1) injury; (2) specific infection by the bacteria of known diseases such as those causing gonorrhoea, syphilis and tuberculosis, by the pneumococcus, septic, typhoid and other organisms responsible for general infection of the body and in these cases attacking the joints and fibrous structures.
Acute rheumatic fever comes into this category, and, like the others, is dealt with under its special heading; (3) gout and other metabolic disturbances; (4) disease of the nervous system as in locomotor ataxia; (6) deficiencies in the diet, as in rickets and scurvy.
The commonest type of so-called rheumatic disease of the joints and fibrous structures however, is that large group of cases included under the terms rheumatoid arthritis, osteo-arthritis, and arthritis deformans. These are dealt with under their special headings, but here it may be said that these again fall into several groups according to their causation and the nature of the pathological changes present. Many of the cases are undoubtedly due to infections of various kinds some of them known, others as yet unknown. They may therefore be classed as arthritis due to non-specific infection. Other types are beginning to be recognized as due to metabolic disorder accompanied by the production in the body of poisonous substances which directly attack the joints and fibrous structures and may destroy them. In other cases both factors may be at work, and the infection may act indirectly by affecting the metabolic processes.
The term "rheumatism" is, however, applied to many conditions in which the joints are not affected. The affection is one of fibrous structures alone. These include the fasciae, the sheaths and supporting fibres of the muscles and one nerves, the tendons and ligaments. These cases are best considered under the general name of fibrositis, to which may be added, if desired the term "rheumatic." This group includes a very large proportion of the disorders prevalent principally in the industrial community and spoken of as "chronic rheumatism." It is dealt with under the heading Fibrositis, but further reference to it may well be made here in view of its great prevalence.
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RHEUMATIC NODES ON ELBOW
In true rheumatism an overgrowth of fibrous tissue may occur in many situations, forming little nodules. Here two of these are shown, attached to bones at the elbow-joint. Children are chiefiy affected in this way.
Before doing so, however, some reference may be made to some other so-called rheumatic manifestations. They include skin conditions such as erythema and the "rheumatic nodule," chorea, inflammation of the tonsils, and other less clearly defined troubles.
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RHEUMATISM: SITES OF FIBROSITIS
Muscular rheumatism, or fibrositis, may occur in any muscle, but is more frequent in the places marked here than elsewhere. The affection in some situations commonly receives a special name, e.g. lumbago.
In all cases the underlying cause is that which has led or will lead to the painful joint or to fibrositis, and is generally of the nature of a specific or non-specific infection. In some cases they, or at any rate some of them, may have origin in metabolic disturbances.
INFLAMMATORY NODULES IN MUSCLE
In muscular rheumatism overgrowth of connective tissue takes place at various places on the sheaths or in the fibrous intersections between muscle tissues proper and presses on nerves, causing pain. When wrapped around a nerve they called trigger points. They can be treated by massage and electrotherapy.
Chronic Rheumatism
Chronic rheumatism is liable to affect any part of the body, but a '"". few varieties have acquired distinct names. Thus stiff neck (q.v.), the form of chronic rheumatism most frequently met with in young people, affects the muscles of the right or left side only, so that the head is held stiffly in a fixed position on one side, called torticollis.
In lumbago (q.v.), one of the most painful and remarkable of the chronic rheumatic affections, the seat of the fibrous patches is in the muscles of the loin and back, on one or both sides.
In pleurodynia (q.v.) the site of the rheumatism is the chest wall. The pain is generally confined to one side of the body, and it is rather severe. Every cough or deep breath makes it worse. The pain comes in stitches.
Any part of the body may be the seat of an attack of chronic rheumatism. The shoulder region is a very common position, sometimes called frozen shoulder.
Individuals of both sexes and of all ages are liable to chronic rheumatism, but the complaint is most frequently met with in the middle and later part of life.
The true cause in the great majority of cases of rheumatism is some focal infection in the body. To medicate the pain itself is a worthless measure and may in fact make the condition worse. The foci of infection are most commonly to be found in the teeth, tonsils, sinuses or bowel. Pyorrhea, chronic tonsillitis or hidden infection in the tonsils or sinus, constipation with chronic bacterial infection of the bowel as a consequence - one or more of these conditions can generally be discovered and must be effectively dealt with if the liability to attacks of fibrositis on slight provocation is to be dispelled. Hygenic measures are of utmost importance.
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RHEUMATISM: ACUTE FORM IN KNEE
In this radiogram from a case of acute rheumatism the separation of the bones by effusion of fluid into the joint and the blurring of the out lines of the bones are points to be noted.
Less commonly septic foci in other parts of the body the ear, womb, testicles or ovaries, etc. are responsible. Heredity is doubtless an important factor (predisposition) in most types of rheumatic disorder, though its exact influence is little understood by regular medics.
The conditions which may induce an attack in the presence of some source of infection are actual exposure to wet, cold or keen winds, which is extremely likely to set up an attack. So common is this happening that the word rheumatic inevitably calls to mind the idea of chilly dampness, lying or sitting on damp ground, resting on a stone seat or stopping in a draught. All are very liable to awaken a chronic rheumatic condition. In some people heat has a similar effect, even an approaching storm.
Sudden changes of temperature and of barometric pressure may determine an attack, and sudden or prolonged muscular strain is a common exciting cause in those predisposed. There appear to be some cases in which dietetic errors and disorders of metabolism play an important part even in the absence of any condition of focal infection. Over-use of a muscle or group of muscles may also lead to a fibrositis in the tendons and ligaments. "Tennis elbow" is a common example. Finally, care must be taken to arrive at an exact diagnosis of the cause of localised pain resembling that of fibrositis, lest in reality it be due to some underlying disease in the deeper and more vital structures.
Treatment
With regard to the treatment of chronic rheumatism the essential thing is to seek out and eradicate any source of chronic infection. This being done the sufferer should then be able to lead a normal life with only the ordinary precautions to secure good health. At the same time it is well to attend to such matters as suitable clothing to ensure warmth and protection, without undue overclothing, which latter will certainly increase the liability to attacks; the avoidance of overexertion and fatigue: and removal from a damp, cold locality to a dry, warm one. It is also necessary to abstain from severe sudden or awkward muscular efforts.
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Left, treatment by total immersion. The patients are provided with supports and a douche the temperature of which can be accurately controlled, plays upon the part affected. Centre the Vichy douche: the patient lies immersed in a shallow trough beneath a series of fine showers, and massage is applied while under the spray. Right, a hot pack induces free perspiration and thus rids the body of poisonous matter.
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RHEUMATISM: TREATMENT AT THE LONDON RED CROSS CLINIC BY BATHS, MASSAGE AND HYDRO-ELECTRICITY
Left, local application of ultra-violet radiation to a rheumatic joint and radiation of a larger area. Centre another form of total immersion bath with aeration. Right, use of the Schnee hydro-electric two-cell and four-cell baths and other electric treatment The baths are made of porcelain or some other non-conductive material, and are set upon a linoleum-covered platform.
The regular use of herbal teas if often helpful as they help the body to fight or prevent infection, supply nutrients, and help cleanse the bowels of pathogenic bacteria. Parsley was used as far back as the times of Hippocrates as a medicine believed to help rheumatism, relieve kidney pains, and improve general health. Coriander leaves are called cilantro.  Coriander has been used by people for thousands of years and has been found in ancient Egyptian tombs dating back 3000 years. The Hebrews of biblical times used cilantro as the bitter herb for joint pain. The Roman soldiers under the reign of Julius Caesar took coriander with them as well as yarrow. The leaves of oregano were often chewed during the Middles Ages to relieve rheumatism, indigestion and coughs.  In ancient Egypt it was used for healing and disinfecting.  
Diet must be attended to. Any tendency to acidosis must be checked by the free use of green vegetables, juicy fruits and dairy produce, and elimination of refined carbohydrate and meat foods. If there is a tendency to constipation the diet must include ample roughage in the shape of whole cereals and vegetable foods. Vitamin deficiency in food may well lead to rheumatism owing to the consequent lack of resistance to infection and the poor quality of bone substance due to faulty metabolism of lime (calcium).
No reliance must be placed on drugs. The known medicine, injection or liniment, no fanciful diet or much-advertised patent medicanes, has any curative influence on chronic rheumatism. It is necessary to emphasise this warning against trusting in drugs, because very large sums of moncy are still wasted on them with a concomitant deterioration in health, if not a morbid addiction.
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RHEUMATISM: TREATMENT OF THE MUSCULAR FORM, OR FIBROSITIS, BY MASSAGE
Left, the pain in muscular rheumatism depends mostly on the existence of nodules, or swellings, in the tissues and consequent pressure on nerves. The position of these nodules can be made out by gentle palpation over the tender spots, and by this manipulation and light rubbing the extent of a nodule may be diminished. Centre, when pain has become less, deep pressure with the thumbs is used. Right, when, although tenderness has disappearsd or almost so, there is still a nodule, it will be useful to massage the part firmly, using the fist and, as it were, boring into the back.
Something may be said for the use of iodine and the iodides in cases in which no focal infection can be found or in which the infection has become so generalised that it cannot be removed in its entirety. Drop doses of tincture of iodine, beginning with 5 drops in a wineglass of water thrice daily is often beneficial. Guaiacum and sulphur are sometimes useful in these cases.
Good results in the treatment of chronic rheumatism in addition to more radical treatment are obtained from massage, baths and counter-irritants. Certain health resorts make a point of providing all the conditions requisite for the treatment of this disorder in its various forms as explained under the heading Fibrositis, the pains of chronic rheumatism are due to fibrous lumps and thickenings in the connective tissue of the body. Skillful rubbing and massage can cause them to disperse.
Efforts must be specially directed to any thickenings which can be felt and to those areas which are painful. Great care being taken not to be too severe at first. After a few days of stroking and rubbing the fibrous thickenings become more defined. Many of them are only then detected. In about a fortnight the massage becomes much less painful, and more pressure can then be exerted. The tips of the fingers, the thumbs and the knuckles are used for the nodules especially, with deep friction and stroking of the whole part. This deep tissue massage should be used, even if painful, so far as the patient can support or tolerate the pain. The counter-irritation sets up bodily resistance and often stirs a healing reaction to the focal infection.
The massage should be carried out every day. Fully three to ten minutes must be devoted to each painful part. A little oil or boracic powder should be used as a lubricant. The length of time required for cure varies in accordance with the severity of the case. Three to six weeks is usual. The use of a vibratory pad activated by an electric motor is often beneficial.
In conjunction with the massage regular exercises sbould be carried out, these being such as are best calculated to stretch the muscles and other parts involved, Undue fatigue should be avoided.
In conjunction with the massage and exercises, temporary residence at a mineral water spa has many advantages. The hotter waters are specially helpful and they may be assisted by douches (q.v.), baths and manipulation. Hot bathing immediately before the massage renders it more effective and less painful, and massage under a stream of hot water, as in the Aix douche, is very valuable. So also is the whirlpool bath (q.v.), in which the water is in violent circulation around the immersed patient.
In early and mild cases a Turkish bath, with manipulation of the affected muscles, may give great relief. Hot air baths, hot sandbags or any other method of applying dry heat are very useful forms of counter-irritation.
Diathermy is probably the most effective method of applying heat locally and deeply. Ultra-violet radiation or sunbathing is recommended by some, especially with a deficiency of calcium metabolism.
Lastly, some reference must be made to vaccine and auto-vaccine treatments in cases of long standing infection which do not respond to removal of the original source. The value of this treatment is variable but is often very satisfactory. Much depends on the character of the infective agent, the powers of response left in the patient after a long fight against the infection, and other factors some of which are of an unknown character. Recently attempts to treat the condition have been based on the isolation of certain chemical substances from the urine, the result of disordered metabolism. . Research work along these lines may prove helpful in dealing with this and the chronic joint manifestations of rheumatism.
RHEUMATISM: In Animals
A painful condition of unknown origin, rheumatism affects the limbs and trunk, especially the joints, muscles and tendinous tissues; producing conditions similar to those in man.
Acute articular rheumatism is usually found in cattle, but is occasionally met with in other animals, especially dogs and piffs. The cause is obscure, but it is probably infections. The so-called rheumatic fever of cattle which occurs just after calving is not really rheumatic at all. The true condition generally appears suddenly, often preceded by rigors. There is fever, lameness on one or more of the legs and a painful swelling of some of the joints. The temperature may be as high as 107 to 109˚ F., but is generally somewhat less and very irregular. It is accompanied by all the usual signs of fever, and endocarditis (although seldom diagnosed) is a common complication.
Animals should be given a mild purge (Epsom salt); as in humans, salicylic acid and the salicylates are specifics. The best drug is sodium salicylate (4 to 6 drachms every three to four hours) with baking soda. Affected joints should be fomented, and later when the pain has become localised, a mild blister may be applied. The diet should be kept light, and during the long convalescence should be combined with iron and bitter tonics. In dogs the treatment is similar, but aspirin (5 grains) gives better results than sodium salicylate.
Chronic articular rheumatism is common in old animals, horses, cattle and others. There is an intermittent lameness and swelling of the joints. The lameness recurs at irregular intervals, especially after exposure to chills and damp. Cure is difficult. Salicylate of soda and baking soda may be given as above. Iodide of potash gives excellent results in some cases, while hot fomentations are useful.
Muscular rheumatism is usually associated with the articular form. The muscles, however, are the parts affected, and groups are involved at the same time. It is generally chronic. The affected groups of muscles are painful to touch, but are neither hot nor swollen. The course is irregular, and the condition usually returns on exposure to damp and chills.
In treatment the most important factor is nursing. The animal must be kept in dry, warm quarters. Light exercise and massage are both beneficial. The diet should be nourishing, easily digested and laxative in character. Laxatives such as Epsom and Glauber's salts or calomel should be given, and sodinm salicylate and bicarbonate are often useful. In the more chronic cases there is usually a response be treatment with potassium iodide. Stimulating liniments should be rubbed into the affected parts.
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