SECTION IX
PSYCHOTHERAPY IN THE JOINT AND MUSCULAR SYSTEM
CHAPTER I
PAINFUL JOINT CONDITIONS—PSEUDO-RHEUMATISM. [Footnote 33]
[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 [{380}] 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 [{381}] 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 [{382}] 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.