Preventable Diseases

by Woods Hutchinson

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.[2]

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.