Preventable Diseases

by Woods Hutchinson

Obviously, the picture of acute rheumatism carries upon its face a strong suggestion of its real nature and causation. The high temperature, the headache, the sweats, the fierce attack and rapid decline, the self-limited course, the tendency to spread from one joint to another, from the joints to the heart, from the heart to the lungs and the kidneys, all stamp it unmistakably as an infection, a fever. On the other hand, there are two rather important elements lacking in the infection-picture: one, that, although it does at times occur in epidemics, it is very seldom transmitted to others; the other, that one attack does not produce immunity or protect against another. The majority of experts are now practically agreed that acute rheumatism, or rheumatic fever, is probably due to the invasion of the system by some microörganism or germ. When, however, we come to fixing upon the particular bacillus, or micrococcus, there is a wide divergence of opinion, some six or seven different eminent investigators having each his favorite candidate for the doubtful honor. In fact, it is our inability as yet positively to identify and agree upon the causal germ that makes our knowledge of the entire subject still so regrettably vague, and renders either a definite classification or successful treatment so difficult.

The attitude of the most careful and experienced physicians and broad-minded bacteriologists may be roughly summed up in the statement that acute rheumatism is probably due to some germ or germs, but that the question is still open which particular germ is at fault, and even whether the group of symptoms which we call rheumatism may not possibly be produced by a number of different organisms, acting upon a particular type of constitution or susceptibility. There is no difficulty in finding germs of all sorts, principally micrococci, in the blood, in the tissues about the joints, and on the heart-valves of patients with rheumatism, and these germs, when injected into animals, will not infrequently produce fever and inflammatory changes in the joints, roughly resembling rheumatism. But the difficulty so far has been, first, that these organisms are of several different kinds and distinct species; and second, and even more important, that almost any of the organisms of the common infectious diseases are capable at times of producing inflammation of the joints and tendons. For instance, the third commonest point of attack of the tubercle bacillus, after the lungs and the glands, is the bones and joints, as illustrated in the sadly familiar "white-swelling of the knee" and hip-joint disease. All the so-called septic organisms, which produce suppuration and blood-poisoning in wounds and surgery, may, and very frequently do, attack the joints; while nearly all the common infections, such as typhoid, scarlet fever, pneumonia, and even measles, influenza, and tonsillitis, may be followed by severe joint symptoms.

In fact, we are coming to recognize that diseases of the joints, like diseases of the nervous system, are among the frequent results of any and all of the acute infectious diseases or fevers; and we now trace from fifty to seventy-five per cent of both joint troubles and degenerations of the nervous system to this cause. Two-thirds, for instance, of our cases of hip-joint disease and of spinal disease (caries) are due to tuberculosis.

The puzzling problem now before pathologists is the sorting out of these innumerable forms of joint inflammations and the splitting off of those which are clearly due to certain specific diseases, from the great, central group of true rheumatism. Most of these joint inflammations which are due to recognized germs, such as the pus-organisms of surgical fevers, tuberculosis, and typhoid, differ from true rheumatism in that they go on to suppuration (formation of "matter") and permanently cripple the joint to a greater or less degree. So that there is probably a germ or group of germs which produces the swift attack and rapid subsidence and other characteristic features of true rheumatism, even though we have not yet succeeded in sorting them out of the swarm. So confident do we feel of this, that although, as will be shown, there are probably other factors involved, such as exposure, housing, occupation, food, and heredity, yet the best thought of the profession is practically agreed that none of these would alone produce the disease, but that they are only accessory causes plus the micrococcus. In practically all our modern textbooks of medicine, rheumatism is included under the head of infections.

This theory of causation, confessedly provisional and imperfect as it is, helps us to harmonize the other known facts about the disease; it has already greatly improved our treatment and given us a foothold for attacking the problem of prevention. For instance, it has long been known that rheumatism was very apt to follow tonsillitis or other forms of sore throat; indeed, many of the earlier authorities put down tonsillitis as one of the great group of "rheumatic" disturbances, and persons of rheumatic family tendency were supposed to have tonsillitis in childhood and rheumatism in later life. Not more than ten or fifteen per cent of all cases gave a history of tonsillitis; but since we have broadened our conception of infection and begun to inquire, not merely for symptoms of tonsillitis, but also for those of influenza, "common colds," measles, whooping-cough, and the like, we reach the most significant result of finding that forty to sixty per cent of our cases of rheumatism have been preceded, anywhere from one to three weeks before, by an attack of some sort of "cold," sore throat, catarrhal fever, cough, bronchitis, or other group of disturbances due to a mild infection. Further, it has long been notorious that when a rheumatic individual "catches cold" it is exceedingly apt to "settle in the joints," and, if these cases happen to come under the eye of a physician, they are recognized as secondary attacks of true rheumatism. In other words, the "cold" may simply be a second dose of the same germ which caused the primary attack of rheumatism.

This brings us to the widespread article of popular belief that rheumatism is most commonly due to cold, exposure, chill, or damp. Much of this is found on investigation to be due to the well-known historic confusion between "cold," in the sense of exposure to cold air, and "cold," in the sense of a catarrh or influenza, with running at the nose, coughing, sore throat, and fever, a group of symptoms now clearly recognized to be due to an infection. In short, the vast majority of common colds are unmistakably infections, and spread from one victim to another, and this is the type of "cold" which causes the majority of rheumatic attacks.

The chill, which any one who is "coming down" with a cold experiences, and usually refers to a draft or a cold room, is, in nine cases out of ten, the rigor which precedes the fever, and has nothing whatever to do with the external temperature. The large majority of our cases of rheumatism can give no clear or convincing history of exposure to wet, cold, or damp. But popular impression is seldom entirely mistaken, and there can be no question that, given the presence of the infectious germ, a prolonged exposure to cold, and particularly to wet, will often prove to be the last straw which will break down the patient's power of resistance, and determine an attack of rheumatism.

This climatic influence, however, is probably not responsible for more than fifteen or twenty per cent of all cases, and, popular impression to the contrary notwithstanding, the liability of outdoor workers who are subject to severe exposure, such as lumbermen, fishermen, and sailors, is only slightly greater than that of indoor workers. The highest susceptibility, in fact, not merely to the disease, but also to the development of serious heart involvements, is found among domestic servants, particularly servant girls, agricultural laborers and their families (in districts where wages are low and cottages bad), and slum-dwellers; in fact, those classes which are underfed, overworked, badly housed, and crowded together. Diet has exceeding little to do with the disease, and, so far from meat or high living of any sort predisposing to it, it is most common and most serious in precisely those classes which get least meat or luxuries of any sort, and are from stern necessity compelled to live upon a diet of cereals, potatoes, cheap fats, and coarse vegetables.

Even its relations to the weather and seasons support the infection theory. Its seasonal occurrence is very similar to that of pneumonia,—rarest in summer, commonest in winter, the highest percentage of cases occurring in the late fall and in the early spring; in other words, just at those times when people are first beginning to shut themselves up for the winter, light fires, and close windows, and at the end of their long period of winter imprisonment, when both their resisting power has been reduced to the lowest ebb in the year and infections of all sorts have had their most favorable conditions of growth for months.

The epidemics of rheumatism, which occasionally occur, probably follow epidemics of influenza, tonsillitis, or other mild infections, and instances of two or more cases of rheumatism in one family or household are most rationally explained as due to the spread of the precedent infection from one member of the family to the other. Instances of the direct transmission of the disease from one patient to another are exceedingly rare.