Rheumatism by Dr. Lance Christiansen
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Editor-in-Chief: Lance Christiansen, D.O.
Undergoing edit with the addition of references through March 2013. (LWC)
- 1 Overview
- 2 References
- 3 (1) Harrison's Principles of Internal Medicine 16th Edition, McGraw Hill Medical Publishing Division, New York, N.Y., 2005
- 4 (2) Harrison's Principles of Internal Medicine 12th Edition, McGraw-Hill Medical Publishing Division, New York, N.Y., 1991
Rheumatism is usually considered to be an archaic term in medical science for it is not listed as a subject within the index of most modern, medical texts. For instance, it is not listed in the index of the text, Harrison's Principles of Internal Medicine, 16th Edition published in 2005. ( 1 )
Within the 12th edition of the same text, published in 1991, the only listing for rheumatism is psychogenic rheumatism; a part of the short paragraph explaining it is quoted as follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 ) The above use of the word rheumatism reflects how the concept of the systemic disease of rheumatism, as readers will soon understand, has become marginalized in modern medicine existing as only an archaic term or, as indicated above, as a figment of a person's imagination. (2)
Many philosophers and natural philosophers appeared during the pre-classic Greek period, and the classic Greek period, who mentally probed the nature of the universe, ideas, and matter, for instance, Socrates, Dioscordes, Plato, Theophrastus, Aristotle and Hippocrates and many others. Philosophy and natural philosophy was further extended during the Hellenistic era by many philosophers and natural philosophers including Praxagorus, Herophilus, Erasistratus, Soranus, Celsus, and Galen, the majority of whom studied, conducted medical research (including anatomical research via human dissection), and/or taught at the Alexandria University and Library in Egypt. Although various new ideas and concepts were developed, via observation and reason, by the above cited individuals are known to modern scholars, directly through their writings, exemplified by those of Hippocrates, Galen and Soranus, it is more common that their ideas, hypothesis, concepts and determinations developed via their research have come down to the modern day through the writings of authors who were active in later periods and frequently written information is thought to be confabulated by their associates, or by other individuals, but those writings have come down to modern readers as written by well known authors such as Hippocrates and Galen. Fortunately, many the works of Galen are still extant after being translated from Arabic, Coptic, Syrian, early Greek and other languages first into Latin and eventually into modern European languages. The knowledge that modern readers have, for instance, about the writings of Herophilus and Erasistratus, have come down to us via the writings of Galen and others.
During the classic Greek period, the Hellenistic period, and thereafter, and during the Middle Ages, many details of classic Greek and Hellenistic philosophic and natural philosophic thought had been absorbed into Arab, Syrian, and Jewish learned society and the writings of individuals such as Ibn Sina (Avicenna (980-1037), Al Farabi (c. 870-950), Ibn Rushd (Averroes) (1126-98) and Moses Maimonides (1135-1204 CE), and others, were eventually translated into Latin at various locations, especially, however, by Moorish and Jewish physicians in Spain, after the removal of the Arab leadership in 1492.
During the second century CE the Greek physician, scientist, philosopher and author Claudius Galenus (129 to about 213 CE), commonly known simply as Galen, was born in Pergamum, which was a thriving city on the west coast of what is now Bergama, Turkey and which was originally founded as early as 1200 BCE during the early archaic period of the Greek Civilization. He was provided a liberal education, which included a thorough education in the various philosophies that had developed in Greece up to that time. At 17 he began medical training at the Aselepieum of Pergamum. He also trained in anatomy, physiology, medical theory and treatment concepts at Smyrna ( now, Turkey), Corinth (Greece) and for four years at Alexandria ( Egypt). Later in his career he practiced in Rome and eventually became physician to a number of emperors including Marcus Aurelius. ( 3 )
William Gilbert (1544-1603), an English physician, philosopher and scientist is often thought to be the first person during the seventeenth century to overtly espouse the scientific method, for instance: "... he was the first person to set out clearly in print the essence of the scientific method - the testing of hypothesis by rigorous experiments - and to put that method into action." ( 4 ) Earlier, however, Nicolaus Copernicus and Galileo Galilei had practiced the scientific method and before that, during the European medieval period, Roger Bacon, Roger Grosseteste, Thomas Acquinas, Albert Magnus, and others, were involved, in thought and practice, in developing what has become to be known as the scientific method of knowledge development.
It appears, however, that Galen's rational, philosophic methodology, which he developed during the second century CE was similar to Gilbert's, and other western European natural philosophers' thought and purposeful experimental processes, which were identical or similar to those now known as the scientific method. His analytical methodology appears in many locations throughout his writings. For instance: "...logical procedures should at all times be checked by experience. Both reason and experience are instruments of discovery and means of testing what has been discovered. The method envisaged by Galen can roughly be characterized as comprising a stage of discovery steered by reason ( i.e. rational methods) followed by one of confirmation or otherwise by means of experience. For Galen, experience means not merely the accumulation of data involving no particular expertise." It "...involves techniques requiring skill and expertise such as in anatomy and experimentation...Galen engaged in the style of anatomical experimentation instigated by..." earlier anatomists, "But in this context he retained the Empiricist requirement of a large number of identical observations, thereby foreshadowing the modern requirement of the repeatability of experimental observations." ( 3 )
Hippocrates, "...first used the term rheuma, which literally means "flowing," to describe an excess of the watery humor (phlegm) thought to flow down from the brain. The words rheuma and catarrhos ("flowing down") were used interchangeably by ancient Greeks to describe a variety of illnesses including joint problems. ( 7 ) Galen adhered to many Hippocratic concepts and he also, like Hippocrates, advocated carefully observing individuals' life activities, such as their immediate living environment, nutrition, hygiene, levels of exercise, the observable factors of disease states, signs, and patient complaints, symptoms, and rationally studied anatomy, physiology and the environment (such as the geographical location and seasonal weather conditions) so as to understand the nature of man concerning the development of disease states more accurately. His study was accomplished in reference to the concepts of Plato and Aristotle as well other natural philosophers and physicians including Diocles, Herophilus, Eriasistratus and others. ( 3 ) Concerning phlegm (rheuma) Galen indicated: "We use the word catarrh whenever the superfluity flows to the mouth, but coryza whenever it flows from the nose." ( 8 )
It may be that another individual of the Hippocratic persuasion, not Hippocrates himself, commented on rheumatism within the Hippocratic Corpus, however, within this text all writings in that work will be considered Hippocratic in origin. Further, then, Hippocrates seems to be the first physician to use the word rheumatismus (rheumatism) as a noun and verb. ( 9 ) In addition, Galen championed and further developed many concepts in medicine first mentioned by Hippocrates. For instance, the pathophysiological concept of rheumatism was one such concept since, concerning the word rehumatism, "Examples of...noun, adjective and verb are far too common in Galen to list (80+)..." ( 10 )
Further, within the Giunta edition of Galen, in Latin, there are over thirty notations within the index on rheuma, rheumatism and related terms. For instance, "Rheumatismum faucium Suffionigmum de dyna.; Rheumatismum stomachi and intestinarum Malagma...; and Rheumatismi articularum, introd." ( 11 ) The preceding subjects are, roughly translated: rheumatism of the throat, rheumatism of the stomach and intestine as soft masses, and rheumatism of the articulations or joints. It seems, as the prior information exhibits, that Galen's concept of rheumatism was that it was a disease that affected many parts of the body (a systemic disease) and that, it was related to rheum, a flowing down of phlegm, catarrh from the mouth and coryza from the nose. In those early times it was thought that phlegm (in the form of cerebrospinal fluid) flowed from the ventricles of the brain through the small holes in the cribiform plate of the ethmoid bone that is located directly above the center of the nasal passages. That idea was rationally appropriate since the cerebrospinal fluid is a semi-clear fluid and it is normally found within the ventricles and within the space between the meninges and the matter of the brain just above the cribiform plate.
An increase in mucous drainage, catarrah and coryza, was related, evidently, to a "...a systemic inflammatory response syndrome (SIRS) that may have an infectious or a noninfectious etiology. If an infection is suspected or proven, a patient with SIRS is said to have sepsis. When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." ( 1 ) If the development of phlegm from the respiratory organs is caused by an infection from a microorganism that has a mechanism to create pathological tissue changes to distant tissues and organs, then, perhaps, that is the mechanism of the development of rheumatism, or better said, rheumatic pathological signs and symptoms in various parts of the body.
To further provide philological information on the words rheuma and rheumatism the following definitions found in dictionaries will be provided: The definition of the word rheum within a reasonably current dictionary is: "rheum...1. a thin, serous or catarrhal discharge. 2. catarrh; cold. [ME reume < L rheuma < Gk rheuma...(to) flow..." ( 11 ) In addition, "rheum, ...Rheuma, (F.) Rheume, ...'I flow.") Any thin watery discharge from mucous membrans or skin; as the thin discharge from the air-poassages arising from cold." and, "Rheuma, gen. Rheumatis, ...(from...'I flow") Catarrh, Diarrhea, Rheum, Rheumatism. Also, inflammation of a fibrous tissue, as in rheumatism and gout. In composition, a flow, a defluxion; also, rheumatism. ( 12 )
During the Renaissance Guillaume Baillou (1538-1616), or Ballonius in the Latinized form, a Parisian physician, apparently was the first to use the term "rheumatism" (rheumatismos) for polyarthritis and to give a fairly good description of this condition, in his treatise, "Liber de Rheumatismo,", which was not published until 1642, twenty-six years after his death." Further, Baillou provided a clinical description of an individual with acute rheumatism (rheumatic fever):
"Before we place this affection in a class of disease or symptoms (since it causes its effects by the primary disease and the symptoms produced by it is commonly and vary badly confused) just as what it is, we shall explain by what and in what manner it arises: we shall point out the train of pains & symptoms also present...
On the other hand the method by which this affection attacks which is falsely called catarrh: (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism, is as follows. . . The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot nor the hand, nor the finger can be moved in the least without pan & and outcry: moreover the greater pain lies in the joints because that part is endowed with greater and more exqusite sensation...When the hand is pressed on the parts, the sensation & feeling, (even if you touch it lightly) is of a definite severe heat. IF you examine the pulse, the fever is seen to be little or nothing...
Indeed the pains are worse at night, the patients cannot sleep, partly because they are unable to be moved from their position & from that posture they first usually lie and recline, they remain in it & are scarcely moved or touched without excruciating on terrible pain...this rheumatism itself is in the entire body; with pain, tension and a somewhat sharp feeling, others say with the sensation of heat (as already mentioned)...This rheumatism is not the same as in those who sin in their way of life." ( 13 )
Somewhat later, Thomas Sydenham (1624-1689), an English physician, who also, like Hippocrates and Galen, carefully observed patients' during disease states. "These observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitis Dance (1686) and gout (1683). "...Sydenham understood the migratory nature of polyarthritis and its tendency to attack the young, characteristics which today we know to be typical of the joint manifestations of rheumatic fever." ( )
Hippocrates mentioned the salient clinical characteristics of rheumatic fever within writings of the Hippocratic Corpus. For instance, "Rheumatism as a disease process became. clinically, more accurately understood so by the the the late 1700's acute rheumatism was the term used for rheumatic fever and chronic rheumatism was known defined as follows: "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 13 )
To think and speak concisely words must have strictly defined meanings. The use of the words empiric, empirical, and empiricism, in various contexts, is somewhat antonymic in nature. For instance, within a reliable dictionary the meanings of the words are established: "empirical, empiric, a. 1. relying or based solely on experiments or experience; as, the empirical method..." Conflictingly, in the same text, the meaning of empiricism is as follows: "empiricism, n. 1. dependence of a person on his own experience and observation, disregarding theory, reasoning, and science. 2. the practice of medicne without a medical education; hence, quackery; charlatanism..." ( 9 )
Within an older medical dictionary the following definition for empiric is described: 1. "Empiric...(...'a trial;.'--'experimental.') One who follows only experience. A sect of physicians, who rejected all theory, and took for their guide experience alone. It was opposed to the dogmatic sect, which prevailed till near the time of Galen." In addition, "... At the present day the word Empiric is only taken in a bad sense, being employed in nearly the same signification as charlatan or quack." ( 10 )
The definition of the word empiric, just related, should be clarified to indicate that the "experience" mentioned is the personal experience of one physician-investigator, or, perhaps, the added experiences of a number of other physician-investigators who have communicated between each other in a fairly casual fashion and not with scientific detail, processes, repetition or scrutiny.
Since there is a conflict of meaning using the English word empiric, and words developed from it such as empirical and empiricism, a solution to the conflict will be used in this article by using, as a convention, an older English spelling: empyric, empyrics, empyrical and empirycism, as in the empyric school of medicine, as it is used in a text published in 1771: "After a knowledge of medicine began to be studied and practiced as a liberal profession, a jealousy of reputation, joined to a thirst for money and ignorance of philosophy, laid a solid foundation for medical disputation. One party of physicians, known by the name Empyrics, excluded all reasoning, and trusted solely to experience." ( 13 )
Alternatively, empiric, empirics, empirical, and empiricism will, in this text, convey a more detailed, scientific concept, for instance, an individual's empiric method would include personal observations, repetitive observation, analysis, at times, experimental observation, testing and further analysis and deductive hypothesis development. After the hypothesis was widely verbally announced, or published, other investigators could, themselves, repeat the same observations, analysis, etc., and agree or disagree with the hypothesis advanced by the original investigator. Empiric, empirical and empiricism would, then, connote a scientific meaning and methodoloy, whereas empyric, empyrical and empyricism would refer to a personal, more or less, opinionated meaning, or a meaning agreed upon by individuals within a certain professional group or group of people with a similar philosophy.
For instance, the empyric concept that is often mentioned in chiropractic advertising indicates that an adjustment of the spine promotes spinal health. Also, Andrew Taylor Still, MD DO, the founder of the osteopathic medical profession, taught that spinal manipulation promoted improved blood flow to various anatomical sites in the body. In addition, individuals are frequently advised to have an annual physical examination for they are generally thought to contribute to a person's general health. All three of the prior concepts, even if they have been repeated for a long period of time, have not, necessarily, been developed through the use of empiric methodology.
The word disease, also, has various meanings. In this article the word disease will connote an adverse medical condition wherein the cause and basic pathophysiology is known. Alternatively, an adverse medical condition, which has no known cause (an idiopathic disease), and which is defined by its general sign and symptom pattern, and, at times, its gross and microscopic anatomy, will be defined to be a syndrome. Ninety-nine percent of diseases mentioned in leading medical texts are more accurately described to be syndromes and not diseases. For instance, coronary artery disease, mental diseases such as schizophrenia and manic-depressive disease, Crohn's disease, Meniere's disease and the disease of diabetes mellitus are all more accurately defined to be syndromes, and not well defined diseases, since their causes are not known.
Galen can be considered for the most part an empiric, but, perhaps, he is more accurately termed a rationalist. He never claimed, however, that he was a member of any one school or sect of medicine. When, however, due to lack of physiological, pathophysiological or micro-anatomical information he, at times, adapted older concepts, such as Hippocrates' fluid (humor) concept, which had been developed by him to explain clinically observed phenomena during a time when anatomical, micro-anatomical, physiological and pathophysiological empiric information was not available. Galen also developed, at times, his own concepts based on observation, which, without modern investigative abilities, have been proven to be not true. He thought, ideally, that diseases should be anatomically and pathophysiologically understood and that included understanding their causes before proper treatments could be developed. He also realized, however, that there were limits to existing knowledge so that a quasi-empiric or a careful empyric approach to treating diseases, based on careful use of experience and reason, had to be used until a more thorough knowledge of the particular medical phenomenon in question was achieved. One of the ways to understand the body was via a thorough an investigation of human anatomy and physiology; such knowledge was not thought to be necessary by empyricists of his time. In an effort to develop his empirical medical concepts Galen accomplished a great deal of original medical research, especially, in neuroanatomy and neurophysiology. ( 3 )
The dogmatist school of medicine was a "...school of medicine formed by Diocles of Carystus. The school put Aristotelian language, system, and speculation into Hippocratic medicine to discover the hidden causes of the constitution of man and of disease: such knowledge, they thought, was necessary for the practice of medicine." ( 14 )
The melding of empyric medicine (using only information developed via personal, idiosyncratic methodology) with dogmatic, empiric medicine (using information developed via scientific methodogy) is, for a physician, a necessary, practicable reality until complete knowledge concerning all disease processes, including their causes, is developed and that approach to professional medical treatment was advanced in 1771: "A judicious mixture of the two is indispensably necessary. Indeed it is difficult to determine whether too great an attachment to empyricism or dogmatism has contributed most to obstruct the improvement of physic." ( 13 )
Progressively, over the last six decades, or so, the empyric treatment paradigm has become quasi-empiric by the development of organized clinical trials, which test more accurately as to whether a certain medicinal chemical treatment, or surgical treatment, produces a meaningful ameliorative change in a syndrome. Such trials, and the research that is is involved with the medicinal chemical's development, however, ignore dealing with the cause of the disease in question so such organized efforts are not thoroughly empiric.
The professional organization of medicine had always features physicians who specialized in certain medical techniques, such as surgical techniques, or in treating certain conditions starting, at least, with archaic Egyptian medicine. ( 15 ) Beginning in about 1920 in the USA, however, the development of various medical specialties was accelerated so that by the 1970's most physicians were of the specialist type and general practitioners who, historically, had treated males and females, of all ages, for all diseases became fewer and fewer in number.
Specialty medicine has been, and is, the practical paradigm, which represents the empyrical, or allopathic, school of medical science, which has dominated modern academic and clinical medical science and practice since that time, the early 1900's. Allopathy is the correct name for the philosophy of modern, empyric, medical practice and it is defined as follows: "...that method of medical practice which seeks to cure disease by the production of a condition of the system either different from or opposite to the condition produced by the disease..." ( 16 ) The term, allopathy was not coined by members of the doctor of medicine profession, but by Samuel Hahnemann, the founder of homeopathy, to distinguish the predominant, functional school of medicine at that time, the late 1700's, from the type of medical philosophy and practice espoused by homeopaths.
The reality is, however, the treatments developed in the members of the doctor of medicine profession, mentioned above, do not cure most diseases except those, such as lacerations and fractures caused by trauma, and since the 1930's, those caused by certain infectious processes. Most medical and surgical treatments have been developed to alter organs, or parts of organs, usually for the better, that have become symptomatically damaged by an unknown, underlying pathophysiological process, or processes, with an unknown cause. Although the term allopathic physician is not used by members of the doctor of medicine profession to describe themselves, members of that profession, the osteopathic profession, the homeopathic profession, the naturopathic profession, the chiropractic profession, the physical therapy profession, and even the traditional Chinese medical profession all practice their own form of allopathic medicine: altering disease, often for the better, by "...the production of a condition of the system either different from or opposite to the condition produced by the disease." An example is the use of insulin to treat diabetes; its use lowers elevated serum blood glucose levels, but it does nothing to improve the function of the Islands of Langerhands of the pancreas, which are not producing adequate insulin due to an underlying autoimmunological process. Similarly, If a person has ulcerative colitis, a portion of the colon that is most severely affected is often surgically removed, but the surgical procedure does not control the underlying autoimmune condition that intrinsically causes such a disease process.
It should be noted that the above paragraph stresses the idea that allopathic medicine seeks to: cure diseases such as fractures, sprains, and specific infections, since their causes are known, by applying proper physical treatments, concerning the first two types of diseases, and by the use of antibiotics in the third. All other adverse medical problems, however, are syndromes and so by the production of a condition of the system (a physical or biochemical change within the body) either different from, or opposite to, the condition produced (damaged organ) by the disease (the syndromic sign and symptom pattern) and that the goal of such a medical philosophy is not, necessarily, to cure the underlying disease in question by effectively removing its cause. That is, the underlying disease, or its cause, does not necessarily have to be known before pathological target-organ manifestations produced by them, biochemical or physical dysfunction, such ischemic cardiomyopathy caused by arteriosclerosis of the coronary arteries and diabetes mellitus caused by partial or complete failure of the Islands of Langerhands of the pancreas, are allopathically treated. At times, one specific treatment modality, or a combination of allopathic, quasi-empirical treatment modalities, manages to cure a patient's syndrome without knowing the nature of its underlying cause. An example of such a treatment is the curative treatment provided patients with certain tissue-types of cancer by applying various combinations of surgery, chemotherapy, and radiation therapy.
For instance, if a patient has congestive heart failure with pulmonary edema, an enlarged heart, and swelling of the lower extremities it is common to provide the patient with diuretics, digoxin, and arterial dilators to improve the adverse physical findings of their condition. Usually, such treatment "works" in a meaningful fashion, but it does not deal with the underlying disease or its cause, which resulted in an acute malfunction of the heart. A similar relationship exists between cholecystitis and cholecystectomy. Surgically removing a patient's gall bladder removes the inflamed, poorly functioning organ and also removes the gall stones that often form within it. The surgical procedure often decreases patient discomfort, but it does not deal with the underlying disease, or its cause, that resulted in the gall bladder's abnormalities to originally develop. Similarly, tranquilizers improve a patient's feelings of anxiety, but they do not change the pathological phenomenon, organic or behavioral, that caused it. Finally, insulin injections lower serum glucose levels, but they do not improve the functioning of the islands of Langerhands of the pancreas, which have been harmed by a poorly understood autoimmune process the cause of which is unknown. Basically, in all the above common therapeutic approaches the therapy provided a different or opposite result as that caused by the underlying pathological process in the certain organ. One could confidently say that the treatments mentioned above altered, for the better, the specific organ damage or malfunction described, which were caused by unknown, underlying disease-processes, which have unknown causes.
The above allopathic, semi-empiric method of medical practice usually provides for an improvement in patients' medical maladies, however, it is limited in concept, because it foregoes a rationalist's concept that, ultimately, the underlying pathological disturbance that causes organ damage, and its cause, must be known before cures can be developed, an idea which was held by Galen. For instance, Galen indicated, "Nature does nothing for no reason." and "Nothing occurs without a cause...So if a natural activity such as vision is damaged or impeded, one should look for the cause, i.e. a particular disposition of the body...The doctor, at any rate, directs his therapy at the disposition being the cause of the impairment." ( 3 )
The development of medical science had progressed, slowly, in a waxing and waning fashion, over a long period of time so by 1850, for instance, if a patient did not have a laceration, burn, sprain, or fracture, medical problems for which causes were known, no medical condition could be treated directly in curative fashion by empiric means. Finally, the most meaningful advance in recent medical history occurred during the 1870's with the discovery of the microbiological hypothesis of infectious diseases by Robert Koch, a "country physician" in Germany. After the "causes" of infectious diseases were determined a rational effort towards curing them was enabled; antibiotic and vaccine development was the result that effort.
Modern medicine, basically, is a syndrome (idiopathic disease) altering art that has incorporated certain treatments to alter, usually for the better, certain syndromes. This paradigm is enforced by the concept of evidence based medicine, which itself defines the organization of medical practice wherein only certain individuals, who work in medical-educational and research institutions, have the right to accomplish medical research and determined that a certain quasi-empiric treatment, usually biochemical in nature, provides some measure of decrease in the signs and symptoms of a certain syndrome. Since the cause of the syndrome, in question, is not known, however, the treatment is syndrome-altering, and not disease curing, in nature.
Unfortunately, over time, the concept of evidence based medicine has mandated the exclusion of the newly developed medical information (rationally developed, empiric, medical information) that has been learned and accumulated by hundreds of thousands of clinical physicians, because they do not work within the confines of the medical, academic establishment. Even though the physicians, mentioned above, underwent training in the same medical, academic establishments they are not allowed to use their institutionally learned knowledge, knowledge that is enhanced through a long involvement in clinical medicine, to augment the functional medical knowledge used by the medical community. Galen, himself, shunned such a scholastic arrangement for he thought that "authority", even academic authority, in any intellectual field shouldn't be respected and that each investigator's contribution to medical knowledge should be rated on its own merits and not depend upon the investigator's position in the medical, academic, political hierarchy.
Hippocrates' (and Galen's) concept of Physis (nature) and the faculties, or powers, that are intrinsically part of it are probably, together, the same as the modern concept of biochemical homeostasis and the elements, genetic or otherwise, that guide its function. In a stable homeostatic state biochemical mechanisms normally maintain the body in a state of health, or vital equilibrium. When a disease-state develops, whether it be, for instance, a fractured bone, an infection by a microorganism, or autoimmunological damage to the thyroid gland causing hypothyroidism, the various biochemical faculties (powers) that are an intrinsic part of the body's Physis (nature) tend to homeostatically combat the individual's disease-state in an attempt to restore health. The physician's task was to aid the body's natural tendency to restore health by the use of "lifestyle" advice, dietary direction, medical treatments (often herbal treatments), and, at times, surgical treatment. Physicians should ideally, in principle, therefore, simply assist the naturally existing faculties, or powers, of "..."Physis" (nature) that exist within the unity of the body so that health is preserved, or, in case of disease, restored. ( 3, 12)
Concerning Hippocrates' contribution to medicine the following is written: "The revolution which he caused in practical medicine, semeiology, pathology, and dietetics, was the more important from the plans adopted before him by the Asclepiadae and the philosophic sects being in no respect adapted for the improvement of the science. He taught physicians that their first duty is to observe attentively the progress of nature. He demonstrated the inutility of theories, and proved that observation alone is the basis of medicine. The curative art, having become, from his example, a science of experiment and of facts, ought to have made the most rapid progress...These brilliant hopes were not, however realized." ( 13 )
Galen, who practiced medicine about 600 years after Hippocrates, emulated many of his concepts, for instance, Hippocrates' humoral concept: Hippocrates, "...supposed the existence of four fluids in the body, -- blood, phlegm, and yellow and black bile. Their common source he ascribed to the stomach, but each had, also, its particular origin, --the blood from the heart, phlegm from the head, yellow bile from the gall-duct, and black bile from the spleen." ( 13 ) Also, there were four qualities, heat, cold, moisture, and dryness associated with the humors. All were important factors in the healthy state and in disease development and treatment. ( 3 )
One can understand the concept of the four humors in a reasonable fashion if it is understood that blood is red arterial blood [with air (oxygen) within it], which originated in the heart; black bile was deoxygenated blood with erythrocyte break-down products within it, which was stored in, and which flowed from, the spleen; yellow bile was normal bile that originated in the liver and which flowed, via the bile ducts, to the gall bladder for storage. Phlegm was mucous or other clear secretions or excretions within, or from, a specific organ. For instance, phlegm, clear or purulent, which is expectorated during coughing; phlegm that composes the matter of sinus drainage, acute or chronic, and tears, which can exist in copious amounts during an allergic episode. Mucous that is normally secreted from the endothelial lining of most organs of the gastrointestinal tract was also considered to be an aspect of phlegm. It was thought that purulent matter, pus, was a type of phlegm. In addition, mucous secreted by the uterine lining and which departed via the uterine os, and saliva, were both categorized as phlegm.
Further, Galen indicates: "The humors are defined by their associated qualities: 'yellow bile is hot and dry in power, black bile dry and cold, blood is moist and hot, while phlegm is moist and cold' " ( 3 ) The four humors all flowed throughout the body especially within the arteries and veins in an appropriate balance during the healthy state. An elevation of yellow bile as in jaundice, or of phlegm as noted in a respiratory disease, dropsy (edema in the legs), within the swollen joints of arthritis, copious amounts of phlegm in chronic sinus drainage, or abnormally abundant tearing as in allergies, for instance, were thought to be imbalances of the above-named humors.
At the time Galen was involved in medical practice it was thought, by many, that mucous from the nose, and possibly that which was expectorated from the lungs and the trachea during respiratory diseases, originated from the brain and it entered the upper respiratory tract through small holes that exist in the cribiform plate, a part of the ethmoid bone located at the base of the brain above the nasal passages. If a person considers the concept anatomically, and realizes that without microscopy there was no way that physicians, in the early days of medicine, could know about secretion from respiratory epithelium, and considering the existence of copious amounts of clear cerebrospinal fluid within and surrounding the brain, the idea of mucous originating from the brain is more understandable. The limited physiological and anatomical knowledge that physicians had during the period of time that Greek medicine was influential caused those physicians to make rational judgements that were, eventually, over a thousand years later, proved to be incorrect, because their observations were not empirically complete, especially without the benefit of microscopy. Later scientific discoveries made by William Harvey, Marcello Malpighi, Andreas Vesalius, and others, were enabled by the earlier efforts by, usually, the earlier Hellenic and Hellenistic natural philosophers.
The Hippocratic humoral concept stressed that individuals' personality type were caused by the predominant humor imbalance within them. An excess of blood caused the sanguine personality, an excess of yellow bile caused the bilious personality, an excess of black bile caused the melancholic personality, and an excess of phlegm caused the phlegmatic personality. Eventually the word humor was taken into the English language as in: Mary, what humor are you in today? Many words in the English language have been developed from the humoral concept of the body's make-up; for instance, the English word, bilious, describes the emotional state of a person who is excitedly angry, irritable or peevish. Depression, perpetual sadness, and a slow moving demeanor were thought to be caused by the patient having an excess of black bile. Thus, the English word, melancholy is derived as follows: [ ME melancholie > LL melancholia < Greek: black bile ]. Phlegmatic has a similarly derived meaning: "1. not easily excited to action or display of emotion; apathetic; sluggish...3. of the nature of or abounding in the humor phlegm." ( 8 )
A certain disease state, which appeared epidemically, at times, caused patients to frequently experience a great amount of pain ( as noted in the text, The Hippocratic Writings, The Epidemics, Books I, II, and III. ( 7 ). In addition, within the above mentioned text, within the chapter titled, "The Sacred Disease", Hippocrates writes as follows concerning conditions that feature an overabundance of phlegm: "Now this disease attacks the phlegmatic but not the bilious." "Sometimes phlegm, which should have been purged out during life in the womb, remains during early life and is only got rid of in the later years.This is what happens in the case of children who suffer from ulcers of the head and flesh, and who salivate and discharge mucus; they get better as they grow older. Those who have been purged of the phlegm in this way are not troubled by this disease, but those who have neither been purged in this way by ulceration and discharges of mucus and saliva, nor have been purged in the womb, are liable to be attacked by it." "...If the discharges should make their way to the heart the chest is attacked and palpitation or asthma supervenes; some patients even become hump-backed. For when cold phlegm reaches the lungs and heart, the blood is chilled and the blood-vessles, as a result of being violently cooled in the region of the lungs and heart, jump and the heart palpates. Such circumstances force the onset of asthma and diseases characterized by orthopnoea because, until the phlegm which has flowed down has been warmed and dissipated by the blood-vessels, it is impossible to inspire as much air as is needed. When the phlegm has been removed, palpitations and asthma stop...Feelings of pain and nausea result from inopportune cooling and abnormal consolidation of the brain and this affects the phlegm. The same condition is responsible for the loss of memory." ( 7 )
Within the book (chapter) Epidemics Book I, the following
Hippocrates and Galen, considering their concept of the functional unity, or holistic view of the body, perhaps developed the idea that rheumatism (rheumatismos) was a painful, systemic, disease process ultimately caused by, or related to, the over-abundance of phlegm that they observed "flowing down" chronically or acutely when patients experienced certain respiratory diseases. Dependent edema (dropsy), lymphedema, asthma, chronic bronchitis, excessive tearing during an allergy attack (rheumy eyes) and swollen arthritic joints are all examples of conditions that, hypothetically, were considered to be caused by an excess of phlegm in the body. The following terms describing rheumatic condition have been conserved from prior eras and they help in an understanding of the systemic disease of rheumatism:
Concerning Hippocrates and Galen's definition of rheumatismos, mentioned above, the key to further understanding is to determine what disease state, in particular, caused, or/or now cause, the flowing down of phlegm, catarrh (a meaningfully severe respiratory disease), and also cause patients to experience a great amount of pain as a symptom of inflammation.
During the philosophy of medicine's intelectual development, a debate, nearly continually, has existed between empiricists and dogmatists (rationalists). Empiricists indicated, "It is not", they said, "the cause but the cure of diseases that concerns us; not how we digest, but what is digestible." ( 5 ) In addition, "...Empyrics, excluded all reasoning, and trusted solely to experience." Contrarily, however, "...Dogmatists, maintained, that no man ought to prescribe, withoput being able to give a theory both of the disease and of the nature of the action of the medicine. This dispute continued for ages , and, like other disputes of a similar nature, remains still in some measure undecided." ( 8 )
At any particular time in history knowledge is finite. Physicians, then, must use "known knowledge" of the causes of diseases to rationally determine proper cures for those diseases. An example of that principle is the discovery of the bacteriological cause of infectious diseases, which occurred in the 1870's, but which had, for thousands of years, been known as contagions. Shortly thereafter, about sixty years later, the discovery and use of antibiotics such as sulfonamide and penicillin occurred. If the cause of a certain disease is not known physicians must use trial and error methods, which have been used for untold centuries, in order to find an alleviating treatment for a syndrome. Currently, the trial and error technique used to determine if a chemical has beneficial or adverse pharmaceutical characteristics is termed, a clinical trial.
Since 99% of diseases that are discussed in modern medical texts have no known cause they should be identified as symptom and sign patterns, syndromes, rather than well-defined diseases. Most treatments for most syndromes, even today, are usually syndrome altering and rarely syndrome curing and that includes surgical as well as medical approaches to treatment. Examples are: orthopedic surgery for arthritis of the knee and hip, coronary by-pass surgery for arteriosclerosis of the coronary arteries and removal of the gall bladder. In addition, the use of steroid and non-steroid anti-inflammatory medications for arthritis, diuretic and vascular dilator medications for hypertension, and various tranquilizers for various mental syndromes.
Perhaps Galen noticed the painful sensations of rheumatism seemed to flow from one body part to another, for instance, to certain nerves as in sciatica (sciatic rheumatism), to certain muscles as in lumbago, toticollis, intercostalitis, dorsodynia, and to muscles in a diffuse fashion such as the pain of fibromyalgia (muscular rheumatism), and to the joints as in acute and chronic arthritis. In addition, painful sensations to the head (headache) is often caused by trigeminal neuralgia and neuralgia of the trigeminal nerve branches that supply the meninges of the brain. Further, to the chest where it causes pericarditis and pleurisy, to the brain where it caused chorea, seizures, stupor and coma (rheumatism of the brain), and to the gastrointestinal system where it causes crampy abdominal pain and other functional abnormalities ( 7, 8, 9 )
Somewhat recently, Benedict Massell, MD, in his classic text, "Rheumatic Fever and Streptococcal Infection" thoroughly reviews, with a historical approach, the disease of rheumatic fever. The following comprises the first sentence of his book: "In The Old Wives Tale, Arnold Bennett called rheumatic fever the "dread disease." Bennett's allusion to this malady in his most popular novel, published in 1908, but set in the second half of the 19th century, shows that so feared was the diagnosis of rheumatic fever that the physician of this story chose to lessen his patients's worry by referring to her condition as "acute rheumatism." ( 9 )
Further, to indicate how acute rheumatism (rheumatic fever) remained a highly serious disease during the middle years of the 1900's, Dr. Massell writes, "For the period 1939-1943, statistics published by the Metropolitan Life Insurance Company indicated that rheumatic fever was the leading cause of death among policy holders for persons from five to nineteen years of age and the second leading fatal disease among twenty to twenty-four year olds." ( 9 )
In addition, Dr. Massell reviews the historical evidence that migratory arthritis, which is often a finding in high-grade cases of rheumatic fever, has been clinically observed for a long period, for instance: "Hippocrates (about 400 B.C.) mentioned acute migratory arthritis which may very well have been rheumatic fever..." In Dr. Massell's text he indicates various investigators determined that individuals who experienced acute rheumatism (rheumatic fever) often, concomitantly, experienced tonsillitis. ( 9 )
In addition, in Hippocrates Writings within the book, Epidemics Book One, the disease described by providing many case histories is very similar to rheumatic fever as described by Sydenham during the 1600's.
In addition, "Guillaume Baillou (1538-1616,...a Parisian physician apparently was the first to use the term "rheumatism" (rheumatismos) for polyarthritis..." "On the other hand the method by which this affection attacks which is falsely called catarrh; (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism..." Dr. Baillou goes on to provide a very good description of acute high-grade rheumatic fever similar to that of Sydenham's of the late 1600's. Further, "Many of the tendons of the superficial muscles of this patient were studded with numerous small hard tumors, an appearance I have observed only in one other person...who also labored under rheumatism." Baillou recognized certain systemic features of rheumatic fever: "The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot nor the hand, nor the finger can be moved in the least without pain & outcry..."
Later, in 1715, Raymond de Vieussens described a patient with acute rheumatic fever. He was determined to have, during autopsy, a severely dilated left ventricle, the walls of the aorta were..."thick, very hard, like cartilage; the semilunar valves are markedly stretched & cut off at their tips: all these cuts which bore some resemblance to the teeth of a saw, were in fact osseous."
The above two early descriptions of individuals who had acute rheumatism (rheumatic fever) contained most of the elements that have been historically known to exist with that disease: The concept that it occurred after a respiratory disease that caused the development of phlegm (catarrh), rheumatic nodules (small hard tumors), rheumatic vasculitis (red face), wide spread, severe body pain, with joint pain in particular. Also, heart enlargement, especially left ventricular enlargement, arteriosclerotic changes to the aorta, and rheumatic cardiac valve abnormalities.
Later, David Pitcairn, in England, lectured, in 1788, concerning rheumatism and its affect on the heart: "...that persons subject to rheumatism were attacked more frequently than others with symptoms of an organic disease of the heart. Subsequent experience having confirmed the truth of this observation, he concluded, that these two diseases often depend upon a common cause, and in such instances, therefore, called the latter disease rheumatism of the heart."
The above information provides the knowledge that after the hiatus of creative academic thought that occurred during the Middle Ages physicians during the Renaissance, and later, used the word rheumatism, rheumatic fever, acte rheumatism and chronic rheumatism somewhat interchangeably for they knew that acute rheumatism would lead to chronic rheumatism and they also knew that a contagion, often connected with tonsillitis, or other respiratory disease presentation, could cause it. Since the above physician-writers have indicated that rheumatic fever (acute rheumatism) causes a great amount of pain and that it, often, develops concomitantly with a respiratory disease wherein phlegm is expectorated with coughing, or it flows from the nose as coryza, it seems logical to think that rheumatic fever is the disease that causes chronic rheumatism.
As further proof indicating that chronic rheumatism was caused by rheumatic fever the following statement was written during the late 1700's: "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds."
Since high-grade, acute rheumatic fever has become so rare in modern counties most currently practicing physicians have never possessed much clinical knowledge about it. They, therefore, have never gained the knowledge that there are lesser semi-chronic and chronic clinical presentations of rheumatic fever, as defined in "Osler's Principles and Practice of Medicine", published in 1935. ( 8 )
In addition, "In childhood the affection of the joints is usually slight, and may be confined to a little pain or stiffness in one or two joints, and is sometimes attributed by parents to "growing pains." Further, Rheumatism "...may be applied to cases in which the joint lesions persist after an attack of rheumatism, and chronic inflammatory thickening of the tissues takes place, so that they become stiff and deformed. It is also appropriate to certain joint affections occurring later in life in rheumatic subjects, who are liable to repeated attacks of pain and stiffness of the joints, usually induced by exposure to cold and wet. This form of rheumatism is less migratory than the acute, and is commonly limited to one or two of the larger joints. After repeated attacks the affected joints may become permanently stiff and painful, and crackling or creaking may occur on movement. There is seldom any constitutional disturbance, and the heart is not liable to be affected...The chief varieties of muscular rheumatism are: 1. Lumbago, in which the muscles of the lower part of the back are affected so that stooping, particularly the attempt to rise again to the erect position, induces severe pain. 2. Intercostal rheumatism, affecting the muscles between the ribs, so that taking a deep breath and certain movements of the arms give rise to pain. 3. Torticollis or stiff neck, affecting the muscles of one side of the neck." ( 9 )
Chronic or semi-chronic rheumatic fever hypothetically causes the development of an acute onset subtype of rheumatoid arthritis, for instance: "In approximately 10% of individuals the onset is more acute, with a rapid development of polyarthritis, often accompanied by constitutional symptoms, including fever, lymphadenopathy, and splenomegaly." ( 1 ) Splenomegaly, lymphadenopathy and fever occur in rheumatic fever, but since modern physicians are not aware of the lower-grade presentations of rheumatic fever they, simply, do not realize that it is causing the onset of multi-articular arthritis. In one popular medical text, however, the following is written: "Prolonged Attacks of RF (longer or equal to 8 months) occur in about 5% of patients, with spontaneously recurrent episodes of inflammation...unrelated to intervening streptococcal infection or to cessation of anti-inflammatory therapy. Such recurrent episodes within a prolonged attack are more likely to be associated with carditis. ( 9 )
"An even clearer description of rheumatic polyarthritis is included in the writings of the famous English physician Thomas Sydenham (1624-1689). Sydenham recognized the importance of careful bedside observations, and these observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitus Dance (1686) and gout (1683). Sydenham's description of polyarthritis, migratory arthritis, is as follows: "...the patient is attacked by severe pains in the joints, sometimes in one and sometimes in another, sometimes in his wrist, sometimes in his shoulder, sometimes in the knee--in this last joint oftenest. This pain changes its place from time to time, takes the joints in turns, and affects the one that it attacks last with redness and swelling." ( 9 )
Within the A Dictionary of Medical Science, published in 1874, rheumatism is profusely defined: "Rheumatism,"...A kind of shifting phlegmasia or neuralgia, sometimes seated in the muscles, sometimes in the parts surrounding the joints; and at others, within them...Hence the names Muscular, Articular, and Synovial, which have been applied to it. The disease may be acute or chronic." Further, "When accompanied by the deformity of a joint, it is called Arthritis deformans. In addition, When it affects the hip-joint of old people, it is called Morbus coxae senilis Further, 'Rheumatism, Cerebral,' Rheumatic Meningitis, Rheumatic Apoplexy. Meningitis occurring during the progress of acute rheumatism..." "Rheumatism, Chronic,...is attended by pains in the hips, shoulders, knees, and other large joints. These are at times confined to one joint; at others, shift from to another, without occasioning inflammation or fever. In this manner the complaint often continues for a great length of time, and then goes off." Continuing, "Rheumatism, Synovial...a rheumatic affliction, in which an accumulation of non-purulent fluid occurs in the synovial sacs, especially of the knee joints." In addition, "Rheumatism, Visceral. Rheumatism affecting the muscular or fibrous tissues of the viscera.", and finally, "Prosoporrheuma,...Rheumatism affecting the face.", which probably was also termed, rhinoscleroma and "...rhinocephale,...A term applied ...to a monstrosity characterized by a projection of the nose..." Rhinophyma is probably the currently used term for the older word, rhinocephale. The above definitions consist of only a small sample of the extensive, detailed, list of maladies, that are aspects of the systemic disease of rheumatism, defined in the above-mentioned dictionary. ( 10 )
Within "The Americana" encyclopedia, published in 1908, rheumatism is defined as follows: "Rheumatism, a constitutional disease characterized by inflammation of the connective-tissue structures of the body, especially of the joints and muscles, and attended by localized pain. It is usually recurrent. Three forms are recognized: (1) acute rheumatism (acute articular rheumatism, acute inflammatory rheumatism, rheumatic fever); (2 ) chronic rheumatism; (3) muscular rheumatism or myalgia." ( 11 )
Within a respected medical text by Sir William Osler and Thomas McCrea, The Principles and Practice of Medicine, Eighth Edition, published in 1912, and a more recent version of the text, Osler's Principles and Practice of Medicine, Twelfth Edition, published in 1935, provide extensive reviews of rheumatic fever, its epidemiology, and its sequeale. ( 7, 8 )
Gene Stollerman, MD, authored the text, Rheumatic Fever and Streptococcal Infection, that was published in 1975, which contains a highly interesting, complete, and wise review of rheumatic fever from a clinical, as well as a historical, approach. Every physician treating patients should read it. ( 12 )
Within Webster's New Twentieth Century Dictionary, published in 1976, rheumatism is defined as follows: "rheumatism, n. [L., rheumatismus; Gr. rheumatismos, libability to rheum.] 1. any of various painful conditions of the joints and muscles, especially, a disease believed to be caused by a microorganism and characterized by inflammation and pain of the joints. 2. Rheumatic Fever. Further, to clarify the statement, "liability to rheum.", the definition of the word rheum is provided: "rheum (rum), n. [OFr. reume, a catarrh; L. rheuma; Gr. rheuma, a flow.] 1.any watery or catarrhal discharge from the mucous membranes, as of the mouth, eyes, or nose. 2. a cold; rhinitis; catarrh. salt rheum, any of the various skin diseases, especially eczema." In addition, the word flux has many definitions. The definition as applied to human pathology is as follows: 1. the act of flowing; the motion or passing of a fluid; flow...6. any excessive or unnatural discharge of fluid matter from the body...to flow or stream out." Additionally, the word, catarrh is defined to mean: "catarrh'...n. [L. catarrhus; Gr. katarhoos, from katarrhein, to flow down; kata, down, and rhein, to flow.] an inflammation of the mucous membrane, more particularly of the throat and nose, accompanied by an increased secretion of mucous; as nasal catarrh; catarrh of the stomach." Finally, within the same dictionary rheumatic fever is defined as follows: rheumatic fever, an infectious disease associated with the presence of streptococci in the body; it most commonly attacks children, and is characterized by fever, pain and swelling of the joints, inflammation of the heart valves, etc." ( 13 )
Within Dorland's Illustrated Medical Dictionary, published in 1988, the Greek word, rheum, the word-root of rheumatism, is defined to mean: "rheum, rheuma...[Gr. rheuma flux] any watery or catarrhal discharge." The word rheumatism is defined extensively, in the same text, and many systemic, pathological manifestations of rheumatism are listed, for instance: "Any variety of disorders marked by inflammation , degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. apoplectic rheumatism, rheumatism associated with brain hemorrhage; cerebral rheumatism, acute rheumatic fever marked by chorea, delirium, convulsions, and coma; rheumatism of the heart, involvement of the heart by the rheumatic fever process; lumbar rheumatism, lumbago; rheumatism confined to the joints is classified as arthritis; muscular rheumatism, fibrositis; and articular rheumatism, rheumatic fever..." There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. Within the text, the word, rhinophyma is defined as follows: "rhinophyma...usually seen in men and characterized by thickened, lobululated overgrowth of the sebvaceous glands and epithelial connective tissue." ( 14 )
In addition, rheumatism is defined in Webster's Encyclopedic, Unabridged Dictionary of the English Language, published in1989 as follows: "...1. any disorder of the extremities or back, characterized by pain and stiffness. 2. see rheumatic fever...catarrh, rheum..." Also rheum is defined as follows: "...1. a thin, serous, or catarhal discharge. 2. catarrh; cold...(to) flow...--rheumic, adj." ( 15 )
For a long period it was known that acute rheumatism (rheumatic fever) was an epidemical disease. For instance, within the first issue of the Encyclopedia Britannica published between 1769 and 1771 the following is written in the section titled, Of the Rheumatism, within the chapter describing the science and art of medicine:
"The rheumatism chiefly attacks persons in the flower of their age...It begins with chillness and shivering, followed by inquietude and thirst. Which is preceded with spontaneous lassitude, a heaviness of the joints and coldness of the extreme parts. When the fever appears, there is an inward heat, chiefly about the-praecordia, attended with anxiety. The pulse is quick and straight, the appetite is lost, the body coftive. In a day or two, sometimes sooner, the patient feels a racking pain,sometimes in one joint and sometimes in another, but more frequently in the wrists shoulders and knees; frequently shifting from place to place...The pain is exasperated with the least motion; it sometimes attacks the loins and the coxendix (coccyx)....When it seizes the loins it is called the lumbago;...it may continue for months and years , but not with the same violence, but by fits." Further, "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds. And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1737, would yield to..." ( 6 )
A few sentences quoted above are particularly salient and rate repeating: "When it seizes the loins it is called lumbago;...it may continue for months and years, but not with the same violence, but by fits....The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 6 )
In addition, within the book (chapter) titled, "Epidemics, Book I" within the Hippocratic Writings many case histories of patients who became sick in an epidemic are provided. By carefully comparing patients' symptoms and signs they seem to be nearly identical to those later described in cases of rheumatic fever by physician-authors such as Thomas Sydenham, the author of the above description of "The rheumatism..." in 1771, and especially the clinical descriptions, provided by Sir William Osler and Thomas McCrea who authored classic medical texts, cited above, during the first half of the 1900's. ( 7, 8 )
Sydenham, Osler and McCrea, and from my experience treating hundreds of patients who have had rheumatic fever, the following symptoms and signs are found in individuals who have had, or have, rheumatic fever:
- 1. Rheumatic fever often attacks healthy, young people; but it also attacks people of all ages.
- 2. It causes a fever and often a feeling of heat in the chest.
- 3. The extremities are often cool.
- 4. Patients often experienced a prior, or concurrent, respiratory disease (bronchitis, sore throat, ear infections or tonsillitis). Often times an attack of rheumatic fever will follow such an infection by one to five weeks or be concurrent with a more chronic respiratory disease.
- 5. Patients often have joint pain or swelling and pain in the joints.
- 6. The disease causes some patients to have hyperesthetic skin, which, I surely think, was termed "causes" by Hippocrates.
- 7. Sometimes individuals have a rash that appears like hives, papules or a miliary rash.
- 8. Patients with rheumatic fever often experience headache.
- 9. Frequently, patients have low-back pain (lumbago) and sciatica and other sources of neurological pain such as headaches and brachial plexus neuritis.
- 10. Rheumatic fever can be mild and wax and wane, over time.
- 11. Patients with rheumatic fever can have delirium, seizures, stupor or coma.
- 12. Individuals who experience rheumatic fever have gastrointestinal disturbances including diarrhea, constipation, abdominal pain, etc.
- 13. Rheumatic fever occurs in a repeated fashion.
- 14. Rheumatic fever often features swelling of the cervical lymph nodes.
- 15. Patients with rheumatic fever usually have a reasonably normal pulse, but with more severe disease they frequently have cardiac arrhythmias.
- 16. At times, patients have hyperesthesia and even gentle pressure to the skin is painful. Perhaps a Greek word for it is causus.
- 17. Mild, subacute rheumatic fever can cause painful feelings in many parts of the body.
- 19. Sweating was common and odiferous.
- 20. Fall, winter and spring feature the most numerous cases.
- 21. Usually, there is a fairly low death rate from rheumatic fever, however, virulence of the Streptococcus, which causes it is highly variable.
- 22. Childbed fever is caused by Streptococcus pyogenes and has similar systemic signs and symptoms as rheumatic fever.
- 23 Splenomegaly is common.
- 24. A change in the weather to a cool, often damp, pattern seems to encourage the development of rheumatic fever.
- 25. Rheumatic fever seems to be a family disease due the highly contagious nature of Streptococcus pyogenes infections.
- 26. Concerning the pain of rheumatic fever: "perhaps no disease is more painful; the inability to change the posture without agonizing pain, the drenching sweats, the prostration and helplessness, combine to make it a most distressing affection." ( 8 )
- 27. Anemia, of various types is common.
- 28. Severe lethargy is a common sign for rheumatic fever.
- 29. At times a hypersensitivity of the skin develops, which, I think, Hippocrates termed in his writing titled "On Regimen in Acute Diseases", causus.
- 30. Epistaxis is common in higher grade cases of rheumatic fever.
- 31. The urine is, as a rule, reduced in amount, of high density and high color. It is very acid, and, on cooling, deposits urates. ( 8 ).
- 32. Individuals who experience repeated attacks of rheumatic fever can develop dropsy (dependent swelling from congestive heart failure).
- 33. Deafness occurs in some individuals; tinnitus develops commonly, photophobia and even blindness can occur in the most severe cases.
- 34. Patients often feature erythematous facial skin, palms, the plantar surface of feet, and often have erythema around the fingers tips and the toes.
- 35. Rheumatic patients often have highly varied skin abnormalities such as nevi of various types, skin tags, cutaneous horns, meaningful dermographism, and often develop premature greying of the hair and various levels of baldness.
- 36. Neuropathy of the median nerve (carpal tunnel syndrome), ulnar nerve (ulnar neuropathy), peroneal neuropathy, sciatic neuropathy, posterior femoral cutaneous neuropathy, pudendal neuropathy (the latter three together secondary to lumbar plexitis), pudendal nerve,and the brachial plexi are often caused by rheumatic vasculitis.
- 37. The classic pedal and neurological findings of Charcot-Maria-Tooth Disease are sequelae of rheumatic fever in a very young individual.
Within the book, Epidemics, Book I, mentioned above, the most common symptoms and signs experienced by various patients were: 1. Causus a word defiined to mean heat; A highly ardent fever...a complication of...inflammatory fever;..." From it, the word caustic evolved. ( 5 ) 2. hemorrhages, the most frequent epistaxis. 3. Swelling near the ears (cervical lymphadenopathy). 4. Young people, especially young men involved with wrestling (close contact) became sick. 5. Patients often had a respiratory disease. 6. Loss of weight in some individuals. The most common combination of symptoms and signs listed were: 5. fever, 6. shivering, and 7. sweating. Further, there was, 8. coolness of the extremities. 9. Their stomachs were disordered and diarrhea occurred. 10. Urine was thin or with a sediment staying dissolved within it. 11. Cough was slight but frequent; in violent cases patients continued to cough up purulent sputum. 12.In most cases the throat was painful, red and inflamed from the first and continued so. 13. Patients refused to take food (lost appetite) and lost weight. They often had no thirst. For instance, "...all suffered from a loss of apetite, and that to an extent which I have never previously encountered." 14. Many became delirious and frequently, thereafter, died. 15. The epidemical disease struck people during all months of the year, but the cool, damp months, and cool damp years featured more sickness. 16 Patients often experienced pain, for instance in the legs, back, head, heart (chest). 17. Patients experienced seizures. 18. Some patients experienced insomnia. 19. Some patients experienced coma. 20. Some patients experienced the development of eruptions (rash)., for instance: "These were red, round and small like those of acne which did not go down."21. Frequently, children, older children (eight to ten years old) and those approaching puberty died. 22. Headache and neck pain. 23. Cases of paralysis (Hypothetically, Guillain-Barre' Syndrome). 24. Childbirth was often followed by disease. 25. Pregnant women aborted. 26. Some women had vaginal bleeding. epistaxis was fairly common. 26. Lividity of parts of the body; extremities. 27. Splenomegaly. 28. Hepatitis. 29. Deafness in some individuals. 30. Hepatitis, signs of jaundice in some individuals. 30 hematuria. 31. Some patients developed dropsy (edema of the legs secondary to heart failure.
By comparing the signs, symptoms and epidemiology of the disease described in each of the above two paragraphs, it can be easily determined that most of the signs and symptoms patients experienced during an episode of rheumatic fever, as detailed by Sydenham, Osler and McCrea, were also experienced by patients who had an epidemical disease as recorded in the chapter, Epidemics, Book I, of the Hippocrates Writings.
In addition, it is similar to the description of severe rheumatic fever as written by Sir William Osler and Thomas McCrea in their text of 1935. ( 9 ) It must be understood that, acute rheumatism (rheumatic fever) has the following nature: "Rheumatic fever is the most serious of all diseases with a low death rate. The mortality is rarely above 2 or 3 percent." In addition, In the human infection , the lesions are exudative at first and later proliferative. A hypersensitive state once established, a chronic infection or repeated infection, a chronic infection or repeated slight infections may serve to prolong it and an acute infection may precipitate another attack." Finally, "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced...The onset may be so insidious that it can hardly be termed even subacute." ( 9 ) An accumulation of rheumatic tissue, and therefore organ, damage, over time, can lead to a highly varied array of abnormal function, which can involve all organ systems.
In addition, frequent mention is made of the existence of phlegm, for instance: "Now this disease attacks the phlegmatic...if these discharges should make their way to the heart , the chest is attacked and palpations and asthma supervenes." and, "For when cold phlegm reaches the lungs and heart...and the heart palpates. Such circumstances force the onlset of asthma and diseases characterized by orthopnoea..." ( 16 ) Orthopnoea, otherwise known as orthopnea, the tendency to have less difficulty breathing in a sitting position, is secondary to heart failure, often rheumatic heart failure, which is precipitated by acute rheumatic fever.
"The word asthma was first introduced in ancient Greece. It originally referred to the symptom of breathlessness rather than the disease that is recognized today. Mild breathlessness was termed dyspnea, moderate breathlessness, asthma, and severe breathlessness, orthopnea. ( 17 ) Asthma is a clinical presentation of moderate breathing distress that occurs, usually, in young individuals, but it evolves, often becoming more symptomatic, over time. For instance, "Longitudinal studies have since shown that a significant proportion of persons who have chronic asthma exhibit an increased rate of decline in lung function over time, leading to the progressive acquisition of a fixed component of airflow obstruction. Furthermore, asthmatic and COPD populations overlap in peak expiratory flow (PEF) variability." ( 17 ) In addition, "Postmortem examination of the lungs of patients who have died of acute severe asthma reveals prominent airway wall thickening, a markedly edematous airway mucosa, and occlusion of bronchial lumen with plugs of viscid mucus. In a patient who has died of acute asthma, the most striking feature of the lungs at necropsy is their gross overdistention...When the lungs are cut, numerous gelatinous plugs of exudate are found in most of the bronchial branches down to the terminal bronchioles. ( 1 ) Asthma is, probably, a clinical manifestation of mild, or severe, rheumatic pneumonitis and the "plugs of viscid mucous" represent the "rheum", or phlegm, aspect of the disease process so, perhaps, asthma, and other related adverse conditions of the lung could, reasonably, be termed: rheumatism of the lung.
In addition, palpations of the heart are, simply speaking, a type of cardiac arrhythmia, which often occur in rheumatic fever. ( 8, 9 )
The exact cause of rheumatic fever puzzled physicians throughout history, even after the bacterial hypothesis of infectious disease was first, firmly, proven by Robert Koch, in Germany, during the 1870's. ( 18 ) Various streptococcal-types of bacteria were suspected, for a long period, to be involved in rheumatic fever's genesis, but it was not until 1931 that Alviin Coburn, in the USA, and Wilfred Collis, in England, somewhat simultaneously, published data that proved that Streptococcus pyogenes caused rheumatic fever. It was later learned that a certain strain of Streptococcus pyogenes caused scarlet fever (scarletina). Rheumatic fever and scarlet fever are, therefore, basically, nearly the same disease. ( 9 ) Streptococcus pyogenes has a great many strains with varying virulence that are often determined by their M protein antigens. ( 19 ) Finally, it was determined that the septic phenomenon that occurs within patients who develop rheumatic fever are autoimmune in nature. ( 12, 19 ) The immunological cause of rheumatic fever provided an explanation for the frequently observed delay between an individual's streptococcal respiratory disease and the onset of rheumatic fever's anatomically widespread and, therefore, severe septic, manifestations.
Differing from most infectious diseases, rheumatic fever can recur and, frequently, recurrences feature a more severe disease presentation. ( 8, 9, 12 ) It is more accurate to understand rheumatic fever to be an "infection-caused autoimmunological disease, not, "purely" an infectious disease, wherein pathological damage to tissues is due to a physically intimate infection as one would note in the development of a dermatological infection such as a folliculitic lesion or a carbuncle. Recurrences of rheumatic fever often occur with more virulence than previous episodes since the immune system experiences an increase in immunological sensitivity and memory with each streptococcal autoantigenic challenge. "Finally,...the trend suggests also that R/I (rheumatic fever attack rate per infection) decreases more strikingly with the time elapsed since the last rheumatic attack than it does simply with the increasing age of the patient. ( 12 ) To decrease rheumatic fever's recurrence rate prophylactic treatment strategies, using chronic sulfonamide and penicillin techniques, have proven to be efficacious. ( 9, 12 ) Immunological (and autoimmunological) sensitivity decreases, over time, if an individual does not experience a meaningful Streptococcus pyogenes infection, and, therefore, does not experience a meaningful, rheumatic, autoimmunological challenge.
Although high-grade acute rheumatism (rheumatic fever) is obviously important, the lower-grade of acute rheumatism occur at a much higher frequency. These infection caused (by Streptococcus pyogenes), pathological, autoimmune attacks are often quite subtle and individuals only know "something is wrong" due to abnormalities noted, that are often painful, in various anatomical locations. Sciatica, for instance may be caused by rheumatic autoimmunity. Depression, fatigue or listlessness, anxiety are all possible central nervous system phenomenon that can be caused by rheumatic autoimmunity. Shoulder pain, low-back pain, torticollis, headache, low-grade semi-chronic gastrointestinal disturbances, growing pains, tendonitis, rosacea, palmar erythema, plantar erythema, and acne, for instance, are all manifestations of rheumatic autoimmunity.
The term, sepsis, is defined as follows: "Animals mount both local and systemic responses to microbes that traverse epithelial barriers and invade underlying tissues. Fever, or hypothermia, leukocytosis, leukopenia, tachypenea, and tachycardia are the cardinal signs of the systemic response often called the systemic inflammatory response syndrome (SIRS). SIRS may have an infectious or noninfectious etiology...When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." Further, " Microbial invasion of the blood stream is not essential for the development of severe sepsis, since local inflammation can also elicit distant dysfunction and hypotension." ( 1 ) Particularly, the invasion of the blood stream by bacteria or virus is termed, bacteremia and viremia, respectively.
Over time, there have been many synonymous terms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever. ( 6, 9 ) The word rheumatism was often used in older, and even in more recently published scientific texts to mean both acute and chronic rheumatism. ( 6, 7, 8, 9 )
If the concept of severe sepsis, the phenomenon wherein pathological abnormalities appear distant from a primary site of infection, is integrated with the above information concerning the nature of acute rheumatism (rheumatic fever) and chronic rheumatism, it appears that both acute rheumatism" (rheumatic fever) which is well known to cause pathology within distant organs such as the heart, kidneys, brain, peripheral nerves, and joints (to provide a partial review), and chronic rheumatism, which also features pathological changes of a similar nature (as indicated by information in references 7, 8, 10, 11, 14, and 15 above), are both varied clinical manifestations of the same disease process as indicated by physicians in the late 1700's. ( 6 ) After all, Sir William Osler indicated that subacute and less-than-subacute rheumatic fever are common disease entities. ( 8 ) They are the disease states that stimulate the development of the various arthritides that are categorized as the various rheumatic diseases.
Both have the same, or similar, pathophysiological mechanisms, which cause damage to a numerous and highly varied group of anatomical structures distant from the primary site of infection and which have key pathological findings such as subcutaneous nodules and the development of coronary artery disease. ( 7, 8, 9, 12, 20 ) Therefore, both clinical presentations of rheumatism, that is acute rheumatism (rheumatic fever) and chronic rheumatism, which both have similar septic manifestations. The key, it seems, to a further understanding of both rheumatic fever, also known, historically, as acute rheumatism, and chronic rheumatism is to understand the pathological mechanism that causes their severe sepsis. It is Streptococcal autoimmunity.
A unifying conceptual statement, integrating the various concepts and definitions from the above-mentioned dictionaries, texts and e-sites is as follows: Rheumatic fever, and therefore chronic rheumatism, represent a continuum of the same variable, clinical, autoimmune disease from the most acute to the most chronic, caused by a variably severe septic autoimmune response, which is inflammatory in nature, secondary to the occurrence of infections by various strains of Streptococcus pyogenes. The various sources of information, quoted above, uniformly indicate that a meaningful sign of acute rheumatism (rheumatic fever) and chronic rheumatism is the presence of mucous drainage from the nose, mouth, or, even the eyes. In addition, the word, catarrh indicates an increased secretion of mucous as in the term, nasal catarrh. Also, the word rheum can be used to denote "...a cold...or...rhinitis..." Acute rheumatic fever is known for its painful manifestations, but chronic rheumatism usually, also, causes painful maladies throughout the body. It appears, then, that mild, or severe, respiratory infection (s) caused by various strains of Streptococcus pyogenes, can both result in the development of rheumatism, acute and chronic. The disease of rheumatism, acute and chronic, is a clinically variable, autoimmune, waxing and waning, severe septic disease since signs and symptoms of rheumatism occur in most of the body's tissues and, therefore, organs. In modern specialty medicine physicians often focus on acute rheumatism's (rheumatic fever's) damage to the heart, but it is a systemic disease process wherein both acute and chronic rheumatism adversely affect all of the body's organs, over time, in a waxing and waning fashion.
Rheumatism was a commonly used term in medicine before 1940 and it was often associated with a specific, painful, muscular syndrome, muscular rheumatism, or, synonymously, fibrositis, as indicated in the definition of rheumatism, above. ( 14 ) In a noted medical text published in 1935 fibrositis, and therefore, synonymously, muscular rheumatism, are described: "MYALGIA (fibrositis, myositis) Definition.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probably that in many cases the fibrous tissue is especially affected==a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia, ...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like.It is often sufficiently intense to cause a patient to cry out...The following are the principle varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and upper part of the back." ( 7 )
It is important to note that within the last two paragraphs the terms muscular rheumatism, fibrositis, myositis, myalgia are connected synonymously. It is apparent that physicians also thought, what seemed to be pain of a muscular nature was suspected to be, more specifically, caused by a neuropathic phenomenon. Also, it is important to realize, as indicated in the above-mentioned definition of rheumatism [reference ( 14 )], that rheumatism affects connective tissue somewhat selectively. Since, however, the terms connective tissue and fibrous tissue define, virtually, the same histological structures, and since all organs in the body have substantial amounts of connective tissue (fibrous tissue) within their substance, conceptually then, rheumatism can affect the heart, kidneys, lungs, brain, muscles, ligaments, tendons, synovial sheaths, the gastrointestinal organs, skin, bones, the liver, nerves, and most meaningfully, perhaps, the various elements of the circulatory system for when they are involved it creates a rheumatic vasculitis.
During the period I had an active medical practice I had wondering thoughts about many phenomenon. I learned that most diseases are connected, in various ways, to each other. For instance, individuals who experience diabetes are at a high risk to develop coronary artery disease and peripheral neuropathy. In addition, individuals who have ulcerative colitis are more at risk to develop other inflammatory maladies of the gastrointestinal tract and they are, also, at a high risk to develop cancer, they frequently experience neuropathic maladies, and they often co-experience other autoimmune diseases. Similarly, individuals who experience neuropathy are at a higher risk to develop cancer (paraneoplastic neuropathy). In addition, individuals who develop ulcerative colitis are at high risk for developing other autoimmune diseases of gastrointestinal tract, including celiac disease and Crohn's disease and patients with all three diseases feature a higher risk for cancer development and they often experience neuropathic maladies. ( 3, 4 ) In addition, individuals with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosis, progressive systemic sclerosis, and dermatomyositis all experience a decreased life expectancy, they all feature accelerated arteriosclerosis, and they all feature neuropathic pain. ( 3, 4 ) Historically, coronary artery disease has appeared in patients who have exhibited "type A" personalities, who have hypertension, elevated cholesterol, and who also have somewhat horizontal earlobe creases. No one knows, however, the nature of the underlying disturbance, which causes the connection and the "type A" personality is hard to define.
Also, I came to realize that since 99% of diseases listed in medical texts have no known cause (they are termed idiopathic diseases), it is more accurate to understand them as syndromes. Syndromes are, simply, adverse medical conditions with somewhat uniform symptom and sign patterns. The word disease is best defined as an adverse medical condition which has consistent symptom and sign patterns, but, in addition, its cause is known. Since the great majority of medical problems have no known cause they are syndromes, therefore, physicians, primarily, do not cure diseases, they alter syndromes, usually for the better. In general, a knowledge of the cause for a disease is a requirement if a cure is to be developed, otherwise medical treatments are, for the most part, syndrome altering in nature.
Prior medical educational and experiential knowledge was important during my investigation, but most of the salient information I learned, which permitted me to develop an understanding of the cause of chronic neuropathic pain, and other associated medical conditions, was gained by repetitiously interviewing patients concerning their, and their family members', medical histories and by repetitiously conducting analytic, neurological, physical examinations. In addition to reading medical information in modern texts, I read parts of many older medical texts, dated from the Hippocratic period, through the Roman period, the Renaissance, and thereafter through the period during which many, great, scientific breakthroughs were accomplished, the 1600's through the early 1900's.
Between 2002 and 2005 I conducted a three-year, clinical investigation in an effort to determine the true cause of most peripheral neuropathies since so many of my patients, through the years, failed to improve after they experienced spinal surgery. I eventually determined that the venerated, herniated spinal-disc concept was flawed, and most of the surgery accomplished for them was, I learned, usually mis-applied. Most patients had suspicious arthritis of the lumbar and cervical spine that featured osteophyte development and bulging of intervertebral spinal-discs, but I learned that typical MRI films did not have the resolution to "see" spinal nerve roots in an analytical fashion. Since the bulging intervertebral spinal-discs are attention-getting on MRI images, and because they do, occasionally, cause symptomatic, spinal nerve root compression, generalizing that almost all bulging intervertebral spinal-discs cause nerve root compression was a classic "red herring". After I managed to determine the cause of the painful neuropathies, I learned that the same disease that causes the neuropathies also causes arthritis of the spine; an anatomical feature of spinal arthritis, herniated spinal-discs, did not necessarily cause the painful neuropathies. There are occassional herniated spinal-discs that cause painful spinal, nerve-root compression, but surgery for them is very common.
Eventually, after a long, investigative period, I learned the most patients' neuroloical pain was caused by rheumatic, autoimmune-mediated, vasculitic neuropathy of the terminal nerves of the sacral plexus located within the piriformis canal, which is located deep in the buttock. Patients who experienced neurological shoulder/cervical pain and who experienced dysesthesias to the appropriate upper extremity, were experiencing rheumatic brachial plexitis. The brachial plexus is located within the axillary canal located deep within the shoulder. I learned that motion of the arm at the shoulder, and of the thigh at the hip, or an accident wherein either of the structures were stressed, would often cause, or exacerbate, patients' neurological symptoms and signs. Patients sensed pain in the lumbosacral region, because of centripetal referred pain from the distal sacral plexus located deep in the buttock. Similarly, they sensed pain in the cervical/shoulder region, because of centripetal referred pain from the brachial plexus located deep within the shoulder.
During the above investigation I attracted 700 miserable, painful patients who had chronic neurological pain. Eventually, I learned that they all had had meaningful, repeated Streptococcus pyogenes infections (tonsillitis, sinusitis, bronchitis, pharyngitis, otitis media, impetigo, and vaginitis) during their lifetimes and often they had experienced chronic tonsillitis. In addition, many of them, who had been born before 1970, had had, when they were younger, rheumatic fever or scarlet fever. Younger patients, born after 1970 had "flu-like" diseases with more mild rheumatic symptoms and signs.
I learned from information in Sir William Osler's text, that there are subacute and less than subacute states of rheumatic fever with more subtle systemic symptoms and signs than "classic" high-grade rheumatic fever. ( 8 ) Such a disease has the same symptoms and signs that are thought to be those of influenza, or "the flu": a respiratory disease, often at least, lethargy, tiredness, at times stupor, body pain, back pain, photophobia, at times, headache, at times, gastrointestinal symptoms and signs, at times, and often a fairly rapid recovery. Often patients who had rheumatic fever had been diagnosed by a physician, or by parents, to have chicken pox, measles, the flu, mononucleosis and viral meningitis. Often the patients had been very ill, but recovered with care at home.
I conducted serology tests (ASO and Anti-DNase B titers) on over 100 patients and 70 were positive with elevated Streptococcus antibodies on one or more tests. Between the positive medical histories, the elevated serology tests, and those who had medical histories of "flu-like" diseases, chicken pox, measles, mononucleosis, and viral meningitis wherein the symptoms and signs were those of rheumatic fever, the great majority of the 700 patients, mentioned above, who had chronic neurological and arthritic pain, and other similar diseases, were qualified to have had rheumatic fever.
The great minority of cases of rheumatic fever are high-grade and qualify by the Jones Criteria to be that disease. Most cases are much more low-grade and semi-chronic in nature and such individuals develop increased, rheumatic, autoimmunological sensitivity and memory so that they are candidates, in the future, to be at risk for developing acute rheumatic fever. Current medical knowledge (Carapetis, JR.,et al., Lancet Jul 9-15; 366(9480): 155-68) indicates that an infection by a virulent strain of Streptococcus pyogenes, in a well rheumatically sensitized individual, can cause the development of acute rheumatic fever, which is known to be an inflammatory, autoimmune disease process.
The septic responses patients experienced, which frequently took place one to four weeks after an episode of respiratory disease (bronchitis, sinusitis, pharyngitis or tonsillitis) were caused by the rheumatic, systemic, autoimmune response to the autoantigens displayed by Streptococcus pyogenes. As the elevated levels of autoantibodies, and other toxic products, decreases after the peak of rheumatic fever, I hypothesize that patients maintain a low-level of rheumatic autoantibodies within themselves and it causes, over time, the signs and symptoms of chronic rheumatism. Since immunological and autoimmunological proteins circulate through the body via the elements of the circulatory system, rheumatism causes a usually subtle vasculitis, that is, arteritis, phlebitis, and lynphangitis. The much more common low-grade infections by Streptococcus pyogenes, and even the carrier state, cause an exacerbation in rheumatic stimulation, which establishes a chronic, waxing and waning autoimmune disease process within hosts, thus the chronic, autoimmune disease of rheumatism develops and is maintained.
Since Streptococcus pyogenes is endemic in human society, and a Russian Encyclopedia article (V. Nasonova & E. Talahaev) indicates that Streptococcus pyogenes is endemic in domestic vertebratres, and I hypothesize it also exists in wild vertebrates, it seems that Streptococcus pyogenes causes a universal, autoimmunological zooinosis among vertebrates including humans so, therefore, all humans have rheumatic disease.
As a reminder, the terms acute rheumatism, acute articular rheumatism, inflammatory rheumatism, and rheumatic fever, all describe the same acute, high-grade autoimmunological disease caused, usually in a delayed fashion, from infections by Streptococcus pyogenes. The terms rheumatism and chronic rheumatism refers to tissue damage that usually appears minor and for which signs and symptoms are often subtle, are slow evolving, and usually cause little or no dysfunction. Over time, however, they can become highly meaningful and conditions such as hip and knee arthritis, symptomatic coronary artery disease, peripheral vascular disease, rheumatoid (rheumatic) arthritis, and lupus erythematosis, for instance, are an indication of its severity.
The pathological anatomy of chronic rheumatism is often relatively easy to observe since, certain superficial signs of disease, for instance the articular signs of rheumatoid arthritis, dermatological features of lupus erythematosis, dermatological features of progressive systemic sclerosis, rosacea, varicosities of veins, seborrheic keratosis, various types of nevi, Raynaud's phenomenon, palmar and plantar erythema, and livedo reticularis are all manifestations of the systemic disease of rheumatism. Rheumatoid arthritis was, historically, thought to be caused by rheumatic fever. At times it has been termed, arthritis deformans. The text, Rheumatism, Rheumatoid Arthritis and Subcutaneous Nodules reviews the historical debates about the proper identification of rheumatic lesions, usually of the hands, and the meaning of subcutaneous nodules. Rheumatoid arthritis, lupus erythematosis, dermatomyositis, systemic sclerosis, Lyme disease, Whipple's disease, erythema nodosum, Dupuytren's contracture, and Interstital lung disease, are all syndromes, which feature as one of their signs subcutaneous nodules. Since acute rheumatism (rheumatic fever) also features subcutaneous nodules, and it is known that it is a highly variable, autoimmune disease, it is likely that the syndromes listed, above, are simply a number of various clinical presentations of chronic rheumatism.
There have been other antiquated terms for acute rheumatism (rheumatic fever) and I hypothesize that two of them are sweating sickness and miliary fever. ( 6 )
ItIt has not been clinically recognized, however, that all infections by Streptococcus pyogenes cause an inflammatory autoimmune response. I hypotheize that Streptococcus pyogenes infections with a high virulence is most meaningful and more frequently cause exacerbations in the rheumatic autoimmune response. In addition, the patients level of rheumatic immunological sensitivity, caused by prior infections, also contributes to the development of an energetic autoimmune response.
After various acute disease episodes, throughout life, and after numerous episode of subacute or less than subacute rheumatic fever ensues during a person's lifetime, rheumatic tissue damage slowly occurs and it eventually rheumatism manifests itself with obvious signs and symptoms of pathological damage to the body's tissues, and therefore organs, in a somewhat subtle, varying, but progressive fashion. Its manifestations are often noted as changes to the skin, tendons, ligaments, nerves and joints so clinical syndromes such as sciatica, brachial plexitis, femoral neuropathy, meralgia paresthetica, carpal tunnel syndrome, ulnar neuropathy, cardiac arrhythmias, headaches, De Quervain's tendonitis, Dupuytren's contracture, Achilles tendonitis, olecrannon bursitis, rotator cuff abrasions and tears, and Dupuytren's contracture appear. One must remember, however, that rheumatism is a systemic disease process so that all tissues, and therefore organs, are pathologically affected. Therefore, arteriosclerosis, endocrinopathies, renal failure, asthma, allergies, inflammatory bowel syndome, primary sclerosing cholangitis, pancreatitis, osteoporosis, spastic bladder, schizophrenia, obsessive-compulsive behavior, depression, and many, many other pathological conditions are caused by rheumatism. Somewhat surprisingly, even cancer, of all tissue types, is caused by the inflammatory, rheumatic, autoimmunological attack that is a response to Streptococcal infections. Perhaps, DNAase toxic products that are secreted by Streptococcus during infections also help its formation. "One must think: each tissue, and therefore each organ, will clinically express the adverse effects of the systemic disease of rheumatism in its own way, thus, many apparent separate diseases develop, over time, in a somewhat random, but often connected, fashion."
High-grade rheumatic fever decreased in incidence starting in the early 1900's within modern, industrialized societies, secondary to the improvements in living conditions which were brought on by advances of basic science that begot the industrial revolution. Advances included larger homes and smaller family size, both of which caused decreased crowding within dwellings, which decreased the spread of Streptococcus pyogenes within families. In addition, more hygienic living habits, the common use of soap, improvements in home bathing facilities, the use of clothes washers, dish washers, and the pasturization of milk all contributed to a decreased spread of Streptococcus pyogenes within society. Later, in the 1930's, the use of broad spectrum antibiotics for respiratory infections was initiated. The environmental changes, and the common use of antibiotics, resulted in fewer and fewer Streptococcus pyogenes infections, but more importantly, perhaps, infections with less virulence, so by 1970 high-grade rheumatic fever was a relatively rare disease in modern, developed countries. Chronic rheumatism also decreased in severity in especially in younger populations, but it still appeared, as a pathological entity, in older people as they lived through the years.
Unfortunately, in 1987 rheumatic fever experienced a resurgence with the first reports appearing in The New England Journal of Medicine with the author, L. George Veasy, MD wrote about a mini-epidemic from the area around Salt Lake City, Utah. Thereafter, numerous mini-epidemics have been reported from many areas in the USA.
A mini-epidemic of acute rheumatic fever took place in Lewis and Cowlitz Counties of Washington State during the winter and spring of 2004 and 2005. A few patients died before that period from rheumatic fever, but I didn't recognize it. During the above mentioned period, about ten people died out of my patient population of about 7000 during the aforementioned period. A number of patients have died thereafter who lived in the same geographic area. The individuals who died were fairly young, in their twenties to their sixties, they all experienced chronic neurological pain and arthritic symptoms, three of them had had a history of previous rheumatic fever or scarlet fever. In addition, a number of them had experienced spinal surgery with no improvement in symptoms or signs, and they were taking opiates for their severe, chronic, neurological pain when they died. Unfortunately, the local coroners and medical examiners, neither of whom had much medical knowledge or wisdom, made a determination that some of the patients died from the affects of opiates that they were taking for their chronic rheumatic pain. Some of the patients, on whom I had accurate information, had classic signs and symptoms of acute rheumatic fever popularized as the Jones Criteria. They had enlarged hearts and pulmonary edema on autopsy as an indication that they had had acute rheumatic carditis (myocarditis and endocarditis) and rheumatic, congestive heart failure.
One of the painful, clinical, rheumatic conditions, which many children commonly experienced in somewhat earlier times, such as before the 1970's, but even currently, are growing pains. Growing pains manifest themselves as a painful sensation in the legs, commonly the thighs and knees, and it develops, often, shortly after going to sleep, or lying down, and wakes the young patient who often complains, and even cries, due to the severity of pain. Other clinical manifestations of rheumatism, which children experience, are torticollis (wry neck) and dorsodynia, which is an older term for upper back pain that is usually felt in the scapular region, which, I determined, is frequently a referred pain pattern caused by rheumatic brachial plexitis. Another syndrome children experience, occasionally, is Kawasaki disease. I surely think that Kawasaki disease is a syndrome that is a presentation of rheumatic fever or scarlet fever) in a child who is "well conditioned" to have a severe rheumatic vasculitic response by having experienced a number of Streptococcus pyogenes infections earlier in life. They could have experienced a chronic infection, which caused an elevated sensitivity to the autoantigens of a virulent subtype of Streptococcus pyogenes. Another syndrome that adults contract is Guillain-Barre' Syndrome. It is a presentation of rheumatic fever wherein the individual experiences an acute, systemic neuropathy and paralysis at some level. Usually they experience a respiratory infection somewhat before their attack and such a pattern of delayed autoimmune disease is classic for Streptococcus pyogenes infections and their delayed rheumatic response.
Simultaneously with a decrease in the frequency of high-grade rheumatic fever, the citizens of modernized countries experienced a steadily advancing life-expectancy; in the USA life expectancy increased from forty-seven in 1900 to about seventy-seven in 2000: an increase of about thirty years, which equates to an increase of 64% over a 100 year period. There has to be a logical reason for the increased longivity. The reason, mainly, I hypothesize, has been a decreased incidence, and severity, in general, of Streptococcus pyogenes infections; a generally decreased level of virulence of Streptococcus pyogenes itself, which resulted in a great decrease in the incidence of acute rheumatic fever and, therefore, chronic rheumatism decreased in severity in the populations of economically advanced countries. The decrease in the incidence of acute rheumatic fever, a disease that often caused the death of children and younger people, greatly contributed to the increase in human life-expectancy. There were other positive factors also, for instance, a better food supply, vaccines for other diseases, and improved medical care, especially supportive care and disease altering surgical procedures.
Rheumatic autoimmunity causes, initially and continually, an inflammatory vascular condition, which is its main pathological mechanism that results in inappropiate intra-arterial thrombosis especially at arterial bifurcations. The immune system reacts to localized intra-arterial thrombosis with an enhanced, localized inflammatory response so that inflammatory, intra-arterial, arteriosclerosis lesions develop. As Streptococcus pyogenes infections decreased, as mentioned above, fewer myocardial infarctions developed early in life and coronary artery disease became, to a great degree, a disease of older people, in modernized portions of the world, since it is caused by more subtle, chronic rheumatic autoimmune condition: chronic rheumatism.
Rheumatism is a disease with frequent acute manifestations, but it has much more common chronic manifestations. It has existed in vertebrates, including humans, ever since Streptococcus pyogenes, and perhaps other bacterial types, evolved the biochemical structures, autoantigens, which, at least to some degree, decrease the ability of vertebrate hosts to identify it as foreign. Eventually, Streptococcus pyogenes is identified to be foreign and its vertebrate host, the human host being the primary subject of this article. The human host develops antibodies to the antigens, but it also develops autoantibodies to the autoantigens it displays during infections. The antibodies, and autoantibodies kill or harm Streptococcus pyogenes, but the autoantibodies also attack humnan tissue chemical moieties, which Streptococcus pyogenes has mimicked. Once the immunological system has formed autoantibodies they continue to be manufactured in a decreasing fashion so that their concentration decreases over time, but they never disappear. If another Streptococcus pyogenes infection ensues at a later date, and since the human host has developed autoantigenic memory and sensitivity, there will be a more brisk manufacture of autoantibodies and the individual will develop recurrent rheumatic fever.
Since Streptococcus pyogenes is one of the most common microorganisms to parasitize vertebrates, especially humans, infections by them, mostly less than subacute and chronic, take place reasonably frequently. Subtypes of Streptococcus pyogenes vary a great deal in their virulence; if a highly virulent strain of Streptococcus pyogenes infects an individual who has elevated rheumatic sensitivity, they may develop acute rheumatic fever.
The above pattern occurs during life in a continual, waxing and waning fashion so that all people have streptococcal autoimmunity, rheumatism, at some level. Eventually, its effects harms all tissues, and therefore organs, and so it manifests itself in what is termed "the aging process".
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Cause: Infections by Streptococcus pyogenes. This fact was determined as indicated above, somewhat concomitantly, by Alvin F. Coburn in the U.S.A. and W. R. F. Collis in Great Britain in 1931. ( AB )
(1) Harrison's Principles of Internal Medicine 16th Edition, McGraw Hill Medical Publishing Division, New York, N.Y., 2005
(2) Harrison's Principles of Internal Medicine 12th Edition, McGraw-Hill Medical Publishing Division, New York, N.Y., 1991
(AB) "The Factor of Infection in the Rheumatic State", Alvin F. Coburn, MD, The William and Wilkens Company, 1931