Rheumatism by Dr. Lance Christiansen
| Rheumatism by Dr. Lance Christiansen | |
| ICD-10 | M79.0 |
|---|---|
| ICD-9 | 729.0 |
| MeSH | D012216 |
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Overview
Rheumatism is a specific term for the chronic, systemic, inflammatory, autoimmune disease triggered by Streptococcus pyogenes infections. Acute rheumatism was the common term for rheumatic fever, the most elevated level of rheumatic autoimmunity, up through the early decades of the 1900's. As high-grade rheumatic fever decreased in incidence in modern western societies, secondary to improvements in living conditions including the development of antibiotics, wherein medical professionals have led in the development of modern, procedural-based medicine, the understanding of high-grade rheuamtic fever has decreased in medical society and therefore the understanding of lesser levels of rheuamtic autoimmunity have simply never been maintained even though as early as the late 1700's, the cause of chronic rheumatism was reasonably well known.
For instance, Galen, the famous Greek physician in the Roman period, who published over 66,000 pages of medical, philosophical, and scientific information, half of which has managed to survive since 200 AD, coined the word rheumatism. Rheum, in Greek, means to flow, or phlegm. The phrase "a defluxion of rheum" could be used. It was later connected with catarrh, influenza, or the grippe or other description of a respiratory disease. Galen knew, that when people developed contagions that caused the development of phlegm, or chronic phlegm development, they would also, eventually, develop chronic, painful problems that were part of the chronic disease of rheumatism. Arthritis, neuropathy (such as sciatica), angina, pericarditis, pleurisy, tendonitis, ligamentitis (for instance plantar fasciitis) are examples of modern names for target-organ manifestations of rheumatism.
The term "rheumatism" is still used in colloquial speech and in historical contexts, but it is no longer frequently used in medical or technical literature; it would be fair to say that there is no longer any recognized disorder simply called "rheumatism". The traditional term covers such a range of different problems that to ascribe symptoms and signs to rheumatism, would violate the artificially developed specialty structure that has developed in modern western medicine since the 1920's.
One of the first organizations that dealt with rheumatism, in the modern day, was the European League Against Rheumatism. Unfortunately, rheumatologists were shouldered out of dealing with infectious diseases, or problems of the body's organs by the other specialty-segregated physician groups and so they deal with "connective tissue" even though they also, historically, have dealt with rheumatic fever, which is a high-grade, inflammatory, autoimmune-mediated, systemic disease process.
As a vestige of past wisdom, many individuals feel that arthritis, neuropathy, and tendonitis has something to do with rheumatism. For instance, during the early 1900's, in America, sciatica was termed sciatic rheumatism or hip gout, eczema of the hands was termed, salt rheum, and gout was termed, gouty rheumatism. Those that understood the collective wisdom of the time knew that the maladies described were part of the rheumatism complex. Old farmers, walking bent over with a cane often say, "Oh, my rheumatism". Non-articular rheumatism, also known as soft tissue rheumatism, and which is now known as "fibromyalgia", was in prior eras known as "muscular rheumatism". Somewhat surprisingly that variously described condition is a dispersed sensory neuropathy: bilateral brachial plexitis and sacral plexitis that is made more symptomatic by use of the arms and legs. To understand the above pathophysiology an examiner must do an analytic neurological examination of the brachial plexus and the terminal nerves of the sacral plexus and "know" the location of the dermatomes of the body.
Within the chapter on rheumatoid arthritis in Harrison's Principles of Internal Medicine, 16th Edition (Kasper,D, McGraw-Hill, 2005) the author describes rheumatoid arthritis as a systemic, autoimmune disease (it is in the section on autoimmune diseases), and in prior editions it indicates, that at times exacerbations appear sometime after a feverish afliction. In the edition mentioned above, the 16th Edition, the following is mentioned: "In approximately 10% of individuals the onset is more acute, with a rapid development of poly arthritis, accompanied by constitutional symptoms, including fever, lymphadenopathy, and splenomegally." It describes that rheumatoid arthritis, better termed rheumatoid disease, features arthritic aspects, vasculitis, neuropathy, and organ infarction, even myocardial infarction. At times, the text indicates,"Neurovascular disease presenting either as a mild distal sensory neuropathy or as mononeuritis multiplex may be the only sign of vasculitis." Anemia, subcutaneous nodules, and osteoporosis are concomitant features of rheumatoid arthritis. It mentions that pericarditis is found in 50% of those with rheumatoid arthritis at autopsy.
The connections, mentioned above, of an acute disease triggering vasculitis, arthritis, neuropathy, myocardial infarction, anemia, pericarditis, and osteoporosis describes many of the causes of pain from rheumatism. The acute disease process mentioned, is a mild case of acute rheumatic fever, the systemic, inflammatory, autoimmune disease process that post-dates, from a week to five weeks, the Streptococcus pyogenes infection that triggers the rheumatic, autoimmunological response. Within the text, Rheumatic Fever and Streptococcus Infection (Massell, B., Harvard Press, 1997) the author indicates that fifty percent of Streptococcus pyogenes infections that trigger rheumatic fever have such mild symptoms and signs that patients do not remember them so it would not be surprising that those low-grade infections and the somewhat higher grade infections would be missed, forgotten, or just thought to be mild concomitant problems. Those individuals who developed high-grade rheumatic fever would seemingly represent a different, and separate, acute disease process, but it has symptoms and signs of vasculitis, arthritis, pericarditis, subcutaneous nodules, and neuropathy also, but it has other more serious manifestations of acute rheumatism, for instance, rheumatic carditis,heart failure, cardiac arrhythmias, rheumatic encephalitis, etc.
Like most diseases, rheumatic fever (acute rheumatism) exists as lower grade phenomenon, most of the time, and relatively rarely, except in certain, favorable epidemiological situations, rheumatic fever exists in the high-grade state that has the symptoms and signs popularized by the Jones Criteria. Surprisingly, T.Ducket Jones, MD did not think that Streptococcus pyogenes was the cause of rheumatic fever even in the early 1950's, even though Alvin Coburn published a monologue that provided proof that it did, in 1931. To keep using the Jones Criteria, nowadays, is improper, I surely think. To think that rheumatic fever is mainly a cardiac disease is also a gross error: it is a systemic autoimmune disease process that in high grade cases has serious cardiac autoimmunological sequela.
Frequently, the target-organ manifestations of rheumatic autoimmunity, rheumatism, clinically appear as seemingly isolated maladies. Examples of them are:
The rheumatic diseases including rheumatoid (rheumatic) arthritis, psoriasis and its arthritis, lupus erythematosis, Sjogren's syndrome, scleraderma, ankylosing spondylitis, dermatomyositis, myositis, Wegener's granulomatosis, and others. Osteoarthritis is simply rheumatic arthritis that appears due to an individuals stress on the meniscus, usually the medial meniscus, when they have more subtle signs and symptoms of rheumatoid (rheumatic) arthritis in other joints.
Peripheral Neuropathies: Sciatic back pain (sciatic, posterior femoral cutaneous, pudendal neuropathy), femoral neuroapthy, carpal tunnel syndrome, ulnar neuropathy, peroneal neuropathy, meralgia paresthetica, and tarsal tunnel syndrome. Fibromyalgia is a dispersed neuropathy of the bilateral brachial plexus and the terminal nerves of the sacral plexus. The femoral nerve and the lateral femoral cutaneous nerves can be involved. Various cranial neuropathies such as rheumatic, trigeminal neuropathy, Bell's palsy, hearing deficits, vertigo, and abnormalities of the motor nerves of the eye are all caused by rheumatic autoimmunity. When neuropathies present more severely they are more systemic in nature so they manifest as the syndromes of multiple sclerosis, Guillain-Barre' syndrome, and, hypothetically, amyotrophic lateral sclerosis.
Endocrinopathies: diabetes, Addison's disease, Cushing's syndrome, hypothetically, polycystic ovary disease, testicular failure, hypothyroidism, hypoparathyroidism, and pituitary abnormalities of various types.
Benign Tumors and cancer of various types. The rheumatic neuropathies often appear before or concomitantly with cancer and it is termed paraneoplastic neuropathy. Often the neuropathy is sciatica.
Central Neuropathies: autism, ADHD, depression, schizophrenia, manic-depressive illness, disassociative reactions, etc. are manifestations of "rheumatism of the brain".
Bursitis such as olecrannon bursitis, pre-patellar bursitis, tibial tuberosity bursitis (house maids knee), and subacromial bursitis.
Tendinitis such as tendonitis of the long head of the biceps, DeQuervains tendonitis, Achilles tendonitis, and rotator cuff abrasions, tears, etc. Ligamentitis such as plantar fasciitis, deltoid ligamentitis of the medial foot, etc.
There are many autoimmunological sequelae that manifest themselves cardiologically: rheumatic cardiac valves, coronary artery disease, acute and chronic myocarditis (LVH, global cardiac enlargement, and decompensated enlarged heart), pericarditis, and cardiac arrhythmias. The kidney is another vital organ that often sufferes from rheumatic vasculitis leading to chronic rhenal failure.
One can consider that rheumatic fever itself is also an acute aspect of rheumatism and its former name, acute rheumatism, more or less, defines that concept.
Although these disorders usually are not thought to have much in common etiologically, they are all target-organ manifestations of one variable inflammatory, autoimmunological disease process:rheumatism. One cannot expect the eye to respond to a systemic disease as the plantar facia responds. One cannot expect the medial meniscus to respond to a systemic inflammatory disease as the hip joint responds. One should not expect the brain to respond to a chronic, inflammatory autoimmunological condition as the heart responds. All rheumatic conditions are inflammatory in nature and share two characteristics: they cause chronic (though often intermittent) pain, and they are difficult to treat. They are also, collectively, very common. Aspirin, however, is used to treat all of them and it "works" reasonably well if taken in adequate doses for protracted periods. Even coronary artery disease is prophylactically treated with aspirin.
Within the first edition of the Encyclopedia Britannica, under the chapter on medicine, under the paragraph, "Of the rheumatism", a description of acute rheumatic fever similar to that written by Syndenham is provided. It mentions fever, chills, rapid heart rate, fatigue, lassitude, gastrointestinal problems, the sciatic pain (lumbago), and migratory arthritis. It saliently mentions, "The proximate cause is the inflammation of the lymphatic arteries." Further, it mentions, "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." It appears, clearly, that physicians in the mid-1600's knew that repeated "...lesser but neglected colds." could cause the systemic disease of rheumatism, but in the modern day, pundits of evidence- based medicine pontificate to new physicians that, all "colds" are caused by viruses and so upper respiratory diseases, even sore throats, are not to be treated with antibiotics. No wonder the American population is becoming populated with millions of cases of fibromyalgia (muscular rheumatism), sciatica, autism, MS, and other conditions.
Treatment
A vast number of traditional herbal remedies were recommended for "rheumatism". Modern medicine, both conventional and complementary, recognises that the different rheumatic disorders have different causes (and several of them have multiple causes) and require different kinds of treatment.
Nevertheless, initial therapy of the major rheumatological diseases is with analgesics, such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), members of which are ibuprofen and diclofenac. Often, stronger analgesics are required.
"Rheumatism" and weather
There has long been said to be a link between "rheumatic" pain and the weather. There appears to be no firm evidence in favour or against, but a 1995 questionnaire given to 557 people by R. Jamison and others at the Brigham and Women's Hospital's Pain Management Center concludes that "changes in barometric pressure are the main link between weather and pain. Low pressure is generally associated with cold, wet weather and an increase in pain. Clear, dry conditions signal high pressure and a decrease in pain"[2].
Miscellany
A Trod in the West of England is a straight line or Fairy Path in the grass of a field with a different shade of green to the rest. People with rheumatism sought relief by walking along these tracks, though animals are thought to avoid them.[1]
References
- ↑ Pennick, Nigel (1996). Celtic Sacred Landscapes. Thames & Hudson. ISBN 0-500-01666-6. P. 132.
External links
- BBC "Your Health" website on Arthritis and Rheumatism
- e-medicine article on Non-Articular Rheumatism
- List of plant species that have been recommended as treatments for rheumatism, from Dr Duke's Phytochemical and Ethnobotanical Databases
- Account of Rheumatism from the website of Retirement Matters Ltd of the UK