A RHEUMATIC NATION By OUR MEDICAL CORRESPONDENT T HE disorders grouped
popularly under the 'general name of rheumatism are the chief cause of adult invalidity in this country, being responsible for one- sixth of the total certified illness among English working men. Sir Walter Kinnear recently estimated the cost of chronic rheumatism in Great Britain at not less than seventeen million pounds a year. Far more important than anything measurable in money cost is the enormous amount of pain and incapacity entailed. It is interesting to speculate on the reasons that account for our continued uncertainty as to the nature and causation of this group of disorders, in spite of the notable advances made in the last quarter of a century in physiological and patho- logical knowledge and in laboratory technique.
For uncertainty there still is. When, a few years ago, the Red Cross Central Clinic for the treatment of chronic rheumatism was opened in London, the present writer commented: " The establishment of this Clinic is a victory for those apostles of hygienic therapy who have remained loyal to the Hippocratic tradition. Not the least valuable of the opportunities which the new treat- ment centre will afford is that of intensive study of the rheumatic diseases. Especially may the systematic collection and tabulation of so large a number of case- histories, correlating symptoms with environment, here- dity and physical idiosnycrasy, throw some light on causaticn, and therefore on possible prevention. It would be surprising if conditions so various as those included in this pathological group could all be traced to one and the same cause. . . . Cures, indeed, in any but mild cases, are likely to be few and far between. But the amount of improvement in physique and capacity may well be very great." The recently published report of last year's work at this clinic shows results fully justifying the efforts which the institution embodies. So far, however, no striking addition to our knowledge has resulted from the enterprise ; but, last April, a scheme was drawn up between the University of Leeds and the Royal Bath Hospital, Harrogate, for the institution of a Research Fellowship in Rheumatism, if the necessary funds could be collected. The public response has now enabled Leeds University to appoint Dr. Douglas Collins of Liverpool as the first Research Fellow to investigate the whole group of diseases lumped together under the name of rheumatism.
Part of the explanation for the doubt still prevailing is undoubtedly afforded by the undiscriminating nomen- clature. The term rheumatism has long been a sort of maid-of-all-work for the busy practitioner. For every painful or crippling disturbance of joint or muscle or nerve-sheath, not otherwise explicable, this ready-made diagnosis has proved all too satisfying to patient and doctor alike. Almost certainly there is little in common, either aetiologically or pathologically, between the various physical states thus verbally classed together. Even symptomatically, apart from their location, the various so-called rheumatic disorders resemble one another but in the most superficial and general way.
A further explanation of the relative lack of scientific effort hitherto directed to the investigation of the rheumatic group may be found in the fact that chronic rheumatism is not directly a fatal disease ; whilst its very frequency has lent support to the popular assumption, that it is as natural an accompaniment of middle and advanced age as measles was formerly assumed to be of childhood.
Such theories as to causation as have been advanced, have been little more than guesses, based on very inade- quate knowledge. For many years, doctors have been inclined to take it for granted that nearly all chronic disorders of joints or fibrous tissue are directly traceable to some septic focus—some seat of bacterial infection from which poisonous products are constantly being emptied into the blood stream. Infected tooth-sockets, septic tonsils, sub-acute inflammation of the appendix and inflammatory trouble in the gall-bladder, have all, in turn, fallen under this suspicion. The fact that occa- sionally such conditions have afforded a prime explanation of the arthritis or fibrositis, and that with the remedying of them the joint or muscle troubles have cleared up, has induced a feeling that failure in other cases to bring about a cure by similar means is due to the original seat of infection not having been located. Thousands of teeth and of tonsils have been sacrificed to this belief.
That occupation and climatic environment are not irrelevant in this connexion is strikingly shown by the rarity of chronic rheumatism in any form in tropical countries with hot and dry climates ; and by the fact that, in this country, it is preponderantly—though not universally—a working-class disease. Commonly, the joints or other parts most used are those first and most severely attacked ; hence, the proneness of gardeners to suffer from lumbago, and of miners from fibrositis of the shoulders. Over-functioning may clearly be as harm- ful as under-functioning— the optimum varying from one individual to another. It seems likely that emotional strain, by its effect on the endocrine glands and the sym- pathetic nervous system, may also, not infrequently, lower resistance to hostile agents of many kinds.
The causative part apparently played by defective peripheral circulation has not yet been adequately studied ; though it is agreed that the functioning of the skin is rarely normal in rheumatic subjects, and the success of many of the most effective methods of therapy —heat, massage, Faradism, and galvanism, ionization, counter-irritation, &c.—depends on the changes they produce in the metabolism and circulation of the surface tissues. Though nearly all forms of treatment are at present based on empiric, rather than on scientific, grounds, they and the results they yield afford significant pointers towards poSsible lines of investigation.
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