Rheumatism has been selected for consideration and shall preface my remarks .
Once upon a time a mother brought her son of twelve to me with the demand that I arrange an x-ray examination on his right hand . When I protested that it seemed normal enough to me she replied that their must be some thing wrong with it as it was going into people’s pockets and taking their money . She was of the opinion that the cause of the misdemeanour of her boy’s hand was to be discovered in a study of the offending organ and that cure was wrapt up in action directed to it . As she pressed her view point I recollected that in the country where I was born , it was not uncommon to amputate the hands . So I sent our boy off to the orthopaedic department of a nearby hospital , requesting a radiological examination of his right hand on the grounds of a felony . The orthopaedic surgeon was a specialist in limbs and in out look who naturally enough resented the levity implicit in the inference that the alpha and omega of faulty limbs might not always be found by scrutinizing them , however meticulously . He dryly reported that the x-ray revealed an old , missed crack fracture for which he had arranged , subject to my approval of course , attendance at the physiotherapy unit three times a week for wax baths , message , passive movements and exercises
When the patient’s mother expressed her esteem of the specialists who last no time in getting to the heart of the matter it was readily apparent that for her , at least , he had handled a difficult and delicate situation with the thoroughness and practicability of all that is best in the west as well as the east . Would however , this solution equally satisfy you or ma ? I for one confess to having reached the belief that the cause of an organ’s disordered functioning will really if ever be discovered by examining the organ concerned . An x-ray examination of the duodenum , for examination may confirm the presence of ulcer in a patient who complaints of pain after eating and gynaecological examination may point to spasm of the cervix in a girl suffering from dysmenorrhoea ; but do these examination contribute any thing to understanding cause as compared to mechanism ? .The study of men and women who get ulcer and girls with dysmennoroea has led me to think that undue concern in seeking a livelihood usually initiates the succession of changes which ultimately results in peptic ulcer , and that severe dysmenorrhoea often coincides with a growing interest in a boy friend . Unfortunately from the therapeutic point of view , we can seldom make the former group less interested in earning or the latter in loving . Nevertheless , it is doubt full that the ideal treatment of these conditions are surgical assault on the duodenum or uterus , whatever the practical effect may be .
THE NATURE OF RHEUMATISM
The term rheumatism , is used to cover a number of clinico-pathological entities , such as osteoarthritis , rheumatoid arthritis ankylosing , spondylitis < Osteochondritis And Acute rheumatism > The urination concept of a fundamental rheumatic process extends to ideas of cause , like infection < Nutritional deficiency , allergic reaction And psychosomatic disorder . However it is probably as illegal to use a single term to include most of the diseases of the central nervous system as to consider the affections of the muscle joint system under an all embracing heading like the rheumatism .
The rheumatic diseases are essentially diseases of connective tissue .Kellignen published in the British medical journal a comprehensive review of the present state of knowledge .He called that the connective tissues are composed of cells and inter cellular material , the latter being made up of large masses of fibrous elements with relatively small cells . The oxygen consumption is negligible . Although cells are doubtless responsible for the growth and maintenance of connective tissues , be they bony cartilaginous or fibrous , their functional efficiency depends entirely on the intercellular material , usually described as a collagen polysaccharide complex . The formation of connective tissue is stimulated by growth hormone . A local reawakening follows injury or inflammation . Fibrous tissue growth is suppressed by large doses of cortisone .
The two characteristics lesions of rheumatic diseases are fibrinoid change results in the collagen elements being largely destroyed leaving polysaccharides in relatively insoluble form . This process is widespread in rheumatoid lesions and is responsible for the classical subcutaneous nodules . Fibrinoid is the chief lesion in acute rheumatism , rheumatoid arthritis polyarteritis and lupus erythematosus .
Chondromalacia, on the other hand , consists of primary loss of the polysaccharide orchondroitin element , leaving the collagen fibers unsupported . Initially there is loss of elasticity in the cartilage followed by the exposed collagen fibrils being worn away with the joint movement . Eventually the cartilage plate is worn through exposing the underlying under lying bone which in turn worn away .This process is accompanied by marginal overgrowth of both and cartilage . It is the inevitable degenerative change of age , but in some subjects comes on prematurely . It largely accounts to osteoarthritic and disc lesions
In acute rheumatism the fibrinoid change is transient and is associated with streptococcal infection , where in rheumatoid arthritis the fibrinoid change is comparatively permanent , in rheumatoid there is also wide spread atrophy of bone , tendon cartilage and other collagenous structures , along with anaemia .In other conditions an inflammatory reaction tends to heal by the formation of new connectie tissue substance , leading to atrophy of supporting structures . The anaemia of rheumatoid is usually intractable unless during a remission or when under treatment with cortisone .
THE PITUITARY ADRENOCORTICAL SYSTEM
The work of Hench (1949) on the effects of cortisone on some of the features of rheumatoid arthritis seemed at first to point to a direct link between pituitary adrenocortical activity and rheumatoid arthritis . How ever it soon became clear that many other conditions could be modified by the administration of cortisone or adrenocorticotrophic. Hormone [ACTH] .Kelgren[1952] believed that rheumatoid arthritis could not be visualized as a deficiency disease in the same way as diabetes , and suggested the failure of certain aspects of rheumatoid disease to improve under cortisone or ACTH therapy showed that the essential error in this disease was not yet understood . The adrenocortical steroids may in fact act simply as suppressors of the connective tissue to the basic rheumatoid lesion . Kendall [1951] , on the other hand adhered to the view that , it might become possible to explain rheumatoid disease in terms of steroid imbalance . He pointed out that there was a marked discrepancy between the hormone complex received by tissues from normal endocrine activity and that from oral or parenteral administration , and went on the add “ I should like to engage in a bit of speculation to the effect that the reason the lower animals do not have rheumatoid arthritis or rheumatic fever may be that they are more adequately protected by a higher concentration of the hormones of the adrenal cortex with in their tissues , perhaps in evolution of mankind , a closer adjustment of the activity of the adrenal gland results occasionally in a failure of this safe guard , and as a result rheumatoid arthritis and rheumatic fever run their course “
STRESS
During 1940,1950,1951 publications on the rheumatic diseases appeared in general medical journals on a scale never seen before or since . Much of the interest in these diseases was aroused by the work Selye in a series of papers 1936 to 1951 . His theories and conclusions were for the most part based on animal experiment and were described under the title under the stress and the general adaptation syndrome . He also attempted to prove a unification namely , that all living organisms responded to stress with the same basic pattern of reaction irrespective of the nature of the stress . This he called the general adaptation syndrome and its derailments , the diseases of adaptation . stress is defined as any thing that endangers life and he went on to say that the full story of the adaptive response will never be fully understood as the complete comprehension of life itself is beyond the limits of the human mind . In the biological sense stress is the interaction between damage and defense and the stress or may take innumerable forms , such as cold or heat , fatigue emotion , infection and so on .
CLINICAL EXAMPLES OF RHEUMATISM
CASE
Rheumatic fever :He was a lad of 18 whom I was called to treat some 20 years ago . His father owned a owned a farm few miles from my home and the boy had been born on it , reared on it , was now working it with his father and had grown to hate it and his father with all his bitterness his heart could muster .As a school boy he was compelled to start work on the farm soon after dawn and to resume when he returned from school , in addition to his work as pupil . For him holidays existed only in dreams . At 17 he was tall and lanky , having outgrown his strength , as the saying is . He told me that , that he was always tired and that he could scarcely remember what it felt like to be otherwise .
He was classical example of acute rheumatism the history of sore throat , variable pyrexia , swollen joints and later endocarditis . After a few weeks when things had settled down apparently and under what pressure , I do not know , he resumed work on the farm . A few nights later I was summoned see him about midnight . His temperature was the highest , I have ever seen , 111 degrees almost to the limit of the thermometer .I watched him until he died , in about half an hour
RHEUMATOID ARTHRITIS :
This case , too goes back more than 20 years , as she was a contemporary of my own as she was a contemporary of my own , though a student at a different university . Her striking qualities combined superlative ability as a sports woman with the energy to participate in an amazing number of sports . She was first rate on the track and in the water and also took a leading part in hockey and tennis . Not withstanding she took her degree in the normal number of years . For the keen observer her tireless entry to one competition after another year after year had a certain significance . It seemed as if it were of more than ordinary importance for her to excel over her rivals or to gain the plaudits of the crowds for her displays , and that there were no limits to the trouble to the trouble she would take to exhibit her talents . It seemed noteworthy too that her need to vanquish other girls found fulfillment in physical prowess , rather than in the class room or the dance hall , where indeed , if not actually careless of her capacities she certainly did not seem to seem to make the most of them .
As she reached her final year she showed unmistakable signs of interest in one male student colleague . When he came on the scene of her eyes , lit up , her conversation became bright and vivacious as her attention rapidly focused on him from whom ever or whatever , it had previously been recorded . It came to be taken by her associates that these to would marry when the time became appropriate . However he took a job as assistant to a doctor in a distant part of the country and in a year later we heard to our surprise he had married to the boss’s daughter . After the lapse of few months our athlete married another young graduates of her social group , a study and hand some enough youth but not one who had never brought fire to her eyes in the student days at least two years later , she became pregnant , but last her baby through pre-eclamptic toxemia . In another year or so she noticed herself becoming stiff and sore after exercise . Before long her joints showed the characteristic changes of rapidly advancing rheumatoid arthritis . In a few more years she was reduced to complete immobility , ultimately dying of pulmonary tuberculosis
CASE
Disc lesion : once or twice every year it has long been my custom to spend a week end with an old friend , in the beautiful home where he lives as medical superintendent of a mental hospital .It is usual for me on these vacations to accompany him on the Saturday forenoons while he is at work when I never cease to admire his facility in handling the psychotics of all types . As a consulting psychiatrist he is often asked to visit in neighbouring hospitals . On one particular Saturday as we motored to orthopedic unit where four patients to be examined , he expressed concern for one of them , A young man of 20 who had been lying on boards for nearly couple of years and for whom arthrodesis of lumbar vertebrae was under consideration . He was believed to have a disc lesion although it was only recently that minimal appearances had shown up radiologically . After a discussion on the bare facts of this case it was agreed that I spend an hour with this patient while my psychiatric friend interviewed the other three . This was the story I obtained
