Medicine: Those Aching Joints

For the seventh month running, a book called Arthritis and Common Sense (Witkower Press; $3.95), by one Dan Dale Alexander, was high on U.S. bestseller lists. It is .sadly misnamed. Alexander is no man of medicine, but a sometime medical technician in the Army (where he rose to the rank of Pfc.) who got a Ph.D. from a London diploma mill. Burden of the book (aside from emphasis on the imagined importance of a full output of ear wax): “Arthritis is a deficiency of specific dietary oils. This deficiency results in a … lack of better-grade lubricating oils for the bodily joints.” The answer to it is just a question of diet, says Alexander. Sample recommendation: “If cereal is eaten at breakfast, be sure that the milk you pour on it is of room temperature.”

The truth is that, for generations, medical science has tried every imaginable dietary trick for arthritis and related diseases and found none of them effective except in gout. The Federal Trade Commission plans to have Alexander up for a hearing next week about his claims and promotion. But the popularity of his book is an accurate reflection of the prevalence of the disease and the despondency of its victims.

Sophisticated Arthritis.’ In the U.S. there are 11 million people who have one form or another of the arthritis group of diseases—what grandma called her “rheumatiz,” the genteel called rheumatism, and the pseudo-sophisticated now call arthritis. Each year, more than 300,000 people are made temporarily unemployable for varying periods by rheumatic diseases, and many of them become rheumatic invalids.

The American Rheumatism Association lists seven forms of rheumatism, the collective term for all diseases marked by pain or stiffness in the joints, muscles and related structures. In six, arthritis (inflammation of the joints) is a symptom. The seventh classification, “nonarticular” (not involving the joints), is a catchall for many of the commonest forms. Of the seven, osteoarthritis and nonarticular rheumatism are the commonest (between them, more than 80% of all cases). Rheumatoid arthritis (10% to 20%) is the most crippling. Many patients have more than one form.

The one thing that all forms of rheumatism have in common is that they affect connective tissue. Despite its wide occurrence in the body, connective tissue* is still something of a mystery to medical researchers. And because rheumatism is a crippler rather than a killer, and victims drag out their lives undramatically, only meager funds have been allocated for research into its causes and cures. Recently research has been stepped up on a broad front. The result has been dramatic progress in some areas, but disappointingly little in others. The scoreboard:

Arthritis Due to Infections. Once a major cause of arthritis, infections by common bacteria (notably gonorrhea and tuberculosis) no longer give the rheumatologists much concern. The joint symptoms, like the underlying disease, can be treated swiftly and effectively with such drugs as the sulfas, antibiotics and isoniazid. Can now be cured in nearly every case.

Arthritis Due to Injury. Caused either by a single severe injury or by endless repetition of minor, unnoticed injuries. Commonest examples: tennis elbow and housemaid’s knee. Treatment: draining away water on the knee, heat, massage, X rays, Novocain injections and, in severe cases, surgery. Now usually curable.

Arthritis of Rheumatic Fever. Now readily dealt with, in most cases, by prompt treatment of the rheumatic fever with aspirin and hormones of the cortisone family, and the use of penicillin to prevent recurrences. For all practical purposes: under control.

Osteoarthritis (degenerative joint disease). No known cause except advancing years, but there are probably other causes, especially in premature severe cases; 97% of persons over 60 have it, though most in such mild form that they have few symptoms. Occurs when bearing surfaces in joints lose their smooth mobility. Resulting handicap may be negligible or severe; it is rarely disabling. Aspirin helps to ease pain, as does heat (hot baths or heating pads); injection of hydrocortisone into a particular joint may give relief for months. A well-balanced, vitamin-rich diet is good for an oldster’s general wellbeing, but has no direct relationship to the disease. Still incurable, but can often be relieved.

Arthritis Due to Gout. The one rheumatic disease for which the cause is known, up to a point (the body’s inability to dispose of purines without creating an excess of uric acid), and the only one for which diet is important. About 95% of victims are males. The disease smolders indefinitely, but is marked by acute flare-ups with excruciating pain in swollen, inflamed joints. In rare cases, it can threaten life by depositing uric acid crystals in the kidneys or heart. Sufferers must avoid foods rich in purines—yeast, herring roe, sardines, asparagus, and many organ meats such as sweetbreads, liver, heart and kidneys. Other treatment: colchicine (an ancient remedy extracted from the autumn crocus), ACTH, phenylbutazone (a powerful but potentially dangerous drug). Another drug, probenecid, is no good for acute attacks and may actually aggravate them, but paradoxically is the best long-term treatment to keep the disease quiescent. Not yet curable, but now usually controllable.

Nonarticular Rheumatism. A grab-bag category. Includes bursitis (inflammation of the sac that helps reduce friction around a joint), myositis (inflammation of muscle tissues), fibrositis (muscle inflammation extending to connective tissues), tenosynovitis (inflammation of a tendon sheath), and such oddities as psychogenic rheumatism. Treatment: aspirin, possibly combined with hormones such as cortisone, prednisone and prednisolone. Codeine helps kill the pain, and heat is helpful. In bursitis, surgery is sometimes used to scrape calcified deposits from the inside of a bursa. In psychogenic rheumatism no physical cause can be found for the patient’s undeniable physical ills. Symptoms most often resemble those of fibrositis and the two are often confused. (Adding to the confusion, some experts hold that the disorders are really one and the same.) Exceptionally common in the armed forces under stress of battle. Only treatment : psychotherapy—an understanding general practitioner can handle mild cases, but stubborn ones may need the analyst’s couch.

For all nonarticular rheumatism: no neat cures, but plenty of opportunities for substantial relief.

Rheumatoid Arthritis. Commonest and most crippling of the acute forms of rheumatism. Cause unknown, although some researchers suspect that (like rheumatic fever) it is the after effect of a streptococcal infection. May occur in childhood (when it is known as Still’s disease) or late in life, but is commonest in the 305, when it strikes three times as many women as men. (Possibly related is rheumatoid spondylitis, or arthritis of the spine, which singles out young men.) Usually attacks virtually all joints in the limbs. Difficult to diagnose, but in 1930 Dr. Russell L. Cecil, now medical director of the Arthritis and Rheumatism Foundation, discovered a clumping factor in the blood serum of patients that has led to a promising test.

Physicians used to treat rheumatoid arthritis by guess and by God, gave aspirin by the carload to ease the pain of inflamed, swollen and exquisitely tender joints. In the 19305 it was found that, for no known reason, injections of certain gold salts brought the disease under control. Treatment was fraught with danger of damage to liver and kidneys. But the net effect was beneficial in perhaps 40% of cases.

Miracles & Disappointments. In 1949 came the dramatized announcement (with before-and-after movies) from the Mayo Clinic of wondrous results with two hormones: ACTH and cortisone. Hopes for miracle cures soared, along with sales of the hormones. Gradually it has become clear that the hormones do not cure rheumatoid arthritis; they suppress its worst symptoms until—as is the way with this baffling disease—it may subside spontaneously after a few months. Victims of other forms of rheumatism, some of whom thought rheumatism was all one disease, were disappointed when the hormones proved of little use to them. In some patients they produced swift and undesirable side effects (high blood pressure, moon face, beards on women).

Today, treatment has settled down to three patterns, the choice depending on local option. In one hospital in any major U.S. city, an acute case will be dosed heavily with aspirin and nothing else at first; in another, he will get aspirin and gold salts, and in a third, one of the hormones. In any good medical center doctors will switch from one regimen to another if they are not satisfied with results.

New Joints for Old. In the past, there was little doctors could do to restore useful movement of frozen joints and wasted muscles after the disease had done its gnarling and crippling work. Lately there have been major advances, largely through new and daring surgical techniques. Typical is the case of Angelina Ferrara, who was severely crippled by Still’s disease at the age. of nine. Her knees were bent and could not be straightened; her elbows were straight and could not be bent; her hips were bent and frozen. Last year, aged 25, Angelina was taken to the arthritis clinic at Manhattan’s superbly equipped Hospital for Special Surgery. There she scored near zero on the ADL (activities of daily living) test: she could not walk, dress or feed herself, comb her hair, or go to the bathroom alone.

First came surgery on her right knee, where the bones had grown together. The surgeons cut them apart and remolded the ends. To keep them from growing together again, they slipped in a layer of tissue from Angelina’s own thigh. Such a knee joint is flexible but not very stable. To make sure that Angelina would not fall in a heap when she tried to walk, the surgeons cut through the bone of the left knee, straightened it, then let it heal in the extended position. They used traction and casts on her hips, made new joints for her elbows. Angelina’s muscles, atrophied from disuse, were strengthened by exercises in the swimming pool (the buoyancy of water neutralizes the weight of the limbs and makes motion easier).

Last week Angelina was taking hesitant steps on her crutches. With a special long-handled comb she could do her own hair; with a tonglike device she pulled on her socks, and she scored a notable ADL victory when she worked a slip over her head. With a hand sewing machine (the exercise of working it is good for her), Angelina can almost be selfsupporting.

Despite the recent flurry of research advances, there is still no cure for rheumatoid arthritis—not in drugs, and certainly not in diet. But from judicious drug treatment and intensive aftercare, the unfortunate victim of this most damaging form of rheumatism can expect substantial early relief, and later, a fair recovery.

-It covers the ball-and-socket bones in hips and shoulders and the bone ends in other joints, serves as a sheath for all muscles and joins them to the bones they operate, and is present in all organs and blood vessels.