Not by Drugs Alone
Arthritis, says DR. DAVID D. RUTSTEIN, is responsible for more crippling and discomfort than any of the other ills of man. What relief is available? What hope for the future? These are questions vital to many households. Head of the Department of Preventive Medicine at Harvard Medical School, Dr. Rutstein is a member of the staff of Massachusetts General Hospital and five other Boston hospitals.
by DAVID D. RUTSTEIN, M.D.
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MOST readers of this article either have arthritis or know someone who does. In arthritis as in other severe illnesses we are accustomed to turn hopefully to a physician for an injection or for a pill. Indeed, we now expect that science will on demand routinely produce a miracle drug. We have inherited such great preventive weapons as smallpox vaccine and diphtheria toxoid. Our era has witnessed the discovery of sulfa drugs and antibiotics such as penicillin which are specific cures for many infections. Infectious diseases, such as lobar pneumonia, epidemic meningitis, gonorrhea, and syphilis all respond readily to treatment with these new drugs. The results have indeed been wonderful, but we tend to forget that immediately curative drugs have not yet been developed for noninfectious diseases. We do have life-saving remedies for some noninfectious illnesses: insulin for diabetes and liver extract for pernicious anemia, for example; but these do not eradicate disease. They merely keep disease under control for as long as treatment is continued.
For arthritis, although intensive research continues, we are not yet so fortunate. We have drugs to relieve symptoms but none to cure the disease itself. Unlike heart disease or cancer, arthritis is not a common cause of death and it usually does not shorten life. Arthritis is probably responsible for more crippling and discomfort than any of the other ills of man. Fortunately, even though medical science has not yet discovered a specific treatment, much of this painful disability can be prevented.
The common name for arthritis is rheumatism. Arthritis really means inflammation of joints; rheumatism is an everyday word for many aches and pains. Actually, these names are used interchangeably not for a single disease but for a great many different diseases of bones, muscles, and joints. This group of diseases may produce symptoms which range from mild discomfort to permanent crippling, and each disease has its own range of severity. Among the milder diseases are those referred to as myalgia, neuralgia, and myositis. The moderately severe varieties of arthritis include those due to local injuries or infection of a joint, and the gout, that picturesque malady marked by sudden painful attacks of joint swelling. Finally, there are two common major forms of arthritis: osteoarthritis and rheumatoid arthritis.
Osteoarthritis, the most frequent form of arthritis, generally involves the spine and the larger weight-bearing joints — the knees, ankles, and hips. It becomes more and more common as we grow older. It is sometimes, but not always, associated with “wear and tear" of joints subjected to continued strain, such as the knees and lower spine of overweight people. The thickening of the ends and edges of the bones and the roughening of the joint surfaces which are characteristic of this disease may cause pain or creaking when the joints are moved.
Rheumatoid arthritis is the most important of all the rheumatic diseases. Occurring only about half as frequently as osteoarthritis, it attacks all ages from early childhood to old age and is the most common form of crippling arthritis. Life expectancy is decreased significantly only when the most severe form of rheumatoid arthritis starts under the age of twenty-five. This chronic illness attacks small joints such as those of the fingers and toes as well as the larger ones of the arms and legs. Rheumatoid arthritis occurs three times as often in women as in men. However, in men the disease may take on a special form which tends to involve the spine. During acute flare-ups the joints become painful, swollen, and limited in movement. If untreated, rheumatoid arthritis may produce scarring of the joints and permanent crippling. The prostrating fatigue, the spasm of the muscles, the cold finger tips, and the occasional fever all testify to the generalized nature of this chronic fluctuating disease. Its course in any one patient is unpredictable. In some it may be acutely progressive while in others it may completely subside.
All of the many diseases included under rheumatism or arthritis are for the most part of unknown cause. The principles of treatment, however, are much the same, and most of the practical suggestions for the treatment of rheumatoid arthritis are also effective for any of the rheumatic diseases. We can suppress inflammation, reduce joint swelling, and relieve pain even though we have no drug to strike at the underlying disturbance in the body. Under the guidance of a wise and conscientious physician the available drugs are helpful as one essential part of a complete plan of treatment.
Of first importance in drug treatment is the aspirin family — the salicylates. In proper dosage, they are safe, cheap, and well tolerated by most patients. Aspirin alone will suppress the disease in many patients, but the treatment of arthritis requires more than an occasional aspirin tablet or the usual small dose in patent medicines for the relief of pain. The effective dose of aspirin required to suppress inflammation is relatively high — very close to that which produces toxic symptoms. This narrow range of dosage between effectiveness and toxicity demands careful supervision by a physician. We are fortunate that the aspirin family of drugs is as safe as any we have. In the range of dosage used for treatment there are no permanent effects on the heart or on any other vital organ.
The hormones ACTH and cortisone were hailed at first as specific cures for arthritis. Unfortunately, they and their newer family members prednisone (metacortone) and prednisolone (metacorlolone) offer merely another means of controlling the symptoms of the disease. They do suppress inflammation and enhance the patients’ feeling of well-being. In certain patients, better relief may be obtained when the hormones are judiciously used together with salicylates than when either is used alone. Another member of this family of hormones, hydrocortisone, in some patients produces much relief when directly injected into a badly inflamed joint. All of these hormones are quite toxic. Moreover, hormone treatment may conceal symptoms and therefore postpone treatment of other, even fatal, diseases. In most states the use of these hormones is properly restricted by law to prescription by a physician.
Some physicians have reported that gold salts, although at times poisonous, greatly relieve symptoms of arthritis in certain patients. But gold treatment has never received general acceptance. Another drug, phenylbutazone (butazolidine), acts like “strong aspirin in suppressing inflammation. Because of occasional severe toxic effects on the blood cells this drug is used only in patients who do not respond well to other forms of treatment.
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THE lack of a specific drug treatment for arthritis is discouraging. It does not mean, however, that rheumatoid arthritis automatically condemns a patient to a future existence as a wheel-chair cripple. In a household survey done in England in 1951, one half of the patients diagnosed by a physician as having rheumatoid arthritis had lost no time from work in five years. In a number of studies here and abroad, great improvement occurred in one half to two thirds of acutely ill patients hospitalized for rheumatoid arthritis. In one of those studies, in Edinburgh, the number of patients able to carry on normal employment increased from approximately 5 per cent before admission to the hospital to approximately 40 per cent after discharge home.
We are fortunate that the permanent crippling effects of arthritis develop slowly. Even in its worst forms, the disease constantly fluctuates in severity with days or weeks when there may be a decrease in symptoms or actual freedom from them. When pain and spasm diminish or disappear and the mobility of joints is temporarily increased, effective treatment can usually be applied. This may prevent crippling and permit the patient to carry on most of his normal activities. Maintenance of joint mobility is important because in many cases the disease eventually burns itself out.
The aim of a complete treatment program in rheumatoid arthritis is to keep the joints mobile and the patient in fit condition to use them. Such a goal sets a difficult task for the physician. He must be sure that the proper treatment is applied at exactly the right moment. Most of the treatment of arthritis can be given at home. (“Home Care of Rheumatoid Arthritis” is an excellent pamphlet issued by the Medical and Scientific Committee of the Arthritis and Rheumatism Foundation.) However, the patient may have to begin treatment in a hospital. There, a special regimen can be designed to fit his particular case. Whether or not the patient is hospitalized, both he and his family must learn about certain features of the disease in order to aid the physician to keep the arthritis under control. This is a crucial step. The physician will instruct them in the correct alternation of rest and exercise, will supervise the application of drugs, heat, and splints, and will obtain for the patient the assistance of experts in physical medicine and rehabilitation. At first, the physician must take sole responsibility; later, as the patient and his family gain experience, the physician can turn over more and more of the details of treatment to them.
Specially prescribed exercises are imperative in the prevention of crippling. They help maintain mobility of the affected joints and keep the surrounding muscles in good condition. The exercises, carefully graded to fit the individual patient, are best done with the assistance of a physical therapist. The Visiting Nurse Association or equivalent local agency often is equipped to provide physical therapy in the home and to teach the patient and his family the performance of proper exercises. Many of the necessary exercises cannot be done by the patient alone, and assistance from a specially instructed member of the family is essential.
When the joints are too stiff or too painful to be exercised, rest of the involved joints decreases swelling and relaxes the surrounding muscles. Heat, locally applied, also relaxes spasm and makes the joints more limber. Soaking in a tub of hot water is an effective way to apply heat to many joints at the same time. Drugs, such as aspirin or the hormones, suppress inflammation and often make exercise possible by relieving pain.
Arthritic joints are particularly likely to swell even after minor injury from bumping or twisting. Moderate caution during the day will prevent this. At night a specially made splint, loosely applied, will protect joints from injury during sleep. Such prevention of joint swelling will favor the program of exercise and therefore help to prevent crippling.
Fatigue is a common and debilitating symptom of rheumatoid arthritis. Patients with this disease require much more rest than well people do. Not only a good night’s sleep but several rest periods during the day are necessary.
A simple study by a trained rehabilitation worker of the patient’s daily activities on the job or in the home will identify the things he cannot do or can do only with difficulty. Some things must be given up. But often minor changes make major differences in the patient’s ability to be self-sufficient. Patients with arthritis of the hand, for example, may find it impossible to grasp and turn an ordinary round doorknob, but even a severely crippled person can easily depress a bar-shaped handle.
In spite of much speculation, there is no evidence that emotional disturbances are the cause of rheumatoid arthritis. However, periods of continued pain and disability may make it difficult for patients to cope with the disease. Also, emotional disorders of any sort may interfere with the regimen of treatment. In such circumstances, the physician or consulting psychiatrist may be very helpful.
All of these details of treatment need careful working out. The physician must provide direction. The family and the patient must learn enough about the disease to cooperate effectively. Once the treatment program is established and working, its maintenance becomes fairly simple. But the physician, like the conductor of the orchestra who brings in the right instrument at just the right time, has to apply the particular treatment for the momentary need of the patient. The fact that in most cases crippling can be prevented makes all this effort worthwhile.
Of course, it would be much easier if we had a miracle drug for the prevention and cure of arthritis. The regimen of treatment recommended demands continuing effort and forbearance of the patient and his family. Our great desire for a simple alternative leads us to be deceived by manufacturers and advertisers of patent medicines. We buy bottles of pills because we read advertisements that promise us miracles or our money back. We are seduced by the reassuring voice of the radio announcer who tells us so positively of the latest and greatest discovery for the treatment of arthritis. On television, the announcer’s voice seems more urgent and is supplemented by animated cartoons with bigger and bolder captions as the “hard sell” reaches its climax. We know very well that all of this is nonsense. The announcer has had no medical training and he hasn’t a ghost of an idea of what he is talking about as he reads the teleprompter. We know also that putting a white coat on a television actor and hanging a stethoscope around his neck does not qualify him as a doctor. We are aware that even though he may try to look like a doctor the main job of the announcer is to sell the sponsor’s product.
Most of the patent medicines now available for arthritis contain aspirin or other salicylates, aspirinlike drugs such as phenacetin, or derivatives of aspirin such as the gentisates. There is no substance in any patent medicine now on the market which introduces a new principle of treatment; no available patent medicine works better than aspirin in the treatment of arthritis. Regardless of the combinations in which any of these drugs are sold, catchy names on attractive labels don’t change the contents of the bottle or their therapeutic effects.
We know all of this, and yet we want so much to believe that there really is a miracle drug for arthritis that we are completely taken in. We buy thousands of copies of a book which claims that if we stay on a special diet and if we drink enough of the right kind of oil it will lubricate our joints. There is not a shred of scientific evidence to support this claim. It makes about as much sense as trying to lubricate the springs of a car by pouring oil into the gasoline tank.
If our wishful thinking had its ill effects only on our pocketbooks less harm would be done. But as we listen to the honeyed words that give us false hope, the evil lies in the neglect of treatment which could prevent permanent crippling.
A most dramatic example of what can happen through neglect was shown a few years ago at the Massachusetts General Hospital. At a teaching clinic Dr. Walter Bauer, an outstanding expert on arthritis, presented a permanently crippled patient. Suffering from severe arthritis of the spine, the patient followed one will-o’-the-wisp after another while his disease progressed. Over a period of fourteen years his spine curved over more and more until his head was inexorably fixed between his knees. Dr. Bauer truthfully said that here was a man who would never see the sun again. It took four years of unremitting effort and exercise and long periods in the hospital to prepare this patient for repeated and complicated bone surgery. All this gave only partial relief for a condition that could easily have been prevented if proper treatment had been started in time.