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Fiske Fund Prize Dissertation. No. LIII. 
 
 The Classification and Treatment 
 
 of Diseases Commonly Known 
 
 as Rheumatism. 
 
 MOTTO: 
 "Vero nihil verius." 
 
 BY 
 
 FRANK E. PECKHAM, M. D., 
 Providence, R. I. 
 
 PROVIDENCE: 
 
 Snow & Farnham Company, Printers. 
 1910. 
 
r "THE Trustees of the Fiske Fund, at the annual meeting of the 
 * Rhode Island Medical Society, held at Providence, May 31, 1910, 
 announced that they had awarded a premium of two hundred ($200) 
 to an essay on " The Classification and Treatment of Diseases 
 Commonly Known as Rheumatism," bearing the motto : 
 
 "Vero nihil verius." 
 
 The author was found to be FRANK E. PECKHAM, M. D., 
 of Providence, R. I. 
 
 Dr. EUGENE KINGMAN, Providence. 
 
 Dr. A. A. MANN, Central Falls. 
 
 Dr. FREDERICK T. ROGERS, Providence. 
 
 Trustees. 
 
 HALSEY DkWOLF, M. D., Providence, 
 
 Secretary of the Trustees. 
 
The Classification and Treatment of Diseases 
 Commonly Known as Rheumatism. 
 
 A classification must be founded on some logical 
 basis, for example an etiological or a pathological, then 
 the treatment can be applied much more accurately 
 and with a much greater prospect of permanent cure. 
 The diseases commonly known as rheumatism are those 
 associated with pain about the joints or muscles. 
 When in the muscles, it is commonly called muscular 
 rheumatism ; when in the back, lumbago. Sciatic 
 rheumatism, used synonymously with sciatic neuritis, 
 are not uncommon terms. When the joints are 
 involved, the term rheumatism, chronic rheumatism, 
 gout, and rheumatic gout are very common. To re- 
 duce all these terms to something tangible in the way 
 of classification, has been a tremendous undertaking 
 and has been attempted by many men. Most of these 
 attempts have resulted in schemes so complex and 
 cumbersome as to render them useless. A scheme to 
 be useful must be as simple as possible and readily 
 applied clinically with knowledge which may be com- 
 paratively easily obtained. A careful history of the 
 case, a careful history of the patient's troubles which 
 
6 THE CLASSIFICATION AND TREATMENT OF 
 
 might have any bearing, a careful physical examina- 
 tion not only of the particular joints or areas of pain 
 but of the physiological processes in general, — that is, 
 bowels, urine, liver ; also an examination for flexibility 
 of spine and for tender spots anywhere up or down the 
 spine and for any slight deviation of vertebrae, an ex- 
 amination of the sacro-iliac joints, and range of motion 
 of legs (with knee extended) on the ilia, and an ex- 
 amination of joints other than those complained of. 
 Add to this a careful X-ray study and outside of some 
 unusual and border line conditions, the case may usually 
 be classified. 
 
 The many classifications offered in literature might 
 all be enumerated but such a waste of time is hardly 
 necessary in the present stage of the development of 
 the subject. There are a very small number of types 
 of these joint conditions which ordinarily may be dif- 
 ferentiated without much difficulty. There are the 
 villous arthritis, atrophic arthritis, hypertrophic arthri- 
 tis, infectious arthritis and gout. These types were first 
 described by Goldthwait. Perhaps the most logical and 
 convincing way to demonstrate this may be to describe 
 a typical case under each type, in this way showing 
 why it is placed in a certain class. This will also make 
 the treatment seem perfectly logical and for the sake 
 of keeping the whole thing in mind as an entity, the 
 treatment had better be placed after such description. 
 
 The simplest form of joint trouble which has formerly 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 7 
 
 fallen under the term rheumatism occurs oftenest in the 
 knee joints. The patient complains of some pain in the 
 knees, some stiffness in the morning especially when 
 first getting about on them or after sitting for an hour 
 or so, and is very apt to notice a grating or creaking 
 on going up or down stairs. A physical examination 
 reveals a " boggy " knee and there may or may not be 
 a small amount of fluid present, usually not. There 
 may be some tenderness, usually on the inner side of 
 the joint. If the patient sits in a chair or on the end 
 of the examining table and extends and flexes the 
 knees, the examining hand over the knees detects the 
 grating which may be very slight or very marked. If 
 the patient stands with bare feet, they are usually found 
 to be pronated. An X-ray picture shows the bones to 
 be normal and may show a shadow or mottled appear- 
 ance just below the patella and anteriorly between the 
 fermur and tibia. Such a knee, if it should be opened, 
 would present, instead of a smooth glistening surface 
 of the serous membrane, a loose tripe-like condition. 
 This is due to a villous growth and then the term villous 
 arthritis may be used. A villous arthritis may be 
 present in most any type of joint trouble, as an infec- 
 tion, or even in tuberculosis ; but in the above described 
 condition, it exists without any apparent accompanying 
 disease, and hence is one type of joint trouble of the 
 so-called rheumatic group. 
 
 This condition is very apt to be accompanied by pro- 
 
8 THE CLASSIFICATION AND TREATMENT OF 
 
 nated feet aud is mostly seen in women. It is not so 
 often seen in men. Women, unless inclined to be thin 
 or of a spare type, are apt to have a more or less fleshy 
 thigh. It may be observed that when such patients 
 stand with inner surface of knees just in contact, the 
 inner malleoli will be separated, some slightly and some 
 quite markedly. In other words, there is some degree 
 of knock knee. This means that there is more or less 
 of a strain on the knee joints, this strain either from 
 pronated feet alone or in conjunction with the above 
 condition of slight knock knee, becoming an etiological 
 factor. A demonstration of the strain of a knock knee 
 causing a villous arthritis has occurred in a very marked 
 manner in two cases coming under the observation of 
 the writer. A young married woman had only one 
 very marked knock knee and the knee on that leg had 
 given trouble for years, at times swelling up and becom- 
 ing tender and painful. Rest and local applications 
 had quieted it each time but it gradually became en- 
 larged so that it was never normal in size and was con- 
 stantly grating and creaking and remaining always 
 tender and boggy and much larger than the other knee. 
 A second case occurred almost exactly like it in a man 
 of middle age. The knee had given him more and 
 more trouble until he was willing to do anything for 
 relief. Where there is tenderness and pain and numb- 
 ness around the knee and particularly on the inner side 
 and often in addition about the ankle and anterior part 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 9 
 
 of the foot, there will usually be found a lax condition 
 of the sacro-iliac joints with sufficient tilting of the 
 sacrum or ilium to impinge on the lumbo sacral plexus, 
 thus interfering with the nerve supply and producing 
 a very direct effect upon the knee joints. In women 
 with saggy abdominal contents, with or without pen- 
 dulous abdomen, the dragging down may assist to pro- 
 duce the tilted sacrum or ilium, or if this is not present, 
 may by their own weight interfere with the large nerve 
 trunks in such a way as to become etiological. The 
 conventional corset alone will produce just this condi- 
 tion in many cases. 
 
 The treatment of this condition must be twofold. 
 It must remove the causes and at the same time this 
 thickened boggy condition must be treated so as to 
 cause its complete disappearance if possible. First, as 
 to the causes. The pronated feet must be corrected 
 by being placed in properly shaped shoes and thus the 
 foot is balanced. This balance is accomplished by pro- 
 jecting the inner corner of the heel farther forward, 
 which in people inclined to be pretty heavy will be 
 sufficient, but in lighter weights the inner side of the 
 heel must be raised in each individual case to com- 
 pletely balance the foot. Although artificial supports 
 might be used occasionally it would not ordinarily be 
 necessary. This balancing would also correct a mild 
 degree of knock knee but not an exaggerated case. 
 The markedly pronated foot in fleshy women would 
 
10 THE CLASSIFICATION AND TREATMENT OF 
 
 call for a heel still higher and still farther forward on 
 the inside. In the two cases cited above, where there 
 was only one very marked knock knee and also a very 
 troublesome and painful villous arthritis, I advised an 
 osteotomy for the correction of the knock knee which 
 was so evidently the cause. In the lax conditions of 
 the sacro-iliac joints, the tipping of the sacrum or the 
 ilium may first be corrected by manipulation. An effi- 
 cient way is to place the patient on an examining ta- 
 ble full length face down. Then by pressing down- 
 ward with one hand on the sacrum, or still better hav- 
 ing an assistant hold the sacrum by pressing strongly 
 downward, with the other hand or with both hands 
 firmly grasping the thigh, preferably with leg flexed 
 at right angle, strongly force the thigh upward. By 
 bending it upward several times the joint surfaces are 
 levered into better apposition. This movement may 
 be repeated at subsequent visits if necessary. In wo- 
 men the corset may then be improved by the addition 
 of a belt or extension so adjusted and made part and 
 parcel of the corset that it really supports the abdomi- 
 nal contents holding the pelvic girdle more firmly to- 
 gether. In men a belt may be made which accom- 
 plishes the same purpose. By these means the etio- 
 logical factors are attacked and remedied. 
 
 Lastly the joint or joints demand treatment for the 
 local condition which, as described above, consists of a 
 thickened boggy condition of serous membrane* 
 
DISEASES COMMONLY KNOWN AS KHEUMATISM. 11 
 
 These villi may be of a very small growth or they may 
 become markedly hypertrophied forming regular tu- 
 mors with enlarged ends and small pedicles. These 
 larger villi may undergo fatty degeneration thus form- 
 ing fatty tumors, the so-called tumor aborescens, which 
 are mostly apt to be located below the patella and be- 
 neath the ligamentum patellae. On the other hand 
 these villi may undergo calcification at the ends and 
 then the pedicle breaks and thus are formed the float- 
 ing bodies. It is necessary to describe the above con- 
 dition in order to illustrate treatment. In the early 
 stages or even in the late stage with secretion of fluid 
 where fatty degeneration or calcification has not taken 
 place, most of these cases are curable without opera- 
 tion. Such knees may be baked in the special ovens 
 and after remaining for an hour may be thoroughly 
 vibrated using the hard ball and beginning with gentle 
 pressure. After a few treatments the pressure may 
 be made pretty hard. The hot air bath brings fresh 
 red blood to these parts (hyperaemia). Vibration stim- 
 ulates the tissues so that both circulation and nerve 
 supply are much improved. The villous condition 
 slowly contracts and becomes less and less spongy. Hy- 
 peraemia may also be produced by the Bier method 
 and might alone be of benefit in some cases, but is not 
 so efficient as the hot air and vibration. Vibration 
 alone is beneficial but not so much so as after the knee 
 is thoroughly heated through. This same effect can 
 
12 THE CLASSIFICATION AND TREATMENT OF 
 
 be produced in some cases by the so-called Morton 
 wave current followed by sparking with the spark se- 
 lector, then in tender joints the brush discharge may 
 follow on this. 
 
 The wave current is administered by applying the 
 circular electrode around the knees, so curved as to 
 avoid contact with the patella and then connected to 
 the positive pole by the static machine. The negative 
 pole is grounded by a special chain connected to a steel 
 rod driven into the earth. The patient is on the insu- 
 lated table. The amount of current forced through 
 the tissues is regulated by the spark gap between the 
 poles of the machine. The best results should be ob- 
 tained when the spark gap is run up to three or our 
 to six inches. Each spark means a surging of electric- 
 ity through the patient with the greatest force applied 
 in the tissues immediately under the electrode. This 
 produces a contraction of the tissues. Thus with each 
 blow there is a squeezing out of any infiltration into 
 the proper channels for elimination. In this way de- 
 pletion is accomplished. Another effect is of the elec- 
 tricity itself by way of stimulation to the nerve supply 
 and circulation, thus tending in a very positive way to 
 assist nature by her own processes to restore locally 
 the " normal." Following the wave current, a short 
 seance of direct sparking, pressing spark selector hard 
 against the boggy area and with the sparking ball giv- 
 ing spark of one-half or three-quarters to one inch in 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. \?j 
 
 length in order to insure its penetration into the villous 
 growth beneath. In a tender and aching joint these 
 treatments may be followed by the so-called brush dis- 
 charge. The patient is seated on the insulated table 
 and connected, by the shepherd's crook with the nega- 
 tive pole of the static machine. Then the operator 
 with the metallic rod or the " wet stick " connected by 
 a special chain with the earth, draws the electricity 
 from the patient at the point of greatest tenderness. 
 This modality is a great sedative and is very soothing 
 to such joints. Another method of treatment, but not 
 advocated as much as formerly is the actual cautery. 
 It is of value and now and then seems to be the one 
 treatment needed for cure. But to use for regular 
 treatment, it will prove disappointing. A simple treat- 
 ment which can be made use of at home is hot and cold 
 douching. Alternately pouring hot and cold water 
 over the knee produces a succession of mild shocks and 
 a mild hypersemia which will be of benefit in a few 
 cases. 
 
 Another simple method is to bandage the joint with 
 a pure (gum) rubber bandage. This produces a local 
 sweating and thus is beneficial. In some few of these 
 knees, the boggy condition may yield, and yet there 
 may remain a tender area way beneath the ligamen- 
 tum patellae, and usually on the inner side. At this 
 point of tenderness, a small tumor may be felt to roll 
 under the finger. This is a villus which may be fibrous 
 
14 THE CLASSIFICATION AND TREATMENT OF 
 
 and hard, or it may have undergone fatty degenera- 
 tion. In either case, surgical removal brings an end 
 to all trouble from that source. 
 
 There are now two types of joint troubles which 
 have been classified as the trophic types. That is, 
 atrophic and hypertrophic arthritis. With the other 
 types to be described, they are all due to faulty metab- 
 olism ; that is, there is somewhere in the system faulty 
 physiology. It is often impossible to locate the exact 
 process at fault, but it has been demonstrated very 
 many times that treatment applied in such a manner 
 as to stimulate the physiological processes to act in a 
 normal or more nearly normal manner, slowly results 
 in an improvement in the joint conditions. One type 
 is usually first observed in the smaller joints (fingers), 
 later involving the larger joints (knees). The cervi- 
 cal vertebrae (joints) may be involved but usually for a 
 short interval only, when it clears up, very seldom in- 
 deed resulting in a completely stiffened neck. The 
 jaws are also involved sometimes (not usually). The 
 synovial membrane becomes thickened and spongy and 
 full of blood, thus giving the joint a swollen and boggy 
 appearance. If the knee is involved instead of getting 
 the sense of fluctuation when the patella is depressed, 
 it gives the sensation of striking on rubber, there being 
 an entire absence of the sharp click which is such a 
 familiar sound and so easily sensed in a simple synovi- 
 tis. Later the cartilage is involved, resulting in a 
 
DISEASES COMMONLY KKOWN AS RHEUMATISM. 15 
 
 thinning or atrophy. If the cartilage becomes more 
 and more thinned, there appears small a,reas of com- 
 plete erosion, these growing slowly larger and when 
 the areas are on opposite bones and near each other, 
 bony anchylosis may ultimately result. When the 
 thinning or atrophy takes place in the finger joints, the 
 cartilage may become destroyed and the ends of the 
 bones being forced together spread out laterally, thus 
 making the joint enlarged. This is the type of finger 
 joint where this enlargement was formerly supposed 
 to be a deposit, but now the X-ray shows the exact 
 condition. These enlarged finger joints were also very 
 apt formerly to be called gout, or worse yet rheumatic 
 gout. The enlargement is thus due to the thickened 
 synovia and villi, and some infiltration of soft parts 
 and to the projecting bony contours, and is not a de- 
 posit at all. As the principal thing in this type of 
 trouble is the thinning or atrophy of the cartilage, it 
 has been classified as atrophic arthritis. 
 
 In the knee joints, the villi become of considerable 
 size and then undergo fatty degeneration or else the 
 ends may become calcified. These calcified tips may 
 break off from the pedicles and thus become floating 
 cartileges. There may be only two or three villi of 
 some size under the ligamentum patellae, usually on the 
 inner side. In this position, they become pinched in 
 walking and getting tender give trouble both on ac- 
 count of the tenderness and pain and on account of the 
 
16 THE CLASSIFICATION AND TREATMENT OF 
 
 mechanical interference with the mechanism of the 
 joint. This Jype of joint trouble is very slow (chronic) 
 but continuously progressive. It requires several years 
 to run through its course and also may remain slowly 
 advancing throughout life. The enlarged terminal 
 joints of the fingers are usually the first symptoms and 
 during the active stage of atrophy and projecting bony 
 contours, may become painful. Later when the larger 
 joints (knees) are involved, there is more pain on ac- 
 count of the villous arthritis as well as the eroded sur- 
 faces and it is not uncommon to have the flexor mus- 
 cles of such joints contract, these muscular contractures 
 becoming of importance in treatment. In this class of 
 cases some patients may go along with slowly enlarg- 
 ing finger joints and involvement of larger joints re- 
 sulting in more or less of an anchylosis. Over these 
 joints some of the enlargement is very evidently due 
 to an infiltration of the soft structures. In some other 
 cases, if observed from time to time, these finger joints 
 mav become more or less tender and even now and 
 then somewhat red and inflamed (low grade). Usually 
 these joints do not give so very much pain but are 
 achy and tender (if knees) when walking or weight 
 bearing. They are stiff and the knees bother much in 
 going up or down stairs, the villi and erosions causing 
 grating and creaking. It is necessary to consider the 
 causes of this trouble as the modern treatment is 
 aimed very largely at such causes. It is becoming 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 17 
 
 more and more evident, as the result of treatment is 
 observed, that this type of joint trouble is due to faulty 
 physiology somewhere and that if it can be stimulated 
 to do its work properly, the joints slowly get well. 
 
 It goes without saying that when cartilage has been 
 destroyed, it cannot be restored. To stimulate the 
 physiology, various means are employed but first of all 
 it may as well be said that medicine (drugs) simply 
 will not do it._ Persons who are under a great deal of 
 tension either from worry, grief, etc., (mental tension) 
 or overwork (physical tension) or both which is still 
 worse, may slowly develop this trouble, but it is caused 
 by the interference with physiology. Patients who 
 have already had this type of trouble, even for years, 
 may be made worse by grief and sorrow and with the 
 passing of such trouble may improve and get back to 
 their former stage of the process just as before. Sor- 
 row or mental strain interferes mostly in the way of 
 digestion. Any one who has had a severe worry for a 
 short time knows of what little use it is to eat, as the 
 food remains in the stomach for a long time as a " lump 
 of distress " before it passes on and even may continue 
 to give intestinal disturbance all the way through. 
 Such people may become constipated or even diarrhea 
 may be produced. In this way, assimilation is inter- 
 fered with or the lymphatic stream is not properly pre- 
 pared. This would cover only a very small number 
 of the cases, however, most of them beginning in a 
 
18 THE CLASSIFICATION AND TREATMENT OF 
 
 very insidious manner, the patient probably not notic- 
 ing it for a long time. A careful history is a great 
 help, followed by a thorough physical examination 
 and an X-ray photograph of one or more of the joints, 
 to make sure of this type. The patient may be doing 
 entirely too much (physical strain) or (usually) it will 
 be found that there is something wrong in the alimen- 
 tary canal somewhere, irregular eating, too rapid eat- 
 ing, faulty preparation of food in the mouth from bad 
 teeth or insufficient teeth. The stomach or intestines 
 may be interfered with in their working by corsets and 
 clothing. The liver may be doing its work poorly and 
 thus be a disturbing factor. 
 
 Perhaps the most typical case simply comes on 
 slowly, usually the finger joints followed by larger 
 joints, or the fingers may never become involved and 
 only the knees and hips be attacked. In such a case 
 there would not be much pain but the symptom most 
 complained of would be stiffness. After sitting for an 
 hour, the joints would be very stiff on first getting up. 
 While sitting or lying down, there would be an entire 
 absence of discomfort. Consequently sleep is not in- 
 terfered with. On getting up and attempting to go up 
 or down stairs, there is a stiffness and later a limita- 
 tion in motion. Now this limitation in motion in such 
 a case where there is no villous arthritis and no ero- 
 sion, is due to a beginning fibrosis. In such a case, 
 the faulty physiology must result in absorption of 
 
DISEASES COMMONLY - KNOWN AS RHEUMATISM. 19 
 
 products which result in this condition without causing 
 any temperature. Such joints, if manipulated under 
 ether appear perfectly freely movable without any ap- 
 parent grating and roughening. In other words they 
 feel like perfectly normal joints. This resistance in the 
 earliest stages would seem to be located in the liga- 
 ments. Such manipulations however are to be avoided 
 as the result is to produce a marked stiffening and pain 
 on voluntary motion. This aggravated condition may 
 last for weeks and months before getting back to the 
 former state, thus causing the patient just so much un- 
 necessary pain and discomfort. That this trouble is 
 due to absorption or faulty assimilation is brought out 
 by the fact that a case that has gone along for months 
 and even years in this way with a slowly increasing 
 fibrosis, may begin to have the first mild attacks of 
 swollen joints especially in the fingers. As time goes 
 on and this phase of the disease appears, these at- 
 tacks may gradually become more severe and a tem- 
 perature exists in proportion to the amount of inflam- 
 mation. In such a case, the patient must be carefully 
 questioned. The method of eating is highly import- 
 ant. In the first place not too much must be placed 
 in the mouth at any one time. This gives a chance to 
 chew and mix it thoroughly with saliva. It will be 
 found that most people put the food into the mouth in 
 rather too large quantities, chew a little and then 
 either swallow it by pushing it down, by taking a drink 
 
20 THE CLASSIFICATION AND TREATMENT OF 
 
 of water, coffee, tea, or whatever the favorite drink 
 may be. Eating in this way, there is not much de- 
 mand made on the salivary glands and in consequence 
 they " get out of practice " as it were ; and as a chronic 
 thing not much saliva is secreted. This is the first 
 step in digestion and it is right here that faulty physi- 
 ology begins and must be corrected. This is a highly 
 important part of the treatment and patients must 
 have it explained to them in detail, so that they may 
 appreciate the situation. When the food is chewed and 
 thoroughly mixed with saliva, swallowing practically 
 becomes an automatic process and the food swallows 
 itself. Towards the end of the meal, one becomes con- 
 scious of forcing the muscles to swallow. Then appe- 
 tite has been appeased and the meal must be consid- 
 ered completed right there. If this method of eating 
 is pursued, the salivary glands secrete the juice much 
 faster and if drinking for the purpose of washing down 
 the food is done away with, the desire for drink while 
 eating disappears. Eating in this way after it has 
 been practised so that one does it unconsciously does 
 not require much, if any more, time than the old way. 
 It will be seen that water is thus done away with quite 
 naturally at meal time, and so must be taken care of 
 between meals. In the morning before breakfast is a 
 good time to drink as the water is absorbed very 
 quickly in the stomach that has been empty several 
 hours, then middle forenoon, middle afternoon and 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 21 
 
 evening. If water is not drunk constipation results 
 with a still greater auto-intoxication. Food prepared 
 in this way enters the stomach ready for its treatment 
 with gastric juice then to be sent on into the intestines. 
 In men the abdominal contents are not displaced by 
 corsets, but in women this is an extremely important 
 factor in digestion. The conventional corset constricts 
 at the waist line (the small waist is a fashionable neces- 
 sity) thus forcing the contents downwards. Even the 
 long corsets do not support from below as they ought 
 to. This constriction and forcing downwards of the 
 abdominal contents interferes with intestinal action 
 and thus the physiological activity, whereby the intes- 
 tinal juices are secreted, is interfered with. This sag- 
 ging of the intestines and diminished intestinal secre- 
 tions mean a slowing of the intestinal stream with its 
 consequent constipation and the formation of bacteria 
 and toxines. Also the end products which are finally 
 supplied to end organs are changed as to their compo- 
 sition. In this way, nutrition is interfered with. The 
 whole physiology is demoralized, any way in portions 
 of it, which seems to result in trophic joint troubles. 
 The liver also is an extremely important organ in all 
 these troubles. It stands between the alimentary ca- 
 nal and the final stream which distributes to the vari- 
 ous physiological depots and serves to filter out the 
 infections and toxines. When it is not acting properly 
 and some of these products are allowed to pass through, 
 then some of these various joint disturbances arise. 
 
22 THE CLASSIFICATION AND TREATMENT OF 
 
 The proper preparation of the food in the mouth 
 having been described, the treatment of faulty diges- 
 tion in the stomach and intestine must be corrected 
 likewise. A liver which is not doing its work properly 
 must be attended to. Each pair of conventional cor- 
 sets which }^ou may examine " in situ " will show a 
 waist line more or less constricted and from this waist 
 line downward the corset is so made that it does not 
 support the abdominal organs. This constant pressure 
 and the downward sagging, causes atony and weak- 
 ening of all the muscular walls, hence a marked slow- 
 ing of the physiological digestive process. As a result 
 there is a backing up of the partially digested products 
 with a resulting putrefaction and growth of the various 
 bacteria and their toxines. These are carried through 
 the system and as a result among other things, the 
 joints are affected. These are the true causative fac- 
 tors and must be remedied. The corset must be taken 
 in hand, and an extension made and fitted in such a 
 manner that the lower end passes beneath the abdomen, 
 and, by being perfectly fitted and moulded, really sup- 
 port the abdominal contents. Then the corset must 
 be laced in three sections, the lower one sufficiently 
 tight so that proper support and pressure upward is 
 really obtained. The section at the waist line must be 
 looser so that the organs will have space for them to 
 go when they are pushed upward and the upper sec- 
 tion should be loosest of all to allow perfect freedom 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 23 
 
 for breathing. The corset makers are apparently 
 unable to do this and so the physician must do this 
 work in order to be sure that it is anatomically correct. 
 In this way support of the abdominal contents is 
 obtained and a shortening of the supporting ligaments 
 and structures. The next thing in treatment is to 
 stimulate in some way the functions of these organs, 
 to restore tone to the muscular fibres which " work " 
 the stomach and the intestines, and to tone up also the 
 supporting structures so that sagging will not be so 
 marked. This is done most effectively by some of the 
 forms of electricity and mechano-therapy (vibration). 
 General vibration will very markedly stimulate phy- 
 siological processes. In the first place a vibrator with 
 a massive base is a necessity, if the vibration is really 
 to be " sent in " and to produce the desired results. 
 "Why so many fail to produce these results is that they 
 buy a small and light vibrator where a large part of 
 the vibration wave is taken up by the hands of the 
 operator and hence not transmitted through the tissues 
 except in a very insufficient way. The hard ball of 
 the vibrator is used on the nerve centres between the 
 transverse processes up and down the spine. In this 
 way, waves of energy are transmitted along the nerves 
 to the various organs and structures at the end of the 
 nerves. A pressure of from five to eight or ten 
 seconds is stimulating. A longer pressure would be 
 inhibitory. The soft brush is now used over the liver 
 
24 THE CLASSIFICATION AND TREATMENT OF 
 
 both front and back. This organ can be very markedly 
 stimulated by this means and in a way which cannot 
 even be approximated by medicine. The soft brush 
 of the vibrator is continued over the stomach area, the 
 hard ball over the abdominal lymphatics and again the 
 soft brush over the general area of the abdomen. 
 These latter measures stimulate the stomach as an 
 individual organ increasing the tone of its muscles, 
 thereby increasing its efficiency in work accomplished. 
 Likewise the muscles in the walls of the intestines are 
 markedly stimulated also increasing their efficiency 
 and the abdominal lymphatics are likewise stimulated 
 to do better work. All this means increasingly better 
 preparation of food for assimilation. The stimulation 
 applied thus directly to the muscular walls raises the 
 tone of these organs and thus largely corrects the sag- 
 ging of the abdominal viscera. In this improved con- 
 dition, the intestines perform their functions better 
 and better and the assimilation of food (end) products 
 is accomplished in a more nearly normal physiological 
 manner. With the improved tone in the muscular 
 walls of the abdominal viscera, there is less and less 
 backing up of the stream and hence less and less de- 
 composition which means less and less absorption of 
 bacteria and toxines. If this absorption of bacteria 
 and toxines is the real cause of chronic joint disease, 
 it is at once seen that these conditions are in this way 
 attacked right at the source of all trouble. With this 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 25 
 
 correction of the physiological process, the bacteria or 
 toxines cease to be sent into circulation for distribution 
 and thus the onward progress of the disease becomes 
 slowly checked. At the same time this general treat- 
 ment is given, aimed at the direct cause of the trouble, 
 the joints themselves must receive careful attention. 
 Vibration may be used to stimulate the tissues and 
 their local processes. The soft brush may be used on 
 the wrist and finger joints making a pretty firm pres- 
 sure on both palmer and dorsal surfaces. The soft 
 brush may also be used on the elbow, shoulders, hips 
 or ankle joints. On the knees much better work may 
 be done by the hard ball. If a villous arthritis is pres- 
 ent, as it is so apt to be, the hard ball is a very efficient 
 means of causing a contraction and slow disappearance 
 of the condition. In addition to the mechanical vibra- 
 tion as above described, some of the newer electrical 
 modalities are of very great service in producing cer- 
 tain very definite results. The wave current is a very 
 strong tonic to the general system. This may be 
 applied by a long flexible metal electrode placed long- 
 itudinally along the spine and connected to the positive 
 pole of the static machine, the patient being seated 
 upon an insulated table. The negative pole of the 
 machine is grounded by a chain leading to a special 
 steel rod driven into the earth and the dosage is reg- 
 ulated by the length of spark gap between the poles 
 of the machine. The longer the spark gap, the deeper 
 
26 THE CLASSIFICATION AND TREATMENT OF 
 
 the impulse of the " wave " penetrates into the tissues. 
 If the metallic electrode is placed over one of the dis- 
 eased joints, it derives more benefit because the 
 greatest effect on tissue is obtained directly under the 
 metallic electrode. In case of knees, if a large machine 
 is employed, a metallic electrode may be applied to 
 each knee and both connected to the positive pole thus 
 getting the maximum effect directly upon the knees. 
 This treatment is allowed to continue usually for 
 twenty minutes. Following this, the affected joints 
 may be given a thorough sparking. It is better to use 
 the spark selector (Snow) by which it is possible to 
 deliver the spark just where it is needed. The patient 
 is seated on the insulated table and connected by the 
 shepherd's crook with the positive pole of the machine. 
 The negative side of the machine is grounded by a 
 special steel rod. The operator with spark selector 
 and ball (the ball being grounded by a chain connected 
 with gas or water pipe) thoroughly sparks the tissues 
 all around the knees with a length of spark which 
 should penetrate one-half or three-quarters of an inch. 
 Neither of these treatments are painful to the patient 
 as the metallic electrodes are in close contact with the 
 skin when the wave current is given and the spark 
 selector is in actual contact with the skin as each spark 
 is delivered, hence it is sent in without discomfort to 
 the patient. With the wave current, as each spark 
 jumps across the poles of the machine, a current of 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 27 
 
 electricity surges through the body with the maximum 
 effect at the joint. A contraction of tissues takes place 
 thus squeezing out any infiltration which may exist 
 and has a marked contractile effect upon the spongy 
 tissue like a villous arthritis. The spark sent in by 
 the spark selector has the same effect only it is local- 
 ized more exactly in this way. 
 
 If the joint is particularly tender or painful, the 
 wave current and sparking may be followed by the 
 brush discharge. This may be obtained by the metal- 
 lic (pointed) electrode or the wet stick electrode. The 
 patient is seated upon the insulated table connected to 
 the negative side of the machine by the shepherd's 
 crook, while the positive pole is grounded. The me- 
 tallic pointed electrode or the wet stick is connected 
 with the earth by means of a chain to the water pipe 
 or gas pipe. The point of either electrode is then held 
 within one or two inches according to the effect pro- 
 duced and if the room be darkened, a fine purple or 
 violet spray may be seen between the skin and the 
 electrode. This relieves pain and tenderness in many 
 cases. Another treatment which strongly stimulates 
 the nerve centres, is to have the patient reclining upon 
 a couch, the back bared to the skin and then exposed 
 up and down its whole length to the light emanating 
 from a five hundred candle power incandescent lamp. 
 The stimulation of these nerve centres conve}^ im- 
 pulses to the various end organs corresponding to these 
 
28 THE CLASSIFICATION AND TREATMENT OF 
 
 centres and thus the physiolog} 7 of the abdominal or- 
 gans is reached. If one joint is especially painful or 
 achy, a twenty minute exposure to this light will often 
 serve to completely alleviate the pain. The enlarge- 
 ment (infiltration of soft structures) of the small joints 
 (fingers) is stimulated usually in a very noticeable 
 manner by the D' Arson val current. These joints may 
 be made to contract and diminish in size in this way 
 sometimes when other methods fail. A small metal 
 electrode is bandaged to the palmer surface of the fin- 
 gers and the D' Arson val current applied by placing 
 the glass vacuum electrode over the dorsal surface. 
 This treatment may be continued for ten minutes on 
 each hand. In an atrophic type with marked villous 
 arthritis of the knees which might resist all treatment, 
 opening the joint and thoroughly cleaning out the vil- 
 lous growth with forceps and scissors will put an end 
 to the trouble in that particular joint. After the oper- 
 ation splints are used and walking is allowed at the 
 end of a week or ten days. Another clinical picture 
 of joint trouble is the hypertrophic type. In order that 
 the treatment may be shown as logical and rational, 
 the condition of the joints will have to be shown a lit- 
 tle in detail and the etiology discussed. The principal 
 characteristic of this condition is the overgrowth of 
 bone or cartilage usually at the edges of the articular 
 surfaces. The stage of actual hypertrophy is a late 
 stage as may be quite definitely proved by considering 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 29 
 
 the process when it attacks the spine where it is most 
 often spoken of as an osteoarthritis. In this location 
 the patient consults a physician at a much earlier stage 
 than when some of the areas of joints are involved. 
 In this stage there is pain on motion of the spine in 
 flexing and side bending which interferes very directly 
 with occupation and from the fact that the spine is in- 
 volved, patients are earlier referred to the orthopedic 
 physician and not so much time is wasted while the 
 condition is treated with the usual anti-rheumatic rem- 
 edies. In the earliest stage hardly any hypertrophy 
 or overgrowth of bone exists, but there is an infiltra- 
 tion of the soft structures which is undoubtedly due to 
 auto-infection (either toxines or bacteria). 
 
 This thickening is usually confined to one side only in 
 the beginning, and so when the patient stands with back 
 towards the observer, lateral bending shows the spine 
 curved normally to one side and limited in its excur- 
 sion on the other. When both sides are involved the 
 excursion on both sides is limited and usually one side 
 more than the other. Slowly as time goes by, there 
 takes place a deposit of bone salts and if not arrested 
 the vertebrae become fused together in a condition of 
 anchylosis. In this stage which precedes actual bone 
 formation the condition is ordinarily completely cura- 
 ble. The wave current may be applied with long me- 
 tallic electrode, twelve to fourteen inches long, by 
 three inches wide, placed directly over the affected re- 
 
30 THE CLASSIFICATION AND TREATMENT OF 
 
 gion and being connected with the positive pole of the 
 machine as described above, continue the treatment 
 for twenty minutes with a spark gap of four to six 
 inches. This should be followed by sparking as de- 
 scribed above with the spark selector, pressing the end 
 deeply into the intervertebral spaces all up and down 
 the affected area. This treatment causes the contrac- 
 tion of the tissues which squeezes out and depletes, 
 also stimulating activity in the nerve supply and cir- 
 culation thus markedly hastening local elimination. 
 This may be followed by a general vibration, the hard 
 ball in the intervertebral spaces, stimulating the nerve 
 centres which convey impulses to end organs (abdomi- 
 nal viscera) and the soft brush over the liver, both 
 front and back, and also generally over the abdominal 
 area. Also the hard ball is used over the abdominal 
 lymphatics. In this way the abdominal organs are 
 stimulated to perform their functions in a more nearly 
 normal physiological manner and as the normal is ap- 
 proached, the backing up of the stream with its conse- 
 quent constipation, formation of ferments, bacteria and 
 toxines are slowly caused to disappear. Many of these 
 patients have more than an unnoticed sluggishness in 
 liver and intestines. They may actively complain of 
 symptoms of indigestion, either stomach or intestines, 
 and it is very common to find, when using the vibra- 
 tor, that there are tender spots over the spine which 
 correspond accurately (as now mapped out in the phys- 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 31 
 
 iology) to the centres for the liver as well as other ab- 
 dominal viscera and it is not uncommon to find the 
 whole liver area somewhat tender on precussion. 
 
 An extremely marked case came under observation 
 this last winter. A woman of forty or forty-five was 
 referred to the writer because of a very tender and sen- 
 sitive spine. It was considered as some spinal disease 
 because of the location in the spine, the patient being 
 confined to bed, because supporting the superincum- 
 bent body weight caused pain in the tender area of the 
 spine. Turning in bed was also uncomfortable. Phys- 
 ical examination revealed three or four vertebrse very 
 tender. Very slight pressure caused pain and flinch- 
 ing. As this area corresponded accurately with the 
 nerve centres for the liver, an examination both front 
 and back showed that this whole surface area directly 
 over the liver was extremely sensitive to pressure. 
 Thus a complete clinical picture showing that conges- 
 ted liver, by its reflex effect on the nerve centres had 
 produced so tender a spine that some disease of the 
 spine had been diagnosed. The proof of the diagnosis 
 seemed to be confirmed by the fact that when the liver 
 was depleted by appropriate treatment, the spine gave 
 no evidence of disease and tenderness, and the patient 
 has remained well several months now since the at- 
 tack. Thus in the early stage of osteo-arthritis often 
 called rheumatism of the spine, in this location it would 
 seem that the direct results of treatment had been such 
 
32 THE CLASSIFICATION AND TREATMENT OF 
 
 as to prove very conclusive]}^ the localized infiltration 
 (auto-infection) and that this condition is usually cura- 
 ble any way in the stages preceding the actual deposit 
 of bone salts. If the infiltration continues there may 
 be severe pressure of the nerve trunks even without 
 bone formation. This pressure usually results in pain 
 in the nerve terminals as well as discomfort and ten- 
 derness at the point of infiltration. This may be so 
 severe that patients are no longer able to continue at 
 their work or occupation. Under such conditions, 
 quick relief may be obtained by the application of a 
 plaster jacket with the spine held in a somewhat hy- 
 per-extended position on a frame, or if too tender for 
 that, the first jacket may be applied with the patient 
 standing in the best position he can assume, and after 
 the relief thus afforded, a second jacket could be ap- 
 plied a week or two later when the spine could be 
 made perfectly straight or even hyper-extended. The 
 first or second jacket could be a removable one in or- 
 der that the treatments as outlined above might be in- 
 stituted and a complete cure obtained. The relief un- 
 der these conditions is somewhat startling in its sud- 
 denness. A case in point may be briefly mentioned. 
 A man of about forty years, whose business called 
 upon him to be on his feet a great part of the day, run- 
 ning in and out, and up and down stairs, was attacked 
 with this condition in the spine. Pressure on the 
 nerve trunks had taken place and the pain developed 
 
DISEASES COMMONLY KNOWN AS KHEUMATISM. 33 
 
 at the terminal nerve areas around the inner side of 
 the knee and about the ankle joint. He had been ex- 
 amined and prescribed for by half a dozen medical 
 men who had all examined his knee and ankle and con- 
 sidered it neuralgia and neuritis of these joints. The 
 patient was in bed at my first visit. The next day a 
 plaster jacket was applied in the standing position and 
 two days later when I made my visit, the patient had 
 gone down town. A few days later he reported at my 
 office. He was back at work and free from pain. 
 
 In the later stages after bone salts are deposited and 
 pressure has taken place with its consequent pain in 
 the nerve terminals usually somewhere down the leg, 
 the jackets as just described are necessary, and if the 
 process has gone on far enough and the spine is bent 
 over forwards, some of the curve and in some cases all 
 of it may be corrected by successive jackets, with or 
 without ether. At the same time that pressure is 
 removed, pain is relieved and the patient really lives 
 again. After the spine is straight, the jacket is made 
 removable or a lace-up leather jacket is applied so that 
 the treatment of the spine and of general physiology 
 may be administered. In such cases, where bone salts 
 have been deposited there can be no absorption, but 
 the process may be halted so that no more will be 
 deposited and the physiology, as described above got- 
 ten in a normal or more nearly normal condition. 
 Under these conditions, there is undoubtedly some 
 
34 THE CLASSIFICATION AND TREATMENT OF 
 
 shrinking of the deposit as it becomes hardened and 
 thus the patient may go through life with a fair degree 
 of comfort. 
 
 In these cases of spinal involvement, the all-over 
 electric light bath is a most valuable addition to the 
 treatment, especially in cases that yield with difficulty 
 to the treatments as outlined above. Where this 
 hypertrophic type involves the knee joint, in the cases 
 that have come under the writer's observation, it is 
 more apt to be accompanied by a villous arthritis. 
 The spurs or lipping may be on the edges of the 
 patella or on the edges of the articular surfaces of 
 either the tibia or femur. These overgrowths may 
 be present in considerable quantities and yet not be in 
 quite a location to interfere mechanically and cause 
 pain and tenderness. In such a knee with villus 
 thickening, it is the boggy and swollen condition of 
 the membrane which causes the pain and discomfort, 
 and the treatment already outlined, — that is, baking, 
 vibration or wave current, and sparking with the gen- 
 eral vibration treatment of the spine, liver, stomach, 
 and abdomen, will cause the slow shrinking and disap- 
 pearance of the congested villi, and then these hyper- 
 trophied areas will give no trouble. They also may 
 shrink some and the patient go on without trouble. 
 On the other hand, in a case which might not yield to 
 this treatment but persist in causing pain and tender- 
 ness in walking or going up or down stairs ; or in a 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 35 
 
 case where bone formation might not be so extensive 
 but in such a location as to interfere mechanically 
 and cause pain, an open operation would be necessary 
 for relief, with removal of the swollen and thickened 
 villi and also of the spurs of bone. 
 
 In these villous conditions which really come to 
 operation, it may be found that the whole joint surface 
 is usually completely covered with this swollen and 
 congested villous tissue. It is completely gorged with 
 blood and consequently bleeds very freely when cut 
 into. This cannot be curetted off as the sharpest 
 curette slips over it without removing it. It must be 
 caught up with forceps and cut off with curved scissors. 
 In this way, the whole joint surface must be thoroughly 
 reached through two longitudinal incisions, one on 
 each side of the knee. The supra patella pouch must 
 not be omitted. Then these bony spurs must be 
 removed and the knee closed. It should not be 
 splinted or placed in plaster of Paris but a sterile 
 dressing applied and the patient will then bend it a 
 little when moving about in bed. At the end of a 
 week or ten days, walking and using should be begun 
 and the knee baked every other day, and passive mo- 
 tion utilized every day. In knees where an extensive 
 growth of these villi exist and the inside of the knee 
 has to be practically skinned to completely remove it, 
 forcible moving and breaking up of soft adhesion may 
 be necessary once or twice before complete motion is 
 
36 THE CLASSIFICATION AND TREATMENT OF 
 
 established. In such cases there may be many villi 
 and small spurs or few villi and many spurs. After 
 recovery from operation, it is very important to go 
 into the general treatment if the patient will do so, as 
 it is the general process (faulty physiology) which 
 needs treatment in order to prevent future trouble. 
 
 Where the hip joint is involved with this overgrowth 
 (morbus coxas senilis) it is very important to know it 
 as early in the process as possible. The hypertrophy 
 may exist around the edges of the acetabulum, making 
 the socket deeper and by mechanical blocking, inter- 
 fere with the extreme range of motion. The same 
 thing results if the growth is on the trochanter. 
 Patients are very apt to experience difficulty in bend- 
 ing over to lace up their shoes as an early symptom. 
 If the hypertrophy takes place when the motion of the 
 joint mechanically irritates, it is better, if the patient 
 will do so, to use crutches, relief thus being obtained 
 from the aggravation of motion with the body weight 
 upon it. Then the physiology of the body should be 
 stimulated and improved by eating properly as already- 
 described, by vibration to the spinal nerve centres, 
 liver, abdomen, and lastly to the hips. Then there 
 should be a fifteen or twenty minute treatment with a 
 glass vacuum electrode connected with a high frequency- 
 coil. This stimulates by reason of the action of the 
 electricity itself and a marked local hyperemia is also 
 produced. In this way a marked impression may be 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 51 
 
 made on the process. If allowed to go on untreated, 
 the bone salts are laid down, going through the process 
 in a longer or shorter time, but usually years rather 
 than months. At the end of this time, the motion is 
 very apt to be much limited mechanically, and in 
 aggravated cases the joint is completely stiffened. If 
 the diagnosis is only made early and the patient will 
 submit to treatment, this course may be very much 
 shortened and the amount of the deposit reduced to a 
 minimum so that at the end, the limitation of motion 
 may not be great and walking and going up and down 
 stairs not much interfered with. 
 
 The process is the same in any joint which may be- 
 come affected. The fingers are often involved in this 
 type of trouble. General treatment must always be 
 instituted, never forgetting that the joints are only 
 external manifestations or symptoms of the general 
 process. This means general vibration to spine, liver, 
 abdomen, and lastly treat the joints. In the fingers 
 the D'Arsonval current is very valuable and in con- 
 junction with exposure to the five hundred candle 
 power lamp, will very markedly relieve pain, thus ren- 
 dering splinting unnecessary and also causing actual 
 diminution of the infiltration of the soft structures if 
 such exists as it usually does. The surgical removal 
 of these spurs is called for when they mechanically 
 interfere with movement. The knee joint, in my 
 experience, is the most often treated in this way. The 
 hip joint is the most difficult one for such removal. 
 
38 THE CLASSIFICATION AND TREATMENT OF 
 
 As all of these types to be described, with the excep- 
 tion of villous arthritis in the ankles and knees which 
 is probably due to mechanical strain, are due to faulty 
 physiology and hence to the absorption of bacteria or 
 toxines, they might all be placed under the head of in- 
 fectious arthritis, but it is a decided help clinically to 
 have the different types, as there are only five of them 
 and as it is usually possible to differentiate one from 
 the other. The help obtained is very great when one 
 has to examine and treat a considerable number of 
 such cases. Under infectious arthritis, as it has been 
 thus far classified, are included cases in a much more 
 active stage than the preceding types and are usually 
 traceable to some definite infection. The joint lesions 
 may be due to the poisons of the bacteria or to their 
 toxines. Perhaps with our present knowledge and 
 with our present methods of examination, it would 
 seem that most of the cases were due to toxines simply 
 because the bacteria are usually not to be found. 
 Probably with increased knowledge and further refine- 
 ments in technique, the bacteria may be found with in- 
 creasing frequency either in the fluid or the surround- 
 ing tissues. In a case from some active infection, the 
 onset is usually sudden. Several joints will be involved, 
 either all at once or one after the other in rapid suc- 
 cession. Most of them will clear up leaving only one 
 or two finally involved, but nevertheless, the condition 
 is manifestly a progressive one. In both cases, the 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 39 
 
 soft structures are swollen, spindle shaped around the 
 joints, the distention causing pain either from the dis- 
 tension itself or from pressure on the nerves. In the 
 acute case, it is severe ; and in the aggravated type, 
 there is delirium from the septic absorption. In the 
 slower type there is usually a rapid pulse, even though 
 there may be no temperature, thus conveying the mes- 
 sage of a septic condition. In the acute type, the 
 organism will be found in the joint fluid and anyway 
 in the structures, and the fluid is more apt to be pus 
 and the destruction of structures greater. 
 
 For treatment to be applied in the most intelli- 
 gent manner, the focus of infection must be sought. It 
 cannot, by any means, always be found, but if it can, 
 much greater good can be accomplished. In a chronic 
 progressive case with acute exacerbations, usually fol- 
 lowing tonsilitis, it is fair to presume that the tonsils 
 are the focal points of infection ; and in such a case the 
 removal of these organs is to be advised. Many times 
 after the joints are restored to normal condition, there 
 may be no further trouble. This would demonstrate 
 that the diagnosis was correct. Septic involvement of 
 the joints may occur in any of the infectious diseases, 
 — typhoid, scarlet fever, pneumonia, grippe, gonorrhea, 
 etc. If due to toxines, any fluid in the joints will prob- 
 ably be serum while if the organisms are present, it is 
 more likely to be pus. Toxic joint troubles may fol 
 low confinement and if serious blood poison be present, 
 
40 THE CLASSIFICATION AND TREATMENT OF 
 
 the organisms are more likely to involve the joints 
 with pus formation. This toxic sequence is more apt 
 to result in some paralysis. Joint involvement in a 
 pneumonia is not very common, but it does happen. 
 The writer has observed two cases. The most com- 
 mon sequence is that following gonorrhea, formerly 
 called gonorrheal rheumatism. If the organism is act- 
 ually present, the result is more apt to be pus and the 
 process may be a very destructive one. In acute con- 
 ditions of joints with contractures in the knees where 
 there is much suffering and tenderness and excrucia- 
 ting pain, the greatest relief may be obtained by fixa- 
 tion in plaster for a few days only. Then it may be 
 changed when it will be found that the knees may be 
 placed in a much straighter position. Fixation ought 
 not to be continued for very long, because it would 
 tend to make the joints stiff. As soon as the plaster 
 is omitted, appropriate treatment may be begun at 
 once. 
 
 In gonorrhea, the joints may become involved early 
 or late. If early, it is fair to presume that the organ- 
 ism or toxine is due to gonococci, but if late it is more 
 than apt to be due to the secondary infection, either 
 streptococcus or stephylococcus. A gonorrheal urethritis 
 is simply a discharging sinus, and, like all such sinuses, 
 it is not very long before secondary infection takes 
 place and the joint involvement may be due to these 
 organisms or to their toxines. In these cases, the sem- 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 41 
 
 inal vescicles sac becomes involved and then as the 
 weeks go by, this sac becomes the reservoir continually 
 distributing some of its store of poison. In this con- 
 dition the joints themselves need treatment but at the 
 same time this focus needs the utmost attention and 
 this will be first discussed. In every case of suspected 
 gonorrheal joints, the rectum should be examined to 
 establish the condition of the seminal sac. This may 
 be much enlarged and tender, or it may be only tender 
 and somewhat more tense not being especially en- 
 larged. If only tenderness exists, it is usually enough 
 to make one feel pretty certain of the diagnosis. 
 When the extreme importance of this focal point was 
 appreciated, stripping (so-called) was employed. This 
 consisted of passing the finger above the sac (if possi- 
 ble), then pressing firmly against it and slowly with- 
 drawing, thus mechanically pressing out some of the 
 contents. Repeating this manoeuvre several times the 
 the sac was emptied to some extent, and keeping it up 
 •every other day, it was finally supposed to remain 
 empty and in consequence the poison ceasing to be 
 distributed, the joints would slowly get well. This 
 was true in some cases, but not in the great majority 
 of them. One all important objection to this method 
 was and is, that in most men the finger is too short and 
 that it does not quite go above the sac, hence there is 
 always some fluid left. The positive proof of this lies 
 in the fact that commercialism attempted to remedy 
 
42 THE CLASSIFICATION AND TREATMENT OF 
 
 this by offering for sale an extension arrangement 
 whereby the finger was made longer. This also was 
 not quite satisfactory because the sense of feel could 
 not be supplied to the mechanical extension. The next 
 step in the attack upon the sac was made by Dr. Fuller 
 who operated by the perineal route and drained it. 
 The next step in the attack is the most efficient of all. 
 It is not nasty like stripping and is not disagreeable 
 to the patient. The patient is placed upon his side on 
 the insulated table with the back towards the static 
 machine. A glass vacuum electrode (Titus) is inserted 
 into the rectum with the concave side toward the sem- 
 inal sac and connected to one ball of the machine, the 
 other ball being grounded. A sufficient amount of en- 
 ergy is generated to allow of a four to six-inch spark 
 gap between the balls. Every spark across these balls 
 means a surging of electricity through the glass vac- 
 uum electrode which is directly against the seminal sac. 
 Every blow means a contraction of the tissues, thereby 
 squeezing out the infiltration and also a succession of 
 such blows means an emptying of the sac which can 
 be demonstrated by finding the contents in the ure- 
 thral canal. In addition to this is the marked stimu- 
 lating effect of the electricity upon the surrounding 
 tissues thus toning them up and restoring them to a 
 normal physiological activity. This modality also ren- 
 ders organisms sterile thus causing a cessation of their 
 ability to propagate. This is far and away superior to 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 4o 
 
 any possible effect to be obtained by stripping. The 
 treatment is always gauged to the agreeable tolerance 
 of the patient so that there is no pain attached to this 
 part of the treatment. Any urethritis which may be 
 present should also receive proper treatment. All of 
 the various injections have been tried, but in the writ- 
 er's hands, the most efficient of the injections is a weak 
 solution of AgN0 3 . (J to one grain to 6 ounces of 
 water). This the patient learns to do himself very well, 
 always remembering to void the urine just before inject- 
 ing. Many eroded surfaces which resist this treatment, 
 may be painted locally with a stronger solution. Stric- 
 tures of either large or small calibre call for appropri- 
 ate treatment, and a word about these. Strictures of 
 large and moderate calibre are perhaps still best 
 treated by " sounds," but the small ones are best and 
 most efficiently treated by galvanism. It is much bet- 
 ter than tearing (divulsion) or cutting as both of these 
 operations result in scar tissue which contracts again, 
 but when done by galvanism there is no scar tissue, 
 and there is no contraction and the result is all that 
 could be desired. Thus the urethra is treated as to its 
 calibre and urethritis and the seminal sac emptied and 
 contents rendered sterile. At the same time, this 
 treatment is inaugurated, the joints themselves must 
 be attacked. After the seance with the glass vacuum 
 electrode against the seminal sac, the patient may be 
 seated upon the insulated table and the affected joints 
 
44 THE CLASSIFICATION AND TREATMENT OF 
 
 thoroughly sparked, using the spark selector (Snow). 
 The spark gap between the balls must be such as to 
 give one-half to three-quarters of an inch spark into 
 the tissue thus causing tissue contraction and thereby 
 squeezing out the inflammatory products into their 
 proper physiological channels for elimination. All of 
 the affected joints ought to have a thorough sparking. 
 If one or two are particularly tender, a few minutes 
 with the brush discharge will often give great relief. 
 For this treatment, the patient is on the insulated ta- 
 ble connected to the negative side of the machine 
 while the positive side is grounded. The balls are 
 widely separated while the operator holding a pointed 
 electrode (either metallic or a wet stick) within one and 
 one and one-half or two inches of the tissues, a fine pur- 
 ple spray ma}^ be seen passing between the tissues and 
 the electrode. This brush discharge if continued steadily 
 for a few minutes will often relieve an aching joint. 
 These treatments applied from a high frequency coil 
 are not the same, and equally good results cannot be 
 obtained. In cases, where ankles, or ankles and knees 
 are involved, both legs may be thoroughly bandaged 
 up to the groins with towels and placed in the hot air 
 oven for one hour with a temperature of three hundred 
 to three hundred and fifty degrees. This produces a 
 profuse local sweating, thus eliminating some products 
 of inflammation locally and at the same time producing 
 a hyperemia and also stimulating the circulation and 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 45 
 
 nerve supply. If baking is thus employed, the joints 
 should be thoroughly vibrated immediately after re- 
 moval from the oven. The soft brush is better used 
 about the ankle joints and feet, and tendo Achilles and 
 firm pressure employed. The knee joints are better 
 treated with the hard ball as deep pressure may be ex- 
 erted and almost direct contact is obtained with the 
 thickened and infiltrated soft parts and the villous con- 
 dition if it exists. 
 
 Another modality may here be made use of. The 
 glass vacuum electrode connected with the high fre- 
 quency coil, may be used for ten minutes on each knee? 
 producing a hyperemia and also the electricity stimu- 
 lating nerve and circulatory supply. While speaking 
 of these physical methods, one method of treating ure- 
 thritis must be mentioned because it is perfectly 
 scientific and must of necessity be more and more used. 
 In a beginning gonorrhea, when the inflammation is 
 confined to the anterior urethra and before there is 
 any secondary infection (in other words entirely 
 gonoccic) the process should be quickly controlled and 
 further extension prevented in the following manner. 
 After voiding the urine, thus thoroughly washing out 
 the urethra, the patient is placed upon the insulated 
 table lying on the back. A urethral glass vacuum 
 electrodeps inserted and connected with the negative 
 side of the machine for the first few treatments. The 
 positive pole is grounded, then the spark gap increased 
 
46 THE CLASSIFICATION AND TREATMENT OF 
 
 up to the agreeable tolerance of the patient, perhaps 
 two. three, or four inches. The treatment should be 
 continued twenty minutes. Connected thus with the 
 negative pole it is supposed to have a greater effect in 
 rendering the organisms sterile and so not capable of 
 propagating. Two or three treatments daily for two 
 or three days, then the vacuum electrode might be 
 connected with the positive pole of the machine. Con- 
 nected thus, the current is much more stimulating and 
 has a greater effect in toning up the parts locally and 
 effecting a complete restoration to a normal physiological 
 condition. In this manner, it will be readily seen that 
 the activity of the organism is very easily destined 
 and secondary infection prevented which is a real cure. 
 Any number of such cases have now been treated and 
 with unvarying success. A recent case of over a 
 year's duration where the ankles and knees were 
 especially involved with an active urethritis and an 
 enlarged and tender seminal sac and prostate, a half 
 dozen treatments with rectal electrode and sparking 
 have done for the patient more than anything pre- 
 viously attempted. 
 
 If an established urethritis complicating a gonorrhea 
 or (as usual) its secondary infection, the joints may be 
 distended with fluid. Usually this will be a serous 
 fluid. This may be at once aspirated and if the joint 
 has been markedly distended, in other words, if there 
 has been a large quantity of fluid present, it may be 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 47 
 
 put in plaster of paris for a few days only for the sake 
 of removing the irritation due to the constant motion. 
 It should after a few days be removed and the joint 
 baked every other day. If an office case, and vibration 
 with the hard ball is possible, it should be done imme- 
 diately after baking. If the amount of fluid is not too 
 large, the knee may be bandaged with a stockinette 
 bandage for the sake of compression and baking should 
 be begun immediately. If possible the baking should 
 be followed by vibration and a hypersemia produced 
 by a glass vacuum electrode from a high frequency 
 coil. In an acute case with a destructive process 
 advancing rapidly, the joint may have to be opened 
 and the contents evacuated. The joint may then be 
 washed out very thoroughly with hot saline, spending 
 twenty minutes or more when it may be possible to 
 close the operating wound tightly and treat as above 
 described with no further trouble from the active pro- 
 cess. Some very bad cases, have behaved very nicely 
 in the writer's experience when treated in this way. 
 If on the other hand, it does not behave well, the joint 
 should be drained through and through so that every 
 portion may be very, very thoroughly irrigated daily or 
 twice daily until the infection is killed out. This 
 infection might be a gonococcus or some secondary 
 infection. As such a case slowly recovers (and it is 
 generally very slowly), the joint is stiffened by adhe- 
 sions and there will be a tendency to contractures ; 
 
48 THE CLASSIFICATION AND TREATMENT OF 
 
 hence the treatment must be planned to prevent these 
 complications. A posterior wire splint with the foot 
 piece at right angles so as to hold foot and prevent 
 contraction of the tendo Achilles, and extending up to 
 the fold of the buttock so that the knee may be placed 
 in a completely extended position, will prevent con- 
 tracture. Twice daily if possible this splint should be 
 removed and knee and ankle manipulated to prevent, 
 as much as possible, the formation of adhesions and as 
 soon as recovery has gone on far enough, the knee and 
 whole leg may be baked and the joints manipulated 
 immediately after; and just as soon as the patient can 
 be moved the various treatments as above described 
 should be instituted. As these treatments cannot yet 
 be obtained in most hospitals, it means that such 
 patients are better treated and recover faster as soon 
 as they can get to the office where such things are 
 available. The finding of the gonococci in the joint 
 fluid is rather rare although it must be present, and 
 would probably, if put through the guinea pig, be 
 demonstrated. If not found in the fluid, it would be 
 more apt to be found in the soft tissues around the 
 joint if in an open operation, some were taken for lab- 
 oratory examination. A recent case of gonorrheal 
 arthritis under the writer's care had fluid in both knees 
 and the gonococcus was actually found to be present 
 in the fluid. It was a very mild case. There is a 
 marked difference in the virulence of the organisms in 
 different cases. 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 49 
 
 The vaccine treatment has been left until the last. 
 It has been demonstrated by Dr. Wright that the 
 opsonic index would show what particular infection 
 was causing the trouble ; and then the vaccine should 
 be made from this particular organism taken from the 
 individual (autogenous vaccine), this to be followed by 
 subsequent injections, the dose to be graduated accord- 
 ing to the opsonic index. To establish this index and 
 to treat each time in accordance with it, has been 
 found impracticable so far. Autogenous vaccines, 
 however, may be used without going through all this 
 work. In gonorrheal joints, this method has been 
 used by various workers and although some of them 
 (not many) report that the results are encouraging, if 
 anyone who is treating a considerable number of such, 
 joints in accordance with the methods above given will 
 read any of the written reports of vaccine work, even 
 by the most enthusiastic of its exponents, and will 
 carefully analyze the results, taking into consideration 
 the time required to produce these few results reported, 
 such a worker will find these results when compared 
 with his own very disappointing and not to be com- 
 pared with what he is already getting. To begin with, 
 scientific workers frankly say that the recognition and 
 isolation of the gonococcic bacillus is very hard and 
 very, very disappointing. This throws very much 
 doubt on some other workers who apparently have no 
 such difficulty. This alone makes the preparation of 
 
50 THE CLASSIFICATION AND TREATMENT OF 
 
 an autogenous vaccine in this particular field an 
 extremely uncertain thing. As far as commercial vac- 
 cine is concerned, after using it faithfully on a line of 
 such cases in hospital (ward) cases, the results were 
 absolutely " nil." It must however be said that in this 
 experimental work absolutely no other treatment was 
 used, the urethritis itself remaining untreated in any 
 other way. Thus any result obtained would have been 
 due to vaccines. There are cases of such joint involve- 
 ment which recover very quickly. The writer's 
 experience with now and then a mild case with a mod- 
 erate effusion in the knee joint is that they never give 
 any further trouble after a single aspiration and a few 
 bakings (hospital Avard cases). If vaccines (commercial) 
 had been used, the result might have been attributed 
 to them. Such a case, by the way, would probably 
 have no urethritis. The use of vaccines then in the 
 writer's opinion should be confined to autogenous, and 
 if used at all would come in on the very chronic cases 
 which resist all treatment and then should be used in 
 conjunction with some of the other methods. In such 
 a case the chief and crippling infection would almost 
 always be the secondary and not the primary or 
 gonococcus. Such a case would almost always be 
 dependent on the seminal sac and the treatment should 
 be planned to attack the focal point as well as the 
 joints, even though vaccines should be used. Some 
 old chronic cases of this type are very resistant to any 
 
DISEASES COMMONLY KNOWN AS RHECJxMATISM. 5 ] 
 
 and all kinds of treatment and no method can yet 
 report one hundred per cent of cures to say the least. 
 An extremely interesting case of such a type presented 
 itself at the clinic one day. Most of the joints of the 
 body were involved and had been for many months. 
 A careful history and examination revealed infectious 
 arthritis with a chronic urethritis and a tender and 
 swollen seminal sac and enlarged and tender prostate. 
 The patient said that he thought he knew what his 
 trouble was much better than almost all of the doctors 
 whom he had consulted because they all persisted in 
 calling it rheumatism and giving him medicines which 
 upset his stomach, thus spoiling his digestion and 
 doing him absolutely no good. He said he was certain 
 his trouble was all due to gonorrhea and that treat- 
 ment which had done him more good than anything 
 else had been in one city where the doctor had inserted 
 in the urethra a glass vacuum electrode and gave him 
 electricity in this way. Here was, as can be seen, a 
 case of gonorrheal arthritis and only one man out of a 
 great many had known the best way to treat it. This 
 corroborates very nicely what has been written above. 
 Infections following some of the infectious diseases 
 are also still called rheumatism, but by what stretch of 
 the imagination it is impossible to know. It is not un- 
 common for the grippe to create joint disturbance. A 
 recent case was that of a young woman who had an at- 
 tack of the grippe and on the second or third day the 
 
52 THE CLASSIFICATION AND TREATMENT OF 
 
 wrist and hand became swollen, tender, and painful. 
 There was no suppuration so that it must be put down 
 as a toxic arthritis. Another case was that of a woman 
 who in November, 1909, had a " quinsy sore throat." 
 It was not opened but slowly subsided after two or 
 three weeks. The last of December, 1909, or first of 
 January, 1910, there was an attack of grippe and 
 early in the disease multiple joints were involved. 
 Each of these cases had been diagnosed as rheumatism 
 but of course in the light of a careful history, such a 
 diagnosis falls to the ground. 
 
 As remarked above, pneumo-coccic joint involvement 
 is not very common. A recent case of infectious ar- 
 thritis of the knee following a pneumonia is very inter- 
 esting. The process became so destructive and the 
 general systemic absorption so great that amputation 
 became necessary as a life saving measure. The 
 stump now has a discharging sinus from which the 
 pneumococcus has been isolated and autogenous vac- 
 cines are being used in treatment, but so far with no 
 effect. More surgery is undoubtedly in sight. The 
 infectious arthritis which is most common is one where 
 the joints have been involved more slowly, with acute 
 exacerbations at intervals. The knees or fingers or 
 both are apt to be involved at first, and as the process 
 continues the joints involved become more and more 
 damaged and other joints become attacked. Sometimes 
 the very first beginning of the trouble may be an acute 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 53 
 
 attack which gives the appearance of being an acute 
 articular rheumatism, but it either subsides in all the 
 joints with a not quite complete recovery or else the 
 joints subside leaving one joint, less often two, as the 
 storm centre in which trouble continues and demands 
 careful treatment. In the acute onset, the fever is 
 high but in the slowly advancing type there is also a 
 temperature and an increased pulse rate showing the 
 systemic septic absorption. When all other avenues 
 of absorption are eliminated, the abdominal viscera 
 must be examined carefully as it is from these that 
 the trouble arises. As before mentioned, in women 
 more especially because of faulty corsets, the abdomi- 
 nal contents are pushed downward and the tighter the 
 lacing and smaller the waste line, the greater is the 
 sagging tendency. In consequence there exists a back- 
 ing up of the intestinal stream with its fermentation 
 and formation of bacteria and toxines and absorption 
 into the general system (systemic poisoning), and lastly 
 joint (toxic trouble). Looked at in this larger way, 
 it at once becomes evident that salicyl soda, iodide of 
 potash, colchicum, etc., can do no good whatever. Sal 
 soda and aspirin may relieve pain, but it cannot touch 
 the cause of the trouble except as it may, in a very mild 
 way, be an intestinal antiseptic. Intestinal antiseptics. 
 Beta Naphthol and Salol, have relieved some cases but 
 only temporarily, as it must be evident with the above 
 explanation that the basic reasons still exist for a con- 
 
54 THE CLASSIFICATION AND TREATMENT OF 
 
 tin nance of faulty digestion and faulty assimilation. 
 To attack this condition the poison already in the sys- 
 tem must be eliminated and its manufacture stopped. 
 Both of these objects may be obtained in the great ma- 
 jority of cases but not in all as yet. The sagging ten- 
 dency may be limited in the first place by making the 
 corset extension (as before described) so that it shall 
 support the abdominal walls from the umbilicus to the 
 pubes, thus holding up (not pressing down) the abdom- 
 inal contents. An important thing to remember in ad- 
 justing any abdominal support to a corset is that the 
 middle section at the waist line must be a little looser 
 than the lower section so that there will be some space 
 for the viscera to go when they are raised. Having 
 thus supported the abdominal contents; they must be 
 stimulated to do their physiological work. In the first 
 place, what is put into them must be prepared in a 
 physiological way by proper mixing with saliva as de- 
 scribed before. Then active stimulation may be best 
 supplied by vibration. The hard ball on the spine 
 stimulates the nerve centres. The soft brush on the 
 stomach and intestines and the hard ball on the ab- 
 dominal lymphatics stimulates all these organs. Let 
 me also reiterate that the liver is an extremely im- 
 portant organ standing between the intestines and the 
 general circulation to filter out the poisons. This is 
 stimulated in a wonderful way by the soft brush over 
 the liver area, front and back. This also stimulates 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 55 
 
 the flow of bile. It is truly remarkable at times to see 
 indigestion of both stomach and intestines which have 
 been treated with no benefit by the best of medical 
 men in probably the most careful (drug) manner slowly 
 yield and get entirely well and also the joint trouble 
 improve " pari passu." Stimulation applied in this 
 manner results in an increased tone to the muscular 
 walls of stomach and intestines and this results in tak- 
 ing up of the slack to a certain extent and a stronger 
 muscular activity in the digestive movements. The 
 various fluids are also in this way stimulated so that 
 they are secreted more copiously and more rapidly. In 
 this way it is fairly easy to understand how a better 
 and better " tone " is obtained and how a more and 
 more physiological digestion takes place. Hence it 
 must also result in a diminution even to complete dis- 
 appearance of fermentation and formation of bacteria 
 and toxines. In cases where constipation is a serious 
 factor in the backing up of the intestinal stream, al- 
 though drugs may be used to produce evacuations, the 
 thing to be desired is to get the tone of the muscular 
 walls so improved that they work once again from the 
 stimuli which are provided in nature's own way. This 
 will be spoken of again in the section on the X-ray 
 study on abdominal viscera when the " rationale " of 
 the treatment will be shown still more clearly. This 
 being the cause and the cause thus removed, the con- 
 sequent joint trouble must disappear. All of this takes 
 
56 THE CLASSIFICATION AND TREATMENT OF 
 
 time. — in many cases months. And at the same time 
 that the treatment is begun, the joints themselves 
 must receive attention in order to cause the swollen 
 tissues (infiltration) to become contracted and restored 
 to a normal physiological condition. Elimination must 
 also be promoted. Elimination is of necessity very 
 markedly improved through the intestinal canal, and 
 it often happens that an obstinate case of constipation 
 is cured by this treatment just described. This means 
 a great deal by way of elimination. In cases where 
 the hot air baths are used, usually on the lower ex- 
 tremities, the sweating results in a local elimination of 
 toxines through the skin. 
 
 In cases where multiple joints are involved, the best 
 results are obtained by the all over electric light baths. 
 The effect here is produced by radiant heat and is 
 one of marked stimulation to the whole nervous sys- 
 tem. The bath used by the writer consists of a hun- 
 dred incandescent lamps, so arranged that they all 
 throw their light on the patient who lies nude upon 
 a couch. All these lamps are in circuit with a regular 
 theatre dimmer (rheostat) so that all the lights are 
 going all the time and the intensity may be graduated 
 from the lowest to the greatest. As the rays of light 
 impinge upon the cutaneous surface, there results a 
 stimulation of the nerve endings. As the rays of light 
 penetrate different structures to different depths, there 
 is a point where each ray is absorbed and at this point 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 57 
 
 work is done, just the nature of which is perhaps not 
 accurately known. Any way, at the point of absorp- 
 tion the energy is transmitted to the living cell or or- 
 ganism, and it is a known fact that the result is a stim- 
 ulation in such a way that the local processes tend to 
 a more normal condition. A first bath should not con- 
 tinue for much more than ten minutes. Subsequent 
 baths may be longer, up to twenty minutes, beyond 
 which it should almost never extend. Toward the end 
 of the bath, sweating begins and in this way elimina- 
 tion is increased. The patient is in the bath all over, 
 except the head which is left out. It is of great im- 
 portance to keep the head cool by an ice cap or elec- 
 tric fan or both. After the light bath, a cool water 
 bath, sponge or shower, is then given followed by a 
 brisk rubbing with a turkish towel. This leaves the 
 patient feeling fine. The general vibration treatment 
 (as before described) is then given with patient lying 
 upon the table. By these methods the poisons are 
 eliminated and vibration and the other physical meth- 
 ods stimulate the physiological processes the stomach 
 and intestines being stimulated to properly perform 
 their work. The liver is also stimulated to function- 
 ate properly with the result that bacteria and toxines 
 cease to be manufactured. Lastly the tissues around 
 the joints are stimulated by the vibration and the va- 
 rious electric modalities as above described, so that the 
 infiltration is reduced and the normal in size and struc- 
 
58 THE CLASSIFICATION AND TREATMENT OF 
 
 ture is restored. Whatever damage has been done to 
 cartilage, by way of destruction, cannot be replaced, 
 but outside of this, normal conditions can be restored 
 very largely. 
 
 There is one type of infectious arthritis which has 
 attacked children very largely. It is a severe infec- 
 tion and there is usually glandular enlargement and 
 the spleen is apt to be enlarged. 
 
 This was first described by Dr. Still and hence the 
 name Still's disease has been applied to it. In the 
 light of modern knowledge and in accordance with 
 what has been written, this condition is one of very 
 definite infection. Any one who has followed such a 
 case medically appreciates that the disease continues 
 without being in the least affected by the so-called 
 medical treatment. If, however, treatment is applied 
 in accordance with the principles just elucidated it 
 will be found that the disease may be very much mod- 
 ified in its course and the patient usually put upon a 
 solid foundation for the future. 
 
 In all classifications gout has a place, as it is consid- 
 ered a disease all by itself. The treatment here, as in 
 preceding types, should be in accordance with the 
 etiology. Now gout has for years been treated upon 
 the uric acid theory, and as everybody now knows uric 
 acid has nothing to do with causing it, but simply is a 
 phenomenon or symptom accompanying an attack. In 
 a typical case, which has existed for a sufficient length 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 59 
 
 of time, tophi exist in the ears or about the joints 
 which consists of urate of soda deposits. When this 
 stage has been reached the diagnosis is easy, but in 
 early cases, it may be difficult or even impossible. 
 The attacks come on at intervals when the joint or 
 joints are swollen, red and extremely painful. Joints 
 may become thus involved following an acute intestinal 
 disturbance and they might also be the result of auto- 
 infection. The great toe joint has been considered es- 
 pecially liable to attack, but any joint may be involved. 
 It is simply a matter of history in such cases, that 
 there may be recurring joint attacks and attacks fol- 
 lowing acute intestinal disturbances which have been 
 called gout, but as the years go by, no urate of soda 
 deposits appear and so most of them are really auto- 
 infections with acute exacerbations. Take the cases 
 that are finally susceptible of positive proof as gout. 
 The X-ray studies will show in some of the joints, con- 
 ditions typical of the classes just described. Hence it 
 is fairly demonstrated scientifically that gout is due to 
 faulty physiology somewhere, often resulting in attacks 
 of acute auto-infection. The following is a case in the 
 writer's experience. A man of forty had a second 
 attack of infectious arthritis with infiltration of the 
 soft structures of the finger joints forming the spindle 
 shaped swelling in all of the fingers. An X-ray pho- 
 tograph showed the bones normal and the process 
 confined to the soft parts. As the process progressed 
 
60 THE CLASSIFICATION AND TREATMENT OF 
 
 and fluctuation appeared, the fluid was aspirated with 
 a hyperdermie needle and the microscope revealed 
 urate of soda crystals. Hence a true case of gout but 
 clinically an infectious arthritis which it would seem 
 demonstrates the idea above expressed of faulty phy- 
 siology (metabolism) and auto-infection. With this 
 description the treatment to be logical would be that 
 just described under infectious arthritis and the results 
 of treatment would completely bear this out. Elimina- 
 tion of poisons induced by all-over electric light baths, 
 all-over hot air baths and physiology stimulated by 
 vibration to spinal nerve centres, to the liver area, to 
 the stomach and abdomen, and lastly to the local tis- 
 sues (joints) stimulated by vibration and by the D'Ar- 
 sonval current. The method of eating is extremely 
 important. Add to this physical exercise enough to 
 keep the weight at the proper point and future attacks 
 will be prevented. One method of treatment where 
 the joints are painful described by French writers is 
 the ionic treatment, that is sending in the ion of Lithium 
 by means of the constant current. A small bath tub 
 for the feet or hands according to the case, is prepared 
 with the following proportions : Chloride of Lithium, 
 20 grams; distilled water, 1000 cc, and sufficient caus- 
 tic Lithium to render alkaline. This solution is con- 
 nected by carbon electrodes to the positive pole of the 
 constant current. Another large carbon electrode, 
 covered with twenty-four or thirty thicknesses of 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 61 
 
 gauze saturated with saline solution, is bandaged in 
 close contact with the skin on the back of the neck, or 
 some neutral point, and connected with the negative 
 point of the source of supply. The current is then 
 slowly turned on until it is one hundred and fifty or 
 two hundred milliamperes, the seance continuing 
 thirty to forty-five minutes. The ion of Lithium is 
 thus driven into the tissues of the affected joints and 
 there is formed a urate of Lithium which is very sol- 
 uble. These seances are repeated three times weekly 
 and should be followed by an alleviation of the pain 
 with diminished suffering and disappearance of the 
 attack. This method gave relief and cure of the attack 
 in the case referred to above and an alleviation of 
 symptoms in one other case. 
 
 Early in the paper the method of eating was discussed 
 and now a word regarding what kind of foods to eat. 
 In former times a great deal was written about not 
 eating meat and restricting the diet very markedly. 
 This was an error which in the light of more modern 
 investigation has been corrected. An editorial writer 
 in the Journal of the American Medical Association for 
 November 30th, 1907, says : " It is striking that the 
 laying up in the body of proteins is, save in the grow- 
 ing young, accomplished only under exceptional con- 
 ditions and that the body seems to have no such place 
 for the storage of proteins as it has for fats and car- 
 bohydrates. The amount of breaking down and build- 
 
62 THE CLASSIFICATION AND TREATMENT OF 
 
 ing up of tissue cells that we can detect seems to be 
 far too small to account for the amount of proteins 
 that is required and yet so far as we know, this is the 
 only purpose for which proteins are indispensable. 
 We know that the characteristics of different cells and 
 tissues depend chiefly or solely on their proteins and 
 the proteins in turn differ from one another in the 
 proportion of the various constituent amido acids that 
 they contain. Each class of animals has cellular por- 
 teins and blood proteins specific for its own kind as 
 shown by precipitin tests and it is possible that the 
 proteins of every individual differ in some respects 
 from those of every other individual. Consequently 
 the conversion of the multitudinous varieties of pro- 
 teins taken with the food into the constant proteins of 
 the individual cells must require a most complete 
 reconstruction of the food proteins. In the intestines 
 the proteins are split into their elementary constituents, 
 the amido acids, through the action not only of the 
 trypsin but especially by the erepsin of the intestinal 
 mucosa. These amido-acids are resynthesized into 
 proteins and it seems probable that this process is 
 accomplished by the cells of the intestinal walls and 
 the proteins resulting are those that are found in the 
 blood serum. The excess in amido acids that are fur- 
 nished in this way by the food and which cannot be 
 used by the organism for the building up of its own 
 type of proteins are, it is believed, deprived of their 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 63 
 
 nitrogen by the action of certain enzymes and the 
 nonnitrogenous residue may then be available for fur- 
 nishing heat and energy. By this means the cells are 
 provided by the blood with protein supplies of prac- 
 tically constant composition and the intestinal wall 
 may be looked on as the guardian of the chemical 
 specificity of the individual. In this case it is easy to 
 imagine that the intestinal wall might, under certain 
 conditions, be unable properly to synthesize serum 
 proteins and from this might result serious disturbances 
 in general metabolism. It will be seen from this 
 description that there goes on in the intestinal wall a 
 selective synthesis by which proteins and the serums 
 are utilized by the different cells of the body since the 
 proteins of these cells contain proportions of the 
 various amido acids different from those of the serum 
 proteins. In the light of this kind of physiology, it is 
 at once evident that the ordinary metabolism experi- 
 ments are erroneous and that it is the mixed diet of 
 the table that is most advantageous for the deficiencies. 
 Certain amido acids of one protein may be replaced by 
 a relative excess of the same amido acids in some other 
 protein." 
 
 This shows the importance of the intestinal wall and 
 the extreme importance of keeping up to normal its 
 physiological activities and also demonstrates the fact 
 that the diet must be a mixed one, also that as the old 
 idea demands that there must be restriction in one 
 
64 THE CLASSIFICATION AND TREATMENT OF 
 
 direction and greater liberty in another, there must 
 result a disarrangement of the stream which is con- 
 stantly supplying the demands all along its course. 
 Hence it is pretty conclusively proven that the mixed 
 diet in eating as already described is the proper phy- 
 siological thing. If this is done not only will less meat 
 be eaten, but less of everything will be eaten to the 
 permanent benefit of the individual. 
 
 After discussing these classes of joint trouble and 
 their logical treatment, it must not be forgotten that 
 there is as yet an acute inflammatory articular joint 
 trouble which still remains as an entity and called 
 acute rheumatism. It has been claimed that a bacillus, 
 called the rheumatic bacillus, has been isolated and 
 similar joint disturbances produced by injecting the 
 same into animals ; but these experiments have not 
 been duplicated and so it is probably an infectious 
 arthritis with the organism not yet proved. Anyway 
 the disease involves the joints, two or three being 
 attacked, then others becoming involved in turn, and 
 when the last are attacked the first ones are apt to 
 have subsided. This disease runs its course in four, 
 six, or eight weeks and there should be complete 
 recovery. If one or more joints remain not quite com- 
 pletely recovered, it means that in due course of time 
 there may be another attack or that this initial explo- 
 sion is to be followed by gradual progressive involve- 
 ment of other joints. In other words this condition 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 65 
 
 would then fall under one of the classes just mentioned, 
 that is infectious arthritis. In a typical attack of the 
 acute type, or acute articular rheumatism, it is a well- 
 known fact that salicylates have a wonderful effect 
 upon pain and temperature, but in hospital (ward) 
 cases a much more beneficial effect has been obtained 
 by the writer when the patient was put into an all- 
 over hot air bath which was followed by a gentle rub- 
 bing. It is remarkable to see pain relieved in this way 
 in a very few minutes when it would require hours if 
 the salicylates were depended upon. If salicylate or 
 aspirin are used it must not be forgotten that the heart 
 is much depressed and needs stimulation. If the case 
 is in a private house the hot water (tubj bath is a fairly 
 good substitute for the hot air. The patient may be 
 gently laid in the tub in just warm water, then the hot 
 water allowed to slowly flow in. The first bath should 
 be only fifteen or twenty minutes, and perhaps never 
 more than one-half or three-quarters of an hour. Con- 
 tractured joints will slowly straighten and pain disap- 
 pear in a most gratifying manner. In the acute stage 
 this may be repeated two or three times daily, the last 
 one being given in the evening, and the patient all 
 wrapped up warmly, and it is surprising to see them 
 sleep fairly well without narcotics or salicylates. With 
 recovery setting in contractures must be avoided by 
 gentle massage and manipulation and even splinting or 
 plaster for a very short time if necessary. 
 
6(5 THE CLASSIFICATION AND TREATMENT OF 
 
 Faulty physiology of the intestines has already been 
 referred to and sagging of all the viscera and the im- 
 portance of their support by an abdominal belt men- 
 tioned. X-ray studies of the position and malposition 
 of the abdominal contents have been made by various 
 X-ray workers. I will not give all of their work but 
 simply refer to the works of two or three because they 
 happen to cover the points which are of importance in 
 this paper. Dr. Henry K. Pancoast contributed a 
 paper entitled "A Study of Gastroptosis from the Rad- 
 iographic Standpoint" in International Clinics, vol. 4, 
 17th series: and Dr. G. E. Pf abler contributed an 
 article entitled " Physiological and Clinical Observa- 
 tions on the Alimentary Canal by means of the Roent- 
 gen Rays" in the Journal of the American Medical 
 Association, December 21st, 1907; and Dr. Guido 
 Holzknecht also contributed a very interesting article 
 entitled " The Normal Peristalsis of the Colon " in 
 Miinchiner Medizinische Wochenschrift for November 
 23rd, 1909. Regarding the sagging of the abdominal 
 viscera the above writers with many others have con- 
 tributed some valuable X-ray studies showing that 
 these organs occupy quite different positions normally, 
 than anatomists have thought. Pancoast and Pf abler 
 show that the stomach might be anywhere in the 
 anterior portion of the abdomen from above the urn- 
 bilicis to a position practically resting on the pubes. 
 
 The article of Dr. Pancoast has sixty-seven figures 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 
 
 67 
 
 showing different positions of the viscera. Only three 
 of his diagrams will be reproduced. 
 
 Figure 19. 
 
 Fig. 1. — This shows Dr. Pancoast's idea of the nor- 
 mal stomach, but in the light of studies of my own in 
 healthy children I should consider this too high. 
 
68 
 
 THE CLASSIFICATION AND TREATMENT OF 
 
 Fig. 15. — This shows the ptosis of the stomach, 
 liver and also the spleen. 
 
 Fig. 19. — This shows in addition to the ptosis of 
 the other organs an extreme ptosis of the transverse 
 colon. 
 
 The above is a drawing made from Dr. Pfahler's re- 
 production and shows his idea of the normal position 
 of the stomach and intestines. 
 
 Pfahler considers that in a normal stomach, the pyl- 
 orous is about one inch above the umbilicus and what 
 seems to be very logical, also, that it is not so much 
 the position of the stomach as the motility. In other 
 words, if the organs are performing their functions 
 properly, there should be no symptoms, but it is under 
 these conditions that dilatation and atony takes place 
 and that trouble begins. It is also in these conditions 
 that the stimulation and toning up is accomplished, 
 so much more effectively by the methods before de- 
 scribed (physical therapeutics) than by medication. 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 69 
 
 The important lesson to be learned from these X-ray 
 studies, however, is that the position of the abdominal 
 viscera is different in the living than .we have been 
 taught from the dissection on the cadaver and from 
 the recognized books on what might be called " dead " 
 anatomy. Now with the coming of "living" anatomy 
 as shown actually "in situ" by the X-ray it is an en- 
 tirely different proposition. As will be noticed in the 
 figures of Pancoast and Pfahler the stomach is more 
 nearly straight up and down hanging in the anterior 
 part of the abdomen like a bag and hanging very much 
 lower than there was any idea of, the normal position 
 being down near the upper level of the pelvis (ilia). 
 This position which at first seems to be away down at 
 the bottom of everything must be now recognized as 
 a " new " and " living " normal. The transverse colon 
 and the "flexures" also become drawn or pushed 
 downward and it would seem thus far in the new X-ray 
 study of these conditions that the colon is really more 
 displaced from normal than the stomach. In all these 
 cases unless there is a marked displacement it would 
 seem that Pfahler' s conclusions were the correct ones, 
 that it is not so much the ptosis of the organs as it is 
 their motility. In other words if the physiological 
 work of these organs is all right a certain amount of 
 leeway may be allowed regarding their position. In 
 sagging organs there is more or less atony and conse- 
 quent sluggishness of action, and then the important 
 thing is to so stimulate them that such action may be re- 
 
70 THE CLASSIFICATION AND TREATMENT OF 
 
 stored. It is just this problem that must be solved and 
 that is at the bottom etiologically in chronic joint diseases. 
 The paper contributed by Holzknecht is the latest 
 and most important communication regarding the 
 intestines and their method of action. I am simply 
 repeating nearly verbatim a part of his extremely 
 interesting message. He calls attention to the fact 
 that radioscopy has shown that peristalsis of the 
 oesophagus consists in an annular contraction some 
 centimeters in length which follows the contraction of 
 the pharanx and forces the bolus along the course of 
 the gullet, also that the normal peristalsis of the fun- 
 dus and the antrum and a terminal contraction 
 (pylorus). The chyme in the small intestine is also 
 propelled by a series of short jerks. Then he has per- 
 sonally observed the abdominal viscera in over one 
 thousand fluoroscopic examinations and with two 
 exceptions has always found the large intestine immo- 
 bile. In these two cases, however, twenty-four hours 
 after a bismuth meal, the following interesting phenom- 
 enon took place. The segmentations in the transverse 
 colon disappeared, the outlines of the intestines becom- 
 ing perfectly smooth like a ribbon with parallel bor- 
 ders and the contents were with equal rapidity forced 
 forward into the descending colon which had been pre- 
 viously empty. The time occupied in this whole move- 
 ment was estimated at about three seconds. Just as 
 soon as this transference was completed the h austral 
 segmentation reappeared and the transverse colon re- 
 
DISEASES COMMONLY KNOWN AS KMKUMATISM. 
 
 71 
 
 mained empty. The patient was entirely unaware of any 
 movement. Experiments in Holzknecht's hands show 
 that kneading, massage, etc., had no effect in the loco- 
 motion of the intestinal contents, while on the other hand. 
 Groedel has observed that vibratory massage hastens 
 the progression of the contents. Normally this move- 
 ment, involving about one-third of the intestine each 
 time, takes place about three times in twenty-four hours. 
 In the interim, it is held in the haustral segmentation 
 perfectly immobile, where absorption takes place. 
 
 Figure 3. 
 
 Figure 4. 
 
72 THE CLASSIFICATION AND TREATMENT OF 
 
 Drawings made from Holzknecht's figures are also 
 here reproduced. 
 
 Fig. 1. This shows (24 hours after the bismuth 
 meal) the colon completely rilled, up to the splenic 
 angle. The sigmoid flexure is also completely filled 
 and all of these portions when observed in the fluoro- 
 scope are immobile. 
 
 Fig. 2. — This shows the observation when the seg- 
 mentations in the transverse colon suddenly disap- 
 peared and the intestine flattened out, the ascending 
 colon remaining the same. 
 
 Fig. 3. — This shows the observation when the 
 transverse colon had been suddenly emptied into the 
 descending colon and then as in Fig. 4, the haustral 
 segmentations immediately reappeared in the whole 
 length of the intestine at the same instant. 
 
 All of this throws light on so-called faulty physiology 
 with the sagging or ptosis of abdominal viscera, its 
 resulting atony and interference with intestinal 
 mobility, first causing fermentation, bacteria, toxines, 
 and absorptions, with consequent joint involvement. 
 This is of importance in constipation. This sudden 
 transference of the intestinal contents of one section 
 to another may be the normal mechanism ; and if so, 
 further study will demonstrate it. While the intestine 
 remains immobile with the contents held tightly in the 
 haustral folds, the juices of the intestine are given out 
 and at the same time whatever is of value in that parti c- 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 73 
 
 ular stage of digestion is absorbed. When the intestine 
 suddenly straightens out and the contents are forced 
 along, it must be done by muscular contraction, and 
 this muscular contraction takes place as the direct result 
 of some physiological stimulus. This stimulus may be 
 due to a certain degree of osmosis which has taken 
 place or the attainment of a certain chemical reaction 
 due to a certain stage of osmosis. Hence it is that 
 vibratory massage to the spinal nerve centers, to the 
 abdomen, and to the muscular walls themselves is a 
 much more rational measure than massage or medi- 
 cation. This is borne out by the actual results of 
 treatment. This does not mean that cathartics are 
 no longer necessary. But it does mean that it is a 
 very logical treatment to get the entire physiology 
 to working properly. 
 
 Another important thing along nature's lines is 
 physical exercise. In many of these chronic joint dis- 
 ease cases, especially in women who are inclined to be 
 stout with the fat tissue predominating around the hips 
 and on the abdomen, physical exercise will reduce the 
 fat in these areas ; and, if the weight is kept down 
 below a certain point, the patient may remain perfectly 
 free from joint trouble. The exercises should be given 
 always at the office gymnasium under competent 
 supervision, and those to be preferred are in the 
 abdominal chair which directly calls into use the 
 muscles of the legs and abdomen, similar to bicycle 
 
74 THE CLASSIFICATION AND TREATMENT OF 
 
 riding. The rowing machine is another excellent 
 exercise. Standing erect with arms by the side and 
 chest expanded and alternately pulling up the lower 
 abdomen by voluntary muscular exertion and allowing 
 it to sag again, standing erect with arms extended over 
 the head, then stooping over forwards and touching 
 the toes with the tips of the fingers while the knees 
 are held straight, are excellent movements which assist 
 in removing fat from the abdomen. The heart is to 
 be looked out for and the patient watched and not 
 very much in the way of exercise done at home 
 especially in older adults, otherwise damage will result. 
 The important rule is that all this work should be 
 done under competent medical supervision. 
 
 It is along physiological (nature's) lines that treat- 
 ment should be administered in the chronic joint dis- 
 eases. It means building upon a perfectly safe and 
 solid foundation and then instructing patients how to 
 keep themselves in proper condition by methods of 
 right living, in this way insuring them perfectly 
 against not only the joint diseases under discussion but 
 probably against all chronic diseases outside of malig- 
 nant diseases and infection introduced from without. 
 
 As a result of this work it will be seen that the types 
 now pretty generally recognized are those originally 
 described by Goldthwait but the writer would classify 
 them a little differently. 
 
 Gout is very definitely shown to be due to faulty 
 
DISEASES COMMONLY KNOWN AS RHEUMATISM. 75 
 
 physiology and hence comes under auto-infection or 
 auto-intoxication. 
 
 Also in the observation of a number of cases of atro- 
 phic arthritis which have remained such for years, it 
 has been observed that attacks, (very mild at first) 
 come on, where the swelling takes place only to 
 shortly disappear, then later, redness and permanent 
 infiltration of soft structures with a more rapidly pro- 
 gressing process, thus placing this type also under 
 auto-infection or auto-intoxication. 
 
 Hence the classification most satisfactory to the 
 writer is the following : — 
 
 Villous Arthritis 
 
 . . >. f Atrophic Arthritis 
 
 Auto-miection i , . * i ■ • 
 
 I Hypertrophic Arthritis 
 
 i Infectious Arthritis 
 
 Auto-intoxication J 
 
 [ Gout 
 
 Fig. 1 and 2 is the same knee showing the calcified 
 tips of the villi "in situ" and also after removal. 
 
 Fig. 3 shows an atrophic arthritis in which the car- 
 tilage is atrophied, but it is to be noted that the bone 
 salts have been washed out so that the bones appear 
 very thin. 
 
 Fig. 4. A normal knee is presented for contrast 
 with Fig. 5 in which joint the cartilage is atrophied so 
 that the bones are in actual contact. 
 
 Fig. 6 shows a later stage of the atropic process 
 
76 CLASSIFICATION AND TREATMENT OF RHEUMATISM. 
 
 when the cartilage has practically disappeared and 
 bony anchylosis has actually taken place. 
 
 Fig. 7 shows the overgrowth of bone or hypertrophy 
 at the upper border of the patella and also along the 
 edges of the joint surface of the fermur. 
 
 Fig. 8 shows the two rows of joints in the lingers 
 with the cartilage atrophied and bone destruction 
 taking place. In the terminal joints the lipping of the 
 bone at the sides is apparent, thus showing the mixed 
 type. 
 
 Fig. 9 is the picture from a demonstrated general 
 infection with multiple joint involvement. 
 
 Fig. 10 shows the ultimate stage in an infectious 
 arthritis. 
 
 Fig. 11 shows a wrist joint involvement from a gon- 
 orrhoea. 
 
 Fig. 12 is interesting when compared with Fig. 14, 
 a gouty elbow, and also that one of the joints might 
 be considered (from the X-ray alone) a Charcot joint, 
 but here again is a case of known infection. 
 
 Figs. 13, 14, and 15 are all from one patient who 
 has a (demonstrated) gout. There were tophi in the 
 ears and he could write on the blackboard with the 
 fingers, there was so much urate of Soda deposited in 
 crystals. 
 
 Fig. 16 was also a demonstrated case of Charcot 
 joint in a man suffering from Tabes. 
 
Fig. i. Villous Arthritis. 
 Showing calcined tips of villi. 
 

 
 
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Fig. 4. Normal Space in Normal Knee Joint. 
 
Fig. 5. Atrophic Arthritis. 
 Demonstrated by diminution of space between bones. 
 
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Fig. 7. Hypertrophic Arthritis. 
 
Fig. 8. Atrophic and Hypertrophic Arthritis. 
 Mixed type. 
 
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Fig. io. Ankylosis of the Knee Joint Following 
 Infectious Arthritis. 
 
Fig. 15. Gouty Knee. 
 
Fig. 16. Charcot Joint. 
 
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 The classification and 
 treatment of diseases com- 
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 Annex 
 
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