No Preventive Prescription

For a man of 75, the commencement speaker at Kansas State University seemed remarkably spry. But under the erect military bearing, the painful truth was that former President Dwight Eisenhower has not fully recovered from the pains in his joints that put him in Washington's Walter Reed Army Medical Center little more than a month ago. Nor is he likely to--a frustrating situation that leaves him no worse off than countless other Americans over 50, who experience physical changes, often painful, involving their joints.

The catalogue of Ike's complaints is considerable: swollen and painful wrists and hands; a touch of arthritis in the left knee, presumably the result of an old football injury; bursitis in the left elbow, similar to some old trouble in his right shoulder. But neither for him nor his fellow sufferers is any preventive medicine effective. Indeed, it took Walter Reed's expert doctors weeks of tests before they could put the label "osteoarthritis" on their patient's wrist pains. After that, the prescription was as simple as the diagnosis had been painstaking: aspirin to ease the pain and a combination of rest with gentle exercises to free the joints. The doctors did not bother to order Ike to ease up on golf; they figured that if it hurt too much, he would simply stop playing.

Fossils & the Stone Age Man. The diagnostic term, osteoarthritis, is merely a modern and less accurate name for the degenerative joint disease that can be recognized in fossils of reptiles that died 100 million years ago and in the remains of Stone Age man. In ancient Egypt, the disease was no more a respecter of Pharaohs than it is of Presidents today. The Greeks supplied one name, arthritis (from arthron, joint, and itis, inflammation), but most victims of so-called arthritic conditions, like Ike, have little or no inflammation. More recent and precise terms are arthrosis and osteoarthrosis. Medieval physicians adopted another Greek term, rheumatikos (from rheuma, flow), because they thought the conditions resulted from a flow of noxious "humors" (fluids) into the joints.

Today it is clear that in most cases, arthritis and rheumatism are not single, definable diseases but names loosely applied to many disorders in and around joints. They make up a majority of the 83 related ills listed by an expert committee of the American Rheumatism Association, and the causes of most of them remain unknown.

Rheumatic disorders vie with the various heart diseases as a cause of handicapping illness, and they are second only to mental illness as a cause of lasting disability. They take a heavier toll of work days lost in industry than do accidents. Even so, total U.S. outlays for arthritis and rheumatism research come to little more than $15 million a year--as against $300 million poured down the drain in desperation for quack "remedies," ranging from diets to sitting in old uranium mines, from bee venom to honey and vinegar. The troubles are classified in four major groups.

sb RHEUMATOID ARTHRITIS, with an estimated 3,000,000 to 5,000,000 victims, is by far the most devastating of all rheumatic disorders because it is the worst crippler. For some unknown reason, it attacks almost three times as many women as men, with a peak incidence at age 35. A juvenile form, Still's disease, is now regarded as true rheumatoid arthritis; so is ankylosing spondylitis (arthritis of the spine), which has a predilection for young men.

In rheumatoid cases, the name arthritis is literally and hideously justified. There is acute and painful inflammation of several or all major joints, with eventual disablement. The cause remains unknown, despite long and intense research, though some authorities suspect an indirect effect of an infection.* Although good nutrition is important, there is no magic in any particular diet nor in any vitamins. There is no cure. The most widely prescribed and useful drug is still aspirin. Cortisone-type hormones are valuable in some cases, but must be used with great care because of side effects. The same is true of gold salts and phenylbutazone (Butazolidin). Indomethacin, a drug of a new chemical family, introduced last year as Indocin by Merck Sharp & Dohme, is about equally effective for certain patients and usually produces less severe side effects. Extravagant claims of miraculous relief from DMSO (TIME, Sept. 17, 1965) have not been substantiated, and research with this protean substance has been virtually halted by FDA order. Physiotherapy is of utmost importance in successful treatment.

sb OSTEOARTHRITIS is not primarily inflammatory, though a degenerative joint may feel warm to the touch and have its pain relieved by fever-suppressing drugs, aspirin and cortisone. Cecil and Loeb's classic Textbook of Medicine notes a "baffling and fascinating" paradox: "A patient with advanced degenerative joint disease may have few or no complaints, whereas another patient showing only minor changes may be most uncomfortable." The most characteristic symptom is an aching pain, worst when the joint is used energetically, and usually relieved by rest. In another paradox, a common complaint is stiffness after rest or sleep, with pain easing gradually as the joints are flexed.

Everyone who lives long enough suffers to some degree from this form of rheumatism. Wear and tear increase its severity, which explains why farmers, manual laborers and assembly-line workers are more likely than sedentary professional workers to get it early in life. The process begins in the cartilage and membranes lining and surrounding the joints. Losing their original glassy smoothness, they become rough and fibrous; clefts and pits appear, followed by erosion, until the cartilage is worn away and bone rubs against bone, causing creaking and crackling in the joints --and pain.

Treatment begins with aspirin (followed in some cases by indomethacin or phenylbutazone but no hormones) to ease the pain, then heat, applied by moist packs, and physiotherapy. Obese patients with painful knees and hips must diet to reduce the weight on their grinding joints. Diet is not otherwise a factor. Climate may be, and University of Pennsylvania researchers have confirmed an old wives' tale: patients with "rheumatics" do indeed feel worse when the barometer is going down and the humidity is going up. For some, a warm, dry climate may be helpful, while cold is better for others.

sb NONARTICULAR RHEUMATISM is a classification containing a host of complaints. The primary trouble lies not in the joints but in the attached muscles and tendons. The common diagnosis of fibrositis is in disrepute, and many doctors are convinced that it is a physical symptom in patients whose real trouble is neurotic. It is true enough that an anxious neurotic is likely to hold himself so stiff and tense that he will develop pain in muscles and joints, but one way of distinguishing between physical and psychogenic complaints is usually revealing: observe the effects of environment. Basically physical ills will ebb and flow with climate and weather changes; psychoneurotic troubles vary with alterations in the patient's emotional state or "internal climate."

Bursitis is perhaps the most common and certainly the best-known of the non-articular forms. Bursae are closed sacs, containing something like brake fluid, which serve as roller cushions for overlying tendons or muscles. Nature has placed them in many parts of the body, and wherever they are, they may get inflamed, fill up with a chalky goo, or become excruciatingly painful when the goo petrifies and forms sharp deposits like stalactites in caves.

Related conditions are inflammation of a tendon sheath (tenosynovitis), inflammation of the tendon itself or surrounding tissue (tendinitis and peritendinitis), inflammation of bony projections at the knee and elbow (epicondylitis), and muscle inflammation (myositis). Most of these disorders result from abnormally intensive or prolonged use of certain muscles or joints.

sb TRAUMATIC ARTHRITIS runs a long gamut:

Housemaid's (or nun's or rug cutter's) knee: inflammation of the bursa in front of the kneecap.

Mailman's (or nurse's) foot: gradual falling of the foot's arch, with pain from unnatural changes in the joints' bearing surfaces.

Soldier's (or policeman's) heel: bursitis at the Achilles' tendon.

Glass (or pitcher's or golfer's) arm: inflammation in the bursa under the sub-deltoid muscle covering the shoulder.

Soldier's (now also skeet shooter's) shoulder: tendinitis or bursitis from repeated recoil of rifle or shotgun.

Golfer's wrist and ballet dancer's ankle: tendinitis.

Tennis elbow: caused with almost equal frequency by tendinitis, bursitis and epicondylitis, and sometimes by a combination of them.

Football (or soccer) knee: deranged or dislocated cartilage.

Chauffeur's shoulder: osteoarthrosis from shifting stiff gears (eliminated for most drivers by automatic transmissions but not for over-the-road truckers or operators of heavy equipment).

Driver's thigh: sciatic neuralgia from pressure on the thigh during continued immobility of the gas-pedal foot.

Riveter's wrist (or jackhammer joints): osteoarthroses from the constant pounding of those infernal racketing machines.

Weaver's bottom: bursitis of the ischial tuberosities (meaning the rearmost bones in the rump).

For all these conditions there is a variety of treatment, mostly of unpredictable value. And as if arthritis and rheumatism were not confusing enough, the same patient will respond at different times in opposite ways to the same treatment for the same condition in the same joint. Treatments most widely used, besides aspirin, are: heat (wet packs are usually preferred), diathermy, ultrasound, X rays, injections of hydrocortisone directly into an inflamed bursa or joint capsule, exercises and other forms of physiotherapy, a change of occupation, and--always--rest.

* As is the case in rheumatic heart disease, which is the result of rheumatic fever, which is in turn the result of "strep throat," infections caused by certain strains of streptococci. Rheumatic heart disease is now largely preventable with penicillin.

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