Rheumatism In The Medical Casebook

 

This Week

Following on from last week’s sample chapter on Rheumatic Fever, this week we’ll take a look at the similarly named Rheumatism. These are largely unrelated conditions, and also little to do with the modern diagnosis of Rheumatoid Arthritis. Even in Victorian times, rheumatism was a rather vague diagnosis, though still an interesting one to look at.

 

Rheumatism 

Rheumatism + Sherlock

I was able to find 3 references to rheumatism in the Sherlock Holmes stories.

It first appears in “Silver Blaze”, a Sherlock story that reads like a Dick Francis novel. Back in chapter 4 we encountered the use of a cataract knife in the story. We then learn how the knife was used.

“You cannot have forgotten the singular knife which was found in the dead man’s hand, a knife which no sane man would choose for a weapon. It was, as Dr Watson told us, a form of knife which is used for the most delicate operations known in surgery. And it was to be used for a delicate operation that night. You must know, with your wide experience of turf matters, Colonel Ross, that it is possible to make a slight nick upon the tendons of a horse’s ham. And to do it subcutaneously, so as to leave no trace. A horse so treated would develop a lameness, which would be put down to a strain in exercise or a touch of rheumatism, but never to foul play.” 

The dead man is John Straker, the horse’s trainer. Holmes works out that Straker has been trying to nobble the horse in an attempt at race-fixing. But instead the horse kicks the trainer in the head and kills him. 

As an aside [as it would be shame not to include it], “Silver Blaze” also contains what is probably the most famous piece of Sherlockian deduction. It is used by Holmes to work out that Silver Blaze has been removed from the stables by someone known by the dog.

“Is there any point to which you would wish to draw my attention?”

“To the curious incident of the dog in the night-time.”

“The dog did nothing in the night-time.”

“That was the curious incident,“ remarked Sherlock Holmes.

We then meet the condition again as something Holmes suffers from, in the preface to the “His Last Bow” collection of short stories.

The friends of Sherlock Holmes will be glad to learn that he is still alive and well, though somewhat crippled by occasional attacks of rheumatism. He has, for many years, lived in a small farm upon the downs five miles from Eastbourne, where his time is divided between philosophy and agriculture. During this period of rest he has refused the most princely offers to take up various cases, having determined that his retirement was a permanent one. The approach of the German war caused him, however, to lay his remarkable combination of intellectual and practical activity at the disposal of the government, with historical results which are recounted in His Last Bow. Several previous experiences which have lain long in my portfolio have been added to His Last Bow so as to complete the volume. John H Watson, M.D.

Finally, we return to “The Disappearance Of Lady Fairfax”, which we met in our Dementia chapter. This time it is Watson who is the rheumatism sufferer.

“But why Turkish?” asked Mr Sherlock Holmes, gazing fixedly at my boots. I was reclining in a cane-backed chair at the moment, and my protruded feet had attracted his ever-active attention.

“English,” I answered in some surprise. “I got them at Latimer’s, in Oxford Street.”

Holmes smiled with an expression of weary patience.

“The bath!” he said, “the bath! Why the relaxing and expensive Turkish rather than the invigorating home-made article?”

“Because for the last few days I have been feeling rheumatic and old. A Turkish bath is what is called an alterative in medicine -  a fresh starting-point, a cleanser of the system.”

“By the way, Holmes,” I added, “I have no doubt the connection between my boots and Turkish bath is perfectly self-evident one to a logical mind, and yet I should be obliged to you if you would indicate it.”

We then get Holmes’s reasoning.

“You are in the habit of doing up your boots in a certain way. I see them on this occasion fastened with an elaborate double-bow, which is not your usual method of tying them. You have, therefore, had them off. Who has tied them? A bootmaker, or the boy at the bath. It is unlikely the bootmaker, since your boots are nearly new. Well, what remains? The bath. Absurd, is it not? But, for all that, the Turkish bath has served a purpose.”

“What is that?”

“You say that you have had it because you need a change. Let me suggest that you take one. How would Lausanne do, my dear Watson—first-class tickets and all expenses paid on a princely scale?” 

The term “rheumatism” is not one we use in modern medicine, though older patients still use it to describe joint or muscular pain. In Victorian times, the term was used for a whole range of conditions causing such pain. In this chapter we are going to discuss chronic rheumatism. We are later going to encounter rheumatic fever, or acute rheumatism.

In the latter 2 story excerpts above, the term is likely being used to describe the aches and pains that come with older age, and are an illustration that Holmes and Watson are aging by the time of these later stories.

 

Rheumatism In Victorian Times 

Since pains are the most ordinary symptoms of rheumatism, it is no wonder that the chief difficulty in discussing rheumatism is to define what we mean by it. [5]

Chronic rheumatism may remain as the result of rheumatic fever, or it may attack those who have been previously healthy. [10]

Chronic rheumatism is most generally met with in persons advanced in life. [10]

Chronic rheumatism is often feigned, especially by malingerers in the army and the navy, and the deception may be difficult to detect. They pretend to be scarcely able to walk, or hobble around with a cane, and complain much of the pain and stiffness in their joints. Yet there is not the least sign of deformity or real stiffness; the pain is always stated to be the same; and their general health is excellent. Their way of using the stick, too, is characteristic: they move it each time they move the crippled leg, but, as a rule, not immediately, thus not employing it as a support. Anaesthetics are of great value in enabling us to decide as to the real amount of immovability of the limb. [3]

In modern medicine there are two primary forms of arthritis. Rheumatoid arthritis is an inflammatory disease, which we now know is caused by an autoimmune mechanism, whereby a sufferer’s joints are attacked by their own immune system. In contrast, osteoarthritis, is a structural disease, where joints wear out gradually with time. All of us are going to develop osteoarthritis if we live long enough, whereas only a minority [0.5-1%] will develop rheumatoid arthritis.

Interestingly this division of types of arthritis was first made by an English physician, Sir Alfred Baring Garrod, in 1859. Yet none of the Victorian medical textbooks seem to utilise this helpful division of arthritis type, and the term rheumatoid arthritis is only used minimally.

There does, however, seem to be a recognition in the excerpts above that the term “rheumatism” was being used too widely.

One wonders if they actually anaesthetised soldiers to determine if their rheumatic pain was real or faked, particularly as anaesthesia would have entailed far more risks than now.

The joints, nerves, fasciae, aponeurosis and periosteum are the seats of the affection. The pains are often worse at night preventing sleep, or in the day destroying all pleasure. Dampness as a rule, makes the pains worse, but cold may relieve or aggravate; generally dry warmth appeases the distress. [5]

There is no fever, but the parts affected are painful and tender, and the suffering is increased by motion. When it occurs in the joints adhesions are apt to take place, so that the motion of the limb becomes restrained, and you can often feel a grating on moving the joint, when the hand is placed over it. [10]

The affection may show itself in the joints, giving rise to stiffness, dull aching, pain produced by motion, but without heat or very obvious swelling, tenderness, and febrile excitement, or marked sweating; or it may attack both joints and muscles; or it may be seated chiefly in the sheathes of the nerves, leading to what is called neuralgic rheumatism of which, for instance, sciatica affords a striking example. [3]

When affecting the smaller joints, alterations of form are more frequently seen as its result than when the larger ones are especially attacked, and, at all events from their situation, the swelling or distortion is more readily perceived; but its site is rather in the latter than the former. [8] 

Prior to the advent of modern immunosuppressive treatment, rheumatoid arthritis would potentially lead to significant deformity, particularly of the hands. We don’t see such cases any more, though I remember seeing them during my medical training.

We have no medicine capable of arresting the disease. As it frequently follows long-continued or excessive discharges, such as leucorrhoea and uterine haemorrhage, these should be checked when they are present. If the patient is anaemic, iron should be given, with or without quinine. Cod-liver oil is especially valuable when there is much emaciation, and should be administered in small doses for a considerable length of time. In most cases iodine is useful; it may be prescribed along with quinine or with lemon-juice. [6]

The diet must be of a different kind from that required in gout. A full supply of animal food is requisite, and fat may be taken with advantage, or a nutritious soup should be given where the appetite is defective. Most patients require some form of alcoholic stimulant; porter and ale are beneficial, or where these do not agree port-wine or burgundy may be substituted. [6]

In the earlier stage of the joint affection the application of iodine or of small blisters is of service. Complete rest tends to produce stiffness, so that a moderate amount of exercise should be encouraged. [6]

Blistering was considered to be an advance on bleeding patients, aiming to achieve the same goal of reducing overstimulation of the body. It consisted of placing hot plasters on the skin, to raise blisters, which were then drained. Famous recipients of blistering included Napoleon Bonaparte and George Washington. It was certainly unsuccessful in Washington’s case, as he died the following day.

 

Cod liver oil ad:

“Cod liver oil advertisement.” [22]

 

Next Week 

Next week we’ll have a look at depression. My chapters on psychiatric diagnoses were the hardest to write – psychiatry was a very new field of medicine when Conan Doyle was practising, and psychiatric disease classification has changed hugely over the years.

Buying The Book 

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.