RHEUMATISM: WHAT IT IS, AND PARTICULARLY WHAT IT ISN'T
What's in a name? All the aches and pains that came out of Pandora's
box, if the name happens to be rheumatism. It is a term of wondrous
elasticity. It will cover every imaginable twinge in any and every
region of the body--and explain none of them. It is a name that means
just nothing, and yet it is in every man's vocabulary, from proudest
prince to dullest peasant. Its derivative meaning is little short of an
absurdity in its inappropriateness, from the Greek _reuma_ (a flowing),
hence, a cold or catarrh. It is still preserved for us in the familiar
"salt rheum" (eczema) and "rheum of the eyes" of our rural districts.
But this very indefiniteness, absurdity if you will, is a comfort both
to the sufferer and to the physician. Moreover, incidentally, to
paraphrase Portia's famous plea,--
It blesseth him that _has_ and him that _treats_;
'T is mightier than the mightiest.
It doth _fit_ the thronéd monarch _closer_ than his crown.
To the patient it is a satisfying diagnosis and satisfactory explanation
in one; to the doctor, a great saving of brain-fag. When we call a
disease rheumatism, we know what to give for it--even if we don't know
what it is. As the old German distich runs,--
Was man kann nicht erkennen,
Muss er Rheumatismus nennen.[2]
[Footnote 2: What one cannot recognize he must call rheumatism.]
However, in spite of the confusion produced by this wholesale and
indiscriminate application of the term to a host of widely different,
painful conditions, many of which have little else in common save that
they hurt and can be covered by this charitable name-blanket, a few
definite facts are crystallizing here and there out of the chaos. The
first is, that out of this swarm of different conditions there can be
isolated one large and important central group which has the characters
of a well-defined and constant disease-entity. This is the disease known
popularly as rheumatic fever, and technically as acute rheumatism or
acute articular rheumatism. In fact, the commonest division is to
separate the "rheumatisms" into two great groups: acute, covering the
"fever" form, and chronic, containing all the others. From a purely
scientific point of view, this classification has rather an undesirable
degree of resemblance to General Grant's famous division of all music
into two tunes: one of which was Old Hundred, and the other wasn't. But
for practical purposes it has certain merits and may pass.
Every one has seen, or known, or had, the acute articular form of
rheumatism, and when once seen there is no difficulty in recognizing it
again. It is one of the most striking and most abominable of
disease-pictures, beginning with high fever and headache, then
tenderness, quickly increasing to extreme sensitiveness in one or more
of the larger joints, followed by drenching sweats of penetrating acid
odor. The joint attacked becomes red, swollen, and glossy, so tender
that merely pointing a finger at it will send a twinge of agony through
the entire body, and the patient lies rigid and cramped for fear of the
agony caused by the slightest movement. The tongue becomes coated and
foul, the blood-cells are rapidly broken down, and the victim becomes
ashy pale. He is worn out with pain and fever, yet afraid to fall asleep
for fear of unconsciously moving the inflamed joint and waking in
tortures; and altogether is about as acutely uncomfortable and
completely miserable as any human being can well be made in so short a
time.
Fortunately, as with its twin brother, the grip, the bark of rheumatism
is far worse than its bite; and a striking feature of the disease is its
low fatality, especially when contrasted with the fury of its onslaught
and the profoundness of the prostration which it produces. Though it
will torture its victim almost to the limits of his endurance for days
and even weeks at a stretch, it seldom kills directly. Its chief danger
lies in the legacies which it bequeaths. Though, like nearly all fevers,
it is self-limited, tends to run its course and subside when the body
has manufactured an antitoxin in sufficient amounts, it is unique in
another respect, and that is in the extraordinary variability of the
length of its "course." This may range anywhere from ten days to as many
weeks, the "average expectation of life" being about six weeks. The
agonizing intensity of the pain and acute edge of the discomfort usually
subside in from five to fifteen days, especially under competent care.
When the temperature falls, the drenching sweats cease, the joints
become less exquisitely painful, and the patient gradually begins to
pull himself together and to feel as if life were once more worth
living. He is not yet out of the woods, however, for while the pain is
subsiding in the joints which have been first attacked, another joint
may suddenly flare up within ten or twelve hours, and the whole
distressing process be repeated, though usually on a somewhat milder and
shorter scale. This uncertainty as to how many joints in the body may be
attacked, is, in fact, one of the chief elements in making the duration
of the disease so irregular and incalculable.
Even when the frank and open progress of the disease through the joints
of the body has come to an end, the enemy is still lying in wait and
reserving his most deadly assault. Distressing and crippling as are the
effects of rheumatism upon the joints and tendons, its most deadly and
permanent damage is wrought upon the heart. Fortunately, this vital
organ is not attacked in more than about half the cases of acute
rheumatism, and in probably not more than one-third of these are the
changes produced either serious or permanent, especially if the case be
carefully watched and managed. But it is not too much to say that, of
all cases of serious or "organic" heart disease, rheumatism is probably
responsible for from fifty to seventy per cent. The same germ or toxin
which produces the striking inflammatory changes in the joints may be
carried in the blood to the heart, and there attack either the lining
and valves of the heart (endocardium), which is commonest, or the
covering of the heart (pericardium), or the heart-muscle. So intense is
the inflammation, that parts of the valves may be literally eaten away
by ulceration, and when these ulcers heal with formation of scar-tissue
as everywhere else in the body, the flaps of the valves may be either
tied together or pulled out of shape, so that they can no longer
properly close the openings of the heart-pump. This condition, or some
modification of it, is what we usually mean when we speak of "heart
disease," or "organic heart disease." The effect upon the heart-pump is
similar to that which would be produced by cutting or twisting the valve
in the "bucket" of a pump or in a bulb syringe.
In severe cases of rheumatism the heart may be attacked within the first
few days of the disease, but usually it is not involved until after the
trouble in the joints has begun to subside; and no patient should be
considered safe from this danger until at least six weeks have elapsed
from the beginning of the fever. The few cases (not to exceed one or two
per cent) of rheumatic fever which go rapidly on to a fatal termination,
usually die from this inflammation of the heart, technically known as
endocarditis. The best way of preventing this serious complication and
of keeping it within moderate limits, if it occurs, is absolute rest in
bed, until the danger period is completely passed.
Now comes another redeeming feature of this troublesome disease, and
that is the comparatively small permanent effects which it produces upon
the joints in the way of crippling, or even stiffening. To gaze upon a
rheumatic knee-joint, for instance, in the height of the
attack,--swollen to the size of a hornet's nest, hot, red, throbbing
with agony, and looking as if it were on the point of bursting,--one
would almost despair of saving the joint, and the best one would feel
entitled to expect would be a roughening of its surfaces and a permanent
stiffening of its movements.
On the contrary, when once the fury of the attack has passed its climax,
especially if another joint should become involved, the whole picture
changes as if by magic. The pain fades away to one-fifth of its former
intensity within twenty-four, or even within twelve hours; three-fourths
of the swelling follows suit in forty-eight hours; and within three or
four days' time the patient is moving the joint with comparative ease
and comfort. After he gets up at the end of his six weeks, the knee,
though still weak and stiff and sore, within a few weeks' time "limbers
up" completely, and usually becomes practically as good as ever. In
short, the violence and swiftness of the onset are only matched by the
rapidity and completeness of the retreat. It would probably be safe to
say that not more than one joint in fifty, attacked by rheumatism, is
left in any way permanently the worse.
But, alas! to counterbalance this mercifulness in the matter of
permanent damage, unlike most other infections, one attack of rheumatic
fever, so far from protecting against another, renders both the
individual and the joint more liable to other attacks. The historic
motto of the British in the War of 1812 might be paraphrased into,
"Once rheumatic, always rheumatic." The disease appears to be lost to
all sense of decency and reason; and to such unprincipled lengths may it
go, that I have actually known one luckless individual who had the
unenviable record of seventeen separate and successive attacks of
rheumatic fever. As he expressed it, he had "had rheumatism every spring
but two for nineteen years past." Yet only one ankle-joint was
appreciably the worse for this terrific experience.
Obviously, the picture of acute rheumatism carries upon its face a
strong suggestion of its real nature and causation. The high
temperature, the headache, the sweats, the fierce attack and rapid
decline, the self-limited course, the tendency to spread from one joint
to another, from the joints to the heart, from the heart to the lungs
and the kidneys, all stamp it unmistakably as an infection, a fever. On
the other hand, there are two rather important elements lacking in the
infection-picture: one, that, although it does at times occur in
epidemics, it is very seldom transmitted to others; the other, that one
attack does not produce immunity or protect against another. The
majority of experts are now practically agreed that _acute_ rheumatism,
or _rheumatic fever_, is probably due to the invasion of the system by
some microörganism or germ. When, however, we come to fixing upon the
particular bacillus, or micrococcus, there is a wide divergence of
opinion, some six or seven different eminent investigators having each
his favorite candidate for the doubtful honor. In fact, it is our
inability as yet positively to identify and agree upon the causal germ
that makes our knowledge of the entire subject still so regrettably
vague, and renders either a definite classification or successful
treatment so difficult.
The attitude of the most careful and experienced physicians and
broad-minded bacteriologists may be roughly summed up in the statement
that acute rheumatism is probably due to some germ or germs, but that
the question is still open which particular germ is at fault, and even
whether the group of symptoms which we call rheumatism may not possibly
be produced by a number of different organisms, acting upon a particular
type of constitution or susceptibility. There is no difficulty in
finding germs of all sorts, principally micrococci, in the blood, in the
tissues about the joints, and on the heart-valves of patients with
rheumatism, and these germs, when injected into animals, will not
infrequently produce fever and inflammatory changes in the joints,
roughly resembling rheumatism. But the difficulty so far has been,
first, that these organisms are of several different kinds and distinct
species; and second, and even more important, that almost any of the
organisms of the common infectious diseases are capable at times of
producing inflammation of the joints and tendons. For instance, the
third commonest point of attack of the tubercle bacillus, after the
lungs and the glands, is the bones and joints, as illustrated in the
sadly familiar "white-swelling of the knee" and hip-joint disease. All
the so-called septic organisms, which produce suppuration and
blood-poisoning in wounds and surgery, may, and very frequently do,
attack the joints; while nearly all the common infections, such as
typhoid, scarlet fever, pneumonia, and even measles, influenza, and
tonsillitis, may be followed by severe joint symptoms.
In fact, we are coming to recognize that diseases of the joints, like
diseases of the nervous system, are among the frequent results of any
and all of the acute infectious diseases or fevers; and we now trace
from fifty to seventy-five per cent of both joint troubles and
degenerations of the nervous system to this cause. Two-thirds, for
instance, of our cases of hip-joint disease and of spinal disease
(_caries_) are due to tuberculosis.
The puzzling problem now before pathologists is the sorting out of these
innumerable forms of joint inflammations and the splitting off of those
which are clearly due to certain specific diseases, from the great,
central group of true rheumatism. Most of these joint inflammations
which are due to recognized germs, such as the pus-organisms of surgical
fevers, tuberculosis, and typhoid, differ from true rheumatism in that
they go on to suppuration (formation of "matter") and permanently
cripple the joint to a greater or less degree. So that there is probably
a germ or group of germs which produces the swift attack and rapid
subsidence and other characteristic features of true rheumatism, even
though we have not yet succeeded in sorting them out of the swarm. So
confident do we feel of this, that although, as will be shown, there are
probably other factors involved, such as exposure, housing, occupation,
food, and heredity, yet the best thought of the profession is
practically agreed that none of these would alone produce the disease,
but that they are only accessory causes plus the micrococcus. In
practically all our modern textbooks of medicine, rheumatism is
included under the head of infections.
This theory of causation, confessedly provisional and imperfect as it
is, helps us to harmonize the other known facts about the disease; it
has already greatly improved our treatment and given us a foothold for
attacking the problem of prevention. For instance, it has long been
known that rheumatism was very apt to follow tonsillitis or other forms
of sore throat; indeed, many of the earlier authorities put down
tonsillitis as one of the great group of "rheumatic" disturbances, and
persons of rheumatic family tendency were supposed to have tonsillitis
in childhood and rheumatism in later life. Not more than ten or fifteen
per cent of all cases gave a history of tonsillitis; but since we have
broadened our conception of infection and begun to inquire, not merely
for symptoms of tonsillitis, but also for those of influenza, "common
colds," measles, whooping-cough, and the like, we reach the most
significant result of finding that forty to sixty per cent of our cases
of rheumatism have been preceded, anywhere from one to three weeks
before, by an attack of some sort of "cold," sore throat, catarrhal
fever, cough, bronchitis, or other group of disturbances due to a mild
infection. Further, it has long been notorious that when a rheumatic
individual "catches cold" it is exceedingly apt to "settle in the
joints," and, if these cases happen to come under the eye of a
physician, they are recognized as secondary attacks of true rheumatism.
In other words, the "cold" may simply be a second dose of the same germ
which caused the primary attack of rheumatism.
This brings us to the widespread article of popular belief that
rheumatism is most commonly due to cold, exposure, chill, or damp. Much
of this is found on investigation to be due to the well-known historic
confusion between "cold," in the sense of exposure to cold air, and
"cold," in the sense of a catarrh or influenza, with running at the
nose, coughing, sore throat, and fever, a group of symptoms now clearly
recognized to be due to an infection. In short, the vast majority of
common colds are unmistakably infections, and spread from one victim to
another, and this is the type of "cold" which causes the majority of
rheumatic attacks.
The chill, which any one who is "coming down" with a cold experiences,
and usually refers to a draft or a cold room, is, in nine cases out of
ten, the rigor which precedes the fever, and has nothing whatever to do
with the external temperature. The large majority of our cases of
rheumatism can give no clear or convincing history of exposure to wet,
cold, or damp. But popular impression is seldom entirely mistaken, and
there can be no question that, given the presence of the infectious
germ, a prolonged exposure to cold, and particularly to wet, will often
prove to be the last straw which will break down the patient's power of
resistance, and determine an attack of rheumatism.
This climatic influence, however, is probably not responsible for more
than fifteen or twenty per cent of all cases, and, popular impression to
the contrary notwithstanding, the liability of outdoor workers who are
subject to severe exposure, such as lumbermen, fishermen, and sailors,
is only slightly greater than that of indoor workers. The highest
susceptibility, in fact, not merely to the disease, but also to the
development of serious heart involvements, is found among domestic
servants, particularly servant girls, agricultural laborers and their
families (in districts where wages are low and cottages bad), and
slum-dwellers; in fact, those classes which are underfed, overworked,
badly housed, and crowded together. Diet has exceeding little to do with
the disease, and, so far from meat or high living of any sort
predisposing to it, it is most common and most serious in precisely
those classes which get least meat or luxuries of any sort, and are from
stern necessity compelled to live upon a diet of cereals, potatoes,
cheap fats, and coarse vegetables.
Even its relations to the weather and seasons support the infection
theory. Its seasonal occurrence is very similar to that of
pneumonia,--rarest in summer, commonest in winter, the highest
percentage of cases occurring in the late fall and in the early spring;
in other words, just at those times when people are first beginning to
shut themselves up for the winter, light fires, and close windows, and
at the end of their long period of winter imprisonment, when both their
resisting power has been reduced to the lowest ebb in the year and
infections of all sorts have had their most favorable conditions of
growth for months.
The epidemics of rheumatism, which occasionally occur, probably follow
epidemics of influenza, tonsillitis, or other mild infections, and
instances of two or more cases of rheumatism in one family or household
are most rationally explained as due to the spread of the precedent
infection from one member of the family to the other. Instances of the
direct transmission of the disease from one patient to another are
exceedingly rare.
Our view of the infectious causation of rheumatism, vague as it is, has
given us already our first intelligent prospect of prevention. Whatever
may be the character of a germ or germs, the vast majority of them agree
in making the nose and throat their first point of attack and of entry
into the system. Hence, vigorous antiseptic and other rational treatment
of all acute disturbances of the nose and throat, however slight, will
prove a valuable preventive and diminisher of the percentage of
rheumatism. This simply emphasizes again the truth and importance of the
dictum of modern medicine, "Never neglect a cold," since we are already
able to trace, not merely rheumatism, but from two-thirds to
three-fourths of our cases of heart disease, of kidney trouble, and of
inflammations of the nervous system, to those mild infections which we
term "colds," or to other definite infectious diseases.
Not only is this good _a priori_ reasoning, but it has been demonstrated
in practice. One of our largest United States army posts had acquired an
unenviable reputation from the amount of rheumatism occurring in the
troops stationed there. A new surgeon coming to take charge of the post
set about investigating the cause of this state of affairs, and came to
the conclusion that the disease began as, or closely followed,
tonsillitis and other forms of sore throat. He accordingly saw to it
that every case of tonsillitis, of cold in the head, or sore throat was
vigorously treated with local germicides and with intestinal
antiseptics and laxatives, until it was completely cured; with the
result that in less than a year he succeeded in lowering the percentage
of cases of rheumatism per company nearly sixty per cent.
At some of our large health-resorts, where great numbers of cases of
rheumatism are treated, it has been discovered that if a case of common
cold, or tonsillitis, happens to come into the establishment, and runs
through the inmates, nearly half of the rheumatic patients attacked will
have a relapse or new seizure of their rheumatism. Accordingly, a
rigorous and hawk-like watch is kept for every possible case of cold,
tonsillitis, or sore throat entering the house; the patient is promptly
isolated and treated on rigidly antiseptic principles, with the result
that epidemics of relapses of rheumatism in the inmates have greatly
diminished in frequency.
If every case of cold or sore throat were promptly and thoroughly
treated with antiseptic sprays and washes such as any competent
physician can direct his patients to keep in the house, in readiness for
such an emergency, combined with laxatives and intestinal antiseptic
treatment, and, above all, with rest in bed as long as any rise of
temperature is present, there would be a marked diminution in both the
frequency and the severity of rheumatism. If to this were added an
abundant and nutritious dietary, good ventilation and pure air, an
avoidance of overwork and overstrain, we should soon begin to get the
better of this distressing disease. In fact, while positive data are
lacking, on account of the small fatality of rheumatism and its
consequent infrequent appearance among the causes of death in our vital
statistics, yet it is the almost unanimous opinion of physicians of
experience that the disease is distinctly diminishing, as a result of
the marked improvement in food, housing, wages, and living conditions
generally, which modern civilization has already brought about.
So much for acute rheumatism. Vague and unsatisfactory as is our
knowledge of it, it is, unfortunately, clearness and precision itself
when contrasted with the welter of confusion and fog which covers our
ideas about the _chronic_ variety. The catholicity of the term is
something incredible. Every chronic pain and twinge, from corns to
locomotor ataxia, and from stone-in-the-kidney to tic-douloureux, has
been put down as "rheumatism." It is little better than a diagnostic
garbage-dump or dust-heap, where can be shot down all kinds of vague and
wandering pains in joints, bones, muscles, and nerves, which have no
visible or readily ascertainable cause. Probably at least half of all
the discomforts which are put down as "rheumatism" of the ankle, the
elbow, the shoulder, are not rheumatism at all, in any true or
reasonable sense of the term, but merely painful symptoms due to other
perfectly definite disease conditions of every imaginable sort. The
remaining half may be divided into two great groups of nearly equal
size. One of these, like acute rheumatism, is closely related to, and
probably caused by, the attack of acute infections of milder character,
falling upon less favorable soil. The other is of a vaguer type and is
due, probably, to the accumulation of poisonous waste-products in the
tissues, setting up irritative and even inflammatory changes in nerve,
muscle, and joint. Either of these may be made worse by exposure to cold
or changes in the weather. In fact, this is the type of rheumatism which
has such a wide reputation as a barometer and weather prophet, second
only to that of the United States Signal Service. When you "feel it in
your bones," you know it is going to snow, or to rain, or to clear up,
or become cloudy, or whatever else may happen to follow the sensation,
merely because all poisoned and irritated nerves are more sensitive to
changes in temperature, wind-direction, moisture, and electric tension,
than sound and normal ones. The change in the weather does not cause the
rheumatism. It is the rheumatism that enables us to predict the change
in the weather, though we have no clear idea what that change will be.
Probably the only statement of wide application that can be made in
regard to the nature of chronic rheumatism is that a very considerable
percentage of it is due to the accumulation of poisons (toxins) in the
nerves supplying joints and muscles, setting up an irritation
(neurotoxis), or, in extreme cases, an inflammation of the nerve
(neuritis), which may even go on to partial paralysis, with wasting of
the muscles supplied. The same broad principles of causation and
prevention, therefore, apply here as in acute rheumatism.
The most important single fact for rheumatics of all sorts, whether
acute or chronic, to remember is that they must _avoid exposure to
colds_, in the sense of infections of all sorts, as they would a
pestilence; that they must eat plenty of rich, sound, nourishing food;
live in well-ventilated rooms; take plenty of exercise in the open air,
to burn up any waste poisons that may be accumulating in the tissues;
dress lightly but warmly (there is no special virtue in flannels), and
treat every cold or mild infection which they may be unfortunate enough
to catch, according to the strictest rigor of the antiseptic law.
The influence of diet in chronic rheumatism is almost as slight as in
the acute form. Persons past middle age who can afford to indulge their
appetites and are inclined to eat and drink more than is good for them,
and, what is far more important, to exercise much less, may so embarrass
their liver and kidneys as to create accumulations of waste products in
the blood sufficient to cause rheumatic twinges. The vast majority,
however, of the sufferers from chronic rheumatism, like those from the
acute form, are underfed rather than overfed, and a liberal and abundant
dietary, including plenty of red meats, eggs, fresh butter, green
vegetables, and fresh fruits, will improve their nutrition and diminish
their tendency to the attacks.
There appears to be absolutely no rational foundation for the popular
belief that red meats cause rheumatism, either from the point of view of
practical experience, or from that of chemical composition. We now know
that white meats of all sorts are quite as rich in those elements known
as the purin bodies, or uric-acid group, as red meats, and many of them
much richer. It may be said in passing, that this last-mentioned bugbear
of our diet-reformers is now believed to have nothing whatever to do
with rheumatism, and probably very little with gout, and that the
ravings of Haig and the Uric-Acid School generally are now thoroughly
discredited. Certainly, whenever you see any remedy or any method of
treatment vaunted as a cure for rheumatism, by neutralizing or washing
out uric acid, you may safely set it down as a fraud.
One rather curious and unexpected fact should, however, be mentioned in
regard to the relation of diet to rheumatism, and that is that many
rheumatic patients have a peculiar susceptibility to some one article of
food. This may be a perfectly harmless and wholesome thing for the vast
majority of the species, but to this individual it acts as a poison and
will promptly produce pains in the joints, redness, and even swelling,
sometimes accompanied by a rash and severe disturbances of the digestive
tract. The commonest offenders form a curious group in their apparent
harmlessness, headed as they are by strawberries, followed by
raspberries, cherries, bananas, oranges; then clams, crabs, and oysters;
then cheese, especially overripe kinds; and finally, but very rarely,
certain meats, like mutton and beef. What is the cause of this curious
susceptibility we do not know, but it not infrequently occurs with this
group of foods in rheumatics and also in asthmatics.
Both rheumatics and asthmatics are also subject to attacks of urticaria
or "hives" (nettle-rash), from these and other special articles of diet.
As to principles of treatment in a disease of so varied and indefinite a
character, due to such a multitude of causes, obviously nothing can be
said except in the broadest and sketchiest of outline. The prevailing
tendency is, for the acute form, rest in bed, the first and most
important, also the second, the third, and the last element in the
treatment. This will do more to diminish the severity of the attack and
prevent the occurrence of heart and other complications than any other
single procedure.
After this has been secured, the usual plan is to assist nature in the
elimination of the toxins by alkalies, alkaline mineral waters, and
other laxatives; to relieve the pain, promote the comfort, and improve
the rest of the patient by a variety of harmless nerve-deadeners or
pain-relievers, chief among which are the salicylates, aspirin, and the
milder coal-tar products. By a judicious use of these in competent hands
the pain and distress of the disease can be very greatly relieved, but
it has not been found that its duration is much shortened thereby, or
even that the danger of heart and other complication is greatly
lessened. The agony of the inflamed joints may be much diminished by
swathing in cotton-wool and flannel bandages, or in cloths wrung out of
hot alkalies covered with oiled silk, or by light bandages kept
saturated with some evaporating lotion containing alcohol. As soon as
the fever has subsided, then hot baths and gentle massage of the
affected joints give great relief and hasten the cure. But, when all is
said and done, the most important curative element, as has already been
intimated, is six weeks in bed.
In the chronic form the same remedies to relieve the pain are sometimes
useful, but very much less effective, and often of little or no value.
Dry heat, moist heat, gentle massage, and prolonged baking in special
metal ovens, will often give much relief. Liniments of all sorts, from
spavin cures to skunk oil, are chiefly of value in proportion to the
amount of friction and massage administered when they are rubbed in.
In short, there is no disease under heaven in which so much depends upon
a careful study of each individual case and adaptation of treatment to
it personally, according to its cause and the patient in whom it occurs.
Rheumatism, unfortunately, does tend to "run in families." Apparently
some peculiar susceptibility of the nervous system to influences which
would be comparatively harmless to normal nerves and cells is capable of
being inherited. But this inheritance is almost invariably "recessive,"
in Mendelian terms, and a majority of the children of even the most
rheumatic parent may entirely escape the disease, especially if they
live rationally and vigorously, feed themselves abundantly, and avoid
overwork and overcrowding.