Rheumatism by Dr. Lance Christiansen: Difference between revisions

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'''Editor-in-Chief:''' Lance Christiansen, D.O.  
'''Editor-in-Chief:''' Lance Christiansen, D.O.  
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{{EJ}}
Undergoing edit with the addition of references through March 2013. (LWC)
==Overview==
Rheumatism is usually considered to be an archaic term in medical science for it is not listed as a subject within the index of most modern, medical texts. For instance, it is not listed in the index of the text, ''Harrison's Principles of Internal Medicine, 16th Edition'' published in 2005. ( 1 )


==Overview==  ( This article undergoing a major edit-January-February, 2012)
Within the 12th edition of the same text, published in 1991, the only listing for rheumatism is psychogenic rheumatism; a part of the short paragraph explaining it is quoted as follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 ) The above use of the word rheumatism reflects how the concept of the systemic disease of rheumatism, as readers will soon understand, has become marginalized in modern medicine existing as only an archaic term or, as indicated above, as a figment of a person's imagination. (2)  


Many philosophers and natural philosophers appeared during the pre-classic Greek period, and the classic Greek period, who mentally probed the nature of the universe, ideas, and matter, for instance, Socrates, Dioscordes, Plato, Theophrastus, Aristotle and Hippocrates and many others. Philosophy and natural philosophy was further extended during the Hellenistic era by many philosophers and natural philosophers including Praxagorus, Herophilus, Erasistratus, Soranus, Celsus, and Galen, the majority of whom studied, conducted medical research (including anatomical research via human dissection), and/or taught at the Alexandria University and Library in Egypt. Although various new ideas and concepts were developed, via observation and reason, by the above cited individuals are known to modern scholars, directly through their writings, exemplified by those of Hippocrates, Galen and Soranus, it is more common that their ideas, hypothesis, concepts and determinations developed via their research have come down to the modern day through the writings of authors who were active in later periods and frequently written information is thought to be confabulated by their associates, or by other individuals, but those writings have come down to modern readers as written by well known authors such as Hippocrates and Galen. Fortunately, many the works of Galen are still extant after being  translated from Arabic, Coptic, Syrian, early Greek and other languages first into Latin and eventually into modern European languages. The knowledge that modern readers have, for instance, about the writings of Herophilus and Erasistratus, have come down to us via the writings of Galen and others. 


During the classic Greek period, the Hellenistic period, and thereafter, and during the Middle Ages, many details of classic Greek and Hellenistic philosophic and natural philosophic thought had been absorbed into Arab, Syrian, and Jewish learned society and the writings of individuals such as Ibn Sina (Avicenna (980-1037), Al Farabi (c. 870-950), Ibn Rushd (Averroes) (1126-98) and  Moses Maimonides (1135-1204 CE), and others, were eventually translated into Latin at various locations, especially, however, by Moorish and Jewish physicians in Spain, after the removal of the Arab leadership in 1492. 


Rheumatism is usually considered to be an archaic term in medical science for it is not listed in the index, as a subject, in most, modern, medical texts. For instance, it is not listed in the index of the text, ''Harrison's Principles of Internal Medicine, 16th Edition'' published in 2005. ( 1 )  
During the second century CE the Greek physician, scientist, philosopher and author Claudius Galenus (129 to about 213 CE), commonly known simply as Galen, was born in Pergamum, which was a thriving city on the west coast of what is now Bergama, Turkey and which was originally founded as early as 1200 BCE during the early archaic period of the Greek Civilization. He was provided a liberal education, which included a thorough education in the various philosophies that had developed in Greece up to that time. At 17 he began medical training at the Aselepieum of Pergamum. He also trained in anatomy, physiology, medical theory and treatment concepts at Smyrna ( now, Turkey), Corinth (Greece) and for four years at Alexandria ( Egypt). Later in his career he practiced in Rome and eventually became physician to a number of emperors including Marcus Aurelius. ( 3 )


Within the 12th edition of the same text, ''Harrison's Principles of Internal Medicine'', published in 1991, the only listing for rheumatism is psychogenic rheumatism; a part of the short paragraph explaining it is quoted a follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 )
William Gilbert (1544-1603), an English physician, philosopher and scientist is often thought to be the first person during the seventeenth century to overtly espouse the scientific method, for instance: "... he was the first person to set out clearly in print the essence of the scientific method - the testing of hypothesis by rigorous experiments - and to put that method into action." ( 4 ) Earlier, however, Nicolaus Copernicus and Galileo Galilei had practiced the scientific method and before that, during the European medieval period, Roger Bacon, Roger Grosseteste, Thomas Acquinas, Albert Magnus, and others, were involved, in thought and practice, in developing what has become to be known as the scientific method of knowledge development.  


I certainly think the above synopsis makes obvious the author's lack of observation skills and lack of patient concern; it is an arch-type example of how some physicians find fault with patients when they ''do not know what is going on'' and they are too imbued with professional defensiveness, to simply say to a patient, I do not know why you hurt so bad.  
It appears, however, that Galen's rational, philosophic methodology, which he developed during the second century CE was similar to Gilbert's, and other western European natural philosophers' thought and purposeful experimental processes, which were identical or similar to those now known as the scientific method. His analytical methodology appears in many locations throughout his writings. For instance: "...logical procedures should at all times be checked by experience. Both reason and experience are instruments of discovery and means of testing what has been discovered. The method envisaged by Galen can roughly be characterized as comprising a  stage of discovery steered by reason ( i.e. rational methods) followed by one of confirmation or otherwise by means of experience. For Galen, experience means not merely the accumulation of data involving no particular expertise." It "...involves techniques requiring skill and expertise such as in anatomy and experimentation...Galen engaged in the style of anatomical experimentation instigated by..." earlier anatomists, "But in this context he retained the Empiricist requirement of a large number of identical observations, thereby foreshadowing the modern requirement of the repeatability of experimental observations." ( 3 )


Near the beginning of the second century CE, Greek physician, scientist, philosopher and author Galen of Pergamum (129 to about 215 CE) was provided a liberal education, which starting at 14 years of age, included an exposure to the philosophical schools of the time. At 17 he began medical training at the Aselepieum of Pergamum. He also trained in anatomy, physiology, medical theory and treatment at Smyrna (now Turkey), Corinth (Greece) and Alexandria (now Egypt). He was highly affected by his studies of anatomy. "According to Galen, the spur to anatomical knowledge originated in Alexandria for it was Herophilus...and Eudemus...who 'increased anatomical knowledge the most' until Marinus and and Numisianus." ( 3 )
Hippocrates, "...first used the term rheuma, which literally means "flowing," to describe an excess of the watery humor (phlegm) thought to flow down from the brain. The words rheuma and catarrhos ("flowing down") were used interchangeably by ancient Greeks to describe a variety of illnesses including joint problems. ( 7 ) Galen adhered to many Hippocratic concepts and he also, like Hippocrates, advocated carefully observing individuals' life activities, such as their immediate living environment, nutrition, hygiene, levels of exercise, the observable factors of disease states, signs, and patient complaints, symptoms, and rationally studied anatomy, physiology and the environment (such as the geographical location and seasonal weather conditions) so as to understand the nature of man concerning the development of disease states more accurately. His study was accomplished in reference to the concepts of Plato and Aristotle as well other natural philosophers and physicians including Diocles, Herophilus, Eriasistratus and others. ( 3 ) Concerning phlegm (rheuma) Galen indicated: "We use the word catarrh whenever the superfluity flows to the mouth, but coryza whenever it flows from the nose." ( 8 )  


Galen coined the term rheumatismos (English, rheumatism), in which rheuma means "to flow" (an alternative meaning is phlegm)." ( 4 )
It may be that another individual of the Hippocratic persuasion, not Hippocrates himself, commented on rheumatism within the Hippocratic Corpus, however, within this text all writings in that work will be considered Hippocratic in origin. Further, then, Hippocrates seems to be the first physician to use the word rheumatismus (rheumatism) as a noun and verb. ( 9 ) In addition, Galen championed and further developed many concepts in medicine first mentioned by Hippocrates. For instance, the pathophysiological concept of rheumatism was one such concept since, concerning the word rehumatism, "Examples of...noun, adjective and verb are far too common in Galen to list (80+)..." ( 10 )  


Galen "...pays a very special tribute---that of his illustrious forerunner Hippocrates...Hippocrates he says, 'was the first known to us of all who have been both physicians and philosophers, in that ''he was the first to recognise what nature does.''" In addition, "What, now is this "nature" or biologial principle upon which Galen, like Hippocrates, bases the whole of his medical teaching, and which, we may add, is constantly overlsdooked---if indeed ever properly apprehended---by many physiologists of the present day? By using this term Galen meant simply that, when we deal with a living thing, we are dealing primarily with a unity, which, ''qua'' living, is not further divisable.; all its parts can only be understood and dealt with as being ''in relation to'' this principle of unity." Further, "Galen expressed this idea of the unity of the organism by saying that it was governed by a ''Physis'' or Nature, with whose "faculties " or powers it was the province of...physiology...or...Nature lore to deal. ( 5 )
Further, within the Giunta edition of Galen, in Latin, there are over thirty notations within the index on rheuma, rheumatism and related terms. For instance, "Rheumatismum faucium Suffionigmum de dyna.; Rheumatismum stomachi and intestinarum Malagma...; and Rheumatismi articularum, introd." ( 11 ) The preceding subjects are, roughly translated: rheumatism of the throat, rheumatism of the stomach and intestine as soft masses, and rheumatism of the articulations or joints. It seems, as the prior information exhibits, that Galen's concept of rheumatism was  that it was a disease that affected many parts of the body (a systemic disease) and that, it was related to rheum, a flowing down of phlegm, catarrh from the mouth and coryza from the nose. In those early times it was thought that phlegm (in the form of cerebrospinal fluid) flowed from the ventricles of the brain through the small holes in the cribiform plate of the ethmoid bone that is located directly above the center of the nasal passages. That idea was rationally appropriate since the cerebrospinal fluid is a semi-clear fluid and it is normally found within the ventricles and within the space between the meninges and the matter of the brain just above the cribiform plate.  


Galen was an adherent to the Hippocratic persuasion and considered the "four humors": phlegm, blood, black bile and yellow bile, and the physical factors of heat and cold, as important factors in disease development. Perhaps his concept of ''rheumatismos'' was connected to an apparent excess of phlegm that he observed in certain patients who experienced chronic sinus drainage and in patients who experienced acute respiratory diseases of various levels of severity, which had, as one of their signs, the acute production of phlegm during coughing, or its chronic production caused by chronic sinusitis wherein phlegm flows from the nose and down the pharynx. Considering his concept of the unity of the body, and that it had to be viewed holistically, perhaps his view of rheumatismos was a concept that rationally developed from that insight. One might consider that Galen was dealing with the nature of man and his/her diseases from a systemic approach.  
An increase in mucous drainage, catarrah and coryza, was related, evidently, to a "...a systemic inflammatory response syndrome (SIRS) that may have an infectious or a noninfectious etiology. If an infection is suspected or proven, a patient with SIRS is said to have sepsis. When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." ( 1 ) If the development of phlegm from the respiratory organs is caused by an infection from a microorganism that has a mechanism to create pathological tissue changes to distant tissues and organs, then, perhaps, that is the mechanism of the development of rheumatism, or better said, rheumatic pathological signs and symptoms in various parts of the body.


During the philosophy of medicine's intelectual development, a debate, nearly continually, has existed between empiricists and dogmatists (rationalists). Empiricists indicated, "It is not", they said, "the cause but the cure of diseases that concerns us; not how we digest, but what is digestible." ( 5 ) In addition, "...Empyrics, excluded all reasoning, and trusted solely to experience." Contrarily, however, "...Dogmatists, maintained, that no man ought to prescribe, withoput being able to give a theory both of the disease and of the nature of the action of the medicine. This dispute continued for ages , and, like other disputes of a similar nature, remains still in some measure undecided." ( 6 )  
To further provide philological information on the words rheuma and rheumatism the following definitions found in dictionaries will be provided: The definition of the word ''rheum'' within a reasonably current dictionary is: "rheum...1. a thin, serous or catarrhal discharge. 2. catarrh; cold. [ME reume < L rheuma < Gk rheuma...(to) flow..." ( 11 ) In addition, "rheum, ...''Rheuma'', (F.) Rheume, ...'I flow.") Any thin watery discharge from mucous membrans or skin; as the thin discharge from the air-poassages arising from cold." and, "Rheuma, gen. ''Rheumatis'', ...(from...'I flow")  Catarrh, Diarrhea, Rheum, Rheumatism. Also, inflammation of a fibrous tissue, as in rheumatism and gout. In composition, a flow, a defluxion; also, rheumatism. ( 12 )


Perhaps Galen noticed the painful sensations of rheumatism seemed to flow from one body part to another, for instance, to certain nerves as in sciatica, certain muscles as in lumbago, toticollis, intercostalitis, and dorsodynia, to the joints as in acute and chronic arthritis, to the head where it caused headache, to the chest where it caused pericarditis and pleurisy, to the brain where it caused chorea, seizures, stupor and coma, and to the gastrointestinal system where it potentially caused crampy abdominal pain. ( 6, 7, 8 ) "Like his master Hippocrates, Galen attached fundamental importance to clinical observation---to the evidence of the senses as the indispensable groundwork of all medical knowledge." ( 5 )
During the Renaissance Guillaume Baillou (1538-1616), or Ballonius in the Latinized form, a Parisian physician, apparently was the first to use the term "rheumatism" (rheumatismos) for polyarthritis and to give a fairly good description of this condition, in his treatise, "Liber de Rheumatismo,", which was not published until 1642, twenty-six years after his death." Further, Baillou provided a clinical description of an individual with acute rheumatism (rheumatic fever):


A theorist in medicine, Asclepiades, during the first century CE, introduced Greek medicine into Rome. He had developed a philosophic system of health and disease that was mechanistic, since it was "...based on  the doctrine of Leucippus and Democritus,..." In addition, "Out of the teachings of Aslepiades that (indicated) physiological processes depend upon the particular way in which the ultimate indivisible molecules come together, there was developed...a system of medicine characterised by the most engaging simplicity both of diagnosis and treatment. This so-called "Methodic" system was intended to strike a balance between the excessive leaning to apriorism shown by the Rationalist (Hippocratic) school and the opposite tendency of the Empiricists..." Further, "They held that the molecular groups constituting the tissues were traversed by minute channels (pores); all diseases belonged to one or the other of two classes: if the channels were constricted the disease was one of stasis, and if they were dilated the disease was one of flux. Flux and stasis were indicated respectively by increase and diminution of the natural secretions; treatment of opposites by opposites--of stasis by methods causing dilation of the channels, and conversely."
"Before we place this affection in a class of disease or symptoms (since it causes its effects by the primary disease and the symptoms produced by it is commonly and vary badly confused) just as what it is, we shall explain by what and in what manner it arises: we shall point out the train of pains & symptoms also present...


Wild as it may seem, this pathological theory of the Methodists contained an element of truth; in various guises it has cropped up once and again at different epochs of medical history; even to-day there are pathologists who tend to describe certain classes of disease in terms of vaso-constriction and vaso-dilation. The Methodists illustrate for us the tyranny of names. In its defects as in its virtues this school has analogues at the present day; we are all acquainted with the medical man to whom a name (such, let us say, as "tuberculosis, " "gout," or "intestinal auto-intoxication") stands for an entity, one and indivisible, to be treated by a definite and unvarying formula.
On the other hand the method by which this affection attacks which is falsely called catarrh: (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism, is as follows. . . The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot nor the hand, nor the finger can be moved in the least without pan & and outcry: moreover the greater pain lies in the joints because that part is endowed with greater and more exqusite sensation...When the hand is pressed on the parts, the sensation & feeling, (even if you touch it lightly) is of a definite severe heat. IF you examine the pulse, the fever is seen to be little or nothing...


To such an individual the old German saying "Jedermann hat am Ende ein Bischen Tuberkulose" (Every man has in the end a little tuberculosis) is
Indeed the pains are worse at night, the patients cannot sleep, partly because they are unable to be moved from their position & from that posture they first usually lie and recline, they remain in it & are scarcely moved or touched without excruciating on terrible pain...this rheumatism itself is in the entire body; with pain, tension and a somewhat sharp feeling, others say with the sensation of heat (as already mentioned)...This rheumatism is not the same as in those who sin in their way of life." ( 13 )
simply---incomprehensible." ( 5 )


In addition it is well recognized in microscopic histology that capillary walls have passageways through which white blood cells, immunological elements, and nutrients pass to the adjacent tissue cells. In addition, the cells themselves have "...the presence of transporters and active pumps. Further, "Cytokines...also increase vascular permeability." ( 1 )
Somewhat later, Thomas Sydenham (1624-1689), an English physician, who also, like Hippocrates and Galen, carefully observed patients' during disease states.  "These observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitis Dance (1686) and gout (1683). "...Sydenham understood the migratory nature of polyarthritis and its tendency to attack the young, characteristics which today we know to be typical of the joint manifestations of rheumatic fever." (   )  


Somewhat recently, Benedict Massell, MD, in his classic text, "Rheumatic Fever and Streptococcal Infection", thoroughly reviews, with a historical approach, the disease of rheumatic fever. The following comprises the first sentence of his book: "In ''The Old Wives Tale,'' Arnold Bennett called rheumatic fever the "dread disease." Bennett's allusion to this malady in his most popular novel, published in 1908, but set in the second half of the 19th century, shows that so feared was the diagnosis of rheumatic fever that the physician of this story chose to lessen his patients's worry by referring to her condition as "acute rheumatism." ( 9 )
Hippocrates mentioned the salient clinical characteristics of rheumatic fever within writings of the Hippocratic Corpus. For instance, "Rheumatism as a disease process became. clinically, more accurately understood so by the the the late 1700's acute rheumatism was the term used for rheumatic fever and chronic rheumatism was known defined as follows: "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 13 )


Further, to indicate how acute rheumatism (rheumatic fever) remained a highly serious disease during the middle years of the 1900's, Dr. Massell writes, "For the period 1939-1943, statistics published by the Metropolitan Life Insurance Company indicated that rheumatic fever was the leading cause of death among policy holders for persons from five to nineteen years of age and the second leading fatal disease among twenty  to twenty-four year olds." ( 9 )
To think and speak concisely words must have strictly defined meanings. The use of the words empiric, empirical, and empiricism, in various contexts, is somewhat antonymic in nature. For instance, within a reliable dictionary the meanings of the words are established: "'''empirical, empiric''', ''a.''  1. relying or based solely on experiments or experience; as, the empirical method..." Conflictingly, in the same text, the meaning of empiricism is as follows: "'''empiricism''', ''n.''  1. dependence of a person on his own experience and observation, disregarding theory, reasoning, and science. 2. the practice of medicne without a medical education; hence, quackery; charlatanism..." ( 9 )
 
In addition, Dr. Massell reviews the concept of migratory arthritis, which is often a finding in high-grade cases of rheumatic fever, for instance: "Hippocrates (about 400 B.C.) mentioned acute migratory arthritis which may very well have been rheumatic fever..." ( 9 )
 
"An even clearer description of rheumatic polyarthritis is included in the writings of the famous English physician Thomas Sydenham (1624-1689). Sydenham recognized the importance of careful bedside observations, and these observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitus Dance (1686) and gout (1683). Sydenham's description of polyarthritis, migratory arthritis, is as follows: "...the patient is attacked by severe pains in the joints, sometimes in one and sometimes in another, sometimes in his wrist, sometimes in his shoulder, sometimes in the knee--in this last joint oftenest. This pain changes its place from time to time, takes the joints in turns, and affects the one that it attacks last with redness and swelling." ( 9 )


Within the A ''Dictionary of Medical Science'', published in 1874, rheumatism is profusely defined: "'''Rheumatism''',"...A kind of shifting phlegmasia or neuralgia, sometimes seated in the muscles, sometimes in the parts surrounding the joints; and at others, within them...Hence the names Muscular, Articular, and Synovial, which have been applied to it. The disease may be acute or chronic." Further, "When accompanied by the deformity of a joint, it is called ''Arthritis deformans''. In addition, When it affects the hip-joint of old people, it is called ''Morbus coxae senilis'' Further, 'Rheumatism, Cerebral,' ''Rheumatic Meningitis, Rheumatic Apoplexy''. Meningitis occurring during the progress of acute rheumatism..." "''Rheumatism, Chronic,...is attended by pains in the hips, shoulders, knees, and other large joints. These are at times confined to one joint; at others, shift from to another, without occasioning inflammation or fever. In this manner the complaint often continues for a great length of time, and then goes off." Continuing, "Rheumatism, Synovial...a rheumatic affliction, in which an accumulation of non-purulent fluid occurs in the synovial sacs, especially of the knee joints." In addition, "Rheumatism, Visceral. Rheumatism affecting the muscular or fibrous tissues of the viscera.", and finally, "'''Prosoporrheuma''',...Rheumatism affecting the face.", which probably was also termed, rhinoscleroma and "...''rhinocephale'',...A term applied ...to a monstrosity characterized by a projection of the nose..." Rhinophyma is probably the currently used term for the older word, rhinocephale. The above definitions consist of only a small sample of the extensive, detailed, list of maladies, that are aspects of the systemic disease of rheumatism, defined in the above-mentioned dictionary. ( 10 )
Within an older medical dictionary the following definition for empiric is described: 1. "Empiric...(...'a trial;.'--'experimental.') One who follows only experience. A sect of physicians, who rejected all theory, and took for their guide experience alone. It was opposed to the dogmatic sect, which prevailed till near the time of Galen." In addition, "... At the present day the word Empiric is only taken in a bad sense, being employed in nearly the same signification as ''charlatan'' or ''quack''." ( 10 )


Within "The Americana" encyclopedia, published in 1908, rheumatism is defined as follows: "'''Rheumatism''', a constitutional disease characterrized by inflammation of the connective-tissue structures of the body, especially of the joints and muscles, and attended by localized pain. It is usually recurrent. Three forms are recognized: (1) acute rheumatism (acute articular rheumatism, acute inflammatory rheumatism, rheumatic fever); (2 ) chronic rheumatism; (3) muscular rheumatism or myalgia." ( 11  )
The definition of the word empiric, just related, should be clarified to indicate that the "experience" mentioned is the personal experience of one physician-investigator, or, perhaps, the added experiences of a number of other physician-investigators who have communicated between each other in a fairly casual fashion and not with scientific detail, processes, repetition or scrutiny.  


Within a respected medical text by Sir William Osler and Thomas McCrea, ''The Principles and Practice of Medicine'', Eighth Edition, published in 1912, and a more recent version of the text, ''Osler's Principles and Practice of Medicine'', Twelfth Edition, published in 1935, provide extensive reviews of rheumatic fever, its epidemiology, and its sequeale. ( 7, 8 ) In the first-mentioned text the subject of "cerebral rheumatism" is discussed, for instance.
Since there is a conflict of meaning using the English word empiric, and words developed from it such as empirical and empiricism, a solution to the conflict will be used in this article by using, as a convention, an older English spelling: empyric, empyrics, empyrical and empirycism, as in the empyric school of medicine, as it is used in a text published in 1771: "After a knowledge of medicine began to be studied and practiced as a liberal profession, a jealousy of reputation, joined to a thirst for money and ignorance of philosophy, laid a solid foundation for medical disputation. One party of physicians, known by the name Empyrics, excluded all reasoning, and trusted solely to experience." ( 13  )


Gene Stollerman, MD, authored the text, ''Rheumatic Fever and Streptococcal Infection'', that was published in 1975, which contains a highly interesting, complete, and wise, review of rheumatic fever from a clinical, as well as a historical, approach. Every physician treating patients should read it. ( 12 )
Alternatively, empiric, empirics, empirical, and empiricism will, in this text, convey a more detailed, scientific concept, for instance, an individual's empiric method would include personal observations, repetitive observation, analysis, at times, experimental observation, testing and further analysis and deductive hypothesis development. After the hypothesis was widely verbally announced, or published, other investigators could, themselves, repeat the same observations, analysis, etc., and agree or disagree with the hypothesis advanced by the original investigator. Empiric, empirical and empiricism would, then, connote a scientific meaning and methodoloy, whereas empyric, empyrical and empyricism would refer to a personal, more or less, opinionated meaning, or a meaning agreed upon by individuals within a certain professional group or group of people with a similar philosophy.


For instance, the empyric concept that is often mentioned in chiropractic advertising indicates that an adjustment of the spine promotes spinal health. Also, Andrew Taylor Still, MD DO, the founder of the osteopathic medical profession, taught that spinal manipulation promoted improved blood flow to various anatomical sites in the body. In addition, individuals are frequently advised to have an annual physical examination for they are generally thought to contribute to a person's general health. All three of the prior concepts, even if they have been repeated for a long period of time, have not, necessarily, been developed through the use of empiric methodology.


The word disease, also, has various meanings. In this article the word disease will connote an adverse medical condition wherein the cause and basic pathophysiology is known. Alternatively, an adverse medical condition, which has no known cause (an idiopathic disease), and which is defined by its general sign and symptom pattern, and, at times, its gross and microscopic anatomy, will be defined to be a syndrome. Ninety-nine percent of diseases mentioned in leading medical texts are more accurately described to be syndromes and not diseases. For instance, coronary artery disease, mental diseases such as schizophrenia and manic-depressive disease, Crohn's disease, Meniere's disease and the disease of diabetes mellitus are all more accurately defined to be syndromes, and not well defined diseases, since their causes are not known.   


Galen can be considered for the most part an empiric, but, perhaps, he is more accurately termed a rationalist. He never claimed, however, that he was a member of any one school or sect of medicine. When, however, due to lack of physiological, pathophysiological or micro-anatomical information he, at times, adapted older concepts, such as Hippocrates' fluid (humor) concept, which had been developed by him to explain clinically observed phenomena during a time when anatomical, micro-anatomical, physiological and pathophysiological empiric information was not available. Galen also developed, at times, his own concepts based on observation, which, without modern investigative abilities, have been proven to be not true. He thought, ideally, that diseases should be anatomically and pathophysiologically understood and that included understanding their causes before proper treatments could be developed. He also realized, however, that there were limits to existing knowledge so that a quasi-empiric or a careful empyric approach to treating diseases, based on careful use of experience and reason, had to be used until a more thorough knowledge of the particular medical phenomenon in question was achieved. One of the ways to understand the body was via a thorough an investigation of human anatomy and physiology; such knowledge was not thought to be necessary by empyricists of his time. In an effort to develop his empirical medical concepts Galen accomplished a great deal of original medical research, especially, in neuroanatomy and neurophysiology. ( 3 )


The dogmatist school of medicine was a "...school of medicine formed by Diocles of Carystus. The school put Aristotelian language, system, and speculation into Hippocratic medicine to discover the hidden causes of the constitution of man and of disease: such knowledge, they thought, was necessary for the practice of medicine." ( 14 ) 


The melding of empyric medicine (using only information developed via personal, idiosyncratic methodology) with dogmatic, empiric medicine (using information developed via scientific methodogy) is, for a physician, a necessary, practicable reality until complete knowledge concerning all disease processes, including their causes, is developed and that approach to professional medical treatment was advanced in 1771: "A judicious mixture of the two is indispensably necessary. Indeed it is difficult to determine whether too great an attachment to empyricism or dogmatism has contributed most to obstruct the improvement of physic." ( 13 )


Rheumatism is usually considered to be an archaic term in medical science for it is not listed in the index, as a subject, in most, modern, medical texts. For instance, it is not listed in the index of the text, ''Harrison's Principles of Internal Medicine, 16th Edition'' published in 2005. ( 1 )
Progressively, over the last six decades, or so, the empyric treatment paradigm has become quasi-empiric by the development of organized ''clinical trials'', which test more accurately as to whether a certain medicinal chemical treatment, or surgical treatment, produces a meaningful ameliorative change in a syndrome. Such trials, and the research that is is involved with the medicinal chemical's development, however, ignore dealing with the cause of the disease in question so such organized efforts are not thoroughly empiric.


Within the 12th edition of the same text, ''Harrison's Principles of Internal Medicine'', published in 1991, the only listing for rheumatism is psychogenic rheumatism; a part of the short paragraph explaining it is quoted a follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 )
The professional organization of medicine had always features physicians who specialized in certain medical techniques, such as surgical techniques, or in treating certain conditions starting, at least, with archaic Egyptian medicine. ( 15 ) Beginning in about 1920 in the USA, however, the development of various medical specialties was accelerated so that by the 1970's most physicians were of the specialist type and general practitioners who, historically, had treated males and females, of all ages, for all diseases became fewer and fewer in number.  


I certainly think the above synopsis makes obvious the author's lack of observation skills and lack of patient concern; it is an arch-type example of how some physicians find fault with patients when they ''do not know what is going on'' and they are too imbued with professional defensiveness, to simply say to a patient, I do not know why you hurt so bad.  
Specialty medicine has been, and is, the practical paradigm, which represents the empyrical, or allopathic, school of medical science, which has dominated modern academic and clinical medical science and practice since that time, the early 1900's. Allopathy is the correct name for the philosophy of modern, empyric, medical practice and it is defined as follows: "...that method of medical practice which seeks to cure disease by the production of a condition of the system either different from or opposite to the condition produced by the disease..." ( 16 )  The term, allopathy was not coined by members of the doctor of medicine profession, but by Samuel Hahnemann, the founder of homeopathy, to distinguish the predominant, functional school of medicine at that time, the late 1700's, from the type of medical philosophy and practice espoused by homeopaths.


Near the beginning of the second century CE, Greek physician, scientist, philosopher and author Galen of Pergamum (129-215 CE) was provided a liberal education, which, starting at 14 years of age, included an exposure to the philosophical schools of the time. At 17 he began medical training at the Aselepieum of Pergamum. He also trained in anatomy, physiology, medical theory and treatment at Smyrna (now Turkey), Corinth (Greece) and Alexandria (now Egypt). He was highly affected by his studies of anatomy. "According to Galen, the spur to anatomical knowledge originated in Alexandria for it was Herophilus...and Eudemus...who 'increased anatomical knowledge the most' until Marinus and and Numisianus." ( 3 ) 
The reality is, however, the treatments developed in the members of the doctor of medicine profession, mentioned above, do not cure most diseases except those, such as lacerations and fractures caused by trauma, and since the 1930's, those caused by certain infectious processes. Most medical and surgical treatments have been developed to alter organs, or parts of organs, usually for the better, that have become symptomatically damaged by an unknown, underlying pathophysiological process, or processes, with an unknown cause. Although the term allopathic physician is not used by members of the doctor of medicine profession to describe themselves, members of that profession, the osteopathic profession, the homeopathic profession, the naturopathic profession, the chiropractic profession, the physical therapy profession, and even the traditional Chinese medical profession all practice their own form of allopathic medicine: altering disease, often for the better, by "...the production of a condition of the system either different from or opposite to the condition produced by the disease." An example is the use of insulin to treat diabetes; its use lowers elevated serum blood glucose levels, but it does nothing to improve the function of the Islands of Langerhands of the pancreas, which are not producing adequate insulin due to an underlying autoimmunological process. Similarly, If a person has ulcerative colitis, a portion of the colon that is most severely affected is often surgically removed, but the surgical procedure does not control the underlying autoimmune condition that intrinsically causes such a disease process.  


Galen coined the term rheumatismos (English, rheumatism), in which rheuma means "to flow" (an alternative meaning is phlegm)." ( 3, 4 ) Perhaps, the disease ''rheumatismos'' to describe a medical condition that patients experienced that featured chronic mucous drainage, and/or, perhaps, he realized that ''rheumatismos,'' was caused by acute respiratory diseases, that individuals developed during their lifetimes, that were accompanied by the production of phlegm or catarrh.  
It should be noted that the above paragraph stresses the idea that allopathic medicine seeks to: cure diseases such as fractures, sprains, and specific infections, since their causes are known, by applying proper physical treatments, concerning the first two types of diseases, and by the use of antibiotics in the third. All other adverse medical problems, however, are syndromes and so  by the production of a condition of the system (a physical or biochemical change within the body) either different from, or opposite to, the condition produced (damaged organ) by the disease (the syndromic sign and symptom pattern) and that the goal of such a medical philosophy is not, necessarily, to cure the underlying disease in question by effectively removing its cause. That is, the underlying disease, or its cause, does not necessarily have to be known before pathological target-organ manifestations produced by them, biochemical or physical dysfunction, such ischemic cardiomyopathy caused by arteriosclerosis of the coronary arteries and diabetes mellitus caused by partial or complete failure of the Islands of Langerhands of the pancreas, are allopathically treated. At times, one specific treatment modality, or a combination of allopathic, quasi-empirical treatment modalities, manages to cure a patient's syndrome without knowing the nature of its underlying cause. An example of such a treatment is the curative treatment provided patients with certain tissue-types of cancer by applying various combinations of surgery, chemotherapy, and radiation therapy.    


During the philosophy of medicine's intelectual development a debates, nearly continually, has existed between empiricists and dogmatists (rationalists). Empiricists indicated, "It is not", they said, "the cause but the cure of diseases that concerns us; not how we digest, but what is digestible." ( 4 ) "...Empyrics, excluded all reasoning, and trusted solely to experience." Contrarily, however, "...Dogmatists, maintained, that no man ought to prescribe, withoput being able to give a theory both of the disease and of the nature of the action of the medicine. This dispute continued for ages , anbd, like other disputes of a similar nature, remains still in some measure undecided." ( 5 )
For instance, if a patient has congestive heart failure with pulmonary edema, an enlarged heart, and swelling of the lower extremities it is common to provide the patient with diuretics, digoxin, and arterial dilators to improve the adverse physical findings of their condition. Usually, such treatment "works" in a meaningful fashion, but it does not deal with the underlying disease or its cause, which resulted in an acute malfunction of the heart. A similar relationship exists between cholecystitis and cholecystectomy. Surgically removing a patient's gall bladder removes the inflamed, poorly functioning organ and also removes the gall stones that often form within it. The surgical procedure often decreases patient discomfort, but it does not deal with the underlying disease, or its cause, that resulted in the gall bladder's abnormalities to originally develop. Similarly, tranquilizers improve a patient's feelings of anxiety, but they do not change the pathological phenomenon, organic or behavioral, that caused it. Finally, insulin injections lower serum glucose levels, but they do not improve the functioning of the islands of Langerhands of the pancreas, which have been harmed by a poorly understood autoimmune process the cause of which is unknown. Basically, in all the above common therapeutic approaches the therapy provided a different or opposite result as that caused by the underlying pathological process in the certain organ. One could confidently say that the treatments mentioned above altered, for the better, the specific organ damage or malfunction described, which were caused by unknown, underlying disease-processes, which have unknown causes.  


A theorist in medicine, Asclepiades, during the first century CE, introduced Greek medicine into Rome. He had developed a philosophic system of health and disease that was mechanistic, since it was "...based on  the doctrine of Leucippus and Democritus,..." "Out of the teachings of Aslepiades that physiological processes depend upon the particular way in which the ultimate indivisible molecules come together there was developed...a system of medicine characterised by the most engaging simplicity both of diagnosis and treatment. This so-called "Methodic" system was intended to strike a balance between the excessive leaning to apriorism shown by the Rationalist (Hippocratic) school and the opposite tendency of the Empiricists...They held that the molecular groups constituting the tissues were traversed by minute channels (pores); all diseases belonged to one or the other of two classes: if the channels were constricted the disease was one of stasis, and if they were dilated the disease was one of flux. Flux and stasis were indicated respectively by increase and diminution of the natural secretions; treatment of opposites by opposites--of stasis by methods causing dilation of the channels, and conversely."
The above allopathic, semi-empiric method of medical practice usually provides for an improvement in patients' medical maladies, however, it is limited in concept, because it foregoes a rationalist's concept that, ultimately, the underlying pathological disturbance that causes organ damage, and its cause, must be known before cures can be developed, an idea which was held by Galen. For instance, Galen indicated, "Nature does nothing for no reason." and "Nothing occurs without a cause...So if a natural activity such as vision is damaged or impeded, one should look for the cause, i.e. a particular disposition of the body...The doctor, at any rate, directs his therapy at the disposition being the cause of the impairment." ( 3 )


Wild as it may seem, this pathological theory of the Methodists contained an element of truth; in various guises it has cropped up once and again at different epochs of medical history; even to-day there are pathologists who tend to describe certain classes of disease in terms of vaso-constriction and vaso-dilation. The Methodists illustrate for us the tyranny of names. In its defects as in its virtues this school has analogues at the present day; we are all acquainted with the medical man to whom a name (such, let us say, as "tuberculosis, " "gout," or "intestinal auto-intoxication") stands for an entity, one and indivisible, to be treated by a definite and unvarying formula.
The development of medical science had progressed, slowly, in a waxing and waning fashion, over a long period of time so by 1850, for instance, if a patient did not have a laceration, burn, sprain, or fracture, medical problems for which causes were known, no medical condition could be treated directly in curative fashion by empiric means. Finally, ''the most meaningful advance in recent medical history'' occurred during the 1870's with the discovery of the microbiological hypothesis of infectious diseases by Robert Koch, a "country physician" in Germany. After the "causes" of infectious diseases were determined a rational effort towards curing them was enabled; antibiotic and vaccine development was the result that effort.  


To such an individual the old German saying "Jedermann hat am Ende ein Bischen Tuberkulose" (Every man has in the end a little tuberculosis) is
Modern medicine, basically, is a syndrome (idiopathic disease) altering art that has incorporated certain treatments to alter, usually for the better, certain syndromes. This paradigm is enforced by the concept of ''evidence based medicine'', which itself defines the organization of medical practice wherein ''only'' certain individuals, who work in medical-educational and research institutions, have the right to accomplish medical research and determined that a certain quasi-empiric treatment, usually biochemical in nature, provides some measure of decrease in the signs and symptoms of a certain syndrome. Since the cause of the syndrome, in question, is not known, however, the treatment is syndrome-altering, and not disease curing, in nature.
simply---incomprehensible." ( 5 )


In addition, perhaps, the Greek word, rheum, the word-root of the English word, rheumatism, referred to a certain disease state, rheumatic fever, in which a "fluxion", or flowing, of joint pain, and at times, swelling, and neurological/muscular pain, such as low-back pain (lumbago) appeared to move, or flow, from one body part to another.  
Unfortunately, over time, the concept of ''evidence based medicine'' has mandated the exclusion of the newly developed medical information (rationally developed, empiric, medical information) that has been learned and accumulated by hundreds of thousands of clinical physicians, because they do not work within the confines of the ''medical, academic establishment''. Even though the physicians, mentioned above, underwent training in the same medical, academic establishments they are not allowed to use their institutionally learned knowledge, knowledge that is enhanced through a long involvement in clinical medicine, to augment the functional medical knowledge used by the medical community. Galen, himself, shunned such a scholastic arrangement for he thought that "authority", even academic authority, in any intellectual field shouldn't be respected and that each investigator's contribution to medical knowledge should be rated on its own merits and not depend upon the investigator's position in the medical, academic, political hierarchy.  


Galen was an adherent to the Hippocratic persuasion and considered the "four humors": phlegm, blood, black bile and yellow bile important factors in disease development. Perhaps his concept of ''rheumatismos'' was connected to an apparent excess of phlegm that he observed in certain patients who experienced chronic sinus drainage and in patients who experienced acute respiratory diseases, which had, as one of their signs, the production of phlegm during coughing or experienced it flowing from the nose.
Hippocrates' (and Galen's) concept of ''Physis (nature) and the faculties, or powers, that are intrinsically part of it are probably, together, the same as the modern concept of biochemical homeostasis and the elements, genetic or otherwise, that guide its function. In a stable homeostatic state biochemical mechanisms normally maintain the body in a state of health, or vital equilibrium. When a disease-state develops, whether it be, for instance, a fractured bone, an infection by a microorganism, or autoimmunological damage to the thyroid gland causing hypothyroidism, the various biochemical faculties (powers) that are an intrinsic part of the body's ''Physis'' (nature) tend to homeostatically combat the individual's disease-state in an attempt to restore health. The physician's task was to aid the body's natural tendency to restore health by the use of "lifestyle" advice, dietary direction, medical treatments (often herbal treatments), and, at times, surgical treatment. Physicians should ideally, in principle, therefore, simply ''assist'' the naturally existing faculties, or powers, of "..."Physis" (nature) that exist within the unity of the body so that health is preserved, or, in case of disease, restored. ( 3, 12) ''


Somewhat recently, Benedict Massell, MD, in his classic text, "Rheumatic Fever and Streptococcal Infection", thoroughly reviews, with a historical approach, the disease of rheumatic fever. The following comprises the first sentence of his book: "In ''The Old Wives Tale,'' Arnold Bennett called rheumatic fever the "dread disease." Bennett's allusion to this malady in his most popular novel, published in 1908, but set in the second half of the 19th century, shows that so feared was the diagnosis of rheumatic fever that the physician of this story chose to lessen his patients's worry by referring to her condition as "acute rheumatism." ( 4 )
Concerning Hippocrates' contribution to medicine the following is written: "The revolution which he caused in practical medicine, semeiology, pathology, and dietetics, was the more important from the plans adopted before him by the Asclepiadae and the philosophic sects being in no respect adapted for the improvement of the science. He taught physicians that their first duty is to observe attentively the progress of nature. He demonstrated the inutility of theories, and proved that observation alone is the basis of medicine. The curative art, having become, from his example, a science of experiment and of facts, ought to have made the most rapid progress...These brilliant hopes were not, however realized." ( 13 )  


Further, to indicate how acute rheumatism (rheumatic fever) remained a highly serious disease during the middle years of the 1900's, Dr. Massell writes, "For the period 1939-1943, statistics published by the Metropolitan Life Insurance Company indicated that rheumatic fever was the leading cause of death among policy holders for persons from five to nineteen years of age and the second leading fatal disease among twenty  to twenty-four year olds." ( 4 )
Galen, who practiced medicine about 600 years after Hippocrates, emulated many of his concepts, for instance, Hippocrates' humoral concept: Hippocrates, "...supposed the existence of four fluids in the body, -- blood, phlegm, and yellow and black bile. Their common source he ascribed to the stomach, but each had, also, its particular origin, --the blood from the heart, phlegm from the head, yellow bile from the gall-duct, and black bile from the spleen." ( 13 ) Also, there were four qualities, heat, cold, moisture, and dryness associated with the humors. All were important factors in the healthy state and in disease development and treatment. ( 3 )


In addition, Dr. Massell reviews the concept of migratory arthritis, which is often a finding in high-grade cases of rheumatic fever, for instance: "Hippocrates (about 400 B.C.) mentioned acute migratory arthritis which may very well have been rheumatic fever..." ( 4 )
One can understand the concept of the four humors in a reasonable fashion if it is understood that blood is red arterial blood [with air (oxygen) within it], which originated in the heart; black bile was deoxygenated blood with erythrocyte break-down products within it, which was stored in, and which flowed from, the spleen; yellow bile was normal bile that originated in the liver and which flowed, via the bile ducts, to the gall bladder for storage. Phlegm was mucous or other clear secretions or excretions within, or from, a specific organ. For instance, phlegm, clear or purulent, which is expectorated during coughing; phlegm that composes the matter of sinus drainage, acute or chronic, and tears, which can exist in copious amounts during an allergic episode. Mucous that is normally secreted from the endothelial lining of most organs of the gastrointestinal tract was also considered to be an aspect of phlegm. It was thought that purulent matter, pus, was a type of phlegm. In addition, mucous secreted by the uterine lining and which departed via the uterine os, and saliva, were both categorized as phlegm.  


"An even clearer description of rheumatic polyarthritis is included in the writings of the famous English physician Thomas Sydenham (1624-1689). Sydenham recognized the importance of careful bedside observations, and these observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitus Dance (1686) and gout (1683). Sydenham's description of polyarthritis, migratory arthritis, is as follows: "...the patient is attacked by severe pains in the joints, sometimes in one and sometimes in another, sometimes in his wrist, sometimes in his shoulder, sometimes in the knee--in this last joint oftenest. This pain changes its place from time to time, takes the joints in turns, and affects the one that it attacks last with redness and swelling." ( 4 )
Further, Galen indicates: "The humors are defined by their associated qualities: 'yellow bile is hot and dry in power, black bile dry and cold, blood is moist and hot, while phlegm is moist and cold' " ( 3 ) The four humors all flowed throughout the body especially within the arteries and veins in an appropriate balance during the healthy state. An elevation of yellow bile as in jaundice, or of phlegm as noted in a respiratory disease, dropsy (edema in the legs), within the swollen joints of arthritis, copious amounts of phlegm in chronic sinus drainage, or abnormally abundant tearing as in allergies, for instance, were thought to be imbalances of the above-named humors.


Within the A ''Dictionary of Medical Science'', published in 1874, rheumatism is profusely defined: "'''Rheumatism''',"...A kind of shifting phlegmasia or neuralgia, sometimes seated in the muscles, sometimes in the parts surrounding the joints; and at others, within them...Hence the names Muscular, Articular, and Synovial, which have been applied to it. The disease may be acute or chronic." Further, "When accompanied by the deformity of a joint, it is called ''Arthritis deformans''. In addition, When it affects the hip-joint of old people, it is called ''Morbus coxae senilis'' Further, 'Rheumatism, Cerebral,' ''Rheumatic Meningitis, Rheumatic Apoplexy''. Meningitis occurring during the progress of acute rheumatism..." "''Rheumatism, Chronic,...is attended by pains in the hips, shoulders, knees, and other large joints. These are at times confined to one joint; at others, shift from to another, without occasioning inflammation or fever. In this manner the complaint often continues for a great length of time, and then goes off." Continuing, "Rheumatism, Synovial...a rheumatic affliction, in which an accumulation of non-purulent fluid occurs in the synovial sacs, especially of the knee joints." In addition, "Rheumatism, Visceral. Rheumatism affecting the muscular or fibrous tissues of the viscera.", and finally, "'''Prosoporrheuma''',...Rheumatism affecting the face.", which probably was also termed, rhinoscleroma and "...''rhinocephale'',...A term applied ...to a monstrosity characterized by a projection of the nose..." Rhinophyma is probably the currently used term for the older word, rhinocephale. The above definitions consist of only a small sample of the extensive, detailed, list of maladies, that are aspects of the systemic disease of rheumatism, defined in the above-mentioned dictionary. ( 5 ) 
At the time Galen was involved in medical practice it was thought, by many, that mucous from the nose, and possibly that which was expectorated from the lungs and the trachea during respiratory diseases, originated from the brain and it entered the upper respiratory tract through small holes that exist in the cribiform plate, a part of the ethmoid bone located at the base of the brain above the nasal passages. If a person considers the concept anatomically, and realizes that without microscopy there was no way that physicians, in the early days of medicine, could know about secretion from respiratory epithelium, and considering the existence of copious amounts of clear cerebrospinal fluid within and surrounding the brain, the idea of mucous originating from the brain is more understandable. The limited physiological and anatomical knowledge that physicians had during the period of time that Greek medicine was influential caused those physicians to make rational judgements that were, eventually, over a thousand years later, proved to be incorrect, because their observations were not empirically complete, especially without the benefit of microscopy. Later scientific discoveries made by William Harvey, Marcello Malpighi, Andreas Vesalius, and others, were enabled by the earlier efforts by, usually, the earlier Hellenic and Hellenistic natural philosophers.  


Within "The Americana" encyclopedia, published in 1908, rheumatism is defined as follows: "'''Rheumatism''', a constitutional disease characterrized by inflammation of the connective-tissue structures of the body, especially of the joints and muscles, and attended by localized pain. It is usually recurrent. Three forms are recognized: (1) acute rheumatism (acute articular rheumatism, acute inflammatory rheumatism, rheumatic fever); (2 ) chronic rheumatism; (3) muscular rheumatism or myalgia. ( 6  )  
The Hippocratic humoral concept stressed that individuals' personality type were caused by the predominant humor imbalance within them. An excess of blood caused the sanguine personality, an excess of yellow bile caused the bilious personality, an excess of black bile caused the melancholic personality, and an excess of phlegm caused the phlegmatic personality. Eventually the word humor was taken into the English language as in: Mary, what humor are you in today? Many words in the English language have been developed from the humoral concept of the body's make-up; for instance, the English word, bilious, describes the emotional state of a person who is excitedly angry, irritable or peevish. Depression, perpetual sadness, and a slow moving demeanor were thought to be caused by the patient having an excess of black bile. Thus, the English word, melancholy is derived as follows: [ ME melancholie > LL melancholia < Greek: black bile ]. Phlegmatic has a similarly derived meaning: "1. not easily excited to action or display of emotion; apathetic; sluggish...3. of the nature of or abounding in the humor phlegm." ( 8 )  


Within a respected medical text by Sir William Osler and Thomas McCrea, ''The Principles and Practice of Medicine'', Eighth Edition, published in 1912, and a more recent version of the text, ''Osler's Principles and Practice of Medicine'', Twelfth Edition, published in 1935, provide extensive reviews of rheumatic fever, its epidemiology, and its sequeale. ( 7, 8 ) In the first-mentioned text the subject of "cerebral rheumatism" is discussed, for instance.
A certain disease state, which appeared epidemically, at times, caused patients to frequently experience a great amount of pain ( as noted in the text, ''The Hippocratic Writings'', The Epidemics, Books I, II, and III. ( 7 ). In addition, within the  above mentioned text, within the chapter titled, "The Sacred Disease", Hippocrates writes as follows concerning conditions that feature an overabundance of phlegm: "Now this disease attacks the phlegmatic but not the bilious." "Sometimes phlegm, which should have been  purged out during life in the womb, remains during early life and is only got rid of in the later years.This is what happens in the case of children who suffer from ulcers of the head and flesh, and who salivate and discharge mucus; they get better as they grow older. Those who have been purged of the phlegm in this way are not troubled by this disease, but those who have neither been purged in this way by ulceration and discharges of mucus and saliva, nor have been purged in the womb, are liable to be attacked by it." "...If the discharges should make their way to the heart the chest is attacked and palpitation or asthma supervenes; some patients even become hump-backed. For when cold phlegm reaches the lungs and heart, the blood is chilled and the blood-vessles, as a result of being violently cooled in the region of the lungs and heart, jump and the heart palpates. Such circumstances force the onset of asthma and diseases characterized by orthopnoea because, until the phlegm which has flowed down has been warmed and dissipated by the blood-vessels, it is impossible to inspire as much air as is needed. When the phlegm has been removed, palpitations and asthma stop...Feelings of pain and nausea result from inopportune cooling and abnormal consolidation of the brain and this affects the phlegm. The same condition is responsible for the loss of memory." ( 7 )


Gene Stollerman, MD, authored the text, ''Rheumatic Fever and Streptococcal Infection'', that was published in 1975, which contains a highly interesting, complete, and wise, review of rheumatic fever from a clinical, as well as a historical, approach. Every physician treating patients should read it. ( 9 )  
Within the book (chapter) Epidemics Book I, the following


Within ''Webster's New Twentieth Century Dictionary'', published in 1976, rheumatism is defined as follows: "rheumatism, ''n''. [L., ''rheumatismus''; Gr. ''rheumatismos'', libability to rheum.] 1. any of various painful conditions of the joints and muscles, especially, a disease believed to be caused by a microorganism and characterized by inflammation and pain of the joints. 2. Rheumatic Fever. Further, to clarify the statement, "liability to rheum.", the definition of the word rheum is provided: "rheum (rum), n. [OFr. ''reume'', a catarrh; L. ''rheuma''; Gr. ''rheuma'', a flow.] 1.any watery or catarrhal discharge from the mucous membranes, as of the mouth, eyes, or nose. 2. a cold; rhinitis; catarrh. salt rheum, any of the various skin diseases, especially eczema." In addition, the word flux has many definitions. The definition as applied to human pathology is as follows: 1. the act of flowing; the motion or passing of a fluid; flow...6. any excessive or unnatural discharge of fluid matter from the body...to flow or stream out." Additionally, the word, catarrh is defined to mean: "catarrh'...''n''. [L. ''catarrhus''; Gr. ''katarhoos'', from ''katarrhein'', to flow down; ''kata'', down, and ''rhein'', to flow.] an inflammation of the mucous membrane, more particularly of the throat and nose, accompanied by an increased secretion of mucous; as nasal catarrh; catarrh of the stomach." Finally, within the same dictionary rheumatic fever is defined as follows: rheumatic fever, an infectious disease associated with the presence of streptococci in the body; it most commonly attacks children, and is characterized by fever, pain and swelling of the joints, inflammation of the heart valves, etc." ( 10 )
Hippocrates and Galen, considering their concept of the functional unity, or holistic view of the body, perhaps developed the idea that rheumatism (rheumatismos) was a painful, systemic, disease process ultimately caused by, or related to, the over-abundance of phlegm that they observed "flowing down" chronically or acutely when patients experienced certain respiratory diseases. Dependent edema (dropsy), lymphedema, asthma, chronic bronchitis, excessive tearing during an allergy attack (rheumy eyes) and swollen arthritic joints are all examples of conditions that, hypothetically, were considered to be caused by an excess of phlegm in the body. The following terms describing rheumatic condition have been conserved from prior eras and they help in an understanding of the systemic disease of rheumatism:


Within ''Dorland's Illustrated Medical Dictionary'', published in 1988, the Greek word, rheum, the word-root of rheumatism, is defined to mean: "rheum, rheuma...[Gr. rheuma flux] any watery or catarrhal discharge."  The word rheumatism is defined extensively, in the same text, and many systemic, pathological manifestations of rheumatism are listed, for instance: "Any variety of disorders marked by inflammation , degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. '''apoplectic rheumatism''', rheumatism associated with brain hemorrhage; '''cerebral rheumatism''', acute rheumatic fever marked by chorea, delirium, convulsions, and coma; '''rheumatism of the heart''', involvement of the heart by the rheumatic fever process; '''lumbar rheumatism''', lumbago; '''rheumatism confined to the joints''' is classified as arthritis; '''muscular rheumatism''', fibrositis; and '''articular rheumatism''', rheumatic fever..." There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. Within the text, the word, rhinophyma is defined as follows: "rhinophyma...usually seen in men and characterized by thickened, lobululated overgrowth of the sebvaceous glands and epithelial connective tissue." ( 11 )
Concerning Hippocrates and Galen's definition of rheumatismos, mentioned above, the key to further understanding is to determine what disease state, in particular, caused, or/or now cause, the ''flowing down of phlegm, catarrh'' (a meaningfully severe respiratory disease), and also cause patients to experience a great amount of pain as a symptom of inflammation.


In addition, rheumatism is defined in ''Webster's Encyclopedic, Unabridged Dictionary of the English Language'', published in1989 as follows: "...1. any disorder of the extremities or back, characterized by pain and stiffness. 2. see rheumatic fever...catarrh, rheum..." Also rheum is defined as follows: "...1. a thin, serous, or catarhal discharge. 2. catarrh; cold...(to) flow...--''rheumic'', adj." ( 12 )
During the philosophy of medicine's intelectual development, a debate, nearly continually, has existed between empiricists and dogmatists (rationalists). Empiricists indicated, "It is not", they said, "the cause but the cure of diseases that concerns us; not how we digest, but what is digestible." ( 5 ) In addition, "...Empyrics, excluded all reasoning, and trusted solely to experience." Contrarily, however, "...Dogmatists, maintained, that no man ought to prescribe, withoput being able to give a theory both of the disease and of the nature of the action of the medicine. This dispute continued for ages , and, like other disputes of a similar nature, remains still in some measure undecided." ( 8 )  


For a long period it was known that acute rheumatism (rheumatic fever) was an epidemical disease. For instance, within the first issue of the ''Encyclopedia Britannica'' published between 1769 and 1771 the following is written in the section titled, ''Of the'' Rheumatism, within the chapter describing the science and art of medicine:
At any particular time in history knowledge is finite. Physicians, then, must use "known knowledge" of the causes of diseases to rationally determine proper cures for those diseases. An example of that principle is the discovery of the bacteriological cause of infectious diseases, which occurred in the 1870's, but which had, for thousands of years, been known as contagions. Shortly thereafter, about sixty years later, the discovery and use of antibiotics such as sulfonamide and penicillin occurred. If the cause of a certain disease is not known physicians must use trial and error methods, which have been used for untold centuries, in order to find an alleviating treatment for a syndrome. Currently, the trial and error technique used to determine if a chemical has beneficial or adverse pharmaceutical characteristics is termed, a ''clinical trial''.


"The rheumatism chiefly attacks persons in the flower of their age...It begins with chillness and shivering, followed by inquietude and thirst. Which is preceded with spontaneous lassitude, a heaviness of the joints and coldness of the extreme parts. When the fever appears, there is an inward heat, chiefly about the-praecordia, attended with anxiety. The pulse is quick and straight, the appetite is lost, the body coftive. In a day or two, sometimes sooner, the patient feels a racking pain,sometimes in one joint and sometimes in another, but more frequently  in the wrists shoulders and knees; frequently shifting from place to place...The pain is exasperated with the least motion; it sometimes attacks the loins and the coxendix (coccyx)....When it seizes the loins it is called the lumbago;...it may continue for months and years , but not with the same violence, but by fits." Further, "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds. And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1737, would yield to..." ( 13 )
Since 99% of diseases that are discussed in modern medical texts have no known cause they should be identified as symptom and sign patterns, syndromes, rather than well-defined diseases. Most treatments for most syndromes, even today, are ''usually syndrome altering and rarely syndrome curing'' and that includes surgical as well as medical approaches to treatment. Examples are: orthopedic surgery for arthritis of the knee and hip, coronary by-pass surgery for arteriosclerosis of the coronary arteries and removal of the gall bladder. In addition, the use of steroid and non-steroid anti-inflammatory medications for arthritis, diuretic and vascular dilator medications for hypertension, and various tranquilizers for various mental syndromes.


A few sentences quoted above are particularly salient and rate repeating: "When it seizes the loins it is called lumbago;...it may continue for months and years, but not with the same violence, but by fits....The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds."
Perhaps Galen noticed the painful sensations of rheumatism seemed to flow from one body part to another, for instance, to certain nerves as in sciatica (sciatic rheumatism), to certain muscles as in lumbago, toticollis, intercostalitis, dorsodynia, and to muscles in a diffuse fashion such as the pain of  fibromyalgia (muscular rheumatism), and to the joints as in acute and chronic arthritis. In addition, painful sensations to the head (headache)  is often caused by trigeminal neuralgia and neuralgia of the trigeminal nerve branches that supply the meninges of the brain. Further, to the chest where it causes pericarditis and pleurisy, to the brain where it caused chorea, seizures, stupor and coma (rheumatism of the brain), and to the gastrointestinal system where it causes crampy abdominal pain and other functional abnormalities ( 7, 8, 9 )


In addition, within the text, ''Hippocratic Writings'' and the book (chapter) titled "Epidemics, Book I", many case histories are provided wherein patients' symptoms and signs are similar to those later described in cases of rheumatic fever by physician-authors such as Thomas Sydenham and, especially, Sir William Osler and Thomas McCrea who authored classic medical texts, cited above, during the first half of the 1900's. ( 14 )  
Somewhat recently, Benedict Massell, MD, in his classic text, "Rheumatic Fever and Streptococcal Infection" thoroughly reviews, with a historical approach, the disease of rheumatic fever. The following comprises the first sentence of his book: "In ''The Old Wives Tale,'' Arnold Bennett called rheumatic fever the "dread disease." Bennett's allusion to this malady in his most popular novel, published in 1908, but set in the second half of the 19th century, shows that so feared was the diagnosis of rheumatic fever that the physician of this story chose to lessen his patients's worry by referring to her condition as "acute rheumatism." ( 9 )


Sydenham, Osler, and McCrea categorized the following symptoms and signs to be those of rheumatic fever: 1. Rheumatic fever often attacks healthy, young people. 2. It causes a fever and often a feeling of heat in the chest. 3. The extremities are often cool. 4. Patients often experienced a prior, or concurrent, respiratory disease (bronchitis, sore throat, tonsillitis). 5. Patients often have arthritis pain or swelling and pain in the joints. 6. The disease causes some patients to have hyperesthetic skin. 7. Sometimes individuals have a rash that appears like hives, papules or a miliary rash. 8. Patients with rheumatic fever often experience headache. 9. Frequently, patients have low-back pain (lumbago). 10.  Rheumatic fever can be mild and wax and wane, over time. 11. Patients with rheumatic fever can have delirium, seizures, stupor or coma. 12. Individuals who experience rheumatic fever have gastrointestinal disturbances including diarrhea, constipation, abdominal pain, etc. 13. Rheumatic fever occurs in a repeated fashion. 14. Rheumatic fever often features swelling of the cervical lymph nodes. 15. Patients with rheumatic fever usually have a reasonably normal pulse, but with more severe disease they frequently have cardiac arrhythmias. 16. At times, patients have hyperesthesia and even gentle pressure to the skin is painful. Perhaps a Greek word for it is causus. 17. Mild, subacute rheumatic fever can cause painful feelings in many parts of the body. 19. Sweating was common and odiferous. 20. Fall, winter and spring feature the most numerous cases.  21. Usually, there is a fairly low death rate from rheumatic fever, however, virulence of the Streptococcus, which causes it is highly variable. 22. Childbed fever is caused by Streptococcus pyogenes and has similar systemic signs and symptoms as rheumatic fever. 23 Splenomegaly is common. 24. A change in the weather to a cool, often damp, pattern seems to encourage the development of rheumatic fever. 25. Rheumatic fever seems to be a family disease. 26. Concerning the pain of rheumatic fever: "perhaps no disease is more painful; the inability to change the posture without agonizing pain, the drenching sweats, the prostration and helplessness, combine to make it a most distressing affection. ( 8 ) 27. Anemia is common. 28. Epistaxis is not uncommon. 29. The urine is, as a rule reduced in amount, of high density and high color. It is very acid, and, on cooling, deposits urates. ( 8 ). 30. Individuals who experience repeated attacks of rheumatic fever can develop dropsy (dependent swelling from congestive heart failure). 31. Deafness in some individuals. 
Further, to indicate how acute rheumatism (rheumatic fever) remained a highly serious disease during the middle years of the 1900's, Dr. Massell writes, "For the period 1939-1943, statistics published by the Metropolitan Life Insurance Company indicated that rheumatic fever was the leading cause of death among policy holders for persons from five to nineteen years of age and the second leading fatal disease among twenty  to twenty-four year olds." ( 9 )


Within the book, ''Epidemics, Book I'', mentioned above, the most common symptoms and signs experienced by various patients were: 1. Causus a word defiined to mean heat; A highly ardent fever...a complication of...inflammatory fever;..." From it, the word caustic evolved. ( 5 ) 2. hemorrhages, the most frequent epistaxis. 3. Swelling near the ears (cervical lymphadenopathy). 4. Young people, especially young men involved with wrestling (close contact) became sick. 5. Patients often had a respiratory disease. 6. Loss of weight in some individuals. The most common combination of symptoms and signs listed were:  5. fever, 6. shivering, and 7. sweating. Further, there was, 8. coolness of the extremities. 9. Their stomachs were disordered and diarrhea occurred. 10. Urine was thin or with a sediment staying dissolved within it. 11. Cough was slight but frequent; in violent cases patients continued to cough up purulent sputum. 12.In most cases the throat was painful, red and inflamed from the first and continued so. 13. Patients refused to take food (lost appetite) and lost weight. They often had no thirst. For instance, "...all suffered from a loss of apetite, and that to an extent which I have never previously encountered." 14. Many became delirious and frequently, thereafter, died. 15. The epidemical disease struck people during all months of the year, but the cool, damp months, and cool damp years featured more sickness. 16 Patients often experienced pain, for instance in the legs, back, head, heart (chest).  17. Patients experienced seizures. 18. Some patients experienced insomnia. 19. Some patients experienced coma. 20. Some patients experienced the development of eruptions (rash)., for instance: "These were red, round and small like those of acne which did not go down."21. Frequently, children, older children (eight to ten years old) and those approaching puberty died. 22. Headache and neck pain. 23. Cases of paralysis (Hypothetically, Guillain-Barre' Syndrome). 24. Childbirth was often followed by disease. 25. Pregnant women aborted. 26. Some women had vaginal bleeding. epistaxis was fairly common. 26. Lividity of parts of the body; extremities. 27. Splenomegaly. 28. Hepatitis. 29. Deafness in some individuals. 30. Hepatitis, signs of jaundice in some individuals. 30 hematuria. 31. Some patients developed dropsy (edema of the legs secondary to heart failure.
In addition, Dr. Massell reviews the historical evidence that migratory arthritis, which is often a finding in high-grade cases of rheumatic fever, has been clinically observed for a long period, for instance: "Hippocrates (about 400 B.C.) mentioned acute migratory arthritis which may very well have been rheumatic fever..." In Dr. Massell's text he indicates various investigators determined that individuals who experienced acute rheumatism (rheumatic fever) often, concomitantly, experienced tonsillitis. ( 9 )  


By comparing the signs, symptoms and epidemiology of the disease described in each of the above two paragraphs, it can be easily determined that most of the signs and symptoms experienced in rheumatic fever, as detailed by Sydenham, Osler and McCrea, were also experienced by patients who had an epidemical disease as recorded in the chapter, Epidemics, Book I, of the ''Hippocrates Writings''.  
In addition, in ''Hippocrates Writings'' within the book, Epidemics Book One, the disease described by providing many case histories is very similar to rheumatic fever as described by Sydenham during the 1600's.  


In addition, frequent mention is made of the existence of phlegm, for instance: "Now this disease attacks the phlegmatic...if these discharges should make their way to the heart , the chest is attacked and palpations and asthma supervenes." and, "For when cold phlegm reaches the lungs and heart...and the heart palpates. Such circumstances force the onlset of asthma and diseases characterized by orthopnoea..." ( 14 ) Orthopnoea, otherwise known as orthopnea, the tendency to have less difficulty breathing in a sitting position, is secondary to heart failure, often rheumatic heart failure that occurs in rheumatic fever.  
In addition, "Guillaume Baillou (1538-1616,...a Parisian physician apparently was the first to use the term "rheumatism" (rheumatismos) for polyarthritis..." "On the other hand the method by which this affection attacks which is falsely called catarrh; (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism..." Dr. Baillou goes on to provide a very good description of acute high-grade rheumatic fever similar to that of Sydenham's of the late 1600's. Further, "Many of the tendons of the superficial muscles of this patient were studded with numerous small hard tumors, an appearance I have observed only in one other person...who also labored under rheumatism." Baillou recognized certain systemic features of rheumatic fever: "The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot nor the hand, nor the finger can be moved in the least without pain & outcry..."


In addition, palpations of the heart are, simply speaking, a cardiac arrhythmia, which often occur in rheumatic fever. ( 8 )
Later, in 1715, Raymond de Vieussens described a patient with acute rheumatic fever. He was determined to have, during autopsy, a severely dilated left ventricle, the walls of the aorta were..."thick, very hard, like cartilage; the semilunar valves are markedly stretched & cut off at their tips: all these cuts which bore some resemblance to the teeth of a saw, were in fact osseous."


Asthma is a clinical presentation of moderate breathing distress that occurs, usually, in young individuals, but it evolves, often becoming more symptomatic, over time. For instance, "Longitudinal studies have since shown that a significant proportion of persons who have chronic asthma exhibit an increased rate of decline in lung function over time, leading to the progressive acquisition of a fixed component of airflow obstruction. Furthermore, asthmatic and COPD populations overlap in peak expiratory flow (PEF) variability." In addition, "Postmortem examination of the lungs of patients who have died of acute severe asthma reveals prominent airway wall thickening, a markedly edematous airway mucosa, and occlusion of bronchial lumen with plugs of viscid mucus ( 15 ) Asthma is, probably, a clinical manifestation of mild, rheumatic pneumonitis and the "plugs of viscid mucous" represent the "rheum" aspect of the disease process. The broncho-constriction, which is pathognomonic of asthma, is, probably, secondary to visceral rheumatic autonomic neuropathy. Both problems are probably severe septic manifestations of the autoimmunological response to Streptococcus pyogenes infections.  
The above two early descriptions of individuals who had acute rheumatism (rheumatic fever) contained most of the elements that have been historically known to exist with that disease: The concept that it occurred after a respiratory disease that caused the development of phlegm (catarrh), rheumatic nodules (small hard tumors), rheumatic vasculitis (red face), wide spread, severe body pain, with joint pain in particular. Also, heart enlargement, especially left ventricular enlargement, arteriosclerotic changes to the aorta, and rheumatic cardiac valve abnormalities.


The exact cause of rheumatic fever puzzled physicians throughout history, even after the bacterial hypothesis of infectious disease was first proven by Robert Koch in Germany during the 1860's. Various streptococcal-types of bacteria were suspected, for a long period, to be involved in rheumatic fever's genesis, but it was not until 1931 that Alviin Coburn in the USA and Wilfred Collis in England somewhat simultaneously published data that proved that Streptococcus pyogenes caused rheumatic fever. It was later learned that a certain strain of Streptococcus pyogenes caused scarlet fever (scarletina). Rheumatic fever and scarlet fever are, therefore, basically, the same disease.( 4 ) Streptococcus pyogenes has a great many strains with varying virulence that are often determined by their M protein antigens. (4 ) Finally, it was determined that the septic phenomenon that occur with rheumatic fever are autoimmune in nature. ( 14 ) The immunological cause of rheumatic fever provided an explanation for the frequently observed delay between an individual's streptococcal respiratory disease and the onset of rheumatic fever's anatomically widespread and, therefore, severe septic, manifestations.  
Later, David Pitcairn, in England, lectured, in 1788, concerning rheumatism and its affect on the heart: "...that persons subject to rheumatism were attacked more frequently than others with symptoms of an organic disease of the heart. Subsequent experience having confirmed the truth of this observation, he concluded, that these two diseases often depend upon a common cause, and in such instances, therefore, called the latter disease rheumatism of the heart." 


Differing from most infectious diseases, rheumatic fever can recur. It is more accurate to understand rheumatic fever to be an "infection-caused autoimmunological disease, not, "purely" an infectious disease that is directly caused by the activity of a microorganism in a direct fashion as one would note in the development of a dermatological infection such as a folliculitic lesion or a carbuncle. Recurrences often occur with more virulence than previous episodes since the immune system experiences an increase in immunological sensitivity and memory with each streptococcal autoantigenic challenge. To decrease recurrences of rheumatic fever prophylactic treatment strategies using chronic sulfonamide and penicillin techniques have proven to be efficacious since immunological sensitivity decreases, over time, if an individual does not experience a meaningful, rheumatic, autoimmunological challenge ( 4 )
The above information provides the knowledge that after the hiatus of creative academic thought that occurred during the Middle Ages physicians during the Renaissance, and later, used the word rheumatism, rheumatic fever, acte rheumatism and chronic rheumatism somewhat interchangeably for they knew that acute rheumatism would lead to chronic rheumatism and they also knew that a contagion, often connected with tonsillitis, or other respiratory disease presentation, could cause it. Since the above physician-writers have indicated that rheumatic fever (acute rheumatism) causes a great amount of pain and that it, often, develops concomitantly with a respiratory disease wherein phlegm is expectorated with coughing, or it flows from the nose as coryza, it seems logical to think that rheumatic fever is the disease that causes chronic rheumatism.


The term, ''sepsis'', is defined as follows: "Animals mount both local and systemic responses to microbes that traverse epithelial barriers and invade underlying tissues. Fever, or hypothermia, leukocytosis, leukopenia, tachypenea, and tachycardia are the cardinal signs of the systemic response often called the systemic inflammatory response syndrome (SIRS). SIRS may have an infectious or noninfectious etiology...When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." Further, " Microbial invasion of the blood stream is not essential for the development of severe sepsis, since local inflammation can also elicit distant dysfunction and hypotension." ( 1 ) Particularly, the invasion of the blood stream by bacteria or virus is termed, bacteremia and viremia, respectively.
As further proof indicating that chronic rheumatism was caused by rheumatic fever the following statement was written during the late 1700's: "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds."


Over time, there have been many synonymous terms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever. ( 4 ) The word rheumatism was often used in older, and even in more recently published scientific texts to mean both acute and chronic rheumatism. ( 4, 13 )
Since high-grade, acute rheumatic fever has become so rare in modern counties most currently practicing physicians have never possessed much clinical knowledge about it. They, therefore, have never gained the knowledge that there are lesser semi-chronic and chronic clinical presentations of rheumatic fever, as defined in "Osler's Principles and Practice of Medicine", published in 1935. ( 8 )  


If the ''concept of severe sepsis'', the phenomenon wherein pathological abnormalities appear distant from a primary site of infection, is integrated with the above information concerning the nature of rheumatism, it appears that ''acute rheumatic fever,'' which is well known to cause pathology within distant organs such as the heart, kidneys, and joints, and ''chronic rheumatism'', which also features pathological changes to organs distant from the site of a Streptococcus pyogenes infection (as indicated by references (  ), above) both have the same, or similar, pathophysiological mechanisms, which cause damage to a numerous and highly varied group of anatomical structures distant from the primary site of infection. Therefore, ''both  conditions'', acute rheumatic fever and chronic rheumatism both have severe, septic manifestations. The key, it seems, to a further understanding of both rheumatic fever, also known, historically, as acute rheumatism, and chronic rheumatism is to understand the pathological mechanism that causes severe sepsis.  
In addition, "In childhood the affection of the joints is usually slight, and may be confined  to a little pain or stiffness in one or two joints, and is sometimes attributed by parents to "growing pains." Further, Rheumatism "...may be applied to cases in which the joint lesions persist after an attack of rheumatism, and chronic inflammatory thickening of the tissues takes place, so that they become stiff and deformed. It is also appropriate to certain joint affections occurring later in life in rheumatic subjects, who are liable to repeated attacks of pain and stiffness of the joints, usually induced by exposure to cold and wet. This form of rheumatism is less migratory than the acute, and is commonly limited to one or two of the larger joints. After repeated attacks the affected joints may become permanently stiff and painful, and crackling or creaking may occur on movement. There is seldom any constitutional disturbance, and the heart is not liable to be affected...The chief varieties of muscular rheumatism are: 1. Lumbago, in which the muscles of the lower part of the back are affected so that stooping, particularly the attempt to rise again to the erect position, induces severe pain. 2. Intercostal rheumatism, affecting the muscles between the ribs, so that taking a deep breath and certain movements of the arms give rise to pain. 3. Torticollis or stiff neck, affecting the muscles of one side of the neck." ( 9 ) 


A unifying conceptual statement, integrating the various concepts and definitions from the above-mentioned dictionaries, texts and e-sites is as follows: Rheumatic fever, and therefore chronic rheumatism, represent a continuum of the same variable, clinical, autoimmune disease from the most acute to the most chronic, caused by a variably severe septic autoimmune response.which is inflammatory in nature, to infections by various strains of Streptococcus pyogenes. The various sources of information, quoted above, uniformly indicate that a meaningful sign of acute rheumatism (rheumatic fever) and chronic rheumatism is the presence of mucous drainage from the nose, mouth, or, even the eyes. In addition, the word, catarrh indicates an increased secretion of mucous as in the term, nasal catarrh. Also, the word rheum can be used to denote "...a cold...or...rhinitis..." Acute rheumatic fever is known for its painful manifestations, but chronic rheumatism usually, also, causes painful maladies throughout the body. It appears, then, that mild, or severe, respiratory infection (s) caused by various strains of Streptococcus pyogenes, can both result in the development of rheumatism, acute and chronic. The disease of rheumatism, acute and chronic, is a clinically variable, autoimmune, severe septic disease since signs and symptoms of rheumatism occur in most of the body's tissues and, therefore, organs. In modern specialty medicine physicians often focus on acute rheumatism's (rheumatic fever's) damage to the heart, but it is a systemic disease process wherein both acute and chronic rheumatism adversely affect all of the body's organs in a waxing and waning fashion, over time.  
Chronic or semi-chronic rheumatic fever hypothetically causes the development of an acute onset subtype of rheumatoid arthritis, for instance: "In approximately 10% of individuals the onset is more acute, with a rapid development of polyarthritis, often accompanied by constitutional symptoms, including fever, lymphadenopathy, and splenomegaly." ( 1 ) Splenomegaly, lymphadenopathy and fever occur in rheumatic fever, but since modern physicians are not aware of the lower-grade presentations of rheumatic fever they, simply, do not realize that it is causing the onset of multi-articular arthritis. In one popular medical text, however, the following is written: "Prolonged Attacks of RF (longer or equal to 8 months) occur in about 5% of patients, with spontaneously recurrent episodes of inflammation...unrelated to intervening streptococcal infection or to cessation of anti-inflammatory therapy. Such recurrent episodes within a prolonged attack are more likely to be associated with carditis. ( 9 )


Rheumatism was a commonly used term in medicine before 1940 and it was often associated with a specific, painful, muscular syndrome, ''muscular rheumatism'', or, synonymously, fibrositis, as indicated in the definition of rheumatism, above. In a noted medical text published in 1935 fibrositis, and therefore, synonymously, muscular rheumatism, are described:  "'''MYALGIA''' (''fibrositis, myositis'') Definition.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probably that in many cases the fibrous tissue is especially affected==a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia, ...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like.It is often sufficiently intense to cause a patient to cry out...The following are the principle varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and upper part of the back." ( 8 )
"An even clearer description of rheumatic polyarthritis is included in the writings of the famous English physician Thomas Sydenham (1624-1689). Sydenham recognized the importance of careful bedside observations, and these observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitus Dance (1686) and gout (1683). Sydenham's description of polyarthritis, migratory arthritis, is as follows: "...the patient is attacked by severe pains in the joints, sometimes in one and sometimes in another, sometimes in his wrist, sometimes in his shoulder, sometimes in the knee--in this last joint oftenest. This pain changes its place from time to time, takes the joints in turns, and affects the one that it attacks last with redness and swelling." ( 9 )


It is important to note that within the last two paragraphs the terms muscular rheumatism, fibrositis, myositis, myalgia are connected synonymously. It is apparent that physicians also thought, what seemed to be pain of a muscular nature was suspected to be, more specifically, caused by neuropathic phenomenon. Also, it is important to realize, as indicated in the above-mentioned definition of rheumatism [reference (3 )], that rheumatism affects connective tissue somewhat selectively. Since, however, the terms connective tissue and fibrous tissue define, virtually, the same histological structures, and since all organs in the body have substantial amounts of connective tissue (fibrous tissue) within their substance, conceptually, then, rheumatism can affect the heart, kidneys, lungs, brain, muscles, ligaments, tendons, synovial sheaths, the gastrointestinal organs, skin, bones, the liver, nerves, and most meaningfully, perhaps, the various elements of the circulatory system for when they are involved it creates a rheumatic vasculitis.  
Within the A ''Dictionary of Medical Science'', published in 1874, rheumatism is profusely defined: "'''Rheumatism''',"...A kind of shifting phlegmasia or neuralgia, sometimes seated in the muscles, sometimes in the parts surrounding the joints; and at others, within them...Hence the names Muscular, Articular, and Synovial, which have been applied to it. The disease may be acute or chronic." Further, "When accompanied by the deformity of a joint, it is called ''Arthritis deformans''. In addition, When it affects the hip-joint of old people, it is called ''Morbus coxae senilis'' Further, 'Rheumatism, Cerebral,' ''Rheumatic Meningitis, Rheumatic Apoplexy''. Meningitis occurring during the progress of acute rheumatism..." "''Rheumatism, Chronic,...is attended by pains in the hips, shoulders, knees, and other large joints. These are at times confined to one joint; at others, shift from to another, without occasioning inflammation or fever. In this manner the complaint often continues for a great length of time, and then goes off." Continuing, "Rheumatism, Synovial...a rheumatic affliction, in which an accumulation of non-purulent fluid occurs in the synovial sacs, especially of the knee joints." In addition, "Rheumatism, Visceral. Rheumatism affecting the muscular or fibrous tissues of the viscera.", and finally, "'''Prosoporrheuma''',...Rheumatism affecting the face.", which probably was also termed, rhinoscleroma and "...''rhinocephale'',...A term applied ...to a monstrosity characterized by a projection of the nose..." Rhinophyma is probably the currently used term for the older word, rhinocephale. The above definitions consist of only a small sample of the extensive, detailed, list of maladies, that are aspects of the systemic disease of rheumatism, defined in the above-mentioned dictionary. ( 10 )  ''


Contained in much older books, for instance, ''The Sacred Disease'', a section of the text titled, ''The Hippocratic Writings'', written by Hippocrates himself or by physicians of the hippocratic persuasion, the symptoms and signs of a common, epidemical disease is discussed. In the book It was termed, "the sacred disease", because practitioners, who were often priest-physicians, commonly thought that individuals who became sick with its signs and symptoms, somehow, had displeased the gods, or a god, and their treatments were directed at appeasing the god, or gods, by having the stricken patient perform one or many acts of appeasement, which, at times, involved pecuniary donations. The disease described is quite like acute rheumatism (rheumatic fever), as it was described by Sydenham in the 1600's. ( 5 ). It is also similar to the description of rheumatic fever in the section: ''of  the Rheumatism'' within the first issue of the ''Encyclopedia Britannica'' printed in 1771. ( 6 )  
Within "The Americana" encyclopedia, published in 1908, rheumatism is defined as follows: "'''Rheumatism''', a constitutional disease characterized by inflammation of the connective-tissue structures of the body, especially of the joints and muscles, and attended by localized pain. It is usually recurrent. Three forms are recognized: (1) acute rheumatism (acute articular rheumatism, acute inflammatory rheumatism, rheumatic fever); (2 ) chronic rheumatism; (3) muscular rheumatism or myalgia." ( 11 )  


The demise of the western Roman Empire caused a dramatic decrease of scientific advances, and, therefore, scientific medical advances, in Western Europe, to be delayed until the Renaissance. During the 1500's physicians such as Guillaume  Baillou (1538-1616) clearly wrote about acute rheumatism (rheumatic fever). For instance:
Within a respected medical text by Sir William Osler and Thomas McCrea, ''The Principles and Practice of Medicine'', Eighth Edition, published in 1912, and a more recent version of the text, ''Osler's Principles and Practice of Medicine'', Twelfth Edition, published in 1935, provide extensive reviews of rheumatic fever, its epidemiology, and its sequeale. ( 7, 8 )  


    "Before we place this affection in a class of disease or symptoms (since it causes its effects by the primary disease and the symptoms produced by it is commonly & very badly confused) just as what it is, we shall explain by what and in what manner it arises: we shall point out the train of pains & symptoms also present.
Gene Stollerman, MD, authored the text, ''Rheumatic Fever and Streptococcal Infection'', that was published in 1975, which contains a highly interesting, complete, and wise review of rheumatic fever from a clinical, as well as a historical, approach. Every physician treating patients should read it. ( 12 )  
   
    On the other hand the method by which this affection attacks which is falsely called catarrh: (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism, is as follows...The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot or the hand, nor the finger can be moved in the least without pain & outcry: moreover in the same way the greater pain lies in the joints because that part is endowed with greater and more exquisite sensation...When the hand is pressed on the parts, the sensation & feeling, (even if you touch lightly) is of a definite severe heat. If you examine the pulse the fever is seen to be little or nothing.


    Indeed the pains are worse at night , the patient cannot sleep, partly because they are unable to be moved from their position & from that posture they first usually lie and recline, they remain in it & are scarcely moved or touched without excruciating pain, tension and a somewhat sharp feeling, others say with the sensation of heat (as already mentioned)...This rheumatism is not the same as in those who sin in their way of life. " ( 5 )
Within ''Webster's New Twentieth Century Dictionary'', published in 1976, rheumatism is defined as follows: "rheumatism, ''n''. [L., ''rheumatismus''; Gr. ''rheumatismos'', libability to rheum.] 1. any of various painful conditions of the joints and muscles, especially, a disease believed to be caused by a microorganism and characterized by inflammation and pain of the joints. 2. Rheumatic Fever. Further, to clarify the statement, "liability to rheum.", the definition of the word rheum is provided: "rheum (rum), n. [OFr. ''reume'', a catarrh; L. ''rheuma''; Gr. ''rheuma'', a flow.] 1.any watery or catarrhal discharge from the mucous membranes, as of the mouth, eyes, or nose. 2. a cold; rhinitis; catarrh. salt rheum, any of the various skin diseases, especially eczema." In addition, the word flux has many definitions. The definition as applied to human pathology is as follows: 1. the act of flowing; the motion or passing of a fluid; flow...6. any excessive or unnatural discharge of fluid matter from the body...to flow or stream out." Additionally, the word, catarrh is defined to mean: "catarrh'...''n''. [L. ''catarrhus''; Gr. ''katarhoos'', from ''katarrhein'', to flow down; ''kata'', down, and ''rhein'', to flow.] an inflammation of the mucous membrane, more particularly of the throat and nose, accompanied by an increased secretion of mucous; as nasal catarrh; catarrh of the stomach." Finally, within the same dictionary rheumatic fever is defined as follows: rheumatic fever, an infectious disease associated with the presence of streptococci in the body; it most commonly attacks children, and is characterized by fever, pain and swelling of the joints, inflammation of the heart valves, etc." ( 13 )


Later, Thomas Sydenham, during the middle to late 1600's, accurately described the clinical features of acute rheumatic fever including the tendency for it to follow a chill, that it seemed to be most common in the autumn, that it was a disease that could attack the young and vigorous, that it was accompanied by fever, disquietude, and thirst, that it featured acute migratory arthritis, and that it was a very painful disease entity. He indicates that its symptoms and signs can wax and wane, over time, so as to be a chronic disease entity. Sydenham's astute clinical observations "...enabled him to record excellent descriptions of many diseases including scarletina (1675), which he named and differentiated from measles, polyarthritis (1767), St. Vitus Dance (1686) and gout (1683)." ( 5 )
Within ''Dorland's Illustrated Medical Dictionary'', published in 1988, the Greek word, rheum, the word-root of rheumatism, is defined to mean: "rheum, rheuma...[Gr. rheuma flux] any watery or catarrhal discharge."  The word rheumatism is defined extensively, in the same text, and many systemic, pathological manifestations of rheumatism are listed, for instance: "Any variety of disorders marked by inflammation , degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. '''apoplectic rheumatism''', rheumatism associated with brain hemorrhage; '''cerebral rheumatism''', acute rheumatic fever marked by chorea, delirium, convulsions, and coma; '''rheumatism of the heart''', involvement of the heart by the rheumatic fever process; '''lumbar rheumatism''', lumbago; '''rheumatism confined to the joints''' is classified as arthritis; '''muscular rheumatism''', fibrositis; and '''articular rheumatism''', rheumatic fever..." There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. Within the text, the word, rhinophyma is defined as follows: "rhinophyma...usually seen in men and characterized by thickened, lobululated overgrowth of the sebvaceous glands and epithelial connective tissue." ( 14 )


During the last half of the 17th, and first quarter of the 18th centuries, Raymond de Vieussens (1671-1715), a French physician, identified, in a given patient, classic historical and clinical features of a fairly young man who has chronic rheumatism secondary to a noted severe disease process occurring earlier in his life. Comments within parenthesis are those of this author. He writes as follows: "Jean Chifort, native of Mouguyo, in Languedoc, Diocese of Montpellier, age thirty-five years (a young age), of a melancholy temperament (depression), & subject to epilepsy for a long time {rheumatism of the brain (  )}, was seized twenty years ago, by a paroxysm of this disease, so violent that he almost fell into apoplexy: (acute rheumatic fever):.." Further, as he was very poor (acute and chronic rheumatism is, classically, often a disease of the lower economic class)..." Further, "After having remarked the sunkenness of his eyes, the puffiness, & the pallor of his face, I examined his pulse, which appeared to be very full, very fast, very hard, unequal, & so strong that the artery of the first one & then the other arm, struck the ends  of my fingers just as a cord would have done which was very tightly drawn & violently shaken...he was suffering from a violent palpitation of the Heart [a case of acute rheumatic fever an individual may experience "...an asymptomatic interval of approximatrely 10 to 20 years, during which the severity of..." aortic regurgitation "...usually increases." ( 10 )]. In addition, "...he told me that for a long time he had not been able to sleep comfortably...if his head were not very high (orthopnea secondary to rheumatic heart disease and, likely, pulmonary edema)." Further, "...the patient died in three days: I opened his body...the left ventricle was extraordinarily dilated (due to increased diastolic pressure); the walls of the trunk of the aorta appeared to me to be very thick, and very hard, & like cartilage (aortic arteriosclerosis); the semilunar valves are markedly stretched & cut off at their tips: all these cuts which bore some resemblance to the teeth of a saw, were in fact osseous (rheumatic cardiac valve disease). And of great importance, "...the lymph which the blood of the canals of the Heart, to which they were very closely attached (canals of the heart: coronary artery system), furnish for nourishment, had no longer a free flow; it was no longer present, at least abundantly enough, in the tissue of the walls of all the branches of the arteries, of which I have spoken; this is why they become dry little by little, & lost enough of their natural suppleness to have the appearance of fingers stretched from one trunk to the other like cords (severe multi-vessel coronary artery arteriosclerosis)." ( 5 )
In addition, rheumatism is defined in ''Webster's Encyclopedic, Unabridged Dictionary of the English Language'', published in1989 as follows: "...1. any disorder of the extremities or back, characterized by pain and stiffness. 2. see rheumatic fever...catarrh, rheum..." Also rheum is defined as follows: "...1. a thin, serous, or catarhal discharge. 2. catarrh; cold...(to) flow...--''rheumic'', adj." ( 15 )


Within the first edition of the Encyclopedia Britannica, printed between 1769 and 1771, it is evident that the physicians of that period had developed a more thorough clinical, as well as basic pathophysiological understanding of rheumatism, in its various forms acute and chronic, since the follow salient informatipn is provided from the chapter on "Medicine", within the article, "of the Rheumatism". The author provides a clinical description of acute rheumatism (acute rheumatic fever) very similar to that provided by Thomas Sydenham during the late 1600's: It includes, an onset in cool weather, fever, lassitude,s gastrointestinal complaints, at times constipation, chest pain, anxiety, a rapid pulse, absent appetite, etc. Thereafter, the author comments on a "...racking pain, sometimes in one joint, sometimes in another, but more frequently in the wrists, shoulders, and knees; frequently shifting from place to place , and leaving redness and selling in the part visited last. The pain is exasperated with the least motion; it sometimes attacks the loins and the coxendix. When it seizes the loins, it is called the lumbago; and there is a most violent pain in the small of the back, which sometimes extends to the os sacrum, and it is like a fit of the gravel (kidney stone), only the patient does not vomit. If this disease is unskillfully treated, it may continue for several month or years, but not with the same violence, but by fits. if it continues and increases it may cause a stiff joint, which will scarce yield to any remedy. Its proximate cause seems to be the inflammation of the lymphatic arteries, of the membranes near the ligaments of the joints, but not so violent as to bring on a suppuration. The blood is like that of persons afflicted with the pleurisy...And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1757..." and further,"...Pringle observes, that rheumatisms are generally mild, though they sometimes appeared with all the violence taken notice of by Sydenham...The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 6 )
For a long period it was known that acute rheumatism (rheumatic fever) was an epidemical disease. For instance, within the first issue of the ''Encyclopedia Britannica'' published between 1769 and 1771 the following is written in the section titled, ''Of the'' Rheumatism, within the chapter describing the science and art of medicine:


The above information is very salient, since the authors understood that acute rheumatism (rheumatic fever) was caused by "...the inflammation of the lymphatic arteries...", now termed, rheumatic vasculitis, the vasculitis that, hypothetically, is a feature of all the rheumatic syndromes described in medical texts. For instance, the vasculitis of rheumatoid arthritis, lupus erythematosis, dermatomyositis, systemic sclerosis, Sjogrens syndrome, etc. That insight indicates that physicians, at that time, the late 1700's, understood the prime, pathophysiological element of rheumatism, acute and chronic, that they understood the clinical features of acute rheumatic fever, which they knew to be a ''highly painful'' disease entity, and they also knew that chronic rheumatism, a chronically painful condition, was caused by a rheumatic fever (acute rheumatism) as well as by lesser levels of respiratory disease, which they termed, "...lesser but but neglected colds."  
"The rheumatism chiefly attacks persons in the flower of their age...It begins with chillness and shivering, followed by inquietude and thirst. Which is preceded with spontaneous lassitude, a heaviness of the joints and coldness of the extreme parts. When the fever appears, there is an inward heat, chiefly about the-praecordia, attended with anxiety. The pulse is quick and straight, the appetite is lost, the body coftive. In a day or two, sometimes sooner, the patient feels a racking pain,sometimes in one joint and sometimes in another, but more frequently  in the wrists shoulders and knees; frequently shifting from place to place...The pain is exasperated with the least motion; it sometimes attacks the loins and the coxendix (coccyx)....When it seizes the loins it is called the lumbago;...it may continue for months and years , but not with the same violence, but by fits." Further, "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds. And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1737, would yield to..." ( 6 )


Later, about 1788, David Pitcairn, A London physician, remarked, "that persons subject to rheumatism were attacked more frequently than others with symptoms of an organic disease of the heart. Subsequent experience having confirmed the truth of this observation, he concluded, that thse two diseases often depend upon a common cause, and in such instances, therefore, called the latter disease rheumatism of the heart." ( 5 )
A few sentences quoted above are particularly salient and rate repeating: "When it seizes the loins it is called lumbago;...it may continue for months and years, but not with the same violence, but by fits....The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 6 )


In addition, the description of severe rheumatic fever as written by Sir William Osler and Thomas McCrea  in their text of 1935 indicates: "Rheumatic fever is the most serious of all diseases with a low death rate. The mortality is rarely above 2 or 3 percent." In addition, In the human infection , the lesions are exudative at first and later proliferative. A hypersensitive state once established, a chronic infection or repeated infection, a chronic infection or repeated slight infections may serve to prolong it and an acute infection may precipitate another attack." Finally, "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced...The onset may be so insidious that it can hardly be termed even subacute." ( 9 )
In addition, within the book (chapter) titled, "Epidemics, Book I" within the ''Hippocratic Writings'' many case histories of patients who became sick in an epidemic are provided. By carefully comparing patients' symptoms and signs they seem to be nearly identical to those later described in cases of rheumatic fever by physician-authors such as Thomas Sydenham, the author of the above description of "The rheumatism..." in 1771, and especially the clinical descriptions, provided by Sir William Osler and Thomas McCrea who authored classic medical texts, cited above, during the first half of the 1900's. ( 7, 8 )  


Sydenham, Osler and McCrea, and from my experience treating hundreds of patients who have had rheumatic fever, the following symptoms and signs are found in individuals who have had, or have, rheumatic fever:
*1. Rheumatic fever often attacks healthy, young people; but it also attacks people of all ages.
*2. It causes a fever and often a feeling of heat in the chest.
*3. The extremities are often cool.
*4. Patients often experienced a prior, or concurrent, respiratory disease (bronchitis, sore throat, ear infections or tonsillitis). Often times an attack of rheumatic fever will follow such an infection by one to five weeks or be concurrent with a more chronic respiratory disease.
*5. Patients often have joint pain or swelling and pain in the joints.
*6. The disease causes some patients to have hyperesthetic skin, which, I surely think, was termed "causes" by Hippocrates.
*7. Sometimes individuals have a rash that appears like hives, papules or a miliary rash.
*8. Patients with rheumatic fever often experience headache.
*9. Frequently, patients have low-back pain (lumbago) and sciatica and other sources of neurological pain such as headaches and brachial plexus neuritis.
*10.  Rheumatic fever can be mild and wax and wane, over time.
*11. Patients with rheumatic fever can have delirium, seizures, stupor or coma.
*12. Individuals who experience rheumatic fever have gastrointestinal disturbances including diarrhea, constipation, abdominal pain, etc.
*13. Rheumatic fever occurs in a repeated fashion.
*14. Rheumatic fever often features swelling of the cervical lymph nodes.
*15. Patients with rheumatic fever usually have a reasonably normal pulse, but with more severe disease they frequently have cardiac arrhythmias.
*16. At times, patients have hyperesthesia and even gentle pressure to the skin is painful. Perhaps a Greek word for it is causus.
*17. Mild, subacute rheumatic fever can cause painful feelings in many parts of the body.
*19. Sweating was common and odiferous.
*20. Fall, winter and spring feature the most numerous cases.
*21. Usually, there is a fairly low death rate from rheumatic fever, however, virulence of the Streptococcus, which causes it is highly variable.
*22. Childbed fever is caused by Streptococcus pyogenes and has similar systemic signs and symptoms as rheumatic fever.
*23 Splenomegaly is common.
*24. A change in the weather to a cool, often damp, pattern seems to encourage the development of rheumatic fever.
*25. Rheumatic fever seems to be a family disease due the highly contagious nature of Streptococcus pyogenes infections.
*26. Concerning the pain of rheumatic fever: "perhaps no disease is more painful; the inability to change the posture without agonizing pain, the drenching sweats, the prostration and helplessness, combine to make it a most distressing affection." ( 8 )
*27. Anemia, of various types is common.
*28. Severe lethargy is a common sign for rheumatic fever.
*29. At times a hypersensitivity of the skin develops, which, I think, Hippocrates termed in his writing titled "On Regimen in Acute Diseases", causus.
*30. Epistaxis is common in higher grade cases of rheumatic fever.
*31. The urine is, as a rule, reduced in amount, of high density and high color. It is very acid, and, on cooling, deposits urates. ( 8 ).
*32. Individuals who experience repeated attacks of rheumatic fever can develop dropsy (dependent swelling from congestive heart failure).
*33. Deafness occurs in some individuals; tinnitus develops commonly, photophobia and even blindness can occur in the most severe cases.   
*34. Patients often feature erythematous facial skin, palms, the plantar surface of feet, and often have erythema around the fingers tips and the toes.   
*35. Rheumatic patients often have highly varied skin abnormalities such as nevi of various types, skin tags, cutaneous horns, meaningful dermographism, and often develop premature greying of the hair and various levels of baldness.   
*36. Neuropathy of the median nerve (carpal tunnel syndrome), ulnar nerve (ulnar neuropathy), peroneal neuropathy, sciatic neuropathy, posterior femoral cutaneous neuropathy, pudendal neuropathy (the latter three together secondary to lumbar plexitis), pudendal nerve,and the brachial plexi are often caused by rheumatic vasculitis. 
*37. The classic pedal and neurological findings of Charcot-Maria-Tooth Disease are sequelae of rheumatic fever in a very young individual.     


Within the book, ''Epidemics, Book I'', mentioned above, the most common symptoms and signs experienced by various patients were: 1. Causus a word defiined to mean heat; A highly ardent fever...a complication of...inflammatory fever;..." From it, the word caustic evolved. ( 5 ) 2. hemorrhages, the most frequent epistaxis. 3. Swelling near the ears (cervical lymphadenopathy). 4. Young people, especially young men involved with wrestling (close contact) became sick. 5. Patients often had a respiratory disease. 6. Loss of weight in some individuals. The most common combination of symptoms and signs listed were:  5. fever, 6. shivering, and 7. sweating. Further, there was, 8. coolness of the extremities. 9. Their stomachs were disordered and diarrhea occurred. 10. Urine was thin or with a sediment staying dissolved within it. 11. Cough was slight but frequent; in violent cases patients continued to cough up purulent sputum. 12.In most cases the throat was painful, red and inflamed from the first and continued so. 13. Patients refused to take food (lost appetite) and lost weight. They often had no thirst. For instance, "...all suffered from a loss of apetite, and that to an extent which I have never previously encountered." 14. Many became delirious and frequently, thereafter, died. 15. The epidemical disease struck people during all months of the year, but the cool, damp months, and cool damp years featured more sickness. 16 Patients often experienced pain, for instance in the legs, back, head, heart (chest).  17. Patients experienced seizures. 18. Some patients experienced insomnia. 19. Some patients experienced coma. 20. Some patients experienced the development of eruptions (rash)., for instance: "These were red, round and small like those of acne which did not go down."21. Frequently, children, older children (eight to ten years old) and those approaching puberty died. 22. Headache and neck pain. 23. Cases of paralysis (Hypothetically, Guillain-Barre' Syndrome). 24. Childbirth was often followed by disease. 25. Pregnant women aborted. 26. Some women had vaginal bleeding. epistaxis was fairly common. 26. Lividity of parts of the body; extremities. 27. Splenomegaly. 28. Hepatitis. 29. Deafness in some individuals. 30. Hepatitis, signs of jaundice in some individuals. 30 hematuria. 31. Some patients developed dropsy (edema of the legs secondary to heart failure.


 
By comparing the signs, symptoms and epidemiology of the disease described in each of the above two paragraphs, it can be easily determined that most of the signs and symptoms patients experienced during an episode of rheumatic fever, as detailed by Sydenham, Osler and McCrea, were also experienced by patients who had an epidemical disease as recorded in the chapter, Epidemics, Book I, of the ''Hippocrates Writings''.  
 
Rheumatism is usually considered to be an archaic term in medicine for it is not listed as a subject in most, modern, medical texts. For instance, it is not listed as a subject in the text, Harrison's Principles of Internal Medicine, 16th Edition published in 2005. ( 1 )
 
Within the 12th edition of the same text, published in 1991, the only listing for rheumatism is psychogenic rheumatism and part of the short paragraph explaining it is as follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 )I think the above synopsis makes obvious the author's lack of observation skills, lack of patient concern, and it is an arch-type example of how some physicians find fault with patients when the they "do not know what is going on" and, in addition, they are too pompous to say, simply, to a patient, I do not know why you hurt so bad. 
 
Physicians, during earlier eras, understood, partially, from a clinical aspect, the disease of rheumatism. For instance, Claudius Galen, who is often, simply, called Galen, was a Greek physician from Pergamum, a city that was located near the present city of Izmir, Turkey. He was provided an eclectic education by his father and he started medical training at a young age. Later, he attended the University at Alexandria, Egypt and became a noted physician in Pergamum and later in Rome. He coined the word, ''rheumatismos'' to describe a condition, which was caused by, or accompanied by, respiratory diseases that featured the production of phlegm or other secretions. ( 3 )
 
For instance, within a reputable medical dictionary, the Greek word, rheum, the word-root of rheumatism, is defined to mean: "rheum, rheuma...[Gr. rheuma flux] amy watery or catarrhal discharge." ( 4 ) It also seems to refer to "a great fluxion which races to various parts of the body, and goes from one to another" ( 5 ) In addition, within the previously cited medical dictionary [reference ( 4 )] the word rheumatism is defined extensively and many systemic, pathological manifestations of rheumatism are listed, for instance: "Any variety of disorders marked by inflammation , degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. '''apoplectic rheumatism''', rheumatism associated with brain hemorrhage; '''cerebral rheumatism''', acute rheumatic fever marked by chorea, delirium, convulsions, and coma; '''rheumatism of the heart''', involvement of the heart by the rheumatic fever process; '''lumbar rheumatism''', lumbago; '''rheumatism confined to the joints''' is classified as arthritis; '''muscular rheumatism''', fibrositis; and '''articular rheumatism''', rheumatic fever..." There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. In addition, over time, there have been many synonyms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever; the word rheumatism, itself, was often used in older, and even more recently published scientific texts, to mean both acute and chronic rheumatism. ( 6, 7 )
 
Rheumatism has, for thousands of years, been generally thought to be a widespread, painful condition with, often, an apparent migrating nature. Severe rheumatic fever, itself, often features migratory arthritis. ( 6, 7 )
 
Rheumatism was a commonly used term in medicine before 1920 and it was often associated with specific, painful muscular syndromes, for instance: "'''MYALGIA''' (''fibrositis, myositis'') Definition.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probably that in many cases the fibrous tissue is especially affected==a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia, ...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like.It is often sufficiently intense to cause a patient to cry out...The following are the principle varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and upper part of the back." ( 8 )
 
It is important to note that within the last two paragraphs the terms muscular rheumatism, fibrositis, myositis, myalgia are connected synonymously. Also, it is important to realize that, as indicated in the definition of rheumatism, above [reference ( 4 )], that rheumatism affects connective tissue somewhat selectively, but since connective tissue and fibrous tissue mean virtually the same histological structure, and since all organs in the body have substantial amounts of it within their substance, conceptually, then, rheumatism can affect the heart, kidneys, lungs, brain, muscles, ligaments, tendons, synovial sheaths, the gastrointestinal organs, skin, bones, the liver, nerves, and most meaningfully, perhaps, the various elements of the circulatory system for when they are involved it creates a rheumatic vasculitis.
 
Much older books, for instance, "The Sacred Disease", a section of the text titled as the "Hippocratic Writings", written by Hippocrates himself or physicians of the hippocratic persuasion, the symptoms and signs of a common, epidemic-like disease is discussed. It was termed, "sacred", because practitioners, who were often priest-physicians, commonly thought that those who became sick with its signs and symptoms, somehow displeased the gods, or a god, and their treatments were directed at pleasing the god, or gods, by having the stricken patient perform one or many acts of appeasement, which, at times, involved pecuniary donations. The disease described is quite like acute rheumatism as it is described by Sydenham in the 1600's. ( 6 ). It is also similar to the description of rheumatism (acute) within the first issue of the Encyclopedia Britannica printed in 1771. ( 7 )


In addition, it is similar to the description of severe rheumatic fever as written by Sir William Osler and Thomas McCrea  in their text of 1935. ( 9 ) It must be understood that, acute rheumatism (rheumatic fever) has the following nature: "Rheumatic fever is the most serious of all diseases with a low death rate. The mortality is rarely above 2 or 3 percent." In addition, In the human infection , the lesions are exudative at first and later proliferative. A hypersensitive state once established, a chronic infection or repeated infection, a chronic infection or repeated slight infections may serve to prolong it and an acute infection may precipitate another attack." Finally, "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced...The onset may be so insidious that it can hardly be termed even subacute." ( 9 ) An accumulation of rheumatic tissue, and therefore organ, damage, over time, can lead to a highly varied array of abnormal function, which can involve all organ systems.  
In addition, it is similar to the description of severe rheumatic fever as written by Sir William Osler and Thomas McCrea  in their text of 1935. ( 9 ) It must be understood that, acute rheumatism (rheumatic fever) has the following nature: "Rheumatic fever is the most serious of all diseases with a low death rate. The mortality is rarely above 2 or 3 percent." In addition, In the human infection , the lesions are exudative at first and later proliferative. A hypersensitive state once established, a chronic infection or repeated infection, a chronic infection or repeated slight infections may serve to prolong it and an acute infection may precipitate another attack." Finally, "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced...The onset may be so insidious that it can hardly be termed even subacute." ( 9 ) An accumulation of rheumatic tissue, and therefore organ, damage, over time, can lead to a highly varied array of abnormal function, which can involve all organ systems.  


Within the first edition of the Encyclopedia Britannica, printed between 1769 and 1771,   
In addition, frequent mention is made of the existence of phlegm, for instance: "Now this disease attacks the phlegmatic...if these discharges should make their way to the heart , the chest is attacked and palpations and asthma supervenes." and, "For when cold phlegm reaches the lungs and heart...and the heart palpates. Such circumstances force the onlset of asthma and diseases characterized by orthopnoea..." ( 16 ) Orthopnoea, otherwise known as orthopnea, the tendency to have less difficulty breathing in a sitting position, is secondary to heart failure, often rheumatic heart failure, which is precipitated by acute rheumatic fever.


 
"The word asthma was first introduced in ancient Greece. It originally referred to the symptom of breathlessness rather than the disease that is recognized today. Mild breathlessness was termed dyspnea, moderate breathlessness, asthma, and severe breathlessness, orthopnea. ( 17 )  Asthma is a clinical presentation of moderate breathing distress that occurs, usually, in young individuals, but it evolves, often becoming more symptomatic, over time. For instance, "Longitudinal studies have since shown that a significant proportion of persons who have chronic asthma exhibit an increased rate of decline in lung function over time, leading to the progressive acquisition of a fixed component of airflow obstruction. Furthermore, asthmatic and COPD populations overlap in peak expiratory flow (PEF) variability." ( 17 ) In addition, "Postmortem examination of the lungs of patients who have died of acute severe asthma reveals prominent airway wall thickening, a markedly edematous airway mucosa, and occlusion of bronchial lumen with plugs of viscid mucus. In a patient who has died of acute asthma, the most striking feature of the lungs at necropsy is their gross overdistention...When the lungs are cut, numerous gelatinous plugs of exudate are found in most of the bronchial branches down to the terminal bronchioles. ( 1 ) Asthma is, probably, a clinical manifestation of mild, or severe, rheumatic pneumonitis and the "plugs of viscid mucous" represent the "rheum", or phlegm, aspect of the disease process so, perhaps, asthma, and other related adverse conditions of the lung could, reasonably, be termed: rheumatism of the lung.   


In addition, palpations of the heart are, simply speaking, a type of cardiac arrhythmia, which often occur in rheumatic fever. ( 8, 9 )


The exact cause of rheumatic fever puzzled physicians throughout history, even after the bacterial hypothesis of infectious disease was first, firmly, proven by Robert Koch, in Germany, during the 1870's. ( 18 ) Various streptococcal-types of bacteria were suspected, for a long period, to be involved in rheumatic fever's genesis, but it was not until 1931 that Alviin Coburn, in the USA, and Wilfred Collis, in England, somewhat simultaneously, published data that proved that Streptococcus pyogenes caused rheumatic fever. It was later learned that a certain strain of Streptococcus pyogenes caused scarlet fever (scarletina). Rheumatic fever and scarlet fever are, therefore, basically, nearly the same disease. ( 9 ) Streptococcus pyogenes has a great many strains with varying virulence that are often determined by their M protein antigens. ( 19 ) Finally, it was determined that the ''septic phenomenon'' that occurs within patients who develop rheumatic fever are autoimmune in nature. ( 12, 19 ) The immunological cause of rheumatic fever provided an explanation for the frequently observed delay between an individual's streptococcal respiratory disease and the onset of rheumatic fever's anatomically widespread and, therefore, severe septic, manifestations.


Differing from most infectious diseases, rheumatic fever can recur and, frequently, recurrences feature a more severe disease presentation. ( 8, 9, 12 ) It is more accurate to understand rheumatic fever to be an "infection-caused autoimmunological disease, not, "purely" an infectious disease, wherein pathological damage to tissues is due to a physically intimate infection as one would note in the development of a dermatological infection such as a folliculitic lesion or a carbuncle. Recurrences of rheumatic fever often occur with more virulence than previous episodes since the immune system experiences an increase in immunological sensitivity and memory with each streptococcal autoantigenic challenge. "Finally,...the trend suggests also that R/I (rheumatic fever attack rate per infection) decreases more strikingly with the time elapsed since the last rheumatic attack than it does simply with the increasing age of the patient. ( 12 ) To decrease rheumatic fever's recurrence rate prophylactic treatment strategies, using chronic sulfonamide and penicillin techniques, have proven to be efficacious. ( 9, 12 ) Immunological (and autoimmunological) sensitivity decreases, over time, if an individual does not experience a meaningful Streptococcus pyogenes infection, and, therefore, does not experience a meaningful, rheumatic, autoimmunological challenge.


During the period I had an active medical practice I had wondering thoughts about many phenomenon. I learned that most diseases are connected, in various ways, to each other. For instance, individuals who experience diabetes are at a high risk to develop coronary artery disease and peripheral neuropathy. In addition, individuals who have ulcerative colitis are more at risk to develop other inflammatory maladies of the gastrointestinal tract and they are, also, at a high risk to develop cancer, they frequently experience neuropathic maladies, and they often co-experience other autoimmune diseases. Similarly, individuals who experience neuropathy are at a higher risk to develop cancer (paraneoplastic neuropathy). In addition, individuals who develop ulcerative colitis are at high risk for developing other autoimmune diseases of gastrointestinal tract, including celiac disease and Crohn's disease and patients with all three diseases feature a higher risk for cancer development and they often experience neuropathic maladies. ( 3, 4 ) In addition, individuals with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosis, progressive systemic sclerosis, and dermatomyositis all experience a decreased life expectancy, they all feature accelerated arteriosclerosis, and they all feature neuropathic pain. ( 3, 4 ) Historically, coronary artery disease has appeared in patients who have exhibited "type A" personalities, who have hypertension, elevated cholesterol, and who also have somewhat horizontal earlobe creases. No one knows, however, the nature of the underlying disturbance, which causes the connection and the "type A" personality is hard to define.
Although high-grade acute rheumatism (rheumatic fever) is obviously important, the lower-grade of acute rheumatism occur at a much higher frequency. These infection caused (by Streptococcus pyogenes), pathological, autoimmune attacks are often quite subtle and individuals only know "something is wrong" due to abnormalities noted, that are often painful, in various anatomical locations. Sciatica, for instance may be caused by rheumatic autoimmunity. Depression, fatigue or listlessness, anxiety are all possible central nervous system phenomenon that can be caused by rheumatic autoimmunity. Shoulder pain, low-back pain, torticollis, headache, low-grade semi-chronic gastrointestinal disturbances, growing pains, tendonitis, rosacea, palmar erythema, plantar erythema, and acne, for instance, are all manifestations of rheumatic autoimmunity.  


The term, ''sepsis'', is defined as follows: "Animals mount both local and systemic responses to microbes that traverse epithelial barriers and invade underlying tissues. Fever, or hypothermia, leukocytosis, leukopenia, tachypenea, and tachycardia are the cardinal signs of the systemic response often called the systemic inflammatory response syndrome (SIRS). SIRS may have an infectious or noninfectious etiology...When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." Further, " Microbial invasion of the blood stream is not essential for the development of severe sepsis, since local inflammation can also elicit distant dysfunction and hypotension." ( 1 ) Particularly, the invasion of the blood stream by bacteria or virus is termed, bacteremia and viremia, respectively.


Over time, there have been many synonymous terms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever. ( 6, 9 ) The word rheumatism was often used in older, and even in more recently published scientific texts to mean both acute and chronic rheumatism. ( 6, 7, 8, 9 )


If the ''concept of severe sepsis'', the phenomenon wherein pathological abnormalities appear distant from a primary site of infection, is integrated with the above information concerning the nature of acute rheumatism (rheumatic fever) and chronic rheumatism, it appears that both ''acute rheumatism" (rheumatic fever) which is well known to cause pathology within distant organs such as the heart, kidneys, brain, peripheral nerves, and joints (to provide a partial review), and ''chronic rheumatism'', which also features pathological changes of a similar nature (as indicated by information in references  7, 8, 10, 11, 14, and 15 above), are both varied clinical manifestations of the same disease process as indicated by physicians in the late 1700's. ( 6 ) After all, Sir William Osler indicated that subacute and less-than-subacute rheumatic fever are common disease entities. ( 8 ) They are the disease states that stimulate the development of the various arthritides that are categorized as the various rheumatic diseases. ''


Both have the same, or similar, pathophysiological mechanisms, which cause damage to a numerous and highly varied group of anatomical structures distant from the primary site of infection and which have key pathological findings such as subcutaneous nodules and the development of coronary artery disease. ( 7, 8, 9, 12, 20 ) Therefore, ''both clinical presentations of rheumatism, that is ''acute rheumatism (rheumatic fever) and chronic rheumatism, which both have similar septic manifestations. The key, it seems, to a further understanding of both rheumatic fever, also known, historically, as acute rheumatism, and chronic rheumatism is to understand the pathological mechanism that causes their severe sepsis. It is Streptococcal autoimmunity. 


Also, I came to realize that since 99% of diseases listed in medical texts have no known cause (they are termed idiopathic diseases), it is more accurate to understand them as syndromes. Syndromes are, simply, adverse medical conditions with somewhat uniform symptom and sign patterns. The word disease is best defined as an adverse medical condition which has consistent symptom and sign patterns, but, in addition, its cause is known. Since the great majority of medical problems have no known cause they are syndromes, therefore, physicians, primarily, do not cure diseases, they alter syndromes, usually for the better. In general, a knowledge of the cause for a disease is a requirement if a cure is to be developed, otherwise medical treatments are, for the most part, syndrome altering in nature.
A unifying conceptual statement, integrating the various concepts and definitions from the above-mentioned dictionaries, texts and e-sites is as follows: Rheumatic fever, and therefore chronic rheumatism, represent a continuum of the same variable, clinical, autoimmune disease from the most acute to the most chronic, caused by a variably severe septic autoimmune response, which is inflammatory in nature, secondary to the occurrence of infections by various strains of Streptococcus pyogenes. The various sources of information, quoted above, uniformly indicate that a meaningful sign of acute rheumatism (rheumatic fever) and chronic rheumatism is the presence of mucous drainage from the nose, mouth, or, even the eyes. In addition, the word, catarrh indicates an increased secretion of mucous as in the term, nasal catarrh. Also, the word rheum can be used to denote "...a cold...or...rhinitis..." Acute rheumatic fever is known for its painful manifestations, but chronic rheumatism usually, also, causes painful maladies throughout the body. It appears, then, that mild, or severe, respiratory infection (s) caused by various strains of Streptococcus pyogenes, can both result in the development of rheumatism, acute and chronic. The disease of rheumatism, acute and chronic, is a clinically variable, autoimmune, waxing and waning, severe septic disease since signs and symptoms of rheumatism occur in most of the body's tissues and, therefore, organs. In modern specialty medicine physicians often focus on acute rheumatism's (rheumatic fever's) damage to the heart, but it is a systemic disease process wherein both acute and chronic rheumatism adversely affect all of the body's organs, over time, in a waxing and waning fashion.   
 
 
Prior medical educational and experiential knowledge was important during my investigation, but most of the salient information I learned, which permitted me to develop an understanding of the cause of chronic neuropathic pain, and other associated medical conditions, was gained by ''repetitiously'' interviewing patients concerning their, and their family members', medical histories and by ''repetitiously'' conducting analytic, neurological, physical examinations. In addition to reading medical information in modern texts, I read parts of many older medical texts, dated from the Hippocratic period, through the Roman period, the Renaissance, and thereafter through the period during which many, great, scientific breakthroughs were accomplished, the 1600's through the early 1900's.
 
 
 
 
 
 
 
Rheumatism is usually considered to be an archaic term in medical science for it is not listed in the index, as a subject, in most, modern, medical texts. For instance, it is not listed in the index of the text, Harrison's Principles of Internal Medicine, 16th Edition published in 2005. ( 1 )
 
Within the 12th edition of the same text, ''Harrison's Principles of Internal Medicine'', published in 1991, the only listing for rheumatism is psychogenic rheumatism; a part of the short paragraph explaining it is quoted a follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 )
 
I think the above synopsis makes obvious the author's lack of observation skills and lack of patient concern, and it is an arch-type example of how some physicians find fault with patients when they ''do not know what is going on'' and they are too imbued with a certain defensive, self-confidence to say to a patient, in a forthright and honest fashion, I do not know why you hurt so bad.
 
Near the beginning of the second century CE, Greek physician  writer and philosopher Galen of Pergamum appears to have coined the term rheumatismos (English, rheumatism), in which rheuma means "to flow" (an alternative meaning is phlegm)." ( 3 ) He, perhaps, coined the word, ''rheumatismos'' to describe a medical condition that, over time, was connected to patients who had experienced chronic mucous drainage, and/or, perhaps, respiratory diseases that were accompanied by the production of phlegm, during their lifetimes.
 
In many texts rheumatic fever was also termed acute rheumatism. ( 4 )
 
In addition, perhaps, the Greek word, rheum, the word-root of the English word, rheumatism, referred to a certain disease state, rheumatic fever, in which a "fluxion", or flowing, of joint pain, and neurological pain, appeared to move, or flow, from one body part to another.
 
Galen was an adherent to the Hippocratic persuasion and considered the "four humors": phlegm, blood, black bile and yellow bile important factors in disease development. Perhaps his concept of ''rheumatismos'' was connected to an apparent excess of phlegm that he observed in certain patients who had chronic sinus drainage and in patients who experienced acute respiratory diseases, which had, as one of their signs, the production of phlegm during coughing or experienced it flowing from the nose.
 
Somewhat recently, Benedict Massell, MD, in his classic text, "Rheumatic Fever and Streptococcal Infection", thoroughly reviews, with a historical approach, the disease of rheumatic fever. The following comprises the first sentence of his book: "In ''The Old Wives Tale,'' Arnold Bennett called rheumatic fever the "dread disease." Bennett's allusion to this malady in his most popular novel, published in 1908, but set in the second half of the 19th century, shows that so feared was the diagnosis of rheumatic fever that the physician of this story chose to lessen his patients's worry by referring to her conditiono as "acute rheumatism." ( 4 )
 
Further, to indicate how acute rheumatism (rheumatic fever) remained a highly serious disease during the middle years of the 1900's, Dr. Massell writes, "For the period 1939-1943, statistics published by the Metropolitan Life Insurance Company indicated that rheumatic fever was the leading cause of death among policy holders for persons from five to nineteen years of age and teh second leading fatal disease among twenty  to twenty-four year olds." ( 4 )
 
In addition, Dr. Massell reviews the concept of migratory arthritis, which is often a finding in high-grade cases of rheumatic fever, for instance: "Hippocrates (about 400 B.C.) mentioned acute migratory arthritis which may very well have been rheumatic fever..." ( 4 )
 
"An even clearer description of rheumatic polyarthritis is included in the writings of the famous English physician Thomas Sydenham (1624-1689). Sydenham recognized the importance of careful bedside observations, and these observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitus Dance (1686) and gout (1683). Sydenham's description of polyarthritis, migratory arthritis, is as follows: "...the patient is attacked by severe pains in the joints, sometimes in one and sometimes in another, sometimes in his wrist, sometimes in his shoulder, sometimes in the knee--in this last joint oftenest. This pain changes its place from time to time, takes the joints in turns, and affects the one that it attacks last with redness and swelling." ( 4 )
 
Within the A ''Dictionary of Medical Science'', published in 1874, rheumatism is profusely defined: "'''Rheumatism''',"...A kind of shifting phlegmasia or neuralgia, sometimes seated in the muscles, sometimes in the parts surrounding the joints; and at others, within them...Hence the names Muscular, Articular, and Synovial, which have been applied to it. The disease may be acute or chronic." Further, "When accompanied by the deformity of a joint, it is called ''Arthritis deformans''. In addition, When it affects the hip-joint of old people, it is called ''Morbus coxae senilis'' Further, 'Rheumatism, Cerebral,' ''Rheumatic Meningitis, Rheumatic Apoplexy''. Meningitis occurring during the progress of acute rheumatism..." "''Rheumatism, Chronic,...is attended by pains in the hips, shoulders, knees, and other large joints. These are at times confined to one joint; at others, shift from to another, without occasioning inflammation or fever. In this manner the complaint often continues for a great length of time, and then goes off." Continuing, "Rheumatism, Synovial...a rheumatic affliction, in which an accumulation of non-purulent fluid occurs in the synovial sacs, especially of the knee joints." Finally, "Rheumatism, Visceral. Rheumatism affecting the muscular or fibrous tissues of the viscera.", and, "'''Prosoporrheuma''',...Rheumatism affecting the face.", which probably was also termed, probably, rhinoscleroma and "...''rhinocephale'',...A term applied ...to a monstrosity characterized by a projection of the nose..." Rhinophyma is probably the currently used term for the older word, rhinocephale. The above definitions consist of only a small sample of the extensive, detailed, list of maladies, that are aspects of the systemic disease of rheumatism, defined in the above-mentioned dictionary. ( 5 ) 
 
Within "The Americana" encyclopedia, published in 1908, rheumatism is defined as follows: "'''Rheumatism''', a constitutional disease characterrized by inflammation of the connective-tissue structures of the body, especially of the joints and muscles, and attended by localized pain. It is usually recurrent. Three forms are recognized: (1) acute rheumatism (acute articular rheumatism, acute inflammatory rheumatism, rheumatic fever); (2 ) chronic rheumatism; (3) muscular rheumatism or myalgia. ( 6  )
 
Within a respected medical text by Sir William Osler and Thomas McCrea, ''The Principles and Practice of Medicine'', Eighth Edition, published in 1912, and a more recent version of the text, Osler's Principles and Practice of Medicine, Twelfth Edition, published in 1935, provide extensive reviews of rheumatic fever, its epidemiology, and its sequeale. ( 7, 8 ) In the first-mentioned text the subject of "cerebral rheumatism" is discussed, for instance.
 
Gene Stollerman, MD, authored a text, ''Rheumatic Fever and Streptococcal Infection'', that was published in 1975, which contains a very complete, and wise, review of rheumatic fever from a clinical, as well as a historical, approach. Every physician treating patients should read it. ( 9 )
 
Within Webster's New Twentieth Century Dictionary, published in 1976, rheumatism is defined as follows: "rheumatism, ''n''. [L., ''rheumatismus''; Gr. ''rheumatismos'', libability to rheum.] 1. any of various painful conditions of the joints and muscles, especially, a disease believed to be caused by a microorganism and characterized by inflammation and pain of the joints. 2. Rheumatic Fever. Further, to clarify the statement, "liability to rheum.", the definition of the word rheum is provided: "rheum (rum), n. [OFr. ''reume'', a catarrh; L. ''rheuma''; Gr. ''rheuma'', a flow.] 1.any watery or catarrhal discharge from the mucous membranes, as of the mouth, eyes, or nose. 2. a cold; rhinitis; catarrh. salt rheum, any of the various skin diseases, especially eczema." In addition, the word flux has many definitions. The definition as applied to human pathology is as follows: 1. the act of flowing; the motion or passing of a fluid; flow...6. any excessive or unnatural discharge of fluid matter from the body...to flow or stream out." Additionally, the word, catarrh is defined to mean: "catarrh'...''n''. [L. ''catarrhus''; Gr. ''katarhoos'', from ''katarrhein'', to flow down; ''kata'', down, and ''rhein'', to flow.] an inflammation of the mucous membrane, more particularly of the throat and nose, accompanied by an increased secretion of mucous; as nasal catarrh; catarrh of the stomach." Finally, within the same dictionary rheumatic fever is defined as follows: rheumatic fever, an infectious disease associated with the presence of streptococci in the body; it most commonly attacks children, and is characterized by fever, pain and swelling of the joints, inflammation of the heart valves, etc." ( 10 )
 
Within ''Dorland's Illustrated Medical Dictionary'', published in 1988, the Greek word, rheum, the word-root of rheumatism, is defined to mean: "rheum, rheuma...[Gr. rheuma flux] any watery or catarrhal discharge."  The word rheumatism is defined extensively, in the same text, and many systemic, pathological manifestations of rheumatism are listed, for instance: "Any variety of disorders marked by inflammation , degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. '''apoplectic rheumatism''', rheumatism associated with brain hemorrhage; '''cerebral rheumatism''', acute rheumatic fever marked by chorea, delirium, convulsions, and coma; '''rheumatism of the heart''', involvement of the heart by the rheumatic fever process; '''lumbar rheumatism''', lumbago; '''rheumatism confined to the joints''' is classified as arthritis; '''muscular rheumatism''', fibrositis; and '''articular rheumatism''', rheumatic fever..." There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. Within the text, the word, rhinophyma is defined as follows: "rhinophyma...usually seen in men and characterized by thickened, lobululated overgrowth of the sebvaceous glands and epithelial connective tissue." ( 11 )
 
In addition, rheumatism is defined in ''Webster's Encyclopedic, Unabridged Dictionary of the English Language'', published in1989 as follows: "...1. any disorder of the extremities or back, characterized by pain and stiffness. 2. see rheumatic fever...catarrh, rheum..." Also rheum is defined as follows: "...1. a thin, serous, or catarhal discharge. 2. catarrh; cold...(to) flow...--''rheumic'', adj." ( 12 )
 
For a long period it was known that acute rheumatism (rheumatic fever) was an epidemical disease. For instance, within the first issue of the ''Encyclopedia Britannica'' published between 1769 and 1771 the following is written in the section titled ''''Of the'' Rheumatism'' within the chapter describing the science and art of medicine:
 
"The rheumatism chiefly attacks persons in the flower of their age...It begins with chillness and shivering, followed by inquietude and thirst. Which is preceded with spontaneous lassitude, a heaviness of the joints and coldness of the extreme parts. When the fever appears, there is an inward heat, chiefly about the-praecordia, attended with anxiety. The pulse is quick and straight, the appetite is lost, the body coftive. In a day or two, sometimes sooner, the patient feels a racking pain,sometimes in one joint and sometimes in another, but more frequently  in the wrists shoulders and knees; frequently shifting from place to place...The pain is exasperated with the least motion; it sometimes attacks the loins and the coxendix (coccyx)....When it seizes the loins it is called the lumbago;...it may continue for months and years , but not with the same violence, but by fits." Further, "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds. And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1737, would yield to..." ( 13 )
 
In addition, within the text, ''Hippocratic Writings'' and the book (chapter) titled "Epidemics, Book I", many case histories are provided wherein patients' symptoms and signs are similar to those described, later, in cases of rheumatic fever by physician-authors such as Thomas Sydenham and Sir William Osler.
 
The latter two physicians categorized the following symptoms and signs to be those of rheumatic fever: 1. Rheumatic fever often attacks healthy, young people. 2. It causes a fever and often a feeling of heat in the chest. 3. The extremities are often cool. 4. Patients often had a prior respiratory disease (bronchitis, sore throat, tonsillitis) or one concomitant with a rheumatic fever episode. 5. Patients often have arthritis pain or swelling and pain in the joints. 6. The disease is highly painful, at times. 7. Sometimes individuals have a rash that appears like hives, papules or a miliary rash. 8. Some some develop erythema of the skin. 9. Frequently, patients have low-back pain (lumbago). 10.  Rheumatic fever can be mild and wax and wane, over time. 11. Patients with rheumatic fever can have delirium, seizures, stupor or coma. 12. Individuals who experience rheumatic fever have gastrointestinal disturbances including diarrhea, constipation, abdominal pain, etc. 13. Rheumatic fever occurs in cooler times of the year; cooler periods are often damp periods of the year. 14. Rheumatic fever often features swelling of the cervical lymph nodes. 15. Patients with rheumatic fever usually have a reasonably normal pulse, but with more severe disease they frequently have cardiac arrhythmias. 16. At times, patients have hyperesthesia and even gentle pressure to the skin is painful. Perhaps a Greek word for it is causus. 17. Mild, subacute rheumatic fever can cause painful feelings in many parts of the body. 19. Sweating was common and odiferous. 20. Fall, winter and spring feature the most numerous cases.  21. Usually, there is a fairly low death rate from rheumatic fever, however, virulence of the Streptococcus, which causes it is highly variable. 22. Childbed fever is caused by Streptococcus pyogenes and has similar systemic signs and symptoms as rheumatic fever. 23 Splenomegaly is common. 24. A change in the weather to a cool, often damp, pattern seems to encourage the development of rheumatic fever. 25. Rheumatic fever seems to be a family disease. 26. Concerning the pain of rheumatic fever: "perhaps no disease is more painful; the inability to change the posture without agonizing pain, the drenching sweats, the prostration and helplessness, combine to make it a most distressing affection. ( 8 ) 27. Anemia is common. 28. Epistaxis is not uncommon. 29. The urine is, as a rule reduced in amount, of high density and high color. It is very acid, and, on cooling, deposits urates. ( 8 ) 
 
Within the book, Epidemics, Book I, the most common symptoms and signs experienced by various patients were: 1. Causus (from, perhaps the Gr., Kausos, heat; perhaps, causalgia, a burning pain; perhaps caumesthesia, with a low temperature the patient feels a burning heat) ( 8 ) 2. hemorrhages, the most frequent epistaxis. 3. Swelling near the ears (cervical lymphadenopathy). 4. Young people, especially young men involved with wrestling (close contact) became sick. 5. Patients often had a respiratory disease with cough and laryngitis. 6. Loss of weight in some individuals. The most common combination of symptoms and signs listed were:  5. fever, 6. shivering, and 7. sweating. Further, there was, 8. coolness of the extremities. 9. Their stomachs were disordered and diarrhea occurred. 10. Urine was thin or with a sediment staying dissolved within it. 11. Cough was slight but frequent; in violent cases patients continued to cough up purulent sputum. 12.In most cases the throat was painful, red and inflamed from the first and continued so. 13. Patients refused to take food (lost appetite) and lost weight. They often had no thirst. For instance, "...all suffered from a loss of apetite, and that to an extent which I have never previously encountered." 14. Many became delirious and frequently, thereafter, died. 15. The epidemical disease struck people during all months of the year, but the cool, damp months, and cool damp years featured more sickness. 16 Patients often experienced pain, for instance in the legs, back, head, heart (chest).  17. Patients experienced seizures. 18. Some patients experienced insomnia. 19. Some patients experienced coma. 20. Some patients experienced the development of eruptions (rash)., for instance: "These were red, round and small like those of acne which did not go down."21. Frequently, children, older children (eight to ten years old) and those approaching puberty died. 22. Headache and neck pain. 23. Cases of paralysis (Hypothetically, Guillain-Barre' Syndrome). 24. Childbirth was often followed by disease. 25. Pregnant women aborted. 26. Some women had vaginal bleeding. epistaxis was fairly common. 26. Lividity of parts of the body; extremities. 27. Splenomegaly. 28. Hepatitis. 29. Deafness in some individuals. 30. Hepatitis, signs of jaundice in some individuals. 30 hematuria. 31. Some patients developed dropsy (edema of the legs secondary to heart failure.)
 
By comparing the signs, symptoms and epidemiology of the disease described in each of the above two paragraphs, it can be easily determined that most of the signs and symptoms experienced in rheumatic fever, as detailed by Sydenham and Osler, were also experienced by patients who had an epidemical disease as recorded in the book, Epidemics, Book I, of Hippocrates Writings.   
 
In addition, frequent mention is made the existence of phlegm, for instance: "Now this disease attacks the phlegmatic...if these discharges should make their way to the heart , the chest is attacked and palpations and asthma supervenes." "For when cold phlegm reaches the lungs and heart...and the heart palpates. Such circumstances force the onlset of asthma and diseases characterized by orthopnoea..." ( 12 ) Orthopnoea, otherwise known as orthopnea, or the need or tendency to have less difficulty breathing in a sitting position, is secondary to heart failure, often rheumatic heart failure that occurs in rheumatic fever.
 
A unifying conceptual statement, integrating the various concepts and definitions from the above-mentioned dictionaries and texts, is as follows: Rheumatic fever, and therefore chronic rheumatism, are clinical disease presentations caused by Streptococcus pyogenes infections. The various sources of information, quoted above, uniformly indicate that a meaningful sign of acute rheumatism (rheumatic fever) and chronic rheumatism is the presence of mucous drainage from the nose, mouth, or, even the eyes. In addition, the word, catarrh indicates an increased secretion of mucous as in the term, nasal catarrh. Also, the word rheum can be used to denote "...a cold...or...rhinitis..." It appears then, that mild, or severe, respiratory infection (s) caused by Streptococcus pyogenes, can both result in the development of rheumatism. The condition of rheumatism seems to a ''septic disorder'' in that signs and symptoms of rheumatism occur in most of the body's tissues and, therefore, organs as defined in references ( 3 ) and ( 5 ).
 
The term, ''sepsis'', is defined as follows: "Animals mount both local and systemic responses to microbes that traverse epithelial barriers and invade underlying tissues. Fever, or hypothermia, leukocytosis, leukopenia, tachypenea, and tachycardia are the cardinal signs of the systemic response often called the systemic inflammatory response syndrome (SIRS). SIRS may have an infectious or noninfectious etiology...When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." Further, " Microbial invasion of the blood stream is not essential for the development of severe sepsis, since local inflammation can also elicit distant dysfunction and hypotension." ( 1 )
 
Over time, there have been many synonymous terms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever; the word rheumatism, itself, was often used in older, and even in more recently published, scientific texts to mean both acute and chronic rheumatism. ( 5, 6 )
 
If the ''concept of severe sepsis'', the phenomenon wherein pathological abnormalities appear distant from a primary site of infection, ''is integrated'' with the above information concerning the nature of rheumatism, it appears that ''acute rheumatic fever,'' which is well known to cause pathology of distant organs such as the heart, kidneys, and joints, and ''chronic rheumatism'', which also causes pathological changes to organs distant from the site of a Streptococcus pyogenes infection (as indicated by reference ( 4 ), above) both have the same, or similar, pathophysiological mechanisms, which cause damage to a numerous and highly varied group of anatomical structures distant from the primary site of infection. Therefore, ''both  conditions'', acute rheumatic fever and chronic rheumatism both have severe, septic manifestations. The key, it seems, to a further understanding of both rheumatic fever, also known, historically, as acute rheumatism, and chronic rheumatism is to understand the pathological mechanism that causes severe sepsis.
 
 
Rheumatism was a commonly used term in medicine before 1940 and it was often associated with a specific, painful, muscular syndrome, ''muscular rheumatism'', or, synonymously, fibrositis, as indicated in the definition of rheumatism, above. In a noted medical text published in 1935 fibrositis, and therefore, synonymously, muscular rheumatism, are described:  "'''MYALGIA''' (''fibrositis, myositis'') Definition.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probably that in many cases the fibrous tissue is especially affected==a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia, ...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like.It is often sufficiently intense to cause a patient to cry out...The following are the principle varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and upper part of the back." ( 8 )
 
It is important to note that within the last two paragraphs the terms muscular rheumatism, fibrositis, myositis, myalgia are connected synonymously. It is apparent that physicians also thought, what seemed to be pain of a muscular nature was suspected to be, more specifically, caused by neuropathic phenomenon. Also, it is important to realize, as indicated in the above-mentioned definition of rheumatism [reference (3 )], that rheumatism affects connective tissue somewhat selectively. Since, however, the terms connective tissue and fibrous tissue define, virtually, the same histological structures, and since all organs in the body have substantial amounts of connective tissue (fibrous tissue) within their substance, conceptually, then, rheumatism can affect the heart, kidneys, lungs, brain, muscles, ligaments, tendons, synovial sheaths, the gastrointestinal organs, skin, bones, the liver, nerves, and most meaningfully, perhaps, the various elements of the circulatory system for when they are involved it creates a rheumatic vasculitis.
 
Contained in much older books, for instance, ''The Sacred Disease'', a section of the text titled, ''The Hippocratic Writings'', written by Hippocrates himself or by physicians of the hippocratic persuasion, the symptoms and signs of a common, epidemical disease is discussed. In the book It was termed, "the sacred disease", because practitioners, who were often priest-physicians, commonly thought that individuals who became sick with its signs and symptoms, somehow, had displeased the gods, or a god, and their treatments were directed at appeasing the god, or gods, by having the stricken patient perform one or many acts of appeasement, which, at times, involved pecuniary donations. The disease described is quite like acute rheumatism (rheumatic fever), as it was described by Sydenham in the 1600's. ( 5 ). It is also similar to the description of rheumatic fever in the section: ''of  the Rheumatism''  within the first issue of the ''Encyclopedia Britannica'' printed in 1771. ( 6 )
 
The demise of the western Roman Empire caused a dramatic decrease of scientific advances, and, therefore, scientific medical advances, in Western Europe, to be delayed until the Renaissance. During the 1500's physicians such as Guillaume  Baillou (1538-1616) clearly wrote about acute rheumatism (rheumatic fever). For instance:
 
    "Before we place this affection in a class of disease or symptoms (since it causes its effects by the primary disease and the symptoms produced by it is commonly & very badly confused) just as what it is, we shall explain by what and in what manner it arises: we shall point out the train of pains & symptoms also present.
   
    On the other hand the method by which this affection attacks which is falsely called catarrh: (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism, is as follows...The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot or the hand, nor the finger can be moved in the least without pain & outcry: moreover in the same way the greater pain lies in the joints because that part is endowed with greater and more exquisite sensation...When the hand is pressed on the parts, the sensation & feeling, (even if you touch lightly) is of a definite severe heat. If you examine the pulse the fever is seen to be little or nothing.
 
    Indeed the pains are worse at night , the patient cannot sleep, partly because they are unable to be moved from their position & from that posture they first usually lie and recline, they remain in it & are scarcely moved or touched without excruciating pain, tension and a somewhat sharp feeling, others say with the sensation of heat (as already mentioned)...This rheumatism is not the same as in those who sin in their way of life. " ( 5 )
 
Later, Thomas Sydenham, during the middle to late 1600's, accurately described the clinical features of acute rheumatic fever including the tendency for it to follow a chill, that it seemed to be most common in the autumn, that it was a disease that could attack the young and vigorous, that it was accompanied by fever, disquietude, and thirst, that it featured acute migratory arthritis, and that it was a very painful disease entity. He indicates that its symptoms and signs can wax and wane, over time, so as to be a chronic disease entity. Sydenham's astute clinical observations "...enabled him to record excellent descriptions of many diseases including scarletina (1675), which he named and differentiated from measles, polyarthritis (1767), St. Vitus Dance (1686) and gout (1683)." ( 5 )
 
During the last half of the 17th, and first quarter of the 18th centuries, Raymond de Vieussens (1671-1715), a French physician, identified, in a given patient, classic historical and clinical features of a fairly young man who has chronic rheumatism secondary to a noted severe disease process occurring earlier in his life. Comments within parenthesis are those of this author. He writes as follows: "Jean Chifort, native of Mouguyo, in Languedoc, Diocese of Montpellier, age thirty-five years (a young age), of a melancholy temperament (depression), & subject to epilepsy for a long time {rheumatism of the brain (  )}, was seized twenty years ago, by a paroxysm of this disease, so violent that he almost fell into apoplexy: (acute rheumatic fever):.." Further, as he was very poor (acute and chronic rheumatism is, classically, often a disease of the lower economic class)..." Further, "After having remarked the sunkenness of his eyes, the puffiness, & the pallor of his face, I examined his pulse, which appeared to be very full, very fast, very hard, unequal, & so strong that the artery of the first one & then the other arm, struck the ends  of my fingers just as a cord would have done which was very tightly drawn & violently shaken...he was suffering from a violent palpitation of the Heart [a case of acute rheumatic fever an individual may experience "...an asymptomatic interval of approximatrely 10 to 20 years, during which the severity of..." aortic regurgitation "...usually increases." ( 10 )]. In addition, "...he told me that for a long time he had not been able to sleep comfortably...if his head were not very high (orthopnea secondary to rheumatic heart disease and, likely, pulmonary edema)." Further, "...the patient died in three days: I opened his body...the left ventricle was extraordinarily dilated (due to increased diastolic pressure); the walls of the trunk of the aorta appeared to me to be very thick, and very hard, & like cartilage (aortic arteriosclerosis); the semilunar valves are markedly stretched & cut off at their tips: all these cuts which bore some resemblance to the teeth of a saw, were in fact osseous (rheumatic cardiac valve disease). And of great importance, "...the lymph which the blood of the canals of the Heart, to which they were very closely attached (canals of the heart: coronary artery system), furnish for nourishment, had no longer a free flow; it was no longer present, at least abundantly enough, in the tissue of the walls of all the branches of the arteries, of which I have spoken; this is why they become dry little by little, & lost enough of their natural suppleness to have the appearance of fingers stretched from one trunk to the other like cords (severe multi-vessel coronary artery arteriosclerosis)." ( 5 )
 
Within the first edition of the Encyclopedia Britannica, printed between 1769 and 1771, it is evident that the physicians of that period had developed a more thorough clinical, as well as basic pathophysiological understanding of rheumatism, in its various forms acute and chronic, since the follow salient informatipn is provided from the chapter on "Medicine", within the article, "of the Rheumatism". The author provides a clinical description of acute rheumatism (acute rheumatic fever) very similar to that provided by Thomas Sydenham during the late 1600's: It includes, an onset in cool weather, fever, lassitude,s gastrointestinal complaints, at times constipation, chest pain, anxiety, a rapid pulse, absent appetite, etc.  Thereafter, the author comments on a "...racking pain, sometimes in one joint, sometimes in another, but more frequently in the wrists, shoulders, and knees; frequently shifting from place to place , and leaving redness and selling in the part visited last. The pain is exasperated with the least motion; it sometimes attacks the loins and the coxendix. When it seizes the loins, it is called the lumbago; and there is a most violent pain in the small of the back, which sometimes extends to the os sacrum, and it is like a fit of the gravel (kidney stone), only the patient does not vomit. If this disease is unskillfully treated, it may continue for several month or years, but not with the same violence, but by fits. if it continues and increases it may cause a stiff joint, which will scarce yield to any remedy. Its proximate cause seems to be the inflammation of the lymphatic arteries, of the membranes near the ligaments of the joints, but not so violent as to bring on a suppuration. The blood is like that of persons afflicted with the pleurisy...And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1757..." and further,"...Pringle observes, that rheumatisms are generally mild, though they sometimes appeared with all the violence taken notice of by Sydenham...The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 6 )
 
The above information is very salient, since the authors understood that acute rheumatism (rheumatic fever) was caused by "...the inflammation of the lymphatic arteries...", now termed, rheumatic vasculitis, the vasculitis that, hypothetically, is a feature of all the rheumatic syndromes described in medical texts. For instance, the vasculitis of rheumatoid arthritis, lupus erythematosis, dermatomyositis, systemic sclerosis, Sjogrens syndrome, etc. That insight indicates that physicians, at that time, the late 1700's, understood the prime, pathophysiological element of rheumatism, acute and chronic, that they understood the clinical features of acute rheumatic fever, which they knew to be a ''highly painful'' disease entity, and they also knew that chronic rheumatism, a chronically painful condition, was caused by a rheumatic fever (acute rheumatism) as well as by lesser levels of respiratory disease, which they termed, "...lesser but but neglected colds." 
 
Later, about 1788, David Pitcairn, A London physician, remarked, "that persons subject to rheumatism were attacked more frequently than others with symptoms of an organic disease of the heart. Subsequent experience having confirmed the truth of this observation, he concluded, that thse two diseases often depend upon a common cause, and in such instances, therefore, called the latter disease rheumatism of the heart." ( 5 )
 
In addition, the description of severe rheumatic fever as written by Sir William Osler and Thomas McCrea  in their text of 1935 indicates: "Rheumatic fever is the most serious of all diseases with a low death rate. The mortality is rarely above 2 or 3 percent." In addition, In the human infection , the lesions are exudative at first and later proliferative. A hypersensitive state once established, a chronic infection or repeated infection, a chronic infection or repeated slight infections may serve to prolong it and an acute infection may precipitate another attack." Finally, "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced...The onset may be so insidious that it can hardly be termed even subacute." ( 9 )
 
 
 
 
 
Rheumatism is usually considered to be an archaic term in medicine for it is not listed as a subject in most, modern, medical texts. For instance, it is not listed as a subject in the text, Harrison's Principles of Internal Medicine, 16th Edition published in 2005. ( 1 )
 
Within the 12th edition of the same text, published in 1991, the only listing for rheumatism is psychogenic rheumatism and part of the short paragraph explaining it is as follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 )I think the above synopsis makes obvious the author's lack of observation skills, lack of patient concern, and it is an arch-type example of how some physicians find fault with patients when the they "do not know what is going on" and, in addition, they are too pompous to say, simply, to a patient, I do not know why you hurt so bad. 
 
Physicians, during earlier eras, understood, partially, from a clinical aspect, the disease of rheumatism. For instance, Claudius Galen, who is often, simply, called Galen, was a Greek physician from Pergamum, a city that was located near the present city of Izmir, Turkey. He was provided an eclectic education by his father and he started medical training at a young age. Later, he attended the University at Alexandria, Egypt and became a noted physician in Pergamum and later in Rome. He coined the word, ''rheumatismos'' to describe a condition, which was caused by, or accompanied by, respiratory diseases that featured the production of phlegm or other secretions. ( 3 )
 
For instance, within a reputable medical dictionary, the Greek word, rheum, the word-root of rheumatism, is defined to mean: "rheum, rheuma...[Gr. rheuma flux] amy watery or catarrhal discharge." ( 4 ) It also seems to refer to "a great fluxion which races to various parts of the body, and goes from one to another" ( 5 ) In addition, within the previously cited medical dictionary [reference ( 4 )] the word rheumatism is defined extensively and many systemic, pathological manifestations of rheumatism are listed, for instance: "Any variety of disorders marked by inflammation , degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. '''apoplectic rheumatism''', rheumatism associated with brain hemorrhage; '''cerebral rheumatism''', acute rheumatic fever marked by chorea, delirium, convulsions, and coma; '''rheumatism of the heart''', involvement of the heart by the rheumatic fever process; '''lumbar rheumatism''', lumbago; '''rheumatism confined to the joints''' is classified as arthritis; '''muscular rheumatism''', fibrositis; and '''articular rheumatism''', rheumatic fever..." There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. In addition, over time, there have been many synonyms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever; the word rheumatism, itself, was often used in older, and even more recently published scientific texts, to mean both acute and chronic rheumatism. ( 6, 7 )
 
Rheumatism has, for thousands of years, been generally thought to be a widespread, painful condition with, often, an apparent migrating nature. Severe rheumatic fever, itself, often features migratory arthritis. ( 6, 7 )
 
Rheumatism was a commonly used term in medicine before 1920 and it was often associated with specific, painful muscular syndromes, for instance: "'''MYALGIA''' (''fibrositis, myositis'') Definition.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probably that in many cases the fibrous tissue is especially affected==a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia, ...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like.It is often sufficiently intense to cause a patient to cry out...The following are the principle varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and upper part of the back." ( 8 )
 
It is important to note that within the last two paragraphs the terms muscular rheumatism, fibrositis, myositis, myalgia are connected synonymously. Also, it is important to realize that, as indicated in the definition of rheumatism, above [reference ( 4 )], that rheumatism affects connective tissue somewhat selectively, but since connective tissue and fibrous tissue mean virtually the same histological structure, and since all organs in the body have substantial amounts of it within their substance, conceptually, then, rheumatism can affect the heart, kidneys, lungs, brain, muscles, ligaments, tendons, synovial sheaths, the gastrointestinal organs, skin, bones, the liver, nerves, and most meaningfully, perhaps, the various elements of the circulatory system for when they are involved it creates a rheumatic vasculitis.
 
Much older books, for instance, "The Sacred Disease", a section of the text titled as the "Hippocratic Writings", written by Hippocrates himself or physicians of the hippocratic persuasion, the symptoms and signs of a common, epidemic-like disease is discussed. It was termed, "sacred", because practitioners, who were often priest-physicians, commonly thought that those who became sick with its signs and symptoms, somehow displeased the gods, or a god, and their treatments were directed at pleasing the god, or gods, by having the stricken patient perform one or many acts of appeasement, which, at times, involved pecuniary donations. The disease described is quite like acute rheumatism as it is described by Sydenham in the 1600's. ( 6 ). It is also similar to the description of rheumatism (acute) within the first issue of the Encyclopedia Britannica printed in 1771. ( 7 )
 
In addition, it is similar to the description of severe rheumatic fever as written by Sir William Osler and Thomas McCrea  in their text of 1935. ( 9 ) It must be understood that, acute rheumatism (rheumatic fever) has the following nature: "Rheumatic fever is the most serious of all diseases with a low death rate. The mortality is rarely above 2 or 3 percent." In addition, In the human infection , the lesions are exudative at first and later proliferative. A hypersensitive state once established, a chronic infection or repeated infection, a chronic infection or repeated slight infections may serve to prolong it and an acute infection may precipitate another attack." Finally, "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced...The onset may be so insidious that it can hardly be termed even subacute." ( 9 ) An accumulation of rheumatic tissue, and therefore organ, damage, over time, can lead to a highly varied array of abnormal function, which can involve all organ systems.  
 
Within the first edition of the Encyclopedia Britannica, printed between 1769 and 1771, 
 
    
 


Rheumatism was a commonly used term in medicine before 1940 and it was often associated with a specific, painful, muscular syndrome, ''muscular rheumatism'', or, synonymously, fibrositis, as indicated in the definition of rheumatism, above. ( 14 ) In a noted medical text published in 1935 fibrositis, and therefore, synonymously, muscular rheumatism, are described:  "'''MYALGIA''' (''fibrositis, myositis'') Definition.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probably that in many cases the fibrous tissue is especially affected==a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia, ...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like.It is often sufficiently intense to cause a patient to cry out...The following are the principle varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and upper part of the back." ( 7 )


It is important to note that within the last two paragraphs the terms muscular rheumatism, fibrositis, myositis, myalgia are connected synonymously. It is apparent that physicians also thought, what seemed to be pain of a muscular nature was suspected to be, more specifically, caused by a neuropathic phenomenon. Also, it is important to realize, as indicated in the above-mentioned definition of rheumatism [reference ( 14 )], that rheumatism affects connective tissue somewhat selectively. Since, however, the terms connective tissue and fibrous tissue define, virtually, the same histological structures, and since all organs in the body have substantial amounts of connective tissue (fibrous tissue) within their substance, conceptually then, rheumatism can affect the heart, kidneys, lungs, brain, muscles, ligaments, tendons, synovial sheaths, the gastrointestinal organs, skin, bones, the liver, nerves, and most meaningfully, perhaps, the various elements of the circulatory system for when they are involved it creates a rheumatic vasculitis.


During the period I had an active medical practice I had wondering thoughts about many phenomenon. I learned that most diseases are connected, in various ways, to each other. For instance, individuals who experience diabetes are at a high risk to develop coronary artery disease and peripheral neuropathy. In addition, individuals who have ulcerative colitis are more at risk to develop other inflammatory maladies of the gastrointestinal tract and they are, also, at a high risk to develop cancer, they frequently experience neuropathic maladies, and they often co-experience other autoimmune diseases. Similarly, individuals who experience neuropathy are at a higher risk to develop cancer (paraneoplastic neuropathy). In addition, individuals who develop ulcerative colitis are at high risk for developing other autoimmune diseases of gastrointestinal tract, including celiac disease and Crohn's disease and patients with all three diseases feature a higher risk for cancer development and they often experience neuropathic maladies. ( 3, 4 ) In addition, individuals with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosis, progressive systemic sclerosis, and dermatomyositis all experience a decreased life expectancy, they all feature accelerated arteriosclerosis, and they all feature neuropathic pain. ( 3, 4 ) Historically, coronary artery disease has appeared in patients who have exhibited "type A" personalities, who have hypertension, elevated cholesterol, and who also have somewhat horizontal earlobe creases. No one knows, however, the nature of the underlying disturbance, which causes the connection and the "type A" personality is hard to define.   
During the period I had an active medical practice I had wondering thoughts about many phenomenon. I learned that most diseases are connected, in various ways, to each other. For instance, individuals who experience diabetes are at a high risk to develop coronary artery disease and peripheral neuropathy. In addition, individuals who have ulcerative colitis are more at risk to develop other inflammatory maladies of the gastrointestinal tract and they are, also, at a high risk to develop cancer, they frequently experience neuropathic maladies, and they often co-experience other autoimmune diseases. Similarly, individuals who experience neuropathy are at a higher risk to develop cancer (paraneoplastic neuropathy). In addition, individuals who develop ulcerative colitis are at high risk for developing other autoimmune diseases of gastrointestinal tract, including celiac disease and Crohn's disease and patients with all three diseases feature a higher risk for cancer development and they often experience neuropathic maladies. ( 3, 4 ) In addition, individuals with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosis, progressive systemic sclerosis, and dermatomyositis all experience a decreased life expectancy, they all feature accelerated arteriosclerosis, and they all feature neuropathic pain. ( 3, 4 ) Historically, coronary artery disease has appeared in patients who have exhibited "type A" personalities, who have hypertension, elevated cholesterol, and who also have somewhat horizontal earlobe creases. No one knows, however, the nature of the underlying disturbance, which causes the connection and the "type A" personality is hard to define.   


Also, I came to realize that since 99% of diseases listed in medical texts have no known cause (they are termed idiopathic diseases), it is more accurate to understand them as syndromes. Syndromes are, simply, adverse medical conditions with somewhat uniform symptom and sign patterns. The word disease is best defined as an adverse medical condition which has consistent symptom and sign patterns, but, in addition, its cause is known. Since the great majority of medical problems have no known cause they are syndromes, therefore, physicians, primarily, do not cure diseases, they alter syndromes, usually for the better. In general, a knowledge of the cause for a disease is a requirement if a cure is to be developed, otherwise medical treatments are, for the most part, syndrome altering in nature.  
Also, I came to realize that since 99% of diseases listed in medical texts have no known cause (they are termed idiopathic diseases), it is more accurate to understand them as syndromes. Syndromes are, simply, adverse medical conditions with somewhat uniform symptom and sign patterns. The word disease is best defined as an adverse medical condition which has consistent symptom and sign patterns, but, in addition, its cause is known. Since the great majority of medical problems have no known cause they are syndromes, therefore, physicians, primarily, do not cure diseases, they alter syndromes, usually for the better. In general, a knowledge of the cause for a disease is a requirement if a cure is to be developed, otherwise medical treatments are, for the most part, syndrome altering in nature.  


Prior medical educational and experiential knowledge was important during my investigation, but most of the salient information I learned, which permitted me to develop an understanding of the cause of chronic neuropathic pain, and other associated medical conditions, was gained by ''repetitiously'' interviewing patients concerning their, and their family members', medical histories and by ''repetitiously'' conducting analytic, neurological, physical examinations. In addition to reading medical information in modern texts, I read parts of many older medical texts, dated from the Hippocratic period, through the Roman period, the Renaissance, and thereafter through the period during which many, great, scientific breakthroughs were accomplished, the 1600's through the early 1900's.
Prior medical educational and experiential knowledge was important during my investigation, but most of the salient information I learned, which permitted me to develop an understanding of the cause of chronic neuropathic pain, and other associated medical conditions, was gained by ''repetitiously'' interviewing patients concerning their, and their family members', medical histories and by ''repetitiously'' conducting analytic, neurological, physical examinations. In addition to reading medical information in modern texts, I read parts of many older medical texts, dated from the Hippocratic period, through the Roman period, the Renaissance, and thereafter through the period during which many, great, scientific breakthroughs were accomplished, the 1600's through the early 1900's.


Physicians during earlier eras understood, partially, from a clinical aspect, the disease of rheumatism. For instance Galen, the Greek physician from Pergamum in Asia Minor, now located in Turkey, first coined the word, ''rheumatismos'' around two hundred A.D. ( 4, 5 ) The Greek word, ''rheum'', the word-root of rheumatism, is defined in a reliable, medical dictionary to mean: "rheum, rheuma...[Gr. rheuma flux] any watery or catarrhal discharge. ( 6 ) It also seems to refer "a great fluxion which races to various parts of the body, and goes from one to another" ( 7 ) In addition, within the previously cited medical dictionary, the word rheumatism is defined, extensively, and many systemic, pathological manifestations of rheumatism are listed, for instance: '''apoplectic rheumatism''', rheumatism associated with brain hemorrhage; '''cerebral''' '''rheumatism''', acute rheumatic fever marked by chorea, delirium, convulsions and coma; '''rheumatism of the heart''', involvement of the heart by the rheumatic fever process; '''lumbar rheumatism''', lumbago; rheumatism confined to the joints is classified as arthritis; '''muscular rheumatism''', fibrositis; and '''articular rheumatism,''' rheumatic fever.  There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. In addition, over time, there have been many synonyms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever; the word, rheumatism, itself, was often used in older, and even in more recently published scientific texts, to mean both acute and chronic rheumatism. ( 8, 9 )
Between 2002 and 2005 I conducted a three-year, clinical investigation in an effort to determine the true cause of most peripheral neuropathies since so many of my patients, through the years, failed to improve after they experienced spinal surgery. I eventually determined that the venerated, herniated spinal-disc concept was flawed, and most of the surgery accomplished for them was, I learned, usually mis-applied. Most patients had suspicious arthritis of the lumbar and cervical spine that featured osteophyte development and bulging of intervertebral spinal-discs, but I learned that typical MRI films did not have the resolution to "see" spinal nerve roots in an analytical fashion. Since the bulging intervertebral spinal-discs are attention-getting on MRI images, and because they do, occasionally, cause symptomatic, spinal nerve root compression, generalizing that almost all bulging intervertebral spinal-discs cause nerve root compression was a classic "red herring". After I managed to determine the cause of the painful neuropathies, I learned that the same disease that causes the neuropathies also causes arthritis of the spine; an anatomical feature of spinal arthritis, herniated spinal-discs, did not necessarily cause the painful neuropathies. There are occassional herniated spinal-discs that cause painful spinal, nerve-root compression, but surgery for them is '''very''' common.   


Rheumatism has, for thousands of years, been generally thought to be a widespread, painful condition with, often, a migrating nature. ( 10 ) Again, the terms fibrositis and muscular rheumatism are shown to be synonyms.  and  results in the understanding that fibrositis, fibromyalgia and muscular rheumatism, describe the same condition.  was defined to be a synonym for fibrositis, ''Fibromyalgia and muscular rheumatism, therefore, are clinical terms describing the same condition.''
Eventually, after a long, investigative period, I learned the most patients' neuroloical pain was caused by rheumatic, autoimmune-mediated, vasculitic neuropathy of the terminal nerves of the sacral plexus located within the piriformis canal, which is located deep in the buttock. Patients who experienced neurological shoulder/cervical pain and who experienced dysesthesias to the appropriate upper extremity, were experiencing rheumatic brachial plexitis. The brachial plexus is located within the axillary canal located deep within the shoulder. I learned that motion of the arm at the shoulder, and of the thigh at the hip, or an accident wherein either of the structures were stressed, would often cause, or exacerbate, patients' neurological symptoms and signs. Patients sensed pain in the lumbosacral region, because of centripetal referred pain from the distal sacral plexus located deep in the buttock. Similarly, they sensed pain in the cervical/shoulder region, because of centripetal referred pain from the brachial plexus located deep within the shoulder.  
 
The following salient information is provided from the chapter on "Medicine", within the article, "of the Rheumatism", within the first edition of the Encyclopedia Britannica published in 1771. The author provides a clinical description of severe, acute rheumatism (rheumatic fever) similar to that provided by Thomas Sydenham during the 1600's. It includes, fever, lassitude, constipation, chest pain, anxiety, fast pulse, absent appetite, etc. Thereafter, the author mentions a ..."racking pain, sometimes in one joint, sometimes in another, but more frequently in the wrists, shoulders, and knees; frequently shifting from place to place, and leaving redness and swelling in the part visited last. The pain is exasperated with the least motion; it sometimes attacks the loins and coxendix. When it seizes the loins, it is called the lumbago; and there is a most violent pain in the small of the back, which sometimes extends to the os sacrum, and it is like a fit of the gravel (kidney stone), only the patient does not vomit. If this disease is unskilfully treated, it may continue several months or years, but not with the same violence, but by fits. If it continues and increases it may cause a stiff join, which will scarce yield to any remedy. Its proximate cause seems to be the inflammation of the lymphatic arteries, of the membranes near the ligaments of the joints, but not so violent as to bring on a suppuration. The blood is like that of persons afflicted with the pleurisy...And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1757..." and further, "...Pringle observes, that rheumatisms are generally mild, though they sometimes appeared with all the violence taken notice of by Sydenham...The chronic rheumatism is either the remains of a rheumatic fever, or a continuations of pains that proceeded at first from lesser but neglected colds. The blood in this case is fizzy (anemia). It is an obstinate disease...." ( 8 ) Within a more recent text, published in 1935, Sir William Osler writes concerning the pain that exists during severe cases of rheumatic fever: " Perhaps no disease is more painful; the inability to change the posture without agonizing pain, the drenching sweats, the prostration and helplessness, combine to make it a most distressing affection. ( 11 )
 
The information in the above paragraph indicates that acute rheumatism (rheumatic fever), in its variable presentations, ''causes'' the painful sequela of chronic rheumatism. One of the localized sources of pain, in rheumatism, is lumbago, an older term for low-back pain and sciatica. In older texts, sciatica is termed, "sciatic rheumatism" or "hip gout". ( 8 ) The prior two terms for sciatic neuropathy were used because it was known that all three medical problems, lumbosacral/buttock pain (lumbago), sciatic pain into the leg, and gouty arthritis often appeared in rheumatic patients.  It relates that chronic rheumatism can be caused by an acute rheumatic fever episode, but it can also be caused "...from lesser but neglected colds" ( 8 ) Also, it indicates that rheumatic fever can be a highly acute disease, but even acute rheumatic fever "...may continue several months or years , but not always with the same violence, but by fits." ( 8 )


Rheumatism, a commonly used term in medicine before 1920, was often associated with specific, painful, muscular syndromes, for instance: "'''MYALGIA''' (''Fibrocitis, Myositis'') '''Definition'''.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probable that in many cases the fibrous tissue is especially affected--a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like. It is often sufficiently intense to cause the patient to cry out...The following are the principal varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and the upper part of the back." ( 10 )
During the above investigation I attracted 700 miserable, painful patients who had chronic neurological pain. Eventually, I learned that they all had had meaningful, repeated Streptococcus pyogenes infections (tonsillitis, sinusitis, bronchitis, pharyngitis, otitis media, impetigo, and vaginitis) during their lifetimes and often they had experienced chronic tonsillitis. In addition, many of them, who had been born before 1970, had had, when they were younger, rheumatic fever or scarlet fever. Younger patients, born after 1970 had "flu-like" diseases with more mild rheumatic symptoms and signs.  


Since the above concept of rheumatic pain decreased in popularity, over time, by the 1970's, physicians held little respect for the words rheumatism, myositis, myalgia, myofibrositis, fibrositis, or fibromyalgia. Patients, however, during the 1970's, started complaining in greater and greater numbers about diffuse body pains and so, eventually, after the resurgence of such complaints, the diagnostic word (and the development of a rigid, administrative, diagnostic, computer code) fibromyalgia became an accepted syndrome. ( 11 )
I learned from information in Sir William Osler's text, that there are subacute and less than subacute states of rheumatic fever with more subtle systemic symptoms and signs than "classic" high-grade rheumatic fever. ( 8 ) Such a disease has the same symptoms and signs that are thought to be those of influenza, or "the flu": a respiratory disease, often at least, lethargy, tiredness, at times stupor, body pain, back pain, photophobia, at times, headache, at times, gastrointestinal symptoms and signs, at times, and often a fairly rapid recovery. Often patients who had rheumatic fever had been diagnosed by a physician, or by parents, to have chicken pox, measles, the flu, mononucleosis and viral meningitis. Often the patients had been very ill, but recovered with care at home.   
 
 
 
 
After I had hypothesized that the disease was wide-spread, that is, worldly in nature, I conducted an epidemiological investigation. During the epidemiological investigation, I traveled to eighteen countries and spoke with physicians in many locals, but more importantly, with people "on the street".  I determined that the great majority the patients who experienced chronic neurological pain were experiencing it as a "target-organ manifestation of rheumatism", which is a chronic, systemic, inflammatory, autoimmune disease caused from infections by "Streptococcus pyogenes". 
 
Rheumatism is usually considered an archaic term in medicine for it is not listed as a subject in most, modern, medical texts. For instance it is not listed as a subject in the text, ''Harrison's Principles of Internal Medicine, 16th Edition'' (Kasper,D., McGraw-Hill, 2005).
 
Within the 12th editon of the same text, published in 1991, the only listing for rheumatism is psychogenic rheumatism and part of the short paragraph explaining it is as follows,  "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis. These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." I think that the above synopsis makes obvious the author's lack of observation skills, the author's lack of patient concern, and it is an arch-type example of how some physicians find fault with patients when the physician does not know "what is going on". In addition, physicians who have the above nature seem not to be able to say to a patient, "I don't know".
 
From, at least, the late 1500's until the early 1900's the terms rheumatism, acute rheumatism, acute articular rheumatism and rheumatic fever were used, at times, in an interchangeable fashion as noted within the chapter "Medicine" and the paragraph, "of the Rheumatism" within the first edition of the "Encyclopedia Britannica" (By a Society of Gentlemen in Scotland, In Three Volumes, Printed for A. Bell and C Macfarquhar, and fold by Colin Macfarquhar, at his Printing-office, Nicolson-street, Edinburgh, M.DCC.LXXI.)  As time passed the terms, "acute rheumatism" and "inflammatory rheumatism" were terms frequently used to describe episodes of acute rheumatic fever. One might think that the term rheumatic fever described a disease, at times with a high fever, which was rheumatic in character since other symptoms and signs of the disease were known to be part of the rheumatism concept (arthritis, back pain or lumbago, neuropathies, gastrointestinal abnormalities, cardiac arrhythmias, cardiac enlargement, cardiac valve abnormalities, pulmonary edema, rash, renal and hepatic abnormalities, delirium, stupor, coma, seizures, etc.). It was known in the late 1700's, as quoted in the first edition of the Encyclopedia Britannica, mentioned above, that: "The chronic rheumatism is either the remains of a rheumatic fever, or a continuations of pains that proceeded at first from lesser but neglected colds." The information within that quote indicates that physician-authors of the day, in the late 1700's, knew that acute rheumatism (rheumatic fever) could cause chronic rheumatism, but also they knew that less severe episodes of respiratory disease, "...lesser but neglected colds.", could also cause chronic rheumatism.
 
Chorea is defined as, "the ceaseless occurrence of a wide variety of rapid, highly complex, jerky movements that appear to be well coordinated and are performed involuntarily...Sydenhams c., an acute, usually self-limited disorder of early life, usually between the ages of five and fifteen, or during pregnancy, and closely linked with rheumatic fever." (Dorland's Illustrated Medical Dictionary, 27th Edition, W.B. Saunders Co., 1985). In older texts such as "Osler's Principles and Practice of Medicine, Eighth Edition" (McCrea, T., Appletonm-Century Co., 1912)  the following is written about rheumatism in the section on acute chorea: "Rheumatism.--A causual relationship between rheumatism and chorea has been claimed by many since the time of Bright. The English and French writers maintain the closeness of this connection; on the other hand, German authors as a rule, regard the connection as by no means very close. Of the 554 cases, in 15.5 per cent., there was a history of rheumatism in the family. In 88 cases, 15.8 per cent., there was a history of articular swelling, acute or subacute. In 33 cases there were pains, sometimes described as rheumatic, in various parts, but not associated with joint trouble, the percentage is raised to 21. It is rather remarkable that in our Baltimore series the percentage with a history of rheumatim was the same, 21.6...with the exception of rheumatic fever, there is no intimate relationship between chorea and the acute diseases of childhood...With no disease, not excepting rheumatism, is it so constantly associated. I collected from the literature the records of 73 autopsies; there were 62 with endocarditis. The endocarditis is usually of the simple variety, but the ulcerative form has occassionally been described...pericarditis is an occasional complication of chorea, usually in cases with well-marked rheumatism."
 
By 1935, when the 12th Edition of Osler's text was published the use, and meanings, of the terms rheumatism and rheumatic fever experienced a segregation and "rheumatism" is not listed in its index. Rheumatic fever, however, is described quite thoroughly (compared to modern texts) since a great amount of clinical knowledge about rheumatic fever, as an ''acute, a subacute, and less than subacute'' disease process had been developed. The knowledge that rheumatic fever was caused by Streptococcus pyogenes, a fact discovered by both Alvin Coburn in the USA and Wilfred Collis in England in 1931, was not, however, mentioned in the text, which is an indication of the time it takes for physicians, even highly experienced physicians, to accept new ideas even if they are well proven. The concept of chronic rheumatism still existed, but it was diminishing in the minds of physicians and medical authors, because, in my opinion, the specialty divisions of medicine, which had been experiencing accelerated development for a few decades, decreased the conceptual understanding of systemic disease processes.
 
Medicine as an art and science, which had its roots in antiquity, was being coerced into following the specialty paradigm wherein disease concepts had to be "fit into" the various specialty divisions that were being  developed. Thus, a systemic disease concept, such as rheumatism, slowly disappeared from the minds of physicians and, therefore, medical texts, even though many diseases were, and are, known to be systemic in nature. For instance, within "Webster's Encyclopedic Unabridged Dictionary of the English Language" (Random House, 1989) the following definition for rheumatoid arthritis is provided: "rheumatoid arthritis,...a chronic disease marked by signs and symptoms of inflammation of the joints, frequently accompanied by marked deformities, and ordinarily associated with manifestations of a general, or systemic, affliction."
 
The following was written, within the prologue, by the editor of the section on "Medicine", in the first edition of the ''Encyclopedia Britannica'', cited above, as he was discussing the various attempts to classify diseases into rational groups: "Of late several attempts have been made to reduce medicine into the form of a regular science, by distributing diseases into classes, orders, genera, and species. Sauvage was the first...Others, as Linaeus, Vogel, Dr. Cullen, Etc., have since endeavored to improve Sauvage's method of classing; but they have contented themselves with an enumeration of the characters and arrangement fo the different genera, without entering into their history or cure. Sauvage enumerates 315 genera, Linnaeus 325, Vopgel 560, and Dr. Cullen has reduced them to 132. The bare inspection of these numbers shews, that physicians are far from being agreed with regard to what constitutes the generic or specific character of a disease. Indeed, we may venture to affirm, that they never will agree upon this point: The diagnostic symptoms of diseases are  not so easily discovered as the stamina or petals in a flower, or the number of teeth or toes in a quadraped."
 
I suggest that the current division of medicine into its current specialty groups is not necessarily rational, but political, at least in many respects, because, for instance, there are various highly variable factors involved in the many specialty definitions. Some are determined, generally, by the age of the patient (pediatrics, geriatrics, internal medicine); some are determined by the organ system attended to (cardiology, psychiatry, nephrology, opthalmology, dermatology, general surgery, orthopedic surgery); some are determined by what high-tech instruments are primarily used (radiology, anesthesiology, pathology); some are determined by the pathological cause of disease (infectious disease specialty); and some are determined by the type of treatment provided (nuclear medicine, oncology). Many of the specialties are further defined by the type of high-tech apparatus that they use: for instance gastroenterologists use colonoscopy and endoscopic techniques most commonly and the various surgical specialties, which are within the organ system specialty groups, use, most commonly, the operating room as do the anesthesiologists.
 
The family practice specialty is really not a medical specialty. It is a politically developed convention that provided general practitioners with the "specialty status" of other physicians. Managed care insurance plans furthered the development of the family practice specialty by mandating that physicians who treated patients "with their insurance plans" had to be specialists. To qualify for various managed care plans, in the early 1990's I had to travel to Atlanta, Georgia and pass a test to be "grandfathered" into the family practice specialty. I functionally, however, remained a general practitioner, that is, a physician and surgeon in medicine. 
 
Specialty physicians limit their practices and therefore their medical thought processes by becoming specialists, as indicated in ''Dorland's Illustrated Medical Dictionary 27th Edition'', cited above: "'''Specialist'''... a physician whose practice is limited to a particular branch of medicine or surgery, especially one who, by virtue of advanced training, is certified by a specialty board as being qualified to so limit his practice ." The semi-strict specialty divisions in medicine cause a division of knowledge so that an integration of medical knowledge, over time, has not been managed in medical science since, about, 1920.
 
Rheumatology has been relegated to deal with abnormalities of connective tissue. One might think that rheumatology was relegated to connective tissue since the various organ systems had been claimed by previously developed specialty groups. It is obvious, however, to any reader of medical texts and medical journal articles, that most rheumatic diseases, such as rheumatoid arthritis, lupus erythematosis, systemic sclerosis, dermatomyositis, Reiter's syndrome, Behcet's sydrome, Sjogren's syndrome, polyarteritis nodosa, Wegener's granulomatosis, mixed connective tissue disease, ankylosing spondylitis, psoriasis, osteoarthritis, and neurogenic arthropathy, all of which have systemic, visceral manifestations, that such clinical syndromes are not necessarily defined to have, only, abnormalities in connective tissue.
 
The above partial description of the medical specialty groups provides an organizational reason why medical knowledge, historically, during the last ninety years, has been formally segregated so that there is little functional integration of medical knowledge. The lack of integration has resulted in a inhibition in the advancement of knowledge development concerning the causes of, and accurate pathophysiology of, diseases.  Without knowing the cause of a disease, cures for them surely cannot be determined. Since fractures, lacerations, burns, sprains, and some infectious diseases have known causes cures for them have been rationally developed. Most other diseases (idiopathic diseases), which are more accurately described as syndromes, since their causes are not known, are provided, by physicians, disease-altering surgery and chemotherapy to alter them, usually for the better. For instance, the use of a diuretic for congestive heart failure and hypertension, the performance of coronary by-pass graft surgery, the performance of a cholecystectomy, and the use of tranquilizers for various adverse mental states, are all disease altering treatments.   
 
Dictionaries, in general, and "Dorland's illistrated Medical Dictionary, 27th Edition", cited above, in particular, tend to preserve the historical meaning, and often the philological evolution, of words, so the word rheumatism is profusely defined. I will select certain aspects of the definition from the above text: "Any variety of disorders marked by inflammation, degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. '''apoplectic r.,''' rheumatism associated with brain hemorrhage. '''Articular r., acute,''' rheumatic fever.  ''articular r''., '''acute r'', rheumatic fever..."cerebral r"., acute rheumatic fever marked by chorea, delirium, convulsions, and coma..."r. of the heart", involvement of the heart by the rheumatic fever process. "Inflammatory r"., rheumatic fever..."lumbar r"., lumbago..."muscular r"., fibrositis..."subacute r"., a mild but protracted form of rheumatism." Since connective tissue, fibrous tissue, are parts of all organs, the skin, bones, tendons, ligaments, muscles, the heart, kidneys, gastrointestinal organs, the brain, etc., a disease that affects such tissue adversely will be, naturally, systemic in nature.
 
Hippocrates, or physicians of the Hippocratic persuasion, recorded within the book, The Sacred Disease, published within the text, "Hippocratic Writings", cited above, many case histories, which, in sum, indicate that the patients discussed, who became sick in an epidemic, experienced rheumatic fever. During the second century AD Claudius Galenus, commonly termed, simply, Galen was the first individual known to have coined the word rheumatism (rheumatismos). In the text, "Rheumatic Fever and Streptococcal Infection" (Massell, M., Harvard Press, 1997) the author provides a historical study of rheumatic fever. Guillaume Baillou (1538-1616) in France, during the Renaissance, wrote clearly about rheumatic fever. Later, Thomas Sydenham, during the mid 1600's, differentiated scarlet fever from measles and described rheumatic fever. Even though a great amount of clinical knowledge was gained about rheumatic fever its cause puzzled physicians, and other investigators, for hundreds of years for it wasn't understood that its cause was Streptococcus pyogenes until 1931. "In 1885,...Dr. Alfred Mantle presented a paper on infectious sore throat before the Section on Public Medicine at the annual meeting of the British Medical Association...He concluded that rheumatism was a common complication of infectious sore throat..." Further, "Because of its joint manifestations, rheumatic fever is included by the American Rheumatism Association as one of more than eighty different rheumatic conditions that it classifies." In addition, "Guillaume Baillou (1538-1616,...a Parisian physician apparently was the first to use the term "rheumatism" (rheumatismos) for polyarthritis..." "On the other hand the method by which this affection attacks which is falsely called catarrh; (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism..." Dr. Baillou goes on to provide a very good description of acute high-grade rheumatic fever similar to that of Sydenham's of the late 1600's. Further, "Many of the tendons of the superficial muscles of this patient were studded with numerous small hard tumors, an appearance I have observed only in one other person...who also labored under rheumatism." Baillou recognized certain systemic features of rheumatic fever: "The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot nor the hand, nor the finger can be moved in the least without pain & outcry..." Later, in 1715, Raymond de Vieussens described a patient with acute rheumatic fever, since he was determined during autopsy to have a severely dilated left ventricle, the walls of the aorta were..."thick, very hard, like cartilage; the semilunar valves are markedly stretched & cut off at their tips: all these cuts which bore some resemblance to the teeth of a saw, were in fact osseous." (rheumatic valve syndrome) Later, David Pitcairn, in England, lectured, in 1788, concerning rheumatism and its affect on the heart: "...that persons subject to rheumatism were attacked more frequently than others with symptoms of an organic disease of the heart. Subsequent experience having confirmed the truth of this observation, he concluded, that these two diseases often depend upon a common cause, and in such instances, therefore, called the latter disease rheumatism of the heart." It was not until 1931 that Alvin Coburn in the USA and Wilfred Collis in England determined that Streptococcus pyogenes caused rheumatic fever, and relying on David Pitcairn's judgement, heart disease. 
 
The above information provides the knowledge that physicians in earlier periods, back to the 1500's, used the word rheumatism, rheumatic fever, acte rheumatism and chronic rheumatism somewhat interchangeably for they knew that acute rheumatism would lead to chronic rheumatism and they also knew that a contagion, often connected with tonsillitis, or other respiratory disease presentation, could cause it. Since high-grade, acute rheumatic fever has become so rare in modern counties most currently practicing physicians have lost the clinical knowledge about it. They, therefore, have never gained the knowledge that there are lesser levels of rheumatic fever, as defined in "Osler's Principles and Practice of Medicine", published in 1935, cited above, and therefore they have even less knowledge about subacute and less than subacute rheumatic fever, which is are, semi-chronic clinical subtypes, of rheumatic fever a systemic, autoimmune-mediated, inflammatory disease.
 
  Between 2002 and 2005 I conducted a three-year, clinical investigation in an effort to determine the true cause of most peripheral neuropathies since so many of my patients, through the years, failed to improve after they experienced spinal surgery. I eventually determined that the venerated, herniated spinal-disc concept was flawed, and most of the surgery accomplished for them was, I learned, usually mis-applied. Most patients had suspicious arthritis of the lumbar and cervical spine that featured osteophyte development and bulging of intervertebral spinal-discs, but I learned that typical MRI films did not have the resolution to "see" spinal nerve roots in an analytical fashion. Since the bulging intervertebral spinal-discs are attention-getting on MRI images, and because they do, occasionally, cause symptomatic, spinal nerve root compression, generalizing that almost all bulging intervertebral spinal-discs cause nerve root compression was a classic "red herring". After I managed to determine the cause of the painful neuropathies, I learned that the same disease that causes the neuropathies also causes arthritis of the spine; an anatomical feature of spinal arthritis, herniated spinal-discs, did not necessarily cause the painful neuropathies. There are occassional herniated spinal-discs that cause painful spinal, nerve-root compression, but surgery for them is '''very''' common. 
 
Eventually, after a long, investigative period, I learned the most patients' neuroloical pain was caused by rheumatic, autoimmune-mediated, vasculitic neuropathy of the terminal nerves of the sacral plexus located within the piriformis canal, which is located deep in the buttock. Patients who experienced neurological shoulder/cervical pain and who experienced dysesthesias to the appropriate upper extremity, were experiencing rheumatic brachial plexitis. The brachial plexus is located within the axillary canal located deep within the shoulder. I learned that motion of the arm at the shoulder, and of the thigh at the hip, or an accident wherein either of the structures were stressed, would often cause, or exacerbate, patients' neurological symptoms and signs. Patients sensed pain in the lumbosacral region, because of centripetal referred pain from the distal sacral plexus located deep in the buttock. Similarly, they sensed pain in the cervical/shoulder region, because of centripetal referred pain from the brachial plexus located deep within the shoulder.
 
During the above investigation I attracted 700 miserable, painful patients who had chronic neurological pain. Eventually, I learned that they all had had meaningful, repeated Streptococcus pyogenes infections (tonsillitis, sinusitis, bronchitis, pharyngitis, otitis media, impetigo, and vaginitis) during their lifetimes and often they had experienced chronic tonsillitis. In addition, many of them, who had been born before 1970, had had, when they were younger, rheumatic fever or scarlet fever. Younger patients, born after 1970 had "flu-like" diseases with more mild symptoms and signs than accepted "Jones Criteria" standards for diagnosing rheumatic fever. I learned from information in Sir William Osler's text, Osler's Principles and Practice of Medicine, Twelfth Edition, cited above, that there are subacute and less than subacute states of rheumatic fever with more subtle systemic symptoms and signs than "classic" high-grade rheumatic fever. Such a disease has the same symptoms and signs that are thought to be those of influenza, or "the flu": a respiratory disease, often at least, lethargy, tiredness, at times stupor, body pain, back pain, photophobia, at times, headache, at times, gastrointestinal symptoms and signs, at times, and often a fairly rapid recovery. Often patients who had rheumatic fever had been diagnosed by a physician or by parents to have chicken pox, measles, the flu, mononucleosis and viral meningitis. Often the patients had been very ill, but recovered with care at home.   


I conducted serology tests (ASO and Anti-DNase B titers) on over 100 patients and 70 were positive with elevated Streptococcus antibodies on one or more tests. Between the positive medical histories, the elevated serology tests, and those who had medical histories of "flu-like" diseases, chicken pox, measles, mononucleosis, and viral meningitis wherein the symptoms and signs were those of rheumatic fever, the great majority of the 700 patients, mentioned above, who had chronic neurological and arthritic pain, and other similar diseases, were qualified to have had rheumatic fever.  
I conducted serology tests (ASO and Anti-DNase B titers) on over 100 patients and 70 were positive with elevated Streptococcus antibodies on one or more tests. Between the positive medical histories, the elevated serology tests, and those who had medical histories of "flu-like" diseases, chicken pox, measles, mononucleosis, and viral meningitis wherein the symptoms and signs were those of rheumatic fever, the great majority of the 700 patients, mentioned above, who had chronic neurological and arthritic pain, and other similar diseases, were qualified to have had rheumatic fever.  


The great minority of cases of rheumatic fever are high-grade and qualify by the Jones Criteria to be that disease. Most cases are much more low-grade and semi-chronic in nature and such individuals develop increased, rheumatic, autoimmunological sensitivity and memory so that they are candidates, in the future, to be at risk for developing acute rheumatic fever. Current medical knowledge (Carapetis, JR.,et al., ''Lancet'' Jul 9-15; 366(9480): 155-68) indicates that an infection by a virulent strain of Streptococcus pyogenes, in a well rheumatically sensitized individual, can cause the development of acute rheumatic fever, which is known to be an inflammatory, autoimmune disease process.   
The ''great minority'' of cases of rheumatic fever are high-grade and qualify by the Jones Criteria to be that disease. Most cases are much more low-grade and semi-chronic in nature and such individuals develop increased, rheumatic, autoimmunological sensitivity and memory so that they are candidates, in the future, to be at risk for developing acute rheumatic fever. Current medical knowledge (Carapetis, JR.,et al., ''Lancet'' Jul 9-15; 366(9480): 155-68) indicates that an infection by a virulent strain of Streptococcus pyogenes, in a well rheumatically sensitized individual, can cause the development of acute rheumatic fever, which is known to be an inflammatory, autoimmune disease process.   


The septic responses patients experienced, which frequently took place one to four weeks after an episode of respiratory disease (bronchitis, sinusitis, pharyngitis or tonsillitis) were caused by the rheumatic, systemic, autoimmune response to the autoantigens displayed by Streptococcus pyogenes. As the elevated levels of autoantibodies, and other toxic products, decreases after the peak of rheumatic fever, I hypothesize that patients maintain a low-level of rheumatic autoantibodies within themselves and it causes, over time, the signs and symptoms of chronic rheumatism. Since immunological and autoimmunological proteins circulate through the body via the elements of the circulatory system, rheumatism causes a usually subtle vasculitis, that is, arteritis, phlebitis, and lynphangitis. The much more common low-grade infections by Streptococcus pyogenes, and even the carrier state, cause an exacerbation in rheumatic stimulation, which establishes a chronic, waxing and waning autoimmune disease process within hosts, thus the chronic, autoimmune disease of rheumatism develops and is maintained.
The septic responses patients experienced, which frequently took place one to four weeks after an episode of respiratory disease (bronchitis, sinusitis, pharyngitis or tonsillitis) were caused by the rheumatic, systemic, autoimmune response to the autoantigens displayed by Streptococcus pyogenes. As the elevated levels of autoantibodies, and other toxic products, decreases after the peak of rheumatic fever, I hypothesize that patients maintain a low-level of rheumatic autoantibodies within themselves and it causes, over time, the signs and symptoms of chronic rheumatism. Since immunological and autoimmunological proteins circulate through the body via the elements of the circulatory system, rheumatism causes a usually subtle vasculitis, that is, arteritis, phlebitis, and lynphangitis. The much more common low-grade infections by Streptococcus pyogenes, and even the carrier state, cause an exacerbation in rheumatic stimulation, which establishes a chronic, waxing and waning autoimmune disease process within hosts, thus the chronic, autoimmune disease of rheumatism develops and is maintained.


Since Streptococcus pyogenes is endemic in human society, and a Russian Encyclopedia article (V. Nasonova & E. Talahaev) indicates that Streptococcus pyogenes is endemic in domestic vertebratres, and I hypothesize it  also exists in wild vertebrates, it seems that Streptococcus pyogenes causes a universal, autoimmunological zooinosis among vertebrates including humans.  
Since Streptococcus pyogenes is endemic in human society, and a Russian Encyclopedia article (V. Nasonova & E. Talahaev) indicates that Streptococcus pyogenes is endemic in domestic vertebratres, and I hypothesize it  also exists in wild vertebrates, it seems that Streptococcus pyogenes causes a universal, autoimmunological zooinosis among vertebrates including humans so, therefore, all humans have rheumatic disease.


As a reminder, the terms acute rheumatism, acute articular rheumatism, inflammatory rheumatism, and rheumatic fever, all describe the same acute, high-grade autoimmunological disease caused, usually in a delayed fashion, from infections by Streptococcus pyogenes. The terms rheumatism and chronic rheumatism refers to tissue damage that usually appears minor for which signs and symptoms are often subtle, are slow evolving, and usually cause little or no dysfunction. Over time, however, they can become highly meaningful and conditions such as hip and knee arthritis, coronary artery disease, peripheral vascular disease, rheumatoid (rheumatic) arthritis, lupus erythematosis, for instance, are an indication of its severity.  
As a reminder, the terms acute rheumatism, acute articular rheumatism, inflammatory rheumatism, and rheumatic fever, all describe the same acute, high-grade autoimmunological disease caused, usually in a delayed fashion, from infections by Streptococcus pyogenes. The terms rheumatism and chronic rheumatism refers to tissue damage that usually appears minor and for which signs and symptoms are often subtle, are slow evolving, and usually cause little or no dysfunction. Over time, however, they can become highly meaningful and conditions such as hip and knee arthritis, symptomatic coronary artery disease, peripheral vascular disease, rheumatoid (rheumatic) arthritis, and lupus erythematosis, for instance, are an indication of its severity.  


The pathological anatomy of chronic rheumatism is often relatively easy to observe since, certain superficial signs of disease, for instance the articular signs of rheumatoid arthritis, dermatological features of lupus erythematosis, dermatological features of progressive systemic sclerosis, rosacea, varicosities of veins, seborrheic keratosis, various types of nevi, Raynaud's phenomenon, palmar and plantar erythema, and livedo reticularis are all manifestations of the systemic disease of rheumatism. Rheumatoid arthritis, historically, was thought to be caused by rheumatic fever. At times it has been termed, arthritis deformans. There have been other more antiquated terms for high-grade rheumatic fever and I hypothesize that two of them are sweating sickness and miliary fever.  
The pathological anatomy of chronic rheumatism is often relatively easy to observe since, certain superficial signs of disease, for instance the articular signs of rheumatoid arthritis, dermatological features of lupus erythematosis, dermatological features of progressive systemic sclerosis, rosacea, varicosities of veins, seborrheic keratosis, various types of nevi, Raynaud's phenomenon, palmar and plantar erythema, and livedo reticularis are all manifestations of the systemic disease of rheumatism. Rheumatoid arthritis was, historically, thought to be caused by rheumatic fever. At times it has been termed, arthritis deformans. The text, Rheumatism, Rheumatoid Arthritis and Subcutaneous Nodules reviews the historical debates about the proper identification of rheumatic lesions, usually of the hands, and the meaning of subcutaneous nodules. Rheumatoid arthritis, lupus erythematosis, dermatomyositis, systemic sclerosis, Lyme disease, Whipple's disease, erythema nodosum, Dupuytren's contracture, and Interstital lung disease, are all syndromes, which feature as one of their signs subcutaneous nodules. Since acute rheumatism (rheumatic fever) also features subcutaneous nodules, and it is known that it is a highly variable, autoimmune disease, it is likely that the syndromes listed, above, are simply a number of various clinical presentations of chronic rheumatism.


It has not been clinically recognized, however, that ''all infections by Streptococcus pyogenes cause an inflammatory autoimmune response''. I hypotheize that Streptococcus pyogenes infections with a high virulence is most meaningful and more frequently cause exacerbations in the rheumatic autoimmune response. In addition, the patients level of rheumatic immunological sensitivity, caused by prior infections, also contributes to the development of an energetic autoimmune response.  
There have been other antiquated terms for acute rheumatism (rheumatic fever) and I hypothesize that two of them are sweating sickness and miliary fever. ( 6 )


After various acute disease episodes, throughout life, and after numerous episode of subacute or less than subacute rheumatic fever ensues during a person's lifetime, rheumatic tissue damage slowly occurs and it eventually rheumatism manifests itself with obvious signs and symptoms of pathological damage to the body's tissues, and therefore organs, in a somewhat subtle, varying, but progressive fashion. Its manifestations are often noted as changes to the skin, tendons, ligaments, nerves and joints so clinical syndromes such as sciatica, brachial plexitis, femoral neuropathy, meralgia paresthetica, carpal tunnel syndrome, ulnar neuropathy, cardiac arrhythmias, headaches, De Quervain's tendonitis, Achilles tendonitis, olecrannon bursitis, rotator cuff abrasions and tears, and Dupuytren's contracture appear. One must remember, however, that rheumatism is a systemic disease process so that all tissues, and therefore organs, are pathologically affected. Therefore, arteriosclerosis, endocrinopathies, renal failure, asthma, allergies, inflammatory bowel syndome, primary sclerosing cholangitis, pancreatitis, osteoporosis, spastic bladder, schizophrenia, obsessive-compulsive behavior, depression, and many, many other pathological conditions are caused by rheumatism. "One must think: each tissue, and therefore each organ, will clinically express the adverse effects of the systemic disease of rheumatism in its own way, thus, many apparent separate diseases develop, over time, in a somewhat random, but often connected, fashion."     
ItIt has not been clinically recognized, however, that ''all infections by Streptococcus pyogenes cause an inflammatory autoimmune response''. I hypotheize that Streptococcus pyogenes infections with a high virulence is most meaningful and more frequently cause exacerbations in the rheumatic autoimmune response. In addition, the patients level of rheumatic immunological sensitivity, caused by prior infections, also contributes to the development of an energetic autoimmune response.
 
After various acute disease episodes, throughout life, and after numerous episode of subacute or less than subacute rheumatic fever ensues during a person's lifetime, rheumatic tissue damage slowly occurs and it eventually rheumatism manifests itself with obvious signs and symptoms of pathological damage to the body's tissues, and therefore organs, in a somewhat subtle, varying, but progressive fashion. Its manifestations are often noted as changes to the skin, tendons, ligaments, nerves and joints so clinical syndromes such as sciatica, brachial plexitis, femoral neuropathy, meralgia paresthetica, carpal tunnel syndrome, ulnar neuropathy, cardiac arrhythmias, headaches, De Quervain's tendonitis, Dupuytren's contracture, Achilles tendonitis, olecrannon bursitis, rotator cuff abrasions and tears, and Dupuytren's contracture appear. One must remember, however, that rheumatism is a systemic disease process so that all tissues, and therefore organs, are pathologically affected. Therefore, arteriosclerosis, endocrinopathies, renal failure, asthma, allergies, inflammatory bowel syndome, primary sclerosing cholangitis, pancreatitis, osteoporosis, spastic bladder, schizophrenia, obsessive-compulsive behavior, depression, and many, many other pathological conditions are caused by rheumatism. Somewhat surprisingly, even cancer, of all tissue types, is caused by the inflammatory, rheumatic, autoimmunological attack that is a response to Streptococcal infections. Perhaps, DNAase toxic products that are secreted by Streptococcus during infections also help its formation. "One must think: each tissue, and therefore each organ, will clinically express the adverse effects of the systemic disease of rheumatism in its own way, thus, many apparent separate diseases develop, over time, in a somewhat random, but often connected, fashion."     


High-grade rheumatic fever decreased in incidence starting in the early 1900's within modern, industrialized societies, secondary to the improvements in living conditions which were brought on by advances of basic science that begot the industrial revolution. Advances included larger homes and smaller family size, both of which caused decreased crowding within dwellings, which decreased the spread of Streptococcus pyogenes within families. In addition, more hygienic living habits, the common use of soap, improvements in home bathing facilities, the use of clothes washers, dish washers, and the pasturization of milk all contributed to a decreased spread of Streptococcus pyogenes within society. Later, in the 1930's, the use of broad spectrum antibiotics for respiratory infections was initiated. The environmental changes, and the common use of antibiotics, resulted in fewer and fewer Streptococcus pyogenes infections, but more importantly, perhaps, infections with less virulence, so by 1970 high-grade rheumatic fever was a relatively rare disease in modern, developed countries. Chronic rheumatism also decreased in severity in especially in younger populations, but it still appeared, as a pathological entity, in older people as they lived through the years.
High-grade rheumatic fever decreased in incidence starting in the early 1900's within modern, industrialized societies, secondary to the improvements in living conditions which were brought on by advances of basic science that begot the industrial revolution. Advances included larger homes and smaller family size, both of which caused decreased crowding within dwellings, which decreased the spread of Streptococcus pyogenes within families. In addition, more hygienic living habits, the common use of soap, improvements in home bathing facilities, the use of clothes washers, dish washers, and the pasturization of milk all contributed to a decreased spread of Streptococcus pyogenes within society. Later, in the 1930's, the use of broad spectrum antibiotics for respiratory infections was initiated. The environmental changes, and the common use of antibiotics, resulted in fewer and fewer Streptococcus pyogenes infections, but more importantly, perhaps, infections with less virulence, so by 1970 high-grade rheumatic fever was a relatively rare disease in modern, developed countries. Chronic rheumatism also decreased in severity in especially in younger populations, but it still appeared, as a pathological entity, in older people as they lived through the years.


Unfortunately, in 1987 rheumatic fever experienced a resurgence with the first reports appearing in The New England Journal of Medicine with the author, L. George Veasy, MD wrote about a mini-epidemic from the area around Salt Lake City, Utah. Thereafter, numerous mini-epidemics have been reported from many areas in the USA. A mini-epidemic of acute rheumatic fever took place in Lewis and Cowlitz Counties of Washington State during the winter and spring of 2004 and 2005. A few people patients died before that period from rheumatic fever, but I didn't recognize it, but about ten people died out of my patient population of about 7000 during the aforementioned period. A number of patients have died thereafter who lived in the same geographic area. The individuals who died were fairly young, in their thirties to their sixties, they all experienced chronic neurological pain and arthritic symptoms, three of them had had a history of previous rheumatic fever or scarlet fever (Scarlet fever is the same disease as rheumatic fever, except it is caused by a separate sub-species of Streptococcus pyogenes, which develops a somewhat specific rash.) , a number of them had experienced spinal surgery with no improvement in symptoms or signs, and they were taking opiates for their severe, chronic, neurological pain when they died. Unfortunately, the local coroners, neither of whom had much medical knowledge or wisdom, made a determination that some of the patients died from the affects of opiates that they were taking for their chronic rheumatic pain. Some of the patients, on whom I had accurate information, had classic signs and symptoms of acute rheumatic fever so they qualified, by the Jones Criteria, to have had severe, acute, rheumatic fever. They had enlarged hearts and pulmonary edema on autopsy as an indication that they had had acute rheumatic carditis (myocarditis and endocarditis). 
Unfortunately, in 1987 rheumatic fever experienced a resurgence with the first reports appearing in The New England Journal of Medicine with the author, L. George Veasy, MD wrote about a mini-epidemic from the area around Salt Lake City, Utah. Thereafter, numerous mini-epidemics have been reported from many areas in the USA.  
 
One of the painful, clinical, rheumatic conditions, which many children commonly experienced in somewhat earlier times, such as before the 1970's, was growing pains. Growing pains manifest themselves as a painful sensation in the legs, commonly the thighs and knees, and it develops, often, shortly after going to sleep, or lying down, and wakes the young patient who often complains, and even cries, due to the severity of pain. Other clinical manifestations of rheumatism, which children experience, are torticollis (wry neck) and dorsodynia, which is an older term for upper back pain that is usually felt in the scapular region, which, I determined, is frequently a referred pain pattern caused by rheumatic brachial plexitis. Another syndrome children experience, occasionally, is Kawasaki disease. I surely think that Kawasaki disease is a syndrome that is a presentation of rheumatic fever in a child who is "well conditioned" to have a severe rheumatic vasculitic response by having experienced a number of Streptococcus pyogenes infections earlier in life. They could have experienced a chronic infection, which caused an elevated sensitivity to the autoantigens of a virulent subtype of Streptococcus pyogenes. Another syndrome that adults contract is Guillain-Barre' Syndrome. It is a presentation of rheumatic fever wherein the individual experiences an acute, systemic neuropathy and paralysis at some level. Usually they experience a respiratory infection somewhat before their attack and such a pattern of delayed autoimmune disease is classic for Streptococcus pyogenes infections and their delayed rheumatic response.
 
 
Simultaneously with the above changes in the frequency of high-grade rheumatic fever, the citizens of modernized countries experienced a steadily advancing life-expectancy; in the USA life expectancy increased from forty-seven in 1900 to about seventy-seven in 2000: an increase of about thirty years, which equates to an increase of 64% over a 100 year period. There has to be a logical reason for the increased longivity. The reason, mainly, I hypothesize, has been a decrease incidence, and severity, in general, of  Streptococcus pyogenes infections; a generally decreased level of virulence of Streptococcus pyogenes itself, which resulted in a great decrease in the incidence of acutge rheumatic fever and, therefore, chronic rheumatism decreased in severity in the populations of economically advanced countries.  The decrease in the incidence of acute rheumatic fever, a disease that often caused the death of children and younger people, greatly contributed to the increase in human life-expectancy. There were other positive factors also, for instance, a better food supply, vaccines for other diseases, and improved medical care, especially supportive care and disease altering surgical procedures.
 
Rheumatic autoimmunity causes, initially and continually, an inflammatory vascular condition, which is its main pathological mechanism, that results in inappropirate intra-arterial thrombosis especially at arterial bifurcations. The immune system reacts to localized intra-arterial thrombosis with an enhanced,  localized inflammatory response so that inflammatory, intra-arterial, arteriosclerosis lesions develop. As Streptococcus pyogenes infections decreased, as mentioned above, fewer myocardial infarctions developed early in life and coronary artery disease became, to a great degree, a disease of older people, in modernized portions of the world, since it is caused by more subtle, chronic rheumatic autoimmune condition: chronic rheumatism.     
 
In 1931 Coburn in the USA and Collis in England determined, somewhat simultaneously, that Streptococcus pyogenes caused rheumatic fever, but professional inertia being what it is, many physicians did not completely accept their theory until the late 1940's and the early 1950's when rheumatic fever, as a high-grade disease, was becoming less and less common, primarily, because of the above-mentioned improved living conditions and use of antibiotics mentioned above. 
 
Starting in the 1920's, slowly, but then accelerating, especially in the 1950's, medical practice and education became conceptually segregated by means of specialty-organized, procedure-dominated concepts and by the 1960's most physicians were specialists and specialty practice settings and knowledge-states were not conducive to an understanding of systemic diseases. Since acute rheumatic fever, and moreso, chronic rheumatism are basically the same disease, with the former being an acute exacerbation of the latter, the latter, chronic rheumatism, which has a multitude of target-organ manifestations, simply was not recognized, or ceased to be recognized, by the members of the specialty-oriented medical community.
 
Individuals in the various surgical specialties concentrated on various target-organ manifestations of rheumatism and developed disease-altering cardiac, surgical procedures such as CABG surgery, angioplasty/stent procedures, cardiac valve modification and replacement procedures, and cardiac arrhythmia altering surgery, etc. Surgical procedures to alter, usually for the better, rheumatic pathology to gastrointestinal organs consist of, in part, surgical procedures such as cholecystectomy for cholecystitis, various surgical procedures for ulcerative colitis, redundant colon, Crohn's disease, esophageal strictures, primary sclerosing cholangitis, and gastric and peptic ulcers. The latter two, gastric and peptic ulcers are primarily caused by rheumatic vasculitis, but that condition is exacerbated locally by Helicobacter pylori infection. In general, infections cause a localized exacerbation of rheumatic vasculitis. In addition, organs that function peristaltically, as do most of the gastrointestinal organs, feature compression and abrasion of tissues, which also causes an exacerbation of rheumatic vasculitis, in a semi-localized fashion, within them. Pyrosis, or heart burn, is another clinical entity caused by rheumatic vasculitis. The peristaltic compression causes enhanced rheumatic vasculitis, which is further exacerbated, usually in the distal esophagus, by the effect of hydrochloric acid and digestive enzymes from the stomach on the esophageal endothelium. 
 
In addition, many chemotherapeutic medications were developed so the use of NSAIDS, steroid anti-inflammatory medications, artery dilators, cancer chemotherapy drugs and countless other chemotherapeutic drugs became commonly used to alter the affects of chronic rheumatism on various organs. Both NSAIDS and steroid anti-inflammatory medications are used for acute, rheumatic fever, in addition. 
 
During the development of "specialty medicine", it seems that rheumatology, one of the last specialty groups organized, was "elbowed" into dealing with only connective tissue, perhaps since other groups of physicians had claimed authority of the other organ systems, although most rheumatic syndromes such as rheumatoid arthritis, lupus erythematosis and psoriasis, for instance, are known to be systemic disease processes. The specialty-medicine paradigm that developed, since the 1920's, simply never provided a systemic disease concrept-base so chronic rheumatism has never been understood in a modern, etiological fashion even though all the clinical elements of its understanding had been provided by investigators in prior eras, by the microbiological breakthroughs of the late 1800's through the early 1900's, and by the insights made concerning autoimmune disease concepts. A valuable text that provides a current understanding about the current state of knowledge about autoimmunity is, "The Autoimmune Diseases" Fourth Edition (Rose, N., Mackay, I., Academic Press, 2006).
 
Even though high-grade rheumatic fever greatly decreased in incidence after1900 lesser levels of rheumatic autoimmunity have still been propagated throughout human society, including modern developed countries, since Streptococcus pyogenes infections still exist endemically, but usually with less virulence, within the populations of all countries. Therefore, since Streptococcus pyogenes infections are endemic at any one time, at some level, in all communities in the world, at some level. For instance, the non-symptomatic carrier state of Streptococcus pyogenes is between 5%-15% of grade school children as per information in the text, "Rheumatic Fever and Streptococcal Infection", cited above. Hypothetically, low grade infections will cause low-grade autoimmunological stimulation within those very mildly sick individuals and they can pass infections on to those around them.
 
The clinical understanding of high-grade rheuamtic fever (acute rheumatism) decreased in modern countries so that, nowadays, in the USA, the average physician has virtually no, or little, knowledge of acute rheumatic fever at this time. Knowledge, therefore, of the much lower-grade, chronic, rheumatic autoimmunity and its more subtle, slowly-developing, target-organ manifestations has never been developed in modern medical science and along the way, rheumatism as a chronic disease concept, was dismissed as a serious medical subject, even though, as early 200 AD, certain knowledge concerning rheumatism was known, and in the late 1700's the "clinical features" of acute and chronic rheumatism was reasonably well known.   
 
For instance, Galen, the famous Greek physician in the Roman period, who published over 66,000 pages of medical, philosophical, and scientific information, half of which has managed to survive since 200 AD, coined the word rheumatismos. Rheum, in Greek, means to flow, or phlegm. The phrase "a defluxion of rheum" could be used. It was later connected with catarrh, influenza, or the grippe, terms that describe a respiratory disease. Galen knew, I hypothesize, that when people developed contagions that caused the development of phlegm, and, perhaps, chronic phlegm development, they would also, eventually, develop chronic, painful problems that were part of the chronic disease of rheumatism. Arthritis, neuropathy (such as sciatica, carpal tunnel syndrome, ulnar neuropathy, brachial plexitis, for instance), angina, pericarditis, pleurisy, tendonitis, ligamentitis (for instance plantar fasciitis) are examples of modern names for target-organ manifestations of rheumatism.
 
As mentioned above, within the first edition of the ''Encyclopedia Britannica'', cited above, on page 124, under the chapter on "Medicine", under the paragraph, "Of the Rheumatism", a description of acute rheumatic fever similar to that written by Thomas Syndenham, during the 1600's, is provided. It mentions fever, chills, rapid heart rate, fatigue, lassitude, gastrointestinal problems, sciatic pain (lumbago), and migratory arthritis. It saliently mentions, "The proximate cause is the inflammation of the lymphatic arteries." Further, it mentions, "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds."
 
It appears, clearly, that physicians in the mid-1700's knew that the "Proximate cause (or pathological finding) was inflammation of the lymphatic arteries (arteries) a condition now known as vasculitis, phlebitis, and lymphangiitis. Of course the rheumatic vasculitis that exists in those with chronic rheumatism is somewhat low-grade. They also knew that repeated "...lesser but neglected colds." could cause the systemic disease of rheumatism, but in the modern day, pundits of evidence-based medicine (whose evidence, how was it gathered, who interpreted it?) pontificate to student-physicians that, all "colds" are caused by viruses so upper respiratory diseases, even sore throats and tonsilitis, are not to be treated with antibiotics unless a positive quick strep test or culture is positive. Unfortunately, such tests are often inadequate or inconclusive and since Streptococcus pyogenes can exist intracellularly within the epithelial cells of the pharynx, and even "within" the tonsils, in which case quick Strep tests and cultures will usually, or often, be negative. (Rheumatic Fever and Streptococcal Infection, cited above) One must remember that when a physician is dealing with Streptococcus pyogenes infections one is dealing with a very important aspect of a patient's health.
 
The term "rheumatism" is still used in colloquial speech and in historical contexts, but it is no longer frequently used in medical or technical literature; it would be fair to say that there is no longer any recognized disorder simply called "rheumatism".  The traditional term covers such a range of different problems that to ascribe symptoms and signs to rheumatism, would violate, more than trivially, the artificially developed specialty structure that has developed in modern, western medicine since the 1920's.
 
One of the first organizations that dealt with rheumatism, in the modern day, was the European League Against Rheumatism. Unfortunately, rheumatologists, to maintain their specialty-mandated specialty status as experts at connective tissue diseases, do not generally deal with infectious diseases or problems of the body's organs even though they also, historically, have dealt with rheumatic fever, which is a high-grade, inflammatory, autoimmune-mediated, systemic disease process stimulated by Streptococcus pyogenes infections and that most "rheumatic diseases" such as rheumatoid arthritis and lupus erythematosis are systemic diseases, per se. 
 
As a vestige of past wisdom, many individuals knew that arthritis, neuropathy, tendonitis, dermatological problems, and many other adverse health conditions had something to do with rheumatism. For instance, during the early 1900's, in America, sciatica was termed sciatic rheumatism or hip gout, eczema of the hands was termed, salt rheum, and gout was termed, gouty rheumatism. Those who understood the collective wisdom of the time knew that the maladies described were part of the rheumatism complex. Old farmers, walking bent over with a cane often have said, "Oh, my rheumatism". Non-articular rheumatism, also known as soft tissue rheumatism, and which is now known as "fibromyalgia", was in prior eras known as "muscular rheumatism". Somewhat surprisingly, that variously described condition is a dispersed rheumatic, sensory neuropathy: bilateral brachial plexitis, sacral plexitis and at times femoral neuropathy that is made more symptomatic by use of the arms and legs. To understand the above pathophysiology an examiner must do an analytic, neurological examination of the brachial plexus, the terminal nerves of the sacral plexus, and the femoral nerve; they must "know" the location of the dermatomes of the body: in SPADES. 
 
Within the chapter on rheumatoid arthritis in ''Harrison's Principles of Internal Medicine, 16th Edition'', cited above, the "NUT" of rheumatism is presented. The author's provides an interesting description: "Rheumatoid arthritis is a chronic multisystem disease of unknown cause." Further, the following is mentioned: "In approximately 10% of individuals the onset is more acute, with a rapid development of polyarthritis, accompanied by constitutional symptoms, including fever, lymphadenopathy, and splenomegally." It describes that rheumatoid arthritis features arthritic aspects, rheumatoid nodules, vasculitis, neuropathy and organ infarction, even myocardial infarction. At times, the text indicates, "Neurovascular disease presenting either as a mild distal sensory neuropathy or as mononeuritis multiplex may be the only sign of vasculitis." Anemia, subcutaneous nodules, and osteoporosis are concomitant features of rheumatoid arthritis. It mentions that pericarditis is found in 50% of individuals with rheumatoid arthritis at autopsy.
 
Referring to the above description of the "...chronic multisystemic disease..." of rheumatoid arthritis, many signs and symptoms are identical to those found in rheumatic fever: subcutaneous nodules, a feverish disease that exists somewhat before arthritis develops, lymphanenopthy, polyarthritis, splenomegally, vasculitis, neuropathy and organ infarction are all found in acute rheumatic fever patients and some sequelae are found in those with chronic rheumatism. 
 
The connections, mentioned above, of a mild, acute disease triggering vasculitis, arthritis, neuropathy, myocardial infarction, anemia, pericarditis, and osteoporosis describes many of the same pathological features  that are historically attributed to rheumatism. The acute disease process mentioned, is, I surely think, a subacute case of rheumatic fever (the type Sir William Osler described in his famous text of 1935), the pathological, systemic, inflammatory, autoimmune disease that post-dates, from a week to five weeks, the Streptococcus pyogenes infection that cased it. 
 
Within the text, ''Rheumatic Fever and Streptococcus Infection'', cited above, the author indicates that fifty percent of Streptococcus pyogenes infections that trigger rheumatic fever have such mild symptoms and signs that patients do not remember them when queried, therefore, it would not be surprising that low-grade respiratory infections and even the somewhat higher grade infections would be missed, forgotten, or just thought to be important. 
 
Individuals who develop high-grade rheumatic fever are often thought to have developed a different, and separate, idiopathic (meaning the cause is not known), acute disease process, but it also has symptoms and signs of vasculitis, arthritis, pericarditis, subcutaneous nodules (which develop due to chronic rheumatism), fever, splenomegally, lynphadenopathy, at times enlargement of the cervical lymph nodes, renal abnormalities, hepatitis, delirium, neuropathy, epistaxis, urticaria (hives) or other rash, and other systemic symptoms and signs, which vary significantly, depending on the severity of the individual disease episode.
 
Individuals who experience severe cases experience severe pain. Sir William Osler has written the following concerning the pain experienced by patients who have high-grade rheumatic fever: "Perhaps no disease is more painful; the inability to change posture without agonizing pain, the drenching sweats, the prostration and helplessness, combine to make it a most distressing affection ("Osler's Principles and Practice of Medicine, Twelfth Edition, cited above). I learned from experience that when individuals experience severe rheumatic fever, with its severe pain, they will take any thing in an effort to decrease it: opiates, aspirin, ibuprofen, alcohol, cold remedies, etc. Since they become delirious they may behave unwisely and/or behave nastily to those around them. Many patients who die from rheumatic fever, in the past, have been experiencing chronic rheumatism with one of its symptoms being chronic neuropathic pain. Not unusually, they have been prescribed chronic opiates so when they become sick with recurrent rheumatic fever and die, usually at home, their deaths are "blamed" on the opiates they took. A tell-tale sign on examination is, often, however, pulmonary edema and an enlarged heart about 20% above normal. In addition, they often will have a history of a respiratory disease, or a "flu-like" disease, concomitantly or a few weeks before. Possibly, celebrities such as Brittany Murphy (who had the autoimmune target-organ disease of diabetes, her husband (rheumatic fever tends to be a family disease, because Streptococcus pyogenes is very contagious among close-living individuals), Cory Haim, Heath Ledger, Michael Jackson (who had the autoimmune syndrome of vitilago and, perhaps, his quick, stuttering dance steps were, in part enabled by   
 
"Rheumatic fever has various serious manifestations, for instance, carditis, endocarditis (heart valve malfunction), pericarditis, clinical heart failure heart failure, pulmonary edema, rheumatic pneumonitis and cardiac arrhythmias. In addition, it features lassitude, stupor, coma, chorea, and, at times, seizures caused by rheumatic encephalitis. Further, patients experience abnormal kidney function leading to kidney failure, at times; chronic rheumatism is a cause for chronic renal failure. Since rheumatic carditis is a life-threatening target-organ manifestation, and since acute rheumatic myocarditis, endocarditis, pericarditis, and cardiac arrhythmias are aspects of its spectrum, most medical attention in acute rheumatic fever cases is, logically, given to the heart, but in truth, it is a systemic disease process. 
 
For a long period, most medical attention connected with acute rheumatic fever is focused on chronic cardiac valve disease. It is known that individual patients who have had rheumatic fever in the past may have chronically developed cardiac valve abnormalities, with the mitral valve the most commonly abnormal. Most cardiologists, in the modern day, specialize in disease altering procedures to alter the disease of the heart; and they rarely think about, or clinically deal with, acute, systemic, rheumatic fever.  The rest of the target-organ manifestations of rheumatic fever have been, more or less, inappropriately disconnected from the acute, disease process and the disease diagnosis that is provided depends on what type specialist attends the patient. If they have meaningful hepatic problems, they may be deemed to have a type of hepatitis. If they have renal failure as a major problem, they may be diagnosed to have acute renal failure. If they have pulmonary failure they may be diagnosed to have interstitial pulmonary disease or, simply, pulmonary failure. Even if they have highly meaningful cardiac problems cardiologists often make the diagnosis of acute heart failure and pulmonary edema, but do not deal with the condition with an etiological approach. The physician, in the modern day, it seems, has the job of providing a "diagnostic code" approved by insurance companies; that is all that is really needed....to get paid.
 
Like most diseases, rheumatic fever (acute rheumatism) exists as a lower-grade, subtle disease phenomenon most of the time, and relatively rarely, except in certain, favorable epidemiological situations, does rheumatic fever exists in the high-grade state that has the symptoms and signs popularized by the Jones Criteria. Surprisingly, T.Ducket Jones, MD, who invented the Jones Criteria, did not think that Streptococcus pyogenes was the cause of rheumatic fever even in the early 1950's, although, as mentioned above, Alvin Coburn published a monologue that provided proof that it did, in 1931. To keep using the Jones Criteria, nowadays, is improper, I surely think. To think that rheumatic fever is mainly a cardiac disease is also a gross error: it is a systemic, autoimmune disease process, which in high-grade cases has serious, acute, somewhat focused, cardiac, autoimmunological target-organ manifestations. 
 
The rheumatic diseases, which are caused by the autoimmunological response to infections by Streptococcus pyogenes (and perhaps other Streptococcus species) include rheumatoid (rheumatic) arthritis, psoriasis and its arthritis, lupus erythematosis, Sjogren's syndrome, scleraderma, ankylosing spondylitis, dermatomyositis, myositis, Wegener's granulomatosis, and osteoarthritis. They are caused by the autoimmune response to Streptococcus pyogenese infections during the patients' lifetimes.  Osteoarthritis is simply rheumatic arthritis that appears in certain joints such as the spine, knees, hips, and hands due to a localized, exacerbation of rheumatic vasculitis that is caused by the mechanical factors of compression and abrasion. For instance, the first three locations feature exacerbated arthritis somewhat commonly due to the compression and abrasion experienced by the joint structures during weight bearing and active use. Individuals' hands, especially womens' hands, often feature arthritis, commonly termed osteoarthritis and rheumatoid arthritis, which are really the same disease state, due to the individual's frequent use, which involves compression and abrasion of the joints, tendons, ligaments and soft tissues of the hands. Also, heat and cold, in general, also cause an exacerbation of rheumatic inflammation in a local fashion. Women are thought to have rheumatoid (rheumatic) arthritis more often then men. Perhaps women use their hands in a more intense and common fashion than most men in the modern day as they do housework and yard work. 
 
Peripheral neuropathies such as lumbosacral/buttock pain with sciatic pain referred down the leg; it is caused by rheumatic inflammation to the terminal nerves of the sacral plexus the sciatic, posterior femoral cutaneous, pudendal nerves. Femoral neuroapthy, carpal tunnel syndrome (median neuropathy), cubital tunnel syndrome (ulnar neuropathy), peroneal neuropathy (lateral lower leg and foot), meralgia paresthetica (neuropathy of the lateral femoral cutaneous nerve), and tarsal tunnel syndrome are all aspects of rheumatism.  Fibromyalgia is a dispersed neuropathy of the bilateral brachial plexus, the terminal nerves of the sacral plexus and femoral nerve, and other nerves). Femoral neuropathy can present in a clinically isolated fashion. Various cranial neuropathies such as trigeminal neuropathy can appear as facial pain or the many branches to the meninges can be primarily affected, which, hypothetically, can cause migraine headaches and other clinical types of headaches. Bell's palsy (rheumatism of the facial nerve), hearing deficits, vertigo, Menier's disease, and abnormalities of the motor nerves of the eye are all caused by rheumatic autoimmunity. When neuropathies present more severely they are more systemic in nature so they manifest as the syndromes of multiple sclerosis, Guillain-Barre' syndrome, and, hypothetically, amyotrophic lateral sclerosis.
 
Rheumatic endocrine abnormalities are common, for instance, diabetes, Addison's disease, Cushing's syndrome, hypothetically, polycystic ovary disease, testicular failure, hypothyroidism, Hashimoto's thyroiditis, hypoparathyroidism, and pituitary abnormalities of various types are usually, more likely, caused by rheumatic autoimmune attack. Hypothetically, children with diabetes probably experienced acute rheumatic fever and the, more or less, acute development of diabetes is one of its sequelae. The others, mentioned above, are due, usually, to chronic rheumatic attack that is caused by rheumatic fever as well as by, or inaddition to, lower grade Streptococcus pyogenes infections during their lifetimes.
 
Benign Tumors and cancer of various types are rheumatic in nature. Nevi (moles) of various types, freckles, seborrheic keratosis, and many more lesions, usually thought to be benign, are secondary to pathological rheumatic stimulation. Cancer of all tissue types are target-organ manifestations of the systemic autoimmune disease of rheumatism. The rheumatic neuropathies (written about two paragraphs, above) often appear before, or concomitantly, with cancer and they are termed, in that case, paraneoplastic neuropathy. Often the neuropathy is sciatica or the individual has a history of sciatica.  Ulcerative colitis, Crohn's disease, celiac disease, primary sclerosing cholangitis, gastritis and esophagitis are also autoimmunological manifestations of rheumatism and like many "systemic rheumatic conditions" such as dermatomyositis and lupus erythematosis, they are also paraneoplastic conditions. I estimate that most individuals who develop cancer have, at least, rheumatoid (rheumatic) arthritis at some level of severity so it, hypothetically, can be thought to be a paraneoplastic, rheumatic disease presentation, also. 
 
Since rheumatism is, first of all, a vascular disease peripheral artery disease of the extremities, carotid stenosis, aneurysm development, CVA's, and kidney vascular abnormalities are all, usually, caused by rheumatic vascultis, the primary lesion of rheumatism. Phlebitis, usually in the lower extremities, is also a manifestation of rheumatic autoimmunity. Lymphedema is probably a condition caused by rheumatic autoimmunity. 
 
Rheumatic central neuropathic conditions are highly variable due to the complexity of the spinal cord and the brain. In recent years there have been breakthroughs that show the "tip of the iceberg, so to speak, in that PANDAS (Pediatric Autoimmune Neurological Deficits caused by Streptococcal infection) is a concept that has wide appreciation. The clinical syndromes, autism, ADHD, Tourette's syndrome (tics, stuttering, stammering, antisocial behavior, explosive personality, coprolallia, echolallia, dysinhibition, etc.), depression, schizophrenia, manic-depressive illness, and disassociative reactions are some manifestations of "rheumatism of the brain", as it were termed in an earlier era.
 
Gastrointestinal system: target-organ maladies: ulcerative colitis, Crohn's disease, celiac disease, primary sclerosing cholangitis, pancreatitis, peptic ulcers, gastric ulcers (Helicobacter pylori is just an exacerbating problem with rheumatic vasculitis), esophagitis, peridontal disease.   
 
Bursitis: olecrannon bursitis, pre-patellar bursitis, tibial tuberosity bursitis (house maids knee), and subacromial bursitis are examples.
 
Tendinitis: tendonitis of the long head of the biceps, DeQuervains tendonitis, Achilles tendonitis, and rotator cuff abrasions, tears, etc. Ligamentitis such as plantar fasciitis, deltoid ligamentitis of the medial foot, etc.
 
Cardiological rheumatic problems: rheumatic cardiac valve syndrome, coronary artery disease, acute and chronic myocarditis (LVH, global cardiac enlargement, and decompensated enlarged heart), pericarditis, and cardiac arrhythmias are all caused by rheumatism. Coronary artery disease and another cardiac problems were termed, "rheumatism of the heart" a concept that was developed by David Pitcairn in 1788 (''Rheumatic Fever and Streptococcus infection'', cited above).
 
Kidney: rheumatic vasculitis leading to chronic rhenal failure, gout, and kidney stones.
 
Special Senses: cataracts, retinitis, iritis, keratokornus, uveitis, subconjuctival hemorrhage, decreased hearing, tinnitis, Menier's syndrome, phorias, tropias, and hyposmia are examples.
 
Skin: seborrheic keratosis, dermatitis, nevi, angiomas, purpura, urticaria, telangectasias, rosacea, erythroderma, poliosis, vitilago, spider nevi, petechiae, actinic keratosis, Stevens-Johnson syndrome, hypothetically, pityriasis rosea, palmar erythema, plantar erythema, dermographism and others.
 
Although the above disorders usually are not thought to have much in common etiologically, they are all target-organ manifestations of one variable, inflammatory, autoimmunological disease process: rheumatism. One cannot expect the eye to respond to a systemic disease as the plantar facia responds. One cannot expect the medial meniscus to respond to a systemic, inflammatory disease as the hip joint responds. One should not expect the brain to respond to a chronic, inflammatory, autoimmunological condition as the heart responds. All rheumatic conditions are inflammatory in nature and share two characteristics: they cause chronic (though often intermittent) pain, and they are difficult to treat. They are also, collectively, very common. Aspirin, other NSAIDS, and streroid antiinflammatory medications are used, however, to treat many of them and they "work" reasonably well if taken in adequate doses for protracted periods. Even coronary artery disease, and recently cancer, at times, are prophylactically treated with aspirin. 
 
Since acute rheumatic fever causes a dampening of the protective immune response, hypothetically the innate immune response, "other" infections often develop with acute rheumatic fever (as enumerated by Sir William Osler in his text, ''Osler's Principles and Practice of Medicine, Twelfth Edition'', cited above. Tuberculosis, diptheria, cholera, whooping cough and other diseases are mentioned. Chronic rheumatism also causes a decreased immune response and I surely hypothetically think that tuberculosis, MRSA, Streptococcal necrotizing fasciitis, erysipelas, Lyme disease, herpex zoster, mononucleosis, AIDS, possibly Chigas disease and malaria, are all infectious disease process that take place more commonly in individuals who have high-grade rheumatic autoimmunity: rheumatism. 
 
One can consider that rheumatic fever itself is also an acute aspect of rheumatism and its former name, acute rheumatism, more or less, defines that concept.
 
 
interested physicians should read articles and texts by Gene Stollerman, M.D. and Benedict Massel, M.D., two of the last physicians who treated many, patients who had rheumatic fever. Dr. Stollerman has written that physicians should treat patients with pharyngeal infections, after clinical inspection provides a reasonable adjudication that Streptococcus pyogenes could be the causual micorbiological agent, with penicillin. No wonder the American population is becoming populated with millions of cases of fibromyalgia (muscular rheumatism), diabetes, sciatica, autism, MS, cancer, cardiac disease, psychological diseases, and other conditions. One aspect of rheumatic encephalitis is Tourette's syndrome and one of its aspects is antisocial behavior. Our prisons are "filled" with hundreds of thousands of inmates, usually the poorer class of person, who is more likely to have experienced rheumatic fever, and many of them have organic mental problems caused by rheumatic encephalitis.
 
Since modern, specialty medicine "missed out" on recognizing rheumatism as an abiding, systemic, inflammatory disease that all humans develop, it evolved the concept that the target-organ manifestations of chronic rheumatism were independent idiopathic diseases. The semantic error of using the term disease, when the cause of a malady is not known, led, I surely think, to the general self-deception that physicians knew more about diseases than was true: they were dealing with syndromes, symptom and sign patterns, and not well defined diseases wherein their causes are known. Coronary artery disease is really coronary artery syndrome, for instance. Crohn's disease is really Crohn's syndrome and the list can go on and on since the great majority of the descriptions of "diseases" that fill medical texts such as ''Harrison's Principles of Internal Medicine, 16th Edition'', cited above, are really syndromes: symptom and sign patterns that commonly appear together. Medical science, has, therefore, for the last sixty years developed a multitude of disease altering treatments for various diseases and not curative treatments since the cause of a disease must be known before definative cures can be developed. Modern clinical trials are organized efforts to find a chemical that will alter, significantly, a syndrome for the better; not to cure a disease.
 
To better understand "where medical science is" at this time, an individual must understand the the scientific revolution of thought started in the modern era, about 1600, and that a modern approach to medical science was not possible without the insights first developed by Antony van Leewenhoek concerning microbiology. Progress was slow, thereafter, so that in 1850, just two long life-times ago, physicians did not know the cause of one disease so all treatments were disease altering. If a patient did not have a laceration, a fracture or a sprain, conditions wherein the cause was known, no curative treatments could be managed. Then the microbiological revolution started in Germany and France with the work of Pasteur, Henle, Koch, Ehrlich, and others. Their breakthroughs stimulated American medical science to become more academic. By the late 1930's sulfonamide and penicillin had been developed and their use was a great boon to physicians and patients alike. It seemed that there was not much further worry about infectious diseases and physicians and medical researches dropped their guard, understandibly.
 
Autoimmune concepts had been developed early in the 1900's, but the excitement over microbiology and antibiotics and the development of specialty, procedural medicine caused interest in immunology to wane. Interest in immunology re-developed in the 1970's and great progress has been made, but there have been few physicians on the street seeing patients of both sexes, of all ages, and for all diseases, who happened to practice in an area where rheumatic fever was active, and who could put the advances in immunology together, at least in a superficial fashion, with clinical medicine. I hope I have succeeded.
 
==Treatment==
Since the etiolgy of rheumatism has not been known, individuals throughout history have used a great number of traditional and more modern treatments for the many symptoms of rheumatism.  Modern medical treatment often consists of non-steroidal anti-inflammatory treatments and steroid anti-inflammatory treatments. Both are used for acute, rheumatic fever also. Treatment for the target-organ manifestations of rheumatism are as varied as cryotherapy for dermatological lesions, both cancerous and benign, surgical treatment for rheumatic arthritis as of the knees and fingers, tendonitis of the rotator cuff, and spinal surgery for heriated spinal-discs, which is usually inappropriate. Aaron Filler, M.D. (backpain-guide.com) accomplishes piriformis canal enlargement procedures to decrease the pressure on the terminal nerves of the sacral plexus and often has good results from his procedures when individuals experience recalcitrant sciatica.
 
Somewhat commonly, initial therapy for mildly painful symptoms of rheumatism is to use non-opiate analgesics such as acetaminophen. Since rheumatism is an inflammatory disease process, of an autoimmunological nature, non-steroidal anti-inflammatory/analgesic medications (NSAIDs) are used, some members of which are aspirin, ibuprofen, naproxen sodium, indomethocin, and diclofenac. Many others exist. Often, more efficacious analgesics are required and if individuals have meaningful pain, opiate analgesics have been safely used for hundreds of years.
 
Most patients will experience a relief of thier severe neurological pain if they are provided a Steroid injection such as triamcinolone 80 mg. intramuscularly via the upper outer quadrant of the buttock. They should experience reasonable relief in three to four days. They should take aspirin, 325 mg, coated, three times a day and indomethacin 25 mg. three times a day, together, also, and also take ranitadine, 150 mg a day to decrease stomach acid production.
 
The current practice of providing steroid injections into the spinal space is not needed, because even when it is injected in that area (by an expensive procedure), it will be absorbed by the arterial and venous circulation and spread around the body: it does not matter where it is given and so an intramuscular injection is adequate as long as the dose is high enough. I surely think, for a short period, like three months, a triamcinolone injection can be given every three weeks, or so.
 
At times a family member, or the patient, can be a Streptococcus pyogenes carrier so I used to see all immediated family members living in the same house and treat them all for a short time with an adequate dose of penicillin. 
 
If individuals know they have had rheumatic fever, or if they have positive or high normal serology tests for Streptococcus pyogenes, ASO, Anti-DNase B, Anti-hyaluronidase, Anti-Streptokinase, for instance, prophylactic use of penicillin VK, G, or amoxicillin can be used to decrease the frequency of high-grade rheumatic fever, by decreasing meaningful Streptococcus pyogenes infections. Keflex or Erythromycin can be used if a person is allergic to penicillin. Certain organizations are working on the development of a vaccine for Streptococcus pyogenes.
 
=="Rheumatism" and weather==
For a long period, it has been suspected that there is a link between "rheumatic" pain and the weather. There appears to be no firm evidence in favour or against that idea, but a 1995 questionnaire given to 557 people by R. Jamison, and others, at the Brigham and Women's Hospital's Pain Management Center concludes that "changes in barometric pressure are the main link between weather and pain. Low pressure is generally associated with cold, wet weather and an increase in pain. Clear, dry conditions signal high pressure and a decrease in pain"[http://www.nervepainandweather.co.uk/Pressure_as_link_pain_and_weath.html].
 
Within the first edition of the Encyclopedica Britannica, the following quote is provided: "The rheumatism chiefly attacks persons in the flower of their age, after violent exercise, or a great heat of the body from any other cause an, and then being too sudenly cooled."
 
Within the text, Rheumatic Fever and Streptococcal Infection, cited above, the following is written: "Haygarth in 1805 was one of the earliest physicians to relate rheumatic fever to the throat when he noted that "persons who have been previously affected with the acute or chronical Rheumatism, the Gout, or sore throat, especially the first, are most liable to suffer attacks of this disease; and ought therefore to be particularly careful to avoid exposure to cold and moisture." In a study of 175 patients with acute rheumatism he observed that sixty-five of them ascribe their disease to "having caught a cold" and he expressed the opinion that the exciting cause was "exposure to cold and moisture.""
 
Within Sir William Osler's text, published in 1912, cited above, within the section of chorea the following is mentioned, "The cases are most numerous when the mean relative humidity is excessive and the barometric pressure is low (Lewis). Concerning rheumatic fever in the same text, "It prevails in temperate and humid climates...The disease prevails in the more northern latitudes...The general impression is that the disease prevails more in the British Isles than anywhere else...In Norway, where cases of rheumatic fever are notified, there were, for the four years 1888-'92, 13,654 cases, with 250 deaths.,,CHILL--Exposure to cold, a wetting, or a sudden change in temperature are among the factors in determining the onset of an attack, but they were present in only 12 per cent. of our cases. 
 
It is well known by mothers and physicians that respiratory diseases, colds, are more common in the autumn, winter and spring and those are the seasons when rheumatic fever is most common. In the above mentioned text, Rheumatic Fever and Streptococcal Infection, cited above, Bernard Schlesinger indicated, " It is no exaggeration to say that acute nasopharyngeal infection is the most serious menace to the rheumatic child with heart disease."


I do not think barometric pressure affects rheumatism's develoment, especially since it varies continually day in and day out and hour by hour, but cooler and damper weather affects the frequency of Streptococcus pyogenes infections. Damp weather is usually connected with lower barometric pressure and cooler dry weather often is connected with clear, high-pressure weather patterns, in the winter. The fall through the late spring is generally cooler in the northern hemisphere.  
A mini-epidemic of acute rheumatic fever took place in Lewis and Cowlitz Counties of Washington State during the winter and spring of 2004 and 2005. A few patients died before that period from rheumatic fever, but I didn't recognize it. During the above mentioned period, about ten people died out of my patient population of about 7000 during the aforementioned period. A number of patients have died thereafter who lived in the same geographic area. The individuals who died were fairly young, in their twenties to their sixties, they all experienced chronic neurological pain and arthritic symptoms, three of them had had a history of previous rheumatic fever or scarlet fever. In addition, a number of them had experienced spinal surgery with no improvement in symptoms or signs, and they were taking opiates for their severe, chronic, neurological pain when they died. Unfortunately, the local coroners and medical examiners, neither of whom had much medical knowledge or wisdom, made a determination that some of the patients died from the affects of opiates that they were taking for their chronic rheumatic pain. Some of the patients, on whom I had accurate information, had classic signs and symptoms of acute rheumatic fever popularized as the Jones Criteria. They had enlarged hearts and pulmonary edema on autopsy as an indication that they had had acute rheumatic carditis (myocarditis and endocarditis) and rheumatic, congestive heart failure.


It is a sure fact that high altitude areas such as the Rocky Mountain area in the USA has an elevated frequency for the development of rheumatic fever cases for it was proved during the WW II period. Rheumatic fever, acute rheumatism, and therefore the development of chronic  rheumatism is not limited, however, to any particular altitude or climate.  
One of the painful, clinical, rheumatic conditions, which many children commonly experienced in somewhat earlier times, such as before the 1970's, but even currently, are growing pains. Growing pains manifest themselves as a painful sensation in the legs, commonly the thighs and knees, and it develops, often, shortly after going to sleep, or lying down, and wakes the young patient who often complains, and even cries, due to the severity of pain. Other clinical manifestations of rheumatism, which children experience, are torticollis (wry neck) and dorsodynia, which is an older term for upper back pain that is usually felt in the scapular region, which, I determined, is frequently a referred pain pattern caused by rheumatic brachial plexitis. Another syndrome children experience, occasionally, is Kawasaki disease. I surely think that Kawasaki disease is a syndrome that is a presentation of rheumatic fever or scarlet fever) in a child who is "well conditioned" to have a severe rheumatic vasculitic response by having experienced a number of Streptococcus pyogenes infections earlier in life. They could have experienced a chronic infection, which caused an elevated sensitivity to the autoantigens of a virulent subtype of Streptococcus pyogenes. Another syndrome that adults contract is Guillain-Barre' Syndrome. It is a presentation of rheumatic fever wherein the individual experiences an acute, systemic neuropathy and paralysis at some level. Usually they experience a respiratory infection somewhat before their attack and such a pattern of delayed autoimmune disease is classic for Streptococcus pyogenes infections and their delayed rheumatic response.  


The high-altitude area of Mexico features endemic rheumatic fever and I surely think that the great number of immigrants to the USA from Mexico, usually individuals from the more economically poor class, have been vectors for virulent strains of Streptococcus pyogenes and that great immigration phenomenon has probably been one of the causes of the increased level of rheumatism as indicated by the increased incidence of acute rheumatic fever in the USA since 1987, and therefore, the cause of the increase in the incidence of autism, diabetes, and other autoimmunological diseases in the USA during the last thirty years.
Simultaneously with a decrease in the frequency of high-grade rheumatic fever, the citizens of modernized countries experienced a steadily advancing life-expectancy; in the USA life expectancy increased from forty-seven in 1900 to about seventy-seven in 2000: an increase of about thirty years, which equates to an increase of 64% over a 100 year period. There has to be a logical reason for the increased longivity. The reason, mainly, I hypothesize, has been a decreased incidence, and severity, in general, of  Streptococcus pyogenes infections; a generally decreased level of virulence of Streptococcus pyogenes itself, which resulted in a great decrease in the incidence of acute rheumatic fever and, therefore, chronic rheumatism decreased in severity in the populations of economically advanced countries.  The decrease in the incidence of acute rheumatic fever, a disease that often caused the death of children and younger people, greatly contributed to the increase in human life-expectancy. There were other positive factors also, for instance, a better food supply, vaccines for other diseases, and improved medical care, especially supportive care and disease altering surgical procedures.  


== Miscellany ==
Rheumatic autoimmunity causes, initially and continually, an inflammatory vascular condition, which is its main pathological mechanism that results in inappropiate intra-arterial thrombosis especially at arterial bifurcations. The immune system reacts to localized intra-arterial thrombosis with an enhanced,  localized inflammatory response so that inflammatory, intra-arterial, arteriosclerosis lesions develop. As Streptococcus pyogenes infections decreased, as mentioned above, fewer myocardial infarctions developed early in life and coronary artery disease became, to a great degree, a disease of older people, in modernized portions of the world, since it is caused by more subtle, chronic rheumatic autoimmune condition: chronic rheumatism.
A [[Trod]] in the West of England is a straight line or ''Fairy Path'' in the grass of a field with a different shade of green to the rest. People with rheumatism sought relief by walking along these tracks, though animals are thought to avoid them.<ref name="Pennick1996132">Pennick, Nigel (1996). ''Celtic Sacred Landscapes''. Thames & Hudson. ISBN 0-500-01666-6. P. 132.</ref>


"For the period of 1939-1943, statistics published by the Metropolitan Life Insurance Company indicated that rheumatic fever was the leading cause of death among policy holders for persons from five to nineteen years of age and the second leading fatal disease among twenty to twenty-four year olds." ''Rheumatic Fever and Streptococcal Infection'', cited above.
Rheumatism is a disease with frequent acute manifestations, but it has much more common chronic manifestations. It has existed in vertebrates, including humans, ever since Streptococcus pyogenes, and perhaps other bacterial types, evolved the biochemical structures, autoantigens, which, at least to some degree, decrease the ability of vertebrate hosts to identify it as foreign. Eventually, Streptococcus pyogenes is identified to be foreign and its vertebrate host, the human host being the primary subject of this article. The human host develops antibodies to the antigens, but it also develops autoantibodies to the autoantigens it displays during infections. The antibodies, and autoantibodies kill or harm Streptococcus pyogenes, but the autoantibodies also attack humnan tissue chemical moieties, which Streptococcus pyogenes has mimicked. Once the immunological system has formed autoantibodies they continue to be manufactured in a decreasing fashion so that their concentration decreases over time, but they never disappear. If another Streptococcus pyogenes infection ensues at a later date, and since the human host has developed autoantigenic memory and sensitivity, there will be a more brisk manufacture of autoantibodies and the individual will develop recurrent rheumatic fever.  


== References ==
Since Streptococcus pyogenes is one of the most common microorganisms to parasitize vertebrates, especially humans, infections by them, mostly less than subacute and chronic, take place reasonably frequently. Subtypes of Streptococcus pyogenes vary a great deal in their virulence; if a highly virulent strain of Streptococcus pyogenes infects an individual who has elevated rheumatic sensitivity, they may develop acute rheumatic fever.
{{reflist}}


==External links==
The above pattern occurs during life in a continual, waxing and waning fashion so that all people have streptococcal autoimmunity, rheumatism, at some level. Eventually, its effects harms all tissues, and therefore organs, and so it manifests itself in what is termed "the aging process".
*[http://www.bbc.co.uk/health/50plus/health_arthritis.shtml BBC "Your Health" website on Arthritis and Rheumatism]
*[http://www.ars-grin.gov/cgi-bin/duke/ethno-actlist.pl?Rheumatism List of plant species that have been recommended as treatments for rheumatism, from Dr Duke's Phytochemical and Ethnobotanical Databases]
*[http://www.retirement-matters.co.uk/gparchive/arthritis.htm#PART%20TWO:%20RHEUMATISM Account of Rheumatism from the website of Retirement Matters Ltd of the UK]


{{SIB}}
Contact information: ecnal-c@hotmail.com


[[Category:Rheumatology]]
===Cause: Infections by Streptococcus pyogenes. This fact was determined as indicated above, somewhat concomitantly, by Alvin F. Coburn in the U.S.A. and W. R. F. Collis in Great Britain in 1931. ( AB )===


*


<br>
==References ==
[[de:Rheuma]]
==(1) Harrison's Principles of Internal Medicine 16th Edition, McGraw Hill Medical Publishing Division, New York, N.Y., 2005 ==
[[it:Reumatismo]]
==(2) Harrison's Principles of Internal Medicine 12th Edition, McGraw-Hill Medical Publishing Division, New York, N.Y., 1991 ==
[[he:שיגרון]]
[[pl:Reumatyzm]]
[[pt:Reumatismo]]
[[ru:Ревматизм]]
[[sl:Revmatizem]]
[[vi:Bệnh phong thấp]]
[[ur:اشعالیت]]


{{WH}}
(AB) "The Factor of Infection in the Rheumatic State", Alvin F. Coburn, MD, The William and Wilkens Company, 1931[[Category:Rheumatology]][[Category:Poor syntax]]
{{WS}}

Latest revision as of 23:42, 19 May 2016

Rheumatism by Dr. Lance Christiansen
ICD-10 M79.0
ICD-9 729.0
MeSH D012216

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Overview

Rheumatism is usually considered to be an archaic term in medical science for it is not listed as a subject within the index of most modern, medical texts. For instance, it is not listed in the index of the text, Harrison's Principles of Internal Medicine, 16th Edition published in 2005. ( 1 )

Within the 12th edition of the same text, published in 1991, the only listing for rheumatism is psychogenic rheumatism; a part of the short paragraph explaining it is quoted as follows: "PSYCHOGENIC RHEUMATISM Patients may experience severe joint pain involving a few to several joints without physical findings of arthritis.These patients are often convinced that they have rheumatoid arthritis, systemic lupus erythematosis, or another rheumatic connective tissue disease. This disorder is recognized by the inconsistencies, exaggerations, and emotional lability of the patient during the history and physical examination..." ( 2 ) The above use of the word rheumatism reflects how the concept of the systemic disease of rheumatism, as readers will soon understand, has become marginalized in modern medicine existing as only an archaic term or, as indicated above, as a figment of a person's imagination. (2)

Many philosophers and natural philosophers appeared during the pre-classic Greek period, and the classic Greek period, who mentally probed the nature of the universe, ideas, and matter, for instance, Socrates, Dioscordes, Plato, Theophrastus, Aristotle and Hippocrates and many others. Philosophy and natural philosophy was further extended during the Hellenistic era by many philosophers and natural philosophers including Praxagorus, Herophilus, Erasistratus, Soranus, Celsus, and Galen, the majority of whom studied, conducted medical research (including anatomical research via human dissection), and/or taught at the Alexandria University and Library in Egypt. Although various new ideas and concepts were developed, via observation and reason, by the above cited individuals are known to modern scholars, directly through their writings, exemplified by those of Hippocrates, Galen and Soranus, it is more common that their ideas, hypothesis, concepts and determinations developed via their research have come down to the modern day through the writings of authors who were active in later periods and frequently written information is thought to be confabulated by their associates, or by other individuals, but those writings have come down to modern readers as written by well known authors such as Hippocrates and Galen. Fortunately, many the works of Galen are still extant after being translated from Arabic, Coptic, Syrian, early Greek and other languages first into Latin and eventually into modern European languages. The knowledge that modern readers have, for instance, about the writings of Herophilus and Erasistratus, have come down to us via the writings of Galen and others.

During the classic Greek period, the Hellenistic period, and thereafter, and during the Middle Ages, many details of classic Greek and Hellenistic philosophic and natural philosophic thought had been absorbed into Arab, Syrian, and Jewish learned society and the writings of individuals such as Ibn Sina (Avicenna (980-1037), Al Farabi (c. 870-950), Ibn Rushd (Averroes) (1126-98) and Moses Maimonides (1135-1204 CE), and others, were eventually translated into Latin at various locations, especially, however, by Moorish and Jewish physicians in Spain, after the removal of the Arab leadership in 1492.

During the second century CE the Greek physician, scientist, philosopher and author Claudius Galenus (129 to about 213 CE), commonly known simply as Galen, was born in Pergamum, which was a thriving city on the west coast of what is now Bergama, Turkey and which was originally founded as early as 1200 BCE during the early archaic period of the Greek Civilization. He was provided a liberal education, which included a thorough education in the various philosophies that had developed in Greece up to that time. At 17 he began medical training at the Aselepieum of Pergamum. He also trained in anatomy, physiology, medical theory and treatment concepts at Smyrna ( now, Turkey), Corinth (Greece) and for four years at Alexandria ( Egypt). Later in his career he practiced in Rome and eventually became physician to a number of emperors including Marcus Aurelius. ( 3 )

William Gilbert (1544-1603), an English physician, philosopher and scientist is often thought to be the first person during the seventeenth century to overtly espouse the scientific method, for instance: "... he was the first person to set out clearly in print the essence of the scientific method - the testing of hypothesis by rigorous experiments - and to put that method into action." ( 4 ) Earlier, however, Nicolaus Copernicus and Galileo Galilei had practiced the scientific method and before that, during the European medieval period, Roger Bacon, Roger Grosseteste, Thomas Acquinas, Albert Magnus, and others, were involved, in thought and practice, in developing what has become to be known as the scientific method of knowledge development.

It appears, however, that Galen's rational, philosophic methodology, which he developed during the second century CE was similar to Gilbert's, and other western European natural philosophers' thought and purposeful experimental processes, which were identical or similar to those now known as the scientific method. His analytical methodology appears in many locations throughout his writings. For instance: "...logical procedures should at all times be checked by experience. Both reason and experience are instruments of discovery and means of testing what has been discovered. The method envisaged by Galen can roughly be characterized as comprising a stage of discovery steered by reason ( i.e. rational methods) followed by one of confirmation or otherwise by means of experience. For Galen, experience means not merely the accumulation of data involving no particular expertise." It "...involves techniques requiring skill and expertise such as in anatomy and experimentation...Galen engaged in the style of anatomical experimentation instigated by..." earlier anatomists, "But in this context he retained the Empiricist requirement of a large number of identical observations, thereby foreshadowing the modern requirement of the repeatability of experimental observations." ( 3 )

Hippocrates, "...first used the term rheuma, which literally means "flowing," to describe an excess of the watery humor (phlegm) thought to flow down from the brain. The words rheuma and catarrhos ("flowing down") were used interchangeably by ancient Greeks to describe a variety of illnesses including joint problems. ( 7 ) Galen adhered to many Hippocratic concepts and he also, like Hippocrates, advocated carefully observing individuals' life activities, such as their immediate living environment, nutrition, hygiene, levels of exercise, the observable factors of disease states, signs, and patient complaints, symptoms, and rationally studied anatomy, physiology and the environment (such as the geographical location and seasonal weather conditions) so as to understand the nature of man concerning the development of disease states more accurately. His study was accomplished in reference to the concepts of Plato and Aristotle as well other natural philosophers and physicians including Diocles, Herophilus, Eriasistratus and others. ( 3 ) Concerning phlegm (rheuma) Galen indicated: "We use the word catarrh whenever the superfluity flows to the mouth, but coryza whenever it flows from the nose." ( 8 )

It may be that another individual of the Hippocratic persuasion, not Hippocrates himself, commented on rheumatism within the Hippocratic Corpus, however, within this text all writings in that work will be considered Hippocratic in origin. Further, then, Hippocrates seems to be the first physician to use the word rheumatismus (rheumatism) as a noun and verb. ( 9 ) In addition, Galen championed and further developed many concepts in medicine first mentioned by Hippocrates. For instance, the pathophysiological concept of rheumatism was one such concept since, concerning the word rehumatism, "Examples of...noun, adjective and verb are far too common in Galen to list (80+)..." ( 10 )

Further, within the Giunta edition of Galen, in Latin, there are over thirty notations within the index on rheuma, rheumatism and related terms. For instance, "Rheumatismum faucium Suffionigmum de dyna.; Rheumatismum stomachi and intestinarum Malagma...; and Rheumatismi articularum, introd." ( 11 ) The preceding subjects are, roughly translated: rheumatism of the throat, rheumatism of the stomach and intestine as soft masses, and rheumatism of the articulations or joints. It seems, as the prior information exhibits, that Galen's concept of rheumatism was that it was a disease that affected many parts of the body (a systemic disease) and that, it was related to rheum, a flowing down of phlegm, catarrh from the mouth and coryza from the nose. In those early times it was thought that phlegm (in the form of cerebrospinal fluid) flowed from the ventricles of the brain through the small holes in the cribiform plate of the ethmoid bone that is located directly above the center of the nasal passages. That idea was rationally appropriate since the cerebrospinal fluid is a semi-clear fluid and it is normally found within the ventricles and within the space between the meninges and the matter of the brain just above the cribiform plate.

An increase in mucous drainage, catarrah and coryza, was related, evidently, to a "...a systemic inflammatory response syndrome (SIRS) that may have an infectious or a noninfectious etiology. If an infection is suspected or proven, a patient with SIRS is said to have sepsis. When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." ( 1 ) If the development of phlegm from the respiratory organs is caused by an infection from a microorganism that has a mechanism to create pathological tissue changes to distant tissues and organs, then, perhaps, that is the mechanism of the development of rheumatism, or better said, rheumatic pathological signs and symptoms in various parts of the body.

To further provide philological information on the words rheuma and rheumatism the following definitions found in dictionaries will be provided: The definition of the word rheum within a reasonably current dictionary is: "rheum...1. a thin, serous or catarrhal discharge. 2. catarrh; cold. [ME reume < L rheuma < Gk rheuma...(to) flow..." ( 11 ) In addition, "rheum, ...Rheuma, (F.) Rheume, ...'I flow.") Any thin watery discharge from mucous membrans or skin; as the thin discharge from the air-poassages arising from cold." and, "Rheuma, gen. Rheumatis, ...(from...'I flow") Catarrh, Diarrhea, Rheum, Rheumatism. Also, inflammation of a fibrous tissue, as in rheumatism and gout. In composition, a flow, a defluxion; also, rheumatism. ( 12 )

During the Renaissance Guillaume Baillou (1538-1616), or Ballonius in the Latinized form, a Parisian physician, apparently was the first to use the term "rheumatism" (rheumatismos) for polyarthritis and to give a fairly good description of this condition, in his treatise, "Liber de Rheumatismo,", which was not published until 1642, twenty-six years after his death." Further, Baillou provided a clinical description of an individual with acute rheumatism (rheumatic fever):

"Before we place this affection in a class of disease or symptoms (since it causes its effects by the primary disease and the symptoms produced by it is commonly and vary badly confused) just as what it is, we shall explain by what and in what manner it arises: we shall point out the train of pains & symptoms also present...

On the other hand the method by which this affection attacks which is falsely called catarrh: (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism, is as follows. . . The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot nor the hand, nor the finger can be moved in the least without pan & and outcry: moreover the greater pain lies in the joints because that part is endowed with greater and more exqusite sensation...When the hand is pressed on the parts, the sensation & feeling, (even if you touch it lightly) is of a definite severe heat. IF you examine the pulse, the fever is seen to be little or nothing...

Indeed the pains are worse at night, the patients cannot sleep, partly because they are unable to be moved from their position & from that posture they first usually lie and recline, they remain in it & are scarcely moved or touched without excruciating on terrible pain...this rheumatism itself is in the entire body; with pain, tension and a somewhat sharp feeling, others say with the sensation of heat (as already mentioned)...This rheumatism is not the same as in those who sin in their way of life." ( 13 )

Somewhat later, Thomas Sydenham (1624-1689), an English physician, who also, like Hippocrates and Galen, carefully observed patients' during disease states. "These observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitis Dance (1686) and gout (1683). "...Sydenham understood the migratory nature of polyarthritis and its tendency to attack the young, characteristics which today we know to be typical of the joint manifestations of rheumatic fever." ( )

Hippocrates mentioned the salient clinical characteristics of rheumatic fever within writings of the Hippocratic Corpus. For instance, "Rheumatism as a disease process became. clinically, more accurately understood so by the the the late 1700's acute rheumatism was the term used for rheumatic fever and chronic rheumatism was known defined as follows: "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 13 )

To think and speak concisely words must have strictly defined meanings. The use of the words empiric, empirical, and empiricism, in various contexts, is somewhat antonymic in nature. For instance, within a reliable dictionary the meanings of the words are established: "empirical, empiric, a. 1. relying or based solely on experiments or experience; as, the empirical method..." Conflictingly, in the same text, the meaning of empiricism is as follows: "empiricism, n. 1. dependence of a person on his own experience and observation, disregarding theory, reasoning, and science. 2. the practice of medicne without a medical education; hence, quackery; charlatanism..." ( 9 )

Within an older medical dictionary the following definition for empiric is described: 1. "Empiric...(...'a trial;.'--'experimental.') One who follows only experience. A sect of physicians, who rejected all theory, and took for their guide experience alone. It was opposed to the dogmatic sect, which prevailed till near the time of Galen." In addition, "... At the present day the word Empiric is only taken in a bad sense, being employed in nearly the same signification as charlatan or quack." ( 10 )

The definition of the word empiric, just related, should be clarified to indicate that the "experience" mentioned is the personal experience of one physician-investigator, or, perhaps, the added experiences of a number of other physician-investigators who have communicated between each other in a fairly casual fashion and not with scientific detail, processes, repetition or scrutiny.

Since there is a conflict of meaning using the English word empiric, and words developed from it such as empirical and empiricism, a solution to the conflict will be used in this article by using, as a convention, an older English spelling: empyric, empyrics, empyrical and empirycism, as in the empyric school of medicine, as it is used in a text published in 1771: "After a knowledge of medicine began to be studied and practiced as a liberal profession, a jealousy of reputation, joined to a thirst for money and ignorance of philosophy, laid a solid foundation for medical disputation. One party of physicians, known by the name Empyrics, excluded all reasoning, and trusted solely to experience." ( 13 )

Alternatively, empiric, empirics, empirical, and empiricism will, in this text, convey a more detailed, scientific concept, for instance, an individual's empiric method would include personal observations, repetitive observation, analysis, at times, experimental observation, testing and further analysis and deductive hypothesis development. After the hypothesis was widely verbally announced, or published, other investigators could, themselves, repeat the same observations, analysis, etc., and agree or disagree with the hypothesis advanced by the original investigator. Empiric, empirical and empiricism would, then, connote a scientific meaning and methodoloy, whereas empyric, empyrical and empyricism would refer to a personal, more or less, opinionated meaning, or a meaning agreed upon by individuals within a certain professional group or group of people with a similar philosophy.

For instance, the empyric concept that is often mentioned in chiropractic advertising indicates that an adjustment of the spine promotes spinal health. Also, Andrew Taylor Still, MD DO, the founder of the osteopathic medical profession, taught that spinal manipulation promoted improved blood flow to various anatomical sites in the body. In addition, individuals are frequently advised to have an annual physical examination for they are generally thought to contribute to a person's general health. All three of the prior concepts, even if they have been repeated for a long period of time, have not, necessarily, been developed through the use of empiric methodology.

The word disease, also, has various meanings. In this article the word disease will connote an adverse medical condition wherein the cause and basic pathophysiology is known. Alternatively, an adverse medical condition, which has no known cause (an idiopathic disease), and which is defined by its general sign and symptom pattern, and, at times, its gross and microscopic anatomy, will be defined to be a syndrome. Ninety-nine percent of diseases mentioned in leading medical texts are more accurately described to be syndromes and not diseases. For instance, coronary artery disease, mental diseases such as schizophrenia and manic-depressive disease, Crohn's disease, Meniere's disease and the disease of diabetes mellitus are all more accurately defined to be syndromes, and not well defined diseases, since their causes are not known.

Galen can be considered for the most part an empiric, but, perhaps, he is more accurately termed a rationalist. He never claimed, however, that he was a member of any one school or sect of medicine. When, however, due to lack of physiological, pathophysiological or micro-anatomical information he, at times, adapted older concepts, such as Hippocrates' fluid (humor) concept, which had been developed by him to explain clinically observed phenomena during a time when anatomical, micro-anatomical, physiological and pathophysiological empiric information was not available. Galen also developed, at times, his own concepts based on observation, which, without modern investigative abilities, have been proven to be not true. He thought, ideally, that diseases should be anatomically and pathophysiologically understood and that included understanding their causes before proper treatments could be developed. He also realized, however, that there were limits to existing knowledge so that a quasi-empiric or a careful empyric approach to treating diseases, based on careful use of experience and reason, had to be used until a more thorough knowledge of the particular medical phenomenon in question was achieved. One of the ways to understand the body was via a thorough an investigation of human anatomy and physiology; such knowledge was not thought to be necessary by empyricists of his time. In an effort to develop his empirical medical concepts Galen accomplished a great deal of original medical research, especially, in neuroanatomy and neurophysiology. ( 3 )

The dogmatist school of medicine was a "...school of medicine formed by Diocles of Carystus. The school put Aristotelian language, system, and speculation into Hippocratic medicine to discover the hidden causes of the constitution of man and of disease: such knowledge, they thought, was necessary for the practice of medicine." ( 14 )

The melding of empyric medicine (using only information developed via personal, idiosyncratic methodology) with dogmatic, empiric medicine (using information developed via scientific methodogy) is, for a physician, a necessary, practicable reality until complete knowledge concerning all disease processes, including their causes, is developed and that approach to professional medical treatment was advanced in 1771: "A judicious mixture of the two is indispensably necessary. Indeed it is difficult to determine whether too great an attachment to empyricism or dogmatism has contributed most to obstruct the improvement of physic." ( 13 )

Progressively, over the last six decades, or so, the empyric treatment paradigm has become quasi-empiric by the development of organized clinical trials, which test more accurately as to whether a certain medicinal chemical treatment, or surgical treatment, produces a meaningful ameliorative change in a syndrome. Such trials, and the research that is is involved with the medicinal chemical's development, however, ignore dealing with the cause of the disease in question so such organized efforts are not thoroughly empiric.

The professional organization of medicine had always features physicians who specialized in certain medical techniques, such as surgical techniques, or in treating certain conditions starting, at least, with archaic Egyptian medicine. ( 15 ) Beginning in about 1920 in the USA, however, the development of various medical specialties was accelerated so that by the 1970's most physicians were of the specialist type and general practitioners who, historically, had treated males and females, of all ages, for all diseases became fewer and fewer in number.

Specialty medicine has been, and is, the practical paradigm, which represents the empyrical, or allopathic, school of medical science, which has dominated modern academic and clinical medical science and practice since that time, the early 1900's. Allopathy is the correct name for the philosophy of modern, empyric, medical practice and it is defined as follows: "...that method of medical practice which seeks to cure disease by the production of a condition of the system either different from or opposite to the condition produced by the disease..." ( 16 ) The term, allopathy was not coined by members of the doctor of medicine profession, but by Samuel Hahnemann, the founder of homeopathy, to distinguish the predominant, functional school of medicine at that time, the late 1700's, from the type of medical philosophy and practice espoused by homeopaths.

The reality is, however, the treatments developed in the members of the doctor of medicine profession, mentioned above, do not cure most diseases except those, such as lacerations and fractures caused by trauma, and since the 1930's, those caused by certain infectious processes. Most medical and surgical treatments have been developed to alter organs, or parts of organs, usually for the better, that have become symptomatically damaged by an unknown, underlying pathophysiological process, or processes, with an unknown cause. Although the term allopathic physician is not used by members of the doctor of medicine profession to describe themselves, members of that profession, the osteopathic profession, the homeopathic profession, the naturopathic profession, the chiropractic profession, the physical therapy profession, and even the traditional Chinese medical profession all practice their own form of allopathic medicine: altering disease, often for the better, by "...the production of a condition of the system either different from or opposite to the condition produced by the disease." An example is the use of insulin to treat diabetes; its use lowers elevated serum blood glucose levels, but it does nothing to improve the function of the Islands of Langerhands of the pancreas, which are not producing adequate insulin due to an underlying autoimmunological process. Similarly, If a person has ulcerative colitis, a portion of the colon that is most severely affected is often surgically removed, but the surgical procedure does not control the underlying autoimmune condition that intrinsically causes such a disease process.

It should be noted that the above paragraph stresses the idea that allopathic medicine seeks to: cure diseases such as fractures, sprains, and specific infections, since their causes are known, by applying proper physical treatments, concerning the first two types of diseases, and by the use of antibiotics in the third. All other adverse medical problems, however, are syndromes and so by the production of a condition of the system (a physical or biochemical change within the body) either different from, or opposite to, the condition produced (damaged organ) by the disease (the syndromic sign and symptom pattern) and that the goal of such a medical philosophy is not, necessarily, to cure the underlying disease in question by effectively removing its cause. That is, the underlying disease, or its cause, does not necessarily have to be known before pathological target-organ manifestations produced by them, biochemical or physical dysfunction, such ischemic cardiomyopathy caused by arteriosclerosis of the coronary arteries and diabetes mellitus caused by partial or complete failure of the Islands of Langerhands of the pancreas, are allopathically treated. At times, one specific treatment modality, or a combination of allopathic, quasi-empirical treatment modalities, manages to cure a patient's syndrome without knowing the nature of its underlying cause. An example of such a treatment is the curative treatment provided patients with certain tissue-types of cancer by applying various combinations of surgery, chemotherapy, and radiation therapy.

For instance, if a patient has congestive heart failure with pulmonary edema, an enlarged heart, and swelling of the lower extremities it is common to provide the patient with diuretics, digoxin, and arterial dilators to improve the adverse physical findings of their condition. Usually, such treatment "works" in a meaningful fashion, but it does not deal with the underlying disease or its cause, which resulted in an acute malfunction of the heart. A similar relationship exists between cholecystitis and cholecystectomy. Surgically removing a patient's gall bladder removes the inflamed, poorly functioning organ and also removes the gall stones that often form within it. The surgical procedure often decreases patient discomfort, but it does not deal with the underlying disease, or its cause, that resulted in the gall bladder's abnormalities to originally develop. Similarly, tranquilizers improve a patient's feelings of anxiety, but they do not change the pathological phenomenon, organic or behavioral, that caused it. Finally, insulin injections lower serum glucose levels, but they do not improve the functioning of the islands of Langerhands of the pancreas, which have been harmed by a poorly understood autoimmune process the cause of which is unknown. Basically, in all the above common therapeutic approaches the therapy provided a different or opposite result as that caused by the underlying pathological process in the certain organ. One could confidently say that the treatments mentioned above altered, for the better, the specific organ damage or malfunction described, which were caused by unknown, underlying disease-processes, which have unknown causes.

The above allopathic, semi-empiric method of medical practice usually provides for an improvement in patients' medical maladies, however, it is limited in concept, because it foregoes a rationalist's concept that, ultimately, the underlying pathological disturbance that causes organ damage, and its cause, must be known before cures can be developed, an idea which was held by Galen. For instance, Galen indicated, "Nature does nothing for no reason." and "Nothing occurs without a cause...So if a natural activity such as vision is damaged or impeded, one should look for the cause, i.e. a particular disposition of the body...The doctor, at any rate, directs his therapy at the disposition being the cause of the impairment." ( 3 )

The development of medical science had progressed, slowly, in a waxing and waning fashion, over a long period of time so by 1850, for instance, if a patient did not have a laceration, burn, sprain, or fracture, medical problems for which causes were known, no medical condition could be treated directly in curative fashion by empiric means. Finally, the most meaningful advance in recent medical history occurred during the 1870's with the discovery of the microbiological hypothesis of infectious diseases by Robert Koch, a "country physician" in Germany. After the "causes" of infectious diseases were determined a rational effort towards curing them was enabled; antibiotic and vaccine development was the result that effort.

Modern medicine, basically, is a syndrome (idiopathic disease) altering art that has incorporated certain treatments to alter, usually for the better, certain syndromes. This paradigm is enforced by the concept of evidence based medicine, which itself defines the organization of medical practice wherein only certain individuals, who work in medical-educational and research institutions, have the right to accomplish medical research and determined that a certain quasi-empiric treatment, usually biochemical in nature, provides some measure of decrease in the signs and symptoms of a certain syndrome. Since the cause of the syndrome, in question, is not known, however, the treatment is syndrome-altering, and not disease curing, in nature.

Unfortunately, over time, the concept of evidence based medicine has mandated the exclusion of the newly developed medical information (rationally developed, empiric, medical information) that has been learned and accumulated by hundreds of thousands of clinical physicians, because they do not work within the confines of the medical, academic establishment. Even though the physicians, mentioned above, underwent training in the same medical, academic establishments they are not allowed to use their institutionally learned knowledge, knowledge that is enhanced through a long involvement in clinical medicine, to augment the functional medical knowledge used by the medical community. Galen, himself, shunned such a scholastic arrangement for he thought that "authority", even academic authority, in any intellectual field shouldn't be respected and that each investigator's contribution to medical knowledge should be rated on its own merits and not depend upon the investigator's position in the medical, academic, political hierarchy.

Hippocrates' (and Galen's) concept of Physis (nature) and the faculties, or powers, that are intrinsically part of it are probably, together, the same as the modern concept of biochemical homeostasis and the elements, genetic or otherwise, that guide its function. In a stable homeostatic state biochemical mechanisms normally maintain the body in a state of health, or vital equilibrium. When a disease-state develops, whether it be, for instance, a fractured bone, an infection by a microorganism, or autoimmunological damage to the thyroid gland causing hypothyroidism, the various biochemical faculties (powers) that are an intrinsic part of the body's Physis (nature) tend to homeostatically combat the individual's disease-state in an attempt to restore health. The physician's task was to aid the body's natural tendency to restore health by the use of "lifestyle" advice, dietary direction, medical treatments (often herbal treatments), and, at times, surgical treatment. Physicians should ideally, in principle, therefore, simply assist the naturally existing faculties, or powers, of "..."Physis" (nature) that exist within the unity of the body so that health is preserved, or, in case of disease, restored. ( 3, 12)

Concerning Hippocrates' contribution to medicine the following is written: "The revolution which he caused in practical medicine, semeiology, pathology, and dietetics, was the more important from the plans adopted before him by the Asclepiadae and the philosophic sects being in no respect adapted for the improvement of the science. He taught physicians that their first duty is to observe attentively the progress of nature. He demonstrated the inutility of theories, and proved that observation alone is the basis of medicine. The curative art, having become, from his example, a science of experiment and of facts, ought to have made the most rapid progress...These brilliant hopes were not, however realized." ( 13 )

Galen, who practiced medicine about 600 years after Hippocrates, emulated many of his concepts, for instance, Hippocrates' humoral concept: Hippocrates, "...supposed the existence of four fluids in the body, -- blood, phlegm, and yellow and black bile. Their common source he ascribed to the stomach, but each had, also, its particular origin, --the blood from the heart, phlegm from the head, yellow bile from the gall-duct, and black bile from the spleen." ( 13 ) Also, there were four qualities, heat, cold, moisture, and dryness associated with the humors. All were important factors in the healthy state and in disease development and treatment. ( 3 )

One can understand the concept of the four humors in a reasonable fashion if it is understood that blood is red arterial blood [with air (oxygen) within it], which originated in the heart; black bile was deoxygenated blood with erythrocyte break-down products within it, which was stored in, and which flowed from, the spleen; yellow bile was normal bile that originated in the liver and which flowed, via the bile ducts, to the gall bladder for storage. Phlegm was mucous or other clear secretions or excretions within, or from, a specific organ. For instance, phlegm, clear or purulent, which is expectorated during coughing; phlegm that composes the matter of sinus drainage, acute or chronic, and tears, which can exist in copious amounts during an allergic episode. Mucous that is normally secreted from the endothelial lining of most organs of the gastrointestinal tract was also considered to be an aspect of phlegm. It was thought that purulent matter, pus, was a type of phlegm. In addition, mucous secreted by the uterine lining and which departed via the uterine os, and saliva, were both categorized as phlegm.

Further, Galen indicates: "The humors are defined by their associated qualities: 'yellow bile is hot and dry in power, black bile dry and cold, blood is moist and hot, while phlegm is moist and cold' " ( 3 ) The four humors all flowed throughout the body especially within the arteries and veins in an appropriate balance during the healthy state. An elevation of yellow bile as in jaundice, or of phlegm as noted in a respiratory disease, dropsy (edema in the legs), within the swollen joints of arthritis, copious amounts of phlegm in chronic sinus drainage, or abnormally abundant tearing as in allergies, for instance, were thought to be imbalances of the above-named humors.

At the time Galen was involved in medical practice it was thought, by many, that mucous from the nose, and possibly that which was expectorated from the lungs and the trachea during respiratory diseases, originated from the brain and it entered the upper respiratory tract through small holes that exist in the cribiform plate, a part of the ethmoid bone located at the base of the brain above the nasal passages. If a person considers the concept anatomically, and realizes that without microscopy there was no way that physicians, in the early days of medicine, could know about secretion from respiratory epithelium, and considering the existence of copious amounts of clear cerebrospinal fluid within and surrounding the brain, the idea of mucous originating from the brain is more understandable. The limited physiological and anatomical knowledge that physicians had during the period of time that Greek medicine was influential caused those physicians to make rational judgements that were, eventually, over a thousand years later, proved to be incorrect, because their observations were not empirically complete, especially without the benefit of microscopy. Later scientific discoveries made by William Harvey, Marcello Malpighi, Andreas Vesalius, and others, were enabled by the earlier efforts by, usually, the earlier Hellenic and Hellenistic natural philosophers.

The Hippocratic humoral concept stressed that individuals' personality type were caused by the predominant humor imbalance within them. An excess of blood caused the sanguine personality, an excess of yellow bile caused the bilious personality, an excess of black bile caused the melancholic personality, and an excess of phlegm caused the phlegmatic personality. Eventually the word humor was taken into the English language as in: Mary, what humor are you in today? Many words in the English language have been developed from the humoral concept of the body's make-up; for instance, the English word, bilious, describes the emotional state of a person who is excitedly angry, irritable or peevish. Depression, perpetual sadness, and a slow moving demeanor were thought to be caused by the patient having an excess of black bile. Thus, the English word, melancholy is derived as follows: [ ME melancholie > LL melancholia < Greek: black bile ]. Phlegmatic has a similarly derived meaning: "1. not easily excited to action or display of emotion; apathetic; sluggish...3. of the nature of or abounding in the humor phlegm." ( 8 )

A certain disease state, which appeared epidemically, at times, caused patients to frequently experience a great amount of pain ( as noted in the text, The Hippocratic Writings, The Epidemics, Books I, II, and III. ( 7 ). In addition, within the above mentioned text, within the chapter titled, "The Sacred Disease", Hippocrates writes as follows concerning conditions that feature an overabundance of phlegm: "Now this disease attacks the phlegmatic but not the bilious." "Sometimes phlegm, which should have been purged out during life in the womb, remains during early life and is only got rid of in the later years.This is what happens in the case of children who suffer from ulcers of the head and flesh, and who salivate and discharge mucus; they get better as they grow older. Those who have been purged of the phlegm in this way are not troubled by this disease, but those who have neither been purged in this way by ulceration and discharges of mucus and saliva, nor have been purged in the womb, are liable to be attacked by it." "...If the discharges should make their way to the heart the chest is attacked and palpitation or asthma supervenes; some patients even become hump-backed. For when cold phlegm reaches the lungs and heart, the blood is chilled and the blood-vessles, as a result of being violently cooled in the region of the lungs and heart, jump and the heart palpates. Such circumstances force the onset of asthma and diseases characterized by orthopnoea because, until the phlegm which has flowed down has been warmed and dissipated by the blood-vessels, it is impossible to inspire as much air as is needed. When the phlegm has been removed, palpitations and asthma stop...Feelings of pain and nausea result from inopportune cooling and abnormal consolidation of the brain and this affects the phlegm. The same condition is responsible for the loss of memory." ( 7 )

Within the book (chapter) Epidemics Book I, the following

Hippocrates and Galen, considering their concept of the functional unity, or holistic view of the body, perhaps developed the idea that rheumatism (rheumatismos) was a painful, systemic, disease process ultimately caused by, or related to, the over-abundance of phlegm that they observed "flowing down" chronically or acutely when patients experienced certain respiratory diseases. Dependent edema (dropsy), lymphedema, asthma, chronic bronchitis, excessive tearing during an allergy attack (rheumy eyes) and swollen arthritic joints are all examples of conditions that, hypothetically, were considered to be caused by an excess of phlegm in the body. The following terms describing rheumatic condition have been conserved from prior eras and they help in an understanding of the systemic disease of rheumatism:

Concerning Hippocrates and Galen's definition of rheumatismos, mentioned above, the key to further understanding is to determine what disease state, in particular, caused, or/or now cause, the flowing down of phlegm, catarrh (a meaningfully severe respiratory disease), and also cause patients to experience a great amount of pain as a symptom of inflammation.

During the philosophy of medicine's intelectual development, a debate, nearly continually, has existed between empiricists and dogmatists (rationalists). Empiricists indicated, "It is not", they said, "the cause but the cure of diseases that concerns us; not how we digest, but what is digestible." ( 5 ) In addition, "...Empyrics, excluded all reasoning, and trusted solely to experience." Contrarily, however, "...Dogmatists, maintained, that no man ought to prescribe, withoput being able to give a theory both of the disease and of the nature of the action of the medicine. This dispute continued for ages , and, like other disputes of a similar nature, remains still in some measure undecided." ( 8 )

At any particular time in history knowledge is finite. Physicians, then, must use "known knowledge" of the causes of diseases to rationally determine proper cures for those diseases. An example of that principle is the discovery of the bacteriological cause of infectious diseases, which occurred in the 1870's, but which had, for thousands of years, been known as contagions. Shortly thereafter, about sixty years later, the discovery and use of antibiotics such as sulfonamide and penicillin occurred. If the cause of a certain disease is not known physicians must use trial and error methods, which have been used for untold centuries, in order to find an alleviating treatment for a syndrome. Currently, the trial and error technique used to determine if a chemical has beneficial or adverse pharmaceutical characteristics is termed, a clinical trial.

Since 99% of diseases that are discussed in modern medical texts have no known cause they should be identified as symptom and sign patterns, syndromes, rather than well-defined diseases. Most treatments for most syndromes, even today, are usually syndrome altering and rarely syndrome curing and that includes surgical as well as medical approaches to treatment. Examples are: orthopedic surgery for arthritis of the knee and hip, coronary by-pass surgery for arteriosclerosis of the coronary arteries and removal of the gall bladder. In addition, the use of steroid and non-steroid anti-inflammatory medications for arthritis, diuretic and vascular dilator medications for hypertension, and various tranquilizers for various mental syndromes.

Perhaps Galen noticed the painful sensations of rheumatism seemed to flow from one body part to another, for instance, to certain nerves as in sciatica (sciatic rheumatism), to certain muscles as in lumbago, toticollis, intercostalitis, dorsodynia, and to muscles in a diffuse fashion such as the pain of fibromyalgia (muscular rheumatism), and to the joints as in acute and chronic arthritis. In addition, painful sensations to the head (headache) is often caused by trigeminal neuralgia and neuralgia of the trigeminal nerve branches that supply the meninges of the brain. Further, to the chest where it causes pericarditis and pleurisy, to the brain where it caused chorea, seizures, stupor and coma (rheumatism of the brain), and to the gastrointestinal system where it causes crampy abdominal pain and other functional abnormalities ( 7, 8, 9 )

Somewhat recently, Benedict Massell, MD, in his classic text, "Rheumatic Fever and Streptococcal Infection" thoroughly reviews, with a historical approach, the disease of rheumatic fever. The following comprises the first sentence of his book: "In The Old Wives Tale, Arnold Bennett called rheumatic fever the "dread disease." Bennett's allusion to this malady in his most popular novel, published in 1908, but set in the second half of the 19th century, shows that so feared was the diagnosis of rheumatic fever that the physician of this story chose to lessen his patients's worry by referring to her condition as "acute rheumatism." ( 9 )

Further, to indicate how acute rheumatism (rheumatic fever) remained a highly serious disease during the middle years of the 1900's, Dr. Massell writes, "For the period 1939-1943, statistics published by the Metropolitan Life Insurance Company indicated that rheumatic fever was the leading cause of death among policy holders for persons from five to nineteen years of age and the second leading fatal disease among twenty to twenty-four year olds." ( 9 )

In addition, Dr. Massell reviews the historical evidence that migratory arthritis, which is often a finding in high-grade cases of rheumatic fever, has been clinically observed for a long period, for instance: "Hippocrates (about 400 B.C.) mentioned acute migratory arthritis which may very well have been rheumatic fever..." In Dr. Massell's text he indicates various investigators determined that individuals who experienced acute rheumatism (rheumatic fever) often, concomitantly, experienced tonsillitis. ( 9 )

In addition, in Hippocrates Writings within the book, Epidemics Book One, the disease described by providing many case histories is very similar to rheumatic fever as described by Sydenham during the 1600's.

In addition, "Guillaume Baillou (1538-1616,...a Parisian physician apparently was the first to use the term "rheumatism" (rheumatismos) for polyarthritis..." "On the other hand the method by which this affection attacks which is falsely called catarrh; (for the name catarrh signifies distillation from the head) it seems better to speak of the others as rheumatism..." Dr. Baillou goes on to provide a very good description of acute high-grade rheumatic fever similar to that of Sydenham's of the late 1600's. Further, "Many of the tendons of the superficial muscles of this patient were studded with numerous small hard tumors, an appearance I have observed only in one other person...who also labored under rheumatism." Baillou recognized certain systemic features of rheumatic fever: "The whole body becomes painful, the face in some becomes red, the pain rages especially about the joints, so that indeed neither the foot nor the hand, nor the finger can be moved in the least without pain & outcry..."

Later, in 1715, Raymond de Vieussens described a patient with acute rheumatic fever. He was determined to have, during autopsy, a severely dilated left ventricle, the walls of the aorta were..."thick, very hard, like cartilage; the semilunar valves are markedly stretched & cut off at their tips: all these cuts which bore some resemblance to the teeth of a saw, were in fact osseous."

The above two early descriptions of individuals who had acute rheumatism (rheumatic fever) contained most of the elements that have been historically known to exist with that disease: The concept that it occurred after a respiratory disease that caused the development of phlegm (catarrh), rheumatic nodules (small hard tumors), rheumatic vasculitis (red face), wide spread, severe body pain, with joint pain in particular. Also, heart enlargement, especially left ventricular enlargement, arteriosclerotic changes to the aorta, and rheumatic cardiac valve abnormalities.

Later, David Pitcairn, in England, lectured, in 1788, concerning rheumatism and its affect on the heart: "...that persons subject to rheumatism were attacked more frequently than others with symptoms of an organic disease of the heart. Subsequent experience having confirmed the truth of this observation, he concluded, that these two diseases often depend upon a common cause, and in such instances, therefore, called the latter disease rheumatism of the heart."

The above information provides the knowledge that after the hiatus of creative academic thought that occurred during the Middle Ages physicians during the Renaissance, and later, used the word rheumatism, rheumatic fever, acte rheumatism and chronic rheumatism somewhat interchangeably for they knew that acute rheumatism would lead to chronic rheumatism and they also knew that a contagion, often connected with tonsillitis, or other respiratory disease presentation, could cause it. Since the above physician-writers have indicated that rheumatic fever (acute rheumatism) causes a great amount of pain and that it, often, develops concomitantly with a respiratory disease wherein phlegm is expectorated with coughing, or it flows from the nose as coryza, it seems logical to think that rheumatic fever is the disease that causes chronic rheumatism.

As further proof indicating that chronic rheumatism was caused by rheumatic fever the following statement was written during the late 1700's: "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds."

Since high-grade, acute rheumatic fever has become so rare in modern counties most currently practicing physicians have never possessed much clinical knowledge about it. They, therefore, have never gained the knowledge that there are lesser semi-chronic and chronic clinical presentations of rheumatic fever, as defined in "Osler's Principles and Practice of Medicine", published in 1935. ( 8 )

In addition, "In childhood the affection of the joints is usually slight, and may be confined to a little pain or stiffness in one or two joints, and is sometimes attributed by parents to "growing pains." Further, Rheumatism "...may be applied to cases in which the joint lesions persist after an attack of rheumatism, and chronic inflammatory thickening of the tissues takes place, so that they become stiff and deformed. It is also appropriate to certain joint affections occurring later in life in rheumatic subjects, who are liable to repeated attacks of pain and stiffness of the joints, usually induced by exposure to cold and wet. This form of rheumatism is less migratory than the acute, and is commonly limited to one or two of the larger joints. After repeated attacks the affected joints may become permanently stiff and painful, and crackling or creaking may occur on movement. There is seldom any constitutional disturbance, and the heart is not liable to be affected...The chief varieties of muscular rheumatism are: 1. Lumbago, in which the muscles of the lower part of the back are affected so that stooping, particularly the attempt to rise again to the erect position, induces severe pain. 2. Intercostal rheumatism, affecting the muscles between the ribs, so that taking a deep breath and certain movements of the arms give rise to pain. 3. Torticollis or stiff neck, affecting the muscles of one side of the neck." ( 9 )

Chronic or semi-chronic rheumatic fever hypothetically causes the development of an acute onset subtype of rheumatoid arthritis, for instance: "In approximately 10% of individuals the onset is more acute, with a rapid development of polyarthritis, often accompanied by constitutional symptoms, including fever, lymphadenopathy, and splenomegaly." ( 1 ) Splenomegaly, lymphadenopathy and fever occur in rheumatic fever, but since modern physicians are not aware of the lower-grade presentations of rheumatic fever they, simply, do not realize that it is causing the onset of multi-articular arthritis. In one popular medical text, however, the following is written: "Prolonged Attacks of RF (longer or equal to 8 months) occur in about 5% of patients, with spontaneously recurrent episodes of inflammation...unrelated to intervening streptococcal infection or to cessation of anti-inflammatory therapy. Such recurrent episodes within a prolonged attack are more likely to be associated with carditis. ( 9 )

"An even clearer description of rheumatic polyarthritis is included in the writings of the famous English physician Thomas Sydenham (1624-1689). Sydenham recognized the importance of careful bedside observations, and these observations enabled him to record excellent descriptions of many diseases including scarlatina (1675), which he named and differentiated from measles, polyarthritis (1676), St. Vitus Dance (1686) and gout (1683). Sydenham's description of polyarthritis, migratory arthritis, is as follows: "...the patient is attacked by severe pains in the joints, sometimes in one and sometimes in another, sometimes in his wrist, sometimes in his shoulder, sometimes in the knee--in this last joint oftenest. This pain changes its place from time to time, takes the joints in turns, and affects the one that it attacks last with redness and swelling." ( 9 )

Within the A Dictionary of Medical Science, published in 1874, rheumatism is profusely defined: "Rheumatism,"...A kind of shifting phlegmasia or neuralgia, sometimes seated in the muscles, sometimes in the parts surrounding the joints; and at others, within them...Hence the names Muscular, Articular, and Synovial, which have been applied to it. The disease may be acute or chronic." Further, "When accompanied by the deformity of a joint, it is called Arthritis deformans. In addition, When it affects the hip-joint of old people, it is called Morbus coxae senilis Further, 'Rheumatism, Cerebral,' Rheumatic Meningitis, Rheumatic Apoplexy. Meningitis occurring during the progress of acute rheumatism..." "Rheumatism, Chronic,...is attended by pains in the hips, shoulders, knees, and other large joints. These are at times confined to one joint; at others, shift from to another, without occasioning inflammation or fever. In this manner the complaint often continues for a great length of time, and then goes off." Continuing, "Rheumatism, Synovial...a rheumatic affliction, in which an accumulation of non-purulent fluid occurs in the synovial sacs, especially of the knee joints." In addition, "Rheumatism, Visceral. Rheumatism affecting the muscular or fibrous tissues of the viscera.", and finally, "Prosoporrheuma,...Rheumatism affecting the face.", which probably was also termed, rhinoscleroma and "...rhinocephale,...A term applied ...to a monstrosity characterized by a projection of the nose..." Rhinophyma is probably the currently used term for the older word, rhinocephale. The above definitions consist of only a small sample of the extensive, detailed, list of maladies, that are aspects of the systemic disease of rheumatism, defined in the above-mentioned dictionary. ( 10 )

Within "The Americana" encyclopedia, published in 1908, rheumatism is defined as follows: "Rheumatism, a constitutional disease characterized by inflammation of the connective-tissue structures of the body, especially of the joints and muscles, and attended by localized pain. It is usually recurrent. Three forms are recognized: (1) acute rheumatism (acute articular rheumatism, acute inflammatory rheumatism, rheumatic fever); (2 ) chronic rheumatism; (3) muscular rheumatism or myalgia." ( 11 )

Within a respected medical text by Sir William Osler and Thomas McCrea, The Principles and Practice of Medicine, Eighth Edition, published in 1912, and a more recent version of the text, Osler's Principles and Practice of Medicine, Twelfth Edition, published in 1935, provide extensive reviews of rheumatic fever, its epidemiology, and its sequeale. ( 7, 8 )

Gene Stollerman, MD, authored the text, Rheumatic Fever and Streptococcal Infection, that was published in 1975, which contains a highly interesting, complete, and wise review of rheumatic fever from a clinical, as well as a historical, approach. Every physician treating patients should read it. ( 12 )

Within Webster's New Twentieth Century Dictionary, published in 1976, rheumatism is defined as follows: "rheumatism, n. [L., rheumatismus; Gr. rheumatismos, libability to rheum.] 1. any of various painful conditions of the joints and muscles, especially, a disease believed to be caused by a microorganism and characterized by inflammation and pain of the joints. 2. Rheumatic Fever. Further, to clarify the statement, "liability to rheum.", the definition of the word rheum is provided: "rheum (rum), n. [OFr. reume, a catarrh; L. rheuma; Gr. rheuma, a flow.] 1.any watery or catarrhal discharge from the mucous membranes, as of the mouth, eyes, or nose. 2. a cold; rhinitis; catarrh. salt rheum, any of the various skin diseases, especially eczema." In addition, the word flux has many definitions. The definition as applied to human pathology is as follows: 1. the act of flowing; the motion or passing of a fluid; flow...6. any excessive or unnatural discharge of fluid matter from the body...to flow or stream out." Additionally, the word, catarrh is defined to mean: "catarrh'...n. [L. catarrhus; Gr. katarhoos, from katarrhein, to flow down; kata, down, and rhein, to flow.] an inflammation of the mucous membrane, more particularly of the throat and nose, accompanied by an increased secretion of mucous; as nasal catarrh; catarrh of the stomach." Finally, within the same dictionary rheumatic fever is defined as follows: rheumatic fever, an infectious disease associated with the presence of streptococci in the body; it most commonly attacks children, and is characterized by fever, pain and swelling of the joints, inflammation of the heart valves, etc." ( 13 )

Within Dorland's Illustrated Medical Dictionary, published in 1988, the Greek word, rheum, the word-root of rheumatism, is defined to mean: "rheum, rheuma...[Gr. rheuma flux] any watery or catarrhal discharge." The word rheumatism is defined extensively, in the same text, and many systemic, pathological manifestations of rheumatism are listed, for instance: "Any variety of disorders marked by inflammation , degeneration, or metabolic derangement of the connective tissue structures of the body, especially the joints and related structures, including muscles, bursae, tendons and fibrous tissue...Rheumatism confined to the joints is classified as arthritis. apoplectic rheumatism, rheumatism associated with brain hemorrhage; cerebral rheumatism, acute rheumatic fever marked by chorea, delirium, convulsions, and coma; rheumatism of the heart, involvement of the heart by the rheumatic fever process; lumbar rheumatism, lumbago; rheumatism confined to the joints is classified as arthritis; muscular rheumatism, fibrositis; and articular rheumatism, rheumatic fever..." There are many more, approximately sixteen, anatomically defined symptomatic maladies of a rheumatic nature defined in the above cited medical dictionary. Within the text, the word, rhinophyma is defined as follows: "rhinophyma...usually seen in men and characterized by thickened, lobululated overgrowth of the sebvaceous glands and epithelial connective tissue." ( 14 )

In addition, rheumatism is defined in Webster's Encyclopedic, Unabridged Dictionary of the English Language, published in1989 as follows: "...1. any disorder of the extremities or back, characterized by pain and stiffness. 2. see rheumatic fever...catarrh, rheum..." Also rheum is defined as follows: "...1. a thin, serous, or catarhal discharge. 2. catarrh; cold...(to) flow...--rheumic, adj." ( 15 )

For a long period it was known that acute rheumatism (rheumatic fever) was an epidemical disease. For instance, within the first issue of the Encyclopedia Britannica published between 1769 and 1771 the following is written in the section titled, Of the Rheumatism, within the chapter describing the science and art of medicine:

"The rheumatism chiefly attacks persons in the flower of their age...It begins with chillness and shivering, followed by inquietude and thirst. Which is preceded with spontaneous lassitude, a heaviness of the joints and coldness of the extreme parts. When the fever appears, there is an inward heat, chiefly about the-praecordia, attended with anxiety. The pulse is quick and straight, the appetite is lost, the body coftive. In a day or two, sometimes sooner, the patient feels a racking pain,sometimes in one joint and sometimes in another, but more frequently in the wrists shoulders and knees; frequently shifting from place to place...The pain is exasperated with the least motion; it sometimes attacks the loins and the coxendix (coccyx)....When it seizes the loins it is called the lumbago;...it may continue for months and years , but not with the same violence, but by fits." Further, "The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds. And Huxham says, that the obstinate rheumatic pains, which remained after the epidemical fever of 1737, would yield to..." ( 6 )

A few sentences quoted above are particularly salient and rate repeating: "When it seizes the loins it is called lumbago;...it may continue for months and years, but not with the same violence, but by fits....The chronic rheumatism is either the remains of a rheumatic fever, or a continuation of pains that proceeded at first from lesser but neglected colds." ( 6 )

In addition, within the book (chapter) titled, "Epidemics, Book I" within the Hippocratic Writings many case histories of patients who became sick in an epidemic are provided. By carefully comparing patients' symptoms and signs they seem to be nearly identical to those later described in cases of rheumatic fever by physician-authors such as Thomas Sydenham, the author of the above description of "The rheumatism..." in 1771, and especially the clinical descriptions, provided by Sir William Osler and Thomas McCrea who authored classic medical texts, cited above, during the first half of the 1900's. ( 7, 8 )

Sydenham, Osler and McCrea, and from my experience treating hundreds of patients who have had rheumatic fever, the following symptoms and signs are found in individuals who have had, or have, rheumatic fever:

  • 1. Rheumatic fever often attacks healthy, young people; but it also attacks people of all ages.
  • 2. It causes a fever and often a feeling of heat in the chest.
  • 3. The extremities are often cool.
  • 4. Patients often experienced a prior, or concurrent, respiratory disease (bronchitis, sore throat, ear infections or tonsillitis). Often times an attack of rheumatic fever will follow such an infection by one to five weeks or be concurrent with a more chronic respiratory disease.
  • 5. Patients often have joint pain or swelling and pain in the joints.
  • 6. The disease causes some patients to have hyperesthetic skin, which, I surely think, was termed "causes" by Hippocrates.
  • 7. Sometimes individuals have a rash that appears like hives, papules or a miliary rash.
  • 8. Patients with rheumatic fever often experience headache.
  • 9. Frequently, patients have low-back pain (lumbago) and sciatica and other sources of neurological pain such as headaches and brachial plexus neuritis.
  • 10. Rheumatic fever can be mild and wax and wane, over time.
  • 11. Patients with rheumatic fever can have delirium, seizures, stupor or coma.
  • 12. Individuals who experience rheumatic fever have gastrointestinal disturbances including diarrhea, constipation, abdominal pain, etc.
  • 13. Rheumatic fever occurs in a repeated fashion.
  • 14. Rheumatic fever often features swelling of the cervical lymph nodes.
  • 15. Patients with rheumatic fever usually have a reasonably normal pulse, but with more severe disease they frequently have cardiac arrhythmias.
  • 16. At times, patients have hyperesthesia and even gentle pressure to the skin is painful. Perhaps a Greek word for it is causus.
  • 17. Mild, subacute rheumatic fever can cause painful feelings in many parts of the body.
  • 19. Sweating was common and odiferous.
  • 20. Fall, winter and spring feature the most numerous cases.
  • 21. Usually, there is a fairly low death rate from rheumatic fever, however, virulence of the Streptococcus, which causes it is highly variable.
  • 22. Childbed fever is caused by Streptococcus pyogenes and has similar systemic signs and symptoms as rheumatic fever.
  • 23 Splenomegaly is common.
  • 24. A change in the weather to a cool, often damp, pattern seems to encourage the development of rheumatic fever.
  • 25. Rheumatic fever seems to be a family disease due the highly contagious nature of Streptococcus pyogenes infections.
  • 26. Concerning the pain of rheumatic fever: "perhaps no disease is more painful; the inability to change the posture without agonizing pain, the drenching sweats, the prostration and helplessness, combine to make it a most distressing affection." ( 8 )
  • 27. Anemia, of various types is common.
  • 28. Severe lethargy is a common sign for rheumatic fever.
  • 29. At times a hypersensitivity of the skin develops, which, I think, Hippocrates termed in his writing titled "On Regimen in Acute Diseases", causus.
  • 30. Epistaxis is common in higher grade cases of rheumatic fever.
  • 31. The urine is, as a rule, reduced in amount, of high density and high color. It is very acid, and, on cooling, deposits urates. ( 8 ).
  • 32. Individuals who experience repeated attacks of rheumatic fever can develop dropsy (dependent swelling from congestive heart failure).
  • 33. Deafness occurs in some individuals; tinnitus develops commonly, photophobia and even blindness can occur in the most severe cases.
  • 34. Patients often feature erythematous facial skin, palms, the plantar surface of feet, and often have erythema around the fingers tips and the toes.
  • 35. Rheumatic patients often have highly varied skin abnormalities such as nevi of various types, skin tags, cutaneous horns, meaningful dermographism, and often develop premature greying of the hair and various levels of baldness.
  • 36. Neuropathy of the median nerve (carpal tunnel syndrome), ulnar nerve (ulnar neuropathy), peroneal neuropathy, sciatic neuropathy, posterior femoral cutaneous neuropathy, pudendal neuropathy (the latter three together secondary to lumbar plexitis), pudendal nerve,and the brachial plexi are often caused by rheumatic vasculitis.
  • 37. The classic pedal and neurological findings of Charcot-Maria-Tooth Disease are sequelae of rheumatic fever in a very young individual.

Within the book, Epidemics, Book I, mentioned above, the most common symptoms and signs experienced by various patients were: 1. Causus a word defiined to mean heat; A highly ardent fever...a complication of...inflammatory fever;..." From it, the word caustic evolved. ( 5 ) 2. hemorrhages, the most frequent epistaxis. 3. Swelling near the ears (cervical lymphadenopathy). 4. Young people, especially young men involved with wrestling (close contact) became sick. 5. Patients often had a respiratory disease. 6. Loss of weight in some individuals. The most common combination of symptoms and signs listed were: 5. fever, 6. shivering, and 7. sweating. Further, there was, 8. coolness of the extremities. 9. Their stomachs were disordered and diarrhea occurred. 10. Urine was thin or with a sediment staying dissolved within it. 11. Cough was slight but frequent; in violent cases patients continued to cough up purulent sputum. 12.In most cases the throat was painful, red and inflamed from the first and continued so. 13. Patients refused to take food (lost appetite) and lost weight. They often had no thirst. For instance, "...all suffered from a loss of apetite, and that to an extent which I have never previously encountered." 14. Many became delirious and frequently, thereafter, died. 15. The epidemical disease struck people during all months of the year, but the cool, damp months, and cool damp years featured more sickness. 16 Patients often experienced pain, for instance in the legs, back, head, heart (chest). 17. Patients experienced seizures. 18. Some patients experienced insomnia. 19. Some patients experienced coma. 20. Some patients experienced the development of eruptions (rash)., for instance: "These were red, round and small like those of acne which did not go down."21. Frequently, children, older children (eight to ten years old) and those approaching puberty died. 22. Headache and neck pain. 23. Cases of paralysis (Hypothetically, Guillain-Barre' Syndrome). 24. Childbirth was often followed by disease. 25. Pregnant women aborted. 26. Some women had vaginal bleeding. epistaxis was fairly common. 26. Lividity of parts of the body; extremities. 27. Splenomegaly. 28. Hepatitis. 29. Deafness in some individuals. 30. Hepatitis, signs of jaundice in some individuals. 30 hematuria. 31. Some patients developed dropsy (edema of the legs secondary to heart failure.

By comparing the signs, symptoms and epidemiology of the disease described in each of the above two paragraphs, it can be easily determined that most of the signs and symptoms patients experienced during an episode of rheumatic fever, as detailed by Sydenham, Osler and McCrea, were also experienced by patients who had an epidemical disease as recorded in the chapter, Epidemics, Book I, of the Hippocrates Writings.

In addition, it is similar to the description of severe rheumatic fever as written by Sir William Osler and Thomas McCrea in their text of 1935. ( 9 ) It must be understood that, acute rheumatism (rheumatic fever) has the following nature: "Rheumatic fever is the most serious of all diseases with a low death rate. The mortality is rarely above 2 or 3 percent." In addition, In the human infection , the lesions are exudative at first and later proliferative. A hypersensitive state once established, a chronic infection or repeated infection, a chronic infection or repeated slight infections may serve to prolong it and an acute infection may precipitate another attack." Finally, "Subacute rheumatic fever represents a milder form of the disease, in which all the symptoms are less pronounced...The onset may be so insidious that it can hardly be termed even subacute." ( 9 ) An accumulation of rheumatic tissue, and therefore organ, damage, over time, can lead to a highly varied array of abnormal function, which can involve all organ systems.

In addition, frequent mention is made of the existence of phlegm, for instance: "Now this disease attacks the phlegmatic...if these discharges should make their way to the heart , the chest is attacked and palpations and asthma supervenes." and, "For when cold phlegm reaches the lungs and heart...and the heart palpates. Such circumstances force the onlset of asthma and diseases characterized by orthopnoea..." ( 16 ) Orthopnoea, otherwise known as orthopnea, the tendency to have less difficulty breathing in a sitting position, is secondary to heart failure, often rheumatic heart failure, which is precipitated by acute rheumatic fever.

"The word asthma was first introduced in ancient Greece. It originally referred to the symptom of breathlessness rather than the disease that is recognized today. Mild breathlessness was termed dyspnea, moderate breathlessness, asthma, and severe breathlessness, orthopnea. ( 17 ) Asthma is a clinical presentation of moderate breathing distress that occurs, usually, in young individuals, but it evolves, often becoming more symptomatic, over time. For instance, "Longitudinal studies have since shown that a significant proportion of persons who have chronic asthma exhibit an increased rate of decline in lung function over time, leading to the progressive acquisition of a fixed component of airflow obstruction. Furthermore, asthmatic and COPD populations overlap in peak expiratory flow (PEF) variability." ( 17 ) In addition, "Postmortem examination of the lungs of patients who have died of acute severe asthma reveals prominent airway wall thickening, a markedly edematous airway mucosa, and occlusion of bronchial lumen with plugs of viscid mucus. In a patient who has died of acute asthma, the most striking feature of the lungs at necropsy is their gross overdistention...When the lungs are cut, numerous gelatinous plugs of exudate are found in most of the bronchial branches down to the terminal bronchioles. ( 1 ) Asthma is, probably, a clinical manifestation of mild, or severe, rheumatic pneumonitis and the "plugs of viscid mucous" represent the "rheum", or phlegm, aspect of the disease process so, perhaps, asthma, and other related adverse conditions of the lung could, reasonably, be termed: rheumatism of the lung.

In addition, palpations of the heart are, simply speaking, a type of cardiac arrhythmia, which often occur in rheumatic fever. ( 8, 9 )

The exact cause of rheumatic fever puzzled physicians throughout history, even after the bacterial hypothesis of infectious disease was first, firmly, proven by Robert Koch, in Germany, during the 1870's. ( 18 ) Various streptococcal-types of bacteria were suspected, for a long period, to be involved in rheumatic fever's genesis, but it was not until 1931 that Alviin Coburn, in the USA, and Wilfred Collis, in England, somewhat simultaneously, published data that proved that Streptococcus pyogenes caused rheumatic fever. It was later learned that a certain strain of Streptococcus pyogenes caused scarlet fever (scarletina). Rheumatic fever and scarlet fever are, therefore, basically, nearly the same disease. ( 9 ) Streptococcus pyogenes has a great many strains with varying virulence that are often determined by their M protein antigens. ( 19 ) Finally, it was determined that the septic phenomenon that occurs within patients who develop rheumatic fever are autoimmune in nature. ( 12, 19 ) The immunological cause of rheumatic fever provided an explanation for the frequently observed delay between an individual's streptococcal respiratory disease and the onset of rheumatic fever's anatomically widespread and, therefore, severe septic, manifestations.

Differing from most infectious diseases, rheumatic fever can recur and, frequently, recurrences feature a more severe disease presentation. ( 8, 9, 12 ) It is more accurate to understand rheumatic fever to be an "infection-caused autoimmunological disease, not, "purely" an infectious disease, wherein pathological damage to tissues is due to a physically intimate infection as one would note in the development of a dermatological infection such as a folliculitic lesion or a carbuncle. Recurrences of rheumatic fever often occur with more virulence than previous episodes since the immune system experiences an increase in immunological sensitivity and memory with each streptococcal autoantigenic challenge. "Finally,...the trend suggests also that R/I (rheumatic fever attack rate per infection) decreases more strikingly with the time elapsed since the last rheumatic attack than it does simply with the increasing age of the patient. ( 12 ) To decrease rheumatic fever's recurrence rate prophylactic treatment strategies, using chronic sulfonamide and penicillin techniques, have proven to be efficacious. ( 9, 12 ) Immunological (and autoimmunological) sensitivity decreases, over time, if an individual does not experience a meaningful Streptococcus pyogenes infection, and, therefore, does not experience a meaningful, rheumatic, autoimmunological challenge.

Although high-grade acute rheumatism (rheumatic fever) is obviously important, the lower-grade of acute rheumatism occur at a much higher frequency. These infection caused (by Streptococcus pyogenes), pathological, autoimmune attacks are often quite subtle and individuals only know "something is wrong" due to abnormalities noted, that are often painful, in various anatomical locations. Sciatica, for instance may be caused by rheumatic autoimmunity. Depression, fatigue or listlessness, anxiety are all possible central nervous system phenomenon that can be caused by rheumatic autoimmunity. Shoulder pain, low-back pain, torticollis, headache, low-grade semi-chronic gastrointestinal disturbances, growing pains, tendonitis, rosacea, palmar erythema, plantar erythema, and acne, for instance, are all manifestations of rheumatic autoimmunity.

The term, sepsis, is defined as follows: "Animals mount both local and systemic responses to microbes that traverse epithelial barriers and invade underlying tissues. Fever, or hypothermia, leukocytosis, leukopenia, tachypenea, and tachycardia are the cardinal signs of the systemic response often called the systemic inflammatory response syndrome (SIRS). SIRS may have an infectious or noninfectious etiology...When sepsis is associated with dysfunction of organs distant from the site of infection, the patient has severe sepsis. Severe sepsis may be accompanied by hypotension or evidence of hypoperfusion." Further, " Microbial invasion of the blood stream is not essential for the development of severe sepsis, since local inflammation can also elicit distant dysfunction and hypotension." ( 1 ) Particularly, the invasion of the blood stream by bacteria or virus is termed, bacteremia and viremia, respectively.

Over time, there have been many synonymous terms for rheumatic fever, for instance, acute articular rheumatism, acute rheumatism, inflammatory rheumatism, and rheumatic fever. ( 6, 9 ) The word rheumatism was often used in older, and even in more recently published scientific texts to mean both acute and chronic rheumatism. ( 6, 7, 8, 9 )

If the concept of severe sepsis, the phenomenon wherein pathological abnormalities appear distant from a primary site of infection, is integrated with the above information concerning the nature of acute rheumatism (rheumatic fever) and chronic rheumatism, it appears that both acute rheumatism" (rheumatic fever) which is well known to cause pathology within distant organs such as the heart, kidneys, brain, peripheral nerves, and joints (to provide a partial review), and chronic rheumatism, which also features pathological changes of a similar nature (as indicated by information in references 7, 8, 10, 11, 14, and 15 above), are both varied clinical manifestations of the same disease process as indicated by physicians in the late 1700's. ( 6 ) After all, Sir William Osler indicated that subacute and less-than-subacute rheumatic fever are common disease entities. ( 8 ) They are the disease states that stimulate the development of the various arthritides that are categorized as the various rheumatic diseases.

Both have the same, or similar, pathophysiological mechanisms, which cause damage to a numerous and highly varied group of anatomical structures distant from the primary site of infection and which have key pathological findings such as subcutaneous nodules and the development of coronary artery disease. ( 7, 8, 9, 12, 20 ) Therefore, both clinical presentations of rheumatism, that is acute rheumatism (rheumatic fever) and chronic rheumatism, which both have similar septic manifestations. The key, it seems, to a further understanding of both rheumatic fever, also known, historically, as acute rheumatism, and chronic rheumatism is to understand the pathological mechanism that causes their severe sepsis. It is Streptococcal autoimmunity.

A unifying conceptual statement, integrating the various concepts and definitions from the above-mentioned dictionaries, texts and e-sites is as follows: Rheumatic fever, and therefore chronic rheumatism, represent a continuum of the same variable, clinical, autoimmune disease from the most acute to the most chronic, caused by a variably severe septic autoimmune response, which is inflammatory in nature, secondary to the occurrence of infections by various strains of Streptococcus pyogenes. The various sources of information, quoted above, uniformly indicate that a meaningful sign of acute rheumatism (rheumatic fever) and chronic rheumatism is the presence of mucous drainage from the nose, mouth, or, even the eyes. In addition, the word, catarrh indicates an increased secretion of mucous as in the term, nasal catarrh. Also, the word rheum can be used to denote "...a cold...or...rhinitis..." Acute rheumatic fever is known for its painful manifestations, but chronic rheumatism usually, also, causes painful maladies throughout the body. It appears, then, that mild, or severe, respiratory infection (s) caused by various strains of Streptococcus pyogenes, can both result in the development of rheumatism, acute and chronic. The disease of rheumatism, acute and chronic, is a clinically variable, autoimmune, waxing and waning, severe septic disease since signs and symptoms of rheumatism occur in most of the body's tissues and, therefore, organs. In modern specialty medicine physicians often focus on acute rheumatism's (rheumatic fever's) damage to the heart, but it is a systemic disease process wherein both acute and chronic rheumatism adversely affect all of the body's organs, over time, in a waxing and waning fashion.

Rheumatism was a commonly used term in medicine before 1940 and it was often associated with a specific, painful, muscular syndrome, muscular rheumatism, or, synonymously, fibrositis, as indicated in the definition of rheumatism, above. ( 14 ) In a noted medical text published in 1935 fibrositis, and therefore, synonymously, muscular rheumatism, are described: "MYALGIA (fibrositis, myositis) Definition.--A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. It is probably that in many cases the fibrous tissue is especially affected==a fibrositis. It is by no means certain that the muscular tissue is the seat of the disease. Many writers claim that in some cases it is a neuralgia of the sensory nerves of the muscles. The affection has received various names according to its seat, as torticollis, lumbago, pleurodynia, ...In the acute forms the affection is entirely local. The constitutional disturbance is slight and, even in severe cases, there may be no fever. Pain is a prominent feature and may be constant or occur only when the muscles are drawn into certain positions. It may be a dull ache, like...a bruise, or sharp, severe, and cramp-like.It is often sufficiently intense to cause a patient to cry out...The following are the principle varieties of myalgia: Lumbago...affects the muscles of the loins...stiff neck or torticollis affects the muscles of the antero-lateral or back region of the neck...pleurodynia involves the intercostal muscles on one side...it is more common on the left than the right side...among other forms...are cephalodynia (head ache),...scapulodynia (pain in the scapular region), omodynia (shoulder pain), and dorsodynia affecting the muscles about the shoulder and upper part of the back." ( 7 )

It is important to note that within the last two paragraphs the terms muscular rheumatism, fibrositis, myositis, myalgia are connected synonymously. It is apparent that physicians also thought, what seemed to be pain of a muscular nature was suspected to be, more specifically, caused by a neuropathic phenomenon. Also, it is important to realize, as indicated in the above-mentioned definition of rheumatism [reference ( 14 )], that rheumatism affects connective tissue somewhat selectively. Since, however, the terms connective tissue and fibrous tissue define, virtually, the same histological structures, and since all organs in the body have substantial amounts of connective tissue (fibrous tissue) within their substance, conceptually then, rheumatism can affect the heart, kidneys, lungs, brain, muscles, ligaments, tendons, synovial sheaths, the gastrointestinal organs, skin, bones, the liver, nerves, and most meaningfully, perhaps, the various elements of the circulatory system for when they are involved it creates a rheumatic vasculitis.

During the period I had an active medical practice I had wondering thoughts about many phenomenon. I learned that most diseases are connected, in various ways, to each other. For instance, individuals who experience diabetes are at a high risk to develop coronary artery disease and peripheral neuropathy. In addition, individuals who have ulcerative colitis are more at risk to develop other inflammatory maladies of the gastrointestinal tract and they are, also, at a high risk to develop cancer, they frequently experience neuropathic maladies, and they often co-experience other autoimmune diseases. Similarly, individuals who experience neuropathy are at a higher risk to develop cancer (paraneoplastic neuropathy). In addition, individuals who develop ulcerative colitis are at high risk for developing other autoimmune diseases of gastrointestinal tract, including celiac disease and Crohn's disease and patients with all three diseases feature a higher risk for cancer development and they often experience neuropathic maladies. ( 3, 4 ) In addition, individuals with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosis, progressive systemic sclerosis, and dermatomyositis all experience a decreased life expectancy, they all feature accelerated arteriosclerosis, and they all feature neuropathic pain. ( 3, 4 ) Historically, coronary artery disease has appeared in patients who have exhibited "type A" personalities, who have hypertension, elevated cholesterol, and who also have somewhat horizontal earlobe creases. No one knows, however, the nature of the underlying disturbance, which causes the connection and the "type A" personality is hard to define.

Also, I came to realize that since 99% of diseases listed in medical texts have no known cause (they are termed idiopathic diseases), it is more accurate to understand them as syndromes. Syndromes are, simply, adverse medical conditions with somewhat uniform symptom and sign patterns. The word disease is best defined as an adverse medical condition which has consistent symptom and sign patterns, but, in addition, its cause is known. Since the great majority of medical problems have no known cause they are syndromes, therefore, physicians, primarily, do not cure diseases, they alter syndromes, usually for the better. In general, a knowledge of the cause for a disease is a requirement if a cure is to be developed, otherwise medical treatments are, for the most part, syndrome altering in nature.

Prior medical educational and experiential knowledge was important during my investigation, but most of the salient information I learned, which permitted me to develop an understanding of the cause of chronic neuropathic pain, and other associated medical conditions, was gained by repetitiously interviewing patients concerning their, and their family members', medical histories and by repetitiously conducting analytic, neurological, physical examinations. In addition to reading medical information in modern texts, I read parts of many older medical texts, dated from the Hippocratic period, through the Roman period, the Renaissance, and thereafter through the period during which many, great, scientific breakthroughs were accomplished, the 1600's through the early 1900's.

Between 2002 and 2005 I conducted a three-year, clinical investigation in an effort to determine the true cause of most peripheral neuropathies since so many of my patients, through the years, failed to improve after they experienced spinal surgery. I eventually determined that the venerated, herniated spinal-disc concept was flawed, and most of the surgery accomplished for them was, I learned, usually mis-applied. Most patients had suspicious arthritis of the lumbar and cervical spine that featured osteophyte development and bulging of intervertebral spinal-discs, but I learned that typical MRI films did not have the resolution to "see" spinal nerve roots in an analytical fashion. Since the bulging intervertebral spinal-discs are attention-getting on MRI images, and because they do, occasionally, cause symptomatic, spinal nerve root compression, generalizing that almost all bulging intervertebral spinal-discs cause nerve root compression was a classic "red herring". After I managed to determine the cause of the painful neuropathies, I learned that the same disease that causes the neuropathies also causes arthritis of the spine; an anatomical feature of spinal arthritis, herniated spinal-discs, did not necessarily cause the painful neuropathies. There are occassional herniated spinal-discs that cause painful spinal, nerve-root compression, but surgery for them is very common.

Eventually, after a long, investigative period, I learned the most patients' neuroloical pain was caused by rheumatic, autoimmune-mediated, vasculitic neuropathy of the terminal nerves of the sacral plexus located within the piriformis canal, which is located deep in the buttock. Patients who experienced neurological shoulder/cervical pain and who experienced dysesthesias to the appropriate upper extremity, were experiencing rheumatic brachial plexitis. The brachial plexus is located within the axillary canal located deep within the shoulder. I learned that motion of the arm at the shoulder, and of the thigh at the hip, or an accident wherein either of the structures were stressed, would often cause, or exacerbate, patients' neurological symptoms and signs. Patients sensed pain in the lumbosacral region, because of centripetal referred pain from the distal sacral plexus located deep in the buttock. Similarly, they sensed pain in the cervical/shoulder region, because of centripetal referred pain from the brachial plexus located deep within the shoulder.

During the above investigation I attracted 700 miserable, painful patients who had chronic neurological pain. Eventually, I learned that they all had had meaningful, repeated Streptococcus pyogenes infections (tonsillitis, sinusitis, bronchitis, pharyngitis, otitis media, impetigo, and vaginitis) during their lifetimes and often they had experienced chronic tonsillitis. In addition, many of them, who had been born before 1970, had had, when they were younger, rheumatic fever or scarlet fever. Younger patients, born after 1970 had "flu-like" diseases with more mild rheumatic symptoms and signs.

I learned from information in Sir William Osler's text, that there are subacute and less than subacute states of rheumatic fever with more subtle systemic symptoms and signs than "classic" high-grade rheumatic fever. ( 8 ) Such a disease has the same symptoms and signs that are thought to be those of influenza, or "the flu": a respiratory disease, often at least, lethargy, tiredness, at times stupor, body pain, back pain, photophobia, at times, headache, at times, gastrointestinal symptoms and signs, at times, and often a fairly rapid recovery. Often patients who had rheumatic fever had been diagnosed by a physician, or by parents, to have chicken pox, measles, the flu, mononucleosis and viral meningitis. Often the patients had been very ill, but recovered with care at home.

I conducted serology tests (ASO and Anti-DNase B titers) on over 100 patients and 70 were positive with elevated Streptococcus antibodies on one or more tests. Between the positive medical histories, the elevated serology tests, and those who had medical histories of "flu-like" diseases, chicken pox, measles, mononucleosis, and viral meningitis wherein the symptoms and signs were those of rheumatic fever, the great majority of the 700 patients, mentioned above, who had chronic neurological and arthritic pain, and other similar diseases, were qualified to have had rheumatic fever.

The great minority of cases of rheumatic fever are high-grade and qualify by the Jones Criteria to be that disease. Most cases are much more low-grade and semi-chronic in nature and such individuals develop increased, rheumatic, autoimmunological sensitivity and memory so that they are candidates, in the future, to be at risk for developing acute rheumatic fever. Current medical knowledge (Carapetis, JR.,et al., Lancet Jul 9-15; 366(9480): 155-68) indicates that an infection by a virulent strain of Streptococcus pyogenes, in a well rheumatically sensitized individual, can cause the development of acute rheumatic fever, which is known to be an inflammatory, autoimmune disease process.

The septic responses patients experienced, which frequently took place one to four weeks after an episode of respiratory disease (bronchitis, sinusitis, pharyngitis or tonsillitis) were caused by the rheumatic, systemic, autoimmune response to the autoantigens displayed by Streptococcus pyogenes. As the elevated levels of autoantibodies, and other toxic products, decreases after the peak of rheumatic fever, I hypothesize that patients maintain a low-level of rheumatic autoantibodies within themselves and it causes, over time, the signs and symptoms of chronic rheumatism. Since immunological and autoimmunological proteins circulate through the body via the elements of the circulatory system, rheumatism causes a usually subtle vasculitis, that is, arteritis, phlebitis, and lynphangitis. The much more common low-grade infections by Streptococcus pyogenes, and even the carrier state, cause an exacerbation in rheumatic stimulation, which establishes a chronic, waxing and waning autoimmune disease process within hosts, thus the chronic, autoimmune disease of rheumatism develops and is maintained.

Since Streptococcus pyogenes is endemic in human society, and a Russian Encyclopedia article (V. Nasonova & E. Talahaev) indicates that Streptococcus pyogenes is endemic in domestic vertebratres, and I hypothesize it also exists in wild vertebrates, it seems that Streptococcus pyogenes causes a universal, autoimmunological zooinosis among vertebrates including humans so, therefore, all humans have rheumatic disease.

As a reminder, the terms acute rheumatism, acute articular rheumatism, inflammatory rheumatism, and rheumatic fever, all describe the same acute, high-grade autoimmunological disease caused, usually in a delayed fashion, from infections by Streptococcus pyogenes. The terms rheumatism and chronic rheumatism refers to tissue damage that usually appears minor and for which signs and symptoms are often subtle, are slow evolving, and usually cause little or no dysfunction. Over time, however, they can become highly meaningful and conditions such as hip and knee arthritis, symptomatic coronary artery disease, peripheral vascular disease, rheumatoid (rheumatic) arthritis, and lupus erythematosis, for instance, are an indication of its severity.

The pathological anatomy of chronic rheumatism is often relatively easy to observe since, certain superficial signs of disease, for instance the articular signs of rheumatoid arthritis, dermatological features of lupus erythematosis, dermatological features of progressive systemic sclerosis, rosacea, varicosities of veins, seborrheic keratosis, various types of nevi, Raynaud's phenomenon, palmar and plantar erythema, and livedo reticularis are all manifestations of the systemic disease of rheumatism. Rheumatoid arthritis was, historically, thought to be caused by rheumatic fever. At times it has been termed, arthritis deformans. The text, Rheumatism, Rheumatoid Arthritis and Subcutaneous Nodules reviews the historical debates about the proper identification of rheumatic lesions, usually of the hands, and the meaning of subcutaneous nodules. Rheumatoid arthritis, lupus erythematosis, dermatomyositis, systemic sclerosis, Lyme disease, Whipple's disease, erythema nodosum, Dupuytren's contracture, and Interstital lung disease, are all syndromes, which feature as one of their signs subcutaneous nodules. Since acute rheumatism (rheumatic fever) also features subcutaneous nodules, and it is known that it is a highly variable, autoimmune disease, it is likely that the syndromes listed, above, are simply a number of various clinical presentations of chronic rheumatism.

There have been other antiquated terms for acute rheumatism (rheumatic fever) and I hypothesize that two of them are sweating sickness and miliary fever. ( 6 )

ItIt has not been clinically recognized, however, that all infections by Streptococcus pyogenes cause an inflammatory autoimmune response. I hypotheize that Streptococcus pyogenes infections with a high virulence is most meaningful and more frequently cause exacerbations in the rheumatic autoimmune response. In addition, the patients level of rheumatic immunological sensitivity, caused by prior infections, also contributes to the development of an energetic autoimmune response.

After various acute disease episodes, throughout life, and after numerous episode of subacute or less than subacute rheumatic fever ensues during a person's lifetime, rheumatic tissue damage slowly occurs and it eventually rheumatism manifests itself with obvious signs and symptoms of pathological damage to the body's tissues, and therefore organs, in a somewhat subtle, varying, but progressive fashion. Its manifestations are often noted as changes to the skin, tendons, ligaments, nerves and joints so clinical syndromes such as sciatica, brachial plexitis, femoral neuropathy, meralgia paresthetica, carpal tunnel syndrome, ulnar neuropathy, cardiac arrhythmias, headaches, De Quervain's tendonitis, Dupuytren's contracture, Achilles tendonitis, olecrannon bursitis, rotator cuff abrasions and tears, and Dupuytren's contracture appear. One must remember, however, that rheumatism is a systemic disease process so that all tissues, and therefore organs, are pathologically affected. Therefore, arteriosclerosis, endocrinopathies, renal failure, asthma, allergies, inflammatory bowel syndome, primary sclerosing cholangitis, pancreatitis, osteoporosis, spastic bladder, schizophrenia, obsessive-compulsive behavior, depression, and many, many other pathological conditions are caused by rheumatism. Somewhat surprisingly, even cancer, of all tissue types, is caused by the inflammatory, rheumatic, autoimmunological attack that is a response to Streptococcal infections. Perhaps, DNAase toxic products that are secreted by Streptococcus during infections also help its formation. "One must think: each tissue, and therefore each organ, will clinically express the adverse effects of the systemic disease of rheumatism in its own way, thus, many apparent separate diseases develop, over time, in a somewhat random, but often connected, fashion."

High-grade rheumatic fever decreased in incidence starting in the early 1900's within modern, industrialized societies, secondary to the improvements in living conditions which were brought on by advances of basic science that begot the industrial revolution. Advances included larger homes and smaller family size, both of which caused decreased crowding within dwellings, which decreased the spread of Streptococcus pyogenes within families. In addition, more hygienic living habits, the common use of soap, improvements in home bathing facilities, the use of clothes washers, dish washers, and the pasturization of milk all contributed to a decreased spread of Streptococcus pyogenes within society. Later, in the 1930's, the use of broad spectrum antibiotics for respiratory infections was initiated. The environmental changes, and the common use of antibiotics, resulted in fewer and fewer Streptococcus pyogenes infections, but more importantly, perhaps, infections with less virulence, so by 1970 high-grade rheumatic fever was a relatively rare disease in modern, developed countries. Chronic rheumatism also decreased in severity in especially in younger populations, but it still appeared, as a pathological entity, in older people as they lived through the years.

Unfortunately, in 1987 rheumatic fever experienced a resurgence with the first reports appearing in The New England Journal of Medicine with the author, L. George Veasy, MD wrote about a mini-epidemic from the area around Salt Lake City, Utah. Thereafter, numerous mini-epidemics have been reported from many areas in the USA.

A mini-epidemic of acute rheumatic fever took place in Lewis and Cowlitz Counties of Washington State during the winter and spring of 2004 and 2005. A few patients died before that period from rheumatic fever, but I didn't recognize it. During the above mentioned period, about ten people died out of my patient population of about 7000 during the aforementioned period. A number of patients have died thereafter who lived in the same geographic area. The individuals who died were fairly young, in their twenties to their sixties, they all experienced chronic neurological pain and arthritic symptoms, three of them had had a history of previous rheumatic fever or scarlet fever. In addition, a number of them had experienced spinal surgery with no improvement in symptoms or signs, and they were taking opiates for their severe, chronic, neurological pain when they died. Unfortunately, the local coroners and medical examiners, neither of whom had much medical knowledge or wisdom, made a determination that some of the patients died from the affects of opiates that they were taking for their chronic rheumatic pain. Some of the patients, on whom I had accurate information, had classic signs and symptoms of acute rheumatic fever popularized as the Jones Criteria. They had enlarged hearts and pulmonary edema on autopsy as an indication that they had had acute rheumatic carditis (myocarditis and endocarditis) and rheumatic, congestive heart failure.

One of the painful, clinical, rheumatic conditions, which many children commonly experienced in somewhat earlier times, such as before the 1970's, but even currently, are growing pains. Growing pains manifest themselves as a painful sensation in the legs, commonly the thighs and knees, and it develops, often, shortly after going to sleep, or lying down, and wakes the young patient who often complains, and even cries, due to the severity of pain. Other clinical manifestations of rheumatism, which children experience, are torticollis (wry neck) and dorsodynia, which is an older term for upper back pain that is usually felt in the scapular region, which, I determined, is frequently a referred pain pattern caused by rheumatic brachial plexitis. Another syndrome children experience, occasionally, is Kawasaki disease. I surely think that Kawasaki disease is a syndrome that is a presentation of rheumatic fever or scarlet fever) in a child who is "well conditioned" to have a severe rheumatic vasculitic response by having experienced a number of Streptococcus pyogenes infections earlier in life. They could have experienced a chronic infection, which caused an elevated sensitivity to the autoantigens of a virulent subtype of Streptococcus pyogenes. Another syndrome that adults contract is Guillain-Barre' Syndrome. It is a presentation of rheumatic fever wherein the individual experiences an acute, systemic neuropathy and paralysis at some level. Usually they experience a respiratory infection somewhat before their attack and such a pattern of delayed autoimmune disease is classic for Streptococcus pyogenes infections and their delayed rheumatic response.

Simultaneously with a decrease in the frequency of high-grade rheumatic fever, the citizens of modernized countries experienced a steadily advancing life-expectancy; in the USA life expectancy increased from forty-seven in 1900 to about seventy-seven in 2000: an increase of about thirty years, which equates to an increase of 64% over a 100 year period. There has to be a logical reason for the increased longivity. The reason, mainly, I hypothesize, has been a decreased incidence, and severity, in general, of Streptococcus pyogenes infections; a generally decreased level of virulence of Streptococcus pyogenes itself, which resulted in a great decrease in the incidence of acute rheumatic fever and, therefore, chronic rheumatism decreased in severity in the populations of economically advanced countries. The decrease in the incidence of acute rheumatic fever, a disease that often caused the death of children and younger people, greatly contributed to the increase in human life-expectancy. There were other positive factors also, for instance, a better food supply, vaccines for other diseases, and improved medical care, especially supportive care and disease altering surgical procedures.

Rheumatic autoimmunity causes, initially and continually, an inflammatory vascular condition, which is its main pathological mechanism that results in inappropiate intra-arterial thrombosis especially at arterial bifurcations. The immune system reacts to localized intra-arterial thrombosis with an enhanced, localized inflammatory response so that inflammatory, intra-arterial, arteriosclerosis lesions develop. As Streptococcus pyogenes infections decreased, as mentioned above, fewer myocardial infarctions developed early in life and coronary artery disease became, to a great degree, a disease of older people, in modernized portions of the world, since it is caused by more subtle, chronic rheumatic autoimmune condition: chronic rheumatism.

Rheumatism is a disease with frequent acute manifestations, but it has much more common chronic manifestations. It has existed in vertebrates, including humans, ever since Streptococcus pyogenes, and perhaps other bacterial types, evolved the biochemical structures, autoantigens, which, at least to some degree, decrease the ability of vertebrate hosts to identify it as foreign. Eventually, Streptococcus pyogenes is identified to be foreign and its vertebrate host, the human host being the primary subject of this article. The human host develops antibodies to the antigens, but it also develops autoantibodies to the autoantigens it displays during infections. The antibodies, and autoantibodies kill or harm Streptococcus pyogenes, but the autoantibodies also attack humnan tissue chemical moieties, which Streptococcus pyogenes has mimicked. Once the immunological system has formed autoantibodies they continue to be manufactured in a decreasing fashion so that their concentration decreases over time, but they never disappear. If another Streptococcus pyogenes infection ensues at a later date, and since the human host has developed autoantigenic memory and sensitivity, there will be a more brisk manufacture of autoantibodies and the individual will develop recurrent rheumatic fever.

Since Streptococcus pyogenes is one of the most common microorganisms to parasitize vertebrates, especially humans, infections by them, mostly less than subacute and chronic, take place reasonably frequently. Subtypes of Streptococcus pyogenes vary a great deal in their virulence; if a highly virulent strain of Streptococcus pyogenes infects an individual who has elevated rheumatic sensitivity, they may develop acute rheumatic fever.

The above pattern occurs during life in a continual, waxing and waning fashion so that all people have streptococcal autoimmunity, rheumatism, at some level. Eventually, its effects harms all tissues, and therefore organs, and so it manifests itself in what is termed "the aging process".

Contact information: ecnal-c@hotmail.com

Cause: Infections by Streptococcus pyogenes. This fact was determined as indicated above, somewhat concomitantly, by Alvin F. Coburn in the U.S.A. and W. R. F. Collis in Great Britain in 1931. ( AB )

References

(1) Harrison's Principles of Internal Medicine 16th Edition, McGraw Hill Medical Publishing Division, New York, N.Y., 2005

(2) Harrison's Principles of Internal Medicine 12th Edition, McGraw-Hill Medical Publishing Division, New York, N.Y., 1991

(AB) "The Factor of Infection in the Rheumatic State", Alvin F. Coburn, MD, The William and Wilkens Company, 1931

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