It is probable that the infection is the result of specific bacterial intoxi-
cation, although thus far no causative germ has been isolated. Various
observers have, however, cultivated from the inflammatory exudates of rheu-
matic patients different micro-organisms which are capable of causing arthritis
Io6 THE INFECTIOUS DISEASES.
and endocarditis in lower animals. Several distinct species of bacteria have
been isolated from rheumatic exudates which goes to show, as suggested by
Flexner and Barker, that perhaps acute articular rheumatism may be the re-
sult of infection of the blood by any one of several species of pathogenic micro-
organisms at a time when circumstances are such as not to favor the develop-
ment of general septicaemia but are favorable to the propagation of inflam-
matory conditions of one or more of the serous membranes.
Various forms of arthritis simulate acute articular rheumatism, such as
those complicating other acute infectious diseases, notably scarlatina, and
the arthritis due to the gonococcus. These are not true rheumatisms but
inflammations of the synovial membranes due to other causes.
Pathology. The affected joint is swollen, hot, sometimes red, and is bathed
in acid perspiration.
Its synovial lining is congested and swollen. The joint cavity is sometimes
distended by fluid. This is usually serous but may be turbid, or rarely puru-
lent. The cartilages within the joint and covering the articular surfaces
may be eroded.
Symptoms. The onset of the disease is usually rapid, one or more joints
becoming, even within a few hom"s, swollen, painful, tender, reddened and
bathed in perspiration. Less frequently there is a short period of invasion
during which the patient has indefinite pains in bones and joints. The onset
is rarely marked by a chill, but is usually followed by a rise in temperature.
The regular course of the infection lasts about six weeks but with proper
treatment we are usually able to shorten the acute stage to six or seven days.
With the inception of the disease there is often nausea and vomiting. The
temperature rises to io2°-io4° F. (38.9° to 40° C). The pulse is accelerated
(95-100), the urine is scanty, high colored and acid with a copious sediment
of urates; it may contain albumin; the bowels are usually constipated.
The febrile movement continues while the joints are acutely inflamed but
usually is of remittent type.
The skin is usually bathed in an acid perspiration and it may be the seat of
various eruptions. These may be erythemata, diffuse papular, tubercular
or marginate, urticaria, or a true purpura with haemorrhagic spots of varying
size. Sloughing may follow these last and with them there may be haemor-
rhages from the various mucous membranes and hsematuria. This condition is
demonstrated peliosis rheumatica and is of doubtful rheumatic origin. Nodules
of various sizes up to that of a pea have been observed in certain cases in the
tendons and muscle sheaths of the extremities, limbs and even over the ver-
tebrae. These are a feature of the declining stage of the disease; they are
more usually seen in children and remain from several days to several
weeks.
The pain is usually very severe, any movement increases it and even the
ACUTE ARTICULAR RHEUMATISM.
107
weight of the bed clothing may cause extreme discomfort. The patient finds
that the pain is less when the joints are held in a position of mid-flexion.
Usually more than one jojnt is inflamed and those most often attacked
are the knee, ankle, wrist, elbow, shoulder and hip, in the order named. The
joints of the fingers are not however exempt. Rarely is a single joint affected,
though this may occur. The inflammation has a tendency to involve succes-
sively one joint after another, the symptoms in one being to some extent
relieved as another is attacked. At times the process will recur in a joint
which has partially returned to normal.
A patient who has once suffered from rheumatic fever is prone to recur-
DAY OF,
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Fig. 6. — Clinical chart of acute articular rheumatism.
rences of the disease at intervals of from one to several years, and it is these
successive attacks which are likely to result in serious complications, more
especiaUy in the heart.
Hyperpyrexia. In certain cases the temperature may rise to a very high
level even to 110° F. (43.3° C). Such a condition is a very serious one and
generally results in death unless the temperature can be quickly reduced.
With this excessive temperature are other symptoms of marked constitutional
disturbance such as headache, delirium, unconsciousness and heart failure.
Complications. These affect the serous membranes and the endocardium
and are the result of the lodgment of the infectious material in the blood
in these situations. The pleura, the pericardium and more rarely the peri-
tonaeum are the membranes involved and their inflammations are amenable
Io8 THE INFECTIOUS DISEASES.
to antirheumatic treatment. In rheumatic pleurisy physical signs are con-
spicuously absent, an important point in differential diagnosis.
Endocarditis is a frequent and most dreaded complication, its usual seat
is in the left side of the heart and it is less likely to attack the aortic than the
mitral valve. The heart should be the subject of very frequent examination
since in even mild rheumatic infections it may become the seat of valvular
disease of severe type. The percentage of heart complications in this disease
is stated by some authorities to be as high as sixty percent. The onset may
be gradual and difficult of diagnosis, while dyspnoea and palpitation may
appear as features of a rheumatic attack with merely a functional cardiac
disorder. The endocarditis is more frequently seen in youthful patients
and is usually of the vegetative type. The heart may regain its normal
condition but most of the cases of chronic endocarditis seen in practice are
the result of rheumatic infection.
Infective or malignant endocarditis may occur, but inflammations of the
myocardium are believed to be rare.
In consideration of the sequelae of acute rheumatism, chorea, exophthalmic
goitre and acute nephritis and the permanent joint changes similar to those
of chronic articular rheumatism and arthritis deformans should be men-
tioned.
The prognosis. Recovery is usual in non-complicated cases. The dura-
tion of the disease untreated is about i6 days but with proper treatment this
may be much shortened. In many cases the infection leaves the patient
with a permanently impaired heart. Rarely the patient passes on to the
condition known as chronic rheumatism.
Death, when it takes place, is usually the result of hyperpyrexia or cardiac
complications.
Prophylaxis. Persons subject to the disease should avoid excessive mus-
cular exertion and especially exposure to cold and wet. Their clothing should
be warm, preferably of woolen next to the skin in winter and of linen during
the hot months. Too much carbohydrate food and malt beverages should
be avoided, and the liver and bowels should be kept active. Daily baths,
cold, preferably, if well borne, should be taken in order to keep the skin
active and healthy. Out-door life and proper exercise are important.
Treatment. The patient should be kept in bed, upon a soft mattress
and covered with blankets, not sheets. Calomel followed by a saline should
be administered and the bowels should be kept freely open during the whole
course of the disease.
Medicinal Treatment. The salicylates are an exact chemical limitant of
the action of the causative bacteria, but the problem is to administer these in
sufficient dosage to accomplish our object without injury to the heart, stomach
or kidneys. Salicylic acid and sodium salicylate, especially the former, are
ACUTE ARTICULAR RHEUMATISM. I09
very likely to disturb the stomach, and being eliminated through the kidneys
these organs are likely to receive harm. The acid in large doses diminishes
the contractile povi^er of involuntary muscle fibre and consequently its adniin-
istration may result in acute cardiac dilatation. The ideal drug would be an
organic combination of the salicyl radical which would pass through the stomach
unchanged to be spilt up in the intestines. Sixty to eighty grains (4.0 to 5.33) per
day of the salicyl radical are necessary to cause a disappearance of the symptoms
within a week and so great a quantity is likely to be harmful and certainly
is objectionable to the patient. The problem being to bring the salicylate into
direct contact with the joint in as great a quantity as possible and to prevent
its getting into the circulation, the following ointment is prescribed : I^ acidi
salicylatis, olei terebinthinse, adipis lanae hydrosi, of each one drachm (4.0),
unguenti, q.s. ad one ounce (30.0) . Sig. Rub one drachm (4.0) thoroughly into
the diseased joint twice a day. The fact that a curative quantity of the salicyl
radical is absorbed may be proven by finding salicyluric acid in the urine
within 20 minutes after an inunction.*
The acutely painful and tender joint of beginning acute rheumatism may
cause the patient to rebel against this form of treatment but the administration
of salophen (two drachms — 8.0 — in divided doses during 24 hours) or antipyrine
salicylate in like quantity will ease the pain so that the inunctions may be
employed.
During the administration of salicylic acid in any form the urine should
be examined daily and the quantity, specific gravity, and presence or absence
of albumin or casts noted. It should be remembered that salicyluric acid
reduces Fehling's solution, consequently such a reaction should not be mis-
understood.
The above treatment usually results in the disappearance of the acute
symptoms of the disease within a week.
In hospital practice the use of sodium salicylate — grains xx (1.33) — and
sodium or potassium bicarbonate — ^grains x (0.66) — every four hours will be
found to be attended with excellent results but in privtae practice such dosage
is objectionable for obvious reasons. The alkali may be diminished when
the reaction of the urine becomes alkaline. With this form of treatment
it is very necessary that the bowels be kept freely open, that water be drunk
copiously and that the condition of heart and kidneys be carefuly watched.
When the acute symptoms of the disease have abated the dosage should be
diminished. Certain authorities advocate the use of salicin, phenyl salicylate
(salol) or methyl salicylate (oil of wintergreen) but these drugs seem to have
no advantage over those above mentioned.
Certain feeble and anaemic patients are not benefited by the alkalies or
♦Test for salicyluric acid: To a test tube of urine add 10 drops of the tincture of ferric
chloride and in the presence of salicyluric acid a port wine color will result.
no THE INFECTIOUS DISEASES.
salicylates and in these iron, codliver oil, potassium iodide and other tonics
and alteratives are indicated.
In gouty patients an attack of acute rheumatism seems to be best treated
by a combination of colchicum and the salicylates.
When the salicylates are too disturbing to the stomach they may be given
per rectum in dosage of 20 to 40 grains (1.33 to 2.66) in solution every four
or six hours.
If larger doses are injected it is wise to add a few drops of tincture of opium.
Acetyl-salicylic acid (aspirin) is recommended as a substitute for the more
commonly used salicylates, chiefly because is passes unchanged through the
stomach, consequently not disturbing this organ, and is split up in the bowel;
its taste is less unpleasant and it is less likely to cause tinnitus. Its dosage
is from ten to fifteen grains (0.66 to i.o) in powder or capsule every three or
four homrs.
It may be said in conclusion that while various other drugs have their
advocates the general consensus of opinion is that in salicylic acid and
sodium salicylate we have the most eflScacious treatment for acute rheumatism.
Disadvantages they have it is true, such as their tendency to disturb the stomach,
heart and kidneys and to produce tinnitus aurium, which may be relieved by
sodium bromide, or even deafness, and while their use does not prevent relapse,
possibly because their administration is not long enough continued, nor heart
complications, it does relieve the pain quickly and effectively, enables the
patient to sleep and causes the fever to fall within a few days.
With regard to hyperpyrexia, energetic cold bathing — 70° F. (21.1° C.) — or
cold packs are the only means of treatment which have given good results.
While the patient is being moved to undergo either of these procedures mor-
phine may be given hypodermatically to control the pain and strychnine
or alcohol may be used to counteract any tendency toward collapse.
The treatment of other complications, pericarditis, endocarditis, etc., will
be dealt with in the sections upon these diseases.
While the febrile movement and the other acute symptoms persist
the diet should be of milk, soups and semi-solids. A retiu-n to ordinary diet
should not be allowed for at least a week after the subsidence of the joint
symptoms.
Menzer has prepared a serum from streptococci from the tonsils of rheu-
matic patients and has used it in more than 30 cases with the following results :
The treatment caused no pain or other local reaction as a rule. A general
reaction, chilliness, fever, and skin eruptions, often resulted. The dose
used was from i^ to 5 ounces (50.0 to 150.0). He believes that in acute cases
the course of the disease was shortened, and he particularly states that the
treatment seemed definitely to prevent severe endocarditis.
Local applications of various kinds may relieve the joint pain and swelling.
SEPTICEMIA AND PYEMIA. Ill
The affected parts should be swathed in cotton covered by oiled silk which
will protect from traumatism and maintain an even temperature. Often
immobilization by means of splints and the use of sand bags and pillows will
add to the comfort of the patient. It is to be remembered in the application
of splints, etc., that mid-flexion is the proper position in which to place the
joint. Blisters of cantharides may relieve the pain in the acute stage and
are often useful later in the disease. Care should be taken lest their action
be carried too far. Injections of lo to 15 drops (0.66 to i.o) of i percent,
solution of phenol beneath the skin of the joint are advocated. These may
be repeated once or twice daily and are said to relieve the pain to a considerable
extent. Painting with tincture of iodine or applications of iodine ointment
are likely to accomplish little, but a 10 to 20 percent, ointment of ichthyol in
lanolin is highly recommended. If wet dressings are applied the temperature
should be warm. Among the most efficacious of these is Fuller's lotion
(sodium carbonate 6 parts; laudanum 80 parts; glycerine 16 parts; water
72 parts), equal parts of guaiacol and glycerin; fluid extract of belladonna
20 drops (1.33) to the ounce (30.0) of glycerin; and oil of wintergreen. These
should be applied upon gauze compresses and renewed twice daily.
After the acute stage is over the joints will be much benefited by properly
applied massage and passive motion; warm and steam baths and galvanic
electricity will also be found useful.
SEPTICAEMIA AND PYEMIA.
Synonym. Bacteriaemia.
Definition. Septicaemia and pyaemia are febrile diseases caused by the
existence in the blood of pathogenic micro-organisms and characterized by
recurring chills and irregular rises and falls of temperature. From these
affections sapraemia or toxaemia are to be differentiated, the latter being the
result of the local development of bacteria and the taking up by the blood
of the toxic products of their growth. The distinguishing mark of pyaemia
is the occurrence in the various tissues and organs of metastatic pus foci;
in septicaemia this manifestation does not take place.
.Etiology. Surgical septicaemia is usually considered to be a result of
infection by pyogenic micro-organisms, particularly staphylococci and strep-
tococci, while to the physician the term septicaemia signifies a condition caused
by the presence of any variety of pathogenic micro-organism in the blood and
tissues while a demonstrable focus of infection may or may not be present.
The basis of pyaemia is analogous to that of septicaemia with the added
factors of thrombosis and embolism. To these latter the occurrence of the
metastatic abscesses is due. For instance a septic phlebitis may occur with
the formation of an infective thrombus from which bits of infectious matter
112 THE INFECTIOUS DISEASES.
may become detached and may be borne as emboli by the blood current until
their final lodgment in a vessel the lumen of which is too narrow for their
passage. Here such infectious particles become stationary and set up inflam-
mator}' processes which soon become abscesses. An example of this often occurs
in infective or malignant endocarditis in which bits of the valvular vegetations
may become detached and carried as emboli by the circulation, imtil lodging
in some perhaps remote part of the body they result in abscesses.
Emboh from septic processes in the periphery and in the bone-marrow
are most Hkely to lodge in the lungs, those from the tissues drained by the
portal system in the liver, those from the female organs of generation in the
pelvic tissues, those from the left side of the heart and those whose size permits
of passage from the right side of the heart through the pulmonary circulation
to the left heart, in the brain, kidneys or spleen.
Of the more common varieties of septicaemia puerperal infection due to
retained secundines, lacerated cervix or perinaeum, scarlatinal or erysipelas
infection and the process which may result in severe forms of enteric fever,
gonorrhoea, diphtheria and other acute infectious diseases, should be men-
tioned.
Symptoms. Before the appearance of constitutional symptoms, those of
the primary local lesion, if such is present, will be noticed. The onset of
the septicemia or pyaemia is usually marked by a severe chill during which
the temperature may rise to 103° to 105° F. (39.4° to 40.5° C). Following
this manifestation there is profuse sweating succeeding which the temperature
may rise again. Chills, rises of temperature and sweats succeed one another
at intervals of one or two days, a general tendency of the fever to be higher
at night being not unusual. The patient is prostrated, thirsty, suffers from
anorexia and nausea, and perhaps vomits. Flesh is rapidly lost, exhaustion
becomes profound and a condition of semi-coma may supervene; transient
erythematous eruptions may appear.
Local symptoms are frequent in pyaemia and are due to the lodgment of
the septic emboli. In the lungs these cause pain, rapid respiration and cough;
in the liver, pain with tenderness, enlargement of the organ and jaundice;
in the subcutaneous tissues, pain, tenderness and swelling, followed by abscess
formation; in the joints, the usual signs of inflammation and the presence of
intraarticular effusion; in the kidneys, albumin or blood in the urine. Emboli
lodging in the brain, unless they shut off the blood supply of portions of this
organ essential to the performance of the body functions, are not likely to
be suspected. Emboli of the spleen cause pain in the side, tenderness and
splenic enlargement, while metastatic abscesses of the pancreas are evidenced
by deep pain and tenderness in the region of that organ.
The diagnosis of septicaemia and pyaemia usually offers little difficulty
when a primary focus is present. When this aid is absent blood examination
SEPTICEMIA AND PYEMIA. II 3
will reveal a considerable leucocytosis and cultures may show the presence
of the causative micro-organism. Enteric fever may be differentiated by
means of the Widal reaction and malaria by examination of the blood and by
the test of quinine treatment. Gonorrhoea and prostatic abscess as well as
tuberculous nephritis and pyelitis due to the presence of calculi may be
factors in causation. In malignant endocarditis a murmur is usually present
but both this condition and acute osteo-myelitis may be unsuspected.
The prognosis is always serious in pysemic conditions. Puerperal septi-
cemia is the least grave type of the affection if proper treatment is instituted.
Chronic cases may last for months with irregular temperature and gradually
increasing anaemia and emaciation until death supervenes.
Treatment. Much may be done in the way of prevention of puerperal
septicaemia by proper cleansing of the patient's genital tract, the physician's
hands and instruments, the complete removal of the contents of the uterus
and proper after-treatment of cervical, vaginal and perinaeal lacerations.
Crede recommends the sterilization of the patient's genitals after partiurition
by first removing all clots, etc., and then inserting a vaginal suppository con-
sisting of I J grains (o.i) each of powdered talc and collargol and 30 grains
(2.0) of cocoa butter; the vagina is then packed loosely with sterile gauze
which later with the introduction of another suppository may be renewed.
If infection takes place douches of i to 2000 to i to 5000 collargol solution are
given and if there is any retention of placenta or membranes these should
be removed by operation. In advanced infection the intravenous injection of
2 to 2^ drachms (8.0 to lo.o) of collargol solution is advised. This last pro-
cediu-e may also be employed in septicaemia and pyaemia of other forms.
The early treatment of septicaemic and pyaemic states by surgical means
is most important. The primary focus should be rendered thoroughly clean
by means of antiseptics, the curette or even the actual cautery. All collections
of pus which can be reached should be opened and drained and even ampu-
tation of a limb may be necessary. Subcutaneous injections of antiseptics
into the tissues may be given just as has been recommended in erysipelas
(p. 104). The bowels, kidneys and skin should be kept active in order that
the poisons may be eliminated in so far as is possible and this may be furthered
by the administrations of high rectal irrigations of hot saline solution given
two or three times daily and two to four gallons (8 to 16 litres) at a time.
The temperature may be relieved by sponging with cool water and quinine
sulphate may be given in doses of 15 to 30 grains (i.o to 2.0) daily. If the
coal tar antipyretics are employed much caution is necessary because of
their depressing effect. The sweating may be controlled by -yV of ^ grain
(0.006) of morphine with yto ^^ ^ grain (0.0006) of atropine, by agaricin
one to two grains (0.065 to 0.13), or dilute sulphuric acid 15 to 30 drops (i.o
to 2.0).
114 THE INFECTIOUS DISEASES.
Tincture of iodine 20 to 25 drops (1.33 to 1.66) daily in divided doses,
given in syrup or rice-water is recommended and inunctions of Crede's oint-
ment may be employed. Intravenous injections of coilargol solution as
advised above may be tried. Stimulation by means of alcohol and strych-
nine is always necessary and in the later stages h}'podermoclyses of hot norma]
saline solution may become necessary.
Treatment by means of antistreptococcus serum should never be omitted
especially in severe cases; 5 to 7 J drachms (20.0 to 30.0) may be injected
every six to eight hours, the doses being diminished as improvement is mani-
fested.
The diet throughout should be of the most nutritious and easily digestible
character and of plentiful amount.
HYDROPHOBIA.
Synonyms. Rabies; Lyssa.
Definition. An acute specific infectious disease to which all warm-blooded
animals are subject. It is communicable to man by inoculation and is