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F. J. (Frederic John) Poynton.

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upon the all-important problem of the treatment of the
disease.

As we have stated in the introduction, no dramatic " Cure "
has appeared to encourage us, but on the contrary the specific
treatment has seemed to become an even more difficult
problem than it was before we commenced these investigations.
How we are to destroy these micrococci in the tissues without
at the same time injuring the tissues themselves is the obvious
difficulty that confronts us, and is the greater because they
may have gained a firm hold in the system before any oppor-
tunity of coping with them is afforded. Then, owing to the
extreme difficulty of differentiating the members of the strepto-
coccal group, and the difficulty we have found in preserving
the virulence of the diplococcus in vitro, a study of the toxines
has been an undertaking beyond our powers. Further clinical
investigation of the results of this infection has brought home
to us the extreme subtlety of the poisons that are produced
which may cause prolonged and most complex results in such
organs as the brain, where the clinical results can be so clearly
recognised.

Many of the methods of treatment that are described in every
text-book can be readily seen to be rational, such as rest, the
relief of pain, the combating of fever, and the prolonged con-
valescence, for they are measures needful in the treatment of
all infections, and the slow convalescence is particularly called
for by the peculiar tendency of the rheumatic infection to
attack the heart. Our researches obviously suggest great
attention to sore throat during the illness.

With more caution as to the interpretation, the employment
of the alkalis would appear to be of value, for the little that
is known of the poisons produced by the diplococcus points to

428



TREATMENT 429

the production of deleterious acids as one of its results in the
tissues.

The great problem every medical man meets with in the
matter of drugs is, we need hardly state, the position of the
salicyl-compounds in the treatment of the disease ; and
upon it we write with the utmost deference to the opinions
of others. No thinking man, with a knowledge of the ravages
of rheumatism before his mind, would deliberately attempt
to obstruct any method of treatment of this disease which
promised to be specific, and nothing that is written here
should be looked upon as an expression of an antagonistic
attitude to those who are not in agreement, but as an
expression of opinion based upon what appears to us the
present evidence.

To us it has seemed astonishing, when we bear in mind the
immense experience of these drugs that has now accumulated,
that the specific action if it exists has not yet been definitely
established. We look upon a specific drug as one which pro-
duces results so definite and incontestable that none but the
blind opponent can mistake them. Our experience has been
that whether very large, medium or small doses of the salicy-
lates are given in this disease, we have failed to discover any
such striking results. We would put a clear issue forward and
state that if ten cases of acute rheumatism in which sub-
cutaneous nodules were appearing were treated by any doses
of these drugs that a physician chose to venture, and ten more
were treated by the simple alkalis, the result would be that
we should see no striking difference in their course under the
two methods. That is, although they are the most easily
appreciated and most characteristic of all rheumatic lesions, we
should not see them melt away under the salicylate treatment
and linger under the alkaline.

We cannot deny that the salicylates relieve pain, and lower
the temperature, but they do this, it must be added, in many
other conditions. Aspirin will relieve the pain of cancer, of
tabes dorsalis and of influenza. Salicylate of soda will ease
the pain of gout and of early suppurative arthritis. Whenever
there is relief of pain there is mental and bodily rest, and
consequently more vital power for the natural resistance to
diseased processes.

It is quite possible that these drugs may have some actual



430 TREATMENT

specific influence upon the rheumatic poisons formed in the
processes of arthritis, and not upon the poisons formed in
different tissues such as the brain and heart. Even this point,
however, does not seem to stand out clearly, for it is remarkable
how rapidly in childhood a rheumatic arthritis will subside
when only rest is employed ; and on the other hand, when in
an adult or child the arthritis is of the stubborn periarticular
type, how the salicylates may fail. The obvious objection that
is always raised is that these latter cases are not rheumatic.
We can only state that our experience has led us to maintain
that they are undoubtedly of that nature, and would add
that we believe that in some delicate subjects these drugs,
if persisted in, do actual harm by producing a general depres-
sion of the resistance. It is worthy of consideration also,
whether these drugs, by lowering temperature and easing
pain, may not sometimes lull the medical man into a sense of
false security.

We would wish to make it quite clear that these expressions
of opinion are concerned only with the specific action of the
salicylates. We realise the great value of these drugs in the
treatment of rheumatism and look upon them as the most
valuable that we possess, and even think that they may have
a specific action on some one of the rheumatic poisons ;
but fully alive as we are to their value we would point out
that they are most efficacious in those cases which are acute
and in which pain and suffering with fever are prominent,
and in which the lesion is the most transitory and most
easily produced of all the rheumatic manifestations, namely
polyarthritis.

The natural conclusion is that we advocate their use for the
polyarthritis, muscular pains, or headache of chorea, but do
not press them for their specific action in heart disease, although
prepared to do so tentatively in severe polyarthritis. We do
not press them in heart disease or chorea, because not being
persuaded of their specific action, we are convinced from
experience that they may produce severe vomiting, general
depression, dizziness, delirium, air-hunger and even fatal coma.
In other words they may introduce into severe cases, added
dangers of their own making.

The various tonics used in the convalescent stages of the
disease require no particular comment, except that the digestion



TREATMENT 431

of these patients is by no means always satisfactory and
caution is needed in giving the iron compounds.

The question of diet is an interesting one, and all our investi-
gations go to show that in childhood it takes no part in causa-
tion of the disease. We have entirely abandoned the idea
that meat is harmful, and are guided only by the general rules
for the diet of invalids dependent upon their powers of
assimilation, the stage of the disease and the occurrence or not
of complications.

It is another question whether persistent errors in diet may
not in the adult deprave the tissues and allow the rheumatic
infection to produce lesions which are more locally destructive
than in the child. In this case it is the evil habit of life that
has altered the constitution before the infection has attacked
the individual.

The treatment by vaccines will, in this country, be the one in
which we should expect the medical profession will show
particular interest, but we would raise a mild protest against
an argument that has been raised of late, that failure with this
method is strong evidence against the causal nature of the
diplococcus. This is indeed a questionable method of reason-
ing, for it assumes that the vaccine methods are perfected and
that their method of action is well understood. Upon these
assumptions obvious and indisputable facts of experimental
investigation are to be thrown aside.

By this method of treatment good results and negative
results have been recorded, and both events would seem to be
possible.

It must, however, be remembered that rheumatism is a very
difficult disease in which to estimate the value of curative
measures, and the real truth can only be obtained by laborious
investigation and the most open statement of all facts. It is
not to be supposed that the pain of the rheumatic lesions will
be speedily quelled by this method, and this will in many cases
involve the employment of the salicylates which must greatly
embarrass the case when viewed by the believers in the specific
action of these drugs.

Our experience has been so far very unconvincing but we
have learnt this practical point, that if these vaccines are
potent for good, they need to be used very cautiously where
there are active cardiac lesions, and we would warn against



432 TREATMENT

the wild use of large doses simply because these methods are so
much in vogue. We ourselves commence with the dose of
1,000,000 and find our way cautiously forward.

The serum treatment presents also great difficulties connected
with the rapid loss of virulence of the micrococcus, and has
been unsatisfactory. Yet it would be very unwise to express
formed opinions upon either method, which are in their infancy
and which may in the future vastly improve with increasing
knowledge.



THE PREVENTION OF ACUTE RHEUMATISM

The possibility of doing more for the prevention of this disease
than has been accomplished heretofore has been the main
purpose of our investigations.

We believe it to be one of the great undertakings in the
medical history of this country.

The importance of the prevention of an infection which is
the great cause of organic heart affections in the young is one
that cannot be over-rated ; and we believe that definite results
will be forthcoming because acute rheumatism is met with
much more frequently among the poorer classes and is encour-
aged by those agencies, which may be summed up in the
single word " poverty."

We are now, we believe, in a position to study the prevention
of this disease guided by a definite and reasonable working
hypothesis, and one which though it exposes our limitations is
in the main an encouraging brie.

The changeable climate and seasons of this country are
elements beyond our control, and must be taken into account
in the problem of prevention as baffling influences. Neverthe-
less, that these agencies are not wholly responsible for the
frequency of the disease is clear from its greater incidence upon
the poorer classes.

In the great hospitals it is clear that we possess ample means
for treating the acute disease and its complications and for
advancing its study in many directions. Their value might
well be strengthened in the future by the establishment of some
special convalescent homes in carefully chosen sites for those
recovering from early rheumatism including heart disease and
chorea. In our experience the ordinary convalescent home is
not suited for such cases, particularly when they are children,
for they need constant medical supervision and nursing.

We are convinced that the medical inspection of children in
the State schools will in the near future provide us with
valuable information upon the influence of school-life on

433 28



434 THE PREVENTION OF ACUTE RHEUMATISM

chronic rheumatic heart disease and on the relation of out-
breaks of acute rheumatism to epidemics of sore throats. It
ma}- perhaps be hardly realised how great a loss of time and
educational energy is due to chorea : many children as the result
of this illness may lose as much as three months' education
each year for some years in succession. It is possible that
careful inquiry may discover that there is some factor in our
present methods of education which introduce too great a strain
or perhaps throw a peculiar strain upon the developing brain
of these children. In support of the importance of the medical
inspection of school children, we would quote from the annual
report for 1911, of the Chief Medical Officer of the Board of
Education, Sir George Newman, the following sentence :
" School inspection provides a wide field for inquiry and
research, and many opportunities of bringing home the danger
of neglecting evidences of rheumatism however slight in
degree." This sentence expresses concisely the important,
indeed indispensable, assistance that can be given by the school
medical officers.

The education of parents and school-teachers in the principal
dangers of acute rheumatism might well be carried on by means
of simple instructions and lectures. Among such instructions
may be suggested the following for rheumatic children.

1. The importance of proper clothing.

2. The care of sore throats.

3. The necessity for attention to " growing-pains."

4. The importance of undue nervousness, clumsiness, and
night-terrors as warnings of chorea.

5. Parents should be warned that the early signs of heart
disease are few, and that shortness of breath is more often
complained of than pain.

6. Much emphasis should be laid upon need for patience
when a child is recovering from heart disease.

7. Parents should be told that rheumatism is very liable to
recur.

We believe that more attention might be given to the
condition of the tonsils and naso-pharynx in the rheumatic
child, and also to the choice of an employment for those who
have been damaged by the disease.

The view that acute rheumatism is an*infective disease raises



THE PREVENTION OF ACUTE RHEUMATISM 435

again the important questions of climatic and local surround-
ings, sanitation and conditions of housing. The possible
relation that it may bear to other infective processes such
as scarlet fever, measles, diphtheria, influenza, or even
tuberculosis seems worthy of further inquiry, more par-
ticularly as in some of these diseases a sore throat is a
prominent symptom. Investigations in these directions
would, we believe, give further assistance in dealing with
the problem of prevention, and come into the province of
the Medical Officers of Health.

We are convinced that the general subject of " Rheumatism "
has only reached the threshold of inquiry, and that in every
direction new fields for research and inquiry are before us.

In conclusion, this is certain ; that at the present time, in spite
of all that has been written upon the treatment of acute rheu-
matism, there are hundreds of young children who are so
damaged by this disease that all known methods of " cure "
are utterly useless to them. It is to prevention, then, that we
look for some advance from this grievous state of affairs, and
it is with the desire of directing the attention of our profession
to this pressing need that we have ventured to publish this
book, in the hope that it may have some influence toward
achieving this end.



INDEX



Abdominal pains, obscure in acute
rheumatism, 361
symptoms in acute rheumatism,
422
Abrahams, Bertram, pathology of

rheumatic chorea, 174
Acetic acid, production by diplo-

bacillus, 217
Achalme, bacillus of, alleged trans-
formation of diplococcus into,
266
bacteriology of acute rheuma-
tism, 96, 97, 109
Adrian, experimental production of

appendicitis, 372, 373
Adult, acute rheumatism in, 411

active rheumatism in causing

injury to heart muscle, 51
chronic rheumatic heart disease

in, 59
prognosis of acute rheumatism
in, 426
Akerman, experimental osteo-mye-

litis, 363, 364
Alcoholism, adverse effect on dilata-
tion of heart of rheumatic
origin, 416
extreme changes in left ven-
tricle from case of, 48, 51
Alimentary canal, lesions of in acute
rheumatism, 407, 408
saprophytic streptococci of, 270
Anaemia, rheumatic, malignant,

process favoured by, 355
Andrews, H. Russell, and Wall, C. ,
chorea occurring in pregnancy, 260
Angina from throat affections, resem-
blance of venous thrombosis in
neck to, 77
faucium, experimental results

from case of, 107, 132
relation to acute rheumatism, 96
rheumatic, 406
Aorta, acute inflammation, termi-
nating in sudden death, 67
Aortic and mitral disease of rheu-
matic origin, 317-321



Aortic and mitral disease, clinical
study of, 319
regurgitation in childhood, 415
valves, condition in rheumatic
heart disease, 34, 39
Apathy, mental in rheumatic venous

thrombosis, 77, 78
Apert, bacteriology of rheumatic
fever, 97
diplococcus in rheumatic chorea,

234

pathology of rheumatic chorea,

175
Appendicitis, aetiology of, 374-377

bacteriology of, difficulties in,
379. 380

blood-infectionincausation|of,382

experimental, produced by diplo-
coccus from acute rheumatism,
367-73, 408, 422

morbid anatomy in human and
experimental disease, com-
parative study of, 378-83

point of origin in human subject,

373
relapsing, 382

relation of rheumatism to, 377
resulting from blood infection

from streptococcal follicular

tonsillitis, 374-377
rheumatic, 3

question of, 381
secondary causes of, 382
streptococcus as cause of, 380
tonsillitis in relation to, 379

See also Perityphlitis
Appendix vermiformis, lymphoid

tissue in, 360
solitary ulcer in, produced in

rabbits by intravenous in-
jection of diplococcus, 383
and tonsils, structural analogy,

359, 360
Arrhythmia (cardiac), 268
Arteritis in rheumatic infection, 404
Arthritis affecting one joint. See

Monarthritis



437



438



INDEX



Arthritis, and fatal endocarditis pro-
duced in rabbits from inocula-
tion of strepto-diplococci from
enucleated tonsil, 274

and purulent pericarditis fol-
lowing mixed infection by
staphylococcus aureus and
diplococcus, 223

associated with perityphlitis,
pyaemic nature of, 364, 365

certain forms of, 150-161

cervical, 413

simulating spinal caries,

413

chronic, infectivity of acute

rheumatism in relation to, 136

diagnosis assisted by recognition

of rheumatic dilatation, 26, 27

effusions about joints in, 142

sterility, 144
experimental, effusion about
joints in, 142, 143
sterility, 144
experimental, produced by intra-
venous inoculation of dip-
lococcus isolated from
cases of rheumatic fever,
141-44, 154, 155
production, in rabbits, 6
gelatinous swelling of fibrous
structures in last stages of, 144
gouty, 399

implication of bursaein, 413
in association with perityph-
litis, 359-66
in acute rheumatism in children
under five years, 283, 286-98
in scarlatinal rheumatism, treat-
ment, 300
infantile, 153-4

suppurative, cause of, case
described, 159
investigations upon, 275
malignant and rheumatoid, 207
multiple, in rabbit from inocu-
lation with diplococcus from
case of osteo-arthritis, 147, 149
non-suppurative, 2, 3
pneumococcus, 157
production by intravenous in-
jection of diplococcus rheu-
maticus, 275
rheumatic, acute, 398, 399

condition of connective
tissues of synovial mem-
branes in, 399
condition of tendon sheaths
in, 399



Arthritis, rheumatic, course of, 413
of morbid processes in,
152
escape of micro-organisms
into joint cavity, vital
process, 152
every variety found, 398
experimental production,

151. 152
local periostitis, round

affected joints in, 399
malignant, 399
most easily overcome of all

rheumatic lesions, 230
osteo -arthritic type, ex-
perimental production,
145-149
See also Osteo-arthritis
periostitis with, 414
perivascular fibrosis in, 153
resembling perityphlitis, 365
rheumatoid, 2, 3, 151, 154-7

and rheumatic fever, 156-7
bacteriology of, 148
case with features resem-
bling, 289
cases of rheumatic arthritis
passing into condition of,
398
infection, results of experi-
mental inoculations, 155
infective, causation, sum-
marised, 161
nervous lesions, 155

puerperal origin, 155
serum for, Menzer's, 161
treatment, summarised, 161
want of exact knowledge
concerning leads to errors
in diagnosis of rheu-
matism, 425
suppurative, 157-160

difficultiesof terminology, 157
from gonococcus infection,

case described, 160
from streptococcus pyaemia,

case described, 160
rheumatic origin proved, by
isolation of diplococcus,
case, 158
various forms mistaken for rheu-
matism, 425
Aschoff and Tawara, gross changes in

cardiac muscular fibres, 268
Ashby, H., on scarlatinal rheuma-
tism, 302
Auriculo-ventricular bundle, damage
to, in lesions of myocardium, 404



INDEX



439



Bacillus as causal agent in acute

rheumatism, theory as to, ioo

of Achalme, 96, 97, 109, no

coli in perityphlitis, 364

pyogenes, fcetidus liquefaciens,95

Bacteria, antitoxic sera set free from,

producing effusion into joints, 230

Bacterial cause of specific disease,

demonstration of, 228
Bacteriology, advances in, results of, 4
of acute rheumatism, history of,

94-101
of appendicitis, difficulties in,

379,38
of rheumatoid arthritis, 148
Bannatyne, rheumatoid arthritis as a
specific disease, 154
Wohlmann, and Blaxall, bac-
teriology of rheumatoid arth-
ritis, 148
Barlow, Sir T., affections of heart ir.
rheumatic children, 181
association of chorea and rheu-
matic fever, 177
development of chorea, 270
on scarlatinal rheumatism, 302
and Warner, F., identity be-
tween rheumatic process and
rheumatic nodule, 80
Barnard, H., and Hill, L., function
of pericardium in relation to heart
wall, 66
Bastian, H. C. pathology of rheumatic

chorea, 173
Beaton and Ainley Walker, isolation
of diplococcus from case of rheu-
matic chorea, 235
Beattie, experimental production of

twitching movements, 239
Bile from infected rabbits, diplo-
coccus isolated from, 422
Blaxall, bacteriology of rheumatoid
arthritis, 148
rheumatoid arthritis as a specific
disease, 154
Blood changes in acute rheumatism,
66, 421
cultures, as evidence of rheu-
matic origin of simple and
malignant endocarditis, dis-
puted value of, 327
infection from streptococcal fol-
licular tonsillitis producing
appendicitis, 374-77
in causation of rheumatism ,382
staphylococcus pyogenes aureus
found in, in mixed infection
with diplococcus, 222



Brain, blood-vessels, engorgement, in
cases of chorea, 246, 249, 251,

253
diplococci found in, in fatal
cases of chorea, 248, 250,
252
in acute rheumatism, 405
in chorea, 170, 238
hyperaemia in cases of chorea,

246, 249, 251, 253
pathological changes in, in acute

rheumatism, 405
perivascular round-cell infiltra-
tion in, in cases of chorea, 246,
249, 251, 253
and membranes, occurrence in, of
diplococcus found in acute
rheumatism, 128
Brazil, perityphlitis with arthritis,

362
Bright's disease, resemblance of
venous thrombosis in neck to,

77

Broadbent, Sir W., origin of rheu-
matic chorea, 172.

Broncho-pneumonia, rheumatic, 3,
407, 419

Buist's statistics of chorea in preg-
nancy, 260

Bullous eruptions rare in acute
rheumatism, 421

Bursa?, implication in arthritis, 413

Bursitis, 142

Buss, relation of angina faucium to
rheumatic fever, 96

Butterfield, H. G., research on endo-
carditis, 324



Caiger, F. F., on scarlatinal rheu-
matism, 301
Cardiac dullness, area in children, 14
grouped according to severity
of heart affections, 15-27
impulse, position in younger and
older children, 15
Carditis, acute, with fatty changes
throughout heart-wall, 52
rheumatic, 2, 49

acute, pulmonary oedema in,

407, 420
experimental production,

268
gross changes in muscular
fibres of heart in, 267, 268
myocardial lesions in, 403,

404
pleurisy in, 406



440



INDEX



Carditis, scattered foci of inflam-
matory change in con-
nective tissue framework
of heart in, 267
severe, with extensive
venous thrombosis,
cases of, 68-78
clinical history, 68,

7°. 72
post mortem results,

69, 71. 73, 74
Cave, pneumococcus arthritis, 157
Charrin, bacteriology of acute rheu-
matism, 95
Chauffard and Raymond, diplo-bacilli

in rheumatoid arthritis, 154
Cheadle, W. B., angina faucium in
relation to rheumatic state in
childhood, 96
case of rheumatic heart disease

with fibrosis of ventricle, 52
chorea in rheumatic children, 178
concurrent myo- and pericardial

changes, 49
development of chorea, 270
fatal acute rheumatism, detailed

case, 167
pathology of rheumatic chorea,

174
rheumatic venous thrombosis,

77.78
Chemical theories of causation of

rheumatism, 388, 394
Childhood, aortic regurgitation in,

415

rheumatic heart disease in,
clinical evidences slender, 415,
416

sex incidence of acute rheu-
matism greater among females
in, 390
Children, acute rheumatism in, 9
fatality of, 59
prognosis, 426

area of cardiac dullness in, 14

association of chorea and rheu-
matism in, 177, 178

chorea in, with acute dilatation
of heart, 13-43

measles and diphtheria in, fol-
lowed by acute rheumatism,



Online LibraryF. J. (Frederic John) PoyntonResearches on rheumatism → online text (page 39 of 42)