Rheumatism

RHEUMATISM, a general term for various forms of disease subdivided more accurately as follows: Acute Rheumatism or Rheumatic Fever.—This disease, the chief characteristics of which are inflammatory affections of the joints with severe constitutional disturbances, is usually asso ciated with inflammation of the pericardium and of the valves of the heart. In childhood the heart is especially liable to be dam aged, whereas in adults joint manifestations and constitutional disturbances are more in evidence. It is essentially a disease of childhood and early adult life, first attacks being most common about the seventh or eighth year of life and later attacks up to about the twenty-fifth year. It never occurs under two years of age and is comparatively rare over forty. Heredity is commonly supposed to be a predisposing cause but it is very doubtful whether this is correct. The importance of climate is shown by the prevalence of the disease in the temperate zone and by its seasonal incidence (October to March) in England; on the other hand, troops in Egypt and South Africa suffer from the disease, Pretoria being notoriously bad. The disease is urban rather than rural in distribution and is essentially one of children of the arti san class living in damp rooms in an industrial town, attending an elementary school and suffering from tonsillar sepsis.

It is now generally agreed that rheumatism is a specific infec tious disease, but there is still some difference of opinion as to the exact nature of the causal micro-organism. Most authorities, however, agree that the causative organism belongs to the group of streptococci (see BACTERIOLOGY) and gains entrance to the body through the tonsils. Evidence has been produced that in children whose tonsils have been removed a subsequent attack of rheumatism is likely to be less severe in all its manifestations ex cept chorea. (See below.) Symptoms.—Although the main features of the disease in chil dren and adults are different, it is probably all one disease, having periods during which it remains latent for a longer or shorter time between acute exacerbations. In childhood a history of sore

throats and indefinite pains—"growing pains"—can usually be ob tained; the constitutional symptoms are often ill-marked and the child does not appear very ill. This insidious onset makes the dis ease of vast importance to the country, as in many cases its pres ence is not recognized until irreparable damage has been caused to the heart. Chorea or St. Vitus's dance is a common manifesta tion in children, and in these cases the heart is less likely to be damaged. Small, painless, rather hard subcutaneous nodules at tached to tendons may appear and indicate that the disease is passing into a chronic condition.

In

adults the most marked feature is the affection of the joints. The onset is abrupt, being fully developed in 24 hours. The attack begins with a feeling of malaise and pain in one or more joints generally of medium or large size. Usually only one or two joints are affected at first, but soon others become attacked very often symmetrically. The affected joints are swollen, hot and acutely painful; the temperature is raised to about 101° to 503° F; the tongue is coated with a thick fur and the body bathed in a profuse perspiration which has a characteristic sour smell; the face is flushed and the pulse rapid. The attacks are of vari able duration up to some weeks, and relapses are common during convalescence. The most dangerous complication is hyperpy renia or rapid and extreme rise of temperature (see FEVER) possi bly up to iio° F, when death speedily ensues unless prompt meas ures are taken such as tepid sponging or icepacks. This is not a common complication and for some unknown reason is becoming rarer; it appears most commonly in the second week of the first attack but never in a person under 12 years of age. The disease is not fatal, the mortality not exceeding 3%, and is less viru lent than formerly; it is, however, the cause of much chronic dis ease in later life owing to its effect upon the heart. It is esti mated that in England and Wales 25,000 persons die annually from heart disease of rheumatic origin.