RHEUMATIC FEVER; OR ACUTE ARTICULAR RHEUMATISM.
The phenomena which present themselves for consideration in this disease are: 1. The occurrence, along with the general febrile disturbance, of a local inflammatory lesion.
2. The almost entire limitation of this lesion (a) to such parts of the motor apparatus of the body as are habitually subject to active movement, and (b) to the left side of the heart.
3. The tendency of the disease to attack those of a particular age.
4. Its hereditary transmission.
5. The presence in the blood of an excess of fibrin.
6. The presence in the blood of an excess of lactic acid.
7. The occurrence of profuse perspirations.
8. The shifting character of the joint affection.
These we shall consider in the order enumerated.
1. The Occurrence, along with the General Febrile Disturbance, of a Local _inflammatory Lesion.—Such association occurs under two differ ent circumstances : (1) The inflammation may precede the fever; or (2) the fever may precede the inflammation. In the former case the fever is the result of the inflammation, and is said to be symptomatic; in the latter its onset precedes the evidence of local inflammation, and it is said to be idiopathic. An instance of the former we have in pleuritis or synovitis following cold or injury ; an instance of the latter we have in the bowel lesion of typhoid fever, and in the sore throat of scarlatina.
The first evidence of the existence of acute inflammation of fibrous or serous tissues is pain. The first evidence of febrile disturbance is a feeling of cold and malaise. In purely local inflammations pain is the first symptom. Shivering, malaise, and general febrile disturb ance may quickly follow, or may even be contemporaneous with the pain; but they do not precede it. In the local lesions of the specific fevers the case is different. Before their existence can be determined, there is evidence of constitutional disturbance. In the one case the local symptoms precede the constitutional; in the other the constitu tional precede the local. Which first show themselves in rheumatic
fever? There is some variety in its mode of onset. Usually the patient complains at first only of chilliness and general malaise ac companied by aching of limbs. Soon fever is decided, and the pains are localized in the joints. But one or two days generally elapse before the joints are distinctly inflamed. In milder and subacute attacks, the local joint affection is often the first and only thing com plained of; but careful inquiry nearly always elicits the fact that the patient has been out of sorts or has had cold for a clay or two before the joint affection declared itself. In whatever way the malady com mences, the joint affection is preceded by evidence of constitutional disturbance. But though this is true it is equally the case that the fever does not reach its height till the articular inflammation is fully established, and that the full development of the fever is contempora neous with the height of the joint affection. When once the disease is fully established, the local inflammation and the constitutional dis turbance go hand in hand—they rise and fall pan passe—and there can be no question that the febrile disturbance, though antecedent to, is much increased by, the local inflammation. In this respect the joint inflammation of rheumatic fever resembles the local lesions of the eruptive fevers more than it does common inflammation due to a. local cause.
How is the inflammation of the fibrous and serous tissues induced? That it results from the action of the rheumatic poison there can be no doubt. The question is, How does the poison act? It may act in one of two ways : either as a direct irritant of these tissues, causing in them the same kind of excitation that cautharides produces in the bladder, and arsenic in the stomach and rectum; or it may act as an organism and owe its action on the fibrous and serous tissues to its propagation in them.