common complications of rheumatic fever. Adding Latham's,[73]
Fuller's,[74] Southey's,[75] Gull and Sutton's,[76] Pye-Smith's,[77]
and Peacock's[78] cases together, we have a total of 920 in which some
one or more of the above pulmonary affections obtained in 109
instances, or 11.8 per centum. A further analysis of Latham's and
Fuller's cases shows that it is especially when rheumatic fever is
complicated with cardiac disease that the lungs suffer; thus, pulmonary
affections obtained in 26.5 per cent. of cases complicated with heart
disease, and in only 7 per cent. of cases free from that disease. It is
more especially when pericarditis complicates rheumatic polyarthritis
that pulmonary affections occur. Thus, these were found in only 10.5
per cent. of cases of recent rheumatic endocarditis, in 58 per cent. of
cases of pericarditis, and in 71 per cent. of cases of
endo-pericarditis. The tendency which inflammation of the pericardium
has to extend to the pleura probably partially accounts for the more
frequent association of the pulmonary affections with rheumatic peri-
than with rheumatic endocarditis. (Sibson found pleuritic pain in the
side twice as frequent in pericarditis, usually accompanied with
endocarditis (31 in 63), as in simple endocarditis, 26 in 108.[79]) But
the greater severity of those cases of rheumatic fever complicated with
peri- or endo-pericarditis must also have a decided influence in
developing the pulmonary affections. {37} Pneumonia and pleuritis are
very frequently double in rheumatic fever, and are often latent,
requiring a careful physical examination for their detection. So
suddenly does the exudation take place in some cases of rheumatic
pneumonia that the first stage is not to be detected either by symptoms
or signs. On the other hand, in some cases the absence of the typical
signs of hepatization, the want of persistence in the physical signs,
and their rapid removal, and even in rare instances an obvious
alternation between the pulmonary and the articular symptoms, suggest
that the process often stops short of true hepatization, and partakes
rather of congestion and splenization, with or without pulmonary
apoplexy--a view which has been occasionally confirmed by the
autopsy.[80]
[Footnote 73: Latham's _Works_, Syd. Soc., i. 98 _et seq._]
[Footnote 74: _Lib. cit._, 317.]
[Footnote 75: _Bartholomew Hospital Reports_, xv. 14.]
[Footnote 76: _Guy's Hosp. Reports_, 3d Series, xi. 434.]
[Footnote 77: _Ib._ xix. 324.]
[Footnote 78: _St. Thomas's Hospital Reports_, x. 12-17.]
[Footnote 79: Reynolds's _System Med._, iv. 233.]
[Footnote 80: Vide Sturges, _Natural History and Relations of
Pneumonia_, 1876, pp. 70-78; T. Vasquez, Thèse, _Des complications
Pleuro-pulmonaires du Rheumatisme Artic. Aigue_, Paris, 1878, pp.
25-31; M. Duveau, _Dictionnaire de Méd. et de Chir._, t. xxviii. p.
443.]
Active general congestion of the lungs has occasionally been observed
in this disease, and has proved fatal in five minutes[81] and in an
hour and a half[82] from the invasion of the symptoms. The rheumatic
poison frequently excites pleuritis, some of the characters of which
are--the suddenness with which free effusion occurs; the promptness
with which it is removed, only perhaps to invade the other pleura, and
then to reappear in the cavity first affected; the diffusion of the
pain over the side and its persistence during the effusion; and its
frequent concurrence with pericarditis, and in children with
endocarditis; its little tendency to become chronic, and its marked
proclivity to become double. It is often latent and unattended with
pain. Sibson asserts that if in rheumatic pericarditis "pain over the
heart is increased or excited by pressure over the region of the organ,
it may with an approach to certainty be attributed to inflammation of
the pleura," etc. The product of the inflammation is commonly serous,
but occasionally purulent.
[Footnote 81: _Thèse d'Aigue pleur._, 1866, par B. Ball.]
[Footnote 82: M. Aran, quoted by Vasquez, _lib. cit._, p. 14.]
The disturbances of the nervous system are amongst the most important
complications of acute rheumatism, and are due either to functional
disorder or very rarely to obvious organic lesions of the nerve-centres
or their membranes. The dominant functional disturbance may be
delirium, which is greatly the most frequent; or coma, which is rare;
or chorea, very frequently observed in children; or tetaniform
convulsions, which occur very seldom per se. As a rule, two or more of
these forms coexist or alternate with or succeed one another, and the
grouping, as well as the variety, of the symptoms may be greatly
diversified. In 127 observations there were 37 of delirium only, 7 of
convulsions, 17 of coma and convulsions, 54 of delirium, convulsions,
and coma, 3 of other varieties (Ollivier et R., cited by Besnier).
Rheumatic Delirium.--Either with or without subsidence of the articular
inflammation, about from the eighth to the fourteenth day of the
illness, but occasionally at its beginning, or sometimes on the eve of
apparent convalescence, the patient becomes restless, irritable,
excited, and talkative; sleep is wanting or disturbed; some excessive
discharge from the bowels or kidneys occasionally occurs; profuse
perspiration is usually present, and may continue, but frequently
lessens or altogether ceases; the skin becomes pungently hot, the
temperature generally--not always, however--rising rapidly toward a
hyperpyrexial point, and ranging from {38} 104° to 111°; and transient
severe headache and disturbances of special sense sometimes obtain. At
a later period, or from the outset in hyperacute cases, flightiness of
manner or incoherence in ideas is quickly succeeded either by a low
muttering delirium, twitchings of the muscles, violent tetaniform
movements and general tremors, and a condition perhaps of coma-vigil,
or by an active, noisy, even furious, delirium. The articular pains are
no longer complained of, and sometimes the local signs of arthritis
also quickly disappear; but neither statement is uniformly true. The
pulse becomes rapid; prostration extreme; semi-consciousness or marked
stupor gradually or rapidly supervenes; the temperature continues to
rise; the face, previously pale or flushed, becomes cyanotic; and very
frequently death ensues, either by gradual asthenia or rapid collapse,
often preceded by profound coma or rarely by convulsions. Deep sleep
often precedes prompt recovery.
The duration of the nervous symptoms varies from one or two, or more
usually six or seven, hours in very severe cases, to three or four days
in moderate ones, or occasionally seven, eight, or sixteen[83] or
twenty-nine days[84] in unusually protracted cases. In the
last-mentioned, however, the delirium is not usually constant, and
frequently disappears as the temperature falls, and recurs when its
rises. Moreover, a rapid and extreme elevation of temperature is
frequently altogether wanting.
[Footnote 83: Southey's case, _Clin. Soc. Trans._, xiii. p. 25.
Sleeplessness preceded it for four days, and there was no
hyperpyrexia.]
[Footnote 84: Graham's case, _ib._, vi. p. 7. Delirium set in on the
seventh day of illness, and three days after invasion of joints.
Temperature 104.8° early in disease; never exceeded 106°, probably
owing to repeated use of cold baths. Temperature at death, 104.2°.]
No real distinction can be established between these protracted cases
of rheumatic delirium and so-called rheumatic insanity, in which occur
prolonged melancholia, with stupor, mania, hallucinations, illusions,
etc., often associated with choreiform attacks. This variety may be of
short duration or continue until convalescence is established, or may
rarely persist after complete recovery from the articular affection.
Coma may occur in acute rheumatism without having been preceded or
followed by delirium or convulsions, although it is very rare; and,
like delirium, it may obtain without as well as with peri- or
endocarditis or hyperpyrexia. It usually proves very rapidly fatal. In
Priestly's case, an anæmic woman of twenty-seven, during a mild attack
of acute rheumatism, one night became restless; at 3 A.M. the pain
suddenly left the joints; apparent sleep proved to be profound coma,
and at 6 A.M. she was in articulo mortis.[85] Southey relates the
history of a girl of twenty who, without previous delirium or high
temperature, suddenly became unconscious, and died in half an hour.[86]
One of Wilson Fox's cases had become completely comatose, and was
apparently dying nine hours after the temperature had rapidly risen to
109.1°, when she was restored to consciousness by a cold bath and ice
to her chest and spine.[87]
[Footnote 85: _Lancet_, ii., 1870, 467.]
[Footnote 86: _Clin. Soc. Trans._, xiii. p. 29.]
[Footnote 87: _The Treatment of Hyperpyrexia_, 1871, 4.]
Convulsions of epileptiform, choreiform, or tetaniform character
frequently succeed the delirium, but in exceptional cases they occur
independently of it, and may even prove fatal.
Besides the choreiform disturbances which occur in connection with
delirium, stupor, tremor, etc. in cerebral rheumatism, simple chorea is
{39} frequently observed as a complication or a sequence, or even as an
antecedent, of acute articular rheumatism, and they occasionally
alternate in the same patient and in the same family. Chorea is perhaps
most frequently seen in mild cases and in the declining and
convalescent stages of rheumatic fever, and, while very common in
childhood and adolescence (five to twenty), it is very rare later in
life.
Such are the chief functional disturbances of the brain met with in
rheumatic fever, and the post-mortem examination reveals in them either
quite normal naked-eye appearances, or more frequently, especially in
rapidly fatal cases, general congestion of the pia mater, and to a less
degree of the cerebral substance, or in more protracted cases a greater
or less increase of transparent or opalescent serum in the subarachnoid
space and ventricles. The serum may be slightly or deeply tinged with
blood. If the serous or sero-sanguinolent effusion be considerable, the
encephalic mass or portions of it may be anæmic. But besides these
conditions, which are also commonly observed in many other febrile
diseases, and which are probably only concomitants of the functional
disturbance arising in the advanced stage of acute articular
rheumatism, certain organic affections of the nervous centres or their
membranes occasionally occur in this disease, and are plainly the cause
of the cerebral disturbance observed during life. Cerebral meningitis,
although very rare as a complication of acute articular rheumatism,
except in certain hot climates, like that of Turkey,[88] does occur,
and lymph or pus is found, usually over the convexity of the brain, but
sometimes at the base and down the cord.[89] The symptoms of rheumatic
cerebral meningitis are very like those of rheumatic delirium;
vomiting, and even, but less frequently, pain in the head, may be
absent, while hyperpyrexia may coexist (Foster's case), although not
necessarily present. Should the pulse from being frequent become slow
and irregular, and any paralytic symptoms ensue, meningitis may be
suspected. In some of these cases the meningitis is a consequence of
ulcerative endocarditis and embolism of the cerebral vessels,[90] but
in others it obtains without endocarditis or any purulent formation
elsewhere than in the meninges, as there is probably a true rheumatic
localization like pericarditis. The articular inflammation may continue
after the invasion of the meningitis, or the latter may promptly follow
the disappearance of the former, as though a metastasis of morbid
action had taken place.[91] In many instances, according to Ollivier,
Ranvier, Behier, and others, although the macroscopic signs of
meningitis are absent, the microscope detects proof of its presence in
the existence of an increased number of vessels, fatty granulations on
their walls, proliferation of nuclei and capillary
extravasations--histological conditions identical with those found in
the mild degrees of rheumatic inflammation of the joints.
[Footnote 88: Senator, in _Ziemssen_, xvi. 50.]
[Footnote 89: Watson's _Prac. Physic_, 1872, Am. ed. vii. 335; Fyfe,
_Med. Gazette_, vol. xxix. 703; Fuller, _lib. cit._, 302; Leudet,
_Clin. Médicale_, 139; Dowse, _London Lancet_, ii. 1872, 9; Foster,
_ib._, ii. 1868, 115; Hicks, _New York Medical Record_, Nov., 1878,
404.]
[Footnote 90: That ulcerative endocarditis frequently produces
meningitis is illustrated by Osler's cases, 4 out of 7 of which were
complicated with purulent meningitis: _Transactions of International
Med. Congress_, 1881, i. 344.]
[Footnote 91: See a case reported by W. L. Ramsey in _New York Medical
Record_, i., 1881, p. 9.]
Embolism of the cerebral arteries, producing meningitis, or more
frequently softening of the cerebral substance or hemorrhage, or
proving {40} fatal before necrobiosis has time to set in, is an
occasional complication of acute articular rheumatism. A young lady,
while under my care suffering from her first attack of articular
rheumatism complicated with endocarditis, became suddenly hemiplegic
and aphasic, and died twelve hours later. In a girl of thirteen, the
subject of acute articular rheumatism complicated with ulcerative
endocarditis, right hemiplegia suddenly occurred, and at the autopsy
Bristowe found an embolon in the left middle cerebral artery and a
softened area in the left corpus striatum. Bradbury reports a primary
acute rheumatism with endocarditis, delirium, and coma, but without
paralysis, in which a plug was found in the right middle cerebral
artery, but the brain was quite healthy.[92]
[Footnote 92: _Lancet_, ii., 1870, 148; also a case in _Lancet_, i.,
1882, p. 605: in eighth week of subacute articular rheumatism;
embolism; right hemiplegia. Autopsy: large vegetations on valves;
obstruction in middle cerebral artery.]
Very much the same observations are applicable to the disturbances of
the spinal cord and its envelopes in rheumatic fever as have been made
in reference to those of the cerebrum and its coverings. They may exist
with or without any alteration of the cord or membranes to which they
can be reliably referred; that is to say, they may be simply functional
in the peculiar sense in which that word is now understood, or they may
be connected with obvious structural changes, and chiefly with those
indicating inflammation of the membranes or substance of the cord. The
spinal symptoms may precede the articular affection, but generally
appear after it. They sometimes closely resemble those of idiopathic
tetanus,[93] or of spinal meningitis, or of myelitis, or of
meningo-myelitis; and in the last case, along with severe rachialgia,
muscular rigidity, cutaneous and muscular hyperæsthesia, and neuralgic
pains, there will occur numbness and more or less paralysis of the
lower extremities,[94] bladder, and rectum (paraplegia). These spinal
disturbances may or may not be accompanied by hyperpyrexia, and when
simply functional they are usually less severe and persistent, have a
greater tendency to alternate with one another and with the articular
affection, and are more amenable to treatment, than when due to those
very rare complications of rheumatic fever, spinal meningitis or
meningo-myelitis. The inflammation may involve both the cerebral and
spinal membranes at the same time.
[Footnote 93: Bright's case, 2, _Med.-Chirurgical Transactions_, xxii.
4; Dr. E. C. Mann, _N.Y. Medical Record_, 1875, 38; Bouilland, _Traité
sur les Maladies du Coeur_, t. i. p. 33.]
[Footnote 94: Leudet, _lib. cit._, p. 139; Dowse, _Lancet_, i., 1872,
9.]
The causes of these disturbances of the nervous system, when not
attributable to appreciable lesions, such as congestion, inflammation,
hemorrhage, embolism, thrombosis, and softening, are not established.
The following appear to be reasonable conclusions from the facts at
present known:
The most constant condition, and without which these cerebral symptoms
very rarely arise, appears to be some susceptibility or vulnerability
of the nervous system, inherited or acquired, rendering it apt to be
disturbed by influences which less susceptible centres would
successfully resist. Trousseau, who has especially advocated this
view,[95] considered intemperance in the use of spirits to be a
frequent source of this nervous predisposition. Accepting this neurotic
predisposition as the factor generally present when acute articular
rheumatism is complicated {41} with disturbances of the nerve-centres,
we may inquire what are the circumstances in the disease capable of
developing into activity the predisposition.
[Footnote 95: _Clin.-Med._, Syd. ed., i. 513 _et seq._]
Unquestionably, the existence of acute pericarditis, or of
endocarditis, or of inflammation of the lungs or pleura, is one of
those conditions.
Probably hyperpyrexia acts in some cases as an exciting cause of the
nervous phenomena, for while the delirium preceded the hyperpyrexia in
6 cases, it accompanied it in 19 and followed it in 10;[96] and the
nervous symptoms disappear when the hyperthermia is removed by the
employment of cold, and recur with the return of high temperature. The
phenomena of sunstroke and heat-apoplexy prove that a high temperature
is capable of producing convulsions and coma. That these grave cerebral
disturbances are so infrequent in acute rheumatism (obtaining in about
3 or 4 per cent. only) is probably owing to the usual moderate range of
temperature and the rarity of hyperpyrexia in the disease. Still, while
hyperpyrexia is a disturber of cerebro-spinal function, too much
importance must not be attached to it, for not only does such
disturbance very frequently precede the hyperpyrexia, but there are
many facts indicating that the hyperpyrexia is itself very frequently,
like the delirium, tremor, and coma which precede or accompany it, but
a consequence of disorder, usually of a paralyzing kind, of the
nerve-centres. It has been met with in lesions of the pons, in tetanus,
in injuries of the cord, in some cases of non-inflammatory softening of
the brain and of cerebral hemorrhage; that is, in a class of affections
not belonging to the specific fevers, but to those directly disturbing
or destroying the functions of the nerve-centres. And cases of acute
rheumatism do rarely occur in which a very high temperature is not
accompanied by cerebral disturbances. Sibson quotes two such,[97] one
of which, with a temperature of 110.8°, was only restless and talked
when asleep, and the other, with a temperature of 106.3°, presented
only vomiting and dyspnoea. Cardiac inflammation was absent in both.
DaCosta relates one in his valuable paper upon cerebral rheumatism in
which, although the temperature was 110°, no cerebral symptoms nor
cardiac affection existed.[98]
[Footnote 96: "Abstract Report upon Hyperpyrexia in Ac. Rheum.," _Brit.
Med. Jour._, 1882, p. 807.]
[Footnote 97: _Lib. cit._, p. 264.]
[Footnote 98: This essay contains a record of 11 cases of cerebral
rheumatism and several autopsies: _Am. Jour. Med. Sci._, 69, 1845, p.
36, case xi.]
The goodly number of instances lately published in which grave cerebral
symptoms have obtained in acute articular rheumatism at ordinary
febrile temperatures, while they prove that hyperthermia is not an
essential condition productive of such symptoms, require to be
explained. Some such, no doubt, have been instances of marked
predisposition, so that a moderate febrile temperature or some
complication sufficed to disturb the brain, as we see in typhoid and
other fevers, in pneumonia, etc. If there be a rheumatic poison--which
has not yet been proved--it may, in predisposed persons, produce the
cerebral symptoms. The argument[99] that such poison should produce
inflammation of the nervous centres if it acted directly on them is not
convincing. It need not necessarily produce similar alterations in
serous or synovial membranes and in nervous tissues. Many toxic agents
disturb, and even suspend, the {42} cerebro-spinal functions, and leave
no appreciable changes in them. Do these cases prove that there is
something peculiar to rheumatic fever which tends to disturb the
nervous centres? Hardly; for while such disturbance is comparatively
rare in that disease, it is observed frequently in many other febrile
affections, notably in typhus, scarlatina, and small-pox; and as in
these, so in rheumatic fever, it is more often observed in the severe
than in the mild cases, as though it were a part of the systemic
disturbance incident to the febrile affection and largely proportionate
to its severity.
[Footnote 99: Maclagan, _Rheumatism: Its Nature, Pathology, etc._,
1881, 287.]
Yet there is something special in acute rheumatism which perhaps has to
do with the occurrence as well as the severity of the cerebro-spinal
symptoms and of the hyperpyrexia; viz. the long duration and severity
of the pain, and the number and importance of the parts, in addition to
the articulations, which are one after the other or simultaneously
involved in severe inflammation--peri-, endo-, myocardium, lungs,
pleura, etc. Perhaps in no other acute febrile disease are so many
distinct and important organs involved in inflammation at the same time
or in rapid succession; and it is no wonder that the functions of the
nervous system should in consequence become greatly depressed,
exhausted, or disturbed.
The kidneys appear very rarely to suffer serious disease in acute
rheumatism, if we except embolism of their arteries due to
endocarditis; and it is very doubtful whether the rare instances[100]
in which an acute parenchymatous nephritis has been observed in acute
rheumatism can be referred to direct rheumatic inflammation, or not,
rather, to the operation of the exposure which induced the rheumatism.
Further investigation is needed to determine whether interstitial
nephritis is even very exceptionally an indirect consequence of
rheumatism, as Lancereaux admits.
[Footnote 100: See DaCosta's cases 1 and 2, _Cerebral Rheumatism, lib.
cit._; case 1 certainly favors the view that either the rheumatic
poison, if there be such, or the constitutional disturbance incident to
acute polyarticular rheumatism, may sometimes produce nephritis. See
also a case by A. Deroye, Thèse, Doctorat, Paris, 1874, quoted by P.
Coubere in _Contribution à l'Étude des Complications Renales du
Rheumatisme Artic. Aigue_, Paris, 1877.]
The other complications, being of less importance, must be but barely
alluded to. A pharyngitis attended with severe dysphagia and high fever
occasionally precedes the other symptoms or occurs in the early stage
of the disease. Gastralgia, enteralgia, simple serous diarrhoea, and
dysentery also rarely occur in acute rheumatism. That they are
sometimes, at least, truly rheumatic appears probable from the
circumstance that they may precede, follow, or alternate with the
articular affection, and are all intensely painful. I have but once met
with acute peritonitis as a complication of acute rheumatism; the
immunity of this serous membrane from rheumatic inflammation is an
inexplicable anomaly in view of the proclivity of the pericardium and
pleura to that process. Cystitis and orchitis are rare.