327

Commentary.Several salient points emerge touching environ-

ment and infection.In Respect of -E’’uOM.met —(a) Altitude and subsoil: The figures are remark-

able and require no comment. It is to be noted thatthe altitudes in Bath vary between under 100 feetto over 500 feet.

(b) Social position of the parents : Is not one ofextreme poverty and slum dwelling, but that per-taining to a more or less skilled worker in constantemployment. This directly opposes the suggestionthat rheumatic infection is a poverty disease.

(c) The family inheritance and predisposition isconfirmed.In Respect of Infection(a) Nervous symptoms : The frequency in which

the parents’ sole complaint was that the child wasnervous and irritable, or was a sleep-talker andsleep-walker, or that there was a combination ofthese symptoms is remarkable. Seeing that efficientanti-rheumatic treatment cured these conditions itwould appear that they are manifestations of therheumatic virus.

(b) Subcutaneous nodules : As a physical sign thesubcutaneous fibrous nodule is a small and apparentlyinsignificant variation from the normal, in conse-

quence of which practice is necessary for the clinicianto be certain of its presence. The final proof thatsuch nodules exist rests on their removal and micro-scopical section.

-

To quote from Prof. 1. Walker Hall’s report" The nodule is composed of fibrillar tissue, aggregations

of histiocytes and inflamed blood-vessels.... It is obviousthat the setiology of the nodule may be associated with apersistent irritant of the sub-infective or mildly infectivetype."This particular reaction to infection, proliferation

of the lining endothelial cells of arterioles and peri-vascular collections of histiocytes, is such as obtainsin response to the virus of rheumatic fever, both inthe. endocardium and pericardium. It would appeartherefore not improbable that these nodules are butpocket editions of the large subcutaneous nodesoccurring in acute rheumatic fever and are analogousto the submiliary nodules of Aschoff.

(c) Treatment: It has been found that satisfactoryresults are more easily obtained by the exhibition ofsmall doses of thyroid or iodine in addition to sali-cylates, alkalis, and arsenic. This treatment wasadopted on the presumption that smouldering infec-tions tax the thyroid gland. Rest, exclusion fromschool, and avoidance of wet were enforced wherenecessary.

Summary.Forty-four cases of rheumatic infection in children

have been investigated. The opinions reached are :1. Rheumatic infection in elementary school-

children is not a poverty disease.2. It is extremely prevalent among such children.3. The potency of heredity and low-lying locality

is emphasised.4. Subcutaneous nodules have been demonstrated

in 35 out of 44 cases (79’5 per cent.), and are signi-ficant of an active rheumatic focus, as shown bytheir association with symptoms and their absence inthree cases of stationary mechanical carditis formerlyrheumatic. Thus their presence not only crystallisesan otherwise nebulous diagnosis, but indicates thenecessity of continuation of treatment, particularlyin nervous children and in those with unsatisfactorycardiac sounds.

We wish to thank Miss Greenall and the voluntarycare visitors under her supervision for their mostvaluable reports and scrupulous attention to detail,without which this investigation could not havebeen made.

1 Brit. Med. Jour., 1925, i., 550.

BRITISH MEDICAL ASSOCIATION.ANNUAL MEETING AT BATH.

SECTION OF MEDICINE.

WEDNESDAY. JULY 22ND.Lord Dawson, President of the Section, in his

inaugural address referred to the especial importanceof the 1925 meeting of the Association. There were,he said, three things that made it notable-themeeting coincided with the important outcome ofrecent research into malignant disease ; it was heldat a time when the duties of the Association wererapidly widening, especially as they affected facilitiesfor learning and teaching and promoted generally thehealth of the public ; and it was held at Bath, whichfor so long a time had been a leading health centre ofthe country. Referring further to cancer. research,he pointed out that the specificity of the factor of thesoil, as opposed to the non-specificity of the virus,illustrated once again the principle that the reactionof man to morbid processes bears upon it the stamp ofhis own individuality. Modern medicine was openingout the questions of trend and tendency, and as aresult medical men of the future must increasinglybe the prophets and not the vassals of statesmen.The President then referred with great respect to thelate Sir Clifford Allbutt, both as a great thinker anda great leader, and especially as a leader to theB.M.A. during the years of the war. He reviewed hisgreat knowledge, broad outlook, and fine scholarship,and, most important of all, his sane optimism, whichhad made him pre-eminently an object of the allegiancewhich age might command in the young.

Sir Humphry Rolleston, after reference to theremarks of the President upon cancer research, andhaving paid further tribute to the memory of SirClifford Allbutt, opened the discussion on

Rheumatoid Arthritis.He submitted that it was generally felt that thedisease, if not entirely due to some form of infection,was, at any rate, chiefly due to it. Was, however,infection the sole cause ? Might, for instance,disordered metabolism initiate the changes thatoccurred in the joints ? Such an authority as SirA. Garrod had expressed the belief that the infectivefactor had been over-emphasised, and it was necessaryto ask whether we were justified in ascribing thearthritis in all cases to infection. Reviewing otherpossible causative factors, he did not believe thatheredity disposition was of much importance. Errorsin carbohydrate metabolism had been thought to havea place in the causation of the disease, and it had beenreported that 20 per cent. of cases showed a loweredbasal metabolism and a diminished sugar-tolerance ;these findings, however, probably represented effectsrather than causes of the disease, and it had beenfound that after removal of a septic focus the sugar-tolerance returned to normal; moreover, diabetesmellitus was not commonly associated with rheumatoidarthritis. Similarly chronic infection was more

probably the cause of thyroid insufficiency and otherendocrine disturbances than vice versa, and on thewhole there was not much evidence that such metabolicdisturbances stood in causal relationship to thedisease.

Speaking of the source of infection, Sir HumphryRolleston said that in one series the teeth and gumshad been found in 90 per cent. of cases to be the mainsource ; in another series the tonsils were infected in75 per cent. Accessory nasal sinusitis, he thought,might be secondary to dental infection. Two varietiesof dental infection had to be distinguished. First,pyorrhoea alveolaris, where the infection was openand probably had not much causal effect in arthritisapart from achlorhydria; secondly, dental apicalabscesses, from which absorption into the blood-streamwas direct. In the former mode of infection it waspossible that perversion of the functions of the liver,which stood between the alimentary canal and the

328

systemic circulation, might be a contributory cause ofthe disease ; in such cases also the small rather thanthe large intestine appeared to act as a source ofinfection. In the genito-urinary tract the B. colimight act as an infective agent in a few cases, especiallywhen harboured in the prostate. The respiratorytract, apart from cases of pulmonary arthropathy,could for practical purposes be exonerated. Althoughthe opinion held in France that some cases of rheu-matoid arthritis might be due to the toxins of thetubercle bacillus found little or no support in England,

yet it was worth bearing in mind a possible analogybetween syphilis and parasyphilitic disease on theone hand and tuberculosis and rheumatoid arthritison the other. He referred also to the occasionalassociation of arthritis with psoriasis and impetigo,and suggested that an anaphylactic relationshipmight exist between them. The chief objections tothe infective theory were that people often haveinfective foci but no arthritis, and that in manycases we can find no infective focus. The uncertainfactor of the soil, however, was to be borne in mindin weighing such objections, and search for a possiblefocus-e.g., in the prostate or nasal sinuses-was oftenincomplete. Again, certain foci of infection might be" closed "-the gall-bladder, for example-or one

joint might act as a reservoir of infection for otherjoints. From the bacteriological standpoint it wasusually a streptococcus that was incriminated, but Ithere was often difficulty in recovering the organismfrom the synovial fluid and membranes.As to treatment, prevention was the keynote.

Eradication of infection, as, for instance, in dentalextraction, must be complete. Just as a match wasas effective as a torch in firing a train of gunpowder,so a small focus of infection might set up an arthritisas severe as a large one. Dead teeth were a favouriteseat for infecting organisms, and there was consequentlya danger in killing the nerves of teeth. As toencouraging the soil, he referred to the possibility ofstimulating metabolism by thyroid extract, para-thyroid, arsenic, iodine, and heliotherapy, and he drewattention to the theoretical uses of protein shock intherapy.

Mr. W. R. Ackland considered the division of dentalsepsis into pyorrhoea and dental abscesses too hardand fast. Apical abscesses sometimes dischargedthrough the gum, while in pyorrhoea, on the other handthe deeper layers could never be properly drained.Gastric juice did not always destroy the streptococcusand it might even liberate an endotoxin. Moreover,there was no gastric juice in the stomach at night,when toxins might pour down into the stomach andultimately produce achlorhydria, and if the liverfunctions were affected the infection would pass tothe general circulation. The streptococcus appearedto have an especial affinity for a dead tooth. Theresults of treatment were, on the whole, disappointing.One might at least hope, however, that patients wouldnot get worse thereafter. X rays of the teeth notbeing infallible, he was in the habit of condemning allbridges, crowns, and dead teeth.

Dr. Rupert Waterhouse, from a hydrotherapeuticstandpoint, said that though the infective hypothesisof rheumatoid arthritis was in full swing in Bath25 years ago, there yet seemed as a result to be nodiminution in the number of patients seeking reliefthere. Since the war especially, and in contrast togout, the disease had increased. Not more than I10 per cent. of the cases recovered ; but it was some-thing from a patient’s point of view to obtain even a ’,slight functional improvement. The ideal was to getthe patient to take intermittent courses of treatment, ilasting not longer than six to eight weeks ; longercourses were undesirable as promoting debility. !

Prof. Osgood (Harvard University) feared that it ’,must be confessed that in most cases removal of ’,infected foci did not lead to recovery ; in one series, Iindeed, there had been more recoveries where thefoci had nof been removed. There might, he suggested,be a missing link between a disordered metabolism

and an infection. As a result of the presence of toxinsoften specific in man (and, indeed, often possessinga strict tissue-specificity), the permeability of theperisynovial capillaries might be modified, and a

lowering of the basal metabolism induced-a matterof sensitisation.

Sir Robert Jones emphasised the disease as beinga conjoint problem for the physician and surgeon.When the surgeon was called in it was usually toolate for him to prevent crippling deformities. Thenatural course of the disease was towards deformity,which it lay in the power of any general practitionerto prevent. The first physical sign of deformity was aspasm of muscles to obtain the position of ease. Asa rule the flexors pulled more and more effectively thanthe extensors, and so deformity of the muscles resulted.Of two types, one proliferative and the other osteo-phytic, the former was the more difficult to treatowing to the greater pain. He then referred to specialjoints ; in the wrist, for instance, palmar flexion andulnar deviation might be countered by an appropriatedorsi-flexion splint; flexion of the knees and adductionof the hips could be prevented by posture, sand-bags,and gentle weight extension. Any movements givenwere only to be within the limits of pain, and thegreatest care was to be taken not to permit rashmovements, such as, for instance, forcible extension ofa knee where posterior displacement of the tibia waspresent in addition to flexion. Open operation wasoften of great avail, even in advanced cases ; masses

could be removed from the joints or arthrodesisperformed with very satisfactory results.

Prof. Cawadias (Athens), after referring to the greatvariability of the factor of resistance of the body toinfection, suggested that disordered metabolism ofsulphur might contribute to this aspect of the disease.In support of this hypothesis he advanced the followingobservations : (1) Cases of rheumatoid arthritis losttoo much sulphur in the urine. (2) This imperfectlyoxidised sulphur pointed to a general defect in oxida-tion. (3) The fact that there was no increase in theoutput of ethereal sulphates showed that the increasedsulphur did not originate from mere destruction ofcartilage.

’

Dr. J. M. H. Monro reviewed several series of cases,showing that changes in the blood—ansemia, leuco-penia, leucocytosis, and complement-fixation-mightbe found, in contrast to normal blood, in about80 per cent. of cases of rheumatoid arthritis. TheStreptococcus viridans appeared to be the usual sourceof infection, and had been found in the roots of teethin which the X ray findings had been negative.While cocci were the usual cause of infection, it wasnot uncommon to find coincident tuberculosis andeven syphilis.

Mr. Timbrell Fisher, speaking from a pathologicalstandpoint, proposed to substitute for the oldernomenclature of rheumatoid and osteo-arthritis a

division of cases into three groups of chronicarthritis : (1) Chondro-osteal type, in which therewas a primary degeneration of the more centralcartilage, with eburnation of the underlying bone,while the lateral part of the cartilage becamehypertrophied. It was only later that the synovialmembranes also became hypertrophied, and therewas never any small round cell infiltration.These cases, occurring usually in later life, constituteda degenerative group. (2) Mixed type, in which thecartilaginous and synovial changes occurred con-

currently. A pannus spread from the synovial mem-brane into the cartilage, and small round cells werepresent. Lipping only occurred later. (3) Synovialtype, which appeared more inflammatory, withabundant infiltration of small round cells.

Sir W. Willcox regarded infection as the primarycause in the great majority of cases, but was carefulto exclude gout, neuropathic joint lesions, and such acondition as intermittent hydrarthrosis from thegroup under discussion. In support of the infectivehypothesis he brought forward the following considera-tions : (1) Other known organisms-e.g., gonococcus,

329

pneumococcus, and B. typhosus-might producearthritis very similar to. rheumatoid arthritis ;(2) rheumatoid arthritis frequently followed parturi-tion ; (3) an infective focus was almost alwaysdiscoverable. Dental sepsis accounted for most cases(72 per cent.) ; the apical infections were not trueabscesses causing pain from pressure, but rathernecrotic areas. Tonsillar cases were fewer (10 per cent.)and occurred in younger patients especially. Diagnosisof antral infections was often difficult, even withradiography and transillumination, and in such casesit was best to puncture the antrum. The colon wasoften the seat of infection in elderly patients. Tuber-culosis elsewhere was not, in his opinion, an importantastiological factor ; on the other hand, he thought thatthe presence of septic foci predisposed to the develop-ment of phthisis. (4) The eradication of the infectivefocus had usually been followed by cessation of activeinflammation. (5) Rheumatoid arthritis was only amanifestation in the joints of a chronic toxaemia.Treatment should aim at the removal of the infectivecause, and might include Plombieres colon irrigationas an important factor. Only after this removalwere vaccines to be employed, and then only insmall doses.

Sir J. Barr expressed his belief that acid fermentationin a dilated stomach was the main cause of the disease,and advocated a diet rich in red meat and poor incarbohydrate.Lord Dawson said that it was an irresistible con-

clusion that infection played apart. The difficulty layin the origin and measure of that infection, and hencea speculative removal of teeth and tonsils might beadvised. Sometimes the source of infection might beinaccessible ; at other times the infection might wellbe one which under ordinary conditions would havebeen non-pathogenic. In such cases treatment mustbe concerned with the raising of resistance. He lookedto the bio-chemist to explain the expression " resist-ance," with the cooperation of the bedside physician.If the results of dental extraction were disappointing,and if it must be admitted that this was an operationof some violence, especially in the aged, yet there wasa compensatory satisfaction in observing the increasedcare which the rising generation was giving to itsteeth, even in hospital practice, as a result, hepresumed, of its observations of its seniors.

Sir H. Rolleston replied. He referred to thesensitisation hypothesis of Prof. Osgood and to theobservations of Prof. Cawadias on sulphur. He hadalways imagined that sulphur was given as an internalantiseptic. With regard to Lord Dawson’s conclusion,he would put the question finally in another way:" Can you," he asked, " have rheumatoid arthritiswithout infection ? "

THURSDAY, JULY 23RD.Hyperpiesia.

Prof. T. R. Elliott having taken the chair, LordDawson opened a discussion on hyperpiesia. Witha view to the necessity of confining his remarks tocertain aspects of hyperpiesia, he postulated theassumption that this was a disease sui generis, involvingcertain disabilities, of which cardiac and vasculardisease was the gravest. But it was better, heconsidered, in this inquiry not to examine those caseswhich showed most evidence of cardiovascular wearand tear, but rather to approach the subject throughthe avenue of youth, thus excluding those graversecondary complications ; for it was in later life thathyperpiesia and arterio-sclerosis hunted in couples,and only by excluding the latter might they hope todetermine whether hyperpiesia had its beginnings instructural change or in faulty function. The systolicblood pressure reached between the ages of 20 and45 years the figure of from 115 to 130 mm. Hg ; duringthis period it did not vary much, and he would fromhis observations view with uneasiness, at that periodof life, a fixed systolic pressure of over 140. Withexercise, of course, there was a rise, but in health a

subsequent fall to normal took place within a fewmoments of resumption of rest. The studies ofAlvarez had shown that of 1500 youths at theUniversity of California 20 per cent. had pressures ofover 140. No doubt there was a passing psychologicalcause for some of these, but it remained a fact that acertain proportion of the young had a true rise ofsystolic pressure. The diastolic pressure had been lesswidely studied, but he suggested that at this time oflife it lay normally between 75 and 80 mm. Hg, andthat at any age a figure of above 100 should be viewedwith uneasiness.Lord Dawson next referred to two families, each of

two generations, in one of which no member had asystolic blood pressure of above 110, while in theother no member had a pressure of below 130. Theseexamples prompted two reflections : (a) That vaso-constriction played a very varying part in differentindividuals ; and (b) that hyperpiesia began as anexaggeration of a quality-in other words, that itbegan in the realm of physiology to end in that ofpathology.A special investigation had been made in 650 school-

children between the ages of 10 and 17, and 52 ofthese, or 8 per cent., had shown a systolic pressureof over 130 mm. Hg. The observations had beenmultiplied to exclude factors of excitement, and ithad not been found possible to identify hyperpiesiawith any particular type of child. Prospects of aschool examination did not raise the pressure ; on

the other hand, the classes for the Oxford SeniorLocal Examinations, attracting as they did ambitiouschildren, in whom they might be supposed to engendersome anxiety as to their prospects in life, showed arelatively high incidence of hyperpiesia in the childrenattending them. He believed that in these cases thehigh blood pressure was an expression of a type ofmind which was naturally striving and ambitious.In this group of 8 per cent. one could fairly rule outany degenerative structural process ; it was morelikely that these cases showed an inborn peculiarityof function, which might become so accentuated asto produce damage in varying degree. Correctionmight be effected by choice of suitable careers ;otherwise vaso-constriction, progressively provokedby slighter and slighter stimuli, might cause a

condition of high pressure to become more or lesspermanent.A more detailed investigation of nine cases selected

from the same group had elicited more definite supportof this view ; these were all boys, and showed in mostcases, in addition to the raised systolic pressure,palpable radial arteries and accentuated aorticsecond sounds ; in four, moreover, there was hyper-trophy of the left ventricle, and in three a blood-urea of over 0’050 per cent. One case had a ureaconcentration of under 1-5 per cent. As would beexpected, there was considerable variation amongthese cases ; they merged on the one hand with aphysiological, and on the other with a pathologicalstate, those showing the most definite cardiac hyper-trophy being those subjected to the greatest strain.Pathological evidence was, of course, not easilyforthcoming ; but in one exceptional case of a girl,often showing a pressure of 240 mm. Hg systolic and140 diastolic at the age of 19, it had been possibleduring an operation for decapsulation of the kidneys tosecure portions of the organs for examination. LordDawson showed these sections on the epidiascope.They illustrated (1) marked hypertrophy of thetunica media of the larger arteries ; (2) slight fattydegeneration of the intima of the smaller arteries ;and (3) patches of partial atrophy of the tubulesdue to small round cell infiltration.

In later life high blood pressure might superveneupon a normal pressure in youth, and here it wasnecessary to consider, in addition to family orindividual predisposition, the possible effects ofchemical agencies, of pressor substances (such asguanidine derivatives), and of the products oferroneous metabolism. But in his view hyperpiesiahad its chief origin as a habit of body and mind,