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Studies in rheumatic fever. I. The natural course of acute manifestations of rheumatic fever uninfluenced by “specific” therapy
576
THE
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(2) condition of the aorta proximal to the site of stenosis; (3) of the constriction; patency or otherwise of the ductus nrtcriosus; (1) relationship between the systemic and pulmonary circulation. The adoption of the proposed classification will also facilitate the interpretation of certain clinical findings presented by thme cases muI more especially will help to explain such appearances as are found on radiological examina It will also help to determine the nature of the tion of the heart and great vessels. changes that are the direct result of a mod&d circulation initiated by the presence of this congenital deformity. The six types are enumerated as follows: Type I, congenital stenosis of the aortic arch with patent ductus arteriosus and hypoplasia of the proximal portion of the nort:>. Type II, congenital stenosis of the aortic arch with a ductus arteriosus closed and Type III, congenital atresia of the hypertrophy of the proximal portion of the aorta. distal portion of the aortic arch with ductus arteriosus closed and hypert,rophy of the proximal portion of the aorta. Type IV, interruption of the aortic arch in its distal portion with a ductus arteriosus widely patent and hypoplasia of the proximal portion of the aorta. Type V, congenital atresia of the proximal portion of the aortic arch with a ductus arteriosus patent. Type VI, congenital absence of the ascending aorta with patent ductus nrteriosus. Features that, characterize each of the six types are outlined, and a short description of the cases is appended in each group. In a study made on 38 cases of congenital stenosis, atresia or interruption of the aortic arch, 06 of which had been examined at autopsy, it was found possible to separate the cases into definite types according to the anatomical featurrs present. Patients living beyond early infancy were found in Tylms I, II and III only; few in Type I with the ductus patent and more in Types II and III with the ductus closed. Other developmental abnormalities that may accompany this congenital deformity of the nortie arch are enumerat.ed. So one symptom or collection of symptoms could be claimed t,o indicate with certainty the diagnosis of congenital stenosis of the aortic arch. In infants the exact nature of A tentative clinical diagnosis of congenital the lesion can only rarely be established. heart disease is usually made. It is also rare for any subjective symptom occurring in an adult suffering from this condition to direct attention to the init,ixl lesion which has caused the illness. The author believes that symptoms presented hy one of the patients may prove peculiar to, or either pathognomic of, the condition, This patient complained of numbness and weakness in both legs whenever he assumed the upright posture after reclining for some little time in the horizontal position. As he changed from the latter to the former posture, he experienced a sensation of “blood rushing back to the legs. ’ ’ He states that the sensation was comparable to the one he experienced when the pressure within the pneumatic bsg of the sphygmomanometer placed around the thigh was released. These symptoms disappeared on walking a short distance and It is seldom very safe to rely were never precipitated by the act of continued walking. upon physical signs obtained from examination of the heart as indicating the diagnosis of this congenital lesion. The deformity is a vascular one, but owing to its proximity to the heart, the lntter does undergo certain changes which have been described and which give rise to certain physical signs. A short note has been added on the prognosis and manner of death in patients presenting this congenital anomaly.
Graef, Irving, Parent, Solomon, Zitron, William, and Wyckoff, John: Studies in of Rheumatic Rheumatic Fever. I. The Natural Course of Acute Manifestations Fever Uninfluenced by ‘ ‘Specific” Therapy. -4111.J. M. SC. 185: 197, 1933. This study is based on a series of 163 patients suffering from acute rheumatic fever admitted to the hospital during two years. The observations made on 105 of these patients receiving no form of therapy which might be considered specific and no antipyretic drug formed the basis of the report. Only 47 of the 105 patients fulfilled the
.IBSTRACTS
577
It is concluded that in adolescence and adult criteria set up for purposes of the study. These life the acute manifestations of rheumatic fever tend to subside spontaneously. manifestations vary in number, degree n.nd duration, and are discussed by the authors. If changes in the number, degree and duration of manifestations are used as criteria for determining the effect of therapeutic agents, such changes must be compared either with a standard control group of rheumatic fever patients of known age, sex, racial and proper geographical distribution, of sufficient size to meet statistical requirements; or controlled cases must be studied simultaneously with cases receiving “specific” ther,apy, in sufficient number so that it may be determined whether or not the effects nssociated with treatment are not simply variations attendant on the n:~tnral course of the disease.
Clawson, B. J., Wetherby, Macnider, Hilbert, E. H., and Hilleboe, H. E.: Streptococcic Agglutination in Chronic Arthritis and Acute Rheumatic Fever. Am. J. 31. Xc. 184: 758, 1933. Rtreptococeic agglutination titers were determined in chronic arthritic and acute rheumatic fever patients for two strains of streptococci. The first strain was isolated from a ease of acute rheumatic fever and the second from a case of chronic arthritis. Comparing the agglutination titers of the above conditions with those of normal persons and of patients with scarlet fever and glomerulonephritis, with the rheumatic strain the agglutination titers of acute rheumatic patients were higher than normal, while those of the chronic arthritic patients were not. With the chronic arthritic strain, the titers were higher than normal in both chronic arthritis and acute rheumatic fever, but higher in the latter. With both strains the titers were decidedly higher than normal in both scarlet fever and glomerulonephritis. In all tests including the normal serums, the chronic arthritic strain was agglutinated in higher dilutions than the acute rheumatic strain. The chronic arthritic strain appeared to be more sensitive to agglutination. These findings suggest that both chronic arthritis and acute rheumatic fever are streptococcie infections. The view that chronic arthritis is due to a specific strain 5s not supported, since the chronic arthritic strain was agglutinated in higher dilutions wit.h serums from acute rheumatic fever patients than with the serums of patients with chronic arthritis. The lack of strain specificity is also shown by the fart that both the rheuma.tic and the arthritic strains were agglutinated in higher dilutions with serums from scarlet fever and glomerulonephritis than with the serums from acute rheumatic fever or chronic arthritis.
Collis, W. R. F., Sheldon, Wilfrid, and Hill, N. Gray: Cutaneous Reactions in Acute Rheumatism. Quarterly J. Med. 1: 511, 1932. The present investigation was undertaken with the view to elaborating and confirming previous observations with hemolytic streptococcal endotoxin on a larger series of eases and at the same time ascertaining whether any analogy existed between the eutaneous reactions to this hemolytic streptococcal extract and to similar products of nonhemolytic streptococci and other pathogenic bacteria. Skin reactions of 303 rheumatic children have been tested, while 356 nonrheumatic children have been similarly examined to serve as controls. The rheumatic series eonsistcd of children who were at the time suffering from or had previously suffered from polyarthritis, carditis or chorea. The results obtained indicate that rheumatic children arc more sensitive to streptococcal extract than are nonrheumatic children, and that of the rheumatic children those with chorea are the most sensitive. Children with active rheumatism, and for a period of six months after the acute attack, show a high percentage of strongly positive reactions (80 per cent). After six months, this reactivity diminishes. Children with ful-
THE
AMERICAX
HEART
JOURNAL
(2) condition of the aorta proximal to the site of stenosis; (3) of the constriction; patency or otherwise of the ductus nrtcriosus; (1) relationship between the systemic and pulmonary circulation. The adoption of the proposed classification will also facilitate the interpretation of certain clinical findings presented by thme cases muI more especially will help to explain such appearances as are found on radiological examina It will also help to determine the nature of the tion of the heart and great vessels. changes that are the direct result of a mod&d circulation initiated by the presence of this congenital deformity. The six types are enumerated as follows: Type I, congenital stenosis of the aortic arch with patent ductus arteriosus and hypoplasia of the proximal portion of the nort:>. Type II, congenital stenosis of the aortic arch with a ductus arteriosus closed and Type III, congenital atresia of the hypertrophy of the proximal portion of the aorta. distal portion of the aortic arch with ductus arteriosus closed and hypert,rophy of the proximal portion of the aorta. Type IV, interruption of the aortic arch in its distal portion with a ductus arteriosus widely patent and hypoplasia of the proximal portion of the aorta. Type V, congenital atresia of the proximal portion of the aortic arch with a ductus arteriosus patent. Type VI, congenital absence of the ascending aorta with patent ductus nrteriosus. Features that, characterize each of the six types are outlined, and a short description of the cases is appended in each group. In a study made on 38 cases of congenital stenosis, atresia or interruption of the aortic arch, 06 of which had been examined at autopsy, it was found possible to separate the cases into definite types according to the anatomical featurrs present. Patients living beyond early infancy were found in Tylms I, II and III only; few in Type I with the ductus patent and more in Types II and III with the ductus closed. Other developmental abnormalities that may accompany this congenital deformity of the nortie arch are enumerat.ed. So one symptom or collection of symptoms could be claimed t,o indicate with certainty the diagnosis of congenital stenosis of the aortic arch. In infants the exact nature of A tentative clinical diagnosis of congenital the lesion can only rarely be established. heart disease is usually made. It is also rare for any subjective symptom occurring in an adult suffering from this condition to direct attention to the init,ixl lesion which has caused the illness. The author believes that symptoms presented hy one of the patients may prove peculiar to, or either pathognomic of, the condition, This patient complained of numbness and weakness in both legs whenever he assumed the upright posture after reclining for some little time in the horizontal position. As he changed from the latter to the former posture, he experienced a sensation of “blood rushing back to the legs. ’ ’ He states that the sensation was comparable to the one he experienced when the pressure within the pneumatic bsg of the sphygmomanometer placed around the thigh was released. These symptoms disappeared on walking a short distance and It is seldom very safe to rely were never precipitated by the act of continued walking. upon physical signs obtained from examination of the heart as indicating the diagnosis of this congenital lesion. The deformity is a vascular one, but owing to its proximity to the heart, the lntter does undergo certain changes which have been described and which give rise to certain physical signs. A short note has been added on the prognosis and manner of death in patients presenting this congenital anomaly.
Graef, Irving, Parent, Solomon, Zitron, William, and Wyckoff, John: Studies in of Rheumatic Rheumatic Fever. I. The Natural Course of Acute Manifestations Fever Uninfluenced by ‘ ‘Specific” Therapy. -4111.J. M. SC. 185: 197, 1933. This study is based on a series of 163 patients suffering from acute rheumatic fever admitted to the hospital during two years. The observations made on 105 of these patients receiving no form of therapy which might be considered specific and no antipyretic drug formed the basis of the report. Only 47 of the 105 patients fulfilled the
.IBSTRACTS
577
It is concluded that in adolescence and adult criteria set up for purposes of the study. These life the acute manifestations of rheumatic fever tend to subside spontaneously. manifestations vary in number, degree n.nd duration, and are discussed by the authors. If changes in the number, degree and duration of manifestations are used as criteria for determining the effect of therapeutic agents, such changes must be compared either with a standard control group of rheumatic fever patients of known age, sex, racial and proper geographical distribution, of sufficient size to meet statistical requirements; or controlled cases must be studied simultaneously with cases receiving “specific” ther,apy, in sufficient number so that it may be determined whether or not the effects nssociated with treatment are not simply variations attendant on the n:~tnral course of the disease.
Clawson, B. J., Wetherby, Macnider, Hilbert, E. H., and Hilleboe, H. E.: Streptococcic Agglutination in Chronic Arthritis and Acute Rheumatic Fever. Am. J. 31. Xc. 184: 758, 1933. Rtreptococeic agglutination titers were determined in chronic arthritic and acute rheumatic fever patients for two strains of streptococci. The first strain was isolated from a ease of acute rheumatic fever and the second from a case of chronic arthritis. Comparing the agglutination titers of the above conditions with those of normal persons and of patients with scarlet fever and glomerulonephritis, with the rheumatic strain the agglutination titers of acute rheumatic patients were higher than normal, while those of the chronic arthritic patients were not. With the chronic arthritic strain, the titers were higher than normal in both chronic arthritis and acute rheumatic fever, but higher in the latter. With both strains the titers were decidedly higher than normal in both scarlet fever and glomerulonephritis. In all tests including the normal serums, the chronic arthritic strain was agglutinated in higher dilutions than the acute rheumatic strain. The chronic arthritic strain appeared to be more sensitive to agglutination. These findings suggest that both chronic arthritis and acute rheumatic fever are streptococcie infections. The view that chronic arthritis is due to a specific strain 5s not supported, since the chronic arthritic strain was agglutinated in higher dilutions wit.h serums from acute rheumatic fever patients than with the serums of patients with chronic arthritis. The lack of strain specificity is also shown by the fart that both the rheuma.tic and the arthritic strains were agglutinated in higher dilutions with serums from scarlet fever and glomerulonephritis than with the serums from acute rheumatic fever or chronic arthritis.
Collis, W. R. F., Sheldon, Wilfrid, and Hill, N. Gray: Cutaneous Reactions in Acute Rheumatism. Quarterly J. Med. 1: 511, 1932. The present investigation was undertaken with the view to elaborating and confirming previous observations with hemolytic streptococcal endotoxin on a larger series of eases and at the same time ascertaining whether any analogy existed between the eutaneous reactions to this hemolytic streptococcal extract and to similar products of nonhemolytic streptococci and other pathogenic bacteria. Skin reactions of 303 rheumatic children have been tested, while 356 nonrheumatic children have been similarly examined to serve as controls. The rheumatic series eonsistcd of children who were at the time suffering from or had previously suffered from polyarthritis, carditis or chorea. The results obtained indicate that rheumatic children arc more sensitive to streptococcal extract than are nonrheumatic children, and that of the rheumatic children those with chorea are the most sensitive. Children with active rheumatism, and for a period of six months after the acute attack, show a high percentage of strongly positive reactions (80 per cent). After six months, this reactivity diminishes. Children with ful-