Acute Rheumatism— It’s Problems and Rehabilitation
By A. L. LO M EY , M .D ., C h .B., D .P hys. M ed.(R and)

C hief Specialist in Physical Medicine, General Hospital, Johannesburg, H ead Sub-departments o f
Physiotherapy and Occupational Therapy, University o f the Witwatersrand, Johannesburg, South Africa.

September, 1961 P H Y S I O T H E R A P Y Page 3

Acute rh e u m a tis m , th e sy n o n y m o f w hich is R h e u m a tic
Fever, is a n a c u te disease c h a ra c te ris e d by fever a n d a rth ritis ,
with a special ten d e n cy to in fla m m a tio n o f th e h e a rt valves
and heart muscle.

C O N IC A L FEATU RES
Cause: The m odern concept attributes the development

of rheumatic fever to a reaction on the p a rt o f the patient
to a preceding infection with a haemolytic streptococcus of
the pharynx and the upper respiratory passages1.

Prevalence: T he disease appears to be less com m on and
less severe than in the past, so much so th at the present day
medical practitioner does n o t often see a case2. T he incidence
of sub-acute cases w ithout arthritis however, is probably not
less than formerly.

Amongst B antu children in South Africa the disease is by
no means rare, and the impression gained is th at it is as
frequent if not m ore so than in the E uropean, and th at it
occurs in a younger age gro u p 3. In 1956, 56 cases o f rheu
matic fever and chorea were adm itted to the children’s wards
at Baragwanath H ospital, and in 1958 the figure was 51.

With regard to the older age groups am ongst the B antu4,
of 1,100 cases o f H eart disease adm itted to the medical
wards at the same hospital in 1957, 246 were suffering from
rheumatic heart disease, so that acute rheum atism can be
considered a com m on disease in the African.

Race and Climate: All races are affected, but a tem perate
climate is more favourable.

Environmental Conditions: Adverse living conditions such
as overcrowding, poverty, exposure to cold and wet, favour
its occurrence o r act as determining factors.

Age and Sex: It is essentially a disease o f childhood, the
first attack usually occurring before the age o f 20 years,
although recurrences may take place well into middle life.
Males are more often affected in later years.

Heredity: It is not hereditary, although there is a here
ditary pre-disposition.

Recurrences: These are comm on and are due to sensitiza
t i o n of the connective tissues o f the body by a previous
ktreptococcal infection, e.g. from an inflamed tonsil. The
"disease can therefore be regarded as one o f the collagen
diseases5, and the characteristic pathological lesions, as
allergic responses to streptococcal infection. Once this
sensitization has occurred further streptococci will cause
further reactions and thus account for the occurrence and
frequency o f the recurrent attacks.

Pathology: The essential lesion is characterized by an
exudation and proliferative process affecting a num ber of
tissues. In the heart the valves, particularly those o f the
mitral, suffer an acute inflam mation characterized by the
development at the edges o f the cusps of m inute pale vege
tations. Beneath the skin multiple discrete nodules the size

j pe^ ,are sornet*rnes found. These are called “R heum atic
nodules” and consist o f a fibrous m atrix with an infiltration
of small round cells and larger m ono-nuclear cells. They are
located most often over bony prominences, e.g. the wrists,
and knuckles, and are an indication o f severe infection,
accompanied alm ost always by cardiac involvement.

S Y M PT O M S
Onset: This is usually abrup t and is ushered in w ith a

cnili and often w ith a sore th ro at and general malaise. A rise
in the tem perature ranging between 102° and 104°F soon
occurs with an accom panying rise in the pulse rate.

Joints: Vague pains in the limbs are present at the onset,
soon however, pains in the joints develop, the larger joints
particularly the knees, ankles and wrists being the favourite
sites, the smaller joints usually rem aining unaffected. The
m ost characteristic feature o f the jo in t involvement is its
tendency to flit from joint to joint. A nother is the fact that
the arthritis is always multiple. T he joints themselves may
exhibit rem arkably little evidence o f involvement even in the
presence o f the most acute pain, but some degree o f swelling
due to an effusion o f fluid, flushing o f the over-lying skin,
and exacerbation o f the pain o f movement o r palpation,
are fairly constant accom panying features present on
exam ination. Suppuration o f the fluid inside the joints
never occurs, but stiffness may ensure and may be trouble
some.

Skin: Sweating is usually profuse, the sweat having a
peculiar acid smell, and there m ay be an accom panying
diffuse erythema.

H e a rt: The heart is alm ost always affected, and it is this
which renders the disease so serious. In most cases some
degree o f myocarditis is present, which may persist for
some time after the main sym ptom s o f the disease have
disappeared. In many cases signs o f definite endocarditis
affecting most comm only the m itral and less comm only
both the mitral and aortic valves, are also present. Peri
carditis too, may occur, particularly in severe cases, and in
recurrent attacks.

Blood: The blood shows a raised sedim entation rate, an
increased leucocyte count, and a m oderate degree o f hypo
chrom ic anaem ia. The sedim entation rate parallels closely
the severity o f the disease and is therefore o f considerable
value in assessing progress.

Diagnosis: This is not difficult in the fully developed case,
but in the absence o f noticeable arthritis as may happen
more especially in children, the diagnosis depends on the
developm ent o f cardiac lesions. G enerally the following
m anifestations are helpful: carditis, polyarthritis, sub
cutaneous nodules, fever, raised sedim entation rate, positive
test for C-reactive protein, evidence o f pre-existing heart
disease, o r a history o f past rheum atic fever. In children too,
the differentiation from acute osteomyelitis is im portant, as
an error may lead to serious consequences. This can be
avoided if it is remembered that rheum atic fever should
never be diagnosed in a m ono-articular arthritis, that the
painful area in acute osteomyelitis is generally over the
lower end o f the fem ur o r tibia, and that this area is the
site o f acute tenderness, and pitts on pressure.

O ther conditions from which the disease may have to be
differentiated are other forms o f arthritis, e.g. acute rheum a
toid arthritis, m ono-articular o r m ultiple arthritis occurring
in the course o f many diseases such as gonorrhoea, gout,
dysentry, pneum onia, etc. Pyrexia from other causes can be
differentiated by the absence o f an adequate response to
full salicylate therapy.

Treatm ent: In view o f the present concept that rheum atic
fever is an inflam mation developing as a com plication o f
infection with H aemolytic streptococci, it is logical for
treatm ent to be directed at eradication o f this organism.
The com m on practice therefore, is to begin treatm ent with a
course o f penicillin, employing large doses fo r a minimal
period o f 10 days.

In order to suppress the inflam m atory process, such as
fever, tachycardia, joint pain, etc., two anti-inflam m atory

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agents are employed, viz.: salicylates and steroids. T he first
is the drug o f choice, but the second has a place particularly
in patients w ith carditis. Sometimes both are used in com
bination.

There is no do u b t th at absolute rest in bed is o f the utm ost
value as is careful nursing, in the warding off o f the cardiac
affections so com m on in this disease. The rest prescribed
m ust be prolonged and thorough—several m onths being
often required in obvious cases o f cardiac involvement.

F o r the sweating, when profuse nursing in between
blankets in preference to the usual sheets is advocated. A
flannel garm ent o f adequate length and with long sleeves is
also preferred for the sam e reason, and must be changed
as frequently as required.

The diet initially should be light, consisting largely of
milk and alkaline drinks. L ater m ore substantial foods
including soup, oatm eal, jelly, fruit juice, etc. may be added.
A bundant fluid is allowed from the beginning to replace
th at lost in the profuse sweats.

F o r the pain the additions o f D over pow der may be
necessary, and is often effective. The affected joints are sup
ported in the position o f m ost com fort, and the patient
himself is the best judge as to when and how much move
ment should be instituted—active movem ents being pre
ferred. Splints are often helpful in fixing the joints and giving
relief from pain, but in m ost cases w rapping the joints in
cotton wool held in place by a light bandage is sufficient
for this purpose.

I t is im portant th at the patient should be given plenty of
time to recover and convalescence should therefore be slow
and unhurried. V arious form s of occupational therapy are
helpful to reconcile the child to prolonged periods of such
enforced rest.

Only when the acute inflammation has completely dis
appeared is physical treatm ent indicated. A table o f gentle
movements for the affected joints is then instituted, this
being graduated carefully to avoid fatigue and over-strain.

L ater still a course o f U.V.L. may prove beneficial and
aid recovery.

The Problems in Acute Rheumatism: In the main these
fall into two categories:

1. The prevention of the initial attack o f rheum atic fever.
2. The prevention o f recurrent attacks.
I f both (1) and (2) above could be m ade more effective

the developm ent o f the serious and dangerous carditis so
com m on in the disease would cease to be a problem .

With regard to the first o f these—all know n o r suspected
cases o f streptococcal infection o f the pharynx should be
treated by the adm inistration o f effective doses o f penicillin
either by the oral or intra-m uscular route. Sulphadiazine is
also effective, b u t it has been superceded by penicillin
because o f the developm ent o f sulpha-resistant organisms,
and o ther disadvantages.

The prevention o f recurrent attacks in patients who have
suffered previously from rheum atic fever also requires the
effective treatm ent o f streptococcal infection particularly
o f the upper respiratory passages and pharynx6. H ere too,
penicillin is the drug o f choice, and m ay be administered
again by the oral o r intra-m uscular route, whichever is
deemed perferable in any particular case. T he dosage here
however, is m uch higher. Such prophylactic measures with
penicillin have to be continued for long periods o f time,
som e content perm anently. Sulphadiazine given orally also
has a definite place in the treatm ent o f these cases.

Rehabilitation in Acute Rheumatism: In general, such
patients are best advised to live in the country. They should
avoid any o f the pre-disposing causes associated with the
disease such as m alnutrition, cold and wet, overwork and
overcrowding.

As convalescence is necessarily so prolonged the establish
ment o f special hospitals has been advocated to accom m o
date long term cases for prolonged periods, such hospitals
to be conveniently situated, preferably also in the country.

Page 4 P H Y S I O T

To meet the educational requirem ents o f young patients
the provision o f special schools and reasonable teaching
facilities follow as a necessity.

Following recovery, a norm al active life may be per
mitted, provided no cardiac lesion is present. In the presence
o f such a lesion however, activity m ay have to be restricted,
b u t reasonable exercise within the p atient’s tolerance is of
benefit.

Sum m ary: A description o f acute rheum atism is given.
This includes consideration o f the clinical features, diagnosis
and treatm ent. T he problem s to be faced in dealing with this
disease are discussed, and m ethods designed to alleviate
them detailed. R ehabilitation processes necessary to restore
these patients are briefly described.

I wish to express my sincere thanks to the following for
perm ission to publish this paper:

D r. K . F. Mills, Superintendent, G eneral Hospital,
Johannesburg.

Prof. J. H. G ear, Acting H ead D ept, o f Medicine, U ni
versity o f the W itwatersrand, Johannesburg, South Africa.

R E F E R E N C E S
1. T albot, J o h n H . and L o c k ie, M a x w ell, L. (1958),"

Progress in Arthritis, pp. 238-276, New Y ork and L ondon,
G rane and Stratton.

2. C o pem an, W. S. C . (1948). Textbook o f the Rheumatic
Diseases, p. 103, Edinburgh, E. and S. Livingston Ltd.

3. K a h n , D r . E., C hief Paediatrician, B aragw anath
Hospital. Personal com m em oration.

4. W ilso n, D r . V. H ., C hief Physician, B aragw anath
H ospital. Personal comm em oration.

5. C onybear, Sir J o hn and M a n n , W. N. (1957).
A Testbook o f Medicine, 12th E dition, p. 62. E dinburgh and
L ondon, E. and S. Livingstone Ltd.

6. British M edial Journal (1959), 5118, p. 351.

H E R A P Y September, 1961

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