F.J Poynton, Alexander Paine
1905 The Lancet  
IN the first place we must thank the council for permission to bring this paper before your society and for an opportunity which we greatly appreciate. We also wish to say that our communication has been somewhat altered in form and arrangement because a feeling has been expressed that the entire subject of the causation of acute rheumatism should be thrown open to discussion. Our original intention had been to devote this paper chiefly to some difficult points in the study of this disease by
more » ... f this disease by giving an account of an investigation upon a very remarkable case rather than to dwell upon an aspect which we feared that we had already laboured to the point of weariness. Now, however, our intentions are to commence this paper by putting before you our present attitude towards the etiology of acute rheumatism and answering some of the objections that have been raised against our interpretation, for we feel that if we do not take this precaution the particular points bearing upon the nervous sJstem which are the subject of this paper will seem to rest upon an insecure basis. PART 1.-THE ETIOLOGY OF ACUTE RHEUMATISM. Five years ago in a paper published in THE LANCET2 we claimed that we had proved that a diplococcus was a cause of rheumatic fever-a cause that had been hazarded by others in England, Germany, and France before the publication of oar article.3 Two years later before the Royal Medical and Chirurgical Society 4 we showed that rheumatic fever might be a cause of malignant as well as so-called simple endocarditis. Since then and up to the present time we have been gradually filling in the gaps in our knowledge and strengthening the weaker links in the chain of proof. Our position now has not altered : we still firmly maintain that this diplococcus is a cause of rheumatic fever ; and further, we believe it to be the only bacterial cause; we also maintain that rheumatic fever is a cause of malignant endocarditis. These views clearly imply that we hold that there is a definite disease-rheumatic fever. We do firmly believe this and hold that it is as definite a di-ease as tuberculosis. Tuere are, admittedly, cases of rheumatic fever that are most difficult to differentiate, but they are no more numerous or more puzzling than are difficult cases of tuberculosis or typhoid fever. These views imply, too, that we have satisfied Koch's postulates. We believe that we have done so, and at various societies in London and at the International Congress in Madrid 5 we have demonstrated the micro-organism, its pure cultures, and its presence in the human and animal tissues damaged by rheumatism. We have isolated it now from 32 cases of undoubted rheumatic fever and the disease can be produced not only in rabbits but, as Vernon Shaw 6 has shown with one of our cultures, in monkeys also. organism. A very different undertaking this one, yet only too often confused with the first; indeed, we venture to put this question prominently before the meeting : Does a demonstration of a bacterial cause of a dise ase demand the demonstration of a specific test for the bacterium ? We named the micro-organism the "diplococcus rheumaticus"-a name which has aroused a little criticism. Yet it is a reasonable and accurate name and for these reasons, in our opinion, the best name. It is reasonable because the bacterium is a cause of rheumatic fever, and it is accurate because a diplococcus expresses the usual appearance of the micro-organism. Some hold that the name i-< badly chosen, because it implies that the microorganism is specific, but clearly it in no way interferes with the appearance on the scene of a spirochæte or trypanosoma rheumaticus. Others hold that it is badly chosen because the adjective "rheumaticus" implies that rheumatism is a definite disease ; our answer to this is that acute rheumatism or rheumatic fever is a definite disease, and that if the term rheumatism has any accurate meaning it should have one corresponding to that which the term tuberculosis bears in relation to acute tuberculosis or tuberculous fever. There are some who believe that rheumatic fever is not the result of an infection. They ought, we think, to demonstrate some non-infective cause and then to explain the coincidence that a bacterium, which has been found in the arthritis, endocarditis, pericarditis, subcutaneous nodules, pleurisy, pneumonia, peritonitis, and nephritis of rheumatic fever, is able to produce similar lesions in animals. Should they look upon all these lesions as complications they should define rheumatic fever when these lesions are put aside as epi-phenomena. Many more believe that rheumatic fever is a result of many different infections. If one other microorganism even can be said to have fulfilled Koch's postulates with reasonable constancy someone should bring forward the evidence in its favour by a clear and decisive demonstration. Lastly, there are others who believe rheumatic fever is a definite disease and that it is infective, but that the infection has not yet been demonstrated. This view naturally implies that the evidence in favour of this diplococcus is not convincing. It is not convincing in the opinion of some because the diplococcus is not constantly present ; indeed, they would go further and say it is generally conspicuous by its absence, or if it is present that it is only found after death. These objections we can only meet by a counter-s'atement, to the effect that it is found ante mortem and post mortem and that in suitably chosen cases it is found with remarkable constancy. We have ourselves found it in 32 cases and many others have isolated a diploccccus in acute rheumatism, notably, Ainley Walker and Beatson, Beattie 8 and Vernon Shaw in this country, von Leyden,9 Triboulet, and Coyon,10 Wassermann,11 Predtetschensky,12 Meyer,13 Singer,14 Allaria, 13 Jarvis,16 Cole,17 Longcope,18 and Herry.11 Never easy to find, it is very difficult to discover if searched for, as it was searched for by Philipp,20 in unlikely places such as the blood and arthritic exudations. The micro-organism multiplies and flourishes in the local lesions and the blood stream is only a channel of conduction; further, rheumatic septicaemia, as clinical experience teaches us, is rare, although two such instances have occurred in our experience. Apart from these very exceptional instances we have several times isolated it from the blood ante mortem but the blood stream is certainly not a favourable site from which to isolate the micro-organisms in an ordinary case of acute rheumatism. Another unlikely place is the arthritic exudation, because the micrococci are 7
doi:10.1016/s0140-6736(00)83181-5 fatcat:2fcqposunjaxndigv4zrdqw64q