Acute Articular Rheumatism 
iu the Nursing Infant. 
BY I 
HENEY KOPLIK, M. D., 
ATTENDING PHYSICIAN TO THE EASTERN DISPENSARY, 
NEW YORK. 
REPRINTED FROM 
Etc Nete Yorft Phtucal Journal 
for June S3, 1888. Reprinted from the New YorJc Medical Journal 
for June 23, 1888. 
ACUTE ARTICULAR RHEUMATISM 
IN THE NURSING INFANT.* 
By HENRY KOPLIK, M. 1)., 
ATTENDING PHYSICIAN TO THE EASTERN DISPENSARY, NEW YORK. 
The rare occurrence of acute articular rheumatism in 
the infant at the breast and the restriction of material 
within certain limits must make this short paper appear 
simply in the light of a contribution to the literature of this 
subject rather than as presenting anything especially striking 
in the study of the disease. So infrequent is the occurrence 
of polyarthritis rheumatica in the nursing infant that those 
authors who have had, perhaps, the best opportunities to 
study its phenomena have completely ignored its existence. 
Most of the writers to whom I have had access find little 
reason to depart very far from the lines first laid down by 
Bouchut concerning the affection. The types, however, 
which Bouchut brings forward as characteristic have al- 
ready been rejected by competent critics (Senator). They 
can not be included under the disease acute articular rheu- 
matism in any sense. In presenting the histories of the fol- 
* Read before the Medical Society of the County of New York, May 
28, 1888. 2 
ACUTE ARTICULAR RHEUMATISM IN 
lowing cases I have endeavored to find those characteristics 
of articular affection and constitutional disturbance which 
we in later life recognize as classical to the picture of acute 
rheumatic polyarthritis. The rarity of the disease in such 
young subjects, I reiterate, may account for the paucity of 
the material. In these little patients we find the presence of 
the disease in a number of articulations, the rapid succes- 
sive involvement of these articulations by the disease, the 
presence of a certain amount of constitutional disturbance. 
I have not been so fortunate in the cases I record as to find 
any symptoms or signs referable to the heart. It is desirable 
to keep this class of cases distinctly separated in our minds 
from those diseases lately designated by Gerhardt as rheu- 
matoid affections of the joints. The rheumatoid affections 
of the joints have their counterparts in those obscure joint 
affections of infancy the pathology of which is still more 
obscure than that of true rheumatic arthritis, those forms of 
multiple synovitis, with or without endocarditis, complicat- 
ing the later stages of the exanthemata. 
Case I.—Female infant, aged six months, nursing at the 
breast, of good development; no previous illness. Mother 
states that six days previous to the time when the child was 
seen by the writer it had developed pain, heat, and redness in 
the joints of the left foot; this was followed by a similar affec- 
tion of the left wrist and finger joints of the left hand. There 
was fever, also some profuse perspiration. "When the child was 
seen the metatarso-phalangeal joints of the great toe and the 
neighboring three toes were much swollen, red, and painful; 
the temperature of the joints was increased to the touch. The 
dorsum of the foot was swollen and oedematous; the last pha- 
langeal joint of the great toe was swollen, red, and painful. 
On the left hand all the metacarpo phalangeal joints, except 
that of the thumb, were swollen, red, and painful; the left 
elbow was in the same condition. The last phalangeal joints 
of the left hand were in the same condition also. The tern'- THE NURSING INFANT. 
3 
perature of all the joints was raised to the touch. The hotly 
temperature in the rectum was 105’5n F., pulse 180, respiration 
48. A profuse perspiration was present, restlessness was ex- 
treme, the skin was clear, there was no eruption. Examination 
of the heart revealed a negative result. The lungs showed the 
presence of an acute broncho-pneumonia. The urine was nor- 
mal, the bowels were regular. No other joints subsequently 
became affected. The temperature gradually began to subside 
three days after seeing the child. At this time the temperature 
was 102,5°, pulse 186. The joint affection in the hands and 
elbow was the same, but the foot was beginning to improve. 
Five days after the child was first seen by the writer, and on 
the eleventh day of the disease, a scarlet-fever eruption ap- 
peared on the chest and spread over the body. During the 
stage of desquamation some of the joints remained swollen and 
painful. This tenderness of the joints did not subside com- 
pletely until the eighth week after the onset of the rheumatic 
affection. At no time were there signs of endocarditis. 
Case II.—Female infant, aged nine months, nursing at the 
breast, of good weight and development; no previous illness of 
any kind ; no history of skin eruption or scarlet fever; no signs 
of rhachitis present. Ten days previous to consultation the 
infant had developed redness and swelling of all the metatarso- 
phalangeal joints of the toes of both feet. Also all the joints 
of the fingers became affected similarly after a short time. 
There were fever, vomiting, extreme restlessness, and cough. 
The patient showed signs of pain when the fingers were handled. 
When seen she had swelling of all the joints named on both 
feet. The infant was very anaemic, and there was an increased 
temperature over the joints. The skin of the dorsum of the feet 
was oedeinatous. The metacarpo-phalangeal joints and all the 
phalangeal joints of both hands were swollen, red, and painful. 
The fingers were held in an extended condition, the thumbs 
adducted, resembling the condition and position seen in athe- 
tosis. The temperature in the rectum was 102°, pulse 126. The 
lungs showed an acute bronchitis. The heart showed nothing 
abnormal. 
On March 30th, nine days after the writer first saw the child, 4 
ACUTE ARTICULAR RHEUMATISM IN 
and in the third week of the disease, recovery was complete. 
Under the influence of treatment the pain in the joints, redness, 
and swelling had slowly subsided, the child became less restless, 
and after the time mentioned could be looked upon as com- 
pletely convalescent. The joints, though stiff, were moved 
somewhat by the little patient; no signs of synovitis were 
present. 
In Case I the tender age of the patient and the complete 
uncomplicated recovery are to be noted. I had occasion to 
see the little patient some time after recovery. The joints 
showed no stiffness or signs of the severe articular distuib- 
ance or synovitis. The heart also revealed no endocarditic 
affection or muscular disturbance. The marked interval 
between the first appearance of the joint affection and the 
scarlet rash (eleven days) is notable. There are no other 
points in Case I except the complication of broncho-pneu- 
monia. The typical swelling, redness, and increased tem- 
perature of the numerous articulations, and the high fever 
from the onset of the joint affection, all give the picture of 
two separate affections (rheumatism and scarlet fever) rather 
than the complication of the scarlet fever in this case with 
the rheumatism. 
In Case II there was no history or symptom which might 
lead to the acceptance of the presence of scarlet fever before 
or after the onset of the joint affection, yet the child was 
said to have been ill with the joint affection for ten days 
previous to the consultation, and under observation and 
treatment the joint affections subsided completely in nine 
days, making a duration of nineteen days. In this case the 
absence of endocarditis was remarked and at no time during 
the height of the disease or the convalescence could that 
complication be discovered. In this case also the general 
febrile movement, the swelling, redness, and increased tem- 
perature of the affected joints, and the pain in the same, THE NURSING INFANT. 
5 
were leading symptoms, and caused the parent to seek relief 
for the patient in treatment. Here I wish to call attention 
to the peculiar position of the fingers atfected in both hands 
—that of various degrees of extension with adduction of 
the thumb. This position reminds the observer of the 
picture met with in the forms of athetosis. I have had 
occasion to see this very same position of the fingers in 
marked acute rheumatic affection of the phalangeal joints 
of the fingers occurring in a boy aged ten years. I attribute 
this peculiar spastic-like position taken by the fingers to an 
involuntary contraction of the extensors of the fingers (in- 
terossei). These contractions are brought about by pain. 
It is also the position, it seems, which would afford relief, if 
such were possible, from pain. 
Bouchut, in the earlier edition of his treatise on the dis- 
eases of infancy and childhood, records three cases of articu- 
lar disturbance in the nursling, and with true scientific dif- 
fidence places them under the heading of polyarthritis rheu- 
matica. These cases have long ago been discussed, and the 
conclusion from competent critics (Senator) has been that 
the cases of Bouchut at the present day would be placed 
under the heading of sepsis rather than that of rheu- 
matism. 
Wiederhofer, however, records a case as acute articular 
rheumatism which seems to be more of the color of the picture 
obtained in this affection. The case was that of a female 
child, aged twenty-three days, suffering from blennorrhoeal 
ophthalmia. A few days after convalescence from the eye 
affection the little patient was attacked with an arthritic af- 
fection of the left knee, wrist, and elbow. After fifty-four 
days complete convalescence resulted. Here it is remarka- 
ble that the child suffered from an affection of the eyes of 
probable gonorrhoeal origin. The joint affection therefore 
takes the form more of those joint troubles seen in the adult ACUTE ARTICULAR RHEUMATISM IN 
6 
after attacks of gonorrhoea of the urethra, both in the male 
and in the female. A careful study must exclude the case 
of Wiederhofer from the simple rheumatic affections of the 
articulations, placing it rather under the rheumatoid affec- 
tions described by Gerhardt. 
Demme records a case of rheumatism and endocarditis 
in a child nine weeks old, of which I have not been able to 
find any detailed history. 
Henoch mentions a case of acute articular rheumatism 
occurring in a child ten months old. This case was com- 
plicated with pleuritis and pneumonia. Its duration was 
four to five weeks. Staeger (Senator) records a case of 
acute articular rheumatism at the early age of four weeks. 
Rauchfuss has met with only two cases of polyarthritis 
rheumatica among 15,000 young infants. Roger records 
a much-cited case of rheumatism in a child aged two 
years. 
This would seem to cover the very meager literature on 
this interesting subject. As to the complications of endo- 
carditis, pleuritis, and broncho-pneumonia, they have all been 
recorded in isolated cases. 
On the whole, Cadet de Gassicourt, after a consideration 
of an immense material, thinks that acute articular rheu- 
matism is a less frequent affection in childhood than in the 
adult. In the nursing infant, however, the affection is so 
extremely rare that authors and writers have more or less 
doubted the authenticity of published cases. Wiederhofer’s 
questionable case was in one of seventy thousand infants. My 
own cases were gathered from a material of seven thousand 
sick children. I place no weight, however, on such meager 
statistics. Henoch remarks that many of these cases in the 
literature are obscure in detail, and thinks that some are, 
perhaps, instances of syphilitic disease of the epiphyses, or 
multiple periostitis and abscess of the joints. Meigs and THE NURSING INFANT. 
7 
Pepper think that many irregular forms of rheumatism oc- 
cur in the nursling, but are lost to observation. D’Espin 
and Picot urge the rarity of the disease below the age of 
two years. Langsteet and Cadet place the cases below four 
to five years in the doubtful category. It would not aid us 
to go at length into the consideration of the relations of 
endocarditis to rheumatism, but certain it is that well-au- 
thenticated cases of endocarditis have been recorded in the 
nursling (von Dusch). 
There is no subject which is surrounded with more ob- 
scurity than that form of rheumatism recorded as accom- 
panying or following the exanthemata. This is notably the 
case with scarlet fever. Thomas, Bohn, Cadet de Gassi- 
court, Gerhardt, Litten, Kohrer, and Bokai all have their 
peculiar views about the nature of this joint affection. As 
yet there are no exact data of the relation of the one disease 
(scarlet fever) to the affection of the articulation. Cadet 
finds rheumatism an epiphenoraenon in about one tenth of 
the cases of scarlet fever. The picture presented in Case I 
of this paper is not that seen, as a rule, in scarlet fever. 
Here the joints first affected in the majority of cases are 
those of the hands. The affection sets in after or during 
desquamation. In the case here presented the articular 
affection preceded the eruption. There being no doubt on 
this point, I feel inclined with Bokai to consider such cases 
rather the rarer complication of true articular rheumatism 
by a subsequent attack of scarlet fever. Such cases have 
been recorded by Larcher and Hiller (Bokai). Knowing 
exactly so little and seeking to gain knowledge on the chief 
forms of articular rheumatism, we should be inclined to side 
with these authors. 
Writers are by no means so ready to regard the form 
of rheumatism occurring in scarlet fever as pure articular 
rheumatism. A. Jacobi, and subsequently Gerhardt, have 8 
ACUTE ARTICULAR RHEUMATISM IN 
presented a most interesting view on this subject. Ger- 
hardt excludes these joint affections from the class of true 
rheumatisms. He regards the possibility in scarlet fever of 
a mixed form of infection. It is very possible that the 
scarlatinous poison, as in typhus erysipelas, may manifest 
itself in an affection of the synovial membranes, as it does 
in that of the raucous membrane of the mouth, larynx, 
glands, etc. Indeed, this view is certainly one of the most 
scientific yet advanced. In Case I this view would be diffi- 
cult to apply, seeing the length of time that elapsed between 
the affection of the joints and the appearance of the rash. 
Yet, as most authors (Immermann among others) are inclined 
to regard rheumatism as an acute infectious disease, its occur- 
rence with scarlet fever is no more peculiar than the occur- 
rence of diphtheria with the same malady. Gerhardt found 
that joint affections were likely to appear in certain epidemics 
of scarlet fever, in some mounting as high as 37 per cent, of 
the cases, in other epidemics being entirely absent. Again, 
the joints of the hand are mostly affected (85 per cent.), and 
in most instances the affection is of slight severity (Litten, 
Bokai). Kohrer found that 6 per cent, of patients with 
scarlet fever had joint affection, and in 66 per cent, the hands 
were affected. Trousseau found one third of the patients 
affected with joint trouble. Lastly, endocarditis is less com- 
mon in the form of rheumatic joint affection occurring in 
scarlet fever than in the pure form of the disease (Ashby, 
“ Brit. Med. Jour.,” 1886, p. 971). Finally, if the pure form 
of acute articular rheumatism is obscure in pathogeny, its 
various subforms are still more so. It is, therefore, peremp- 
tory in diagnosis not to obscure classification by recklessly 
applying the terms rheumatic and rheumatoid to all possible 
joint or muscular affections, and this is more the truth in 
infancy. Here a number of affections in a hasty examina- 
tion may be easily confounded, and I will only glance at THE NURSING INFANT. 
9 
some of the more important joint affections which in their 
incipieucy or outset may resemble acute rheumatism, though 
they can hardly be said to be difficult of diagnosis. 
Congenital Syphilis.—There are obscure cases of in- 
flammatory trouble at the epiphyses of the bones in the 
vicinity of a joint which might be incorrectly diagnosticated, 
especially in the absence of signs familiarly present in this 
disease. The mothers of these infants can not be depended 
upon for a very correct history. There must be many cases 
resembling the following, in which the previous history 
would aid the diagnosis : Male child, aged three months, 
nursing at breast; all external evidences of syphilis absent; 
brought back to me with redness and swelling at the 
epiphyseal junction, the redness and swelling spreading over 
the joint, the right elbow swollen and painful, redness and 
swelling of the ungual phalanges. No suppuration present. 
Immediate improvement and disappearance of symptoms 
under appropriate treatment. I saw this case at the eighth 
month; it then presented a late papular syphilide and 
plaques. 
In rhachitis I have met with cases where there was some 
excessive enlargement of the articular ends of the bones, thus 
causing parents to think the joints were the seat of disease. 
The cases occurred in very young infants, and the various 
phenomena of rhachitis were exaggerated, and rapid and 
acute in their onset. Movements in these cases were ap- 
parently very painful to the infant; it would cry out with 
pain when fondled by the mother. There was marked club- 
bing of the articular ends of most of the long bones, with 
apparent joint enlargement, but the shafts of the bones 
were also broadened and thickened to a marked degree. 
Pressure on the joints and along the shafts of the bones 
elicitated signs of pain. There were in ray cases cranio- 
tabes, lack of development, and intestinal disturbance. ACUTE ARTICULAR RHEUMATISM IN 
Cases of circumarticular abscess may at the outset closely 
simulate rheumatic arthritis. In these cases there are often 
abscesses in other parts of the body ; the infection may be 
from the patient’s own person or from some external source. 
The history of a preceding attack of an acute infectious dis- 
ease will aid in the diagnosis, as such abscesses are prone 
to follow in the course of an exanthematous fever. 
Acute osteomyelitis may at first mislead to the more 
favorable diagnosis of rheumatism. The formation of ab- 
scess, the swelling along the shaft, as well as in the joint 
vicinity, aid the diagnosis. 
Sepsis, in its multiple forms, may affect the joints, and 
we have only to refer to the literature for many of these 
cases. To-day the diagnosis can scarcely be said to be ob- 
scured by any difficulty. 
Beyond the rheumatoid affections discussed above, I 
have of late noted that very young nurslings, when vac- 
cinated, give evidences of pains in the joints, just as would 
be likely to be found in the adult. The mothers in several 
cases came to me with the remark that the child would cry 
out when handled, and investigation showed an actual ten- 
derness about the knees and elbows when even slightly 
manipulated. These symptoms appear when the vaccine 
vesicle is turning pustular. These cases would be classed 
with the rheumatoid affections of the exanthemata. 
In every infant the subject of a joint affection suspected 
to be rheumatic, the heart naturally receives a good share of 
attention. Yet I know of nothing more difficult than the 
determination of an adventitious sound in the heart of these 
little patients. The overconfident diagnosis of cardiac mur- 
mur in these infants will often account for the good prog- 
nosis given by some clinicians to cardiac disease of infancy 
and later childhood. I refer to the ultimate disappearance 
of murmurs, or so-called cardiac dilatations. Error is easily THE NURSING INFANT. 
11 
made in these infants for many reasons: The restlessness 
of the patient, the great rapidity of the heart’s action, the 
difficulty of distinct localization over the limited area of a 
small chest, sometimes distorted by the processes of rha- 
chitis. I have not infrequently found adventitious sounds, 
heard at the base of the heart and also at the apex, dis- 
appear after a cessation of fever or a diminished rapidity 
of cardiac action. These murmurs, heard as I have heard 
them in the course of exanthemata, must be regarded as 
dynamic. Murmurs occurring with the first sound and dis- 
appearing after a few days, as above mentioned, I have 
always regarded as not referable to the endocardium. 
It is imperative in all cases to wait for a slower cardiac 
action, or to reduce the number of heart-beats with artificial 
means (digitalis), before entering the diagnosis of endocar- 
dial complication. The nursing infant, we conclude, is not 
exempt from the liability to attacks of acute rheumatism. 
In these little patients endocarditis may be absent. This 
latter fact only strengthens the belief generally entertained 
by authors (Gerhardt), that the prognosis of rheumatism, 
good as it is in the adult, is still better in infancy and child- 
hood. 
In connection with the subject of rheumatoid affections 
in infants who are suffering from any disease due to the in- 
fluences of the gonococcus or the micro-organisms of ery- 
sipelas (blennorrhceal ophthalmia or erysipelas), I desire to 
add the following: 
A female infant, three months and a half old, nursing at the 
breast, was vaccinated on the left arm. The vaccine pustule, 
in active suppuration, was opened by a traumatism. Necrosis 
of tissue to an extreme degree followed, with a very red and 
angry-looking areola spreading toward tbc elbow on the ex- 
tensor side of the arm, and with fever. On the day after the 
first visit the pustule was still suppurating, but the ulcer was 12 
ACUTE ARTICULAR RHEUMATISM. 
cleaner. The child had very marked swelling of the left knee; 
it was twice as large as its fellow, red, and very painful to the 
touch, and when movements of the joint were made there 
seemed to be some effusion. The mother had noticed the swell- 
ing during the previous night. The knee was put up in an im- 
mobilizing splint, which was removed after two days, as the 
knee was smaller than at first. The joint was still painful, red, 
and of heightened temperature; the vaccine pustule was heal- 
ing kindly, and the blush around its base was subsiding. The 
knee symptoms improved from this time onward, together with 
the vaccine pustule and ulceration ; but at the present time (a 
week afterward) the joint is still painful. 
Here we have a typical case of joint trouble due in great 
probability to infection of the structures of the joint by the 
micro-organisms playing the active destructive role about 
the vaccine lesion. REASONS WHY 
Plysicians stionM Suliscritte 
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