Acute rheumatism, or rheumatic fever, commences with a feeling of cold, occasionally with a distinct rigor, succeeded by a sense of weakness and general malaise. These symptoms are accompanied by aching pains in different parts of the body, especially in the limbs. These quickly increase in severity and are seated chiefly in the large joints, which soon become swollen and very tender. The temperature rises at the same time, and the skin is covered with a free perspira tion which has a sour and disagreeable odor. Acute pain in the affected joints is the dominating feature of acute rheumatism; and the inflammation of the joints which causes this suffering is the most prominent and characteristic lesion of the fully developed disease. As a rule it is confined to the large joints—the knee, ankle, wrist, elbow, shoulder, and hip joints being attacked with a frequency which corresponds very much to the order in which they have been enumerated. Of the small joints the knuckles are most apt to suffer. In striking contrast with what is observed in gout, the joints of the foot, other than the ankle, are rarely affected.
The local symptoms of this lesion are pain, swelling, and great tenderness of the inflamed joints. Occasionally there is redness of the surface, but such redness is less marked and less common than it is in gout.
The inflammation shows a decided tendency to shift from joint to joint. This alternation of pain and freedom from pain may be ex perienced by most of the large joints of the body more than once during an attack of acute rheumatism. The invasion of fresh joints is not always accompanied by diminution of the inflammation of those already affected ; though occasionally there is noted what seems to be, and is by many regarded as a true metastasis—a sudden passage of the inflammation from one joint to another.
Febrile symptoms are marked. The pulse and respirations are increased in frequency. The temperature varies from 101° to 104° Fahr., but has no distinctive range; the general course of the fever being irregular rather than continued. While the ailment continues there is no time at which the patient is free from fever or pain, but there may be many ups and downs in the course of both before the ailment comes finally to an end.
The skin is very active in acute rheumatism : the surface is usu ally bathed in a profuse perspiration which is a source of much dis comfort. It has a sour, disagreeable odor and an acid reaction. The
naturally alkaline saliva may also be acid. The urine is hyperacid, scanty, high-colored, and on standing throws down a copious deposit of urates. Its specific gravity is high, and it contains an increased quantity of urea. The bowels are constipated; the tongue is coated with a thick white fur; the appetite is gone, and there is considerable thirst. The patient's condition in a severe case is pitiable in the extreme. He lies on his back unable to move, the least effort to do so causing intense pain. The perspiration trickles down his face, but be cannot raise his hand to wipe it away. Even the weight of the bedclothes cannot be borne. He dreads the approach of his friends, screams with agony at the least touch, and sometimes even without such a cause. His expression is that of intense suffering and abject helplessness. He gets no rest. His one desire is to have some relief from pain.
The disease varies in duration. When uninfluenced by treat ment the acute symptoms generally last for two or three weeks. But the fully developed disease, as here described, is never seen nowa days, so efficacious is treatment iu arresting its course; and those who have entered the profession since 1876 can have no adequate idea of the acute and prolonged suffering which characterized an attack of acute rheumatism left to run its natural course.
During its course there is a marked tendency to inflammation of the structures of the heart. This constitutes the chief danger and anxiety of the illness, for the heart when once affected is apt to he permanently damaged; while in not a few cases the cardiac inflam mation proves directly fatal in its acute stage. The great majority of cases of acute rheumatism do recover. The prognosis, therefore, is favorable.
In some cases, fortunately in few, the temperature runs up to 106 -, 108°, or even 110°. With this high temperature there are associated alarming nervous symptoms. This constitutes that form of the dis ease to which, from its fatality, the term " malignant" has been ap plied. It is now generally described under the name of rheumatic hyperpyrexia. To its consideration we shall by and by return.