DIAGNOSIS - RHEUMATISM.
The diseases for which acute and subacute rheumatism are most apt to be mistaken are acute gout, acute rheumatoid arthritis, pycemia, and gonorrheal rheumatism. As a rule the differential diagnosis presents no serious difficulty.
Acute gout is a disease of mature years; acute rheumatism a dis ease of youth. Gout generally affects only one joint; rheumatism several. Gout attacks chiefly the small joints; rheumatism the large. In acute gout the skin over the affected joint is red and glis tening; in acute rheumatism, as a rule, redness of the surface is not marked. In acute gout the skin is dry and unperspiring ; in acute rheumatism it perspires very freely. In acute gout the blood con tains uric acid; in acute rheumatism it does not. Acute gout is not benefited by salicin and salicylic acid; acute rheumatism is speed ily cured by them. Acute gout is much less apt to affect the heart.
Acute rheumatoid arthritis resembles subacute rather than acute rheumatism. It is distinguished from it by the following peculiari ties : Acute rheumatoid arthritis is a comparatively rare disease. It occurs chiefly among young women whose health has already been impaired by some debilitating cause, generally menstrual or uterine disturbance, or prolonged lactation. It comes on more gradu ally than rheumatism. It attacks the small joints as frequently as the Large. It shows no tendency to shift from joint to joint. The skin does not perspire profusely as in acute rheumatism. The urine is generally pale in color and of low specific gravity. It is a more obstinate ailment, and does not yield to remedies which speedily cure rheumatism. It does not tend, like this, to affect the heart.
Pycein ia. —Cases of pymmia sometimes occur in which the presence of joint inflammation, possibly also of endocardial inflammation, of febrile symptoms, and of free perspiration give to the ailment some resemblance to a case of acute rheumatism.
The diagnosis is not difficult. In pymmia there is the existence of some wound or other lesion to explain its occurrence; the rigors are more marked; the joint inflammation does not shift about; the perspiration is not acid; and the general symptoms are of a more markedly typhoid type. Should we fail to make a diagnosis by these
means, the doubt is not unlikely to be soon set at rest, if the case be one of pymmia, by the onset of alarming typhoid symptoms and a speedily fatal result.
Gonorrheal rheumatism occurs in connection with gonorrhoea. It is not accompanied by the same amount of febrile disturbance as acute or even subacute rheumatism. It affects fewer joints, has a special preference for the knee, and does not show the same tendency to shift about. Acid perspirations do not occur; and it does not tend to affect the heart. Remedies which speedily cure true acute rheuma tism have no influence on the gonorrhoeal form of the disease.
There is another morbid condition to which the term rheumatism is usually applied, but which is more properly a sequence of rheuma tism than a distinct form of the disease ; and which is so apt to be mistaken for the subacute and chronic forms of the malady, that it will be well to refer to it here. When a man has suffered from re peated rheumatic attacks, especially when these have followed each other in quick succession, there is apt to be induced a state of chronic thickening of the fibrous textures involved in the disease. The nature of the change, and the influence exercised by it on subsequent rheu matic attacks, will be considered hereafter. Meantime its existence is indicated with the object of pointing out that this condition, though of rheumatic origin, exists, when developed, independently of the rheumatic poison; and may give rise to symptoms indistinguishable from those caused by it—pain and stiffness of the joints. The im portance of recognizing its existence will be apparent when we come to consider the question of treatment.