Fever is always present in the acute stage, but it is irregular and not of a very acute type. The temperature sel dom or never rises so high as in the rheumatic fever. The pulse is higher than usual, but even in the later stage of the disease, when the fever has passed away, a pulse of from SO to 100 is no rare occurrence.
Amemia is always observed in rheuma toid arthritis, especially marked in the very acute cases and in the chronic forms of very long standing. Hwmor rhages are rare, but spots of purpura are witnessed.
Neuritis often spreads from the af fected joint to the nerves in its prox imity; pain along the course of the nerves is experienced. Faradic irrita bility is lost, but that to the galvanic current is increased; commonly the dis ease from the first affected nerves spreads to other branches. A polyneuritic in flammation, symmetrical in develop ment, may also be observed. The skin may show pigmentation, or that covering the diseased joints (glossy skin) becomes atrophied. Erythema and oedema are also met with. Sweating is observed in almost all cases. The urine is, as a rule, normal.
The disease may assume an acute type. This is particularly the ease in children and young adults. The onset of this form is characterized by pyrexia, thick ening of the joints affecting the synovial membranes and cartilages as well as the ligaments around the affected joint, but without osteophytic changes. The glands are always enlarged.
At first the disease only attacks one or a few small joints of the hand or the foot; but from there it spreads very rapidly to most other joints of the body, affecting them symmetrically. In the early stages the articulations are soft, doughy, and swelled; later on they be come harder and stiffer. The other symptoms—atrophy of the skin and of the muscles, etc.—develop in a short time. The pain is very marked, and sometimes sleep can only be obtained by narcotics. Complications in the direc tion of the heart are very common.
The chronic form of rheumatoid ar thritis is either the later stage of the acute form or the disease may from the beginning take a chronic course, ing much more slowly and producing thickening and hardening of all the tis sues of the affected joints as well as osteophytes, deformities, ankylosis, etc.
Fever is absent or is of no importance, the pain much less marked, and the glands commonly remain normal.
Diagnosis.—Rheumatoid arthritis may be confounded with the pathological changes caused by chronic gout, or by some diseases of the nervous system (tabes, syringomyelia, etc.) and with the sequehe of acute rheumatism, tuber culosis, gonorrhoea, syphilis, etc.
Records of 37 recent cases with a his tory of pain in one or more joints ana lyzed. Four were due to traumatism, in 2 cases with painful ankles and feet the patients had flat-feet, 4 were afflicted with rheumatoid arthritis, and 6 were distinctly gouty. In the remaining 21 cases, all complaining of chronic rheuma tism or of an excess of uric acid in the system, there was a previous history of 5 cases of acute articular rheumatism, in 1 of small-pox, in S of gonorrhoea, in 2 of syphilis, 1 was tuberculous, and in 4 cases no satisfactory previous history could be obtained. Of the above 21 eases, indistinguishable as far as clinical appearances go, no less than 17 gave the history of having previously suffered from some disease of microbic origin. ;Some recent contributions to the litera ture of this subject are referred to, deal ing especially with the results of in fectious disease producing subsequent joint lesions. A clear classification of joint affections may be made according to their pathogenesis in one or other of the following divisions or combinations of them: (1) traumatism, (2) bacterial infections. (3) toxins and other chemical irritants, (4) nerve-degeneration. Mer rilis (Medical Record, March 22, 1902).
From c1[1to\ic GOUT rheumatoid ar thritis is distinguished by the absence of the characteristic features of gout. There is no history of attacks of acute gout, no affection of the kidneys, and the patient has not suffered from uric acid gravel or sand. Examination of the sediment by means of the centrifu gal apparatus reveals no renal casts—al ways present in chronic gout—in the urine.