RITEUMATOID ARTIIRITIS.—It may in many cases be difficult to distinguish between the chronic gouty affection of a joint and the morbid change caused by rheumatoid arthritis,—or, as it is more properly called, the polyarthritis defor mans,—which disease attacks the car tilages, as well as the bone, and leads to destruction of the cartilage, to prolifer ation and thickening of the ligaments, and frequently to growths of osseous protuberances. In this malady there is no trace of uratic deposits.
The chief points of difference between gout and polyarthritis deformans are the following: In goat hereditary predispo sition is commonly observed; the disease occurs more frequently in the latter classes than among the poor; it is most prevalent among males; in the clinical history there is often a record of abuse of alcoholic stimulants, beer, or strong wines; the patient may suffer from lead poisoning.
The estimation of the amount of uric acid in the urine before, during, and after an attack of gout is of no value unless the amount of that substance taken in with the food is estimated. The power to destroy uric acid ingested as food is lowered in gouty subjects. If a gouty subject is given a weighed quan tity of uric acid and then excretes more uric acid than he should from the amount taken in, the result may be of diagnostic importance. A. C. Croftan (Phila. Med. Jour., June 21, 1902).
In many cases the appearance of gout has been preceded by repeated attacks of renal colic or by long-continued evacua tions of uric-acid sand in the urine.
Thirty-four cases of gout compared with 49 cases of rheumatism. In the for mer the attack is more apt to be mon articular, the pulse is almost invariably of high tension, tophi can be occasionally observed, and in all cases of inflamma tion of the joints the points of greatest tenderness to pressure were the condyles or malleoli. In the latter disease the pulse is most frequently of low tension; the heart is commonly affected; a num ber of cases exhibit tonsillitis or pleurisy, and the first attack is nearly always polyarticular. When the joint is acutely
inflamed there is much more superficial tenderness, and at the same time there are points of special sensitiveness, usu ally situated over the tendons in most immediate relation to the joints. When the hips and shoulders are affected it is exceedingly difficult to make out special points of tenderness in either condition. W. II. Thomson (Amer. Jour. Med. Sci., Aug.,''96).
Frequently (but by no means always) gout begins with an acute attack; tophi may be found on the external ear or else where. The urine is usually found de ficient in urea and uric acid by treating it in the centrifugal apparatus, while by examination of the sediment with the microscope, casts of the tubuli, hyaline or granular, will always be detected in quantities more or less great. After the discovery of Roentgen the X-rays have been used as a diagnostic means; various investigators, especially French, have demonstrated that the uric-acid com pounds offer no resistance to the X-rays. In a Roentgen photogram of a hand or foot affected by gout the clear lines be tween the bones indicating the articula tions appear quite unaltered, and the extremity resembles very much a healthy extremity and differs only from it by the enlarged outlines of the fingers and toes. Greater deposits, such as tophi, are quite invisible in Roentgen photograms. The reproduction of a hand or foot affected by polyarthritis deformans presents quite a different aspect; all the articula tions affected by the disease, even if it be not developed far enough to cause stiff ness or enlargement of the joint, have lost their clear, transparent appearance, and are of an obscure, almost black, color. When the joint has been affected for sonic time, it is absolutely impossible to discern the exact place of the articu lation, the bones seem soldered together, and that even in cases where a rather good mobility of the articulation still exists.