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Symptoms of Acute Articular Rheumatism

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SYMPTOMS OF ACUTE ARTICULAR. RHEUMATISM Prodromal Symptoms. —Very frequently manifestations of an indefinite nature precede the outbreak of the disease itself, as languor, anorexia, dragging pains in the joints, and sometimes even abdominal pains. Catarrhal or follicular angina appear as forerunners in a num ber of cases; but as far as clinical observations go they do not play such an important part as some recent authors ascribe to them. Often all prodromal symptoms are wanting, and the disease appears with or with out vomiting in its full severity.

Joint Localization.—The knee- or ankle - joints are those which are primarily and most frequently attacked. Often, however, it is the elbows, wrists or shoulders, which initiate the disease. But some times the hip or the cervical vertebra, and less frequently the joints of the small fingers or toes, are first attacked. As in the case of adults, the disease passes in its course from joint to joint, either symmetrically or often advancing irregularly in its progress. More than one joint is always attacked. When new joints are involved, the inflammation in those primarily affected as a rule recedes, but it may persist. It is not rare that a joint may, in the course of the disease, be repeatedly at tacked. The attacks in an individual joint will generally last only several hours; a duration of two or three days in childhood is the excep tion. In the disease which is characterized pathologically and anatom ically as a serous synovitis, the joints involved are particularly painful upon active and passive motion, and tender to palpation. Still the pains are seldom so intense as to cause complete immobility of the joints. An exception to this rule is that in children the frequent localization in the hip-joints may cause an intense degree of suffering. The objective symptoms of inflammation in children are apt to be moderate, slight swel ling and periarticular oedema are often found, while intense redness and copious effusions are absent as a rule. Pain is often the only symptom.

The temperature does not follow any definite type, still it seems that invasion of new joints or the serous membranes is accompanied, as a rule, by a higher degree of fever; also mild cases often begin with a single rise of temperature, over 39° C. (102° F.); in severer cases the fever may last several weeks, but this is the exception. In general, however, particularly under the constant influence of salicylate ther apy, the temperature returns after a few days to the normal, although the rectal temperature in the evening may continue for some time at 37.6°-37.9° C. (99.6°-100.2° F.).

The general condition of the patient in the beginning is often con siderably affected. Children show an unusually distressed countenance;

the tongue is coated and pasty, the skin becomes remarkably pale, such palor is often seen from the outset of the disease, but especially if the pain continues for any length of time. Careful. examination of the blood does not show any special findings aside from an insignificant occasional leucocytosis (llaginsky). The marked tendency to profuse acid per spiration common in adults, is frequently observed in children, although in a lesser degree. The bowels are generally constipated; there is severe, tormenting thirst, with anorexia and insomnia. The general condition depends upon the course of the fever; in most cases it im proves by the end of the first week.

The duration of the disease, as regards the joints, seldom exceeds ten to fourteen clays; often the whole illness is over in five to seven days. As a special peculiarity of rheumatism in children it must again be pointed out that the joint disease with its entire symptom-complex may take an uncommonly light, almost afebrile course without seriously influencing the general behavior of the patient. Nevertheless, these abortive cases may be attended with very severe heart complications.

complications of acute articular rheumatism we here classify a series of processes which either positively or with more or less probability may be taken to be nothing more than further manifestations of the disease developing from its irritant poisons. First in importance must be mentioned the involvement of the heart. The frequency of cardiac complications characterizes rheumatism in children as a serious dangerous disease. More than half of all cases leave behind them permanent cardiac defects. The heart remains nor mally active during the entire course of the disease only in a small minority of the patients. This explains the disproportionately high pulse rate which we see in nearly all cases, even if clinically there can be demonstrated no defect in the heart itself. In most cases (from 60 to SO per cent.) verrucose endocarditis results, localized in the great ma jority of cases at the mitral valve. Only by careful and exact clinical observation can we determine the occurrence of such an unfortunate development. Then there appear recognizable heart murmurs, are generally accompanied by rise of temperature, irregularities or other changes in the action of the pulse. Since children under eight years of age seldom suffer from intense localized pain and palpitation, it may happen that children whose acute rheumatism has had an abortive course are first brought for medical treatment with signs of beginning cardiac insufficiency.

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