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Rheumatism and Gout

pain, patient, limb, joints, acute and especially

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RHEUMATISM AND GOUT - has been already noticed that the objective phenomena grouped under position or posture have a direct bearing on the diagnosis of rheumatic affections. In general terms the indica tion is derived from the limited movement of certain joints, either in consequence of the pain produced by motion, or of the stiffness arising from alteration of texture. Along with this we may observe swelling, thickness, or distortion, more or less marked in different cases.

The history is simply comprised in an account of pain of longer or shorter duration, with or without the coincidence of general febrile disturbance; and in some cases the swelling of the joint is more spoken of than its painfulness. The complaint on the part of the patient, that he is suffering from rheumatism, is very liable to mislead the medical attendant—no expression is in more common use, and none more open to fallacy; the much abused term, "inflammation," is not more false in its application. The student should be especially careful to resolve all such state ments by further inquiry into their true and simple meaning; and "rheumatism," in the majority of cases, is no more than an asser tion of the existence of pain. Another source of fallacy connected' with the patient's description is, that he speaks of having "lost the use of his limb," when its immobility is due to pain or to stiffness of the joint, as well as when it is caused by paralysis. Handling the limb is the most effectual mode of discriminating these three conditions.

The history of the case may be also available for distinguishing between the various affections embraced under the head of rheu matism, as it points out the severity of the sufferings and the duration of the attack, its limitation to one limb, or its transference to others. We should never omit to inquire whether there have been any previous attack of a similar character; both because of the bearing this has on disease of the heart, and also because the characters of the affection are at to be less pronounced in pro portion to the frequency of their repetition.

§ 1. Acute Rh.eumatism.—The general symptoms indicate the presence of a febrile or inflammatory disorder; the sensations of the patient refer especially to the existene,e of pain. Our next step is to ascertain its locality—whether felt in the limbs, and spoken of as "pains in the bones," so common in fever; or in some defined situation, as the effect of simple inflammation; or whether confined to the joints themselves. If the patient, in his description, follow it from one joint to another—the ankles, the knees, the hips, the wrists, elbows, and shoulders—we may be sure that the disease is a,cute rheumatism.

In this form, the pain is severe--not coming in twinges, nor accompanied by startings (muscular spasm)--but continuous, aggravated by motion, and intolerant of pre,ssure; sometimes so intense, that the weight of the bedclothes cannot be borne; every posture alike uneasy, the patient would fain alter it, but that the dread of increased suffering in the attempt commonly restrains him. Flying from one limb to another, or affecting all nearly alike, the wrist and ankle,s are more especially prone to suffer in a,cute rheumatism; and these joints are commonly tumid and ex tremely tender, and marked by a superficial erythematous blush. Along with these evidences of general disturbance and local suffering the profuse perspiration, of a peculiar odor, distin guishes it, in a most unmistakable manner, in its severer forms. But the student must remember that sour-smelling perspiration, though very constant in this dise,ase, will certainly mislead him if the more essential indications be overlooked. This acid odor has sometimes a certain rancidity combined with it, which, when present, is perhaps more diagnostic; in all cases, however, solitary signs are not trustworthy. The urine is usually more remarkably acid, and loaded with lateritious sediment, in this than in most other febrile disorders.

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