Fever may run high, the tongue be foul, and the pulse quick, and the local indications of pain and swelling be very slight at the time of observation. This may be caused by various circumstances.
a. The case may be one of continued fever, with alight rheumatism super added. The pain will at no time have been intense, the limbs never having been rendered motionless from suffering; the febrile symptoms present some what of an asthenic type ; the pulse is weak as well as quick, and perspiration is less common. In acute rheumatism, it may be remarked, that the general symptoms of a febrile state differ in many important respects from those of continued fever, as they indicate a certain amount of inflammatory action ; on the other hand, they form a striking contrast to most of the asthenic inflam mations in the presence of excessive perspiration.
b. In children, when evidence of the disease being acute is not wanting, the local affection may be comparatively slight, the joints, perhaps, never tumid or red, the patient tossing about in bed in such a way as to lead us to doubt whether there be any real inflammation of either ligaments or synovial mem branes. Yet serious mischief may result by inflammation of the lining mem brane of the heart or the pericardium. In forming a diagnosis in such cases, it is also to be remembered that children are not conscious that perfect still ness will best remedy their sufferings, and the internal inflammation may prevent any external development of the disease. The continued or remit tent fever of childhood is never accompanied by local pain, and, therefore, when pain in the limbs is observed as a concomitant of a febrile state, rheu matic affection is at least to be suspected.
c. Not merely in childhood, but also among adults, the occurrence of severe internal inflammation will often abolish the signs of local affection of the joints; and here we shall derive most aid from a careful inquiry into the patient's previous state. In comparatively rare instances, the external signs of the disease only follow after the subsidence of some internal inflammation.
These occurrences are moat particularly associated with pericarditis ; but endocanlitis and pleurisy may also become causes of obscurity in febrile con ditions connected with rheumatism.
There is really little practical difficulty in recognizing a case of acute rheu matism; we have only to distinguish it from gout, and from the inflammation of the joints attending on secondary deposit; and their diagnosis must be more fully considered in subsequent sections. A first attack is generally the best defined : the patient is probably under thirty ; the redness of the skin confined to the part immediately over the joint, the pain and tenderness out of all proportion to the aspect of inflammation, and various joints suffering simultaneously. In any other than a first attack, the history of the former seizure may prove that to have been gout, and will naturally lead us to sus pect that this, though less defined, is probably gout too. The previous occur rence of either renders it probable that the present illness is not connected with purulent contamination of the blood. The history, again, of its com mencement and progress, in gout or rheumatism, differs from that usually obtained in a case of pysemis: in the latter, there is some existing suppura tion or inflammation of veins or absorbents, which was, perhaps, recognized long before inflammation attacked the joints; and we are thus prepared to look for its occurrence; sometimes, however, the process is a very rapid one, and the attack exceedingly like acute rheumatism to the inexperienced. One or two points aid very much in the discrimination, as they are connected with the essential nature of the disease. The inflammation round the joint is more erysipelatous in appearance, and is combined with oedema, and the pain is less severe ; other parts, at a distance from any joint, are similarly affected ; or there may be inflammation about the eyelids, soreness of throat, &c. : the fever is adynamic, and the patient depressed; the inflammation constantly passes on to suppuration—which never happens in acute rheumatism.