observed in some cases of gonorrheal synovitis. The diagnosis depends upon a knowledge of the existence of a specific urethritis. Sometimes, the course of the temperature is suggestive of a pyemic or of a septic condition.

Syphilitic Arthritis.

What is syphilitic arthritis?

Every now and then, in the course of syphilis, one or more joints become involved in inflammation, with all of the characteristics of an arthritis. The discrimination of the condition depends upon a recognition of its association with syphilis. As a rule, cardiac complications are wanting in syphilis, and the arthritis is more strictly limited to one, or at most, two joints, the migratory tendency of acute articular rheumatism being

absent.

Subacute Rheumatism.

What is subacute rheumatism?

At times, as a result of exposure to cold and wet, muscular movement becomes painful, in consequence of a rheumatic involvement of the muscle-sheaths. The patient sometimes mistakes for paralytic weakness the restraint of motion by pain. The pain is also in some degree spontaneous and influenced by meteorologic conditions. Affecting the muscles of the lumbar region, the condition is termed lumbago. Affecting the muscles of the neck it may give rise to torticollis or wry-neck. How are subacute rheumatism and neuralgia to be differentiated?

Both subacute rheumatism and neuralgia occur in paroxysms, superinduced by suitable meteorologic conditions. Rheumatism is more common in men; neuralgia in women. The pain of the former is rather dull and diffused; that of the latter sharp and confined to the distribution of an affected nerve, in the course of which may be found several tender points. Rheumatic pain more commonly than neuralgic pain is aggravated by movement.

How are subacute rheumatism and trichiniasis to be differentiated?

In trichiniasis, in addition to symptoms simulating those of subacute rheumatism, there are evidences of a cachexia, wasting, debility and symptoms of gastro-intestinal derangement, with a history of the ingestion of diseased meat. At an advanced

stage of the disease, it may be possible to detect the nodules to which the encapsulated parasites give rise.

What is myalgia?

Myalgia.

As a result of muscular strain, groups of muscles become painful to touch and on movement, in association with some degree of cutaneous hyperesthesia.

Chronic Rheumatism.

What are the symptoms of chronic rheumatism?

As a result of an attack or of repeated attacks of acute rheumatism, numerous joints in different parts of the body remain enlarged, stiff and painful. Sometimes the condition is insidious, progressive and chronic from the outset. However produced, the functions of the various joints are impaired ; attacks of pain occur and are apparently influenced by meteorologic conditions. Wasting of the muscular structures adjacent to the diseased joints takes place.

Chronic rheumatism may affect both joints and muscles, or the muscle sheaths or tendons only (muscular rheumatism), or it may attack the nerve-sheaths (rheumatic neuralgia). The principal symptoms of muscular and of nerve-rheumatism are pain, spontaneous and on motion, with accompanying tenderness, usually localized.

How are the enlarged joints of chronic rheumatism to be distinguished from those of chronic spinal disease?

Trophic changes in the large joints-enlargement, effusion, subluxation, arthropathies-take place in the course of some

chronic spinal affections, notably posterior spinal sclerosis. As a rule, but one or a few joints are involved. In chronic rheumatism, many joints are involved. In case of disease of the spinal cord ordinary scrutiny should detect the existence of symptoms indicative of such a condition.

Acute Gout.

What are the symptoms of acute gout?

Acute gout is a recurrent paroxysmal affection thought to be dependent upon the presence of an excess of uric acid in the blood. It occurs chiefly in those of a sedentary or inactive mode of life, who indulge excessively in the luxuries of the table, more especially in meats, sweets, sweet wines and malt liquors. Those that have been active in out-door sports and afterwards, while diminishing their exercise, maintain the heavy diet formerly appropriate, are extremely liable to gout. The tendency to gout is distinctly hereditary, and in some cases of marked gouty diathesis the attacks may occur despite personal abstemiousness.

The paroxysm may be brought on by an unusual excess, by a fit of anger, by worry or anxiety or by exhaustion. Its advent is sometimes unannounced; at other times, it is preceded by symptoms of indigestion, by mental irritability or depression. The attack usually sets in suddenly at night, the patient being awakened by intense pain most commonly referred to the metatarso-phalangeal joint of the great toe. There is fever in proportion to the intensity of the local affection. The pain moderates somewhat towards morning, when the patient falls into a gentle perspiration and is again able to sleep. Towards night the pain returns. The joint is now noticed to be tender, red, swollen and edematous; finally desquamation takes place. Other joints are successively involved, the morbid process showing an affinity for the smaller articulations. The attack gradually subsides, leaving the affected joints a little stiffened and swollen. At the height of the attack the proportion of uric acid in the blood is increased, while that excreted in the urine is diminished. When the paroxysm is over the quantity of uric acid in the urine is increased. In an attack of acute gout, the

joint-symptoms may suddenly subside, and gastric, cardiac or even cerebro-spinal symptoms be substituted.

Sometimes the attack is manifested from the first by visceral rather than by articular crises. Visceral crises are more likely to occur late in the history of the case than early in its course, and they sometimes prove fatal.

Chronic Gout.

How are acute rheumatism and acute gout to be differentiated? Gout is an hereditary affection, occurring in paroxysms, in which the first metatarso-phalangeal articulation and other small joints are involved. In acute rheumatism, a history of heredity is frequently wanting; the large joints are especially involved. The duration of an attack of rheumatism is many weeks; an attack of gout subsides in the course of a week or two. The uratic deposits of gout are wanting in rheumatism. sweats of rheumatism are absent from gout. Cardiac complications are common in acute rheumatism; gout never occasions endocarditis, but chronic interstitial nephritis is a common sequel.

What is chronic gout?

The

In those that have had a number of paroxysms of acute gout, or sometimes chronically from the first, deposits of urates take place around the diseased joints, in the articular cartilages and elsewhere, as in the lobe of the ear, in the kidneys and in the spleen. As a result there is painful thickening of the affected articulations, which are stiff and finally become deformed. Sometimes distinct "chalk-stones" may be felt, and in extreme cases these may cause ulceration and appear externally. Gout is a potent cause of arterio-capillary fibrosis. An excess of fibrous tissue develops in the viscera and in the walls of the bloodvessels, with secondary contraction. Chronic interstitial ne

phritis is a common sequel.

Lead-poisoning may give rise to lesions exactly resembling those of chronic or of subacute gout.

Lithemia.

What are the clinical features of lithemia ?

Lithemia is modified gout-a manifestation of the uric-acid diathesis. It is caused by defective oxidation within the body and is dependent upon imperfect tissue-metabolism.

Lithemia manifests itself by varied symptoms, among which are sallowness or abnormal redness of complexion, impaired or perverted appetite, a metallic taste, deranged digestion, constipation, headache, vertigo, irritability of temper, a tendency to melancholia, abnormal drowsiness or sleeplessness, palpitation of the heart, irritative cough, disturbances of vision, noises in the ears, anomalous cutaneous eruptions, transient localized edema, and cramps in the calves of the legs. Micturition is frequent and burning, the urine usually being diminished in quantity and containing an excess of uric acid and urates; phosphates and calcium oxalate are likewise frequently in excess; in cases attended with paroxysmal flushing red blood-corpuscles and albumin are occasionally found; sometimes a small number of tube-casts. Chronic catarrhal hepatitis and functional inactivity of the liver are frequently-perhaps causally-associated with lithemia. Fibrous degeneration of the kidneys and of the walls of the smaller arteries, with cardiac hypertrophy, may be an ultimate sequel.

For what affections may lithemia be mistaken?

Unless in a given case one bears in mind the possibility of the existence of lithemia, and is on the alert for its detection, the condition may be mistaken for almost any functional disorder, or even for serious organic disease of the heart, brain, stomach, intestine, or other organ.

The discrimination depends partly upon the exclusion of visceral lesions, and partly upon the results of urinalysis: the finding of an excess of urates or free uric acid pointing to the existence of lithemia. An hereditary tendency to gout or rheumatism, or the existence of gout, rheumatism, or diabetes in other members of the patient's family, or the fact that the patient's habits of life are such as are likely to lead to the de