is restlessness and lack of sleep, and laryngismus stridulus sometimes occurs. Tetany is not uncommon.

Prognosis. The intercurrent affections which develop in this disease are more to be dreaded than the affection itself, which is rarely fatal. The skeletal deformities do not disappear.

Treatment. The child should have the best of food, and if the mother can not nurse it, a wet-nurse should be procured. Abundance of fresh air and sunshine are essential. Daily bathing in warm water is necessary. The child should not be encouraged to walk. The drugs that have been recommended are phosphorus, cod-liver oil, and the syrup of the iodid of iron.

ARTHRITIS DEFORMANS.

Definition.-A chronic joint affection, characterized by great progressive deformity, with functional and anatomic changes in the osseous, cartilaginous, and synovial structures. Synonyms. Rheumatoid arthritis; rheumatic gout.

Etiology. The disease bears no relation to either rheumatism or gout. The exciting cause is still unknown, and by many it is supposed to be of nervous origin. The view that the disease is of microbic origin has lately been advanced by Max Schiller, who describes a peculiar form of bacillus obtained from the fluid of the diseased joints. The same microorganism was also found in the blood of the persons affected.

The disease occurs more often in the female sex, in the proportion of five to one. It may appear at any age, but the greater number of cases develop in young adults between the ages of twenty and thirty. In a few instances the disease has appeared to be hereditary. Bad hygiene, mental strain, worry, grief, and care have been cited as etiologic factors. The disease shows an especial tendency to develop among the poorer classes; however, the well-to-do do not escape.

It is sometimes associated with chronic pulmonary tuberculosis. It has followed attacks of influenza, and sometimes arises in sterile women.

Pathology. The disease involves all the structures of the joint, and the nutrition of the affected part suffers greatly. The lesions usually begin in the cartilages of the articulations, where the circulation is lessened and the friction greatest.

The cartilages of the joints become softened, thinned, and gradually so nearly absorbed that the ends of the bone are in

apposition; proliferative changes ensue at the extremity of the bones, which become thickened; osteophytes develop (which are called Haygarth's nodosities), the ligaments are thickened, and finally partial ankylosis may result. The muscles around the joint become atrophied, and the nerves may show some degree of inflammatory change. In long-standing cases the ends of the bone may undergo atrophy and softening. The small joints of the hands and feet are most frequently involved; however, some of the larger joints are sometimes affected. Deposits of urate of soda are never found around the joints.

Symptoms. The disease shows great variability in its mode of onset; it is common for the affected person to go to bed apparently healthy, and to awaken in the night with a sharp pain, especially in the joints. There is a sense of tingling and burning in the affected part. Soon a swelling takes place in the affected joint, which comes on exceedingly slowly. The metacarpophalangeal joints are those most commonly affected. In some cases hard nodules develop at the sides of the distal phalanges; these are known as Heberden's nodes. The disease may now be quiescent for months and years; sooner or later, however, other joints are attacked, the swelling and pain in the mean time never entirely subsiding in the joints which were primarily affected; the condition may continue until nearly every joint in the entire body has become affected. At first there may be synovial effusion under the implicated articulation; this is followed by atrophy in the muscles of the involved parts, and occasionally this atrophy is in advance of the joint implication. The nutrition of the parts is affected, especially the nails of the hands and feet. Bursal swellings sometimes occur in the neighborhood of the affected joints, especially upon the dorsal aspects of the wrists. If the disease exists in the joints of the hand or foot, the characteristic fin-like deformity develops. Almost from the beginning of the disease there is increased rapidity of the heart's action; the pulse gradually rises from 90 to 120 or more per minute. This vascular disturbance is not associated with cardiac murmurs; even functional murmurs are absent, as a rule. Generally, during the course of the attack fever does not occur, but with each fresh outbreak a temporary subfebrile range of temperature may be encountered. Pigmentation and glossiness of the skin of the affected area are often observed. This disease is found among children, girls being

more frequently affected than boys, the onset being accompanied by fever. The spleen and lymphatic glands may be enlarged, the joints become stiffened, and the functions limited, accompanied by muscular wasting.

Prognosis. The prognosis as to cure is unfavorable; however, life may be prolonged for many years. Under proper treatment it is sometimes possible to arrest the progress, but the affected joints can never be restored to their normal functions.

The treatment consists in appropriate diet and in careful hygiene. As a rule, meat should be liberally allowed, with a suitable vegetable diet. Exposure to wet and cold must be carefully avoided, and, if possible, the patient should live in a warm, dry climate. Massage, warm baths, and electricity are of decided use. The hot-air treatment has also proved of decided benefit in some cases. The drugs which are of most value in the treatment of this condition are the iodids, particularly the syrup of the iodid of iron, and arsenic. Cod-liver oil is of use as a general tonic. Arsenic should be given in increased doses to the point of tolerance as a tonic.

GOUT.

Definition.-Gout is a constitutional disease, characterized by polyarthritis affecting particularly the small joints and by a deposition of urate of soda in and about the articulations.

Synonym. Podagra.

Etiology. The disease occurs most commonly between the ages of thirty-five and fifty, except in the cases marked by strong hereditary tendency, in which the affection may show itself much sooner. It is more common in the male than in the female. Corpulent persons are more predisposed to become gouty, especially those of sedentary habits. Errors in diet are extremely likely to bring on the affection. This applies particularly to the indulgence in red meats and alcoholic beverages. Chronic lead-poisoning also predisposes to attacks of gout. The disease occurs in the well-to-do much more frequently than in the poor; in the latter it is due to overindulgence in malt liquors (poor man's gout).

Pathology. In gout an increase in urates is found in the blood, which gives rise to supersaturation, and it is believed that this causes the inflammatory changes which develop in

the joints. The involvement first begins in the articular cartilage, thence spreading to the other joint-structures. The characteristic chalk-like deposits (urates) are formed. The joint most commonly involved is the metatarsophalangeal joint of the big toe on the right side. The ankle, knee, small articulations of the wrist, and the hand are also sometimes involved. Chronic interstitial changes are common in many organs, especially in the blood-vessels and the kidneys.

Symptoms of Acute Gout.-The first attack begins suddenly, and usually at night, with intense pain in the great toe, particularly involving the metatarsophalangeal articulation. In the morning it is noticed that the joint is red, swollen, tense, and exquisitely painful. With this there is a slight rise in temperature, the urine being scanty and high-colored and containing sediment (urates). There is great thirst and anorexia. Toward morning the pain subsides somewhat, but in the evening returns with increased severity. The fever continues to rise. Upon the following two or three days the swelling in the joint increases. The pain, however, diminishes, and the fever subsides. The attacks commonly last from a week to ten days. The tenderness and swelling, as a rule, pass away, and the health is restored. Occasionally, it happens that other joints are affected besides those of the great toe, particularly the tarsal and metatarsal joints, and the opposite foot may become involved. In cases of this sort the paroxysm is more prolonged, lasting from two to three weeks; however, recovery from the first attack is usually quite complete. There may now be an interval of about three years or longer before the attack recurs, and after this as the attacks return from year to year they are liable to show marked periodicity, occurring in the spring and fall. As the disease progresses, the larger joints may also become involved, and with each succeeding attack recovery is less complete, so that the joints become permanently enlarged, stiff, and deformed, and the characteristic chalk-stones make their appearance in the hands and the toes, at the knees and the elbows. Large quantities of urates are often found in the urine just after the onset of or following the attack. After the first seizure the patient often has prodromes which warn him of the oncoming of an attack; they most commonly consist of digestive disturbances, such as loss of appetite, pyrosis, flatulency, and irregular action of the bowels. There may be marked nervous disturbances, such as cramps, irritability of temper, neuralgia, depression of spirits,

and cardiac palpitation. These prodromal symptoms disappear suddenly as the seizure comes on.

Symptoms of Irregular Gout.-As a rule, between attacks, especially when the disease has existed but a short time, the patient is free from pain, but this is not invariably so. In chronic cases, especially after repeated attacks, the patient is troubled with irregular pains in the joints, and with many gastric and nervous symptoms, just as in the acute form, except that they are much less severe. This condition has been termed chronic or irregular gout. Occasionally, it happens that the inflammation in the gouty joints subsides suddenly from exposure to cold or as the result of the application of cold to the joints. This condition is often followed by severe symptoms referable to some internal organ, such as the brain, heart, or stomach. The condition is serious, and often has a fatal issue. It is known as retrocedent gout.

Symptoms Referable to the Skin.-Eczema is common, especially of the face, forehead, external ear, neck, and back. As a rule, it is not severe, but is persistent. Psoriasis may occur. Pruritus, local or diffused, which is apt to be troublesome at night, is common. The nails become brittle, and are kept in order with difficulty.

Symptoms Referable to the Eye.-Conjunctivitis and sclerotitis are the most common affections of the eye in this disease. Glaucoma, retinitis, and gouty iritis have been known

to occur.

Diagnosis. The diagnosis of acute gout depends upon the sudden onset with the arthritis, with special exacerbations at night, affecting the small joints, and upon the gastric and nervous symptoms. The disease rarely occurs before the age of thirty or thirty-five.

Prognosis. The prognosis depends upon the appearance of complications; when these are absent, the prognosis is good. If the kidneys remain sound, the general health is not appreciably lowered. Albumin occurring in the urine is always an unfavorable sign.

Treatment.-Diet and General Hygiene.-As nearly as possible a vegetable diet should be adhered to, as animal food gives rise to uric acid. Water should be partaken of plentifully. Alcoholic and malt liquors, especially the rich, sweet wines, such as port, sherry, and champagne, should particularly be prohibited. Systematic bathing, regular exercise in the open air, avoidance of exposure to cold and dampness, are important.