rical and surgical gown and cap are put on with such pride after years of painful, expensive and anxious preparation? It is because the traditions of our profession, the motives and ethics of doctors in the past have earned the esteem, the respect and the confidence of the public at large. The unselfish efforts of medical men to accomplish good outside any tradesman-like duty gives our profession its enviable reputation. The tardy protection of the world from cholera and from yellow fever, the antituberculosis and antiplague crusades, the fresh air and pure milk societies for saving the babies are the real ennobling acts of medicine. It was the medical service of the Japanese army and navy which eventuated the struggle between Russia and Japan. It will be the service of a national medical profession which in the near future determines the end of the economic struggle between the yellow and the white. RHEUMATISM-ITS SYMPTOMS AND DIFFERENTIAL DIAGNOSIS.1 BY SIDNEY V. HAAS, M. D., Pediatrist to Lebanon Hospital; Physician to There are not many diseases in which the symptomatology in the juvenile and adult type differs so markedly as it does in rheumatism. In the adult, the type is characteristic; in childhood, on the other hand, the disease presents many pictures. For this reason, age, previous history, heredity, sex, etc., are of prime importance in arriving at a diagnosis in early life. If one were to attempt to draw a picture of joint rheumatism as it most commonly presents itself in childhood, it would be about as follows: A child who has been enjoying usual good health, complains of The medical library must be a potent pains in the limbs, or in only one limb, often factor in medical culture. It contains the record of the efforts, ideas, hopes and fears of all medical men in the world. Its mastery is not easy. Even a conception of its extent and possibilities is difficult to attain. It should be an engine of medical education and culture. Few men have time in the active years of practice to study in the medical library but if they are trained in the use of the library in their college days. they need not waste much time in ineffectual rummaging. They can go and read and come away. The library promotes medical modesty, close observation, accurate notation and a critical judgment of the evidences of our senses. Reading makes a full man, but in medicine a cautious one. called growing pains-and shows disinclination to activity. An examination shows a temperature of 100 to 101.5. Pulse rate increased slightly, if any. An examination of the extremities shows nothing, or perhaps a slight swelling of wrist or knee, or of the small joints of the hands or feet, with some stiffness of the adjacent tendons. There is no redness, and little if any tenderness. This condition persists for a few days or weeks. Salicylates relieve the pain and reduce the temperature. Upon a later examination a cardiac murmur is heard over the apex, which usually persists. 'Read before the Soc. of Alumni of Lebanon Hospital, Dec. 1, 1909. Occasionally a case is identical in character with that of the adult. The onset may be gradual but is usually sudden. The diagnosis must take into consideration: The previous history, wherein tonsillitis, scarlet fever, less frequently measles, endocarditis, pericarditis, pleurisy, rheumatism, chorea or a combination of these are of great importance. The present history is of little or no value excepting in straightforward cases. The age, inasmuch as the disease is almost unknown under two years; and uncommon under five years. The sex; in childhood females are more frequently affected than males; in adult life the two sexes are affected about equally. Heredity plays an important role. This does not mean that the disease is transmitted, the tendency certainly is. From twenty-five to thirty-five per cent. of cases. give a family history of rheumatism, chorea or cardiac disease. The temperature is usually under 101.5; infrequently over 103, and persisting ordinarily only a few days. The pulse, excepting as a result of the acute endocarditis, is not more rapid than the temperature would warrant. The skin is sometimes the seat of an erythema multiformi, which occurs as a macular or papular lesion, of bright red color, paling on pressure with a tendency to eccentric extension; often passing through the various ecchymotic shades. The distribution is symmetrical and bilateral upon the back of the hands, forearm, face, neck, and behind the ears; also upon the The skin is also sometimes the seat of erythema nodosum or peliosis rheumatica, which occurs as a round or oval tender node; in size, from a split pea to a split walnut, projecting above the surface and situated upon the shins, sometimes upon other parts. At first red in color, and passing through the various ecchymotic shades as they disappear. Fibrous nodules, so-called, vary in size from a pin head to that of an almond, or larger; situated just beneath the skin. They are not tender, are found chiefly in the vicinity of joints, upon the extensor surfaces, at the back of the elbow, margin of the patella; also along the vertebral spines, extensor tendons of hands and feet; and in the scalp. They vary in number from a few to fifty or more; come in crops appearing rather rapidly and taking a long time to entirely disappear. They are considered as denoting a severe type of disease, and when present are exceedingly characteristic of rheumatism in childhood. As in the adult, any joint or combination of joints may become affected. The smaller joints are more frequently affected than in the adult. The swelling is rarely very great, it may be so slight as to escape notice. The tendons about the joint and for some distance along their course may be stiff and tender. This is somewhat characteristic. There is rarely noticeable redness or heat. Motion is possible except in the most aggravated cases. In fact the arthritis has little in common with the picture as seen in the adult. As Cheadle puts it, “Arthritis is at its minimum, endocarditis is at its maximum." In the rheumatism of childhood cardiac disease is most prominent. Only in a few cases in which there is arthritis does the endocardium escape. It may begin with the arthritis but usually is found later. Frequently it is only the expression of the rheumatism, or it may be accompanied by chorea or by one of the characteristic skin manifestations of rheumatism. The valve most frequently affected is the mitral, after that the aortic. A reduplication of the second sound at the apex is usualy indicative of a beginning endocarditis. In spite of these sounds in the heart there may be no fever, increase in pulse rate, or dyspnoea. In some cases the murmur disappears after a time but in most instances it persists. Relapses are common. Pericarditis may be the only sign of rheumatism, usually it is accompanied by some other manifestation. Like the endocarditis, it is usually subacute and tends to relapse. Pleurisy as an expression of rheumatism is fairly common. It has been stated to occur in 10% of the cases, but this estimate is probably too high. Tonsillitis as a manifestation of the rheumatic state can hardly be denied, in spite of the fact that it is such a common affection and so often occurs without rheumatism. It precedes articular rheumatism in 25% of cases. Disturbances in the blood vessels such as thrombosis, embolism, etc., are uncommon, and occur only as a result of the cardiac condition. ingly rare. Personally I have never seen it in childhood. Chorea must be considered a manifestation of rheumatism, it sometimes precedes, sometimes follows the arthritis or endocarditis. Nervous symptoms in the form of emotional excitability are prominent in childhood, according to some observers, but this is not my experience. Muscles are sometimes the seat of pain in true articular rheumatism, the pain being reflected from a neighboring joint. This is well shown in rheumatic torticollis. Epistaxis is fairly frequent in children suffering from rheumatism. Excepting in severe cases the tongue is neither coated nor dry. The urine in the ordinary cases is not changed. The acid profuse sweating of the adult is also absent in childhood. The blood picture shows nothing characteristic. Differential Diagnosis. The diagnosis of rheumatism in early life is sometimes very difficult even when the case is carefully studied. There are many conditions with which it may be confounded. The more common of these are the following: Scurvy. This is most frequently mistaken for rheumatism. It is only necessary to remember, however, that rheumatism is never seen before two years, and scurvy rarely after that time. Whatever doubt exists can be cleared up within 48 hours by the administration of orange juice or potato in a case of questionable diet. It must not Anaemia, however, is a marked feature be forgotten, however, that scurvy may of rheumatism in childhood. Meningitis as a manifestation of rheumatism, if it exists at all must be exceed occur after the second year. Syphilis. Here the diagnosis is more dificult. The pain is usually severe; the swelling is more along the shaft of the bones than in the joint; the pain is worse at night; and there are usually other signs of the disease present. The pseudo-paralysis due to a syphilitic epiphysitis need only be mentioned; its occurrence in early infancy makes it necessary to diagnose it from Erb's palsy, rather than from rheumatism. Acute pyaemic arthritis of infants. This when it involves several joints, and is of gradual onset, is frequently mistaken for rheumatism. The early age, usually under six months, and the presence of temperature, and the blood picture will serve to differentiate it both. from rheu matism and scurvy. In the acute cases, the high temperature, the great swelling, and local inflammation make the diagnosis unmistakable. In this connection must be mentioned the pneumococcic and gonococcic joints. Osteo-myelitis. In older children this process when arising in the neighborhood of a joint, as it usually does, may be mistaken for rheumatism; but the high temperature and severe local process will clear the diagnosis. It is just in these cases however, that the use of salicylates is sometimes so valuable in assisting in making a diagnosis. Tuberculosis of joints. In this condition. the rheumatism is more apt to be mistaken for a tuberculous joint than the tuberculous joint for rheumatism. The slower onset, the tendency to involve one joint, the history of exposure to infection, the various tests which have been placed at our disposal; the absence of benefit from salicylates, all these should make the diagnosis plain. There is however a type of mon-articular rheumatism which is not very rare and is frequently mistaken for a tuberculous joint. Three cases among children between six and nine years of age have been observed by me; the hip is the joint involved; the onset is sudden, often at night; temperature around 102, pain is severe, there is complete disability; limitation of motion is marked, especially abduction and rotation. Under salicylates it rapidly clears up. That this type of rheumatism is liable to be mistaken for tuberculosis may be judged from the fact that I made a false diagnosis in the first case, and two other men made the mistake in the second and third cases. Flat foot is a condition frequently mistaken for rheumatism. This may be present in any child who is walking; may occur in one or both feet; with pain localized either in ankle, knee or hip. An inspection of the feet, the absence of endocarditis; and the lack of benefit from salicylates, with relief upon the use of proper shoes and appropriate treatment will make the diagnosis. Trauma may in the absence of history be mistaken for rheumatism, especially when a synovitis supervenes; but this is almost invariably in one joint, with no temperature, and is apt to be more painful than a true rheumatism. There is, however, one condition due to trauma that is so common as to require mention. Children between eighteen months and three years, while being led by the hand stumble, and in the effort of the person holding the hand, to prevent a fall, there is a quick jerk; at once the arm falls helpless by the side; the child screams with pain and continues to do so upon every renewal of motion of the arm, active or passive. Upon examination the whole upper extremity is sensitive to the touch, perhaps a little more so in the neighborhood of the wrist, and it is here that the trouble lies in the epiphysis. A simple splint such as a few turns of adhesive plaster around the wrist, gives prompt and permanent relief. After three days nothing is noticed. This is the "Painful Paralysis of Infants," of the French. Rheumatoid arthritis is exceedingly difficult to differentiate from rheumatism in the early stage. It is, however, very rare in children under ten years of age; there is no endocarditis; and salicylates have no effect upon the process. When atrophy and crepitus occur there is of course no difficulty. Rickets. When pain occurs in the joints in this disease it is probably scurvy in the younger children. Among older children. the two diseases can hardly be confounded. Local oedema, or angio-neurotic oedema, as it is also called; may localize itself over a joint, most commonly the wrist. The intense pruritis, and the appearance of areas of oedema unrelated to a joint make the diagnosis. Antitoxic sera when injected will occasionally produce swelling of a joint. It is well to bear this in mind. The history and early disappearance of the swelling explains its origin. Among other conditions which need only be mentioned as requiring elimination in a differential diagnosis from rheumatism are, anterior poliomyelitis, neuritis neuritis due to plumbism, alcoholism, or arsenic, haemophilia; and new growths in or about a joint. 666 West End Ave., New York. SURGICAL HINTS. Digital examination of the seminal vesicles is rendered much easier if the patient's bladder is full and if he is placed in a leap-frog position. CORRESPONDENCE. AN INQUIRY. To the Editor of AMERICAN MEDICINE: As one of the founders of AMERICAN MEDICINE as well as one of its uninterrupted readers, I beg to draw attention to editorial paragraphs in the July issue of the journal, p. 342-3 on phases of sects in medicine. I am unable to appreciate why a part of the medical profession may place distinguishing or defining words before their names as physicians, and condemn the use of the words "eclectic" and "homeopath" in similar positions as to others. Is not the act of one as consistent as that of the other? Are not all these words distinguishing prefixes? I fail to see that the use of one is permissible on ethical grounds if the others are not so. The editorial referred to regards it as highly objectionable for eclectic and homeopath physicians to make use of these prefixes, and at the same time commends the use of a prefix for regular physicians. Why would it not be in the interest of harmony for all the so-called schools to abstain from the use of any prefixes at all? I can better make clear my position by referring to a personal experience. About twelve years ago, when the act creating a state board of medical examination and registration in Indiana became a law, blanks were sent out to physicians to be filled out for registration, each in his own county, and the mixed board undertook to classify physicians throughout the State as to schools. Since I didn't sympathize with these arbitrary distinctions, I didn't answer the question-"To what school do you belong?" I left this space blank. due time the annual report of the board was published, and I received a copy, and discovered that I had been classified, thus: In "Not classed." After a time I wrote a protest to the board saying I did not wish to be classified and that the board had done so, and that its act was arbitrary and injurious. I set forth my reasons for my position as follows: The lines dividing socalled schools were uncertain, arbitrary, variable in different parts of the country, and were based upon therapeutic differences of opinion, not facts, etc. The |
