RHEUMATISM 



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toms, and as affording a complete picture of a condition 

 which is only occasionally procurable by the medical man ; 

 as already said, its subject followed its progress with the 

 greatest interest and intelligence, and supplied the follow- 

 ing details of the case : A. A., a gentleman past middle 

 life and previously healthy, was some time ago, during a 

 very hot summer, in the habit of sitting with his window 

 open and enjoying the fresh air, which blew in a current 

 between the window and the fireplace, and struck his head, 

 neck, and back on their right antero-lateral aspect. This 

 was continued during the hot months, and produced no 

 injurious effects until near their close, when he began to 

 experience pain in the neck, extending to the point of the 

 shoulder, of the exposed or air-struck area, and to perceive 

 a gradual extension of it from the trapezius down the 

 deltoid muscle, to its insertion, where the periosteum of 

 the humerus became acutely painful, both to pressure and 

 on movement of the muscle ; here it remained for some 

 time, the area of periosteal pain extending laterally and 

 downwards until the biceps became involved at its origin, 

 and afterwards at its insertion in the forearm, when shortly 

 afterwards there began to be felt a thickening of the distal 

 phalanx of the thumb, both on its palmar and dorsal 

 aspects, with pain on pressure and use. This thickening 

 continued to increase in hardness, and gradually to assume 

 the character and "feel" of an exostosis at the points of 

 insertion of the distal ends of the flexor and extensor 

 tendons respectively. No other parts were involved to 

 even a slight extent, except for a vague general aching 

 when the arm was "lain upon," and the acuteness of the 

 train of muscular pains began to diminish as soon as the 

 phalangeal pain and thickening began to be decidedly 

 manifest. No disturbance, constitutional or otherwise, 

 took place, and the case pursued a slow and even course, 

 leaving a thickening of the distal phalanx of the thumb 

 at the points mentioned, with at times a slight aching 

 down the area originally involved. Now this seems the 

 record of an ordinary slight case of rheumatic-gout, or 

 rheumatoid arthritis, and so it was ; but it is meant to 

 convey the truth that the attack arose from a prolonged 

 partial exposure of the origins of one or two of the 



