ACUTE ARTICULAR RHEUMATISM. 



529 



and soon grows very decided. As long as the patient makes no 

 attempt to move the affected joint, and it is not touched, the pain is 

 endurable ; but every attempt to move the joint or the slightest pres- 

 sure on it, in severe cases even the weight of the bedclothes, increases 

 the pain so that the patients often moan and cry till they have re- 

 mained quietly for a time in a comfortable position protected from 

 any injury. If we examine the affected joint, we sometimes find it 

 moderately, sometimes very much swollen. As we have already 

 said, the swelling only partly depends on the effusion into the joint ; 

 being partly due to oedema of the skin and subcutaneous tissue, it 

 usually extends to the neighboring parts of the limb, and on careful 

 examination it looks as if the ends of the bone were enlarged. The skin 

 over the affected joint is either of normal color or else light, or excep- 

 tionally dark red. The degree of the swelling and the severity of 

 the pain are not always in exact proportion; the pain is often very se- 

 vere, while the swelling is scarcely observable. The large joints, par- 

 ticularly the knee, foot, hand, elbow, and shoulder, are most frequently 

 affected ; but the small joints, especially the finger, sterno-clavicular 

 and intervertebral articulations, are be no means exempt. The toe- 

 joints are only exceptionally implicated. Occasionally also the sym- 

 phisis pubis is attacked. Not very unfrequently the inflammation 

 extends to the muscles and fascia about the affected joint. The num- 

 ber of joints involved varies. Even at the commencement of the dis- 

 ease it is rare for a single joint to be attacked ; far more frequently, 

 two, three, or even more, are simultaneously diseased. It is customary, 

 as the disease progresses, for joints, that have previously remained free, 

 to become involved, and for the symptoms to reach their height in 

 these, while it is subsiding or has even disappeared in those first 

 inflamed. If the pain and swelling disappear slowly in the joints first 

 seized, while they develop in others, the number of joints implicated 

 at one time may be very large, and the patient's state be very help- 

 less and pitiable. Occasionally such patients cannot make any move- 

 ments ; they are unable to stir from any position in which they have 

 been placed ; they fear even the most careful passive motion rendered 

 necessary for urination, defecation, eating, or drinking. Even slight- 

 ly shaking the bed increases their pain, and induces groans and com- 

 plaints. But this extent and severity of the symptoms are not frequent. 

 In most cases two or three, or at least only a moderate number of 

 joints, are simultaneously affected with severe pain, while the others 

 remain free, or are somewhat stiff and only pain when freely moved ; 

 sometimes also they crepitate. 



Fever usually accompanies the commencement of the disease; 

 occasionally it precedes the local symptoms, and only exceptional] v 



