52 CLINICAL APPLIED ANATOMY. 



joint swelling and surface redness are best seen in rheumatism of 

 the hands and feet, of the ankles and wrists, and of the elbows 

 and knees. By examining superficial joints it may be obvious 

 that the swelling is not strictly limited to the joint cavity, but 

 also involves the periarticular structures, and sometimes the 

 surrounding tendon sheaths. In joints, such as the hip and 

 shoulder, which are deeply seated and surrounded by muscles, 

 the objective signs of rheumatism may be limited to muscular 

 rigidity. 



The attitude assumed by a patient suffering from articular 

 rheumatism is determined in great degree by the joint effusion 

 and consequent joint tension. The position of greatest joint 

 capacity and least joint tension is assumed. Hence the knees 

 and elbows are flexed when inflamed, whilst the ankles and 

 wrists are extended, and there is some tendency for the hand to 

 be deviated towards the ulnar side. 



Rheumatism may influence the gait quite apart from articular 

 affection. In children a peculiar form of progression on tip- 

 toe with flexed knees may sometimes be met with, and is attri- 

 buted to rheumatic inflammation of the tendons of the hamstrings 

 and their surrounding structures. A transitory limp, at first 

 closely resembling that of tuberculous hip disease, may be seen 

 when the fibrous structures around the hip-joint are involved. 

 Wry-neck is the expression of the inflammation of the fibrous 

 structures of the cervical region, and occasionally retraction of 

 the head results from the same cause. The broad lumbar fascia, 

 which gives origin to the erector spinae, the gluteus maximus, 

 the latissimus dorsi, and other muscles, when inflamed by rheu- 

 matism may be the seat of agonising pain readily provoked by 

 movements of the trunk, thigh, or arm. 



The subcutaneous nodules of rheumatism have a great tendency 

 fco form over thinly covered bony points, and so may at times 

 be found in the following situations : about the olecranon process, 

 the margins of the patellae, and the malleoli of the ankle ; along 

 the vertebral spines, the clavicles, the iliac crests, the temporal 

 ridges, and the superior curved line of the occipital bone. 



