244 CHRONIC ARTICULAB, RHEUMATISM 



Just as diverse is the nomenclature. Almost every author has attempted 

 to arrange the varying pathological pictures in distinct groups (all mentioned 

 by Pribram), and of the names that have been chosen some refer to the clinical 

 course (for instance, Charcot's rheumatisme ariiculaire chronique progressif). 

 some to the shapes assumed by the joint {arthritis deformans of Virehow and 

 E. Volkmann, rheumatisme noueux of Trousseau), some to the anatomical 

 findings (M. Schiiller's polyarthritis villosa) and some to their authors' etiolo- 

 gic views, for example, rheumatisme goutteux, diathesique (Pierre Marie) and - 

 infectieux (Teissier and Eoque). 



This confusion is increased by the fact that the same title is applied to 

 quite opposite pathological conditions. Thus, the rheumatisme deformant of 

 the French, with effusion, proliferation of the capsule, and spindle-shaped 

 swelling of the joint, is identical with what the German surgeons and clin- 

 icians (following E. Volkmann) call chronic rheumatism in contrast with 

 arthritis deformans, which is characterized by atrophy of the capsule and 

 proliferation of the bone, in many joints or in one alone (for example, the 

 malum senile coxse). 



This confusion can only be cleared up by describing briefly all the principal 

 types of joint disease. 



1. When a young person, after brief prodromal symptoms or a tonsilitis 

 with fever, is attacked with painful swelling of the joints, the inflammation 

 spreading from one joint to another, affecting large and small joints alike, 

 and without predilection for any — when the endocardium, the myocardium, 

 the pericardium, the pleurse, perhaps even the meninges are involved — ^we 

 recognize in this picture an infectious disease, acute articular rheumatism, 

 and we know that, as a rule, it runs its course without leaving permanent 

 changes in the joints. Exceptionally, however, swelling of one or more joints 

 and moderate pain and stiffness remain. After weeks or months the joint 

 function is more or less completely restored or the diseased condition becomes 

 permanent. This is chronic arthritis, resulting from an attack of typical 

 acute articular rheumatism. 



ISTow as the primary forms of chronic arthritis may begin with acute 

 febrile attacks, their differentiation is often difficult. Davaine closely studied 

 the disease, and laid especial stress upon possible prodromes, splenic tumor, 

 visceral complications, the ease with which the effusion in the joint may be 

 displaced, the absence of trophic disturbances (atrophy of the muscles), and the 

 absence of family predisposition to acute articular rheumatism. Unquestion- 

 ably Davaine has arranged this in too schematic a manner, and, therefore, 

 in any individual case we may waver for a time in our decision; the occur- 

 rence qf secondary chronic rheumatism is, however, recognized by all later 

 authors. 



2. The second form is prone to attack persons between thirty and forty 

 years of age. The disease is ushered in with fever and pains in the joints, 

 which are swollen but not to the same extent as in acute rheumatism. They 

 have an elastic, tense feeling, but fluctuation is obtained with difficulty; the 

 skin is slightly reddened, and is edematous above and below the joint so that 

 the affected joint shows a spindle-shaped swelling. Gradually new joints are 



