CHRONIC ARTICULAR RHEUMATISM 245 



attacked or those affected improve, but a number of those first attacked always 

 remain permanently diseased. 



The joints exhibit conspicuous regularity in the order of their involve- 

 ment. First, the smaller joints of the body are attacked ; the phalangeal and 

 interphalangeal joints of the fingers with the exception of the thumh, the 

 corresponding joints of the toes, then those of the hands, of the elbows and 

 knees; the shoulder and hip are almost always exempt. The disease, how- 

 ever, shows a preference for certain joints which are usually spared by acute 

 polyarthritis, such as the jaw, the sternoclavicular joint and the sternocostal 

 joints.^ Secondly the affection is conspicuously symmetrical : Almost always 

 both hands, both feet, both knees are attacked; only the joints mentioned 

 above are, as a rule, attacked unilaterally. The further course of the disease 

 varies. Either the joints return more or less to the normal, to be similarly 

 attacked after months or years (often acutely and with fever) or the affection 

 is " chronic from the onset," and in time changes occur in the joints which 

 prefigure the third form now about to be described. 



3. The third form generally attacks elderly persons, particularly women 

 during the menopause; the disease begins with indistinct nervous symptoms, 

 drawing or tearing pains, furry sensations or formication, sensations of cold, 

 etc., in the hands and feet. The patients notice that the motility of the 

 fingers gradually decreases. Fine movements such as sewing, knitting, writ- 

 ing, become difficult, particularly in the morning and during cold weather. 

 Careful observers note that the ends of the joints and the basic and inter- 

 phalangeal joints are slightly thickened; they feel hard and are not very 

 tender on pressure. The fingers gradually deflect toward the ulnar side, and 

 this is first noticeable in the proximal joint with the extended interphalangeal 

 joints; finally complete subluxation results in the basic joint, though in this, 

 as well as the other changes, the thumb is rarely implicated. The inter- 

 osseous spaces show deep grooves; the ball of the thumb and little finger are 

 atrophied. The same changes take place in the toes. Muscular contractures 

 appear early and cause abnormal positions of the extremities. Charcot, with 

 his artistic mind, attempted to arrange these positions according to a system : 

 A flexion and an extension type (more correctly a hyper-extension type) each 

 type with several sub-varieties. If, with Vidal, we accept also an extension 

 type (straight line) every imaginable form results, and if we reflect that the 

 fingers of the same hand may present various types side by side, the value 

 of this schematic division will not appear great. Besides the muscular con- 

 tracture, changes in the joints add to the immobility; the capsule shrinks to 

 fibrinous strands, the surfaces of the joints coalesce by connective tissue liga- 

 ments, exostoses and ecchondroses appear: The final result in well marked 

 cases is complete immobility of the joints in abnormal positions; the unfor- 

 tunates are condemned to permanent invalidism, and fill a large part of our 

 almshouses and homes for incurables. 

 ' This form differs from the two first mentioned by its gradual and afebrile 



1 These, however, although rarely, are sometimes attacked in acute polyarthritis; 

 indeed, the jaw may be the only joint attacked (Hamm, Manasse). 



