246 CHRONIC ARTICULAR RHEUMATISM 



onset, its slow course, the absence of efEusion into the joints, cutaneous edema 

 and capsular swelling. It resembles them in a preference for the small joints 

 and in the cbnspicuous symmetry; moreover, every possible transitional form 

 occurs, so that they can only arbitrarily be difEerentiated. More correctly, 

 perhaps, we may call them different developments of the same disease. There- 

 fore I have not yet accepted the division which is often made (lately by 

 Curschmann) into chronic articular rheumatism and arthritis deformans. I 

 agree with Charcot, who designates the two as the exudative and the dry 

 form of primary chronic progressive polyarthritis. 



4. The fourth form is characterized by appearing in elderly persons and 

 in the aged, by a markedly chronic course, by invariable limitation to one 

 or more large joints, and frequently, although not always, by its connection 

 with trauma. This is the arthritis deformans of R. Volkmann, the rheuma- 

 tisme chronique partiel of Charcot, the best known type of which is the malum 

 senile coxse. But this affection is not infrequently noted in the fourth and 

 fifth decades of life, most often, perhaps, in the shoulder after a fall or 

 contusion. 



Effusion is almost always absent. When the patient is at rest the pains 

 are moderate or cease entirely; movement is limited to a great extent, muscle 

 contractions or, at least, constrained positions, generally occur and atrophy 

 is frequent (in the shoulder, mostly of the deltoid and triceps). Upon move- 

 ment, friction and cracking are heard and felt in the ends of the joints. After 

 the disease has lasted a long time deformities due to exostoses and ecchon- 

 droses invariably appear. These will be described below. 



5. The fifth form includes the chronic, deforming and ankylosing dis- 

 eases of the vertebral column (Pribram). Julius Braun, in 1875, was the 

 first to collect a large number of cases. Striimpell described the implication 

 of the hip-joint in arthritis of the vertebral column. Pierre Marie ia 1898 

 worked out the symptomatology of " spondylose rhizomelique " which appears 

 in men immediately after the completion of their growth, and consists in com- 

 plete adhesion of all vertebra, scoliosis and kyphosis of the shoulder- and hip- 

 joints, but with intact extremities. Another form was described by Bechterew 

 in 1892 : Limited movement in the vertebral column with anterior curvature, 

 particularly of the upper parts; associated with this pareses of the muscula- 

 ture of the neck, trunk and extremities, and atrophy of the muscles of the 

 back and scapula. Common to both of these forms are nervous disturbances 

 ■ — anesthesia and paresthesia, neuralgia, paralyses and muscular atrophies in 

 varying form and extent. The Striimpell-Marie form distributes itself from 

 below upward ; Bechterew's variety from the shoulder to the hip. 



In the meantime, in a large number of observations, particularly those 

 compiled by W. Anschiitz, it was noted that a sharp differentiation of these 

 forms is impracticable, that, on the contrary, numerous transitional stages 

 are observed. Some of these begin at the upper or lower end of the vertebral 

 column, with or without involvement of the joints of the trunk, or, finally, 

 in combination with chronic arthritis of the extremities in one or another 

 order. Joh. Miiller described a case with extreme stiffness of the articulations 

 of the ribs, respiration being maintained entirely by the diaphragm and the 



