248 CHRONIC ARTICULAR RHEUMATISM 



muscles and those of the back. Beer, Zenner, and lately Cassirer and Senator 

 have described such " myogenous " vertebral stiffness, some of which may be 

 due to hysteria and some to acute fibrous myositis. 



These conditions indicate that chronic rigidity of the vertebra may be 

 due to very different causes, but we may be certain that those forms which 

 occur in connection with acute or chronic articular rheumatism or with disease 

 of the joints of the extremities should be classed as chronic arthritis. 



6. As the sixth and last type, I must mention those almost painless or 

 only temporarily painful nodes which occur in the terminal joint of the three- 

 jointed fingers, appearing upon their posterior surface, giving them, an oval 

 shape, hard to the touch, and gradually, from rigidity of the joint, fixing the 

 fingers in a position of flexion or abduction. They are often looked upon as 

 the signs of uric acid gout; B. Pfeiffer believes them to be a certain guide 

 in diagnosis even in the absence of other gouty symptoms. 



Heberden, who discovered them, did not attribute them exclusively to 

 gout, and I coincide in the opinion of the majority of later authors who find 

 these Heberden's nodes occasionally in gout, occasionally in chronic arthritis, 

 but most often as the only arthritic symptom in otherwise healthy individuals. 

 The Rontgen picture shows them to be exostoses, and they form a connecting 

 link between chronic rheumatism and arthritis deformans; with the former 

 they have in common symmetry and multiplicity, with' the latter, the bony, 

 marginal proliferations, and the usually painful and chronic course. It is 

 well to follow Charcot and to separate them as special forms of disease. 



This finishes the description of the most common types; but it must be 

 added that in individual cases transitional stages occur which tend to merge 

 the types into each other. For this reason clinical findings do not permit a 

 fine differentiation, and an attempt has been made to found a classification 

 upon the anatomical changes. 



PATHOLOGY 



The anatomical changes extend to all parts of the joint, cartilage, bone 

 and capsule, and frequently also to the adjoining muscles, tendons and tendon 

 sheaths. In the earlier stages these changes are relatively but little known; 

 they are found as accidental lesions, and often run their course during the 

 life of the patient without symptoms. Thus, the patient from whom illustra- 

 tion 5 was taken was a chorus girl and dancer until a few weeks before her 

 death. Moderate changes are noted by surgeons, who look upon chronic 

 rheumatism as a border-land which should be gradually brought under their 

 dominion. The later changes are well known anatomically, but they illumi- 

 nate the problem of their origin as poorly as ulcerative phthisis explains the 

 onset of pulmonary tuberculosis. 



Even to-day it is not quite clear whether the affection begins in the car- 

 tilage of the joint or in the synovial membrane. Sometimes the one, some- 

 times the other, appears to be the case ; nevertheless both are early attacked. 

 In the cartilage the basic substance appears cotnpletely detached, the cartilage 

 cells proliferated, and sometimes discharged from their capsules into the 

 joint fluid. 



