250 CHRONIC ARTICULAR RHEUMATISM 



The bony substance becomes rarefied and fragile^ the capsule, which was 

 at first flaccid, proliferated, and infiltrated with serum, is transformed into 

 fibrous tissue which cicatrizes around the ends of the joint and limits motion. 

 In the proliferated villi, islands of cartilage or bony tissue form, and these 

 may be thrown off as free joint bodies. The final stage is complete osseous or 

 fibrous ankylosis of the joint which is fixed ia more or less unnatural position 

 and greatly deformed. 



All these processes are common to the various forms of chronic arthritis; 

 at one time one, at another time another, becomes prominent. Thus, in the 

 exudative form of progressive chronic polyarthritis, proliferation and edema- 

 tous infiltration of the synovial membrane and its surroundings dominate 

 the situation, hence the spindle-shaped form of the joints. The cartilage 

 often appears to be secondarily implicated. 



In polyarthritis " sicca " which has a chronic beginning, the proliferation 

 of the joint is not as marked as the fibrous transformation of the cartilage. 

 The outlines of the joint ends as a consequence of this become prominent, 

 and exostoses, if present, may be felt through the tense skin as hard, prom- 

 inent nodules which may sometimes be seen. This form also shows a tendency 

 to fibrous ankylosis. In senile deforming monoarthritis these osseous border 

 proliferations with disappearance of cartilage play the main role in the limita- 

 tion of movement; the capsule forms no essential part of the clinical picture. 

 Finally, Heberden's nodes are exostoses which at first slightly limit motion. 



If the anatomical descriptions of later authors are compared (particularly 

 Schuchardt and Weichselbaum) we are forced to agree with Charcot who 

 declines sharply to separate the forms according to the anatomical findings. 

 He regards them as in some sense branches of the same trunk. 



CLINICAL SYMPTOMS 



The clinical picture would be incomplete if only the joint lesions were 

 considered. Very frequently there is early impairment of the general health. 

 The cases occurring in young persons with fever are particularly apt to show 

 from the onset emaciation and conspicuous cachexia. This can hardly be 

 attributed to the fever. Occasionally the fever lasts for weeks and reaches 

 102° F. and higher, but there is no proportion between the height or duration 

 of the fever and the emaciation. Indeed even after the temperature falls the 

 patients remain weak. The inactivity of the patient, the want of fresh air, 

 and the constant pain have been urged in explanation. But if we bear in mind 

 that patients with disease of the spinal cord become abnormally fat despite 

 the fact of constant pain and immobility, we cannot concur in this view, 

 but must look upon these forms of arthritis as conspicuous instances of 

 wasting disease. Amyloid degeneration (Roese) which frequently appears 

 confirms this. It is true other cases of arthritis belong to the fat plethoric 

 type and here also transitional cases are recorded. Frequently, particularly 

 m the young, there is moderate anemia and oligocythemia. 



Most of the muscles of the body take part in the emaciation; in some cases 

 the entire musculature suffers but almost invariably the muscles in the neigh- 



