CLINICAL SYMPTOMS 251 



borhood of the joints are involved, and among these the extensors are most 

 seriously afEected." If rheumatism attacks the hand the interossei atrophy very 

 early, often before the patients notice any hindrance in movement. This 

 occurs in the exudative as well as in the dry form. In the latter we find a 

 very characteristic ulnar abduction of the basic joint of the fingers from the 

 first to the fourth. An attempt has been made to explain this by contractures 

 of the muscles or from the flaccid condition of the capsule ; this, however, I 

 believe to be incorrect. For in older persons this is frequently the first symp- 

 tom noted, even before there is any abnormal distention of the capsule or any 

 muscular contractions. It is more reasonable to assume that the lumbricales 

 atrophy simultaneously with the interossei, which normally have the property 

 of adduction, besides that of extension of the basal phalanx. Later this devia- 

 tion terminates in well marked subluxation. That the bones take part in the 

 atrophy is well known; in the senile monoarthritic deforming variety this 

 begins in the end of the joint; but in the juvenile polyarthritic form the 

 Eontgen picture often shows a conspicuous coalescence and disappearance of 

 the spongiosa in the neighborhood of the affected joint. Perhaps this is the 

 effect of immobilization. But since Sudeck has shown that in every form of 

 arthritic inflammation, distortion or trauma may produce within a few weeks 

 decided atrophy of the bones, transient or permanent, similar conditions should 

 also be looked for in chronic arthritis. The shin and its structures take part 

 in the process, and Herz has described a case in which, with every new attack, 

 a glove-like desquamation of the skin of the hand and shedding of the nails 

 occurred; such cases are rare. The changes resembling scleroderma are more 

 frequent; the shining ivory-like skin adheres to the deformed joint, smooth 

 and immovable. In the juvenile cases there is frequently an excessive func- 

 tional hyperhidrosis. The contractures which occur particularly in the flexor 

 muscles of the fingers and toes are important, but these may also be noted 

 in the extensor groups which are to a high degree responsible for the terrible 

 and incurable deformities in some of which the knees are drawn up to the chin. 



Frequently the tendons and tendon sheaths are involved in the process and 

 along these structures tough subcutaneous nodules occasionally appear which 

 may be temporary or permanent; these are also noted in acute rheumatism 

 (see a dissertation by Eabinowitsch). Pribram asserts that he has only ob- 

 served them in acute rheumatism; Fig. 6, however, is an example of such 

 nodules in a case of undoubted chronic polyarticular arthritis. 



In conclusion, I must mention intermuscular or intramuscular, dense, cal- 

 lous infiltrations which are rarely alluded to in literature, but are well known 

 to orthopedists and masseurs, and are skilfully treated by them. 



The visceral complications are especially interesting on account of their 

 importance in the conception of the disease. That the endocardium may be 

 attacked has been admitted, and the frequency with which this happens varies 

 in different reports from 4 per cent, to 80 per cent, of the cases. The second- 

 ary and the senile deforming varieties do not attack the heart. In the statis- 

 tics of primary chronic polyarthritis there are differences of opinion as to 

 whether functional heart murmurs or only the genuine valvular affections have 

 been included. Pribram, who was the first to call attention to this variation, 



