Arthritis Deformans Clinical Features Condition of the Joints Coal Muscles

nodules, developed, rheumatic, seen, spots, sometimes, skin and joint

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If looked for, spots of pigmentation, frequently so dark as to appear almost black, will often be found in the neighborhood of the affected joints, and in a considerable number of cases their develop ment has been apparently directly associated with that of the articular lesions; but such spots are often to be seen upon the skin of patients who are not suffering from arthritis deformans but who have reached the period of life at which that disease is most com mon; and even where the two are associated the patients will often state that the pigmentation has been there as long as they can re member. It is often very difficult to ascertain whether the pigmen tation of the skin has any real connection with the joint troubles, and therefore, while fully admitting the accuracy and interest of Spender's observations, I am not prepared to attach to the pig ment spots the same diagnostic importance that he does.

In a considerable proportion of cases some degree of glossiness of the skin is observed. Sometimes the skin in the neighborhood of the affected joints has merely an unusually shiny appearance and seems to be unduly thin; but occasionally the typical pink tint and glossy surface of cutaneous dystrophy is met with. The late Dr. Hidden" recorded an instance in which the changes had progressed a stage further, and trophic ulcers had developed.

Dystrophic changes may also be present in the nails, but usually the impairment of nutrition is slight and shows itself as a rule in the form of longitudinal striation such as is so commonly seen in gouty subjects. (Edema of the legs was observed by Charcot and Vidal, and such oedema is certainly sometimes developed in cases of arthritis deformans apart from any recognizable visceral lesions to which it can be ascribed. Local sweating has been observed by Spender, Wichmann, and others, but this phenomenon is not peculiar to ar thritis deformans among diseases affecting the joints.

SItheutaneous Nodules.—The occasional development in appar ently typical cases of arthritis deformans of subcutaneous nodules closely resembling both in their seat and characters those seen in children suffering from acute or subacute rheumatism, presents a problem which is not yet ripe for solution.

As long ago as 1883 Payne" called attention to the occurrence of subcutaneous nodules in cases of chronic rheumatoid arthritis, sug gesting that they probably were only developed in the hood of inflamed joints. A noteworthy example of the condition has been placed on record Anderson." They are also tioned by Fagge Howard and some other authors. Some cases of

this kind were lately recorded by Newton Pitt.

The following case, which was under the care of Dr. Andrew in St. Bartholomew's Hospital, affords an excellent example of the con dition: E. C., male, aged 39, with no family history of joint disease, suffered fifteen years previously from a slight rheumatic attack. His present illness began with an attack of influenza five months before his admission. A fortnight later he had pain in the back, and artic ular pains which shifted rapidly from joint to joint, and was confined to bed for seven weeks. The pains had never ceased in the interval. The nodules were first noticed two or three weeks after the joints be came affected, and had gone on forming ever since. When seen lie had many nodules upon the scalp, forehead, elbows, palmaris and ex tensor tendons of the hands, knees, and in many other situations. He stated that some were decreasing in size. 'The finger-joints were considerably enlarged, and there was marked muscular atrophy as well as some ulnar deflexion of the fingers. The shoulders, wrists, hips, knees, and feet were also involved. He had suffered from some stiffness of the temporo-niaxillary joints, and on the back of the hands were many small pigment spots which he said had appeared since the commencement of his illness. The noddles on the knees were well marked, but there was no bony enlargement. All the nod ules were curiously tender and in this respect only differed from the ordinary rheumatic nodules. The heart's apex beat was outside the nipple line and the first sound was impure, but there was no distinct murmur. The patient stated that in the earlier part of his attack lie had sweated profusely.

It is possible that the above case was originally one of rheuma tism on the top of which arthritis deformans had developed, as sometimes happens, and that the two disorders were both present side by side ; or possibly the disease was not true arthritis deformans bnt the condition simulating it which is sometimes met with as a sequel of rheumatism, although certain features of the case, such as the implication of the temporo-maxillary joints, are opposed to such a view of its nature.

A third possible explanation is that in the course of arthritis do formaus nodules closely resembling true rheumatic nodules may be developed, the acceptance of which explanation would, it must be confessed, lend strong support to those who maintain the rheumatic nature of the malady.

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