CASES OF PRIMAP,Y CHRONIC ARTHRITIS The disease begins subacutely or chronically, without or at tended by more or less severe attacks of pain, and may run a sub febrile course. Centripetal progression starts from the small finger- or toe-joints. Sometimes the knee and elbow may have been previously attacked. Endocarditis is only exceptionally noticed.
Of sixty-six cases I found the beginning of the disease mentioned in twenty-seven individuals, in the first to the fifth year of life (two of them in the first, eight in the second, ten in the third, fourteen in the fourth), twenty-two in the six to the tenth, seven in the eleventh to the fourteenth year.
The articular changes themselves cannot be strictly distinguished clin ically or anatomically in either type. In general, there is at first an effusion or a doughy swelling; later on more marked changes in the capsular ligaments and the surrounding soft parts (vinous proliferation, contraction of ligaments) in consequence of which there is a decided impediment to motion, finally positive contractions and immobilization, resulting in fibrous adhesions and production of ankylosis together with erosion and connective tissue transformation of the articular cartilages. Further, and usually later development shows participation of the bones, changing them into the types which cannot be distinguished from the so-called deforma tive joint processes. Separations of the epiphyses likewise occur (Spitzy).
From a clinical standpoint, the nodular swelling of the finger-joints is particularly striking (Figs. 112u, 114, 114a, b, c). The skin from time to time assumes a glazy inflamed appearance. Deviations of the fingers or toes to the ulnar side do not seem to occur in childhood, but another kind are seen.
Certain localizations, quite frequent in the chronic forms, are apt to put the poor suffering patient into a most lamentable state. This is also the case where the vertebral column is affected, particularly the cervical portion, and sometimes in the temporomaxillary and costal articulations.
Fig. 112 represents a girl in the pagoda attitude, with almost com plete immobilization; only move ments of the knees and slight motion of the arms were possible, the hips and the head were nearly immov able. She could lie only on her side.
The symmetrical attack of both halves of the body is extremely per sistent and this gave rise to the opinion that the entire affection is to be regarded as a tropho-neurosis. In some cases, however, this sym metry is not well marked. Atmos pheric changes may bring on an aggravation of pain, passive motion sometimes elicits marked crepita tion, particularly if the immobility in the stiffened joints is diminishing. Extreme atrophy of the muscles surrounding the joint is very notice able in all severe cases, produced partially by inactivity, partially through reflex tropho-neurotic in fluences (Iloffa).
The extremities assume with the thickening in the joints, quite a char acteristic appearance (see Fig. 112).
The diminution of the bone at the diaphysis is in part due to a high grade concentric atrophy of the bones themselves (Johannessen, Kien bOck, Reiner). The X-ray pictures show a continuous interstitial atrophy of the bones involved. An unusual diagnosis by means of the X-rays is reported by Reiner, namely, a corroded or split appearance of the badly swollen epiphyses of the phalanges of the fingers.
The children for the most part show a moist anaemic skin, once in a while, profuse perspiration with a miliary eruption, especially in primary cases, followed in one of my cases by furunculosis. Generally there is no fever, but it is more apt to occur in the primary cases.
Endocarditis with valvular lesions is found only in cases of the first group (see above).
Rare occurrences are abnormal lengthening and thickening of the large toe (Johanncssen, Spitzy), diminution and lessening of the lower jaw (Diamantberger), prevention of the growth and development of all the extremities (Hoppe-Seyler) and exoph thalmos (Diamantberger). Only one case belonging to the first type, that of Henoch, exhibited rheumatic nodules.