Rheumatism

456 Rheumatism (from Greek rheuma-flow, stream). Historical sketch. R. was already known to physicians of antiquity. However, for a long time, rheumatic diseases were united into one general group of 'arthritic diseases.' In 1635, Ballonius first introduced the term 'rheumatism,' designating by it pulling pains in the muscles and joints. The isolation of acute R. as an independent nosological unit initially proceeded by way of extracting other diseases from the collective group of rheumatism. Thus, first Ballonius (1635), Sydenham (1650), and Cullen separated gout as an independent disease. The remaining group of 'rheumatic' diseases was divided by Cullen into muscular and articular (joint) rheumatism (acute and chronic). Subsequently, in the 1830s, Bouillaud isolated from the joint lesions a group of 'pseudorheumatism,' including joint lesions in other diseases (gonorrhea, sepsis, typhus, etc.). This division was later more clearly carried out by Gerhardt, who gave these lesions the name still used today 'rheumatoid.' Chronic rheumatism is a collective concept, which includes chronic diseases of the locomotor apparatus, united by a specific reaction of the components of this apparatus to various pathogenic influences. This reaction consists of varying degrees of chronic inflammatory and dystrophic processes of the joints, bones, muscles, tendons, aponeuroses, peripheral nerves, etc. This reaction develops, as already indicated, as a result of the action of various pathogenic influences, apparently in the presence of a certain reactive capacity of the organism. This reactive capacity is either present due to inheritance or is acquired during extrauterine life as a result of the influence of various factors-meteorological, intoxication, infectious, etc. This basic feature of chronic rheumatism brings it closer to 'acute rheumatism,' in relation to which the allergic theory (see Acute rheumatism) has recently gained more and more supporters. But unlike chronic rheumatism, acute rheumatism is characterized, as is known, by a typical patho-anatomical picture-infiltrates and granulomas with a characteristic evolution into rheumatic sclerosis. For chronic rheumatism there is no typical patho-anatomical picture; patho-anatomical changes in chronic inflammatory processes of various etiologies can be completely identical, which incidentally gives, from the corresponding point of view, the right to unite all these processes with different etiologies into one large group of diseases. From this point of view, terms such as, for example, gonorrheal chronic rheumatism or chronic syphilitic rheumatism, gouty rheumatism, tuberculous rheumatism are also understandable. These terms denote those forms of diseases of the locomotor apparatus of corresponding etiology that proceed as a chronic inflammatory or dystrophic process, not differing essentially from each other patho-anatomically and even histologically. It is also necessary to avoid misunderstandings, it should be noted that for acute rheumatism, localization of changes in the cardiovascular system is especially characteristic, whereas lesions of the motor apparatus are not mandatory. On the contrary, in the diseases united under the term 'chronic rheumatism,' we have a dominant localization of the process in the locomotor apparatus, while lesions of internal organs and the cardiovascular system are not at all characteristic. In the 'unified working classification of rheumatic diseases and diseases of joints of different origins,' developed by a special commission of the Committee for the Fight against Rheumatism in the USSR, the term 'chronic rheumatism' is absent at all. Indeed, from an etiological point of view, the diseases united by this term are currently distributed as arthritis of various clinical types and different etiologies and pathogenesis. This undoubtedly has significance from the point of view of the further very desirable differentiation of these forms, but since these various diseases from an etiological point of view are accompanied by the same reaction from the tissues of the locomotor apparatus and in many respects similar, accordingly this identical tissue reaction, clinical picture, their conditional unification under the term 'chronic rheumatism' is quite permissible. It is justified moreover by the enormous practical significance of these forms of diseases, the difficulty of their differential diagnosis and in particular the possibility of their confusion with the so-called acute rheumatism. Etiology and pathogenesis. When studying etiology, one must take into account the significance of both indirect and direct immediate causes. Predisposing factors: general-heredity, age and sex; local-dynamic (traumatism) and static; to these should also be included climatic and meteorological conditions (cold). All these factors are summed up in the conditions of the social environment and professional labor. The indicated moments create and prepare the soil for the action of immediate factors-infections and intoxications. Among infections, the following play a role: chronic-septic gonorrhea, tuberculosis and syphilis. It is remarkable that for infection, significant virulence is not required, but on the contrary, artrotropic action is possessed by mild, low-virulence infections. One should add some more infections, which are sometimes complicated by rheumatoid phenomena, such as scarlet fever, dysentery, typhoid fever. It should be mentioned that some infections have a selective relationship to certain joints, for example, gonorrhea more often affects the knee, while typhoid fever affects the spine. Microbes of the infectious focus (in the tonsils, intestines, teeth, etc.) primarily create local sensitivity from various parts of the body, so that subsequently the entry into the blood of antigens, microbes or their toxins is sufficient to provoke, intensify or maintain rheumatic changes (the so-called allergic action). Still practically, we encounter many patients in whom, in the presence of joint lesions, we find no focus at all with the most careful examination. On the other hand, there are also such persons whose joints are completely healthy, while they are obvious carriers of infection of the oral cavity and teeth. The influence of exogenous intoxications seems simpler, for example, lead arthropathies (former name-lead gout), the influence of other external poisons is less proven (alcohol). Endogenous intoxications are more complex and diverse: metabolic disorders (uric acid, oxalic acid, cholesterol, calcium, etc.), with which the concept of arthritism (see) and humoral processes in the form of allergic reactions are associated. One must think that the resolution of the problem of pathogenesis of chronic R. lies in deciphering the influence of toxic factors on the physicochemical properties of the internal environment of the organism, and intoxication should be understood broadly; it consists of endogenous and exogenous moments. The endogenous status of the patient in the sense of his constitutional peculiarities and his so-called humoral individuality has great significance for understanding the pathogenesis of rheumatism and should be analyzed from different sides. New information obtained through the study of allergy, in particular anaphylaxis and sensitization, should shed bright light on the pathogenesis of R. The countless number of sensitizins, which are the result of all infections and intoxications undergone, all hygiene and nutrition errors, can give each individual his own humoral individuality. The so-called arthritic soil can be inherited by heredity; the general and vague concept of the latter is beginning to differentiate. Significant shifts are observed in the protein formula of the blood in the direction of coarse-dispersion fractions. The accumulation in the blood of large, easily flocculating molecules of fibrinogen may be a moment maintaining the severity of these processes. On the other hand, the accumulation in the blood of fibrinogen and globulin may be a reflection of delayed protein metabolism, delayed at an earlier stage of their sequential formation, which is, according to the theory of Herzfeld and Klinge, the fraction of fibrinogen and globulins. One must think that the study of the physicochemical properties of blood will open up a number of new facts, which will even more brightly illuminate the significance of the endogenous status. In addition to the mentioned moments in the pathogenesis of chronic rheumatic processes, three more systems are of importance: vascular, nervous and hormonal. Weakened infections clearly prefer joints, which represent 'dead spots' of blood circulation. In arteriosclerosis, the conditions for nutrition of various parts of the locomotor apparatus of course become even worse, therefore it is known that chronic forms of R. are more often characteristic of elderly subjects with developed arteriosclerosis. Further, one should touch upon the significance of lesions of the nervous system (in the sense of violation of trophic function) in the origin of various changes in the locomotor apparatus. In this respect, the experimental works of A. D. Speransky, concerning the study of the participation of the nervous system in various pathological processes, are of enormous interest.

In pathology, more and more facts were accumulating, indicating that the starting point of pathological processes occurring on the periphery is the primary lesion of the nervous system. A. D. Spersky, through experiments on dogs and rabbits with simple chemical substances, toxins, and viruses, elucidated a number of questions about the role of the nervous system in general and local pathological processes. There is a whole series of clinical data speaking in favor of the 'trophic' influence of the nervous system in various rheumatic processes; symmetry of lesions, trophic changes in the skin, lesions of joints in hemiplegias, in tabes and syringomyelia, etc. From this arises a new view on the pathogenesis of R., according to which the dominant position in the pathogenesis of the disease is occupied by the lesion of the nervous system. If under the influence of infectious or toxic irritation, reaching the nerve cell not only through the bloodstream but also through the nerve trunk, the latter has changed its structure and function, then this alone is sufficient to maintain trophic disorders on the periphery. Changes in the locomotor apparatus are thus possibly the result not of the action of the irritant on the local tissue on the periphery, but these changes are the consequences of the trophic influence of the nerve cell affected by the rheumatic process. This new neurotrophic ingredient in the pathogenesis of R. could explain to us many dark sides of the complex process. Among these sides, special importance has the elucidation of the question of the transition of various acute lesions of joints into chronic form. The ease and frequency of such a transition, the absence of immunity, the tendency to relapses could be explained by the lesion of the nerve cell itself, since its repeated irritations cause more persistent changes in it, and consequently in the peripheral tissues connected with it. One could think that under this influence there finally comes a moment when the restoration of the normal state of the nerve cell becomes impossible and then peripheral disorders in the form of lesions of the locomotor apparatus become persistent and acquire a chronic course. Another moment, determining the chronicity of the course of R., possibly lies in deviations on the part of the hormone-forming apparatus, in particular in the lesion of the thyroid gland or sex glands. It has long been pointed out (Sergent) that in acute R. there are signs of thyreosis. If the rheumatic virus acts on the thyroid gland and causes a disorder of its function mainly in the direction of its decrease, then the latter circumstance can contribute to the transition of acute rheumatism into a chronic course. General semiotics. The beginning of chronic R. is varied: 1) it either arises secondarily from acute R., namely the usual attack of acute R. passes into chronic form (see Acute Rheumatism), and it can give on the background of chronic course exacerbations, 2) or, which happens more often, the process begins imperceptibly, silently, without an acute onset and takes a slow, chronic and progressive course. This is primary, chronic, progressive polyarthritis (Vyalyaminov), which does not give repeated relapses and drags on for years with the outcome in deforming arthritis or bony ankylosis. When chronic R. reaches its full development, it is expressed by many symptoms: 1) arthralgia, i.e. pains in the joints on pressure and especially on movement; 2) crepitation, which can be combined with pains or observed without them, it is felt on palpation and auscultation of the joints and is very characteristic of dry arthritis; 3) swelling of the joint due to the accumulation usually of a small amount of exudate in the synovial bursa; 4) fibrous tightening of periarticular tissues with ankylosis; 5) more or less considerable deformation or disfigurement of the joints, which are the consequence of destruction of ligaments, melting of cartilage, formation of osteophytes and tightening of tendons, finally atrophy of muscles; the latter is always present and is very characteristic of deforming arthritis. All these signs are usually combined with functional deviations, which are expressed by pains and disturbance of movements in varying degrees from temporary painful contractures to complete immobility due to ankylosis. Chronic R. is usually not accompanied by fever and other general symptoms. Huge importance for the diagnosis of chronic arthritis and the degree of lesion have X-ray photographs (and not only fluoroscopy) of the affected joints. The thing is that sometimes we can have enormous disfigurement and swelling of the joints, but at the same time the bone and cartilage are not changed, all changes go at the expense of soft tissues, which are permeable to X-rays, and therefore the photographs do not reflect these pathological cases. In other cases the process goes more deeply and affects the hard tissues: cartilage and bone, and then on the photographs we see characteristic changes in the form of atrophy or destruction of cartilage and bone or formation of osteophytes due to reactive proliferation of bone elements. Those arthritides which are accompanied by changes in the hard parts have received the name of osteoarthritides. Thus the X-ray method makes it possible to make a deeper differentiation and divide arthritides into two groups with bone-cartilage changes (osteoarthritides) and without them. X-ray signs are schematically reduced to the following: deformation of the epiphyses of the joints, which due to destruction of cartilage come into contact, sink, form subluxations, are worn down, atrophy or hypertrophy, are covered with spines due to formation of osteophytes or fuse together. Especially expressively these changes are expressed in the joints of the hand and wrist, when the deformed bones form a continuous bony mass in which it is difficult to distinguish one bone from another. Clinical forms of 'chronic rheumatism'. Classification of diseases belonging to 'chronic rheumatism' still serves as the subject of heated disputes and with the present state of our knowledge a scientifically based classification is impossible. Using purely practical purposes, we divide all forms of chronic rheumatism into two groups: 1) forms with multiple localizations (polyarthritis) and 2) local forms with lesion of one joint or one spine. I. Forms with multiple localizations (polyarthritis). 1. Simple chronic R., also called synovial R.-this is the mildest form of chronic R. without deep anatomical lesions; the process affects only the synovial membrane. The disease occurs in adults and develops primarily, independently or after acute R. The beginning is usually imperceptible, without inflammatory phenomena and great pains. Usually the large joints (knee, shoulder) are affected without any symmetry, sometimes the process localizes on one side of the body. It is manifested by certain pains in the affected joints, and these pains are mild and dull, on physical examination no changes are found on the part of the joints (no swelling nor changes of configuration), except crepitation, which can be so strongly expressed that it is heard at a distance when the patient makes any movements, e.g. climbs stairs, rises from a chair, turns in bed, etc. However sometimes this crepitation is so weak that it is felt only in the form of slight friction on palpation of the joint or even only on its auscultation. This form has a favorable course. Treatment with warm salty sea baths is indicated. For some more stubborn cases treatment with mud and saline baths on the liman (Saki) or by the sea (Yevpatoriya, Odessa) is useful. Various local, thermal and physiotherapeutic procedures are also successfully applied. 2: Chronic disfiguring polyarthritis (see also Arthritis--deforming arthritis); it was described by Charcot under the name of chronic disfiguring R. This disease is observed at any age, even in children, but more often in adults from 40 to 60 years, especially in women in the climacteric period. Its beginning is sometimes acute and is expressed by attacks of acute arthritis with redness and swelling of the joints and even with fever, though short-lived. More often however it immediately takes a chronic course and is manifested by swelling of the joints (without redness) and pains in the joints, which have the character of dull and aching. Lesions are usually located symmetrically, beginning in the small joints of the hands, and sometimes also in the big toes, then the shoulder joints are affected, then the disease passes also to the lower extremities: ankle joints, knees; hip joints are rarely involved in the process. In very severe cases the spine and jaws are affected. At the beginning the patient is troubled by pains, aggravated at night and accompanied by cramps of the muscles surrounding the joints, and then soon the deformation of the joints begins to appear, which in essence is the most characteristic symptom of this suffering. This deformation depends on the swelling of the soft parts both forming the joint and those surrounding it, on the thickening of the synovial membrane, as well as on a small exudate in the cavity of the joint itself. The hard parts-cartilage and bone also swell due to regenerative hyperplasia and formation of osteophytes. For this disease abnormal positions and postures of the corresponding segments of the affected extremities are very characteristic.

These deviations in position arise as a result of deformation due to atrophy and contracture of adjacent muscles and the tightening of their tendons. The appearance of the hand in a state of pronation with deviation of the fingers toward the ulna bone is particularly characteristic, with the phalangeal joints of the fingers being in a state of either flexion or extension. Poses are also observed where the fingers are extended in a straight line with flexion of the metacarpophalangeal joints. If the elbow joints are affected, the arm is immobilized in a bent position. When the shoulder is affected, it is fixed to the chest, and its movements are extremely limited. The legs are in a varus equinus position, less often valgus. The ankle joint is ankylosed. The internal condyle of the knee is protruded, and the patella is thrown outward. The cervical vertebrae may also be affected, in which case the head is sometimes bent so far that the chin touches the chest. To these joint deformations are added trophic disorders affecting the muscles, skin, and its appendages. Muscle atrophy is always present, it is especially striking on the hands, where the bones and tendons abnormally protrude under the skin, and the interosseous spaces are considerably sunken. This atrophy is not accompanied by fibrillary twitching, however, tendon reflexes are usually heightened. The skin is thinned in places, especially where it is subjected to pressure, and calloused. The hair is atrophic and falls out, the nails are thickened, transversely striated, and easily broken. Movements are impaired depending on the degree of affection, ankyloses, subluxations, atrophy, etc. 3. Fibrositis. A special form of chronic R. deserves mention, which in England has been named fibrositis. This disease occurs very frequently, has diverse localization: in the muscles, ligaments, joint capsules, sheaths of peripheral nerves—in short, wherever there is connective tissue. Fibrositis represents an inflammatory process arising as a result of infection or intoxication, characterized by the formation of connective tissue nodules (they can be palpated when the muscles are relaxed). Among the diverse clinical manifestations of fibrositis, persistent headaches caused by inflammation of the aponeurosis of the head and fibrositis of the right m. recti, which in the presence of dyspeptic disorders simulates chronic appendicitis, ulcer, and even stomach tumor, are noteworthy. Fibrositis most often localizes in the muscles of the neck, back, and shoulder. It often involves the sheaths of peripheral nerves and gives a picture of neuritis (polyneuritis multiplex). An important form of fibrositis is periarticular fibrositis, which can easily be mistaken for true affection of the joint itself. In this process, the fibrous capsule of the joint and surrounding ligaments participate, but not the synovial membrane. Usually this disease is one of the manifestations of general fibrositis. It is characterized by pain on movement and limitation of joint mobility, in the absence of crepitus and in the presence of muscle atrophy. X-ray examination indicates the integrity of the joint (no osteophytes are visible on the radiograph). Some deformation, not as typical as in deforming arthritis, is noticeable on the small joints. The process often ends in fibrous ankyloses. In diagnostic terms, fibrositis must be differentiated from arthritis and osteoarthritis of various origins, as well as from hysterical rigidity of the joints. This form was separated from deforming arthritis by old clinicians (Jacque) under the name of chronic polyarticular fibrous R. Treatment should be carried out in the early period, before the development and shrinkage of scar tissue has occurred. In severe cases of the latter, it is not possible to prevent it. In differential-diagnostic terms, all these three described forms of the polyarticular process (simple chronic polyarthritis, deforming polyarthritis and fibrositis) can first of all be confused with chronic gout, which can cause generalized arthritis with at least apparently significant deformation of the joints (see Gout). Besides gouty arthritis, in differential diagnosis, mention can be made of other rarer affections, such as hemophilic arthropathies, tabetic, etc. The diagnosis of these forms is easily established by the presence of signs of the underlying disease (characteristic gouty attacks, tophi in gout, bleeding in hemophilia, symptoms of syphilis). It should be borne in mind that the differentiation between chronic R. and gout has only "conditional significance, because affections of the locomotor apparatus are most often of a combined nature. Thus, in one patient, if predisposing and producing causes are taken into account, several diseases can develop simultaneously, and one can pass into the other. For example, a patient can simultaneously have gouty arthritis, deforming arthritis, and fibrositis, and he may also have the effect of focal infection—infectious arthritis. II. Forms with localizations. These forms should be considered regional, because they involve affection of one joint or a group of neighboring joints. The most typical localizations are as follows: affection of the hip, shoulder, spine, and hand. 1. Chronic R. of the hip and shoulder. Here we are dealing with affection of homologous joints, deeply situated with a round head. Therefore, each of these affections has many common features. The disease is observed in both sexes at the age of 50 to 60 years. Usually one joint is affected, sometimes another nearby, but symmetricous affection never occurs. The process from the very beginning acquires a chronic course. a) Chronic R. of the hip—malum coxae senile—(see also Arthritis). It begins with difficulties in movement of the hip joint up to complete loss of movement; pain in the joint on movement and less intense at rest; crepitus noticeable to the patient, and atrophy of the muscles of the thigh and buttock on the corresponding side complete the clinical picture. b) Chronic R. of the shoulder is expressed by the same symptoms, but they are more striking due to the less deep position of the joint. Dull pains in the shoulder area are sharply intensified with pressure on the head, crepitus is felt on palpation and movement, sometimes a small effusion is observed, movements in the joint are limited or impossible, when the shoulder is abducted, the scapula moves. Atrophy of the muscles is pronounced (especially of the deltoid and subscapular), from which the acromion protrudes sharply. In differential diagnosis of these two forms of local R., it is necessary to exclude tuberculosis, osteosarcoma, and syphilis. TB more often affects young subjects, pains and crepitus are sharper in R. Painful points on the bones and swelling of the lymph glands speak in favor of TB. The question is decided by X-ray. In osteosarcoma, pains are more intense and more persistent, while movements are freer. X-ray shows rarefaction of bone tissue due to its replacement by cells of the new growth. Syphilitic osteo-arthritis rarely localizes in the hip and shoulder. In it, pains are often at night, movements in the joints are little limited. Fracture of the femoral neck and its congenital dislocation can sometimes be confused with malum coxae senile, but the question is easily resolved by X-ray. Finally, affection of the sciatic nerve, especially with its high localization, in rare cases can simulate rheumatism. 2. Affections of the spine. Two forms of chronic affection of the spine should be distinguished: a) pure R. of the spine and b) R. of the spine with subsequent ankylosis and accompanying affection of the shoulder and hip joints—spondylosis rhizomelica (see Marie's disease). Rheumatism of the spine in pure form was first described by Leiden in 1874 under the name of deforming arthritis of the spine. According to localization, three forms of this affection are distinguished: lumbar, dorsal, and cervical. The most frequent is lumbar localization (lumbago, according to Leri), especially widespread during the last war. The disease affects relatively young subjects from 20 to 40 years and is manifested by pains in the lumbar region in the form of lumbago, pains radiating to the area of the sciatic nerves, less often to the area of the outer part of the thigh along the n. cruralis, and accompanied by irritation of the nerve roots. These secondary nerve phenomena lead to muscular atrophy of the adductors and m. quadriceps and weakening of the knee and Achilles reflexes. The lumbar region is straightened with disappearance of the normal lordosis, and movements of the spine in the lumbar region are limited, however without its rigidity. The dorsal form is observed less frequently. Pains are localized in the dorsal vertebrae with radiation along the intercostal nerves. Deformation is observed in the form of kyphosis or kyphoscoliosis. The cervical form is expressed by pains in the occiput and neck, stiffness of the cervical region, sometimes by incorrect position of the head (torticollis—wry neck), and finally by nervous disorders, such as root pains, paralyses, and atrophy of muscles. Diagnosis of all three mentioned forms of rheumatism of the spine is often difficult on the basis of clinical signs alone. It is elucidated by X-ray examination of the spine, which shows characteristic affection of the vertebrae: formation of osteophytes in the form of hooks, spurs, resembling a "parrot's beak," etc., and formation in the bodies of the vertebrae of islands of osteoporosis in the form of "wasp nests."

These spondylitic changes are observed in those lesions of the spine that arise as a complication after typhoid fever. 3. Chronic rheumatism of the hands. Some specific deformities of the hands depend on the local localization of chronic rheumatism. a) Heberden's nodes are located symmetrically on both sides of the finger phalanges (usually excluding the thumb), they are hard to the touch and the size of a pea. Mostly they are painless and do not particularly impede movement in the joints. X-ray examination reveals that these are not tophi, but bone hypertrophy. Most often these nodes are combined with other signs of deforming arthritis. b) Contracture of the palmar aponeurosis or so-called Dupuytren's contracture. The disease begins with difficulty in extending the fingers, usually the fourth and fifth, which gradually bend and remain in a state of flexion. The affected fingers seem to grow into the palm. On the palm, dense tissues fused with the skin form along the axis of the flexor tendons. The skin over them is dry and hard. The course of all the above forms of chronic rheumatism is chronic, slowly progressive, wave-like, in which periods of remissions are replaced by exacerbations, and after each exacerbation the patient's condition progressively worsens. The duration of chronic rheumatism is indefinite, it can last more than 20 years. Its outcomes: 1) complete recovery is a very rare exception and is observed only in childhood, 2) under the influence of rational treatment, improvement or at least cessation of the process or delay in its progressive development is possible, but this is often only temporary, 3) fatal outcome is the result of cachexia occurring due to such prolonged immobility of these patients. Patients often die from pulmonary tbc or chronic nephritis, which have affected a weakened soil. Only rational therapy can alleviate the poor prognosis, and the latter requires in each individual case a more careful study of etiology. We have already pointed out the significance in the etiology of rheumatism of infection, exogenous intoxication and endogenous intoxication or auto-intoxication. Now, after describing the clinical picture of chronic rheumatism from the morphological side, we will proceed to the analysis of the three indicated etiological factors, and then elements of etiological diagnosis will be revealed. Forms of rheumatism by etiology. 1. Chronic rheumatism of infectious origin. A. Chronic rheumatism as a consequence of acute or true rheumatism (see Acute rheumatism). It is necessary to know that one of the main etiological factors of chronic rheumatism is a past attack of acute polyarthritis. It usually begins in young subjects after the classical picture of acute rheumatism with fever, pains and swelling of many joints. The acute attack ends, and pains remain mainly in the small joints, and they gradually begin to deform. Most often this form takes the appearance of progressive arthritis or fibrositis. It is often accompanied by lesions of the cardiovascular apparatus in the form of mitral or especially aortic defects. Some authors (Sergeant) point out that the transition of acute rheumatism to chronic is observed mainly in cases where patients have goiter or myxedema or if during the acute attack irritation of the thyroid gland was observed. This irritation of the thyroid gland during the acute attack is expressed by swelling of the neck: in the area of the gland and mild symptoms of Basedow's disease (tachycardia, tremor, feeling of heat). This dysthyroidosis possibly creates the soil for the chronic course of rheumatism. For therapy, it is sometimes useful to use thyroidin. B. Gonorrheal chronic rheumatism (see Arthritis, gonorrheal arthritis). It is necessary to recognize the possibility of the existence of chronic gonorrheal rheumatism, since in many chronic arthritis gonococci were found in the exudate during joint punctures. The process is more often localized in the large joints, knees, elbows, wrist in the form of plastic ankylosing arthritis, which usually occurs after an acute attack. C. Chronic tuberculous rheumatism. The problem of tuberculous rheumatism, which arose under the influence of observations by the Italian clinician Grocco (1892) and the Lyon school headed by Poncet (1896), has recently regained importance. The issue is not about a specific lesion of cartilage and bones in the sense of so-called surgical tbc, but about the fact that a patient with lesions of other tuberculous organs, in the second period according to Ranke's classification, in the period of bacillary generalization and increased allergy, may give changes from the side of the joints and even an acute attack of the nature of acute polyarthritis. According to the observations of Reitter and Lowenstein, tubercle bacilli were found in the synovial fluid and in the blood. However, the latter fact was not given specific significance by subsequent authors, and they considered tuberculous rheumatism pathogenetically as an allergic reaction as a result of the action of tub. ultra virus (Bezancon), and histologically in some cases typical Aschoff granulomas were found, which are regarded as the anatomical substrate of the indicated allergic reaction. There is no doubt that in the clinic we not infrequently observe in tuberculous patients various changes from the side of the locomotor apparatus, having either a persistent or transient character. - Chronic tuberculous rheumatism, according to Poncet, is represented in the clinic in four types: a) deforming generalized polyarthritis, similar to the described typical form of disfiguring polyarthritis; b) ankylosing plastic arthritis, localized mainly in the large joints: knee, hip, elbow, ankle joint, but sometimes with involvement of the fingers; c) the type of chronic synovitis with pains, with multiple localizations and simultaneously occurring arthritis; d) spondylosis, completely analogous to rhizomelic spondylosis. The diagnosis of the tuberculous nature of these various arthropathies is based on the following data: 1) Development of the process in the joints in subjects with clearly tuberculous conditions with active phenomena or who have definitely had tbc (tuberculous pleurisy, pulmonary tbc). 2) The diagnosis is based on the X-ray picture, showing characteristic X-ray changes in the form of white islands on the ends of bones due to uneven rarefaction of bone tissue under the influence of the action of tubercle bacilli, this is more often observed on the heads of finger phalanges. 3) Positive results from inoculating pigs with fluid extracted from the joint confidently speak for the tuberculous nature of the suffering and finally 4) the same is indicated by the above-mentioned bacteriological finding of Koch's bacilli. D. Chronic syphilitic rheumatism, arthrolues - see Arthritis, syphilitic arthritis. E. Other forms of infectious chronic rheumatism (see also Arthritis, rheumatic arthritis). Of other infections causing chronic rheumatism, the greatest role is played by septic infections, mainly streptococcal. Similar to acute, chronic rheumatism can occur after scarlet fever, erysipelas, pneumonia, dysentery. But special significance and interest are arthritis appearing after acute or in conjunction with chronic angina, tonsillitis and other hidden septic foci (in teeth, tonsils, intestines, genitourinary organs, from nasal sinuses, middle ear, in bronchi and in the gallbladder). This arthritis received the name of focal arthritis and is characterized by the most severe course. The disease is expressed by signs of general intoxication: anemia, general weight loss (especially muscles), weakness, subfebrile temperature. Joint lesions are quite symmetrical. Large joints do not always suffer. There is a special predisposition to the disease of the small joints of the hands and feet. The joints take on a spindle-shaped form, depending partly on thickening of the joint capsule, partly on an increase in the amount of synovial fluid. The skin over the joints becomes pale, bluish-gray and loses elasticity. For late stages of the disease, atrophic, shiny skin is extremely characteristic. There are no edemas. On X-ray films, the transparency of the bones adjacent to the joints is noticeable. In advanced cases with far-reaching degenerative changes, erosion of cartilage and even articular ends of bones is observed. An important symptom is muscle contractures. Shrinking of tendons and thickened inflamed joint capsules causes a sharp limitation of mobility, especially of extensors, and sometimes complete immobility with subluxations. On the hands, the metacarpophalangeal and interphalangeal joints are most often affected. Contracture of these joints gives the hand a characteristic shape. Relaxation of the ligaments of the foot and ankle leads to displacement of the head of the talus and causes severe flatfoot. Elbow, wrist, hip and knee joints are fixed in the flexion position, shoulder joints in the adduction position. - Juvenile focal arthritis (Still's disease) (see below). 2. Chronic rheumatism of toxic origin. Among external poisons, lead gives the most definite picture. In workers dealing with lead, chronic arthropathies (lead gout) sometimes develop in the form of arthralgia (joint pains) and hydroarthrosis.

At the same time, these patients also exhibit other signs of lead poisoning (anemia, lead line on the gums, lead paralysis, etc.). Chronic rheumatism from alcohol and carbon monoxide oxide has been described, but these poisons are not causative factors, but can only be considered as predisposing moments or aggravating factors. Chronic rheumatism due to auto-intoxication. Endogenous toxic factors can hardly serve as the sole causative cause of chronic rheumatism; rather, it should be thought that they are important components in a series of other factors. However, we must point out those syndromes when joint damage is closely associated with auto-intoxication. 1) Bouchard described nodules located on the lateral sides of the finger phalanges with stomach dilation under the influence of hydrochloric acid intoxication. 2) In biliary cirrhosis of the liver, arthropathies (Gilbert, Fournier) have been described, localized in the large and small joints: the fingers take on the appearance of drumsticks (so-called Hippocratic fingers); similar changes are also observed in some other diseases (see Drumstick fingers). Sometimes the process is not limited to the nail phalanges, but extends higher, also symmetrically involving the forearms and shins and affecting the large joints. This is a special form of arthropathy described by Marie and Bamberger under the name arthropathie hypertrophiante pneumique. The genesis of this hypertrophic process is unclear. The symmetry of the lesion speaks for the trophic influence of the nervous system, the distant peripheral localization for the influence of the circulation, and the connection with respiratory system damage indicates internal intoxication. 3. Rheumatism of endocrine origin. A. Thyrogenic forms of rheumatism were first described by Sergent in 1894 in France, and in our country by Professor Velyaminov. In 1910, Konchalovsky gave an outline of this question at the Moscow Therapeutic Society and presented two cases successfully treated with thyroidin. It is indicated that in acute rheumatism, the thyroid gland is almost always affected (see Acute rheumatism). As a result of this, after the disappearance of the acute attack of rheumatism, phenomena of dysthyreosis remain, which affect the joints. Some patients suffering from thyrogenic rheumatism had in their anamnesis signs of extinguished Basedow's disease. More often, joint phenomena are combined in patients with signs of hypothyroidism or myxedema, namely, mental lethargy, swelling of subcutaneous tissue, dryness of the skin, loss of hair, etc. The prescription of thyroidin gives a rapid effect; with the onset of pregnancy, in which the activity of the thyroid gland is revived, improvement also occurs. One cannot consider that the impaired function of the thyroid gland is the sole cause of these arthropathies. Apparently, other above-mentioned factors also play a role here - arteriosclerosis, metabolic anomalies, latent infection, etc. Each case requires careful analysis in terms of etiology, but one cannot refuse the predominant importance of dysthyreosis. This is especially evidenced by the therapeutic effect of thyroidin. B. Climacteric arthritides. With the disappearance of ovarian function during the climacteric period in women, joint lesions are observed, most often in the knees, having the character of deforming arthritis. The joints of the hand and the metacarpophalangeal joints of the thumbs are also affected. The prescription of ovary preparations gives improvement. In this form, one must also take into account age, metabolism (obesity, gout) and other moments. Climacteric arthritis usually begins between the ages of 40 and 50, almost exclusively in women of the hypothyroid type. Patients complain of gradually increasing pain in the knee joints and their stiffness. On examination, attention is drawn primarily to the accumulation of fat in the pelvic area, on the buttocks, thighs, and abdomen. The fat feels dense to the touch. Signs of insufficient thyroid activity are observed simultaneously: apathy, drowsiness, lethargy, loss of hair, dryness of the skin. On examination of the knee joints, their enlargement is found, depending partly on periarticular thickenings, but mainly on inflammation of the synovial membrane. On palpation, crepitation is clearly felt, which in the early stages of the disease is so weak that it can only be detected by auscultation. The disease is a chronic synovitis. The synovial membrane, as observations of some cases show, is thickened, abnormally vascularized, and loses its characteristic luster. In early stages, no changes are visible on X-ray. In advanced cases, the inflammatory process, which initially affects only the synovial membrane, spreads to the cartilage and bony elements of the joint, and as a result, typical osteoarthritis develops with loss of cartilage, rarefaction of bone, and proliferation of osteophytes. For the success of treatment, general dietary conditions are extremely important, namely restriction of flour and sweet foods, warm baths, massage, gymnastics. The endogenous origin of these arthropathies is confirmed by the therapeutic effect that patients receive from the prescription of ovary preparations and thyroidin. Prevention and treatment. The treatment of chronic rheumatism requires enormous patience on the part of the patient and the physician. In almost all cases, complex, combined treatment is proposed. However, its basis is primarily the physician's desire to act on the cause of the disease. Unfortunately, the evolution in the course of chronic rheumatism shows that the treatment of this disease is rarely curative in the true sense of the word. It is good if it is possible to delay the generalization of the process, stop the beginning deformations, and avoid ankyloses. In the first place are general hygienic measures that affect the arthritic soil of the patient. Attention is paid to the place of residence, housing, clothing, nutrition, skin hygiene, exercise, and appropriate dosing of mental and physical work. All these measures also serve as the best means of prevention. The latter with respect to chronic rheumatism is based on the following points: 1) it is necessary to energetically treat acute rheumatism with sodium salicylate, vaccines, protein therapy, etc. until the complete disappearance of arthropathy; 2) the consequences of acute rheumatism must be subjected to careful sanatorium treatment (warm, saline, sea, brine baths, mud); 3) it is necessary to prescribe to arthritics who have recurrent subacute rheumatism attacks a corresponding dietary regime with prohibition of foods rich in purines (game, ham, animal offal, etc.). In oxaluria, spinach, tomatoes, chocolate, etc. are prohibited. At the same time, mineral waters and such means as atophan, urodanal, lithium, sidonal, piperazine, etc. are prescribed. Drug treatment varies depending on the main cause of suffering. We have already indicated the importance of thorough treatment with salicylate preparations in cases where chronic rheumatism arises from acute. We have also indicated the basis for specific therapy in arthralgia. In gouty joint damage, the importance of a vegetarian regime and the use of means that dissolve uric acid is noted. In tuberculous rheumatism, a strengthening diet including meat foods and iodine therapy in the form of t-rae Jodi (from 10 to 25 drops per meal and even 50) or Lugol's solution (Jodi puri 0.3, Kalii jodati 3.0, Aq. destill. 15.0) 10-20 drops 2 times; cod liver oil, sometimes tuberculin injections. In gonorrheal arthritis, vaccine therapy must be applied. As stated above, focal arthritis requires removal of the focus of infection, as well as the use of vaccines and sera. A large place in treatment is also occupied by symptomatic therapy, which is aimed at fighting anemia and general weakness, pain and dyspepsia and intestinal intoxication. Anemia and weakness require the use of tonic means and drugs that stimulate hematopoiesis, for example, arsenic, iron, quinine, strychnine. To fight pain, which is a constant symptom of all forms of chronic rheumatism, the following are prescribed: pyramidon, antipyrine, phenacetin. Aspirin can be combined with bromine. In extreme cases, narcotics - opium and morphine - are used. A huge number of ointments and rubs have been proposed for chronic rheumatism (10% salicylic ointment, salicylic methyl, ointments with camphor, belladonna, etc.). Dyspepsia is often found in focal arthritis and fibrositis. Usually, achylia or hypochylia is observed. The patient must be prescribed hydrochloric acid and diet. Intestinal disinfectants usually do not achieve the goal. To prevent abnormal intestinal fermentation or at least reduce it, bowel evacuation is regulated with the help of laxatives, mineral waters or enemas. The best laxatives are sulfur preparations, which cause mild laxation without pain and moreover have bactericidal properties. Sulfur is recommended besides as a good symptomatic remedy against rheumatism in oil solution under the skin or in colloidal form intravenously (according to Lenner, from 1/2 to 2 cm³ of 1% solution daily for 10 days). A huge place in the treatment of chronic rheumatics is occupied by the use of natural and artificial forces of nature.

Such factors as climate, mineral waters, various baths, mud, the application of heat, light, ionization, diathermy, massage, gymnastics, and finally various orthopedic methods have very serious significance and in each specific case require strict establishment of indications. The restoration and improvement of lost or limited functions of the motor apparatus and thus the return of the rheumatic patient to work is possible with the help of such, admittedly often prolonged, combined and complex treatment. It has long been known that chronic R. is especially common not in elevated, sunny places, but in cold, low-lying and damp ones. It has been proven that ultraviolet rays have a great influence on general metabolism and nutrition, improve the condition of the blood and increase the body's resistance to chronic infection. Ultraviolet rays are absorbed by a humid atmosphere. Therefore, it is possible that the frequency of rheumatic diseases in damp localities depends partly on the lack of these rays. Thus, rheumatic patients need a warm, dry, even and sunny climate. Balneotherapy is widely used in the treatment of R., in the form of prescribing mineral waters of various concentrations and temperatures, and externally hydrotherapeutic procedures (baths, showers, douches and rubdowns). A special role is played by mud therapy. In the USSR there are numerous mud resorts in the north (Staraya Russa, Shira, Karaga), in the center (Lipetsk, Sergievsk, Slavyansk) and in the south by the sea (Odessa, Yevpatoria, Saki, Anapa) and lakes (Tambukan, Elton, etc.). Mud therapy is indicated for all slowly inflammatory processes developing on the basis of infection or intoxication and accompanied by the formation of effusions, infiltrates, adhesions and scars. Among physiotherapeutic procedures, ionization and diathermy are particularly beneficial.

M. Konchalovsky. The organization of rational rest and periodic medical examinations can play a significant role in detecting early forms of R. and implementing specific measures of assistance (in Moscow and Leningrad, Kharkov, Staline, committees for the fight against R. have organized special anti-rheumatic clinics at unified dispensaries on railway and water transport, in machine building and metallurgy). Finally, it is necessary to widely develop work in the area of developing rational treatment methods. We will here dwell only on the most effective methods of treatment and restoration of work capacity of rheumatics—on resort therapy, which is one of the major links in the healthcare system. The number of rheumatics treated at all resorts of the Union in 1931 exceeds 120,000 people. Of this number, only at 9 largest all-state resorts in sanatoriums, not counting outpatients, 69,100 people were treated (in 1930 - 56,300 people, and in 1925 - 28,250 people). Such methods of struggle based on the growth of the material level of the working class, naturally, lead in the USSR to a decrease in rheumatic diseases. This is clearly visible from the latest data of the sanitary statistics department of the Erisman Institute; in all branches of industry in the city of Moscow, the morbidity rate of R. in 1932 decreases compared to 1931 [for acute and chronic R. we have in 1931 - 22.6 days of disability against 18.3 days in 1932 per 100 insured, for neuritis - 19.8 (1931) against 16.2 (1932) and for muscular rheumatism instead of 11.6 (in 1931) only 8.0 (in 1932)]. This decrease occurs in almost all branches of industry (metalworkers, machine building, chemistry, textile, food, sewing and shoe industries). _t Rheumatism as a social problem. The widespread occurrence of so-called 'rheumatic' diseases, causing great economic damage, has led to a large movement in all countries to study these diseases, clarify their causes, preventive measures and rational therapy. The enormous economic significance of R. has led to the international unification of forces to fight this evil. The idea of organizing an International Committee for the Fight against Rheumatism was put forward in 1912 (Paris) at the congress of the International Society of Medical Hydrology, where a series of reports aroused great interest in the problems of 'rheumatism'. In 1913 at the International Congress of Physiotherapy (Germany) on the report of Van Breemen it was decided to organize a methodical study of 'rheumatic' diseases in different countries. The war interrupted this work until 1925, when at the International Society of Medical Hydrology (London) an international committee for the fight against R. was founded, renamed in 1928 the International League. The task of the league, according to its charter, is: to study the etiology and pathogenesis of diseases combined under the concept of 'rheumatic', to establish a unified classification, to develop methods of prevention and treatment. On the initiative and proposal of the International League, national committees were established in almost all countries: in Germany, France, Austria, Belgium, Denmark, USSR (1927), USA and others (over 20). On the initiative of the committees, special institutes were established in Aachen (Krebs), in Vienna (Freund), in Budapest (Koranyi), a special consultation bureau and an international library were created in Amsterdam. The League has had its printed organ 'Acta rheumatologica' since 1929. The International League has held three congresses (Budapest-1929, Liege-Amsterdam-1931, Paris-1932). The idea of organizing an All-Union Committee for the Fight against R. in the USSR was supported by a joint meeting of the plenums of the Vth Resort and II Physiotherapy Congresses in Moscow (1927), which decided it was necessary to establish a committee at the People's Commissariat of Health of the RSFSR. Under the leadership of the Committee, corresponding institutes and scientific institutions are to be united for the purpose of studying the problem. On the initiative of the Committee, 23 rheumatic committees have now been organized in the USSR in a number of republics, university cities and at resorts. The Committee has been publishing the journal 'Acta rheumatologica' since 1929, renamed in 1930 to 'Questions of Rheumatism'. The task of the committees in the USSR is: to assist in the development of methods of prevention and treatment, to develop a classification of so-called rheumatic diseases and methods of their registration, to attract the attention of medical, public circles and health authorities to the systematic fight against R., to publish scientific research and popular brochures, to familiarize with the experience of Western Europe, etc. Despite the fact that the International League puts forward the slogan 'the fight against any disease of a social nature must be carried out at the beginning of its occurrence, and not at the end', this tendency of correct resolution of the question, for quite understandable reasons, encounters insurmountable obstacles in Europe. Soviet rheumatology has deeply developed the socio-prophylactic aspect of the R. problem, opening up exceptional possibilities in the USSR for a radical fight against R. This social aspect of the problem has been developed mainly by Prof. Danishevsky and presented by him in reports at the congresses of the league. In 1932 in Paris a report was presented on the topic 'Rheumatism and professional labor'. The International League and the European medical press recognize the leading role of the USSR in the study of R., showing great interest in Soviet methods of struggle and their unlimited possibilities under the conditions of labor legislation and healthcare of the Union. Statistical data. Zimmer on the basis of studying the material of insurance funds for 1923-25 comes to the conclusion that 'rheumatic' diseases give in some places 3.2 cases of disease per 1 case of tbc; the duration of diseases on average is 3.4 times longer than with tbc. Disability caused by 'rheumatism' amounts to 7% for Germany, up to 18% of total disability for England. In France the total number of disabled people who have lost work capacity due to various rheumatic diseases is estimated at 70 thousand. According to Glover's data, in England more than 20 million rubles are spent annually to pay for loss of work capacity due to rheumatic diseases. In Sweden in 1918 20% of all cases of disability were caused by rheumatic diseases. In Denmark these diseases accounted for 14% of all cases of disability, while tbc as a cause of disability accounted for only 13%. In Vienna in 1928 per 100 insured there were 6 cases of acute and 0.98 chronic R. According to 15 district insurance funds in Germany for 1900-14 years, 70,962 cases of rheumatic disability and 91,265 cases of tubercular disability were noted. According to the statistics of the Leipzig hospital fund cited by Grotjahn, per 100,000 members subject to compulsory insurance and under observation for a year, there were 590 cases of chronic joint R. In total these cases took away 19,020 days associated with loss of work capacity. The morbidity rate among women turned out to be lower (277 cases and 9,970 days per 100,000 people). According to the same fund, per 100,000 men there were 3,316 cases of muscular 'rheumatism', which took away 59,099 days of illness, in women - 1,816 cases and 38,708 days. In the USSR, according to Danishevsky, the prevalence of rheumatic diseases (per 1,000 population) in cities is as follows: Table 1. Sex | Acute joint R. | Chronic joint R. | Muscular R. | Total rheumatic diseases | Tbc of respiratory organs Moscow (1926) Men .... Women .... Both sexes . 7.9 8.5 8.2 3.7 4.5 4.1 28.2 13.0 20.8 39.8 26.0 33.1 31.5 27.9 29.7 Tver (1925) Men .... Women .... Both sexes . 7.4 14.7 11.1 5.0 1 49.3 11.0 31.7 8.0 ! 47.0 i 61.7 60.4 61.1 24.7 21.3 23.0 From these data it is found that the morbidity rate among the urban population, i.e. the number of newly occurring rheumatic diseases per year, according to all disease groups ranges from 33.1 (Moscow) to 61.1 (Tver) per 1,000 population of these cities, while the morbidity rate of tbc gives respectively 29.7 for Moscow and 23.0 for Tver. According to these data, acute and chronic joint R. show greater prevalence among women. According to Leningrad, the morbidity rate with loss of work capacity (according to Vasiliev) for all types of R. is at least 3.4% per year in relation to the number of all insured (tbc - 6.5%). A comparison of the morbidity rate of rheumatic diseases of the urban and rural population (per 1,000 people) is given in table 2 (according to Danishevsky). The rural population is more often affected by rheumatic diseases than the urban population. Acute joint R. has a particularly strong prevalence in rural areas. The morbidity rate of tbc gives the opposite ratio between city and village. In these data the significance of the factor of colds is reflected, so 15 Table 2. Moscow and province Acute joint R. Chronic joint R. Muscular R. Total rheumatic diseases Tbc of respiratory organs m- Both.

Female population, female population of both sexes, male population of both sexes, male population of both sexes, settlements of Moscow province... 7.9, 11.8, 8.5, 21.4, 8.2, 18.1, 3.7, 2.9, 4.5, 6.9, 4.1, 4.9, 28.2, 33.3, 13.0, 32.7, 20.6, 33.0, 39.8, 48.0, 26.0, 72.7, 32.9, 56.0, 31.5, 14.9, 27.9, 12.7, 29.7, 13.7 characteristic of the peasant way of life and agricultural labor. - The ratio of chronic joint and muscle diseases to the total number of diseases that led to disability, according to Gelman, was for the Union in 1925: among workers - 4.5%, among employees - 3.5%, among transport workers - 4.6%, of which chronic rheumatism of the joints - 3.0, 2.7, 9.5% respectively. Among working women, these figures are 5.3%, among female employees - 5.2%, and among transport working women - 6.6% (of which chronic rheumatism of the joints - 4.3, 4.4, 5.1% respectively). As for the geographical distribution of rheumatic diseases, according to Danishevsky, they are least prevalent in the provinces of the central belt of the Union, in the Middle and Lower Volga region, in most of Ukraine and in the steppe regions of the North Caucasus. The maximum prevalence of rheumatism is observed in the northeastern part of the Union, in the Urals, in Belarus, along the Black Sea coast and in the mountainous regions of the Caucasus. - Prot'yan and Danishevsky note that rheumatic diseases more severely affect older age groups. As for disability, according to Gelman, the average age of disability in rheumatic diseases is among the lowest and is surpassed only by epilepsy, tuberculosis and traumatic injuries (men - 41.1, women - 38.5). The prevalence of rheumatic diseases in individual industries, according to Danishevsky, is as follows: leather industry - 103.6, oil extraction - 89.5, basic chemistry - 72.5, glass production - 63.1, metal processing - 64.5 days per 1,000 insured (1930). Among the groups listed below, the lowest indicators are given for insured persons in the field of credit and trade (14.1), education and upbringing (26.1), workers in nutrition and housing (6.5). In almost all industries, acute and chronic rheumatism ranks first in the number of days of disability, reaching 51.9 days in the leather industry, 51.4 in the oil industry, 40.4 in the coal industry, etc. The struggle in the USSR for improving working conditions ("anti-rheumatic" sanitary minimum, improvement of sanitary-hygienic conditions in general, implementation of sanitary supervision on new construction) leads to a regular decrease in the incidence of rheumatism. In those enterprises where in 1931 exemplary work was carried out on the sanitary minimum, Danishevsky found a significant decrease in the number of days of disability due to rheumatic diseases compared to 1930 ("Parostroy" from 77.9 to 55.3, "Manometr" from 68.7 to 47.2, "Elektrosvet" from 60 to 45.7 days per 1,000 insured, etc.). In the newly built advanced factories of Moscow and Leningrad, the reduction in rheumatic diseases is even greater (a decrease of 3-4 times or more). - In addition to improving working conditions, a decrease in the incidence of rheumatism is also brought about by improved housing conditions. Danishevsky studied the incidence of rheumatism based on data from unified dispensaries on newly occurring rheumatic diseases in 1931 in areas of continuous new construction and for comparison examined areas where the construction of new residential houses, although carried out, is on a much smaller scale. His data show that the incidence rates per 1,000 population living in the first areas are significantly lower than in those areas where housing developed to a lesser extent. The socialist reconstruction of agriculture and the transformation of agricultural labor into a variety of industrial work allow us to predict a decrease in the high incidence of rheumatism among the rural population. --The data presented testify to the greatest possibilities of eliminating the social and economic causes of the spread of rheumatism, which are inherent in the socialist reorganization of labor and way of life.

S. Artyamiev. Chronic rheumatism in children. The many forms described in adults are not characteristic of childhood. Chronic arthritis, excluding tuberculosis, occurs in children very rarely and probably all have an infectious origin. In addition to tuberculosis, in some cases, the cause of usually symmetrical effusive lesions of the knee joints is congenital syphilis. There are also other more or less prolonged infectious arthritis (chronic sepsis). If the question of whether typical disfiguring arthritis (arthritis deformans) is characteristic of childhood at all cannot be considered finally resolved at present, then in any case, primary osteoarthritis in children belongs to the greatest rarities. But if osteoarthritis is a disease of adults, chronic infectious progressive arthritis (Still's disease, rheumatoid arthritis of English authors) apparently usually begins in childhood, sometimes at the very earliest, and in adults is observed in further stages. This form was first described in detail (22 cases of his own observations) by the London pediatrician Still (Frederik Still). After this, a considerable number of descriptions appeared in different languages (for a detailed list of literature, see Leichentritt). The disease was observed in children starting from 18 months, more often in girls than in boys. According to data from the English Ministry of Health, "rheumatoid arthritis" predominates in the age group under 40 years, while osteoarthritis predominates in the age group over 40 years. The characteristic signs of Still's disease are a gradual onset in the form of swelling of the tissues surrounding one or more joints; pains are not always significant; small joints of the extremities, as well as the neck and spine, are often involved; deformities (external disfigurement) of the joints, atrophy of adjacent muscles are soon discovered. In addition to joint swelling, in typical cases of Still's disease, large (up to a bean or more) lymph glands can be palpated in different parts of the body and the spleen is usually quite significantly enlarged. The mentioned signs, as well as fever of an incorrect type, sometimes phenomena of pericarditis, etc., bring the disease closer to chronic sepsis. However, there is no tendency to suppuration. As a rule, with prolonged and progressive joint damage, endocarditis and heart defects are not observed in Still's disease. In the further course, progression of the lesion and disfigurement of the joints is observed, confining the patient to bed and making him a cripple for the rest of his life, which sometimes continues to deep old age. Progression can stop at one degree or another of crippling. The period of progression is accompanied by a delay in development, partial (of the affected extremities) or general. In not all cases does the picture unfold fully according to Still's classical description. The spleen is not palpable in all cases; sometimes lymphadenitis is not very pronounced; in some cases there is no predominance of small joint involvement, the form of the lesion is not typically spindle-shaped in small joints and not spherical in large joints; finally, sometimes endocarditis is noted. Such "atypical Still" cases may be due either to the fact that Still's disease does not exhaust all forms of chronic arthritis in children, or to the fact that the picture of Still's disease is not sufficiently studied and allows for different forms or variations of course. Atypical cases of prolonged arthritis in children, standing on the border between Still's disease on the one hand and acute rheumatism on the other (as well as partly bacteriological observations), give some authors reason to consider the question of the genetic connection between these two diseases open. According to the unanimous opinion of pediatricians, the prolonged course of joint damage in rheumatism in children, if it occurs, is very rare and in any case apparently much less often than in adults (Ibrahim, Feer). As a rule, clinically and patho-anatomically, chronic infectious progressive arthritis (Still's disease) and rheumatism in children are very clearly distinguished from each other, even opposite: the former is characterized by persistent progressive changes in the area of joints, significant changes in the external lymphatic system and spleen, little involvement of the cardiovascular system (absence of heart defects), absence of the characteristic patho-anatomical substrate (Aschoff nodules), while in the latter all phenomena are the reverse. Therefore, it is preferable not to designate both diseases with the same term (rheumatism), but to call Still's disease and other joint lesions that do not fit the modern understanding of rheumatism chronic (or acute) arthritis. - Patho-anatomical changes in Still's disease are limited to soft tissues and only with further progression can joint cartilages be involved, in contrast to disfiguring arthritis ("osteoarthritis"), in which cartilage and bone tissue are already involved in the lesion at an early stage. --The etiology of Still's disease remains as little clarified as that of other chronic arthritis. The participation of an infection, not yet firmly established, is undoubted. Some consider Still's disease a special form of tuberculosis of the joints (from the group of tuberculous rheumatism Ponce), however, this assumption does not have sufficient justification. The role of other exo- and endogenous factors also requires further study. In terms of treatment, the same applies to Still's disease as to chronic arthritis in general (see above).

v. markuzon.