In the term Chronic Rheumatism of Joints I include, as is now becoming general, the condition following rheumatic fever. In these cases there has always been fever, often frequent attacks of fever, we often find endocardiac changes in the valves of the heart, and the disease occurs as often in men as in women, quite irrespective of age. These points distinguish it from the disease previously described. The disease may occur in childhood or early youth. The pathological anatomy may show great likeness to the above-mentioned non-infectious "dry" arthritis, but in most cases there is considerable exudation to be found in the joint cavity at some stage of the disease. The symmetry is not so pronounced as in the previous disease. But even in these cases thickenings and hyperplasia are to be found in the capsular and pericapsular tissues, atrophic and hypertrophic changes in bone and cartilage; and it not infrequently results in a condition which cannot be distinguished from arthritis deformans as now generally understood.

As a whole the prognosis is better, as far as the joints are concerned, in these cases than in those previously described. As far as general health and length of life are concerned, the prognosis depends essentially on the presence or absence of endocardiac changes.

It is obvious that differential diagnosis from the disease previously described may be difficult or even impossible. It sometimes happens that chronic rheumatic (secondary) polyarthritis is difficult to distinguish from "gonorrhoeal rheumatism" or from joint affections resulting from other infectious diseases. Fortunately the treatment of these affections is similar to that of chronic rheumatism.

The mechano-therapeutic treatment, consisting of massage and hard frictions as well as other means, may often be a severe test of patience for both the doctor and patient, and in the end may still leave much to be desired with regard to functional power. If left alone, or if insufficiently treated, serious contractures or fibrinous or even osseous anchylosis may occur. The last complication does not commonly occur in arthritis deformans, and though not altogether unknown is more uncommon in it than in the disease just described.

Those diseases which begin by attacking the joints and ligaments of the spine deserve special mention here. They very often proceed to attack the joints between the ribs and vertebrae as well as the ligamenta flava, and often even the intervertebral cartilages and all the ligaments. They may also attack the hip and shoulder joints. These diseases also are often clearly of bacterial origin and begin with fever. In other cases we are again confronted with aetiological riddles, and often observe progressive changes similar to those in a non-infectious polyarthritis, frequently leading to deformity.

It was towards the end of the nineteenth century that these diseases became better known, and especially through the publications of Strumpell, von Bechterew, and P. Marie, which I, like most other people, believe refer to these forms.

The disease may begin with or without fever, with or without pain on tapping the spinous processes of the vertebrae, with ascending (Strumpell-Marie) or descending (von Bechterew) stiffness of the spine. There is often anchylosis, often, but not invariably, kyphosis and a straightening of the physiological lordosis, sometimes accompanied by slight scoliosis and more or less severe atrophy of the back muscles. Sensory symptoms and paraesthesia (girdle sensation), neuralgia, and, more uncommonly, motor symptoms (tremblings, jerkings, paresis) may also occur.

In these forms, especially in those cases where movement is very much limited, for example when the hip and shoulder joints are affected, the general nutrition suffers badly, and intercurrent disease of the heart and lungs or kidneys is liable to cause a fatal termination.