GONORRHEAL RHEUMATISM.
Gonorrhoeal rheumatism is an important, although relatively in frequent, complication or sequela of gonorrhoea. The possibility of its occurrence is disputed by some surgeons, but the majority of authorities admit that some individuals, who are perhaps free from predisposition to ordinary rheumatic troubles, are attacked with severe pain and tenderness of one or several articulations, attended with more or less constitutional disturbance and synovial effusion, in the course of urethritis, and that in others the same process attacks various tendinous and ligamentous structures of the body. Some patients' are affected with this complication with every attack of urethritis. It rarely begins during the acute stage of the affection, being most likely to occur after the disease has become chronic. The writer has known it to occur, however, within three days after the onset of the disease. Few diseases have been the source of more controversy regarding their origin than has gonorrhoeal rheumatism, and as yet its pathology must be regarded as sub judice. It does not appear to arise as a consequence of varying atmospheric conditions, from over-exertion, nor, it is claimed, from any particular method of treatment of urethritis. . The latter proposition, however, the author is inclined to question, from practical experience with the disease, espe cially in a case which recently came under observation, in which the rheumatic affection speedily followed successful abortive treatment. Its dependence upon purulent inflammation of the urethra is all that has so far been absolutely established, and it is by no means necessary that actual suppuration of the mucous membrane should be present in order to give rise to it. It is claimed that, inasmuch as it occurs independently of the ordinary predisposing and exciting causes of rheumatism, and is seen in only a small proportion of the subjects of urethritis, it must necessarily be the result of individual idiosyn crasy. There is probably much truth in this assertion.
The most generally accepted opinion in regard to the pathology of gonorrhoeal rheumatism is that it is a mild sort of ppoinic infection, clue to absorption of the products of purulent inflammation of the urethral mucous membrane. There is hardly a doubt of the correctness of this view; still, as might be supposed, it would be difficult to posi tively prove it. According to Neisser and others the disease is clue to
secondary infection, the specific germ being said to have been found in the fluid of gonorrhoeal arthritic effusions. It is well-nigh certain that some poisonous material—toxin—elaborated by the virulent germ infection of the urethral mucous membrane, is absorbed into the circulation and conveyed to the joint structures. In some indi viduals these tissues are extraordinarily sensitive, and as a conse quence reaction occurs in the form of arthritic effusion. Whether the gonococcus or the toxins formed by the mixed infection be the exciting cause of the affection, is open to question; the author inclines to the latter cause. It is probable that pus microbes are at the bottom of those exceptional cases in which suppuration occurs, and that certain elements in the surgical treatment of gonorrhoea are primarily re sponsible for the absorption of infectious materials. The destructive effect exerted by strong injections and the rude introduction of in struments upon the epithelium covering the urethral mucous mem brane has already been alluded Lo. When the mucous membrane is abraded, or, as is often the case, almost entirely removed, it is ob vious that the absorption of organic poisons is greatly facilitated. Absorption probably does not occur very readily through the intact mucous membrane, even when it is severely inflamed. Wheii once the epithelium is destroyed, however, it may easily occur. It is probable that the relative facility of absorption in certain individuals explains their susceptibility to gonorrhoeal rheumatism, and the escape of others who are more fortunate. The immunity from the disease enjoyed by women is an evidence of the correctness of this view, for the only possible explanation of the rarity of the disease in the female that can be offered is that the relatively tough vagina and endometrium, and not the urethra, are the seat of the gonorrhoeal inflammation, and as a consequence absorption does not readily occur. It will be found that when it does occur in the female a typically virulent and acute vaginitis has existed and has extended into the urethra and bladder. The rheumatism does not usually follow primarily simple urethritis, and this shows that the severity of the virulent form of the gonorrhoea bears a certain causal relation to its arthritic complications.