There is a question in the mind of the author whether gonorrhoeal rheumatism is always due to specific properties of the poison of viru lent urethritis, as the disease arises in cases in which, so far as can be learned upon examination of the suspected party, and from a mi croscopical study of the discharge, there is no reason to believe the origin of the disease to have been of a virulent character. Under such circumstances the severity of the purulent process is as marked as though the origin of the disease were indubitably virulent infection. Some cases are probably due to mixed infection.
It is probable that cachectic, strumous, gouty, and rheumatic pa tients have a more pronounced predisposition to the disease than per sons who are perfectly healthy.
Symptoms.—The symptoms of the disease resemble those of rheu matic gout rather than the ordinary form of articular rheumatism. As a rule, the local evidences of the disease are not severe, and con sequently the constitutional symptoms are comparatively mild, but this is not always true. The disease develops, as a rule, during the decreasing stage, and sometimes occurs during the second or third month. Some authorities claim that it occurs in from five or six to sixteen days, but in most of the cases observed by the author it has occurred later in the course of the disease. The explanation that sug gests itself is that the inflammatory thickening of the urethra inhibits to a certain extent absorption from the surface of the mucous mem brane. Then, too, abrasion and removal of the epithelium are not so apt to occur within the first few days as later on, when the poison ous material has been in contact with it for some time. The products of the purulent process are not so virulent in the first few days as later in the course of the disease.
There is usually neither diminution nor increase of the urethral discharge coincidentally with the development of the rheumatism ; rarely it is lessened, most probably because the patient keeps quiet after the development of joint complications, and this in itself is likely to benefit the urethritis. It is doubtful whether gonorrhceal rheumatism acts as a revulsive or derivative upon the inflammation of the urethra. It is said that, when the rheumatism comes on late in the course of gonorrhoea, there is liable to be an increased discharge for a few days. In this matter the propter and post are probably con founded; it is more probable that from some particular cause ex acerbation of the urethritis occurs with a coincident rapid formation of its characteristic toxic principles ; the mucous membrane of the urethra being extensively abraded at this time, absorption readily occurs and produces arthritis or other rheumatic symptoms.
The location of gonorrhoeal rheumatism varies in different indi viduals, and sometimes in the same patient in different attacks.
The structures involved, in the order of frequency, are: (1) artic ulations; (2) the synovial thecfe of tendons and muscles ; (3) syno vial bursa-; and the sheaths of nerves. Associated with the latter form we may meet with inflammation of the pericardium, the cerebral meninges, and the deeper structures of the eye. The author has seen several cases in which the eye alone was involved (gonorrhoeal des cemetitis). A marked predilection is exhibited for the more impor tant joints, the knee being perhaps most often affected. As a rule, the inflammation expends most of its violence upon one joint, al though iu perhaps the larger proportion of cases several joints are eventually affected.
Varities.—Fournier presents a classification involving three dis tinct varieties of the disease, as follows : 1. Generally monoarticular inflammation, most often attacking the knee, occasionally the ankle or elbow. This form is really a passive hydiarthrosis with much effusion, characterized by very in sidious development. Pain, tenderness, redness, heat, and constitu tional disturbance are either absent or very moderate. Resolution takes place very gradually, and it is usually some months before recovery can be said to be complete; but even in these cases ankylosis may occur. In some instances the mono-articular form is excessively painful, is attended by marked constitutional disturbance, and tends to affect secondarily the bones entering into the formation of the articulation. The fluid in such cases is apt to contain more or less purulent material, strongly resembling that which is discharged from the urethra.
2. A variety not unlike articular rheumatism. This is accom panied by a moderate amount of local and constitutional reaction. Several of the joints are usually involved, and very often the tendons, various other fibroid structures, and the eye are implicated. The symptoms are not so severe as in acute rheumatism, and generally reaction is very mild as contrasted with the magnitude of the joint and other difficulties.