The disproportion between general and local symptoms is an im portant point in differential diagnosis. The involvement of the joints is usually consecutive, but there is none of the articular delitescence characteristic of acute rheumatism. Profuse sweating, acid urine, and excessive plasticity of the blood, which are so characteristic of inflam matory rheumatism, are usually absent in the gonorrhoeal variety. The serous membranes, such as the pleura, endocardium, and peri cardium, are not often attacked. A favorable result generally occurs, but chronic synovitis, strumous arthritis in certain subjects, joint stiffness and complete ankylosis are possible sequelm. Fournier claims that acute suppuration does not occur in gonorrhoeal rheuma tism; some other authorities say that it is occasionally seen. The author believes that a joint may contain a moderate amount of puru lent fluid and still go on to a favorable issue without radical surgical interference, which is not apt to be the case with ordinary suppura tive arthritis.
That suppurative arthritis may occur as a complication of gonor rhoea, the author is convinced from experience.
3. (a) This form consists in indeterminate transitory pains in various joints without any local or general evidences of disease. In such cases there is apt to be an exacerbation of the pain, and perhaps a distinct involvement of the joint coincidentally with increase in the urethral inflammation. (b) Thecitis occurs, the synovial sheaths become swollen and and somewhat tender, there being moderate red ness along the affected tendon in some cases. Movement of the muscle attached to the tendon is very painful. The synovial bursae may become involved; the one lying under the tendo Achillis and another beneath the inferior tubrosity of the os calcis are most usually implicated. Patients thus affected complain of pain and ten
derness in the heel. This particular symptom is not unusual in the course of gonorrhoea. Myalgia, resembling the ordinary form, and pen-neuritis sometimes occur in the course of gonorrhoea, and seem to be attributable in certain instances to the same pathological con dition which gives rise to ordinary gonorrhoeal rheumatism., Pain in the back, of a severe character, simulating acute lumbago, is very frequently seen; in the majority of instances this is due to over-stim ulation of the kidneys by various balsamic preparations, sandalwood being particularly apt to produce it. It does occur, however, in pa tients who have not taken such drugs. Whether reflex neuralgia would explain these cases is open to question.
Cases are occasionally seen in which gonorrhoeal rheumatism limits itself to a single nerve. One of the author's patients has an attack of sciatica coincidentally with every attack of gonorrhoea. Attacks of simple urethritis are sufficient to bring it on in his case. The first attack of gonorrhoea which he ever experienced was attended by sciatica of a very severe character, both nerves being involved.
It is somewhat remarkable that authorities so universally con cede the comparative painlessness of gonorrhoeal rheumatic pro cesses when, as a matter of fact, quite a liberal proportion of cases are attended by severe pain, and not infrequently by sweats quite as pro fuse as those which attend ordinary rheumatic fever. The tendency to sweating seems to be most marked at night, the only difference be tween the perspiration in these cases and that of ordinary rheumatism being the absence of acidity, its more prostrating character, and its greater profuseness.