In addition to the finger-joints the knees, feet, ankles, wrists, shoulders, and elbows were more or less seriously involved. There was pain in the lower part of the back, but no stiffness of the neck nor of the temporo-maxillary joints.
The rheumatic nature of the original attacks was demonstrated by the presence of well-marked signs of mitral regurgitation.
In another instance a woman, aged 39, came under observation with the characteristic lesions of arthritis deformans. She had suf fered from no less than four attacks of rheumatic fever, after the last of which the deforming changes had developed. She also had well marked signs of mitral regurgitation.
Just as after rheumatic fever so after gonorrhoeal rheumatism the articular lesions of arthritis deformans may be developed, and may extend in time to other joints besides those which were implicated as the result of the gonorrhoeal attack.
A number of authors have recorded cases of this kind, but here again it is necessary to be on one's guard against mistaking for ex amples of arthritis deformans cases in which aukylosis of joints and considerable deformities resulting from the gonorrhoeal rheumatism itself may more or less closely simulate that disease. Some at least of the recorded cases are not beyond question on this account.
In the following case the disease from which the patient was suf fering when seen was undoubtedly arthritis deformans, as far as a certain diagnosis can he arrived at by purely clinical methods, and the evidence of the patient's regular attendant left no room for doubt that the original arthritis, although separated by a considerable in terval of time from the original gonorrhoeal infection, was of gonor rhoeal origin.
The patient was a young man, 27 years of age, who until three years previously had never suffered from any joint affection. Some six months after an attack of gonorrlicea, while lie was still suffering from gleet, he developed an affection of one knee-joint which was at tended with much pain and great swelling. There was no attendant affection of the eyes. The knee never recovered completely, and a year later many other joints became involved until he presented the clinical picture of multiple arthritis deformans in a most typical form.
I am not acquainted with any case of this kind in which the na ture of the resulting joint disease was placed beyond all question by a post-mortem examination. Such cases are certainly less common than those in which a condition somewhat resembling arthritis de formans results from chronic changes in the joints which were the original seats of gonorrhoeal arthritis, and perhaps the far greater liability of males to gonorrhoeal arthritis, taken in conjunction with their far less liability to arthritis deformans, may be partially respon sible for their rarity.
No one will question that in chronic gout osteophyte formation and ulceration of the cartilages may take place, but on the other hand many will call in question the propriety of speaking of these changes as clue to the development of the lesions of arthritis deformans in joints damaged by gout. Certainly ulceration of cartilage may be connected with uratic deposits, and Ebstein even maintains that ne crosis of the cartilages precedes the deposition of sodium bi-urate in them.
E. Wynne " has pointed out that the lipping of the bones ob served in chronic gouty cases is clue to a different morbid process from that which produces the similar lipping in arthritis deformans. He finds that in gouty lipping the cartilaginous covering ceases at the summit of the outgrowth instead of completely clothing it, and that over the remainder of the projecting part there is an investment of dense fibrous tissue, which is continuous with the periosteum and synovial membrane. He looks upon the outgrowths in such cases as true exostoses rather than as osteophytes.
The view taken as to the relation of these changes to the original gout will differ according to the views held as to the nature of ar thritis deformans. If with Mr. Hutchinson we look upon the latter disease as a product of the admixture of gout and rheumatism, we may regard the supervention of these lesions as due to the importa tion of a rheumatic element into the case; and if, on the contrary, we look upon arthritis deformans as a dystrophic change in joints, we may readily suppose that such dystrophy may affect joints which have been the seats of long-standing or often-repeated gouty inflam mation.