RHEUMATISM, Gonorrhoeal.
The disease should be treated by local agents applied at the entrance of the poison—the urethra, vagina, vulva, or conjunctiva—if such treat ment has been neglected or inefficiently carried out. Drugs are of very little value in the treatment of the joint affection. In the early painful stage absolute rest of the affected articulation is imperative, but the physician must ever be mindful of the remarkable tendency of the gonococ cal inflammation towards the formation of adhesions of a most obstinate nature, and if rest be prolonged ankylosis is almost certain to become in tractable.
Salicylates may he employed to relieve pain, but as a rule their analgesic effects are so slight that many authorities profess that a differential diagnosis can be made between gonorrhoeal and ordinary rheumatism by noting the failure of full doses.
Iodides even in colossal doses generally fail to make any impression upon the arthritic manifestations. Mercurials, Quinine and agents useful in other infections are also generally useless.
The only reliable method of constitutional treatment consists in Vaccine Therapy. This has of late years been proved to produce marked specific results, though these plans of treatment have usually failed in dealing with the acute urethritis in gonorrhceal infection. Serum therapy may be dismissed with a few words; the antigonococcic serum usually employed is a polyvalent antistreptococcic preparation, and though Parkinson has obtained successful results from the rectal administration of so c.c. daily, the best procedure is to resort to vaccine treatment. The serum obtained by injecting animals with the gonococcus was proved by Dowson to be a good medium for the cultivation of the cocci, but the polyvalent anti streptococcic serum inhibited their growth—a fact which establishes that the latter serum when injected possesses the power of either neutralising the toxins or preventing the growth of the cocci in the tissues as believed by Parkinson.
Vaccine treatment is carried out by the injection of a gonorrhceal vaccine prepared by cultivating the cocci obtained from a first attack of gonor rhceal urethritis before local treatment has been started. The Wimpole Institute vaccine is obtainable in sterile tubes containing from so to r,000 million killed organisms. Many specialists advocate the superior advan tages to be obtained by employing an autogenous vaccine, though others maintain that almost equal results may be obtained by using a stock vaccine prepared from a dozen different strains. The ideal procedure
would be to start treatment with a stock vaccine and afterwards to prepare a culture from the urethral discharge when this is still procurable or from the joint fluid, as many authorities insist upon the mixed nature of the joint infection.
Eyre and Stewart in order to avoid a prolonged negative phase recom mend that a dose not exceeding 5 million organisms should be at first injected at short intervals. These doses may be rapidly increased to 25 millions and in chronic cases to Soo millions at intervals of 5 to 7 days. By early resort to vaccine treatment ankylosis may be effectually prevented provided the urethral affection is at the same time skilfully treated locally.
When ankylosis has already occurred, the vaccine treatment alone is of little or no avail.
With the vaccine therapy in all cases local joint treatment must be assiduously carried out. Pain may be relieved by anodyne applications and by counter-irritation with strong Iodine preparations or blisters. The application of Bier's elastic bandage to induce hyperzemia often affords considerable relief. In the dry form of gonorrhceal arthritis and especially in the polyarthritic type which involves the small joints of the hand and wrist, Tallermann's heated cylinder may be used with advantage or any of the hot-air or thermo-electric appliances mentioned under Rheumatism may be resorted to. After the application of heat, massage and passive movements should he industriously employed to prevent ankylosis, and some authorities recommend that the vaccine should be injected directly into the affected joints or into the tissues in their im mediate vicinity.
When much fluid has accumulated in the articulation, aspiration should he performed or a free incision having been made the cavity is to be thoroughly irrigated with hot Saline solution and a io per cent. Carbolic Acid or a i per cent, solution of Protargol injected.
When suppuration has occurred, free opening of the joint is imperative, after which the diseased synovial membrane should be completely curetted or dissected away as in the operation of arthrectomy or erasion. Drainage or packing with Iodoform gauze will be indicated in most of these latter cases. After the relief of the acute symptoms, the incised joint must be treated by passiee movement to prevent ankylosis, but in the knee, where arthrodesis (removal of cartilages) or excision may be necessary, firm hone union is desirable.