Part 14

On the other hand, while the disease cannot be regarded as curable under the employment of drugs, very much can frequently be done, especially in the polyarticular form, to relieve the suffering and to retard, if not arrest, the progress of the disease, and even to restore sometimes very considerably the functions of the joints. Neither of these forms of rheumatoid arthritis can be said to be dangerous to life, and they often exist ten or twenty years and more without seriously injuring the general health. Heberden's nodosities are incurable, but they are little more than deformities.

TREATMENT.--The treatment of rheumatoid arthritis is, as a rule, disappointing, and perhaps no affection requires more perseverence and self-reliance on the part of the physician or more hopeful resolution on that of the patient. Our first duty is to make an exhaustive search as to the probable cause of the disease, as its removal is an important step in the treatment of the affection, although such search is frequently futile, and many of the alleged causes may, after all, be mere antecedents or coincidences. However, inasmuch as the pathology of the disease is very obscure, any abnormal condition of organ or function that may be discovered should receive strict and prompt attention, lest it should, either through disturbed innervation or malassimilation or impaired nutrition or defective excretion, be the predisposing or exciting cause of the disease. In women the most careful inquiry should be made into the state of the ovario-uterine organs and functions, and the least departure from their norm should be at once treated. Deficient, excessive, or painful menstruation, leucorrhoea, ovarian irritations, or pain, even displacements of the uterus or ovary, should be corrected as soon as possible. Repeated pregnancy and prolonged lactation, recurring mental anxiety and physical fatigue, defects of diet, want of food, of sunlight, and of good air, residence in damp dwellings, occupations involving exposure to cold and wet, are conditions supplying important indications which too often are {97} beyond the control of the physician, although they peremptorily require his attention. The general form is often met with in anæmic persons and in those of impaired health and vigor, and probably very rarely occurs under opposite circumstances; and there is a consensus of opinion that a lowering system of treatment is contraindicated in rheumatoid arthritis.

Having efficiently set about correcting or removing these various predisposing or determining causes of the disease, we next direct our care to the disease itself. The remedies which had been found most useful in rheumatoid arthritis before the introduction of salicylic acid were cod-liver oil, quinia, iodine, iron, arsenic, and various mineral waters, employed either externally or internally, usually in both ways. Judging from my own late experience and from the results obtained by Sée and other French physicians, as communicated by Jules Compagnon, sodium salicylate, given in sufficient doses, promises to be more generally useful in the more acute forms or in the actively inflammatory periods and exacerbations of the disease than any of those agents. Including Sée's cases, Compagnon has related 17 examples of rheumatoid arthritis, most of them of the general progressive form, in which great improvement as regards pain, stiffness, swelling, and even deformity, followed promptly the employment of that salt, even after the failure of other remedies. It proved signally useful recently in a rebellious chronic case of my own. Pollock has lately published an instance in which 5 grains of salicylate of quinia three times a day were in three or four days followed by great relief. The testimony already given of Dr. J. T. Eskridge as to the great value of this salt in chronic rheumatism will be held by some to be corroborative of its value in rheumatoid arthritis. It is hardly necessary to say that it often fails in this intractable disease, but it has frequently relieved the pain and swelling and arrested the progress of it, at least for the time, even when alkalies, iodine, arsenic, baths, etc. had failed.

It is probable that less than 45 grains per diem of the sodium salt is of little value in even the most chronic forms, and that the quantity requires to be increased in proportion as the febrile symptoms are active, so that a drachm and a half or two drachms may need to be administered in the day to some persons. It should be given in divided doses at intervals of two hours, and, what is of primary importance, it should be continued for a long time, even after much improvement has resulted, and should be resorted to from time to time, especially during recurrences of the pain, heat, or swelling. It is of consequence, especially in elderly patients, to ascertain that the medicine is being promptly eliminated by the kidneys and to watch its effect upon the heart. The administration along with it of a little old rye whiskey or brandy will sometimes be necessary in feeble people. In those rather common cases in which the skin is inactive and perhaps harsh the salicylate often improves that important organ of oxidation and elimination, and should it not do so the addition of the ammonium carbonate may be tried, especially in feeble persons with weak hearts.

{98} Moreover, the other drugs which sometimes prove serviceable in this disease may be given at the same time or alternately with the salicylate, or instead of it if it is not found to be of use or is not tolerated. In chronic cases a prolonged course of cod-liver oil, alone or along with malt extract, often seems to be of real service, especially when nutrition is much impaired or when the patient is the subject of acquired or inherited struma. Iodide of potassium, in combination with quinia or other tonic, will often prove signally useful in chronic cases unaccompanied by pyrexia, in which the pains are worst at night. It should be first tried in moderate doses (5 to 8 grains), and be continued for a long time with occasional intermissions, and before discarding it from disappointment--which often arises--15- to 20-grain doses may be given tentatively for a short period. Milk or coffee or Vichy water are good vehicles for its administration. Whether free iodine in the form of the tincture, so highly spoken of by Laségue, acts as well or better than the iodide of potassium is doubtful. He gave it at meals, in doses progressively increased from 10 drops to 5 or 6 grammes twice a day, in sherry or sweetened water, and persevered with it for a long period. Garrod has had many restorations to health in severe forms of this disease from the persevering employment of the syrup of the iodide of iron. The iron in these preparations may deserve as much commendation as the iodine, for it has often proved signally useful in this disease, not alone on account of the anæmia which so frequently attends it, but through its beneficial influence upon the nutritive functions and the circulation.

The usual rules regulating the employment of iron are to be observed, and the condition of the digestive organs will demand special attention during its employment. Although the influence of arsenic upon rheumatoid arthritis is not uniform, yet as it sometimes proves really useful it should be tried. Like iron, it may prove beneficial in several ways--by improving the quality of the blood, promoting the circulation in the superficial layers of the skin, or exerting some influence upon either the nerve-centres or perhaps upon the vaso-motor nerves of the cutaneous or articular tissues. The last-mentioned suggestion is favored by the circumstance noted by Charcot--viz. that the first effects of arsenic in nodular rheumatism are often intensification of the articular pains, and sometimes the production of redness and swelling where they did not exist before. That author found arsenic without effect or injurious in very inveterate cases and when the disease had appeared at an advanced age. Five to ten minims of Fowler's solution, or of the solution of the arseniate of sodium, which is perhaps less irritating than the former, should be given immediately after meals, and its effects upon the gastric and hepatic functions carefully watched. De Mussy has highly recommended arsenical baths (drachm ss-ij of arseniate of soda to 30 gallons of water), but as the arsenic is not absorbed by the unbroken skin, any improvement which may follow its employment is probably owing to the temperature of the bath or the bath itself.

A similar remark has been made respecting the value of the various {99} thermal mineral baths, natural and artificial, so much employed in this disease. It is neither the nature nor proportion of their mineral ingredients, but the degree of temperature, which constitutes the essential point in the action of a bath. This, if true, explains the almost equal reputation of the many varieties of thermal mineral springs in the treatment of rheumatoid arthritis and chronic rheumatism. It is this that permits the physician to promise the poor patient as much benefit from the employment of hot baths of simple water as of those of New Zealand, Plombières, or Arkansas.

The time for a resort to hot baths in rheumatoid arthritis is when the very violent pains have subsided sufficiently to allow of their employment; and while they may be hopefully used in the most chronic and advanced cases, the earlier they are employed the more curative they are. The temperature of these hot baths need not, as a rule, exceed 95 to 100° F., although some authorities approve of raising the temperature to 110° or 112° while the patient is in the water. A series of twenty to thirty such baths, taken every second day for ten to twenty minutes, is sufficient for one trial, and often effects very great improvement in the disease. The aggravation or return of pain in the joints which often follows the employment of warm baths will cease after the fifth or sixth bath. Garrod's experience of the Turkish bath is not favorable; it very often does much mischief by causing debility, and its excessive use has induced rheumatoid arthritis in persons previously free from the disease.

Now, while it may be true that simple hot-water baths employed at home are as good as mineral thermal baths taken at their source, it is generally admitted that it is best to send persons who can afford the expense to the springs themselves, where they may drink the waters as well as employ them externally, and at the same time secure all the advantages arising from change of habits, scene, and climate, from restriction to a proper diet, and from the systematic employment of the waters and baths under the direction of persons experienced in their administration, etc. No reliable rules can be laid down for the selection of the mineral waters best adapted to each case: the stronger alkaline waters perhaps had better be used with great care, such as those of Carlsbad, Vichy, Mont Doré, Weisbaden, and after a course of thermal mineral baths at such places as Aix-les-Bains, Wildbad, Bath, Aix-la-Chapelle, etc., Garrod advises resort to some place where the air is bracing and the waters tonic or chalybeate, as Buxton, Spa, Schwalbach, or St. Moritz. In this country good results are often obtained at the Hot Springs of Arkansas and the Hot Sulphur and the Lithia Springs of Virginia. The use internally and in the form of hot baths of the mineral springs of Saratoga, of Michigan, of the Licks of Kentucky, and of California, of St. Leon and St. Catherine's (Canada), is frequently very beneficial. In the selection of the mineral waters to be drunk, and of the temperature and other qualities of the baths to be employed, careful attention must be paid to the condition of the functions of the skin, liver, kidneys, and nervous system; but space cannot be afforded here for the consideration of this extensive topic. Moreover, it occasionally happens that after failure of {100} sulphur or alkaline baths some other form may succeed, as the vapor or hot-air, or tepid or very hot-water bath. If decided benefit follow the first series of baths, recourse should be had from time to time to a fresh series, even for several years, in obstinate cases. Mud and peat baths are much valued in Germany, although they do not always agree with weakly or aged people.

The local treatment is of equal importance with the general, and it is not unfrequently more effective in restoring the functions of the articulations. In that rare variety, acute rheumatoid arthritis, attended with much pain and heat in the joints, perfect rest in bed is called for, together with other measures adapted to subdue the inflammation and allay the pain. Compresses wet with warm water, rendered anodyne by the addition of laudanum or belladonna, or both, and covered with oiled silk, suit some cases--light linseed poultices, applied moderately warm and extending considerably beyond the limits of the articulation and covered with gutta-percha or oiled silk, in others. As the pain and local heat subside, the tincture of iodine may be applied extensively, or blistering-fluid over limited areas above and below the affected joints, but not on them until the inflammation has very much abated and is becoming chronic. These simple methods should be employed assiduously and be aided by appliances to secure actual rest of the inflamed joints. In the chronic variety complete rest is not needed unless during the acute exacerbations, but the movements should be at first somewhat restrained and be regulated by the effects produced. But the severe pain experienced during the movements must be borne; it will subside promptly. Decided increase of pain and heat in the part, lasting many hours, would indicate more reserve in the use of the joints. It is frequently very difficult to determine when and to what extent movement may be permitted in this disease. No fixed rule can be laid down of universal application, but it may be stated that in proportion as the local disease becomes indolent and inactive may pressure and active movements of the joints be resorted to, for they then have a beneficial influence in preventing stiffness, contraction, and deformity. Indeed, in my opinion it is not wise to delay these movements long even in subacute cases. The editor of this work has especially insisted upon the importance of systematic daily movements of the affected joints as the most essential part of the treatment, "combined with thorough massage of all the muscles whose functional activity is impeded and impaired."

The abiding chronic inflammation indicated by local heat, swelling, and inflammation of the affected tissues may be variously treated. The joints may be thoroughly fomented with tolerably hot water or by means of the local vapor bath for half an hour, morning and night, and then be gently rubbed for ten or fifteen minutes with iodine or weak mercurial ointment or with the compound camphor or acetic turpentine liniment, or, if these are too stimulating, with some bland oil, such as cod-liver or neats' foot or cocoa oil, after which should be applied hot-water compresses or linseed poultices or a wrap of soft cotton wool covered with oiled silk and secured by an elastic, moderately tight roller. If these means prove inefficient and the inflammatory process grow more {101} indolent, counter-irritants may be conjoined with or substituted for them. Small fly blisters or strong iodine paint may be applied close to the joints, or the ordinary iodine tincture may be brushed over them, or the above ointments or liniments and one of the bland oils may be more forcibly rubbed in. The prolonged rubbing of these stiff, swollen joints with oil is not valued as much as it deserves.

Compression of the thickened tissues by means of a thick envelope of cotton wool and thin flannel or rubber bandage sometimes acts very well, probably by reducing the amount of blood and interfering with cell-growth or promoting cell-degeneration. Hot sand-baths to the affected joints are sometimes useful.

These several measures should be perseveringly applied, and in proportion as chronicity prevails the active and passive movements of the articulations and massage of the muscles and adjacent tissues should be daily and efficiently practised.

Electricity will often be found an important adjuvant in this as well as in an earlier stage, not only in improving the nutrition of the muscles, but in promoting absorption, allaying pain, and subduing excitability of the peripheral structures, removing muscular contractions, and probably modifying the local inflammatory processes. It appears also in some cases to improve the general health. The constant current is generally the most useful, and should have an intensity of about ten to fifteen milliampères, and be applied daily for ten or fifteen minutes. The positive pole, terminating in a large flat moistened sponge, is applied to the spinal origin of the brachial or lumbar plexus, according as the superior or inferior members suffer, while the negative pole is immersed in a vessel of warm salt water in which the hands or feet are placed. Some apply the negative electrode to the joints and the positive to the limb higher up. The faradic current may also be employed on account of its action upon the muscles and small vessels. In the advanced stage attended with marked thickening of the articular and periarticular tissues, with contractions of the muscles and greater or less impairment of movement, the above measures are still our chief resources; but they may be employed more vigorously. We have little fear now of lighting up inflammation; we indeed desire to excite a more active circulation in the part with a view of removing the congested state of the capillaries and venules, so favorable to the development of fibroid growths. In this stage especially vigorous active and passive movements of the affected joints, and massage of the muscles which move them, and gymnastics, are imperatively needed, and it is sometimes almost marvellous what an amount of mobility and usefulness may thereby be restored to apparently helplessly crippled and deformed articulations and members. Persons who have not walked for years are frequently so much improved as to be able to leave their sofa or bed, and with or without crutches or mechanical aids walk about, while their abiding pains depart, and this notwithstanding the permanent deformity of the articular surfaces. (For the various mechanical appliances that are sometimes necessary in this advanced stage works upon surgery may be consulted.)

The hygienic measures to be observed are probably very much the {102} same as those indicated in the article upon simple chronic articular rheumatism--some of them at least--and are such as may be inferred from a review of the exciting causes of rheumatoid arthritis. Be it remembered also that acute and chronic articular rheumatism appear amongst the causes of that disease. We are hardly justified in promising arrest of the disease on removal to a warm, dry, and even climate; yet wealthy patients need not be dissuaded from trying the experiment. The use of flannel underclothing and the employment of tepid or even moderately cool baths, followed by the use of the flesh-brush or rough towel, are important means of protecting persons predisposed to this disease. The ordinary hygienic laws adapted to maintain a healthy state of all the functions, mental as well as physical, are to be observed, for in this disease the influence of the mind over the body is shown by the frequency with which rheumatoid arthritis follows closely upon mental shocks, worry, etc.

The diet, it is generally admitted, should be of a nutritious character, yet plain and digestible, and, unless specially required to meet certain indications, should not include heavy wines or fermented liquors. However, Garrod affirms that uncomplicated rheumatoid arthritis is not aggravated by the use of porter, ale, or sound wines; and his rule is to give sufficient of these alcoholic beverages to support the tone of the whole system, but not enough to excite the circulation and thereby produce subsequent reaction.

Finally, the above system of treatment must be persisted in year by year with the object of securing arrest when cure has not been effected.

Gonorrhoeal Rheumatism, or Gonorrhoeal Arthritis.

SYNONYMS.--Arthrite ou Arthropathie blennorrhagique, Tripper-rheumatismus, Gonocele, Urethral Rheumatism, Urethral Synovitis.

ETIOLOGY.--As its name implies, the cause, par excellence, of the disease is gonorrhoea, as was perhaps first indicated by Selle and Swediaur, although, no doubt, an affection apparently identical is rarely observed associated with non-contagious urethral discharge and with the urethral irritation incident to catheterism and to stricture. I have seen it associated with a simple mucous urethral discharge in a man of gouty habit, married and free from the suspicion of specific infection. Such discharge has been attributed to gouty irritation, to dietetic and venereal excesses, and to the contact of non-specific vaginal secretion; and such origin is well established. More than one observer has noticed a susceptibility to urethritis on the part of persons who have had gonorrhoeal rheumatism. A gouty taint is undoubtedly often present in urethral rheumatism. These non-gonorrhoeal cases require more close investigation than they have received. Fournier has not met with them.

The stage of the gonorrhoea at which the articular affection may appear varies very much. It frequently sets in from the sixth to the sixteenth day of the discharge; it is common enough between the third and sixth or twelfth weeks, and may be delayed as late as the twelfth month. There {103} is no constant relation between the severity of the urethral inflammation and the frequency with which, or the time at which, the articular symptoms arise; and these, once established, appear to be largely independent of the state of the urethra. On the advent of the joint affection the discharge usually continues as it was, although it often abates somewhat. Fresh attacks of gonorrhoea, even when very mild, often develop new invasions of the articular affection, as though an idiosyncrasy existed.

While the ordinary exciting causes of simple acute articular rheumatism are not necessary to the production of gonorrhoeal rheumatism, they do now and then act as adjuvants. Such are cold, fatigue, and injuries of the joints, and a severe acute arthritis is not infrequently developed during gonorrhoea under such circumstances. Other predisposing influences probably exist, the absence of which in some measure explains the infrequency of gonorrhoeal rheumatism as compared with the prevalence of gonorrhoea. Besnier holds that constitutional rheumatism, the arthritic habit, or l'héredité arthritique, is not infrequently present in the victims of gonorrhoeal rheumatism as a predisposition; Nolen found an inherited rheumatic predisposition in 6 out of 88 cases, and that 4 others had had rheumatism before contracting gonorrhoea; and Hutchinson maintains that it is the existence of the arthritic diathesis which enables urethral inflammation to produce gonorrhoeal rheumatism. He says: "From statistics that I have carefully collected I have no hesitation in believing that the predisposing cause of it usually is the inheritance of arthritic tendencies;" and adds, "Very often the subject of gonorrhoeal rheumatism will give a family history of gout." However, the disease often occurs in the absence of any discoverable tendency, hereditary or acquired, to simple articular rheumatism. On the other hand, persons have had one or several attacks of gonorrhoea previously that did not give rise to rheumatism. Nolen's table of 88 cases contains 12 instances of this kind. It is probable that by reducing the resisting force of the organism, scrofula, the so-called lymphatic diathesis, anæmia, and debility favor the development of the disease.

Gonorrhoeal rheumatism, like gonorrhoea, is proportionally as well as actually much more frequent in men than in women (111 men, 7 women, Nolen); and the greater proclivity of the former has been attributed to the greater delicacy, sensibility, and complexity of the structures involved in them than in women by gonorrhoea.

MORBID ANATOMY.--The lesions of gonorrhoeal rheumatism in the early stage resemble closely those of acute articular rheumatism; and it is probable, for opportunities of ascertaining by actual dissection are very rare, that the synovial membrane chiefly suffers. In more advanced stages the joints contain serous fluid in which fibrinous flakes and numerous leucocytes are found; the cartilages may be eroded and softened; and in some protracted cases even the bones may participate in the inflammation, and the changes found in polyarticular rheumatoid arthritis may be developed. Ultimately fibrous adhesions, resulting in ankylosis, may occur. Suppuration very rarely takes place, and it is probable that in such cases pyæmia is added to gonorrhoeal arthritis.

{104} SYMPTOMS.--Gonorrhoeal rheumatism may attack any of the joints; it most commonly invades the larger at first, more especially the knee; the ankle is next in order of frequency, and then succeeds the shoulder, closely followed by the smaller joints of the hands and feet, which are very seldom affected primarily and antecedently to the larger joints. The temporo-maxillary, the sacro-iliac, the sterno-clavicular, the intervertebral, do not escape gonorrhoeal rheumatism more than they do rheumatoid or pyæmic arthritis. The disease most frequently invades several joints simultaneously or successively, but, soon declining in many of them, it finally becomes localized in a few or rarely in a single articulation. It is monoarticular from the first in about 20 per cent. of cases, especially in the knees.

Gonorrhoeal rheumatism presents several clinical forms: First, Arthralgic: pains of greater or less severity, sometimes increased by movement, but unaccompanied by redness or swelling, affect one or frequently several joints; they wander from joint to joint, are liable to exacerbations, and sometimes resist treatment. This form occurs either in a chronic state in the course of an old gonorrhoea, and without other rheumatic symptoms, or as an acute affection along with other rheumatic symptoms, as in the second form. Second: Rheumatic: in this the symptoms are almost identical with those of subacute articular rheumatism or the more active forms of polyarticular rheumatoid arthritis. Several joints are usually implicated, perhaps suddenly, either quite spontaneously or after chill, exertion, or strain, or rheumatic-like pains having been felt for two or three days in the soles, ankles, or loins, the painful joints become moderately swollen, tender, and hot; pyrexia supervenes with its early chilliness, malaise, and anorexia; the temperature is not high; the profuse acid sweating and the very acid, high-colored urine of acute articular rheumatism are not observed or but transiently and to a very slight degree. In a few days the moderate febrile disturbance subsides, but the local inflammation persists, and extends to other joints, without promptly leaving those first invaded; while lingering in all it often fixes itself in one or more joints, and is apt to produce a copious and rebellious intra-articular effusion. Still, it very rarely involves as many articulations as primary acute rheumatism. The periarticular tissues usually are more involved than in subacute or even chronic primary articular rheumatism. Hence the considerable swelling from oedema on the back of the hand or foot, around the knee, behind the elbow, and the copious effusion into the adjoining bursæ and tendinous sheaths, and in the case more especially of the small joints of the fingers and toes the fusiform enlargement and deformities resulting from periostitis of the articular extremities. The pain, deformity, pseudo-ankylosis, etc. produced by these periarticular processes are very persistent and rebellious, and, although they do usually disappear at last, occasionally the inflammatory irritation extends to the cartilaginous and osseous structures, and rheumatoid arthritis with its permanent deformities results. It is perhaps chiefly in this polyarticular form of gonorrhoeal rheumatism that cerebral, spinal, cardiac, pleural, and ocular complications most frequently occur. {105} In the Third form, or Acute Gonorrhoeal Arthritis, after two or three days of pain wandering from joint to joint, a single articulation suddenly, and frequently about the middle of the night, becomes the seat of atrocious and abiding pain, followed in a few hours by very considerable swelling of the articulation, not due chiefly to articular effusion, but to periarticular oedema and enlargement of the bones. The pain and tenderness are most severe at the line of junction of the articular surface; the swelling begins at that point, and extends widely, especially over the dorsal aspects of the wrists and elbows, the joints most liable to this form, although any articulation may suffer. The joint is also hot, it may be pale, but is usually more or less red, and occasionally presents the appearances of severe phlegmonous inflammation, and excites a sensation of pseudo-fluctuation. The affection may resolve, or fibrous ankylosis may ensue, or very rarely suppurative destruction of the articulation may occur, although such issue has been denied (by Fournier, Rollet, Voelker). It is remarkable that, like the other forms of gonorrhoeal rheumatism, the acute inflammatory form is not accompanied by a general febrile disturbance at all proportionate to the severity of the local disease. A Fourth form occurs as a Chronic Hydrarthrosis. Although occasionally accompanying the polyarticular variety, it is frequently observed independently, and is then often monoarticular, and affects especially the knee; however, both knees sometimes are involved. The ankle- and elbow-joints suffer much less commonly than the knee. The effusion into the articulation takes place insidiously, although rapidly producing considerable enlargement of and fluctuation in the joint, without local heat, redness, or tenderness, and often with but little or no pain or pyrexia. It is not as often associated with inflammation of the tendinous sheaths and bursæ or of the eye as the polyarticular form, but it is apt to be very slow in resolving, and may last for two or three months, a year, or several years, and in scrofulous patients may degenerate into white swelling. The formation of pus in the joint is very rare. It occurred twice in 96 cases tabulated by Nolen; hydrarthrosis obtained 12 times; and serous synovitis 64 times; chronic rheumatism or arthritis deformans 5 times; tumor albus once. A Fifth form of gonorrhoeal rheumatism, like other varieties of so-called secondary rheumatism, involves predominantly the tendons and tendinous sheaths, the bursæ and periosteum, sometimes without, but far more frequently in association with, affection of the joints. Pain, sometimes severe and increased by movement and pressure and aggravated at night, with local swelling and tenderness, are the symptoms. In their fixity and persistence, their tendency to relapse, and their chronic course these periarticular affections resemble gonorrhoeal inflammation of the joints. Gonorrhoeal bursitis is often severe enough to resemble phlegmon, but it does not end in suppuration; it is most common in the bursæ covering the patella, the olecranon, and especially in that under the tendo Achillis and the deep one covering the inferior tuberosity of the os calcis; but any of the bursæ may suffer from gonorrhoeal rheumatism. The periosteum in the vicinity of the affected articulation and over the most prominent parts of the bones is sometimes the seat of small circumscribed firm nodes which {106} are painful and tender, and may either resolve rapidly or very slowly (Fournier).

Along chiefly with the third form of gonorrhoeal rheumatism, or independently, the various muscles and nerves may be the seat of myalgia and neuralgia. The sciatic nerve is specially liable. In the same form are often met those ocular affections observed not infrequently in rheumatoid arthritis and very rarely in acute articular rheumatism--viz. conjunctivitis and iritis. Aqua capsulitis is more common than the others, according to Fournier. The ocular affections may precede, accompany, or alternate with the articular, and, not being due to direct introduction of the urethral contagium into the eye, are regarded as manifestations or localizations of gonorrhoeal rheumatism. The varieties of erythema sometimes present in primary acute articular rheumatism have been observed in gonorrhoeal rheumatism.

Much difference of opinion obtains as to whether inflammations of the heart, lungs, and serous membranes occur as manifestations or localizations of true gonorrhoeal rheumatism. Even those who, like Besnier, contend for the rheumatic nature of gonorrhoeal rheumatism admit that they are quite exceptional in that affection. Endocarditis is probably more frequent than pericarditis, and the aortic are more liable than the other valves to suffer. Gonorrhoeal endocarditis has been observed without the articular affection, although it is especially when several joints are involved and the pyrexia is well marked in gonorrhoeal rheumatism that the above visceral complications occur. While admitting that Morel, Marty, Pfuhl, and others have reported what appear to have been authentic cases of gonorrhoeal endocarditis, I would remark that it must be almost impossible at times to distinguish a polyarticular acute gonorrhoeal rheumatism from ordinary acute articular rheumatism, and that in other instances the possibility of pyæmia developing in gonorrhoea, and producing both the articular and the visceral lesions, or the latter only, cannot be denied. And the same remarks are applicable to the cerebral and spinal disturbances that Vidart and others have recorded as occurring in gonorrhoeal rheumatism.