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[269] 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.
[Footnote 269: "Rheumatismus gonorrhoicus," _Deutsches Archiv für klin.
Med._, Bd. xxxii., 1883.]
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.[270] 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.
[Footnote 270: Vide Fournier, _Nouv. Dict. de Méd. et de Chir. Prat._,
t. v. p. 230: in 119 cases, knee, 83; ankle, 32; fingers and toes, 23;
hip, 16; wrist, 14; shoulder, 12; elbow, 11; temp.-maxillary, 6; etc.]
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.[271] 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.[272] 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).
[Footnote 271: _De l'Arthrite aigue d'origine blennorrhagique_, par le
Dr. André Felix Bieur, Paris, 1881.]
[Footnote 272: _Loc. cit._, p. 133.]
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,[273] Marty,[274] Pfuhl,[275] 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.
[Footnote 273: _Rev. des Sciences Méd._]
[Footnote 274: _Archives générales de Méd._, Dec., 1876.]
[Footnote 275: _Deutsche Zeitschrift für pract. Med._, No. 50, 1878.]
The course, termination, duration, and prognosis need not be insisted
upon after what has gone before. The duration is very variable. Many
recover in four to eight weeks, many not for three to six months and
longer; relapses are of frequent occurrence; complete and tolerably
prompt recovery is not uncommon in first attacks and in young and
healthy subjects; rebellious persistency, and even deformity, with
impairment of the articular movements, and not infrequently even
fibrous ankylosis of one or many joints, sometimes including the
vertebral, may be observed. Indeed, the most formidable examples of
spondylitis are associated with gonorrhoeal rheumatism as its exciting
cause.[276] These unfavorable issues are most apt to follow repeated
attacks in unhealthy and especially scrofulous persons. Both rheumatoid
arthritis and strumous articular disease have appeared as sequels of
gonorrhoeal rheumatism. Life is not endangered, except in very rare
instances in which cardiac or cerebral {107} complications obtain; and
to stiffened enlarged joints the functions may often be restored by
efficient treatment.
[Footnote 276: Brodfurst cites two such cases: Reynolds's _System of
Med._, i. 980. So does Nolen in an elaborate article upon rheumatismus
gonorrhoicus in _Deutsches Archiv für klin. Med._, Bd. xxxii., 1883. I
had not seen it before this paper was written.]
DIAGNOSIS.--In some instances no doubt what appears to be ordinary
gonorrhoeal rheumatism, owing to the coexistence of urethral discharge
and articular inflammation, is really pyæmic arthritis. The
intermediate link in the causation may be suppuration in the prostate
or its veins or in the testicle or the penis or in its dorsal vein, or
the urethral pus may undergo changes and become septic and be absorbed.
In other instances it is highly probable that true primary acute
articular rheumatism sometimes occurs coincidentally with gonorrhoea.
If in addition to the presence or recent existence of gonorrhoea the
case present several of the following features, gonorrhoeal rheumatism
may be said to exist: moderate or mild pyrexia and articular pain; the
number of joints attacked being few, with a tendency to concentration
in one, either from the first or secondarily; no migration from one
joint to another; no delitescence, but marked chronicity and indolence,
with a tendency to hydrarthrosis and to implication of the synovial
sheaths and bursæ; an absence of cardiac complications; the frequent
and often early coincidence of special ophthalmic affections.
TREATMENT.--The patient should be confined to bed, so as to secure rest
to the inflamed articulations, and when severe arthritis (third form)
exists an efficient splint is peremptorily required, and its
application is often followed by prompt relief to the pain. It should
be retained until not only all pain, but all tenderness on pressing the
articulation, has disappeared. In short, the principles and details of
local treatment suited to gonorrhoeal rheumatism are the same as those
recommended for rheumatoid arthritis, which it so closely resembles;
and the reader is referred to that article for information. Although
there is a greater proclivity to copious effusion into the joints in
gonorrhoeal rheumatism than in rheumatoid arthritis, there is less to
those deeper lesions which affect the bones, and complete recovery is
usually more certain and more prompt in the former than in the latter.
Measures to prevent stiffness and even ankylosis of the articulations
are often an urgent indication. In the general treatment, also, almost
the same remedies are indicated as have been recommended for rheumatoid
arthritis. The salicylate of sodium, given freely, is sometimes
signally useful, more especially when several joints are acutely
inflamed. In the more chronic stages, when much articular effusion
exists, a prolonged course of potassium iodide is occasionally
beneficial. The local measures, however, simultaneously employed,
doubtless co-operate efficiently. Iron and quinia will frequently be
demanded by general debility, anæmia, and impaired nutrition; and the
same may be said of cod-liver oil, extract of malt, etc. The
circumstances under which the various baths are likely to be useful
have been mentioned in connection with the treatment of rheumatoid
arthritis.
The gonorrhoea should be treated in the same way that it ought to be if
no arthritis existed. The rest, the moderate diet, and even the
salicylate of sodium, favor its removal, but the frequent employment of
mild astringent injections should not be omitted.
{108}
GOUT.
BY W. H. DRAPER, M.D.
DEFINITION.--Gout, as a disease, in the traditional acceptation of the
term, is a specific arthritis, characterized by the deposit of the
salts of uric acid in the affected joints. Gout, as a diathesis, is a
blood crasis in which there is an accumulation in the blood serum of
the uric acid salts, the consequence either of the increased formation
or of the defective excretion of these products of proteid
metamorphosis. The manifold irritations of the different tissues, and
the accompanying subjective and objective symptoms provoked by this
dyscrasia, are termed gouty.
SYNONYMS.--(_a_) _Eng._, Gout; _Lat._, Gutta; _Fr._, Goutte; _Sp._,
Gota; _Ger._, Gicht--derived from the nomenclature of humoral pathology
and descriptive of the distillation (goutte à goutte) of the poisonous
humor into the joints--arthritis uratica. (_b_) Gouty diathesis;
constitutional gout; irregular gout.
CLASSIFICATION.--(_a_) Gout as a specific form of articular
inflammation is classified according to its location--cheiragra,
onagra, podagra, gonagra, etc. (_b_) Gout as a constitutional disease
is classified, 1st, according to the structures affected--_e.g._
articular gout; tegumentary gout, embracing mucous as well as cutaneous
affections of gouty origin; nervous gout; parenchymatous or visceral
gout; 2d, according to the degree of the inflammatory process--acute,
subacute, and chronic; 3d, according to certain irregularities
manifested in the development and progress of gouty lesions as
metastatic, retrocedent, and suppressed gout. This classification of
constitutional gout is based upon the well-recognized clinical
observation in the history of gouty persons and gouty families, that
the characteristic lesions of the joint-structures are often correlated
with lesions of the skin, mucous and serous membranes, vessels, nerves,
and parenchymatous organs, which are marked by the same blood dyscrasia
that exists in articular gout, and which are most successfully treated
by the same measures which experience has suggested in the management
of the arthritic disease.
Musgrave in his work[1] treats of a great number of varieties of gout,
as follows: De arthritide anomala; de colica arthritica; de diarrhoea
arthritica; de dysenteria arthritica; de abscesse intestinorum
arthritica; de melancholia arthritica; de syncope arthritica; de
calculo renum arthritico; de asthmate arthritico; de catarrho, tussi,
et peripneumonia arthritica; de phthise arthritica; de angina
arthritica; de capito dolore et {109} vertigine arthritica; de
apoplexia arthritica; de paralysi arthritica; de doloribus in corpore
vagis, fixis; de ophthalmia, de erysipelate et achoribus arthriticis;
etc.
[Footnote 1: _De Arthritide Anomala, sive Interna, Dissertatio_,
Geneva, 1715.]
HISTORY.--The records of medicine furnish simple evidence of the
prevalence of gout in all ancient as well as in modern civilized
communities. Its origin in the perversion of physiological functions
was as clearly recognized by the prophets of the old testament of the
medical art as it is by the founders of the gospel of modern science.
The refined processes of animal chemistry have simply revealed the
materies morbi which was foreshadowed in the "peccant matters" of the
humoralists, which were supposed to be distilled into the joints and
other structures, provoking inflammation and tophous deposits. This is
the most notable and interesting fact in the history of gout, that it
has from the earliest times been regarded as a specific form of
arthritis and dependent upon the circulation in the blood of peccant
matter. It was not, however, until the latter part of the eighteenth
century, when Murray Forbes, and a few years later Wollaston, called
attention to the fact that uric acid was the chief ingredient in
urinary calculi and in tophous deposits, that our knowledge of the
pathology of gout may be said to have had its beginning. The
demonstration by Garrod, in 1848, of the presence of lithate of soda in
the blood of gouty persons, also marks an era in the history of the
pathology of gout.
While the humoralistic theory of gout has prevailed almost to the
exclusion of all others, it is historically interesting to note that
the views of the solidists, as represented by Cullen, who maintained
that "gout was an affection of the nervous system in which the primary
moving powers of the whole system are lodged," have been recently
revived and are attracting considerable attention.
ETIOLOGY: PREDISPOSING CAUSES.--Heredity may be regarded as the most
prominent of the predisposing causes of gout. Statistics of arthritic
gout show this tendency in a varying but always large proportion of
cases. Scudamore observed it in nearly 60 per cent. of his cases;
Garrod, in 50 per cent. of his hospital cases and, in a much larger
proportion, in his private practice; Gairdner found it in 140 out of
156 cases. If all the manifestations of the gouty vice were taken into
consideration in determining the influence of heredity, it would
doubtless be shown in a still larger percentage of cases.
It is generally supposed that there is a greater frequency of
inheritance from the male ancestors and in the male descendants. This
may be explained by the fact that men are more exposed to the other
predisposing and to the exciting causes of gout. My own experience
leads me to suspect that if we took into consideration the irregular
manifestations of this morbid inheritance, we should find it as
frequently in the female, both in the ascending and descending line; of
the greater frequency of acute articular gout, however, in the male,
there can be no question. While it is true that acute attacks are
comparatively rare in women, both before and after the menopause, it is
undeniable that the subacute and chronic forms of gouty arthritis are
by no means rare in them, both before and after the cessation of
menstruation. The Hippocratic proposition that women enjoy immunity
from gout by reason of the menstrual flux can hardly be entitled to
much consideration in view {110} of the fact that they are commonly
less exposed to the exciting causes of the disease, and that when they
subject themselves to the same vicious habits which entail the disease
in men they suffer like men.