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Beprinted from 
 Tho American Journal of The Medical HcienceB, for January, 18!tl. 
 
 CARDIAC COMPLICATIONS IN GONOHRIKEAL RHEUMATISM.' 
 
 By Richard Lka MacDonnei>l, K.A., M.D., 
 
 riorrMOR or clinical mkiucinc, m'qill uNiVRrfHiTr ; piiykician to mdntkral oiNrRAi, hohpital. 
 
 Inasmuch as many are in doubt as to whether gonorrhceal rheuma- 
 tism ever affects the heart, I piopose to review briefly tlie literature of 
 the subject, to give the results of a critical examination of the histories 
 of twenty-seven cases of gonorrhceal rheumatism, and to relate some- 
 what in <letail the history of a remarkable case in which I believe the 
 urethral affection was closely connected with the morbid processes which 
 subsequently attacked the pericardium, the endocardium, and the 
 ple\ira. 
 
 I shall not deal with the question as to whether gonorrhoeal rheu- 
 matism exists, whether the affection we know by that name is a real 
 rheumatism, or whether, if it be a rheunuitism, it is caused by a gonor- 
 rhcfia. I shall merely state that there is a form of joint affection asso- 
 ciated with a discharge from the urethra, and that this joint affection 
 differs from ordinary acute or subacute rheumatism in certain charac- 
 teristics, one of which is said to be that it is never associated with affec- 
 tions of the heart. 
 
 In English and American treatises little mention is made of the pos- 
 sibility of the c<mnection. Howard, in his article on " GonorrlKeal Illieu- 
 matism " in Pepper's Sj/Mem 0/ ^/(sr/ /(;("» e, speaks of the connection as 
 being a point on which there is much difference of opiniou. He admits 
 that cases have been reported which appear to have been autiientic 
 cases of gonorrhoeal endocarditis, but remarks that it would be impos- 
 sible at times to distinguish a polyarticular acute gtmorrhteal rheunui- 
 tism frotn ordinary acute articular rheumatism, and he mentions the 
 possibility of the heart symptoms being due to pyaMuia. 
 
 Cases have been from time to time recorded in the journals. The 
 connection is alluded to by Davies Colley, who in an essay on "Gonor- 
 rheal Rheumatism" in Gwjs Hospital Reports, »i)oke of onciovm of the 
 disease which he called the inflammatory form, and which is specially 
 liable to attack fibrous structures not connected with joints, e. g., j)lantar 
 fascia, the sclerotic coat of the eyeball, the iris, the pericardium, and the 
 
 
 ' A paper rend ut tlio aunuul meeting of tliu Canudiun Medical Association at 
 Toronto, Sept. 18'JO. 
 
 mM^:. P 
 
mIm 
 
 HHiHM 
 
 2 MACDONNELL, OONORRHCEAL RHKUMATISM. 
 
 endocuriliuni, the attack on these lost two being usually associated with 
 gonorrhiBul arthritis. 
 
 In an article on the same subject in the same publication Dr. Pyo 
 Smith iMialyzed the histories of twenty nine cases of gonorrhoeal rheu- 
 matism and found that in one of them a basic systolic Tnurmur was 
 reported, which he passed over as being most probably of functional 
 origin. 
 
 In 1884 11 ca'^e was reported by Railton of a man, nged twenty-one, who after 
 having sulferHd for six weeks from a g(»norrhoeal discliarge, was uttacke<l with 
 sore throat, fever (102°), headaeha. Four days afterward there was pain in 
 the right wrist and sour-HMieiiing perspiration, but no cardiac implioati m. 
 Two days after this tiiere were evidences of endocarditis. He recovered alter 
 some weeks' illness, and the murmurs were said to have disappeared. 
 
 The subject is dealt with more fully by French writers. Marty, in 
 1876, published an article in the Archives Gmeralen de Medecine, in 
 which the literature of the subject up to date was reviewed and the 
 histories of nine ciises were given as well as one which he observed him- 
 self. One of those cases is of )articular interest, as it resembles my 
 case in the comparative insignificance of the joint affection. It is that 
 reported by Lacassagne. The patient was a young man who entered 
 hospital with diarrhoea as well as a gonorrhoea. Two days after ad- 
 mission there was sudden pain in the chest, physical signs of endo- 
 carditis, and elevation of temi)erature. No joint pain was observed. 
 
 Marty's own case presented the following history : 
 
 D., aged twenty-two. No rheumatic or cardiac antecedents. When five 
 years old he was subject to palpitations, but for several years past he has been 
 in the habit of lifting heavy weights witliout any trouble. In the fifth week 
 of his gonorrhoea he ha«l repeated rigors and intense headache, and a few 
 days afterward it was noticed that there was a systolic murmur at the base of 
 the heart. This was followed by a rise of temperature, presternal pain and 
 vomiting followed by palpitation. The patient eventually recovered, though 
 the murmur renuiined. 
 
 Marty's general conclusions are as follows: 
 
 Gonorrhoea may be complicated with inflammation of all the serous mem- 
 branes, and may act in a direct way on each of them. Rheumatism is by no 
 means a necessary middle term between the specific lesion and the lesion of 
 the serous membrane, although the cases of coexistence of the two complica- 
 tions are most frequent. The cardiac complications are rare. Of the several 
 orifices the aortic one is most commonly attacked. Endocarditis appears to 
 have occurred as frequently as pericarditis, if not more so. 
 
 In 1884 a case was recorded by MM. Derignac and Moussons in the 
 
 Gazette Mcdicale de Paris : 
 
 A man, aged twenty-five, in the fourth week of his gonorrhoea was seized 
 with pain in his left shoulder which soon ahifted to his right shoulder and 
 there remained. No other joint was affected. There was no previous history 
 of joint affections, or family history of rheumatism. He had never had scarlet 
 or typhoid fever, and he presented no signs of syphilis, alcoholism, or chorea. 
 Two weekn later there was a sudden rise of temperature (102.6° F ), with car- 
 
 i^iP 
 
 -mmnfn 
 
MACDONNELL, OONORRUOJAL RHEUMATISM, 
 
 8 
 
 isons in the 
 
 diac (liHtreHH. Well-marked ayatolic murmur. The Hvmptom<t subsided but 
 the bruit remained, and there was subsequent atrophy of the deltoid and 
 brachial muscles. 
 
 In Germany the subject has attracted more attention than elsewhere, 
 several important monographs having been published during the hist 
 twenty years by Nolen, Pfuhl, Loeb, Guntz, and others. The first of 
 these has collected fifteen cases of so-called heart complications. I have 
 not been able to see this monograph, but I infer from the criticism of 
 Loeb that the writer includes cases in which no further evidences of 
 cardiac disease existed than reduplication of the first sound. Such cases 
 cannot be included under the category of organic lesions, and the number 
 of his cases must therefore suffer reduction. 
 
 Quite recently the subject has been dealt with somewhat exhaustively 
 by Gluzinski, an abstract of whose paper is given in the Vienna corre- 
 spondence of the British Medical Journal for the early part of 1889. It 
 is stated that Brande, in 1854, published two cases of endocarditis and 
 pericarditis, respectively, in connection with gonorrhoeal rheumatism, 
 and that Sigmund, in 1858, published two cases. Gluzinski himself col- 
 lected thirty-one cases, and derived from them the following conclusions : 
 1. Pericarditis as well as endocarditis might supervene in the course of 
 gonorrhoea. 2. These may develop after gonorrhoeal rheumatism, but 
 also without the presence of such an affection. 3. The complaint some- 
 times assumes the character of a severe infectious disease, as in endo- 
 carditis ulcerosa, and runs an acute course, and sometimes gives rise to 
 failure of the heart. Gluzinski believes that the endocarditis is the 
 result of the action of microorganisms on the valves, and he quotes a 
 case published by Weichselbaum where gonorrhoea was complicated with 
 endocarditis and cardiac failure, and the streptococcus pyogenes was 
 found in the vegetations of the valves. 
 
 In eight of Gluzinski's cases the syrapt?ms were mild. The patients 
 complained of " stitch " in the left ches>. *. id palpitations. There was 
 accelerated and increased action of the ii,eart, and frequently also a 
 slight pericardial rAle. In the majority rheumatism was either quite 
 missed or it came on after the cardiac affection had set in. In all the 
 patients there was gonorrhoea of long standing. 
 
 This is, therefore, a summary of the literature of the subject. I pass 
 on to what is more interesting — namely, clinical experience. 
 
 The medical case-books of the Montreal General Hospital for the last 
 eight years contain the histories of twenty-seven cases — twenty-six males 
 and one female — which have been diagnosed as gonorrhoeal rheumatism. 
 Possibly some more cases of the kind may lie concealed among the 
 numerous histories of so-called subacrtte rheumatism. Of these twenty- 
 seven cases, physical signs of cardiac disease were present in six cases, 
 but of this number two cases can be excluded on the ground that there 
 
 ■■■■■ 
 
 mm 
 
M Al' DOXNKM,, fJoN'OUIMKi: A L lUl Kf M AT ISM 
 
 I 
 
 WHH H lii!*tt>rv <tt" luuitti rliciinmtisni itroviMiisly to the liivt iiUiick of jjou- 
 orrhd'u. A liiHiory of HcarK't CcviT in cliiltllioiMl, fur a like rciiMon, cx- 
 cliitU'H II third cuHc, leaving tliive ca.Hcs in wliicli il is prohahlc thai tlie 
 lieart allt'«li<>ii tlrpcinU'il iijioii a ironon-ho'a. 
 
 (!.\si; 1. Iti^lor'i of iii'iilf fill omul tmn in r/illil/iotxl, vrri/ /trohnhfi/ with 
 citnlidc cntiiii/iriifionn. In uiliiH /Ifr n r/nttntntixin, /inihiihii/ ij<»ion'/t(Knt, 
 ^')j/■<^)//(• nniniiiir /iriMnil. -V. .]., iv{. twcnty-fivo, lalmrrr, adniiUiMl into 
 lilt' Muntical (Ji'iicral Hospital .luiif .'>, 18MM, under Dr. Wilkins, com- 
 plainiii;; of pain in Until kiurs and in tlu> lott iinkk'. lie Iiiih had 
 attacks similar to tlu' present one, the lirst wIumi he was twelve years 
 old, the second when he was nineteen. After the lirst of these attacks 
 he iie;_'aii to siiHer from palpitation and faintness on e.xertion. When 
 twentv-tliiee contracted a uonorrlitea for the first time, and six montliH 
 aj^o contracted another. On admission the joints involved w(!re painful, 
 but not swollen or nul. A nrethral disehari;e is present. There is n 
 soft, lilowin<r systolic innrmnr, londest at apex and transmitted as far as 
 the axilla. 
 
 C'ask II. JIIntin'ii of arnff rhcumatiHtn In c/ii/dliomL Onuorrhcpn at the 
 aye of rlj/hln n, fol/on'rd hi/ ftrllirillc fxilnn. I'j'iihnris of ih'sfusr of the 
 viiln'i/ rii/i'f. — ,1. II., let. nineteen, admitted May 24, If^H.'i, under Dr. VVil- 
 kiiis. I'ain and swelling; of hitli knees. Thirteen years aj^o had acute 
 rheiinialism. Coiitraeted ;ronorrho'a oik; year a^o, and the disciiarj^e 
 has iiecii present ever since. Never sulfered from tlyspiKea. The 
 pre.M'iit illiHss l»e};an six weeks a^o, with pain in the rijfht hip, then in 
 the ri;.dit knee and in snUs of the feet. No history of ex|)osnre to cold. 
 I'ulse irre^Milar and inlermitteiit. No perspiration. Uretliral diseharj^e. 
 The eanliac action is diH'used. Apex displaced a little downward and 
 outward, and cardiac dulne.ss alii,ditly increased. Jjoud, harsh presystolic 
 murmur; a systolic murmur al.so. Alter a few days in hospital the 
 pains sulisiilc(l and the patient was dischar;;ed. 
 
 In these two cases I regard the occurrence of gonorrhiwal rheumatiam 
 a** accidental, and in no way connected with the valvular disease. It 
 may lie fairly assumed that in these patients the injury to the valve 
 occurred in childhood. It is curious to note, however, that in both cases 
 the rheumatism took the form most commonly found in connection with 
 gonorrhoea, an<l not that of acute rheumatism. The fever was slight, 
 and there was no sweating. The joint atfection was not general, and in 
 one of the cases it was limited to one knee and one ankle; in the other 
 to one hip, one knee, and the plantar fascia, and in neither case did any 
 metastasis occur. 
 
 CAHii: III. Acufe articular pa! 11." snpjtoxed to he of gonnrrha'.af oriffin. 
 Evldrnci'x of cardiac, enlargement a)id endocarditis. JfiKton/ of Kcariet freer 
 in vhildliood. — S. U., let. twenty-six, a gliussblower, was admitted to the 
 General Hospital, April 2'.i, 18!)(), under the care of Dr. lioss, com- 
 phiining of pain in the left ankle«und knee. He had had scarlet fever 
 and measles in childhood, but he had never had rheumatism.' About 
 a month or six weeks before admission he contracted a goiiorrhiea; the 
 discharge was copious, but liad nearly cesused when the joint pains began. 
 
 t... .t,. 
 
liari 
 
 •k of fjon- 
 '«'iiw(»n, cx- 
 t' thai the 
 
 ')/>iihhf ivlth 
 
 iiinn'rhanl, 
 
 ilti'd into 
 
 viiis, coin- 
 
 liiis had 
 
 kelvo years 
 
 'sc altackH 
 
 When 
 
 MX months 
 
 re painl'iil, 
 
 Tliere is a 
 
 '»! MS far as 
 
 rhaa at the 
 ntui' of the 
 
 rDr.'Wil- 
 
 had acute 
 
 dinoharge 
 
 Kea. The 
 
 i|), then in 
 
 ire to eold. 
 
 disehar^je. 
 
 nward and 
 
 presystolic 
 
 ospital the 
 
 hennmtisrn 
 lisease. It 
 > the valve 
 both casea 
 jction with 
 was sli/^dit, 
 ml, and in 
 1 the other 
 se did any 
 
 ml orif/in. 
 ('(irlet fever 
 ted to the 
 ioss, coin- 
 arlet fever 
 I.' About 
 rhiea ; the 
 ins began. 
 
 MAC UONNKI,!,, <i () NO It It II <K A I. it 11 K |i M A 11 S M . ,*» 
 
 A week before adiniHsion he had been drinking; anri had l)een much 
 expoHcd to th(! weather. Tlie joints attaekeil were the knees, ankles, and 
 elbows. The joint affection was not severe and sid)sided in four days 
 
 State of the lienii : The inipidse is seen and fell one inch below, antlhalf 
 an inch outside the nipple. I)ulne>'s begins at the third rilt above, and 
 extends transversely from the l)oriler of the sternum to one inch outsider 
 the nipple. A faint systolic blowinjr sound can Ih; heard at the ap(>x, 
 and one inch externally. 
 
 The patient left the hospital in one month, the joint afhu-tion having 
 entirely subsided. There was evidently nothing like suppuration in the 
 joint. 
 
 Cask IV. Tivo dinHiirt nttaen!* of ijounrrhirn. Each fitlluwnl In/ nrthri- 
 ti» ; the first by eonJitnetivitiH and mutllen teMicle, A'o hlsturii whatever of 
 rhenmntimi or of Hcarlet fever. S\intollc. mantmr at the apex if heart. — .1. 
 McN., H't. twenty-four, admitteil September 4, 1M8!(, under Dr. Wil- 
 kins. Dull |)ain in left hip and ankle. I'linilent urethral discharge. 
 No history of^ rheumatism. (lood health until twi) years ago, when he 
 had an attack of gonorrho>H which was fillowed very soon by pains in the 
 left ankle. H*; was laid up for four months, and was thought to have 
 recovered completely, lie was well until three months ago, when he had 
 a new attack of gonorrhcea, followed as before; by joint pains. The 
 left ankle began gradually to be painful t>ne week after the discharge 
 appeared. At about the same time the right eye became painful and 
 lignt became intt>lerable. He was treated for gonorrlueal ophthalmia 
 in the out-patient department of the hospital. In five weeks the 
 eye was well but the discharge was unchecked, and he suffered from 
 obscure joint pains until a fortnight before admission, when the left hi|) 
 became very painful. At the out.set of the gon »rrh(ea the testicle had 
 been swollen. There was no fever. Severe pain in letl hip. Thick 
 urethral discharge. 
 
 Heart : No increa.sed area of dulness. A .soft blowing systolic mur- 
 mur was heard at the apex but was not transmitted in any direction. 
 The patient lefl the hospital fairly well in about a fortnight. 
 
 There can be, in this case, no doubt of the gonorrlxwal origin of the 
 two articular attacks. There was no fever, no sweating. The attack 
 was gradual, and there wius never any severe pain. In his first attack 
 but one joint was involved, and with it the conjunctiva, a most signifi- 
 cunt coincidence, In the second attack one hip and one ankle alone 
 were attacked. There was no metastasis. The strongest evidence lies in 
 the fact of the attack havir followed twice in the course of a recent 
 g(morrh(ea. 
 
 The heart affection here was evidently a s-luw endocarditis possibly 
 dating from the first attack, arising as it does in ordinary rheumatism 
 without giving rise to symptoms, and so escaping attention. 
 
 Cask V. Gonorrhfal dlxehanje of thn-e weekn' MaiuUiuj. Acute 
 arthritis in left elbow ending in snj)i)ar(ttioii and .'subsequent anchylosis. 
 
 • No inention i.s inadi! of his biiving -siiilbred from ciinliiK,' .lymptoiiis previously to 
 his adiiiiBMioii to iioapital. 
 
H 
 
 M A L' JH) N N ELI,, (J o N () |{ |{ IKK A I, It 11 K U M A T I H M . 
 
 • 
 
 EndiirnrdltiM pnmhhf rrrrnf. Xo hiMovij of rliruinufii^m. — J. S., ji't. 
 twciily-oiu', iulinittru Soiit. ;»(), IJ<87. uikUt I)r. HdHn, Ex|M».siiri! to cold 
 tlirt't' (lays itrcvioiirily toildwctl In- cliillH, Hli^lit More tliroiit, mid tmiiHietit 
 pain ill t]ie ri^^dit tliiiiiili. On tli(< t'(i||(iwiii);(lay pain and HWi^lliii^ of Idl 
 ollxiw-joint. Has iii-vcr had rluMiiiiatisin in any t'oriii. A ^onorrliiiMil 
 discliar^c prt'Hcnt tor tlit> liiHt thn>(> weeks. Has had no lieadiiehc or 
 sweating. On udiiiissioii the tiuiees and iiviiia were t'oiind to lie hoiiiu- 
 what red, hnt there WHS no tonsillitis. l'uls«>llK); temp. 100.4'. IMiyoi- 
 cal si^ns of lun^rs nepitive. 
 
 The apex-bent of the heart is in its usual position and the extent of 
 cardiac diiliiesH is not increased. A roii;;h lilowiii;; systolic nuiriniir in 
 heard over the mitral area, most tlistincily just ov(>r the apex. It in 
 tra!isiiiitt«-d to the anterior axillary border, and can be heard at the back 
 between the midline and the dorsal border of the scapula. A sotler sys- 
 tolic murmur, blowing in characler. is heard in the second iiitereoHtnl 
 space close to the left border of the sternum. 
 
 On the fourth day of the illness tlu're were some fu^^itive pains in the 
 left wrist. Temperature fell to normal. During; the next fortnight the 
 left elbow-joint became distended with fluid, which, on aspiration, proved 
 to be pus. The case was transferred to the sur>;eoiis. The patient 
 recovered with a stiff joint. Durin^r his stay in hospital the heart-mur- 
 mur diminished in intensity but never disappeared. 
 
 Thcro is nothing in this history to warrant the assumption that ordi- 
 nary acute rheumatism was the cause of the heart affection. There is 
 no history of a previous attack. I^xposurc to cold is well reco^'iiized as 
 the exciting cause of gonorrli(eal, as well as of ordinary acute rheuma- 
 tism. A one-joint afiection ending in suppuration can hardly be acute 
 rheumatism. It must be either gonorrho>al rheumatism or u pyseiuia, 
 and it ia highly probable that the distinction betwi'cn these two morbid 
 states is merely one of degree. ("a>es of goiiorrlKeal rheumatism ending 
 in pyartlirosis are very rare but they have be«'n descrilied. Fifty years 
 ago Vii\n\ (de Cassis) mentioned this termination in his famous treatise 
 on the venereal diseases and gave the particulars of a case ending like 
 this in suppuration and iinchylnsi.s. 
 
 ('ask VI. iiimin'rhtai ; rlfiorx; a/li/lil Juiiit iminx; KHihlnt (iiid iirr/t'iit dyn- 
 pmrn ; i>ericnrilitlK ; rn(l<ic(irillll.'< ; jilrnrilt^ ; rerorrri/ with /)n\'<istnil viltnil 
 murmur. — D. l«.,a't. twetity-twd, a mercliant's clerk, of fair complexion, 
 short stature, and very muscular build, had alway been in good health 
 until .May M, ISIMI, when after a long, cold, wet drive he became thor- 
 ougiily chilled, and when he alighled from the vehicle he noticed that his 
 knees had become stiff and painful. He took some hot brandy and 
 water and was obliged to go to beil immediately, feeling vt'ry ill and 
 uncomfortable. He slept badly, owing to his chilly sensations as well 
 as to the pains he felt in the knees. These pains were not very severe 
 and were not relieved by ^e^tillg — in i'ael, he found some relief in mov- 
 ing them about. On the following morning, though he felt tired and 
 uncomfortable, he went to his office, but in the middle of the day he 
 began to experience a sense of oppression in the chest and was obliged 
 to rest that afternoon, though he did not take to bed. The next day 
 
 .Mittk: 
 
H., jt't. 
 
 r«! to colli 
 
 ti'uiiHicnt 
 
 in^' of left 
 
 )iiorrli(i>iil 
 
 luiachc or 
 
 Im' H(»inc- 
 
 . IMivHi- 
 
 ♦'Xtcnt of 
 
 iiriiMir id 
 
 |)fx. It is 
 
 the buck 
 
 Hortcr HVrt- 
 
 ntt'iT<)atal 
 
 liiis ill tiio 
 tiii^'lit the 
 on, proved 
 le patient 
 icart-iiiiir- 
 
 that ordi- 
 Tiiore ia 
 o;riii/e(l aa 
 rheiiina- 
 y be acute 
 H pyjoiiiia, 
 wo morbid 
 ism ending 
 b'itVy years 
 Ills treatise 
 iidiii;; like 
 
 Krfffiil (li/n- 
 'Iriil vn'fnil 
 miplexioii, 
 >od iioaltit 
 •aiiK' ihor- 
 'd that ilia 
 I'Miidy and 
 'ly ill and 
 •lis lis well 
 cry si'vere 
 »'f' in mov- 
 
 tired and 
 lie day he 
 18 obliged 
 
 next day 
 
 '/ 
 
 M AC HON N KI,r,, (HtNOUIilKKA I, It II i; I M A T I S M . 7 
 
 was Saturday. \U'. returned to the otlice in the iiiorniii^', did all that 
 wiiH rei|uire<i of him, went home to dinner, and in the ahernooii took 
 part in the inspeeiioii of the volunteer corps to which he beloii|re(|. He 
 felt a little sliir in the knees at stiirliii;.' but a. that time Cell no short- 
 news of bn-atli or cardiac pain. There was a ^Teat deal of marching 
 about and as the afternoon wore on In; ti-lt very still" in the knec« and 
 be^'aii then, for tint tirst time, to feel pain in the wrist and the ankles. 
 The next day beinj; Sunday he rested in beil all day suderiiij,' merely 
 from slijjht pains and stifliicsM in his knees, the [laiii havin;; entirely letl 
 the wrislH and ankles. On the following (the linhjdayoii altempt- 
 iny to dress he found him.seif verv short of biratli, iiikI duriii;«' the day 
 this distn'.ss increased rapidly. He found siltiii:,' more comfortaiile than 
 lyiii^ and soon he could only breathe comfortably when standin)^. He 
 now sought advice, and I)r. Herbert Ueddy, who was summoned, found 
 liini in a stale of ur^^'iit dyspno-a and breathin;^' forty to the minute. 
 The pupils were widely dilated, and he witre an exprer<sion of dt'ep dis- 
 tress and anxiety. 'I he pulse was rapid, but the temperature was not 
 very hi^^h. There were no physical sijjns, and the joint symptoms had 
 at that time completely disappi'ared. The ;.'eiieral appearanci? was that 
 of a |»atieiit in liie early sta;.fe of a severe pneumonia. 
 
 On the afternoon of the follow in;,' (sixth) day, when I saw him in 
 consultation at Dr. Ketitly's re(piest,the patient was in K-ss dislre^'D than 
 on the previous day. There was still orthopiicea. Respirations were 
 I}() and the temperature \)d°. The rcsembliiiice to liie appearance of a 
 patient in the early stages of pneumonia was very remarkable, but there 
 were no pliysical 8i;,'ns in the luiiys. Over the base of the heart a 
 double friction-murmur was distinctly audible, exteii(lin;r oyer an area 
 of about an inch and a half in diameter, with its centre at the middlt; 
 of the junction of tin* third costal eartila;:e with the sternum. 
 
 'I'lie heart's action was excited but ie;^fiilar, ami there was no increase 
 ill the area of su|)erlicial cardiac <lulness. 
 
 With such symptoms and physical si;;!is a dia;,ninsis of acute icricar- 
 dilis was made, and it wii- not until this sta;;e ot' the examination was 
 arrived at and a cause for the pericarditis was sou^^ht, that he told us 
 about the joint pains, and that he was sntUM'ing from a g( iiorrlaeat 
 discharge of some live weeks' standing. 
 
 On the following day (seventh) the iVi' tion-murmur could not be 
 detected. From the eighth to the tenth day of the illness, when he was 
 umh'r Dr. Keddy's care, the dyspmea gradually ^ubsi(led, and the fric- 
 tion-murmur was not again detect^'d. 
 
 On May 18th (eleventh day) he was admitted to the Montreal 
 (leneral Hospital, when the following eondiiiou was noted : Patient 
 somewhat pale; jiupils dilated; no manirest dyspmea while at rest; 
 respirations "JO; no swi'llings of the joints; dorsal decubitus. The 
 anxious expression observed at my lirst examination is no longer present. 
 There is no constant cardiac pain or palpitations. The patient com- 
 plains of pain merely when he takes a v«'iy long breath. The apex- 
 beat of the heart is in its normal position. The heart's action is slow 
 and deliberate. The area (tfsupirlicial cardiac dulness is not inereased, 
 and there is no diminution of the intensity of the cardiac sounds. A 
 systolic murmur is faintly audible at the apex, but it is not heard 
 around the chest. At tiims when the patient is lying U|)on his back 
 this murmur is not audible, but it becomes so when he sits up and leans 
 
 -w^ 
 
8 
 
 MAC DONNELL, GO NO R R IIO': A L RITKUMATISM, 
 
 ' 
 
 forward. At the base of the heart both tlie cardiac soands are (iiiite 
 clear ; the j)ijlse beats at 60, rejjiihvr and compressible. 
 
 A urethral discharj^e has been present for tiie last six weeks. It had 
 nearly ceased at the time he went out drivinjj^, but atler the chilling it 
 returned, owing, he thought, to the large quantity of hot brandy and 
 water which was given to him at the time. This is his second attack of 
 gonorrluva, the Hrst occurred some months previously, and was accom- 
 panied by a swollen testicle, but no joint pain. The urine is of normal 
 ([uantity an ' specific gravitv, and contains no albumin. Temperature 
 99°. 
 
 There is no evidence of any ))revious illness showing a tendency to 
 rheuni.itic affections, no scarlet fever, no tonsillitis, no chorea. 
 
 Famihj hitUmj : With the aid of the patient's brother, who is a 
 medical man, I was able to look into the family history thoroughly. 
 On the father's side there is no trace of any rheumatic or gouty ten- 
 dency whatever. On the mother's side, of five uncles and aunts of the 
 patient, one aunt is the subject of heart disea.se, and the two sous of 
 another aunt have had, the one a chronic affection of the heart and the 
 other recurrent attacks of acute rheunuitism. 
 
 June 2 (2oth day). Me has now been a fortnight in hospital, and up 
 to to-day has been doing well. The temperature has been normal or 
 nearly normal ; tlie pulse cjuiet. There has been very little dyspiuea. 
 The .systolic, miinoiir has been becoming more distinct, and it is now 
 ))lainly audible in any position of the body. During the day the tem- 
 perature rose to 100^, and he complained of epigastric distress. 
 
 4tli (27th day). The evening t('m|)erature h:us gone just beyond 100° 
 for the last three days. Pains in the back of the neck and about the 
 shoulders. Flatus in alxlomen troublesome. 
 
 Itli (.'iOth day). Temj)erature rises to above 100° at night, and last 
 night it touched 101°. Pain on taking a long breath. Orthopnoea. No 
 new physical signs. 
 
 8//i (.'51st day). Evening temperature was 102^. Dulness on percus- 
 sion at the base of the right lung, weakened breath sounds and dimin- 
 ished vocal resonance. At the left ba.se there is a slight lo.ss of resonance. 
 The heart's action is now rapid, the sounds are somewhat mufHc<l. Res- 
 piration '24. 
 
 9//( (.">2d day). To-day a distinct to-and-fro murmur is heard over the 
 pra'conlium, with its maxiunini intensity at the junction of the fourth 
 costal cartilage with the sternum on the left side, aiitl it is audible at 
 any point within a radius of an inch and a half from here. Tlie limits 
 of cardiac dulness are not perceptibly increased. There is evidently 
 fluid in both pleura, for on both sides of the chest there is now fiatness 
 as far up as the angles of the scapuhe; breath-.sounds al)sent. On the 
 left side over the dull area there is very distant :eg()|)hony. 
 
 10//t (:!3d day). The temperature "reached its highest (104°) last 
 night. (Jreat restlessness and discomfort. Physical signs unchanged, 
 except that tlie cardiac dulness is increasing toward the right side, 
 extending to half an inch beyond the right border of the sternum. 
 
 He coni|)lains greatly of gastric eructations, and the cardiac pain and 
 dyspnceu interfere with sleep. 
 
 12^/(, (.'(Otli day). The temperature has been falling. Cardiac dulness 
 is unchanged, but the toand-fro nuirmur is no longer present. Sounds 
 muffled. 
 
 9iPP 
 
IM. 
 
 ^s are quite 
 
 cs. It had 
 
 shilling it 
 
 )randy and 
 
 " attack of 
 
 |was acconi- 
 
 of normal 
 
 nnperatiire 
 
 tendency to 
 
 who is a 
 ;horoii<rhly. 
 gouty ten- 
 iints of the 
 two sous of 
 :irt and the 
 
 tal, and up 
 normal or 
 
 ! dyspmea. 
 
 I it is now 
 
 ly the tem- 
 
 ■ss. 
 
 eyond 100° 
 about the 
 
 it, and last 
 )pno3a. No 
 
 on percus- 
 and dimiii- 
 ' resonance. 
 fHcd. Kes- 
 
 rd over the 
 the fourth 
 audil)le at 
 The limits 
 1 evidently 
 ow flatness 
 t. On the 
 
 104°) last 
 
 inchanged. 
 
 right side, 
 
 Ilium. 
 
 (' pain and 
 
 ac duhiess 
 • 'Sounds 
 
 MACDONNKLL, OONORTi H(E.\ L RHEU.MATISM 
 
 1> 
 
 l']fh (.'}fith day). The .sounds less muffled. A systolic murmur again 
 audible just below the nip|)le. 
 
 18</t (4l8t day). There is general improvement. Very slight rise of 
 temperature in the evenings. iEgophony not so well marked. Systolic 
 murmur now very ])lain. 
 
 July 9. Went to his home in the country to-day. From the date of 
 last note he improved very rapidly, especially after he was allowed t(t 
 move about. When he left the hosj)ital tiie cardiac dulness was of 
 normal extent, and though the ajgophony entirely disappeared, there 
 still remained a margin of dulness at botii bases. The systolic murmur 
 presented its old character, i)eing limited stri<;tly to the apex. The 
 urethral divScharge gradually disappeared. 
 
 Such is the history of the case which carries with it the greater part 
 of the evidence I have to bring before you in favor of the view that 
 gonorrhccal rheumatism may set up cardiac altections. A young man, 
 not personally nor hereditarily disposed to rheumatism, in the fifth 
 week of his second attack of gonorrlio'a, is ex|)08ed to cold, suffers from 
 a succession of rigors, followed by slight joint pains, chieHy in the knees, 
 not of a character sufficiently severe to confine him to bed. After four 
 days these transient joint pains leave him and he is suddenly attacked 
 with pra'cordial pain and dypnnea. The ])hysical signs of pericarditis 
 are recognized. Nothing more is heard of the articular i)aiiis, but the 
 urethral discharge continues and evidences of pericarditis disappear, 
 (Jn the thirtieth day of the illness fresh effusion takes place in the peri- 
 cardium, and in the pleura the same process is noticed, (rradual ab- 
 sorption of effused fluid takes j)lace. Finally, all physical signs disap- 
 pear except a well-marked apex systolic inuniiur. 
 
 I'^ither it was a case of gonorrhical rhfuiiKUisni in which the endo- 
 cardium, pericardium, and the pleura were attacked, or it was an ordi- 
 nary case of acute rheumatism with ordinary c()m])lications, and the 
 gonorrhtea was merely an accidental circumstance. I believe that the 
 gonorrhu'a was the cause of the attack on the serous membranes, for 
 these reasons : 
 
 1. There was no jjrevious history of acute rlicuMuitism nor of any 
 rheumatic manifestations whatever; no tonsillitis, no chorea, no growing 
 pains. His mother assured me that u|) to the present illness he had 
 been perfectly well. 
 
 2. The fact of cold having acted as an exciting cause in no way 
 affects the probability of gonorrlKca having been the predisposing cause. 
 In the twenty-seven cases of gonorrlueal rheumatism I have collected 
 cold was put down as the exciting cause in seven, and this is no new 
 observation. 
 
 ;>. Pyrexia was by no means prominent. For the first fourteen days 
 the temperature scarcely went over 100''. .\t the time the pleurisy and 
 pericarditis were discovered there was elevation, but not at the outset 
 
10 
 
 MACD(>NXEMi, GONOUUHCKAL UHKUMATISM, 
 
 of the disease, ii8 would most probably have been the case in ordinary 
 acute rheuiuatisin. 
 
 4. The joints were involved to a very slight degree. He was never 
 obliged to take to bed on account of joint pains, and at the very height 
 of the attack he was still able to walk about. The pain Wius mainly 
 felt in the knees, and there was no metastasis. The wrists and ankles 
 were merely sititf. We know that in children the joint affection of rheu- 
 matism bears no relation to the severity of the heart affection, but in 
 adults one does not commonly see cardiac affections follow joint affec- 
 tions 80 slight as these were. 
 
 5. There was no sweating at any period of the disease. • 
 
 The conclusions which may be drawn from this paper are as follows: 
 
 1. That a review of the literature of gonorrh(wal rheumatism shows 
 that although a considerable number of cases have been recorded to 
 prove the connection between gonorrhcea and afflictions of the serous 
 membranes, yet those histories which will bear close inspection are very 
 few. In some, the actual presence of the heart lesion is open to doubt, 
 and ill others the existence of ordinary acute rheumatism cannot be 
 excluded. 
 
 2. That although of remarkably infrequent occurrence, cases do occur 
 where the poison of gonorrhoea attacks the endocardium, the pericar- 
 dium, and the pleura as well as the fibrous structure of joints. 
 
 ',i. That if such be the case it is the duty of physicians to regard gon 
 orrhiea in a more serious light, to confine patients to bed whenever the 
 symptoms are at all severe, to examine more frecpiently the condition 
 of the heart, and to ascertain in cases of chronic valvular affection 
 where there is no history of acute rheumatism, whether a possible cause 
 mav exist in a bvijrone uonorrlKea. 
 
 My thanks are due to my (M)lleagiu's, Drs. Ross, Wilkins, and Molson 
 of the medical staff of the Montreal ( Jcneral Hospital, for permission 
 to make use of their case-books, as well as to Dr. V^idal, my house 
 jiliysician, for the aid he aff'onled me in collecting the clinical histories 
 used in the jn-eparation of this paper. 
 
 LiTKRATUUE. 
 
 Howard, Robert Palmer : Article on (louorrhiBal Rheumatism in I'epper's 
 System of Medicine. 
 
 Pije Smith : (luy's Hospital Reports, 1S74. 
 
 Diirif!^ ('iillfy: (Jny's liospiliil Reports. 
 
 Marty: I)e I'F.iKlociirdile illeiinorrliagiciuo. .Vrehives Geiic'raies de Meiie- 
 ciiie, vol. ii., 1870. 
 
 L<icai!t'i(/ue : Arcliives Gi'm'rales de M('(lccine, 1872. 
 
 Deri'fHdc fiml Afdx^fDiis: (Ja/cttc M('(lii'iili' de I'aris, No. 7, 1S84. Also in 
 the lioiidon Medical Record, May 1"), 1SS4. 
 
 Rdiltiin, T. C: Notes ot'a (Jase ofdoriorrlKea with Acute Rheumatism and 
 Endocarditis occurriiij^ in its course. British .Medical .rournal, .luly 14, 1884. 
 
MACDONNELL, GONOHRIKKAL Ull E L' M ATISM . 
 
 11 
 
 )r<liimry 
 
 lis never 
 |y height 
 iiiainiy 
 |1 ankles 
 of rheu- 
 |i, but in 
 int iift'ec- 
 
 follovvs: 
 n shows 
 Dided to 
 \e serous 
 are very 
 o doubt, 
 mnot be 
 
 Fournier: Nouveau Dictionnaire de Mwlecine et de Ohirurgie pratiques, 
 tor* v., Paris, 18()G. 
 
 ziunki: An abstract of this paper will be found in the Montreal Medical 
 J(. ...al, vol. xviii, p. 92. 
 
 Jsnlen, W. : Ueberden sogenannten lllieunintisniusGonorrlioicus. Deut.sche 
 Arch, fiir klin. Med., Bd. xxxii. S. 120-148. 
 
 De Fkury : Arthrite blennorrha^ique; endocardite ulcureuse; mort. Jour- 
 nal Med. de Bordeaux, 1883-4, xiii. 65. 
 
 Morel, E. : La blennorrhagie et les aflections du Cojur. Revue de Thurap. 
 M6d. Ohir. dc Paris, 1883, 540-544. 
 
 Pfuhl: Herzaffectionen bei der Aciiton Blennorrhagie der Harnnihre. 
 Deutsche Zeitschrift fiir prakt. Med., 50, 51, 1878. 
 
 Loeb, M. : Die Rheumatoiderkrankung der Gonoirlioiker. Deutsches 
 Arch, fiir klinische Medicin, 188(5. 
 
 Oiintz, E. : Schmidt's Jahrbiicher, 18G7, H. 248, ff. 
 
 Zeml: Lehrbuch der Syphilis, 1871. 
 
 Tixier: Considerations sur les accidents a forme rheumatism: de la blen- 
 norrhagie, 18(56, p. 34. 
 
 Traube : Bd iii. S. 240, and Band ii. S. 764. 
 
 Brant/es (of Copenhagen) : I)u rhumatisnie blennorrhagique. (A French 
 translation will be found in the Archives Ciunorales dc Mcdecine, 1854.) 
 
 FtWaMdc Caxsis): A Treatise on Venereal Diseases. American transla- 
 tion by G. C. Blackman, M.D.. New York, 1854, p. 101. 
 
 do occur 
 j)eri('ar- 
 
 ard gon 
 ever the 
 'ondition 
 afi'ection 
 )le cause 
 
 1 Molson 
 rniission 
 ly house 
 liistories 
 
 Pepper's 
 
 le M.'de- 
 
 .\lso in 
 
 I ism and 
 
 14, 1884. 
 
 ■M 
 
f 
 
 »if 
 
 I 
 
 If 
 
 I 
 
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 K* <^m^ 
 
I» 
 
 J? 
 
 
 
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 w^^Bb*' ffSj^^Bf 
 
 
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 M^ 
 
 ^'f? 
 
 Si ., ., S^w 
 
 HK^i 
 
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 msm 
 
 l^fa^'^^f® 
 
 
 
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 mmi^^ 
 
 
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 1 
 
 
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 ili7rtli''MB 
 
 
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 'f0%m 
 
 )y Kleinporer, tlint 
 ty, arc often tlio ca| 
 
 luch cases arc not; 
 sent tlii!in8olveH to 
 gits. Tlie attacks 
 , and it beliooves 
 ' tliis condition of 
 i serious l)y tiio pi] 
 ay. 
 
 
 I 
 
 
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 _..mUiiitrtftt'f^"- organs lie so close together explain tlie tact 
 
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