ankle. There is a
sudden onset of severe pain and swelling in and around the joint, with
considerable fever and disturbance of health. The slightest movement
causes pain, and the part is sensitive to touch. The skin is hot and
tense, and in the case of the elbow may be red and fiery as in
erysipelas.

The deposit of fibrin on the synovial membrane and on the articular
surfaces may lead to the formation of adhesions, sometimes in the form
of isolated bands, sometimes in the form of a close fibrous union
between the bones.

(4) A _suppurative arthritis_, like that caused by ordinary pus
microbes, may be the result of gonococcal infection alone or of a mixed
infection. Usually only one joint is affected, but the condition may be
multiple. The articular cartilages are destroyed, the ends of the bones
are covered with granulations, extra-articular abscesses form, and
complete osseous ankylosis results.

The _diagnosis_ is often missed because the possibility of gonorrhoea is
not suspected.

The denial of the disease by the patient is not always to be relied
upon, especially in the case of women, as they may be ignorant of its
presence. The chief points in the differential diagnosis from acute
articular rheumatism are, that the gonorrhoeal affection is more often
confined to one or two joints, has little tendency to wander from joint
to joint, and its progress is not appreciably influenced by salicylates,
although these drugs may relieve pain. The conclusive point is the
recognition of a gonorrhoeal discharge or of threads in the urine.

The disease may persist or may relapse, and the patient may be laid up
for weeks or months, and may finally be crippled in one or in several
joints.

The _treatment_--besides that of the urethral disease or of the
ophthalmia--consists in rest until all pain and sensitiveness have
disappeared. The pain is relieved by salicylates, but most benefit
follows weight extension, the induction of hyperaemia by the rubber
bandage and hot-air baths; if the joint is greatly distended, the fluid
may be withdrawn by a needle and syringe. Detoxicated vaccines should be
given from the first, and in afebrile cases the injection of a foreign
protein, such as anti-typhoid vaccine, is beneficial (Harrison).

Murphy has found benefit from the introduction into the joint, in the
early stages, of from 5 to 15 c.c. of a 2 per cent. solution of formalin
in glycerin. This may be repeated within a week, the pa