(3) An acute synovitis with peri-articular phlegmon is most often met with in the elbow, but it occurs also in the knee and 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induction of hyperaemia by the rubber bandage and hot-air baths; if the joint is greatly distended, the fluid may be withdrawn by a needle and syringe.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 patient being kept in bed with light weight extension.  In the chronic hydrops the fluid is withdrawn, and about an ounce of a 1 per cent. solution of protargol injected; the patient should be warned of the marked reaction which follows.

After all symptoms have settled down, but not till then, for fear of exciting relapse or metastasis, the joint is massaged and exercised.  Stiffness from adhesions is most intractable, and may, in spite of every attention, terminate in ankylosis even in cases where there has been no suppuration.  Forcible breaking down of adhesions under anaesthesia is not recommended, as it is followed by great suffering and the adhesions re-form.  Operation for ankylosis—­arthroplasty—­should not be undertaken, as the ankylosis recurs.