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However, I do However, I do

not think that it has been the custom to regard cases of gonorrheal rheu

matism as cases of surgical abscess which could be drained. As a rule, this is a disease which occupies a rather general place in assignment in the hospital. It usually goes to the medical service. If it is true that there frequently is a surgical aspect to this disease, it opens up a new kind of treatment and furnishes grounds for hope for better results in the future treatment of gonorrheal rheumatism. Before taking up the data offered by a small amount of clinical evidence I want to review briefly the results of investigation of the pathology of streptococcus arthritis which Dr. Wu and I undertook last year.

The animal used was the rabbit and the organism the hemolytic strep tococcus. It was thought this would furnish a basis for a better understanding of the pathology in joints, and in general it is quite possible that the pathology is comparable with that of any pyogenic infection in the joints.

Slide 1. This table shows the tabulated results in a study of 22 rabbits studied from the first day to

'Presented before the American Congress on Internal Medicine, St. Louis, Mo., February 18 to 23, 1924.

the one hundred and twenty-fifth day after inoculation with hemolytic streptococcus. If enough hemolytic streptococci are injected, practically all rabbits will develop arthritis. Attempts were made to find out how soon they showed evidence of arthritis. Cultures were taken and studied. In the first twenty-four hours there was congestion and an associated hemorrhage that usually penetrated the joint cavity at about the fifth day. More than half of the animals studied within that time did not have penetration of the joints.

One interesting thing brought out in the blood cultures on these animals is that the cultures usually became sterile by the fourth or fifth day and remained sterile unless the animal died of some intercurrent infection. Under these circumstances the culture returned to the hemolytic streptococcus. This is interesting as showing how an intercurrent infection may cause reinfection of the blood stream.

Slide 2. This is a cross-section of a wrist joint. The initial hemorrhage at twenty-four hours is in the locality where you see the dark spot. The nearest joint cavity is up here and over there (indicating). In forty-eight hours this initial amount of hemorrhage becomes invaded with polynuclears, so that at about the ninetysixth hour it is converted into an abscess. At about the fifth day this

of simple antiseptics, with or without Buck's extension. That is an "effusion" type of which the principal lesion must be just under the synovial surface. It is hard to get bacteriologic evidence in these cases. Frequently one or two tappings with removal of as much fluid as possible results in a cure of the patient.

The much more important type seems to be like the joints we have just seen, in which the inflammation seems to be almost entirely periarticular, in which there is much inflammation of the periarticular tissue, extreme tenderness of the tissue and almost always a red area. We have regarded this periarticular type of gonorrheal rheumatism as amenable to this surgical procedure, and we have used the red spot which we always see as the guide for opening into this effusion. It has been easy to establish bacteriologic evidence in these cases. when no pus is obtained a few drops of the bloody fluid yield better cultures than the pus. In these cases movement of the joint does not seem to be painful. The pain seems to come from the intense inflammation of periarticular tissues. Dr. Stewart has operated on the cases we have had since we began this work last fall, and underneath this area with the red spot

Even

he has found 5 to 15 cc. of pus. The operation has consisted in opening into that purulent area, without touching the joint cavity

As we saw in the pictures of streptococcus arthritis it takes considerable time before the bacteria can penetrate into the cavity. The streptococcus is three or four times as active as the gonococcus, and we have seen cases of two or three weeks standing in which the operation released considerable fluid and debris, in which the joint was free from infection and recovered completely. pletely. I think the periarticular type is the type that is apt to go on to ankylosis. If we can save the joint and remove the infective focus which may be capable of spreading this disease and affecting other joints, particularly in the spine, we can do much to prevent these very distressing cases of late gonorrheal arthritis. Of course the

local urethritis is of the utmost importance.

We have seen 6 cases since beginning this work. Dr. Stewart has opened 3 ankles and 1 wrist of the periarticular type and we have had other instances, one of which cleared up promptly and another which failed to show any red spot but which was clearly an effusion type.