It was formerly taught that wherever there was tubercular arthritis, there was in the person, strictly, a scrofulous diathesis. An extensive search was always made to find a history of some of the patient's ancestry, who had had tuberculosis, or this constitutional taint-scrofula; but we now know that the healthiest man or woman cannot always resist tubercular infection, and if exposed to the germs, may, in some manner, become their slave. And, if once infected by them in any way, they may show themselves in some organ or part that does not have the proper amount of resisting force. So a healthy individual, if inoculated, may have a disabled joint from injury, or disease or said joint may be weakened from an inherited taint, and the patient may find it difficult to give a satisfactory history why he should be affected with tubercle.

Two boys may be playing and both have a knee or ankle joint slightly injured. One gets well without being seriously discommoded, and the other becomes afflicted with a chronic tubercular arthritis. In this case the question presents itself at once; was he constitutionally affected, or was it from the local injury? If it were from the local injury we all know the tissues would repair themselves, and the parts would soon be well, unless on receiving the injury, there was inoculation. Then there must be in the blood tubercular germs or spores waiting a condition for favorable development.

How long these germs will be permitted to remain in the tissues without in some way manifesting themselves, is one of those mysteries that has not been solved by science; and, as to the length of time which these germs or spores may live without attacking tissues some way or some how, cannot well be understood. Another unsolved question is, How long will they live under proper conditions without losing their power to reproduce themselves? Years have been known to intervene between the time when we were satisfied parties were infected, before there was any decided manifestation of the trouble. Leneck in making a post mortem examination upon a tubercular subject allowed the saw to wound his finger, and from this wound a tubercle grew and was destroyed. He lived afterwards for twenty years when he died of pulmonary tuberculosis. We have known children to give evidence of tuberculosis by having enlarged tubercular glands, get apparently well, and in years afterwards die of tubercular consumption, or have tubercular osteomyelitis or synovitis. A Frenchman has recently excited the scientific world in his own country by declaring that the "white plague" which we are all so much interested in trying to control was not known until the imperial tombs of Egypt were invaded by the relic hunter and scientist, and from the dust of mummies, this disorder had spread over the entire civilized world. He shows that tuberculosis was not known in France until Napoleon's army brought these antiquated bodies to that country, and instead of being harmless, he claimed they spread the contagion throughout that entire nation and then to other countries.

If there is truth in this statement, it would seem that life in these germs under favorable conditions may live an indefinite period. We, therefore, conclude that it is reasonable to suppose that infection may take place, first, by predisposition; second, by food and drink; third, by inhalation; fourth, by inoculation.

With these methods of infection who can say that he himself may not be the custodian of these germs? All slight injuries to the joints. should be particularly watched, for they are much more conducive to tubercular arthritis than extensive ones. In the former, the tissues are only weakened, and for repair no great amount of activity takes place, while in the latter more blood is invited to the damaged structure and the activity in the way of repair is greater, and germ life is more readily destroyed by the great number of leucocytes drawn to such parts for this purpose. So we conclude that tuberculosis of joints takes place by the germs, or spores, being carried to them by the blood introduced by one of the four ways mentioned above.

It does not follow in this assault upon a joint that they by any means begin at first to damage the synovial membrane. This comes afterwards. They find a convenient place to do their work by depositing themselves in the cancellous tissue, and in Howship's lacuna, and here multiply most rapidly, consuming the nourishment and shutting off the blood supply in the spaces and cells intended for free and undisturbed nutrition and circulation in these bony parts.

Then we soon see the proximal tissues, osseous, muscular, and membraneous taking on the conditions as described by Wiseman, and quoted in the beginning of this paper. A convenient and commonplace site in children for these germs to assert themselves is between the epiphysis and diaphysis, and they may get in their work so well as to completely arrest the growth of the bone in length by separating the epiphysis from the diaphysis and by destroying the former.

The symptoms of tuberculosis of the joints may be mild, and cause the practitioner at first to suspect rheumatism; but the fact that the trouble is only confined to one joint should awaken suspicion in his mind. Further, at the first visit we are very likely to think the suffering and pain is caused by a slight sprain from jumping, or some trivial accident; but we should not be too ready to dismiss the matter with this statement. The appearance of the child, and family history will help along this line, but not always. If the child is very precocious, or if there is in the family a history of tuberculosis, the doctor should move along very cautiously in his study of the case and not give too favorable a prognosis. If the trouble still lingers after keeping the patient quiet for a day or two, and at the same time using local applications as heat and remedies to allay pain, then grave suspicions as to it being tubercular shculd enter the mind. The drawing of the tendons, the enlargement of the bone next to the joint, and the continuous swelling and pain in and around the joint are strong symptoms. Hydrops which may take place sooner or later is evidence of the true cause. Fungus growths in the joints or floating cartilages that may and are often felt, either with or without hydrops, are valuable symptoms to confirm diagnosis. Pus may show itself if there is mixed infection, which is noticed in many cases.

As to the prognosis, some cases, no doubt, recover spontaneously; others with but slight improvement leaving the patient with partial ankylosis or contraction of the tendons, as well as enlargement of joint, or a few floating cartilages within the synovial sack. These occasionally give trouble, but may prove to be most serious and extensive, and require constant attention and radical treatment.

As to treatment, great diversity is certainly necessary. The conditions which present themselves will have everything to do with shaping the course to be pursued by the intelligent physician. No absolutely set rules can be followed. At the outset by encouraging rest we are rewarded not only by benefit, but by occasional cures, as some cases, without doubt do recover. The immobilization of the joint is valuable. Rest in bed is a damaging thing if kept up too long, for the patient needs exercise and fresh air, and as soon as the limb can be secured as to prevent it being moved, and the patient allowed to exercise on crutches the better. This may be done with plaster of paris or silicate of soda. I prefer the latter on account of its light weight. Neither should be applied without protecting the joint well, first by a snugly fitting piece of cloth; then the joint well protected with cotton so as to prevent any undue pressure on knuckles of bone. If the limb is too much flexed at the hip or knee, an effort should be made to extend it almost to its natural position. This may be done under an anesthetic, or, if it has not gone too long, by the use of weights. The knee and hip-joints should not be completely extended before immobilizing them. Sayers' extension splint should be used.

When there is hydrops, aspiration was formerly used more than at this time, but we have never had very satisfactory results from this method, and have known it to give only temporary relief.

After the fluid is drawn off in hydrops, some good may be accomplished, if the joint is immobilized and compression applied by adhesive strips. This is recommended by several good surgeons.

If

Iodoform has certainly proven itself to be one of the most valuable agents in our hands for treating these cases, and it is the opinion of most surgeons that many cures are effected by its timely use in the joints. there is hydrops, the fluid should be removed and the joint washed out with either salt solution, sterile water, or by a solution of boric acid with the hope of getting rid of all rice bodies or any other solid or semi-solid material. Then an emulsion of iodoform should be injected, and every effort made to have it come in contact with the entire surface of the membrane.

This emulsion should be 10 per cent iodoform rubbed up in glycerine or olive oil, and should be thoroughly sterilized before using. Some recommend the addition of one drop of carbolic acid to the drachm. The quantitiy used should be one-half drachm of iodoform in any formula, for not more than thirty grains of the iodoform should be used at a time, and this repeated no oftener than twice a week. If there are no bad symptoms from the use of this amount, the dose may be increased. Some of the best surgeons of Germany open up the joint and apply the emulsion to the entire surface of the synovial membrane. I believe this is a good way, and better than the subcutaneous method as advocated by most of the American surgeons, for it enables the operator to more clearly clean out the sac. By the open method my experience has not been extensive, but in three cases, in which I have used it, I have been pleased with the results.

In all cases where the joint is, or is not infected, if there is evidence that the cancellous tissue in the ends of the bones are involved, these bones should be opened and the parts of the osseous portion involved curetted away. After the iodoform emulsion has been used, with or

without the opening of the bone affected, above or below the joint, and has proven a failure, arthrectomy should be employed, and all the diseased membrane and bone should be removed. The results of this operation have been satisfactory, but the surgeon should see that every diseased point is removed and nothing of this character left behind. Hahn's method for the knee joint is recommended by Senn. In fact, arthrectomy is more satisfactory of the knee than of the other joints.

Too much must not be expected; we can rarely, if ever, get anything like a perfect joint. There will in a very large majority of cases be partial or complete ankylosis. This operation should always be made before fistulas are established.

Resection is not very satisfactory, and is not promising unless the bones are sound above and below the articulation. Arthrectomy has largly taken the place of resection.

OPERATIVE TREATMENT OF GONORRHEA IN THE MALE.

A. C. Stokes, M. D., Omaha, Neb.

Associate Professor of Surgery, University of Nebraska; Surgeon to Swedish Hospital.

ONORRHEA has been and is to my mind, the most neglected subject in the whole catalogue of diseases, which have presented themselves since the birth of rational medicine. Even after the work of Neisser and Bumm, Guyon and Neoggarth, it has only been within the last few years that the enormous havoc of this disease has become recognized by the profession, and we, as a profession, must hold ourselves responsible for the light way in which such a disease is regarded among men. However, at the present time, here and there, arises a man who realizes the terrible devastation which the disease has wrought upon civilization, and comes forth wih a plea for its more careful consideration. It is not an over-statement of the fact to say that at least 75 per cent of all so-called diseases of women are gonorrheal in origin, and fully 75 per cent of the invalidism among women is due to this disease, and a great per cent of sterile marriages is due to gonorrhea either of the male or the female. I have no hesitation in making the statement that gonorrhea causes more pain and sorrow and trouble, than all other known diseases at the present time; and in point of importance to the health and earning capacity of a community, gonorrhea stands second only to tuberculosis, if second at all.

A certain per cent of the ravages of this disease is due to our neglect and incomplete and imperfect treatment of these cases. Some few extremists among genito-urinary surgeons have laid down the dictum that once a gonorrheaic, always a gonorrheaic; while others of the old school who, themselves, have been more or less, as the phrase has it, "rounders" in their day, declare that a gonorrheal infection is no worse than a bad cold, and amounts really to nothing.) Between these two extremes there is a mean which seems to me to be a more correct position. Just what per cent of men who have had gonorrhea get entirely over the dis

ease, it is a difficult thing to say, but that there is a large per cent who do not, no one will question. Some from want of treatment; some from conditions which do not yield to treatment; and some through carelessness. Nevertheless, there is quite a per cent of gonorrheaics who have gonorrhea for years, and which infection resists all the present forms of treatment, and anyone studying the case would not hesitate for a moment to pronounce the patient infectious. They may have no discharge, they may have no symptoms, but still appears occasionally the famous "morning drop," following an extra exertion, a carouse, or excessive sexual excitement; or it may be possible at times to find cases in which the evidence of an old gonorrhea can only be found by the expression of the prostatic secretion, and the examination with a microscope, where we will find leucocytes or sometimes the micrococcus itself. It is a fair statement to say that anyway 80 per cent of all gonorrheas become posterior, and most of the posterior gonorrheas affect the prostate gland. And gonorrhea of the prostate is the most common and the most stubborn of the present complications of this disease. The gonococcus may lie dormant for years in the urethra, and then be stirred up by some unusual excitement. Bumm has found it there ten years after a infection, and Bransford Lewis claims to have two cases in which auto-infection occcurred after a period of twentyfive years. With all the array of facts concerning the enormity of the disease, it is certainly a duty which we owe to ourselves and to the sufferers to look more carefully after them. Many of my friends continually inform me that they do not see any of these cases. I can't but think that they are not looking for them. Others of us are inclined to smile at the sufferers who apply for treatment and, oftentimes for want of knowledge of a definite treatment, they are either superficially treated or are dismissed without any satisfaction as to their condition. Chronic incurable gonorrhea is too common to be left to the genito-urinary man entirely. The general surgeons must endeavor to handle these cases in a more rational and scientific manner than we have in the past. Some of us take the attitude that it is beneath the dignity of our consideration. We would rather let them marry and remove the pus tubes from their wives afterwards.

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It is not my purpose in this paper to discuss either the pathology of gonorrhea in general, or to say anything in particular about the medicinal treatment, either local or internal, which is in common in the profession at the present time; but rather to recite something of personal experience which I, myself, have had in handling these cases. I shall take it for granted that you will accept the proposition that there are certain gonorrheas in the male which either cannot be cured at all by the present recognized methods, or can only be cured by years of constant treatment, and the consequent expenditure of a great amount of time and money. That such cases do exist, I know positively, from my own experience, and the man does not live who cures all his cases of gonorrhea.

I am persuaded, however, that the problem is, after all, not so much a problem of treatment as it is of diagnosis. Not so much a diagnosis of the presence of gonorrhea alone, which is oftentimes difficult enough, but also the diagnosis of the point of the urethra infected and the pathology existing at that point. This means a careful study of the bladder, the urethra, anterior and posterior, the prostate, seminal vesicles, vas deferens