symptoms are added. Immobilization and antirheumatic remedies fail to influence either the local or the constitutional symptoms. Instead of a lesion limited to the synovial membrane, we now have an articular lesion, one which involves the articular structures and one which will destroy them. Now there is a period in the course of every such inflammation when timely treatment of the proper sort will save such a joint. This period is a very early one in the course of the disease and must be coincident with the period of pus formation. When the articular cartilages become involved, and the glistening joint-surface destroyed, adhesions and jointimpairment are inevitable.

The first question that arises is as to how we are to know when pus has begun to form. The answer must certainly be to aspirate. If this is done under absolute surgical rule the introduction of a needle into a joint is a perfectly safe procedure and can only result in good. If any detail of surgical precaution is neglected, then this and every other operation of surgery becomes extremely dangerous and the careless man will do well not to attempt it.

Preparatory to aspiration the skin should be scrubbed, first with green soap and water, then with alcohol and finally with bichlorid 1 to 1,000. A working antitoxin syringe with a needle somewhat larger and longer than the ordinary hypodermic needle, and a scalpel should be boiled. The hands should be prepared for surgical procedure. A minute incision is made through the skin alone, at one side of, and posterior to the patella and the needle is inserted into the joint through this incision. Should the small needle fail a larger should be attached. When pus is found a large needle or cannula should be inserted into the joint at once at the site of the first puncture and a larger cannula from the opposite side of the patella. All pus should be drained off and the joint washed with two to six quarts of normal salt solution. When this solution runs away perfectly clear, three to six ounces of 5% carbolic acid should be injected in such manner as to distend the joint and this should be allowed to remain

from two to five minutes. The carbolic solution is now thoroughly washed away by salt solution, the cannulas are withdrawn, the knee is dressed aseptically and a plaster of Paris splint applied. This operation should usually be done under ether anesthesia but may be done with cocain.

The pus will usually not reaccumulate, both local and constitutional symptoms will subside and the splint may be removed in one week. Physiologic motion should be practiced early and continued unless unfavorable symptoms arise. The ultimate results will vary with the degree of articular destruction that had already occurred before irrigation and may be perfect.

Should pus reform and the constitutional symptoms persist, a second irrigation may be practiced, but a second recurrence will call for free drainage by liberal incision and rubber drainage-tubes.

Such conservative treatment by irrigation will restore many gonorrheal joints to their full physiologic value, it will give partially useful or stiff joints to other patients, who formerly lost the extremity by amputation, and it saves the patient both suffering and enforced absence from work.

The subject of tubercular infection of joints cannot be discussed in the present paper, even though it properly belongs among the joint infections. Suffice it to say, articular tuberculosis is always a local disease and that there must be a time in the course of any given lesion when this disease is narrowly circumscribed. The treatment of tubercular joints by immobilizing has certainly failed to give me good results. I have seen patients in the very early stages of this disease who seemed to be perfect subjects for treatment by immobilization, yet after six months of such treatment these patients have returned to me with an extensive joint lesion or with sinuses. On the other hand I have treated early cases. of joint tuberculosis by prompt clean excision of the tubercular focus, then immobilized the joint and obtained most satisfactory results. An aseptic operation which preserves the important anatomic srtuctures will not seriously impair the

efficiency of a joint, and the removal of a tubercular focus en masse will certainly lighten the burden of repair exceedingly.

ACUTE PYOGENIC INFECTION OF CLOSED JOINTS

When an arthritis results from an acute streptococcus or staphylococcus infection, all of the pathologic conditions that have been described under the head of suppurative gonorrheal arthritis are presented in a much intensified form. The process of destruction advances rapidly and the constitutional symptoms are severe. Conservatism in the treatment of a joint of this variety means drainage at the very earliest possible moment. Uncertainty as to the type of infection present may justify a trial aspiration and irrigation through two cannulas as has been described above. Should this fail to give prompt relief to both local and constitutional symptoms, however, two to six free incisions should be made into the joint cavity and free drainage established. Should simple lateral incisions fail or seem inefficient in the severe streptococcus infections the joint should be opened widely by a transverse incision, the crucial ligaments divided, and a wet dressing applied, with the knee in a flexed position. When the acute inflammation has subsided (three to four days) the leg should be straightened. The treatment of a joint by this method requires the greatest patience on the part of both surgeon and patient, and a stiff joint invariably results, yet the patient is left with an extremity which is vastly superior to any artificial limb that can be constructed.

LACERATED WOUNDS OPENING INTO THE KNEE-JOINT

When a knee-joint is opened in a machine, a railroad or other accident, the infection of this cavity is almost inevitable and such wounds should be treated as infected wounds from the start. There is no section of joint surgery, however, which presents more difficult problems in treatment and none in which it is more necessary to meet the indications in the individual case.

The treatment of machine injuries of the knee-joint may

be well presented by the following report of a case. A boy six years of age fell from a moving ice-wagon, and a wheel passed over the angle of the flexed knee. The patella and the soft parts on the front of the knee were crushed and torn away, and the joint cavity was left wide open. Fragments of clothing and the dust of the street had been ground into the joint. This patient was taken to the hospital, and the entire extremity was thoroughly sterilized and the wound was washed as thoroughly as possible, with large amounts of sterile salt solution. Fragments of devitalized tissue were trimmed away, a voluminous wet dressing of aluminium acetate was applied and the leg placed on a pillow.

On the following day the patella was removed and a splint applied with the knee somewhat flexed. There was a moderate degree of infection in both the wound and the joint cavity, and a rather sharp constitutional reaction, yet the treatment by wet dressings was continued. These symptoms subsided after a few days, and an interrupted plaster of Paris splint was applied. This patient had a prolonged convalescence, his extensive wound healed by granulation, and a valuable extremity has been preserved even though the knee is stiff. This is but a single illustrative case from which we may conclude that the rational treatment of infected wounds of the knee-joint must be based on the same general principles that have been advocated throughout this paper. Here, as in the case of an infection in a closed joint, the greatest possible conservatism may mean to lay a joint more widely open. Conservatism certainly always means to preserve the joint if at all possible, and not to amputate, because a joint is involved in a crushing or a lacerated wound, and may become infected, or because the joint as such has been destroyed. Infection in a joint can be controled with the same certainty that it can be controled elsewhere.

The conclusions which it has been my wish to justify in the discussion of this subject are:

(1) Clearer pictures of the pathology of joints must be formed in the minds of practicians of medicine and surgery.

(2) The diagnosis of rheumatism is too often the refuge of ignorance.

(3) A more prompt recognition of the true lesion within a joint will save much tissue and many joints.

(4) Early exploratory puncture of joints is a safe procedure and an imperative duty of the physician when in doubt.

(5) Immobilization is the most important therapeutic agent that we possess in the treatment of joints.

(6) When pus or a seropurulent fluid is found in a joint, this fluid should be promptly removed by mechanic

means.

(7) A purulent gonorrheal synovitis or arthritis should be treated by aspiration through cannulas and free irrigation of the joint cavity.

(8) Streptococcus or staphylococcus infection of a kneejoint should be treated by free incision and drainage at the earliest possible moment.

(9) The opening of a knee-joint in a dirty machine. injury does not justify amputation of the leg.

Simple Cyst of the Kidney, Diagnosis and
Treatment, with Report of Two Cases

BY JOSEPH F. FOX, M. D., TOLEDO

In selecting the subject of simple cyst of the kidney for my paper today, it is not my intention to attempt to give anything new or original, but simply to present as nearly as I am capable, the present view of the profession on this somewhat rare affliction, and to report the result of the two cases which came under my care for treatment.

Simple cysts should not be confounded with other cysts and more frequently met-with tumors of the kidney, such as the small cyst so frequently found in the granular kidney, nor the cystic degeneration, when the organ is converted into numerous cysts found congenitally or in adults. This