1/4 CLINICAL BACTERIOLOGY AND H^MATOLOGY 



treatment alone in empyema. The pus should in all cases be 

 removed, either by aspiration or resection of ribs and drain- 

 age. After this has been done the use of vaccines may confer 

 benefit, and lead to more rapid healing". 



FLUIDS FROM JOINTS 



The technique of the process of withdrawing these fluids is 

 exactly the same as in the case of pleurisy; the needle will 

 naturally be inserted at a point where there is definite 

 evidence of the presence of fluid, and where it lies near the 

 surface. 



The bacteriological examination is conducted on exactly 

 similar lines. A few drops of the fluid should be allowed to 

 flow on to the surface of a sloped tube of agar, and the culture 

 obtained after twenty-four hours' incubation examined in the 

 manner already described. Films should also be made 

 directly from the fluid, and some stained by Gram's method 

 and others by a simple stain such as carbol thionin. 



A great number of organisms may be present : the strepto- 

 cocci, staphylococci, the pneumococcus, gonococcus, and 

 tubercle bacillus, are the most important. The coccus which 

 has been described by several observers as the cause of acute 

 rheumatism cannot be considered as of diagnostic importance 

 at present. 



Streptococci are readily distinguished on microscopical 

 examination, and may be present even if the fluid is perfectly 

 clear. When they are present in a joint which is not the 

 seat of a perforating wound, they indicate a general infection 

 with the streptococcus, ulcerative endocarditis, etc., and the 

 prognosis is most grave. The author was enabled to diag- 

 nose a case of streptococcic septicaemia a few hours after the 

 onset of symptoms by finding numerous chains in a single 

 drop of clear fluid aspirated from the knee-joint. The clinical 

 aspect was at that time very similar to that of severe rheu- 

 matism, and the case had been so diagnosed. 



In such cases the use of antistreptococcic serum offers some 

 hope to the patient, and should be tried. 



Staphylococci are generally found in cases of arthritis due 

 to perforating wounds, or in the course of a general infection. 



