146 CLINICAL BACTERIOLOGY AND HEMATOLOGY 



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 streptococci, 

 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 ; the same remark 

 applies to the bacillus which is possibly the cause of rheumatoid 

 arthritis. 



Streptococci axe readily distinguished on microscopical examina- 

 tion, 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 diagnose 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 

 rheumatism, 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 wounrls, or in the course of a general infection. They 

 may also occur along with the gonococcus in cases of gonorrhceal 

 arthritis. 



The pneitmococctis occurs in general infection from a primary 

 focus in the lung, middle ear, etc., or in the course of ulcerative 

 endocarditis, and may also occur as a primary infection— at least 

 cases occur in which no other lesion is found. The prognosis 



