LUMBAR PUNCTURE 147 



appears on the whole to be fairly good in these cases of suppura- 

 tive arthritis of pneumococcic origin, and complete recovery with 

 a fully movable joint may occur. 



The gonococcus occurs in some cases of gonorrhoeal arthritis ; it 

 may be present in pure culture, or it may be mixed with other 

 organisms, especially the pus cocci. In other cases of gonorrhceal 

 arthritis no bacteria are found, either microscopically or on cultural 

 examination, and in these the bacteria have probably died out 

 before the fluid was withdrawn or are localized deep down in the 

 tissues. 



The t-uleycle hacillus may be found in cases of tuberculous syno- 

 vitis, but it is more probable that the most careful search will be 

 unsuccessful. If bacilli having the general appearance of this 

 organism are found in the Gram Specimen, the carbol fuchsin 

 method of staining should be applied to a fresh film. 



Fluid from a joint may be sterile in cases of tubercular synovitis, 

 gonorrhoeal arthritis, synovitis due to an aseptic injury, rheumatism, 

 gout, or in rheumatoid arthritis, etc. 



LUMBAR PUNCTURE 



Fluid may be removed from the spinal meninges for a bacterio- 

 logical or other examination by means of Quincke's lumbar 

 puncture. The information furnished by this means is often of 

 very great value ; in fact. Osier says that " during the past ten 

 years no single measure of greater value in diagnosis has been 

 introduced." The process is simple, easy, and entirely devoid of 

 danger, and can be carried out without an anaesthetic. I have 

 now performed this operation over three hundred times, and have 

 only seen bad after-effects (in all cases temporary) in three or four 

 cases. On the other hand, a very large amount of benefit is often 

 derived from it, and it must be regarded as the most useful 

 therapeutic agent at our disposal in the treatment of meningitis, 

 especially chronic forms ; one case at least of tuberculous menin- 

 gitis has been cured by repeated punctures. It acts, of course, 

 by relieving the high intracerebral tension and by removing some 

 of the toxin- containing cerebro- spinal fluid. In basic meningitis 

 I have seen several cases in which the patient's life was saved by 

 it : the urgent pressure symptoms are often relieved at once, the 

 temperature falls, and the patient's general condition is greatly 

 improved. The symptoms frequently recur, necessitating repeated 



