e scissors or knife. If the cartilages are
sound, and if a movable joint is aimed at, they may be left; but if
ankylosis is desired, they must be removed. Localised disease of the
cartilage should be removed with the spoon or gouge, and the bone
beneath investigated. If the articular surface is extensively diseased,
a thin slice of bone should be removed, and if foci in the marrow are
then revealed, it is better to gouge them out than to remove further
slices of bone, as this involves sacrifice of the cortex and periosteum.

Operative treatment of deformities resulting from tuberculous joint
disease has almost entirely replaced reduction by force; the contracted
soft parts are divided, and the bone is resected.

_Amputation_ for tuberculous joint disease has become one of the rare
operations of surgery, and is only justified when less radical measures
have failed and the condition of the limb is affecting the general
health. Amputation is more frequently called for in persons past middle
life who are the subjects of pulmonary tuberculosis.

SYPHILITIC DISEASE

Syphilitic affections of joints are comparatively rare. As in
tuberculosis, the disease may be first located in the synovial membrane,
or it may spread to the joint from one of the bones.

In #acquired syphilis#, at an early stage and before the skin eruptions
appear, one of the large joints, such as the shoulder or knee, may be
the seat of pain--_arthralgia_--which is worse at night. In the
secondary stage, a _synovitis_ with serous effusion is not uncommon, and
may affect several joints. Syphilitic _hydrops_ is met with almost
exclusively in the knee; it is frequently bilateral, and is insidious in
its onset and progress, the patient usually being able to go about.

In the _tertiary stage_ the joint lesions are persistent and
destructive, and result from the formation of gummata, either in the
deeper layers of the synovial membrane or in the adjacent bone or
periosteum.

_Peri-synovial_ and _peri-bursal gummata_ are met with in relation to
the knee-joint of middle-aged adults, especially women. They are usually
multiple, develop slowly, and are rarely sensitive or painful. One or
more of the gummata may break down and give rise to tertiary ulcers. The
co-existence of indolent swellings, ulcers, and depressed scars in the
vicinity of the knee is characteristic of tertiary syphilis.

The disease spreads throughout the capsule and synovial membrane, which