COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64065880 R D684 F86 Tuberculosis of the RECAP (Unlumbia Ilntupraitg in tijp OlttB of Nm f nrk ^^tfnmrt ICtbrarij -f Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/tuberculosisofboOOfras ^\)t Cbintmrst ilebical Series! KDITED BY JOHN D. COMRIE, M.A., B.Sc, M.D., F.R.C.P. (Edin.) DISEASES AND INJURIES OF THE EYE .\ Text-Tiook for Students and Practitioners. By William George Sym, M.D., F.K.C.S.E., Ophthalmic Surgeon, Edinburgh Royal Infirm- ary: Lecturer on Diseases of the Eye in the L'niversity of Edinburgh. Crown 8vo, cloth, containing 25 full-page Illustrations, 16 of them in col. our, and 88 figures in the text: also a Type Test-Card at end of volume. PRACTICAL PATHOLOGY. MORBID ANATOMY. AND POST-MORTEM TECHNIQUE A Text- Hook for Students and Practitioners. By James Miller, .M.D.. E.R.C.P.E.. Assistant Pathologist to the Edinburgh Royal In- firmary: Lecturer on Pathology in the School of Medicine of the Royal Colleges, Edinburgh. Crown 8vo, cloth. Containing in Illustrations, and a Frontispiece in colour. A TEXT-BOOK OF MIDWIFERY For Students and Practitiones. By R. W. Johnstone, M.A., M.D.. F.R.C.S.E., ALR.C.P.E.. Assistant to the Professor of Midwifery and to the Lecturer on Gynecology in the University of Edinburgh; Extern Assistant Physician. Royal Maternity Hospital: Obstetric i^hysician. New Town Dispensary: University Clinical Tutor in Gynaecology, Royal Infirmary: Gyntecologist, Livingstone Dispensary. Edinburgh. Crown 8vo, cloth, containing 264 Illustrations. RADIOGRAPHY, X-RAY THERAPEUTICS AND RADIUM THERAPY A Handbook for Students and Practitioners. By Robert Knox, M.D.. (Edin.), M.R.C.S. (Eng.). L.R.C.P. iLond.). Hon. Radiographer. King's College Hospital; Director, Electrical and Radiotherapeutic Department. Cancer Hospital, London: Hon. Radiographer. Great Northern Central Hospital, London. Containing 60 Plates and 50 Illus- trations. Super royal 8vo. cloth. THE LAWS OF HEALTH FOR SCHOOLS By A. ^L Malcolmson. M.D. Small crown 8vo, cloth, illustrated. This book, intended for the teaching of the ordinary rules wh ch guide one in the care of the general health, has been written specially for use in schools. Elementary anatomy and physiology have been described only in so far as these were deemed essential to a sufficient understanding of the methods used for the preservation of health. Other I'olumes in Preparation The Macmillan Company, 64-66 Fifth Ave., N. Y. ^f)e Cbinburgf) ifflebtcal ^trit& General Editor. — Jons D. Comrie M.A.. B.SC. M.D., F.B.C.P.E. TUBERCULOSIS OF THE BONES AND JOINTS IN CHILDREN ^ 9 '^"* o ■ ■ THE MACMILLAN COMPANY NEW VOKK • BOSTON ■ CHICAC;0 DALLAS • SAN FRANCISCO MACMILLAN & CO.. Limited LONDON • BOMBAY ■ CALCUTTA MELBOURNK rilE MACMILLAN CO. OF CANADA. Ltd. TORONTO TUBERCULOSIS OF THE BONES AND JOINTS IN CHILDREN BY JOHN FllASER, M.D., F.R.C.S.E., Ch.M. ASSISTANT SriU;EC)X. IIOYAl. HOSI'ITAL FOIl SICK lllIinilEX. EDIMinUill WITH .-,1 Fl'I.l.-I'A(;i'. PLATES (•.' IN COI.OHi AND KU FICIUKS IN" TIIK TEXT i2cU) porU THE MACMILLAN COMPANY 1914 All rlijh's risfrreil TO HAROLD J. STILES, M.B., F.R.C.S.E. SURGEON TO THE ROYAL HOSPITAL FOR SICK CHILDREN ANU CHALMERS HOSPITAL, EDINBURGH, ETC. THIS VOLUME IS DEDICATED IN TOKEN OF HIGH ESTEEM AND AFFECTIONATE REGARD PREFACE Some years ago, through the kindness of Mr. Stiles, I was enabled to carry out an investigation of a number of cases of tuberculous disease of the bones and the joints. The pathological and etiological aspects of these studies were presented as a Thesis for the degree of M.D. of Edinburgh University in the year 1912, and a number of isolated papers have been published in various periodicals. The disease was also observed from the clinical aspect, and a combination of these two investigations has resulted in the publication of the present work. I recognised that a collation of experimental and patho- logical results were of little value unless combined with the more practical clinical side. The present work deals with the disease purely as it occurs in children, and this accounts for the omission of regional diseases which do not occur in childhood, e. Etiology ..... ... 3 The Pathiii.ouy of Tuberculosis of Bone . . . .11 Tuberculous Diaphysitis . . ... 33 The PATHOLOIiY OF TUBERUUL0.SIS OF JoiXT.S . . . .34 The Clinical Features of Bone Tiuerculosis . . . .44 The Clinical Features of Joint Tiiierculcsis . . . . 4G The Uiaqno.sis of Bone Tubekcolosis . . . . .50 The Diagnosis of Joint Tuberculosis . . . . . b-i The X-Ray Appearances in Negatives of Tuberculous Bones and Joints 08 Prognosis in Bone and Joint Tdberculosis . . . .64 Treatment of Bone Tuberculo.sis . . . . .65 Treatment of Joint Tuberculosis ..... 100 i'AKT lI.—SrEClAi Ti'BERCiLous Disease of the Spine Hip-Joint Disease Tuberculous Disease of the Knee-joint' Tuberculous Disease of the Ankle-joint Tuberculous Disease of the Tarsu.s Tuberculous Disease op the Long Bones of ti Tuberculous Disease oir the Shoulder-joint Tuberculous Disease of the Elbow-joint Tuberculous Disease of the Wrist-joint Sacro-iliac Dlsease Tuberculous Disease of the Skull-p.ones Tuberculous Disease of the Lower Jaw Tuberculous Disease of the Upper Jaw and .\Iaiah 1 Tuberculosis of the Kids GENERAL INDK.X INDKX Ol' AUTHORS . K Hand and 1' 111 204 258 281 290 297 304 312 319 324 328 330 333 33 1 337 347 LIST OF ILLUSTRATIONS PLATES FACING PAOE I. The Normal Anatomy of the End of a Long Bone, etc. n. The Scheme of the Arterial Blood-supply of Bones m. A Volkmami's Canal in Section .... IV. The Histology of the Original Tubercle V. The Histology of the Original Tubercle VI. Secondary Changes in the Tuberculous FoUicle vu. Marrow Changes in Tuberculous OsteomyeUtis vm. The Rarefaction of Bone ..... IX. The Lamellar ('hanges secondary to Tuberculous Osteomyelitis X. The Stages in the Formation of new Subperiosteal Bone . XI. The Final Picture of new Subperiosteal Bone xn. The Vascular Changes secondary to Tuberculous OsteomyeUtis . xm. Corona! Section through Head of Femur, etc. .... XIV. The Stages in the J)evelopment of an Encysted Tuberculous Disease of tho Bone . • . XV. Infiltrating Tuberculous Disease of tlic Bone XVI. Infiltrating Tul)erculosis of Bono .... xvn. Infiltrating Tuberculous Disease of the Bone xvm. The Atrophic Type of Tuberculosis of Bone XIX. The Aijpearance of the Marrow in Atrophic Tuborculo.sis . XX. Atrophic Tuberculous Disease of the Bone . XXI. Hy^jertrojihic Tuberculosis of the Tibia XXII. Hypertrophic Tuberculosis of the Til)ia xxm. Stages in tho Dovolojimcnt of Hypertrophic 'J'uburculosis . XXIV. A FuUy-doveloped Hypertrophic Tuberculosis of tho Tibia XXV. Sequestrum Formation ...... XXVI. Extensive Sequestrum Korination in flu- liil(ii(ji- of (lie l<"(iiuir . J xxvn. Tuberculow.'i Dactylitis ........ XXVIII. The Anatomy of I lie Articular ami Kpiphyseal Regions XXIX. Tuberculous Disease of the Synovial .Membrane .... XXX. Changes in the Cartilage secondary to Tuberculous DLscaso of the Joint XXXI. Tuberculous Disease of Joint.s ..... {Coloured) (Coloured) 10 12 14 16 17 18 19 Between 20 & 21 22 23 24 25 25 Between 24 & 25 26 27 Between 28 & 29 32 ;!3 35 36 38 TUBERCULOSIS OF THE BONES AND JOINTS xxxu. Tuberculous Disease of the Synovial Membrane xxxni. The Varieties of Tuberculous Disease of Joints XXXIV. The Varieties of Tubei'culous Disease of Joints XXXV. The X-Ray appearance of early Tuberculous Disease of the Bone xxx\^. The X-Ray appearance of new Subperiosteal Bone XXXVII. The X-Ray appearance of Tuberculous Disease of the Bone associated with Sequestrum Formation and a Cavity . xxxvrn. The X-Ray appearance of Hypertrophic Tuberculosis of the Tibia xxxix. The X-Ray appearance of Atrojihic Tuberculous Disease of the upper end of the Uhia ...... XL. The X-Ray appearance of Early Tuberculous Disease of the Knee-Joint XLi. The X-Ray appearance of an Advanced Tuberculosis of the Knee-.Toint XLii. The Stages in the making of a Plaster Case . . . . XLiii. The Pathological Varieties of Pott's Disease . . . . XLiv. Advanced Tuberculous Disease of the Ankle-Joint XLV. Tuberculous Disease of the Ankle-joint . . . . . XLVI. Tuberculous Dactylitis affecting the Proximal Phalanx of the Finger . XLVii. The X-Ray appearance of Tuberculous Dactylitis SLViu. The X-Ray appearance of Tuberculous Disease of the Shoulder-Joint XLix. The Pathology of Tuberculous Disease of the Elbow-Joint L. Advanced Tuberculous Disease of the Elbow-Joint LI. Tuberculous Disease of the Lower Jaw . . . . . FArlNn FAOK . 38 40 . 41 . 58 Between 60 & 61 62 63 70 114 282 284 299 302 303 312 314 330 IN THE TEXT 1. The Original Culture Test . 2. Pacinian Bodies in the Periosteum 3. A Developing Perivascular Tubercle 4. Bier's Passive H3rper;Temia applied to the Uppfii: Extremity o. The Technique of Abscess Aspiration 6. Methods of applying Extension Plastei'S . 7. Dorsal Pott's Disease affecting several Vertcbrse 8. Dorsal Pott's Disease affecting a single Vertebra 9. Scohosis in Pott's Disease ..... 10. The Kinking of the Great Vessels secondary to Tuberculous Disease of the Vertebrse ....... 11. Thoracic Deformity in Dorsal and Dorso-Lumbar Kyphosis 12. The Arrangement of the Cervical Fascia 13. The Distribution of the Posterior Primary Divisions of the Dorsal Nerves 14. The Relations of the Fascise in regard to the Development of Abscesses secondary to Pott's Disease 15. The Arrangement of the Lumbar Fascia 4 14 17 74 78 101 115 115 116 118 119 121 123 124 125 LIST OF ILLUSTRATIONS Dorso FItt. 16. Large Psoas Abscess originating in Tuberculous Disease of the Lumbar Spine 17. The Position of the Head iu Various Varieties of Cervical Disease . 18. Characteristic Elevation of the Shoulders in High Dorsal Pott's Disease 19. The Characteristic Attitude of High Dorsal Disease 20. Dorso-Luinbar Pott's Disease .... 21. High Dorsal Pott's Disease .... 22. Mid-Dorsal Pott's Disease. SUght Deformity . . 23. Low Dorsal Disease with Spinal Rigidity and no K3rphosis 24. Low Dorsal Pott's Disease with Marked Deformity 25. Low Dorsal Disease ...... 26. Dorsal Pott's Disease with SUght ScoUosis 27. Dorsal Pott's Disease with Marked Scoliosis 28. Early Kyphosis in Pott's Disease .... 29. An Unusual Form of Gibbosity in Pott's Disease 30. Active Flexion of the Healthy Spine showing a Uniform and complete Curve 31. Passive Extension in a Healthy Spine 32. Young's Apparatus for Recording the Extent of a Spinal Deformity 33. Free Lateral Movement of the Healthy Spine 34. Passive Extension of the Spine demonstrating Boarding due to Lumbar Pott's Disease ..... 35. Position Test for Cervical Disease — patient lying prone 36. Position Test for Cervical Disease — patient lying supine 37. Bed arranged for Recumbency Treatment of Pott's Disease 38. Head Extension apphed for Cervical Tuberculous Disease 39. Tubby's Spmal Pillow 40. Fisher's Bed Frame . 41. Tlio IJouble Hamilton Splint 42. The Double Thomas Splint 43. A Modified Double Tliomas SpUnt 44. The Bradfoici Bed-Frame . 45. The Bradford Bed-Frame . 46. The Bradford Bed-Frame . 47. The Whitman Frame 48. Sayre's Cuirass 49. Phelps' Plaster Bod . 50. Gauvain's Spinal Board 51. Gauvain's Back-door Splint 52. Gauvain's Posterior Suspensory Splint 53. Gauvain's Wheelbarrow Splint 54. Phelps' Box .... 55. Pliclps' Box with Paticnl in po.sition 56. The U-Sb,i|icd Pillow for tlie Trcalm Cx'rvical Sjiine 1. of Tuberculous Disoaao of tlie PAOE 126 131 131 131 132 132 133 133 133 133 134 134 134 134 135 136 137 1.38 138 139 139 149 150 150 151 152 152 153 153 154 154 155 155 156 157 158 159 159 160 160 161 xiv TUBERCULOSIS OF THE BONES AND JOINTS Fin. PA(iF. 57. Gauvain's Apparatus for the Gradual Assumption of the Vertical Position . 162 58. Suspensory Sling applied in preparation for the Application of the Plaster Jacket .......... 165 59. The " Minerva " Plaster Jacket applied . . . . . .166 60. The " Minerva " Plaster Jacket appUed — Lateral View . . .166 61. The " Fillet " Plaster Jacket applied 167 62. The Hani mock Frame Method of applying the Plaster Jacket . .168 63. Ridlon's Bridge for supporting the Patient during the AppUoation of a Plaster Jacket . . . . . . . . .168 64. A Modification of the Brackett Apparatus for applying a Plaster Jacket . 170 65. An tero- Posterior Brace fitted with the Taylor Ring .... 171 66. Davies' Quadrilateral Brace ....... 173 67. Thornton's Back Brace for Pott's Disease ..... 174 68. Thomas Cuirass showing the framework before it is covered with leather . 176 69. The Complete Thomas Cuirass ....... 176 70. The Making of a Plaster Cast in Potfs Disease . . . .177 71. The Plaster " Negative " 177 72. The Completed " Positive " 178 73. The Plaster " Positive " covered with the original layers of " Stockingette " and Gauze .......... 178 74. The Flexible Convalescent Back Brace for Pott's Disease . . . 179 75. The Jury-Mast with chest piece for incorporation in a Plaster Jacket . 180 76. The Taylor Brace with the Jury-Mast attached .... 181 77. The Posterior Spine Brace with Taylor Ring attachment . . . 181 78. The Wire Chin Rest 183 79. The Goldthwait Head Support for Cervical and Cervico-Dorsal Disease . 183 80. The Thomas Collar for Cervical Pott's Disease ..... 184 81. Incision for Retro-Pharyngeal Abscess ...... 192 82. Incision for Supra-Clavicular Abscess ...... 193 83. Incision used in the operation of Costo-Transversectomy . . . 194 84. Incision for the Evacuation of a Sub-Costal Abscess .... 196 85. Incision for the Evacuation of an Ihao Abscess secondary to Tuberculous Disease of the Vertebra- ........ 197 86. The Hip-Joint 205 87. The early variety of Limp in Right Hip-Joint Disease . . . 208 88. The Gait in advanced Hip-Joint Disease ..... 208 89. " Position of Self-Protection " in Hip-Joint Disease .... 209 90. " Position of Self-Protection " in an advanced case of Hip-Joint Disease . 209 91. Position of the Limb associated with Tuberculous Disease of the Right Hip-Joint 210 92. Position of the affected Limb in advanced Hip-Joint Disease . . 211 93. The Gait in advanced Left Hip- Joint Disease . . . . .211 94. Alteration of the Contour of the Buttock in Left Hip-Joint Disease . 212 LIST OF ILLUSTRATIONS xv PACE 95. Thomas's Test to demonstrate the persistent muscular spasm producing flexion of the Right Hip-Joint in Hip-Joint Disease . . . 213 96. The Manoeuvre to demonstrate the movements of rotation at the Hip-Joint 214 97. The Amount of Adduction which may exist in Hip-Joint Disease . . 216 98. Simple Traction applied in the Treatment of Hip-Joint Disease . . 222 99. Right-angled Traction in the Treatment of Hip-Joint Disease . . 223 100. The Long Plaster Bandage applied in the Treatment of Hip-Jomt Disease 224 101. Thomas Hip Splint .224 102. Thomas Hip SpUnt — a " Nurse " and Abduction Wing are attached . 225 103. Traction Hip Sphnt 226 104. The Ridlon Long Traction Hip SpUnt . . . . . .226 105. The Shaffer Hip SpUnt 226 106. The Judson Hip Sphnt with Perineal Crutch . . . . .227 107. The Judson Traction Hip Splint ....... 227 108. The Short Plaster Spica ........ 229 109. Bradford's Abduction Sphnt for Tuberculous Disease of the Hip-Joint . 231 110. The Phelps Traction Hip SpUnt . . . . . . .232 111. Dane's Hip SjiUnt ......... 233 112. Convalescent SpUnt with Attachment on Shoe ..... 233 113. The Tubular Hip SpUnt for use in the Convalescent Treatment of Hip- Joint Disease .......... 234 114. The Combination Ridlon SpUnt ....... 234 115. Combined Thomas Knee and Hip SpUnt for use in Hip Disease and Knee Disease on the same side ....... 234 116. The Convalescent Hip SpUnt ....... 235 117. Incision for Anterior Excision of the Hip- Joint .... 244 118. Excision of the Hip by the Anterior Route — Steps in the Dis.section . 244 119. Incision for Excision of the Hip by the External Route . . . 245 120. Excision of the Hip by the External Route. Steps in the Dissection . 246 121. Kocher's Incision for Posterior Excision of the Hi2)-Joint . . . 247 122. Excision of the Hip by the Posterior Route. Steps in the Dissection . 248 123. The Knee-Joint ......... 258 124. Early Tuberculous Disease of the Kneo-Joint ..... 260 125. The Deformity of Flexion in early Knec-Joint Disease . . . 260 126. Tuberculous Disease confined to the Synovial Jlcmbrane of the Knee-Joint 261 127. Tuberculous Disease of the Kncc-.Joint witli t\u- .Aciuuiulation of Fluid in the Johit .......... 261 128. Advanced Tuberculous Disease of the Knee-Joint .... 262 129. The Thomas Kneo Splint viewed antero-posteriorly .... 266 1.30. The Thomas Knee Splint viewed from above ..... 266 131. The Bed Splint Variety of the Thomas Knee S])lint . . . .266 132. Thomas Kneo Splint applied ....... 267 133. The CalUper Sphnt 268 TUBERCULOSIS OF THE BONES AND JOINTS via. rAGE 134. Thomas Kneo Splint in use ....... 268 135. Miller's Incision for Excision of the Knee-joint. .... 272 136. Textor's Incision for Excision of the Knee-joint .... 272 137. Kocher's Incision for Excision of the Knee-joint .... 272 138. The Vertical Excision SpUnt used after Excision of the Knee-joint . 275 139. The Crab SpUnt for use in Tuberculous Disease of the Ankle-Joint . . 286 140. Kocher's Incision for Excision of the Ankle-Joint .... 287 141. Incisions for Excision of the Anterior Tarsus ..... 293 142. Incision for Excision of the Mid-Tarsus ...... 293 143. Incision for Excision of the Os Calcis ...... 294 144. Incision for Excision of the Astragalus ...... 294 145. Multiple Tuberculous Dactylitis with Abscess and Sinus Formation . 298 146. Comparative shortening of a Finger as a result of Tuberculous Disease of the Metacarpal ......... 299 147. Tuberculous Disease affecting the Phalanges and the Metacarpals . . 299 148. Healed Tuberculous Disease of the Metacarpal with resulting shortening of the Finger 300 149. Aluminium Splint appUed for Tuberculous Disease of the Metacar23a!s . 300 150. Incisions for Excision of the Metacarpals and the Phalanges . . 301 151. Tuberculous Disease of the Right Shoulder-Joint with Sinus Formation . 305 152. Incision for Excision of the Shoulder by the Anterior Route . . 309 153. Advanced Disease of the Elbow-Joint and lower end of Humerus . . 313 154. The Halter Sling for use in Tuberculous Disease of the Elbow-Joint . 315 155. Kocher's Incision for Excision of the Elbow-Joint .... 317 156. Tuberculous Disease of tlie Wrist-Joint with characteristic swelhng on the Dorsum . . .320 157. Tuberculous Disease of the Wrist-Joint ...... 320 158. Jones's SpUnt for the Treatment of Tuberculous Wrist Disease . . 321 159. Tuberculous Disease of the Frontal Bone with Abscess Formation . . 328 160. Tuberculous Disease of the Ramus of the Lef*JjOwer Jaw . . . 330 161. Tuberculous Disease of the Left Malar Bone ..... 332 162. Tuberculous Disease of both Malar Bones ..... 332 163. Tuberculous Disease of Right Lower Jaw and Left Malar Bone . . 333 164. Central Tuberculous Disease of the Patella ..... 334 PAET I.-GENEEAL ETIOLOGY The actual causation factor in tuberculous disease as it affects the bones and the joints is the tubercle bacillus ; but such a simple statement is by no means a dismissal of the matter, because bound up with it there are other factors which are important in their occurrence, and unfortunately much more difficult in their investigation and their elucidation. There are three of these related problems : (1) Is there any special importance in the identity of the bacillus ? Is the human or the bovine bacillus more commonly at fault ? (2) What are the routes which the organisms follow in reaching the bones and the joints ? (3) Are there any factors which predispose certain parts to infection by the tubercle bacillus, more especially the relationship of injury to the later development of the disease ? The Type of Organism. — Pathologists have divided the tubercle bacillus as a group into four subdivisions — human, bovine, avian, and piscine. As far as the pathology of man is concerned one may neglect the two latter. Since the memorable dictum of Koch in 1897 endless investigations have been carried out to clear up the inter-relationship between human and bovine infection, and the dissimilarity or unity of the two organisms. One may say,, probably beyond question, that the human and the bovine bacillus, originally a common stock, have each acquired, by reason of their residential environments, definite characteristics which enable the observer to distinguish tiie one from the otlier. In tuberculous diseases of hones and joints, as in other forms of tuberculosis, careful investigations have been made to demonstrate the relative ])roportion of disease which is human or bovine in origin. The metiiod of difl'orentiating between the bacilli is tedious and prolonged, but it is necessary to give a summary of the technique by which the separation is carried out. No attempt is made to isolate the bacillus by direct cultivation. Guiuea- pigs are inoculated with the diseased material, a piece of tuberculous bono or synovial membrane bcini; ini])lantf'(l beneath tlie skin of the Hank. An animal 80 infected is peiinitted to live for foin- or si.x weeks. During this time the condition of the animal is noted and a careful weight-history kept. At the end of the period tiic animal is killed, and from the tuberculous organs, more especi- ally the glands and the spleen, cultures are made upon suitable media. E.xperi- 3 1 TUBERCULOSIS OF THE BONES AND JOINTS ence has shown that plain egg medium (Dorset) ^ and glycerin egg medium (Lubenau) ^ are the most suitable. The diseased organ is rubbed upon the surface of the culture tube with a sterile spud. Tubes so inoculated are sealed with paraffin to prevent evaporation, and to diminish the possibility of infection by moulds. About ten days after inoculation a growth is usually apparent. With the successful growth of the organism in pure culture, the first stage of the investigation is completed, and it remains to decide to which class the organism belongs. To solve this question the organism is submitted to a series of tests. In the author's original investigation a series of five different tests were em- ployed : (fl) The original culture test ; (b) The morphological test ; (c) The special cultm'c test ; {d) Theobald Smith's test ; (e) The inoculation test. (o) Original Culture Test. — Smith ' noted cultm-al distinctions between different strains of tubercle bacilli when they were grown upon blood serum. Kavenal * described similar distinctions upon glycerin agar, and Dorset upon egg medium. The British Royal Commission ^ found such a constant distinction that they formulated two classes : a eugonic, or readily growing class, and a dysgonic, or slowly growing class. To the first the great majority of human bacilli belong. Bovine bacilli are most suitably described under the second heading. This test cannot be considered absolute because a margin of error exists in those cases which are on the border line between eugony and dysgony, but it is useful in so far as it forms the first clue. A rapidly growing and profuse culture is likely to be human in type, while a weak and scanty growth is in all proba- bility bovine. The fallacies of the test have been discussed by Rabinowitsch,^ Fibiger and Jensen,^ Park and Krumwiede.® (b) Morphological Test. — At one time it was believed that structural differ- ences between the strains of tubercle bacilli might prove of value as a distinguishing test. The Iiuman bacillus is usually considered to be slender, regular in shape, and long, while the bovine bacillus is squat and thick (Kossel, Weber, and'Heuss).^ If these differences were con- stant the test might be a valuable one, but if the test is to be of any assist- ance the bacilli must be observed in an early and original culture ; prolonged residence or multiple subculture tends to produce a common morphological mean. Dorset affirms that he found no such distinctive features between the bacilli, and his views are in agreement with those of Wolbach and Ernst.^" Fig. 1. — The ovigiual cullme te.st : The centre tube contains a human bacillus, the lateral ones contain bovine bacilli. 1 M. Dorset, Am. Med., 1902, iii. 55.5. ^ C. Lubenau, Ilyg. Rundschau, 1907, .wii. 1455. ' T. Smith, Tr. Ass. Am. Pliijs., 1896, xi. 75. * M. P. Ravenal, Univ. Penii Med. Bull., 1901-2, xiv. 238. ^ Royal Commission on Tuberculosis, Second Interim Report, 1907, Pt. I., 23. « L. Rabinowitsch, Arb. a. d. path. Inst, zu Berlin, 1906, 365. ' J. Fibiger and C. O. .Jensen, Bert. Bin. Wchnschr., 1908, xlv. 1876. * W. H. Park and C. Krumwiode and othor.s. Studies from the Research Laboratory oj the Department of Health of the City of New York; 1908-10, iv. 7. » H. Ko.s.scl, A. Weber, and Heu.s.s, Tubcrk. Arb. a. d. k. Osndhtsamie, 1904, i. 1 ; 1905, ii. 1. i» S. B. Wulbaeh and H. C. Ernst, Journ. Med. Research, 1903-4, x. 313. ETIOLOGY 5 If the observer is careful to examine the early and original culture, the test is useful as a suggestive one. In tubercle bacilli there has been frequently noted the presence of deeply- staining, spore-like bodies, and they have been described in considerable detail by Coppen- Jones. '^ These are found occurring most constantly in bacilli from a human source, and their presence is best demonstrated by the use of Much's stain. (c) SjKcial Culture Test. — The presence of glycerin has a restraining effect on the growth of the bovine bacillus (Moeller),^ but it has rather a stimulating effect on the growth of the human bacillus. The glycerin is incorporated in such a medium as glycerin egg. This test must be employed from primary cultures, as the vegetative capacities of the bovine bacillus increase on frec^uent subculturing. One may say that cultures growing luxuriantly from the beginning upon glycerin egg medium are of the human type, while cultures growing sparsely or even not at all on this medium are bovine in character. (d) Theobald Smith's Test.^ — By inoculating glycerin bouillon medium it is possible to produce upon its surface a pellicular growth of tubercle. The growth is easily started by loading a tiny cork raft with the culture mass, and floating it upon the medium. From this nucleus a growth soon extends over the surface. The rate of growth of the pellicle is an indication of the type of the bacUlus, but the development of the pellicle gives rise to a change in the reaction of the medium which is valuable as a distinguishing test. Before the medium is inoculated its acidity is carefully estimated by titration and made up to a standard reaction by adding 0-05 N/.5 of hydrochloric acid to glycerin bouillon neutral to litmus. As the organism grows and the pellicle develops, in the human case the acidity increases, while in the instance of the bovine bacUIus the acidity for a time diminishes, and the medium may even become alkaline. It is recognised that the reaction actually depends on the different rates of growth of the two varieties of bacilli. From a medium so inoculated five cubic centimetres of fluid are removed every ten days, and the reaction estimated by titration. Smith recommends that the medium be titrated when hot ; before titration it ought to be diluted to 10 per cent of its usual strength. The titration results may be graphically demonstrated by plotting them upon a curve. (e) Inoculation 'Test. — It has long been noted that tuberculous material from different sources varied in its etTects on bovines and on man. Villemin ■* observed tlie fact, and Smith may be said to have fornmlated it into a test ; he published articles on the subject in 1896 ^ and 1898.^ The test may be stated as follows : If a rabbit with an average weight of 2000 grams is inoculated with a small known quantity of tubercle bacilli it will react to tln^ inoculation in various way.s. If a human bacillus is employed, tiie resulting lesions are small and few in numljer, and after a time they show a tendency to undergo retrogression. If (h^ath occurs, it is usually more than six months after the original inoculation, and frequently tuberculosis is not the cause of death. If a bovine bacillus is used, an acute disseminated tuberculosis develops which is rapidly fatal. ' A. ('(i|i|ioii-Ji)ncs, Centralbl. j. Balcteriol., 18!t.'), xiii. 70. ■' A. .Mueller, Deutsche med. Wrhnnchr., l'J02, .\xvii. 7 IS. ' T. Smith, .fourti. Med. Reaearch, l!)04-.5, xiii. 40'). * ■!. A. \'illeinin, Ulitdes experimtiitates «ur la luberciiluw, Paris, 1808, ii. 237. ' 'I'. Smilli, Journ. Kxper. Med., 1898, iii. 451. ^ Loc. nup, rit. 6 TUBERCULOSIS OF THE BONES AND JOINTS The quantity of tubercle bacilli introduced varies according to tlie method of injection. 0-01 mgni. is a suitable amount for intravenous inoculation ; 10 mgms. may be given subcutaneously. Such bacteriological investigations have been carried out by the British Royal Commission (14 cases)/ Park and Krumwiede (71 cases), ^ Buckhardt (29 cases),^ Kossel, Weber, and Heuss (36 cases),* and the author (70 cases).^ The results of these different enc|uiries show a marked divergence of results. In Kossel, Weber, and Heuss's series only one case — a percentage of 2-7 — was due to a bovine infection, while in the author's series of 70 cases a proportion of 60 per cent owed their origin to infection with the bovine bacillus. But these results, so apparently irreconcilable, can be perfectly understood. A large proportion of bovine infection is closely related to two other facts — an infected milk supply and a young age incidence. Let us take the facts in their natural secpence. Until the age of twelve years milk forms a staple article of diet among the large majority of our population. If such milk be infected with the bacillus of bovine tuberculosis, as it most probably will be if it is obtained from a tuberculous cow, there will in all probability result from its ingestion tuberculous disease of the lymphatic glands, cervical or mesenteric. From this primary source the bones and joints become infected, and in such lesions bovine tubercle bacilli can be demonstrated. Therefore a large proportion of infection, due to the bovine bacillus, at once suggests to one's mind that the real source of the trouble lies in a contaminated milk supply. The considerable proportion of bovine infection is, in fact, explanatory of a fact which is discussed elsewhere, namely, the relatively great occur- rence of osseous tuberculosis in the periods of infancy and youth. Channels of Entry of the Bacilli into the Body.^One may neglect as a most unlikely possibility the question of a pre-natal infection by tubercle. In post-natal existence there are two obvious channels by which the disease gains admission — the respiratory tract and the ahmentary tract. Both of these have had their chamj)ions, men who have urged each in its individual importance. Calmette ^ and von Behring " have contended that in the ahmentary tract one has the medium through which the disease most commonly enters. Hamburger, Jacobi, and Holt have championed the claim of the aerogenous route.* There is, however, no necessity to dogmatise. Both routes are available, and at varying periods of life the relative importance of each differs. In children surgical tuberculosis is usually the primary manifestation, and if pulmonary disease appears it is ^ as a rule a secondary infection. In adult life the process is reversed, the * Royal Commission on Tuberculosis, Final Report, 1911, Ft. I., 13. ^ Loc. sup. cit. 3 H. Buckhardt, Deutsche Ztsch: f. Cliir., 1910, cvi. 1. * Loc. sup. cit. ^ J. Fraser, Journ. of Expt. Med., xvi., No.'4, 1902, p. 432. " C. Calmette, Ann. de VinM. Pasteur, Paris, 1905, tome xix. p. GUI. ' L. V. Behring, Deutsche vied. Wchnschr., Leipzig, 190.3, S fJ89. ' Tliese contentions have arisen more especially in deciding the route of infection in phthisis. ETIOLOGY 7 lungs are most frequently the first to suffer, and from tliem infection extends to the bones and glands. And as the sequences differ, so probably do the channels of infection, the alimentar}- system in youth, the respiratory system in later life. In urging the importance of the alimentary infection, one must bear in mind that the apparent resistance of the mesenteric glands — the first to show signs in an ingestion infection — varies considerably in early and in later life. The mesenteric glands of a child are more readily infected than those of an adult. Through the latter tubercle bacilli may enter the body, and leave no sign of their passage (Guerin). Therefore one must not consider the alimentary routes of infection a monopoly of youth. There are other less common means of entrance — the tonsils and the mucous membrane of the pharynx, the skin, the genito-urinary passages, and the teeth. We have frequently noted that tuberculous disease of the submaxillary group of lymphatic glands owed their infection to the presence of tubercle bacilli in the pulp of decayed teeth. Tubby ^ believes that tuberculous dactylitis sometunes owes its occur- rence to infection of overlying skin wounds with tubercle, the bacilli being obtained by crawling upon dirty floors. Routes of Infection of the Bones and the Joints. — One may assume that direct infection of a bono or joint from without is rare in its occurrence, and negligible as an etiological factor. There therefore remain the more indirect routes of the blood stream and the lymph streams. These are the questions to be answered, Does one or do both of these routes provide the paths of infection ? and, further. Are the bones and the joints equally liable to infection, or do they stand in relation to one another as primary and secondary infections ? It might be well briefly to epitomise the more important work which has been done to aid in the elucidation of these questions. Schiiller ^ in 1880 described how he iiijectcil tiiherculinis niateiial. sputum, glands, etc., tlirougli a tracheotomy opening into the lung.s of dogs and rabbits, coincidentally injui-ing one of the knee-joints of the infected animal ; he suc- ceeded in producing generalised tuberculosis and a tuberculous synovitis of the injured joint. Miiller ' in 1886 injected the nutrient Ixme vessels of goats ; apparently there resulted a multiple tuberculous osteomyelitis of the bone .su])])lied by the infected blood-vessel with accompanying infection of the neighbouring joints. Miiller quoted his results in demonstration of the hematogenous infection of osseous tubercle. In 1891 Krause * published the results of his experimental work, lie injected pure cultures of tubercle bacilli subcutaneously into guinea-pigs and intravenously into rabbits. Directly before or immediately after the inocula- ' Tulil)\', Tuberculous Disease uf the Hones and Joints, ii. |>. (i. ' M. .Scliiillfr, ExpcriinenteUe unti liisloloijisclie Viitersuchunijcn iiber die Entstehunij und Uraaclicn der shrophulOsen und tubcrkuhisen Oclenklciden, Stuttgart, 1880. » W. Miiller, Centmtbl. f. Cliir., I8HG, xili. 2X1 * v. Kiause, Die Tubcrkulose der Knuchen und Gclcnkcn. Li'ip/.ii:. 1891. 80-102. 1 a 8 TUBERCULOSIS OF THE BONES AND JOINTS tion, or after a variable space of time, a joint was injured or a bone broken. In no case was there evidence of tubercle at the site of fracture, but in the instance of the joints many of them became tuberculous, — fifteen joints out of forty-four in guinea-pigs, and fourteen out of twenty-eight in rabbits. The uninjured joints with one exception remained healthy. A number of experiments upon rabbits were carried out by Benda ^ in 1899. He intimated his belief that the original lesion was an actual focus of tuberculous disease in the tunica interna of the blood-vessel, and from such a focus there was a continuous liberation of bacilli into the blood stream. Lannelongue and Achard ^ (1899) found that it was b}' no means an easy matter to trace experimentally the source and origin of osseous or joint tubercle. They inoculated guinea-pigs in various ways, and directly afterwards or some time later they produced local injuries of the bones or joints, but they failed to produce tuberculous lesions. With a view to investigating the haemic routes of infection, Friedrich ^ in 1899 introduced tuberculous cultures of low virulence into the left ventricle of rabbits. He succeeded in producing tuberculous joint affections. Certain of the joints had been previously injured, but he found that those subjected to traumatism were less likely to become infected than the apparently healthy ones. What practically amounted to the antithesis of this view was expressed by Pietrzikowski * (1903). According to this view 20 per cent of all tuber- culous affections of bones and joints were connected with some forms of injury ; this rarely amounted to a fracture or dislocation, but usually an injury of lesser . degree, such as a sprain or bruise. In 190-1 Salvia ^ injected virulent cultures of tubercle intravenously into rabbits ; simultaneously various parts of the body were subjected to trauma- tism. He found that in the flat bones the violence practically always decided the localisation of tubercle ; no localisation could be obtained in the long bones of the limb, but slight injuries to the parts sometimes resulted in tuberculous disease. Out of such a mass of experimental evidence it is difficult to unravel certainties ; there are so many apparent contradictions, but there are two facts which are clear, and they are : (1) That it is difficult to reproduce experimentally tuberculous lesions of the bones and the joints ; (2) That trauma as a localising factor is slight in degree rather than severe. The possibility of the lymph stream being an important route of infection one may dismiss ; neither the bones nor the joints bear a close connection with the lymphatic system, and many authorities deny their presence in either structure. And further from the naked-eye and the microscopic appearance of the lesion in both situations there can be no shadow of a doubt that the blood stream is the main, in fact one would say the only route of infection. But there follows a que.stion which is much more difficult in its decision, Are bones and joints ec^ually susceptible to infection, or is the one more readily infected than the other ? 1 K. Benda, Verliaiidl. d. deiUscIi. Oesellsch-. f. C'liir., 1899, .xxviii. 48. - O. M. Lannelongue and C. Achard. Compt. rend. Acad, des He, 1899, cxxviii. 1075. « P. L. Friedrich.^ Deutsche Zlsckr. J. Chir., 1899, liii. 512. « E. Pietrzikowski, Ztschr. f. Heillc, 1903, xxiv. 187. ^ E. Salvia, PolicUnico, 1904, xi., sez. chir., 367. ETIOLOGY 9 As far as the relative percentage of occurrence is concerned, joints are to a slight degree more commonly affected than bones. During a period of ten years there were admitted to the wards of the Edinburgh Sick Children's Hospital 464 cases of tuberculous joint disease, while the number of cases of pure bone tubercle amounted to 353 cases. Practically the only way in which such a question can be decided is by experimental research, and in such an investigation one must remember that one is not reproducing exactly the condition one finds clinically. The result of the most recent experimental work may be summed up in the following conclusions : (1) The joints are more susceptible to infection by tuberculous disease than the bones. (2) The joints are infected through the medium of the blood stream. Predisposition by reason of Injury.— Every clinician must have noted the regularity with which one obtains in tuberculous disease of a bone or joint, the history of a previous traumatism. If such is not im- mediately forthcoming, a little detailed cross-examination rarely fails to extract it. There can, however, be not the slightest doubt that in a certain number of cases traumatism does play a part in the etiology. The trauma is not a severe one, it may be so minor as to have escaped the patient's attention. The explanation of the minor degree of injury lies probably in this fact. An injury of some severity produces such a state of tissue reaction that the lodged organism is neutralised and destroyed. When the trauma is slight no reaction follows, but instead a small effusion of blood and lymph, a condition of affairs which, by a temporary local arrest of blood flow, favours a stagnation of the organism and the development of a definite pathological lesion. There is another aspect to the influence which injury has upon the development of a tuberculous lesion. Not only may it favour its original deposit, but when it has developed it may very materially alter its further characteristics, and from this point of view the influence of trauma- tism is probably under-rated (Wilson). ^ A form of disease which has hitherto remained defined and encapsulated may become, after the receipt of an injury, an actively-spreading and infiltrating tubercle ; and on a larger scale, disease previously limited to the articular extremity of a bone, may be suddenly complicated by a wholesale infection of the near-lying joint, or of the surrounding soft parts. These relations of traumatism to the spread of the disease are of much greater importance in their practical bearing than any influence they may have upon the original development of the disease. Predisposition by Heredity.— Above twenty cases of apparent true congenital tuberculosis have been reported, and liaumgarten ^ believes that the virus is actually transmitted to the subject during intra - uterine development. Baumgarten suggests that the developing tissues retard ' H. A. Wilson ami K. C. Rosenberger, " Tho Relation of Trauinii to Bone 'ruborculosis,' New Yoric M.J., I'JKi, xcvii. 122:j-1225. ' IJannigarten, Deutsche med. Wchnechr., Leipzig, 1909, S 1729. 16 10 TUBERCULOSIS OF THE BONES AND JOINTS the growth of the infecting organism, which, lying latent, produces active tuberculosis in later post-natal life. This is a view which has aroused strong opposition. It would probablj' be more correct to say that the presence of tuberculosis in the parents leads to a weakening in the developing embryonic and foetal tissues, with a resulting predisposition to disease in any form. A special source of infection to tubercle exists in the person of the tuberculous parent, and the infection of the offspring is the all too frequent result. The question of germinal infection is still very largely one of speculation. Predisposition by General Causes.— There are many other factors which predispose to disease. The exanthemata are important. Their ravages are followed by a lowering of vitality and a surrender to the disease, and so it is with influenza. Then there are the questions of feeding, be it bad, insufiicient, or improper, and unhygienic surroundings, want of fresh air and sunlight. The Frequency of Affection of the various Bones. — During a period of ten years there has come under treatment in the wards of the Edinburgh Sick Children's Hospital a total of 353 cases of bone tuberculosis (entirely exclusive of joint disease and spine disease). The incidence of individual bones is represented in the following table : Bone. Number. Percentage. Bones of skull, mastoid and malar . Si 23 Metatarsus, tarsus, and jihalanges . 80 23 Tibia 39 10 Ulna 26 7-3 Metacarpus, carpus, and phalanges. 26 7-3 Femur 24 7 Humerus 21 a Lower jaw 18 5-4 Rib 14 4 Radius 14 4 Fibula 10 3 The high percentage of disease affecting the skull bones is largely due to tuberculous conditions of the mastoid. Excluding thesC; the short bones are the most frequently affected, and those of the foot in a greater degree than those of the hand. Of the long bones, the tibia and the uhia are most frequently involved. Vertebral disease has been purposely excluded. It of course forms by far the greater proportion of bone tuberculosis, yet the peculiar structure of the bone and the relation of the intervertebral discs lead us to consider it in a separate and distinct class (see p. 111). The Frequency of Affections of the various Joints.— During the period above mentioned 46-1 cases of joint disease were admitted for treat- ment. The relative frequency was as follows : [Table . <^>'^. •\-li^ <»^^. >;■ >! X,,^.'' 4.' ^ '^\^^' ■^'^ - - ^ . >¥ Jr «> •. — ^ /^^^ tu^ <««_^::; :-^- ^0 1/ ' ■ i^ I'LATK I. Till' iirniiia] jitiatniny o!" tin* cinl oi' u Ion;,' Ipoiu-, showing tlie avtiriiliir surface, the ejiiitliysis, the p'seal cart ila;;*', ami tlif tiietapliysis. A, 'I'lic articular cinl of tlic liunierus. c, Tlie c|>ii>liyscal ge with (-pijihysis uhovr and irictaphysis lichiw. (K A Volkmaun's canal i»ieroing the cortical bone, lig Willi it a blood-vessel. THE PATHOLOGY OF TUBERCULOSIS OF BONE 11 Joint. Number. Percentage. Hip . 171 37 Knee . 133 27 Elbow • 1 " 18 Ankle 72 15-5 Wrist 8 2 Shoulder . 3 5 The proportions are in keeping with those published elsewhere. The hip is the joint most frequently affected ; the knee is sUghtly less common. The elbow and the ankle are very similar in the percentage of their infection. THE PATHOLOGY OF TUBERCULOSIS OF BONE Normal Anatomy of Bone Bone is really a type of connective tissue in which the ground-work has become impregnated mth salts of lime, and a comprehension of this fact simplifies considerably the apparent complexity of its structure. The connective tissue is a variety of areolar tissue, and the earthy salts are chiefly lihosphate of lime. Bone is said to be compact or cancellous according to the degree of interspaces in its structure. As a rule the outer layers of a bone are compact and the deeper tissues cancellous. The marrow occupies the interspaces. Each bone is built upon definite architectural lines, and, more especially in the long bones and short long bones, a knowledge of the scheme of archi- tecture is essential to an understanding of the pathology. The scheme is most complete, and is seen to its best advantage in any of the long bones. The greater portion of the length is formed by the shaft. At the end of the shaft there is the epiphyseal cartilage, and that portion of the shaft which immediately abuts upon tlie cartilage is given a special name, that of the metaphysis. On the distal side of the epiphyseal cartilage there lies the epiphysis, and the free surface of the epiphysis is usually covered with hyaline articular cartilage. In all the long bones an arrangement such as is described occurs at both extremities of tlie sluift. In the siiort long bones, where there is only a single epiphysis, one end has such an arrangement, the other extends directly to the articular cartilage. There are no special features in the formation of the flat and the short bones. Blood Supply of Bones Lexer ^ traced the course of blood-vessels in bone by stereoscopic X- ray photographs. The vessels were injected with a solution of mercury ' Lo.xor, Unlerauchunj/en ilbcr Knocheimrterien, 1904, Lexer, Tuliga, and Turk. 12 TUBERCULOSIS OF THE BONES AND JOINTS in oil of turpentine, and the photograplis were taken with the periosteum and attached ligaments in situ. Under these conditions, while the periosteal vessels were clearly visible, the intraosseal branches were indistinct and blurred ; these latter were shown in a second series of photographs taken after removal of the periosteum. The vascular arrangements differ in the long tubular bones, the short long bones, the flat bones, the vertebrae and ribs, and such a composite bone as the ilium. Long" Tubular Bones. — About the centre of the shaft the nutrient vessel enters the bone. Just before its entry it becomes tortuous, an arrange- ment which has a double purpose. It partly permits of an elongation of the vessel, according to certain positions of the part, and further it reduces the pressure before the blood stream bifurcates. Having entered the bone the vessel divides almost immediately into two divisions, which run in exactly opposite directions towards the extremi- ties of the bone. These vessels are the nutritise ; they do not long remain single, they rapidly subdivide and extend to the epiphyseal cartilage in a parallel and leash-like arrangement. A second series of vessels pass into the bone immediately on the diaphyseal side of the epiphyseal cartilage. They are usually derived from the anastomosis around a neighbouring joint, and from their relationship to the epiphyseal cartilage they are called the juxta-epiphyseal vessels. They anastomose with the termination of the nutrient vessels in the metaphysis. The third group is formed by the epiphyseal vessels, they also are derived from the anastomosis around the joint, they perforate the epiphysis and the epiphyseal cartilage, and their termination is an anastomosis in the metaphysis. The scheme is completed by a complex anastomosis beneath the periosteum. The ultimate anastomosis in the metaphysis of three different groups of vessels is the point of greatest practical importance. The Short Long Bones. — The scheme is very similar to that in the tubular bones, but the presence of usually only a single epiphysis constitutes an important difference. The nutrient vessel enters the shaft about its centre, but there is a point of distinction in so far as it breaks up almost immediately into a plexus : there are no long parallel nutritise. At that extremity of the bone which possesses an epiphysis the vascular arrange- ments are exactly similar to those in the tubular bones. At the other extremity the juxta-epiphyseal vessels are necessarily absent, and only those analogous to the epiphyseal vessels exist. Flat Bones and Vertebrae. — Each of the flat bones is supplied by a nutrient vessel, which enters about the centre of the bone, and rapidly subdivides ; the periosteal vessels are of greater importance than in the long bones. The vertebrae have a distinctive distribution — two large and parallel vessels enter the body from behind, and reaching the centre of the body, they are joined by a series of small vessels, running inwards from the front. Corresponding to the juxta-epiphyseal vessels of the long bones there are vessels entering at the attachment of the transverse process B rrATE II— The Scheme of the Abtehial Blood Hvvvlx of Bones. A. T..e ,,.00.. s.pp,y or ..e ,c.« ^>---^,Zt:i:;Zl^T-J:^l ai-.^'^i" tlie OS iiinoiniu«tuni aiul the nbs. t^, i"i- "i""" "i I '.' arnini;./iiiciit In tli.' At.iis. (Alter Lexer.) THE PATHOLOGY OF TUBERCULOSIS OF BONE 13 to tlie body. The vascular arrangements are similar in all the vertebrae, ^vith the exception of the atlas : it, not possessing a body, derives its blood supply from two large lateral vessels. Ribs. — Each rib is supplied by a nutrient vessel, which enters the bone from its outer surface, just beyond the tubercle, and runs forwards inside the bone as far as the costal cartilage, where it is joined by vessels from the perichondrium. The Pelvis. — On account of the composite formation the vascular distribution in the pelvic bones is peculiar. The main nutrient vessel enters the ilium obliquely from behind through a large-sized foramen close to the great sacrosciatic notch ; it breaks up into fine radial twigs which extend to the crest of the acetabulum. A second vessel enters at the sacro-iliac synchondrosis and distributes branches upwards. The periosteum is independently well supplied with blood. Microscopic Anatomy of Bone Lamellae or strands of connective tissue in a calcified ground substance constitute the framework of a bone. Between the lamellae are the inter- spaces which the marrow occupies, and scattered through the substance of the lamellae there are the branching bone corpuscles, each occupying its space or lacuna. The branching processes of the bone corpuscles extend into the surrounding bone, along the minute channels spoken of as canaliculi. Studded throughout the bone there are larger channels, the Haversian canals carrying the blood-vessels. They are most numerous in compact bone, as the vascular marrow in the more cancellous type precludes their necessity. Li each canal there lies an artery and its accompanying vein, and the vessels are surrounded by a protective covering of loose connective tissue which may contain lymiihatic vessels. Most of the lanicllao are arranged concentrically around the Haversian canals, constituting Haversian systems. Some are arranged parallel to the periosteum, the ])eriostcal lamellae. Any spaces wliich exist between the Haversian and the periosteal lamellae are occupied by what are called the intermediate lamellae. Piercing the periosteal lamellae in a vertical direction one finds vascular canals similar to the Haversian. They carry vessels from the j)eriostoum to the interior of the bone, and they are called Volkmann's canals. While the bone lamelUc as a rule run parallel they sometimes cross and intermingle, and so constitute what are known as the " decussating fibres of Shar])ey." The Periosteum. - The perio.steum is the fibrous vascular membrane which covcr.s tlie cxtrrior of a bone. It is arranged in two layers, an outer fibrous, in which the blood-vessels run, and an inner cellular :iiid osteogcnetic, endowed with active bone-forming properties.' ' Sir William M'Kwoii clonics that the periostt'iiiii [lo.'i.scs.scs boiicforiiiiiig ])ro|nTtics. 8eo The Qruwih of Hone, Glasgow, 1912. 14 TUBERCULOSIS OF THE BONES AND JOINTS * ^ - ' ^^ ^^^\* The function of the periosteum is a double one — it helps to maintain the nutrition of the bone by the blood and lymph vessels which it contains, and by virtue of its cellular layer it is the medium by which a bone increases in thickness. In the " resting stage," i.e. when no special demands upon the periosteum arise, the cellular layer is thin and imperfect ; when special demands for activity are called for the layer becomes thick and active. There is an important detail which must be mentioned in regard to the relationship which the periosteum bears to the epiphyseal cartilage. AVhen the periosteum comes into contact with the edge of the epiphyseal cartilage, it sphts into two layers — one, the outer, is continued onwards over the epiphysis, the other turns acutely inwards and is continuous with the deeper layers of the epiphyseal cartilage. This anatomical detail is explanatory of the fact that a subperiosteal ab- scess cannot easil}' infect the epiphysis or the neighbouring joint. The Articular Car- tilagfe. — The articular cartilage is a cap of hyaline cartilage covering that portion of a bone which enters into the formation of a joint. It extends over the extre- mity of the bone, and meets peripherally the periosteum covering the shaft. The cells of articular cartilage are more numerous than those of ordinary hyaline cartilage, the ground substance is correspondingly less. The cartilage cells are arranged on a uniform plan. Peripherally the cells are small and flattened, arranged with their long axes parallel to the surface. Deeper the cells proliferate and become arranged in columns, springing radially from the head of the bone. Where the periosteum joins the articular cartilage the fibres of the periosteum actually pass inwards between the cells, and separating them become uniform with the gromid substance of the cartilage. The Epiphyseal Cartilag'e. — It is by means of the epiphyseal cartilage that a bone increases in length. is an essential feature at each extremity of the long bones, short long bones possess only a single epiphyseal cartilage. Macroscopically it appears as a thin plate of bluish cartilage separating epiphysis from diaphysis; microscopically it is cartilage of the hyaline variety. Fi(!. 2. — Pacinian bodies in the periosteum. Situated near the articular cartilage it Most of the PI, ATI-: III.— -A Volkmann's Canai. in Seition. It cniitaiii^ :ui artery, n vi'in, two 1\ iii|ilialii's, and a iniaiitity of lnosi- rouia'ctivi' tissue. THE PATHOLOGY OF TUBERCULOSIS OF BONE 15 Each plate of cartilage can be diflferentiated into two distinct zones. Lnmediately beneath the bone of the epiphysis there is a zone of clear cartilage, typically hyaline in appearance, but rather sparsely provided with cells ; at a lower level there is a zone which is scarcely recognisable as cartilage ; it forms nine-tenths of the total thickness of the plate, and its structure is essentially cellular. The cells of this second zone are actively proliferating, and they are arranged in pod-like spaces in which the cells are packed together exactly like peas. Where the cartilage lies actually in contact with the diaphysis, the cells have escaped from their collective confinement, and they form irregular masses l3'ing upon the diaphysis. These escaped cells are large, oval, or circular, each with a distinct cell membrane, a considerable amount of cytoplasm and a nucleus containing eosinophile granules. The superficial layer of the epiphyseal cartilage plays no part in the ossification of the bone, it is from the deeper layer that this entirely proceeds. Calcareous material is deposited between the cells, and passing inwards, later invades the cell membrane. The Epiphysis. — In structure the epiphysis is similar to the meta- physis, but the interstices of its substance contain only red marrow. The Diaphysis. — The diaphysis or shaft of the bone is filled with yellow marrow, except the portion which immediately abuts upon the epiphyseal cartilage and which contains red marrow. Bone Marrow. — One has no intention of entering into any depth of detail regarding the structure of the bone marrow,, but sufficient must be said to make clear certain points in pathology. Different types of marrow have been classified, depending upon the variety and number of cells present. If many of the blood-forming cells and their derivatives occur, the marrow is spoken of as red marrow. Absence of the cellular element and the proliferation, apparent or real, of the fatty element results in the production of yellow marrow. There is a third variety, of which more will be said later, namely, the myxomatous or embryonic marrow. It results from a proliferation of the loose, fine connective tissue, which everywhere supports the cellular elements. The actual marrow cells are classified into different divisions, according to the presence or absence of granules in the protoplasm and tlie character of these granules. A. Tliere are noii-granuhir ceils, and ])robab!y two varieties of such. (i.) Large non-granular bas()))hilic cells, (ii.) Small non-basophiiic ceils. B. There are granular celi.s, subdivided according to the type of granule wliicli the cells contain. (i.) Neutr<)])hiie myelocytes, the forerunner of the polymorpho- nuclear leucocytes, (ii.) ]'>)sinophile myelocytes, (iii.) Basophile myelocytes including mast cells. C. There arc precursors of red blood cells; these are characterised l>y 16 TUBERCULOSIS OF THE BONES AND JOINTS their nuclei, and they are subdivided according to size into normoblasts, megaloblasts, and microblasts. D. Finally, there remain fat cells, connective tissue cells and different varieties of giant cells. The Histology and Histogenesis of the Original Tubercle When tuberculosis attacks a bone it develops primarily as an osteo- myelitis, and the changes which lead to the development of the primary tubercle originate entirely within the marrow. The infection reaches the marrow by one of two possible routes. (1) It is carried directly inwards by the blood stream — the intravascular infection. (2) It extends into the marrow along the perivascular tissues, more especially in relation to the vessels which connect the interior of the end of a bone with the synovial membrane of the neighbouring joint — the 'perivascular infection. While the final development of the tubercle is similar in both these varieties, the preliminary histogenesis and histology varies. 1. The Intravascular Tubercle. — The tubercle originates as the result of an intravascular infection, caused probably by occlusion of the vessel lumen with an embolus charged with tubercle bacilh. At the point where the infection has occurred, upon the vessel wall, there appears a circum- vascular area of tissue necrosis. It is an area of a diffuse ground-glass appearance, and it owes its origin to the toxic effects of the neighbouring arrested bacilli. Around this central necrotic area there is a ring of mononuclear cells and more peripherally a granular change in the fat cells, which apparently residts from a breaking up of the fat and the deposit of crystals of fatty acids. Such constitutes the earliest stage-in the development of the intra- vascular tubercle. Epithelioid cells next make their appearance ; they probably originate from the mononuclear cells and the connective tissue cells of the part, and they can be recognised by their irregular shape, the excessive amount of faintly granular protoplasm and the whorl-like arrangement of the nuclear chromatin. These cells intermingle with the ring of mononuclear cells, they pass through the ring and invade the central necrotic area. The focus has now the appearance of a tuberculous follicle, viz. a cluster of epithelioid cells, and a surrounding zone of mononuclears. 2. The Perivascular Tubercle. — Disease of the neighbouring synovial membrane is the usual source from which the perivascular tubercle of bone develops. The lymphatics become invaded, and the development of the tubercle is slower and gradual. Changes occur in the vessel in relation to which the affected lymphatics run (vascular changes), and in the tissues around the vessel (perivascular changes). Vascular Changes. — The lodgment of the infection in the perivascular I'LATK IV.— Thk Histolojy ok the Okuiinal Tubkulli:. a, All caily stage in tile ilevelopnient of a tuberciiloiis foUiele in the marrow. A blooil-vessel, oeelinleil by a tilbereulons enil)obis, lias beeoine tlie centre of a celUilar iiiBlti'atioii. Ii, Vaseiilar oliaiige< secoiulary to the developiiient of a tiibeniilons folliele. The endothelial eells lining the blooil-vessel are beconiing dctaeheil, ami they later become eonveitni into epitheliofl ami giant c^ells. r, A fnrtlier stage in the ilevelopineiit of the niarrow tulierele. Tile hnigment of the bai-illiH has jji-ijilueed a surroiiniling neeroti<* area, through the centre of which a blood-vessi'l runs. The infection probably originated in tliis vessel, d. The eilge of a. tnbercillons follicle ; a liniiting baml of tibrou» tissue is beginning to be deposited. '-NfSfe' *.•»- ■.* • ■ i ■^ <' *:^/-.. 5,' "^ . • " V ' a J 'I ^'--y:::^^ /^ MF -MM "<v nkw Sriii'i;nnisTF.AL UoNi:. (I. (Vli I'lirly stiW ill tliu deposit. Notu lliv ovi-rlyiiiK niiisLnilai- liluvs tlie two liiycrs of tlir lifiiosti'uiii, tlic sliKlitly inv^'iilur ii|i|)t'iiniiic, Second stage in the ilejiosit. 'I'liu new bone is Kiowinx outwunls in tlie fonii ol spicnles. c, Tliiid stiige ill the deposit. Till' liiine is now lieiiig deposited in tlie form of nrclies, ami tlie inteiveiiiiig space.'* ore occiipiea by v.-iseuliir eoiiiiuctive tissue. PLATE XI. — The Final Picture of new Suepehio.steal Bone. There is a complete case enveloping the shaft of the original bone ; the centre of the original bone shows a tuberculous osteomyelitis. THE PATHOLOGY OF TUBERCULOSIS OF BONE 21 3. Periosteal Chang'es. — It is recognised clinically that a subperi- osteal thickening is one of the earliest features of tuberculous disease of the underlying bone. Such a subperiosteal thickening is the result of a deposit of periosteal bone, and the activity of the periosteum depends on an increased vascularity secondary to the underlying disease. The deposited bone is one of two kinds, porous bone or dense bone, and in each variety the method of formation diiJers. Method of Formation of Porous Bone. — In the deeper layers of the periosteum, in addition to numerous osteoblasts, there are always to be found a number of osteoclasts. The function of these is normally in abeyance, but by their activity they carry out a preliminary which is essential to the later stages of new periosteal bone formation. The osteoclasts eat out a series of lacunae along the shaft of the bone, until the usually smooth surface becomes rough and irregular. Their activity is short-lived, and the com- pletion of the surface excavation is the signal for the cessation of their labours. As soon as the osteoclasts cease their activities, the osteoblasts, which meantime have been proliferating in thedeeper parts of the periosteum, suddenly begin to functionate, and a thin layer of new bone becomes deposited upon the uneven surface of the irregular shaft. The introductory excavation of the osteoclast is quite an intelhgible proceeding. If the periosteal bone had been deposited upon a perfectly smooth and even shaft, it would have required only a slight degree of violence to dislodge its attachment, but the preliminary roughening of the surface is sufficient to prevent the possibility of this occurring. After the first layer of bone is deposited a second tier is begun. At certain points conical projections of new bone appear. They extend out- wards as small spines, and in the interspinous intervals there is a quantity of granulation tissue and one or more blood-vessels. The scheme of architec- ture undergoes further changes when tin; spines become joined at their extremities, and a series of arches is formed. Successive series of arches are in this way deposited until a varying thickness of porous bone has been laid down. It is a scheme of architecture in which nature combines a maximum of strength with a minimum of weight. Method of Formation of Dense Bone. — Occasionally the new periosteal bone is compact in character. The preliminaries are similar to those in the deposit of porous bone, but in the later stages no arches are formed, the bone remaining compact throughout. This is the metiiod of deposit which one finds occurring in the neighbourhood of joints, the reason being that the amount of its (l(>posit is luiver excessive ; the more profuse porous bone might easily interfere with the mobility of the joint. 4. Chang'es in the Blood-vessels. — One cannot fail to be struck by the frequent occurrence of endarteritis ol)literiins in bone tuberculosis. The disease affects the smaller vessels and occasionally the primary divisions of the nutrient vessel. In histological detail the changes closely resemble those which occur in syphilis, but the changes in the tunica adventiliii illus- trate a distinctive feature. In syphilis the external coat is infiltrated and 22 TUBERCULOSIS OF THE BONES AND JOINTS surrounded by a number of small lymphocyte cells, in the endarteritis of tubercle no such cells are to be found, instead there is a development of perivascular connective tissue. The condition arises from the circulation through the vessels of a tuberculous toxine. The change has far-reaching results, the narrowing of the vessel lumen gives rise to considerable disturb- ance in nutrition, and many of the fibroid changes in the marrow are sequelae to it. Further, the disease of the vessel wall has an effect on the local development of tubercle. Many of the cases of so-called primary tuber- culous disease occurring in the metaphysis of the long bones, the short long bones, and the short bones, owe their origin to an antecedent endarteritis of the larger blood-vessels. The Gross Pathological Varieties of Osseous Tuberculosis The previous chapter has been devoted to what one might term the general pathological changes, changes which in some degree at least .are common to all forms of the tuberculous lesion. But each case of tubercu- losis possesses some peculiarity in its general features which justifies its- classification into a special type of the disease. Therefore one may classify four different varieties : 1. The encysted tuberculous lesion. 2. The infiltrating tuberculous lesion. 3. The atrophic tuberculous lesion. 4. The hypertrophic tuberculous lesion. 1 . The Encysted Tuberculous Lesion. — When the disease focus, after enlarging to a certain extent, becomes shut off and locaUsed, it is termed an encysted tubercle. The encysted tubercle is the commonest variety, it is also the most chronic, and its chronicity is evidenced in every step of its formation. Macroscopic Appeara7ices. — The fully developed lesion varies consider- ably in size, a common gauge is from a pea to a walnut. For descriptive purposes it may be considered in a series of zones. The centre is occupied by an area of translucent jelly-like material, through which are scattered a number of opaque grey points, rather resembling putty in appearance. AVhen the lesion is of some age the individual opaque spots amalgamate and form a central caseous patch, which is surrounded by a thin shell of the original jelly-like material. Passing to the periphery, there is a band of pinkish-white colour running round the translucent zone and sharply defined from it. The circumference of this zone merges imperceptibly in the surrounding marrow, which at the line of junction is somewhat more congested than usual. "When the disease is of considerable age, the central portion becomes converted into a collection of semi-fluid debris, giving the part a cystic appearance. Microscopic Appearances. — The disease begins as a follicle of the loose reticular type. It enlarges imtil it can be appreciated by the naked eye as I'liATK Ml. 'I'llK Vasi'I I.AU ClIANlMOS SWIINDAHY TCI 'I'l'llKUrUI.OIS OSTKOM YKI.ITIS. «, Tuberculous eiiilaiti'iitis. 6, The nutrient vessel of a bono allVcted with tulicniilous cmlnrteritis ; the boiic itself was tlie subject of tuberculous disease, c, A vessel entirely oeeluded as the result of tuberculous endarteritis. I'LATE XUI. «, Coronal section through the head of the femur : tlie disease originated in the inetaphysis on the under surface of the neck and has resulted in extensive se(|uestrum formation. b. Encysted tuberculous disease in the lower end of the humerus. THE PATHOLOGY OF TUBERCULOSIS OF BONE 23 a grey opaque pin point in a setting of red marrow. There is a ground- work of branching connective tissue cells, and the interspaces are filled with epitheUoids and mononuclears ; giant cells are usually present. The impression afforded is one of a chronic and slowly developing tubercle. As the disease develops in the marrow, it comes to surround and enclose a number of bone laraellse, and these latter undergo rarefaction and absorption by means of osteoclasts, the slow development of the folhcle usually affording sufficient time for the absorption to become complete. If the absorption of the lamellae should not be complete, the particles which are left, being isolated by the diseased tissue, undergo necrosis, and become converted into small sequestra, commonly known by the term " bone sand." In the central clear deposit areas of caseation appear, and they may coalesce into a patch of considerable size. Around the tuberculous tissue there is a limiting band of connective tissue. It is the pink limiting band which has been noted in the macroscopic appearances, and it is developed from the connective tissue elements of the surrounding marrow. The changes iu the surrounding marrow are not extensive ; close to the disease the connective tissue cells proliferate, and the marrow acquires a loose fibro- myxomatous character. One would summarise the sequence of events as follows : A deposit of reticulated tubercle appears in the centre of the marrow, and it increases in amount, the bone lamellae being absorbed, until it forms an appreciable gelatinous-looking patch. Caseation appears in the centre of the patch, and the lesion is localised by the formation around its periphery of a pale pink band of loose connective tissue. 2. The Infiltrating- Tuberculous Lesion. — Nelaton described an infiltrating type of bone tuberculosis in 1836, and it was probably the first variety to be distinctly classified. It essentially represents the acute form of the disease. Macroscopic Appearances. — The naked-eye appearances are best ap- preciated in a lesion of some considerable size. As in the encysted disease, there is a natural division into a series of zones. The centre is occupied by a pale-yellow area, yielding and crumbUng when touched : it is the rarefied bono framework, the interstices being filled with caseous debris. Nelaton described it accurately when ho called it rinfiltration puri- forme. Extending around the central patch there is a zone of grey semi- transparent tissue (V hifiltration f/rlse), which merges almost imperceptibly into both the central and the peripheral tissues. The appearance is afforded by the infiltration between the lamellae of tuberculous granulation tissue which has not yet passed on to caseation. Around the grey zone the marrow is more congested than usual. It constitutes the third or red zone {V infiltration liee de vin). At t]w lino of junction of the grey and the red the latter is sometimes modificcl to form a paler {)iiikish band. Microscopic Appearances. In its earliest stages tlie infiltrating type of disease begins as a deposit in the marrow of a number of groups of epithelioid cells. Those coalesce until an appreciable area is occupied by 24 TUBERCULOSIS OF THE BONES AND JOINTS the diseased tissue. The naked-eye appearance is that of a grey, semi- transparent tissue fining the interiamellar spaces. Its exact structure is difficult to elucidate. It is composed of densely packed masses of mono- nuclear and epithehoid cells. Intercellular connective tissue is at a minimum, and here and there there are branching connective tissue corpuscles. There is an early arrest of the vascular supply, and to this change one must attach considerable importance ; it hastens the process of caseation, and in all probabiHty it greatly depreciates any attempt at resistance in the surround- ing tissues. Areas of caseation appear in the centre of this semi-transparent diseased tissue, at first isolated but later coalescing, and it is this caseous change which gives the characteristic yellow appearance to the central part of the lesion. As the disease develops, numbers of the bone lamellas become surrounded. When this occurs an effort is made to remove each individual lamella by means of osteoclasts, and in this the process of rarefaction consists. In an infiltrating disease all active changes are arrested long before rare- faction becomes complete, the blood flow ceases, perhaps the toxicity of the bacillus is great ; at any rate the process of absorption is arrested, the lamella dies, and as such it constitutes a sequestrum. Scattered throughout the tuberculous tissue there may be numerous sequestra (seque^tres parcellaires), each bearing evidence by its worm-eaten appearance of the degree of rarefaction which it has undergone. If the infection has been specially rapid and acute, necrosis may occur before any degree of absorption has become possible, in which case a large lamellar area dies, and remains in contact with the surrounding bone until it becomes separated by granulation tissue. Such constitutes a composite sequestrum. In the surrounding marrow there is a leucocytic reaction around the periphery of the disease, and the type of cell which constitutes the reaction is mainly the polymorph, the representation of lymphocytes and mononuclears being sparse. There is, in fact, a cellular reaction re- sembHng that which one finds in acute infections, and it has been sug- gested that a mixed infection is the dominating factor in the pathology of infiltrating tubercle. Occasionally the cellular reaction becomes modified, and there is an attempt at fibrous limitation of the disease ; this is the explanation of the pink band which one occasionally finds at the periphery. The periosteum becomes early activated, and forms masses of new bone. The details of the method have already been described. The essential factor is a congestion of the overlying periosteum, secondary to the central disease ; the deposit may be localised or it may extend widely over the shaft of the bone. Special Features of Infiltrating Tuberculosis of Bone : (1) The original tubercle is a closely packed collection of epithelioid cells, and in appearance a tubercle of the acute type. (2) Early in the course of the disease the blood-vessels become occluded, not by a chronic process of endarteritis as one generally sees in tuberculous disease, but rather by a sudden clotting and destruction of the epithelium. (3) Caseation early appears in the diseased area and spreads rapidly. N. ^J?.l I'LVri; .\l\. I'HK STAOKs in THK UKVKI.DI'MENT ()!•■ A.N KNL'YSTKD TUUKUCILOI^S DISKASK OF THK BoNK. », All fiirly I'licj'stiMl tuliiTculosis of tlu^ lione : tlir follirli- tiikcs tlif form of ii rcticiiliilcil tiilxTck'. /', 'I'liu I'llge i>f an eni;ysleil tiilicnjuloiis disease, sliowiiii; tlif ilevrlopnuMit of tlu' limiting filirmis liand. i', 'I'lu' tilirous sticicture of tlic liniitiu),' lianil : tliiTe is a ilcposil of new bcHiu upon tlic oiiliT surface of tlie liand. il, A central eiicysteil tnliiMrulous disease. PLATE XV.— iNKILTIiATINcI TUBKRCULOUS DISEASE OK THE BoNE. rt, The advancing edge of an infiltrating tiilieicnloiis disease : tliere is a comparative absence of reaction in the neighbouring marrow. Ii, Commencing iiililtrating tuberculous di.sease : note the absence of a fibrous reaction in the n]arro\v. c, Acute infiltrating tuberculosis of the bone ; the lamellae in the lowei- jjai-t of the section enclosed in the disease have lieen coiiverteil into sequestia. PLATE XVI. IntiltratiiifJ tuberculous osteomyelitis of the tibia. The central portion is occupied by caseous debris . around this there is a band of tuberculous granulation tissue infiltrating between the lamellae U'infiltration griseh at the periphery there is the zone of congested marrow U'infiltration lie de vint. I'LATK W 11. iM'll.THATlNU TlBKUCILUU.S DiStASK ol THh lill>iE. a, Acutu iiililtriiting tuberculosis ai)rea,,d, the upper end of tlie ulna. The articular cartilage ,s intact, her a niirked rarefiction of the hone lamellae and the interlamellar spaces are filled >vith tnl.erculous grann- latTon ti'sne c, A transverse section through the npper end of the ulna. The section shoe's the rarefaction of the lamellae and the occupation of the spaces by tuberculous tissue. I'liA'l'K XIX.-TllK AlTKAHANCE UK THK MaIUIUU IN AtHOI'HIC TUBElU'l'LOSl.s. Noll' tlie liiiL'fftctioii of tliu liiiiii'lliie and the icpliiCfiiR'Ht of tlie iniirrow 1)y tuberculous granulation tissue. PLATE XX. — Atrophic Tubeuculous Disease of Bone. rt, The appearance of the bone in transverse section. Note the extreme rarefaction of the bone and the case of new subperiosteal bone, b. Atrophic tuberculous disease of tlie bone in transverse seetion. THE PATHOLOGY OF TUBERCULOSIS OF BONE 25 It results partly from the toxicity of the bacillus and partly from the inter- ference with the blood supply. (4) Sequestra of varying forms occur, and they are the result of necrosis appearing before rarefaction is complete. (5) The attempt on the part of the marrow and the surrounding tissues to localise the disease is inefficient, and consists in an accumulation of cells rather than a fibrous reaction. (6) The disease has a characteristic spreading and infiltrating character. 3. The Atrophic Tuberculous Lesion.— The distinctive feature of this variety of tubercle is a wasting and atrophy of the bone lamellae. In some respects it resembles the caries sicca first described by Volkmann ^ in 1879, and later by Koenig^ in 1896 ; but on the other hand it has charac- teristics which associate it with the caries carnosa of Koenig and the tuber- culose charneu of Mauclaire.* It is more correct to consider caries carnosa and caries sicca as the same type of disease in different stages of its develop- ment, and confusion is avoided if both terms are combined in the single descriptive title of atrophic tubercle. The reason for this will be more obvious when the lesion has been fully described. Macroscopic Appearances. — The situation of the disease is typical in so far as it attacks the metaphyseal end of a long bone. The affected bone is uniformly and diffusely enlarged. It is much Ughter than healthy bone, and its surface yields to the application of a moderate degree of pressure with a curious crinkling sensation. The periosteum undergoes a moderate degree of activity, and a thin sheath of new periosteal bone is deposited. On cross section of the bone, after the outer shell is divided, the interior is found to be occupied with a soft granulation tissue in which atrophied lamolla; are scattered. The granulation tissue is of a flesh colour, and throughout its substance there are numerous spaces, producing a spongy appearance. The changes may extend to the articular cartilage, but the latter is never invaded. Microscopic Appearances. Changes in the Marrow. — The earlier changes appear in the marrow, and in their development they are slow and insidious. Gradually the connective tissue elements increase at the expense of the fatty tissue, and the marrow becomes transformed into a variety of granula- tion tissue. The granulation tissue is largely composed of connective tissue cells of a myxomatous type, and the vasculaiity of the part is considerable. There are numbers of mononuclear cells and osteoclasts, and there is a tend- ency for the tiss\ie to become cystic. Scattered throughout the bone there are tuberculous iollicles, but their numbers are few, and in structure they are almost without exception reticulated. As the disease progresses there is an ev(u-increasing tendency for the graiuilation tissue to become converted into fibrous tissue. Changes in the Lamella:. — With the replacement of the nianow by ' Volluimim. Sammlutuj klin. Vortrdge, 1879, S. 1402. '' Koenig, Die 7'itberculose. der Knochcn und Oelcnkcn, 1806. ' Mauclairp, Maliidirs rfci oi, I'aiis, 1910. O » 26 TUBERCULOSIS OF THE BONES AND JOINTS granulation tissue the bone lamellae undergo a rapid absorption. It begins in the centre of the shaft, and it is the result of the activity of osteoclasts. The absorption extends to the compact bone of the shaft, the lacunae are increased in size, and the whole appearance is one of extreme porosity. Changes in the Periosteum. — With the appearance of radical changes in the centre of the bone, the periosteum acquires a sudden activity ; the result is the deposit of a sheath of new subperiosteal bone of the vascular cancellous type. The fm-ther history of the periosteal bone is thoroughly distinctive of this type of lesion. When a considerable amount has been formed, the foundation from which it springs becomes undermined ; that portion which Ues in contact with the shaft becomes absorbed, and between the new bone and the original shaft there is a ring of granulation tissue. The periosteum goes on forming new bone peripherally, but the deeper portion continues to be removed, and this is maintained until there is a considerable thickness of granulation tissue separating the new peri- osteal bone from the original shaft. The result is an increased but very unstable circumference. The confusion in the nomenclature is explained by the changes which the lesion undergoes when it has reached a certain point of development ; the soft vascular granulation tissue becomes converted into a dry contracting granulation tissue. The caries carnosa of Koenig and the tuberculose charneu of Mauclaire are descriptive of the lesion when it is at an early stage in its development, and the granrdation tissue is young and vascular. The caries sicca of Volkmann and Koenig is the same lesion when the granulations have become fibrous tissue and the vascularity has diminished. 4. The Hypertrophic Tuberculous Lesion.^ — As there is a type of bone tubercle in which an atrophy of the lamellae is the distinguishing feature, so there is a form in which a thickening of the lamellae is the pre- dominating factor. Its occurrence is rare, and its situation is typical in so far as it attacks the metaphyseal end of a long bone. Macroscopic Appearances. — There is a diffuse thickening of the bone, beginning where the diaphysis joins the epiphyseal cartilage, and extending towards the centre of the shaft. The periosteum is readily detached, and in the later stages there is a deposit of new subperiosteal bone. The weight of the part is considerably increased. When the bone is divided in transverse section its structure is found to be unusually dense and firm. From the healthy tissue a h3^perostosis can gradually be traced, and the hyperostosis is the result of an endosteal formation. The thickening is not uniform throughout the whole diameter. In the centre there is an area from which the lamellae have been absorbed, their place being taken by a quantity of grey semi-diffluent material. Embedded in the centre of the soft tissue there is usually an elongated sclerosed sequestrum. Microscopic Appearances. Changes in the Blood-vessels. — These are * Since the description of this lesion was written the author has made observations which have led hira to beUeve that the hypertrophic type is primarily a syphilitic infection, secondarily infected with tuberculous disease. PLATiO \\l. — II vi'KH'iiun'tiK' TruEUcui.iisis of the Tibia. Tlu; bone is IhirkeiK-il in its upper two-tliinls .is a result of tlie emlosteal lieposit tif iii'W hone. ^t- PLATE XXII. — HTPEKTEorHic Tubeuculosis ok the Tibia. a, The appearance of the tibia. 6, The appearance of the boue on transverse section. Note the central sequestrnm. c, An early stage in the development of hypertrophic tuberculosis. There is an etinsion around one of the branches of the nutrient vessel. THE PATHOLOGY OF TUBERCULOSIS OF BONE 27 given the premier consideration because they are ujidoubtedly the first changes to appear, and probably the vascular derangement is the essential etiological factor in the pecuharities possessed by this type of the disease. The changes appear in the larger divisions of the nutrient vessels soon after the latter break up into their primary divisions, and they take the form of a structureless effusion around the vessel, and an endarteritis in the substance of its wall. The perivascular effusion does not remain structureless, it becomes organised and converted into granulation tissue. The endarteritis in the wall progresses, and the vascular and perivascular sclerosis soon leads to an almost complete obliteration of the vessel lumen. It is a peri- and an endarteritis. Changes in the Lamellce. — When the thickening of the central vessels has developed, the lamellae immediately surrounding the vessel undergo an absorption and a fibrous metaplasia. These changes depend upon nutri- tional disturbances, resulting from the thickened blood-vessel. Where the lamellae have become absorbed the resulting space is occupied by a fibromyxomatous tissue. Outside the central area of absorption the lamellae become thickened and the hyperostosis results from the deposit of bone by osteoblasts lining the lamellar surfaces. It is essentially an endosteal thickening, and the result is a remarkably firm dense bone. Formation of Sequestrum. — When an area in the interior of the bone has been absorbed and replaced by granulation tissue a variety of sequestrum occurs about the centre of the bone. It is the type of sequestrum which OlUer ^ called le sequestra dur. Its method of formation is as follows : A number of osteoblasts, assuming a sudden activity, deposit a quantity of closely arranged new bone in the centre of the area from which the lamellae have been absorbed. This original deposit is not permanent, when it has reached a certain size it becomes absorbed and redeposited as a firmer, denser bone. This .process of absorption and remodelhng is repeated until the deposit is densely sclero.sed. Up to this point of development the term sequestrum is a misnomer, the tissue is not dead. Later it becomes a true sequestrum from the interference with its blood supply. These are the appearances which one finds on cutting through the centre of the diseased bone : an outer zone of hyperostosis, an elongated central sclerosed sequestrum, and an intermediate area of soft granulation tissue. Changes in the Marrow. — Mention has been made of the formation of fibromyxomatous tissue in the centre of the bone. Generally the marrow undergoes a fibrous degeneration. True histological evidence of tubercle occurs in the shape of a number of follicles developing in the granulation tissue in the centre of the bone. Changes in the Periosteum. — In the early stages of the disease the periosteum shows no reaction, and the thickening is entirely endosteal in its origin. In later stages the periosteum is activated, and deposits a thin layer of new bone around the sclerosed shaft. The changes in the disease are essentially those of a chronic infection. ' OUior, Encijc. ititernal. rfc cliirurg., 1885. 28 TUBERCULOSIS OF THE BONES AND JOINTS The primary endarteritis of the nutrient vessel is the original change, and it depends on the circulation within the vessel of a tuberculous toxine. The thickening of the vessel wall results in a focal nutritional disturbance, an absorption of the surrounding bone, and its replacement by granulation tissue. The irritation of the central changes leads to a hyperostosis and sclerosis of the surrounding lamellae. The actual cytological development of tubercle occurs late, and it is by no means the outstanding feature. Sequestrum Formation. — In the progress of tuberculous disease sequestrum formation almost inevitably results. According to the type of sequestrum three diiierent varieties may be classified — minute sequestra, (bone sand or sequestres parcellaires), rarefied sequestra, and sclerosed sequestra. Minute Sequestra. — These are the commonest, and they are met with in the encysted and the infiltrating types of the disease. They appear as small irregular particles of bone scattered among the tuberculous tissue. The method of their formation is as follows : Secondary to the de- velopment of tubercle an active absorption of the lamellae begins, and is carried on by means of osteoclasts. The absorption has been almost com- pleted and the lamellae have been disorganised into a collection of irregular • particles when the progress of the disease leads to the arrest of the circula- tion ; the broken up lamellae become converted into sequestra. In appearance they are of varying size and irregular shape, the edges are serrated, the lacunae in which the bone corpuscles lie are enlarged, and the bone cells have disappeared. The staining reaction is peculiar. Healthy bone stains pink with eosin, but small sequestra take on the basic stain, either as purple lines or as a diffuse maroon colour. Rarefied Sequestra. — The term " complete " would be more applicable to this variety. The condition is met with in acute infiltrating tubercle. The disease spreads with remarkable activity throughout the bone, and large areas of tissue are rapidly invaded. Attempts are made by rare- faction to remove the invaded lamellae, but long before absorption is com- plete, before the lamellae have reached the stage of minute sequestra, necrosis occurs, and the whole extent of invaded lamellar substance becomes a sequestrum. At first the connection of the sequestrum with the surrounding bone is maintained, later the irritation of the dead tissue gives rise to a reaction in the surrounding living bone, and a line of demarcation is formed. The line of demarcation is really a band of granulation tissue, which being possessed of considerable phagocytic powers, absorbs the lamellae which unite the living with the dead, and leaves the sequestrum free. Sclerosed Sequestra. — This type of sequestrum was probably first de- scribed by Oilier in 1885. He gave it the name of le sequestre dur. It is the type which one finds in the hypertrophic variety of bone tubercle. The origin of the formation of the sequestrum is an irritative one, and it is intimately related to an endarteritis of one of the larger nutrient vessels. The nucleus of its formation is a portion of the original bone-tiss\ie, and usually a portion of bone which either is already a sequestrum, or is in process n.ATi; will.— Sta.iks in thk 1)kvi;i.(i|..mknt of IIvi'Kkticoi'iiic Tuukhcilosis. «octim,'''to'' si! '17,7 "■™"'°" • """'."• " " '"•"'if'''-""'"' of "'" ™nn.,,-tlv« tissu. f™.nework. 6. The l.ono on t,„nsv...se X t 1 will •, u r"T r T- '• 7t, 't''"-""' ""'I'-^l'-""' ^'"'i«'> •"">"lly occupies tl,e centre of „ l,onc hone Tls ,!.':'" "'""■"''":"'■ ''• '!■'■ ''O"" "" transverse section : tl,e excessi've fornn.tion of endosteal he ,ele.OHe,l Zm.st'^:,, ■ '"" T l\'"""' "'"'■' '"'f""- ^^" endarteritis „r I he nntrient vessels is illustratcl. also uie aclciosed sequestrum surrounded liy an area of hone absorpti(Ui. PLATE XXIV. — A FuLLY-DEVKLOPKD Hypekthciphic Tobekculosis ok the Tibia. Tlie shaft is tliickeued by a deposit of endosteal bone, around the perijihery there is a depcsit of new periosteal bone and the interior is occupied by an area of tuberculous osteomyelitis. ri.A'I'i: .\ \\ .^SEliUKSTltUM I'oli.MATInN. ". A large composite sequestrum occupying the upper end of tlie tiV)ia. h, Seqiiestrcs parceflaireii or " lioiie siiiid" secjuestra. c, The edge of a sclerosed scqui'strum. rf, The rarefiod or complete sequestrum : tlie seciuestrum occupies the lower part of the tiidd. PLATE XXVI. — Extensive Sel.5." RiDOLi'T. " L,a TuhcTculoac ossea ed artioolaro nolle case di pona," .-Inn. di Ippocratt, Milano, 1008-9, iii. 87-90. VoQiu.MANN, U. " Isolierto tuberkuloso Knoehenherde," Forlachr. a. d. Ocb. Rontgcn- sirahlcn, Hamburg, 1908-9, xiii. 80-89. 32 TUBERCULOSIS OF THE BONES AND JOINTS Massini, G. Tubercidosi ossca ed articolari, Tommasi, Napoli, 1908, iii. 352-354. CowDEN, C. H. " Tuberculosis of Boucs," South M. and S., Chattanooga, 1008, ix. 189-193. Van Mette, B. F. " Tuberculosis of Bone," Ketitucky M.J., Bowling Green, 1908, vi. 272-275. TisiEK. " Ost^omalacie tuberculeuse limitee," Rev. de Chir., Paris, 1908, xxxvii. 722. Mauclaire. Maladies des os, Balliere et fils, Paris, 1908. Bradford, E. H. " Tuberculosis of Bones and Joints," South M.J., Nashville, 1909, ii. 613-019. EwiNO, W. G. " Tuberculosis of Bones and Joints," Wash. Med. Ann., 1909-10, viii. 383-387. GiMENEZ, L. H. " Artritis tuberculosa abierta de la rodilla derecha," Med. de nos Ninos, Barcel., 1909, x. 83. Batut. " Syphilis et tuberculose craniennes," Marseille mid., 1910, xlvii. 290-300. Lentaigne. " Multiple Bone Tuberculosis two years after Treatment," Tr. Royal Acad. M., Ireland, Dubhn, 1910, xxviii. 206. Marfak, a. B. Maladies des os, Balliere et fils, Paris, 1910. Brown, E. M. " Tuberculosis of Bones and Joints," New York M.J., 1910, xcii. 905-912. ToEPEL, T. " Tuberculosis of the Bones and the Joints," Atlanta Journ. Eec. Med., 1910-11, Ivi. 239-244. Goldthwait, J. E., Painter, C. F., and Osgood, C. B. Diseases oj the Bones and the .Joints, Boston, 1910. Bkown, E. M. " Tuberculose inflammatoire du squelette, I'osteomalacie d'crigine tuber- culeuse," Bull. Acad, de Med., Paris, 1911, 3. S. Ixv. 22-28. PoNCET, A., and Leriche, R. " Tuberculose inflammatoire du squelette," Gaz. des H5p., Paris, 1911, Ixxxiv. 3-5. JouoN, E. " Pieces de tuberculose osseuse," Gaz. Med. de Nantes, 1911, xxix. 33. Eraser, J. " Observations on the Situation of the Lesions in Osseous Tubercle," Edin. M.J., 1912, N.S. ix. 436-441. Fraser, J. " The Pathology of Tuberculosis of Bones," J. Path, and Bad., 1912-13, xvii. 254-277. Jones, R. " Tuberculous Disease of Bones and Joints," Pracl., London, 1913, xc. 182-189. I'LATE XXVll. — TouEncui.ous Dactylitis. There is .i tiilicTcviIoiis emlarteritis of the mitiieiit vessel, unci iis n result of the endarteritis the zone of bone supplied by thi' diseased vessel has undergone rarefaction : the zones supplied by the periosteal ami the articular vessels are healthy. PLATE XXVIII. — The Anatomy of the Articui.ak and Ehphyseal Eegions. a. This illustration indicates the relationship of the various structures at the reflection ol tlie synovial membrane : the articular cartilage, the eyiiphysis, the epiphyseal cartilage, the metaphysis, and the synovial reflection. Ii, Tlie junction of metaphysis and epiphyseal cartilage, c. The edge of the aiticulai- surfaces showing the reduplication of syuo\ ial membrane between the ends of the bones, f/, The structure of synovial membrane : lining cells and deeper coimective tissue. TUBERCULOUS DIAPHYSITIS 33 TUBERCULOUS DIAPHYSITIS Spina Ventosa. — This need not be classified as a distinct pathological variety of tuberculous disease, because it is simply an infiltrating tuber- culosis affecting the diaphysis of a long bone or of a short long bone. There are certain peculiar facts in its pathological etiology, and they are best illustrated in such a tuberculous diaphysitis as a spina ventosa of the phalanges or metacarpals. An endarteritis of the nutrient vessel just before and after it enters the bone is the localising factor. The endarteritis leads to a fibromyxomatous degeneration of the marrow, which predisposes the part to infection by tubercle bacilli. BIBLIOGRAPHY ViONARU and Mounguand, E. " Tuberculose diaphyaaire spina ventosa des grands oa longs," Rei\ d'orlhnp., Paris, 1908, 2- s ix. 481-504. Charitonoff, S. Ei)i Beilray zur SchafUnberkulose der rjrossenrohren Knochen, Berlin, 1909, C. Siebert. Bkoha, a. " Spina Ventosa de.s grands os longs," Rco. gen. de din. e.t de therap., Paris, 1910, xxiv. 353-3.55. Benf-t, a., and Vacorand, H. "Spina Ventosa du peronee," Ann. med., Paris, 1910, xxi. 107. Smoler, F. " Zur chirurgisohen Behandlung der Spina Ventosa," Beitr. zur klin. Cliir., Tubingen, 1910, Ixvii. 79-95. Peter-S. "Spina Ventosa," Milnch. nyd. Wnrhensrhr., 1911, Iviii. 221. ToirRNEAU.x, .1. P. " Sur deux cas do tubereuloso diaplivsaire," .-{rchives mid. dc Toulouse, 1912, xix. 151-1,5.5. Mattuevvs, v. 8. "Tuberculosis of the Shaft of the Long Bonos," Am. Surg., 1913, Ivii. 133-135 Melchior. " Obcr symmetrische Diaphysontuberkulose," Berl. klin. Woclien-whr., 1913, 1. 513. Alamartine and Lanoeron. " Tumour de VoxtriSmit^ superieure du tibia choz un tubcrcu- Icux," Lyon med., 1913, cxx. 1177-1179. 34 TUBERCULOSIS OF THE BONES AND JOINTS THE PATHOLOGY OF TUBERCULOSIS OF JOINTS Normal Anatomy of Joints The structures which enter into the formation of joints vary with the type of articulation. In every instance there are the skeletal elements — bones or cartilages — and in addition there are uniting media, simple or intricate, according to the variety of joint. In the economy of nature there are two varieties of joints : (a) the Synarthrodial, which permit of no movement between the approximated surfaces ; (b) the Diarthrodial or movable joints. In the synarthrodial type the opposing surfaces are united by means of fibrous tissue (suture) or by hyaline cartilage (synchondrosis), and in the progress of ossification the uniting medium tends to disappear. A diarthrodial joint may be one of two possible varieties, the movement between the surfaces may be limited — the amphiarthrodial, or it may be free — the diarthrodial joint proper. An amphiarthrosis is united by ligaments and by an interposed plate of fibrocartilage, in the centre of which there is a rudimentary synovial cavity. The joints belonging to this group occur in the mesial plane of the body, and it includes the symphisis pubis, the intervertebral joints, and the joint between the manubrium sterni and the gladiolus. The diarthrodial is the most elaborate and the most complete form of articulation. It is characterised by the freedom of its movements and the presence of extensive lining by synovial membrane. The diarthrodial is the type of joint which is most liable to infection, and the following remarks are in relation to it. Structures which enter into the Formation of a Joint. — The opposing surfaces of bone are held in apposition by means of ligaments, and every diarthrodial joint possesses a ligamentous envelope or capsule, vari- ously arranged thickenings constituting special ligaments. Within the attachments of the capsule there are the opposing surfaces of the bones, each covered with hyaline cartilage. The capsule itself is lined with synovial membrane, which is continued on to the surface of the intracapsular portion of each articulating bone. The synovial membrane ceases at the edge of the articular cartilage, and its most apt description is that of a tube open at each end. Within the joint interarticular ligaments may extend between the opposing surfaces of the bones, and interarticular fibrocartilages or menisci may divide the joint cavity into distinct compartments. All around the joint, in localities between the synovial membrane and the surfaces which it covers, there is found a varying quantity of fat. > > Q O ^ a CI ^ < >. « rr Q M J 2 m x: ii D £ ^ H , "o 1 I- ^ Tt OJ 'u > o > V r^ S s .2 ^ OJ o V a w: rt u J =2 O) ■" i s g o o '9 THE PATHOLOGY OF TUBERCULOSIS OF JOINTS 35 Structure of Synovial Membrane. — Lining the interior of the synovial membrane there are a number of flattened endothelial cells ; their distribu- tion is irregular, in places they are absent, in others they may exist several layers thick. The distribution is most plentiful at the synovial reflection. Beneath the cellular lining there is a condensation of connective tissue, which really forms a basement membrane. Occasionally the connective tissue is prolonged into the joint in the form of pedunculated villi covered with endothelial cells. The synovial structure is completed by a quantity of loose connective tissue, largely interspersed with fat cells, and carrying a network of blood-vessels. Blood Supply of a Joint. — The blood-vessels of the joint freely an- astomose in the capsule, and in the deeper parts of the synovial membrane. The vessels are most profuse at both synovial reflections, where they form a vascular zone around the articular extremities of the opposing bones. To this special portion of the vascular supply the term circus vasculosus has been applied. From the circus vasculosus the metaphyseal and epiphyseal vessels pass into the underlying bone. The Pathology of Tuberculous Joints The changes are best considered under three distinct headings ; A. The formation of the primary tubercle. B. The changes in the component parts of the joint, synovial mem- brane, articular cartilage, underlying bone, blood-vessels, ligaments, and soft parts. C. The gross pathological varieties of the disease. A. The Formation of the Primary Tubercle. — It is in the tissues of the synovial membrane that the original tubercle first makes its appear- ance, and more especially in the deeper parts of the synovial membrane where the blood-vessels run. Tlie infection being blood-borne the lesion quite often appears in the wall of the vessel, and from this original deposit dissemination occurs. In appearance, the follicle is usually of the chronic variety, there is a well-marked reticulum, and the epithelioid cells are separated by intervals of varying size. Caseation is a change which rarely occurs. Giant cells are commonly present, and, as in bone disease, the giant cells are peculiar in so far as they often possess an enormous luiniber of nuclei. B. Changes in the Component Parts of the Joints. 1. Synovial Menihram'. Syiichronou.s with antl subsequent to the development of the primary tubercle a whole series of changes may occur in the synovial membrane. Considering the changes in their sequence from the surface, one finds that the lining endothelium may be considerably increased in thickness, tlie thickening giving it a curious velvety sensa- tion wlien handled. Scattered IliKnighout the thickened endotheJinni there an; distinctive cells, whicli in nuclear arrangement and amount of protoplasm resemble the simple epithelioid cell. Also there are giant cells 36 TUBERCULOSIS OF THE BONES AND JOINTS scattered about in isolated positions, and apparently developing quite in- dependently of any secondary lesion ; they are the result of a chronic irritative change. Important alterations occur in the connective tissues — the changes are sometimes spoken of as those of a gelatinous degenera- tion — the tissue fibres become swollen and pellucid, and the subjacent fat is increased in amount. 2. Changes in the Articular Cartilages. — The absence of blood-vessels renders cartilage practically immune to the development of original tubercle, but it does not prevent it from becoming involved secondary to disease of the synovial membrane. The changes in the cartilage may be described under two headings : (fl) The involvement of the cartilage from its superficial, i.e. from its joint, surface ; (6) The involvement of the cartilage from its deep or osseous surface. («) Superficial Involvement. Perichondral Infiltration. — Koenig ^ be- lieved that the superficial involvement of the cartilage had its origin in a deposit upon the articular surface of a quantity of fibrin, and by organisation, of the fibrin the underlying cartilage became softened and vascularised. This view is not correct. Schlabowski ^ has shown that the changes begin where the diseased synovial membrane is reflected on to the bone. The diseased membrane becomes adherent to the cartilage, and when detached from it a pitted and irregular surface is left. The granulating diseased synovia is a vascular tissue, and as it grows and extends it gives rise to certain changes in the underlying cartilage. The cartilage cells within their capsules begin to multiply and the capsules to enlarge correspondingly ; only the superficial cells at first are affected, the deeper ones later. The proliferated cartilage cells are not healthy, they shrink and retract from the capsule wall, and ultimately degenerate entirely. The intercellular tissue becomes altered. Normally cartilage is a matrix in which there exists a quantity of fine connective tissue fibres, but in the healthy state these fibres are disguised and practically unrecog- nisable. When the cartilage becomes diseased the connective tissue fibres proliferate at the expense of the matrix, a change which is spoken of as " fibrillation of the cartilage." It consists in a conversion of the cartilage, at first into fibro-cartilage and later into fibrous tissue. At this stage the cartilage becomes infiltrated with tuberculous granulations, which force their way downwards among the tissue fibres. The appearance of a cartilage so affected is characteristic. Over its surface there is spreading a pannus of tuberculous granulation tissue, derived from the surrounding synovial membrane. The underlying cartilage' appears congested, it has lost its characteristic glitter, and there are intervals of its surface which are pitted and replaced by patches of soft, vascular, velvety-looking tissue. (6) Deep Involvement : Subchondral Infiltration. — Synovial tubercle begins and is most intense at the reflection of the membrane. From the * KfK'iiig, Joe. sup. cit. ^ Schlabowski, Archiv fur klin. Chir. l.x.x. S. 762. [;. I'LATK X.\.\ riiAX(;Ks rN Tin; c.mitii.ai.i; m.i umiaiiv m 'Irin luri.nrs l)l^^•.A^^; nv thk Joint. a, Pi'iiclionilial iilii'iiition st'comliuy to lUswisi' of llie synovial iiu'iiilinuii'. To tlii? riglit of tile illustialioii lies tlic tiilificiilous ^'lariiilation tissue, to tlii' li'fl tlic caitilapt'. Note tlie irregular iilceraleil sui'faee of tlio latter. '', " Kilirillutioii " of the curtilage. Tiiis appearauee is fouml secoiulary to a spreailiiig of tuberculous tissue over the surface of the cartilage, r, Subchomlral ulceration of the cartilage : a layer of tulierculous granulation tissue has spreail inwanls from the cilge of the joint lictween the caitilage anil the umlerlying hone. THE PATHOLOGY OF TUBERCULOSIS OF JOINTS 37 reflection it may extend along the deep surface of the cartilage, between the cartilage and the underlying bone, and by doing so it constitutes a sub- chondral infiltration. The infiltrating zone is a vascular granulation tissue, which does not possess an extreme degree of disease ; in fact the cytological evidence of tubercle is at a minimum ; its thickness is considerable, and it may under- mine the whole extent of the articular cartilage. In its deeper parts the tissue tends to become fibrous, and by doing so it provides the bone with a protective covering or cap. Should the overlying cartilage be destroyed the bone is not left entirely exposed, but is protected by the fibrous shell. Sooner or later the result of the subchondral infiltration is a casting off of the overlying cartilage. It separates in flakes, or sometimes as the complete articular surface which comes to lie free within the joint cavity. Watson Cheyne ^ has described a type of cartilage change secondary to tubercle, which differs from the two already mentioned. He thus describes it : " The cartilage was intact except at the margin and at one spot towards the centre and anterior surface of the internal condyle of the femur, where there was a small depression on the surface. . . . The depression on the cartilage is due to destruction of the cartilage at this point. " There are further a number of flask-shaped spaces in the cartilage, which, under a high power, are found to be filled with young fibrous ti.ssue. Some of these spaces communicate with the surface of the cartilage, either freely or by narrow channels, while the majority, and perhaps all, are connected with the superficial cancelli of the bone by similar channels. At various other points along the deeper parts of the cartilage we see flask-like projections communicating with the bone, and when these occur the most superficial cancelli show osteitis. " I have not been able to find any tubercle in the bone. In this instance we have undoubtedly destruction of the cartilage commencing from the deeper parts in a manner totally different from the usual modes." Changes in Ike Vnderli/iny Bone. When the synovial membrane becomes diseased, changes appear in the portions of the bones which enter into the foiination of the joint. According to the ))osition of the attachment of the capsular ligament, there lies within the joint the epiphysis or the epiphysis and a portion of the metaphysis. Both of these in the healthy state contain red marrow. Secondary to the synovial disease the first change to appear is an alteration of the red marrow into yellow marrow, due to a disappearance of the cclhilar elements. Insidiously the yellow marrow undergoes an extensive structural alteration, the loose connective tissue which normally exists in the spaces between the fat cells and around the blood-vessels proliferates, and l)y its ])r(ilif(Mation converts the fatty nuirrow into a fibro- myxoinatous tissue. The inacro.scopic a])pearance of such a bone changes from a red to a yellow, and eventually to a grey gelatinous colour. ' W. \V. CIk viir. 'I'lthrrculi/.iis of Huiic« and Joints, l^dndoii, 1011. 38 TUBERCULOSIS OF THE BONES AND JOINTS Here one word of warning is necessary. The gelatinous appe'arance of the marrow is constantly being mistaken for a tuberculous infection of the bone, and without microscopic evidence it is sometimes extremely hard to distinguish between the two conditions. The marrow change lowers the resistance of the bone, and renders it more liable to a secondary infection. To what are the changes due ? Their etiology can be traced to two sources — to a toxic process resulting from the development of tubercle in the synovia, and to an endarteritis of the epiphyseal and metaphyseal vessels, itself the sequel to a tuberculous toxaemia. Changes in the Blood-vessels. — Attention has been drawn to the import- ance of endarteritis in tuberculous disease of bones ; it is just as frequently found in tuberculous disease of joints. The blood-vessels run in the sub- synovial tissues, and they are most plentiful around the synovial reflection. The vessels undergo an early primary endarteritis and a later peri- arteritis ; the perivascular changes form the starting-point of more extensive fibrosis in the surrounding tissues. So marked may be the tendency to vascular obliteration that even the largest periarticular vessels may suffer. Lannelongue ^ has recorded that in hip-joint disease the lumen of the femoral artery is considerably narrowed. The endarteritis extends from the synovial vessels along the meta- physeal and the epiphyseal vessels, and many of the changes in the articular ends of the bones are secondary to the vascular obhteration. Changes in the Ligaments and Soft Parts. — In the neighbourhood of a synovial tubercle the surrounding soft parts undergo degenerative changes, and the most important of the soft parts are the ligaments which build up the joints. These ligaments are composed of dense fibrous tissue. Under the influence of disease they become swollen and gelatinous. This change depends upon an increased deposit of fat in the surrounding parts, and an accumulation in the interfibril spaces of a myxomatous material. From these alterations there results an abundant laminated tissue, having the same character as cicatricial tissue, and from the loss of form and boundary it is often impossible to say where individual ligaments begin and end. Sometimes in the ligamentous degeneration there is a deposit of osseous material in the shape of stalactites or plaques, more rarely in the shape of a ferrule of bone, which produces a complete osseous ankylosis (Henocque). The changes spread beyond the ligaments ; the muscles, tendon sheaths, and the overlying skin become pale, swollen, and cedematous, and these peculiarities have been the source of the term " white swelling." At a late period there may be actual involvement of the soft parts with tubercle ; the disease spreads beyond the synovial tissues, burrowing along the lines of the blood-vegsels. In the neighbourhood of the periarticular changes there are gelatinous degenerations in the intermuscular tissues (Legg ^), and the muscles undergo considerable atrophy. 1 Lannelongue, Abcis froid et tuberculosa osseuse, Paris, 1881. 2 A. T. Legg, "The Cause of Atrophy in Joint Disease," Amer. ,/. Orth. Surg.. 190S-9, Ti. 84-90. HLAT1-: XXXI. It. Tuberculous disease of the hip joint. This sprciuit-n illustiutcs the iippcarancc of thi; cartilafjc when it has undergone a ^ub-chroiutral vilceration. b. Tuberculous disease of the hip joint. The articiihit cartilage shows the ivpical appearance of a peri-chondral ulceration. I'LATK XXXII. TiiiiKin uldi s Iiiskask THK .-IVMIVIAI. .Ml; Mil HANK. ", Myxiiiiiatons .vnnvi:il tulKTcwl.isis. h. Tin- iiiili,-iry type of synovial tuberculosis. PLATE XXX1\^ — The Vakikiies ok Tubehccluus Disease of Joints. a, Chronic tuberculous synovitis. Ij. Fibrous tuberculous synovitis. THE PATHOLOGY OF TUBERCULOSIS OF JOINTS 41 contains an excess of fluid, sometimes semi-purulent and often blood- stained. (d) Fibrous Tuberculous Sy)iovit'is. — There is a type of synovial tubercle which is associated with a progressive formation of fibrous tissue. French observers have christened it synovite lubereuse, and Demoulin ^ has associated its development with the caries sicca of bone tuberculosis. Its essential peculiarity is the conversion of the entire synovial tissue into dense fibrous tissue. The interior of the joint is of a light flesh colour ; the synovial surface is rough and covered with tiny nodules — an appearance rather resembhng fresh pigskin. Over the surface there are numbers of grey tuberculous follicles. There is an excess of fluid in the joint, and foreign bodies or rice bodies are often present. These are smooth, rounded bodies, sometimes flattened, sometimes spherical, covered with a mucous-like exudate, and occasionally attached by a pedicle of connective tissue. Microscopical examination shows that the characteristic fibrosis begins around the original developing follicles, its function probably being a local- ising one. From the periphery of the folhcle the fibrosis gradually extends into the surrounding tissue, and it progresses throughout the synovial membrane. The articular cartilage is not extensively aft'ected ; there is some fibrillation round its periphery. The blood-vessels are character- istically thickened. The rice bodies already mentioned are found micro- scopically to consist of nodules of fibrous tissue. Their method of formation is disputed. Reise ^ and Koenig* believe that they owe their origin to a deposit of fibrin upon the synovial membrane. Should the deposit become displaced it constitutes a rice body. Goldmann* and Garie maintain that they are degenerative products of diseased synovial membrane, and that while they most usually occur in tuberculosis they may occur independently of it. The Various Clinical Evidences and Sequelae of Joint Tuberculosis. 1. The disease in tlu^ joint may bo chiefly evidenced by the acouniukitiou within the joint cavity of a quantity of fluid — a tuberculous hydrops. It is analogous to the ascitic form of peritoneal tubercle, and it is characteristic of a chronic type of tlu; disease. 2. The joint may become distended with tuberculous pus. This may be the sequel to a true synovial tubercle, but more frequently it is the result of a sudden invasion of the joint by a bone focus. 3. Tuberculous thickening of the synovial meinbi-ane may he the outstanding feature of the disease, the outline of the joint is enlarged according to the arrangement of the synovial membrane. The hyperplasia extends beyond the synovial membrane, and the surrounding soft tissues share in the (■liang<'. To tliis variety the term tuiiuir (ilhu.s or white swelling has been applied. ' Oi'tiKiuliii. Arrliites ghi. de mid., lX!t4. - R<'iso. Diiilirlir Zrilschr. fiir Cltir. xlix. I. " KcH'iii).', Die Tuhrrkiilnse dir iiien.irlilirlini Ocleiiken, Horliil, li)0(>. * GuKlnmiiii, IJcilraye zar kiin, C'liii: Bil. xv. 3, S. 157. 42 TUBERCULOSIS OF THE BONES AND JOINTS 4. The extension of the disease from the joint into the surrounding soft parts leads to the development of periarticular cold abscesses, and these by bursting through the skin are the origin of sinuses. 5. The infection of the articular cartilages and their destruction permits of an exposure of the opposing osseous surfaces. The disease invades the cancellous tissue of the bone, and the joint becomes disorganised. Method of Healing- in Joint Tuberculosis. — The process of heaUng in a tuberculous joint will depend upon the extent of the original dis- ease. If the disease has been purely synovial, the process of cure will consist in a development of fibrous tissue in the synovial membrane. There will probably be some degree of stiffness in the joint. ^Vhen the disease has been more extensive and the articular cartilages have been destroyed, the formation of fibrous tissue is necessarily great. The opposing joint surfaces are bound together by it, the articular cartilages and the synovial tissues become converted into it, and the interlamellar spaces of the adjacent bones become occupied with it. Even the periarticu- lar vessels share in the fibrosis. When a cure necessitates such extensive changes as these, there naturally results a fibrous ankylosis. Sometimes, just as in bone tubercle, the process of cure extends further, and the osseous tissue plays its part. The remains of the joint surfaces become united by new bone, and there is a fresh bone formation around the periphery of the joint. BIBLIOGRAPHY Arce, J. " Tuberculosis articular," Rev. Soc. Med. Argent., Buenos Aires, 1907, xv. 377-465. MoRO, G. " Tuberculosi articolari," Boll. d. r. Accad. Med. di Genova, 1907, xxiii. 251-267. G.iNGOLPHE. Arthrites tuberculeuses, Balliere et fils, Paris, 1908. Lego, A. T. " The Cause of Atrophy in Joint Disease," Amer. J. Oilh. Surg., 1908-9, vi. 84-90. Treboulet, H.; Rebadean ; Dumas and Boye. "A Propos d'une observation de poh-arthrites tuberculeuses," Bull. Soc. de Pediat. de Paris, 1908, x. 285-295. Reinh-ARDT, A. " Die jjriniar sklerosierende Tuberkulose der Schleimbeutel," Deutsche Zeit. fiir CJdr., Leipzig, 1909, xcviu. 63-74. Ely, L. W. " Joint Tuberculosis with special reference to its Pathology," Med. Bee, New York, 1909, Ixxvi. 551-554. Keith, J. R. " Acute Tuberculous Arthritis," Brit. M..J., London, 1909, ii. 205. TiK, V. A. "' Diseases of the Joints Etiologically and Pathologically considered, and their Rational Classification," Kherurg. Arkh. Velyaminom, St. Petersburg, 1910, xxvi. 926-960. Daniel, P. L. Arthritis : a Study of the Inflammatory Diseases of Joints, J. Bale, Sons, & Danielsson, London. FiNBERG, A. H., and Woolley", P. G. " Osteochondritis dessicans, concerning its Nature and Relation to the Formation of Joint Mice," Ainer. J. Orth. Surg., Philadelphia, 1910— 11, viii. 477-494. Ely', L. W. " The Pathology of Tuberculous Joints," J. Am. M. Assoc, Chicago, 1910, Iv. 1283. NicHOL, A. G. "Tubercular Arthritis," South M..J., Nashville, 1910, iii. 317-322. Ely, L. W. " Further Observation on the Pathology of Joint Tuberculosis and Practical Deduction therefrom," Med. Per., New York, 1910, Ixxviii. 147-149. Ely', L. W. " Observations of the Pathology, Diagnosis, and Treatment of Joint Tubercu- losis," New York State M..J., New York, 1910, "x. 273-278. NOTT, J. J. " Tuberculous .Joint Diseases," ./. Am. Med. Assoc, Chicago, 1911, liv. 178. RiDLON, J. " Joint Disease from the Orthopaedic Standpoint," Illinois M.J., Springfield, 1911, xix. 4-8. Broca, a. " Osteoarthrites tuberculeuses procedees de type bacilloso-tuberculose osseuse a foyers multiples," Rev. de la tuberculose, Paris, 1911, 2 S., viii. 1-19. THE PATHOLOGY OF TUBERCULOSIS OF JOINTS 43 Albert, Maitkin. De la pijarthro.se tubercideuse d'origine synoviale saiis lesion osseuse, St. :fitienne, 1911. ANzrLOTTi, G. " Recerche sperimentale suUa pathogenesi dclle artropatie tubercolari," Path. riv. quindecim. Geneva, 1911-12, iv. 709-716. Lancial, d'Aekas. " Peri-arthrite fongeuse chez un enfant, etc.," J. des 3C. med. de Lille, 1912, ii. 481. Peltesohn, S. " tJber tuberkulo.se Gelenkdeformitaten der unteren Extremitaten und ihre paraartikulare Korrektur," ChareVs Ann., Berk., 1912, xxxvi. 526-544. 44 TUBERCULOSIS OF THE BONES AND JOINTS THE CLINICAL FEATURES OF BONE TUBERCULOSIS It is necessary ttat one should insist on the paucity of symptoms in a pure type of bone tuberculosis ; there is much confusion between the symp- tomatology of bone disease and joint disease. That the symptoms should be few in the case of the bone is what one would expect from the patho- logical features of the disease. From its deep situation its manifestations are hidden, and by reason of its slow progress the symptoms have little of the nature of the acute. But there are certain featm-cs which occur, and they are best considered in the order in which they appear in the jjrogress of a case. Local Features Thickening". — Local thickening of the affected bone is usually the first feature to appear. Its recognition will largely depend on the situa- tion of the diseased bone, whether it is superficial or deep. The increase in the circumference of the bone is the result of a periosteal reaction and the deposit of a quantity of new subperiosteal bone. Its origin is insidious, but its progress is steady, and it may advance until the shaft of the bone may have acquired twice its original circumference. At first the thickening is yielding and indentable, because it is virtually a granula- tion tissue, but as ossification proceeds it becomes as hard as healthy bone. The original position of the deposit is a fairly exact indication of the situa- tion of the original disease, but in advanced cases it may surround the entire circumference of the bone. It is slightly tender when palpated, and in the early stages of the disease there is no increased local temperature or redness. Local thickening, such as has been described, is the most characteristic feature of bone tuberculosis. Pain. — In bone disease pain is the result of pressure upon the nerve endings. Acute conditions in which the increase of tension is rapid and extreme have intense pain as the predominating symptom. In tuberculous disease, however, the pain is slight and frequently entirely absent. While the disease is confined to the interior of the bone the slow progress of the infiltration precludes any degree of tension, and it has been suggested that tuberculous disease exerts a degenerative, or at least an ansesthetic in- fluence upon nerve tissue. But in certain cases pain is certainly present, and the explanations of its occurrence are as follows : (1) The deeper layers of the periosteum are well supplied with nerves, and sometimes the nerve endings are of a highly specialised type. While the disease is still confined to the interior of the bone a simple serous efi'usion occurs beneath the peri- THE CLINICAL FEATURES OF BONE TUBERCULOSIS 45 osteum ; the effusion exerts tension upon the nerve endings, and local pain is the result. It is therefore an early feature in the sequence of symptoma- tology. And it is only temporary, for with the formation of new periosteal bone the subperiosteal tension is relieved. (2) In the more rapid infiltrating types of tuberculous osteomyelitis it is quite possible that a considerable increase of intraosseous tension may occur, and, as in acute osteomyelitis, pain may be induced. (3) The pain met with may be not local, but referred. There is an irritation of nerve trunks, and the irritating factors vary, alterations in the architecture of the bone, the formation of masses of tuberculous granulation tissue, the pressure of a cold abscess. The pain is referred to the distribution of the affected nerve trunk, and the best illus- tration of it is found in Pott's disease, in which pain is often referred to the middle line in front. Muscular Wasting". — It is difficult to estimate the extent to which muscular wasting is actually secondary to osseous tubercle. In joint disease it is uniformly quoted as a most outstanding feature, and it has been stated that it owes its occurrence to reflex irritation from the diseased joint. If such be its true explanation in joint tubercle, it very likely \\'ill explain its occurrence in bone disease. But the difficulty lies in deciding the question of to what extent atrophy is the result of want of use. The chances are that with the first appearance of symptoms and the diagnosis of tubercle, rest treatment is at once begun, and this must lead to a certain degree of disuse atrophy. Abscess Formation. — As the disease progresses caseation and softening occur in the interior of the bone ; when the periphery of the bone is invaded a subperiosteal cold abscess develops. Presently the periosteum gives way, and the abscess formation extends into the surrounding soft parts. Its further course will vary according to questions of gravity, position, and tissue arrangement. The French appreciation of the pathology of a tuberculous abscess is a good one. 'I'lioy look upon the condition as one would a type of tumour formation, with central degeneration. Always at the periphery there is the infiltrating tuberculous granulation tissue ; in the centre there is usually caseation and abscess formation. Considered in this light it is not diflicult to understand how sometimes the abscess become? pedunculated and sessile, and occasionally becomes entirely cut oft" from the focus which gave it origin. 'J'lie further stage of untreated abscess formation is the opening on a free surface and the establishment of a sinus. General Features. — Three factors are at work in jnoducing the general fi'aturcs of osseous tubercle — ^they are the dissemination of the disease, the absorption of tuberculous toxins, and the occurrence of sinuses with the inevitable mi.xed infection. The dissemination of the disease is not common. (Hands are the earliest tissiu-s to become affected, and a spread to llii' mcniiigis is (il'tm (lie terminal feature. The absorption of tuber- culous toxins is of cdinse continually jiroceeding, in small measure or in great. It produces such features as loss of weight, increasing debility, 46 TUBERCULOSIS OF THE BONES AND JOINTS disordered digestion, and occasional rises of temperatnre. But far more important than any of these is the part played by sinus formation and mixed infection. The infection of a cold abscess with organisms other than the tubercle bacillus is often tantamount to signing the patient's death warrant. Wlien it has occurred, a cure is most diificult to obtain, and quickly in the train of the infection there come the complications of hectic fever, emaciation, sweating, diarrhoea, and the features of waxy disease. THE CLINICAL FEATURES OF JOINT TUBERCULOSIS In comparison vnth. bone disease, tuberculosis of joints is accompanied by a much wider range of cUnical features. There are several reasons why this should be the case. The majority of joints from their position are comparatively superficial, and those which are movable and diarthrodial joints are practically the only ones affected by the disease. The symptoms are exaggerated by the possibility of apposition and friction. Following the plan hitherto followed, the features are best considered in the order in which they clinically occur. Local Features stiffness in Joint. — Free and untrammelled action of a joint is very largely guaranteed by the presence of synovial fluid, and any diminu- tion in amount of this latter is demonstrated by varying degrees of stiffness. When the synovial membrane becomes infected with tuber- culous disease one of the earliest sequelse is a diminution in the amount of true syno^dal fluid. The amount is least in the morning, but as the day passes and the joint surfaces are stimulated by movements, the amount increases, though it never reaches a normal standard. One is therefore not surprised to find that the joint stift'ness so characteristic of early joint tubercle has a distinct diurnal occurrence. It is most marked after the joint has been rested for some time,, e.g. in the morning, and it disappears after movements have been indulged in. It is important to recognise the true etiology of this symptom, as it is often confused with the feature of muscular rigidity. Alteration in Use of the Joint.^Each joint possesses a prescribed degree of movement, and any alteration in the degree is quickly evidenced. The evidence may take various forms. In the lower extremity it usually appears as a limp, in the upper extremity it may be as an error in the execution of some of the finer and more compHcated movements. What is the explanation of this sign ? It depends on an early degree of muscular irritability. It would appear as though the muscles were unwilling to trust the joint to its full range of movement. In the lower extremity the recog- nition of a limp may be comparatively easy, but in the upper extremity THE CLINICAL FEATUEES OF JOINT TUBERCULOSIS 47 the development of the feature may be so insidious that very considerable care may have to be taken before the condition is recognised. Alteration in Position of the Joint. — In certain positions the opposing joint surfaces are more widely separated than in others, and it may be taken as a rule, to which there are few exceptions, that flexion is the position which most completely secures this. Therefore one finds that while the disease in the joint is as yet early, the limb tends to take up an altered position, and, as has been said, usually one of flexion. When the disease is fully estabUshed there are more extensive alterations in position, and they depend upon one or other of two possible causes. The first of those is a very considerable increase in the amount of joint fluid, actually forcing the joint surfaces into an abnormal position. It has been shown experimentally that when the hip-joint has been filled with fluid under pressure the limb automatically takes up a position of abduction, flexion and external rotation. The second factor is one which is found comparativel}' late in the course of the disease, and it is a considerable alteration in the architecture of the bones which enter into the formation of the joint. According to the positions and the degree of bone destruction, a great variety of abnormal postures may be demonstrated. Pain. — Pain is the feature which one generally associates with joint disease, and as a rule it is one of considerable prominence. Why should pain occur ? The reasons differ according to the extent of the dis- ease. In the early stages it is due to intra-articular tension and pressm'e. The tension is exerted upon the synovial membrane and the joint surface as a whole, or it is borne by the articular cartilage. In the first instance it is partly tlie result of a thickened synovial membrane and partly an increased amount of fluid within the joint. In the second instance it is the sequel to a subchondral infiltration of the disease, spreading between the articular cartilage and the underlying bone, and exerting pressure upon both these structures. In the late stages of the disease ])ain is the result of a varying degree of disorganisation within the joint, a destruction of the articular cartilages, and an exposure of the osseous surfaces. Not only is the pain variable in its cause, but it is also variable in degree. Sometimes it is agonising, and accompanied by general symptoms of con- siderable acuteness ; at other times it may be slight, and even completely absent. It is increased By movements of the joint surfaces. The site of the pain is also hable to change. Generally it is local in the affected joint. Occasionally it is referred to the distribution of a nerve trunk lying in relation to the diseased joint. The best example of referred pain is found in tuberculous disease of the hip-joint, when the pain is often referred to the front and the inHer side of the knee, following the distribution of till' ant(uior crural a!id the oliturator nerves. Night Cries. -Tiiey arc usually considered as constituting a special variety of pain. They indicate an extension of the disease to the under- lying bone, and (licir occurrence is evidence of ulceration of the articular 48 TUBERCULOSIS OF THE BONES AND JOINTS cartilages. During sleep the relaxed muscles permit the diseased surfaces to come into contact with each other ; pain is at once induced, and the alarmed muscles contract. Their contraction is intended to fix the opposed surfaces, but before fixation is complete there is a momentary increase of pain. In some instances the pain is not suflicient to wake the patient, he is merely restless and may moan in his sleep. In other cases the pain is so severe as to waken the child with a start. Sometimes he wakens to find the pain gone, and cannot tell what disturbed him, sometimes it remains after consciousness is complete. Tenderness and Increased Temperature.— When the diseased joint is palpated tenderness may be induced. The handling may increase the intra-articular tension, it may j)ress upon some disorganised constituent of the joint, or it may irritate some periarticular structure (a bursa) which has shared in the joint inflammation. It is not a constant feature, and one should not be inclined to insist on its demonstration. If the joint is superficial, and the skin temperature be compared with that of the healthy joint, it is often found to be appreciably elevated. The raised temperature is the result of an increased vascularity secondary to the intra-articular changes. Muscular Rigidity. — Nature provides the key to the treatment of tuberculous joint disease by her continual efforts to keep the diseased part at rest, and the medium which she employs is a muscular one. Intra-articular disease reflexly produces a rigidity of the muscles which normally move the joint. The degree of muscular spasm varies ; it may be induced only by extreme degrees in the arc of possible movement ; it may be so intense as to simulate ankylosis. The degree of rigidity is probably an indication of the amount and also of the position of the disease. The cause of the spasm is twofold. It is reflex from the intra-articular changes, and it is voluntary on the part of the patient to prevent friction of the diseased articular sur- faces. Clinically it may be manifested on the slightest palpation, or it may require some degree of movement to demonstrate it. It is characterised by a most distinctive sudden contraction of the surrounding muscles. Swelling". — In the more superflcial joints swelling is a prominent feature. Its origin may be twofold ; it may depend on a tuberculous thickening of the synovial membrane, or it may be the result of the distension of the joint cavity with fluid. When the synovial membrane is responsible for the enlargement, the thickening corresponds exactly to its anatomical distribution, and the thickening being most marked at the synovial re- flexion, the swelling is noticed more especially at the periphery of the joint. To palpation a synovial thickening is characteristically doughy. When there is free fluid in the joint the sweUing is a uniform distension of the joint capsule, and fluctuation can of course be elicited. In estimating the degree of swelling in a tuberculous joint one must take into consideration the muscular wasting which exists around the joint. By comparison a swelling which is actually slight may appear very con- siderable. THE CLINICAL FEATURES OF JOINT TUBERCULOSIS 49 The skin over a diseased joint often loses its natural hue, and acquires an anaemic and sodden appearance. The superficial veins may be distended. If the disease has spread from the joint into the neighbouring bone there may be some degree of osseous thickening. Muscular Wasting". — Early atrophy of the muscles aroimd the diseased joint is a constant sign. It is partly the result of disease and partly the result of a reflex impulse which originates within the joint. Accompanying the atrophy there is a diminution in the reaction to the faradic current, and the tendon reflexes around the joint are frequently diminished. The atrophy extends beyond the muscles, the bones become rarefied, and growth may be interfered with. In old-standmg cases the degree of muscular wasting may give an exaggerated importance to the amount of joint thicken- ing which is present. Alteration in Bony Outlines. — As the joint disease progresses, there sooner or later ensues a destruction of the joint surfaces and of the under- lying bones. Such a destruction may be responsible for an actual alteration in the outline of the joint, or it may induce simple shortening. In joints sueh as the hip, where the arrangement of the bones is irregular, the destruc- tion may give rise to such deformities as abduction or adduction. There are cases in which the joint is infected secondary to a bone focus, and in such cases the destruction of bones is probably more extensive, and the alteration in the outline correspondingly prominent. Abscess Formation. — The abscess formation which occurs may appear in three different regions : it may be piirely intra-articular — a type which is sometimes designated empyema of the joint ; it may be periarticular, being more exactly situated outside the capsule opposite the synovial reflexion ; finally, it may be superficially in relation to any part of the joint. And as there arc three positions of occurrence one finds that in each instance the etiology varies. The intra-articular abscess is the result of the conversion of a simple serous effusion — a hydrops of the joint — into a puru- lent fluid, or it owes its origin to the eruption of a bone focus into the joint. The periarticular abscess is in the majority of instances located op- posite the reflexion of the synovial membrane, and this peculiarity of situation oilers the key to its exact etiology. From the synovial ri'flexioii a number of blood-vessels extend outwards, piercing the capsular ligament, and spreading into the surrounding soft tissues. When the synovial mem- brane becomes diseased, offshoots of tuberculous tissue extend outwards along the line of the vessels, and give rise to periarticular abscesses. An intra-articular abscess may become periarticular by forcing its way through a weakened portion of the capsular ligament. The etiology of the superficial abscess is quite distinctive. It only occurs when there is a considerable degree of white swelling in the sur- rounding tissue, and its development depends upon pus formation in the (Edematous tissue. It has no traceable connection with the diseased joint. Bacteriological examination shows that these abscesses often contain a mixed infection. 4 50 TUBERCULOSIS OF THE BONES AND JOINTS The development of a cold abscess is always of serious import, because the chances of mixed infection of the joint are considerably increased. General Features. — In addition to these local changes there are general changes. They are in every respect similar to those which have been described in bone tuberculosis, and there is no purpose to be gained by their repetition. THE DIAGNOSIS OF BONE TUBERCULOSIS The system of diagnosis includes, or at least ought to include, two distinct psychological processes. The steps by which one comes to the decision that one is dealing with a certain recognised condition constitutes what one may term the actual diagnosis. The other process, the differential diagnosis, necessitates the recognition and the exclusion of conditions resembling the one under consideration. The Actual Diag'nosis. — How does one come to the decision that a definite bone lesion is tuberculous ? The answers are gleaned from a variety of sources, and they are best considered in order of sequence. Milk History. — In the examination of any condition suggestive of • tuberculous disease, an interrogation regarding the milk supply is of the utmost importance. The assertion that the child has been breast-fed does not dispose of the possibility of infection by this source ; for, except in very young children, cows' milk is almost certain to have been administered at some period. Two lines of further investigation must be followed. Has the milk which the child receives been boiled ? Has there been any history of disease among the herd from which the milk was supplied ? In bone tuberculosis bovine infection is a most fertile source, and no investigation is complete in which these questions have been omitted. Family History. — Elsewhere the question of heredity in application to tuberculosis has been discussed. Of the importance of an inherited pre- disposition to infection no doubt can be entertained. But the occurrence of a tuberculous family history has a bearing even more important than that of inherited predisposition, for it may provide a fertile source of direct infection. A child residing in the house of a tuberculous father or mother may develop tubercle by direct infection from the parent. Some time ago the writer investigated a series of cases of bone tuberculosis from which the human bacillus had been isolated. In 71 per cent of these cases there was a history of the child having been in residence with a consumptive. Age. — While tuberculosis of bones may occur at any age, its incidence is greatest during childhood, and more especially between the ages of five to twelve years. During the first year of life bone lesions are rare. After the first year they become increasingly common, and reach their acme about ten years. THE DIAGNOSIS OF BONE TUBERCULOSIS 51 Position of Lesion. — In disease of the long bones tubercle has a predilec- tion for the ends of the bones, the metaphysis or the epiphysis. In this respect it resembles acute osteomyeUtis, and differs from specific disease, except the epiphysitis of congenital syphihs. A certain proportion of cases develop in the centre of the shaft, the situation favoured by syphihs. Not only has the disease a partiality for certain situations in the bone, but some bones are more liable to the disease than others. The vertebrae are the most common to be affected, and the short bones of the hands and feet are frequently diseased. Symptomnlologi/. — If one were asked to mention the characteristic which distinguishes the clinical features of tuberculous bone disease, one would have no hesitation in giving first place to its insidiousness. Every- thing favours a gradual development. The bone is often deeply situated and protected by soft parts, its particiilarly dense structure is difficult of destruction and invasion, and there can be no doubt that the disease is more chronic in this situation than in many others. The general symptoms which are common to tubercle in any situation may be of extreme value in the diagnosis of a doubtful case. Plu/sical Signs. — Of the physical signs which may appear, thickening and abscess formation are certainly the most imjiortant. The thickening from the deposit of new subperiosteal bone is an early sign, the abscess formation is late. To the occurrence of pain one does not attach much importance ; frequently it is entirely absent. X-Ray Examination. — While one may come to a definite diagnosis of bone tubercle from a consideration of the several above-mentioned points, the reasoning is not complete until an X-ray photograpli of the part has been taken. A good negative gives information on the following points. It tells one that tlie condition under examination is tuberculous, it delineates exactly the situation of the disease, and it affords information as to the exact type of the tuberculous disease, whether it is encysted, infiltrating, etc. Full details are given of the various X-ray features (page 58). Tuberculin Tests. No discussion upon general diagnosis is complete without making mention of certain well-known tuberculin tests. Space does not jjermit of more than a few remarks about the various methods. Calnietfe's Ophlluilnio-Tiibercvlin Heart ion .^ - AW the tuberculin tests depend upon a heightened susceptibility on the ])art of the tuberculous to the poison of the tubercle bacillus. Tlie increased suscejitibility shows itself partly by a general disturbance, malaise, and fever, and partly by a local disturbance, the result of increased hyperacmia of the tuberculous focus or the point of inoculation. The oplithalmic reaction consists in the instilla- tion into the eye of a drop of tuberculin, either one-half per cent tuberculin prepared from the precipitate of Koch's old tuberculin by 95 per cent alcohol, or a standard solution prepared by dissolving old tubercidin in O-.*^ p(>r cent phenol, 'i'lie reaction begins in six hours, and it is fully devel()[)ed in twenty-four. It consists in a varying degree of simple conjunctivitis. Tln' ' Triiii.i. Sirlli hitrniiil. Congress Tuber., Washington, 1!K)8. vol. ii. so(n. iii.iv. pp. 642-681. 52 TUBERCULOSIS OF THE BONES AND JOINTS inflammation lasts several days, occasionally weeks. The test must never be applied in cases of disease of the cornea or conjunctiva, as in such cases it is apt to lead to severe inflammation, ulceration, and even perforation of the cornea. The Cutaneous Tuberculin Reaction (von Pirquet).^ — This consists in a skin vaccination with tuberculin. The reagent employed is composed of tuberculin 1 part, normal saUne 3 parts, containing 25 per cent carboUc acid. Two small abrasions are made upon the cleansed upper arm. The abrasions must not be deep enough to draw blood. Into one a drop of the tuberculin solution is rubbed, the other is kept as a control. If tuberculous disease is present the infected abrasion shows within twenty-four hours a reactionary redness ; this may pass on to actual papule formation. Mora's Test.^ — This is really a modification of the cutaneous von Pirquet test. It consists in rubbing into the skin a preparation of 5 per cent old tuberculin in lanoline. A reaction appears in the region into which the ointment has been rubbed. The Focal Reaction Test. — The three tests already mentioned possess a great common fault ; positive results are given by tuberculous disease in any part of the body, and the presence of a reaction does not necessarily mean that the lesion under examination is the tuberculous one. The local reaction test does not possess this disadvantage. It is a clinical test, and it consists in the injection into any part of the body of a small dose of tuber- cuhn. If the lesion is a tuberculous one, it becomes congested and hyper- aemic, and there are constitutional signs such as malaise, headache, and rise of temperature. The amount of tuberculin injected varies. A useful standard is -1 milHgramme in children and -2 milligramme in adults. In Germany it is customary to begin with an injection in children of •! milli- gramme. If no reaction results the injection is repeated with 2-5 milH- grammes, and if there is still no reaction with 5 milligrammes. In using this method it must be remembered that susceptibility to tuberculin increases with each injection, so that even the healthy may react to large doses. With a focal reaction, however, the possibility of this error is diminished. In doubtful bone cases this is certainly the most reUable test. Take, for example, a swelling of the tibia. A study of history, symptoms, and physical signs leaves the diagnosis obscure. X-rays may not be available. The injection of -1 milligramme of tuberculin is followed in the twenty-four hours by increased pain in the doubtful part, swelling, cedema, tenderness, and redness of the overlying skin, if the condition is a tuberculous one. The test is not without its disadvantages. The focal reaction has been blamed for causing a dissemination of the disease, and the use of the test is absolutely contra-indicated in conditions of fever. The Diagnostic Use of the Tuberculo-Opsonic Determination. — A con- sideration of the facts embodied under this test is admirably given by ' Wien. klin. Wochenschr., Oct. I, 1908, s. 1375; "Die kutane Tiiberkulinprobe," Oesellschaft KinderheAlk., Dresden, 1907. ^ MilTich. med. Woclienschr., Feb. 4, 1908. THE DIAGNOSIS OF BONE TUBERCULOSIS 53 Riviere.^ One presupposes a knowledge of the details of the opsonic estimation and its principles. The application of the results is summed up by Riviere as follows : (1) The index for normal people is found to vary between 0-8 and 1-2 (Bulloch). When the index is persistently below this, if there is a localised infection which may be tuberculous, it probably is so. When the index remains normal it is not tubercle ; when it is high, and especially when it fluctuates from time to time, there is active tuberculosis. (2) The effect of a small dose of tuberculin on the opsonic index is of diagnostic value. In the tuberculous it leads to a negative phase, followed by a positive phase. The negative phase is absent in non-tuberculous subjects. (3) When the local lesion contains fluid (abscess) the bacteriotropic power of the fluid is lowered towards the organism causing the lesion, i.e. the opsonic index of the fluid is found to be lower than that of the patient's blood serum. (4) The " heated serum test " depends on the fact that the serum of the tuberculous and tuberculinised retains more of its opsonic power after heating to 60"^ C. for ten minutes than does normal serum. The tuberculo- opsonic determination has little use in clinical application. Differential Diag'nosis. — There are certain conditions which require to be differentiated from tuberculous disease, and confusion is more apt to occur before the stage of abscess formation. Syphilis, Periostitis and Periosteal Nodes, and more especially Gummala and Sclerosing Osteitis. — These are excluded by the history of syphihs, congenital or acquired, by the specific intensity of the pain during the night, by the affection occurring usually about the middle of the shaft, by the X-ray appearance, and by the result of the Wassermann reaction. Chronic Staphylococcal Osteomyelitis. — In this condition the onset has characters which betray the acuteness ; its course is curiously liable to exacerbation and interval relapses, there are frequently considerable rises of temperature, there are often signs of local inflammation, oedema, and tender- ness. An X-ray examination may be of value, but frequently the radio- graphic appearance closely resembles that shown in tuberculosis. The dis- tinguishing points are, that in the subacute condition the deposit of new subperiosteal bone is scanty and incomplete, and sequestrum formation is more common. Subperiosteal Lipoma. — The mistake is made of confusing this with a subperiosteal cold abscess, and therefore assuming the presence of under- lying tuberculous-disease. The condition is recognised by the entire absence of bone thickening, the limitation and slowness of the disease, and the X-ray appearances of a healthy bone. Periosteal Sarcoma. ~Th\s condition is the most dillicult to distinguish. It may usually, however, be recognised by the rapidity of its growth, the severity and the persistence of pain, and tlie entire absence of suppuration. ' Hivierp, Tiihernilnsi.1 in I njinnij and Cliitdliood, Kolynack, 1908, ji. 2S3. 54 TUBERCULOSIS OF THE BONES AXD JOINTS X-ray examination affords the most powerful diagnostic aid. In periosteal sarcoma there is the formation of new periosteal bone, but the line of junction between the new bone and the original shaft is irregular and eroded. In tuberculous disease the junction between old and new bone is sharply defined and clear cut. In exceptional cases an exploratory inicsion may be required to clear up the diagnosis. Central Sarcoma. — Rarely this may be confused with central tubercu- lous disease. Its distinctions are the rapidity of its growth, the persistence of pain, the umform character of the swelling, the presence of " egg-shell " crackling, and the distinctive X-ray appearance of a central growth expand- ing the outer shell of bone. THE DIAGNOSIS OF JOINT TUBERCULOSIS Actual Diagnosis. — Many of the remarks made in the section on the diagnosis of bone disease may be applied to jomt disease. There is nothing further to be said upon the questions of age, family history, and milk history. In joints, as in bones, these facts are of immense importance. Symptomatology and Physical Sig7is. — There are certain of the signs of joint disease which are important because they are vinicpie, and therefore their value in diagnosis is correspondingly great. The three features to which one would apply the term unique are those of synovial thickening, muscular wasting, and night pains. The distinctiveness of each may be questioned, but closer examination will show how characteristic each may be. Synovial thickening may occur in other diseases, e.g. in syphilitic synovitis, but in tubercle there are two features which are pathognomonic, the uniform outline of the swelling delimiting the synovial membrane, and the doughy sensation on palpation. Muscidar wasting occurs in the neigh- bourhood of any joint when the part is kept at rest, but the wasting in tuberculous disease is much more rapid and excessive than in any form of disease atrophy. Night pains owe their origin to destruction of the articular cartilage, and the cartilage may be destroyed in a variety of conditions ; but the night cries of tubercle are characterised by their gradual onset and the relief afforded them by extension. The alterations in the use and position of the joint, while not unique, are exceedingly suggestive. The alteration in use is so gradual that the patient may be unconscious of it until his attention is directed towards it. Abscess formation is quite dis- tinctive of the disease, but it would be well that a diagnosis be made before the disease had progressed so far. Muscular rigidity is important. It is essential to recognise that the fixation on account of the rigidity need not necessarily be complete, it may consist in a limitation of complete move- ment, but one attaches great weight to the fact that every movement of which the joint is capable is more or less affected. General Tests. — These have been fullv dealt with in the diagnosis of THE DIAGNOSIS OF JOINT TUBERCULOSIS 55 bone disease. In application to joints the foc^l reaction following the inoculation of a small quantity of tuberculin is certainly the most reliable. A tuberculous joint becomes characteristically altered by increased pain, rigidity, and swelling. X-Raij Examination. — Any doubt in diagnosis which a clinical study may leave is usually cleared up by X-ray examination. In the later stages of the disease the recognition of a tuberculous joint is an easy matter, the difficulty lies in the early stages. The appearances are hereafter described. The earliest is the indistinctness and blurring of the bone ends, an impres- sion which is partly the result of the synovial thickening and partly of the increased vascularity of the membrane. \\Tien the cartilage edges become eaten out and their deep surface undermined, recognition is simplified. In the later stages of the disease no mistake can be made. Differential Diagrnosis. — There are a number of conditions which may increase the possibility of doubt and error ; the following are the most important. Traumatic Sipiovitis. — When a synovial effusion quickly follows on an injury such as a sprain, or on overuse or any form of internal derange- ment of the joint, it is a case of traumatic synovitis. In typical cases, seen soon after the injury, there is not much possibility of confusing the condition with tubercle, but if the case is seen some time after its onset there may be doubt. The synovial membrane may remain thickened after a traumatic synovitis, more especially if the traumatism has been recurrent. A distinction may be made by the history and the progressive nature of the tuberculous disease. Infective Synovitis and Arthritis. — These diseases are characterised by more or less rapid and abundant effusion of fluid into the joint ; in children they are pneumococcal, staphylococcal, or streptococcal in origin. In their early stages it may be impossible to distinguish them from tuberculous disease, but they quickly become recognisable by their sudden onset, the gravity of the general illness, and the tendency to pass on quickly to sup- puration. Sonietimes a study of age is helpful; these acute joint conditions are most conunonly met with during the first year of life, a period when tubercle is comparatively rare. Epiphi/sitis and Osteitis in the Neiffhbniirhnnd of the Joint. A neighbour- ing bone focus may produce a reflex joint effusion, and in this way a possi- bility of error may arise. The symptoms, however, are always in some degree acute, there is considerable swelling, and the temperature is con- tinuously high. Early recognition of the condition is important on account of the ever-present tendency towards invasion of the joint. Periarticiihir Bursitis. Many joints are intimately related to over- lying bursx>, and lesions of the bursa; may produce considerable similarity to tuberculous disease. This is well illustrated in the hip-joint, when dis- ease of the bursa beneath the {.'liiteus inaxinnis, or that lying in relation to the psoas, may very closely simulate hip-joint disease. In bursitis, iiow- ever, there is an absence of the characteristic signs of joint disease — the 56 TUBERCULOSIS OF THE BONES AND JOINTS synovial thickening, the muscular wasting, and the night cries. In the presence of further doubt an X-ray examination will clear up the point. Syphilitic Joint Disease. — In application to children one need only consider the jomt lesions of hereditary syphilis. The earUest are those associated with an epiphysitis in the ends of the bones. The condition occurs in infants, usually between the fourth and twelfth weeks of hfe, and the joint effusion is a simple serous one. The age of the child and other evidences of syphilis are sufficient to exclude the condition. The gummatous synovitis of older children may give rise to great difficulty in diagnosis ; it has, however, certain distinctive features, and they are its insidious development, the absence of constitutional disturbances, the bilateral character of the disease, the tendency for the knee-joints to be most commonly affected, the absence of pain, and the presence of free mobility. Rheumatoid Arthritis or Osteoarthritis. — This has occasionally been confused with tuberculous disease. Its occurrence in children is rare, but when it is met with it may be recognised by the bony changes which are present and the polyarthritic character of the disease. Still's Disease of the Joints. — The possibility of confusion is more prob- able in this disease than in rheumatoid arthritis. It resembles tubercle in so far as the synovial membrane is thickened and pulpy. The joints in the later stages become stiffened, simulating rigidity, and there is marked muscular wasting. It differs from tuberculous disease in being a poly- arthritis, in being free from pain and true muscular rigidity, and in being associated with an enlargement of the spleen and the lymphatic glands. Infantile Paralysis. — With the onset of anterior poliomyeUtis there may be for a short time marked pain and tenderness, with immobility of the joint. The acute changes quickly subside, and the paralytic phenomena become obvious. Hysterical Joint Affections. — In nervous children, dming the period of hfe immediately before puberty, a condition of joint sensitiveness with lameness and pain is observed. If functional, these features may be recog- nised by the variabihty of their intensity and their inconsistency with one another. BIBLIOGRAPHY Wyn Koop, E. J. " Observations relating to the Early Recogmtion and Treatment of Tuberculous Bone and Joint Disease in Childi-en," Post Graduate, New York, 1908, xxiii. 608-613. ConRMONT, p. " Rhumatisme tuberculeux de Poncet," Lyon med., 1908, ex. 210-212. Alusandke, G. " Sul valore deUa ophthalnioriazione di Calmetti," Gaz. di hup., MUano, 1908, xxix. 400-403. Poncet and Rheuter. " Un cas de rhumatisme tuberculeux," Bull Soc. Med. de VIIop. d« Lyon, 1908. vii. 151. Poncet, A. "Rhumatisme articulaire tuberculeux," Bidl. et Mem. Soc. Med. des Hop. de Paris, 1908, 3^ S. xxv. 711-715. Genevier. " Un Cas de rhumatisme peut-etre tuberculeux," Ann. de wed. et de chir. inf., Paris, 1908, xii. 487-490. Steanoeway.s, T. S. p. " The Conjunctival Reaction to Tuberculin in Arthritic Diseases," Bull. Com. Study Spec. Dis., Cambridge, 1908, ii. 125-130. THE DIAGNOSIS OF JOINT TUBERCULOSIS 57 Esau, P. " Rheumatismus tuberculosus : Poncet," Miinch. med. Wochensclir., 1908, Iv. 390-392. Jack, H. P. " Diagnosis and Treatment of Tubercular Bone and Joint Disease," Ann. Gynec and Pediat., Boston, 1908, xxi. 498-504. Arnaud, L. " Rhumatisme tuberculeux," Rev. d'orthop., Paris, 1908, 2. S. ix. 510-522. Paquet, a. " Diagnostic prccoce des turaeurs blanches," BiiU. med. de Quebec, 1908-9, X. 105-112. CoLVTN, A. " Diagnosis of Joint Disease," .S(. Paid M..J., St. Paul, Minn.. 1909, xi. 81-95. Bakbik. " Notes sur les erreurs de diagnostic, etc.," Ann. de chir. et d'orthop., Paris, 1909, xxii. 43-76. CoLViN. "The Diagnosis of Joint Disease," J. ilinn. M. Ass., Minneapolis, 1909, xxix. 171-178. Davidson, J. T. " The Importance of the Early Recognition of Bone Tuberculosis," Med. Rec, New Yorlc, 1909, Ixxvi. 60-62. WalderstkBom. " Early Diagnosis of Tubercular Disease of the Bones and the Joints," Hygiea, Stockholm, 1909, 2. f. ix. 270-275. SuBBLEY, E. F. " Tuberculin Diagnosis of Bone and Joint Tuberculosis," New York- State J.M., 1909, ix. 423-425. Melchior, E. " Die tuberkulose Gelenkrheumatismus," Centralis, j. d. Grenzgeh. d. Med. und Chir., Jena, 1909, xii. 801-818. C.u,DWELL, C. B. " Diagnosis in Suspected Joint Disease," Lancet Clinic, Cincinnati, 1909, cii. 448-451. O'Reilly, A. " A Pica for an Early and more Complete Diagnosis in .Joint Tuberculosis in Children," J. Miss. Med, Assoc., St. Louis, 1909-10, vi. 615-623. Bredi, C. S. " The Early Diagnosis of Tuberculosis of the Bone," West. Med. Review, Omaha, 1910, XV. 70-75. Horwitz, a. E. " Differential Points in the Character of the Bone Lesion in Tuberculous and Acute Osteomyelitis, Rachitis, and Syphilis," Weekly Bull., St. Louis Med. Soc, 1910, iv. 162. Privat, T. " Tulierculose externe, syphilis et scrofulate de vcrole, diagnostic et traitement," Sev. gen. de din. et de therap., Paris. 1910, xxiv. 249-231. Mehans. " Die Rollc dcr isolierten Muskclatropie als diagnostisches Symptom zu Lokalisa- tion von tubcrkuhison Knochenhcrdcn," Zentrnlbt. fiir Chir., Leipzig, 1910, xxxvii. 8.52. OoiLVV, C. " The Early Diagnosis of Tuberculous Joint Disease," Post Graduate, New York, 1910, XXV. 60-06. Holmer, B. "Diagnosis and Treatment of Osteal Tubercle without Abscess Formation." Med. Rec, New York, 1910, Ixxviii. 1003-1005. SwETT, P. P. " The Diagnosis and Treatment of Tuberculous Joints," New York Med. Journ., 1910. xcii. 912-915. Horwitz. " Differential Points in Bone Lesions in Tuberculous and Acute Osteomyelitis, Rickets, and Syphilis," Interstate Med. Jonrn., St. Loui.s, 1910, xvii. 515-520. Schwartz, A. " Examen d'uno articulation maladc," Progres med., Paris, 1910, '.i" S. xxvi. 465. Brackett, E. 0. "The Diagnosis of the Tiilicrculous Character of Joint Disease," Boston M. and S. .fourn., 1913, cxviii. 673-67l>. 58 TUBERCULOSIS OF THE BONES AND JOINTS THE X-RAY APPEARANCES IN NEGATIVES OF TUBERCULOUS BONES The Apparatus. — In taking a radiograph, the Rontgen or X-ray tube forms the most important part of the armamentarium. It is occasionally- possible to get a good result from an inferior outfit if only there is a suitable tube, but the best outfit will be useless if an inferior tube is the only one available. The suitability of a tube depends upon the degree of vacuum within, and tubes may be classified into three groups — soft, hard, and medium. Soft tubes possess a low degree of vacuum, and they give off rays of a low degree of penetration ; hard tubes have a high degree of vacuum, and their rays have a correspondingly high penetrating power ; medium tubes strike an average. Substances are penetrated by X-rays in relation to (1) their atomic weight, (2) their thickness. The greater the atomic weight and the thick- ness the harder must be the ray in order to penetrate. It will therefore be understood why, in taking a radiograph of such a superficial part as the hand, one chooses a soft tube, and in deeply placed bones — femur and pelvis — a hard tube is to be preferred. The Reading- of the Radiog-raph.— The X-ray plate ^ may be looked at from the glass or from the film side. If observations are made from the film side there is the advantage that the observer's eye occupies the position of the X-ray tube, but it must be remembered that the positions are reversed, and the right hand of the observer corresponds to the left hand of the nega- tive. In studying the negative from the glass side, the observer may imagine that he is looking at the part from behind, and the sides of observer and plate correspond. It is an advantage to examine the plate in an illumin- ating box. A diffuse light which can be varied in intensity is the best. Normal X-Ray Appearance of Bone. — In a good X-ray considerable anatomical detail is shown. The periosteum is visible as a faint clear line, covering the surface of the bone. Beneath it there is the compact bone of the shaft ; the arrangement of the lamellaB may be demonstrated, and occa- sionally Haversian systems. In the centre of the bone the cancellous tissue appears as a porous network, the lamellae appearing as irregular clear lines. Coursing through the interlamellar spaces blood-vessels may sometimes be made out. In the '■ In the following description the terms light and dark refer to the appearance of the negative. Dark areas in the plate signify that the tissue has been more permeable to X-rays than the surrounding parts, and vice versa. PLATE XXXV.—TiiK X-uav Aim'Eahanck of kaklv Tlbeucli.ous Diseask of the Bosk. In the under surfftce of the neck of tlie femur there is a focus of encysteil tuberculous disease. The riMitrc of tlie focus sliows an inilcfinite c)cai' area which corresponds to a deposit of tulierculous (iranu- hition tissue. Arouml tlic I'cntral focus tlicrc is a darl< liand convsiioiulin); to an area of liluous tissue, whicli as a soft tissue structure liiis olfered little obstruction to the passage of the rays. Beyond this d.irk band there is a well-defined light l>and which corresponds to an area of condensed lamellae. X-RAY APPEARANCES OF TUBERCULOUS BONES 59 growing child the epiphyseal cartilages appear as clear bands of varying depths passing across the outline of the bone. It is important to observe that the distal surface of the cartilage, that is, the surface lying next the epiphysis, is smooth in outline, while the surface which looks towards the shaft, being the growing surface, is more irregular. Beyond the epiphy- seal cartilage lies the epiphysis. According to the age of the child it may appear structureless, no ossification having yet developed, it may show a small developing centre of ossification, or it may have a structure similar to that of healthy cancellous bone. It is most essential to have a definite knowledge of the normal X-ray anatomy in order to appreciate the finer discrepancies of the diseased condition. Patholog'ical Changes. — The changes will be described according to subdivisions of situation, whether they occur centrally or peripherally, within the cancellous tissue or beneath the periosteum. The description is concluded with a synopsis of the changes which one finds in the four types of bone tubercle — the encysted, the infiltrating, the atrophic, and the hypertrophic. Central Changes. — One rarely has an opportunity of witnessing the X-ray appearance of an early central disease. The original marrow tubercle appears in the negative as a rounded light point. The cellular collection which constitutes the tubercle offers an increased resistance to the passage of the rays, with the result that the negative demonstrates its presence as a point of diminished density. At this early period no other change is visible. Now let us suppose that the disease is more extensive and has come to involve a greater extent of the bone. The principal changes are similar. A portion in the medulla of the bone appears, of diminished density, and stands out from the negative as a light area. But the changes do not stop there ; there are characteristic appearances in the lamella?. Those which lie within the light area, that is to say, those which lie in the diseased tissue, have either been absorbed or are in process of absorption. The lameiiaa which are around the diseased area appear wasted and rarefied, a preliminary in the process of absorption. Sometimes lamellae which lie well beyond the diseased area ap))ear thickened. Then there are radiographic alterations in the marrow between the lamella?. Normally marrow appears in the negative as a dark, structureless background, from which the clearer lauiilla; stand out. For some distance around a tuberculous focus one finds that the marrow loses its dark homogeneous character and becomes lighter with a faint striated appearance. The skiagraphic impressions arc con- comitant with a histological marrow fibrosis. One would sum up the X-ray appearances of a well-defined central disease as follows : An area in the medulla of the bone appears of diminisliod density, it corresponds to the tuberculous granulation tissue. Within tiio light area the lamella? are absorbed, and around the periphery they are rarefied. There is an area well outside the diseased focus in which the lamella; appear thickened. Between the lamell.T, around the periiihery of 60 TUBERCULOSIS OF THE BONES AND JOINTS the central deposit, the cai'ijet of marrow loses its dark uniform appear- ance ; it becomes lighter, and its structure has a suggestion of striation. This, which may be taken as the typical appearance, is altered under two conditions, namely, cavity formation and sequestration. AVhen cavity formation occurs there is a diminution in resistance to the passing rays, and the area is registered as a dense black shadow, it may be in the centre of the light tuberculous area. If a detached sequestrum is present, it, as an object, offers very considerable resistance to the rays. And in the skiagram it appears as an area somewhat lighter than that afforded by the diseased granulation tissue. Peripheral Changes. — In the section on pathology attention has been drawn to the importance of new subperiosteal bone, and the deposit is well shown by an X-ray negative. If a series of negatives be examined at different stages of the disease, the earUest periosteal appearance is the development of what looks like a space between the periosteum and the underlying bone. In reality it is the picture afforded by the first stage of the deposit of new subperiosteal bone granulation tissue, which has not yet become ossified. At a later examination there is a typical deposit of pew bone between the periosteum and the underlying shaft. If the new bone is deposited upon the shaft it is cancellous ; if it is laid down in the neigh- bourhood of a joint its thickness is not so great, and its composition is comparatively denser. In examining an X-ray negative of new subperiosteal bone, one should never omit to exanxine the surface of the underlying compact bone. In tuberculous disease such ought to be smooth. This is important, because it is the distinguishing feature between the X-ray appearances of a periosteal thickening, due to underlying tubercle, and that due to periosteal sarcoma. In the latter the outline of the compact bone is eaten out and irregular. The X-Ray Negative Appearances in Special Types of Bone Tuberculosis Encysted Tubercle. — The situation is usually in or about the region of the metaphysis. In a fully developed focus the appearances are typical. Standing out from the centre of the bone there is a light area, from which all trace of lamellar structure has been removed. Within that light area, which corresponds to the actual tuberculous disease, there may be demon- strable the dark shadow of a cavity formation, or the lighter irregular appearance of a sequestrum. Around the periphery of the focus there is a dark, dense ring. It corresponds to the encapsulating fibrous tissue which has locahsed the disease, and it, as a soft tissue, offers little obstruction to the passage of the rays. Beyond this narrow dark band there is a broader and lighter zone, corresjDonding to an area of condensed lamella?. Some- times the periosteiim shows no reaction, but occasionally the picture is completed by the deposit of a varying amount of new periosteal bone. Infiltrating' Tubercle. — This is the most difficult type of tubercle I'LA'l'l'; XXXV'I.^THK \-HAV yVri'KAItANtK OK NKW Sriil-KHIOSTKAL HoNi:. Thf new lioiK' is sccomlarv l<> tul)LTrnIi»us disi-asc of tin- Hist nu'tiitarsal Ihhic. PLATE XXXVII.— Thk X-kav ai'I'eaka.nck in Ti-beuculous Iuseask vt ihe Bone associated WITH Secjuesthum Formation and a Cavity. I'l.A'I'K XX.W Ml. TllK XllAV Ali'K.VIlANC'K OK llvi'KllTHIll'Mlr TOHKKCUI.OSIS OK TIIK TiBIA. There is very considunaile hypcTostosis of tliu bono nml a central sequestnim surrouiulra liy an area of granulation tissue. PLATE XXXIX. — Thk X-hay appeabancit'op Atrophic Tubebcdlol's Disease of the UITEU END OF TBE ULNA. Note tlie tliin "glassy " appearance of tlie boue. X-RAY APPEARANCES OF TUBERCULOUS BONES 61 in which to obtain a satisfactory radiograph. The best results are obtained by attention to a detail in the technique of development, and that detail con- sists in giving a long exposure, and subsequently retarding the development of what would otherwise be a dense negative. In appearance the cancellous tissue of the bone is occupied by an irregular light area corresponding to the diseased tissue. Within the clear area there may be darker spots of cavity formation, there certainly are lighter points which represent multiple minute sequestra. Occasionally the area may be occupied by a large composite sequestrum. The distinctive points in the interrogation of the plate lie at the periphery of the central disease. Here there is no limiting band to be seen and no condensation of lamellse. The periosteum always reacts, and there is the appearance of a quantity of new subperiosteal bone. Atrophic Tubercle. — The X-ray appearances of this type are distinct- ive. The outline of the bone is enlarged, but it looks like an empty shell. The interior is clear, here and there are traces of lamellae, but they are wasted and thin. There is a deposit of new periosteal bone, but the deposit is meagre. All through the field there are dark areas of cavity formation, there is nothing suggestive of sequestra. Hypertrophic Tubercle. — The diseased area is usually situated about the centre of the shaft. In examining a radiograph of the part, the first point to catch one's attention is an abnormality in the nutrient vessel. The vessel is apparent, which it ought not to be, and it is thickened. These changes are explicable by the endarteritis, which one knows to have occurred pathologically. AVithin the centre of the bone there is an oval dark area, and in the dark area the impression of a central sequestrum standing out in a light relief. All around the lamellse are hyperostosed and thickened. Finally, it is most important to observe that there is little formation of new periosteal bone, the thickening is mainly an endosteal one. The X-Ray Negative Appearances in Tuberculous Joints The X-Ray Appearance of a Normal Joint. The characteristic of a healthy joint is its invisibility. The articular cartilages may be apparent as indefinite light lines, covering the opposing ends of the bones. The synovial membrane should certainly not be visible. The ligaments often may be traced on a good negative as faint light bands, and the surrounding tendons and muscles may often be similarly demonstrable. But of the true joint structure little or nothing should ho visible. The X-Ray Appearance of a Tuberculous Joint. — A comprehensive idea may be obtained if the changes are considered at three stages in the course of the disease — early, medium, and late. Earlij Joint. Disease. — Two joint structures show changes in even the earliest stages of joint disease, and these structures are the synovial mem- brane and the ends of the bones which lie within the synovial reflexion. The synovial membrane, invisible in a healthy joint, now becomes visible ; 62 TUBERCULOSIS OF THE BONES AJSID JOINTS its distribution can be traced as a smoky indefinite band. It bulges out- wards the overlying ligaments and muscles, and it projects into the interior of the joint. The other distinctive feature lies in the ends of the bones. They have lost their clear-cut cancellous structure, their outline is blurred, shadowy, and indistinct. The explanations of these changes are obvious, the synovial membrane is thickened because it has become diseased. The ends of the bones are indistinct for two reasons, partly because the rays require to pass through thickened synovial membrane, and partly because they penetrate a mem- brane the vascularity of which has greatly increased. Medium Joint Disease. — When one considers the changes in a joint in which the disease is more advanced, one finds, in addition to the above, other features making their appearance. The synovial membrane is thick- ened and the ends of the bones are blurred, but in addition the articular cartilage is most suggestively altered. It is altered in three situations — around its periphery, on its free surface, and on its deep surface. At the periphery there is an appearance as though pieces had been gouged out from the cartilage edges, it is a destruction of the extremity of the cartilage by the diseased tissue of the synovial membrane. On the free surface the cartilage has lost its smooth outline, and has become irregular — the result of • a perichondral ulceration. On the deep surface the cartilage is irregular, and it looks as though it had been lifted off and separated from the under- lying bone ; this appearance is produced by the infiltration subchondrally of a quantity of diseased granulation tissue. Late Joint Disease. — The X-ray appearances may vary within wide limits. All traces of the origmal joint outline become lost. A space between the ends of the bones is occupied by a white, blurred mass. The bone sur- faces are eroded and irregular, and within the bone substance there are secondary tuberculous deposits, the radiographic appearance of which has been already described. If a quantity of fluid has collected within the joint it will be noticed that the articular surfaces are more widely separated than usual. BIBLIOGRAPHY Skinnek, E. H. " A Rontgenological Discussion of Bone Lesions," Interstate M.J., St. Louis, 1908, XV. 431-438. DiEFFBNEACH, W. H. " Differential Diagnosis by means of X-Rays of Diseases of the Osseous System," Journ. Admnced Therap., New Yorls, 1908, xxvi. 283-296. EWALD, P. " Fusswurzel Tubcrculose und ihre Diagnose mittol Rontgenstrahlen," Fortschr. a. d. Geb. d. Rontgenstrahlen, Hamburg, 1908, xii. 30-35. Granger, A. " Rontgen Rav Diagnosis of the Diseases of the Bones and Joints," Journ. Advanced Therap., New Yorlv, 1908, xxvi. 561-566. Jacobsohn, E. " Die chronischen Gelenkerkrankungen im Rontgenbilde," Mitt. a. d. Grenzgeb. d. Med. und Chir., .Jena, 1909, xx. 757-813. YOTINO, J. K. " X-Ray Diagnosis of Tuberculous Hip-joint Disease," Penn. 3I.J., Athens, 1909, xii. 714. FoRSSEL, G. " X-Ray Diagnosis of Tubercular Diseases of Bones," Hygiea, Stockholm, 1909, 2. f. ix. ; Svetis. Ldk. SalM: Forhandlung, 258-270. Harris, L. H. " Rontgonography in Disease of Bone," Australasia M. Congress Tr., Victoria, 1909, iii. 175-183. I'LATIO Mi. 'I'lIK XllAV AlTKAllASCK UK KAIll.V 'I'l'BKUCL'LOUS DlsKASK dl' TUB KNKK-JoINT. Tlu' enils of llic l>ou(/s fonniiiK tliu joint liiivc a I'tiiiracteristic "smoky " iipiMMrniief ; the outline of 11 thielii'iUMl synoviiil iiicmbniiie can lie traced, ami the wide separation ol the ends of the bones indicate the presence of llniil. PLATE XLI.— The X-uay ai'I'Eahance op an Advanxed TnBERCuuisi.s of thk Knee-Joint. The articular surface of tlie femur is eroded and destroyed, the outliiie of tliicliciied synovial membrane can Ije traced ; there is little or no fluid in the joint. X-RAY APPEARANCES OF TUBERCULOUS BONES 63 RuCHMASX, M. " The Diagnosis of Bone Lesions b_v means of the Rontgen Rays," Illinois Med. Journ., Springfield, 1909. xvi. 118-120. Freund, L. " The Treatment of Tuberculous Osteoarthritis by Rontgen Rays," Arch. RotUgeii Ray, London, 1908-9, xiii. 89-98. CuSHWAY, B. C. " Differential Diagnosis of Pathological Conditions of the Bones and Joints by means of Rontgen Rays," Quart. Bull. Norlhwesl Univ. M. Sch., Chicago, 1909-10, xi. 105-11.5. Pfahler, G. E. '■ Diseases of Bones and their Differentiation by means of the X-Raj'," Amer. J. Surg., New York, 1910, xxiv. 377-381. PiRlE, G. A. " Diseases of the Bones and Joints as shown by X-Rays," Edin. M. Journ., 1910, N.S. iv. 427-430. Skinner, C. H. " The Rontgen Diagnosis of Bone Lesions," Oklahoma M. News Journal, 1910, xviii. 143-152. Brooa, a., and Philbert. " Radiographics de tuberculose diaphysaire des os longs," Paris med., 1912-13, ix. 578-582. 64 TUBERCULOSIS OF THE BONES AND JOINTS PROGNOSIS IN BONE AND JOINT TUBERCULOSIS If the prognosis of bone and joint tuberculosis be considered from a scien- tific view-point, it will be found to depend upon two facts : (1) the general resistance which the body offers to a tuberculous toxaemia and bacillary dissemination ; (2) the local resistance to the spread of the disease by the formation of a circumscribing fibrosis. Viewed from this standpoint, it would appear that the prognosis in bone disease, in comparison with many other forms of tubercle, is decidedly good. The disease is situated in a tissue which it is difficult to destroy and still more difficult to remove. Moreover, it is a tissue from which absorption is small because of the peculi- arity of its blood supply and the meagreness of its lymphatics, and for the same reason the dissemination of bacilli is unlikely. Lastly, the disease is surrounded by marrow possessing cells of considerable phagocytic powers. Each of these points is favourable to an arrest of the disease, both local and general, and, from a pathological standpoint, one cannot help being struck by the frequency with which spontaneous cure occurs. Arguing from the same basis, conditions are not so favourable in joint disease. The local powers of resistance are less, and the tendencies to dissemination of toxins and organisms are greater. But to pass from theory to practical facts : any question of prognosis must be considered from two aspects — the prognosis regarding the fife of the individual and the prognosis regarding the limb or the local part affected. Life Prognosis. — As regards the life prognosis, it may be considered in application both to bones and joints, and at once it may be said that the prognosis is distinctly good. Children respond readily to treatment, and their powers of resistance and recuperation are considerable. A good life prognosis is therefore indicated in the great majority of cases. Under certain conditions the outlook is not so hopeful. There are certain features which, if present, increase the risk to life. These are : (1) The Age of the Child. — If the disease occurs during the first two years of life, the life prognosis is grave. (2) The Position of the Lesions. — Lesions in certain bones are much graver than those in others. The skull bones and the spine are the most unfavourable situations. (3) The MuUiplicifij of the Lesions. — An extension of the disease to other parts indicates a want of general resistance, which forebodes ill in the ultimate prognosis. (4) Abscess Formation. — This is serious in so far as it is so often the precursor of the next danger, namely, septic infection. Yet in itself it increases the gravity of the disease, because by its tendency to burrow it may open up to infection wide areas of soft tissue. TREATMENT OF BONE TUBERCULOSIS 65 (5) Mixed Infection. — A superadded septic infection in tuberculous disease is the most serious complication which can occur. It follows abscess formation or imperfect surgical interference, and its danger lies in the apparent impetus which it gives to the tuberculous process. Life is actually eventually threatened either by long-continued siims formation with septic infection and waxy disease, or by the invasion of vital organs by the disease. In this respect the meninges most frequently suffer, the lungs are rarely invaded. Sometimes death occurs from a miliary dissemination. Local Progrnosis. — The prognosis in respect of the local part differs considerably, according to whether a bone or a joint is affected. In bone disease the local prognosis is good. The tissue is a resistant one, and there is a strong natural tendency towards cure. Further, as long as the disease is limited to the bone, the mobility of the part may not be seriously inter- fered with. In joints the conditions are not so favourable. The resistance is certainly less, and even the earliest disease interferes with the functions of the part. Sometimes in dealing with joints a cure cannot be obtained unaccompanied by some degree of ankylosis, and ankylosis in a joint necessitates a loss of its function in whole or in part. Therefore, every- thing considered, the local prognosis in joint tuberculosis is not so promising as it is in bone tuberculosis. TREATMENT OF BONE TUBERCULOSIS The treatment of bone tuberculosis embraces a wide variety of jirinciples, treatment local and general, preventive and curative. It will be well to discuss the treatment under several distinct headings : 1. Preventive treatment. 2. General treatment. 3. Conservative treatment. 4. Treatment by tuberculin. 5. Operative treatment. I. Preventive Treatment It is an adage as old as time that prevention is better than cure, and surely nowhere can the application be more suitable than in this bearing. When one realises how distressing are the sequels, no trouble is surely too great, no details too minute, that these may be prevented. First and fore- most in the order of prevention there comes at the very threshold of life the question of milk. Bovine infection most undoubtedly plays its part in the origin of bone tuberculosis, and here is a cause crying for prevention. Sterilise the milk and the danger disappears. Milk may be guaranteed free from bovine infection, or it may have been sterilised, and yet in spite 66 TUBERCULOSIS OF THE BONES AND JOINTS of these precautions a most obvious preventible error occurs, and that is the contamination of milk or food of some kind with dust infected with tubercle bacilli. This applies more especially to the conditions under which the poor exist. The third order in the scheme of prevention would be the non-associa- tion of infants or children with consumptives. In a susceptible child infection may so easily occur. A careless consumptive spits upon the floor, the sputum dries and becomes converted into dust, and as such it is inhaled or ingested by the child. It seems unnecessary to enter a warning against the danger of an infant kissing a consumptive, and yet time and again it is a medium of infection. How simple are the principles of prevention, and yet how rarely are they recognised and observed. 2. General Treatment (a) Hygienic Home Conditions. — The treatment of bone tuberculosis is such a long-drawn-out process that only in the minority of cases is the child detained in hospital until cure is complete. The treatment, therefore, has often to be carried out at home, where much may be done to improve the methods under which it is conducted. One has frequently had necessity to visit these cases in their homes, and one cannot avoid being struck by the absolute disregard so often displayed of the mere elements of hygiene. One must preach the doctrine of fresh air, a simple subject, but a most necessary one. If a balcony is available there the sufferer is placed, and there li3 is kept, fijie weather and foul, night and day. The only incon- venience may be a passing catarrh ; the benefits are too obvious to mention. If a balcony is not available, invention will meet the necessity. During the day he is carried to some open space, and at night his cot rests beneath an open window. Attention is drawn to the clothing. How often one sees the little suft'erer actually groaning beneath the weight of garments and bed- clothes. One is apt to be branded as unkind if one substitutes a single garment and fewer blankets, but one earns the gratitude of the small being who wears them. You certainly have put him in a more favourable condi- tion for his ultimate recovery. According to the type of disease from which the child suffers, he probably is fitted with a certain variety of splint, and frequently this necessitates a continuous recumbency. If it does, it is advisable that the patient should not be put in a large bed, as is so often the case, a bed shared perhaps by several members of the family. He should lie in an open crib, or even upon a home-made trestle. These facts may appear trivial in their simplicity, but they are most essential to proper home treatment. There are others too numerous to mention, and they can only be recognised and dealt with in the light of actual experience. (6) Hygienic Hospital Conditions. — In this country the average tuberculous child, when under active treatment, has to be content with a place in an urban children's general hospital. No doubt in every one of these institutions the hygienic conditions are as perfect as they can be made, TREATMENT OF BONE TUBERCULOSIS 67 yet the principle of treating surgical tuberculosis in such for any length of time is fundamentally wrong. During active or operative treatment residence in a general hospital is usually essentia], but during the long-drawn-out period of after treatment it is distinctly inadvisable. There are obvious reasons for this : (1) It is impossible to keep the case in the wards of a general hospital until cure is complete. (2) No matter how perfect may be the hygiene of an urban hospital, it cannot for a moment compare with the conditions under which tuberculous children may exist in a country sanatorium. (3) The presence of a child often with discharging sinuses in a general hospital is a distinct source of danger and infection to those in contact with him. The ideal which one lays down is not a very hard one. During the period of active treatment the child is kept in a general children's hospital. When that portion of the treatment which requires expert interference is completed the child is transferred to some country sanatorium, where it may be kept indefinitely, or at least until cure is completed. This ideal has been reached in several instances. England has its Lord Mayor Treloar Home at Alton and its hospital at Neuwall. France has its Berck-sur-mer and many others ; Germany has at Rappenau an ideal institution. It is a matter for regret that as yet Scotland has not attained to a single institution of this kind. In the building of these country sanatoria no elaborateness of construc- tion is necessary. The actual building should be as simple as possible, the essential feature is the possession of abundant out-door space. At Berck, in front of the hospital, there is a wide plage, the sea-front of Brittany, and the space is thronged with recumbent patients, some on cadres, some on the ground, and some in voiturettes, being pulled along by donkeys. One has got to see cases treated under this regime to appreciate the excellence of the after results. Surgical sanatoria require no elaborate buildings of stone and lime. There is a brick and concrete foundation, and the walls are built of wood and glass. The wards each hold an average of twelve to twenty children, and for preference they face south and west. An elevated situation and the most thorough drainage are necessary. (c) Climatic Conditions. — Children, especially those resident in the larger towns, derive the most extraordinary benefit from change of air and sceiu^ and it is in the early stages of tuberculosis that such changes are particularly to be advised. Now change of air and scene does not necessarily imply a change of climate. The latter is often the privilege of only the well- to-do, and it is from the poor that the bulk of our patients are drawn. But change one's surroundings, be it only the matter of a measured mile, and sometimes the benefit is enormous. There are many classifications of chmate. Sufficiently useful for one's purpose is that wliicli classifies three varieties — sea-coast, inland, and moun- tainous. Each of these has got something to recommend it, and one will endeavour to give .some ]ioints which will help towards a decision. 68 TUBERCULOSIS OF THE BONES AND JOINTS The sea-coast climate is one which is characterised by a low temperature, some degree of moisture, and the occurrence of winds. In the treatment of bone and joint tuberculosis it forms an ideal en\aronment, and most especially for children. It is contra-indicated in certain conditions — when the disease is advanced, when there is considerable cachexia and wasting, and when the bone or joint disease is complicated by infection of the lungs. Inland situations are on the whole dry and, when compared to the sea-coast, of a higher temperature. They are more suited for pulmonary infection than for the surgical tuberculosis of children. Mountain climate has the characteristics of a rarefied atmosphere, a slight degree of humidity, and a low temperature. Of these the first is cer- tainly the most important. In 1900 and 1901 some German physiologists (Zuntz, Loewy, Miiller, and Caspari) carried out experiments upon dogs to demonstrate the changes produced by alteration in degree of rare- faction of the atmosphere. They showed that at the higher altitudes there are in the growing animal an increase in the amount of red blood corpuscles and haemoglobin, a stimulation of the active blood - making function of the marrow, and a relatively greater increase in growth. Now these changes necessitate an improvement in the blood and in the nutrition, and in the successful general treatment of tuberculosis no factors could be of more importance. Therefore, if from no other than a physiological reason, a mountain climate is ideal, the misfortune is that its enjoyment is only within the power of the few. Mountain climate possesses only one i^ossible contra-indication, and that is an excessively irritable state of the nervous system. Dr. A. Rollier of Leysin has urged the value of heliotherapy in surgical tuberculosis. The successful results which he claims are largely ascribed to the influences of the ultra-violet rays obtained at high altitudes. (d) Diet. — In surgical tuberculosis, more especially when it is accom- panied by a chronic febrile condition, there is a continuous loss of weight, and it is mainly to the diet that one looks in counteracting the progressive wasting. It may be taken as a general rule that in the ideal diet fats and carbohydrates; i.e. the more especially fattening forms of food, should be superabundantly represented, and combined with them there ought to be a considerable proportion of albuminates. There are two difficulties which meet one at the very outset. The first of these is the occurrence of fever. If this is persistent and high, one may require to have recourse to fluid and easily absorbable foods, in much the same manner as in acute febrile diseases. The second difficulty is the ease with which the digestion is upset, and then ensues a want of appetite, and even a positive disgust for food. This can usually be prevented by the provision of well-cooked, appetising,- and attractively served food. The diet of a child with tuberculous disease should contain a liberal allowance of fatty foods in the form of milk, cream, aiid butter. Raw meat is strongly recommended, and it is well digested by children. The milk ought to be sterilised or pasteurised, and some expedient may be followed to promote TREATMENT OF BONE TUBERCULOSIS 69 its digestibility, the best is the addition to each glass of milk of two table- spoonfuls of hot water, in which about six grains of bicarbonate of soda and five grains of common salt are dissolved (Burney Yeo). Cream is well tolerated, and its value lies in the amount of fat which it contains ; some- times it may be diluted with hot water, and this procedure renders it more digestible. The use of raw meat has been largely extolled. It may be reduced to a state of fine subdivision, it may be administered as a dry powder, or it may be given in the form of small, round pellets. Some children have an absolute antipathy to raw meat. The difficulty may be overcome by using meat- juice or underdone meat. Deboue's forced feeding — alimentation forcee — was once popular in the dietetics of tuberculosis ; it is now rarely used. Eggs are always well borne by children, and they form an excellent diet. The general rule which would guide one would be a diet of food, regular and plentiful, containing a large proportion of fat. (e) Drug's. — There are no specific drugs in the treatment of bone tuber- culosis, any which appear to benefit act by improving the powers of assimila- tion and nutrition. The preparations of cod-liver oil have a world-wide reputation ; their benefit lies in the amount of fat which they contain. A common ^rror in administration is the giving of the drug in far too large quantities, assimi- lation is much more perfect with small doses than with large. Malt and pepsin are often combined with cod-liver oil ; their advantage lies in the stimulation which they offer to digestion. Iron is frequently prescribed, and the most favourite forms in which it is given are the syrups of the iodide and of the phosphate of iron. One may with advantage combine these two preparations. In children the prescription of iron should be begun with one of the simpler preparations, one of the scale preparations for preference, or even dialysed iron, and the more complex preparations are introduced later. In children who are in any degree ana;mic, the saccharatcd carbonate of iron is most beneficial, but it must be given in large doses, thirty grains t. i. d. Arsenic is recom- mended as a general tonic. Fowler's solution being one of the most convenient forms. Much has been written lately upon the effect which intestinal toxaemia has on the progress of tuberculosis, and undoubtedly its effect is a dele- terious one, therefore one of the first princi})les ouglit to be careful regula- tion of the bowels. In children petroleum emulsion, ,"; i-, given at bedtime is an excellent laxative, or tinct. podophyliT \]\ ii. t. i. d. If there is intestinal fermentation, salol or sodium sulplio-carbolate ought to be administered. Creasote-guaiacol or iodine given in pepsin is good. When a syphilitic taint is suspected a fraction of a drop of Donovan's solution (iii]. arsenii et hydrarg. iodidi) given after meals, alternating each week with Fowler's solution (liq. arsenicalis), will be found beneficial. Succininiide of mercury has beei\ recommended by Wright.^ It is given hypoderniically in ' Wright, Lancet, 1902, vol. i. p. 1712. 70 TUBERCULOSIS OF THE BONES AND JOINTS doses of ^ly to -^ig of a grain daily for fifteen days, a,nd the dose then gradually increased. Satisfactory results are obtained by the use of tonic doses of mercuric chloride. 3. Local Conservative Treatment Fixation of the part. — No treatment has yielded such good results as that of simple fixation of the part. The necessity entailed is a fixation, not only of the local part, but also of the neighbouring joints, a detail which one frequently finds omitted. Principles. — The principle upon which the treatment is based is a simple one — the nutrition and resistance of a tissue which is resting within limits are apparently superior to those of a tissue in constant use, and as a result of the improved resistance and nutrition the disease is opposed and frequently overcome. It has been asked why movement, with the increased blood supply which it entails, should not be rather antagonistic to the spread of tubercle than otherwise. The answer is that the arrest of tuberculous disease is not the result of an increased blood supply, but rather of a diminished one with subsequent fibrosis. Methods. — There are numerous materials which at one time and another have been used for the purpose of fixation ; those in most common use will be mentioned. (1) Plaster of Paris. — Plaster of Paris is in many waj's an ideal im- mobiliser. Its advantages are its cheapness, the adaptability of its applica- tion, and the complete fixation which it affords. Its disadvantages are few, possibly two are most obvious — the weight of the material and the muscular atrophy which the weight entails. In the application of plaster to a part, the operator must provide himself with three different materials : stocking- ette, plaster, and muslin. Some points of explanation about each are necessary. Stockingette is a light cotton material, made in a tubular form, and sold in rolls of varying sizes. It hes next the skin, and by its elasticity it naturally accommodates itself very closely to the part. It is a more satisfactory material than the boracic lint which is so commonly used. Plaster or gypsum is a natural sulphate of lime prepared b}^ heating at a temperature of 300° to 350° F. to drive off the water of crystallisation. There are two varieties of plaster — dental, and the grey or commercial. For use with bandages the dental plaster is the more satisfactory. Certain substances are recommended to be added to the plaster to improve it. There are those who advocate the addition of dextrin, on the ground that it lessens the tendency which the plaster has to crack. It has the dis- advantage of considerably delaying the setting. Salt, alum, and sulphate of potash are used because they increase the rate at which the plaster sets. They all share the disadvantage of weakening the plaster. Probably the best addition to make is Portland cement ; it is added to the plaster in the amount of one-twentieth part by volume. It increases the rate of setting and it materially strengthens the plaster. I'l.A'I'K M,I1.— TiiK Stalks in ihk siAKiM; (iK A I'l.AsTiii Casi:. «, Tlie matcriiil wliidi is iiscil in tlic nmliiii(,' of tlio jilnster l)unilnKc ; the filgos ni-e carefully fniycil. A, Tlu' teclinii' of loa.liii;; the liiimliigo with i)la!.ti-r ; one hiinil rolls tlii; biiiulnnc wliili' thf olhcr lioliis Ihu ]i.irt ulinnt to Iw rolled iindiTnunlh n lolk'clion of ilry i>lnster. r. The eorri-ct iniuMifr of wrlngiiiK 11 phistcr li.-inilane— it hus \m-i\ sohUcmI in water. (/, The wroiij; niethoil of wriiiginj; a hanilage— l>y this incthoil the centre of the bandage is exlnnled. c, Stockingette adjusted to the liiiih. ./', The idaster liandages have lieeii apiilied and the ends ol the stockingette are tnrned over the case, i/, The completed plaster case: the free ends of the stockingette are incorporated in the case with n few turns of the jihisler bandage. TREATMENT OF BONE TUBERCULOSIS 71 The muslin is the crinoline type of starch muslin, sometimes called " tarlatan " or book muslin. Its mesh ought to be of such a size that there are seven or eight threads in each centimetre, and it is most important that it should have retained its starch. The muslin is used in the preparation of plaster bandages, and in the preparation of reinforcing plaster pads. Such bandages and pads may be made in one of two ways : — They may be prepared at the moment of use. A solution of the plaster is prepared, and the dry bandage is soaked and loosely rolled up in the plaster solution, to be immediately applied to the part. The alternative method consists in preparing the bandage or pads beforehand by rubbing the dry plaster into the muslin. The bandage lengths are cut, and the edges frayed. This is done to prevent cotton threads holding the bandage up as it is being put on. The lengths are loosely rolled into bandages. The end of the bandage is placed in a bowl full of dry plaster and pulled underneath the plaster. The bandage is re-rolled from this end, each portion being held under the plaster with the left hand, and pulled through and rolled with the right hand. The bandages are rolled loosely. The technique of the application of a plaster case to the part is as follows : The part is carefully washed with a solution of alcohol and ether in equal parts. It is then dusted over with a light dusting powder, French chalk and talc in equal parts being useful. A single or a double layer of stockingette is now pulled over the part, and adjusted so that it lies free of ail creases. The plaster bandage is then applied ; if the bandages have been prepared beforehand they are placed endways in cold water and wrung out. In wringing out the bandage an important detail should be observed. It should not be wrung out with a closing fist, as this makes it bulge at one end, and it becomes irregular ; it must be wrung out by compression of each end towards the centre. To secure a homogeneous setting, each bandage is wrung out drier than the preceding. The casing of bandage is put on uni- formly and carefully, taking the greatest care to avoid creases. The case may be composed entirely of bandages, or it may be formed partly of pads — flat pieces of muslin — cut to fit the limb, wrung out of plaster, and applied anteriorly and posteriorly. Tlie plaster should extend beyond the local part so as to embrace the joints at each end. After it has become firm, but not hard, it is moulded with the hands to the more prominent outlines of the part. While the ))laster is setting it will be noticed that the casing becomes distinctly warm. This is due to the latent heat which is set free. When dry there is little change in the bulk of the splint, the plaster expands, the cloth shrinks, ami there is an actual expansion of about 1 per cent. The stockingette siiould extend at each end for about one inch beyond the plaster, and a neat finish is given to the part if this free end is turned back- wards over tlie plaster casing. (2) Cclluluid. Celluloid is a material whicii lias not been used sulli- ciently for bone fixation. It possesses many advantages — perfect fitting, lightness, and durabilit\-. I'crliaps its only disadvantage is the time wiiich is required to conqilete the splint. The method of its formation may be 72 TUBERCULOSIS OF THE BONES AND JOINTS described in a few words. Consider, for example, the making of a splint to be applied in tuberculous disease of the tibia. The limb from above the knee to the toes is covered with warm olive oil, and upon the part a thin casing of plaster bandages is applied, and carefully moulded to the bony outUnes. When the casing is dry it is cut up one side, and carefully removed from the limb. From the mould a positive cast of the limb is taken. This is made by applying a single plaster bandage around the negative to keep it in position, blocking up one open end by standing the negative in a basin of sand, and then filling the cavity with a quantity of plaster of the consistence of cream. When the inner plaster is hard the negative is peeled off, and there is left a cast of the affected part. The actual size of the cast is now increased by covering its surface with an addi- tional layer of plaster, about a sixteenth of an inch in thickness. When this is perfectly hard the cast is covered with a layer of stockingette. The stockingette must fit the cast very accurately, and to do so tapes are tied around the various inequalities and fastened with stitches. The celluloid solution is prepared by dissolving sheet celluloid in acetone, and adding to the solution 3 per cent of a solution of calcium chloride in water, to render the celluloid non-inflammable (Gauvain). The fluid celluloid has the property of rapidly impregnating any loose tissue to which it is applied, and as the acetone evaporates a thin, firm coating of celluloid is deposited. The fluid is applied with a brush to the stockingette, covering the cast, and thoroughly worked in. Two or three coats are thus applied. When this original application has dried, the cast is covered with two pieces of unstiffened book muslin, applied one in front and one behind, slightly overlapping at the sides. A further coat of celluloid is applied. This is repeated until from ten to fifteen layers of muslin have been applied, each layer being allowed to dry before a further one is added. The celluloid is then cut up the middle and removed from the cast. Its edges are trimmed, and they may be bound with leather. Hooks for lacing are applied along each side of the cut surface. The inside is lined with some soft material, and the outside strengthened with narrow steel bands. It is a wise precaution to punch a number of holes in the circumference of the splint to favour evaporation from the skin. Made in this way a celluloid splint is excellent, and the results which it gives are well worth the trouble its manufacture may have cost. (3) Wood. — W^ood is not a suitable material. It is difficult to fit, and still more difficult to fasten so as to secure absolute fixation. (4) Metal Splints.— Oi the various metal splints which have been used aluminium is the best. It can easily be cut into desirable shapes, it is light, and it can be securely fastened to the part by bands of sticking-plaster. It makes an excellent splint in disease- of the wrist and hand bones. Many other materials have been used : poroplaster, silicate of potas- sium, isinglass, but each and all of them have serious drawbacks. What is the length of time which a tuberculous bone requires to be kept at rest in order to effect a cure ? It must be realised that the process of TREATMENT OF BONE TUBERCULOSIS 73 healing in bone tuberculosis is a most gradual one. At least twelve months are required before a cure is properly established, and it is often wise to add an additional six months. In certain regions a still longer period is necessary. These are dealt with later. Hypersemic Treatment Biers HypercBinic Method. — With August Bier there lies the credit of having introduced a new method in the local treatment of tuberculosis. The idea was based upon Rokitansky's observation that patients suffering from mitral lesions with pulmonary stasis rarely develop pulmonary tubercle. Underlying the method there are three possible processes upon which the apparent benefits depend. Sources of Benefit. — (1) The circulation in the tissues is altered, the corpuscular elements become infused into the lymphatics of the hyperajmic limb, and there is a diffuse oedema throughout the part. This oedema spreads from the periphery to the centre ; but when the stasis has been kept up for some time, the circulation changes in direction, and its course comes to be from the centre to the periphery. This circulatory disturbance is beneficial in two ways : the csdema carries into the very centre of the tuberculous area antagonistic products such as leucocytes, lysins, and opsonins ; the later reversal of the circulation provides for a rapid removal of the dead bacteria and their products. (2) Artificial hyperaemia is a great aid to absorption. This occurs chiefly after removal of the medium by which the hyperaemia is induced. By absorption a large amount of deleterious matter is rapidly removed. (3) Bier asserts that hypersemia exerts a solvent action on organising tissues and exudation, and the solution is preparatory to absorption. Methofh of Employment. — There are four methods by which a part may be made hypencmic : (a) Active hyperaemia. (6) Passive hyperemia. (c) Hyperaemia by cupping (mixed hypcra>inia). (d) Suction hyperaemia. {a) Active Hyperaemia. — This is procured by the local application of dry heat. The part to be treated is put into a bo.x or chamber, made of white wood soaked in a solution of silicate of sodium to prevent charring. The part is introduced into the chamber through a terminal opening, and the opening is rendered airtight by a felt cuff, which fits round the enclosed member. Into tlie chamber there opens a metal tube. Tiie outer end of the tube ends in an inverted funnel, beneath which a gas-jet plays and suj)plies heat. Above tlu; inner end of the tube, within the box. there is a flat, wooden flange ; upon it the hot air entering tiie chamber st likes, and is equally distributed. The amount of heat is regulated by raising or lowering till' tniniiT, and tin' cliiinibcr carries a tliernioinctcr. Ilyperffimia commences 74 TUBERCULOSIS OF THP: BONES AND JOINTS at 30° C, perspiration appears at 60° C, and reaches its maximum at about 100° C. 114° C. is the limit of saturation. Each seance varies in time from thirty minutes to an hour ; it may be repeated twice or three times each day. Active hyperaemia is an excellent analgesic ; its outfit and conduction are expensive, however, and the ultimate results are probably not so suc- cessful as in passive hypersemia. (6) Passive Hypersemia. — The most commonly used method of inducing passive hyperemia is by the application of a Martin's elastic bandage. The bandage is of thin rubber about two inches wide, and it is applied to the limb some distance above the site of the disease. The bandage ought to be applied at such a pressure that while the thin- walled, deep, and superficial veins are compressed, the thicker arteries are not obstructed. One or two layers of gauze are applied to the limb and upon these the bandage is fastened. To the end of the rubber a piece of tape is stitched in order to facilitate the tying. The bandage need not be more than eighteen to twenty-four inches long. Some practice is required to gauge the degree of tightness to which the bandage should be applied. The skin should be of a bluish tint, with dis- tended superficial veins. Prolonged pressure with the finger should show the presence of oedema. The pulse should remain full and strong, there should be no subjective coldness in the part, and no pain. Wilson ^ has demonstrated a mechani- cal method of regulating the pressure. The pressure bag of a Riva-Rocci sphygmomanometer is applied to the limb and adjusted in position. The blood-pressure is taken, and allowed to fall 5 or 10 mm. below systolic pressure. The tube from the arm-pad is securely clamped, and it is disconnected from the apparatus. The arm-pad is kept in position, and it induces a perfect passive hyperaemia. The bandage should be applied for from one to two hours each day, and the treatment will probably extend over nine months. It is not advisable to apply the bandage for longer than two hours a day, as a more extended ap- plication appears to hasten the formation of cold abscesses. Passive hyper- ajmia is excellently adapted in lesions of the arm up to the level of the elbow. In the lower extremity the proper degree of hyperaemia is difficult to induce. Ritchie Thomson " has described a method which he has found useful in dealing with the lower limb. An elastic bandage is applied above the knee, sufficiently tightly to render the limb bloodless. The bandage is kept in 4. — IJier's ]);Ls>i\L' liypriii'iiiiu api'lied to the upper extremity. ' Wilson, Journ. Amer. Med. Assoc, April 4, lfl08. - G. Ritchie Thomson, Transvaal Med. Journal, 1909. TEEATMENT OF BONE TUBERCULOSIS 75 position for five minutes and then removed. Its removal is tlie signal for a very active hyperaomia of the limb. While the active hypera-mia is in progress the elastic bandage is reapplied, just sufficiently tightly to induce a passive hypertemia. The results of treatment by passive hypersemia are good in the upper limb — more especially in the terminal portions, carpus, metacarpus, and phalanges. In the lower extremity the results are not so good, probably on account of the difficulty in inducing the hypersomia. The disadvantage of the treatment is the tendency which it undoubtedly has to hasten abscess formation ; this, however, can be largely avoided by minimising the length of application. (c) Hyperaemia by Means of Dry Cupping (Mixed Hyperaemia). — In localised tuberculous lesions hypera3mia is sometimes induced by a modi- fication of the ordinary dry cup. The method was devised by Klapp, Professor Bier's assistant. Glass cups of varying shapes and sizes are used, to fit the different parts of the body, and to the cups rubber bulbs are attached in order to exhaust the air. A negative pressure of 200 to 400 millimetres of mercury may be obtained. The area to be treated is washed with benzine, and then covered with a thin layer of vaseline and lanoline. This aids the adhesion of the cup, and if any sinuses are present it diminishes the tendency to skin infection and ulceration. The cup is left in place for five minutes and removed for three ; it is reapplied for five more minutes in a slightly different place to avoid skin irritation. The application should extend over forty-five minutes, at first daily, then every second or third day. Klapp uses these cups for simple osseous tuberculosis, for infected abscesses and sinuses, and for uninfected cold abscesses. These last are opened by a small incision and " cupped." The explanation of the benefit which the treatment produces is partly the result of a hypersemia, and partly of an actual suction action. (d) Suction Hypersemia. — AVhen hypcra'mia is to be induced in an entire limb, glass chambers of varying shapes and sizes are employed. These are provided at their open extremity with a loose rubber cuff. When the part has been placed within the chamber the rubber cuff is fastened to the limb with a few turns of an Esmarcli bandage, to render the apparatus air-tight. The air in the chamber is partially withdrawn by an exhaust pump, and a partial vacuum maintained for about five minutes; the air is then readmitted. After two minutes the procedure is repeated, and so on, until the treatment has extended over half an hour. The a})plicatioii is made at first every day, and later every second or third day. Conclimon. — In the upper limbs liyper.Tmic treatment of tuberculosis frequently gives good results, in the lower limbsthc benefits are not so marked, and in the neighbourhood of the shoulders and hip its use is imi)ractical)le. The results obtained in (children are better than those met with in adults. As a method of treatment it must be combined with mechanical ininioI)ilisa- tion. Its undoubtrrl drawback is the teiulcncy to hasten cold abscess formation. 76 TUBERCULOSIS OF THE BONES AND JOINTS Counter-irritation In these days when radical treatment is so common, qne feels one ought to apologise for including counter-irritation in one's scheme of treatment ; there are, however, certain cases which undoubtedly benefit from its use. The class of case which one finds reacts most beneficially is bone disease, uncomplicated by abscess or sinus formation, and accompanied by considerable pain. The pain is the result of increased pressure within the unyielding bone, and counter-irritation improves the symptoms by withdrawing blood from the deeper parts to the periphery, and thus relieving the congestion. Methods of Application. — An excellent method of employing counter- irritation is by the use of the cautery. Sometimes the simple actual cautery is applied to the overlying skin at such a degree of heat as to produce a slight superficial eschar. More recently another method has been introduced. The thermo-cautery, provided with a fine platinum point two millimetres in thickness, is used; and v^dth it at a white heat a number of points of cauterisation are made into the soft tissue overlying the bone. The bone itself is sometimes penetrated. As many as fifty to sixty points of cauter- isation may be made. The points of entry of the cautery are very small; and the whole operation is conducted with the most rigorous antiseptic precaution. There are other varieties of counter-irritants which are some- times employed, viz. cantharides blisters, tincture of iodine, etc. None produces the improvement which follows the use of the actual cautery. X-Rays It is held that X-rays produce improvement in tuberculous lesions. This is certainly true when the lesion is a superficial one, the affected bone must not lie at a greater depth than 4 mm.^ In applying the rays the surrounding soft parts ought to be protected, and it is advisable to filter the rays through an aluminium plate 1 millimetre thick. ^ No more than three successive applications should be made to the one part. This method of treatment has the disadvantage that if the disease lies in the neighbourhood of the epiphyseal cartilage, the growth of the cartilage cells may be inhibited by the action of the rays. Treatment of Cold Abscesses Abscess formation is the most frequent complication in bone disease. Its pathology has already been fully dealt with, but to facilitate the discussion of the treatment of the condition, it will be well to recall that a cold abscess extends by an actual tuberculous change taking place at its periphery, and gradually extending throughout the tissues. It is not a true extension of pus, but a gradual extension of tuberculous granulation ' Iselin, Miinch. med. Wochenschr., Dec. 3 and 10, 1912. - Quervain, La Semaine med., Jan. 1, 1913, p. 347. TREATMENT OF BONE TUBERCULOSIS 77 tissue, and the conversion of the granulation tissue into pus. When the complication arises, its treatment must be considered, and there are a number of diiTerent methods which may be employed. They may be classified as follows : (1) Conservative measures. (2) Simple aspiration. (3) Aspiration with the injection of medicaments. (4) Simple incision without drainage. (5) Simple incision with drainage. (1) Conservative Treatment. — There is no doubt that an untreated cold abscess may be entirely absorbed or may be converted into an innocent collection of calcareous debris. For this reason there exists the method of leaving tuberculous abscesses severely alone. This purely expectant treat- ment must not be blindly adhered to in every instance. There are certain conditions which are suitable for it, and these are the maintenance of good health on the part of the patient, a diminution in the size of the abscess, and an abscess which is deeply situated. Spinal abscesses are the type which most completely fulfil these desiderata. If treatment is persevered in under suitable conditions, the abscess may become shut off from its origin, and the locahsed collection of pus undergoes contraction and absorption. It may disappear entirely, more often it becomes converted into a small fibrous nodule with a caseous or calcareous centre. Tubby ^ gives the follow- ing as indications for the conservative treatment : — (a) When the abscess is single, and not tracking in two or more directions, (b) When the recumbent position is immediately followed by cessation from pain and improvement in the general health, (c) The expectant plan should be persevered with if after a short trial the abscess ceases to enlarge, (d) A large collection of pus is no hindrance to tlie trial of this method, provided that the appetite is good and the temperature is normal. (2) Simple Aspiration. — Too often the tendency is for a tuberculous abscess to increase steadily in size ; active interference then becomes neces- sary, and of the more active measures, simple aspiration is the first which should be tried. A Potain's aspirator is used for the removal of the fluid, and the most scrupulous asepsis must be observed. When inserting the aspirating needle it is unwise to enter it directly into the most superficial part of the abscess ; the puncture is apt to be followed by a tuberculous sinus. The needle should ]>c inserted through healthy tissues, being entered at some distance from the abscess. When the fiuid is being withdrawn, trouble may arise by blocking up of the cannula by caseous debris. To obviate this, a needle with a large bore sliouid be used, the needle Iteing provided with a stiletta in case it should be necessary to clear the lumen. The fluid is withdrawn under a negative pressure, and the ca\'ity emptied as completely iis possiljlc. 'I'he needle puncture is scaled with collodion, and it is wise to diminish the potential cavity of the abscess by applying firm ' Tubby, Deformities, including Diseases oj llie Bones and Joints, vol. ii. p. 171. 78 TUBERCULOSIS OF THE BONES AND JOINTS pressure with a pad and bandage. A single aspiration is almost certainly followed by a reaccumulation of fluid. Several successive aspirations may bring about a cure. The benefit which follows aspiration is the result of a diminished or negative pressure within the abscess cavity. The surrounding blood and lymph vessels become distended, and a quantity of serous fluid is poured out. In the fluid which collects there are a number of bodies antagonistic to the bacillus and its products : precipitins, lysins, and opsonins. It is from the action of these that a benefit accrues. The collapse of the abscess wall brings the parts in contact with the altered fluid. (3) Aspiration with the Injection of Medicaments. — The idea underlying this treatment is that after removal of the pus, if a medicated fluid is intro- FiG. 5. — The technique of abscess aspiration. The two npper drawings illustrate the danger of sinus formation following tlie direct introduction of the needle. The lower drawings illustrate the beneficial valve-like arrangement of the tissues when the puncture is an oblique one. duced into the cavity, the fluid will act upon the surrounding disease and produce a cure. The technique isvery similar to that employed in aspiration. After removal of the pus the cannula is disconnected from the aspirating bottle. At the side of the cannula there is an opening into which a large syringe fits ; by this lateral opening the medicated fluid is injected along the cannula into the cavity. A great variety of materials have been used for injection. A 10 per cent solution of iodoform in glycerin is one in most common use. Its advantages are the simplicity of its composition and manufacture, its slow absorption, and therefore slight toxicity, and, finally, the property which it possesses of uniform dissemination over the cavity. Kirmisson ^ recommends a solution of iodoform in ether. According to the age of the patient and the size of the cavity, four standard amounts of solution may be injected : 5, 10, 15, or 20 grammes of the solution, representing respectively 50 centigrammes, 1 gramme, 1 gramme 50 centigrammes, and 2 ' Kirmisson, Surgery of Children (trans, by Keogh Murphy), p. 384. TREATMENT OF BONE TUBERCULOSIS 79 grammes of iodoform. After the abscess is thoroughly evacuated the cavity is washed out with sterile boracic lotion, and the ether and iodoform injected. Soon after injection the ether passes into a state of vapour and distends the abscess. It is therefore ad\'isable to keep the trocar, with closed stop- cock, in position until this occurs, and then to open the stop-cock. The ether vapour thus escapes, and the iodoform is disposed upon the walls of the cavity. Menard ^ recommends the use of a thymol-camphor injection, prepared in a strength of thymol 1 part and camphor 2 parts. The amount injected varies from 5 to 40 grammes. He had previousl}' used a preparation of naphthol and camphor, but after two cases of acute poisoning he gave up this method. It would appear that the thymol-camphor solution has a solvent effect on the caseous material within the abscess, and thus subsequent evacuation is rendered more complete. It induces an irritation of the abscess wall and later a curative fibrosis. Menard recommends that the process should be repeated in from eight to twenty days. Calot ^ makes use of two solutions, and the indications for each differ. The first is an oily solution of creasote and iodoform (olive oil, 70 grammes ; ether, 30 grammes ; creasote, 5 grammes ; guaiacol, 1 gramme ; iodoform, 10 grammes). The second is a solution of naphthol and camphor in glycerin (naphthol-camphor, 2 grammes ; glycerin, 12 grammes). The first solution is the one most generally used ; the second is employed when the abscess cavity contains a quantity of thick caseous matter. Calot considers that there is a further important indication for the use of the naphthol-camphor solution, namely, abscesses which are not yet localised, but which are really masses of tuberculous granulation tissue, with some caseation in the centre. In such cases the solution increases, so to speak, the matiu'ity of the abscess by liquefying the gratuilation tissue of the abscess wall. Successive aspira- tions, therefore, yield increasing quantities of fluid. Other materials have from time to time been used. Good results have been obtained by a 10 per cent solution of zinc chloride, also with a solution consisting of — Tincture of iodine ... 1 part. Iodide of potash ... 1 part. Water to . . . .100 parts. Calve and Gauvain ' have published excellent results from the use of a solution containing - loiloforiii .... 5 grammes. Kthcr 10 „ Guaiacol .... 2 „ Creasote .... 2 „ Sterile olive oil . . . 100 ec. The Explanation of the Improvement which follows the Injection of Medica- menls. — It is supposed that tlic injection of a modiciited fluid ])ro(hice.s an ' Mi'dard, fjludc pnitiqur, ,^tir Ic mill df l*otl, Paris, I!(00, p. 'M)\ rt .svvy. - Calot, Orthnpi'die indi-tj)e»»tihlr^ p. 17(> I't .s/v/. ' Calvi' aiul (iauvain, I.ancrl, Marcli 5, 1!)I(J. 80 TUBERCULOSIS OF THE BONES AND JOINTS inflammatory reaction, with the exudation of blood cells and lymph. There is an active diapedesis of the white cells, and a fibrinous exudate forms around the cavity. By a proliferation of the fixed connective tissue cells a barrier of limiting fibrous tissue is deposited. Thymol has a specific action in actually liquefying caseous material. Coyon and Fiessinger ^ offer a clinical explanation. In the pus of an ordinary abscess they have shown that there exists a proteolytic ferment, analogous to the tryptic ferment of the pancreas, which has the power to digest coagulated albumens, and to transform them into peptones and amido acids. This ferment is liberated by the destruction of polymorph leucocytes. It does not exist in a simple tuberculous abscess, because there are no polymorphs. The injection of a medicated fluid induces the accumu- lation of leucocytes and the production of the ferment. (4) Simple Incision without Drainage. — By this is meant the opening of the abscess, the evacuation of its contents, and the closing of the wound to secure primary union. It is a method which is indicated in deeply situated abscesses, and it is absolutely contra-indicated in cases in which the skin has become stretched and undermined from the accumulation of subcutaneous pus. Primary healing is essential to the success of the method. After opening the abscess, opinion varies as to the treatment which ought to be meted out to the abscess wall. In Barker's method the abscess wall is thoroughly scraped with a flushing curette, the debris being washed away by a stream of hot boracic lotion or saline. There are some who condemn such drastic means, on the grounds that the curette destroys a beneficial wall of connective tissue which forms outside the abscess and limits it. They believe and practise that it is sufficient to scrape the interior of the cavity lightly with a pledget of gauze, afterwards washing away the debris with hot lotion. Before the wound is closed, an antiseptic application should be made to the wall. An excellent 2)reparation is that used by Stiles. It is a paste made up with 2 parts of subnitrate of bismuth and 1 part of iodoform, stored in a solution of 1 in 1000 corrosive sublimate. The bismuth is included to lessen the absorption and toxicity of the iodoform. Phelps has advocated that the interior of the abscess should be touched with pure carbolic acid, and the cavity washed out with absolute alcohol. A good application is the tinctura iodinei (Ph., Edinburgh). Its strength is 1 part of iodine in 16 parts of 90 per cent alcohol, and it dift'ers from the ordinary tincture in being without potassium iodide. The wound is carefully closed. If possible deeper structures, muscles and fasciae, are brought together over the cavity. The skin edges are united preferably with " MichaeFs " clips ; they secure a broad, healing surface, and there is no penetration of the skin by a suture, which often acts as a seton. A careful and copious dressing must be applied, and it is important to exert considerable jiressure over the abscess cavity by means of a specially arranged pad and bandage. ^ Coyon, Fiessinger, and Laurens, Journ. des prat.. No. 40, Oct. 20, 1909. TREATMENT OF BONE TUBERCULOSIS 81 This is an operation in which one's technique cannot be too careful. If there is any doubt about asepsis it is wiser to adopt antiseptic methods throughout. After operation the abscess cavit}- practically becomes a hsematoma, and one knows the persistency of an infected haematoma. But even more important is the complication of a mixed infection in a hitherto pure tuberculous lesion. The primary disease spreads rapidly, cachexia and waxy changes develop, and the ultimate result is too frequently fatal. For these reasons the operation entails a very considerable responsibility. Occasionally a complete removal of the abscess cavity by dissection has been recommended, the operator cutting through healthy tissues. The conditions under which such an operation would become possible are excessively rare. Too often size, position, and migration render the thing an impossibility. (•5) Simple Incision with Drainage. — Primary drainage should never be attempted in a tuberculous abscess. A drained wound is infinitely more- liable to infection than one which is completely closed, and a drainage tube is often the originator of an infected sinus. In a pure tuberculous abscess; drainage is never necessary ; it may become so, however, when a mixed infection makes its appearance. Treatment of Sinuses This troublesome complication is usually the result of the secondary infection of a tuberculous abscess. It is possible, however, for a sinus to exist which is purely and entirely a tuberculous one. The track, leading from the abscess to the surface of skin or mucous membrane, is frequently of great length, not because the abscess lies specially deep, but because the sinus is usually branching and tortiious. The wall of the sinus is lined by numerous tuberculous follicles, many of them caseating. Around the tuberculous granulation tissue there is a deposit of fibrous tissue, which keeps the circumference of the sinus within limits. In itself a sinus gives rise to no symptoms beyond its discharge, but indirectly it is responsible for a continuation of the secondary infection, the development of temperature and cachexia, and eventually for amyloid degeneration and death. No pains therefore should be spared to prevent the formation and to cure the condition when it does occur. The prevention of sinuses has already been dealt with. It consists in the treatment of cold abscesses by aspiration or incision without drainage, and the most scrupulous care to prevent secondary infection. When a sinus has been established its cure may be excessively difficult. It is rarely possible to (excise it on account of the extent and tortuosit}' of its course, and tlu! dilliculty in securing piiniary union of the wound. One therefore has to fall back upon more conservative measures. These resolve themselves into two groups : the injection of the sinus with niedicanionts. and I?ier's hypera;nuc niellu)d. 6 82 TUBERCULOSIS OF THE BONES AND JOINTS Injection of Medicamenls. — Dr. Beck ^ of Chicago found that after inject- ing sinuses with bismuth paste for the purpose of radiography, many of them healed. He acted upon the hint, and was successful in obtaining some cures. At first Beck used a preparation containing : Bismuth subnitiate . . .6 parts. White wax . . . . .1 part. Soft paraffin . ... 1 part. This mixture he later discarded because he found it difticult to maintain a temperature suitable for its injection. He substituted instead a mixture of Bismuth subnitrate . . .1 part. Vasehne . . . . .2 joarts. The ingredients are thoroughly mixed, and the mixture is heated in a water bath. The injection is made at a temperature of about 40° C. A glass syringe with a conical vulcanite nozzle is used. The syringe is sterilised by boihng, and afterwards washed out with absolute alcohol to prevent any water gaining access to the mixture. The skin around the sinus is sterilised with alcohol or 2 per cent iodine in spirit, no water being used. The injection is made slowly, and the amount varies according to the length of the sinus and the age of the child ; an average amount is rather less than 10 cc. As soon as the injection is made the syringe is withdrawn from the orifice of the sinus, and the opening closed by quickly applying a tampon of sterilised gauze ; this is fastened in place by a rubber bandage or a piece of sticking-plaster. The injection is repeated, only if a quantity of the original injection escapes and the amount injected is approximately equal to that evacuated. Ridlon and Blanchard ^ jjublished in ] 908 the result of an extensive trial of bismuth paste injections. They employed the bismuth vaseline mixture for diagnostic purposes, and the bismuth, white wax, and paraffin mixture for treatment. When the first mentioned fornmla was used for diagnosis it was evacuated within twenty-four hours, and the second men- tioned was then injected until the sinus was full. The details of injection were similar to those already mentioned. It is doubtful to what exactly the beneficial effect of the injection is due. By some it is supposed that the bismuth has a stimulating effect upon the formation of healthy granulation tissue, by others the improvement is said to be entirel}^ due to the mechanical effect of the injection. There are certain conditions which contra-indicate the use of bismuth injection. They are summarised thus by Ridlon and Blanchard : * (1) The presence of a sequestrum ; (2) Coincident wax\' changes in the internal organs ; (3) When there are large distal pus sacs which become filled after repeated injections with residuary bismuth ; (4) In sinuses of tuberculous bone disease which have existed for less than two or three months ; (5) In ' E. G. Beck, " The Surgical Treatment of Tuberculous Sinuses and their Prevention," Transaction of the Sixth Iniernat. Congress on Tuberculosis, 1908. ^ Ridlon and Blanchard, Amer. Journ. Orth. Surg., Aug. 1908, vol. vi. No. 1. p. 13. 3 Ibid., 1909, vol. vii. No. 1, p. 34 et seq. TREATMENT OF BONE TUBERCULOSIS 83 old tuberculous sinuses with extensive skin destruction and large areas of skin undermined. The most urgent danger is the occurrence of bismuth poisoning. It takes the shape of ulcerative stomatitis, black lines at the gum-edge of the teeth, diarrhcea, cyanosis, desquamative nephritis, and loss of weight. If the injections are producing benefit the secretion from the sinuses changes its character, it becomes seropurulent and serous, and organisms diminish in number and ultimately disappear. In a paper entitled " Some Experimental Work on Materials for Plugging Sinuses and Bone Cavities," ^ Prescott le Breton has derived benefit from certain preparations. The first is composed of : Cacao butter . . .7 parts. White wax . . .1 part. Iodine flakes. It is a useful preparation, but in children it may produce very considerable irritation. The second preparation which he recommends is : Borax ... 2 parts. Wax ... 1 part. Lanolin . . .24 parts. This, while not so rapidly efficacious as the first mentioned, is much less productive of irritation. Calot '" uses solutions very similar to those which he employs in the treatment of cold abscesses, iodoform, creasote oO, and naphthol-camphor glycerin. The composition of the fir.st is as follows : Phenol camplior ) _ Naphthol camphor I ' ' ' Ciiiaiacol ..... Iodoform ..... Lanohnc or Spermaceti The second is a weaker mixture : Phenol camphor | _ Naphthol cam]ihor / ' ' Guaiacol ..... Iodoform ..... LanoUn or S()erinaceti The first preparation is twice as active as the second, and it is used in the smaller tracts. Conversely the second composition is employed in the larger and more tortuous sinuses. Hypcrcvmic Tmilmenl of Sinuses. — The details of this treatment are best quoted from Bier's * original monograph upon the subject : Recently we have made a great step forward in the treatment of tubcrcu- Icsis witli sinuses . . . by the resumption by Klapp in the Bonn polyclinic of ' Amer. Journ. Orlh. Surg., May 1010. vol. vii. No. 4, p. 404. - Cali'it, Orlliopedie iiiiii/ipnitinblr, .'iih cd., lltll, p. 170. ' Bior, Text-book of Ibjperccmia, Trannlatioii ISIOI, p. 2(13. 6 grammes. 15 >> 20 00 " 3 grammes. 8 »» 10 „ 84 TUBERCULOSIS OF THE BONES AND JOINTS my treatment for tubercular afEections with cupping glasses, which I practised about ten years ago. . . . The cupping glass is at first appUed three-quarters of an hour daily to all forms of open and fistulous tuberculosis, which have not been treated heretofore. The rule laid down for acute inflammation, that the cupping glasses should be removed for three minutes after it has been applied for five minutes, holds good here also. The patients are given daily treatment until the indolent, pale, tuberculous granulations become red and hard, and until the immediate vicinity of the sinus becomes hard. It is then time to increase the intervals between the treatments, at first every second, later every third, and finally every eighth day. ... In the vicinity of tuberculosis with sinuses which have been treated with the cupping glass, one often sees ulcers, which must be regarded as inoculated tuberculosis. To avoid this, Klapp suggests the following method. After removal of the dressing, and previous to suction, the vicinity is cleansed with benzine, and a large surrounding area is covered with fat (lanoline, vaseline, aa). After suction the first fat is removed with benzine and fresh applied. Wright's Treatment. — In treating tuberculous sinuses Wright endeavours to bring the body lymph, into contact with the diseased tissues of the sinus. This fluid contains active bacteriotropic powers, and if it is allowed to bathe the tissues excellent results may follow. A free circulation of lymph 'is largely prevented by fibrinous deposits in the tissues around. Wright introduces into the sinus a solution of -5 per cent sodium citrate and 5 per cent sodium chloride. A double purpose is fulfilled, the sodium citrate prevents coagulation within and around the sinus, while the sodium chloride induces osmosis and a free fiow of lymph. The method of treatment is founded upon an excellent theoretical basis, and in practice it is well worth a trial. Special Forms of Treatment Trypsin Treatment of Bone Ttiberciilosis. — This treatment is based upon the idea that the injection of a proteolytic ferment will induce the resolution of a tuberculous lesion. The method consists in the injection subcutaneously of a sterile 60 per cent solution of trypsin in glycerin. The dose varies from 1 to 2 cc, diluted with one to ten parts of physiological salt solution, and injections are made at intervals of two to seven days. The solution is injected preferably in the region of the tuberculous focus. The injection is followed by smarting pain, occasionally a rise in temperature, and local signs of inflammatory reaction. The symptoms disappear in from twenty-four to forty-eight hours ; the swelling continues for about five days. It is said that under the influence of the ferment injection a vigorous reaction takes place in the tuberculous focus, and ensuing hypera'mia, cellular infiltration, and proliferation lead to a transformation of the sub- stance and structure of the pathological tissue, and to necrosis of the fungoid masses, without impairing in any way the vitality of the healthy parts. Biitzner ^ quotes four cases of advanced tuberculosis of the ankle joint which yielded admirably to the treatment. Several of these were compli- 1 Batzner, Practitioner, 1913, xc. p. 213. TREATMENT OF BONE TUBERCULOSIS 85 cated by superficial ulceration and sinuses, leading down to bare bone. The cases were cured respectively in 1 year 9 months ; 1 year 2 months ; 2 years ; and 1 year 8 months. He notes that among the general effects of treatment there is improvement in general physical and mental condition, and unusual improvement in appetite. He advises the treatment in all surgical tuberculosis, especially those cases complicated by sinuses and abscesses. Treatment of Bone Tubercle with Mesbe. — Hermann and Spangenberg introduced this substance into the field of therapeutic medicine. Bietzen- gieger ^ has recounted his experiences with it in the treatment of bone tuber- culosis. Seven cases of fistulous bone disease were treated. The mesbe was applied pure, or as a 50 per cent ointment. Two of the cases healed after ten weeks" treatment, and apparently the cure was a permanent one. In one case a local reaction resulted from the application, and there was a slight rise of temperature. In most of the cases there was an increased discharge from the fistula. The remedy is thought to possess a specific action upon tuberculous processes on account of its containing anti-tuberculous bodies. Treatment of Bone Tubercle ivith Allyl Sulphide. — Doctor Minchin - of Dublin published in the British Medical Journal of August 24, 1912, the results which he had had from the use of an ointment containing the active principle of garlic — ailyl sulphide. Its use has been tried with benefit in cases of superficial bone tubercle, such as tuberculous dactylitis of the hand and foot. There is remarkable improvement when it is employed in cases in which the bone lesion is associated with tuberculous ulceration of the overlying skin. The ointment is applied directly to the affected part, and the dressing is changed twice dail}'. 4. Tuberculin Treatment Tuberculin is a product of the tubercle baciUus, containing cither the soluble products of the bacillus, tlie insoluble fragments of the bacillus, or a combination of both. The first may be spoken of as an extract, the second and third come under the heading of vaccines. Tuberculin is used in diagnosis, and its application in this relation has already been examined. It is also used in treatment, and it is this (piestion whicli will now be discussed. Varieties of Tuberculins. — These may be divided into two groups : extract tuberculins and vaccine tuberculins. Exiracls. Koch's old tiilK'reuliii (Syn. T.A.). Bcrancck'.-! tulxTculiri (Syn. T.Hk.). Donys' tulji^rculiii (Sp. B.F.). Bovine liihcn'ulin (Syn. P.T.O.). ' ^fanch. med. Wocheii-irlir., l!)i:i, Ix. 12«. = \\'. C. Minchin, Treatment oj T utjerculosU and Lupu^ witli Allyl Sulphide, BdiUiiTP. Tindiill & Co. 86 TUBERCULOSIS OF THE BONES AND JOINTS Vaccines. Koch's new tuberculin (Syn. T.R.). Tubercle bacilli emulsion (B.E.). Tulase (Von Behring). Bovine tuberculin (P.T.R.). Vacuum tuberculin. Mode of Preparation. (1) Extract Tuberculin. — The human tubercle bacilkis is grown upon a medium of nutrient broth, containing 5 per cent glycerin. Into this medium a certain amount of toxic products from the bacilli find their way. When a fair amount of growth has been obtained, broth medium and organ- ism are sterilised by steam for thirty minutes, evaporated to one-tenth of their volume by a temperatm-e which never exceeds 70° C, and finally filtered. 0-5 per cent of phenol is added to the resulting fluid, and the preparation allowed to stand for some weeks, when it is again filtered. It is now a dark- brown fluid, syrup like in consLstence, and perfectly miscible with water. It contains a large proportion of glycerin (about 50 per cent), 10 per cent of albumoses, the toxic products of the tubercle bacilli, and substances obtained from the bacilli in the processes of sterilising and filtering. (2) Vaccine Tuberculin. — This is prepared in two different ways, as illustrated by Koch's new tuberculin on the one hand, and Koch's bacillary enuilsion on the other. Koch's new tuberculin is prepared by grinding up dried cultures of virulent bacilli in an agate mortar. When the organisms have been disintegrated, distilled water is added, and the mixture centri- fuged. There results a clear supernatant fluid and a white deposit. The fluid is decanted ofl', and the deposit, which is really composed of the in- soluble portions of the bacilli, is retained. With the deposit the process of dilution and grinding is repeated, until an opalescent fluid is obtained. To that fluid 20 per cent glycerin is added to prevent decomposition. Koch's bacillary emulsion has a more simple method of preparation. Dried powdered cultures are mixed with a solution of equal parts of glycerin and water, in such a proportion that half a gramme of powdered bacilli is suspended in 100 cc. of the glycerin solution. By prolonged shaking a fine emulsion is produced. These three methods may be taken as the standards upon which the manufacture of aU tuberculins is based. The Result of Inoculation into the Body. — In the healthy individual there is absolutely no result from the introduction of even an enormous amount of tubercuhn (1000 cmm.). In the person already infected by tuberculosis, the inoculation of a minute dose produces a very considerable disturbance. This disturbance is spoken of as the tuberculin reaction. The tuberculin reaction embraces three different changes : (1) A local reaction, some degree of swelling and redness at the point of intro- duction of the tuberculin. (2) A focal reaction, due to changes occurring in the neighbourhood of the tuberculous foci, increased circulation of blood, and serous exudation. (3) A general reaction, due to the circulation of toxic TEEATMENT OF BONE TUBERCULOSIS 87 products derived from the introduced tuberculin, and characterised by fever, malaise, body pains, and headache. The most satisfactory scientific explanation of these changes is supplied by Wolff-Eisner's theory. He supposes that there is circulating in the tissues of the tuberculous a specific anti-body. On the introduction of tuberculin this anti-body attacks the tuberculin molecule, and liberates from it certain toxic products. The circulating toxins produce the local reaction, and, if sufficient in quantity, a general reaction, and finally the focaJ reaction. This peculiar property of the tuberculous tissue to act upon tuberculin is spoken of as " tubercular sensitiveness." In addition to " sensitiveness " there exists another factor, which must be understood before one can pass to speak of the cUnical bearings, and that is the question of " tolerance." When a small amount of tuberculin is injected into a tuberculous subject, the " tuberculin reaction " appears. If a few weeks later a second amount is injected the process is faithfully repeated, but if the second injection is made very soon after the first (three or four days) its efficiency in producing a reaction may be almost com- pletely annulled. This phenomenon depends upon a degree of " tolerance " induced by the first injection. No proper explanation has been given of the occurrence of tolerance, but it may depend upon the formation of an anti- body, which either partly or wholly counteracts the degree of sensitiveness present. Methods of Administration of Tuberculin.— At the present time two methods of administration are practised: (1) The clinical method; (2) The scientific method. (1) The Clinical Method. — The aim of this method is to attain a well- marked focal reaction without inducing any general disturbance, and at the same time to produce a tolerance to tuberculous poisons. " The local hyperajmia supplies to the local lesions an abundance of whatever anti- bodies the patient's blood may possess. The increased tolerance raises the well-being of the patient by removing to some extent the symptoms which interfere with his progress " (Riviere '). The amount injected varies with dilTerent preparations, but the ideal is to use the higliest possible dose without inducing a reaction, and to inject gradually increasing amounts at short intervals in order to produce a rising tolerance. The dosage varies with the preparation used. AVith old tubercu- lin, in infants the initial dose is usually , ,',„ milligramme ; in older childi-en, ^',, or .y\, milligramme ; witli new tuberculin, children under one year old may hv. begun with .,-,,',,,,, milligramme, older children with i„,\„o or ^,,,'„„ milligramme. The bacillary enuilsion is given to infants in a dose of I ,,,',(,0 milligramme, older children getting o r,\,o ^r ^oofi milligramme. Injections ought to be given twice weekly in steadily increasing doses, the amount of increase being gauged by the degree of reaction induced. (2) " The Scieydific Method."— '\'\\\s method was originally introduced by Wright, and it is the one most commonly practised in this country. Wright ' Kiviric, 'riilicriiilii.iin in tiifdiiri/ iiiiil CliUdhiind (Kolytiach), p. 2i)0. 88 TUBERCULOSIS OF THE BONES AND JOINTS pointed out that the tubercle baciUus is one of a class of organisms which is resisted by the body through the medium of opsonins. These opsonins so alter the tubercle bacillus that it becomes readily destroyed by phagocytes. The degree of phagocytosis which occurs is expressed as " the opsonic index," and among healthy people the quantity of opsonin remains relatively con- stant between 0-8 and 1-2. If the opsonic index in a tuberculous subject falls below 0-8, there is very probably a localised lesion, and the index is lowest at the tuberculous focus. If the index fluctuates widely, now high and now low, it points to a more extensive disease, lying in more open relation to the blood stream. " The object of the scientific method of tuberculin administration is to keep the opsonic power of the patient for the longest possible time at the highest possible figure " (Riviere). ^ To fulfil this object tuberculin is administered in minute doses, with a sufficient interval between the injections, and avoiding any increase of dosage. In regard to dosage, Rivike recommends ^xjo^y to ^ o o oo milligramme for children less than one year old. At five years ^(j-^to o milligramme. For children of twelve years and upwards, xstioo milligramme. The interval between doses ought to be judged very largely upon the opsonic index, but on an average an interval of two weeks is usually most suitable. Choice of Method. — Now the question arises which of these two methods is the one to adopt ? Bone and joint tubercle comes under the class of localised lesions. There is no great degree of auto-inoculation, and in the neighbourhood of the focus the opsonic index is low. These indica- tions are sufficient to justify one in adopting the scientific method of admini- stration. Are there any circumstances under which one would adopt the clinical method ? If the tuberculous lesion is extensive, and from its relationship to the blood stream a considerable degree of auto-inoculation is occurring, one employs the clinical method, because by it the steady increase of dosage produces a tolerance sufficient to counteract in part at least the tuberculous auto-inoculation. Choice of Tuberculin. — In regard to the type of tuberculin which should be used, success may be attained with any variety if its characteristics and dosage are thoroughly understood. Riviere and Morland ^ recommend that one of the vaccine tuberculins (endoplasm) be used. Its rate of absorption is slower, and therefore a mild and prolonged focal reaction is produced, with the minimal amount of general disturbance. Human and Bovine Tuberculins. — A certain proportion of bone and joint tuberculosis undoubtedly owes its origin to infection with the bovine bacillus. This fact, in application to surgical tuberculosis generally, has inaugurated the idea that these lesions should be treated with a specific tuberculin, human or bovine. If the. plan is to be adopted, there must necessarily be either an examination and separation of the organism in each individual case, or an acceptance of the belief that surgical tuberculosis is due 1 Riviere, op. cil. p. 294. 2 Riviere and Morland, Tuberculin Treatment, 1912, p. 197. TREATMENT OF BONE TUBERCULOSIS 89 to the bovine bacillus, while pulmonary tuberculosis is human in its origin (Nathan Raw).i Workers who believe in the specific use of human and bovine tubercle are divided into two schools : (1) There are those who believe in the use of autonomous vaccines, and treat a lesion due to a bovine bacillus with a bovine tuberculin, and vice versa. (2) There are those, such as Spengler - and Nathan Raw, who use a human tuberculin for conditions due to the bovine bacillus, and vice versa. Good results have been obtained by representatives of both schools, and the probability is that human and bovine bacilli are so closely related that the respective tuberculins produce very similar results. There is one point which clinically has been shown to be of advantage, and it is this : If a continuous course of one type of tuberculin (human or bovine) does not produce improvement, benefit often results from suddenly altering the course and using the other variety. Mixed Infections. — Before tuberculin treatment is adopted, a large proportion of bone and joint disease undergoes a mixed infection, usually through the medium of cold abscesses and sinuses. The most common organisms to produce this secondary infection are certainl}^ the staphylo- cocci and streptococci (Petroff ^). When the clinical method of tubercu- lin administration is used, mixed infection is looked upon as a distinct contra-indication, but it is no precluder of the scientific method. If a mixed infection exists, it is essential that the secondary organism should be recog- nised and isolated, and a vaccine prepared from it. In the treatment the secondary vaccine may be added to the tuberculin, and the com- bined injection used throughout. It is more satisfactory at first to treat the lesions with a pure tuberculin. Improvement will proceed to a certain point, and the condition will then come to a standstill. This is the most appropriate time at which to introduce the secondary vaccine, and its introduction often succeeds in curing the disease. Autogfenous Tuberculins.— Some authors have attached considerable importance to the use of an autogenous vaccine, i.e. a tuberculin prepared from the actual bacillus which is causing the disease. Krause * has carried out a number of investigations upon the method, and he is satisfied that the results obtained compare favourably with those obtained by the stock preparations. The method entails an enormous amount of labour, and it is doubtful whether the results are sufficiently good to justify its use. Another method of autogenous treatment is that in which a tuberculin is prepared from the actual diseased tissue (Eraser and MacGowan ^). A portion of the tissue is ground up in a mortar and made into an emulsion with saline. The supernatant fhiid is jiijietted away, and stcrili.^ed and standardised like a vaccine. The standardisation is carried out by the weight of the original tissue used in the preparation. ' Nathan Haw, Tuhcrcutose (lierlin). ^ Spenf^Ior. Tuhftrk-ulinfirhftntlhimj in Ilnchfjfibirge (Davos, 1004). ' IVtnilT, .■Innalcs (It I'liiM. 1'ii.iliur, 1904, vol. xviii. p. 502. * Krauso, Zeitsriir. fiir 'I'lihertulo.w, lilOi). .xiv. s. 73. ' Fraaer and Alacgowan, Lancet, .luiio 1912. 90 TUBERCULOSIS OF THE BONES AND JOINTS The treatment is begun by an injection of 10 cms., and repeated at intervals of ten days. Succeeding amounts are increased upon each occasion by 5 cmm., unless there is a severe reaction, in which case the amount injected is somewhat diminished. Results of Treatment. — There has now been sufficient time and opportunity to judge of the results which follow tuberculin treatment in bone and joint tuberculosis. Opinions upon the subject can be gathered by quotations from a series of articles published during the past six years. They will be considered in sequence of date. In 1906 Gray ^ published a paper upon the vaccine treatment of surgical tuberculosis. Speaking in relation to tuberculous bones and joints, he says : Here again the prospect is a hopeful one, but ultimate complete success in restoring full healthy function will be obtained, only by making a correct diag- no.sis in early stages, and adding T.R. injections to those well proved and approved lines of treatment usually carried out. ... A very different feature fi'oni the point of view of rapid results is presented usually by cases when abscess formation with subsequent development of sinuses and compound infection has occurred. In none have I obtained satisfactory results with T.R. alone, unless after operation, and in the majority, although great improvement has occurred, yet it has been slow and subject to occasional retrogression. In 1908 Nathan Raw ^ recorded his experiences of the treatment. Twenty-seven cases of tuberculous joints, mostly of a chronic or subacute variety, have been treated, 15 disease of the knee, 8 of the hip, 4 of other joints. The cases where the best results were obtained were those in which there was some suppuration or sinus directly leading down to tuberculous disease. ... In the great majority of cases the suppuration first ceased, and then the sinus closed. ... In cases of pulpy disease of the joints there was in many instances marked diminution in the size of the joints, with absence of inflammation and more movement. ... I have not yet seen any case where fixed and aukylosed joints have been benefited. The next in the series are the results of Maynard Smith,* published in 1909. Information was gathered from 34 cases. In 16 cases treatment by splinting, rest, and operation was first tried, and because there was no improvement tuberculin treatment was introduced. In 10 out of tlie 16 cases complete cure resulted, with absolute restoration of jomt function. Three cases were treated with tuberculin from the beginning, two were completely cured. Of the remaining 15 cases, 6 were cured, 5 improved, while 2 showed no improvement. Painter * published in 1910 a long paper upon " Vaccine Therapy in the Management of Arthritis." His conclusion is as follows : As regards tuberculous joint infection, there does not seem as yet to be any ^ H. M. Gray, " Vaccine Treatment in Surgery," Lancet, April 21, 1906. ^ Nathan Raw, " Tuberculosis treated by different Kinds of Tuberculin," Lancet, Feb. 13, 1908, p. 482. » Smith, " The Inoc. Treatment o£ T.B. Arthritis," B.M.J., Oct. 9, 1909, p. 1040. ■• Painter, Trans. Amer. Cong. PJiys. arid Sura., 1910, vol. viii. p. 344, et seq. TREATMENT OF BONE TUBERCULOSIS 91 ■well-established ground for a belief that vaccination after infection could play a curative role. Practically there is very little evidence that it ever does. Finally, one records the most recent opinion ; it is that of Forster.^ He reports the tuberculin treatment in 21 cases of tuberculous bones and joints in children. Of the 21 cases recorded, 3 were not benefited, while marked improvement was shown in all the others. The routine treatment of surgical tuberculosis — rest, fresh air, and food — was used Ln all the cases. Conclusions. — In judging of the ultimate value of the treatment, it is difficult to appreciate the exact amount of benefit which is due to the tuberculin. Much of the improvement which one sees is the result of the rest and the other conservative measures adopted, and of course one never has an opportunity of judging a case treated purely by injection. In early cases it may be unnecessary to employ tuberculin, but on the other hand it may advantageously be combined with the usual conservative measures. In later cases, when suppuration and sinus formation have occurred, tuber- culin has perhaps its widest sphere of usefulness, especially when there is combined with it a vaccine of the organism or organisms producing the secondary infection. Marmopek's Serum. — Marmorek's - serum is prepared by injecting horses for seven or eight months with filtered young cultures of tubercle bacilli, grown on a fluid medium consisting of calf serum and glycerinated liver bouillon. The calf serimi is rendered leucotoxic by previously treating the calf with injections of guinea-pig's blood. The effect of the leucotoxic property is that bacilli growTi in the blood set free tuberculo-toxin. By injecting the filtered cultures into horses, it is claimed that a special anti- toxin is obtained, which is able to confer immunity of a passive character on animals. The serum is given by subcutaneous injection, or by the rectum after a cleansing enema. Hoft'a * has used the .scrum in a number of cases of bone and joint tuber- culosis. He concludes that it exerts a specific reaction, and he believes that it is likely to become a valuable means of combating surgical tuberculosis. Van lluellen ' n'])()rts Sonnenburgs ox])erionces with 37 cases. The results on the whole were good. Joint disease showed the least im- provement. Results have been published by Schenker,'' Hohmeier," and Glaessner," and the general conclusion arrived at is that the use of the serum produces distinct iinprovi'nicnt in the tuberculous lesion. Spengler's I.K. Serum.- This is a preparation of tuberculosis-immune liloiKJ made by extracting the red blood cells of immunised sheep and rabbits. ' C. Forater, " Tuberculin Treatment of Surgieal Tuberculosis in Children," Beilr. zu Klin, der Tubcrkulose, Wiir/.biirn, 1913. ^ Marniorok, Von Siitlim- Ilifijeia, 1900. » llomi., IJerlin. klin. \i<,rheu«chr.. 190(i. No. 44. ' \iin lluclion, Cenlmlhl. far fhlr., 1907. No. 3. ' SilionUcr, Milnili. iiirtl. Wocliensrhr., 1907, No. 3. " Holimcicr, Miimli. iiiiil. \Viielieii«rhr., April 14, 190S. ' Glaessner, Uculschc tiud. W'oclieiiDchr., 1909, No. 17, p. 763. 92 TUBERCULOSIS OF THE BONES AND JOINTS It is described as cLemically pure, free from albumen and hsemoglobin, and containing one million lytic and antitoxic units in each cubic centimetre. Dilutions are prepared, varying in strength from 1 in 10 to 1 in 10,000,000, of the original I.K., and in all there are seven of these dilutions. In children a suitable initial dose is 0-1 cc. of the fifth dilution i.e. 1 in 100,000. The injections are repeated at intervals of a week, the amount of each injection being increased by 0-1 cc. Experiences of the treatment have been pub- lished by Porter and Quinn,^ and by H. 0. Eversole.^ The results obtained have been satisfactory. Mehnarto's Serum. — Dr. Mehnarto of Heidelberg has introduced a serum to which he has given the name of contra-toxine. The idea underlying contra-toxine is to use the serum of a warm-blooded animal naturally immune to tuberculosis, and to sensitise or correct the serum by the addition of other sera, which will prevent the hsemolytic and anaphylactic tendencies of the original serum without impairing its bactericidal qualities. With regard to dosage a child is given, 2 cc. At the end of a week a second injection of 4 cc. is given, and the injections are repeated twice a week, until the physical condition shows a complete cessation of activity. The treatment is still sub judice. So far the results obtained have been promising. 5. Operative Treatment of Bone Tuberculosis At this stage only the leading points can be dealt with, full details are given in the sections on indi\'idual bones and joints. The question under consideration entaUs two problems : What are the indications for operative treatment ? and, when operative measures have been decided upon, In what do they consist ? Indications for Operative Treatment. — Every one is agreed that a full and complete trial ought to be given to conservative means before there is any question of operation. The majority are convinced, on the other hand, that it is unwise to delay operative measures until there is much bone destruction, secondary infection, and sinus formation. There exists, therefore, between what one may term certainties, a wide area of dubiety. It is here that the difficulty arises, and it is well that one should consider the points which help one in deciding the line of treatment to adopt. Age. — It is important to keep in view the fact that one is dealing entirely with children, and one's remarks are necessarily influenced by this fact. As a class, children offer considerable resistance to the development of tubercle, and in application to bone tuberculosis this is especially true. When one comes to examine the age-period more individually, one finds that this resistance is at its lowest during the first year of life, thereafter it increases steadily dming the age-period of childhood. The practical bearing ' J. L. Porter and L. C. Quiiin, Chicago Med. Re,c., 1912, xxxiv. 84-91: 2 H. 0. Eversolc, Amer. Journ. Orih. i^urtj., 1912-13, x. 234-242. TREATMENT OF BONE TUBERCULOSIS 93 of these points upon the question at issue is as follows : If operation pro- cedure is recommended, it must of necessity be complete and thorough. In a child of less than two years old this may necessitate a most extensive operation, and one associated with considerable shock. Further, if the disease be not thoroughly removed, the small resistance of infancy greatly increases the risk of recurrence, a risk which may be counterbalanced in older children. One may put it in this way. Looking at the matter purely from the point of view of age, one is disinclined to urge operation during the first two years of life. At a later period, in a case perhaps exactly sinrilar from a clinical aspect, one would recommend operative interference. Family History. — This is a point which ought to be carefully considered. The question of heredity has been already discussed, and while one may neglect such a possibility as a true congenital tuberculosis, there is un- doubtedly an inherited predisposition to tuberculosis. If tuberculous disease appears in a child whose family history is bad, and the disease is at all amenable to operative treatment, then undoubtedly such treatment ought to be adopted. If the disease is treated early, complete removal may spell a complete cure. If there is delay, one finds scanty tendency towards natural cure, but rather a metastasis and progression of the disease. Therefore, other things being equal, a tuberculous family history influences one in urging operative treatment where otherwise there might be doubt. Social Position. — The conservative treatment of tubercle may necessi- tate a prolonged and exacting recumbency. In the children of the well-to-do such a course is perfectly feasible, but among the poorer classes it may constitute an impossibility. The time will come, and one hopes it is not very far distant, when this statement will be in error, at present one must face the fact of its veracity. As operative measures therefore shorten the duration of treatment, there are cases in which, purely from the consideration of the wretched social conditions, one recommends an operation. The child is admitted to hospital, the disease is entirely removed, a period is spent in a convalescent home, and the treatment is terminated. There may have been a sacrifice from the ajsthctic point of view, but that is much more than counterbalanced by the brevity of treatment. The Position of the Lesion and the Bone Affected. — There are certain bones which, from their anatomical position do not permit of operative measures, these are comparatively few. Upon the other hand there are bones which from the point of view of their locality indicate operation. For example, in dealing with fingers and toes, one would advise operation in the toes but conservative measures for the hands. Where a limb is supported by two bones, and one is diseased, operation may be recommended, whereas had there been only a single bone, such a procedure would have been con- sidered contra-indicated. Hut even more important than the gross position is the e.xact localisation of the focus in the affected bone. If the disease lies in the immediate neiglibourhood of a joint, and has not yet invaded that joint, there is a very distinct advantage in removing the infected tissue before the joint becomes involved. 94 TUBERCULOSIS OF THE BONES AND JOINTS The Multiplicity of the Lesion. — It is difficult to appreciate whether this should be taken as an indication for operation or the reverse. It is probably wisest to consider the matter in the light of the case history. If the affected bone has been the original source of the infection, and if from it by dissemina- tion there have appeared a number of minor secondary foci, it is wise to attempt the removal of the original disease. It is possible that the secondary foci may themselves resolve spontaneously or under suitable treatment. But if, on the other hand, the bone focus is itself secondary to an earlier infection, or if the dissemination which it has induced is well developed and advanced, operation is certainly inadvisable. Tlie Clinical Features. — The first consideration is the opportunity which has already been given for the disease becoming cured by non-operative measures. If at the end of six to nine months of conservative treatment the disease is not improving, but is becoming rather more extensive and estab- lished, it is well to interfere, and few mistakes are commoner than that of delaying too long. The second clinical feature to which importance must be attached is the question of cold abscess formation. It does not of necessity indicate operation, but in a doubtful case its occurrence influences one in that direction. Lastly, there are the signs which are so often terminal, such as cachexia and waxy disease. They are the signals that nature's resistance is at an end, and if life is to be saved, drastic measures require to be employed. X-Ray Appearances. — Apart from what has been said in regard to the situation of the disease, and it of course is best demonstrated by radiography, there is the important point of sequestrum formation. A sequestrum, if it is of any size, is not readily absorbed, it leads sooner or later to cold abscess and sinus formation. One may take it that sequestrum formation is a definite indication for operation. These are the points which influence the observer, but they have special bearings in individual situations, and under the head of these situations they will be discussed. Varieties of Operative Measures. Preliminaries to Operation — Opsonic Index. — There are several points which require special mention. The first is the question of opsonic index, and its application in relation to positive and negative phases. By estimating the opsonic index there may be chosen, as far as science can tell, the most suitable period at which to conduct the operative measure, the most advantageous time being after the commencement of the positive phase. Local Preparation. — The second preUminary deals with the local pre- paration of the part. It is essential that this should be extensive, even more thorough than might at first appear necessary ; it is often impossible to foretell to what extent the operation may extend. Further, in the prepara- tion it is unwise to use strong antiseptics. The skin overlying a cold abscess is usually of very doubtful vitality, and the application of 1 in 20 carbolic, for example, may produce sloughing. Three per cent iodine in rectified spirit is the most suitable application to use. Tourniquet. — Lastly, there is the question of using an Esmarch's TREATMENT OF BONE TUBERCULOSIS 95 bandage as a prelude to operation. Its supporters have argued that its use prevents a troublesome oozing. This may certainly be true, but there is the disadvantage, that if the oozing does not occur at the time, it makes its appearance later, and often necessitates a most undesirable drainage. It is well to avoid the application of the elastic bandage. Types of Operation (1) Gouging- and Scraping-. — This consists in freely exposing the affected bone, and removing from it with gouge and sharp spoon the diseased focus. In exposing the bone it is usual to choose a suit- able intermuscular plane in order to avoid damaging the tissues. Of necessity the incisions .will vary in different localities. The periosteum is separated to expose healthy bone, above and below the disease. The medulla is opened with gouge and hammer, or with a small trephine. With a sharp spoon the diseased material is thoroughly curetted from the interior of the bone, until there is a cavity lined by healthy cancellous tissue. As it is almost impossible to avoid infecting the wall with tuberculous material, it is well to disinfect the walls with some preparation of iodoform or pure carbolic. The cavity that is left may be treated in various ways. The following are the most important. (a) It may be stufEed with iodoform gauze, and the space encouraged to close partly by the formation of fibrous tissue, and partly by the develop- ment of new bone, the packing being continued until there is complete obliteration. (b) Moselig MoorhoJ's Plug} — All blood clot is removed from the cavity by packing with gauze wrung out of hydrogen peroxide. The walls of the cavity are thoroughly dried with a hot-air douche, of which the dentist's pattern, upon a larger scale, is one of the best. The material used to fill the cavity is next prepared. It is composed of iodoform 60 parts, spermaceti 40 parts, oil of sesame 40 parts. The total ingredients are heated slowly to a temperature of 100° C, and after being thoroughly mixed, are allowed to cool. Immediately before use the mixture is heated in a water-bath to 60° C. to render it fluid, and then poured carefully into the dry bone cavity. In filling the cavity it is exceedingly important to prevent the entry of any air bubbles, and further to fill the space as completely as possible. When the mass solidifies the soft parts are replaced. {(■) Nciibcr's lodojorm Starch. This is used in the same fashion as Mosetig-Moorhof's wax, and Neuber considers the method most suitable in the removal of superficial tuberculous foci. Ten grammes of wheat-starch arc mixed witli the smallest ])ossible quantity of water, and to the mixture one adds 2(J0 grammes of boiling "2 i)er cent watery carbolic solution. After partial cooling, 10 grammes of ])owdcred iodoform are added. The prepara- tion should !)(! kejit in the dark, and it is used in exactly the same fashion as Mosetig-Moorhof's wax. ' Mosotig-lloorliof, Xeitschr. fiir Cliiniry., Aiiril 18, 190H. 96 TUBERCULOSIS OF THE BONES AND JOINTS (d) Schede's Aseptic Blood Clot. — If the bone cavity is not packed or filled in any way, sufficient bleeding occurs to fill it with a quantity of blood clot. The periosteum and soft parts are sutured over the cavity, the skin wound is closed, except to permit of drainage by a single strand of catgut or rubber tissue. The part is abundantly dressed and put up in a vertical position. This prevents any inconvenient bleeding, and the excess of blood is carried by the drain into the dressings. The organising blood clot acts as a scaffolding, upon which fresh tissue quickly develops, and even a cavity of considerable size will close in about six weeks. It is absolutely essential to observe the most rigid asepsis ; infection is disastrous to the success of the method. (e) Senn's Decalcified Bone Chips. — The chips are prepared from the compact fresh bone of the ox. The bone is cut into long narrow strips, and decalcified by immersion in a 10 per cent watery solution of hydro- chloric acid. The fluid is changed frequently, and the decalcification is complete in about two weeks. To remove all traces of the acid, the bone is washed in running water for twenty-four hours, soaked in I in 1000 mercuric chloride for forty-eight hours, and stored in a saturated solution of iodoform in ether. Before use the chips are soaked in alcohol to remove the iodoform and ether and then carefully dried. The cavity is filled completely with the bone chips, and the interspaces are occupied by blood clot. It is claimed that the bones strengthen the frame-work of blood clot into which the healthy granulation tissue penetrates. Instead of decalcified bone, chips of fresh bone have been used. (/) Murphy's Glycero-gelatin-Jormalin Plug. — 100 cc. of white gelatin are boiled in 150 cc. of glycerin and 500 cc. of water. To the mixture 1 to 2 per cent of commercial formalin is added. {g) Beck's Paste (page 82). This may be used in a manner similar to iodoform wax or Neuber's starch. When the cavity has been treated by one of the above methods, the soft parts are brought together over it. It is usually impossible to obtain a periosteal covering, but muscles and fasciae are available. After-treatment. — There are certain important features in the after- treatment which require to be recognised. It is important to maintain rigid asepsis, and for this reason it is well to avoid frequent and unnecessary dressing. While the wound is healing the part must be immobilised upon some form of light splint, readily adaptable to the limb. Aluminium answers the purpose in the majority of instances. When the wound is healed the part is encased in a light splint of plaster of Paris, and this is kept in position for from three months to six. If the wound is not com- pletely healed a plaster case may still be ajjplied if a window is cut out to permit of dressing. The prolonged fixation in after-treatment is very essential, even though it would appear that all trace of the disease had been removed. (2) The Resection Operation.~Mr. Stiles ^ first brought this procedure 1 stiles, Burgliard's Operative Surgery, vol. ii. p. 7. TREATMENT OF BONE TUBERCULOSIS 97 into active use, and for many years he has used it to the exclusion of other methods. By the aid of skiagraphy the disease is locaUsed within the bone, and conditions are most favourable when a limited area is involved. Not that diffuseness is a contra-indication, for the whole diaphysis may be removed. It is well that the disease should lie within the hmits of the bone and not have involved the surrounding soft tissues. The bone is exposed by a suitable incision, and the periosteum separated from it well above and below the disease. The bone is divided at one side of and at some distance from the disease. The division is best carried out with a Gigli saw, or in small bones with a bone forceps. When the bone has been divided, a strong sharp hook is introduced into the medullary ca\aty, and by the leverage of the hook the diseased bone is strongly pulled upwards, and fiuther separated from its periosteal bed. The further limit of the disease having been reached, the bone is again divided, and the diseased portion removed. If the upper extent of the disease lies in relation to the epiphyseal cartilage, the bone should not be divided, but wrenched away from its attachment to the epi- physis. When this is done it will be found that the epiphyseal cartilage remains attached to the epiphysis. Much of the success of the operation is based upon this anatomical fact ; were it otherwise the operation would often be contra-indicated on account of the shortening which it would entail. " As long as the epiphyseal cartilage is not actually involved in the disease, the operation does not give rise to any subsequent shortening." ^ Subse- quent to the removal of the bone there is little bleeding ; occasionally the main nutrient vessel requires to be tied. There is left a flaccid tube of periosteum, and this is closed with a series of interrupted catgut sutures. Special care is taken to cover over the divided ends of the bones. The periosteal tube fills with blood clot, and this, by organising, forms a scaffold- ing upon which new bone is enabled to regenerate. The regeneration occurs partly from the separated periosteum and partly from the divided ends of the bones. Any overlying muscles and fasciae are united with catgut sutures, and the skin edges are brought together with silkworm gut sutures or Michel's clips. After-treatment. — The part must be kept at rest in good position for some weeks after the operation. It is sometimes found, more especially when a single bone has been removed, that the pull of the overlying muscles tends to cruiniile up the lax periosteum, and thus gives rise to considerable shortening. Tiiis complication may be avoided by applying extension to the limb of suiHcient degree to overcome the muscular pull. When the wound is firmly healed, the part is encased in a light splint of plaster of Paris, and this is renewed at intervals of three months until new bone formation is completed. Regeneration is usually complete at the end of nine months. Even when iciforniation of bone may appear complete, it is unwise to permit full wciglit-bearing U|)()n tlu^ |)art ; some form of protection splint should be applied mid worn for about three mori' months. • Stilos, loc. sup. cil. viil. ii. p. 7. 98 TUBERCULOSIS OF THE BONES AND JOINTS BIBLIOGRAPHY Hygienic Treatment Wallace, C. " The Effect of Imperfect Hygiene in the Production of Bone Tuberculosis," Amer. Journ. Orth. Surg., PhUadelphia, 1907-8, v. 335-338. GiLETTi, A. J. " The Importance of caring for, and how the State of Minnesota cares for its Indigent Children suffering from Tuberculosis of the Bones and the Joints," St. Paul M.J., St. Paul, Minn., 1909, xi. 1-9. Taylor, R. T. " The Care and Treatment of Crippled Children," Virginia 31. Sem. Month., Richmond, 1910-11, xv. 513.517. M'NuRTEN. The Permanent Betterment of the Crippled Child, New York, 1911, 11 pp. ; Lancet, London, 1912, i. 4-7. Climatic Treatment Various Authors. " L'Influence du climat marin, de I'altitude, et de la campagne sur revolu- tion de la tuberculose osseuse," Sev. des mal. de la nutrition, Paris, 2'^ .ser., 1910, viii. 256-266. Lozano, R. " Impressiones de un viage d Berck-sur-mer ; tratamiento de las artritea tuber- culosae," CUn. mod., Zaragoza, 1910, ix. 752-761. HoRWiTZ, H. S. " Berck-sur-mer : a City of Hospitals for the Treatment of Bone Tuber- culosis," J. Missouri Med. Assoc, St. Louis, 1910-11, vii. 219-222. Vbrneuil, H. " La Cure marine en general et le traitement de la tuberculose osseuse en particuliere," Clinique, Brux., 1911, xxv. 529-536. Franzoni. " De I'influence des rayons solaires sur les ankyloses consecutives aux arthrites tuberculeuses," Rev. med. de la Suisse rom., Geneve, 1911, xxxi. 39-44. Doumer, E. " Traitement des osteites tuberculeuses par I'air marin et par relectrosation," Rev. de therap. med. chir., Paris, 1912, Ixxix. 758. RoLLiER, A. Die Heliotherapie der Tuberkulose mit besonderer Berucksichtigung ihrer chirurgischen Formen, 1913. Hyper.emic Treatment Bennet, W. " Induced Hypersemia as a Means of Treatment with Special Reference to Tuberculous Joint Disease and Stiffened Joints," B.M.J., London, 1908, ii. 1533-1535. WiLREX, C. " Les Traitements de Bier appliques aux affections osaeuses," Archives prov. de chir., Paris, 1910, xviii. 462-506. Ely, L. W. " The Bier Treatment in Tuberculous Joint Disease," Surg. Gynec. and Obst., 1910, X. 63-69. Chaput. " Traitement des tumeurs blanches et des synovites tuberculeuses par la m^thode de Bier," Bull, et mem. Soc. de Chir. de Paris, 1909, N.S., xxxv. 546-554. Thiery, p. " Le Traitement des tumeurs blanches par la methode de Bier," Bull, et mem. Soc. de Chir. de Paris, 1909, N.S., xxxv. 597-600. Treatment of Cold Abscesses Dalla Vendova, R. " Del trattamento della tuberculosi osteoarticolare mediante le in- iezioni de soluzione jodoioduata," Bull. d. r. Accad. Med. di Soma, 1907, xxxiii. 105-114. Nove-Josserand. " Plombage iodoforme dans les resections articulaires," Lyon chirurg., 1908-9, i. 299-301. ViouARD, P., and Grijber, G. " Du plombage des articulations," Lyon chirurg., 1908-9, i. 93-114. Redard, p. " Modifjring Injections in the Treatment of Tuberculous Osteoarthritis," Atner. Journ..Orth. Surg., 1909-10, vii. 508-511. Mayet. " Les Injections intra-articulaires d'ether iode dans les tumeurs blanches," Par. chir., 1910, ii. 103-233. Loewy. " Les Injections intra-articulaires dans les tumeurs blanches," Par. chir., 1910, ii. 111-115. Belhant. " Injections antiseptiques dans les osteoarthrites tuberculeuses," Ann. de chir. et d'orthop., Paris, 1911, xxiv. 65-70. Tuberculin Treatment Painter, C. F. " Experiences with Opsonins and Bacterial Vaccines in the Treatment of Tuberculous and Non-tulierculous Arthritis," Med. Communicat. Mass. M. Soc, Boston, 1907, XX. 613-633. Dunne, F. " Tuberculou.s Joint Disease treated with Denys's Tuberculin," Med. Press and Circ, London, 1908, N.S., Ixxxv. 430. TREATMENT OF BONE TUBERCULOSIS 99 Mn.T.En, H. B. " Opsonic Therapy in Tuberculosis of Bones and Joints," Vniv. Pcnn. M. Bull, 1908, xxi. 64-67. Freiberg, A. H. "The Treatment of Joint Tuberculosis with Marmorek's Serum," Amer. Jmirn. Orth. Surg., Philadelphia, 1908-9, vi. 69-78. OoiLvy, C. " A Contribution to the Study of Tuberculin in Orthopaedic Practice," Amir. Journ. Orth. Surg., 1908-9, v. 35-47. NuTT, J. J., and Hastings, T. W. "Tuberculin in Orthopsedic Practice." Amer. Journ. Orth. Surg., 1908-9, vi. 48-68. Smith, M. " The Inoculation Treatment of Tuberculous Arthritis," Brit. Med. Journ., London, 1909, ii. 1046-1049. OcHSNER, E. H. " The Effects of Vaccine Therapy in Joint Tuberculosis," Illinois Med. Journ., Springfield, 1909, xv. 137-141. RiDLON, J. " Investigations as to the Value of Tuberculin in the Treatment of Tuberculous Joint Diseases," Trans. Am. Ass. Oenito-Surg., N.Y., 1910, v. 328-339. WiLLiVRD, De F., and Thomas, B. H. " Therapy by Bacterins and Tuberculins in Mixed Suppurative Bone and Joint Disease," Ann. Surg., 1910, li. 261-267. OcHSNER, E. H. " Vaccine Therapy in Joint Tuberculosis," St. Louis Clinique, 1909, xxii. 256-264. OcHSSEK, E. H. " Vaccine Therapy in Joint Tuberculosis," South M.J., Nashville, 1909, ii. 445-450. SouRDAT, P. " La Reaction locale a la tuberculin dans les tuberculoses ost^oarticulaires," Clinigue, Paris, 1910, v. 760. WiLLARD, I)E F., and Thomas, B. H. " Therapy by Bacterins and Tuberculins in Mixed Suppurative Bone and Joint Disea.se," Tr. Am. Surg. Ass., Philadelphia, 1910, xxxiii. 359-373. RiDLON, J. " Investigations as to the Value of Tuberculin in the Treatment of Tuberculous Bone Disease," Amer. Journ. Orth. Surg., 1910-11, viii. 565-577. Plimmer, W. W. " The \'acciiies in Operative Treatment of Tuberculous Joints," Amer. Journ. Orth. Surg., Philadelphia, 1910-11, viii. 525-537. Painter, C. F. " The Uses and Limitations of Vaccine Therapy in the Management of Arthriti.?," Amer. Journ. Orth. Surg., Philadelphia, 1910-11, viii. 538-564. Packard, G. B. " Results obtained from the Use of Tuberculin in Joint Tubercle," Amer. Journ. Orth. Surg., 1911-12, ix. 17-24. Porter, J. L., and Quinn, L. C. " The Treatment of Tuberculous Joint Disease with Karl Spcngler's I.K. Serum," Chicago j\[. Hecnrd, 1912, xxxiv. 84-91. Silver, D. " Vaccine Therapy in Tuberculous Bone and Joint Disease," Penn. M.J., Athens, 1912, xvi. 219-223." EvERSOLE, H. 0. " The Use of Karl Spengler's I.K. Serum in the Treatment of Tuberculous Joint Disease," Amer. Journ. Orth. Surg., 1912-13, x. 234-242. Gillespie, E. " The Results of P.T.O. in Tuberculous Bone and Joint Ijesions," Journ. Vaccine Therajn/, 1913, ii. 91-101. Prevost and Depos. " Traitement de la tubcrculoso osseuse par les paratoxines," Jiei: mod. de mid. et de chir., Paris, 1912, x. 55-58. Treatment of Bone Cavities CoDET-BoissE. " Le Traitement des cavit(5s osseuscs par la methode do Mosetig," Journ. de med. de Bordfaux, 1908, xxxviii. 821-824. CoLLENET, A. Ciintril>uli(>n a l' etude de V obliteration des caviles osseuses par le melange de von Mnsetig-Monrhof, Lyon, 1908. Hn.L, R. "The Treatment of Bono Cavities," Mobile M. and S.J., 1908. xii. 41-48. Walton, A. J. " Cases of Bone Cavities treated by stopping with Paraffin," Lancet, London, 1908, i. 155-157. VVetiiehill, H. G. " Bone Cavities and Interspaces and their Treatment," Colorado Med., Denver, 1908, v. 9-15. Le Breton, P. "Some Experimental Work with Materials for Plugging Sinuses and Bono Cavities," Amer. Journ. Orth. Surg.. 1909-10. vii. 464-468. Sherman, H. M. "Salt Solution as a Killing for Bone Cavities," Surg. Oyn. and Obst.. 191 1. xiii. 147-151. Machahi). " Traitement des cavitds tuberculousos ostdoarticulaires par lo proc6d<5 do Mosetig," liev. med. de In Suisse rom., Geneve, 1912, xxxii. 797-802. 100 TUBERCULOSIS OF THE BONES AND JOINTS TREATMENT OF JOINT TUBERCULOSIS It is unnecessary to deal with preventive, general, or tuberculin treat- ment. These have been already discussed in application to bone tubercu- losis, and their conduction is exactly similar in joint disease. Conservative and operative treatment, upon the other hand, have more special applica- tions, and they require to be considered. Conservative Treatment A number of methods are included under the " Conservative treatment." The following will be dealt with : Fixation. Counter- irritation. Hypersemia. Extension. Injection. Fixation Treatment. — This will be discussed under three headings : (1) The stage of absolute fixation of the joint ; (2) The stage of partial fixation, in which slight movement is permitted, but no weight-bearing ; (3) The final stage, in which moderate weight-bearing is allowed, but the extremes of movement are curtailed. (1) Absolute Fixation. — As in bone tuberculosis, absolute fixation of the part must be put in the forefront of conservative treatment. The materials which may be suitably used are less numerous than in the treatment of osseous disease, because there are only certain substances which are suffi- ciently and completely adaptable. Of the available material a premier position must be given to plaster of Paris, applied by the method already described. A casing of sufficient thickness is used, and while still soft it is moulded with the hand to the outlines of the enveloped joint. Celluloid makes an excellent fixation splint, but it necessitates the taking of a cast and a prolonged preparatory process. A well-fitting celluloid splint provides absolute fixation, with the minimum of weight and the greatest possible degree of comfort. Splints of wood and metal are not suitable. They are not readily adaptable to the joint outline unless they have been thoroughly padded, and when padded they often lose a considerable degree of their fixing power. In applying the fixation splint, two principles must be kept in view. The first is that it is not sufficient to fix merely the joint afl'ected. It is essential that the joints immediately above and below should also be rendered rigid. This may necessitate considerable increase in the size of the splint. The second essential is in regard to the position of the limbs, when the splint is in position. The cure of a tuberculous joint sometimes necessitates ankylosis of the joint, and it is all-important that the ankylosis should occur in a position most useful to the patient. Therefore, when a fixation splint is necessary, TREATMENT OF JOINT TUBERCULOSIS 101 it ought to be applied with the joiiit in such a position that if ankylosis occurs the sacrifice of limb function is reduced to a minimum. This point is dealt with fully in application to the individual joints. Joints treated in this way are in a condition of absolute fixation, and depending on the position, size, and weight-bearing necessities of the joint, the treatment will extend over a period varying from six months to several years. At the termination of this period the second stage of fixation treatment is entered upon. (2) Partial Fixation. — The fixation is no longer absolute, a slight degree of movement is pos- sible, but all idea of weight- bearing is rigidly avoided. To secure this effect, numerous splints have been devised for individual joints, and this is the principle upon which the well - known Thomas's hip and knee splints are based. The duration of the second stage of treatment varies according to the joint affected. A suitable average period is one of six months. (3) Final Stage. — Lastly, one enters on the final stage in fixation treatment. Movement is now permitted, but within limits. The extreme movements of the joint are avoided; weight-bearing is begun, at first in a slight degree, Fia. 6.— Three possible methods of applying ex- and then gradually increasing. ension p as ers. ■.. r 1 • 1 . .1. A single strip is applied to the limb on each .side. Very often this last stage is /;. Lateral strips are applied with a circular turn above the ankle-joiut. C. Each lateral strip has three subdivisions ; the outer ones are wound spirally arouml tlie limb, neglected, but if it is adopted the joint is fitted with a light retentive apparatus, usually of leather, which prevents the more extensive of the joint movements. Treatment by Extension. — A diseased joint may be in such a con- dition that it cannot be immediately placed in a position of absolute fixation, and a preliminary period of treatment by extension becomes necessary. There are two conditions which give rise to the necessity : the presence of pain in the joint with muscular spasm, and deformity of the joint due to irregular muscular contraction. Extension is apjjlicd to the limb by elastic tension or by weight. The latter method is preferable, as its amount can be easily varied at will. The 102 TUBERCULOSIS OF THE BONES AND JOINTS actual application is made in different ways. Some form of adhesive strapping is applied to the limb, it may be in the form of single lateral strips, or in the more complicated form originated by Taylor. In the Edinburgh Children's Hospital a modification of Taylor's method is used. Its application is simple, and may be understood by reference to Fig. 6, C. Before applying the strapping the limb should be shaved, and any bony prominence over which the extension may play ought to be protected by small pads of lint. To the lower end of the adhesive strapping, tapes are stitched, and to the tapes, weights are attached through the medium of an ordinary wooden stirrup. The weight-cord runs over a pulley, the position of which can be altered at will. Fig. 99 illustrates a useful form of pulley- holder, which can be attached to most varieties of cots. The amount of weight varies with three factors : the age of the child, the degree of muscular development, and the pathological condition which necessitates the use of the weight. During the first three years of life it is often stated that a pound is added for each year. Above three years the proportion cannot be increased so rapidly. The muscular strength varies enormously, and it must be carefully considered in judging the degree of weight required. The type of lesion is a most important consideration. If extension is applied on. account of pain in the joint, the pain resulting from muscular contraction and tissue destruction, a comparatively small amount of weight is sufficient to relieve the symptoms. But if the extension is being used to correct a joint deformity, a much greater weight becomes necessary. It is important to apply the extension in the actual axis which the limb occupies. If this is a deformed axis it does not matter, because by extend- ing, first in the deformed position and gradually bringing the axis towards the normal one, the deformity is overcome. A warning must be given in regard to the danger of using too much weight. Joint pain which is not relieved by extension often means an excessive degree of weight, and when this is reduced the relief may be immediate. Excessive weight application also tends to stretch ligaments and weaken joints, and even to produce some separation of epiphysis. Counter extension may be necessary, the weights being applied in op- posite directions. The weight of the body may be used instead of a second application of weights, as, for example, in the extension used in lower spine Pott's disease, in which weights are applied to the lower limbs, and the foot of the bed raised. In certain cases, second extension must not be applied as a true counter or opposite extension, but as an oblique or right-angled extension ; for example, in tuberculous disease of the hip-joint, simple exten- sion in the long axis of the femur may not relieve the symiDtoms, because the lower part of the head is pressing against the rim of the acetabulum. There is immediate relief when a second extension is carried out at right angles to the first in the axis oi the neck of the femur. Counter-irritation of Joint. — Many authors have drawn attention to the marked benefit which appears in joint symptoms after the application to the joint of some form of counter-irritation. There is almost universal TREATMENT OF JOINT TUBERCULOSIS 103 agreement that the best way in which to apply the counter-irritation is by means of the actual cautery. Heated to a black heat, a broad cautery is applied momentarily to the skin over the affected joint. Blisters form, and are suitably dressed. Other counter-irritants, and more especially tincture of iodine, have been recommended. It is rarely that the reaction they produce is sufficient to give rise to any symptomatic improvement. Injection of the Joint Cavity and its Surroundings. — Medicated injections are among the accessories of local treatment. They are intro- duced into the interior of the joint or into the thickened tuberculous tissue around. When the injection is made into the interior of the joint, the solu- tion is distributed as completely as possible over the synovial surface. The fluid contents a^e^^^thdrawn,and the medicament introduced through a single puncture. The technique is exactly similar to that described in the account of the treatment of a cold abscess. When the injection is made into the peri- articular tissues, small amounts are introduced through a number of separate punctures. Solutions. — A favourite solution to employ is a sterile emulsion of 10 per cent iodoform in glycerin. It produces a benefit in cases in which the synovial membrane only is affected ; it is useless when the bone is diseased. A disadvantage is the intense reaction which, more especially in children, sometimes follows its employment. There is a local reaction in the joint — pain and swelling. But the general reaction is of more import ; it consists in symptoms of fever, headache, malaise, rash, and unfortunately sometimes the graver symptoms of sickness, delirium, and haematuria. Iodoform in ether, 5 or 10 per cent, is used less commonly than the glycerin emulsion. It possesses the disadvantages common to all iodoform preparations, and in addition the special disadvantage of the volatility of its ether, which sometimes distends the joint to a dangerous degree. Calot recommends the use of naphthol-camphor and creasote-iodoform solutions. He distinguishes two varieties of tuberculous joints from the point of view of injection treatment : {a) tuberculous joints with effusion, and (6) dry tuberculous joints. The former he treats exactly upon the line of a cold abscess. Creasote and iodoform emulsion is injected at intervals of six or eight days, over a period extending in all to two months. In the dry form of tuberculous joint he offers a choice of two modes of cure : (1) By producing a simple sclerosis without effusion. This he secures by injecting once a week for eight or nine weeks a quantity of the iodoform- creasote emulsion. The amount injected varies from 2 to 12 grammes, according to the age of the child and the capacity of tlie joint. (2) In the second metiiod the object is to produce an effusion into the joint, and this is secured by using the naphthol-camphor solution (1 gramme naphtliol-rainj)hor to 5 grammes of glycerin). The amount injected varies from (J to .'50 drops, and the treatment is continued each day until an effusion appears into the joint. When an effusion appears the joint is treated as in class I . Hyperaemic Treatment. — A tuberculous joint was the first disease to 104 . TUBERCULOSIS OP THE BONES AND JOINTS which Bier applied his hyperfemic treatment. He recommends only the passive method of treatment, as he considers that symptoms tend to become aggravated by the use of an active hyperaemia. At first Bier applied hyper- semia for a prolonged period on each appUcation, but he found that this induced the formation of large cold abscesses and quantities of fungating granulation tissue. To avoid these complications he altered his regime. The treatment was begun by aj^plying the bandage for a period of eight or ten hours a day, gradually reducing the time, until at the end of a few weeks only one hour's application was made each day. The change produced a decided improvement, but cold abscesses continued to form, though perhaps with less persistency. Bier now makes use of the method employed by Tilmann in the Greifswald Surgical Polyclinic : a method in which he applies the con- gestion treatment only one hour daily. Por this period it is permissible to allow the hyperemia strongly to afiect the limb, but the bandage must not be applied tightly enough to cause pain or pareesthesia in the treated extremity. If the joint lesion is an especially intractable one, an hour daily is too short a period ; two or even three hours may be necessary. Cold Abscesses and Sinuses. — When cold abscesses and sinuses develop, they are treated by the methods already described. Summary of Treatment. — In concluding this outline of the con- servative treatment of tuberculous joints, it will be well to mention the sequence one follows in employing the different methods of treatment. When the joint first comes under treatment, if there is much pain or any degree of deformity, weight extension is applied until the pain disappears or the deformity is corrected. The joint is then placed at absolute rest, in the most suitable position — the most suitable should ankslosis occui'. While it is kept at rest the auxiliary treatment of hyperaemia or medicated injection may be used. If plaster of Paris is employed to secure the complete fixation, and it is intended to employ joint injection in addition, suitable windows will require to be cut out of the plaster over the joint to allow the injections to be made. When the hypersemic treatment is to be used in conjunction with fixation, plaster is not so suitable, as the swelling of the part may be too intense. The fixation material, plaster or whatever it may be, is changed at intervals of three months, and on the occasion of each successive change it is advisable to have the part X-rayed in order to record the progress which is being made. At each interval it is important carefully to examine the joint for the formation of a cold abscess. This applies more especially to such deeply situated joints as the hip, in which a cursory examination may easily overlook a small collection of pus. The period of complete fixation will extend upon an average over twelve months. A further period of time is spent in some form of ambulatory apparatus, and then the joint is allowed to perform limited movements, unless of course the cure has been accom- panied by ankylosis. TEEATMENT OF JOINT TUBERCULOSIS 105 Operative Treatment Indications for Operation. — The indications for operative treatment are very similar to those discussed in regard to bone tuberculosis. Nothing can be added in regard to the questions of age and family history. The social condition of the patient is even a more important guide than it is in bone tuberculosis. A tuberculous joint interferes with movement and locomotion more completely than a tuberculous bone ever can, and when the disease appears in the joint the whole limb is crippled. You give the patient a choice of a period of conservative treatment, extending over many months, with perhaps a movable joint at the end of that time ; or an operation, a period of post-operative treatment, and a stiff joint. Among the classes from which hospital patients are drawn the tendency is to choose the latter alternative. The joint affected is of premier consideration. In the knee-joint the results of operation are so good that one has little hesitancy in recommending it ; but in such a position as the wrist-joint one prefers to persevere with conservative measures. Lastly, there are indications in regard to the clinical features. One should take into consideration the duration of conservative treatment which has been already attempted, the development of cold abscesses and sinuses, and the appearance of bone foci as demonstrated by X-rays. There are special indications for individual joints, and these will be dealt with separately. Types of Operation The operative measures to be considered are : Arthrotomy and Curetting. Ajcthrectomy. Amputation. Synovectomy. Excision. Arthrotomy and Curetting-. — There are cases in which there can be demonstrated a small localised area of disease in the synovial membrane or in the underlying bone. By removing this single focus, it may be possible to completely arrest the disease, and at the same time obviate the necessity for any prolonged after-treatment. The joint is opened by a suitable incision, and the diseased tissue cut out or curetted away. The cavity is touched with absolute alcohol, containing 10 parts of carbolic acid, and the wound is closed witiiout drainage. The operation should be followed by traction upon the limb, and the after-treatment should include a period of absolute fixation. Synovectomy, Arthrectomy, and Excision. -These three procedures may be considered together. Synoveclomy. — Theoretically, synovectomy is a removal of the synovial membrane, without interfering in any way with the underlying cartilage or bone. The joint is freely opened, and the diseased membrane clipped away with a pair of scissors curved on the flat. Natunilly the indications calling for such an operation arc exceedingly limited, and as an 106 TUBERCULOSIS OF THE BONES AND JOINTS operation it carries with it the risk of recurrence, because in a complicated joint it may be impossible entirely to remove synovial membrane and synovial membrane only. Arthrectomy . — Arthrectomy may be looked upon as a further stage of synovectomy, but instead of restricting one's attention to the membrane, a layer of the underlying cartilage is removed. The bone is not exposed, and thus there is not the same tendency to ankylosis. As an operation, a pure arthrectomy is frequently indicated, and the results obtained are often excellent. It possesses the advantage of not necessarily being followed by ankylosis. Excision. — Excision is the dernier ressort of the local removal treat- ment. The entire joint-bearing surface is removed, all the intricacies of the synovial arrangement are followed out, and the underlying bone surfaces are exposed. As an operation it is indicated in cases too extensive to permit of arthrectomy, in which there is disease of the subarticular bone. When the procedure is thoroughly carried out, recurrence of the disease is rare. It has one distinct disadvantage, and one -which may be a possible disadvantage. The first is the shortening which necessarily results in the limb, most marked when the epiphyseal cartilage is destroyed. The second possible disadvantage is the osseous ankylosis which is so likely to result. In many joints this latter is looked upon as an advantage rather than a disadvantage, e.g. the knee-joint. Amputation. — The question of amputation of the diseased limb remains for consideration. It is indicated when there is steady progression of the disease, mixed infection with sinus formation, and a general health decline from waxy disease and cachexia. The mutilation which results is the chief objection to the operation. It is most important not to delay amputation too long, and in the actual technique of the operation one must avoid the danger of encroaching upon the diseased area, and so running the risk of tuberculous infection of the flaps. The operation is described under the head of each individual joint. Correction of Deformity. — As the result of neglect or improper treat- ment, tuberculous joints may become fixed in deformed positions. The deformity is at first the result of a muscular contraction, and usually the greater power of the flexors decides that the deformity is one of flexion. In the later stages adhesion between the joint surfaces renders the alteration in position more permanent in character. The deformity may be corrected by conservative or by operative means. Conservative Treatment. — The conservative measures adopted may be gradual or immediate. (fl) Gradual. — Speaking generally, it may be said that gradual correction is obtained by some form of extension.- The variety may vary within wide limits. It may be accomplished by head or by foot extension, by horizontal extension in the hip and knee, first in the line of the deformity, then gradually towards normal, by fastening the bent limb to a straight frame, as in the spine, or by a series of plaster of Paris fixations in improved positions. TREATMENT OF JOINT TUBERCULOSIS 107 It is unnecessary to give more exact details at this point, as they are dis- cussed under the individual joints. (6) Immediate. — Under a general anaesthetic, a cautious and experienced surgeon can secure great improvement in the position of a deformed joint by gradually straightening the part and fixing it in the corrected position. Myotomy of shortened muscles may be necessary before complete correction can be obtained. Operative Treatment. — Different operative procedures are adopted in different joints. A complete division of shortened soft parts may be suffi- cient. Frequently it becomes necessary to divide the bone by a transverse or a cuneiform osteotomy. BIBLIOGRAPHY Le Moniat. " Du danger des interventions sanglantes dans les tuberculoses articulaires," Bull. Soc. Scient. el Med. de VOuest, Kennes, 1907, xvi. 108-112. Maktens, W. " Die Behandlung der Gelenktuberkulose," Therap. d. Oegenw., Berlin, 1907, xlviii. 481-493. Wilson, H. B. " Modern Tendencies in the Treatment of Bone Tuberculosis," Trans. Lehigh Valley Med. Ass., Easton, Pa., 1907, ii. 51-58. RuDES-.JicciNSKY, J. " Tuberculosis of the Joints and its Modem Treatment," Iowa M.J., 1908-9, XV. 2.57-261. SchSffer, K. " Om recidiverende tuberkul^s polyarthroitis," Hosp. Tld., Kjdbenh., 1908, 5, R. i. 642-649. OcHSNER, E. H. " The Treatment of .loint Tuberculosis," Illinois M.J., Springfield, 1908, xiv. 31-37. Primrose, A. " The Treatment of Tuberculous Arthritis," Canad. Journ. 31. and S., Toronto, 1908, x.xiii. 13-22. Todd, C. E. " Treatment of Tubercular Diseases of Joints," Australian M. Gaz., 1908, xxvii. 166. Swift, H. " The Treatment of Tuberculous .Joint Disease by Open Cut and Exposure to Sunlight," Austral. M. Oaz., Sydney, 1908, xxviii. 221-2i>3. OcHSNER, E. H. "The Treatment of Joint Tuberculosis," Trans. Mich. M. Soc., Detroit, 1908, vii. 389.396. Menoi{;re, L. " Ph^nolisation et phfno-puncture dans les tuberculoses osseuses et articu- laires," Clinique, Paris, 1908, iii. 616-621. Cal3t. " C'c qui doit etro le traitement des tumeurs blanches," Oaz. deshSp. de Paris, 1908, Ixxxi. 1 5.") 1 - 1 .'554. Kantor, M. Die Behandlung der Kniegelenktuherkulose in der Konigl. Chir. Klinik zu Berlin von lasX nach 190.'!, Hrrlin. 1908, ill. Shade. Mui.LEK, W. " ffber Knochengelenkresektioncn," Deutsche med. Wochenschr., 1908, xxxiv. 11291131. Paintbr, ('. F. "The Place of Operative Surgery in the Treatment of Chronic Arthritis," Amer. Journ. Orth. Surg., 1908, v. 413-424. Neil-Philipi'e. Contrilmlion h I'elude de Varthreclomie, Paris, 1908, 86-366. Peollett and Codernel. " Sur les r^'sections des grandes articulations dans les osteo- arthrites tuberouleuses," Contr. med. et pharm., Gaunat, 1908-9, xiv. 104-139. Adams, G. E. " The Treatment of Tuberculous .loints from the Standpoint of the General Practitioner," Texas Stale, .limrn. MeA., Kurt Worth, 1909-10, v. ii. Penoree, H. A. " Tlie Conservative Treatment of Tubcriulous .loints," .-I hit. Journ. Surg., New York, 1909, xxiii. 194-198. Haobena, p. " The Modern View in Regard to the Treatment of Tuberculous Diseases of the Bones in Children," Iliigiea, Stockholm, 1909, 2. f. ix. ; Svens. Liik. Salhk. Forhand- lung. 24I-2,'J8. GuERMONi'iKZ. " Sur le traitement des tumeurs blanches," Journ. des sr. med. de Lille, 1909, i. 615-619. JiMixKZ, L. " De las ostcoartritis tubcrculosas y suyo tratamionto," Bol. d. /n.tt. Patol., Mexico, 1909 10. 2. ep. vii. 224-2.34. Cre.si'Oi.ti, L. " La Kesezione del genocchio per ostcomyolite tulxjrcolarc," Hull. d. sc. med. di liologna, 1909. S. S. ix. 42-44. 108 TUBERCULOSIS OF THE BONES AND JOINTS Cn.LEY, A. H. " Report of Work done on Tuberculous Joints at the City Hospital," Post Gradmte, New York, 1909, xxiv. 840-844. MaoEwan, Sir W. " Discussion on Modern Methods in the Treatment of Tuberculous Disease of Joints," Brit. M. Journ., London, 1909, ii. 949-956. Stern, W. G. " The Treatment of Tuberculous .Toint Disease in Children," Ohio M. Journ., 1909, V. 250-254. HoEFTMAN. " Die Behandlung der Gelenktuberkulose," Deutsche med. Wochenschr., Leipzig, 1910-11, xxxvii. 1723. Lange, F. " Die orthopadisehe Behandlung der Knochen- und Gelenktuberkulose," Monatsschr. f. d. phys. DiateK, Hcllmcth. 1910. Stbauss, M. " Die Karbolsaurebehandlung der Knochen- und Gelenktuberkulose," Klin. therap. Wochenschr., 1910, xvii. 99-102. Shands, a. R. " The Prevention and Correction of Deformities in Chronic Joint Disease," Internal. Journ. Surg., New York, 1910, xxiii. 97-102. Porter, J. L. " The Modern Treatment of Tuberculous Joints," Lancet Clinic, Cincinnati, 1910, ciii. 485-489. Baden, C. " Le Traitement des exudates inflammatoires et de la tuberculose osseuse par isolation," Clinique, Paris, 1910, v. 218. Wilson, H. A. "Treatment of Bone Tuberculosis," Therap. Gazet, Detroit, 1910, 3. S. xxvi. 391-397. Lederet, Q. " Les Idees directrices dans le traitement de rhydrarthrose," Scalpel, Liege, 1910-11, Ixiii. 151-154. Lattwees. " Synovitis tuberculosa," Oeneisk. Tijdschr. v. Belgie, Amsterdam, 1910, i. 55-57. Hauser. " .Jothim Behandlung tuberkulosen GelenkentzUndungen," Med. Klin., Berlin, 1911, vii. 1006. Ely, L. W. "Joint Tubercle in Children," Amer. Journ. Orth. Surg., 1911-12, ix. 31-36. Ely, L. W. Joint Tuberculosis. 1911, Wood & Co. Perthes, G. " tjber die Behandlung der Knochen- und Gelenktuberkulose," Therap. d. Oegenw., Berlin, 1912, Uii. 529-533. Peterka, H. " Zur Behandlung der kindlichen Kniegelenktuberkulose," Beilr. zur Iclin, Chir., Tiibingen, 1912, Ixxxi. 721-727. Marshall, H. W. " Causes of Failure in Treatment of Chronic Joint Disease and how greater Success can be obtained," Boston M. and S. Journ., 1912, oxlvi. 759. Burguet, p. Contribution a I'etude du traitement connervateur dans les arlhrites tttberculeuses, Paris, 1912. Calve, J. " Articular and Bone Tuberculosis," Amer. Journ. Orth. Surg., Philadelphia, 1912-13, X. 468. Menard, V. " Introduction a I'etude des osteoarthrites tuberculeuses," Gaz. des hdp. de Paris. 191.3, Ixxxvi. 165. VuLPms, 0. " Knochen- und Gelenktuberkulose," Zeitschr. /. Tnberk., Leipzig, 1913, xx. 105-107. Garbi, C. " Die Behandlung der Knochen- und Gelenktuberkulose," Arch. f. klin. Chir:, Berlin, 1913, ci. 376-397. Ely, L. W. " Joint Tuberculosis," Interstate M.J., St. Louis, 1913, xx. 334-342. Ely, L. W. " Gelenktuberkulose," Be.rl. klin. Wochenschr., 1913, 1. 256-260. Baebarin, p. " Le Traitement des tuberculoses osteoarticulaires chez I'enfant," Clinique, Paris, 1913, viii. 290-292. Ely, L. W. " Diseases of Joints and Bone-marrow, etc.," Amer. Journ. Surg., New York, 1913, x,xvii. 179-184. Chalier and Maurin. " Pyarthrose tuberculeuse primitive sans lesions osseuses," liev. d'orthop., Paris, 1913, 3. S. iv. 41-54. Lozano, R. " Artritis tuberculosas poco frecuentes en la practica profesional," Clin, mod., Zaragoza, 1913, xii. 2-33. DouMER. "Le Traitement des ost^ites tuberculeuses par Tair marin et par releotrisation," Ann. de la Policlin. de Fechner, 1913, xxiv. 35-38. PoHL, F. " Uber Phenolkampferbehandlung verschiedener auch tuberkuloser Gelenk- erkrankungen und kalter Abszesse," Zenlralbl. f. Chir., Leipzig, 1913, xl. 814-818. DocHE, J. " Immobilisation des arthrites tuberculeuses et heliotherapie," Journ. de med. de Bordeaux, 1913, xliii. 402. Porter, J. L. " The Treatment of Tuberculous Joints," Surg. Giin. and Obst., 1913, xvi. 334-3,39. Oeebst, Adole. " Die herdformige Tuberkulose der grossen Extremitaten Knochen," Deutsche. Zeitschr. [ur Chir., Sept. 1913, S. 431. Garri, C. Die Behandlung der Qelenkluberkulose, Tiibingen, 1913. PAPiT II.-SPECIAL TUBERCULOUS DISEASE OF THE SPINE The vertebrae are, of all ther bones, the most liable to tuberculous infection, and as the spinal column is the axis upon which the whole osseous arrange- ment depends, the importance of a spinal infection cannot be overestimated. It is calculated that one-fifth of all cases of bone disease have their seat in the spine ; it is slightly more common in boys than in girls. Etiology The condition is essentially due to infection of the vertebrae \sith tubercle bacilli. The method by which the infection gains admission, and the changes which the organism produces, are discussed under pathology, but there are certain features bearing upon the etiology which must now be considered. Age. — The disease is most common in children, and probably its most frequent incidence is found during the first five years of life. Lannelongue ^ has given statistics gained from a study of 180 cases occurring in children under sixteen years old. In 7 per cent of the cases the disease first appeared when the child was less than two years old. Between two years and five years no less than 50 per cent of the cases occurred. In the period from five years to ten, 32 per cent of the cases could be placed. The remaining 10 per cent occurred over ten years of age. It is generally acknowledged, and all statistics support the fact, that five years of age is the most common period at which the disease appears. Sex. — Sex does not appear to be a factor of any importance. The disease is slightly more common in boys than in girls, but according to Wiillstein ^ the proportion is wonderfully equal : 53-29 per cent males and 46-71 females. Injury.- It is quite certain tiiat in the history of a number of cases one finds some account of an injury, in particular a fall from some small height. From what one knows of the pathology, it is possible that accident does play its part in originating the disease, but too often the history of injury is more imaginary than real. It is a slight injury rather more than a severe one which predisposes to the disease. ' I-iimicloiiKuc, Tuherruloim Vertchrnls, ji. 1.17. - W'lilLsU-in, J oachi mnlhaV a Chir. Ortli., Part I. Ill 112 TUBERCULOSIS OF THE BONES AND JOINTS Heredity. — Tuberculosis is so common and so widespread that it is never very difficult to trace its ravages. In Pott's disease, as in tuberculosis elsewhere, there is usually a tuberculous family history. Gibney ^ found that 76 per cent of cases showed a family history of tubercle — in 38 per cent on the mother's side, in 35 per cent on the father's side, in 31 per cent on both sides. Statistics published by Waterman and Jaeger ^ differ considerably from these. According to them only 10 per cent of the children were born of tuberculous parents. There are other subsidiary facts in the predisposing etiology. One frequently finds the disease coming on after an attack of one of the exan- themata ; the predisposition is due to a lowering of the body vitality. Then there is the fact of tuberculosis elsewhere. Vertebral tuberculosis is rarely a primary manifestation. Autopsy usually reveals a primary focus in some other part, most commonly in the bronchial or mesenteric glands. In regard to the association of other bone and joint lesions with Pott's disease, one is thoroughly in agreement with Tubby * when he says : "At the Evelina Hospital for children we have often observed the sequence of events : tuberculous dactylitis, glands, coxitis, or other varieties of arthritis, persisting for some months or a year, and then the onset of spinal caries. Very rarely is the reverse order of events met with." Pathology The Localisation of the Disease. — The majority of authorities are agreed that the lower dorsal portion of the spine is the part most frequently affected. This rule of location is, however, not universally accepted. Thorndike '' holds that the proportion of occurrence is that of one cervical for three dorsal and five lumbar cases ; but he adds that in New York, out of 1000 cases 6-6 per cent were cervical, 70-9 per cent dorsal, and 22-5 per cent lumbar. As regards the individual vertebrae affected, the most common are those from the eighth dorsal to the first lumbar, vertebrae which require to stand greater superincumbent weight than any others in the spinal column. General Structure of Vertebrae. — The anterior portion of each vertebra is formed by the large rounded body, filled with cancellous tissue, and bounded above and below by the discs of the intervertebral cartilages. From the postero- lateral aspects of the bodies there project backwards the two pedicles, which with the two transverse processes, the articular processes, the two laminae, and the spinous process, complete the vertebrae, and enclose the spinal canal. With the exception of the atlas and axis vertebrae, all the vertebrae of the column may be said to be articulated upon the same scheme. Three ' Quoted by Bradford and Lovett, Orth. Surg., p. 11. - Trans. Amer. Orth. Surg., 1901, vol. xiv. p. 287. ' Deformities, including Diseases of the Bones and Joints, 1912, vol. ii. p. .57. * Thorndike, Ortliopa'dic Surgery, 1907, p. 208. TUBERCULOUS DISEASE OF THE SPINE 113 separate joints exist between opposing bodies, a central amphiarthrodial joint, and two lateral diarthrodial joints. The amphiarthrodial joint occupies the greater part of the space between the vertebral bodies, where the two bone surfaces are brought into contact by a layer of fibrocartilage. Between the opposing articular processes there are joints of the diarthrodial variety. The ligaments which bind the bodies together are the anterior common ligament in front of the vertebral bodies, the posterior common ligament which lies on the posterior aspect of the vertebral bodies, and the various interspinous and intertransverse ligaments, with the ligamenta subflava between the adjacent lamina?. It is unnecessary to describe the distinct and numerous articulations between the axis, atlas, and occipital bones. All the joints are of the diarthrodial variety. Blood Supply of Vertebrae. — The largest amount of the blood supply is distributed to the interior of the body of the vertebra. The vessel is derived from the posterior spinal artery, and it enters the body by one or two distinct foramina upon the centre of the posterior surface. Narrow zones of bone at the attachment of each intervertebral cartilage upon the upper and lower surfaces of the body derive special blood supplies from what are termed the epiphyseal arteries, derived from the posterior spinal artery. An area of bone in the front of the body obtains its blood from branches of the intercostal arteries. Each vertebral body therefore has four distinct sources of blood supply. At the base of each transverse process a separate vessel on each side penetrates the front of the process at its junction with the pedicle. It owes its origin to the intercostal vessels. The scheme of blood supply is distinct in the atlas vertebra. It pos- sesses no proper body, and therefore the large central artery is absent. Its place is taken by two lateral vessels, which enter one from each side and run forwards and backwards within the bone. Pathologry. — The infection is carried by the blood stream into the bone, and, according to the distribution of the vessel, different areas are infected by the disease. (1) It may occur in the centre of the vertebral body, and this constitutes by far the greatest proportion of the cases. It may be spoken of as ihc central variety. (2) 'IMic infection may begin at the epij)hysis of the body, beside the attachment of the intervertebral disc. From the epiphysis it extends into the body of the vertebra or into the 8ub.stance of the di.sc : the epiphyseal varietij. (3) The anterior or peripheral variety occurs in the anterior portion of the vertebral body, supplied with blood tlirough the intercostal vessels, and lying immediately beneath the anterior common ligament of the vertebra. This type of the disease is practically limited to adults. (4) Lastly, there are extremely rare forms of the disease, which attack one or other of what one may terra the vertebral appendages, and most commonly tiie transverse processes. In each of these four varieties the exact pathology is very similar, but it is best observed as it occurs in the centra! form. Chang-es in Individual Vertebra. — It is probable that a vertebra 8 114 TUBERCULOSIS OF THE BONES AND JOINTS is predisposed to tuberculous disease by a preliminary change in the main nutrient vessel.^ This change is of the nature of a tuberculous endarteritis obliterans ; it is the result of a tuberculous toxaemia, and it affects these vessels which supply vertebrae most liable to trauma and strain ; hence the common localisation of the disease to the lower dorsal spine. The thicken- ing of the vessel wall interferes with the nutrition of the bone and its marrow, and the marrow becomes altered from a resistant red marrow to one of a pale, myxomatous and less resistant type. It is in such an altered tissue that the original tubercle makes its appearance. If there has been a pre- disposing trauma, it acts by producing a small ecchymosis in the weak and friable tissue, and the extravasation of blood is responsible for an arrest of the tubercle bacilli. The formation of a tuberculous follicle is the first stage in the actual pathology. It is situated in the centre of the marrow. It is composed of the usual arrangement of epithelioid cells, lymphocytes, and giant cells, and to the naked eye it appears as a tiny grey point, standing out from the surrounding marrow. The tubercle enlarges, others appear around it, and as they eventually coalesce, a considerable focus of disease is formed. Caseation appears in the centre, and the original grey colour of the diseased area is now altered and replaced by a variety of colour, a yellow interior, a grey periphery, and a thin limiting zone of congested marrow. As the disease spreads throughout the cancellous spaces it comes into contact with the bone lamellae. These are rarefied, and if possible entirely absorbed before they become surrounded by the diseased tissue. Should the lamellae become isolated before they are completely absorbed, they form minute sequestra. Attention has been drawn to the preliminary changes which the marrow undergoes. When the disease is well established the myxomatous marrow in the immediate neighbourhood of the disease shows a tendency towards the development of fibrous tissue and the limita- tion of the tuberculous tissue. It is an interesting fact, and one which has never been explained, that in tuberculosis of the vertebrae the periosteum rarely forms any degree of new bone. It is difficult to understand when one remembers how typical is the formation of new subperiosteal bone in other situations. The entire architecture of the bone is now altered ; the interior of the body has lost all stability, and the weight and pressure are entirely borne by the thin compact bone of the periphery. It is like a box with walls of unstable cardboard. Upon each vertebra a considerable amount of pressure is normally exerted, and such pressure, most marked in the anterior part of the column, is borne by the thick bodies and the strong intervertebral discs. If the strength of the body of one or more vertebrae is undermined by a central rarefying disease, the continuation of pressure produces a crumpling up and a collapse of the body. The body having collapsed, and the posterior part of the spine, pedicles, laminae, and transverse processes remaining healthy and mi situ, the result is the development of an angulation or kyphosis. 1 Fraser, Ediii. ^r. J.. 1912, N.S. ix. 430-441. PLATK XMII «, Till- Thk I'atiiol(k;ical Vahiktiks ok Pott's Disease (after WuUstcin). iitriil viiT'ii'ty of I'ott's ilisease. b. The c])ipliyseal variety of Pott's disease. r, The anterior or peripheral variety of Pott's disease. TUBERCULOUS DISEASE OF THE SPINE 115 The vertical pressure which is exerted upon the diseased vertebra is the result of the superincumbent weight and of the contraction of the irritated muscles which lie along each side of the spine. The natural tendency which the disintegrated vertebra has to produce a kyphosis, places the anterior muscles at a mechanical advantage over the posterior. The gradual increase in power of the anterior muscles accentuates the kyphosis, and the posterior muscles by becoming stretched act at a greater and greater disadvantage. With the collapse of the body the disease is more widely disseminated, it may be extended among the surrounding soft parts to form the origin of a cold abscess. When secpestra occur they are of the minute variety, intimately KlQ. 7. — Dors.il Pott's disease. Tliu roiiiuleil kyphosis inilicates disease affecting tlie bodies of .several vertelirse. Fill. S. — Dorsal Pott's disea.se. The anguhir lirojeotion inilicates a disease affeeting prob- ably a single vertebrae. mi.ved with the caseating and purulent debris. Sequestra of larger size may occur, hilt they are broken up and destroyed when the body of the vertebra colla])ses. The amount and tiie character of the kyphosis depend upon two factors : the number of vertebrae affected, and the situation in wiiich the disease has occurred. Disease in a single vertebra ])roduces a sharp kyphoses, with probably little general deformity. Co-o.xistcnt disea.se of several vertebra; gives rise to a rounded gibbosity, with considerable general deformity. The alterations in different regions of the spine have been demonstrated by -Menard. ^ In the cervical legion de.stiuction of the vertebral bodies does not produce much kyphosis, because inflexion is largely prevented by interposition of the rof)ts of the pedicles where they come off from the .sides of the vertebne. The cervical region, on account of the .space which normally ' Kfudc pratique sur Ic mill ilv I'ult, I'aris, Slasson & Cic, 1900. 8 a 116 TUBERCULOSIS OF THE BONES AND JOINTS exists between the posterior arches, permits of a considerable degree of hyperextension, and when inflexion occurs it is corrected by hyperextension. The result is a slight kyphosis and some degree of shortening in the spinal column. In the dorsal region of the spine, destruction of a single body produces a distinct kyphosis, and the deformity is more marked as other vertebrae are affected. This striking difference depends upon the anatomical fact that in the dorsal spine the pedicles do not come oS from the side of the body, but from the posterior surface, therefore they cannot by interlocking prevent a spinal inflexion. The deformity cannot be neutralised by hyperextension as in the cervical region, because the laminae and the spine are normally so close together that very little extension is possible. When the lumbar spine is diseased, the results resemble those found in the cervical spine. On account of the thick intervertebral discs and the large interlaminary and interspinous spaces, there is considerable power of hyper- extension. Collapse of the lumbar body is counterbalanced by a corre- sponding degree of hyperextension, and the result is a slight kyphosis and some amount of shortening. Sometimes, although the diseased vertebra has collapsed, the body above does not come into contact with the body below. Until there is actual contact, a supposed cure is more apparent than real. In addition to the changes in the bodies of the vertebrae, there are changes in the arches. The posterior arch of the diseased body is partly dislocated backwards, giving origin to the early spinal prominence. The posterior segment is wasted and atrophied, and sometimes it is firmly ankylosed to segments above and below by the C[uantity of new bone thrown out from its surface and attachments. Chang'es in Vertebral Column as a Whole. — The essential deformity of Pott's disease is a kyphosis, but there are compensatory changes above and below. These compensations are in the shape of curves, to maintain the figure in a correct attitude. In cervical disease the axis of the skull becomes altered, and there is a compensatory curve in the dorsal spine. When the disease attacks the dorsal spine, its most favourite situation, there are com- pensatory lordotic curves in the cervical and lumbar regions. If the angulation is in the lower part of the lumbar region, any kyphosis which may occur is largely compensated for by hyperextension of the hip-joints. Lateral Deviation of the Spine. — Occasionally one finds that in addition to a kyphotic deformity there is also a lateral one, and the complication the erroneous diagnosis of simple scoliosis. A -Scoliosis in Pott's disease. sometimes leads to TUBERCULOUS DISEASE OF THE SPINE 117 lateral deviation occurs in Pott's disease for two reasons. The first is that when in the collapse of the spine, owing to the destruction of a vertebra, the upper segment does not fall true upon the lower one, a sharp and almost angular scoliosis results. The second possible cause is the irregular course of the disease. If only one-half of the vertebral body is destroyed, and the disease spreads to the vertebral half immediately below, a lateral deviation will result. It is usually uniform, and, apart from the muscular rigidity, it closely resembles at first sight a simple scoliosis. Chang-es in the Spinal Cord and its Membranes. — From the close proximity of the spinal cord to the disease, it is but natural to expect that when a kyphosis occurs, pressure will be exerted upon the cord, pressure of such a degree as to give rise to symptoms. In reality such a sequel is the exception rather thau the rule. The power of accommodation is so great that even a very extensive deformity will produce no nervous tissue change. In a certain proportion of cases pressure upon the cord does occur, producing what has been called " compression paraplegia," and the changes which produce it may originate (1) in the bones of the spinal column ; (2) in the spinal membranes ; (3) in the spinal cord itself. ( 1 ) Bone Causes. — It is very exceptional to find that the bending of the spinal column is of such a nature as to compress the spinal cord. It angles, but rarely compresses. A partial dislocation is a more common source of bone pressure. When the diseased vertebra collapses, the upper segment is displaced somewhat backwards, and its posterior edge comes into contact with the enclosed nerve tissue. Cases have been recorded in which a seques- trum has gradually been extruded from the diseased area, and has exerted pressure upon the nerve tissue. The commonest manner in which the diseased bone causes compression is an actual extension of the disease, either as tuberculous granulation tissue or as a cold abscess. The disease within the body of the vertebra has a tendency to extend to the exterior through the posterior surface, and more especially along the vessels entering the bones through the large nutrient foramina. At first the extension is limited by the posterior ligament. When this becomes perforated the epidural space is invaded, and pressure is at once exerted upon the cord. (2) Membrane Causes. — By the extension of the disease a tuberculous perimeningitis is produced ; this is followed by a pachymeningitis, and later even by a leptomeningitis. As the membranes become diseased they become thickened, and then blood and lymph vessels are obliterated. In this way the cord undergoes a slow and gradual compression witli resulting changes in its nerve elements. (3) Spinal Cord Cau.^es. — The nervous tissue of the cord is })rttctically never actually infected with tuberculosis ; the changes which it undergoes are secondary. Its actual circumference may be Hattened and constricted by pressure. Owing to the obliteration of the blood and lymph vessels in the spinal nnMnhranrs, there is a local o'denin of the cord, and the avlcina may 118 TUBERCULOSIS OF THE BONES AND JOINTS become a subacute myelitis with softening. If myelitis occurs, there will be a destruction of a certain number of the nerve filaments, a proliferation of the neuroglia and sclerosis, followed at a later date by ascending and descending nerve degeneration. Fortunately it is the exception for the changes to be so severe as to produce myelitis. The nerve roots undergo changes very similar in every respect to those which occur in the spinal cord. Chang-es in the Heart and Great Vessels. — The heart is altered in position and in size. It is altered in position as a result of the kyphosis, and naturally the most marked alterations occur when the deformity is situated in the upper and mid -dorsal regions. The change in position is of such a nature that the base of the heart is displaced down- wards, while the apex ap- pears to be tilted upwards. The heart appears to be rotated upon a transverse horizontal axis. The upward displacement of the apex is more apparent than real, as it is exaggerated by the alteration in the position of the ribs. The size of the heart is changed by the hyjaertrophy which it consistently under- goes. Attention is drawn later to the kinking of the aorta. As a result of the kinking, the work of the heart is increased, and there is an hypertrophy, and later a dilatation of the left ven- tricle. The other chambers of the heart undergo similar changes. The aorta and the vena cava are altered in direction and in size. The aorta is liable to become kinked in two positions, about the centre of the transverse portion and again opposite the kyphosis. The vessel may be kinked antero-posteriorly or deviated laterally, sometimes a combination of both. The antero-posterior deformity is the more serious, there is a val\Tilar formation of he anterior wall which offers very considerable obstruction to the blood flow. The changes in the vena cava are very similar to those found in the aorta ; on account of the thinness of its wall this vessel accom- Fi( 10. — The Uinkiug of the great vessels secondary to tuberculous disease of the vertebrte. (WuUsteiu.) TUBEECULOUS DISEASE OF THE SPINE 119 modates itself more easily to the alteration in position than is the case in the aorta. These vascular changes are responsible for the coldness and malnutri- tion of the lower extremities which one so constantly finds in Pott's disease. Chang-es in the Thorax, — These are so excellently summarised by Tubby that one cannot do better than cpote his words : ^ " In the chest three varieties of deformity are seen : A. li the curve is high up in the dorsal region, the true ribs are held at an angle greater than the normal, the sternum is displaced downwards, and the antero-posterior diameter Mid-ilorsal. High ilor-sal. Dorso-lumb.ar. Fig. 11. -A cUagramatic representation of the thoracic deformity in mid dorsal kyphosis, high dorsal kyphosis, and dorso-liimliar kyphosis. (Menard.) of the thora.x is diminished. In fact the chest is in an c.\])iratorv position. B. If the disease is low down in the dorsal region, the ribs and sternum are raised, the antero-posterior diameter of the chest is lengthened, and the che.st is barrel- shaped, and is in a position of iiis]iiration. Therefore the hreatliing is dia- phragmatic, and the patient is short of breath. C. Wiien the lumbar region is affected the whole thorax sinks downwards and forwards, the lower ribs over- ride the pelvis, the ensiform cartilage approximates to the symphysis pubis, and tlie abdominal wall is thrown into folds. " Changes in the Pelvis.— Disease of the cervical or upper dorsal spine is unaccompanied by any change in the architecture of the pelvis. When the disease occurs in the dorso-lunibar region, producing there some degree of kyphosis, there are changes in the pelvis compensatory to the angulation. The sacium is rotated upon a central, transverse, horizontal axis, its upper ' 'ruld)y, Urfuniiiticn, including Diseases of the Hones and Joints, vol. ii. p. !I5. 120 TUBERCULOSIS OF THE BONES AND JOINTS half is displaced backwards, while the lower half is carried forwards. The iliac crests become splayed outwards, and the inlet of the pelvis is increased in its antero-posterior and transverse diameters. The outlet of the pelvis is diminished in size by the tilting forwards of the lower part of the sacrum, and an approximation of the tuberosities. The ischia are approximated because the displaced sacrum acts as a wedge, forcing apart the upper parts of the pelvis, while the lower parts in compensation are approximated. The pelvis is said to become funnel-shaped in outline. "When the disease affects the lumbosacral region, there is no tilting of the sacrum. The whole bone is displaced downwards and backwards, and therefore there is not the tendency to narro^ving of the pelvic diameters which one finds in disease higher up. Abscess Formation. — There is no more common complication met with in tuberculosis of the spine than that of abscess formation, and while it is discussed later in its clinical aspect, it is essential to study it here from its pathological side. It is calculated that 20 per cent of cases pass on to abscess formation (Townsend).^ The Origin of the Abscess. — The caseation and rarefaction which goes on within the bone is really a modified cold abscess formation, but as long as the disease is localised to the bone the term abscess cannot be theoretically applied. In process of time the disease extends to the surface and perforates the limiting zone, or the osseous shell collapses and the caseous matter is disseminated into the soft parts around. To either of these possibilities the cold abscess owes its origin. There is a third possi- bility which one occasionally finds illustrated, the cold abscess may begin as an extension of tuberculous disease from the interior of the vertebra, along the course of one of the larger nutrient vessels, and more especially along the sheath of the large artery which enters the body from its posterior surface. The abscess which is really a progressive caseation in the soft tissues and intermuscular septa may remain in the proximity of the original osseous lesion, or it may become wandering or migratory. The Course of the Abscess. — The course varies in the different regions of the spine — cervical, dorsal, or lumbar. A. Abscesses originating in the Cervical Spine. — To understand the possible directions of a cervical abscess it is-essential to describe first the relation of the deep cervical fascia, because the situations of the abscesses are guided almost entirely by the attachments of this structure. The deep cervical Fascia. — From the spine tips of the cervical vertebras the ligamentum nuchae passes backwards in the middle line of the neck. From the posterior edge of the ligamentum nuchae, the superficial layer of the deep cervical fascia passes forwards to reach the posterior margin of the trapezius muscle. Here the fascia divides into two lamellaj, which enclose the trapezius and reunite at its anterior border. From this point the fascia sweeps forwards to form the roof of the posterior triangle, and then splits to enclose the sterno-mastoid muscle. It again reunites at 1 Townsend, Trans. Amer. Orth. Assoc, vol. iv. p. 164. TUBERCULOUS DISEASE OF THE SPINE 121 the anterior margin of the muscle, to become continuous with the fascia of the opposite side. The fascia forms a complete collar around the neck, splitting to enclose the trapezius and sterno-mastoid muscles of each side. This superficial collar has most important vertical attachments. Above, it can be traced to the superior curved line of the occiput, the mastoid process, over the parotid gland, to the zygoma, and along the inferior aspect of the lower jaw from the angle to the symphisis. Below, the fascia is attached to the spine of the scapula, the acromion process, the clavicle, and the manubrium sterni ; as transversely it splits twice to enclose structures, so vertically it splits twice. Above, between the lower jaw and the hyoid bone, it embraces the submaxillary gland ; below, two inches above the suprasternal notch, it separates into two lamellae, enclosing a triangular interval (Burns's space). This space con- tains the sternal head of the sterno- mastoid, one or two lymphatic glands and vessels, and portions of the anterior jugular veins. This layer of fascia is pierced by the external jugular vein just above the clavicle. From the deep sur- face of the circular superficial layer, two deep processes pass across the neck : the ^ pretracheal and the prevertebral layers. The pretracheal layer springs from the lamella lining, the deep surface of the sterno-mastoid muscle. It passes across the neck in front of the trachea and ocsophagiis, enclosing in its course the thyroid gland. It is attached to the lamella upon the deep surface of the opposite sterno-mastoid muscle. Verti- cally it is attached above to the hyoid bone, while below it passes into the mediastinum. The prevertebral layer extends in- wards from the deep surface of the cervical fascia as it passes across the roof of the posterior triangle. It covers the prevertebral muscles and the spinal column. Above it is attached to the base of the skull, below to the first rib, where the inner portion becomes continuous with the posterior mediastinum. The outer portion forms the sheath of the sub- clavian ves.sels, and continues downwards with them into the axilla. The carotid sheath is a special investment formed by the pretracheal and pre- vertebral fasciae. The neck is therefore subdivided by these processes into three compartments : («) The muscular, between the superficial and the |)retrachcal layers, containing the depressor nuiscles of the hyoid bone ; (6) the visceral, between the pretracheal and prevertebral layers, containing the hirynx, pharynx, oesophagus, trachea, aiul thyioid gland ; and (c) the Vh,. 12. — The arraiigenient of the cervical fascia. The fascia is coloureil red. 122 TUBERCULOSIS OF THE BONES AND JOINTS vertebral compartment, behind the prevertebral layer, containing the pre- vertebral muscles, the cervical sympathetic, and the vertebral column. AVhen the cold abscess is secondary to disease in the cervical spine, the pus will follow tracks which largely depend upon the attachments of the cervical fascia. The possibilities are as follows : (1) The pus may accumulate behind the prevertebral fascia, between it and the anterior surface of the cervical vertebrae. It bulges the fascia for- wards, and it is designated a retro-pharyngeal abscess ; laterally it ajipears at the posterior edge oj the sierno-mastoid muscles. (2) The pus may penetrate the prevertebral fascia, in which case, if situated high up, it enters the mouth, if low down it enters the visceral compartment of the neck, infiltrating around the gullet and the air passages. Pus in this region has no special tendency to point in the neck ; it more frequently passes downwards into the mediastinum or into the axilla. It may find its way into the interior of the oesophagus. (3) The pus may track along the lateral surface of the cervical vertebrae, between the spine and the ligamentum nuchse upon the inner side, and the posterior cervical muscles upon the outer side. It penetrates the deep cervical fascia, and appears at one or other side of the vertebral spines. B. Abscesses originating in the Dorsal Spine. — Dorsal abscesses are generally small, and they usually remain in close contact with the spine. Owing to the depth of the dorsal spine from the surface, the pus is frequently retained, and it may make its way within the spinal canal, and give rise to a paraplegia. The possible course of the abscess is guided by the anatomical relations of the lateral aspects of the dorsal spine. With the exception of the first rib and of the last three ribs, the head of each rib articulates with the bodies of two vertebrae and the intervening intervertebral substance. The heads of the first, tenth, eleventh, and twelfth ribs are implanted directly upon the bodies of the corresponding vertebrae. Each rib is attached to the side of the vertebrae by several ligaments, the most important of which are the anterior capitular or stellate ligament and the superior costo-trans- verse ligament. Between the inner edge of the superior costo-transverse ligament and the lower and upper edges of adjacent stellate ligaments there is a weak point in the anterolateral aspect of the spinal column. The interval between the posterior extremities of the ribs is filled up by the internal and external intercostal muscles and the posterior inter- costal membrane. The external intercostal muscles extend inwards as far as the tubercles of the ribs, the internal intercostals end at the angles of the ribs, the further interval being filled up by the posterior intercostal mem- brane. The inner edge of the posterior intercostal membrane is attached to the outer edge of the superior costo-transverse ligament. The bodies of the vertebrae are bound together in front by the anterior common ligament. The anatomical relation of the posterior primary divisions of the dorsal nerves must be briefly mentioned. They make their appearance in the intervals between the transverse processes, and immediately divide into external and internal branches. The external branches pass outwards TUBERCULOUS DISEASE OF THE SPINE 123 under cover of the middle column of the erector spinse muscle, and of their number only the lower five become cutaneous about the position of the rib angles. The internal branches are distributed in a fashion almost the reverse of the external ; the lower five branches are very small, and they do not become superficial ; the upper seven pass inwards between the multifidus spinae and the semispinahs, and after piercing the splenius, rhomboideus, and trapezius muscles they become superficial. As will be shown later, special interest attaches to the arrangement of the posterior divisions of the dorsal nerves. The aortic intercostal arteries have important bearings upon abscess Fig. 13. — The ilistribution of the posterioi- [iriniaiy ilivision of tliu dors.il iicrvi-s. illu.-tr.iUil liy a section at the level of the seventh dorsal vertebra'. Note the superlicial clistrilmtioii ol the inner branch of the nerve. situation. One is given oil to each of the nine lower intercostal spaces upon both sides of the body. In both cases they pass outwards over the body of the vertebrae, and as they leave the vertebral column to enter the intercostal spaces, each of the vessels gives oflt a large dorsal branch, which passes backwards in the interval between the transverse processes, and is distributed to the muscles and skin of the back. From this branch a special twig is supplied through the intervertebral foramen to the spinal cord and its membranes. In each space the intercostal artery proceeds outwards, first lying be- tween the pleura and the posterior intercostal membrane, and afterwards between the muscular layers of the internal and external intercostals. These anntoniical points have been given in detail becau.se each of them 124 TUBERCULOSIS OF THE BONES AND JOINTS has important bearings upon the position which a dorsal abscess may take. The various positions which a dorsal abscess may assume are as follows : (1) It may be retained in front of the spine, behind the periosteum or the anterior common ligament (prevertebral abscess). (2) It may extend through the anterior common ligament, and invade the space of the posterior mediastinum. (3) It may pass more laterally and come to lie beneath the pleura, sometimes penetrating the jileura and producing a tuberculous empyema. (4) It may gravitate downwards beneath the ligamentum arcuatum internum, and assume the positions compatible with a lumbar abscess (see below). (5) It may make its way backwards between the transverse processes, through the weak, triangular interval, bounded by the superior costo-trans- verse and the stellate ligaments. AVhen it gets into this situation its further course depends upon whether it follows the course of the blood-vessels or the j)Oster;or primary division of the nerves. (6) Following the track of the blood-vessels, the abscess may extend along the dorsal branch of the intercostal artery, or it may pass outwards, accompanying the main intercostal vessel, and appearing on the surface, sometimes where the lateral branch is distributed and sometimes at the anterior extremity of the intercostal space. (7) When the nerves act as guides, the abscesses may follow either the internal or the external branches of the posterior primary divisions. If the external branches are followed, the ab- scess appears at some distance from the middle line, and as only the five lower nerves of this group become cutaneous, abscesses are likely to appear in the corresponding positions. When the abscess tracks along the internal branch, it appears close to the middle line, and usually in the upper seven spaces, as the lower five nerves do not become super- ficial. (8) An abscess from the first four dorsal vertebrae may follow the same course as a cervical abscess. I ^^w.^ i\lllu\Uu il]|lll P t'- Abscesses originating in the Lumbar ' ^-JJy ,lillliU\lllr Spine. — The lumbar vertebrae are peculiarly related to the attachments of the psoas, iliac, and lumbar fasciae, and FlG.14.-Therelationsofthefasci^inregar,l ^S the positions of the VarioUS absceSSeS to the iieveiopraeut of abscesses secondary are determined by these structures, it is to Pott's disease of the lumbar spine. u • ii 1 i -t xr, rni, '^ necessary brieny to describe them. Ihe fascia covering the psoas and iliacus is one continuous sheet. Above it is thin and comparatively narrow, covering over the psoas muscle, TUBERCULOUS DISEASE OF THE SPINE 125 below it expands to cover the psoas and iliacus muscles, and it becomes much denser and stronger. The attachments of the fascia are all important. Superiorly it forms the thickened band of the liga- mentum arcuatum internum, arching over the psoas muscle, and attached by one extremity to the tip of the transverse process of the first lumbar vertebra, and by the other to the body of the second lumbar vertebra, and the tendonous part of the corresponding crus of the diaphragm. Externally its attachment differs above and below the crest of the ilium. Above it is attached, externally to the fascia covering the quadratus lum- borum, the anterior lamella of the lumbar fascia. Below, when it becomes the fascia iliaca, it is firmly fixed to the crest of the ilium. Internally its attachment also varies. In its upper part it is fixed to the spine by a series of fibrous arches which bridge over the lumbar arteries ; lower down Fig. 15. — The arrangement of the lumbar fascia. The various ilivisioiis of the fascia are coloured red. it sweeps over the psoas, and is attached to the brim of the true pelvis. Inferiorly, to the outer side of the iliac vessels, the fascia becomes adherent to the fascia transversalis, when both are attached to Poupart's ligament. Behind this outer division of the fascia the ilio-psoas, the anterior crural nerve, and the external cutaneous nerve are carried downwards into the thigh. The inner portion of the lower end of the fascia is prolonged downwards into the thigh, behind the femoral vessels, to form the posterior wail of the femoral sheath. The lumbar fascia is really the posterior aponeurosis of the transversalis muscle. As the fascia approaches the spine it splits into three layers or lamellte: the posterior lamella is attached to the spine tips of the vertebrse, the inter- mediate lamella to the tips and adjacent sides of the transverse processes, the anterior to the bodies of the vertebraj at the roots of the transverse processes. Two compartments are thus formed : in the anterior the quad- ratus luinboruni lies, the posterior is occupied by the erector sjiinn?. The 126 TUBERCULOSIS OF THE BONES AND JOINTS fascia of the anterior lamella is continuous with the outer side of the psoas fascia. The lumbar arteries are arranged on much the same plan as the intercostal vessels. They proceed outwards upon the bodies of the lumbar vertebrae, and disappear under cover of the psoas muscle. In the intervals between the transverse processes they divide into a dorsal and an abdominal branch. The dorsal branch turns backwards, and after giving off its spinal twig to the spinal cord, pierces the posterior muscles, and ends in the integuments of the back. The posterior divisions of the lumbar nerves are very similar in arrangement to those described in the dorsal region. The internal branches are of small size, and their distri- bution is purely muscular. Of the external branches the upper three are of large size, and they become cutaneous by piercing the superficial lamella of the lumbar fascia. Each of the above anatomical details has important bearings upon the abscess course. (1) The disease originating in the front of the body of the vertebra may pass directly forwards, and failing to enter the sheath of the psoas, it passes behind the aorta, and extends downwards along the great vessels. It may extend by the external iliac into the thigh, or it may follow the internal iliac into the pelvis, and open by the side of the rectum or through the great sacro-sciatic foramen. (2) The disease may enter the sheath of the psoas muscle, and gravitate downwards along it until it appears beneath Poupart's ligament, at either the inner or the outer side of the femoral vessels. Menard has noticed this type of abscess extend in the thigh along the course of the internal circumflex vessels, and point behind the great trochanter. (3) The abscess may enter the sheath of the psoas muscle, but in the lower part of its course it extends outwards beneath the fascia iliaca, to appear as an iliac abscess internal to the anterior superior spine. (4) It may extend laterally into the sheath of the quadratus lumborum, and piercing the lamellae of the lumbar fascia, it becomes superficial above the crest of the ilium at Petit's triangle. (5) The abscess ma}' enter the fascial layers, further from the middle line than the quadratus lumborum, in which case it may extend forwards between the muscles as far as the anterior abdominal wall. (6) The course of the abscess may be guided by the dorsal branches of Fig. 16. — Large psoas abscess originating iu tuberculous disease of tlie lumbar spine. TUBERCULOUS DISEASE OF THE SPINE 127 the lumbar arteries, and the fluctuation appears close to the spine and often below the last rib. (7) Sometimes the disease extends along the nerve sheaths, and com- monly along the three upper of the outer divisions of the posterior primary nerves, the abscess ])ointing some distance from the middle line. The Natural Method of Cure. — Natural cure is most quickly brought about when the osseous surfaces come into contact. The period required is more prolonged when the diseased body remains intact than when it collapses, and in this respect the k}'phosis has a certain salutary influence. Before repairs can occur the tuberculous debris must be absorbed, or at least localised by surrounding fibrosis. The diseased area is replaced by fibrous tissue, and this at a later period by contraction may account for an apparent increase in the degree of deformitj^. The fibrous tissue is after- wards ossified, and until ossification is complete a cure cannot be guaranteed. The fibrosis and ossification is most prominent in relation to the body of the vertebra where the disease primarily occurred. Around the periphery of the posterior arch new bone formation may occur, binding the pedicles and occasionally the laminaj together. These evidences of repair are never met with inside the neural canal. The period of time required for complete fixation and cure varies in different regions of the spine. It is least in the lumbar spine. Under treat- ment fibrosis occurs during the end of the first year, and ossification is well marked at the end of the second. In the upper part of the cervical region the periods are longer, averaging two years and three years for fibrosis and ossification. The period is certainly longest in the dorsal spine. Fibrosis appears only in the end of the third year, and certainly the fifth year will have been completed before a proper ossification is recognisable. These facts are mentioned later in regard to treatment. Spondyl Arthritis. — In the occipito-atloid and the atlo-axoid articu- lation there are numerous synovial articulations and the pathology of tuberculous disease in these regions is peculiar. The disease begins as a synovial tuberculosis, usually in the atlo-axoid joints, subsequently it spreads beyond the membranes, and becomes an osseous tuberculosis. Tuberculous Disease origrinating* in a Portion of a Vertebra other than the Body. — Occasionally one sees tuberculous disease attack- ing the transverse process or the vertebral spine, but such occurrences are exceedingly rare. Still more uncommon is it to find tuberculous disease originating in the costo-vertebral articulation or in the joints of the articular processes. Symptoms and Physical Signs Symptoms. In eni|uiring into the history of Pott's disease, one is frequently told that tiie first thing noticed was the angulation of the spiiu'. With some trouble, however, one can usnally obtain information of a train of symptoms introductory to the actual deformity. 128 TUBERCULOSIS OF THE BONES AND JOINTS (1) Latent Period. — The original onset can frequently be traced to an attack of one of the exanthemata, and probably during the lowered resistance of convalescence the organism first gains a footing. Before any definite and specific symptoms are complained of, the child exhibits symptoms which ought to attract attention. The weight does not continue to increase, it remains stationary, or it diminishes. The general nutrition is not main- tained and the child becomes thin and pale. There are slight evening temperatures, sometimes so slight as to be scarcely perceptible. The energy is lessened. A child who has been bright and active becomes dull and listless, refuses to indulge in the games of its comrades, and complains of feeling tired after the slightest exertion. This constitutes what one may term the latent or the introductory period. It may last several weeks or as many months. (2) Pain. — The pain in Pott's disease may be of the nature of a referred pain or of a local pain. The local pain, that is to say the pain which occurs in the region of the spmal column, may be spontaneous or it may only be induced on movement or pressure. In character it is sharp and stabbing, and it is more especially localised to the actual diseased vertebra or vertebrae. When judged from the point of view of diagnostic value, one attaches less importance to it than to the referred variety. In attempting to induce the pain, Kirmisson recommends the examination of the whole length of the spine by percussion, tapping each individual spine ■with the finger. This method has two fallacies. In a nervous child the mere act of percussion produces alarm, and pain is complained of when it is not really present. Fm-ther, there are areas of the spine which one may term normally sensitive — the sixth cervical, the seventh dorsal, and the first lumbar. These areas may respond to percussion in such a way as entii'ely to mislead one. Local pain may be tested for by applying over the spine a sponge wrung out of hot water. When it is brought over the site of disease, a sudden sensation of pain is induced. Ice-cold water may be used for the same purpose, producing a similar eft'ect. Some authors have recommended the use of an electrode with a constant current. A delicate test of the presence of pain is obtained by pressure upon the transverse processes. Rotation of the bodies occurs, and pain is at once produced. In this way the fallacy of pain from pressure on the skin is got rid of. A local pain produced by movement of the spine, the pain being accom- panied by muscular rigidity, is often present. Its diagnostic significance is discussed with the clinical feature of spinal rigidity. But much more important than local pain is the presence of referred pain. As the disease in the spine develops, pressure comes to be exerted upon the nerve roots, and according as these are distributed, so is the pain referred. The pain is usually subacute, but it is subject to sudden exacer- bation. Its distribution varies when different regions of the spine are affected. In cervical disease it may be referred to the occiput and the arm. Dorsal disease is associated with sternal or intercostal neuralgia, dorso- TUBERCULOUS DISEASE OF THE SPINE 129 lumbar with epigastric and girdle pain, lumbar disease with pains in the hips and legs. In addition to the pain being referred to a certain area, the skin over the area of distribution is hypersensitive to touch and to painful stimuli. Referred pain is the most common cause of error in diagnosing early Pott's disease. Epigastric pain, for example, is frequently judged as being due to indigestion, when in reality it is the result of tuberculous disease in the dorsal spine. It has been urged that it is important to induce local vertebral pain by sudden pressure upon the vertex, the pressure being exerted with the patient erect. This is a perfectly unnecessary method of demonstration. It is painful and alarming, and any knowledge it may provide can easily be determined by less barbarous means. (3) Night Cries. — These are not so common in Pott's disease as they are in tuberculosis of the larger joints. They are sometimes met with when the disease affects the cervical and upper dorsal regions. They indicate a progressing state of the disease, and they correspond to the pathological condition in which the vertebral body has partially but not entirely collapsed. Night cries disappear quickly under suitable treatment. (4) Symptoms dependent on Paralysis. — Paralysis occasionally comes on before spinal deformity, and by doing so may cause confusion. The symptoms appear gradually. The child is noticed to trip and stumble with a quite unusual persistence, there is difficulty in going up or in coming down stairs, and the child is conscious of a progressive stiffness and tiredness in the extremities. The physical signs found upon examination are dis- cussed later, sufficient for the present to say that they are those of a spastic paralysis, with no involvement of sensation. Such early symptoms as have been mentioned should at once arouse one's suspicion of Pott's disease, and in every case of doubtful paralysis it is well to strip the child and carefully examine the back. (5) Symptoms dependent on Abscess Formation. — These vary accord- ing to the position occupied by the abscess. In cervical disease, a retro- pharyngeal abscess being the most common complication, one may find the symptoms of dyspnoja, hoarseness of voice, and difficulty in swallowing. When the disease occurs in the upper dorsal region, and the abscess takes up an anterior position, it may press upon the recurrent laryngeal nerves, producing dyspnoea and an alteration in voice. One of the best symptomatic evidences of abscess formation is found when the abscess invades the sheath of the psoas, producing irritation and contraction of the muscle. The loading symptom is tliat of difficulty in walking, owing to the persistent flexion and eversion of the limb. Physical Sig'ns. — Method of Examination of Patient. — In examining a case of Pott's disease one ought to follow a definite scheme. The results and po.ssible complications of the disease are so widespread and diffuse that it is ea.sy to overlook important facts, unless some routine is followed. (1) At one's introduction to the patient one has an opportunity of studying 9 " 130 TUBERCULOSIS OF THE BONES AND JOINTS the body attitude and gait. There are many jjoints to be learned from these as they differ in each situation-development of the disease. (2) One notes the general facial appearance and body nutrition. (3) The spine is inspected, and any irregularities noted and locahsed. (4) Some form of permanent record is made of every deformity which exists in the spine. (5) The spinal movements are tested, each tvpe of movement, and each region of the spine being examined. The movements are examined when carried out by the active muscular movements of the child, and when performed passively. (6) Certain areas of the body are carefully examined for the presence of cold abscesses. (7) The reflexes, superficial and deep, are tested, and irregularities of sensation or movement noted. (8) Compensatory changes are observed as they occur in the cranium, the thorax, or the pelvis. (9) The heart and great vessels are examined by the usual clinical methods. (10) The examination is concluded by the taking of one or more X-ray photographs, illustrative of the portion of the spine affected. Such is the scheme which one adopts, and there are no details of it which can afford to be neglected. We shall now examine each feature in detail. 1. Attitude and Gait. — Peculiarities of attitude are usually conspicuous. There is a distinctive general attitude, and it corresponds to what one may term the " spring " type. All the weight-bearing joints of the body are kept to a slight degree flexed. The child walks on its toes, the knee and hip joints are partially flexed, the head is brought down to the shoulders, and the arms hang loose by the side. It is an attitude of expectation, produced by the constant fear of sustaining a sudden shock. Every joint becomes a spring intended to minimise an injury, and all acting to lessen the impact received by the diseased spinal column. There are specific attitudes which correspond to disease in different regions of the spine. In cervical disease the position of the head is changed. It may assume a position resembling wryneck, with an approximation of the ear to the shoulder tip, but without that rotation of the face which is pathognomonic of wryneck. Sometimes the head is thrown well back and to one side. Less frequently the chin droops forwards on to the chest, and the head is supported by the palms of both hands. Sa3rre differentiates between the attitudes when the disease is in the upper or in the lower cervical region. If the upper cervical vertebrae are affected, the head takes up the position resembling wryneck. If the disease has occurred in the lower cervical or upper dorsal region, an effort is made to keep the head in balance by pushing the chin forwards and throwing the occiput slightly backwards. In the upper dorsal region the shoulders are raised, gi^ang the appearance of a sunken neck, and the shoulders and arms are thrown backwards in a stiff military attitude. Owing to the displacement downwards of the ribs, the upper part of the chest is flattened, and the lower chest and the end of the sternum project forwards. When mid-dorsal disease is present there is considerable spinal rigidity and early deformity. The attitude assumed is one of a stiff, rigid back ; both arms, which, owing to the displacement of the vertebral column, appear TUBERCULOUS DISEASE OF THE SPINE 131 longer than usual, hang down by the side. If there is much deformity Fig. 17. — The position of the head in various varieties of cervical disease. (Jones and Ridlon.) A. Wrynecli position : disease affecting upper two or three cervical vertebrce. B. Hexed position : disease affecting tlie middle cervical vertebra?. C. Extended position : disease affecting tlie lower cervical vertebrae. the thorax acquires a globular shape, with upward tilting of the ribs and displacement of the whole sternum forwards. A typical attitude is noticed when the disease attacks the dorso-luinbar Fio. 18. — Higli dorsal Pott's disease. There is the cliaracteristic elevation of the slioulders. Flu. 19. — The characteristic attitude of high dorsid disease. The short neck, tlie higli slioulder.s, and tile deep chest are well illus- trateil. and upper lumbar regions. The head and upper jjart of the body are thrown backwards. The abdomen is prominent, and the patient stands upon a broad base, with both legs well apart. He walks with what has been termed 132 TUBERCULOSIS OF THE BONES AND JOINTS the " alderman's gait," with the abdomen projecting and the chest and shoulders thrown well back. He tends to waddle slightly from side to side. Pott's disease of the last lumbar vertebra produces a deformity to which the term spondylohjsthesis has been applied. It depends upon a destruction of the body of the last lumbar vertebra, and a displacement forwards and downwards of the lower part of the spinal column. The attitude which characterises it is a very marked lordosis of the back and Fig. 21. — High dorsal Pott's disease. Fig. 20. — Dorso-liirabar Pott's disease. Tiiere is the typical "aldermau gait." projection of the belly forwards. The thorax is depressed, the last rib almost touching the iliac crest. There is a deep transverse fold, which begins upon each side above the crest of the ilium, and extends across the abdominal wall at the level of the umbilicus. These attitudes and gaits are so typical that one can frequently locate the disease in those who pass us on the street. 2. General Appearance and Body Condition. — Sufierers from this disease have the general appearance which one associates with tuberculosis elsewhere, and which requires no detailed description, but in addition they illustrate in their features the presence of a symptom which is so common in bone or joint disease, that of pain. The facies acquires an anxious strained TUBERCULOUS DISEASE OF THE SPINE 133 expression, the evidence of a persistent effort to prevent the sustaining of Fia. 22. — Mill dorsal Pott's disease. Slii^'lit deformity. Fig. 23. — Low dorsal disease with spinal rigidity and no Ijyphosis. Fio, 24. — Liow dorsal I'ott's diseiise with marked deforniitv. Km. 25. — Low dorsal Pott's disease. the slightest jar. The general nutrition of the bod}' is poor, and while the disease is progressing the weight probably diminishes. 134 TUBERCULOSIS OF THE BONES AND JOINTS 3. Inspection of the Spine. — For this purpose the child should be stripped. In older children a loose skirt may be fastened around the hips in such a way as to expose the whole extent of the spine. Running one's eye Fig. 26. — Donsal Pott's disease, with slight scoliosis. Fig. 27. — Dorsal Pott's disease, with marked scoliosis. along the vertebral column, one may have the attention attracted by four possible changes : (a) A posterior angulation of the spine affecting one or Fig. 28. — Early kyphosis in Pott's disease. Fig. 29. — An unusual form of gibbosity in Pott's disease. more vertebrae ; (6) A lateral deviation of the spinal column ; (c) An unusual degree of " boarding " or flattening of the spine ; (d) An abnormal amount of spinal lordosis. (a) Posterior Angulation of the Spine. Kyphosis. — This is the most strik- TUBERCULOUS DISEASE OF THE SPINE 135 ing of the deformities, and by it the disease usually declares itself. It is the result of the collapse of the body of one or more vertebra?. If a single vertebra is destroyed the angulation is sharp, and produced by the knuckle- like prominence of a single spine. When the disease has occurred in several vertebrae the projection is more rounded and diffuse. One expects the amount of displacement to be greatest in the dorsal spine, less in the cervical, and least of all in the lumbar region. There is a diffuse superficial tj^pe of tuberculous disease which extends over the bodies of a number of vertebrae, and gives rise to a gradual kyphosis, very strongly resembling the simple round shoulders of adolescence. (6) Lateral Deviaiioti- of the Spinal Column. Scoliosis. — It is by no means true that the curvature of Pott's disease is invariably angular and in the middle line. In a considerable proportion of cases, and more especially Via. 30. — Active He.\iou of the liealthy spine showing a iiniforni and conipletc curve. in the lumbar region, the destruction of the vertebral bodies is irregular, and the result is a lateral deviation of the spine, which may in some respects resemble a scoliosis. In these cases, in almost every instance an angular curvature by means of which one may distinguish and classify the disease is added. There is another variety of lateral deviation found in Pott's disease which is liable to cause confusion, that is the type of lateral deviation which occurs at the very commencement of the disease, before there is any appear- ance of a kyphotic curvature. At first sight the superficial resemblance of this condition to a simple scoliosis may be very striking. It may be recognised by its rapid onset, and the concurrence of pain and muscular rigidity (c) " Boarding " or Flattening of the Spine. The hoaitliy spine ought to present a series of uniform curves. An interruption of those curves, as in- dicated by :iii area of flattening, is evidence of some underlying muscular 136 TUBERCULOSIS OF THE BONES AND JOINTS rigidity, and the muscular siJasm is itself the result of disease of the vertebral column. It is one of the most valuable clinical evidences, because it is perhaps the earliest to make its appearance, and because it distinguishes tuberculous disease so absolutely from simple deformities. The phenomenon becomes more obvious when the movements of the spine are tested. Its distribution is guided by the situation of the disease, but it affects the muscles for some distance upon each side of the lesion. The explanation of the muscular spasm which produces the rigidity is simply that it is an attempt to im- mobilise the diseased spine, and so to lessen the amount of injury which it is Fk;. -il. — Passive extension in a healtliy spine. J^ote the free and nnil'orm curve. liable to receive. There are very few conditions which simulate the rigidity of tuberculous disease. It is found occurring in acute and subacute infections of the vertebral column, and in the more painful varieties of scoliosis. {d) Abnormal Degrees of Sjnnal Lordosis. — When a kyphosis occurs in the spinal column, the alteration which the displacement must produce in the axis of the body is compensated by lordotic cm-ves in other situations. There is a lordosis above and below the lesion, produced at first by muscular action, and later by an adaptation in the shape of the intervertebral discs. Cervical disease is accompanied, not by an actual lordosis of the dorsal spine, but by a considerable lessening of the normal kyphosis. The lumbar region, however, shows an increased compensatory lordosis. A tuberculous dorsal TUBERCULOUS DISEASE OF THE SPINE 137 kyphosis is compensated by exaggerated lordotic curves in the cervical and lumbar regions. When the disease occurs in the lumbar region, while there can be compensation above, no lordosis can exist below. Its place is taken by a hyperextension at the hip-joint. 4. The Taking- of some Form of Permanent Record of the Spinal Deformity. — It is exceedingly important to keep some permanent record of the spinal deformity, for it is obviously necessary to know at some future visit whether the deformity has increased or receded. The outlines may be cut from stiff paper, and corrected by refitting it against the spine. The actual pattern may be kept for future reference, or its outline may be transferred to soft paper,' which can be rolled up into small bulk. A simple method is to use a strip of lead about eighteen inches long and half an inch Flu. 32. — Young's apparatus for recorJing the extent of a spinal deformity. wide and an eighth of an inch in thickness. This is laid along the spine and carefully moulded to the outline of the deformity. From it a tracing is made upon paper, and the tracing is kept for future use. Dr. (i. B. Young of Boston has introduced an ingenious device, by means of which the spine outline can be rapidly delineated. It consists of a wooden bar, with a slot, in which a number of pieces of wood of equal lengths play, the whole being clamped in place by a screw at one end. When the apparatus is set upright against the spine, and the screw loosened, the individual pieces of wood adjust themselves to the outlines of the spinal column. When the screw is tightened, the exact outline is retained until it has been transferred permanently to paper. A useful apparatus has been introduced by Beely. It consists of a series of horizontal movable rods, fixed in a vertical stand, and capable of apposition to the outline of the spine when the patient stands erect. The pattern is transferred from the rods to paper. 138 TUBERCULOSIS OF THE BONES AND JOINTS If in addition to the kyphosis there is some scoUosis, both deformities cannot be recorded upon the same scheme. A separate impression must be taken of the scoliosis. This is conveniently done as follows : A long strip of netting about 18 inches long and 4 inches wide is used. The netting has a half-inch mesh, and running lengthwise along its centre a coloured line is marked. The material is held along the spine in such a way that the median line lies exactly in the centre of the body, as judged by the seventh cervical vertebra and the natal cleft. The line of the scoliosis is marked out upon the netting with ink. In this way a permanent record can be kept, and the state of affairs compared at intervals. Ebner ^ records the amount of lateral deviation by laying a strip of adhesive plaster, 3 inches wide, along the spine. Upon this the spinous processes are marked and outlined, and the plaster backed with brown paper for future reference. Fir. 33. — Free lateral luoveinent of the liealtby spiue. Fig. 34. — Passive e.\tension of the sjiine demonstrates "hoarding" due to dorso-lumbar Pott's disease. 5. Examination of the Movements of the Spine. Muscular Rigidili/. — The possible movements which the spine can carry out are those of flexion extension, and hyperextension in the sagittal planes, lateral flexion in the 1 Ebner, Archir. pedirilr.. Feb. 1900, 07, and vi. 391. TUBERCULOUS DISEASE OF THE SPINE 139 coronal plane, and rotation or torsion about its own long axis. Lateral flexion and rotation cannot exist as isolated movements, they are inter- dependent upon one another. When tuberculous disease occurs in the vertebrae, it gives rise to a rigidity in the long para-spinal muscles, chiefly the erectores spinse, and the resulting rigidity necessarily interferes with the carrying out of the proper spinal movements. Therefore, of all signs of vertebral disease, muscular rigidity is the most characteristic. While the interference with movement is evidenced in all the movements, it is most striking when those in the sagittal direction are performed. In each region of the spine each individual type of movement ought to be examined. The Cervical Spine. — In the cervical spine free flexion and extension are permitted between all the cervical vertebrae, and nodding movements Fig. 35. — Positioutestfornervicaldisea.se. Tlie patiiMit lying prone, tlie head ia not allowed to bend forwards. (.Jones and Ridlon. ) Fi(i. 36. — Position test for cerviial disease. Tlie patient lying supine, the head is not allowed to hang. (Jones and Kidlon.) of the head are permitted at the occipito-atlantal articulation. Lateral flexion is free throughout the cervical region. Rotatory movements take place chiefly at the atlanto-axial joints, and to a slight degree in the lower cervical vertebrae. In young children it may be exceedingly difficult to persuade them to carry out voluntarily the various movements, but often a simple manoeuvre overcomes the difficulty. Place the child on its back across its mother's knees, so that the head projects without support ; if the spine is healthy, extension is carried out, and the head falls back. By reversing the position and placing tlie cliikl face downwards flexion is tested, and in one or other lateral posture lateral flexion is brought into i)lay. Even the youngest child can be persuaded to carry out rotation by the judicious exhibition in varying positions of attractive bright objects. The movements are tested passively by moving the head in the direction required. Oroat care nuist be exercised in doing this to avoid any degree 140 TUBERCULOSIS OF THE BONES AND JOINTS of force, as when the disease attacks the atlo-axial articulation, even a slight strain might produce death by rupturing the transverse ligament, and per- mitting dislocation of the odontoid process and pressure upon the spinal cord. When disease attacks the vertebrae of the cervical spine or the synovial sacs at its upper extremity, there is produced a limitation or total abolition of the spine movements, and a certain degree of muscular rigidity. The muscular rigidity is more difficult to appreciate than when it is lower down in the spine, but it may be appreciated by laying the palm of the hand across the posterior part of the neck. Flexion and extension and lateral flexion are limited in whatever part of the cervical region the disease may appear. Rotation is only moderately affected, unless the disease has involved the atlanto-axial joints. The Dorsal Spine. — All four movements are carried out by the dorsal spine, and it is easy to demonstrate any rigidity which may exist. The various active movements are attempted, and any limitation can at once be noticed. The flexion movement is the more valuable, and while it is being performed, the spine tips ought to be marked out with colour. In the rigid portion of the spine it will be noticed that there is no widening of the spaces between the colour dots as ought to occur in a healthy spine. While the part is moving the hands ought to be laid upon each side of the spine, and they appreciate the fact that where the disease exists several of the vertebrae move en bloc. In testing the active movements, it is a common manoeuvre to get the child to pick something up from the floor. The act is performed with none of the quickness and the agility of health, but with a slow, deliberate action. Instead of bending the back the joints of the lower limbs are bent, and the trunk is supported by placing both hands upon the knees. In recovering the erect position the hands are used to climb up the thighs in much the same way as one finds occurring in pseudo-hypertrophic paralysis. Another favourite method of testing flexion is to ask the child while it is sitting up to touch the toes of its extended legs. When examination of the active movements is completed the passive movements are tested. The child lies completely prone, with the elbows flexed and the arms by the sides. The lower limbs are grasped by the ankles, and gradually raised into the air. As the lower limbs are raised the spine ought to sink into an almost uniform curve. When disease is present the curve is not uniform.' A portion of the spine remains flat and rigid, and the trunk is lifted from the table with the lower Hmbs in order to prevent any sinking of the column. The Lumbar Spine. — Examination of the lumbar spine is carried out in a manner similar to that used in the dorsal region. The presence of rigidity is best tested by raising the lower extremities. By this act the healthy lumbar spine ought to be hyperextended ; in disease it remains stift' and rigid. In judging of the value of lumbar rigidity, the close relationship of the psoas muscle to the lumbar spine must be borne in mind. Anything TUBERCULOUS DISEASE OF THE SPINE 141 which by irritation produces spasm of the psoas will certainly give rise to rigidity of the lumbar spine. One has seen typical lumbar rigidity produced by the tracking abscess of high dorsal tuberculous disease and by an acute pelvic-rectal abscess which had entered the sheath of the psoas muscle. Palpating the spine at this stage one may be able to recognise the presence of thickening around the spines or transverse processes. 6. Examination of certain Areas for the Presence of old Abscess Formation. — The formation of these and the course most usually followed have been discussed. The back of the throat, sides of the neck, iliac fossae, loins, Poupart's ligaments, Scarpa's triangles, and the regions of the gluteal folds are carefully palpated for swelling and deep fluctuation. By percussion and by X-ray examination a mediastinal or prevertebral abscess may be discovered. A psoas abscess may be suspected before it becomes palpable by the rigid psoas muscle preventing hyperextension of the hip. 7. Examination for Paralysis. — The j^aralysis is a motor one, involv- ing usually the lower extremities. The bladder and rectum are rarely affected, and it is unusual to have any sensory disturbance. It is the result of pressure upon the spinal cord, and one has mentioned the various means by which pressure may be exercised. It is often secondary to high dorsal disease because in this situation the spinal canal is narrowest. At first the paralysis is a spastic one, but when the degeneration of the cord becomes advanced the paralysis is complete. In low dorsal and lumbar disease the paralysis affects the lower limbs and sometimes the sphincters. In this situation the paralysis may be complete from its beginning, or it may rapidly pass from the spastic to the flaccid variety. In dorsal disease there is a spastic paralysis of the lower limbs ; it is unusual to find the sphincters affected. If the disease is in the cervical region, the arms may suffer before the legs. In specially high disease — occipito-atlantal disease — the diaphragm may be paralysed, also the spinal accessory and hypoglossal nerves. In the examination a complete investigation must be made of the various nerve functions. Motor functions are tested by movements and walking. If early paralysis is i)rpsent, movements are carried out in a mi.sguided and jerky manner. The child walks badly, with a tendency to lose equilibrium and to stumble, the toes being dragged. Sensory dis- turbances may be subjective in the form of dull aching pains in the body and limbs. Objectively an actual loss of sensation may be demonstrated. The reflexes superficial and deep are exaggerated, especially the deep re- flexes of the knee and ankle. If the cord is degenerated, or if the lumbar enlargement is involved, the refle.xos are absent. Examination of the sphincter may show that incontinence of urine and faeces occurs. There may be trophic disturbances, the affected muscles become wasted, bed sores are not unconnnon, and arthropathies may occur in the larger joints of the extremities. Vasomotor disturbances show them- selves in the form of per'^istent coldness of the limbs and a tendency to free perspiration. In special regions specific nerve lesions may appear, for 142 TUBERCULOSIS OF THE BONES AND JOINTS example, in cervical disease the cervical sympathetic may be afEected, pro- ducing at first dilatation of the pupil, and afterwards contraction, and in many cases flushing and sweating of the face upon one side. 8. Compensatory Chang-es in the Cranium, Thorax, and Pelvis. — These have been fully discussed in the section on pathology. The changes are now studied from a clinical point of view. The alteration in the position of the head, the possible changes in the obliquity of the ribs and sternum, and the distortion of the pelvic girdle, all should be noted. 9. Examination of the Heart and Great Vessels. — When a kyphosis occurs in the dorsal region, the alteration in the internal anatomy of the thorax may very seriously affect the heart and the large vessels. By the usual methods of clinical examination, the presence of cardiac hypertrophy and dilatation are discovered, valvular disease is sought for, and the relative condition of the large blood-vessels investigated. 10. X-Ray Examination. — "When clinical examination has aiiorded its information, one's knowledge of the case is completed by X-ray examination. Certain facts are learned which otherwise might remain obscure. The degree of the disease is estimated, and its extent is depicted. The presence of an otherwise unsuspected prevertebral abscess may be demonstrated and the situation of sequestra divulged. When the disease is healing, X-ray exam- ination will yield information of how the cure is progressing. The radio- graph is taken antero-posteriorly, but in the cervical region a lateral view is necessary in order to expose the upper true vertebrae. Antero-posteriorly they are concealed by the presence of the lower jaw. Symptoms and Sigrns in Special Reg-ions. — The symptoms and signs vary in different parts of the spine, and while they have been discussed generally, it is necessary to individualise in sjiecial regions. (a) Upper Cervical Disease. — Here the disease really begins as a syno- vitis, involving the occipito-atloid and atlo-axoid articulations, from which it spreads to the underlying bones. The odontoid process is early affected, and also the anterior arch of the atlas. In the introductory stages of the disease the leading symptoms are those of difficulty in moving the head, local pain over the sjDine, and referred pain radiating about the back of the head and along the course of the upper cervical nerves. Pressure upon the vertex causes pain, the movements of nodding and rotation are limited or abolished, there may be a deformity which closely resembles wryneck, and the hollow of the suboccipital region frequently becomes filled up. In the absence of treatment the amount of pain increases, the weight of the head becomes unbearable, and the patient supports his head on his hands or by lying down. An abscess may form and take up the position of a retropharyngeal collection or of an accumulation in the suboccipital region. At any moment grave symptoms of spinal compression may appear as the result of a thickening of the soft tissues or of a displacement of the bones. In the latter case the odontoid process is most frequently to blame, and immediate death may occur. Much more commonly the paralysis TUBERCULOUS DISEASE OF THE SPINE 143 comes on as an increasing feebleness of the limbs, the arms being usually first affected and then the lower extremities. WTien recovery takes place, ankylosis is usually the result. (6) Cervical and Cervico-dorsal Disease. — In this region the spinal rigidity is very apparent, and there are probably the associated deformities of wry- neck, shortening of the neck, and angular curvature. In upper dorsal disease the position of the ribs becomes altered, and they pass almost vertically downwards, reducing the antero - posterior diameter of the thorax. Pain is present, and it is referred to the branch distribution of the cervical or brachial plexuses. If abscesses appear they are retro- pharyngeal, supraclavicular, or mediastinal in position. Cord pressure effects are iiot so common as in the other regions of the cord. If they occur the upper extremities are usually first affected, and afterwards the lower limbs. Very often there are nerve pressure effects, pupillary changes from sympathetic pressure — myosis or mydriasis — recurrent laryngeal and vagus effects, as evidenced by cough, slow pulse, vomiting, etc. There may be the characteristic signs of turning the head and body to look at an object, and in upper dorsal disease the grunting breathing which denotes pressure on the intercostal nerves. (c) Dorsal and Dorso-lumbar Disease. — The deformity of the spine is usually striking, and from the displacement upwards of the ribs and the projection forwards of the sternum, the antero-posterior diameter of the thorax is increased. There may be local spine pains and referred pams which are of the girdle variety. Sometimes pains are referred down the lower limbs. Paralysis is common in disease of the mid-dorsal region ; it is not so frequent in lumbar disease. When the pressure is at the level of the lumbar enlargement the limbs remain flaccid, the reflexes are feeble or abolished, and there is incontinence of urine and faeces. (d) Lumbosacral Disease. — There is usually only a slight amount of deformity. Sometimes a vertebral thickening indicates the site of the disease. Occasionally the somewhat rare deformity of spondylolysthesis occurs. The pelvis is apt to be deformed, and in children it may become funnel-shaped. Pain is present, and it is referred chiefly to the outer side of the thighs. The nerve troubles which result are due to neuritis, and therefore they are chiefly local in their distribution, affecting iiulividuai groups of nuiscles which are not necessarily symmetrical or bilateral. Diagnosis of Pott's Disease The diagnosis of Pott's disease offers few ditliculties if deformity is present, but from the point of view of successful treatment it is essential that the disease should be recognised while it is in its earliest stages. The diagnosis is made to a certain extent from the history, but more especially from the physical examination. The most important point in history is 144 TUBERCULOSIS OF THE BONES AND JOINTS the occurrence of referred pain, referred to the arms or legs or the anterior middle line of the body. Sternal or epigastric pain in a child should at once suggest the possibility of Pott's disease. Referred pain is of more value than local pain as a diagnostic feature. More productive than symptom- atology is the physical examination. Muscular spasm is one of the first signs to appear. In exceptional cases its duration is a short one, and it may be overlooked, but it occurs at some period in every instance. It should be evidenced on active and on passive movement. When the angular deformity is visible the diagnosis may be said to be removed beyond doubt. Abscess formation may be among the first signs of Pott's disease, and it is important to remember that a cold abscess may appear suddenly : even in the course of a single night. This more especially happens when the abscess appears in a dependent position. It remains to mention the importance of recognising early spastic paralysis ; it may appear before there are any other evidences of spinal disease. The type of Pott's disease in which compression symptoms come on without any vertebral irregularity may give rise to considerable difficulty in diagnosis. The subject is exhaustively dealt ■nnth by Alquier,^ whose papers ought to be consulted. An X-ray examination is unnecessary for making a diagnosis in the majority of cases, but in doubtful instances it may be of inestimable value. Differential Diagnosis. — The differential diagnosis only presents difiiculties in the early stages, and at this period many experienced surgeons , have been at fault. There are cases which appear to conform to no rules, the symptoms of which appear absolutely contradictory. Tuberculous disease of the cervical spine may be confounded with : (1) Torticollis. — This one recognises by the presence of shortened muscles and fasciae, the rotation of the face towards the opposite shoulder, and the hemiatrophy of the face. (2) Stiff Neck, Acute Wryneck. — The attitude of this condition may strongly suggest cervical caries, but it may be distinguished by the acuteness of its history, and the rapidity with which it yields to treatment. In the upper dorsal spine simple round shoulders with stiffness may simulate Pott's disease. The former lacks the muscular spasm of the tuberculous condition, and any dubiety remaining may be removed by the use of the X-rays. Dorsal Pott's disease is simulated by : (1) A Rachitic Kyphosis. — The points of distinction in favour of rickets are the absence of muscular spasm, the non-existence of pain, and the evenness of the kyphotic curve. (2) Simple Scoliosis. — The diagnosis of this condition is generally easy. There is usually absence of muscular rigidity and pain, and the rotation of the vertebrse and ribs produces the typical posterior rib hump. In scohosis ' Alquier, Gaz. des hopitaux. May 19, 1906, and Feb. 19, 1907. TUBERCULOUS DISEASE OF THE SPINE 145 the ribs rotate backwards on the convex side, in caries on the concave side. (3) Syphilitic Kijphosis. — This condition is rare in children, and it can only be distinguished by the occurrence of other sypliihtic phenomena. (4) Spinal Neuralgia. — An error which is frequently made consists in confoundinji; vertebral disease with what has been called spinal neuralgia. This latter occurs in nervous young girls, and there are many features which differentiate it from tuberculosis. The pain is much more diffuse, and extends over a considerable part of the vertebral column. It is more superficial and much more acute. The rigidity so characteristic of Pott's disease is entirely absent.' (5) Anatomical Abnormalities. — In the lower dorsal region an anatomical abnormality is sometimes met with which may raise difficulties in diagnosis. The abnormality consists in an unusual prominence of certain of the verte- bral spines closely simulating a kyphosis. The physical examination is sufficient to establish a distinction. The Lumbar Spine is the situation in which the most difficulties in diagnosis arise. There are several reasons for this. The lumbar vertebrae are more deeply situated, and physical signs are therefore apt to be masked for a considerable time. The movements of the lower part of the spine are so limited that neither sjinptoms nor deformity may constitute prominent features in the case. Confusion may arise with the conditions which have been mentioned in the diagnosis of dorsal disease. In addition there are certain difficulties which are peculiar to this situation. (1) Hip-joint Disease. — It might seem impossible that this could be mistaken for lumbar disease, but mistakes are frequently made. From a focus in the lumbar spine a cold abscess tracks its way into the psoas muscle and sheath. Contraction of the psoas is set up, and there is produced a deformity of the leg with flexion and eversion of the thigh. Superficially the attitude resembles that found in hip-joint disease. The most satisfactory method of differentiation is that of testing the movements of the hip. In coxitis all the movements are limited or abolished. In the pseudo- coxitis of lumbar disease extension and hyperextension are the only move- ments which are markedly interfered with. In exceptional instances lumbar disease and hip disease may co-exist. Parsons ' draws attention to a most important point in the differential diagnosis of hip disease from spinal caries. The distinction is based upon the principle laid down by John Hilton, that the same trunks of ncrvt^s, the branches of which supply the groups of muscles moving any joint, furnish also a distribution of nerves to the skin over the same muscles and their insertions, while the interior of the joint receives its nerves from the same source. A hip-joint may be fixed by muscu- lar spasm, which is the result, not of disease of the joint, but of irritation of the nerve trunks by a lumbar caries. A distinction is made by noting the distribution of the cutaneous pain. In lumbar disease the affected cutaneous ' Parsons, B.M.J., I'JIO, ii. 112(1. 10 146 TUBERCULOSIS OF THE BONES AND JOINTS distribution would include the fi-ont of the lower part of the abdomen, the front of the thigh, the region over the great trochanter, and to the inner side of the knee. In hip disease, the cutaneous affection, in addition to the above, includes the distribution of branches of the sacral plexus, because the interior of the joint is partly supplied by branches from the nerve to the quadratus femoris and from the great sciatic. The cutaneous distribution of these branches is limited to the skin over the buttock and the upper and back parts of the thigh. (2) Sacro-iliac Disease. — Sacro-iliac disease is distinguished by the absence of spinal rigidity and the elicitation of pain at the synchondrosis by pressing the two iliac bones together anteriorly. (3) Perinephritis and Perityphlitis. — These in children may simulate Pott's disease, because they are associated with contraction of the psoas muscle. A distinction is made by examination of the spine, the abdomen, and the urine, and by an X-ray investigation. If there is much difficulty in coming to a diagnosis it is a good plan to temporise, keeping the child in complete recumbency for a few days. Pott's disease remams unaltered at the end of the period. Simulating conditions may have disappeared. Prognosis in Pott's Disease The prognosis as regards life is good. Tuberculous meningitis, for example, claims fewer victims in Pott's disease than it does in hip-joint disease. If death should occur the causes in addition to meningitis are' pulmonary tuberculosis, acute miliary tuberculosis, amyloid degeneration of the spleen, liver, and kidneys, and exhaustion. The prognosis is exceedingly grave when the disease occurs during the first two years of life. The life prognosis is endangered by formation of abscesses, sinuses with mixed infection, and the spread of tubercle elsewhere. The ultimate duration of life is not a long one. Neidert ^ has shown that of all cured cases of Pott's disease attaining adult life, the total expectation of life was not more than 49| years. This is almost entirely the result of kinking and displacement of the larger vessels, with consequent hypertrophy and dilatation of the heart chambers. The prognosis as to the amount of deformity depends very largely upon the condition of the spine at the time treatment is begmi. If the disease is early, appropriate and thorough treatment ought to prevent any marked degree of kyphosis occurring. If a kyphosis has occurred, but has not yet become a fixed one, corrective measures may be employed to diminish the deformity. As regards the effect of the situation of the disease, cases of cervical and lumbar caries recover with less deformity than do the dorsal ones, on account of the physiological lordosis which is already existent, and — this applies to the lower lumbar spine — the slight degree of movement which occurs. ^ Neidert, Inaugural Dissertation, Munich, 1886. TUBERCULOUS DISEASE OF THE SPINE 147 The prognosis of the duration of treatment varies considerably in dorsal disease, it probably should not be less than four to five years. In cervical and lumbar disease, for reasons stated above, the duration often does not exceed three years. Treatment of Pott's Disease The treatment of Pott's disease is general and local. General Treatment. — The principles embodied in this line of treat- ment have been already fully discussed. The patient should have an abundance of nourishing food, and be kept out of doors as much as is possible. As recumbency is an important factor in the local treatment, a spinal carriage must be provided in which the patient can be wheeled about from place to place. The whole day is spent out of doors, and at night the child should sleep in a shelter, which during winter may be artificially heated. Under conditions such as these, children improve very rapidly. The use of drugs is unsatisfactory, with the exception of these which act as general tonics. Local Treatment. — The principles underlying the local treatment of Pott's disease aim at removing from the focus the dangerous influences of movement, weight, and pressure ; to fix the spine, as it were, in splints, and having fixed it, to hold it so. The Principles of Mechanical Treatment.— Normally the weight of the head, and often the weight of the thoracic and abdominal viscera, tend to bend the spine forwards and downwards. This is resisted by the posterior spinal muscles. If the body of a vertebra becomes destroyed, the tendency to bend is increased, and the pressure of superincumbent weight in the upright posture is a most important factor in the production of the deformity. Therefore the principles in mechanical treatment are : (1) To support the back and to prevent further bending ; (2) To extend the back, and so diminish the strain on the posterior muscles ; (3) To apply traction, and thus prevent antero-posterior deformity. Local treatment may be divided into two groups : (.4) Treatment by recumbency ; (B) Ambulatory treatment. The value of each varies accord- ing to the age of the patient, the state of the disease, and the portion of the spine affected. A. Recumbency. — This method consists in keeping the patient lying in such a position that movements of the spine are abolished, and all weight bearing is removed from the vertebra). Indications. — The indications for its use are as follows : (1) In cases of Pott's disease which come under treatment before a spinal deformity has appeared. (2) Whenever the symptoms are acute (pain). (3) When am- bulatory treatment has been tried and has failed to give satisfaction. (4) When paralysis has appeared, or is threatening. (5) When the spinal disease is complicated by a lateral deviation or a p.soas contraction, either of which complications render an ordinary support inefficient. (6) When abscess formation has occurred. 148 TUBERCULOSIS OF THE BONES AND JOINTS Explanation of Benefit. — The question may be asked, What is the reason of the improvement which results from the treatment ? That there is great improvement is obvious to every one who has seen the method employed. The pain disappears, the irritability diminishes, the patient gains in weight, and the face loses its anxious tense expression. The explanation of the improvement may be said to be a double one. Tuberculous disease is an inflammatory lesion, and in common with all inflammatory lesions, it benefits from the provision of complete rest. Recumbency ensures this rest. The second explanation depends upon the counteraction of muscular spasm. Muscular rigidity is the result of a certain degree of destruction of the body of the vertebra. Essentially it is protective, being nature's method of lessen- ing the possible movement of the diseased part, but actually it is productive of further harm. The eroded vertebra, imder the constant strain of the contracted muscles, gradually gives way. As it does so, the diseased bone surfaces come together, and a further reflex spasm is set up, in fact a vicious circle is brought into action. When the vertebral body has partially collapsed the shortening of the anterior spinal muscles places these at a mechanical advantage over the posterior ones, and the continued contrac- tion of the former increases and aggravates the deformity. If recumbency is properly carried out, it provides more than simple rest to the spine ; it ought to provide some degree of counter-extension, an opening out of the collapsing vertebra, and a lengthening of the contracted anterior muscles. The muscular balance is restored, the spinal deformity is lessened, and as the diseased surfaces do not now irritate one another, the symptoms are relieved. Disadvantages. — There are certain disadvantages associated with re- cumbency. When the case is an out-patient, with imperfect home condi- tions, it is exceedingly difficult to ensure that the treatment is being thoroughly and conscientiously carried out. Yielding to the entreaties of the child, an unscrupulous mother will allow the child to sit up in spite of the most solemn warning of the danger it may entail. Parents frequently complain of the trouble which there is in carrying the child about. Un- doubtedly this is a disadvantage ; it may be minimised by the use of a spinal carriage or go-cart. In many of the reciimbent methods nursing is carried on at a disadvantage. This, however, does not apply to the more recent introductions. Advantages. — The advantages far outbalance the disadvantages. They are the relief of pain, the arrest and improvement of the deformity, the gradual improvement of paresis, and the arrest of the increase in size of an abscess. Appliances. — Of the various appliances for securing recumbency, mention will be made of a simple bed prepared for recumbency ; Tubby's spinal pillow ; Fisher's frame ; the double Hamilton splint ; the double Thomas splint with head - piece ; Bradford's bed frame ; "WTiitman's stretcher frame ; the plaster bed of Lorenz and Hoffa ; GauvaLn's spinal board ; the back door splint ; the wheelbarrow splint. TUBERCULOUS DISEASE OF THE SPINE 149 Fig. 37. — Bed arranged for the recumbenuy treatiueut of Pott's disease. Special Requirements. — Any application to be suitable must fulfil four requirements : It must permit of easy nursing ; it must ensiue absolute rest to the spine ; the apparatus when applied should provide a certain degree of hyperextension of the vertebral column ; if double extension is necessary, the splint must be of such a kind that extension apparatus can be easily applied to it. Each type of apparatus will now be examined in detail. Bed specially adapted to Reciimbency. — There are patients who refuse to allow any treatment which is associated with the ap- plication of splints, and yet are quite willing to undergo recumbency as long as it is carried out in bed. For this reason, and occasionally for that of expense, it becomes necessary to fit up a bed in such a way that the treatment is possible. The bed employed must be a narrow one, as it facilitates the nursing ; and it ought to be provided with wheels in order to permit of the patient being wheeled into the open air. It is essential that the patient should lie upon a firm, unyielding surface, otherwise sagging of the spine and increased deformity will occur. A suit- able surface is provided by placing beneath the mattress an ordinary broad fracture board. The usual head pillows must be removed, but two small oblong pillows ought to be attached to the sheet in such a way that they lie one on each side of the vertebral column, opposite the kyphosis. A simple ring pad may be allowed, to prevent pressure upon the back of the head, but there must be no employment of air or water cushions. The position of the patient in bed is a matter about which there is difference of opinion. In cervical caries, when extension becomes necessary, the dorsal position is essential, but when disease attacks the dorsal or the lumbar spine, either the supine or the prone position may be chosen. The supine position is the more comfortable, but it may tend to aggravate a deformity. The prone position is certainly uncomfortable, but it diminishes muscular spasm, it counteracts the deformity, and it certainly lessens the congestion of the spine. The clothing worn by tlie patient is important. Flannel ought to be used, and the garments ought to take the form of night- gowns, which can be put on from the front and button at the back. Some form of retention apparatus requires to be fitted to the bed. Efficient fixation is given by two broad straps, one passing across the chest at the level of the upper chest, and ringed to fit each shoulder, the other passing at the level of the iliac bones. Both of these straps are made cheaply, 150 TUBEECULOSIS OF THE BONES AND JOINTS yet quite efficiently, of strong canvas. When they are fastened, the buckles must be upon the under part of the bed, otherwise they are being continually undone by the child. If it is considered desirable to fasten the lower limbs, Fig, 38. — Head extension .applied for tuberculous disease of the cervical spiue. they are best secured by a simple ring or clove hitch round the ankle, fastened by a strap to the lower posts of the bed. Narrow sand pillows must be Fig. 39. — Tubby's spinal pillow. available in case it is necessary to fix a part, and wooden blocks are required to tilt the end of the bed dming extension. \Mien extension becomes necessary it may be applied as single or as TUBERCULOUS DISEASE OF THE SPINE 151 double extension. When it is applied to the lower extremities, the foot of the bed is raised to provide the counter-extension of the body. The limbs are extended by weights passing over pulleys, or by elastic bands fastened to the limbs and to the foot of the bed. In head extension the upper end of the bed is raised, and a bridle attached to the head, with straps passing beneath the chin, below the occiput, and around the forehead. The point of junction of these straps is fastened upon each side of the head to a weight apparatus. Tuhby's Spinal Pillow. — Tubby has introduced a pillow which is a com- fortable and useful means of treatment. His own description of the article is quoted : ^ I have designed and largely used a pillow, which is placed beneath the seat of the disease and for some distance above and below it. It is convex from above downwards, and is centrally grooved in the same direction so as to receive the spinous processes, whilst pressure is made upon the transverse processes. It is stifiened in the required situations with felt. To each side of the pillow two pieces of stay material are attached. The upper pieces from each side are of such a size and so provided with lacing that they can be laced across the chest, and help to keep the child recumbent. The lower pieces on each side are fixed by safety pins, or by stitching them to the sheet and mattress so as to prevent movement or any attempt at turning over. If the pillow itself is covered with macintosh it is easily cleaned. After a month or so it requires making up again, as the effect of constant pressure is to flatten it. Its use prevents deformity in early cases, and helps its recession and sometimes its disappearance. This apparatus has one disadvantage in so far as it is difficult to fit it up with extension appliance. The difficulty which is ex- perienced in providing exten- sion on a bed or pillow may be obviated by using a Fisher's Bed Frame, in which the extension is carried from the shoulders, and fixation at the same time secured. From the extremities of a transverse bar, which lies above the head, two vertical bars are hinged in such a way that they extend down- wards one along each side of the body ; where they pass beneath the shoulders, leather loops arc attached, through which the patient's arms are passed ; from the transverse bar two leather or elastic bands extend to the bed rail. It is a cheap and an easy fitting ' Tubby, loc. sup. cit., vol. ii. p. I Kl. Fiii. 40. — Kislier's beil-fraiue lor the tiTiitinciil of Pott's (liauase by lecumbeiicy. The frame keeps the patient ill tile reeiiiiibeiit jmsitioii. 152 TUBEECULOSIS OF THE BONES AND JOINTS appliance, but the degree of recumbency which it induces is insufficient unless it is combined with body bands of some description. The Double Hamilton Splint. — In out-patient hospital work this is a favourite type of splint, its chief recommendation being the easiness and rapidity with which it can be made, and the comparative cheapness of the completed article. It can only be employed in mid-dorsal and dorso-lumbar disease, and at best it provides but imperfect fixation. Two pieces of wood extend one upon each side of the body, from the axillae to about six inches Fig. 41.— The double Hamilton splint. Fig. 42. — The double Thomas splint for use in Pott's disease or double hip disease. beyond the feet. These two lateral halves are fastened together by a transverse bar, which extends between the lower ends at a level just above the heel. The distance between the lower ends of the splint varies, but the most suitable position for nursing is one of slight double abduction. The contact portions of the splint are well padded. The limbs are fastened to it by ordinary roller bandages, the body by means of a binder. The special disadvantages of the splint are its non-control of the upper part of the vertebral column, the posterior sagging of the spine, and the trouble which there is in securing the bandages. The Double Thomas Splint. — This form of spUnt is useful, especially TUBERCULOUS DISEASE OF THE SPINE 153 when it is fitted with a support for the cervical spine. The usual pattern can be improved by a few alterations. The ordinary double Thomas hip-spUnt is made by joining two single splints, united by the chest band above and a cross bar below. In adapting the splint to spinal use, the two vertical pieces are carried in upon each side to near the middle line, so that they lie upon the transverse processes of each side. They end opposite the posterior-superior spines of the iliac bones, where they are attached to a semicircular piece extending outwards upon each side. The ends of this semi- circular portion pass down the posterior aspects of the thighs as in an ordinary double Thomas splint. The vertical spinal portions are moulded to fit any kyphosis which may be present. The moulding ought to be somewhat less than the degree of actual bend, as in this way some degree of extension is maintained on the spine. The efficacy of the support is con- siderably increased by fitting to the body transverse some vertical apparatus which will control the head and neck. The advantages of the splint are the ease with which the patierrt can be carried about, the degree of fixation which it affords, the continuous hyperextension, and the facility of nursing. Its dis- advantages are its expense, and the degree of care ^''"'- ''''■~''^™°''.'^,'"V^°"'^'^ ... .■- T,^i» Thomas splint for use With which it requires to be made and fitted. A h, pott's disease. badly-fitting splint of this type is worse than useless. Bradford Bed Frame. — The bed frame of Bradford keeps the patient in a horizontal recumbent position. It is a rigid rectangle, usually made of four pieces of |-inch galvanised iron gas-piping, screwed into an elbow at each corner ; one elbow has a reverse screw to allow of putting the whole together. The width should be equal to the distance between the shoulder tips, and the length a few inches more than the height of the patient. The rectangle is wound with two pieces of cotton sheeting, double thickness, with a four- inch space between the two pieces to permit of nmsing. The covers are cut to three times the width of the frame, they are doubled and laced behind with a sail needle and strong cord. Two linen pads are placed upon the canvas opposite the diseased portion of the spine. They exert no pressure upon the spinous processes, but instead thoy raise and hyperoxtcnd the spine. The child wears an undershirt and a cotton night-gown, opening behind. To prevent the patient wriggling about, he is secured to the frame by two webbing straps, buckled round the frame and across the chest like a Fig. 44. — The Bradford bed frame. Thi.s e.vami)le is fitted witli cross straps. It may he fitted wifli a corset arrangement instead. 154 TUBEECULOSIS OF THE BONES AND JOINTS soldier's cross belts, the buckle being on the under surface of the frame. Two loops are with advantage fastened to the canvas in order to secure the shoulders. The pelvis is secured by a broad binder pinned round the frame, and the knees by a towel. No pillow is allowed, or only a flat ring-pad. In attend- ing to the hygiene of the back, the child is laid face downwards, the splint re- moved, and the back bathed with alcohol and powdered with talc. In feeding, some diffi- culty may be experienced at first in the taking of fluids. This can be over- come by using a " feeding duck " or tube. The child and splint can be completely wrapped up in blankets, and there is no danger of catch- ing cold. This is a most excellent Pig. 45.— Tlie Bradford bed frame for Pott's disease. ^^rm of splint ; it is Com- fortable, cheap, and effica- cious. It is suitable for a lesion in any part of the spinal column, and if extension becomes necessary, this can be easily adjusted to either end. Fig. 46. — The Bradford frame for the treatmeut of Pott's disease. Tlie spiue is kept extended by pads fastened to the canvas of the frame on each side of the spine opposite tlie Icyjihosis. Whitman Stretcher Frame. — This is very similar in character to the Bradford frame, but it carries out a continual hyperextension. It is much narrower, and it is bent so as to he convexly upon the back opposite the kyphosis. It is made of iron gas-piping, and while it is about six inches longer than the child, it is of such a breadth that the sides of the frame lie TUBERCULOUS DISEASE OF THE SPINE 155 opposite the glenoid cavities and the acetabula. The cover is a single piece of stout canvas, laced posteriorly from end to end. Upon the canvas felt pads three-quarters of an inch thick are sewed, so as to press upon either side of the spinous process at the level of the deformity. The patient is fastened to the frame by an apron, which extends over Fia. 47 -The Whitiiiau frame for the treatnieut of Pott's disease. Tlie frame is bent opposite the kyphosis. the abdomen and the lower chest, and is fastened by buckles to the under surface of the canvas upon each side. At first the frame is bent slightly opposite the angulation on the spine. The bend is increased each day until the de- formity and the physiological dorsal curve have become obliterated. When the frame is sufficiently arched, double traction is exerted by the weight of the head and the legs. The child should be clothed in a cotton under- vest, but the outer garment should include both the frame and the child. The splint possesses all the advantages of the Bradford frame, and in addition it possesses the benefit of keeping up a continual hyj^erextension. It is perhaps less comfortable than the Bradford frame on account of its narrowness, and the unin- terrupted stretch of canvas makes the nursing slightly more difficult. The Planter Bed.^~A jjlaster shell is fitted to the back, and in it the patient is kept recumbent. To make it, an ordinary hammock is arranged, and upon it the patient is laid face downwards. By adjusting the hammock screw the spine can be hyperextended to different degrees. A\Tien the hypercxtension is suit- able, the patient's skin is well oiled, and the hair ^'"i.^^'iT"^"?'^'^" cuirass, protected with linen pads. Plaster bandages are IJonble extension is on- ^ _ ^ ~ tallied by the liead .siiiij; applied evenlv over the back, from the top of the and by traction from ),p.,^j ^,, j^ ,f ^^.; bpt^^-pg,, tjie gluteal fold and the bend tne feet, for use in • *" Pott's disea.se. of iW knee. It is advised to apply five layers of bandages running ])arailel to the long axis of the body, three layers extending radially from the deformity, and two layers ' Holla, hrhrhiirh drr orlhnpadischen C'hir., \i. .'tl:t. 156 TUBERCULOSIS OF THE BONES AND JOINTS to the sides of the bed in straight longitudinal turns. The shell is completed by numerous cross turns, binding the whole fabric together. Weak points are strengthened by incorporating strips of aluminium, wire- gauze, or cotton padding wrung out of plaster cream. When the case is well hardened it is lifted off, and the patient's back washed and dried. The walls of the plaster bed are carefullysmoothed and cut away from the arm-pits. The case is then thoroughly dried, and varnished outside and inside \\ith shellac. When it is thoroughly dry the interior is lined with padded muslin, stork linen being specially fitted to the portion over the buttocks. The patient is secured in the bed by circular turns of bandage. The above is the simplest method of making the plaster bed, but it possesses one disadvantage. When the plaster is moulded directly to the skin, it allows of no after-contraction in the plaster, and when the bed is completed, it may be found that it fits so tight as to be distinctly uncom- fortable, more especially when the thickness of lining is added. It is therefore preferable to first take a plaster cast of the entire back. Plaster bandages are applied directly to the oiled skin, and carefully moulded to the anatomical irregularities. When the casing is hard it is removed, and the inner surface having been well oiled, a positive is taken either by filling the shell with plaster or by means of a layer of plaster bandages. When the positive is thoroughly dry, its size is increased by covering it evenly with a thin layer of plaster of Paris about one-quarter of an inch in depth. Upon this the plaster bed is moulded as described above, and there is now no risk of a misfit. This appliance gives perhaps the most complete and absolute recumbency of all others, but it possesses many disadvantages. Its manufacture is diSicult, tedious, and uncertain ; although one would expect it to be comfort- able, it is as a matter of fact most irksome ; it is readily broken ; and its weight is a distinct drawback. It is difficult to apply traction, but it may be done by cutting away the head portion, and using head bands with weight and pulley. A jury-mast may be used, the upright being incorporated in the wall of the plaster bed. Helbing ^ strongly advocates the use of the plaster bed during the active stage of the disease. He considers it excellent in the treatment of very young children, and he continues it for one to three years. Phelps' ^ Bed is made in a slightly different way. A thin board is cut to the outline of the body and the extended legs. It is padded with wadding and covered with cotton cloth. The patient is placed upon it, and plaster bandages are applied to encase the body and the legs. Later the front is cut away so that the jJatient may be removed from the bed. Fig. 49.— Phelps' plaster bed. '■ Helbing, Berlin klin. Wochenschr., Nov. 13 and 20, 1905. ' Phelps, Trans. Amer. Orlh.' Assoc, 1891, iv. 83. TUBERCULOUS DISEASE OF THE SPINE 157 Gauvain's Spinal Board. — This is a modification of the board used at the Maritime Hospital, Berck-sxir-mer.^ It has been modified by Gauvain of Alton, and his description of the apparatus is quoted : ^ The board consists of an oblong tray made of strong but hght wood. The length should be from 12 to 18 inches longer than the patient, and the width about 8 inches greater than his greatest width. The sides of the board are about the same height as an ordinary Phelps' box, roughly 3 or 4 inches, with the exception of the foot end, which is raised to a height of from 15 to 18 inches, and thereby takes away from the patient's feet the weight of the bed clothes, and tends to prevent the onset of foot drop. The bottom of the board is per- forated with numerous holes to admit ample ventilation of the mattress. The corners are bound with' sheet - iron angle pieces. . . . Across the board is placed a piece of wood of suitable height, usually 2 to 3 or 4 inches, and of almost the same width, which stretches from one side of the board to the other, and is designed to be placed immediately under the most prominent part of the angular curvature. It is fixed by means of two iron pins, which serve a double purpose. (1) To retain the cross-piece in position ; (2) To indicate at a glance where on the patient the angular curvature is. A firm pillow, if fixed, forms a suitable substitute for the wooden cross - piece, a well-prepared horse-hair mattress occupies the tray over the cross-piece, and on it the patient reclines. At the head and foot ends of the board are slits cut for the hands to facilitate transport. At the head end of ' the board two pieces of strong elastic web- bing, 1 inch wide and about 6 inches long, are attached, and to them a bridle can be buckled when head extension is desired. At the foot end ... are two longitudinal slits, through which the cords of a leg extension can be passed over a suitable pulley. This pulley is fixed to two perforated, upright pieces of wood, attached to the board on each side of each longitudinal slit, and these are so arranged that between them an upright extension rod can be arranged if there is much flexion. . . . The patient is fixed to the board in a simple and effective manner. A jacket composed of stout jean, fitted accurately to the body and preferably stificncd with whalebone, encases the patient. On the back of the jacket two strips of webbing are let in, which strips cross each otlier as a St. Andrew's cross, and these are buckled to the sides of the board, and effectually prevent the patient from moving in any direction, and keep him in the exact position which has been decided upon as desirable. The jacket should be laced and buckled over the front of the patient. This splint has many advantages : it is simple, light, efficacious, and convenient. It possesses two disadvantages : the first is the tendency ' Menard, Etude pratique sur le mal de Pott, Masson et Cie, 1900. * Gauvain, " Tho Mechanical Treatment of Spinal Caries," Lancet, March 4, 1911. Fig. 50. — Gauvain's spinal board. 158 TUBERCULOSIS OF THE BONES AND JOINTS towards the development of pressure sores, the second is the Uability for the jacket to loosen, permitting movement which depreciates its value. Gauvain's Back-Door Splint. — The great majority of splints have the common disadvantage that if they are to be efficacious m controlling the spine, there will result a corresponding difficulty in attending to the hygiene of the back. To overcome this difficulty, Dr. Gauvain has introduced what he calls the back-door splint. The original description of it is quoted : Measurement of the Splint. — The patient is stretched on his back ou a piece of paper, the head is held by one assistant and the legs by another, and the contour of the trunk is traced out. The splint should be a shade smaller than the contour of the trunk. The bottom of the splint should be jiist above the natal cleft. The tracing is then cut out and a piece of beech-wood cut to exactly a similar size. Well-seasoned beech is especially chosen, because experiment has shown that it is very strong, that it does not warp readily, and it has the additional advantage of being cheap. The outer part of this is cut away 1 inch from the perijihery all round, forming an outer frame. This is covered with FlQ. 51. — Gauvain's back-door splint. The door has lieen removed and is being held to the left. sheet-iron screwed to the frame, and forms a strong and rigid framework. The iron is then lacquered to prevent it rusting when subjected to the heat and moisture of the body. The inner part or back door, which fits into the outer frame accurately, is pared down a little so that it can be removed and replaced with great ease, and is perforated with holes for a double purpose — both to ventilate and to assist in fixing the padding which is later to be applied to it. The Padded Outer Frame and Back Door. — The outer frame is padded evenly all round, but especial care must be taken in padding that part which will come in contact with the sacrum. The padding should be perfectly even, and the best material to employ is animal wool, because this never cakes, and has a springiness and elasticity which make it peculiarly suitable for this purpose. The padding is firmly bound down to the splint by splint hnen, and should be covered on the lower part with jaconet to prevent it being soiled or saturated if the patient is not able properly to control his evacuations. The back door has on the lower aspect a suitable handle, which facilitates its introduction or re- moval from the outer frame. It is kept in position by four small clips, which are attached to the outer frame. The surface of the back door next to the body is also padded thickly with animal wool, and this padding should be especially thick and firm at the site of the disease, so that due hyperextension of the spine may be obtained. It will be found convenient to use tape in the fixing of the splint lining in.stead of ordinary thread, as with the tape the padding can be made more secure and much more durable. The patient is fixed on to this splint by means either of a jacket or by webbing. Webbing is simpler to apply and is TUBERCULOUS DISEASE OF THE SPINE 159 better in warm weather, but the jacket is neat, and gives the apparatus a more finished appearance when in use. If a jacket is employed it will be found most convenient to attach it to the outer frame on its inner side, and the jacket should be made in two pieces, each in duplicate, so that should it become soiled the soiled portion can be immediately removed and replaced. In any case it would be desirable to remove the jacket at intervals so that it may be cleaned — about once monthly is commonly sufficient. To facilitate the removal, it will be found convenient to employ patent placket fasteners. By the use of these the jacket can be removed with the greatest ease and speed, and be instantly replaced. The jacket should be strapped and laced over the front of the patient, as in the manner described previously. Should webbing be used in place of the jacket, a piece of webbing should come over each shoulder. Two pieces should come round the trunk, and all should be fixed to the inner side of the outer frame of the splint. They should be buckled appropriately on the front of the trunk. It will be found that by employing a splint of this nature the patient's back can be attended to without the j)atient being moved, and with the very greatest ease. Fk;. 52. — Giiuvain's posterior suspensory splint. When extension becomes necessary it can be arranged. iFor head extension a simple bridle may be employed, or the outer framework of the splint may be prolonged on each side of the head to terminate in an upright iron bar, to which the bridle is attached by elastic extension. In dorsal or lumbar disease, extension is obtained by swinging the patient in his splint, so that the head and the lower extremities are gradually dependent. The same result may be obtained by mounting the outer frame of the splint upon short legs, the head and the legs being dependent. The Wheelbarrow Splint. — WTien there is spinal disease associated with spasm of the psoas muscle or with a psoas abscess, Dr. Gauvain has introduced what he calls " the wheelbarrow splint." The back- door splint, already described, is made, and supported upon four short logs. The patient's legs are attached to posterior splints, which are fixed to the splint frame by special hinges which permit of abduction, adduction, and hyperextension, but no degree of flexion, inver- sion, or eversion. When it is desired to ap[)ly extension to the lower limbs, 53. — Gauvain's wlieelbarrow .splint. 160 TUBERCULOSIS OF THE BONES AND JOINTS small wooden foot-splints are fastened on, and the extension strapping is fastened directly to them. In this way the entii-e weight of extension comes directly on the splint. Head extension may be applied by means of a bridle. Phelps' Box. — This is a good sphnt for use among the poorer class of patients. It is best understood by reference to illustrations. A shallow wooden box is made to fit the patient's entire stature, both legs being slightly abducted. The required shape is cut with a fret-saw from a flat piece of beech wood, and boards of sufficient depth are screwed to the sides. Lateral Fig. 54. — Phelps' box. Fia. 55. — Phelps' bo.\ with patient iu position. slits are cut to accommodate the shoulders. The box is lined, and a cushion is fixed to the bottom opposite the situation of the spinal prominence. At each of the upper angles of the box curved steel supports are fastened, and to these supports a chin strap is secured. It is impossible to apply extension to the lower limbs. Recumbency in Application to Special Regions. — Cervical Region. — Disease in the cervical spine has two peculiarities, which render the choice of recumbent splints rather limited. These peculiarities are : (1) The difficulty in properly fixing the head and neck ; (2) The necessity in many cases of applying extension. The patient may be kept in a bed prepared for recumbency, but special TUBERCULOUS DISEASE OF THE SPINE 161 Fia. 56. — The U -shaped pillow arranged for the treatment of tuberculous disease of the cervical spine. precautions must be taken in regard to the head and neck. If head extension is in use, it is sufficient to fix the head laterally by two heavy sand-bags, placed one on each side of the head. Around the sand-bags a towel is rolled, and passed across the forehead. If no head extension is applied, a special sand - pillow is used, shaped Uke a IJ . The transverse part of the U is about 2 inches thick, and it lies against the nape of the neck. The limbs of the U are much larger and heavier, being about 6 inches in depth ; they lie one on each side of the head ; a narrow towel is fastened as before round the Umbs of the sand-bag and across the forehead. The Bradford frame, the ^^^litman frame, and Gauvain's spinal board are excellent for use in cervical disease. In each of these the head and neck is partially controlled, and extension can be readily applied. Phelps's box is useful, and also the plaster bed, if it is made to include the head and neck ; but the usefulness of both is lessened by the difficulty in fastening extension apparatus. Dorsal Region. — When expense has to be avoided, a dorsal lesion can be excellently treated in bed. For out-patient work the spinal board and the Phelps's box are very suitable, because they are the easiest in transport. In private work, where expense is probably not so important a consideration, one frequently advises a Bradford or a Whitman frame, the latter when the symptoms are urgent. Gauvain's back - door and wheelbarrow splints require a considerable amount of manipulation and attention, and for that reason one uses them most frequently in hospital cases, where good nursing facilities are always at hand. Lumfxir Region. —Owing to the tendency which lumbar disease has to be associated with psoas spasm and flexion of the thigh, one is careful in recommending a splint for this region to choose one in which extension can be readily applied. Otherwise one is guided by much the same principles as hold good in the dorsal region of the spine. Duration of Treatment by Recumbency.— It is essential that recumbency nuist not be given up until the disease in the vertebra; has ceased to spread, in other words, until the process of cure has been begun. In point of time, one knows that this never occurs in less than one year, and in all probability the greater part of two years has elapsed before signs of commencing cure are apparent. Complete recumbency must therefore 11 162 TUBERCULOSIS OF THE BONES AND JOINTS continue for at least one year, or preferably for a year and a half. At the end of that period, if the signs are favourable, the ambulatory treatment may be begun. There are certain indications which one assumes as favour- able to the commencement of the ambulatory stage. 1. All pains, local or referred, must have disappeared. 2. No deformity should be present, or if such existed before the treatment was begun, the degree of kyphosis should not have increased. 3. The evening temperature must have remained normal for some months. 4. The child becomes restless, and is perpetually making efforts to get up. 5. The weight has increased. 6. On examination of the back, it is found that the situation of the dis- ease is firm and unyielding. If it is decided that the conditions favour the commencement of the ambu- latory stage, it must be remem- bered that it is unwise to allow the patient immediately to assume the vertical position. He has been so long in the horizontal position that any sudden change to the vertical is associated with considerable changes in blood pressure, and if these facts are not borne in mind, alarming symptoms may develop when the patient is- suddenly set upright. He should therefore be gradually raised upon his couch to the upright sitting position, later he is allowed to walk about, at first for a few minutes only, the time being gradually extended. He must never be allowed to assume the vertical position without wearing some form of spinal support. Gauvain has overcome the difficulty of gradual elevation by using a stand in which the patient may be placed in any position or angle. His original description is quoted : The essentials in this stand are that tfie patient at will may occupy any position, either horizontal or vertical, or at any intermediate angle. This altera- tion is very simply effected by merely turning a handle, which governs a screw fitted into the cogs of a semicircular piece of brass, which will be seen attached to the under-surface of the spinal board. The patient when tilted in this way should have, at any rate in the case of an adult or large child, additional support to that given by the jacket before described, for while this jacket alone will hold him firmly, yet without other assistance it may cause him undue and unnecessary discomfort. It will therefore be found desirable to have two pieces of webbing passing longitudinally down the board from the head end and let into the back of the spinal jacket on either side of the spine. These pieces are continued under Fig. 57. — Ganvain's cippar.itus for the gradual assumption of tlie vertical position. TUBERCULOUS DISEASE OF THE SPINE 163 the crutch, and are there padded with a small pad of animal wool and covered with jaconet, and this pad is so adjusted that it will press on each of the tuber ischii. The webbing continued from the crutch passes over the front of the patient, and is strapped to the board on each side at about the level of the nipple. This simple contrivance will effectually and comfortably support the patient even in the vertical position, and will not in any way bring undue pressure to bear upon his spinal lesion provided he has in the first place been so placed on his board that the spine is sufiiciently hyper-extended. In many cases it is per- missible to allow the patient to rest on a seat, which can be suitably adjusted to the spinal board. This is permissible when there has been no spasm of the psoas muscle, or when there have been no complications, such as gluteal abscesses. It will be at once seen that when the patient is in this position he has the great advantage of seeing surrounding objects with ease, and when a suitable book- rest is adjusted to the board he can read and feed him.self with comfort in the natural position. Such a contrivance will be found of the very greatest service to these patients, who are so helpless and so debarred from simple pleasures and conveniences, and it will be of particular value in the case of children, who can thereby continue their education within reasonable limits without in any way complicating or interfering with the treatment which is being applied. It will be noted that this tilting stand is mounted on wheels, and can easily be wheeled out of the ward or room into the open air, and in fact can be wheeled anywhere as easily as could a bath-chair, and the delight which this possibility of change of scene gives to the child is of value and assistance in the treatment. He can. be conveniently and expeditiously removed out of doors and attended to through- out the day, and this in itself is, as will be readily seen, of the greatest value. B. Ambulatory Treatment. — This term is applied to the course of treatment wlicn the patient i.s allowed to go about, his spinal column being supported and stiffened by some type of apparatus. The various forms of appliance are described as spinal supports and head supports. Characteristics of efficient Spirud Supports. — It is a matter of regret that in the making of these supports instrument dealers too often neglect the very points which ensure successful treatment. An appliance which comes short of certain necessities is a useless encumbrance. A serviceable support must fulfil the following conditions : (1) As its principle is to exert a considerable amount of pressure upon the spinal cokunn, it is essential that there shall be a fixed point from which this pressure can be exerted. This fixed point is usually obtained by an accurately fitting pelvic band. (2) The pressure brought to bear up(jn the spine should be exerted along the transverse processes of each side. (3) The support must be of such a kind tluit it does not compress the lateral chest wall, and so intorfere with the healthy respiratory movements. (1) In dorsal and in lumbar disease the posterior pressure on the spine must bo counterbalanced by support given to the chest in front. If this is not provided, the pressure exerted upon the spine behind is simply accom- modated for by a compensatory anterior enlargement of the chest or abdomen. (5) If the disease is situated above the tenth dorsal vertebra antl below the level of the eighth, the support must extend above and in front of the 164 TUBEECULOSIS OF THE BONES AND JOINTS shoulders ; if it lies above the level of the eighth dorsal vertebra, the head and neck must be included in the support. Indications for Ambulatory Treatment. — Briefly it may be said that ambulatory treatment is indicated when the active stage of the disease is ended, when there is no indication of a further extension of the disease, and when there is a reasonable prospect of the diseased spine becoming com- pletely cured, if it is efficiently immobilised. Spinal Supports The Plaster Jacket. — One has no hesitation in saying that a properly applied plaster jacket is the most effective immobiliser of the spine which we possess. Advantages and Disadvantages. — Many arguments have been urged against it : its efficacy has been doubted ; it is said to be unsuitable for children ; its weight has been condenmed ; it is said that if it is applied sufficiently accurately to be of any real value it must of necessity interfere considerably with respiration and digestion ; and finally it has been objected to as insanitary. Most if not all of these charges are groundless. "When properly applied, the spine can have no more efficacious support, because the plaster can be so accurately moulded to the spinal outline. Its use in children has been opposed, because the pelvis is said to be so insufficiently developed that a proper purchase cannot be obtained. As a matter of fact the jacket can be fitted to a child's pelvis just as efficiently as to that of an adult. The weight depends entirely upon the amount of plaster used in making the jacket. As the operator's skill increases, the amount of plaster required to give fixation is lessened ; and when the support is completed, its weight can be greatly reduced by cutting out anterior and lateral windows. By the removal of windows the objection of imijeded respiration and digestion is removed. The argument of the jacket being insanitary has some foundation. It should not therefore be employed in the poorer class of out-patients, but rather in those whose cleanliness can be trusted. Indications. — The cases which one considers as favourable for treatment are those which have reached a degree of cure permitting ambulatory methods, which are physically strong, and which have the privileges of con- scientious parents and good homes. The situation of the disease matters little. It is of course easier to apply a plaster jacket for low dorsal disease than one for cervical disease, but both can be applied to act equally well. The presence of a sinus or of an abscess is not a contra-indication, if it is possible to cut a window in the jacket in such a position as to give free admission to the part. Method of Af plication. — The method of making plaster bandages has been detailed. It remains to describe the technique observed in the applica- tion of a plaster jacket. Gauvain's Method. — The patient has-been educated to assume the vertical TUBERCULOUS DISEASE OF THE SPINE 165 position until he is able to stand upright without any danger of syncope occurring. The skin is carefully cleansed and powdered, the bowels are thoroughly emptied, and food likely to cause flatulence is avoided. A closely fitting vest is applied to the patient's body, and over the epigastric region, beneath the vest, a pad of cotton wool is placed, so that if distention should occur before a window is cut out no discomfort will ensue. The lower part of the vest is pinned in the perineum. If the cervico-dorsal or cervical spine is diseased, the vest is carried upwards as far as the occiput, and this is best done by using a vest with a specially long neck, which is drawn over the head and pinned above. A diagonal window is cut out opposite the nose, and when the window is stretched the patient can see and breathe. The patient is now ready for suspension. A bridle specially made for .each individual case is fitted to his head. The bridle is made by tying an ordinary knot in a 2-inch calico bandage 4 feet long. The knot is tied in such a way that there is a free loop. The knot is placed immediately above the right ear. One limb of the bandage is now passed beneath the chin and the second limb beneath the occi- put, and both are tied above the left ear. One end of the bandage is passed through the loop left from the knot upon the right side, and the free ends of the bandage are firmly tied. The patient is suspended from a gallows by the bandage passing across the top of the head. By altering the situation of the knots the posi- tion of the head is changed ; the more anterior the knot the more extended does the head become, the more posterior the knot the more flexed the head. The patient is suspended to such a degree of extension that the heels are off the ground, and he rests entirely upon his toes. He acquires a certain amount of support by holding adjust- able pegs fixed to the sides of the gallows. The bandages are now applied, those 6 inches wide are employed, and each bandage is wrung out of cold water. The operator stands in front of his patient and an assistant behind. The free end of the bandage is applied below the crest of the ilium upon the right side, and the roller is unwound, covering in the body from below upwards. At least once in each circuit the bandage is pleated by doubling it backwards in its course for about one inch, and then proceeding as before. Pleating has a double advantage — it allows the jacket a comfortable degree of yield before it actually sets, and after a pleat is made, the bandage can be carried in any desired direction. No reverse nuist be made. After each circuit the bandage is gently r\il)l)ed into the turn lying imnicdiatcly beiieatli. When the patient's trunk has Flo, —Suspensory sling npplied in preparation for the application of tliu plaster jacliet. 166 TUBERCULOSIS OF THE BONES AND JOINTS been efficiently encircled, and usually three 6-incli bandages are sufficient for the purpose, the technique of moulding to the jielvic bones is proceeded with. This is carried out very carefully, and the secret of the success of the method is to avoid all pressure upon the bony pelvis, but to centre one's pressure upon the soft parts immediately above. When this is complete the shoulders are incorporated in the bandage. They are pressed well back, and a bandage is passed backwards and forwards above them until sufficient support has been gained. The cross bandages are held in position by circular turns passing below the axilla. Fig. 59. — The "Minerva" plaster juL-ket applied. Fio. 60.— The " Mlii. rva " plaster jacket applied, lateral view. The system of moulding is now applied above and below the clavicles. The neck is encased by successive turns of the bandage, and in each circular turn at least two pleats are included. The bandage passes from the neck, around the head, under the chin, and under the occiput. It is carefully moulded under the chin, under both mastoid processes, and beneath the occiput. When the jacket has hardened sufficiently, windows are marked out ; they are not, however, cut until the second day after application of the plaster. A large window is cut out in front to allow free respiration and digestion, and if there is any angulation of the spine, a window is cut out over TUBERCULOUS DISEASE OF THE SPINE 167 it. The plaster is cut away around the head, below each ear, and in its lower part, to allow free flexion of the thighs. The plaster is cut with a small, strong penknife, the blade of which is continually moistened with water, and when the various windows have been cut and edges trimmed, the vest is turned back over the plaster, and fastened securely around by a layer of plaster cream. The whole sur- face of the jacket is afterwards covered with a thin layer of plaster made up in 3 parts of water to 5 parts of plaster. When the jacket extends so high as to be below the jaw, the mastoid, and the occiput, the name " Minerva " is applied. It has the disadvantage that it interferes with mastication, and in eating the patient has to keep continually throwing his head back. To overcome this difficulty, and the further one that it interferes with the de- velopment of the lower jaw, Gauvain introduced the type of jacket which he calls " the Fillet." It will be understood on reference to the illustration. While the head portion is moulded carefully to the mas- toids and the occiput, the an- terior portion does not come into contact with the lower jaw. Fixation is gained instead by carrying a narrow band of the plaster around the forehead in such a position as to keep the head extended. The Hammock Fmme Method. — In this method the jacket is applied with the child lying prone upon a strip of cloth, the cloth being attached to a frame by which it can be tightened or loosened at will. The cloth or hammock is made from cotton sheeting. It is double the width between the iliac spines, and it is some inches longer than the child. In use it is doubled, and a wide hem made at each end. The frame is a parallelogram of 1-inch galvaTiised iron piping. It usually measures 6 feet by 2 feet, and it is fixed in such a position that the upper end is (i inches higher than the lower one. At the upper end of the frame there is a transverse iron rod attached to the upper end by two S hooks. At the lower end a bar stretches across the breadth of the frame, and the bar can be revolved by turning a winch handle at tlu^ side. A ratchet is provided to control the amount of reverse move- Fio. 61. — Tlie "Fillet" pListcr jacket aiiplieJ. 168 TUBERCULOSIS OF THE BONES AND JOINTS ment of the bar ; near the centre is a second bar, similar to that at the upper end. The hammock is attaclied to the frame by passing the two transverse bars through the hems in the canvas. The upper bar is fastened to the frame by its screws, the lower bar is connected with cords to the ratchet bar at the extreme lower end of the frame, and by manipulating the screw handle Fig. 62. — The liammock frame nietliod of applying the plaster jacket. the hammock can be loosened or tightened at will. The child is placed upon the hammock face downwards, and the screw is loosened sufficiently to Fio. 63. — Ridlou's bridge for supporting the p.itieut during the application of ;i plaster jacket. produce the requisite amount of lordosis. The arms of the child grasp the top bar of the frame, and additional support is given by broad webbing straps which pass across beneath the upper chest and the knees. The child's trunk is clothed in stockingette, and padding is adjusted to protect the sacrum, the crests of the iha, the sternum, the claxacles, and the axillae. Felt pads are placed upon each side of the deformity. The plaster TUBERCULOUS DISEASE OF THE SPINE 169 bandages are applied below and to include tlie point of deformity, and when the plaster has set the hammock is further loosened. There is a corresponding sagging of the body, but as the lumbar spine is fixed in the plaster which has been already applied, and cannot therefore bend further back, the pressure is exerted upon the deformity, which improves in degree and may even disappear. In this corrected position the application of the jacket is com- pleted. A\Tien the jacket has hardened, the child is removed from the frame by cutting the hammock cloth above and below — the cloth of course being retained as part of the jacket. The advantages of this method are the comfort of the child during application, the absence of any tendency to syncope, and the correction by hyperextension which can be obtained. The Goldthicait Method. — Goldthwait uses a frame very similar to that employed in the hammock frame method, but instead of the patient being prone he lies on his back. The frame is, as before, a gas-pipe frame measur- ing 6 feet by 2 feet. Suspended from the frame there is a cross bar from the centre of which rises a vertical bar, forked at the top and extending upwards to a level with the frame. ' The position of the cross bar can be altered at will, as it is suspended from the frame. A simple transverse bar rests on the frame lower down, the distance between the two usually being about 16 inches. Upon the vertical fork above and the transverse bar below rest two malleable steel bars about 18 inches long. They are fixed in grooves about 1 inch apart, and they are moulded to conform with the curve of the lumbar spine. The patient is clothed in a vest of stockingette, and laid upon the parallel steels, which are specially padded with thick felt. When the patient is in position the upper ends of the bars project one inch beyond the deformity, while the buttocks lie opposite the lower cross bar. The legs are supported by bands of webbing, which pass beneath them and can be tightened at will. At first the head is supported by the operator's hand, and allowed to sag until the spine is sufficiently hyper- extended. The head is then supported by a broad band of webbing, and the plaster jacket is applied with the steel bars inside it. After setting, the patient is lifted off the frame and the bars slipped out. The jacket is trimmed in the usual way. Bracl-elCs Method. — Brackett uses a frame in which the patient lies on his back. The patient is supported at the kyphosis by two short metal plates which impinge one on each side of the middle line. These plates are padded with felt, and they can be raised or lowered at j)leasure by a Y-shaped support. By elevating the plates the deformity is gradually corrected. When the jacket is applied the plates remain inside it. The head is supported upon a series of parallel transverse bands which can be tightened or loosened at will, while the feet rest upon a board. Lovett's Method. — Lovett also employs a frame. The patient lies on his face on two broad straps of webbing, with one cross strap at the trochanters, and one at the level of the forehead. The upper part of the frame is made double and hinged so that it can be raised at will. The first part of the 170 TUBERCULOSIS OF THE BONES AND JOINTS jacket is put on below and up to the level of the deformity. It is applied with a straight lumbar spine, and this is secured by having the patient's body resting upon the frame straps while his legs hang down. When the first half of the jacket has hardened, a thickly padded webbing strap is tied across the child's back opposite the deformity. The hinged front half of the frame is raised, and a corrective pressure is exercised by the webbing upon the kyphosis. In this position the application of the jacket is com- pleted. Fig. 64. — A modification of the Brackett apparatus for applying a plaster jai;ket. Metal Braces The Taylor Brace.— In 1863 C. F. Taylor published a description of a brace which was intended to oppose forward movement of the spine. With certain minor modifications this splint is still largely used. The brace is made of steel, and it consists of two uprights, a base, two shoulder-pieces, and one or two cross bars. The uprights are two vertical bars of malleable steel, -^ inch thick and ^ inch wide, which lie one upon each side of the middle line over the transverse processes. They are curved to fit the outline of the spine with the patient lying down, and in length they extend from the seventh cervical spine to 1 inch below the posterior- superior spine of the ilium. The lower ends of the uprights must pass between the posterior-superior spines, and yet leave an interval of |- inch. If the child is so small that this is impossible, the uprights must then end at the horizontal part of the brace. Opposite the deformity in the spine, each upright has attached to it a thin steel plate ^ inch wider than the upright, and curved to fit the bac'K from above, downwards and laterally. These plates are made of spring steel No. 22 gauge. They should be perforated around the free border to allow a pad to be stitched in place, and if they are intended to exert special pressure upon the spine, they are carried forward some distance in front of the upright. The bottom piece or base may vary in shape ; usually it takes that of an inverted U . The transverse portion crosses the lower part of the back, above / TUBERCULOUS DISEASE OF THE SPINE 171 the sacrum, and to it the lower ends of the uprights are attached. The inverted Hmbs extend downwards on each side, two finger-breadths within the inner side of the trochanter, and end above the ischial tuberosities, so that they do not interfere with sitting. Each free end is provided with a circular leather-covered pad. The shoulder-pieces are separate pieces, each 7i inch wide and ^^ of an inch thick, attached behind by rivets to the upper ends of the uprights. They are fir.st bent outwards on the flat at an angle of 45 degrees, and then they are bent over so as to conform to the outline of the root of the neck. In front they end at the edge of the trapezius muscle. The cross bars are usually two in number ; the upper one is attached just below the pos- terior border of the axilla, the second one lower down. They are ^ inch wide and ^^ inch thick, they are a little shorter than the breadth of the trunk, and they are fastened by rivets to the posterior surface of the up- rights. For fastening the brace to the body buckles are used. These are 1 inch wide, and they are secured by copper rivets. Buckles are fastened to each of the tips of the D, one to each corner, and one to the end of each cross bar. To the extremity of the shoulder-piece a webbing strap 1 inch wide is riveted. The front of the body is covered with an apron of stout drilling or canvas. In width it extends from one posterior axil- lary line to the other, ending above at the axilla and below at the symphysis pubis. The corners of the jacket are cut away so that they do not interfere with flexion of the thighs or movement of the pectorals. If the apron is stiffened at the sides by bones there is less liability to crinkling, hemmed, and to them, webbing straps are fastened which are attached to the buckles on the brace. Webbing straps are fastened one on each side about an inch above the lower end of the jacket. They pass across the perineum, and are attached to the buckles at tiie tips of the D-shaped base. In this way the tendency of the brace to slip upwards is prevented. If in association with Pott's disease the shoulders are dLsplacod forwards, it becomes necessary to attach a Taylor chest-piece to the ordinary brace. This consists of two triangular pads of hard rubber, made to fit into the chest wall beneath the clavicles, and joined to one anotlier by a jointed bar of iron, which can be shortened or extended at will. The pads are attached above by straps to the shoulder-pieces and below to the extremities of tin- upper cross bar. When the caries is situated higher than The edffeS are ^""'" ^^' — Antero-posterior braco fittoi with the Taylor ring. A case of upiier dorsal Pott's disease. 172 TUBERCULOSIS OF THE BONES AND JOINTS the seventh dorsal vertebra, a Taylor head support is added to the brace. This is described later. AVhitman recommends that if there is no deformity when the brace is applied, the uprights ought to follow exactly the spinal outline. But if there is an existing deformity, the uprights should be made soiiiewhat straighter than the curve of the kyphosis, so that a corrective pressure is exerted. The brace has many advantages to recommend it : it acts as a most efficient spine immobiliser and it is light. As the child grows the brace can be easily altered to suit the requirements of increasing girth and height. The objections which have been urged against it are few and unimportant. It is said to be uncomfortable, but the discomfort quickly lessens and eventually is unnoticed. Pressure sores are said to have been produced, but with care and attention to cleanliness they should never occur. Perhaps the only real objection is the difficulty which there is in obtaining an accurately fitting brace. The apparatus requires to be made with great care, as its efficacy entirely depends on its correct fit. It ought to be made directly under the surgeon's supervision and guidance. Schapp's Brace. ^ — Schapp criticises the types of spinal support, and describes a modification of the Taylor brace which is worth attention. There is a flat steel band, which crosses the abdomen as low as possible without being displaced by the thighs when the patient sits, and extends closely around the sides of the pelvis and downwards for 2 or 3 inches. It is then connected with the horns of a posterior hip band by straps. The pelvis is actually clamped between the bands. The anterior-superior spines are protected by pads of kersey and leather, and the middle portion of the front band is arched forwards, so that when the patient is supine there is a space behind it of 1| inches or more. This will be filled by the abdomen when the patient stands. At the location of the anterior-superior spines, flat uprights are riveted at right angles ; they reach nearly to the top of the chest, and at the level of the axillae are crossed by a flat band extending jound the sides of the chest and nearly meeting. Davies' Quadrilateral Brace. — Taylor's brace, while it prevents antero- posterior movement of the spine, does not prohibit a certain degree of lateral movement. Davies' brace was designed to combine the action of a back brace with that of a side support. It consists of a base or pelvic band, two uprights, a top bar, and a pad plate bar. The pelvic band is made of No. 15 gauge cast-sheet steel. It is moulded to fit the back just above the trochanters, and in front it ends behind and slightly below the anterior- superior spines. Its ends are usually joined in front by a strap of webbing. The uprights are made of No. 12 gauge flat steel. They are half an inch wide, and they are riveted to the pelvic band, one on each side, about one inch beyond the posterior-superior spines. They end a finger-breadth above the spines of the scapulae, they follow the curves of the flanks, and when the shoulder-straps are tightened they exert most pressure upon the posterior I Schapp, Medical Record, Sept. 9, 1905. TUBERCULOUS DISEASE OF THE SPINE 173 surfaces of the scapulae. The top bar passes across the upper end of the chest. In length it is equal to the distance between the glenoid cavities, when the shoulders are pressed back. Its ends are bent downwards to a right angle, and they are riveted to the upper extremities of the uprights. The pad plate bar is a horizontal bar of half-inch flat steel, No. 14 gauge, which is fastened to the uprights by screws opposite the kyphosis. At its centre the bar is bent into a semicircle, convex backwards. In order to avoid pressure upon the spinous processes, and just before the bend begins upon each side, pad plates are attached. These pad plates are made of No. 18 gauge steel, they measure ^ inch by 3i inches, they are fixed with the long axes vertical, so as to press directly upon the transverse processes. The pad plate bar is not ' fastened with rivets, but with slots and adjust- able screws, so that the position of the pressure of the pads can be altered at will. The front of the body is covered with an apron of soft leather ^g to | of an inch in thickness. It extends from the level of the ensiform cartilage to the sym- physis pubis in the middle line, and 1 inch F[a. 66. — Daviea' quadrilateral brace. below the anterior-superior spines laterally. Webbing straps from the apron are fastened to buckles on the brace. These buckles are attached at each upper corner — three at intervals along the sides of the uprights, and one at each end of the pelvic band. The special head support for attachment to this brace is described later. Thornton's Back Brace. — This brace is most suitable for use in Pott's disease of tlie lower dorsal and dorso-hunbar spine. TIic advantages claimed for it are those of secure fixation and tiie encouragement of free chest and lung expansion. It is composed of a base-piece, two uprights carrying pad plates, cross bars, and a shoulder-piece. The base-piece is shaped like a 174 TUBERCULOSIS OF THE BONES AND JOINTS widely separated V. It covers most of the sacrum, and laterally the limbs extend outwards just below the iliac crests to a point behind and below the anterior-superior spines. The uprights are placed in exactly the same position as in a Taylor brace, and opposite the deformity pad plates are used. The lower cross bar is attached just above the iliac crests, and it is moulded to the curves of the loin. The upper cross bar is placed below the tips of the scapulae. The uprights are riveted above to a steel plate, V-shaped. The size at the apex is equal to the distance between the uprights, while above the limbs are 3 or 4 inches apart. At the extremities of this plate L-shaped steel pieces are loosely riveted. The vertical limb of the L runs outwards to the glenoid cavity, then there is the angle, and the horizontal limb passes vertically downwards to the lower fold of the axilla and curves slightly forwards. From the angle of the L to the end in the axilla a buckling strap passes, and in front of the body there is an apron of leather or cloth, extending mesially from the nipple to the symphysis and laterally from the eighth rib in the mid-axillary line to just below the anterior-superior iliac spine. The apron is attached to the brace by straps and buckles. The Flexible Steel Brace. — In the convalescent stages of Pott's disease, when the spine requires only a slight degree of protection, the essentials are supplied by a flexible steel brace. A horizontal pelvic band encircles the posterior part of the pelvis, and ends on each side at a point 1 inch behind the antero-superior spine of the ilium. This band is carefully figured to a paper pattern. It is 1^- inches wide, and it is cut from No. 16 gauge sheet-steel. The uprights are fastened to the pelvic band, li inches apart. They pass upwards on each side of the middle line until they reach the first dorsal vertebra, when they are 1 inch apart. From this point they bend outwards at an angle of 45 degrees, extending as shoulder-pieces for 2 inches. A cross bar | inch wide is riveted to the uprights 1 inch below the posterior axillary folds. It extends upon each side to within 1 inch of the width of the body. Straps connect the tips of the shoulder-pieces to the ends of the cross bar, the straps arching across the front of the shoulders. Fig. 67. — Thornton's b.ack brace for Pott's disease TUBERCULOUS DISEASE OF THE SPINE 175 The ends of the pelvic band are united in front with strap and buckle, and it is a further benefit to have a broad abdominal belt, divided into two halves, each attached to the upright behind and the half of the opposite side in front. Tubby's Spinal Support. — This is an apparatus which acts on the principle of a Taylor brace. It affords considerable lateral and antero- posterior fixation. The original description is as follows : The first e.sseiitial is a good base of support, which is afforded by a well- fitting and accurately adjusted pelvic band, so arranged that it can be opened iu front. The band has fixed to it two pieces of steel, each arching over on either side from just in front of the anterior-superior to the posterior-superior spines. At the centre of the pelvic band, posteriorly, a double steel upright is fixed, which reaches above to a little below the level of the line joining the spines of the scapulae, thence two transverse steel bands pass outwards to beueath the axillse. In order to ensure sufficient rigidity, two lateral steel uprights pass from the pelvic band, and are joined to the upper transverse bands just below the axillae, and end in horned and pear-shaped extremities. They lie between the coracoid processes and the heads of the humeri. The utility of the apparatus depends upon an accurate fitting, which is made while the patient is suspended, and when it is removed at night the patient ought to be lying down. It is replaced in the morning before the patient rises from the horizontal position. The posterior uprights lie exactly in the lines of the transverse processes, and there must be no pressure on the transverse processes nor on the ribs. The uprights are made so that they first fall short of exactly following the curves of the vertebral column, thus exercising a lever-like action, as in the Taylor brace. When the posterior deformity is small and the vertebrse are not fully ankylosed, advancing plates may be fitted to the uprights, so as to bring moderate pressure to bear on the transverse processes at the projection. The main object of the apparatus is to exert antero-posterior leverage on the spinal curvature, exactlv in the same way as if one stands behind a healthy person and puts the arms and hands beneath the subject's axillae and exerts backward traction. The effect is that the patient is absolutely prevented from flexing his spine. To cover the chest and abdomen, stay material with lacing down the front is used, and further, if the disease is above the eighth dorsal vertebra, a head support with a chin piece is added.^ Leather Jackets. — In the later stages of convalescence leather jackets may be used. A piaster cast is first taken of the chest and spine. If an old jacket is available, a cast may be obtained by blocking up its apertures with brown paper and filling the interior with plaster. If this is not possible a negative is taken of the chest with piaster bandages (see later) and a positive made. By adding an additional thin layer of plaster the size of the cast is slightly and evenly incrca.sed. This is necessary as the leather contracts during its application and drying, and what may appear to be a well-fitting jacket is actually too small. Oak-tanned English leather is used. It is soaked in water niitil thoroughly soft, and then stretched U])on the cast. It is made to conform to every outline and hollow. One edge is secured to the cast by tacks, and the other edge secured when it is properly fitted. Sometimes it may be adapted by tightly and evenly winding a ' 'I'lilpliy, loc. Klip. cil. viil. ii. ]). KU. 176 TUBERCULOSIS OF THE BONES AND JOINTS small rope round the cast with the leather in position, or it may be tightly bandaged on with webbing. The leather is allowed to harden at ordinary temperature, or it may be baked at a temperature not exceeding 120° P. When it is thoroughly dry, hot bayberry wax is painted on until no more is absorbed. The wax has a double advantage — it bears a dull non-absorbent surface which is pleasant to the touch, and if any portion of the jacket requires to be remodelled, this can easily be done by heating the part. The wax melts, the leather softens, and the part may be remodelled as desired. The jacket may be painted with three or four coats of shellac. This increases its durability. The free edges of the jacket are bound with strips of soft sheepskin, and if any portion of the border sticks inwards and is uncom- FlG. 6S. — Thomas cuirass showing the framework before it is covereil with leather. I. — The complete Thomas cuirass. fortable, it may be softened by scoring it with a number of parallel nicks, and rubbing it until it yields. Celluloid Jackets. — Jackets made of celluloid have many advantages. They are comparatively cheaply made ; as they are made upon a cast their fit can be guaranteed ; they combine lightness and a certain degree of elasticity with considerable strength. A plaster cast is first taken of the patient's body. For this purpose the patient is held in a position of slight extension, most conveniently by being suspended from a gallows. In this position the part to be cast is thordughly anointed with vaseline or warm olive oil, and, beginning below, the trunk is encased with a plaster bandage ; the first turns of the bandage encircle the trunk below the iliac crests and at the level of the symphysis pubis. TUBERCULOUS DISEASE OF THE SPINE 177 It then gradually rises, and the shoulders are included by cross turns passing from chest to back and vice versa. If the neck is to be included the case extends upwards as far as the occiput. As the plaster is drying it is carefully moulded to certain body outlines : below the iliac crests, above the sym- physis pubis, along the length of the spine, and over the outlines of the scapulae, above and below the clavicles, and, m a high case, around the occiput and the mastoid processes. When the plaster has sufficiently set, the casting Fui. 70. — III making tliu cast the ri'iiioviil of tlie itlastL-rcitst; from the Ijody is fiicilitateil if a atrip of boraciu lint ia laid on tlie sije of tlie body as is shown in the illustration. F[i;. 71. — The plaster "negative." The lateral iueision, which was made to enable the negative to be removed from the body, is repaired by an ensheathiug plaster bandage. is removed from the body by slitting it up one side of the body, above the shoulders and along the side of the neck. In removing the casting it may sometimes be difficult to avoid cutting the patient's skin. The risk is obviated by laying a narrow strip of boracic lint upon the skin beneath the plaster and along the line of removal. The shape is carefully restored. It is kept in proper position with a few turns of a plaster bandage, and the jacket is allowed to harden. The positive is now made. The interior of the negative is carefully oiled. It is placed upright in a box of sand so that its lower outlet is closed, and the arm openings are obliterated by a few turns 12 178 TUBERCULOSIS OF THE BONES AND JOINTS of a plaster bandage. A quantity of the ordinary commercial plaster is made up, using 5 parts of water to 3 parts of dry plaster, and the interior of the mould filled wath it. As the plaster is hardening, a stout wooden rod is thrust into it to form a useful handle, projecting above the cast. As soon as the plaster is hard the negative is removed, and the work of modelling the positive is begun. With a strong penknife it is sculptured so as to ac- centuate the depressions from which the jacket will take its purchase. This manipulation requires to be carried out with great judgment and care. The whole of the cast is now covered with a thin additional layer of plaster to Fig. 72. — The completed "positive." Fig. 73. — The " positive " covered with the original layers of " stockingette " aiid gauze. increase uniformly the bulk of the cast, and so ensure the better fit of the jacket. Over the cast a vest of cotton or stockingette is drawn. It must fit the cast outline exactly, and therefore it ought to be in actual size some- what smaller. Its fit is made accurate by a few adjusting stitches, and by bands of narrow tape that stretch across uneven places and are stitched upon the under surface. The celluloid solution has meantime been prepared by dissolving celluloid cuttings in a solution of acetone. To render the mixture non-inflammable, to every 150 oz. of celluloid dissolved in acetone 5 oz. of a solution of calcium chloride in water is added, the strength of the calcium chloride solution being in the proportion of 3 oz. of calcium chloride to 2 oz. of water (Gauvain). TUBERCULOUS DISEASE OF THE SPINE 179 This mixture is painted on to tlie vest with an ordinary stiff brush, and thoroughly worked in. As each coat dries, a successive one is painted on until three or four layers have been applied. When this original application has dried, and it requires about four hours to do so, a layer of unstiffened book-muslin is applied to the cast in two antero-posterior halves, over- lapping at the sides. The layer of muslin is impregnated with celluloid and allowed to dry. Successive layers are thus applied until a sufficient strength has been obtained. Anything from ten to twenty layers may be required. • Portions of the jacket which are likely to bear the greatest strain are specially strengthened by small additional layers, and the jacket is finished by the addi- tion of several coats of celluloid. The jacket is removed from the cast usually by cutting it an- teriorly up the middle line. It is now placed on the patient and carefully fitted. The edges are trimmed, and MTith a pencil the windows to be cutout are marked. A large anterior window is the most essential. The interior of the jacket is lined with wash leather, and the edges are bound with strips of similar material. Along opposite sides of the middle line a number of lacing hooks are inserted. The lower part of the jacket is sometimes complained of as giving rise to pressure. In front it ought to extend just to the upper border of the j)ubis ; later- ally it extends over the centre of Poupart's ligament, and just above both great trochanters ; posteriorly it passes across the centre of the sacrum ; above it ought to be out away freely beneath the arms. This form of jacket will bi' found a most excellent splint during con- valcHCpnfo. The Knight Spinal Brace. In the final stage of treatment, when convalescence is well advanced and cure is practically complete, it may be of advantage to supply the patient with a brace which gives support and a 12 a Fia. 74. -The lli'.\il>le conv.ile.sLi'iit liack brace for Pott's disease. 180 TUBERCULOSIS OF THE BONES AND JOINTS slight amount of fixation. An ordinary long corset, strengthened by steel bars along the spine, may be used, or a Knight spinal brace. The structure of the latter is best understood by reference to Fig. 74. A pelvic band of light steel passes round the pelvis, below the crest of the ilium, and ends below and behind the anterior-superior spine of each side. Two vertical steel bands 1 inch wide extend upwards from the jjelvic band upon each side of the spine to the level of the sixth dorsal vertebra. Their upper ends are connected by a costal band, which from the level of the sixth dorsal vertebra passes obhquely downwards into the centre of the axilla. It ends on each side at the anterior axillary line. The termination of the costal and pelvic bands are united by vertical bands on each side. There is a single cross-bar at the centre of the posterior part of the brace. Support is given in front by a lacing corset. Other varieties of jacket have been made from poroplaster, aluminium, papier mache, and silicate of potash. Each of these substances possess disadvantages, which render them inferior to the materials already described. Head Supports . For cervical disease, cervico-dorsal disease, and dorsal disease occurring above the level of the seventh dorsal vertebra, certain modifications have to be added to the brace or jacket to support the head. The more important of these various supports are now described. The Jury-mast. — The jury-mast should be made of tempered steel. Its base is composed of a flat bar, measuring usually 3 inches by l^ inches. To the extremities of this bar are riveted flat steels curving downwards and outwards, and upon the lateral steels, at their extremities and at their centres, plates of perforated tin are fastened. The base piece is intended to be incorporated in a plaster jacket, the transverse bar crosses opposite the second dorsal vertebra, and the lateral pieces pass over the scapula of each side. The upright of the jury-mast must be made of tempered steel, sufficiently strong to bear the weight of a halter which is attached to its extremity. It is riveted below to the centre of the cross-piece of the base. It passes upwards to below the occiput when it is curved backwards, conforming to the outline of the skull, but being about 1^- inches distant from it. It ends over the centre of the vertex and about 2 inches above it. To its extremity a cross-bar of narrow but strong tempered steel is riveted by its centre. The cross-bar extends laterally to a level with the lateral aspect of the skull. Round the chin and below the occiput leather bands are attached. They meet at a point above the ear, and from the junction they are attached by an adjustable strap to the extremities of Fig. 75. — The jury-mast with chest piece for incorpora- tion in a plaster jacket. TUBERCULOUS DISEASE OF THE SPINE 181 the cross-bar. The halter, the term applied to the leather head bands, should be applied with as much tension as can be borne comfortably by the patient. The chin should be tilted slightly upwards in order to extend the cervical spine, and this is done by carrying the strap junction some- what forwards in front of the ear. If it is desirable to prevent lateral movement of the head a modification is applied. From the curved upright, lateral bands pass forwards above the ears, and lie in contact with the side of the skull. They extend forwards to a level with the external angular process, and they are united in front with a strap of webbing. They very efficiently prevent lateral movement. The jury-mast has the advantage of combining traction of the spine with a certain degree of fixation. Its disadvantage lies in the fact that the fixation afforded is by no means absolute. It is most frequently used in conjunction with a plaster jacket, but by slightly varying the base piece it may be conveniently fitted to any form of spinal support. The Taylor Ring-. — This is an attachment of the Taylor brace, and it is used in cases of caries higher than the seventh dorsal vertebra. It consists of a ring, a spindle, and a socket. The ring is oval in shape. Antero-posteriorly it extends from occiput to the tip of the chin ; later- ally it is wider than the breadth between the angles of the iaw. ^ ,^ ,n, "m , i -^i °. J Fia. 76. — The Taylor brace with Opposite the left jaw angle a hinge the jury-mast attached. is placed which allows the ring to open horizontally into an anterior and a posterior division. The halves are united opposite the right jaw angle, with a pin and a ring clasp. The ring is made of steel spring, measuring J by J inch. Upon that portion of the ring which lies beneath the chin, a small tin ])late is soldered, measuring about 1^ inches wide and f of an inch long. To the plate a moulded pad of hard rubber is fastened to support the chin. To the back of the ring a piece of A case of cervico- dorsal Pott's disease. The steel is pierced with a hole Fio. 77. — Th. , , , ■ . posterior spine forged steel IS riveted brace with ^IjjqJj admits the top of the spindle. The inner side of the Tayl or ring . ^ . . ' attachment for posterior jjart of the ring is covered with rubber. The J,'?'.' ''<»''"'' spindle is attached to the brace by a socket riveted to the Pott 9 disease. ' . ■' upright of the brace. It is bent to the curve of the neck, so that the ring, whicii is attached to it above, supports the occiput and tlie chin at the proper angle. Above, the spindle enters the«hole in the steel at the back of the head-ring. The junction between the ring and the spindle 182 TUBERCULOSIS OF THE BONES AND JOINTS permits of rotation of the head, but this may be checked by a screw. The spindle is made of soft steel. In its lower two-thirds it is flat in front and rounded behind, in its upper third it becomes circular to fit the socket at the back of the ring. A shoulder attached to the spindle below the socket prevents undue descent of the head support. The socket by which the spindle is fastened to the brace is made of machine steel J inch wide and I inch thick. Through its centre there is a hole which admits the lower flat end of the spindle. The movements of the spindle in the socket are controlled by two set screws turning in threaded holes, and fitting into depressions on the posterior half of the socket. If absolute fixation of the head is indicated, as in disease at or near the occipito-axoid region, two steel uprights are attached to the back of the ring, and bent to fit closely the posterior and lateral aspects of the head. A band of webbing passes in front of the forehead from one upright to another. In applying the support the chin must always be tilted slightly upwards in order to throw the weight of the head backwards. Shafi'er has recommended that the attachment of the ring to the spindle should be made by means of a ball and socket joint regulated by a screw and key. This arrangement permits of an easier adjustment of the ring and therefore of the head. The Taylor ring has one disadvantage — the continuous pressure of the anterior portion of the ring upon the chin ultimately causes a recession of that structure, with a result which may be exceedingly unseemly. If this is feared, the position of the ring may be altered to pass beneath the occiput and in front of the forehead. The Loop Head Support. — If the disease in the spine is at a low level, and all that is required as a head support is something to prevent forward inclination of the head, this can be obtained by using the loop head support. It consists of a loop of steel which, attached behind to the cross-bar or the uprights of the brace, passes forwards in front of the neck below the chin. For convenience of application it ought to be provided ■svith a lateral hinge to enable the anterior portion to open forwards. Beyond limiting flexion it provides little support to the head. The Wire Chin Rest. — This application may be used either with a plaster jacket or with a steel brace. The fixation which it affords is unequal to that of the jury-mast or the Taylor ring. Its anterior part is manufactured of wire, the posterior or occipital portion is of steel. The wire portion is made first. It is modelled in soft flexible wire, and completed in strong wire, No. 5 or 6 gauge. A large U with a square foot is made to fit the chest in such a way that the transverse bar lies across the xiphisternum, while the vertical bars rise one on each side over the centre of the clavicles as far as the edges of the trapezius muscles. These vertical bars are well sprung forward when they pass over the clavicles, so that no unnecessary pressure is exerted. At the edge of the trapezius the wire is bent so that it rises vertically upwards to behind and just outside the angles of the jaw. It is there bent forwards, and following the line of the lower jaw it passes beneath TUBERCULOUS DISEASE OF THE SPINE 183 the chin. When this is satisfactorily modelled a permanent duplicate is made in the No. 5 gauge wire, care being taken that the joining of the wire occurs in the centre of the transverse bar of the (J, not beneath the chin. The wire portion is completed with certain additions. Under the horizontal portion of the U , and under 3 inches of each vertical limb, there is soldered a flat piece of tin 2 inches wide and lined with leather. It secures a good apposi- tion upon the chest. Beneath the angles where the uprights rise at the root of the neck, and extending for 1| inches forwards and backwards, are soldered oblong pressure pads of steel f inch wide and 3 inches long. Upon the centre of the chin loop a small piece of tin is soldered, with a rubber pad to fit the chin upon its upper surface. The occipital portion of the rest is made of a half -band of fiat malleable steel J by ^^g- inch. By one side it is attached to the right vertical wire behind the angle of the jaw, upon the left side it is clasped by its hooked extremity to the corresponding vertical wire, and where Fio. "8. — The wire chiu rest. Fid. 79. — The Cioklthwait lieail .support for cervical and cervico-ilorsal disease. it passes behind the occiput two pad plates are fastened. Vertical movement is prevented in the posterior part by stops which are soldered to the wire. The principal advantage claimed for this apparatus is that of lightness ; further, it is easily made and requires no special skill. It is, however, not rigid enough to be an efficient support. Its use ought to be limited, therefore, to convalescents. The Goldthwait Head Support.^The Goldthwait head supjxirt con- sists in the upper part of a wire chin rest, fastened to yoke-like metal bands which pass over each shoulder. The yoke-piece is first carefully moulded from a strip of thin lead I inch wid(\ From the lead copy a careful paper pattern is made, and a piece of fiat malleable steel, J inch wide and ^^• inch thick, bent to correspond with the paper pattern. In front the yoke passes collar- wise acro.ss the upper end of the sternum, opposite the junction of the manubrium and body. It bends backwards over the shoulders, and extends down the back as far as the lumbar region. The wire portion is made exactly the same as for a wire chin rest. The u|)riglit wires at their base are 184 TUBERCULOSIS OF THE BONES AND JOINTS bent forwards for about 2 inches, and soldered to the yoke on each side, where it bends over the top of the shoulder. The apparatus is fastened in position by straps and buckles. One strap encircles the body from the tips of the yoke. Other straps upon each side pass from the yoke tips to buckles on the curved portion of the yoke in front. The apparatus is applied by opening the posterior band of the head-piece, pushing the yoke ends over the shoulders and down the back until it falls comfortably into position. The posterior band is then closed. There are no special advantages to be claimed for this appliance. It is more stable than the wire chin rest. Davies Head Support. — This is especially for use with Davies' quadri- lateral back brace, but it may be modified to suit other forms of spinal support. It consists of two flat uprights, a sling for the occiput, and a strap for the forehead. The uprights are bars of flat malleable steel ^ inch wide and -^^ inch thick. They pass upwards on each side of the middle line, and they are attached to one or more of the cross-bars of the brace. They are attached to the cross-bars by means of sockets and set screws, so that their vertical position can be altered at will. The uprights pass straight upwards to about 1 inch below the occiput, when they curve upwards and outwards to a point 1 inch above and ^ inch behind the ears. Again their direction alters, and they pass directly forwards to the level of the external angular process. Buckles are here provided for attachment of the forehead strap, which is made of soft leather 1 inch wide. The occipital strap passes from that portion of the upright above the ear to a corresponding point on the opposite side. It passes behind the occiput, and it is reinforced on the outside with a thin strip of brass to prevent curling. The Thomas Collar. — In disease of the cervical spine a certain amount of support and fixation may be obtained by collars. Various materials have been used for this purpose — poroplaster, etc. The Thomas collar is the best of this type of support, and it is the only one which will be described. The original Thomas collar was made by stuffing a tube of soft calf -skin with sawdust, the diameter being greatest beneath the chin, and smallest under the ears. It was secured at the back of the neck with straps and buckles. A more effi- \ ^ I cient collar is made by cutting out from ^ J \ ^ tlii'^ sheet of steel a metal pattern 1 ^ / 1 wide enough to reach from the sternum to the chin in front, and from the back of the neck to the occiput. The edges of the metal are carefully turned out all round, so that no harmful pressure is exerted upon the neck. The metal Fig. 80.- -The Tliomas collar for cervical Pott's disease. TUBERCULOUS DISEASE OF THE SPINE 185 is covered with felt, and if necessary padded. When fitted round the neck the collar is secured in place by a strap and buckle fastening behind. Many other forms of support of greater or less merit might be described, but space forbids their inclusion. The most important ones have been mentioned. General Routine of Treatment Amidst the medley of appHances which have been described, one is apt to lose sight of the scheme of treatment which ought to underlie one's dealings with every case. Therefore it will be of advantage at this stage to summarise the detail which has been dealt with, and apply it in its proper sequence. Recumbency. — It is one's practice to treat every case of the disease in its early stages by complete recumbency, and this is done quite irrespective of the situation in which the disease occurs. The recumbency is always associated with some degree of hyperextension of the spine. The method of applying this and the reason of its value have been already described. If the disease is associated with pain or considerable muscular spasm, one combines traction with the recumbency and hyperextension. The traction is continued until the symptoms disappear. Duration. — The duration of recumbency varies in different parts of the spine. The Lumbar Region. — In the lumbar region the prognosis is good, and in the absence of complications one considers the recumbent period sufficient if it extends over twelve months. The occurrence of symptoms in the shape of psoas contraction, night pains, and abscess formation must be considered as absolute indications for a further continuance of recumbency. Lower Dorsal Region. — In the lower dorsal region the duration of re- cumbency need not be any longer than in the lumbar region. It is a favour- able part of the spine from the view of treatment, because there is not the tendency to deformity which occurs higher up, and there is an absence of those complications (psoasitis, etc.) which one finds in the lumbar spine. One advises, therefore, a minimum of twelve months' recumbency. The Middle and V])per Dorsal Regions.— From the point of view of the prevention of deformity this is the most difficult region of the spine to treat, although symptomatically it may be quickly improved. There is no better method of preventing deformity, and during its early stages of improving it, than recumbency combined with hyperextension. The treatment must be maintained for a longer period than in the other situations. Eighteen months is certainly the minimum required. The Cervical Region. — This is the most favourable region of the spine for treatment. The disease is rarely extensive on account of the com- paratively small size of the bodies involved. The weight-bearing necessities are minor, and the tendency to deformity is correspondingly lessened. When deformity does occur, the mobility of the cervical region is so great that it 186 TUBERCULOSIS OF THE BONES AND JOINTS readily compensates for it. Recumbency is carried out for about six months, and during the greater part of that time it is combined with head-traction. The Occipito-axoid Region. — Under efficient treatment the prognosis is good, and recovery without deformity should be the rule. The proximity of the disease to the vital centres makes the prognosis a guarded one, however. The course of the disease is short, probably because it begins as an arthritis. Recumbency is carried out for six months, and light traction is maintained until the symptoms have disappeared. Type of Apparatus. — As regards the apparatus used in carrying out the recumbency, one's best results have undoubtedly been obtained by the use of the Bradford bed frame and the Whitman stretcher frame. In lumbar and lower dorsal caries one recommends the Bradford frame, because the tendency to deformity is small, and therefore little hyperextension is required. The Whitman frame is indicated in mid dorsal, high dorsal, and cervical caries, as the bend in the frame permits of a thorough hyperextension of the spine, and a continuous double extension is carried out. Ambulatory Treatment.— With the completion of recumbency, ambulatory treatment is begun. Type of Apparatus. — One recommends that a plaster jacket or a Taylor brace be the spinal support chosen ; both are equally good but the plaster case is cheaper. Among the poorer classes of patients one therefore recommends it in preference to the brace. In upper dorsal and cervical caries the plaster jacket is applied as a " Minerva " or as a " Fillet " jacket, , or a jury-mast is incorporated into the jacket. Similarly with the brace a head support should be added, and from experience one favours the Taylor ring. If the disease is low down, at the lumbo-sacral junction for example, the steel support is better than the jacket, as the former can be carried lower down and more closely fitted. And when it is necessary to support the head it is wiser to use a steel brace than plaster, because of the better attachment for the head-piece. A plaster of Paris jacket is mcst useful in disease of the spine from the tenth dorsal to the third lumbar vertebra.^ A spinal support of this kind is worn for one year, except in the mid and upper dorsal regions, when it is continued for eighteen months. A less absolute support is then used, and it has become one's routine practice to employ for this purpose a celluloid jacket. This is worn for a varying period, from one year to two, and with its removal the cure ought to be complete. If any further support is required a light Knight brace is ordered. A considerable amount of moral courage is necessary to insist upon the completion of treatment so prolonged, but half-measures are worse than useless ; and it is wise to thoroughly explain the situation to the parents, and obtain their co-operation. In one's out-patient work these cases are detailed in a spinal case-book and register. They report for examination at stated intervals, and every effort is made to trace the progress from start to finish. ' Tubby, loc. sup. cii. vol. ii. p. 103. TUBEECULOUS DISEASE OF THE SPINE 187 The Abolition of the Deformity by Correction Under this heading two distinct lines of treatment are described : ( 1 ) A rapid method of correction, in which the ideal aimed at is to dispose of the deformity at a single sitting. (2) A gradual method of correction, in which the obliteration of the deformity is carried out by a series of gradual corrections. (1) Rapid Correction of the Deformity. — In 1895 Chipault^ published a paper in which he described a re\'ival of a very much older method of cor- recting by force the deformity of Pott's disease. Further papers followed in the successive years of 1896 and 1897. The method was taken up by Calot of Berck-sur-mer, who popularised it, and published an account of it in 1897.^ Since Calot's original publication hundreds of these operations have been performed, and it has been demonstrated that if suitable cases are chosen, it is possible entirely to correct a Pott's deformity at one or more sittings with but little danger to the patient. The Operation. — As ordinarily performed, the patient is anaesthetised and suspended face downwards in the horizontal position by five assistants, who exert traction upon each of the extremities and upon the head. There need be no fear of injuring the neck, as the amount of force expended cannot possibly do any harm. While the traction is being exerted, the surgeon, standing by the side of the patient, gently presses directly downwards upon the kyphosis. The angulation gradually yields and straightens, and as it does so, there is often the audible yielding of adhesions. Calot states that the amount of pressure required to correct the deformity varies from 30 to 80 lb. WTien the correction is successfully completed, or when it has been improved as far as possible, the spine is hyperextended, and in this position a plaster jacket is applied. If the disease is in the lumbar or lower dorsal regions, the shoulders are braced well back and included in the jacket ; if the disease is of the upper dorsal region, the head and neck must be in- cluded. In applying the jacket it is recommended that the bony prominences be carefully jjaddcd with thick felt ; this is probably unnecessary. A large window i.s cut out in front to prevent interference with respiration or diges- tion. In tlie after-fixation of the spine all surgeons do not apply piaster jackets ; some prefer a well-fitting brace, and others the Whitman stretcher frame. The after-treatment consists in keeping the patient at rest in the recumbent position for from three to six months. He is then allowed to get U]) and go about, but a sj)inal support is worn for at least anotlicr year. hvlications for the Operation.- -The most suitable cases are those in which the deformity is of short standing. In such, adhesions and changes in the soft parts are not sufficiently developed to offer undue resistance, and the internal organs have not become displaced or c(>m])ressed. The middle and iowii' dorsal regions of the spine are tlie most suitable for treatment. Contrn-indiralinns. — The most unfavourable cases are those of fixed ' Chipault, Travaux de nciiroloijie cliir., IS!).'). ' Cal6t, Archives prov. de chir., Feb. 18i)7, tomo (i, N. 2. 188 TUBERCULOSIS OF THE BONES AND JOINTS deformity, in which repair is well advanced or completed, and in which soft tissues and internal organs have become altered in shape and position. The presence of an abscess should contra-indicate the operation, but the occurrence of paralysis does not ; in fact, in many instances the operation relieves a paraplegia. As a rule, deformity of the lumbar and of the cervical regions is not sufficient to require a forcible correction. Results of the Operation. — One of the most complete analyses has been carried out by Bradford and Cotton.^ Six hundred and thirty-nine cases were corrected by thirty-four operators. The time elapsed since operation varied from a few days up to three years or more. Of the isolated cases, in 7 more than one year had elapsed, in 35 more than six months. The total number of deaths from all causes was 25, and the distribution as follows: from various causes, 5 ; from general tuberculosis, 4; from trauma of the operation and chloroform, 5 ; from intercurrent disease, 7. As regards immediate consequences of the operation, 7 suffered from respiratory embarrassment, 6 from severe pain, and 3 from severe shock. In 19 cases abscess was present before operation, i of these ruptured with deleterious results, 6 were benefited and in some cases absorbed. In two instances abscesses appeared after the operation. Paralysis was present before opera- tion in 23 cases, 17 of these were relieved, 2 were not reheved, and 1 case was made distinctly worse. The operation was followed by paralysis in 4 cases. As regards the direct effect on the deformity, this was estimated in 240 cases — 130 showed complete correction, 94 an incomplete improvement.. In 77 cases the ultimate result was judged to be that in 20 cases no relapse had resulted, in 50 cases there was some relapse, in 7 cases the deformity had recurred as badly as before. Jones and Tubby ^ published in 1898 and 1900 their experiences with 79 cases. They found that the results of the operation were by no means discouraging. In applying the plaster jacket, after rapid correction of the deformity. Tubby and Jones criticise the method recommended by Redard and Calot. They point out the great tendency for the jacket to become infected with vermin. To avoid this they recommend thorough and complete skin disinfection, the use of tarry tow as a lining, and the application of pressure on the hump by means of boiler felt. They believe that the amount of hyperextension required is so great as to make the patient's life miserable, and that difficulty during anaesthesia is a very real danger. Instead of the plaster jacket they recommend the use of a modified Thomas splint. The great disadvantage of the operation is the marked tendency towards recurrence, and the feeling at the present day is that the method about to be detailed, that of gradual reduction, is preferable. (2) Gradual Correction of the Deformity. — A beneficial pressure is exerted upon the deformity during and after the application of a plaster jacket. Three methods will be described : (a) Goldthwait's method by 1 Boston Med. and Surg. Jounuil, Sept. 20, 1900. 2 Clin. Soc. Trans, vol. xxxi. p. 19, and vol. xxxiii. p. 152. TUBERCULOUS DISEASE OF THE SPINE 189 horizontal traction and leverage ; (b) The method of the extension couch and weight traction ; (c) Calot's method. (a) Goldthwait's Method. — This has been alluded to in the application of a simple jacket (page 169) and need not be fully redetailed. The principle is that- the patient rests supine upon a frame in such a posture that the spine is hyperextended, and in this position a plaster of Paris jacket is applied. To secure the maximum hyperextension, traction may be desirable, and if so it can be applied by means of a windlass which is attached to each end of the frame. The method is repeated at intervals. (6) The Extension Couch and Weight Traction. — The patient is placed on an extension couch, and by leverage and weights the maximum degree of correction is obtained. A steel support is added, and the support is provided with advancing plates and screws which exert a steady corrective action upon the deformity. The application is maintained and repeated until the correction is complete. (c) Calot's Method of Gradual Correction. — Advantage is taken of the ordinary plaster jacket to act as the source of leverage. After the jacket is applied, a small window is cut out posteriorly over the deformity and a large window in front. The skin over the deformity is covered with a thick layer of vaseline. A number of sheets of wadding are cut, each a little larger in size than the posterior window, and each about 1 cm. in thickness. These are carefully introduced through the posterior window, all around between the jacket wall and the skin over the deformity. For the first compression eight or ten layers of wadding are sufficient. The introduced material bulges out through the opening on the jacket, and further compression is exerted by forcing it inwards with the successive turns of a bandage of plaster of Paris or gum. The total amount of wadding introduced varies ; if there is no actual deformity, one insertion of eight or ten layers is sufficient to guard against the appearance of the deformity. If there is a deformity, there will be of course much greater difficulty in introducing a sufficiency of packing. At the third or fourth insertion fifteen to eighteen layers ought to have been inserted. This may appear to be an enormous amount, but it is marvellous how quickly it becomes accommodated. A gradual reduction of the deformity is thus obtained. Operative Treatment of the Gibbosity Under this heading one does not iiicliKlc operative measures for the relief of abscess formation, but those wliieli are directly concerned with the reduction or the fixation of the gibbosity. Many years ago Calot advocated an operative reduction of the deformity. The operation entailed chiselling through the ankylosed vertebraj and removing the spinous processes. Calot attempted to completely correct the deformity. This operation is not now performed. In 1891 B. E. Hadra ' advocated the wiring together of the spinous » B. E. Hadrtt, Trans. Amcr. Orth. Assoc, 1891, p. 209. 190 TUBERCULOSIS OF THE BONES AND JOINTS processes of the diseased and the neighbouring vertebrae. The spines are exposed by a median incision, the centre of the incision being over the diseased vertebra. The longitudinal muscles are separated from each side and retracted, and the tissues in the interspinous spaces are divided with a knife. Silver wire is threaded in a strong, curved needle, and carried through the interspinous spaces above and below the processes in a figure of eight fashion. The ends of the wire are secured by twisting. In children it is advisable to wire at least three spinous processes, as the tissues are apt to lose their hold upon the wire loops. The wound is completely closed. The results of this operation are disappointing, and its employment has been abandoned. The next attempt at operative interference was made by Lange.^ He advocated the replacement of external support by internal splints. Splints made of tin-plated steel 10 cm. by 5 mm. are used. Incisions are made through the skin and fascia corresponding to the upper and lower ends of the splints. The latter are inserted beneath the muscles, close to the spinous processes, one on either side of the diseased vertebrae. The splints are provided with bulbous extremities, and these extremities are attached to the spinous processes by silk threads. For six weeks a Calot plaster jacket with a posterior window is used, and at the end of that time a celluloid jacket. The operation has two outstanding disadvantages — the splints do not afford sufficient fixation, and they frequently give rise to irritation and have to be removed. More recent attempts have been made to fix the diseased vertebrae with transplanted bone, and Albee's ^ operation is based on this principle. The patient is placed in the vertical position, and an incision is made over the tips of the spinous processes with the kyphosis in the centre. Each process is split longitudinally for about IJ inches into two portions, one-third of the process on the left and two- thirds on the right. The soft tissues between the spines are separated with a scalpel. Greenstick fractures are produced at the base of the left one- third portion of each of the processes. A wedge-shaped cavity is thus produced. From the tibia of either leg a prism-shaped portion of tibia, measuring 4 by | by | inches, is removed, and placed in the gap between the spinous processes. The dense fascia over the tips of the processes is united to keep the graft in position. Dobrotworski * has recommended that a portion of rib be used in preference to tibia. The immediate results of this operation are good, but sufficient time has not yet elapsed to enable one to judge of the ultimate measure of success. Dr. Russel H. Hibbs * has recently introduced an operation which aims to produce a fusion of the posterior aspect of the vertebrae, to obliterate motion of the vertebral articulations over the diseased area, and to relieve pressure on the involved bodies, thereby hastening the cure and preventing 1 Lange, Journ. Amer. Orth. Assoc, Nov. 1910. 2 Albee, Journ. Amer. Med. Assoc. Chig., 1911, Ivii. 885 ; Post Graduate, New York, 1912, xxvii. 999-1017. 3 Dobrotworski, Zeilschr. fiir Chir., Aug. 12, 1911. * Annals of Surgery, May 1912. TUBERCULOUS DISEASE OF THE SPINE 191 the deformity. The proposal is to accomj)lish by operation what nature attempts to do, viz. to eliminate motion of the diseased joints by an extra- ordinary bony growth. The operation is described as follows : A longitudinal incision is made directly over the spinous processes through the skin, supraspLnous ligament, and periosteum to the tips of the spinous processes. The periosteum is split over both the upper and lower borders of the spinous processes and the laminae, and stripped from them to the base of the transverse processes. The spinous processes are partially fractured, and used for bridging the gap between the vertebrae. The lateral walls of periosteum and of the spht supraspinous ligament are brought together over these processes by interrupted chromic catgut sutures. The skin wound is closed by silk and a steel brace applied, with the space between the uprights increased somewhat at the site of the wound, so as not to make pressure upon it. The author reports a number of cases with excellent results. The Treatment of Complications Abscess Formation. — This has been already thoroughly discussed from a general point of view. It remains to discuss some specific points, more especially the various operative measures which spinal abscesses necessitate. Abscess formation is a most troublesome complication of Pott's disease. It interferes with ajjpropriate mechanical treatment, it produces additional temporary and permanent deformities (hip flexion, etc.), it extends the boundaries of the disease by its ever-present tendency to migrate, and when it becomes secondarily infected, prolonged suppuration, waxy disease, and death may result. The treatment of spinal abscesses may be grouped into three classes: (1) Expectant treatment; (2) Con- servative treatment ; (3) Operative treatment. 1. Expectant Treatment. — Of necessity this is sometimes the treatment adopted, because the situation of the abscess is so inaccessible that other measures are impossible. And in certain cases the inactivity is justified by the fact that the abscess spontaneously resolves into a collection of caseo- calcareous debris. Prevertebral collections are the most important group under this heading. 2. Conservative Treatment. — By this term one means the treatment by aspiration and the injection of various kinds of medicaments. The various points have already been fully discus.sed. 3. Operative Treatment. — This may be the treatment of choice, and there is a school which recommends it in every available instance ; or it may be the treatment of necessity for the relief of pressure symptoms (retro- pharyngeal abscesses). IT operative treatment is decided on, situation is no bar. Certain abscesses are more difficult of access than others, but almost without exception metliods liave been devised for their exploration. Tliere are certain principles which ought to guide one's operative techni(pie. They are well siunmarised by Tubby, ^ and briefly they are as follows : • Tubby, toe. aup. cil. vol. ii. p. 176. 192 TUBERCULOSIS OF THE BONES AND JOINTS («) Let the patient remain recumbent, and if the abscess is increasing, allow it to make its way as much as possible into a place where it may be reached easily. (6) Place the incisions as far as possible from sources of contamination. (c) Single incisions into abscesses of any size are hopeless ; at least two or three openings are required. With a single incision into a psoas abscess free evacuation from remote corners is prevented, because the pressure of the air on the opened sac holds back the pus and the caseous material. One incision must be near the source of the mischief, and at least one if not more at a distance. (d) Endeavour to get primary union. (e) Always apply firm pressure with pads along the track of the abscess. (/) Asepsis from the first incision mi til every drop of pus has ceased to flow is the prime necessity, and let the surgeon always remember that slips in aseptic technique may cost the patient his life. {g) Remember that recumbency in the open air always assists the disappearance of the abscess. Retro-pharyngeal op Prevertebral Cervical Abscess. — This abscess must not be opened from the mouth, as such a procedure would certainly be fol- lowed by all the dangers of secondary in- fection. It is opened under strict aseptic precautions by an incision behind the upper third of the posterior border of the sterno- mastoid muscle. That side is chosen towards which the abscess inclines. After the incision is deepened the spinal acces- sory nerve is exposed, leaving the posterior border of the muscle, and as it is very superficial here, care must be taken to avoid Fig. 81. — Incision for retro-pbaryiigenl ... . „, ■ i i r xi abscess. injuring it. ihe posterior border of the muscle is freed and retracted forwards. Its retraction can be facilitated if the muscle is partially divided transversely just below the mastoid process. The separation of the sterno-mastoid exposes the fibres of the splenius and levator anguli scapulse muscles as they pass downwards from the transverse processes of the vertebrae. The abscess lies immediately in front of the transverse processes, and its cavity is entered by passing one's finger inwards along their anterior surface. The internal jugular vein, covered by its sheath, lies in front of the abscess, and it is displaced forwards by the finger as the latter enters the abscess. The cavity is emptied as completely as possible by pressure upon the opposite side of the neck. Curettage is dangerous on account of the liability of perforating the posterior pharyngeal wall, and the cavity is most safely and thoroughly cleaned with a plug of dry gauze. If the abscess extends across the neck to the opposite side, a counter opening should be made behind the opposite sterno-mastoid. It is wiser TUBERCULOUS DISEASE OF THE SPINE 193 not to close the wound completely, but to secure drainage for a few days with a strip of iodoform gauze or rubber drain. After-treatment. — These cases require careful watching after opera- tion. A certain proportion of them develop oedema glottidis, and require immediate attention. The head is immobilised by lateral sand-bags, and it is an advantage to apply weight extension. When the wound is healed, steps must be taken to secure fixation of the head and the usual treatment of tuberculous spondylitis. When there is urgent dyspnoea and dysphagia it may be justifiable to open the abscess through the mouth. No ansesthesia is used, or the child is kept very Ughtl}' under with chloroform. The mouth is forced wide open with a gag, and the child is placed with the head hanging well over the edge of the table ; this obviates any possibility of aspiration of the pus. One usually employs a fine tenotomy knife to open the abscess, and the pus is swabbed away as quickly as possible. The child is quickly turned over upon its face, and kept in this position until the abscess cavity is evacuated. The after-treatment is similar to that described when the abscess is opened from the exterior, but in addition weak antiseptic mouth washes are recommended. Supra-clavicular Tubepculous Abscesses.— A\T] en tuberculous dis- ease of the middle cervical spine gives rise to abscess formation, the pus passes outwards to the interval between the trapezius and sterno- mastoid muscles, and bulges in the posterior triangle above the clavicle. The operative procedure is very similar to that employed in the retro- pharyngeal abscess. An incision is made along the posterior border of the sterno-mas- toid muscle in its lower two-thirds ; the spinal accessory nerve is defined and pre- served. The posterior border of the sterno- mastoid muscle is cleared and retracted inwards until the outer edge of the scalenus F'«- 82.-incision for supra-ciavicuinr abscess. anticus comes mto view. The pus passes outwards between the scaleni and the longus colli muscles, and the interval between them is enlarged with the finger or forceps. The wound may be drained or immediately closed. The post-operative treatment is similar to that ali'cady described. Prevertebral Thoracic Abscess. — As a rule an abscess in this situation gives rise to no symptoms. At first it is a sul)[)eri()steal collection of pus ; the periosteum later becomes perforated, ami the nuitter collects between the mediastinal pleura and the bodies of the vertebrae. Operative interference becomes justifiable when pressure symptoms appear, and pressure may be exercised upon the oesophagus, tiie trachea, the left recurrent laryngeal nerve, or the spinal cord. Operation. — In some cases an area of dulness may be demonstrated 13 194 TUBERCULOSIS OF THE BONES AND JOINTS upon one or other side of the spine. If the abscess Ues in the middle line it may not be demonstrable by clinical means, except by X-ray examination, and in such cases it is recommended to choose the right side for one's exploration. The operation may take the form of a rib resection, or of a resection of the transverse process of the vertebra, together with a portion of the rib (costo-transversectomy ^). Rib Resection. — The patient is placed semi-prone, with the side to be operated on uppermost. A vertical incision is made parallel to the spinous processes, and about 1-| inches from the middle line. The articulations between the transverse processes and the ribs are exposed. The periosteum over the posterior surface of usually two ribs is divided and separated from the bone. A portion of each rib is removed external to the costo-transverse articulation. The anterior periosteum is divided, and the finger is inserted inwards and forwards along the anterior surface of the transverse process and in front of the body of the vertebra. The abscess cavity is then opened, a tube is inserted, and the cavity drained. The operation has three dis- advantages : (1) By this route the abscess cavity is difficult of access ; (2) When the cavity is entered the drainage secured is imperfect ; (3) The pleura is liable to be injured during its separation from the fi'ont of the ribs. Costo-transversectomy. — To obviate these disadvantages the operation , .^ of costo-transversectomy (costo- /^ N> transverse excision) was intro- duced by Heidenhain, practised by Menard, and modified and improved by Kocher. Heiden- hain employed a straight vertical incision close to the spines. The soft tissues are separated out- wards from the laminae as far as the tubercle of the rib, the transverse process is resected first, and then the head and neck of the rib. Heidenhain has shown that by the resection of a single costo-transverse articu- lation one is enabled to introduce the finger, strip the pleura from the side of the vertebra, and penetrate the abscess. Kocher has modified the operation by using an oblique incision, which is begun over the most prominent dorsal spine, and carried obliquely downwards and outwards along the line of the rib which is to be resected. Fig. 83. — Incision used in the operation of costo-transversectomy. '■ The term " costo-transversectomy " is not a good one, but, for its use, one has the precedent of many eminent authorities. It would be better to employ the term " costo- transverse excision." TUBERCULOUS DISEASE OF THE SPINE 195 After dividing the integuments, the trapezius and then the rhomboids, the ceUular interval is reached between these muscles and the fascia covering the divisions of the erector spinse (sacro-spinahs) muscles. The longissimus dorsi and accessorius (ilio-costalis dorsi) are divided in the line of the original incision. The cross division of the deep muscles is of no moment, as they possess a segmental nerve supply. . . . The periosteum of the exposed rib is divided for a short distance external to its tubercle. The muscular attachments, along with the periosteum and the posterior costo-transverse ligament, are then separated from the transverse process, and its base is snipped through with a pair of curved bone forceps. The divided process is seized with bone or necrosis forceps, held in the left hand, while the knife is used to free it from the remaining ligamentous attach- ments, namely, from the .superior costo-transverse ligament, passing from the neck of the rib below to its lower border, and from the middle costo-transverse ligament, which passes between its anterior surface and the posterior aspect of the neck of the rib with which it articulates. The next step consists in the removal of the head, neck, and tubercle of the rib. The periosteum is first separated from the posterior aspect of the neck, and a strong hook is then inserted into the end of the divided rib, which is dragged backwards, while the periosteum is detached from its anterior aspect, carrying with it the costal attachment of the anterior costo-vertebral (stellate) ligament. When this has been done, the freed portion of the rib is seized with necrosis forceps and twisted away from the spine. The pleura is not injured. Care must be taken not to wound the intercostal vessels, which pass outwards a little below the lower border of the neck of the rib. If the forefinger be now introduced into the bottom of the wound, it will enter the abscess cavity which occupies the ceUular tissue of the posterior mediastinum. ... If more room be desired in order to reach the upper of the two vertebrae into which the rib articulates, the upper edge of the wound must be retracted, and a second transverse process removed. If the mediastinal abscess be small it may be gently packed with iodoform gauze for a few days, and the wound then allowed to heal. As a rule, however, if the cavity be large, and especially if paraplegia be present, a drainage tube should be inserted and kept in for a considerable time.^ When an abscess involves the spinal canal, it is more satisfactorily dealt with by costo-transversectomy (costo-transverse excision) than by laminectomy, because the latter operation exposes the posterior part of the cord rather tiian the actual site of the disease. After-treatment. — ^The patient is kept recumbent for at least one year after the operation, and if at the end of that time ambulatory treatment is begun, fixation of the spine must be secured with a well-fitting brace. Lumbar Abscess. — -When there is disease of the lower dorsal and the lumbar .spine, pus may appear in the loin in one of two common situations — ■ in the angle between the erector spinas and the last rib, or above tiie crest of the ilium in Petit's triangle. Subcostal Abscess. — -When the abscess lies beneath the last rib an in- cision is made from the outer edge of the erector spinaa beneath and paraiK>l to the rib. The latissimus dorsi and the serratus posticus inferior are divided, and, lying deeper, the outer fibres of the quadratus lumborum ' Stiloa, Bar-7, iv. 505-509. Chalier, A. " La Scoliose d'originc tuberculouse," Lyon med., 1907, eix. 777-782. ViKcnow, H. " Eine nach Forme zusammcngesetzo kyphothetische Wirbelsaule," Berlin. klin. Woch., 1907, xliv. 1235-1278. Bastianelli, R. " La Cura della spondiliti tubercolare," Arch, di orlop., Milano, 1907, xxiv. 448-461. LooAN, G. K. " Pott's Disease," .V. Orl. M. and S.J.. 1907-8, Ix. 995-1003. Armour, D. "Spinal ('arics." Hnspilal, Lonnlile ot doulile tuberculoao du eoude," Btill. et mem. Soc. Anal, de J'ar., 1908, Ixxxiii. '.iriAl. Ruoii, J T. "Course of I'Icxion in Hip Disease," Amcr. Journ. Orlh. Sun/., 1908, v. 471-470. Perret, C. " t)bor dio Dauorresultato bei Coxitis tuberculosa an dor Hand, von 05 KilUoM," Archil! f. klin. Chir., Boilin, 1908, Ixxxv. 601-612. 254 TUBERCULOSIS OF THE BONES AND JOINTS HoEAND. " Double Coxa Vara d'origine tuberculeuse," Lyon mid., 1908, cxi. 685. HoRAND, R. " Coxa Vara double, genu valgum d'origine tuberculeuse," Rev, d'orthop., Paris, 1908, 2. S. is. 505-510. M'MrRPHY, N. W. '■ Tuberculous Hip Disease," Vermont. Med. Month., Burlington, 1909, XV. 238-243. Anderson, F. C. " Morbus Coxarius or Hip Joint Disease," South M.J., Nashville, 1909, ii. 957-962. Jaka Mills Bruce, R. "Coxitis tuberculosa," Rev. Med. di Chili, Sant. di Chile, 1909, xxxvii. 170. Salve, W. E. " Tuberculosis of the Hip Joint," Canad. J. 31. and S., Toronto, 1909, xxvi. 168-172. Weeks, S. W. " Tubercular Arthritis of the Hip Joint," South M.J., Nashville, 1909, ii. 432-439. M'Mtjrphy, N. W. " Tubercular Hip Disease," Tr. N. Hampshire M. Soc, Concord, N.H., 1909, 173-185. Saabfils. " Uber Coxitis," St. Petersb. med. Wochenschr., 1909, xxxiv. 89-91. Cayre, E. " Les Coxalgies douloureuses rebelles," CUnique, Paris, 1909, iv. 86-90. Kjrmisson. " Les Recidives de la coxalgie," Rev. gen. de din. et de therap., Paris, 1909, xxiii. 566. Mitt, J. J. " A Device for Measuring Flexion Deformity in Hip Joint Disease," J. Am. M. Ass., Chicago, 1909, In. 382. Larny, L. " Coxalgie gauche chez un enfant de 3 ans, etc.," Rev. d'orthop., Paris, 1909, 2" ser. X. 367-371. FioLLE and Barbe. " Sur les attitudes vicieuses de la coxalgie," Marseille med., 1909, xlvi. 712-718. Sexton, L. " Observations on Tubercular Hip-joint Disease," N. Orl. 31. and Surg. J., 1909-10, Ixii. 633-638. Gallie, W. E. Tuberculosis of the Hip-joint, Canada, London, Toronto, 1909-10, xliii. 337-341. Steishabdt, I. D. " Tuberculosis of the Hip-joint," N. York 3I.J., 1910, xci. 803-807. Aemstrong, G. E. " Tuberculosis of the Hip," Ann. Surg., Philadclpliia, 1910, U. 520-523. Wyeth, J. A. "A Case of Hip-joint Disease," 3Ied. Rec, New Yorls, 1910, Ixxvii. 707.. M'MuRPHY, N. W. " Tuberculous Hip Disease," 3Ied. Progress, Louisville, 1910, xxvi. 27-31. Sexton, L. " Observations on Tubercular Hip-joint Disease," Virginia 31. Semi-3Ionth., Richmond, 1909-10, xiv. 133-135. Rowlands, R. P. " Tuberculous Disease of the Hip-joint," Guij's Hosp. Gaz., London, 1910, xxiv. 421-425. Liebenthal " Tuberculosis of the Bones and Joints of the Lower Extremity," N. York 31. Journ., Ixxxvi. 1200-1202. Jankooski, I. I. " Chronic Hip-joint Disease caused by Pyogenic microbes and its comphcations," Khirurg. Arkh. Vebyaminova, St. Petersburg, 1910, xxvi. 1049-1056. Kirmisson, E. " Forme fruste ou anormale de la coxalgie," Bull. Acad, de Med., Paris, 1910, Ixiv. 51-55. Mencieeb, L. " fitude cinematographique du mouvement dans la guerison de la coxalgie et des tumeurs blanches," Pediatric prat., LiUe, 1910, viii. 371-373. Beoca, A. " Tuberculose de la rotule, hydrarthrose tuberculeuse du genou," Rev. prat. d'obst. et de pediat., Paris, 1910, xxiii. 97-108. Eheinghatjs, O. " Zur Atiologie der Knochenatrophie bei tuberkuloser Koxitis," Charitc- Ann., Berlin, 1910, xxxiv. 755-761. KiEMissoN. " L'Inversion dans la coxalgie," Revue internal, de med. et de chir., Paris, 1910, xxi. 63-65. Kjrmisson. " La Coxalgie avec adduction," Pediatrie prat., LUle, 1910, viu. 76-80. Ray, J. H. " The Surgical Affection of the Hip-joint in Infancy and Childhood," 3Ied. Chir., 1911, Hv. 249-271. Smith, E. H. " Tuberculosis of the Hip," Pacific M.J., San Francisco, 1911, liv. 412-414. Campbell, W. C. " Chronic Affections of Hip," Memphis 3Ied. 3Ionth., 1911, xxxi. 287-292. D'Antona, a. "La Coxite tubercolare," Studien, Napoli, 1911, iv. 95-98. Schlee, H. " Coxitis tuberculosa," Med. Klin., Berlin, 1913, ix. 339. Geeaed, C. M. Des differentes varietes cliniques et anatomiques (radiographic) des affections tnberculeuses de la hanche, Nancy, 1912. Elmslie, R. C. " Three Cases of an Uiuisual Form of Disease of the Hip-joint : Calve's Pseudo-coxalgie," Proc. Roy. Soc. 3Ied., London, 1912-13, Children's Sect., 102-106. HIP-JOINT DISEASE 255 Diagnosis Jacobs, C. M. " Symptoms and Differential Diagnosis of Tubercular Hip-joint Disease," Quart. Bull. North-west Univ. Med. Sch., Chicago, 1908-9, x. 80-84. OsTERHAM, K. " Diagnosis and Treatment of Coxalgia," Virginia M. Semi-Month., Rich- mond, 1908, xiii. 78-82. Marshall, V. F. " Concerning the Diagnosis and Treatment of Hip-joint Disease," Wis- consin M.J., Milwaukee, 1908-9, vii. 399-409. Salaghi, M. '■ Nuovo Segno per la diagnosi iniziale deUa coxite," Arch, di orlop., Milano, 1908, XXV. 262-266. Calve, J, " Difficultes du diagnostic de la coxalgie au debut," Presse med., Paris, 1909, xxii. 122-125. Shands, a. R. " The Diagnosis and Treatment of the Early Stages of Hip Disease," Virginia M. Semi-Month., Richmond, 1909-10, xiv 121-125. Steen, W. G. " The Diagnosis of Tuberculous Hip-joint Disease," Cleveland M.J., 1909, viii. 686-696. Savariana. " Co.xalgie fruste simulant la coxa vara des adolescents," Bull, et mem. Sac. de Chir. de Par., 1910, N.S. xxxvi. 891-895. Maire. " Diagnostic et traitement de la coxalgie au debut," Centre med. et pharm., Gannat 1909-10, .XV. 291-305. Walderstroom, H. " Die Herdreaktion auf Tuberkulin bei der Koxitis," Zeitschr. fiir orlh. Chir., Stuttgart, 1910, xxvi. 623-642. Forbes, A. M. " The Condition of the Lymphatic Glands as a Factor in the Diagnosis of Tuberculosis of the Hip and Lower Spine," Montreal M.J., 1910, xxxix. 518-526. DucROQUET, C. " Le Diagnostic de la coxalgie," Rev. d'hyg. et de med. inf., Paris, 1910 ix. 482-491. Jacobs, C. M. " Symptoms and Differential Diagnosis of Tuberculous Hip-joint Disease," Iowa M.J., Des Moines, 1910-11, xvii. 555-560. KiRMissoN, K. " Sur un point particulier de I'histoire de la coxalgie double," Rev. d'orthop., Paris, 1910, d" ser. i. 559-562. Mauclaire. " Symptomes, diagnostic et traitement de la coxotuberculose," J. de med. int-, Paris, 1910, xiv. 91. Bboca. " Le Diagnostic de la coxalgie au debut," Pediatric prat., Lille, 1911, ix. 1-6. Savariana. "Coxalgie au debut: diagnostic et traitement," Med. inf., Paris, 1911, viii 32-37. RociiER, H. L. " Le Signe de la clef dans la coxalgie au debut," Gaz. hebd. des sc. med. de Bordeaux, 1912, xxxiii. 608. Treatment Lannelonotje. " Traitement de la coxotuberculose dans la phase de debut," Bull. Acad. de Med., Paris, 1907, 3« ser. IvUi. 595-601. M'Ilhenny, p. a. " The Treatment of Coxitis," X. Orl. M. and S.J., 1907-8, Ix. 635-643. Bradford, E. H., and Soutter, R. " Traction in the Treatment of Hip Disease," Am. J.M. Sc, Philadeli)hia and New York, 1908, N.S., cxxxvi. 794-818. GiBENEY, H. " Some Observations on the Treatment of Hip Disease," Virgin. M. Semi- Month., Richmond, 1908-9, xiii. 529-531. Calot. " Co qui doit etre lo traitement do la coxalgie," Bull. mid. de Quebec, 1908-9 x 481-490. Marion, G. "Traitement de la coxalgie," Rev. internat. de mid. et de chir., Paris, 1908 xix. 143-145. Wynkoop, E. J. " The Use of Traction in the Treatment of Hip-joint Disease in Children," Arch. Pediat., New York, 1908, xxv. 198-202. ViLLEMiN. " Traitement de la coxalgie," Bull, med., Paris, 1908, xxii. 77-83. Abbott, E. G., and Popohe, H. A. " The Ambulatory Treatment of Hip-joint Disease," Med. J. Am. Med. Ass., 1908. i. 427-432. Wills, W. Le M. "Treatment of Uip-joint Disease," Calif. State J.M., San Francisco, ^1908, vi. 22-24. Calot. " Lo Traitement de la coxalgie," liev. gen. de din. et de thcrap., Paris, 1908 xxii 161-168. Hoffa, A. " Die Behandlung der tuberkuloscn Koxitis," Monataschr. f. orlhop. Chir., Berlin, 1908, viii. 1-3. Rankin, H. B. " Hip Disease : the Responsibilities of the Surgeon and the Indications for Treatment," Quart. Bull. North-West Univ. Med. Sch., Chicago, 1908-9, x. 51-54. Villemin. " Traitement do la coxalgie," Ann. de mid. et chir. inf., Paris, 1908, xii. 80-100. 256 TUBERCULOSIS OF THE BONES AND JOINTS Babkakin, p. " L'Appareil platre dans la coxalgie chez I'enfant," Clinique, Paris, 1908 iii. 529-532. Bareabian, p. " Traitement de la coxalgie sans abces et sans attitude vicieuse," Clinique. Paris, 1908, iii. 313. GiBNEY, V. P. " The Influences of Weight-bearing on the Treatment of Tuberculous Hijj- joint Disease," Amer. Journ. Orth. Surg., 1908-9, vi. 21-34 and 128-132. Benoit, C. " Evolution du traitement de la coxalgie," Fediatrie prat., LUle, 1908, vi. 229-234. ViONARD. " Tuteur a point d'appui ischiatique jjoui coxalgie guerie," Lyon mid., 1908, cxi. 464-470. BiDATjx, R. " Etudes sur lo traitement de la coxalgie," Rev. internal, de la tuberc, Paris, 1909, xvi. 403-409. Weber, H. " tjber die Behandlung der Kontrakturen tuberculoser Hiiftgelenke," Arch. f. Orthop., Wiesbaden, 1909, viii. 193-197. WiLCHET, J. " A propos do !a coxalgie et de son traitement local conservateur," Scalpel, Liege, 1909-10, Ixii. 241-253. Von Bonsdorfe, H. " The Surgical Treatment of Tuberculous Coxitis," Finska Labr. Sallsk. Handl, Helsingfors, 1909, li. v. 2. 901-921. Delchef, J. " Technique de la methode de Lorenz pour le traitement de la coxalgie," Scalpel, Liege, 1909-10, Ixii. 635-641. BiDAUX, K. " Traitement regulier d'un coxalgie prise au debut," Rev. internal, de la tuberc. Paris, 1909, xv. 414-425. Maybt, H. " Comment faut-il traiter la coxalgie?" Rev. metis, de gynec, d'obstet. et de pediai., Paris, 1909, iv. 155-lGl. Savaeiana. " Appareils platres dans la coxalgie, etc.," Jour, de med. de Paris, 1909, 2e. ser. xxi. 223-225. ScHWATT. " The Treatment of Abscesses in Hip Disease," Internal. Clin., Philadelphia, 1909, 19. n. U. 177-189. Wilson, H. A. " Treatment of Tuberculous Hip by Weight-bearing and Fixation by the Lorenz Short Hip Spica," South M.J., Nashville, 1909, ii. 440-444. Belham. " Coxalgie : quelques notes sur son traitement," Ann. de chir. et d'orlhop., Paris, 1910, xxiii. 321-326. Belham. "Quelques notes sur le traitement de la coxalgie," Ann. de chir. et d'ortho'p., Paris, 1910, xxiii. 353-358. ViGNABD. " Traitement de la coxalgie avec plombage," Lyon med. 1910, cxiv. 637. Mencibee, C. " Technique du traitement de la coxalgie et des tumeurs blanches pour la conservation du mouvement dans I'articulation," Arch. prov. de chir., Paris, 1910, xix. 135-171. Hendrex, G. " Le Traitement de la coxalgie par la methode conservatrice do Lorenz,"' Policlinic, Brux., 1910, xix. 65-75. Neuber, G. " tJber die Behandlung der tuberculosen Koxitis," Archiv f. Iclin. Chir., Berlin, 1910, xciii. 96-118. Hendrex. " Un Cas de coxalgie traite par la methode ambulatoire," Policlin., Brux., 1910, xix. 201-203. Alapy, H. " Die Endergebnisse der konservativen Coxitis- und Gonitis-Behandlung," Zeitschr.f. orth. Chir., Stuttgart, 1910, xxvii. 243-278. DooHE, J. " Prognostic et traitement de la coxalgie fistulee," J. de mid. de Bordeaux, 1910, xl. 561-563. Menciere, L. " Technique du traitement de coxalgie, etc.," Pediatric prat., LiUe, 1910, viii. 366-371. Murphy', T. B. " Lesions of the Hip-joint and their Management," Surg. Gyn. and Obstr., 1911, xii. 200. Calve, J. " Quelques considerations sur les appareils amovibles en celluloid dans le traite- ment de la coxalgie et du mal de Pott," Clinique, Paris, 1911, vi. 241-244. Feiss, H D. " Treatment of Hip Disease as based on its pathological Mechanics," Ohio M.J., 1911, 165-169. CoNDEAY, P. " Coxo-tuberculose et son traitement," Rev. de chir., Paris, 1911, xliii. 420-467. Snively, J. H. " Extension Apparatus for Hip-joint Disease," North-west Med., Seattle, 1912, N.S., iv. 269. Keppler, C. B. " The Short Spica in the Treatment of Hip-joint Disease," Am. J. Obst. New York, 1912, Ixvi. 888-892. Keppler, C. R. "The Short Spica in the Treatment of Hip-joint Disease," J. 3Ied. Soc, New Jersey, Orange, 1912-13, ix. 599-603. Packard, G. B. "The Mechanical Treatment of Hip Disease," Amer. Journ. Orth. Surg.. 1912-13, X. 329-332. HIP-JOINT DISEASE 257 Bradford, E. H. " Fixation in the Treatment of Hip Disease," Amer. Journ. Ortli. Surg., 1912-13, x. 354-362. Taylor, H. L. " Results in Hip Tuberculosis after Mechanical Treatment without Traction and Hygiene," Amer. Journ. Orth. Surg., 1912-13, x. 333-353. Operative Treatment Berry, W. T. " Some Thoughts on Resection of the Hip-joint for Tuberculous Disease," Charlotte {N.C.) M.J., 1907, xxxi. 293-299. RoOTH, H. C. " Radical Operation for the Cure of Incipient Hip-joint Disease," Buffalo M.J., 1908-9, Ixiv. 594. . M'BuRXEY', C. " Amputation at the Hip-joint for Tuberculosis," Med. Rec, New York, 1908, Ixxiii. 667. ViGNARD. " De I'osteotomie sous-trochanterienne et sous-cutanee dans le redressement des attitudes vicieuses de la coxalgie gueric," Bull. Soc. de Chir. de Lyon, 1908, xi. 24-27, ViGNARD. " De I'osteotomie sous trochanterienne et sous cutanee dans le redressement des attitudes vicieuses de la coxalgie giierie," Lyon Med., 1908, ex. 494-497. Jeanne and Fortin. " La Desarticulation de la hanche dans les vieilles coxalgies fistuleuses," Rev. mid. de Normandie, Rouen, 1908, 446-448. BowLBY, A. A. "An Address on 900 Cases of Tuberculous Disease of the Hip . . . with a Mortality of less than 4 per cent," B.M.J., 1908, i. 1465-1469. KoNio. " Die operative Entfernung (Resektion) des tuberkulos erkranktcn Hiiftgelenks," Berl. klin. Wochen.'iclir.. 1909, .xlvi. 429-431. De Beule, F. " Huftgelenks-Resektion," Zentralbl. f. Chir., Leipzig, 1909, xxxvi. 1077. Vignard. " Deux cas dc coxo-tuberculoso grave traites par la resection suivie de plom- bages," Lyo7i mid.. 1909, cxii. 112-115. Greenbero, H. J. " Resection for Tuberculosis of the Hip-joint," Wisconsin Med. Journal, Milwaukee, 1909-10, viii. 448-463. ViNANT, E. "Notes sur la coxalgie et la resection de la hanche," Puris chirurg., 1909, i. 712-722. Herman and Maffei " La Resection de la hanche dans la coxalgie," J. de chir. el Ann. Soc. beige de Chir., Brux., 1909, ix. 229-237. Calot, F. " Les Injections articulaires dans le traitement de la coxalgie," Rei: de med. et de chir., Paris, 1910, viii. 48-57. Ingram, J. W. " Hip-joint Amputation in Complicated Tuberculous Hip-joint Disease," Med. Sentinel, Oregon, 1910, xvii. 100-102. Binet, A. " La Resection dans la coxalgie," Rev. mid. d'esi, Nancy, 1910, xliii. 513. CoNDRAY, P. " Traitement operatoire et traitement conservateur dans la coxalgie infantile," Oaz. mid. de Paris, 1911, Ixxxii. 153. OoiLVY', ( '. " The Results of Excision of the Hip in Tuberculosis of the Joint," Post Qraduate, New York, 1912, xxvii. 989-998. 17 258 TUBERCULOSIS OF THE BONES AND JOINTS TUBERCULOUS DISEASE OF THE KNEE-JOINT Etiology Tuberculosis of the knee is essentially a disease of early life, although it is less strictly confined to childhood than disease of the hip and spine. As in tubercle afEectiug other joints there is often the history of injury preceding the development of the disease, and from the exposed position of the knee it, of course, is specially liable to various kinds of injuries. There is also very often the previous history of one of the exanthemata. The disease occiu-s almost equally in the two sexes. The other etiological factors are similar to those discussed in other joints. Pathology Anatomy of the Joint. — The knee is the largest joint in the body. The strength and numbers of its ligaments make it one of the strongest also. A distinctive feature of the joint is the presence in its Ulterior of ligaments (crucial) and cartil- ages (semi-lunar). The synovial membrane forms a large surface. Its upper limit extends about three finger-breadths above the upper border of the patella ; laterally it covers the anterior thud of the outer surface of each con- dyle, posteriorly there is no extension upwards above the condyles. The lower limit extends anteriorly and laterally as far as the upper border of the tibia ; posteriorly it dips down- wards for a short distance behind the popliteal notch of the tibia to form a cul-de-sac. The membrane lines the capsule, the deep aspect of the infrapatellar pad of fat, and both surfaces of the semi-lunar cartilages. It forms an almost complete investment for the crucial ligaments and the tendon of the popliteus. The upper synovial reflexion extends on to the metaphysis of the femiu in front ; laterally and posteriorly it does not extend beyond the epiphysis. The majority of the vessels communicating between the synovial tissues and the bone enter posteriorly and therefore enter the epiphysis. Below, both synovial reflexion and blood-vessels Ue in relation to the epiphysis. m Fig. 123.— The knee-joint. TUBERCULOUS DISEASE OF THE KNEE-JOINT 259 Pathological Anatomy. — The first question which arises in pathology is that of whether the disease is primarily osseous or primarily synovial. Some have stated that in childhood the disease is primarily an epiphysitis commencing in the head of the tibia or the lower end of the femur and rarely in the patella or fibula. The experience of others has been that the disease starts more frequently in the synovial membrane than in the bone, and with this view the author agrees. When a secondary osseous focus occurs, it is more common to find it in the lower end of the femur than in the tibia or patella, and, speaking more exactly, the epiphysis of the femur is more commonly affected than the metaphysis. The explanation of the location is dependent upon the arrange- ment of the overlymg synovial membrane, more especially the reflexion of the membrane and the circus vasculosus. The vessels which pass from the synovial membrane into the femur lie almost entirely upon the posterior surface, a few pierce the lateral parts and a few enter in front. The upper reflexion of the synovial membrane posteriorly does not extend above the epiphyseal cartilage, it lies entirely in relation to the epiphysis. Therefore, with these facts before one, it is easy to understand why tuberculous lesions at the lower end of the femur, secondary to synovial disease, are epiphyseal and so rarely metaphyseal. If the anatomical reflexion of the synovial membrane extends to the metaphysis the bone lesion is in all probabiUty a metaphyseal one. The more intimate pathology dealing with the changes in the synovial membrane and other constituents of the joint are similar to those described in the general section (page 35). Symptoms and Physical Signs It is very frequently noted by the parents or the patient that the symptoms came on some little time after an injury had been sustained by the joint. The effects of the injury may almost imperceptibly pass into the features of the disease, or there may be an apparent complete recovery from the injury, followed after a period by the signs of the more serious condition. Summary of Clinical Features. — The affection begins with a limp and some limitation of movement in the affected knee. At intervals pain is complained of, and as the disease progresses the pain becomes more constant and severe. There is swelling in the neighbourhood of the joint, and the swelling is rendered more prominent by an atrophy of the muscles of the thigh and leg. The degree of movement becomes progressively less, and the joint is distorted into a position of flexion with displacement back- wards of the leg u])on the thigh. In the last stages periarticular abscesses form, and by bursting externally constitute sinuses. The infection of the underlying bone is evidenced by osseous thickening and deformity. Such is an outline of the sequence of the disease ; the more important features may now be discussed in detail. Pain. — The pain of the affection is, as a rule, not severe. Its onset may 17 « 260 TUBERCULOSIS OF THE BONES AND JOINTS be very insidious ; for example a joint which appears quite as strong as formerly, tires more easily, or at the end of a long walk or day's work there may be a distinct limp. Pain is exacerbated by movements of the limb and jars and by weight-bearing. Night-cries are much less common than in hip-joint disease ; their presence would indicate considerable advancement of the disease. There are cases in which pain is entirely absent. Patho- logically this peculiarity appears to corre- spond with a hydrops of the joint, and the forcible separation of the articular sur- Fi(i. 124. — The cluaracteristie appearaiiLie of early tuberculous disease of the knee-joint. There is slight fle.\iou and an early synovial thickening. Fig. 125. — Tlie deformity of tlexion in early knee-joint disease. Note the antero-posterior bulging, the result of the thickened synovial membrane. faces. Local tenderness may be present in one or other of the adjacent bones ; it denotes a periostitis secondary to an intraosseal focus. Muscular Rigidity. — Muscular rigidity is a feature of this, as it is of other tuberculous joint diseases, but it is less prominent than in the hip-joint. In the early stages it may be so slight that its detection is diflacult. It may be evidenced only by a limitation of the extreme degrees of movement, flexion very often not being quite so complete as it ought to be. The muscular fixation is the explanation of the lameness which is so characteristic of the disease, the limp being the result of a fixation of the hamstrings and some degree of persistent flexion. TUBERCULOUS DISEASE OF THE KNEE-JOINT 261 Deformity. — The positions of deformity arise from the greater power the flexors possess in contrast to the extensors, and therefore the position is one of gradually increasing flexion. As the disease continues and the ligaments and periarticular structures become stretched, the flexion is accompanied by an external rotation of the tibia upon the femur and a backward displacement of the leg upon the thigh. These deformities often offer very grave obstacles to the satisfactory treatment of the disease. Swelling. — The appearance of the knee becomes early altered by an indistinctness of outline which is apparent to both sight and touch. In its begin- nings the swelling is found to delimit with considerable exactness the distri- bution of the synovial reflexion. It is evidenced by a filling up of the natural hoUows around the suprapatellar liga- ment and the ligamentum patellas and Km. 126.— 'I'lic swi-llinj; (if tlie Itft knee is the result of luherculous disease confined to tlie synovial nienilirane. The ontline of the swelling follows the ilistriliution of tlie synovial membrane. Fill. 127. — Tuliereuhnis iliseaso of the knee-joint with the aeennmlation of lluiil in the joint. The swelling is a general distention of the synovial sac. a thickening upon the lateral surface of the condyles of the femur and the tuberosities of the tibia. Posteriorly the depth of the joint from the surface generally obscures the swelling, although it may be apparent as cyst-like tumours in the popliteal space. The synovial thickening some- times pushes the patella forwards and so makes it appear unusually prominent. In this relation Tubby has drawn attention to an important detail. When the healthy patella is handled and pushed back against the femur there is produced the patellar click. No such sensation can be elicited if the patella is resting upon a pad of thickened synovial membrane. When the joint 262 TUBERCULOSIS OF THE BONES AND JOINTS is distended with fluid, the cUck can be produced as long as the membrane is not thickened. This distinction may constitute an important point in diSerential diagnosis. When fluid collects within the joint, the swelling increases in amount, but its character alters. It is now a general distension of the synovial sac, fusiform in shape, and tapering above and below. Secondary to a focus in the interior the outline of the neighbouring bones becomes altered. There is thickness and irregularity from a reactionary deposit of new sub-periosteal bone. In the late stages of the disease the character of the swelling becomes further changed by the development of periarticular abscesses. Muscular Atrophy. — Atrophy of the muscles both of the thigh and of the calf is present, and in acute cases it reaches a marked degree. The wasting gives an exaggerated importance to the swelling of the diseased joint. Fig. 128.— Ativan. ■'[ tulierculous disease of tlie knee-joint. Tliere is marked flexion and a partial backward dislocation of the tibia. Changes in Appearance of the Joint. — In addition to the swelling, the skin over the joint soon looses its natural healthy hue. It becomes pale and anaemic with an oedema tons sodden appearance. The surface veins stand out in blue lines, giving the part a marbled appearance, and as the soft tissue changes advance, the veins in the centre become stretched and empty while those arotmd the periphery increase in size and prominence. "When pus has formed within the jomt the skin becomes reddened in several places. The abscesses burst through the skin and sinuses develop. Alterations in Length of the Limb. — The destruction of the articular surface and the rarefaction of the underlying bones lead in nearly every case of any seriousness to a diminution in the length of the limb. Under one condition it is possible to imagine an increase in the leg measurements, and that is a stimulation of the epiphysis secondary to the presence of tuberculous disease either in the bone or in the joint adjacent. TUBERCULOUS DISEASE OF THE KNEE-JOINT 263 Method and Results of Examination. — A detailed history of the illness and its symptoms is taken. The examination opens with a careful general scrutiny, enlarged glands are noted, perhaps the presence of osseous tuber- culosis elsewhere. The general appearance is observed and commented on. Giving detailed attention to the diseased hmb inspection will j-ield information on the facts of skin changes, swelling, deformity, and muscular atrophy. Examination by palpation will add to the store of knowledge in respect of increased temperature of the part, thickening of the neighbouring bones, enlargement of the synovial membrane, the mobility or fixation of the patella upon the underlying femur, and the presence of fluid in the joint. Measurements, both longitudinal and circular, are made. The longitudinal measurements must include the complete length of the Hmb, as measured from the anterior superior spine or trochanter to the internal malleolus, and also the measurements of the individual bones of the leg, the femur and the tibia. The femur is measured upon its outer side from the top of the great trochanter to the lower edge of the external condyle, the knee being kept slightly flexed. The tibial measurement is estimated from the articular edge above the internal tuberosity to the tip of the internal malleolus. Measurements are made of the circumference of the limb in these localities, the centre of the thigh, the centre of the calf, and the diseased joint. For future reference any degree of deformity present is carefully noted ; for example, the degree of flexion is recorded by laying the limb upon its side and outlining on paper the displacement which exists. The degree of move- ment present in flexion and extension is tested, care being taken to avoid any unnecessary production of pain. The investigation is completed by an X-ray examination of the joint with its associated bones. Diagnosis Actual Diagnosis. — There is usually no difficulty in arriving at the correct diagnosis. Assistance will be gained from the family history and perhaps the presence of tuberculous disease elsewhere. The actual account of the onset of the disease is usually very suggestive. The exact diagnosis is made from the facts gained by inspection and palpation of the diseased joint. When fluid is present, and there is still some dubietv as to the exact nature of the condition, it is justifiable to withdraw a syringeful of fluid from the knee under strict aseptic precautions, and with it to inoculate an animal. A posi- tive result will remove all doubt, a negative result does not of necessity mean that the condition is non-tuberculous. It is necessary to mention Yon Pirquet's test as an aid in diagnosis. In the differential diagnosis certain conditions rc([uire to be excluded. Differential Diagnosis. — Syphilitic Synovitis. — Perhaps the condition most commonly confused with tuberculous disease is syphilitic synovitis. One distinguishes the latter by the bilateral effusion into the knees, the ab-sence of pain, and the small amount of functional disturliance. Glutton remarks that he has never seen lioth knee-joints filled with fluid, causing uo 264 TUBEECULOSIS OF THE BONES AND JOINTS pain, while the other joints remain unaffected, except in cases of hereditary syphiUs. If one fiads that the synovitis is associated with other syphilitic stigmata, and that it yields to anti-syphilitic treatment, there should be no difficulty in arriving at a diagnosis. Infection and Gonorrhceal Arthritis. — These may sometimes be confused with a tuberculous condition. If serious doubt should arise it may be dispelled by the examination of fluid withdrawn from the knee. Trauma. — Contusions and sprain may be followed by pain, tenderness, and effusion, but under rest and fixation the symptoms of acute synovitis speedily disappear. Rheumatism. — An unjustifiable confusion sometimes arises between tuberculosis and rheumatism. Rheumatism of a single joint in childhood is practically never seen without the positive signs of fever, heat, sudden swelling, sweating, and cardiac lesions.^ Hwrnorrhage into the Joint. — In " bleeders " an effusion may occur into the joint, and the synovial membrane acquires an oedematous thickened appearance. In nearly every instance the complication follows a slight injury, and the exact nature is made clear by a careful study of the general history. Arthritis Deformans and Hysterical Joints. — In children these are sufficiently rare to be almost negligible in diagnosis. Prognosis The prognosis depends largely on early recognition and efficient treat- ment. If the case comes imder appropriate care sufficiently early one can usually guarantee a complete cure. In certain of these cases the movement of the joint will be perfect in every respect ; in the majority, while there is healing of the actual disease, the movements may be limited through varying degrees. The longer the period before treatment is undertaken the graver does the prognosis become. If the articular siufaces are involved cure will almost certainly necessitate an ankylosis. The outlook becomes infinitely more serious when suppuration and sinus formation appears. Unless amputation is performed suppuration cases rarely reach middle life. When death occurs it is due to prolonged suppuration, waxy disease, or general tuberculosis. Treatment A. General Treatment. — What has been said in regard to the treat- ment of hip disease may be repeated in speaking of disease of the knee-joint. Sunshine, fresh air, and an outdoor life are invaluable, and as ambulatory treatment may be begun early there is no reason why these general benefits should not be fully taken advantage of. B. Local Conservative Treatment. — As in dealing with tuberculosis 1 Willard, Tenn. State Med. Journ., March 1910, p. 425. TUBERCULOUS DISEASE OF THE KNEE-JOINT 265 of the hip, conservative treatment indicates fixation and protection, and the various methods of securing these will now be enumerated. Welgrht Extension. — In early cases, accompanied as they so often are by flexion, deformity, and considerable pain, it is well to begin the treatment by fixation and weight extension. The child is confined to bed. The extension is applied to the limb up to the knee, and care is taken that the extension is carried out in the proper axis of the limb, or in the line of any deformity which may be present. When the position of the limb is a straight one, sufficient counter-extension is obtained by raising the foot of the bed upon blocks or pillars. If there is deformity in the form of flexion, the knee is supported in this position by a splint, while counter-extension is secured by a leather band which passes round the thigh above the knee and is con- nected with weight extension. The employment of this treatment for some weeks is sufficient to relieve the pain and to correct any early flexion deformity which is present. With the relief of symptoms one enters upon a course of fixation treatment. Fixation Treatment. — Plaster of Paris. — Perhaps there is no material so satisfactory as this ; it provides the most absolute fixation and protection and its application is simple and rapid. It is contra-indicated when the knee is flexed, and in the presence of abscess or sinus formation. Its use is indicated when the knee is straight and deformity is reduced. It has a special value in children of tender years who are too young to use crutches. The general details of plaster application have been discussed elsewhere. The bandage is applied from the upper part of the thigh down to and includ- ing the foot. If there is a suspicion of mobility the plaster should include the hip-joint. A casing extending from the middle of the thigh to the middle tjf the leg is insufficient. The fixation of the part leads to muscular atrophy, and as the diameter of the limb diminishes the plaster slips down- wards until quite a considerable range of movement may be permitted at the knee. It is well to have the knee fixed in a pcsition of slight flexion, in case ankylosis should occur during the period of resolution, and to prevent a tendency to genu recurvatum. As the splint frequently breaks behind the knee it should be strengthened in this situation by strips of aluminium. The first splint is kept in position for three months, at the end of that time the patient returns and the casing is removed. The joint is e.xamined and radiographed, and if the conditions are favourable a second splint is applied for three more months. Six months from the date of the commencement of treatment may be considered appropriate for the commencement of the ambulatory stage. Diuing the period of treatment by plaster it is advisable to keep the patient off his feet. The difficulty in ensuring this is common knowledge, and if it is found impossible to prevent the patient from getting up, he must be provided witli a patten upon the opposite boot and a pair of crutches. Upon no account should he be permitted to bear weight on Ihc iiffcctcd limb. Ambulatory Treatment. —From tiic position of the knee it is possible in the sequence of treatment to ensure fixation of the part and yet to avoid 266 TUBERCULOSIS OF THE BONES AND JOINTS the deleterious effects which would arise from pressure upon the joint. Certain well-known splints are employed in this connection. Thomas Knee Splint. — This consists of two lateral uprights which support the limb upon either side, terminating below in a cross-bar which serves as a stilt, and above in a ring which fits the upper extre- mity of the thigh and supports the body weight. The uprights are made of round steel wires of No. 2, 3, or 4 gauge. They are secured to the ring above and the bar below by brazing. The ring is of an ovoid , shape, flattened in front, expanded be- hind, and wider on the are brazed to it at a Fig. 129. — The Thomas knee splint viewed antero-posteriorly. A. The posterior view showing the concave upper surface of the riu] B. Tlie anterior view showing the straight upper surface. inner than on the outer side. The uprights Fig. 130. — The Thomas knee splint viewed from above. A. The outer and longei- bar. B. The shorter inner bar placed nearer to the front. C. Anterior portion of ring. D. Posterior portion of ring upon which the tuberosity of the ischium rests. Fig. 131.— The bed splint variety of tiie Thomas knee splint. lateral and antero-posterior inclination — 135 and 145 degrees respec- tively. There are definite reasons for the irregular shape of the ring TUBERCULOUS DISEASE OF THE KNEE-JOINT 267 and its inclination. Its anterior surface is flat because the surface of the groin is flat ; it is expanded behind to fit the thickness of the buttock ; the antero - posterior inclination allows the ring to rest with comfort beneath the tuberosity of the ischium ; the lateral inclination is necessitated by the greater length of the outer bar which rises above the level of the great trochanter. The ring of the splint is made larger than the thigh to permit of padding, the padding is thickest on the posterior and inner surfaces where the greatest weight is borne. To serve as posterior supports for the thigh and leg a single or two separate pieces of soft leather are stretched across the splint from side to side. A strap is attached to either side of the foot-piece, to provide for traction in the limb and to increase the fixation of the splint. Method of Adjustment. — The limb is passed through the ring so that the extremity lies between the uprights upon the posterior leather supports. Adhesive plasters are applied to eacli side of the limb, each plaster terminat- ing below in buckles. The splint is pushed iirmly against the perineum, and it is held in position by buckling the straps of the foot cross-bar to the ends of the extension tapes. By means of these straps as much exten- sion is carried out as may be neces- sary. The splint is further secured by turns of a bandage around the knee, and sometimes above the ankle. Many splints are fitted with a shoulder strap, which, fastened to the ring in front and behind, passes over the opposite shoulder. The sole of the boot upon the healthy limb is raised, and the patient uses crutches. In this variety of splint the foot is entirely off the ground, and as the joint continues to improve a further stage in the treatment may be reached by the employ- ment of the Calliper splint. The Calliper Splint. — This splint possesses the advantage that instead of walking upon a stilt ring the patient walks on the sole of the boot. The splint differs from the Thomas splint at its lower end. In the Calliper splint the two lateral bars are cut off at their lower end and turned inwards at a right angle. Tliey are inserted into a steel tube wliich pas.scs tlirough the heel of the boot. The lateral bars are made slightly longer than the leg, so that the patient's heel is lifted nearly an inch from the inside of the sole when walking. Tlie jar of impact with the ground is thus diminished. When the heel strikes against the back of the boot it sometimes excoriates, Fig. 1S2. — Tlionias knee splint applied. There is a patten fastcneil to the sole of the boot of the opposite sic-lc. 268 TUBERCULOSIS OF THE BONES AND JOINTS in which case a triangular piece of leather should be put in the back of the shoe for the heel to play on, and it is sometimes necessary to slit the back seam just above the counter for a short distance. The limb may be kept in position by a knee-cap or by wide thigh and calf leather lacings. The splint is kept in position until sufficient time has elapsed for a natural cure. If there have been no active symptoms of disease for several months, the splint is tentatively removed at night and worn during the day. Later the splint is removed entirely, or a light supporting brace jointed at the knee is worn. Sitmmary of Conservative Treatment. — When the case is first seen, if there is anything about it of the nature of the acute in the shape of pain and flexion deformity, the joint is treated by fixation with weight extension. A very few weeks of this treatment is sufficient to relieve the symptoms to such an extent that it becomes possible to enter upon the second stage of treatment, namely complete fixation by means of a plaster of Paris case. During a period of six months two separate cases are applied. With the conclusion of the treatment by plaster, the ambulatory stage is entered on, and to secure fixation during this period a Thomas knee splint is , the most suitable apparatus to employ. The period during which it will be necessary to continue wearing the knee splint varies according to the clinical condition of the dis- eased joint. Certainly the splint must be worn until all traces of the disease have dis- concluding stages of the treatment are carried out with a Such is the routine which one attempts to follow in actual Fig. 133.— The Cal- liper splint. The turned - in lower ends are inserted into a tunnel pass- ing through the heel of the boot. Fig. 134.- -Thonias knee splint in use. appeared. The CalHper splint, practice. In addition to the treatment of fixation and protection which has been described, there are various local measm'es which can be adopted, and which have been already described in the general section upon the treatment of tuberculous joints (page 103). Among the methods which may be mentioned are the injection of a sterile emulsion of iodoform in glycerin (10 per cent) into the joint cavity in amounts of 5 to 10 cc. at intervals of three to four weeks. Bier's congestive treatment, the application of allyl sulphide ointment, and counter irritation of the skin by means of a cautery. TUBERCULOUS DISEASE OF THE KNEE-JOINT 269 Lannelongue's Sclerog-enic Injections. — The natural cure of tuberculous disease is by the imprisoning of the focus in a capsule of dense fibrous tissue. Lannelongue has attempted to forestall or at least to stimu- late nature by injecting into a joint an irritant which will induce the forma- tion of scar tissue, and thus indirectly overcome the disease. The method is as follows : A 10 per cent solution of chloride of zinc is prepared, and with a fine hypodermic needle from 8 to 10 minims of the solution are in- jected at various points around the diseased area. The injections are made into healthy tissue immediately adjoining the disease. Excellent results have been obtained by this method. The Correction of Deformity. — The deformities which may exist are those of flexion, external rotation, and backward displacement of the tibia upon the femur. The causes of each are different. The flexion deformity is in its early stages the result of a reflex contraction of the ham- strings, and later of an actual structural shortening and contracture. Ex- ternal rotation is mainly due to an exaggerated action of the biceps. The backward displacement is an indication that the ligaments, more especially the crucial, have become infected, softened, and stretched. The weight of the limb with the contracting posterior muscles is responsible for the commencing backward dislocation. Considering, therefore, the various etiologies the treatment of the different deformities must vary. Correction by Traction. — As muscular contraction is the earliest cause of flexion deformity it may be corrected by simple weight traction. The leg must be supported so that no direct leverage is exerted upon the seat of the disease (see page 101). Correction by Plaster Bandage. — The plaster bandage has much the same action as weight extension in reducing deformity when the deformity is the result of simple muscular contraction. A close-fitting plaster bandage is applied from the groin down to and including the foot ; no attempt is made in any way to correct the deformity. At the end of a week the plaster is removed, when it will be found that the muscular spasm has diminished, and the deformity may now be considerably reduced. In persistent cases several applications of the bandage may be necessary. Immediate Reduction under Anceslkesia and the Application of the Plaster Bandage. — Under anaesthesia the more resistent deformities may be reduced by traction and leverage. When the deformity is corrected a plaster case is applied to keep the limb in position. This method has the advantage of speed to recommend it. It is advised to break down adhesions by flexing the limb, and then by forcible extension to straigliten it. There are certain drawbacks, however. In reducing the deformity care must be taken to avoid using too much force. Tlie epiphysis of children becomes rarefied in tuber- culous disease and easily displaced. Further, the deformity has a strong tendency to recur when treated by such an immediate reduction. Reduction bg the Billroth Splint. -In obstinate cases the Billrotli splint as modified by iStiliman may be employed. The prominences of the lower limb are well and carefully padded, especially over the outer surface of the 270 TUBERCULOSIS OF THE BONES AND JOINTS condyles of the femur, and the popliteal region over the upper border of the tibia. A plaster bandage is applied from the groin to the toes, being made especially strong in the popliteal region, and in the plaster on either side of the knee there are incorporated expanded tin splints to which curved and slotted steel bars are attached. When the bandage has hardened, it is divided into two parts by a circular cut above the knee, and the slotted spUnts being connected, the bolts in the slots are adjusted in such a way as to form a hinged splint, the centre of movement being slightly above and in front of the knee joint. If the limb be extended slightly the action of the lateral hinges is such as gradually to force the tibia away from the femur. This opens up the posterior part of the circular incision, and the part is held open by the insertion of a cork wedge. From day to day larger wedges are introduced, and the deformity gradually corrected until the limb is straight. When the correction is complete a new plaster bandage is applied and kept in position for some weeks. Correction by the Thomas Knee Splint. — The Thomas splint may be used as a corrective of deformity in two ways. By employing simple traction it overcomes the flexion deformity which is the result of simple muscular contraction. At a later period, when there may be true contracture and shortening, the splint can be made to exert a correcting action by forcing the knee towards the splint with the aid of a firmly appUed elastic or domette bandage ; as the bandage slackens it is reapplied. Forcible Correction by the Genuclast. — Certain mechanical devices or genuclasts have been employed to correct long standing deformities, more especially when the displacements are associated with a subluxation back- wards of the tibia. Lateral steel bars, attached below to a handle in a catapult shape, are placed upon each side of the leg. Pressure can be exerted posteriorly over the head of the tibia by a plate attached indirectly to the lateral bars and furnished with an adjustable screw. Counter extension is exerted over the lower end of the femur and the lower end of the tibia by means of strong linen bands. Pressure forward on the head of the tibia is exerted by turning the screw handle. The calf muscles protect the artery and nerve from injurious pressure, and gradually the deformity is overcome. The instrument is one of considerable power and care must be used in its manipulation. Correction by Operation. — When bone ankylosis is present the flexion deformity is overcome by operation. Operative measures consist in a linear osteotomy or the removal of a wedge of bone — a cuneiform osteotomy. In children a linear osteotomy of the femur is to be preferred, as it does not in any way interfere with the growing parts of the bone, and yet answers well iu straightening the limb. Linear Osteotomy. — On either the inner or the outer side of the rectus tendon a longitudinal incision is made, the centre of the incision being a finger-breadth above the upper portion of the external condyle. A MacEwan's osteotome is inserted into the incision and the bone divided. It may be found that contraction of the hamstrings renders correction TUBERCULOUS DISEASE OF THE KNEE-JOINT 271 impossible. Should this be so, one must have no hesitation in di\'iding the shortened muscles. It sometimes happens that di\'ision of the femur is insufficient ; the tibia is then divided below the anterior tubercle. J. W. Perkins recommends an osteotomy carried out some distance above the joint, and in support of his recommendation he quotes the following argu- ments : (f/) There is entire avoidance of injury to the epiphyseal line. (6) There is avoidance of injury to or undue stretching of the great vessels and nerves of the popliteal space. As the operation includes the removal from the femur of a rhomboid of bone there is a considerable amount of shortening. The operation has nothing to recommend it over linear osteotomy. Cuneiform Osteotomy of the Anhjlosed Knee. — It is presumed that the femur, tibia, and patella are fused into one bony mass. The front of the knee is exposed by a large U-shaped flap having its base directed upwards. With a saw or a very broad chisel a segment of bone is excised. The upper cut through the bone should be nearly at a right angle to the axis of the femur, the lower cut nearly at a right angle to the axis of the tibia. It is not advisable to carry the apex of the wedge as far back as the ligaments of the joint, by doing so there is a danger of wounding the popliteal artery, and when the deformity is corrected an awkward projection remains at the posterior part. The wedge should therefore be planned so that the apex lies about half an inch in front of the posterior bony surface. The wedge is removed and the remaining bridge of bone broken down by firm flexion of the knee. If the remaining bone offers a reduction to proper apposition it should be chiselled carefully away. By this procedure all chance of injuring the popliteal artery is avoided. The osseous surfaces may be approximated by means of nails inserted obliquely through the head of the tibia into the femur (see later, p. 274). The limb is fastened on a posterior splint. Treatment of Abscesses and Sinuses. — The treatment of abscessesand sinuses is similar to that recommended in disease of the hip-joint. Abscesses are generally superficial and are easily recognised and treated. The sinuses are usually short and direct ; they do not dissect tortuously among muscles as hip sinuses so often do. Operative Treatment of Knee-joint Disease Operations for Tuberculous Disease of the Knee-joint. — The operative measures which may be called for are those of excision, syno- vectomy, and amputation. Excision. — E.xcision necessarily means the removal of tiie entire synovial surface, the ablatiot\ of the articular ends of the bones, and the exposure of healthy bone surfaces beneath. A successful and complete operation is almost necessarily followed by an ankylosod joint. Indications. — The operation is indicated in cases in wiiicli conservative 272 TUBERCULOSIS OF THE BONES AND JOINTS treatment has failed to arrest the disease, iii which originally the disease is too extensive to render conservative treatment justifiable, or in which the general health is beginnmg to fail. It is said that the operation should not be performed in young children, because of necessity it interferes with the epiphyseal cartilages, and therefore with the growth of the limb. It should rather, perhaps, be stated that in young children, if there is a likelihood of operation becoming necessary, such ought not to be delayed too long. It ought to be performed at such a period that the articular surfaces may be removed without interfering with the epiphyseal cartilages. Any method of exposing the joint is good if it fulfils the following requirements : free access to the joint, the easy removal of all diseased tissues, with the minimum destruction of healthy structures, the possession after operation of a strong, useful limb with an ankylosed knee, and as little shortening as possible. Fig. 135. — Miller's incision for excision of the knee-joint. Fig. 136. — Te.\tor's incision for excision of the knee-joint. Fig. 137. — Kocher's incision for excision of the knee-joint. Incisions. — A large number of incisions have been planned to expose the joint. Volkmann recommends a transverse incision passing across the front of the joint from condyle to condyle over the centre of the patella. The patella is divided to expose the interior of the joint. Miller advocated a similar incision, his operation including not a division but a complete removal of the patella. Diakonow uses an incision which passes vertically over the centre of the joint. He splits the patella from above downwards in the middle, and separates the insertion of the patellar ligament from each side together with a scale of cartilage or bone. An excellent manner of exposing the joint is by a transverse curved incision, convex downwards as far as the tubercle of the tibia, the horns of the incision being over the condyles and opposite the centre of the patella. With this incision Textor's name is associated. Cheyne and Burghard recommend an H -shaped incision. The vertical incisions should reach from the upper limit of the suprapatellar pouch well on to the anterior surface of the tibia, and should be from 1 inch TUBERCULOUS DISEASE OF THE KNEE-JOINT 273 to 1| inches away from the edges of the patella.^ The verticals are united by a transverse incision passing over the centre of the patella. Kocher ^ formerly advocated a Textor's curved incision, but he has now replaced it by an external J -shaped one. The incision which begins over the vastus extermis, a hand-breadth above the upper border of the patella, extends at first vertically downwards a finger-breadth external to it, and then curves slightly inwards to end at the anterior border of the tibia just below its tuberosity. Kocher claims for this incision an excellent access to the joint and a minimum of disturbance in the strength of the part. Openition. — Beyond the differences in the origmal incision, the stages of the operation are practically the same in each instance. Many operators recommend the use of a tourniquet, but while this has the advantage of rendering the operation field clear, it is apt to be followed after operation by a most troublesome and persistent oozing. As a standard the operation will be described as it is carried out with a curved Textor incision. The incision is carried down to the deep fascia all round, and the large U-shaped flap so outhned is raised carrying with it the patella. To permit of raising the patella its ligament must be divided about the centre, or the insertion of the ligament must be chiselled off with the tubercle of the tibia. When the patellar flap is thus raised the capsule of the joint is opened on each side as far as the posterior limit of the incision. The knee is bent and the interior of the joint partly exposed to view. It may not be necessary to divide either the internal or the external lateral ligaments, but in the event of such a step becoming essential the ligaments are separated sub- periosteally from their attachments to the femoral condyles. With the joint fully flexed the crucial ligaments are brought into view, and they are divided about their centre. A careful survey is now made of the Ulterior of the joint, and the exact extent of the disease ascertained. Having satisfied one's self on this point, the removal of the synovial membrane is proceeded with. A knife and scissors are conveniently used in the dissec- tion. The separation is begun in front and carried deeper. In front and below, the infrapatellar pad of fat and its synovial membrane are removed. In front and above, the synovial membrane is dissected away from either side of and above the patella, and from the suprapatellar and sub-crural pouches. Laterally the membrane is dissected off the surfaces of the femoral condyles and the tuberosities of the tibia, especially from the internal tuber- osity of the tibia, where there is a distinct sacculation from the main synovial cavity. Before the synovial tissue can be satisfactorily removed from the posterior part of the joint more room must be obtained. The crucial liga- ments are carefully dissected from their attachment to the inter-condyloid notch of the femur. The semi-lunar cartilages may be removed from the iiead of the tibia, or they may be kept in position to be taken away later wit li the articular cartilage. ' Cheyno and lJurglmid, Manual of Surgical Treatment, Part iv. p. 209. ^ Kochor, Text-book of Operative Surgery, translated by Stiloa, ]>. 201. 18 274 TUBERCULOSIS OF THE BONES AND JOINTS Each articular surface is removed with a saw. The amount must be sufficient to include the whole disease-bearing area. The bone is divided in a plane parallel to the articular surface. It may be sawn in such a way as to leave opposing flat surfaces, or by using a strong fret saw the raw surfaces may be so shaped as to fit one another with less liability to displace- ment. The lower end of the femur is left slightly convex, and the upper end of the tibia is sawn somewhat concave in order to receive the lower end of the femur. In dividing the bone it is an advantage to slip over and behind the articular surface a sterilised triangular handkerchief or bandage ; by it one has more control over the end of the bone, and it is possible to pull the bone well forward, and so to avoid the risk of injuring the posterior structures. There may be such extensive disease of the underlying bone that the removal of the articular surface is insufficient. Isolated foci are scraped out with a sharp spoon, and the interior of the cavity curetted. If the disease is suffi- ciently extensive to involve an entire condyle or tuberosity. Stiles ^ recom- mends that the affected condyle or tuberosity be sawn through beyond the seat of the disease at a deeper level than its fellow. The opposite bone is dealt with in a similar but converse manner. The result of this manoeuvre is to produce two Z-shaped sawn sm'faces which must be so fashioned that when the limb is brought into good position they dovetail accurately the one into the other. In other cases an oblique section is made from before backwards, or from side to side according to the position of the focus. The slice of bone removed is thus wedge-shaped, with the disease towards the base of the wedge. The extremity of the opposing bone is also sawn obliquely, and care must be taken that the surface which is left is in a plane exactly parallel to the first. When it has been necessary to saw the bones obliquely, they should be nailed into position to prevent the risk of a gliding movement between the two surfaces. If the patella is to be left, its articular surface is removed, and a corresponding flat surface is made for its reception upon the outer part of the trochlear surface of the femur. With the removal of the articular surfaces free access can be obtained to the back of the joint, and the synovial membrane from this part is care- fully dissected away. Tuberculous debris lying around the tendon of the popliteus muscle is hable to be overlooked, the tendon therefore ought to be exposed and examined. Bleeding is carefully arrested, as it is most essential to be able to close the wound without drainage. The limb is put into proper position, and the osseous surfaces being brought together it is seen whether the line of section has been properly made or not. If there is any unusual divergence a correcting scale of bone must be removed. To secure good approximation of the bones until fixation has become firm. Stiles recom- mends that the opposed surfaces be fixed by long steel nails which are driven one on each side upwards through the head of the tibia into the femur. They are left in position for about three weeks. At the end of that time they are easily taken out, and there is sufficient union of the opposed surfaces to prevent a deformity occurring. In closing the wound, if the patella has ' Stiles, Oper. Surg. (Burghard), vol. ii. p. 99. TUBERCULOUS DISEASE OF THE KNEE-JOINT 275 not been removed, the divided ligamentum patellae is reunited, or the separated tuberosity is stitched back to the tibia. The remains of the capsule are brought together with interrupted catgut sutures, also the opening above the knee in the vastus externus. The skin wound is closed with sutures of silkworm gut or with Michel's clips. After Treatment. — After the operation it is sometimes an advantage to secure the limb in a vertical excision splint (Fig. 138). This is a modifica- tion of Liston's long splint, in which a short vertical bar is attached opposite the hip-joint, extending upwards for a slightly greater length than the limb. The limb is flexed at the hip to a right angle and bandaged to the vertical. This splint has the advantages of minimising bleeding and of lessening the liability of post-operative displacement of the ex- cised surfaces. It has one disadvantage — its use seems to cause a considerable degree of pain, probably by the continual apposition under pressure of the two raw surfaces. It is sufficient to keep the limb in the vertical splint for forty - eight hours. At the end of that period the limb is brought straight and secured to a lateral splint with a piece passing behind to support the parts. Stiles recommends the use of a MacEwan's knock-knee splint for this piu'pose. AVhen the wound is firmly healed the limb is fitted with a plaster case extending from groin to ankle. The case is kept on with interval changes for six months. At the end of that period the patient is allowed to go about with crutches, and finally to bear full weight upon the limb. Synovectomy. — For this operation the terms synovectomy, erasion, and artlirectoiiiy have been employed. The word arthrectomy ought to be applied to a true excision, synovectomy essentially means a removal of ail the disease-bearing synovial membrane. Should it become necessary to carry synovectomy further, and to gouge out diseased foci from the under- lying bones, no special name should be applied to the procedure, as it partakes of the nature of both synovectomy and excision. G. A. Wright,^ who first advocated the operation, recommended it in children in preference to excision, because he claimed that it was accompanied by a less degree of shortening, and that its performance was less likely to be followed by ankylosis. The advocate is correct when he claimed that » Lancet, 1881, vol. ii. p. 992. 18 « Fig. 138. -The vertical e.'ccision splint used after exci.sioii of tlie knee-joint. 276 TUBERCULOSIS OF THE BONES AND JOINTS the operation is associated with a minor degree of shortening. That it is likely to be followed by a movable joint is a false hope ; a satisfactory and therefore necessarily a complete operation is almost certain to be followed by some degree of ankylosis. ^Vhat one might designate as a case typically suitable for this operation, would be one in which the disease was entirely limited to the synovial membrane, and more especially to a localised area at the front of the joint, in which the articular cartilage and underlying bones were intact and in which there were no sinuses or abscesses. When these facts are all taken into consideration it would appear that there are really very few conditions under which the operation would be called for. A case sufficiently early to be suitable would probably do equally well under a conservative regime. When the operation is performed it has such a tendency to be followed by a fibrous ankylosis that one is better advised to carry the procedure further, and by removing the articular surfaces perform an excision, and so give the child a stiff but at least a strong limb. In performing the operation the joint is opened by one of the incisions described under excision. A Volkmann's straight transverse or a Textor's ciu-ved transverse are excellent. With forceps, knife, and scissors curved on the flat, a free removal is made of the synovial membrane. To obtain complete exposure it will be necessary to divide the crucial ligaments. The membrane is dissected away from the popliteal surface with great care. If it is possible the divided crucial ligaments are reunited with catgut sutures. The wound is closed without drainage. The after treatment of the case is at first similar to that of excision. If an attempt is to be made to secure a movable joint, massage and exercises must be begun within a reasonable time, at least within three weeks after the operation. The Results of Excision of the Knee. — Mr. Stiles ^ reports in his paper that during the past ten years 63 excisions of the knee have been performed, and 30 of these cases have been traced. In regard to the immediate post-operative results there was healing by first intention iii 53 cases, while in 9 cases the wound broke down or recurrence set in within one month after operation. Of the 30 cases which had been traced and examined, and which, therefore, might be considered as constituting examples of the late results of operation, it was found that in 29 instances there was complete bony ankylosis, and in 1 a slight degree of movement. The position in 27 cases was one of slight flexion, it averaged 10 degrees. In one instance the leg was perfectly straight, and in 2 there was a tendency to genu recur- vatum. Three cases showed a slight degree of genu valgum. Considering the question of shortening, in one case there was no differ- ence in length between the limbs, and it would appear that the operation had stimulated the growth of the neighbouring epiphyses. In nine cases the shortening amounted to less than 1 inch, in twelve to between 1 and 2 inches, in three it reached 3 to 4 inches, and in two it amounted to 5^ inches. 1 StUes, Brit. Med. Jour., Nov. 16, 1912. TUBERCULOUS DISEASE OF THE KNEE-JOINT 277 In those instances in whicii the amount of shortening exceeded 3 inches, a secondary cuneiform resection had been performed, and therefore these cases cannot be considered as true instances of excision. In regard to the amount of inconvenience produced by the greater degrees of shortening, Mr. Stiles says that the patient experiences little or no inconvenience from an amount of shortening which does not exceed 2 inches. Amputation was subsequently performed in twelve cases. One month after operation there was a total mortality of 4 — one from tuberculous meningitis, two from general tuberculosis, and one from measles. Operations for para-articular Tuberculosis. — Original deposits of tubercle in the epiphyseal or metaphyseal regions at the lower end of the femur or the upper end of the tibia are usually early associated with invasion of the joint. It is, however, possible for the disease to be for a short time confined to the bone, and in such cases it is advisable to remove the diseased focus by an extra-articular route in order to eliminate the possibility of a later joint infection. The position of the disease is accurately localised by X-ray examination, preferably by a stereoscopic photograph. The lesion is exposed and thoroughly evacuated. The operation is eminently satis- factory, if by it one is able to prevent a later infection of the joint cavity. Amputation. — With our improved knowledge of treatment by general means, and the advances which have been made in conservative and operative technique, the necessity for amputation has greatly diminished. Indications. — This dernier ressort is called for in those cases in which local attempts at removal of the disease have failed, in which the part is riddled with abscesses and sinuses, in which there is a diffuse osteomyelitis extending from the joint along the bones, and in which the general health of the patient is beginning to be seriously affected. Further it is to be recommended in early childhood when the epiphyseal cartilage is extensively diseased, and natural cure would necessarily be associated with great shorten- ing and a useless limb. The amputation practised is usually one through the middle of the thigh. The danger must be avoided of attempting to secure a long stump at the risk of recurrence of the disease. Arthroplastry. — An ankylosed knee is by no means a severe handicap, provided that the ankylosis is sufficiently rigid. None the less, attempts have been made to restore movement to a stifTened knee, and it is necessary to make some record of these attempts. Before any operation of this nature is tried it is most essential to satisfy one's self that the original disease is entirely cured. Latent tubercle lying in the interior of the bone may easily be lighted up by such manipulation. Murphy's Operation. — Murphy practises an operation very similar to that which he employs in cases of hip ankylosis, the essential feature of which is the introduction of a connective tissue flap between the separated osseous surfaces in the hope that a new synovial cavity may be formed, liriofiy, the operation is as follows : Bleeding is controlled by a tourniquet. A long external incision is made from a point 6 inches above to a point 3 inches below the knee-joint. 278 TUBERCULOSIS OF THE BONES AND JOINTS The incision is comparatively superficial except over the joiat, the remains of which it opens. A vertical 4-inch incision is made over the inner side of the joint. Through these incisions the lateral ligaments are divided and removed. The ankylosis is now reduced, the patella is lifted from the femur with a chisel, and the femur is separated from the tibia with chisel or saw. The lower end of the femur is trimmed to a convex shape, the upper end of the tibia to one correspondingly concave. From the outer surface of the vastus externus a flap of muscle and fascia with the base downwards is detached. The flap must be so planned that it extends laterally across the joint, and antero-posteriorly covers over the entire raw osseous surface. The flap is fastened in position with interrupted catgut sutures. A smaller flap is similarly interposed between the patella and the femur. The after treatment consists in keeping the limb rigid and extended for one week. At the end of that time massage and movements are begun. Joint Transplantation,— In 1908 Lexer ^ described two cases in which he had overcome an ankylosis by transplanting the entire knee-joint. In one case the ankylosis had occurred in a flexed position as the result of tuberculous disease, in the other instance acute suppuration was responsible. The operation is carried out by exposing the remains of the joint through an anterior curved incision. The soft parts are separated laterally from the neighbourhood of the joint, and the synostosis is excised. With the limb extended there now exists between the femur and tibia a space of about 1^ inches in extent. Into this gap a healthy knee-joint, from a freshly amputated limb, is introduced and accurately fitted. The implant is fixed in position by means of wire sutures or nails. The skin flap is brought into position, and the continuity of the ligamentum patellae restored. In Lexer's cases healing by first intention occurred in both instances. The present result is said to be one of slight movement, and no pain on walking or standing. Ankylosis of Patella to Femur. — Cases have been described in which local disease has produced fixation of the patella to the femur, the rest of the joint being healthy. Such a fixation necessarily means complete immobility. It is possible to correct such a complication by separating the patella from the femur and interposing between the surfaces a flap of muscle. The region is exposed by a longitudinal incision on the inner side of the patella, the muscular flap is obtained from the vastus internus. BIBLIOGRAPHY Pathology Barbarin. " De rallongement atrophique de.s o.s du raembre inferieur dans la tumeur blanche du genou chez I'enfant," Rev. d'orthop., Pari.s, 1908, 2<' ser. ix. 182-184. Defais, a. " Contribution a I'etude des synoviales tuberculeuses a graines riziformes de I'articulation du genou," Bev. internal, de la tuberc, Paris, 1909, xv. 426-432. Symptoms and Physical Signs Swan, R. L. " A Clinical Lecture on a Reference to some Tubercular Diseases of the Knee- joint and to the Treatment of Synovial Cavities," Med. Press and Circ, London, 1907, N.S., Ixxxiv. 542. ' Lexer, Archiv fiir klin. Chir. Ixxxvi. 952. TUBERCULOUS DISEASE OF THE KNEE-JOINT 279 Bakbarin, p. " Les Attitudes vicieuses dans les turaeurs blanches du genou chez I'enfant : leurs causes, leur traitement," Clinique, Paris, 1907, ii. 773-777. Broca, a. " A propos de 3 cas de tuberculose da genou," Pedlatrie prat., Lille, 1910, viii. 301-306. Drem, D. " Tuberculous Synovitis of Knee-joint, etc.," Proc. Roy. Soc. Med., London, 1907-8, i., Clin. Sect. 10. Johnson, R. " Enlarged Knee-joint, probably Tuberculous," Clin. Journal, London, 1908-9, xxxiii. 63. Lanz, O. " Gonarthritis tuberculosa," Nederl. Tijdschr. v. Getiusk., Amsterdam, 1908, ii. 69H Van Kaatoven, J. .J. A. " A Case of Tuberculous Arthritis of the Knee, apparently much aggravated by Biers Congestion," Therap. Gaz., Detroit, 1908, xxxii. 170-172. SwYNGHEDAUW. " Tumeur blanche du genou," Echo med. du nord, Lille, 1908, xii. 252 Cabanas, E. " Tuberculose et ankylose vicieuse du genou," Bull. med. de I'Algerie, Algeria. 1908, xix. 284. DuvERC.EY, J. " La Tuberculose du genou circonscrite au cul-de-sac quadricipital," Gaz. hebd. des sc. med. de Bordeaux, 1908, xxix. 397-400. Barbarin, p. " Les Durations consecutives a la tumeur blanche d\i genou chez I'enfant : leur mechanisme, leur traitement," Paris chirurg., 1909, i. 533-539. Rives, A. "Tumeur blanche du genou," Montpel. med., 1909. xxviii. 38-41. Peckiiam, F. E., and Hammond, R. " Ankylosis of the Knee following Tuberculosis," Boston M. and S. J., 1909, clx. 447. Sternhardt, L D. " Tuberculosis of the Knee-joint," New York M. Journal, 1909, xc. 395-398. DnpUY de Fbenella. " Les Deviations dans les tumeurs blanches du genou chez I'enfant," Paris chirurg., 1909, i. 723-725. JuDET. " Les Deviations dans les tumeurs blanches du genou chez I'enfant," Paris chirurg., 1909, i. 651-656. Waitiker. '■ Tumeur blanche du genou," Bull, et mem. Soc. de Chir. de Par., 1909, N.S., sxxv. 1154-1156. Broca, A. " A Propos de 3 cas de tuberculose du genou," Pediatric prat., Lille, 1910, viii. 301-306. Broca, A. " Les Attitudes vicieuses dans la tumeur blanche du genou," Pediatric prat., Lille, 1910, viii. 323-326. Addison, O. L. " Old Healed Tuberculous Disease of Knee-joint : Increase in Length of Limb," Proc. Roy. Soc. Med., London, 1910-11, iv.. Sec. Stud. Dis. Clin. 39. FlDON. " Tuberculose du genou, etc.," Bull. Soc. Me.d. Chir. de la Drome, Valence, 1910, xi. 56-59. SiiERiLE, J. G. " Observations on the Surgery of the Knee-joint," Surg. Gxjn. and Obstetr., Chic., 1910, X. 205-207. Mathews, F. S. " Tuberculous Synovial Cionitis," Ann. Surg., Philadelphia, 1910, Ii. 946. Du Croquet, C, and Beau, U. "Les Deviations du genou dans la tumour blanche," Arch. de med. d'enf., Paris, 1911, xiv. 241-249. Diagnosis GuiRiN, A. " Diagnostic d'evolution tuberculeuse de I'hemarthroso du genou," Rev. gen de din. et de therap., Paris, 1909, xxiii. 201. Treatment Hammond, VV. N. " The Modern Surgical Treatment of Knee-joint Diseases," Hahneman Month., Philadelphia, 1909, xliv. 749-7.53. Impallomeni, (!. " Lo Traitement de I'osteoarthrito tul)crculeuse du genou chez I'enfant doit etre resolument conscrvateur," Rev. d'orlhop., Paris, 1909, 2° s6r. x. 501-536. De Vbeese, C. " Nouveau Traitement de I'hvdarthrose du genou," Ann. Soc. d'Anvers, 1910, Ixxii. 131-137. Zeldovich, Y. 1$. " Treatment of Tuberculosis of the Knee-joint," Ru.i.ik. Xach., St. Peters- burg, 1911, X. H42, 876, 911. Charkur, A. " Kesiillats I'loignes du traitement de? tumeurs blanehes du genou par les injections profoiidis ilc chloride de zinc," Gaz. hebd. des sc. med. de Bordeaux, 1911, xxxii. 7.5. BiDOU, A. J)u traitement aclud de la tumeur blanche du genou, Lyons, 1912. Baldwin. " Tuberculous Disease of the Knoe-joint," West London M.J., London, 1913, xviii. 39. Gallocun. " Osteoarthritis tuberculeuse du genou," Normandie med., Knuen, 1913, xxix. 10-15. 280 TUBERCULOSIS OF THE BONES AND JOINTS Operative Treatment of Knee-joint Disease Davis, H. " Secondary Excision of the Knee-joint," St. Earth. Ho.9p. Reps., 1908, London, 1909, xliv. 143-151. Ferguson, A. H. " Excision of the Knee-joint," Sii.rg. Gyn. and Obstelr., 1908, vi. 68-71. Bekger. " Les Indications operatoires dans la tumeur blanche suppuree du genou," Rev. gen. de chir et de therap., Paris, 1908, xxii. 38. Lbnhart, H. " Beitrag zur Resektion des tuberkulosen Kniegelenks," Beitr. z. klin. Chir., Tubingen, 1909, Ixi. 455-477. Clarke, J. J. " Excision of the Knee-joint," Polyclin., London, 1909, xiii. 40. Crespolti. '' La Resezione del ginocchio per osteomyelite tubercolare," Gaz. internaz. di med., Napoli, 1909, xii. 62. Edmunds, A. " Arthrectomy of the Knee-joint," 3Ied. Press and Circ, London, 1909, N.S., Ixxxvii. 581. Lehr, H. " Die Resektiondeformitat des Kniegelenks : ein Beitrag zur Frage der operativen Oder konservativen Behandlung der Kniegelenkstuberkulose in Kindesalter," Zeitschr. fur orth. Clin., 1909, xxiii. 529-556. Gibney, V. P. " The Part Arthrectomy plays in the Treatment of Tuberculous Joints, more particularly the Knee-joint," Amer. Journ. Orth. Surg., 1909-10, vii. 22-30. Olliviek. " Resection sans drainage pour un arthrite tuberculeuse du genou," Lyon chirurg., 1910, iv. 68-74. MoREAU, J. " Resection totale du genou pour tumeur blanche," Clinique, Brux., 1912, xxvi. 679-695. TUBERCULOUS DISEASE OF THE ANKLE-JOINT 281 TUBERCULOUS DISEASE OF THE ANKLE-JOINT Etiology It is generally stated that tuberculous disease of the ankle-joint ranks third in the order of occurrence, taking in the sequence next place to disease of the knee-joint. The illustrative statistics most frequently quoted are those of Whitman.^ In five consecutive years 1788 cases of tuberculous disease of the joints of the lower extremity were treated at the outdoor department of the Hospital for Ruptured and Crippled. In 54-1 per cent of these the hip-joint was affected, in 36-2 per cent the knee-joint, and in but 9-7 per cent the ankle- joint. Statistics obtained over a period of ten years from the Edinburgh Sick Children's Hospital show somewhat different results. Considering tuberculous joints of all varieties the ankle was found to constitute a pro- portion of 15-.5 per cent. This difference is probably to be explained by the fact that while ^\^litman's results were obtained from cases of all ages, the Edinburgh figures are drawn entirely from children less than twelve years old. In comparison with the occurrence of tuberculous joint disease in other situations ankle disease is more common in childhood than in later life. It is more common in boys than in girls in the proportion almost of 2 to 1. The increased occurrence of injury in the male sex has b?en made responsible for the greater proportion in boys. Pathology Anatomy of the Joint. — The bones which enter into the formation of the ankle-joint arc the lower ends of the tibia and fibula and the astragalus. The tibia and fibula, aided by the transverse inferior tibio-fibular ligament, form a three-sided socket within which the astragalus is accommodated. The joint is completely invested by ligaments, aiul, with the exception of the anterior, they are of considerable strength. Synovial membrane lines the capsular ligament, and the joint cavity communicates directly with the inferior tibio-fibular joint. The movements of which the joint is capable are those of dorsi-flexion and extension ; it is extremely d()ul)tful whether any degree of lateral movement is possible. Patholog'ical Anatomy. The actual ))iithology differs in no respect from tliat \vlii( h lias Ijrcii described in other situations. I'lider tiiis heading one nnist discuss the exact location of the disease, and tliis question is com- plicated by the proximity of the ankle-joint to the tarsal hones and .synovial ' Wliitnmn, he. cil., p. 440. 282 TUBERCULOSIS OF THE BONES AND JOINTS sacs. Hahn ^ has published an investigation of the situation of the disease as ilhistrated by a series of 309 cases. Of these, .51 per cent had apparently originated in the bone, the remainder were primarily synovial. The situa- tion of the osseous lesion varied \vithin wide limits. The primary focus was in the internal malleolus in 11 instances, in the external in 7, and in 5 both tibia and fibula were affected. In 116 cases the disease had begun in the astragalus, in 16 instances in the os calcis, and in 5 both astragalus and OS calcis were diseased. During the past ten years 29 cases were operated on in the Edinburgh Sick Children's Hospital.^ The disease was primarily syno\aal in 6 cases, while in 23 it was both synovial and osseous. The astragalus was involved in 15 cases, the os calcis in 5, the tibia and fibula in 2, and the scaphoid in 1. It was more especially observed that when the astragalus was diseased, the focus was originally localised to the neck of the bone. Statistics therefore appear to indicate that the neck of the astragalus is the situation of choice in which the disease begins. This distinctness and peculiarity of origin is to be explained upon anatomical grounds. If the popliteal artery of a limb is injected with a solution of lampblack, and the bones afterwards cut and examined, it will be found that a considerable quantity of the injection becomes deposited in the interior of the neck of the astragalus. The deposit is usually sufficient to produce a distinct blackened area in this portion of the bone. The injection has collected in this situation, because the part is an exceedingly vascular one. Its vessels originate from those around the synovial reflection, and they extend into the interior of the bone, at the attachment of the anterior liga- ment to the neck. As one finds anatomically, so one finds clinically, tuber- culous disease of the ankle-joint is mainly osseous in origin, and its origin is more especially localised to the neck of the astragalus. From the original deposit in the neck of the astragalus the disease may extend in various directions. It may pass directly to the surface in front of or behind the anterior ligament of the joint. If in front of the anterior ligament, it forms an extra-articular cold abscess upon the dorsum of the foot ; if posterior to the ligament, it invades the ankle-joint directly. Its other possible direc- tion is backwards into the body of the astragalus, from which it secondarily usually invades the joint. Sometimes it makes its way forwards into the astragalo-scaphoid joint, and eventually into the various bones of the tarsus. The surrounding tendons are in such close proximity to the ankle-joint that they soon become infected, and the disease spreads upwards and downwards along the sheaths. Symptoms and Physical Signs Limp. — Perhaps the earliest symptom of ankle-joint disease is a slight limp. At first it is noticed only after unusual exertion, but it becomes more persistent until it is permanently established. In its beginnings the limp 1 Hahn, Beiirage zur klin. Chir., Bd. xxvi. H. 2, 1900. 2 Stiles, Brit. Med. Jour., Nov. 16, 1912. I'l.A'I'IO X[.\\. Ai)V\NrK[) 'l'i;ni;iii.'i:r.()fs Diskask iik tmk AmvI.k-.Ioint. Sectiiiic of till' Iniit >liciw,s lli;vt IIh- iliscnse angiiuite3. — TiiWrculnia .ii ta-.i ; :. ,.■.•- '. .i .,... .ml left iiiiiliir buiif. best incision for the e.xposure of the part is one which begins a little bi'low the middle of the infraorbital margin, and pa.sses downwards and outwards over the malar bone for the necessar}' distance. The incision lias the double advantage of avoiding the braiiclies of the facial nerve and of leaving a .scar which is concealed in tin- natural folds of the skin. The ab.scess cavitv is 334 TUBERCULOSIS OF THE BONES AND JOINTS cleaned out, the periosteum is separated from the bone and the diseased focus removed. Fig. 164. — Central tuberculous disease of the patella. (Dr. Kirk's case.) TUBERCULOSIS OF THE RIBS The ribs may be infected -with a primary tuberculous osteomyelitis, or they may become involved secondary to tuberculous disease of a neigh- bouring part, such as the pleura, in which case the disease begins as a peri- ostitis. The clinical features are indefinite, pain is often complained of before the appearance of an abscess. Early abscess formation is characteristic. It may be situated over the site of the bone focus ; sometimes it makes its way along the line of nerves, blood-vessels, or tissue-planes, and appears at a considerable distance from the original disease. From a focus in the posterior extremity of the rib the pus may burrow along the line of the intercostal vessels, and appear in the mid-axillary line or at the side of the sternum. When the disease is situated at the costo-chondral junction a secondary abscess may gravitate downwards, enter the sheath of the rectus, and filter down the whole length of the abdominal wall. It is exceptional, but it sometimes happens, that the abscess collects between the pleura and the chest wall. The treatment consists in complete and early excision of the diseased rib. A horseshoe-shaped incision is preferable to one in the line of the rib, as it gives more complete access. The convexity of the incision is directed downwards, and the flap is dissected upwards off the chest wall. If an underlying abscess is exposed, it is completely dissected away. The ribs are carefully examined for signs of disease, it may be a periosteal thicken- ing, it may be a sinus leading into the bone. The diseased bone is resected TUBERCULOSIS OF THE RIBS 335 subperiosteally, and any disease in the periosteum is dissected out. The flap is sutured back into position with or without drainage. When the abscess has travelled some distance before becoming super- ficial enough to be recognised, it may be difficult to decide on the situation from which the infection originated. In such circumstances it is proper to open the abscess, and by following the track taken by the pus, to expose, if possible, the original focus. BIBLIOGRAPHY Rowlands, R. P. "The Treatment of Caries of the Ribs," Guys Hasp. Rep., London, 1907, Ixi. 245-247. Barbakin, p. " Un Cas de tuberculose costale traite par le radium," Paris chirurg., 1911, iii. 433-435. Gross. " Spina Ventosa Costal," Prov. tiied., Paris, 1912, xxiii. 515. Special Regions ' Patella. GoLDiNG Bird. " Tubercle of the Patella," Guy's Hasp. Gaz., London, 1907, xxi. 465-468. Murphy, J. B. " Tuberculosis of the Patella," Surg. Gyr>ec. and Obstelr., 1908, vi. 262-273. KiRMissoN. " La Tuberculose primitive de la i-otule," Bev. gen. de din. et de therap., Paris, 1908, xxii. 773. Bourgeois, Paul. " Contribution a I'^tude de la tuberculose de la rotule," Paris, 1908. Pubes. MoiGNET, fiiaiLE. Contribution & I'etude de Vossitis tuberc. du pubis, Paris, 1911, Journ. etc. Circ, 48 pages. Ischium.. Zellmeyer. " fitudes cliniques de la tuberculose de I'ischion," Rev. internal, de la tuberc, Paris, 1909, xv. 101-104. Mastoid. Mackenzie, D. " Tuberculous Disease of the Petrous or Mastoid Process," Clin. J., London, 1910-11, xxxvii. 190. Malar Bone. LiPRAT, J. H. (i. Tuberculose de Vos malaire, Paris, 1908. Palate. DiTTRiBU. '■ Tuberculosis mucosae jjalati duri," J. Cutan. Dis. incl. Syphilis, New York, 1910, xxviii. 300. Sternum. Jacques, R. " De la tuberculose du sternum," Rev. inlernat. de la tuberc, Paris, 1910, xviii. 408-414. Batut, L. " Affections des os : tuberculose du sternum," Bull. Soc. Med. Chir. de la Drome, Valence, 1911, xii. 186. MoRK.STON. " Tumcur blanche sterno-claviculaire traitee par Ics injections do parniol," Bull, et mem. Soc. de Chir. de Paris, 1912, M.S., xxxviii. 1462-1464. GENERAL INDEX Abduction in hip-joint disease, 216 Abscess, dorsal, 122 iliac, 197 in Petit's triangle, 196 intra-articular, 49 intra-pelvic, 325 lumbar, 195 periarticular, 49 prevertebral, 124 thoracic, 193 retropharyngeal, 122 supra-clavicular, 193 Abscess formation in bone tuberculosis, 45 hip-joint disease, 217 treatment of, 240 joint tuberculosis, 49 Pott's disease, 120 examination for presence of, 141 symptoms dependent on, 129 treatment of, 191 sacro-iliac disease, 325 tuberculosis of the lower jaw, 331 Abscesses, in tuberculous disease of the knee- joint, treatment of, 271 shoulder-joint, 306 wrist-joint, 321 originating in the cervical spine, 120 dorsal spine, 122 lumbar spine, 124 treatment of cold, 76 Adam's operation for hip-joint disease, 238 Adduction in hip-joint disease, 216 Administration of tuberculin, methods of, 87 Ago in bono tuberculosis, 50 hip-joint disease, 204 Pott's disease, 1 1 1 Alderman's gait in Pott's disease, 132 Alexan4 Schliiselcr (K.), 201 Schonicdler (\'.), 318 Schuflel, 18 SchiUler (M.), 7 Schulthess, 202 Schulz (G. B.), 253 Schwartz (A.), 57 Schwatt, 256 Scudder (C. L.), 311 Seilhan (Fran^oise), 329 Selby (C. D.), 202 Senn, 96 Sever (J. W.), 296, 311, 318 Sexton (L.), 254 Shaffer, 182 Shands (A. R.), 108, 255 Sharpev, 13 SherUe"(S. G.), 279 Sherman (H. M.), 99 Sick Children's Hospital (Edin.), 9, 10 Silver (D.), 99 Skinner (C. H.), 02, 63 Smith (E. H.), 254 Smith (Maynard), 90, 99 Smith (Theobald), 4, 5 Smoler (F.), 33 Snively (J. H.), 256 Soutter (R.), 255 Spangenberg, 85 Spengler, 89 Starr (C. L.), 200 Steinman, 302 Stern (W. G.), 108, 202, 255 Sternhardt (I. D.), 279 Stich (R.), 295 Stienar, 201 Stienhardt (I. D.), 201, 254 Stiles (H. J.), 80, 96, 97, 195, 248, 249, 252, 274, 275, 276, 277, 282, 288, 289, 318 StiU, 56 Stillman, 269 . Strauss (M.), 108 Streda (H.), 327 Stuia (I. D.), 201 Subblev (E. F.), 57 Swan (R. L.), 278 Swett (P. P.), 57 Swift (H.), 107 Swyiighcdauw, 279 Tavlor (C. F.), 170, 226 Taylor (H. L.), 257 Taylor (K. T.), 98, 102 Ternier, 200 Terrier-Hannequin. 240 Textor, 272 Thierv (P.), 98 Thomas (B. 11.), 99 Thompson (G. Ritchie), 74 Thorndike, 1 12 Thornton, 173, 233 Tik (V. A.), 42 Tilmann, 104 Tis.sot (F.), 200 Tixier, 32, 295 Todd (C. K.), 107 Tocpel (T.), 32 Touchot (F. II.), 200 352 TUBERCULOSIS OF THE BONES AND JOINTS Tourneaux (J. P.), 33, 329 Townsend, 120 Traversier, 200 Treboulet (H.), 42 Trcloar (Lord Mayor), 67 Treves, 196 Tridon (P.), 200 Tubby, 7, 77, 112, 119, 151, 175, 186, IS 191, 261 Vacorand (H.), 33 Van Hook, 324 Van Hucllen, 91 Van Mette (B. F.), 32 Vassalin (C. N.), 295 Vendova {R. DaUa), 98 Verneuil (H.), 98 Vignard (P.), 33, 98, 202, 256, 257 ViUard, 323 Villemin, 5, 255 Vinant (E.), 257 Vincent, 297 Virchow (H.), 199 Vogel (K.), 201 Vogelmann (R.), 31 Volkmann, 13, 25, 26, 272, 304 Von Behring (L.), 6 Von Bonsdorff (H.), 256 Von Pirquet, 52 Vreese (C. de), 279 Vulpuis (0.), 108 Wagner, 221 Walderstroom (H.), 57, 255 WaUace (C), 98, 201 VVallis (F. C), 197, 200 Walther, 295 Waltiker, 279 Walton (A. J.), 99 WassiUew (M. A.), 198, 200 Waterman, 112 Weber (A.), 4, 6, 256 Weeks (S. W.), 254 WeUs (A.), 201 WetherhUl (H. G.), 99 Wheeler (W. I. de C), 327 Whitbeck (B. H.), 202 Whitman, 172, 203, 204, 229, 281 Wiener (A. C), 202 WUchet (J.), 256 Willard (de F.), 99, 264 Wills (W. le M.), 255 . Wibex (C), 98 Wilson (H. A.), 9, 74, 108, 256 WUson (H. B.), 107 Wolbach (S. B.), 4 Wolff-Eisner, 87 WooUey (P. G.), 42 Wright (G. A.), 69, 84, 87,f212,'275 Wullstein, 111, 118 Wyeth (J. A.), 202, 254 Wyn-Koop (E. J.), 56, 255 Yeo (Burney), 69 Yoiing (G. B.), 137 Young (J. K.), 62, 201 Zeldovich (Y. B.), 279 Zelhneyer, 335 Zhachenko (H. S.), 311 Zuntz, 68 THE END Printed by R. & R. Clakk, Limited, Edinburgh. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE i 7 ! 1 j C2S(S46)M2S TlllU^ tu COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 684 F86 C 1 Tuberculu'ji', d' :::" imr. ', ,!"i: ,iiiii:\ .11 2002279576