ably present, as well as reflex spasm of the muscles. The degree of flexion corresponds largely to the acuteness of the infection. Other deformities of a secondary character may take place. The various

Fig. 124. Complete recovery from an extensive tuberculous infection of the right hip-joint in infancy. The skiagraph shows that the head of the femur has been absorbed. Firm bony union has taken place between the thickened neck and the acetabulum, permitting no movement at this joint but the patient has a useful limb.

displacements of the tibia upon the femur with certain other deformities are late manifestations of the condition, and do not require more than mention of their occasional existence in such cases.

CHAPTER LXV

TREATMENT OF TUBERCULOSIS OF BONES AND JOINTS

It is possible to consider but briefly the principles upon which is based the management of tuberculous bones and joints. Obviously, no attempt can be made to discuss special methods of treatment, particular mechanical contrivances, or other technical features.

The treatment consists, first, of general hygienic management, and, secondly, local measures, which may be non-operative or purely surgical. General Hygienic Management. The hygienic treatment of tuberculosis of bones and joints is identical with that of tuberculosis of the lymphatic glands, to which attention has been directed. It is important to emphasize again the inestimable value of an out-of-door existence, combined with a suitable environment at the seashore, the country, or the mountains. It is possible that the wonderful advantages accruing from the application of these principles of treatment are more conspicuous in bone and joint tuberculosis than in cases of glandular involvement. Greater recognition is being accorded by surgeons to the benefits resulting from improved nutrition and increased individual resistance. By this means direct surgical interference is often avoided entirely, whereas in other cases such intervention is permitted to take place at a time when the general vitality and condition of the tissues are such as to insure not only a more rapid healing, but to lessen materially the likelihood of further tuberculous dissemination. In the event of moderate fibrous tissue proliferation about a tuberculous focus, operative surgery is attended with much less danger of general tuberculous infection than when fresh open surfaces are brought directly in contact with infective material. The process of repair in such cases consists essentially of the inclosure or incapsulation of the tuberculous focus by a barrier of protective connective tissue. Absorption, as well as elimination through abscess formation, at times plays an important part in an arrest of the disease, but the formation of granulation tissue in the periphery of the diseased area, and its subsequent organization resulting in dense fibrous tissue development constitutes nature's constructive efforts toward the arrest of the tuberculous lesion. It must be remembered that the condition is tuberculosis presenting the same features of pathology as the pulmonary affection, exhibiting, it is true, distinct differences in type, but, nevertheless, subject to the same principles, and affording similar indications in the way of therapeutic management. The reparative processes are accelerated directly in proportion to the increased general vitality and the local resistance of the tissues. The essential consideration, therefore, in all cases is the primary effort to fortify the general condition by a conscientious and sometimes radical application of the principles of nutrition and hygiene. Life in the open air, with an abundance of nutritious food and opportunity for recreation, increases the reparative forces to an extent unequaled by any other therapeutic agent.

In those cases in which the articular surface of the joint is not seriously involved, although an intact cartilage may be found to conceal an extensive destructive process in the bone, general hygienic

management alone is sometimes sufficient to bring about an ultimate quiescence, if not arrest, of the tuberculous process. Even in cases in which the joint is involved to such an extent as to preclude the control of the disease and to necessitate active surgical intervention there may be afforded, through a period of rest in the open air, with enforced nutrition, a heightened soil resistance and a suitable preparation for the surgical ordeal. The importance of the constitutional treatment, therefore, can scarcely be exaggerated, and equals in many instances the efficiency of all local measures of treatment, including the various forms of apparatus.

The value of the general régime, aside from the immediate environment and other features of management, is dependent upon the amount of sunshine and the number of hours in the day that the patient is permitted to remain in the open air. As stated in connection with the hygienic treatment of glandular tuberculosis, there is a conflict of opinion in regard to the relative advantages of the sea, country, or mountain air. It is apparent that the sea-coast sanatoria upon the shores of the Mediterranean or the Adriatic are hardly suitable for comparison at all times of the year with resorts upon the Atlantic coast, on account of differing weather conditions. If the good effects in various locations are produced to any extent by the amount of sunshine and other climatic conditions affording an outdoor existence, it is reasonable to believe that the very best results can be obtained in those regions permitting the most complete elaboration of the principles. upon which depend the efficiency of the treatment. Judged by this token alone, the climate of the eastern Rocky Mountain slope offers opportunities for improvement from bone and joint tuberculosis unsurpassed in any other section of the country. The every-day experience of clinicians in Colorado affords convincing proof of the truth. of this assertion. The consensus of opinion among general and orthopedic surgeons, as well as internists, is to the effect that, in spite of the peculiar hereditary predisposition on the part of a large portion of our infant population, tuberculous bone and joint lesions are remarkably

There is, beyond question, decidedly less tendency toward suppuration and active symptoms than is reported to exist in other regions. Actual experience has demonstrated a shorter duration of the disease in Colorado and, as a rule, the attainment of better functional results. The details of an open-air régime, either within or without sanatoria, will be reserved for the Treatment of Pulmonary Tuberculosis.

General medicinal measures are of but slight avail, though tonics and nutrients are sometimes indicated by an anemic, impoverished condition. The administration of the bacilli emulsion of Koch is now recognized to be of undoubted value for many of these cases, and promises to constitute one of the exceedingly important features of treatment.

The local management of tuberculous joint lesions includes nonoperative measures and active surgical intervention. The choice. between these two general methods of procedure depends upon essential differences in the type of the disease, its acuteness, the extent of destructive change, location, impairment of function, presence of suppuration, especially if associated with secondary infection, the danger to life. existence of tuberculous foci in other parts of the body, and the age of the patient. The decision should rest not solely upon the consideration

of a single factor, but rather upon a review of all the clinical features. It is essential that a well-sustained estimate be made of their bearing upon the life of the individual and the preservation of function. clearly the duty of the surgeon to be prepared to employ all rational measures with a wise discrimination according to widely varying conditions, to the end that life may be saved without unnecessary mutilation. Treatment along the lines of conservative surgery has been productive of highly gratifying results, save in those instances demanding immediate operative interference upon the basis of certain clinical or pathologic data. In the latter event mechanical contrivances are as much out of place as amputation would be in favorable cases. When the exigency exists, however, there should be no hesitation even in sacrificing a limb in order to preserve life.

In general, it may be stated that in children with tuberculous bones and joints the field of operative surgery is comparatively limited. At this age the lymphatic spaces are more permeable and there is greater danger of dissemination of the disease. This is particularly true if operations are performed before opportunity is afforded for abundant fibrous tissue formation about a tuberculous area. Fibrosis takes place much more quickly among children than adults, on account of the rapidly forming granulation tissue in early life. the process of repair is often sufficient in the very young to insure such a degree of arrest of the tuberculous process as would be impossible in later life. At the same time, after growth has been attained, excision of a tuberculous area does not involve the loss of as wide a portion of healthy bone as is true in the growing tissues of children.

Thus

Nichols has shown that there is an undoubted tuberculous infection of bone, at least an inch beyond the limits of its macroscopic appearance, thus suggesting the expediency of removing a considerable portion of apparently unaffected bone whenever excision is practised. Such a procedure, unfortunately, involves a site of operation outside the protective barriers of fibrous tissue formation, and does away at once with the advantages derived from this source, to which allusion has been made. Again, it is questionable if it is always advisable to attempt the complete removal of infected tissues. As a matter of fact, the operation is often more or less incomplete at best, though attended by excellent results, thus suggesting the important rôle of the natural reparative forces. Therefore, operations upon children, in whom the constructive efforts toward arrest are most pronounced, are to be avoided on account of the unnecessary sacrifice of healthy bone and the greater likelihood of further extension of the process. In this connection it is well to call attention to the fact that in nearly all cases the bone lesion is secondary to other foci in the lymphatic glands. The removal of the secondary focus is not followed by a complete restoration of health unless the surgical treatment is accompanied by so complete an elaboration of the principles of hygienic management as to insure the incapsulation of the primary seat of disIn adults the primary focus is more likely to be quiescent, if not entirely arrested, and the extirpation, therefore, of the local secondary lesion, even of long standing, is less apt to be followed by renewed infection than in early life. Conservative measures, then, are to be employed in children whenever not positively contraindicated.

ease.

Local non-operative procedures consist of the application of such varying forms of apparatus as will enforce rest and secure a degree

of fixation and extension. As far as the local treatment is concerned, these three conditions constitute the essential desiderata in an effort to arrest the tuberculous process. Thus protection is also afforded against further injury, and suppuration rendered less likely. The ultimate preservation of the function of the joint is rendered more probable as the local irritation diminishes. Fixation of the joint, with complete rest and traction, not only lessens the joint pressure, but relieves pain and muscular spasm.

Goldthwait differs from the majority of orthopedic surgeons in believing that the joint should not be absolutely confined. He favors merely a limitation of function rather than complete fixation. He limits the motion of the joint only to such an extent as will control the symptoms, and permits the use of the joint up to the point of toleration, believing that by this means there results less disturbance of the circulation and nutrition. In other words, he regards the principles of treatment of tuberculous joint lesions as closely analogous to, if not identical with, those involved in the management of pulmonary tuberculosis. He takes the position that the respiratory function in the latter cases should be in no way restricted, and in order still further to increase respiratory effort, he advocates considerable activity in high altitudes, combined with special exercises along the lines of pulmonary gymnastics. His conclusion as to the wisdom of retaining a limited function of affected joints is entitled to an appreciative consideration, for his views are based upon an experience sufficient to carry conviction as to the accuracy of his opinion. The principles of treatment of the pulmonary involvement, however, as regards exercise, should not be accepted as belonging to the same category with those applicable to affected joints. In one case the condition is purely local, not directly involving the preservation of life, and subject almost entirely to mechanical principles. In the other, the vital organs affected are constantly performing the function necessary for the continuance of life.

Nearly all orthopedic surgeons agree that after the acute stage has been passed, with extension in the recumbent position, limited motion may be cautiously permitted, provided the diseased joint is protected from bearing the weight of the body. It is manifestly impossible to discuss the relative merits of the various methods of securing rest, fixation, and extension for the tuberculous joint, or to enter into a consideration of the numerous special appliances, all of which aim to afford as much protection as possible to the joint. The purely technical consideration of mechanical contrivances is strictly within the province of the orthopedic surgeon.

In contradistinction to the employment of apparatus whose action is confined as far as possible to the restriction of motion, utilization is sometimes made of passive congestion without confinement of the joint. The so-called Bier treatment of tuberculous joints consists of the establishment, through mechanical means, of a localized passive congestion. The venous circulation is constricted by means of a rubber bandage above the affected joint, applied in such a manner as not to interfere with the arterial supply. In order to localize the congestion the limb is bandaged from its distal portion nearly to the lower part of the tuberculous joint. The principle of treatment is based upon the clinical fact that pulmonary tuberculosis is seldom observed in people suffering from passive congestion of the lungs incident to cardiac dis