TUBERCULOSIS OF JOINTS* WITH E. W. LEE, M.D. MILIARY tubercles in the synovial membranes of the joints were first mentioned by the father of modern pathology-Rokitansky.† No attention was paid to the subject, however, for a number of years. Richard Volkmann, the eminent author in modern surgery on bones and joints, was the first surgeon who published in the leading surgical literature investigations which confirmed Rokitansky's previous observations on tuberculosis of the bones and joints.‡ Volkmann considered tuberculosis of the bones and joints as a rare disease, as is readily seen in his description of the white swelling and the caries of the adjacent bones. He justly pointed out the errors of the previous French authors on the subject, Nélaton and Lebert, who, retaining the original and old doctrine of Laennec, "where cheesy matter is found tubercles preexisted," had described tuberculosis of bones and joints where no miliary tuberculosis had been demonstrated. Laennec's mistake as to the identity of cheesy matter and tubercle was cleared up by Virchow, who proved that necrosis of any variety of original or newly formed tissue might result in its transformation into cheesy matter, and that consequently it was premature to conclude that because we found cheesy matter present it was due to the presence of previously existing tubercle. Thus, utilizing Virchow's observations, Volkmann was right in repudiating Nélaton's and Lebert's descriptions as false and unfounded, and he was at that time justified in pronouncing it an original discoverythe tuberculosis of the organs in question. We were not able to make an indisputable diagnosis of miliary tubercle until Langhans, about ten years ago, gave an exact histologic description of the young growth in its most minute details. Previously Virchow's description was accepted, viz., that it consisted of a small conglomeration of round lymphoid cells embedded in a fine stroma of non-vascular connective tissue; and that the fate of these cells was a speedy fatty degeneration, due to lack of blood-vessels in the little growth. By the microscopic examination alone we could not make a differential diagnosis between miliary tubercle and the miliary forms of malignant growths, as carcinoma and sarcoma. Also the same difficulty presented itself in the microscopic examination of normal elements, such Chicago Med. Jour. and Examiner, 1880, vol. xl, p. 465. † Pathological Anatomy, Sydenham Society edition, London, 1850, vol. iii, p. 296 Pitha and Billroth: Chirurgie die Krankheiten der Bewegungsorgane, Abschnitt V, p. 260. as the lymphatic follicles of the intestinal tract; the tonsils; solitary follicles from Peyer's patches and from the colon, in which a diagnosis based upon histologic grounds could not be made from miliary tubercle. Since Langhans' investigations we have been able to recognize, by the aid of the microscope, the miliary tubercle, even in places and tissues where none of its well-known characters were visible to the naked eye to call our attention to the true nature of the disease. The unmistakable anatomic characters of the miliary tubercle thus established enabled Köster* to make the most remarkable and unexpected discovery that, in the great majority of the cases of so-called white swelling, tumor albus, caries of joints, chronic destructive inflammation of joints, miliary tubercles were found to be the origin of the disease. Thus the same miliary tuberculosis that in the lungs, brain, and urogenital organs was recognized as an inevitably fatal disease of variable duration, made its appearance in the joints in a disease the prognosis of which as to the life of the patient was not considered grave, provided the proper treatment was resorted to. It was quite natural that Köster did not believe the facts evident to his own eyes, and expressed the opinion that fungous arthritis (white) swelling), in spite of the thousands of miliary tubercles so often found in the various tissues of the affected joint, was a separate disease from the true tuberculosis of the joints, producing or accompanying the fatal and general tuberculosis of the internal organs. It was now necessary for surgical pathology to engage in the investigation of a question of such vital import, and to sift our knowledge of tuberculosis in general, and especially with reference to its bearing on, and the consequent treatment of, this disease in the joints. The latest investigators, Volkmann, Friedländer, Schüppel, König, and ourselves, though not numerous, form but one conclusion, and the results of their investigations all tend to confirm the true tuberculous character of the disease in question, and do not admit the distinction of Köster between general tuberculosis and local tuberculosis of joints,the one benignant, the other fatal,—but rather seem to foreshadow a change in our inherited views of the necessarily fatal prognosis of every disease originating in, or complicated with, the presence of miliary tubercles in the affected tissues. Numerous future investigations will be required to determine the theoretic as well as the practical importance of the new epoch in the doctrines of tuberculosis. Hoping that surgeons in this country will take their part in the solution of these problems, we will give the pathologic anatomy of the disease, and later point out the main question in its relations to general tuberculosis, and its consequent rational treatment as far as our actual standpoint will permit. The miliary tubercle shown in Fig. 14 is a small, round tumor not visible to the naked eye. Its main characteristics are as follows: (1) The giant-cell reticulum, forming the central part of the growth and containing one or more giant-cells. (2) The lymphoid reticulum, con*"Ueber fungöse Gelenkentzündung," Virchow's Archiv, 1869, vol. xlviii, p. 49. taining a large number of lymphoid cells, forming the peripheral part of the tubercle and surrounding the former. The giant-cell is a large, irregular, and uniformly finely granulated protoplasmic mass (A, Fig. 14), containing a variable number of large, oval nuclei, with one or more nucleoli. The nuclei are either scattered irregularly over the cell mass or are arranged in a row along the peripheral part of the cell. From the surface of the giant-cell pass out long branched processes which are continuous with the reticulum of the central portion of the tubercle. The giant-cell reticulum (Fig. 14, B), forms a network with large round or irregular meshes. Many of the meshes are empty, i. e., do not contain any cells, but are filled up with clear serous fluid. In a few of the meshes are found large epi Fig. 14.-Young miliary tubercle in fungous granulations from excision of knee-joint (Fenger): A, Giant-cell; B, giant-cell reticulum with some large epithelial and many small lymphoid cells; c, c, lymphoid reticulum. The wound was mainly healed by first intention, but in circumscribed areas edematous fungous granulations sprang up, and later broke down in circumscribed abscesses. These masses of soft, newly formed tissue were removed with the sharp spoon, and after hardening the same in solution of chromic acid, the tissue shows young miliary tubercles only a few weeks old. thelial cells with a plainly visible protoplasmic surrounding and a welldefined round or oval nucleus. A large number of the meshes contain two, three, or more small lymphoid cells or nuclei, many of which are -B Fig. 15.-Young adenoid tissue surrounding the miliary tubercles, from a case of excision of knee-joint: A, Tissue with large round meshes; B, tissue with oval, narrow meshes; c, transverse section of a small vein filled with blood-corpuscles; D, longitudinal cut of a small vein at E, filled with blood, at F empty, showing the nuclei of the endothelial cells; G, the outer wall of the vessel, forming the reticulum of the interstitial network (framework). highly refracting. Outside of this giant-cell reticulum we find the peripheral part of the tubercle, consisting of the lymphoid reticulum (c) or smallcelled tissue of adenoid-like structure. The meshes of this reticulum are narrow, long, oval, or spindle-shaped spaces, their long diameter being perpendicular to the radius from the center of the tumor. They are filled entirely with innumerable. small, round, more or less refracting cells or nuclei. The surrounding tissue, of recent growth, in which the tubercles are embedded, has, in its young state, invariably all the characteristics of the so-called adenoid or lymphoid structure, as is shown in Fig. 15. It derives its name from its similarity in structure to the lymph-glands or the tonsils, or the adenoid tissue as we find it along the whole of the intestinal tract, or the adenoid vegetations from the nasopharyngeal cavity. It consists of a fine connective-tissue network with round or oval meshes, filled with lymphoid cells and nuclei. It contains numerous blood-vessels with thin walls, the external coats of which are transformed into or take part in the formation of the branches of the reticulum. This adenoid-like structure of the connective tissue around the tubercles we found in all cases. (The same structure may be found in young connective tissue, the formation of which plays no part in the growth of tubercle.) It grows out between the bundles of the normal tissues,-fibrous, muscular, etc., creeps along the vessels into the fatty tissue, and causes thus the thickening of the soft structures of the joints, as we so often find it in the white swelling, where the capsule is transformed into a grayish- white, firm, inelastic, fibrous mass, varying from one to two lines to half an inch or more in thickness. D D Fig. 16.-Thickened capsule of knee-joint (case of resection of Dr. Fenger): A, Outer layer of normal fibrous tissue; B, bundles of fibrous tissue inlaid with lymphoid tissue; c, c, inner layer of adenoid tissue containing numerous tubercles; D. D. D, D, tubercles without giant-cells; E, E, tubercles with giant-cells; F, F, vessels. A transverse section through such a thickened capsule is shown in Fig. 16. The following are the microscopic features: A, An outer layer of normal fibrillar connective tissue of the fibrous capsule of the knee-joint. Inside of this, at B, two obliquely cut bundles of fibrous tissue, partially transformed into adenomatous tissue. Finally, the thickest inner layer, c, c, consists of adenomatous tissue, with a large number of disseminated miliary tubercles, some of which contain a large giant-cell, E, E, while others, D, D, D, D, have a center consisting of the giant-cell reticulum without giant-cells, but all of them are surrounded by a darker ring of the lymphoid reticulum. The metamorphoses and alternate fate of the miliary tubercle, as we learn from the most recent authors, are as follows: After an as yet undetermined term of existence, either simple atrophy or fatty degeneration commences in the center of the tubercle, where first the cellular elements and later the interstitial tissue become transformed, partly into irregularly shaped, soft corpuscles, the so-called tubercular corpuscles, and partly into a finely granulated fatty detritus. In rare instances simple atrophy may occur in the cellular elements alone; meanwhile the reticulum gets thickened, and the tubercle becomes transformed into a hard, horny mass. This transformation is considered a cornification, and is only rarely observed. The partially atrophied and fatty degenerated tubercle will further undergo one of the three following metamorphoses: Resorption may take place, especially where the tubercles are wide-spread and isolated. Wagner* regards this as a most rare occur rence. Calcification is more frequent, and means transformation of the fatty detritus into cheesy matter, intermixed with chalky masses, finally encapsulated, viz., surrounded by a capsule of dense cicatricial connective tissue. Softening and liquefaction are justly considered the most important change, because it is most often accompanied by suppurative inflammation in the surrounding tissue. If the seat of the tubercle is on the surface, mucous membrane, skin, etc., -ulcers are formed, and if they are located in the interior of the organs, tuberculous cavities result, and tuberculous abscesses form and often become the starting-point for suppurative processes, i. e., the formation of abscesses around the tuberculous foci. Wagner best expresses the general opinion of the profession when he says that the last-named form of fatal transformation of the tubercles is of most frequent occurrence. In the remainder of this paper it will be seen that we do not quite agree with him in this conclusion. We consider, and are obliged to state, that so far as the tuberculosis of joints is concerned, absorption of the tubercles is of frequent occurrence. A. PRIMARY OSTEOTUBERCULOSIS IN ULAR SURFACE OF THE BONES Fig. 17.-Longitudinal cut of right kneejoint: 1, Upper extremity of the tibia. 2, the patella; 3, the lower extremity of the femur, 4, the fibula; 5, the ligamentum patella (inferior), with 6, its subjacent adipose tissue; 7, ligamentum patella (superior), i. e., the tendon of the quadriceps femoris; 8, the ligamenta cruciata; 9, posterior wall of the capsule with its fibrous ligaments; 10, large tuberculous cavity in the upper end of the tibia, lined with a thick, grayish membrane studded with miliary tubercles and filled with cheesy matter. At the posterior end of the roof is an opening through which the cavity communicates with the joint; 11, a smaller round tuberculous cavity lined with a tuberculous membrane and filled with cheesy matter; 12, a large loss of substance (carious ulcer) in the external condyle of the femur, with several smaller and one large, loose spicule of osseous tissue (sequestra). of the epiphyseal extremities constituting the joint, i. e., it commences outside the joint as a tuberculous caries, or rather as a local miliary tuberculosis of the epiphyses. A typical specimen illustrating this fact is shown in Fig. 17. It represents a longitudinal cut through the knee-joint, removed at a postmortem examination of a patient at the Cook County Hospital. A short résumé of the records gives the following facts, taken from the history published by Dr. Murphy, of Cook County Hospital, in the Chicago Medical Gazette: * Manual of General Pathology, translation, New York, 1876. |