Recently Edward H. Nichols, of Bos ton, read before the American Ortho pmdic Association an elaborate paper on joint-tuberculoses, and he states as his opinion that primary synovial tuberculo sis is exceedingly uncommon, and that of 120 tubercular joints he has not seen one in which on sawing open all the bones in thin layers one or more old bone foci were not found. I am inclined to believe that he is right in his opinion and that those joints which have been examined and pronounced to be synovial tuberculosis would have showed in most cases to have bony involvement if the bone had been examined in a number of• thin sections. Whatever the true pathol ogy of tubercular joint diseases is, they certainly manifest themselves clinically in the two forms.
Symptoms.—Joint-tuberculosis, while essentially a chronic affection, still some times runs an acute course. When it does so, it may exhibit all the signs of inflarnmation,—viz.: heat, redness, swell ing, pain, and disturbance of function. Commonly, however, the disease begins insidiously. Disturbance of function is apt to be the first symptom, particularly if the hip or knee is affected. The skin orinarily remains white, the joint be comes swelled, due to the swelling of the synovial membrane and increase of fluid. Pain begins gradually, and, while some times almost entirely absent, at others is felt only on use of the joint. Redness occurs when pus has formed and is work nig its way to NN ant the surface. This occurs usually at certain definite spots ineli break dom u and form sinuses hich leakl down to carious bone and in eases of long standing directly into the joint. The pain is felt in the joint itself, 111 the epiphyseal ends of the bones, and in ecrtain cases in distant parts as the ain along, the inner side of the knee in hip disease. As the disease progresses the joint becomes disorganized, pieces of bone exfoliate, sequestra are formed, the gcneral health deteriorates, and in a cer tain number general tuberculosis ensues and causes death.
Almost any joint can become affected, but the most commonly attacked are the spine, hip, knee, ankle, elbow, and wrist.
The small bones and joints of the foot and hand are also not seldom involved.
In tubercular joint disease an early diagnos.is is essential if the case is to be cured with a return of function. Pain and stiffness are two important symp toms. Pain is rarely located iu a certain spot, but in indicating it the hand is usually passed over a certain region. It is worse on motion, and is apt to come in paroxysms at night, when the muscles holding the joints quiet are relaxed. Strippin,g the patient is of the utmost importance. The history is important. That of 453 cases studied was negative in 309, in 76 heredity was not mentioned, but in 63 a positive tubercular family history was obtained. L. W. Ely (Med. Record. Dec. 16, '99).
Experiments to ascertain the value of the tuberculin test in tuberculosis of the bones and joints. Seventy-eight per cent. of those who recovered, 100 per cent. of the "quiescent," and SO per cent.
of the active responded in a positive manner. Those cases in which for peri ods varying from one to seven years there had been no clinical evidence of aetive tuberculosis reacted with t'he san-e relative frequency as those in which there was- every reason to believe the tuberculous process was active.
This high percenta,e of positive re actions in apparently healthy individ uals probably attributable to remnants of the disease, such as small islets of tissue, microscopical in 5ize perhaps, wholly encapsulated, in which were im bedded the bacilli of tuberculosis in a. dormant state, especially about a joint which had for years been the seat of the disease. Frazier and Biggs (Univ. of Penna. Med. Bull., Afar., 1901).
Treatment.—Tubercular disease of the bones and joints is not so serious a dis ease as is that of the lungs. The patients usually recover; but are left in a more or less crippled condition according to the severity of the affection. As so many pa tients preserve a fair state of general health, while possessing a diseased joint, the local treatment becomes more impor tant than the constitutional. In other words, the best way to improve the gen eral health is to better the joint affection. Attempts to "build up the system" while neglecting the local trouble will only end in disaster. The main element of local treatment is rest. Tubercular attacks often follow injuries. Not only is this so, but the disease is kept active by re peated, slight irritations due to move ments and use of the part. Therefore protection is required. The more acute and marked the trouble the more abso lute must the rest be. It is practically nupossible to secure this when the spine or knee or hip are affected unless the patient is placed in bed. Parents, and even physicians sometimes, think that prolonged rest in bed will be injurious to the general health, but experience has abundantly proved that this is not so, and whenever it is possible to do so the patient should be put abed and kept on his back until all symptoms of activity of the disease have subsided. This should be done for months or even a year or two if necessary. In order to keep small children in bed and to prevent their sitting up, it is desirable to fasten them down by means of a towel passed across the chest and pinned fast with safety pins to the mattress. Bradford devised a frame of iron gas-pipe to sur round the child and covered with canvas or unbleached muslin. The child may be fastened to this by means of a sort of apron passing across the chest with straps passing over the shoulders. This is useful in affections of the hip as well as of the spine. Extension is of service in diseases of the hip and knee; its ob ject is to keep the joint-surfaces from being pressed together by muscular con traction. Its good effect is at once seen by the diminution of pain. It allays muscular spasm. Even when the patient is allowed to go about, the same object is aimed at by the use of a suitable apparatus.