The radiogram may show the minimal reaction of the tissues and the lack of a periosteal wall in tuberculosis. The fever, course, and degree of pain may also be useful, but still there are some cases in which the diagnosis can only be made during or after operation (Lexer).
In smaller children we have an excelgent means of proving the presence in the body of tubercle bacilli or their immune bodies in v. Pirquet's cutaneous reaction. If this should be positive, it will make a bone tuberculosis probable in small children. In older children, who usually have gone through some form of tuberculosis, only the negative result will be of any use. In very weak patients who are already suc cumbing to the general infection from miliary and meningeal tubercu losis, and in measles, etc., this test is inconclusive. But in these cases the general condition must be considered when making our diagnosis.
The syphilitic affections will not give any diagnostic difficulties when their gummat OUS character, their predilection for certain bones (diaphy sis of the tibia), and the characteristic appearance of their products on close examination are considered. Finally, the result of antisyphilitic treatment, serodiagnosis, and the finding of spirochtette will be decisive.
The general condition will be the principal factor in the diagnosis from rickets and from the rarer bone diseases (Paget's disease, etc.).
The outcome of the suppuration of the bone is generally favorable. If nothing should be done for it then the further course of the disease of the bone will depend entirely upon the general condition of the child.
Even very large foci will heal when the general health of the child improves. Should the body not be able to overcome the disease, then the foci in the bones and joints will multiply and the child will usually succumb to a general infection. Small encapsulated foci which persist in the scar tissue are by no means rare (Kaufmann).
Treatment of Tuberculosis of the has frequently advanced in the wrong direction. When we began to speak of surgical tuberculosis, we condemned these cases to the knife and often forgot to treat the general condition.
The following points should be borne in mind: Large foci and multiple affections of bones and joints heal spontaneously. An injury in a tubercular individual may be followed by a focus at the site of injury. As long as we guard against malpositions of the joints, nature will effect a spontaneous cure in the most satisfactory manner, which we cannot hope to imitate in an operation. As long as the body remains
affected the healing of one focus will be followed by the formation of new foci and an operation is therefore useless.
From the above facts and also from the knowledge that tuberculosis of the bones is a secondary process and that even with the most radical cleaning out of this focus the primary seat of infection will still remain, we come to the conclusion that for the treatment of tuberculosis of the bones and joints in children only one method is permissible—general systemic treatment aided by symptomatic local surgery, which latter must be adapted to the nature of the trouble.
It therefore follows that the wide opening of tubercular foci and the customary curetting must sursdy be condemned, because we damage the surrounding tissues, open the road for new infection, and not only do we not remove the secondary focus but, on the contrary, we favor spreading the disease.
The injection of antiseptic drugs is not to be recommended, as they cannot be controlled on account of the deep seat of the disease. Strong drugs, such as formalin, crude carbolic acid, and camphor-naphthol, destroy the tissue. None of the newer remedies can surpass the iodo form treatment of Billroth.
The hyperradical treatment might sooner be advocated; this regards tubercular disease of the bones and joints as malignant growths which have to be removed within the healthy tissues (extra-articular resec tion of the elbow according to Bardenheuer, resection of the hip accord ing to Lorenz)—resection of bones and amputations. But what of the primary focus, what of our much-vaunted conservative surgery when important parts of the body are sacrificed? A little thought will convince us that nature does this much more gently and with greater saving of life and How many times have we not observed a new process immediately after an ample resection, and how many times have we caused a general infection (miliary tuberculosis, meningitis) with these major operations, either by spreading the infectious material or by lowering the vitality! These considerations have induced us to avoid in our hospital serv ice all major or "radical" operations for tuberculosis in children, and we are glad to say that our results have wonderfully improved.