Presented by Mrs. G. W. Haas COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA TUBERCULOSIS LJ OF BONES AND JOINTS: BY N. SENN, M.D., PH.D., CHICAGO, ILL. PROFESSOR Or PRACTICE OF SURGERY AND CLINICAL SURGERY IN RUSH MBDICAL COLLEGE ; PROFESSOR Or SURGERY IN THE CHICAGO POLYCLINIC ; ATTENDING SURGEON PRESBYTERIAN HOSPITAL; SURGEON-IN-CHIEF ST. JOSEPH'S HOSPITAL; PRESIDENT or THE AMERICAN SURGICAL ASSOCIATION; PRESIDENT or THE ASSOCIATION OF MILITARY SURGEONS OF THE NATIONAL GUARD OF THE UNITED STATES; PERMANENT MEMBER or THE GERMAN CONGRESS or SURGEONS, ETC. PHILADELPHIA AND LONDON : THE F. A. DAVIS CO., PUBLISHERS. 1892. U)t~ Entered according to Act of Congress, in the year 1892, by THE F. A. DAVIS COMPANY, In th Office of the Librarian of Congress, at Washington, D. C., U. S. A. All rights reserved. Philadelphia, Pa., U. 8. A.: The Medical Bulletin Printing IInae. 1916 Cherry Street. THE AUTHOR TAKES GREAT PLEASURE IN DEDICATING THIS VOLUME TO HIS FRIENDS, THE FELLOWS OF THE AMERICAN SURGICAL ASSOCIATION, WHO HAVE CONTRIBUTED SO MUCH TOWARD THE ADVANCEMENT OF SURGERY IS THE UNITED STATES. F PREFACE. TUBERCULOSIS of bones and joints is such a common affection that a large percentage of the clinical material of the surgeon and the general practitioner is made up of such cases. The tubercular nature of most of the chronic affections of bones and joints is not as freely accepted and as fully realized as it should be by the mass of the profession, and consequently a correct diagnosis is often not made before the disease has become in- curable. The successful treatment of these affections depends largely on an early, correct diagnosis and the adoption of a timely, rational, local, and general treatment in consonance with the true nature of the disease. The object of the author in writing this book has been to collect from recent literature the modern ideas on tubercular disease of bones and joints and present them to the reader in a condensed form, mingled, in appropriate places, with the results of his own experience. Old authorities are occasionally quoted for the purpose of showing the contrast between the old and recent views regarding the etiology and nature of this form of bone and joint disease. My thanks are due to Dr. Stehman for correcting the galley-proofs, and to Mr. Rettig for a number of original drawings. If this work should become useful in alleviating one of the most com- mon ailments of" the poor, and add something toward the advancement of the surgery of the bones and joints, the hope and ambition of its author will be realized. N. SENN. CHICAGO, September 1, 1892. TABLE OF CONTENTS. PAGE PREFACE, v TABLE OF CONTENTS, vii LIST OF ILLUSTRATIONS, xi CHAPTER I. HISTORY, 1 CHAPTER II. PROOFS WHICH ESTABLISH THE TUBERCULAR NATURE OF THE SO- CALLED STRUMOUS DISEASE OF BONES AND JOINTS, . . 7 CHAPTER III. BACILLUS TUBERCULOSIS, . . . 22 CHAPTER IV. HISTOLOGY OF TUBERCLE, . . 27 CHAPTER Y. HlSTOQENESIS OF TUBERCLE, 41 CHAPTER VI. CASSATION, 46 CHAPTER VII. TUBERCULAR ABSCESS, . .49 CHAPTER VIII. TOPOGRAPHY OF BONE AND JOINT TUBERCULOSIS, .... 65 (vii) viii TABLE OF CONTENTS. CHAPTER IX. PAGE BONE TUBERCULOSIS, 69 CHAPTER X. ETIOLOGY OF BONE TUBERCULOSIS, 91 CHAPTER XI. SYMPTOMS AND DIAGNOSIS OF TUBERCULAR BONE AFFECTIONS, . 97 CHAPTER XII. PROGNOSIS OF TUBERCULAR DISEASE OF BONE, Ill CHAPTER XIII. TREATMENT OF TUBERCULOSIS OF BONE, 116 CHAPTER XIV. TUBERCULOSIS OF JOINTS, 127 CHAPTER XT. SPECIAL POINTS IN THE PATHOLOGY OF SYNOVIAL TUBERCULOSIS, . 145 CHAPTER XVI. ETIOLOGY, 157 CHAPTER XVII. SYMPTOMS AND DIAGNOSIS, 166 CHAPTER XVIII. PROGNOSIS, ... ... 180 CHAPTER XIX. TREATMENT OF TUBERCULOSIS OF JOINTS, 185 CHAPTER XX. LOCAL TREATMENT, 192 TABLE OF CONTENTS. IX CHAPTER XXI. PAGE LOCAL TREATMENT (continued), * 205 CHAPTER XXII. TUBERCULIN TREATMENT, . . .215 CHAPTER XXIII. TREATMENT OF TUBERCULOSIS OF JOINTS BY PARENCHYMATOUS AND I NTR A.- ARTICULAR. INJECTIONS, 238 CHAPTER XXIV. TREATMENT OF TUBERCULOSIS OF JOINTS BY PARENCHYMATOUS AND INTRA-ARTICULAR INJECTIONS (continued), . . . . 255 CHAPTER XXV. OPERATIVE TREATMENT, 281 CHAPTER XXVI. RESECTION, 292 CHAPTER XXVII. ATYPICAL AND TYPICAL RESECTION, 306 CHAPTER XXVIII. IMMEDIATE AND REMOTE RESULTS OF RESECTION, .... 316 CHAPTER XXIX. AMPUTATION, 332 CHAPTER XXX. POST-OPERATIVE TREATMENT, . . . . . . . 337 CHAPTER XXXI. TUBERCULOSIS OF SPECIAL BONES, 340 X TABLE OF CONTENTS. CHAPTER XXXII. PAGE TUBERCULOSIS OF THE BONES OF THE TRUNK, 353 CHAPTER XXXIII. TUBERCULOSIS OF PELVIC BONES, SCAPULA, CLAVICLE, STERNUM, AND RIBS, 385 CHAPTER XXXIV. TUBERCULOSIS OF JOINTS OF UPPER EXTREMITY, .... 397 CHAPTER XXXV. TUBERCULOSIS OF HIP-JOINT, 428 CHAPTER XXXVI. TUBERCULOSIS OF KNEE-JOINT, 452 CHAPTER XXXVII. TUBERCULOSIS OF ANKLE-JOINT AND TARSUS, 473 INDEX, 497 LIST OF ILLUSTRATIONS. FIG. PAGE x l. (Plate I.) Tubercle bacilli containing spores (R. Koch), 22 2. (Plate I.) Tubercle bacilli from a tubercular cavity, . . . ' . . .23 3. (Plate II.) Vegetations of tubercle bacilli (Baumgarten), 24 4. (Plate III.) Colony of tubercle bacilli (Frankel and Pfeifler), .... 24 5. (Plate IV.) Preparation from tissue-juice of inoculation tubercle (Baum- garten), 25 6. (Plate IV.) Giant-cell with radiating arrangement of bacilli (Koch), . . 25 7. Primary tubercle, 30 8. Giant-cell from centre of tubercle of lung (Hamilton), 31 9. A giant-cell from the lung in a case of chronic phthisis, showing the large number of nuclei with eight nucleoli (Green), . . . . . .32 10. Multinucleated and branched cells from a fine, gray, miliary tubercle of the lung, in a case of acute tuberculosis (Green), 35 11. Fully-developed reticular tubercle of lung (Hamilton), 36 12. (Plate V.) Circumscribed tubercle of iris (Baumgarten), 37 13. Miliary tubercle in the pia mater (Cornil and Ranvier), 42 14. Abscess-membrane from a tubercular abscess (Volkinann), ..... 56 15. Typical granulation tuberculosis of bone with many round and oblong tubercles and with stripes of tubercular tissue, tubercle tissue (Konig), ... 74 16. Upper portion of femur of boy six years old who died of general tuberculosis (Krause), 76 17. Lower articular extremity of femur with cheesy focus, which at a has reached the surface outside the insertion of the synovial membrane. Joint not affected (Konig), 79 18. Wedge-shaped tubercular sequestrum in the head of the tibia. Bone and seques- trum divided longitudinally. Base of sequestrum extending into joint (Konig), 81 19. Resected upper end of femur from a girl five years old (Krause), ... 82 20. Fistula over middle of trochanter major, leading into the neck of the femur, in a girl twelve years old (Volkmann), 123 21. Common form of osteotuberculosis of elbow-joint (Volkmaun), .... 130 22. Typical granulation tuberculosis of synovial membrane with many round and oblong tubercles, and between them stripes of tubercular infiltration (Konig), 131 23. Secondary tuberculosis of knee-joiut. Great hypertrophy of synovial and sub- synovial tissues. Half natural size (Krause), . ...... r 140" 24. Secondary tuberculosis of knee-joiut. Great hypertrophy of synovial and sub- synovial tissues. Natural size (Krause), 140 25. Secondary tuberculosis or knee-joint. Great hypertrophy of synovial and sub- synovial tissues. Natural size (Krause), 140 26. Resected upper end of femur (Volkmann), 143 27. Extirpated piece of capsule of knee-joint, showing numerous papillomatous pro- jections (Konig), 146 28. Primary osseous tuberculosis of head of femur (Krause), 151 29. Early stage of coxitis slight flexion of thigh and rotation of limb outward (Sayre), 171 (Xi) Xll LIST OF ILLUSTRATIONS. FIG. PAGE 30. Typical appearance of knee-joint, caused by long-standing tubercular disease of the joint (Sayre), 171 31. (Plate VI.) Acromegalia (?). Osteitis deformans (Marie), .... 177 32. Permanent extension by weight and pulley in three directions in disease of the knee-joint which was caused by flexion and subluxation of the tibia back- ward (Krause), 202 33. Koch's syringe, . 215 34. (Plate VII.) Bacilli before injection (Koch), 217 35. (Plate VII.) Bacilli after injection (Koch), 217 36. Partial arthrectomy of knee-joint (Medical News), 285 37. Atypical resection of knee-joint, with splicing of articular ends, .... 308 38. Konig's operation of resection of the hip-joint, 311 39. Baker's pins to hold bone surfaces in apposition (British Medical Journal), . . 315 40. Tuberculosis of cranial bones. Inner surface of cranial vault after separation of durajnater and brain, which are pushed toward the left (Krause), . . 342 41. Lower dorsal and lumbar portion of spinal column of child (Krause), . . 356 42. Tubercular spondylitis of lower dorsal vertebrae (Krause), 358 43. Same specimen, vertical section (Krause), 359 44. Vertical section through spinal column (Krause), 363 45. Extensive tubercular destruction of the bodies of a number of adjoining dorsal vertebrae, causing a long posterior curve instead of an angular gibbus (Krause), 363 46. Sharp angular curvature of spine, caused by extensive destruction of the ninth dorsal vertebra, of which only a small triangular piece remains at a; at this point a fistulous opening leads into a psoas abscess (Krause), . . . 364 47. Spondylitis of middle dorsal vertebrae. Rauchfuss's apparatus combined with head-extension by Glisson's swing (Krause), 372 48. Caries of lower lumbar vertebrae. Rauchfuss's apparatus with extension on both legs (Krause), 373 49. Sayre's suspension apparatus, 374 50. Child suspended and ready for application of plaster-of-Paris bandage, . . 375 51. Spondylitis of upper dorsal vertebrae. Sayre's plaster-of-Paris jacket, with jury- mast. Volkmann's walking-stool (Krause), 375 52. Sacro-iliac disease. Rope of oakum passed through sinus whole length of joint (Sayre), 386 53. Same case. Sinuses in perineum drained in same manner (Sayre), . . . 387 54. Caries sicca of Bhoulder-joint (Volkmann), 398 55. Resection of shoulder-joint, straight anterior incision, 403 56. Excision of shoulder-joint and upper third of humerus. Result twenty-five years after operation (Annals of Surgery), ....... 405 57. Tuberculosis of the elbow-joint, with marked atrophy of muscle of arm and forearm, 407 58. Langenbec"k's incision (Bryant) , 410 59. Listen's incision (Bryant), 410 60. Bracketed double splint (Esmarch), . 414 61. Wooden splint with opening for internal condyle (Stromeyer), '. 414 62. Curved wooden splint, ............. 415 63. Wire splint incased by plaster-of-Paris bandage, 416 64. Langenbeck's incision, . . . . 419 65. Lister's double incision, 420 66. Coxltis, left side, 431 67. Coxitis, left side, second stage, 431 68. Third stage of coxitis, . 432 LIST OF ILLUSTRATIONS. Xlll FIG. PAGE 69. Third stage of coxitis, 432 70. Position of limb in dorsal recumbent position of patient during the early stage of coxitis, 433 71. Tilting of pelvis and curving of spine when affected limb is brought down even with the limb on the opposite side, 433 72. Extension by weight and pulley, 435 73. Thomas' splint arranged for walking, with crutches and patten under foot on sound side, 436 74. Double Thomas' splint, . . .436 75. Sayre's long hip-splint, 437 76. Volkmann's splint applied, ............ 437 77. White's posterior curved incision, 444 78. Langenbeck's longitudinal incision, . . . 444 79. Sayre's line of incision, 445 80. M. J. Robert's operation of excision of the hip-joint, 445 81. Resection of hip-joint four months after operation (Harwell), .... 449 82. Resection of hip-joint twelve years after operation (Harwell), .... 449 83. Resection of acetabulum. Sections through bone, 450 84. Tubercular synovitis of the knee-joint, with effusion, 452 85. Tubercular osteomyelitis of internal condyle of femur, 453 86. Tubercular osteomyelitis of both condyles of femur, 453 87. Caries necrotica of tibia (diastasis), . . . 454 88. Anterior curved incision. Convexity of flap directed upward, . . . . 456 89. Ollier's incision, . . .- . . 458 90. Mackenzie's anterior curved incision, 458 91. Drill and bone-nails for direct fixation of fragments after resection of the knee- joint (Bryant) , 461 92. Epiphysial cartilage and line of section in excision of the knee-joint (Bryant), . 462 93. Gluck's ivory joint, 463 94. Shortening of limb after complete resection of the knee-joint, with removal of both epiphysial cartilages (Pemberton's case), 466 95. Sagittal section of os calcis (Krause), 473 96. Tubercular osteomyelitis of astragalus, 474 97. Fungous synovitis of ankle-joint, 474 98. Heuter's anterior incision, 476 99. Konig's incisions, 478 100. Lauenstein's operation. External incision, 483 101. Lauenstein's operation. Deep dissection, 484 102. Girard's method of excision of the ankle-joint, 487 103. Excision of ankle-joint in child several months after operation, .... 489 104. Excision of the os calcis, 490 105. Mikulicz-WladimirofPs osteoplastic resection of the tarsus. Incision through soft parts, 490 106. Bone sections, 491 107. Position of foot and toes after this operation, .,,,.... 491 TUBERCULOSIS OF BONES AND JOINTS. CHAPTER I. HISTORY. THE history of tubercular affections of bones and joints is quite an interesting one, as the early part of it gives an account of the crudest ideas in reference to the etiology, pathology, and treatment of these affections ; while that part which covers the last decade bristles with new revelations and startling discov- eries, based on accurate clinical observation, microscopical examination, bacteriological investigation, and experimental research. No department in medicine or surgery has witnessed a more radical change than the etiology of tuberculosis of bones and joints. During the time of Hippocrates some general facts were understood, such as that phthisis develops more or less directly after certain surgical accidents or diseases ; but nothing definite was known. Less than a century ago, we find chronic inflammatory affections of bone designated by such vague terms as spina ventosa, osteoplitlioria, osteospongiosis (Lobstein), and pcedartJirocace (Severin). J. L. Petit did not know under what head he should classify these affections. He was in serious doubt whether they should be classified with exostosis, softening of bone, caries, atrophy, necrosis, or whether they formed a separate group of bone-lesions, which should be brought under a distinct head. Tuberculosis of bone, as we now understand it, was described by Boerhave as a destructive process in the epiphyses, extending from within outward. A. G. Richter, Bottcher, and Hebenstreit regarded it as a caries commencing in the interior of the medullary canal. Augustin defined it as an inflammatory process in the interior of bone, which, in its course, brought about complete textural changes CD 2 TUBERCULOSIS OF THE BONES AND JOINTS. of the parts affected. Voigtel looked upon it as a hypertrophic process, in some cases ; in others, as a softening of the tissues, leading to perforation externally. Boyer gave no definite opinion regarding the nature of the disease. Beclard thought that it consisted of an active proliferation of the endosteum. Otto regarded it as an internal, central caries, with expansion and softening of the bone, accompanied sometimes by the formation of osteophytes. Astley Cooper described it as a spongy exos- tosis. Ph. v. Walther maintained that it is produced by the formation of a steatoma in the medullary tissue. Lobstein recognized a total, central, cortical, and epicortical spina ventosa. The first accurate clinical picture of a tubercular joint was drawn by Wiseman (several chirurgical treatises, London, 1676). He applied to this affection the term white swelling (tumor albus), which, since his time, until recently, and, to a certain extent, even at the present time, has retained its place in surgical nomenclature. Under this term he grouped all joint-lesions characterized by chronic inflammation and enlarge- ment of a joint, and maintained that, in the majority of cases, it is caused by scrofula. He was of the opinion that the disease may have its primary starting-point either in the soft tissues or the articular extremities of the bones composing the joint. Benjamin Bell (" On the Theory and Management of Ulcers, with a Dissertation on White Swelling of the Joints." Edin- burgh, 1779) taught that a tumor albus may be caused by a trauma or a, scrofulous or rheumatic inflammation. Later, Laennec, by a stroke of genius, and profiting by the previous labors of Bayle, demonstrated the unicity of the tubercular process and its various products, phthisis, its granulations, gray tubercles, and caseous foci, and that most of the lesions considered scrofulous were, in reality, tubercular in their nature. The fruits of this great discovery were soon realized in surgery. Delpech studied the subject in its surgical aspects. Michet wrote on tubercular ostitis ; and Nelaton, in his classical treatise HISTORY. 3 on tubercular affections of bone, applied to the osseous structure the discovery of Laennec, and showed that in bone, as in other organs, tubercle may appear either as a circumscribed or diffuse lesion, and that many chronic snppurative lesions in bone origi- nated in tubercular foci. Samuel Cooper (" A Treatise on Diseases of the Joints." London, 1807) called attention to the heredity of the scrofulous predisposition, and to the influence of traumatic lesions in exciting a local manifestation of the disease in persons so predisposed. Benjamin Brodie (" Patho- logical and Surgical Observations on the Diseases of the Joints." London, 1818) believed that tumor albus is caused by a chronic inflammation of the synovial membrane in joints of the same character as granular conjunctivitis. Rust (" Arthrokakologie." Wien, 1817) made a wide distinction between tumor albus proper and scrofulous inflammation of joints. Bonnet (" Traite des Maladies des Articulations." Paris, 1845) enumerated scro- fula and tuberculosis as causes of the different forms of tumor albus. The first anatomical demonstration of the identity of the process in the synovial membrane in some cases of tumor albus, with tubercular lesions in the lung, was furnished by Rokitansky in 1844. A number of years later Virchow (Virchow's Ar- chiv, B. iv, S. 312) pointed out that in the most intractable joint-lesions the disease is caused by miliary tuberculosis of the synovial membrane; and in 1865 Volkmann (KranWieiten der Bewegungs organe Chirurgie, von Pitha-Billroth, B. xi, S. 2. Erlangen, 1865) corroborated this statement by his own observa- tions. The results obtained from the crude inoculation experi- ments, which were made by Villemin (1865-1869), pointed strongly toward the infectiousness of tuberculosis, and since that time diligent search was made to discover and isolate a specific micro-organism which should be characteristic of this disease. In 1869, Koster (Virchow's Archiv, B. xlviii) furnished con- vincing proof that miliary tubercles can be found in every fungous joint, and discovered and described the giant-cells which, until recently, have been regarded as the pathogno- 4 TUBERCULOSIS OF THE BONES AND JOINTS. monic histological element of tubercle. Hueter (DeutscJie Zeitsclirift f. Chirurgie, B. xi, S. 317) and Schueller (" Ex- perimentelle u. Histologische Untersuchungen," etc. Stutt- gart, 1880) made interesting experiments to establish the mi- crobic origin of tuberculosis, and their work led others to make investigations in the same direction. Lanceraux, Coyne, and Labbe, in 1873, showed the simi- larity existing between the fungous masses in tubercular joints and in tendon-sheaths, and since that time the absolute identity of the two analogous conditions has been made clear by the labors of Trelat, Latteau, Terrier, and Verchere. In 1879, Brissaud and Josias published the results of their investiga- tions, establishing the tubercular nature of cold abscesses. In 1879, Lannelongue and Kiener made known their views con- cerning the identity of 'lesions in bone and joints that had heretofore been regarded as of a scrofulous nature, with well- recognized tubercular affections in other organs. Volkmann, Billroth, and Konig made valuable clinical contributions which established the tubercular nature of stru- mous disease of bone and tumor albus long before the bacillus of tuberculosis was discovered. Great activity was displayed in all countries to establish the parasitic nature of tuberculosis. Theories were advanced and discussed, microbes were found and described, which were supposed to bear a direct etiological relationship to tuberculosis, but nothing definite was known on the subject until Robert Koch, the father of bacteri- ology (" Die ^Etiologie der Tuberculose." Berl. klin. Wochen- schrift, 1882, No. 15), in 1882, announced to the profession his great discovery. He had found and demonstrated the true cause of tuberculosis, the bacillus of tuberculosis, and in his first publication brought such convincing proof of the correct- ness of his claim that, with few exceptions, it brought convic- tion even to the most skeptical. He had not only found the bacillus, but showed that it was constantly present in all tuber- cular lesions. He had isolated and cultivated the bacillus from HISTORY. 5 tubercular tissue, and finally he had furnished the crucial test, had produced artificial tuberculosis in animals by inoculation which was identical with tuberculosis in man. He examined 19 cases of miliary tuberculosis, in which bacilli were found in every nodule ; 29 cases of pulmonary phthisis, in every one of which bacilli were found, most numerous, with the exception of the sputum, in recent caseous foci and in the walls of cav- ities undergoing speedy destruction. He also found them con- stantly in tubercular ulcers of the tongue, tubercular pyelo- nephritis, and tuberculosis of the uterus and testicles ; also, in 21 cases of tuberculosis of lymphatic glands. Further, in 13 cases of tuberculosis of joints, and in 10 cases of tuberculosis of bone ; in 4 cases of lupus, in which only a single bacillus could be seen in the giant-cells; in 17 cases of perlsuclit in cattle. Finally, in animals inoculated with tubercular virus: 273 guinea-pigs, 105 rabbits, 44 field mice, 28 white mice, 19 rats, 13 cats, besides dogs, chickens, pigeons, etc. A number of pathologists, who inoculated animals with non-tubercular material, claimed that they had produced pathological condi- tions analagous to those found in animals which had been infected with the virus of tuberculosis. Further experimenta- tion soon showed that these were instances of pseudo-tuberculo- sis ; that while the gross appearances of the lesions resembled true tuberculosis, inoculations with this material never repro- duced the disease, while inoculations with tubercular material could be done throng] i a series of animals without impairing the potency of the virus or varying the constancy of the results. Toussaint showed that true tubercle, both in man and animals, reproduces itself indefinitely with absolutely constant and iden- tical properties, and that it is quite capable of being transmitted from animal to animal without losing its virulence. Koch's discovery did not lead to such energetic search for the bacillus of tuberculosis among surgeons as physicians, because, as Konig asserts, the symptoms and signs of the tubercular affections coming under the notice of surgeons are O TUBERCULOSIS OF THE BONES AND JOINTS. so characteristic that, for practical purposes, a correct diagnosis could be made in a majority of cases without a knowledge of their microbic nature and the improved methods for making a positive diagnosis derived therefrom. Koch called special atten- tion to this fact, that the bacillus can be constantly found in the giant-cells and between the epithelioid cells in young tubercles, while it is more difficult to find it in cheesy products, unless caseation has taken place quite rapidly. Schuchardt and Krause (" Ueber das Vorkomrnen der Tuberkelbacillen bei fungosen und scrofulosen Entziindungen." FortscJiritte der Medi- cm, B. i, S. 277) examined forty cases of tuberculosis of bones, joints, tendon-sheaths, and the skin, in Volkmann's clinic, and never failed in finding bacilli, although in some specimens care- ful and prolonged search had to be made. W. Mueller and Watson Cheyne have demonstrated experimentally that typical tuberculosis of bones and joints can be made artificially in animals by injecting tubercular material or a pure culture of tu- bercle bacilli directly into the tissues or indirectly by the way of the arterial circulation. It must now be considered as an established fact, based on clinical observation and experimental research, that all lesions, including affections of bones and joints, in which the microscopical and bacteriological characteristics can be found, must be regarded as tubercular in their origin and tendencies, thus establishing the microbic origin of tuberculosis upon a strictly scientific basis. CHAPTER II. PROOFS WHICH ESTABLISH THE TUBERCULAR NATURE OF THE SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. FOR centuries most of the chronic inflammatory affections of bones and joints have, almost by common consent, been re- garded as a local manifestation of a general dyscrasia, which, for want of a better knowledge, was called scrofula. Some of the text-books even at the present time continue to discuss the sub- ject of strumous disease of bones and joints. Others, promi- nent among them, Sayre, of New York, and Bauer, of St. Louis, assign to trauma the principal role in the production of the inflammation, ignoring the action of a more subtle cause. I will now enumerate the most important evidences which tend to establish the fact that the diseases of bones and joints hereto- fore regarded as scrofulous or strumous in their origin, or the product of a chronic inflammation following an injury, are tubercular in their origin and their clinical tendencies, and the inflammatory product presents histological appearances which are identical with the tissue-lesions found in pulmonary and other well-recognized forms of tuberculosis in other organs. Presence of Tubercle Bacilli in the Affected Tissues. Tubercle bacilli are only found in the body in connection with tubercular affections, and their constant presence in the joint and bone affections now under consideration furnishes a strong proof of the tubercular nature of the lesions. Koch, Krause, Schuchardt, and Cheyne always succeeded in demonstrating the presence of tubercle bacilli in fungous disease of bones and joints. Koch ("Die JEtiologie der Tuberciilose," Mittli. aus dem Kais. Gesundheitsamte, B. xi, S. 1-188. Berlin, 1884) gives the result of his examination of thirteen specimens of bone and joint tuberculosis. He found tubercle bacilli within giant- cells and between epithelioid cells and the cheesy material in m 8 TUBERCULOSIS OF THE BONES AND JOINTS. all of them except one, and this was a case of tubercular abscess of the vertebrae in which no bacilli could be found in the pus, but inoculation experiments yielded positive results. Castro-Soffia ("Recherches experimentales sur la tuber- culose des Os." These de Paris, 1885) was one of the first to make a careful methodical search for the bacillus in tubercular lesions of bone. As the result of quite an extensive clinical inves- tigation he assures us that he never failed in demonstrating the presence of the microbe, not only by microscopical examination, but also by inoculation experiments. In this connection it is well to mention incidentally that Schuchardt and Krause (Fortschritte der Medicin, May, 1883) have examined specimens from forty cases of surgical tuberculosis in the clinics at Halle and Breslau ; they comprise : Synovial tuberculosis, . . - . . . 10 cases. Osseous tuberculosis, . ' . . . . . 3 Glandular tuberculosis, . ... . 3 Cold abscesses, . . , . . . 14 Tubercle of muscle, 1 case. Tubercle of tongue, 1 Tubercle of testicle, . . . . . I Tubercle of female genitalia, . . . . 1 Miscellaneous, 6 cases. Total, ~4(T " In every one of these cases they found the characteristic bacilli. Schlegtendal (" Ueber das Vorkommen der Tuberkelbacil- len im Eiter." Fortschritte der Medicin, B. i, S. 537) exam- ined five hundred and twenty specimens of pus from tubercular abscesses, and found bacilli present in about 75 per cent, of the cases. As the bacilli are never as numerous in tubercular pus as' in the granulation tissue, there can be but little doubt that in the remaining 25 per cent, of the cases they were present, but were not discovered ; or, perhaps, that in some of them the primary lesion was not of a tubercular nature. Experiments have repeatedly shown that pus from tubercular lesions in which no bacilli could be found produced, when injected into the SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. 9 tissues of animals susceptible to inoculation, typical tuberculo- sis, a positive demonstration that the material injected con- tained the essential cause of the disease. W. Mueller (" Ueber den Befund von Tuberkelbacillin bei fungosen Knochen u. Gelenkaffectionen." Centralblatt f. Chirurgie, No. 3, 1884) has learned, from his own experience in the examination of numerous specimens of tuberculosis of bones and joints, that it is very difficult to find the tubercle bacilli in some of them. In about twenty specimens he failed to find them ; nevertheless, he believes that they were tubercular, and that the bacilli were so few in number that their detection was difficult, or that they were not properly stained. In many of the specimens he found masses resembling drops of fat sur- rounded by fine granules, which could be deeply stained with methyl-violet, and expressed the opinion that these bodies were fragments or parts of bacilli, and were capable of reproducing the disease in animals by inoculation. Mogling (" Die Chirurgischen Tuberculosen." Tubingen, 1884) found the bacilli never absent in tubercular pus from fifty-three patients. Among others who have shown the never-failing presence of the bacillus in different forms of surgical tuberculosis, includ- ing bones and joints, may be mentioned Kanzler, Bouilly, and Letulle. Tuberculosis of bone and fungous disease of the joints, like lymphatic tuberculosis, have been, and by some are still, regarded as scrofulous affections. Kanzler wished to make a distinction between scrofula and tuberculosis, as he found bacilli not as constant in the former, and observed that, after implantation of tissue of what he regarded as scrofulous affec- tions in animals, the process was slower than after inoculation with the products of recognized forms of tuberculosis. Letulle considers scrofula and tuberculosis as belonging to one and the same disease, of which the former constitutes the milder form and appearing externally, while the latter represents the graver form, attacking by preference the internal organs. The points 10 TUBERCULOSIS OF THE BONES AND JOINTS. made by the last two authors are too unimportant for further con- sideration as a scientific or even practical distinction between scrofula and tuberculosis as applied to affections of the bones and joints. The surgeon must recognize every lesion as tuber- cular in its origin, nature, and course in which the bacillus of tuberculosis can be found, from which successful cultivations can be made, and with which the disease can be artificially produced in animals by inoculation. Watson Cheyne asserts that as the result of Ids numerous experiments bacilli can always be found in the tissue-lesions, but that in most cases they were extremely few in number. He believes that the difficulty in finding them more constantly and in greater number is owing to our present defective means for staining them. Direct Infection of a Joint through a Wound or Extension of Disease to it from a Tubercular Focus near a Joint. A few well-authenticated cases are on record in which infection occurred by the entrance of the tubercular virus into a joint through a penetrating wound. Middledorpf (" Ein Fall von Infection einer penetrirenden Kniegelenkswunde durch tuberculoses Virus." Fortschritte der Medicin, 1886) reports the case of a healthy carpenter who opened his knee-joint by the cut of an axe and dressed the wound with a soiled handkerchief. The wound healed kindly, but later the joint became swollen, tender, and painful. Resection was performed, and on examining the capsule it was found very much thickened. In the granulation tissue bacilli were found. Czerny (Centralblatt f. Chirurgie, 1886) relates two cases in which tuberculosis followed in granu- lating surfaces treated by Reverdin's transplantation of skin. In both instances the patients were healthy, and the skin trans- plantation was made during the treatment of extensive burns. The skin was taken from limbs amputated for tubercular affec- tions. In both cases tuberculosis of the adjacent joint occurred, and in one of them tuberculosis of the granulating surface. Verneuil refers to the case of a student who injured the fold of SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. 11 the nail of his right ring-finger at a post-mortem, with the result of causing a local tuherculosis of the skin. This was treated in various ways without permanent improvement, and, after treat- ment of three years, there was still a tubercular ulcer on the finger and a tubercular abscess on the back of the hand. This abscess was opened and the ring-finger was amputated, but chronic abscesses continued to form, and the patient died, six years after the injury, of spinal meningitis, due to suppuration in connection with tubercular disease of the vertebrae. In Pfeiffer's case, a veterinary surgeon, without any heredi- tary tendency to tuberculosis, punctured the phalangeal joint of his thumb while dissecting a tubercular cow. The wound soon healed, but the joint became the seat of a tubercular inflammation. Some months later symptoms of pulmonary phthisis set in, and he died a year and a half after the injury. The infected joint showed all the macroscopical and microscopi- cal appearances of typical tubercular disease. Barker's (" Three Lectures on Tubercular Joint Disease and its Treatment by Operation." British Medical Journal, 1888, vol. i, pp. 1202, 1259, 1322) case was that of an assistant in the post-mortem room, aged 54, with good family history, who first inoculated his finger ten to fourteen years previously, and at that time the tubercular papilloma healed. Seven or eight years before his admission into the hospital he acquired another wart, which, however, disappeared under treatment, but had previously 'extended to the wrist, necessitating a resection of this joint. If a tubercular focus in bone or in the soft tissues near a joint perforates into a joint infection occurs at once, and the joint disease which ensues resembles the primary extra-articular lesion in every respect, showing conclusively that it resulted from the same essential cause. Inoculation Experiments. One of the most convincing evidences in support of the identity of fungous joint disease with well-recognized tubercular lesions in other organs is the fact that implantation of fragments of the diseased synovial 12 TUBERCULOSIS OF THE BONES AND JOINTS. membrane into the subcutaneous tissue or peritoneal cavity of animals susceptible to tuberculosis almost without exception reproduces the disease in the animal. Inoculation experiments have shown that it is necessary to inject a certain quantity of tubercular material or tubercle ba- cilli in animals in order to produce a positive result, which goes to prove that healthy tissues are capable of disposing of a non- pathogenic dose of the tubercular virus. Gerhardt experimented with the milk of tubercular cows, and found that, in cases where the original milk was virulent, it produced no effect, whether injected subcutaneously or into the peritoneal cavity, when it was diluted forty times or more. In experiments on feeding animals with phthisical sputum, he found that infection did not occur when the sputum was diluted more than eight times, although the same sputum diluted one hundred thousand times caused infection when injected subcutaneously. He has also ascertained that the disease runs a much slower course when the number of bacilli originally introduced was very small. Wyssokowitsch found that it was necessary to inject more than forty tubercle bacilli into the veins of rabits in order to produce infection, and he makes the same observations as to the more severe character of the disease the greater the number of bacilli primarily introduced. It has further been shown that the endothelium of the blood-vessels takes up microbes floating in the blood, and this fact is of great interest in connection with the development of tubercles from the vascular endothelium. According to Pawlowsky ( kt Experimental Contribution to the Pathogenesis of Joints." Annals of Surgery, vol. x, p. 225) an intra-articular injection of a pure culture of tubercle bacilli in animals produces a well-marked incipient tubercular inflammation of the sy no vial membrane at the end of the fourth day. About the sixth day the membrane becomes rough and grayish, while there appears sometimes serous effusion into the joint, and swelling of the adjacent lymphatic glands. On the twelfth day he found joints thus artificially injected dis- SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. 13 tended with fluid, and the para-articular tissues swollen and cedematous. By the end of three weeks the process advanced to the formation of granulation tissue and beginning suppura- tion. Microscopical examination of the synovial membrane shows that the bacilli invade the tissues along the course of lymphatic vessels and connective-tissue spaces. General infec- tion is prevented indefinitely by a zone of lymphatic glands. Tavel (Senn : " Four Months Among the Surgeons of Europe," p. 154. Chicago, 1887) has for several years re- sorted to implantation experiments as a means of diagnosis in obscure cases, and the results obtained have yielded infallible diagnostic information. Granulation tissue from tubercular joints in his experiments on guinea-pigs invariably produced acute, diffuse tuberculosis, and death in from five to six weeks. The course of the disease in the animal is typical ; at the point of inoculation a hard nodule appears first, the result of a trau- matic inflammation of the tissues around the graft. Next, a lymphatic gland becomes enlarged in the immediate vicinity of the primary seat of infection, which was invariably the in- guinal region ; consequently, the inguinal glands enlarged first. Glandular infection increases rapidly ; after the whole chain of lymphatic glands in the groin are involved, the axillary glands become affected. Death occurs in the course of five or six weeks. At the post-mortem it was always found that of the internal organs the spleen becomes affected first, then the liver and lungs, but usually the disease is so diffuse that scarcely an organ remains entirely exempt. When the diagnosis between a syphilitic and tubercular disease of a bone or joint cannot be made either clinically or by aid of the microscope, inoculation ex- periments always give positive and reliable information. When the lesion is tubercular the disease is always communicated to the animal through the graft, and the animal dies of miliary tuber- culosis within six weeks. When it is syphilitic, the inoculation is harmless and the animal remains well. At the time Tavel communicated these facts to me, only one guinea-pig that was 14 TUBERCULOSIS OF THE BONES AND JOINTS. inoculated with tubercular material had survived the infection and was living at the end of five months, and in this case a large abscess formed* at the point of inoculation a few weeks later. Examination of the contents of the abscesses showed a large number of bacilli ; a gland in the groin remained enlarged, and the disease, if not arrested by the suppurative inflammation, had probably passed into a latent stage. In Kocher's wards at Berne (British Medical Journal, June 29, 1888), the inoculation of guinea-pigs has been em- ployed for some time as a bacteriological test of the existence of tubercular disease, such animals being very susceptible, and the development of the affection in them being rapid enough to permit of a positive diagnosis being made in from two to four weeks. From the results obtained in one hundred and twenty cases where this diagnostic inoculation was practiced, from one to five animals being used in each case, Tavel lays down the following propositions: 1. If the case is of a tubercular nature, inoculation invariably gives rise to the development of tuber- culosis in the animal experimented upon. 2. The method re- quires far less time and trouble, and gives more trustworthy results than microscopic examination. 3. The method is certain, even where anatomical examination is practically impossible. Cheyne has been equally successful in transferring the dis- ease from man to animal by implantation of granulation tissue from tubercular bones and joints. Inoculation experiments are equally valuable in making a differential diagnosis between true and tubercular abscess. If a hypodermatic syringe is filled with the contents of an abscess from a case in which it is necessary to make a correct diagnosis, and the injection is made into the peritoneal cavity of a guinea-pig, the result following will make a positive diagnosis. If it is true pus, the injection will either be harmless, if the peritoneal cavity possesses sufficient absorp- tive capacity to absorb the pus and eliminate the pus-microbes, or a circumscribed or diffuse suppurative peritonitis will follow promptly. If, on the other hand, the abscess is tubercular the SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. 15 injection will produce a typical tubercular peritonitis and death from miliary tuberculosis. Artificial Production of Bone and Joint Tuberculosis in Animals by Direct Inoculation. It has already been shown that tubercular joint disease in man has been caused by direct inocu- lation of the joint through a penetrating wound or extension of the disease to it from an extra-articular focus near to it. The same results have been produced in animals artificially by direct inoculation. Hueter (" Ueber scrophulose u. tuberculose Gelen- kentzimdung." Verh. der DeutscJien Gesellschaft f. Oliirurgie, B. vii, S. 107) was positive in his assertions that scrofulous and tubercular affections of joints were identical anatomically and etiologically. He succeeded regularly in producing tuberculosis of the iris by implanting into the anterior chamber of the eye in rabbits fragments of granulation tissue taken from a fungous synovial membrane. Schueller ("Untersuchungen iiber die Entstehung und Ursache der scrofulosen und tuberculosen Gelenkleiden," 1880) claimed in 1880 to have discovered the microbe of tuberculosis by fractional cultivation from lupus- tissue, which when conveyed into the vessels of the lungs pro- duced phthisis, and when injected into joints tubercular inflam- mation, caseation, and finally miliary tuberculosis. The same author (" Experimentelle und Histologische Untersuchungen iiber Entstehung der Skrofulosen u. Tubercu- losen Gelenkleiden." Stuttgart, 1880) studied the localization of the tubercular virus experimentally in the same manner as others have studied the localization of pus-microbes. He in- oculated animals with the products of tubercular inflammation, subsequently produced contusions and sprains of joints, and observed that localization usually occurred at the seat of injury. If the tubercular virus was introduced by inhalation, the same typical lesions occurred in the injured joints as when injec- tion was made more directly. In all cases the products of the local lesion corresponded with the character of the material introduced through some remote point. 16 TUBERCULOSIS OF THE BONES AND JOINTS. W. Mueller (" Experimentelle Erzeugiing der typischen Knochentuberculose." Centralblatt f. Chirurgie, 1886, p. 233) produced experimentally the typical form of tuberculosis in bone by the injection of tubercular material into the nutrient artery of the tibia. Konig has claimed for a long time that the wedge-shaped sequestrum so frequently found in tubercular foci in the articular extremities of the long bones was due to occlusion of a small artery by a tubercular embolus. Mueller proved the correctness of this conclusion derived from clinical observation by experimentation. He made sixteen experiments on rabbits, injecting tubercular pus into the femoral artery, some in a peripheral, some in a central, direction, without any posi- tive results. In a second series the same material was thrown into the nutrient arteries of the femur and tibia. Of ten of these cases, two showed a tubercular focus in the medulla of the diaphysis of the tibia ; in another case miliary tuberculosis in the femur and tibia, and in the latter bone a small caseous spot in the spongy part, which contained numerous bacilli. The animals were killed eight weeks after the injection, and showed no evidences of organic disease, except a few tubercles in the lungs. Twenty experiments were made on young goats, five on sheep, and two on dogs. The tubercular material was injected directly into the nutrient artery of the tibia, the tibial artery being tied above and below the vessel. Primary union of the wound was obtained in all cases except in one dog. In the dogs and sheep, all experiments yielded negative results. In the goats, bone affections were produced which were identical with tubercular bone-lesions found in man. Most frequently the disease was established in the diaphysis, cheesy masses and granulation tissue showing themselves 'in the medulla, the result of tubercular osteomyelitis with or without sequestration. Typical lesions were also found in the ends of the bones, with and without implication of the adjacent joints. In two of these cases the epiphysis was aifected, while in three the shaft alone was involved. The following experiment furnishes a good illus- SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. 17 tration of the identity of the bone disease produced experiment- ally and the disease as it occurs in man. Tubercular material was injected into the tibial artery of a goat three months old. Wound healed in eight days. Some lameness four months later, gradually increasing during the next nine months. At the same time a swelling appeared at the knee-joint. Tibia painful on outer side. Animal killed thirteen months after the injection. There was found a typical fungous disease in the knee-joint most advanced at the sides, a wedge-shaped seques- trum in one of the tuberosities of the tibia, and a small granu- lation mass in the centre of the head of the tibia, and two similar granulating foci in the lower epiphysis of the femur. With the exception of the lymphatic glands of the knee-joint, no other organs were affected. In some cases pulmonary tuber- culosis developed, twice general miliary tuberculosis. The rest of the animals were killed when they began to show lameness, fourteen days to thirteen months after the inoculation. The tubercular lesions thus produced were examined for bacilli, and these were constantly found. The starting-point in every instance must have been a tubercular embolus in one of the small arterial branches in the extremity of the affected bone. Phthisical sputum or a pure culture of tubercle bacilli injected directly into a bone or joint will produce a localized tuberculosis in rabbits, goats, and other animals susceptible to infection. Cheyne (British Medical Journal, April 11, 1891) injected tubercular sputum, diluted with distilled water, into the knee- joints of two rabbits, and produced in this way a typical synovial tuberculosis, with extension of the disease later to the cartilages and articular extremities. In two rabbits, holes were drilled in the upper part of the tibia and tubercular sputum injected into the interior of the bone. In the first experiment the result was very slight ; the second animal showed, in a short time, evi- dences of a positive result, and was killed ninety-one days after inoculation. The specimen revealed a focus of tuberculosis in the interior of the bone, at the point of inoculation, which had 18 TUBERCULOSIS OF THE BONES AND JOINTS. extended to the epiphysis and finally to the synovial membrane, at a point corresponding to the posterior recess of the capsule of the joint. The results obtained in four guinea-pigs were not as typical as in the rabbit. Injection of an emulsion of tubercu- lar pus in distilled water into the femoral artery of a rabbit pro- duced a cheesy mass in the upper part of the tibia, just below the epiphysial line. There was no tuberculosis in any of the internal organs. Injection of an emulsion of a pure culture of tubercle bacilli made by taking the culture from a tenth series of tubes from Koch's laboratory and rubbing it up in distilled wa ter into the knee-joints of a number of rabbits produced in every instance typical tuberculosis, followed by extension of the disease to the cartilages and articular extremities of the bones. In three cases a similar injection was made into the lower epiphysis of the femur, and in each instance with positive re- sults. The experiments made on goats, by injecting the tuber- cular material directly into joints, nutrient artery of tibia, and epiphysial extremities of the long bones, yielded positive results. Krause (" Die Tuberkulose der Knochen und Gelenke." Leipzig. 1891) produced tuberculosis of joints in rabbits by injecting pure cultures suspended in distilled water. Two weeks after the injection he found the joint swollen, and the animal dragged the leg in walking. The swelling increased quite rapidly, and the temperature of the surface of the joint was increased. As a rule, flie animal died in from four to five weeks. In every specimen examined the para-articular tissues were much swollen, and in one of the animals an abscess had formed outside of the joint. The synovial membrane was always found swollen and very vascular, but its inner surface was usually smooth. In the superficial layers miliary nodules are few ; but these were more numerous near the surface. Some of the nodules were larger and showed central caseation. The histological structure of the nodules was typical. In guinea- pigs he infected the animals by injecting a pure culture into the subcutaneous connective tissue in one of the inguinal regions. SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. 19 Ten days after the injection a nodule formed at the point of puncture, followed by infection of the inguinal glands. About the eleventh day he produced injuries of joints and bones, such as sprains, contusions, and fractures. In rabbits the injuries were preceded by intra-peritoneal or intra-venous injections of pure cultures. The latter method of injection was often fol- lowed by death from acute miliary tuberculosis before the process had time to locate at the seat of injury. The animals that sur- vived the injection three to seven weeks furnished positive results in reference to disease of the injured joints and bones. Of fifteen guinea-pigs that were inoculated, and in which injuries of bones and joints were produced, and that died of general tuberculosis, only in one were the bones and joints intact. The fractures united by bony callus ; the process of repair showed no deviation from that in healthy animals. There were no evidences of tubercular disease. Of three dislocations of large joints, only in one was the capsule the seat of tubercular disease. Of forty-four sprained joints, only fifteen became tubercular. In these cases the syno- vial membrane was infiltrated with round-cells and quite vascu- lar. The nodules, which often attained considerable size, were made up of round and epithelioid cells. In the centre of the larger nodules was incipient caseation ; no giant-cells ; tubercle bacilli always present, but few in number; articular cartilages normal. In six cases there was well-marked tuberculosis in the medulla of the epiphysial extremities of the long bones. Bacilli in this locality were as scanty as in the synovial membrane. In one specimen in the lower end of the femur he found three emboli which contained tubercle bacilli. In the rabbits that were inoculated he produced twenty-eight sprains in as many different joints, and found later tubercular lesions in half of the injured joints. The fractures made in these animals healed in the same manner as in the guinea-pigs, by bony union without a sign of tuberculosis, although tubercles in the medul- lary tissue were found more frequently than in the guinea-pigs; but these, when present, were always found from one to several 20 TUBERCULOSIS OF THE BONES AND JOINTS. centimetres distant from the fracture. In the joints thus in- fected the disease was limited to the synovial membrane. Casea- tion appeared sooner than in the guinea-pigs. Of seventy-nine distortions of joints in rabbits and guinea-pigs, only in twenty- nine did the injured joint become the seat of disease, although all of the animals died of general tuberculosis. Only in a single case, in a rabbit, did a healthy joint become the seat of tuber- cular infection ; in all the other cases the injury determined the localization. Association of Bone and Joint Tuberculosis with Tnbercu~ losis in Other Organs. The frequency with which joint and bone tuberculosis gives rise to tuberculosis in other organs points to a direct etiological relationship between the primary and secondary affection. Every surgeon is also conversant with the familiar clinical fact that bone and joint affections frequently develop in the course of tubercular affections in other organs, showing again a causative connection between the primary and secondary disease. Cheyne (British Medical Journal, April 11, 1891, p. 790) states that, of 386 patients suffering from bone or joint tuberculosis observed for a period of three years, after the termination of treatment, forty-two, or 10 per cent., had become affected with or had died of phthisis or some other form of tuber- culosis. Billroth and Menzel found, on searching the post- mortem records at Vienna for a period of 50 years (1817-1867), that there had been 2106 cases of caries of bones and joints, and of these more than half were complicated with tuberculosis of the internal organs. Neumeister has collected 438 cases from the Wiirzburg clinic and other sources, with sixty, or 15 per cent., of deaths from acute tuberculosis. Willemer has ascertained, from statistics which he collected and studied, that in the case of chronic affections of the knee-joint, 1 per cent, of the patients die of tuberculosis during the first year of the disease, 7 per cent, during the second, 6 per cent, during the third, making a mortality of 14 per cent, from acute tuberculosis within three years. Konig states that in only 21 per cent, of all cases of joint tuberculosis is the disease confined to the joint. SO-CALLED STRUMOUS DISEASE OF BONES AND JOINTS. 21 Microscopical Structure of Diseased Tissue and Caseation of Inflammatory Product. Rokitansky, Virchow, Koster, Kiener, and others have shown that the primary nodules in bone and synovial membrane during the early stages of tuber- cular disease show, under the microscope, the same structure as miliary tubercle in the lungs. The primary inflammatory product is a minute tubercle, in which the same histological elements can be found and can be seen to be arranged in a similar manner as in miliary tubercles in the lung. The primary tubercle here, like in the mng, is an avascular struc- ture, and undergoes the same secondary pathological changes as in the latter organ. Coagulation necrosis and caseation of the inflammatory product takes place, slower, but with the same regularity in tubercular products in bone and joints as in pulmonary phthisis. The very fact that the inflammatory product in bone and joint tuberculosis presents the same histo- logical structure, and is subject to the same pathological changes as tubercle in the lungs, warrants the assertion that they are produced by the same cause and undergo analogous degenerative processes. Reaction to Tuberculin. One of the benefits derived from the treatment of tubercular affections with Koch's lymph is the knowledge gained, that tubercular affections of bone and joints react under the use of tuberculin in the same manner and with the same promptness as tubercular lesions in the lungs. The general reaction is often very intense, as I have observed a tem- perature of nearly 106 F. six hours after injection of 5 milli- grammes of tuberculin in a case of uncomplicated synovial tuberculosis in a girl 18 years of age, who had a normal tem- perature before the injection was made. The local reaction is prompt, and sets in within twelve hours after the administration of the remedy, and consists of swelling, increased pain, and tenderness, in fact, the substitution of a brief acute attack in place of the chronic inflammation. CHAPTER III. BACILLUS TUBERCULOSIS. THE bacillus tuberculosis, bacillus Kochii or tubercle bacillus, is one of the smallest of the known bacilli. In length it is about one-fourth to three-fourths of the diameter of a red blood-cor- puscle. It appears in the tissues and cultures in the shape of very thin rods from two to eight micro millimetres in length, and rounded at the ends. (Plate I, Fig. 1.) The length is always from five to six times greater than its breadth. In cultures the bacillus is always somewhat shorter and more delicate than in the living tissues. The largest bacilli can be found in phthisical sputa. In the tissues and in fresh cultures the bacilli appear as nearly straight rods, while in old cultures and in the expectoration of phthisical patients they are often curved, and sometimes acutely flexed. As a rule, they are seen under the microscope as isolated rods; only seldom are they arranged in pairs, and when this is the case the two rods form an obtuse angle. The tubercle bacillus is a non-motile microbe, and consequently possesses no power of locomotion, and it cannot penetrate on the tissues without assistance. In old tubercular products and cultures the rods do not stain uni- formly ; oval spots in their interior do not take up the staining material and impart to the rods a chain-like appearance. Koch has interpreted these light spots as endogenous spores. Sporulation occurs within the living body when the bacillus is imbedded in a soil favorable to its rapid growth and reproduc- tion. The staining properties of the tubercle bacillus are of a specific and peculiar nature, which distinguish this microbe from all other pathogenic organisms. Koch's original assertion that the bacillus can only be stained with alkaline aniline dyes, or by the addition of aniline oil, carbonic acid, etc., has not been sustained by subsequent researches, as this microbe can be stained with an aqueous or alcoholic solution of aniline dyes, (22) PLATE I. FIG. 1. TUBERCLE BACILLI CONTAINING SPORES. Zeiss T \ 0.4. (K. Koch.) FIG. 2. TUBERCLE BACILLI FROM A TUBERCULAR CAVITY. CARBOL-FUCHSIN, NITRIC^ ACID, METHYL-BLUE. Zeiss T ^ 0.4. BACILLUS TUBERCULOSIS. 23 although not as intensive or brilliantly as with the more com- plicated solutions. In reference to the staining process, tubercle bacilli differ from all other known pathogenic microbes, in that they are penetrated very slowly by the aniline dyes, and in their specific behavior to decolorizing agents like mineral acids and alcohol. Upon what this differential behavior rests is as yet unknown. For section-staining Ehrlich's method is the best : Saturated alcoholic solution of methyl violet or fuchsin, ........ 11 parts. Aniline water, 100 " Absolute alcohol, 10 " Sections are left for twelve hours in this solution. Treat the specimen with 1 : 3 solution of nitric acid a few seconds. Wash in alcohol (60 per cent.) for a few minutes; after stain with diluted solution of vesuvin or methylene blue for a few minutes ; wash again in 60-per-cent. alcohol, dehydrate in abso- lute alcohol, clear with cedar-oil, mount in Canada balsam. Ziehl-Neelsen's method has also been frequently employed; 100 grammes of distilled water are mixed with 5 grammes of crys- tallized carbolic acid and 1 gramme of fuchsin, and to the filtered solution 10 grammes of alcohol are added. As a de- colorizing agent a 5-per-cent. solution of sulphuric acid is used. The remaining technique is the same as in Ehrlich's method. (Plate I, Fig. 2.) The examination of fluids for tubercle bacilli can be done rapidly and very satisfactorily by Gibbes' method. Gfibbes' Magenta Solution. Magenta, . 2 parts. Aniline oil, . . . . . . . 8 " Alcohol (specific gravity 0.830), . . . . 20 " Distilled water, . 20 " Stain cover-glass preparation in this solution for fifteen or twenty minutes; wash in (1 : 3) solution of nitric acid until the color is removed; rinse in distilled water. After stain with methylene blue, methyl green, iodine green, or a watery solution of crysoidin, five minutes ; wash in distilled water until no more 24 TUBERCULOSIS OF THE BONES AND JOINTS. color comes away. Transfer to absolute alcohol for five minutes, dry, and preserve in Canada balsam. Frankel's method requires only four minutes. Aniline water with 7 per cent, of alcohol is boiled in a test-tube and is then poured in a watch-glass and saturated with an alcoholic solution of fuchsin. This staining material is always prepared fresh, and from it the slide preparation is dipped into a. mixture of acid with methyl blue (50 parts distilled water, 30 parts alcohol, 20 parts nitric acid, methyl blue as much as can be dissolved). After this, as in Ehrlich's method, wash in water or a weak acid solution, 1 per cent, acetic acid, 50 per cent, alcohol; examination of specimen in water, or, after drying in alcohol-flame, mount in Canada balsam. The best culture medium of the tubercle bacillus is solid sterilized blood-serum of the cow or sheep, Avith or without the addition of gelatin, at a temperature of 37 to 38 C. (98.6 to 100.4 F.). The bacillus grows very slowly and only between the temperatures of 30 and 41 C. (86 and 105.8 F.). In about a week or ten days the culture appears as little whitish or yellowish scales and grains. In cultures on serum ten to fifteen days elapse before growth can be detected by the unaided eye. (Plate II, Fig. 3.) The bacillus can also be cultivated in a glass capsule on blood-serum, and the appearance of the growth studied under the microscope. The scales or pellicles are then seen to be made up of colonies of a perfectly characteristic appearance. (Plate III, Fig. 4.) The growth ceases after three or four weeks. The blood- serum is not liquefied, unless putrefactive bacteria contaminate the culture. Besides solidified blood-serum, the only substance on which the tubercle bacillus can be cultivated is agar (meat- infusion peptone-agar), and in fluid blood-serum and bouillon. According to Nocard and Roux, the addition of glycerin to the proper nutrient media favors the growth of the bacillus. The bacillus of tuberculosis offers a somewhat high degree of resist- PLATE II. FIG. 3. VEGETATIONS OF TUBEKCLE BACILLI UPON STERILIZED BLOOD-SERUM, TWENTY-SIX WEEKS OLD. Natural Size. (Baumgarten.) PLATE III. FIG. 4. TUBERCLE BACILLI. COLONY ON SOLIDIFIED BLOOD-SERUM, FOURTEEN DAYS OLD; STAINED WITH CARBOL-FUCHSIN, DECOLORIZED WITH DILUTE NITRIC ACID. X 100. (Frankel and Pfeiffer.) BUKK & M^FEIRIOGE UTH. PH/L PLATE IV. FIG. 5. GLASS-SLIDE PREPARATION FROM THE TISSUE-JUICE OF A FRESH INOCULATION TUBERCLE. EHRLICH'S STAINING. Zeiss, homog. immers., ^ 0.4, magnified about 1500 times. (Baumgarten.) FIG. 6. FROM ENCYSTED BRONCHIAL GLANDS IN MILIARY TUBERCULOSIS. GIANT- CELL WITH RADIATING ARRANGEMENT OF BACILLI. 700 diam. (Koch.) BACILLUS TUBERCULOSIS. 25 ance to injurious influences from without, and is thus able to preserve its power of infection under circumstances which would prove fatal to most other pathogenic microbes. It can bear temperatures approaching the boiling-point, though it is soon destroyed if it is heated in a thoroughly moist condition. Schill and Fischer have fixed the thermal death-point of the bacillus of tuberculosis at 212 F., with an exposure to this temperature of four minutes. It was not affected by drying during a period of 186 days, or by being kept in putrefying sputum for 43 days. No attempt has been made to determine precisely how far these powers of endurance are confined to the spores or belong also to the vegetative rods, but our knowledge of the life-history of other microbes would indicate that the spores possess a greater power of resistance to thermal and chemical agents than the protoplasm of the bacillus. The bacilli and spores succumb more readily to chemical agents than heat. Cavagnis, Schill, and Fischer found that they were destroyed in a 3-per-cent. solution of carbolic acid in 20 hours. Cavagnis ascertained that the bacilli in tubercular sputum are destroyed in a 1 to 5000 solution of corrosive sublimate in 20 hours, and in a stronger solution in a much shorter time. Experiments and clinical observation have shown that iodoform, if it does not possess the power to destroy the bacilli and their spores, at least exerts a potent inhibitory effect on the growth in the tissues, to which must be attributed at least one of its therapeutic actions in the treatment of tubercular affec- tions. In the tubercular tissue the bacilli are found within and between the epithelioid and giant cells. (Plate IV, Fig. 5.) In the giant-cells the bacilli occupy the periphery of the cell whel'e they are arranged in a radiate manner, singly or in pairs. (Plate IV, Fig. 6.) The number of bacilli diminishes toward the centre of the cell where coagulation necrosis has occurred. The bacillus dis- appears in old tubercular products, caseous material, and tuber- cular pus ,- but these substances retain their infectious proper- 26 TUBERCULOSIS OP THE BONES AND JOINTS. ties, owing to the presence of living spores, which remain indefinitely in an active condition in soils in which the bacillus cannot thrive and grow. It is on this account that in active tubercular foci with a central area of degeneration the bacilli are found in greatest number toward the periphery of the inflammatory product within and between the living cells. CHAPTER IV. HISTOLOGY OF TUBERCLE. A CORRECT knowledge of the minute morbid anatomy of tubercular disease of bones and joints is of great practical importance at the present time, as the tendency among sur- geons now is to limit operative procedures to removal of dis- eased tissue only. The microbic cause of the tubercular inflammation resides within, between, and in the immediate vicinity of the cells which constitute the inflammatory product, and in order to treat successfully a tubercular lesion in a bone or joint by direct surgical procedures it is necessary to remove all of the histological elements of the inflammatory lesion and the product of cell degeneration, or to destroy the tubercle bacilli by antibacillary agents. A primary tubercle is an aggre- gation of cells, the product of a minute focus of inflammation, produced by the presence of the essential cause of tuberculosis. The primary nodule is invisible to the naked eye, and when it becomes so large that it can be recognized without the aid of the microscope it already consists of a confluence of a number of minute microscopic nodules. For a long time great confu- sion prevailed in regard to the identity or non-identity of caseous foci and gray or miliary tubercle. Some pathologists believed these formations represented the product of distinct and specific types of inflammation, while others regarded them as different stages of the same process. The distinguished Laennec entertained the latter view. This author described four varieties of tubercle : 1 . Miliary tubercle, where the visi- ble product of tubercular inflammation appears in the form of nodules the size of a millet-seed, of a grayish color, and usually arranged in groups. 2. Crude tubercle, where the miliary nodules have become confluent and undergo cheesy degenera- tion. 3. Granular tubercle, where the nodules are extremely small, nearly the size of a millet-seed, a and .scattered uniformly through a whole organ. They are not arranged in groups, and (27) 28 TUBERCULOSIS OF THE BONES AND JOINTS. have no tendency to become confluent. In the centre they become transformed into yellow tubercle. 4. Encysted tuber- cles, or such as are constituted of a hard mass of crude tubercle in the centre, surrounded by a firm, fibrous capsule. These varieties only represent different phases of the same process and different stages of inflammation produced by the same cause. The anatomico-pathological basis of tubercle was created by Virchow, and has been firmly established through the labori- ous researches of Langhans, Wagner, Klebs, Schueppel, Ilind- fleisch, Koster, Friedlander, Fox, Baumgarten, and many others. The specific-cell theory has had many able advocates and has been the subject of many animated discussions ; but it has at last been abandoned as fallacious and unscientific. Lebert's tubercle-corpuscle is a thing of the past, and is only referred to as a landmark in the history of tuberculosis. There are no specific tubercle-cells. Reinhart showed that these cells, which were regarded by Lebert as characteristic and pathognomonic of tubercle, could be found in all products of chronic inflamma- tion, and their presence was only an evidence that a certain amount of inflammation existed. When we speak of a tuber- cle we mean a nodule or granule, which is composed of leuco- cytes derived from the capillary vessels damaged by the bacillus of tuberculosis, or new cells resulting from tissue-proliferation of pre-existing cells acted upon by the same cause. The dis- tinguishing anatomical character of the nodule consists not in the presence of any particular cell-elements, but in the peculiar arrangement of the cell ; and this feature is the only reliable anatomical guide in making a diagnosis by the use of the micro- scope. The product of tubercular inflammation occurs either in the form of submiliary, microscopic granules, visible miliary nodules, or a cheesy deposit, which may occupy an entire organ, as a lymphatic gland ; or large, isolated foci, as in bone. Every tubercular product commences as submiliary nodules, which, when they become confluent, are transformed into visible, gray, miliary nodules, which again coalesce after they have under- HISTOLOGY OF TUBERCLE. 29 gone caseous degeneration from cheesy masses, which may be either small and circumscribed or large and diffuse. Virchow defines a tubercle as a nodule representing a hetero- geneous growth, a product originally necessarily of a cellular na- ture, taking its starting-point from the connective tissue or from other mesoblastic structures, as marrow, fat, lymphoid tissue, or bone. He asserts that the microscopic or submiliary granule con- tains all the essential histological elements of tubercle, and, by ag- gregation, forms the ordinary miliary nodule of Laennec. When the nodules become confluent they may form masses the size of a walnut, surrounded by a common zone of embryonal tissue. The yellow tubercle the crude tubercle of Laennec is a more advanced stage of the gray, the histological elements of the latter having undergone caseation. Tubercular tissue in bone and joints, as in other organs, presents itself in two forms, either as a circumscribed nodular product or tubercular infiltra- tion, and both forms are often seen in the same specimen. In the diffuse variety the epithelioid cells are not collected in small masses, but they are scattered irregularlythrough the other tis- sues. The part which is the seat of this infiltration presents two types, namely, granulation tissue or young fibrous tissue. In the former the granulation tissue contains numerous epitheli- oid and giant cells. This condition is found in synovial mem- branes, where caseation is in progress, and also precedes the formation of abscesses, and the disease always manifests pro- gressive tendencies. The fibrous form is best seen in caries, and we find young fibrous tissue infiltrated with epithelioid and giant cells, and is characterized by a lesser tendency to degeneration. Minute Anatomy of Tubercle. The essential histological elements which make up a primary tubercle-nodule are: (a) leucocytes ; (6) giant-cells ; (c) epithelioid cells ; (d) reticulum. Leucocytes. One of the convincing proofs of the inflam- matory nature of tuberculosis is the presence of leucocytes in the tubercular nodule. The bacillus of tuberculosis appears to 30 TUBERCULOSIS OF THE BONES AND JOINTS. exercise only a mild pathogenic effect on the capillary wall, and the primary inflammatory product is always scanty. As the colorless corpuscle can only escape in considerable number through inflamed capillary walls which have undergone altera- tion from the action of some specific microbic cause, it 4s evi- dent that its migration into the paravascular tissues, where it forms a part of the tubercular product, can only occur after such alteration has taken place from the action of the bacillus upon the cement-substance of the endothelial lining of the FIG. 7. PRIMARY TUBERCLE, x 350. a, giant-cells ; b, epithelioid cells; c, leucocytes. capillary vessels. The leucocytes invariably undergo degener- ative changes, and are never transformed into other forms of cells found in the tubercular product. Although constantly present, they are most numerous when the process is acute. The leucocytes are most numerous in the peripheral zone of the tubercle-nodule, but they are also found between the epithelioid and giant cells, gaining entrance into the interior of the nodule by migration. Giant-Cells. After Virchow had repeatedly called atten- HISTOLOGY OF TUBERCLE. 31 tion to the occurrence of giant-cells in tubercle, Langhans ("Ueber Riesenzellen." Virchow's Archiv, B. xlii, S. 382) made the histogenesis and structure of these cells the sub- ject of special study. He found them almost constantly in recent tubercle. He showed that while their morphological characters vary greatly they resemble each other, in that they always contain numerous nuclei which are arranged radiate toward the centre of the cells in their periphery, and, further, that many of them are surrounded by a granular, striped, often D FIG. 8. GIANT-CELL FROM CENTRE OF TUBERCLE OF LUNG. X 450. (Hamilton.] A, granular protoplasmic centre ; B, peripheral more-formed part ; C, crescent of nuclei ; D D, endothelial cells ; E, two vacuoles within the giant-cell, or are arranged in a crescent at one end. very thick envelope. Besides these large cells with homo- geneous envelopes, lie described many intermediate forms be- tween these and cells with a complete capsule. He believes that giant-cells are genetically different things, as they originate from small multmuclear cells, others from stellate cellular ele- ments; while those with cell-mantels are produced by conflu- ence of cells which retain their nuclei. The giant-cells, or, as Klebs calls them, macrocytes, are finely granular, and contain multiple nuclei, which usually occupy the periphery of the cell. 32 TUBERCULOSIS OF THE BONES AND JOINTS. The giant-cells are the most striking histological elements in a tubercle, but as they are not constantly found they are not essential. The giant-cell found in tubercular tissue has its pro- totype in normal tissue. The giant-cells were first discovered in normal tissue (marrow of bone) by Robin, who called them myelophiques. Wegner (" Myeloplaxen und Knochenresorp- tionszellen." Virchow's Archiv, B. Ivi, S. 523), as the result of his own careful investigations concerning resorption of bone in normal and pathological conditions, maintains that the giant- ce lls or osteoclasts which perform this function are not pro- duced by the bone-cells. He has traced them to small cells of the blood-vessels, which, at first, contain only one nucleus, but later increase in size, and at the same time become multinu- clear. He has found such cells always in the immediate vicinity of capillary vessels and small arteries and veins. In a normal condition they are constantly FIG. 9. A GIANT-CELL FROM THE LUNG IN A CASE OF CHKONIC PHTHISIS, SHOW- ING THE LARGE NUMBER OF NUCLI EIGHT NUCL.EOLI. X 400. (Green.) found in bone and the placenta. ING THE LARGE NUMBER OF NUCLEI WITH They are also found occasionally in fat-tissue, especially in cases of rapid emaciation. Kundrat has found them in inflamed serous membranes, and Strieker and Heitzmann in the inflamed cornea. They are always found around foreign bodies, becoming encysted in the tissues. Friedlander found them present in the alveoli of the lungs in cases of chronic pneumonia. Heubner found giant-cells in endarteritis, Baumgarten in gummata, Buhl and Jacobson in granulating wounds, and finally Johne and Pflug in actinomycotic foci. The giant-cells found in inflammatory products under such variable circum- stances resemble the large multinuclear cells found in some forms of sarcoma, and appear to be simply certain embryonal cells HISTOLOGY OF TUBERCLE. 33 which have outgrown others by taking up a greater amount of nourishment in the shape of leucocytes which have undergone fragmentation. Watson Cheyne believes that they are derived from epithelioid cells, either by hypernutrition or coalescence of neighboring cells. The histological source of these cells has been traced to epithelial cells by Zielonko and Weigert; to endothelial cells by Kundrat, Klebs, Herrenkohl, and Zielonko ; to connective tissue or endothelial cells by Virchow, Fleming, and Ziegler. Sclmeppel and Rindfleisch believe that they invariably originate within blood-vessels or lymphatics, where these authors regard them as the first step toward the develop- ment of tubercle-nodules. Ziegler claims to have seen giant- cells develop from white blood-corpuscles. Herig, Aufrecht, Woodward, Schueller, and Treves are of the opinion that what appear as giant-cells in tubercular tissue are not cells, but only represent spaces which correspond to transverse sections of lymphatic vessels, the portion of the cell representing the proto- plasm being the coagulated lymph within these vessels, and what appear as nuclei being enlarged, swollen, endothelial cells. Each tubercle usually contains one giant-cell in its centre. The periphery of the giant-cell presents projections or protoplasmic strings uniting with the epithelioid cells, or ramify among these cells. Young giant-cells possess amoeboid movements, and by virtue of these they are capable of taking up in their proto- plasm fine particles such as microbes, pigment material, and blood-corpuscles which have undergone fragmentation. RufFer (" Notes on the Destruction of Micro-organisms by Amoeboid Cells." British Medical Journal, August 30, 1890) has lately discovered, quite accidentally, one fact which illus- trates the destructive function of giant-cells. In the spleen of many animals, more especially of guinea-pigs, the non-nucleated epithelioid cells often contain a quantity of pigment, which is really the remainder of red corpuscles, destroyed in the interior of these cells. RufFer has shown that the number of these cells is greatly increased in certain infective diseases, that is, 34 TUBERCULOSIS OF THE BONES AND JOINTS. quarter-evil. In the spleen of tubercular guinea-pigs, in which the tubercle has invaded that organ, the destruction of red blood-corpuscles in the macrophages of the spleen is an extremely active one ; but and this is the most interesting point the giant-cells of tubercle take an active part in this process, and the same author has demonstrated in their interior blood-pigment and debris of partially digested leucocytes, a further proof that giant-cells are amoeboid, and, like other amoeboid structures, have the power of taking into their interior and digesting red blood-corpuscles, leucocytes, and micro-organ- isms. The giant-cells in tubercular tissue are nothing more nor less than hyperplastic epithelioid cells, and, consequently, are derived from the same histological source as these. Epithelioid Cells. Cells intermediate in size between the giant-cells and the leucocytes are found in every tubercle-nodule in which cell identity has not been destroyed by caseation and liquefaction of the tubercular product. These cells were first described by Bindfleisch, and were called by him epithelioid cells, from their structural resemblance to epithelial cells. Klebs calls them platijcytes. They are about two or three times larger than a white blood-corpuscle, and in shape they are round, or somewhat elongated. (Fig. 5.) In structure they are finely granular, and contain one large nucleus and often a number of small nuclei. They form the bulk of all recent nodules, are scattered between the giant-cells, and are often arranged in layers around them. Baumgarten has found that in tubercular tissue karyokinesis only occurs in the epithelioid cells and in the cells from which they are derived, and hence he comes to the conclusion that they are the essential histolog- ical element of tubercle. The histological source of these cells was supposed to be the leucocyte by Schueppel, Ziegler, and Treves ; the endothelial cells of the lymph-spaces by Aufrecht, Hering, and Woodward ; the endothelial cells of the blood- vessels and lymphatics, or connective-tissue cells, by Bindfleisch. and many of the modern authors. The histological source of HISTOLOGY OF TUBERCLE. 35 epithelioid cells is manifold. In the synovial membrane they are derived most often from the endothelial cells of blood- vessels, and in bone from the medullary tissue. The epithelioid cells are the embryonal cells, the product of proliferation from any of the fixed tissue-cells in a tubercular inflammation, and they remain as such until they are destroyed by degenerative changes from the continued action upon them of the bacillus of tuberculosis or its ptomaines, or until some of them become, by hypernutrition, giant-cells ; or, on cessation of FIG. 10. MtTLTINUCLEATED AND BRANCHED (JELLS FROM A FINE, GRAY, MlLIARY TUBERCLE OF THE LUNG, IN A CASE OF ACUTE TUBERCULOSIS. X200. (Green.) Wide meshes are seen in the immediate vicinity of the cells, inclosing a few lymphoid elements. The branched processes are directly continuous with the adenoid reticulum of the tubercle. the primary cause, they are transformed into tissue of greater durability. Reticidum. Schueppel first called attention to the .reticu- lated structure of tubercle by his description of the reticular arrangement within tubercles of lymphatic glands. The reticu- lum, according to most authors, consists of the pre-existing connective tissue pushed asunder by the new cells. According to Wagner, Schueppel, Brodowski, Thaon, and Ziegler, it is made up of protoplasm. Buhl taught that the giant and epi- 36 TUBERCULOSIS OF THE BONES AND JOINTS. thelioid cells secrete a substance at their periphery, which, on becoming firm, is formed into a structure resembling connective tissue. According to his researches, only the marginal zone is supplied with loose, ready-formed connective tissue of the organ. Wahlberg maintained that the principal reticulum consists of protoplasm, which is traversed by a net-work of connective A- -/- D -A C -": C FIG. 11. FULLY-DEVELOPED RETICULAR TUBERCLE OF LUNG. X450. (Hamilton.) A, A, A, giant-cells ; B. vacuoles in one of them ; C, peripheral capsule of fibrous tissue ; D. reticu- Inm of the tubercle; E. large, endothelium-like cells lying on the reticulum and within its meshes: F, smaller " lymphoid " cells occupying the same situation ; G, peripheral, fibrous-looking border of the giant-cells. tissue. The reticulum is always more marked in the periphery of the tubercle-nodule, where, from pressure, it is condensed into a fibrous capsule. Watson Cheyne was never able to dis- tinguish a reticulum in tubercle, and he believes what has been regarded as such has been processes of giant-cell, bands of con- nective tissue, and diffraction appearances due to imperfect illu- PLATE V. FIG. 12. CIRCUMSCRIBED TUBERCLE OF IRIS, CONSISTING OF EPITHELIOID CELLS. KARYOKINETIC CHANGES OBSERVED ONLY IN A FEW OF THE PERIPHERAL CELLS. DOUBLE STAINING. X 950. (Baumgarten.) HISTOLOGY OF TUBERCLE. 37 mination. Anything like a reticulated frame-work in tubercle can, of course, only be found during the very earliest stage of the tubercular inflammation, before the pre-existing connective- tissue spaces have become obscured by the inflammatory exuda- tion. In the centre of the nodule the connective-tissue frame-work soon disappears, as it takes an active part in the inflammatory process and becomes transformed into epithelioid cells, while toward the periphery it remains for a longer time. Arrangement of Cells in a Recent Tubercle-Nodule. The earliest evidences of the formation of a tubercle-nodule, as wit- nessed under the microscope, is the appearance of small cells, which resemble ordinary embryonal cells, which are the product of tissue-proliferation from a mesoblastic matrix usually the connective tissue and its embryological and histological proto- type, the endothelial cells of blood-vessels and lymphatics. (Plate V, Fig. 12.) From these cells the epithelioid and giant cells are, later, developed. Some of the central cells, by appropriation of a superabundance of food furnished by leucocytes in a state of fragmentation, become hyperplastic, and are transformed into giant-cells ; these occupy the centre of the nodule. Around these cells the smaller or epithelioid cells arrange themselves, and between them and in the periphery of the nodule are. found the smallest cells, the leucocytes. Gaule and Tizzoni distinguish three zones in a tubercle : (1) an external, composed of small round-cells; (2) a lesser, epithelial, or middle zone, 'containing the reticulum ; (3) a cen- tral space containing a giant-cell. The structure of a tubercle is not always typical, and hence the division into zones is based more on theoretical grounds than actual observation. The giant- cell is not an essential histological element of tubercle, but an accidental product. In some tubercles giant-cells cannot be found, while in others they are numerous. Giant-cells can only develop from epithelioid cells if the local conditions are favor- able for hypernutrition ; that is, if the leucocytes, in a condition 38 TUBERCULOSIS OP THE BONES AND JOINTS. of fragmentation, are within their grasp. If they are present they always mark the location of the starting-point of the tubercular infection, as only the older leucocytes undergo this change. The number and size of the epithelioid cells are also subject to great variation, and are further modified by the nutri- tive conditions within and in the immediate vicinity of the nod- ule. If cell-proliferation is active the epithelioid cells appear densely packed in the reticulum, nutrition is greatly impaired, and the new cells undergo degenerative changes before they attain their average size. The leucocytes are scattered among the giant and epithelioid cells, and as they reach the part through the inflamed wall of the capillaries in the immediate vicinity they are most numerous in the periphery of the nodule and along the course of the affected vessels. TJie product of tubercular inflammation acts as an irritant, and produces an inflammation of a chronic type in its immediate vicinity. Blood- Supply of Tubercle-Nodule. If tubercle is primarily an endovascular product, as is so often the case, its outer wall is fibrous, composed of remnants of blood-vessels, in the interior of which the essential tubercular product can be seen and studied. The blood-vessel, at a point corresponding with the tubercle, becomes obliterated by a tubercular thrombus from the very beginning, and the tubercular tissue is cut off from further blood-supply, as new blood-vessels never form in tubercle. If the tubercle-nodule originates in the paravascular spaces, the cells which accumulate push the vessels apart and form an avas- cular inflammatory product between them. If a number of tubercles become confluent, the capillary vessels between them are blocked and are converted into tubercular tissue, thus cut- ting off permanently the blood-supply to the infected area. Some of the old authors were familiar with the defective blood- supply of tubercle. Mr. Stafford (" A Treatise on the Injuries, the Diseases, and the Distortions of the Spine," p. 151. London, 1832); in speaking of scrofulous affections of the vertebrae, in reference to the blood-vessels in and around the foci, says : " If HISTOLOGY OF TUBERCLE. 39 the bone, as may be seen in some preparations in St. Bartholo- mew's Museum, be injected with subtle injection in the early stage of the disease, before caseous matter has begun to accu- mulate, the vessels are seen to ramify freely through the cancelli ; but if the injection be made when the cancellous structure has become loaded with this matter, there is still to be seen a degree of vascularity at the line of demarcation between the disease and the sound parts, though the injection has failed to enter the newly-formed matter. From this, we may infer that this deposition is like pus, a mere unorganized secretion." The absolute ischcemia of the tubercular product is one of the conditions which determines speedy death of the cel- lular elements, coagulation necrosis, caseation, and liquefaction of the dead material. Distribution of Tubercle Bacilli in Nodule. The distribu- tion of bacilli in tubercular tissue is peculiar, the bacilli are either within or between the epithelioid cells, while they are not found beyond the inflammatory zone. In the epithelioid cells they are usually found near or within the nucleus. The disposition of bacilli is seen in the tubercle-nodule and in the tubercular infiltration. The bacilli can be found best by first locating, under a low power, tracts of epithelioid cells. If giant-cells are present, bacilli can be found in their interior in largest number. They are found most numerous among the peripheral zone of nuclei, and arranged in such a manner that the long axis radiates from the centre of the cell. Some of the bacilli are distributed irregularly through the intercellular spaces, isolated or in little groups. (Fig. 6.) As degeneration of cells takes place the number of bacilli is diminished, and they either cannot be found at all or an isolated bacillus can be detected here and there, on most careful examination. Even in cases where no bacilli can be found in the cheesy material or tubercular pus, these substances retain their infective properties, as numerous inoculation experiments have shown, a proof that they still contain the bacilli, which, 40 TUBERCULOSIS OF THE BONES AND JOINTS. perhaps, are refractory to the staining process, or the bacilli have disappeared, or, what is more probable, spores have remained, and the propagation of tile disease is due to their presence. Groioth of the Tubercle- Nodules. The typical tubercle- nodule is microscopical in size. The growth of the swelling depends on the formation of new tissue, migration of leucocytes, and confluence of nodules into larger masses. The bacillus of tuberculosis, when brought in contact with fixed tissue-cells susceptible to its pathogenic action, incites tissue-proliferation, which always takes place by karyokinesis. Baumgarten's investigations leave no doubt that epithelioid cells constitute the entire mass of the forming tubercle. (Fig. 12.) He has also observed karyokinetic figures in tubercular tissue in cells derived from the connective tissue, endothelia, and epithelia. Each tubercle-nodule increases in size by the growth of new cells from pre-existing tissue, and, as the primary cause the bacillus of tuberculosis multiplies in the tissues, bacilli are conveyed into the surrounding tissues by leucocytes or the plasma-current, and new centres for tubercle formation are established, which, later, become confluent, forming masses of considerable size, the numerous foci of caseation corresponding to the centres of so many nodules. The growth of tubercle is favored by local and general conditions, which diminish tissue-resistance, while retardation takes place, in consequence of degenerative changes in the cells of which it is composed, or, if the cells are con* verted into tissue of a higher type, from disappearance or sus- pension of activity of the primary cause. The anatomico- pathological conditions which characterize tubercle put a limit to its growth, and further increase in size of the swelling takes place by confluence and the formation of new centres of infection in a peripheral direction. CHAPTER V. HlSTOGENESIS OF TUBERCLE. THE histological source of the inflammatory product was determined nearly fifty years ago by Virchow, who traced the cell-proliferation to the connective-tissue cells. Histological researches since that time have added but little to our knowl- edge of the histogenesis of tubercle. The connective tissue is the principal histological source of the cellular elements of the tubercular product, irrespective of the anatomical location of the inflammation. It appears that the bacillus of tuberculosis exer- cises a special predilection for the connective-tissue cells. While the connective-tissue proliferation furnishes the bulk of the inflammatory product in every tubercle-nodule, in whatever part or organ this may be found, it is now generally conceded that the pathogenic action of the tubercle bacillus is not limited to the connective-tissue cell alone, but that other mesoblastic tissues are affected in a similar manner, and contribute to a lesser extent to the building up of the tubercle-nodule. Endo- thelial cells and lymphoid structures in different organs not infrequently are the primary seat of the tubercular inflammation, and, when excited to tissue-proliferation by the presence of tubercle bacilli, furnish the first material in the construction of the tubercle-nodule. Bastian observed tubercle-nodules upon the small vessels in cases of basilar meningitis, but refers their origin not to proliferation of the nuclei of the endothelial lining of the vessels, but to new cells springing from the endothelial cells of the paravascular lymphatic sheaths which surround the vessels of the meninges of the brain. Knauff demonstrated the lymphoid character of the adventitia by examining the capillary vessels of the visceral pleura in dogs which had been exposed for a long time to an atmosphere impregnated with coal-dust. He found the pigment-granules lodged in small masses close to the walls of small arteries and veins. Examining the same vessels in other dogs not thus treated, he found, upon the outer (41) 42 TUBERCULOSIS OF THE BONES AND JOINTS. surface of the adventitia, opaque, whitish-gray nodules, sur- rounded by round and oval cells containing nuclei ; also, lymph- corpuscles. The same structures, which he named lymph- nodules, are also found around the same vessels of the pleura in man, and Knauff looks upon these lymphoid structures as the starting-point of tubercular inflammation. Klebs maintains that the endothelial cells of lymphatic vessels are the most frequent location for the formation of the primary tubercle-nodule. He observed that in cases of tubercular ulceration of the intestines the peritoneum is reached through the lymphatic vessels. FIG. 13. MILIARY TUBERCLE IN THE PIA MATER, x 100. (Cm-nil and Ranvier.) The dotted line indicates the original size of the tubercular nodule ; A, the lymphatic sheath ; V, the blood-vessel ; F, proliferation of elements within the sheath. Silver-stained preparations of inoculation-tuberculosis in rabbits showed that the most recent products occurred in the interior of the lymphatic vessels at points of intersection. In some places the nodules extended into the tissues between the lymphatic channels, but their centre always corresponded to the location of a lymphatic vessel. At some points the nodules were seen to branch out, but these projections, in reality, were within the lymphatic vessels, as the net-work of lymphatic endothelia could be seen above and underneath the tubercular product. Toward the centre of the nodule no endothelial cells could be distin- HISTOGENESIS OF TUBERCLE. 43 guished, and this fact led him to the belief that the endothelial cells are directly concerned in the production of the new tissue. In the mesentery he saw the tubercles adhere to the outer wall of the capillary vessels, and, as the spindle-shaped cells of the outer coat appeared to be pushed apart by the new tissue, he regards the adventitia as a genuine lymphoid structure. Rind- fleisch traces the beginning of the process in miliary tuberculosis of the lungs to a proliferation of the endothelia and the external connective-tissue layer of the capillary lymphatic vessels. Manz studied the development of tubercle in the choroid in patients suffering from general miliary tuberculosis. So constantly does this disease show itself in this structure that von Graefe, Cohn- heim, Frankel, and Bouchut recommend ophthalmoscopic exam- ination as a diagnostic measure in cases of suspected general tuberculosis. Manz traces the commencement of the disease in the choroid to cell-proliferation in the tunica adventitia of the small vessels. The process is, however, not limited to this structure ; the non-pigmented stroma-cells may also assist in furnishing material for the new product. Bart, on the other hand, asserts that the vessels, in cases of tuberculosis of the choroid, are not primarily affected; according to his observation, the process depends exclusively on a degeneration of the stroma- cells, as the remaining tissue did not appear to be affected. Cohnheim, Ziegler, and others maintain that the leucocytes furnish most of the material in the building up of the tubercle- nodule. This idea is no longer tenable, as the tubercle bacillus, when brought in contact with fixed tissue-cells, is known to cause active cell-proliferation, while it does not produce a sufficient alteration in the walls of blood-vessels to enable free cell-migration to take place. At the last meeting of the Inter- national Medical Congress. Ziegler announced that he had changed his ideas in reference to the function of leucocytes, and that he is now a firm believer in the origin of inflammatory tissue from pre-existing fixed tissue-cells. As a constant patho- logical condition, we also find, in every tubercle-nodule, early 44 TUBERCULOSIS OP THE BONES AND JOINTS. disappearance of most, if not of all, of the capillaries, a con- dition unfavorable to cell-migration. The foundation for every tubercle-nodule is laid by cells derived from the fixed tissue- cells, the presence and number of leucocytes being accidental, depending upon the number of capillary vessels within and in the immediate vicinity of the nodule, and the intensity of alteration of their walls, induced by the irritation caused by the presence of tubercle bacilli and the inflammatory product furnished by the fixed tissue-cells. In bone, the medullary tissue, being a lymphoid structure, is acted upon by the tubercle bacilli, and furnishes the corpuscular elements of the inflamma- tory product, if the process is extra-vascular, while the endothe- lial cells and connective tissue of the blood-vessels are the struc- tures first acted upon in tubercles of this structure of endovascular origin. In primary tuberculosis of joints the synovial membrane is first affected, and the process extends from here to the subjacent cartilage and bone. Experiments on animals, as well as micro- scopical examinations of pathological specimens, have sufficiently demonstrated the fact that the tubercle-nodule in bones and joints, as well as in other organs, is nothing more nor less than a circumscribed inflammatory product, the histological elements of which are composed, for the most part, of new tissue, formed by proliferation of fixed tissue-cells, which have been acted upon by the bacillus of tuberculosis, or its ptomaines. The specific pathogenic effect of the bacillus consists in its power to cause a chronic inflammation of the tissues with which it has been brought in contact. The tissues primarily affected are the cells which are nearest the essential microbic cause, irrespective of their embryological origin, their histological structure, or physiological function. The mesoblastic tissues are the primary starting-point of the tubercular process, in the majority of cases, for the reason that it is Jiere that localization of the tubercle bacillus takes place most frequently. In cases of inoculation- tuberculosis, the primary nodule develops at the point of inser- tion of the virus from connective-tissue proliferation, and from HISTOGENESIS OF TUBERCLE. 45 here the bacilli enter the lymphatic channels, and the secondary nodules are composed of cells derived from the endothelial, lymphoid, and connective-tissue cells which compose these structures. If the bacilli are injected in sufficient quantity directly into the circulation, or gain entrance into the blood- current from some tubercular focus, they become implanted upon the wall of distant capillary vessels, and the nodule which forms at the seat of implantation consists of cellular elements formed by the tissues of the vessel-wall. As soon, however, as bacilli reach the extra-vascular tissues, they, in turn, furnish their part of the material for the further growth of the nodule. If the tubercle bacillus become implanted upon a mucous sur- face, as the bladder, intestines, nose, larynx, uterus, etc., if such surface is susceptible to tubercular infection, the epithelial cells take an early and active part in the inflammatory process. From the manner of entrance into and diffusion through the tissues, it is apparent that the mesoblastic tissues, especially the connective tissue and endothelial cells, being the Jirst to become infected, furnish the greatest amount of the new material in most tubercular lesions; but all tissues, when infected, take part in the process. CHAPTER VI. CASEATION. THE gray or miliary tubercle is transformed into the yellow, crude, or cheesy tubercle by a process which is called caseation, or tyrosis. The exact nature of this process remains unknown. The cheesy material is composed of the products of cell-necrosis. Early death of cells is the most characteristic pathological fea- ture of tubercle, wliicli distinguishes it from all other forms of chronic inflammation. Two causes can be advanced to explain this peculiar and almost pathognomonic form of degeneration, which occurs, almost without exception, in every tubercle, if a sufficient length of time has elapsed: (1) inadequate blood- supply ; (2) specification of the bacillus of tuberculosis or its ptomaines. Caseation always commences in the centre of a nodule, consequently at a point most remote from the vascular supply, and in cells which have been exposed longest to the deleterious eifect of the primary microbic cause. Tubercle is a non-vascular product. From causes which as yet are not fully understood, vascularization of the nodule never takes place. The angioblasts in the infected area are transformed into epi- thelioid cells that have lost permanently their intrinsic anatomi- cal structure and physiological function. Nodules which have primarily an intra-vascular origin are rendered avascular by closure of the vessel from intra- and peri- vascular cell-prolifera- tion. If the primary starting-point of the nodule is outside of the vessels the rapidly-accumulating cells exert pressure upon the surrounding vessels, and thus diminish the blood-supply to the part affected. The new cells require an adequate quanti- tative and qualitative blood-supply for their further development, and if this fail to take place, as is the case in every tubercular product, they necessarily suffer from malnutrition, and undergo degenerative changes at an early stage of their existence. A deficient blood-supply, in the absence of other more specific causes, would result in fatty degeneration ; but caseation is (46) CASEATION. 47 something different from ordinary fatty degeneration, and the bacillus of tuberculosis or its ptomaines must be regarded as its immediate and essential cause. Caseation is preceded by coagu- lation necrosis, which is one of the results of the specific action of the bacillus on the tissues. The coagulation necrosis com- mences in the giant-cells and in the epithelioid cells in the centre of the nodule, and caseation follows as soon as the dead cells have lost their histological identity and appear under the micro- scope as a debris, in wliich no distinct cell-forms can be identi- fied. Caseation is attended by softening, which can be readily recognized in tubercular masses, the size of a hazel-nut to that of a walnut, composed of numerous confluent nodules, with as many caseating foci. In such masses the small, cheesy foci become confluent and form larger caseous centres. Caseation proceeds from the centre of each nodule toward the periphery, layer after layer of epithelioid cells being destroyed and changed into cheesy material. The part of a tubercle-nodule which has undergone caseation contains few or no bacilli, and yet inocula- tion experiments show it to be highly infectious. The cheesy material does not furnish the proper nutrient material for the growth and development of the bacillus, which dies from star- vation, while the spores, being more durable and possessing greater power of resistance, remain in an active condition for an indefinite period of time in the caseous material, and it is due to their presence that infection takes place from old, cheesy foci, and that successful inoculations can be made with cheesy ma- terial. While the disease has become arrested in the centre of a nodule, with the appearance of caseation, its growth in a peripheral direction pursues the same relentless course. The bacilli multiply in fresh tubercular tissue, and are carried beyond the peripheral zone into the surrounding tissues, where new, independent foci of infection are established, which, in the course of time, pass through the same series of pathological changes as the primary nodules. It is a well-known clinical fact that acute miliary tuberculosis is not a primary affection, 48 TUBERCULOSIS OF THE BONES AND JOINTS. as ill all such cases a careful post-mortem examination will reveal the presence of a cheesy focus in a lymphatic gland, the lungs, testicles, a joint, or bone, or some other organ from which the general infection occurred. A cheesy mass is, therefore, always a source of danger, as it may become the distributing- point of the essential cause of tuberculosis, and produce gen- eral miliary tuberculosis years after the local disease has been arrested. The cheesy material may lie latent for twenty to fifty years as long as it remains firm and encysted, but as soon as it undergoes softening and liquefaction the spores which it con- tains can be taken up by the blood-vessels and become then the cause of general infection. CHAPTER VII. TUBERCULAR ABSCESS. THE pathogenic effect of the bacillus of tuberculosis on the tissues is to produce a chronic inflammation, which invariably results in the production of granulation tissue. The embryonal cells furnish, as it were, a wall of protection for the time being for the surrounding healthy tissue. The characteristic patho- logical feature of every tubercular product consists in the tend- ency of the cells of which it is composed to undergo early degen- erative changes, which are caused by local ischaemia and the specific chemical action of the ptomaines of the tubercle bacilli, and consist in coagulation necrosis, caseation, and liquefaction of the cheesy material into an emulsion, which has, until quite recently, always been regarded as pus, until modern researches have shown that it is simply the product of retrograde tissue metamorphosis, and not true pus, I believe that it can now be considered as a settled fact that the bacillus of tuberculosis is not a true pyogenic microbe, and that in the absence of other microbes it produces a specific form of chronic inflammation, which invariably terminates in the formation of granulation tissue ; and that, when true suppuration does take place in the tubercular product, it occurs in consequence of secondary infec- tion with pus-microbes. The earliest commencement of such an abscess is a small nodule, which slowly increases in size to that of a walnut, when softening takes place in the centre by degeneration and liquefaction of the inflammatory product. The solid mass at first is composed of confluent tubercles. Liquefaction of the caseous material takes place by imbibition of fluids. In the walls of the primary abscess new foci liquefy, and thus, by increase of the liquid contents of the first cavity, and by the addition of new spaces, the abscess-cavity is enlarged to the enormous dimensions so frequently met with at the bed- side in the treatment of tubercular affections of bones and joints. At the last meeting of the French Congress of Tubercu- (49) 50 TUBERCULOSIS OF THE BONES AND JOINTS. losis (1891), Hallopeau stated his belief that cold abscesses are caused by chemical products of the tubercle bacillus independ- ently of the microbes of suppuration proper. Arloing diminished the virulence of the tubercular virus by heating, and produced with it limited suppuration, a result which agreed with the statement previously made by Koch. Verneuil and Beretta spoke of the transformation of cold or chronic into hot or acute abscesses, a change which is occasion- ally observed in tubercular lesions, and which they attribute to the presence and action of pyogenic microbes, especially the streptococcus. In their experience such a change always resulted in a cure, whether the abscess opened spontaneously or was incised. They maintain that the pus-microbes destroy the tubercle bacillus. The so-called tubercular, congestive, wandering, or cold abscess contains a fluid which, macroscopi- cally, resembles pus, but which, when examined under the microscope, shows none of its characteristic histological elements. Chemical Analysis. Lannelongue (" Absces froids et tuberculose osseuse." Paris, 1881), in comparing the pus con- tained in cold abscess with the pus bonum, calls attention to the fact that the former contains a much lesser quantity of solid constituents, and the quantity of albumen is correspondingly less. He gives the following result of a chemical analysis of tubercular pus : Serum (949.30). Solid Ingredients (50.70). Mucin, 13.82 Pus-corpuscles, 5.16 Serum-albumen 25.57 Cholesterin, > . ft ~ Metalbunien, 13.07 Lecithin, Cholesterin, 4.50 Inorganic salts, 0.52 Leucin and similar substances, . 7.25 Water 43 87 Inorganic salts, 6.44 Undetermined substances, . . 0.13 Water, 877.20 If such a chronic cold abscess is converted into an acute hot abscess, it is almost positive proof that a secondary or mixed infection with pus-microbes has occurred. Tubercular TUBERCULAR ftfefeSOE ~ 5 J. 3 T E G P A T K I C ~ pus can usually be distinguished from ordinary pus, without much difficulty, by its macroscopical appearances. Tubercular pus, so-called, is an emulsion which presents a whitish or almost chalky appearance, in which minute fragments of dead tissue and shreds of fibrin are suspended, while ordinary pus is a homogeneous fluid, of the consistence of thin cream, presenting a yellowish appearance, with a tinge of green. If the bacillus of tuberculosis meets with sufficient resistance on the part of the surrounding tissues, it finally exhausts the nutrient material in the granulations and dies, or remains in a latent condition ; the sterile granulation material is converted into cicatricial tissue and the local lesion is cured. The cases in which the tubercular product is removed by cicatrization terminate most frequently in spontaneous cure. If, on the other hand, bacilli in sufficient number are present to destroy the granulation cells, coagulation necrosis, caseation, and liquefaction of the infected tissue take place ; a spontaneous cure is still possible if a part of the fluid portion is absorbed and the solid debris becomes encapsulated. The same favorable termination is expedited, under similar cir- cumstances, if the primary lesion has healed and the inflamma- tory product is removed by operative interference, under strictest antiseptic precautions ; or if, at the same time, the primary focus can be completely removed by extending the operation to the primary lesion. Secondary infection of a tubercular product with pus-microbes, without a direct infection atrium, is possible, although practically a very infrequent occurrence, and, if the primary lesion is located in an unimportant organ, and in such a place where the inflammatory product can be reached at an early stage, or can be eliminated spontaneously, a cure is often effected, as the suppurative inflammation frequently proves successful in destroying all of the tissues inhabited by the bacillus, and the whole nidus, with the microbes it contains, is eradicated permanently from the body. Such a course is not seldom observed in cases of tuberculosis of the lymphatic glands of the neck. If, however, the tubercular process affect 52 TUBERCULOSIS OP THE BONES AND JOINTS. important organs, or parts deeply located, with extensive infection of tissue, and secondary infection with pus-microbes takes place, then the patient incurs the danger of septic infec- tion and local and general dissemination of the tubercular process, from the breaking down of the protective wall of granulation tissue. Garre has shown that pus-microbes grow luxuriantly in the soil furnished by a tubercular abscess, while they do not grow in ordinary pus. Watson Cheyne states that liquefaction of the tubercular product is determined by the constitution of the patient, as it occurs most frequently in persons in whom the disease is hereditary. That the bacilli do not multiply in a tubercular abscess has been definitely settled by Schlegtendal. He examined 520 specimens of fluid taken from tubercular abscesses, and found bacilli present in only 75 per cent. Garre (" Zur ^Etiologie der kaltenabscesse, Driiseneiterung, Weich- theil u. Knochen Abscesse u. der tuberculosen Gelenkeiter- ungen." Deutsche Med. Wbchenschrtft, B. xxi, No. 34, 1886.) has also made an extended series of observations to ascertain the presence of the bacillus in cold abscesses. He examined the contents of tubercular abscesses in thirty cases, and only seldom found bacilli. Cultivation experiments proved usually also negative, but inoculations yielded always positive results. He believes that tubercular pus contains many active spores after the bacilli have disappeared. According to this author, many tubercular ulcerations and abscesses are the result of a mixed infection, as has been claimed by HofFa for some cases of empyema complicating pulmonary or pleura! tuberculosis. In cold abscesses, and in the liquefied, cheesy material of tubercu- lar cavities in bones and joints, no pus-microbes could be found, not even in cases that pursued a rapid course. Cultivations made with such material remained sterile, while inoculations produced typical tuberculosis in animals. Specimens of such fluid, examined under the microscope, showed none of the morphological elements of pus, but were seen to consist of an TUBERCULAR ABSCESS. 53 emulsion of fat-globules and detritus of broken-down tissue, suspended in serum. Garre believes it is possible that, in many cases of suppuration following in the course of a tuber- cular process, pus is the result of a mixed infection, and that the pus-microbes disappear before the examination is made. Tavel (" Beitrag zur ^Etiologie der Eiterung bei Tubercu- lose. Separat Abdruck aus den Beitragen zur Chimrgie. Fest- schrift, herausgegehen zu Ehren des Professor Kocher in Bern., 1891 ") has made, recently, a valuable contribution to the etiology of suppuration in tubercular lesions. In his classifica- tion of suppuration Verneuil has divided pus into " mono et poly- microbique" and brings tubercular pus under the latter head, as he believes it is the product arising from the action of both tubercle bacilli and pus-microbes. Garre, Krause, and Steinhaus are of the opinion that tuber- cular pus is in reality no pus, but simply the product of cellular disintegration brought about by the bacillus of tuberculosis. G. Roth and de Ruyter regard tubercular pus as the product of a mixed infection following invasion of a tubercular product with pus-microbes. In the Berlin Hygienic Institute experi- ments made with Koch's lymph showed that large quantities injected subcutaneously in animals produced a circumscribed suppuration, which appears to demonstrate that the chemical products of tubercle bacilli possess mild, facultative, pyogenic properties. Inoculation experiments almost invariably result in the formation of an abscess at the point of inoculation, and the pus contained no other microbes besides tubercle bacilli. It has recently, also, been shown that syphilitic gummata and actino- mycotic foci may become the seat of suppuration without an additional infection, and at the same time the pyogenic proper- ties of the bacillus of glanders has been demonstrated. The typhoid bacillus, the gonococcus, the pneumococcus, the mi- crobe of scarlatina, and the anthrax bacillus are known to cause, at least occasionally, suppuration. Tavel studied the contents of tubercular abscesses by means of stained preparations 54 TUBERCULOSIS OF THE BONES AND JOINTS. under the microscope, by cultivation and inoculation experi- _ments, taking- special precautions to prevent contamination of the material after its removal from subcutaneous tubercular lesions. In the selection of cases special pains were taken to study those which pursued a subacute course in which the sus- picion of the existence of a mixed infection could be entertained. In all, forty cases were subjected to a critical examination as to the presence of mixed infection, and in all of these a positive or probable diagnosis of tuberculosis was made before the opera- tion. In the first thirty cases of tubercular abscess the exclusive presence of the tubercle bacillus was demonstrated by inocula- tion experiments and the clinical course of the lesions from which the material was obtained. In the first five cases the results of the inoculation experiments and the clinical course proved the tubercular nature of the lesions. Besides tubercle bacilli, streptococci or staphylococci were found in the cases of mixed infection. The haematogenetic origin of this mixed in- fection could be excluded, as in all cases a connection could be found between the focus and the external or internal surface of the body. In the last five cases, in which he demonstrated ha3inatogenetic infection with the streptococci and staphylococci, and in which the clinical course before the operation spoke for tuberculosis, the subsequent course, as well as inoculation ex- periments, showed that they were memo infections, and that here the tubercle bacillus was out of question. From these experiments and clinical observations, he came to the conclusion that the mixed infections with a haematogenetic origin are exceedingly rare. In most of the cases of mixed infection some connection with the surface of the body can usually be demon- strated. The author is of the same opinion as Garre, that tubercular abscesses are caused exclusively by the tubercle bacillus ; but, unlike Garre, he believes that the process is the same, or at least very similar, during the early stages of a tuber- cular affection, and in acute cases, as in acute suppurative inflammation, attributing to the chemical products of tubercle TUBERCULAR ABSCESS. 55 bacilli mild pyogenic properties. According to the author, the leucocytes and embryonal cells of the inflammatory product of the fixed tissue-cells are first transformed into pus-corpuscles, and that these undergo later fatty degeneration, and, after com- plete disintegration, furnish the granular detritus which has been regarded as the characteristic part of tubercular pus. As the greatest difference between pus-corpuscles in acute and tubercular abscesses, he regards a more speedy granular degen- eration and disintegration of the latter. A tubercular abscess is always lined by a tubercular membrane, which contains the typical structure of the tubercular lesion and the primary and essential cause of the inflammation, the bacillus of tuberculosis. The tension in such abscesses is much less than in abscesses caused by acute phlegmonous suppuration, and on this account fluctuation is a well-marked symptom in most cases. Lannelongue (" De la tension dans les absces Tubercu- leaux." Bull, de la Soc. de Chir., December 23, 1886) exam- ined, by means of a modified Ludvvig hsemo-dynamometer, the degree of tension in tubercular abscess of the extremities, and found it, as a rule, equal to the blood-pressure in veins between 12 and 22 millimetres. Only in abscesses of the wall of the thorax was the tension higher in consequence of respiration- pressure, which increased it to 30 to 50 millimetres. During continued extension with 3 kilogrammes' weight, and after in- jection of iodoform ether, the pressure was increased in for- mer instances to 60 millimetres, and in the latter case 50 to 80 millimetres, mercury-pressure. The thickness of this membrane depends on the length of time the abscess has existed and the duration of the infection. This membrane is formed by the extension of the tubercular process from the primary starting-point to the surrounding tissues. The color of the membrane is yellowish gray or grayish violet. It is, on an average, a few millimetres in thickness and loosely attached to the subjacent tissues. This membrane is the most characteristic anatomical feature of every tubercular abscess, as 56 TUBERCULOSIS OF THE BONES AND JOINTS. it is never found in any other abscess, and bears a very strong resemblance to the wall of an echinococcus-cyst. It consists of fragile tissue, which is composed essentially of heaps of miliary tubercles. Between the tubercles, and upon the surface of the membrane, masses of coagulated lymph can be found. If the membrane is rich in tubercles it presents somewhat the appear- ance of frogs' spawn. The surface is often dotted with yellowish spots, each one FIG. 14. ABSCESS-MEMBKANE FROM A TUBERCULAR ABSCESS. Surface view, slightly enlarged. ( Volkmann.) of which is a caseation-centre. At times such abscess-cavities are spanned by strings of connective tissue, which are also cov- ered with tubercles, and when torn or cut, during the operative treatment of the abscess, often give rise to troublesome haemor- rhage. In scraping out such abscesses with a sharp spoon the greatest caution must be exercised to remove every particle of the membrane, as incomplete removal, almost without excep- tion, is followed by relapse. Often, after thorough scraping, examination will reveal islets of tubercular tissue, which must TUBERCULAR ABSCESS. 57 be removed separately. After spontaneous evacuation of a tubercular abscess, or after incomplete removal of the infected tissue, a tubercular fistula forms. Such fistulse are always lined with soft granulations, which appear in a wonderfully short time. The softness, pallor, and oedematous appearance of these granulations, lining the tract and opening of such fistulas, dis- tinguish these granulations from syphilitic and osteomyelitic inflammatory products in similar tissues and localities. In exceptional cases the tubercular infiltration from the abscess- wall extends to the muscles, which then become the seat of a typical tubercular myositis. Such abscesses often travel great distances ; for instance, from the bodies of the verteb.rse down to and below Poupart's ligament. The entire track over which they have passed is lined by the tubercular membrane, the abscess and the primary lesion being connected with an uninter- rupted path of tubercular tissue. The infection follows the migration of the abscess, in whatever direction that may take place. If an additional infection from without take place, fol- lowing either a spontaneous discharge or after incision, the superficial granulations are destroyed by the suppurative process which is initiated, exposing the patient to the additional risks of septic infection and a more rapid local and general dissemination of the tubercular process. Symptoms and Diagnosis. - The tubercular abscess is called a cold abscess because it lacks tUe characteristic clinical phenomena which attend the development of an acute or hot abscess. There is but little, if any, rise of the local tempera- ture, and, unless the abscess has reached the skin, the surface looks rather preternaturally pale than red, and the abscess itself is always painless, and not tender on pressure. The pain, if present, is referred to the primary seat of the tubercular inflam- mation. Fluctuation is usually well marked, as the tissues around the abscess are not much infiltrated. The most impor- tant clinical feature of a cold abscess is its tendency to migrate from the place where it originated to distant localities by gravi- 58 TUBERCULOSIS OF THE BONES AND JOINTS. tation ; hence the name given to it by German writers, Sen- kungsabscess. Thus, in tubercular spondylitis, the abscess may appear in the lumbar region, and is then called lumbar abscess ; it may follow the iliac muscle and appear in one of the iliac regions, and is then, from its location, termed iliac abscess ; or, finally, it may follow the psoas muscle and appear above or below Poupart's ligament, when it constitutes a psoas abscess. In tuberculosis of the hip-joint the abscess appears posteriorly underneath the gluteal muscles, if perforation of the capsule take place in this direction ; or it appears anteriorly, usually a considerable distance below the hip-joint, if perforation of the capsule has taken place in an opposite direction. As the con- tents of the abscess carry the original cause of the disease, infection of the tissues takes place along the whole course traveled by the abscess, which is always lined with infected granulation tissue. Although the primary cause of a tubercu- lar abscess is most frequently tuberculosis of a bone or joint, it can also develop in the course of any localized form of tubercu- losis, and it is quite frequently met with in the course of tuber- culosis of the lymphatic glands. One of the largest tubercular abscesses in the iliac fossa that ever came under my observation formed in the course of two weeks after extirpation of a tuber- cular testicle. The affection of the spermatic cord extended beyond the internal inguinal ring, and the part not removed undoubtedly served as -the starting-point of the abscess. The diagnosis must be made with special reference to the nature and location of the primary lesion. In tuberculosis of the spine, the fixed pain in the region of the affected vertebrae, radiating from here in the direction of the nerves, taking their exit from the affected part on each side, is an important symptom, and this symptom is always aggravated by flexion and alleviated by extension of the spine. In coxitis the pain in the beginning of the disease, especially in the osseous form, is usually referred to the inner aspect of the knee-joint, and is always increased by motion of the hip-joint, and by making pressure over the tro- TUBERCULAR ABSCESS. 59 chanter in the direction of the axis of the neck of the femur. In cold abscess caused by glandular tuberculosis, the clinical history will point to a chronic inflammation of the glands which preceded the formation of the abscess. Fluctuation is usually a well-marked symptom. As soon as the abscess reaches the skin, that structure becomes inflamed, red, and more and more attenuated by pressure and inflammation, until spontaneous perforation takes place at a point subjected to greatest pressure. If a tubercular abscess become the seat of a secondary infec- tion witli pus-microbes, the subsequent symptoms, local and general, are suddenly changed, and are then those of an acute suppurative inflammation. The temperature which was normal, or nearly so increases, and presents the daily curves characteristic of acute suppuration and the general symptoms arising from it are those of septic infection, while the abscess, which has been heretofore painless, becomes painful, hot, and tender on pressure ; in fact, the clinical picture indicates that a chronic inflammation has been supplanted by an acute one. If any doubt remain as to the character of the swelling and the nature of its contents, this can be dispelled at once by resorting to an exploratory puncture. In cold abscess the fluid removed presents the appearance of serum in which minute particles of broken-down tissues are suspended, while in an abscess caused by a mixed infection it presents the macroscopical and micro- scopical appearances of true pus. Prognosis. The danger attending tubercular abscess must be estimated by the extent and location of the primary disease, the presence or absence of secondary infection, and the general condition of the patient. An open tubercular abscess, which has become infected with pyogenic microbes, and which com- municates with an important bone or joint, is always a serious source of danger to life. Such a condition is also unfavorable, in reference to successful surgical treatment, in obtaining a satisfac- tory functional result. The treatment by iodoformization holds out little encouragement in securing a permanent result, and operative 60 TUBERCULOSIS OF THE BONES AND JOINTS. treatment usually becomes an urgent necessity. If 'suppuration has given rise to organic disease of any of the important internal organs the prognosis is always grave, as the removal of the primary cause by operative treatment will not prove successful in averting a fatal termination from the complicating lesions. Tuberculosis in other organs renders the case almost necessarily fatal. If the general health remain unimpaired, even an exten- sive local tubercular disease may be amenable to a spontaneous cure or successful surgical treatment. On the other hand, a tubercular abscess developing in the course of an insignificant and unimportant local lesion occurring in an anaemic person, the subject of incipient multiple foci in different organs, must be regarded as a most formidable condition, with little or no prospects of a favorable termination. From quite an extensive clinical experience with cases of tuberculosis of bones and joints, I have learned to regard pronounced anosmia as an unfavorable symptom in the different forms of surgical tuberculosis^ as it is often an expression that general infection has occurred or that important internal organs are the seat of serious organic changes. Another important matter to be taken into consideration in mak- ing a prognosis, in cases in which general infection can be ex- cluded, is the possibility of eradicating the primary lesion by operative interference. If the disease is so located that this can be done, the chances of successful treatment of the local disease are much better than if the opposite is the case ; at the same time, the complete removal of the infected tissues is the best possible guarantee against general infection. Other things being equal, the prognosis is better in patients without a hereditary his- tory of tuberculosis, and in young subjects than those advanced in years. Treatment. Patients suffering from suppurating tubercular cavities require nutritious food, ale, porter, or some of the sub- stantial wines, as Tokayer, Aussbruch, port, or sherry ; out-door air will often prove the best tonic. Change of residence to the country, the sea-shore, or some mountain-resort has often been TUBERCULAR ABSCESS. 61 known to effect a cure when recovery was despaired of as long as patients lived in less favorable localities. In the way of medication the treatment must be purely symptomatic. Appe- tite is restored by the use of bitter tonics ; anaemia is treated by the administration of some mild preparation of iron, as the syrup of iodide of iron, tincture of chloride of iron, albuminate of iron, or citrate or tartrate of iron. If codliver-oil is given, it should be administered pure, and not in emulsion, and never upon an empty stomach. Holler's pale Norwegian oil is the best and most palatable. It can be given floating upon any agreeable menstruum, such as black coffee, brandy, whisky, or wine. The best time to administer the drug, without disturb- ing the digestion, is an hour or an hour and a half after each meal, in doses of from a teaspoonful to a tablespoonful, accoixU ing to the condition of the digestion and the age of the patient. Tapping of Abscess, Followed by Antiseptic Irrigation and Subcutaneous lodoformization. This method of treatment will be more fully described in another part of the book, to which the reader is referred. This treatment has been followed by most signal success in the treatment of tubercular abscesses, and should invariably receive a faithful trial before operative measures are resorted to. The procedure should be repeated every two weeks until the abscess-cavity has become obliterated. Washing out of the cavity with a 4-per-cent. solution of boracic acid prior to the injection of the iodoform emulsion is of great importance and value, as it secures more thorough removal of the dead, broken-down tubercular tissue, thus bringing the cavity in a more favorable condition for the antibacillary action of the iodoform. If the treatment prove successful, re-accumu- lation takes place more slowly and the character of the tubercu- lar pus changes. As soon as an active reparative process has been initiated the granulations lining the cavity no longer undergo caseation, and the fluid removed at this time is scanty and resembles mucus more than pus. In a number of cases that have come under my observation I have found, after the 62 TUBERCULOSIS OF THE BONES AND JOINTS. second or third injection, a moderate swelling, which presented well-marked fluctuation, but which, when punctured, yielded no fluid. The swelling and fluctuation were evidently due to the presence of a mass of granulation tissue, which was under- going transformation into permanent tissue. I have always, in such cases, made the iodoform injection, and in a few weeks the abscess was found healed, and the swelling gradually disap- peared. In open, suppurating, tubercular abscesses this treat- ment has not proved as successful as in cases of uncomplicated, subcutaneous, tubercular lesions. If iodoformization is to be employed in such cases it should be preceded by measures directed toward the suppuration, and thus remove the cause and inflammatory products of the secondary infection. Incision, scraping of inner surface of abscess-wall, and thorough applica- tion of peroxide of hydrogen will answer these indications most effectually. After the abscess has been rendered aseptic by such treatment, iodoformization is to be made in the same man- ner as in closed tubercular cavities. The most rigid antiseptic precautions must be observed in order to prevent a new infection with pus-microbes. Incision and Removal of Infected Tissue by Scraping. In all cases where, from the anatomical location of the primary lesion, it is possible to remove the tubercular product by opera- tive interference, and the patient is free from other tubercular affections and other fatal complications, a radical operation is always indicated after simpler measures have failed in curing the primary affection. In such cases the abscess-cavity is laid freely open in a direction which will secure most ready access to its interior with least injury to surrounding parts. When- ever it is found possible, from the anatomical relations of the parts, the incision should be made large enough to expose for direct treatment the whole of the interior surface of the abscess. After the abscess has been incised, its contents are washed away by irrigating with an aqueous solution of iodine, after which the granulations lining the cavity are scraped out with a large, TUBERCULAR ABSCESS. 63 sharp spoon, and the primary lesion is removed in a similar manner. In dealing with such cavities, it is important not to forget that the tubercle bacilli are contained in the granulations, because if these are not completely removed the principal object of the operation removal of the primary cause has not been accomplished, and a return of the disease is to be expected. In many instances prolongation of the tubercular membrane be- tween the interspaces of muscles and tendons renders it neces- sary to look carefully for such side-tracks and clear them of tubercular material with the sharp spoon. If the abscess com- municate with a primary focus in a bone, it is advisable to resort to ignipuncture of the bone after the cavity has been cleared of the granulations with the sharp spoon. The wound is to be closed in the usual manner after iodoformization of the whole surface, leaving only a small opening at the most depend- ent point for drainage. The scraped surfaces are now in the same condition for primary union as a recent aseptic wound, and, if kept in accurate apposition by the antiseptic dressing, which answers at the same time the purpose of an elastic com- press, primary union throughout is frequently obtained. Ab- scesses which have opened spontaneously, or during the treat- ment of which infection has occurred, must be treated on the same principles as acute abscesses. As far as can be done, the suppurating granulations should be removed with the sharp spoon, and after disinfection and iodoformization efficient tubu- lar drainage established, and, if the ultimate object is not attained by the first operation, frequent antiseptic irrigations are to be subsequently made until the cavity has been rendered aseptic. Landerer has recently called attention to the value of balsam of Peru in the treatment of tubercular abscesses. He maintains that this drug acts beneficially by stimulating the tissues to renewed activity; thus neutralizing indirectly, at least to a certain degree, the pathogenic effect of the bacilli, while at the same time it hastens the process of repair by its stimulating action on the tissues. In the treatment of open, suppurating, 64 TUBERCULOSIS OF THE BONES AND JOINTS. tubercular surfaces this drug should be tried as a local applica- tion. As a fluid for irrigation, under the same circumstances, nothing can surpass the efficacy of a strong, aqueous solution of tincture of iodine. Rest is an important element in the treat- ment of tubercular abscesses, irrespective of their location. Pro- longed confinement in bed and room should be avoided, and rest secured by appropriate mechanical support while the patient enjoys the benefit of out-door air and exercise. CHAPTER VIII. TOPOGRAPHY OF BONE AND JOINT TUBERCULOSIS. IT is a well-known clinical and experimental fact that cer- tain bones and joints are predisposed to tubercular infection. The new vessels in the vicinity of the centres of growth in the bones of young persons, on account of their imperfect struc- ture and irregular contour, furnish the most favorable conditions for the mechanical arrest of floating granular matter and the localization of pathogenic microbes. This predisposing anatomical element goes far to explain the frequency with which we meet with tubercular foci in the epiphysial ex- tremities of the long bones. The following table, prepared by Schmalfuss (" Beitrage zur Statistik der chirurgischen Tubercu- lose." Archivf. klin. Chirurgie, B. xxxv, S. 167) gives a good idea of the relative frequency with which different bones are affected with tubercular lesions : Billroth. Jaffe". Per cent. Schmalfuss. Per cent. Vertebra . . . Vertebra . . . 26 Knee 23 Knee . . Foot 21 Foot 19 Cranium and face . . Hip 13 1 Hip . . 16 Hip ... ... Knee 10 Elbow 9 Sternum and ribs . . Hand 9 Hand 8 Foot Elbow 4 Vertebra 75 Elbow. Pelvis 3 Tibia . . 4 Cranium ....... 3 Cranium 4 Tibia, fibula, and femur Shoulder Sternum, clavicle, ribs . Shoulder 3 2 Pelvis . Sternum, etc. Femur . 3.6 3.6 1.9 Femur 1 Shoulder 1 5 Humerus Tibia 1 Ulna . . 1.4 Ulna Fibula ... ... 1 Humerus 1 Radius Humerus .... 1 Radius 07 Scapula 06 Fibula . 0.5 Ulna 06 Patella . 0.1 It is safe to state that before puberty the primary lesion in tubercular affections of joints is most frequently located in one or both of the epiphyses of the bones which enter into the (65) 66 TUBERCULOSIS OF THE BONES AND JOINTS. formation of the joint, while in the adult primary tuberculosis of the synovial membrane is of more frequent occurrence. As age advances and the process of ossification is completed, the predisposing localizing causes in bone apparently disappear, while the synovial membrane becomes more susceptible to primary, localization. Of 204 specimens of tubercular joints, obtained from patients of all ages, examined by Mueller, 158 were primary osteal and 46 primary synovial tuberculosis. The predominance of the osseous form in these figures is owing to the large contingent furnished by patients under the age of puberty. Jaffa's (" Ueber Knochentuberculose." Deutsche Zeits- chrift f. Chirurgie, B. xviii, S. 432) statistic is based on 317 cases that were observed in Schede's clinic. A much larger number of cases, comprising the statistics of Jaffe, Schmalfuss, Billroth, and Menzel, is given by Cheyne (British Medical Jour- nal, April 25, 1891, p. 898), who added to these 602 other cases. He gives the following topographical distribution of tubercular affections of bones and joints : Bone or Joint Affected. Per cent. Spine, 23.2 Knee-joint, . . 16.5 Hip-joint, . ... . . . . . 14.6 Tarsus and ankle, ........ 14.4 Elbow-joint . . 6.3 Wrist and hand, . . . ... . .6.0 Skull and face, 5.5 Sternum, clavicle, and ribs, ^ 5.2 Pelvis, 3.5 Femur, tibia, and fibula, 3.5 Shoulder, 1.5 Scapula, ulna, and radius, 1.0 Humerus, . :*. 0.8 Patella 0.1 According to this table the vertebrae are the most frequent seat of tuberculosis of all bones. Of the large joints, according to the same author, the order of frequency is as follows : Knee- joint, 16.5; hip-joint, 14.6; tarsus and ankle, 14.4; elbow- TYPOGRAPHY OF BONE AND JOINT TUBERCULOSIS. 67 joint, 6.3; wrist and hand, 6 ; and shoulder-joint, 1.5. A vast amount of material illustrative of the number of cases of joint affections requiring resection, and showing the relative number of the large joints involved, is furnished by Culbertson. This author, in an encyclopedic work on the subject of resection, gives 3908 cases of excision of the larger joints. Of this num- ber, 596 cases belonged to the hip-joint, 745 to the knee, 326 to the ankle, 984 to the shoulder, 1079 to the elbow, and 182 to the wrist. As this table includes resections for gunshot wounds, compound fractures and dislocations, and other forms of trau- matism, it does not furnish any accurate information concerning the relative number of operations done on different joints for tubercular affections. The two infective diseases which attack the bones most frequently are acute suppurative osteomyelitis and tubercular osteomyelitis, and in reference to their location and pathological anatomy they present a series of analogies. In other respects they differ widely. Acute osteomyelitis attacks in preference the shaft of the long bones, while the tubercular form remains limited to the epiphysial extremities, as a rule, and frequently starts in the short and flat bones that are not often the seat of primary acute osteomyelitis. Lesions occur in acute osteomye- litis which are common to the tubercular variety, and both forms are equally prone to cause secondary joint diseases. The apophyses are more frequently affected by acute osteomyelitis than the shaft by tubercular osteomyelitis, with the exception of the cases of multiple miliary tubercles in the medulla of the long bones, which is found occasionally in the bodies of persons who have died of general miliary tuberculosis. Extensive tubercular disease of the marrow and shaft of the long bones is so exceedingly rare that the post-mortem room and operations on bones and joints will furnish hundreds of cases of limited tuberculosis of bone to one in which the shaft is extensively infiltrated. The favorite anatomical locations for tubercular affections of bone are in the epiphysial regions of the long 68 TUBERCULOSIS OF THE BONES AND JOINTS. bones and in the spongy bones, and only in exceptional cases are the shaft and central medullary tissue involved. To this rule the phalanges of the hands and feet furnish an exception, as in these bones a diffuse central tubercular osteomyelitis, known as spina ventosa, is quite a common affection. CHAPTER IX. BONE TUBERCULOSIS. Pathology and Morbid Anatomy. Some of the ancient authors were well aware of the frequency with which primary bone affections precede the development of joint disease. Mr. Lloyd (" On the Nature and Treatment of Scrofula," p. 1 20) says : " It often happens that the whole of the cancelli are nearly filled with this cheesy matter, or that several of the cellu- lar partitions being broken down, a large mass of it is collected at one spot, while the rest of the cancelli remain entire, and are partly filled with the yellow fluid ; while many of them may appear altogether empty, not even containing any of their natural secretion. Sometimes we find that only a part of the cancellous structure of the head of the bone has undergone this change. Indeed, I am inclined to believe that it often begins in the centre, as I have found the deposition of the new matter is very frequently greater there, and the exterior of the bone remains hard, as has been observed by Wiseman ; while the interior is completely deprived of its earth, and so soft as to be readily cut with the knife." Albers (" Preisfrage worin besteht eigentlich das Uebel, das unter dem Sogenannten frey- willigen Hinken der Kinder bekannt ist 1 " Beantworted von J. A. Albers, Wien, 1807) expresses his convictions on this point as follows : " I was a long time uncertain whether really the bones, as Ford asserts, were the parts first affected in this complaint (hip disease). But, partly through the excellent work of Doerner, and partly through the opportunity of open- ing a body in the first stage of the disease, I felt myself com- pelled to adopt that opinion. I found, for instance, an exten- sive destruction of the edge of the acetabulum, while the other parts of the hip-joint, viz., the cartilages, with the exception of a yellow spot, had suffered little or nothing." Rust ("Arthrokakologie oder Ueber die Verrenkungen, (69) 70 TUBERCULOSIS OF THE BONES AND JOINTS. durch innere Bedingungen," etc., Wien) says: " I believe that this disease has its origin in a morbid state of the head of the femur, and that the diseased appearances in the other parts of the joint are to be considered as the effect of the previously exist- ing mischief of the head of the bone." Benjamin Brodie is also of the opinion that in strumous constitutions the disease commences in the cancellated structure of the bone, and that the affection of the cartilages and synovial membrane is secondary in the order of attack. Even among the comparatively modern writers tuberculosis of bone was con- sidered a rare affection, and most of the chronic inflammatory conditions were regarded as one of the many manifestations of scrofula or struma. Ried, in his classical work ("Die Resectionen der Knochen," etc., 1847, p. 79), makes a sharp distinction between scrofulous and tubercular caries, and informs us that, of the many cases of bone disease that came under his observation, he saw only four cases in which he found tubercles. He places great stress on the importance of making a distinction between the two varieties of caries which he described, as in the tubercular form he be- lieves resection is not a justifiable procedure. Stanley ("A Treatise on Diseases of the Bones." London, 1849) speaks of a scrofulous inflammation as preceding tuberculosis, and states that a favorable prognosis should only be given before the tubercular stage has arrived, as after that time the affected bone necessarily undergoes destructive changes. He had noticed the existence of masses of chalk-like substance in the cancellous texture of bone; but did not interpret this morbid appearance in the way that Rokitansky has, by regarding the cretaceous mass as the result of the metamorphosis of tubercle in bone, analogous to the change it undergoes in other organs and tissues. Only a few cases had come under his observation in which he could satisfy himself as to the co-existence of tubercular affec- tions of bone and pulmonary phthisis. Even as late as 1859, Mr. Bryant ("On the Diseases and BONE TUBERCULOSIS. 71 Injuries of the Joints," p. 72. London, 1859) wished to ex- clude as strumous or tubercular all lesions in bone in which the inflammatory product did not consist of caseous material, as ap- pears from the following: "I cannot for one moment doubt that the majority of the cases which are described by surgeons as strumous or scrofulous disease of a joint, and of the articular extremities of the bones, depend upon a chronic inflammation in the bone. The disease is, in its origin and progress, inflamma- tory, and by early treatment may be arrested. The pathologi- cal conditions found upon examination are those which an inflammatory cause will produce, and it is quite exceptional to find in any bone that yellow, cheesy material which pathologists so well know as strumous deposit. I do not deny that such a deposit may be occasionally present, but the cases in which it is found are so rare that we may fairly regard such a specimen as a pathological curiosity. If, then, we confine the term " strumous disease of bone," as I believe we should, to such instances only where such a deposit is present, as surgeons, we shall seldom have occasion to employ it." Koster's ("Ueber locale Tuberculose." Centralblatt f. d. Ned. Wissenschaften, No. 58, 1873) researches shed a flood of light on the pathology and morbid anatomy of chronic inflam- matory affections of bone. He showed that miliary tubercles could not only be constantly found in the fungous granulations in diseased joints, but that they could be seen with equal regularity in the granulation masses in bone, tendon-sheaths, and bursa3, and later he added caseous ostitis, osteomyelitis, and caries. In this country, H. H. Smith ( Transactions of the Ameri- can Medical Association, 1879) was one of the first to call at- tention to the fact that most cases of chronic osteomyelitis are of a tubercular nature. He pointed out the influence of con- gestion of the medulla on cell-proliferation and on the increased number of leucocytes, also the defective elaboration of blood as a result of perverted myeloid collection, and arrived at the con- 72 TUBERCULOSIS OF THE BONES AND JOINTS. elusion that struma and tubercle are so closely allied that their differences cannot well be demonstrated. Tuberculosis of Bone a Specific Form of Chronic Osteo- myelitis. The tubercle bacillus has a special predilection for the medullary tissue of the bones, and especially for the red medullary tissue in the cancellated tissue in the region of the epiphysial cartilage of the long bones and some of the short bones, notably the vertebrae and the carpal and tarsal bones. As an inflammatory affection it is more correct to speak of tubercular osteomyelitis than ostitis, since the medullary tissue and the blood-vessels ivhich it contains are ilie jiarts that take an active share in the inflammatory process. In his experiments on animals, made for the purpose of studying the initial pathologi- cal changes in bone the seat of an active inflammation, F. Busch (' Ueber die Veranderungen des Marks der langcn liohren- knochen bei experimentell erregter Entzundung eines dersel- ben." Berl. klin. Wocheuschrift, No. 13, 1874) found, as the first histological changes, the medulla hyperaemic and an ac- cumulation of lymphoid cells. In the red marrow he found, under the microscope, an aggregation of round, colorless cells, containing a large nucleus, but no nucleated red blood-cor- puscles. These cells were evidently embryonal medullary cells, the product of tissue-proliferation from the fixed myeloid cells. The bone-cells take an active part in tubercular inflammation of bone, and it is therefore not proper to speak of the affection as an ostitis. The anatomical conditions of the vessels in the epi- physial region of the long bones in young persons, and in the vessels of the medidlary tissue, favor implantation of floating tubercle bacilli upon the inner surface of the vessel-wall, and they also explain the frequency with ichich localization of the tubercular process takes place in this locality. The shaft of the long bones is peculiarly exempt from tubercular disease, with the exception of the phalanges of the fingers and toes and the metacarpal and metatarsal bones in children, where the tubercu- lar osteomyelitis gives rise to the well-known spina ventosa of the old authors. BONE TUBERCULOSIS. 73 Pathological Varieties of Tubercular Osteomyelitis. The same cause the bacillus of tuberculosis produces different forms of tubercular osteomyelitis according to the method of infection, the number of foci, the anatomical location, the extent of the inflammation, and the stage of the disease. Miliary Tuberculosis. This form of tubercular osteomye- litis is not of much interest to the surgeon, as it seldom occurs as an independent affection, being usually associated with gen- eral tuberculosis. Circumscribed miliary tuberculosis often occurs in the periphery of older foci, and this is more especially the case if the primary product has undergone caseation, and the tissues around the cheesy mass are not protected by an impermeable wall of granulation tissue. The miliary nodules in bone, when found as a part of general miliary tuberculosis, present the same typical structure as in other organs. The nodules are arranged in groups in certain parts of the bone predisposed to tuberculosis, or they may be disseminated throughout the entire bone. Lazarus has recorded five cases of acute general tuberculosis in which the bones were examined with positive results. Miliary tubercles have been found in the sternum and ribs in post-mortem examinations of cases of pulmonary phthisis in the absence of general tuberculosis. Fungous Osteomyelitis. If the tubercular inflammation from the beginning involve only a limited area of bone- tissue, the specific product is granulation tissue. This form has been described by Konig as granulating focus. The process is an exceedingly slow one, and necrosis of the cancellated bone is either wanting or the particles of necrosed bone are so small that it often requires the aid of a microscope to detect them. The granulating focus is found as single or multiple, round or oval spaces, from the size of a millet-seed to that of a pea or hazel-nut, filled with granulation tissue, in which are often found imbedded minute spiculae of bone. Histologically, the granulation tissue is composed of the same cell-elements as recent tubercle in other organs, only that, as a rule, the giant- 74 TUBERCULOSIS OF THE BONES AND JOINTS. cells are more numerous and of larger size. Direct infection of bone is an extremely uncommon occurrence ; consequently, bone tuberculosis must be regarded clinically as a secondary lesion caused by an embolic infection from an older tubercular focus in some other organ. As soon as embolic infection in bone has taken place, a process of osteoporosis and decalcifica- tion occurs around the tubercular embolus or thrombus, and the FIG. 15. TYPICAL GRANULATION TUBERCULOSIS OF BONE WITH MANY ROUND AND OBLONG TUBERCLES AND WITH STRIPES OF TUBERCULAR TISSUE, TUBERCLE TISSUE. (Konig.) pre-existing medullary and connective tissues are transformed into embryonic or granulation cells, which impart to the prod- uct of the specific inflammation its characteristic appearance. According to Kiener and Poulet (" De Posteoperiostite tubercu- leaux chronique ou carie des os." Archiv de Phys. normal et path., 3 series, tome i, p. 224), rarefaction of the bone around a tubercular focus takes place in two different ways, either in the usual manner, by the formation of Howship's lacunae, or by BONE TUBERCtfLOSlS. 75 liquefaction and disappearance of the cement-substance,^after the bone has previously presented a vitreous appearance. It is not often that only a single focus of tubercular infection in bone is present ; more frequently two or three foci appear in the same region simultaneously, or in slow or rapid succession, and it is not unusual to find that, two neighboring epiphyses are infected at the same time or during the course of the disease. Under favorable circumstances the granulations remain for an indefi- nite period of time without undergoing caseation. As long as decalcification of the surrounding bone goes on the infection is progressive, but as soon as the zone of granulation tissue around the infected focus is transformed into bone, osteosclero- sis takes place, and the tubercular process, for the time being at least, becomes arrested ; the micro-organisms are shut in, as it were, by an impermeable wall of sclerosed bone. The grann- hifing focus ivithout caseation is the most favorable form of tubercular osteomyelitis, often resulting in a spontaneous cure, and most amenable to successful surgical treatment. During this stage general tuberculosis is not likely to occur, as the liv- ing cells hold the bacilli in captivity, as it were, thus preventing local and general dissemination. Caseous Foci in Bone. A caseous focus in bone only indi- cates the site of a former fungous osteomyelitis, and we often meet with these two conditions side by side, a zone of tuber- cular osteomyelitis around a cheesy centre. Cheesy tubercular cavities in bone resemble the same con- dition in the lungs, only that secondary infection with pus- microbes is of less frequent occurrence, and on this account the cavity never attains such large size as in the latter organ. If the cavity is larger than a hazel-nut it usually contains a seques- trum of considerable size. If such a cavity is exposed in a fresh specimen by a transverse section through the bone it's interior presents appearances according to the stage the tuber- cular process has reached. If caseation has not advanced far it contains grayish-red granulations, or the granulations present a 76 TUBERCULOSIS OF THE BONES AND JOINTS. yellowish-gray color if caseation is well marked, or the cavity is filled with a cheesy mass when this degenerative process has been completed. If the contents of such a cavity are rubbed between the fingers minute particles of bone can usually be detected in this manner. If these particles are too small to be recognized by the sense of touch or sight their presence can almost always be demonstrated by microscopical examination. In other cases larger sequestra are imbedded in the cheesy material, and in some a large sequestrum occupies almost the entire cavity, being sepa- rated from the walls by a thin layer of granulation tissue. The color of the dead bone, owing to the presence of cheesy material in its meshes, corresponds with that of the surround- ing soft mass. If the wall of the cavity is soft it usu- ally, although not always, denotes that the disease is in an active state. As soon as the inflammatory process has subsided the osteoporo- tic bone becomes sclerosed, and the tubercular material is walled in and, for the time being, is rendered quite harmless. If, in the former instance, the contents of the cavity are removed with a sharp spoon, the inner portion of the wall comes away with the infected tissue, the line of demarcation between healthy and diseased tissue not being very well defined ; while in the latter cases the infected material can be thoroughly removed by the same procedure without removing a portion of the wall of the cavity. In the latter instance the sclerosis of the wall of the FIG. 16. UPPER PORTION OF FEMUR OF BOY Six YEARS OLD WHO DIED OF GENERAL, TUBER- CULOSIS. Natural Size. (Krause.) a, cheesy focus in head of femur; b ft, infiltration of cancel- lated tissue, extending from focus to shaft of femur ; d, defect of head of femur, caused by pressure against acetabulum, which resulted in subluxation. BONE TUBERCULOSIS. 77 cavity indicates that the healing process has been completed, or at least is progressing favorably. The wall of the cavity is usually lined with granulation tissue containing the characteristic histological elements of tubercle, and if the wall is osteoporotic it usually is also infiltrated with tubercle. (Fig. 16, b 5.) The more advanced the retrograde changes, the less marked the histo- logical structure of the inflammatory product. In case caseation has far advanced the microscope shows only granular detritus, and the contents of the cavity are no longer connected with the inner surface of the wall. Cheesy foci are frequently found in the epiphysial extremities of the long bones entering into the formation of a tubercular joint. The number of such foci varies from one to seldom more than three in one articular extremity. They are also frequently met with in the bodies of the vertebrae. As in other localities, caseation in osseous foci always commences in the centre and extends toward the periphery. Numerous caseous centres in different portions of the infected area become confluent and form large masses. Near the deposit in some specimens it can be seen that the trabeculse are thickened, and some of the cancellous spaces have lost their fat-cells and are occupied by a semi-fibrous material resembling the pathological product in some forms of synovial tuberculosis. In this form of bone tuberculosis plastic periostitis in the vicinity of the foci is not well marked. The granulation tissue, which is the charac- teristic product of the tubercular inflammation, absorbs the bone with which it comes in contact, and thus makes room for the inflammatory product. The gradual substitution of granulation tissue for bone explains the absence of intra-osseous tension, which is one of the prominent conditions in acute suppurative osteomyelitis. As the tubercles infiltrate the surrounding bone- tissue the lacunar absorption covers a larger field, while casea- tion extends from the centre of the infected area from different points. In some cases the tubercular process is more rapid, and time is not afforded for total absorption of the trabeculse by the granulations before caseation is complete ; hence, we find in 78 TUBERCULOSIS OF THE BONES AND JOINTS. such specimens minute particles of necrosed bone. Sequestra imbedded in cheesy material remain unchanged in size, as their diminution in size or complete removal by absorption can only take place as long as they are in contact with and are acted upon by living granulation tissue. The pathologico-anatomical diagnosis of these osseous foci is rendered more difficult by the occurrence of small foci in the apophyses which are occasionally found in acute osteomyelitis. For the expert, however, the macroscopical evidences are suffi- cient upon which to base a differential diagnosis. The resem- blance consists only in the form and location of the foci, while the contents present characteristic peculiarities in both forms. In acute osteomyelitis the foci contain flabby granulations and pus ; usually, also, small sequestra of a yellow color. If the pus in old cases become inspissated, it may present some resemblance to tubercular material, but is of an entirely differ- ent appearance. The pus is of the color and consistence of cream ; or, if inspissation has advanced further, it bears a strong resemblance to moist, unslacked lime. In the granula- tions no tubercles can be found. If the disease, spontaneously or by appropriate treatment, come to a stand-still before it has implicated an adjacent joint or resulted in the formation of a tubercular abscess, the granulations, if they have not undergone caseation, may become transformed into connective tissue or bone, and the patient recovers not only the function of the part affected, but is protected against local and general infection from this source. If caseation has occurred, a spontaneous cure under such circumstances is still possible by encapsulation, calcification, and the formation of a wall of dense bone around the area of infection. Nelaton has given an excellent descrip- tion of encapsulation of tubercular foci in bone. If the disease show no tendency to limitation, the tubercular product under- goes the typical pathological changes, coagulation necrosis, caseation, and liquefaction of the cheesy material. If it travel in the direction of a joint, it involves the latter as soon as per- BONE. TUBERCULOSIS. 79 foration takes place. The escape of tubercular material into a joint is followed, as a rule, by diffuse tubercular arthritis, the bone affection giving rise to an inflammation of the joint iden- tical in character with the primary bone-lesion, the primary disease and the complication being known as tubercular osteo- arthritis. If the joint escape and the disease extends toward the periphery, it finally reaches the periosteum, causing a tuber- FIG. 17. LOWER ARTICULAR EXTREMITY OF FEMUR WITH CHEESY FOCUS, WHICH AT a HAS REACHED THE SURFACE OUTSIDE THE INSERTION OF THE SYNO VIAL MEMBRANE. JOINT NOT AFFECTED. (Kbnig.) cular periostitis, and finally appears on the surface as a tuber- cular abscess. Perforation of the periosteum often takes place close to the insertion of the capsular ligament of the adjacent joint ; the joint escapes by the interposition of only a few lines of healthy tissue between it and the infected route along which the inflammatory product travels toward ilie surface. Although the joint may at first escape infection by the tubercular abscess traveling in this direction, it often becomes 80 TUBERCULOSIS OF THE BONES AND JOINTS. involved later by the disease attacking the capsule, and finally the synovial membrane. The extension of the bone disease to the joint by this indirect, circuitous route is a very rare occur- rence, as compared with direct infection by perforation of an osseous focus into adjacent joint. Tubercular Necrosis. By tubercular necrosis is not meant that form of bone tuberculosis in which death of minute par- ticles of bone occurs as one of the consequences of tubercular osteomyelitis, but in which necrosis of a fragment of bone of considerable size takes place as one of the early effects of the tubercular inflammation. Tubercular necrosis, especially in its most characteristic forms, is an entirely different condition from tubercular granulating foci. It also differs materially from acute necrosis, which is caused by suppurative osteomyelitis, as the sequestrum remains for a longer time in connection with the surrounding tissues. It also differs from it in regard to the location of the sequestrum, as in the acute form the shaft is usually affected, while the tubercular variety is found almost exclusively in the epiphyses of the long bones and the short and flat bones. The sequestrum is also, as a rule, smaller, and consists of cancellated bone-tissue. The common articular sequestrum is seldom larger than a pigeon's egg. It is occa- sionally derived from the surface of a bone ; but more fre- quently it is in the interior of the bone, and very often in the epiphyses of the long bones. It is wedge-shaped, the base of the wedge being directed toward the articular surface, and the apex toward the medullary cavity. Tubercular necrosis necessarily follows if the infected area, from the beginning, exceed the size of a hazel-nut. The non- vascularity of the tubercular product and the blocking and destruction of blood-vessels, during the early stages of the inflammation, determine early death of the bone, corresponding in extent to the limits of the inflammation, and if this exceed the resorption capacity of the granulations the dead tissue is not removed by absorption, and is found as a sequestrum as BONE TUBERCULOSIS. 81 soon as it has become detached from the surrounding healthy bone. The density of the dead bone is very variable, in some less than that of normal bone ; in others it resembles compact bone. If the tubercular process has been rapid, and the granu- lation tissue is scanty, the necrosed bone is not osteoporotic ; but if the disease has pursued a more chronic course, and has resulted in the production of an abundance of granulation tissue, it presents a honey-combed appearance, is irregular in FIG. 18. WEEGE-SHAPED TUBERCULAR SEQUESTRUM IN THE HEAD OF THE TIBIA. BONE AND SEQUESTRUM DIVIDED LONGITUDINALLY. BASE OF SEQUESTRUM EXTENDING INTO JOINT. (Kijnig.) shape and variable in size, and does not correspond with the area of the infected district, as part of it has been absorbed by the granulations. In shape the tubercular sequestra are irregu- lar, quadrilateral, or wedge-shaped, according to the structure of bone involved, the method of infection, the length of time which has elapsed, and the nature of its immediate surroundings. The cancellous spaces are filled with the products of tubercular inflammation in different stages of degeneration. The color of 82 TUBERCULOSIS OF THE BONES AND JOINTS. the necrosed bone depends on the condition of the granulations which surround it ; if these have not undergone secondary de- generative changes it may resemble healthy bone, but if casea- tion has taken place it is infiltrated with the cheesy material, and then presents a grayish-yellow or yellow appearance. If the dead bone has undergone no reduction in size, and the granulations surrounding it are few, it remains firmly wedged in position, and under such circumstances it is often difficult to locate the exact boundary-line between it and the surround- ing healthy bone or dislodge it from its incarcerated position. Konig has described a form of necrosis of the articular extremi- ties of the long bones, as a distinct variety, under the name of tuber- cular infarct. According to Konig, such an infarct, like infarcts in other tissues and organs, is always caused by impaction of an embolus in one of the distal arterial branches, and presents the same wedge-shaped appearance and peripheral zone of FIG. 19. RESECTED UPPER END OF FBMUK FROM: A GIRL FIVE YEARS OLD. Natural size. (Krause.) Large, wedge-shaped, subohondral sequestrum in head of femur, partially detached by tubercular granulations, articular cartilage elevated from base of sequestrum. congestion. In some cases the articular cartilage is destroyed and the base of the sequestrum projects into the joint, and if the joint has still been used the surface of the bone presents a polished surface. Cheyne does not agree with Konig in the etiology of this form of bone tuberculosis, because, as he maintains, the dead bone shows invariably evidences of an antecedent inflam- mation. He asserts that certain areas of bone-tissue are de- stroyed by the tubercular inflammation, and that sequestration always takes place by the absorption of trabeeulae in the pe- riphery of the necrosed bone. That a fragment of tubercular tissue impacted in a small artery may be the cause of a tuber- cular necrosis has been shown experimentally by Miiller. That tubercular necrosis, like other forms of bone tuberculosis., is BONE TUBERCULOSIS. 83 usually associated with antecedent tubercular foci is well known. If a minute fragment of tubercular tissue should reach the general circulation, localization would most frequently occur in the tissues and vessels predisposed to such an occurrence, and this is notably the case in the medullary tissue and blood-vessels in the epiphysial region of the long bones in children and young adults. The size of the vessel obstructed by an infected embolus will determine the extent of the necrosis. If the embolus is small, the area of necrosis may be increased by the blocked vessel becoming the seat of secondary thrombosis, obliteration of the vessel taking place in a proximal direction by growth of the thrombus toward the heart. The common articular sequestrum is seldom larger than a pigeon's egg. As the cortical portion of bone is seldom involved by a tubercular infarct, the necrosed area is often overlooked in operations on tubercular joints unless the bone is sawn through. In the living bone it is sometimes very difficult to demonstrate the presence and contour of the sequestrum, so small are the differences be- tween the dead and living bone; we often have to rely on the color alone to determine the presence and outlines of the seques- trum. The dead bone appears of a dirty-white or yellowish- white color, while the surrounding 'bone presents a normal pinkish hue. If the dead bone is scraped, cheesy material is obtained. The difficulty in recognizing the dead bone is often enhanced by the density of the sequestrum, which often equals that of the surrounding healthy bone. In other cases the sequestrum appears sclerosed, harder than the surrounding bone, a condition which can only be explained by the fact that soon after the commencement of the disease the bone around the sequestrum becomes rarefied, so that the sequestrum represents the normal density of bone, while the surrounding bone has be- come osteoporotic. At other times the impression is received that sclerosis of the sequestrum is an initial condition of the tubercular process. An anatomical diagnosis is often a matter of great difficulty, 84 TUBERCULOSIS OF THE BONES AND JOINTS. as no line of demarcation can be seen separating the living from ,the dead bone. Separation of the sequestrum takes place more slowly than after suppurative osteomyelitis, the process requiring often, according to the size of the sequestrum and the activity of the inflammatory process, months and years for its comple- tion. If the granulations which surround the sequestrum do not undergo cheesy degeneration the bone becomes imbedded and tits accurately into the cavity, and if the surrounding zone pf granulation is converted into connective tissue it may become permanently encapsulated ; but even from such an apparently healed depot local and general infection can occur at any time. Intermediary forms of bone tuberculosis occur between the gran- ulating foci and tubercular necrosis just described. In such foci the granulations become gradually more and more abundant at the expense of the sequestrum or the sur- rounding osteoporotic bone, and finally the detached necrosed bone lies in the cavity, loosely imbedded in the granulations. In the necrotic form of osseous tuberculosis we observe, as a rule, more frequently hyperplastic tissue-proliferation around the seat of inflammation after the formation of fistulse than in the granulating focus. The microscopical examination in this variety of bone tuberculosis presents greater difficulties in demon- strating the presence of tubercle bacilli than is the case in fungous osteomyelitis ; yet, as a rule, they can be found in the sequestrum and granulations. In conducting this method of examination it is necessary that the bone should be decalcified and sections of it stained and examined under the microscope. In specimens thus prepared it can be seen that the blood-vessels still exist in some of the Haversian canals to a certain depth ; those of the Haversian canals are filled with cells and granular detritus. Scanty remnants of epithelioid and giant cells can also be found. Such sequestra may remain in the place where they originated years alter apparent healing has taken place, and are then connected with the surrounding bone by connective tissue. Konig is of the opinion that the tubercular infarct in BONE TUBERCULOSIS. 85 bone is caused by a tubercular embolus derived from some distant antecedent tubercular focus, and that this plug contains the essential cause of the tubercular process, the bacilli of tuberculosis. He claims that necrosis would not take place if, from such an embolus, bacilli would not reach the terminal arterial vessels, causing complete obstruction in these vessels on the distal side of the primary obstruction. The extension of the disease is due to spreading of the tubercular inflammation along the course of the small vessels. The fate of the affected bone and the surrounding tissue is variable. Under the most favor- able conditions a tubercular focus heals completely. Such, a favorable termination can be expected most frequently in the granulating form of osseous tuberculosis. After the tubercular granulations have undergone retrograde metamorphosis their place is taken by vigorous granulation tissue, which spring from the adjacent healthy tissue, and these are transformed into con- nective tissue, which, by growing into and around the tubercular material, gradually takes its place. Spontaneous cure is often more apparent than real, as some of the tubercular granulations remain, and in such a partially healed focus a new tubercular inflammation may be lighted up at any time under the influ- ence of adequate local or general conditions. Such recidiva- tions are often observed in tubercular affections of the hip- and knee- joints after the original partially healed affection has remained in a latent condition for years. Small sequestra are often completely removed by granulation tissue if caseation of the tubercular product has not occurred, but not infrequently it is the case, in the event that they are too large to be completely removed in this manner, that they are rendered innocuous by becoming permanently imbedded in connective tissue, while encapsulation of a large sequestrum never occurs. Diffuse Tubercular Osteomyelitis. Independently of gen- eral miliary tuberculosis diffuse tubercular osteomyelitis is quite rare. It occurs more frequently as a secondary affection from a tubercular joint than as a primary osseous lesion. 86 TUBERCULOSIS OP THE BONES AND JOINTS. Kiener and Poulet (pp. cit.) have described a form of secondary tuberculosis of bone with rapid extension of the pro- cess. Here the disease originates in persons debilitated in con- sequence of a primary tuberculosis in a bone that has already undergone extensive pathological changes. This form is char- acterized by a tendency to suppuration and the production of fungosities in the surrounding tissues. It appears under two principal varieties: 1. Progressive tuberculosis with attached sequestrum ; that is, the meshes of the sequestrum are filled with granulations growing into them from the interior surface of the cavity ; this is the caries fungosa of the old authors. 2. Circum- scribed tuberculosis with small sequestra, surrounded by sup- purating granulations ; by the rapid extension of the tubercular process at circumscribed points several sequestra are produced simultaneously, which excite massive fungosities in their vicinity. The same authors describe another form of bone tuberculosis which they term acute progressive tubercular osteomyelitis, and which, according to their observation, is characterized by a tendency to early suppuration. This form is exceedingly rare and often involves almost an entire epiphysis, the analogue of acute cheesy pneumonia. It resembles closely acute suppurative osteomyelitis, but microscopic examination shows all the char- acteristic appearances of tuberculosis, condensating and rarefying osteomyelitis, cheesy degeneration, and tubercle formation upon the blood-vessels, production of small sequestra and fungosities. The clinical and pathological characteristics of this local form of bone tuberculosis consist in the rapid extension of the affection and the danger to life from general infection. On making a longitudinal section through a long bone affected by diffuse tubercular osteomyelitis, we observe conditions which closely resemble acute suppurative osteomyelitis. We find large, irregular, often multiple areas of a yellowish- white infiltration, with numerous foci of liquefied cheesy material. The infection extends from the epiphyses of long bones to the medullary cavity and the periosteum, along the Haversian canals and the BONE TUBERCULOSIS. 87 blood-vessels. The secondary periostitis caused in this manner, as a rule, assumes a plastic type, resulting in the formation of diffuse, irregular masses of new bone. In these cases there is no tendency whatever to limitation in the formation of sequestra, but rather a tendency to spread indefinitely and to invade even the medullary tissue of the shaft. If the spongy bones are the seat of this process the disease extends with great rapidity, and in a short time the entire bone is diffusely infiltrated. Patients suffering from this rapid form of tubercular osteomyelitis are exposed to all the dangers incident to diffuse general miliary tuberculosis if the infected tissues are not removed by a timely and thorough operation. In operating it is important to recog- nize this form, since it requires more radical measures,^-either amputation or very extensive excision of the entire thickness of the affected bone. Less heroic local measures, such as will meet the indications in other less diffuse varieties of osteotuberculosis, are of no avail. Caries. Caries 'of bone should no longer be spoken of as a disease, but as one of the effects of some destructive disease of bone. Macroscopically and microscopically caries of bone re- sembles an ulcer of the soft parts, and it would not be inappro- priate to describe it as an ulcer of bone. Tuberculosis of the periosteum and of bone are the affections which most frequently produce caries. Every tubercular cavity in bone lined with granulations presents a carious surface as long as the primary disease remains in an active state. Every tubercular abscess in communication with a tubercular osteomyelitic focus has carious bone at its bottom. A tubercular periostitis leads to caries at an early stage by the extension of the tubercular process to the sub- jacent bone. Caries of the articular extremities of the long bones arises in the course of primary or secondary tuberculosis of joints as soon as the articular cartilages, in whole or in part, are de- stroyed by the tubercular granulations. Caries of the vertebrae, like that of other short, flat, and irregular bones so frequently referred to in the old text-books, and even in many of more 88 TUBERCULOSIS OF THE BONES AND JOINTS- recent date, as a disease, is, in a great majority of cases, nothing more or less than tuberculosis of those bones. Destruction of articular cartilage by primary or secondary synovial tuberculosis does not always necessarily result in caries of the articular ends, as, under favorable conditions, the de- structive process is arrested before it extends to the bone, and a new covering of fibrous tissue takes the place of the articular cartilage. Carious bone is always covered more or less by granulations, and the enlarged cancellous spaces are occupied by the same material. The granulations detach small frag- ments of bone, which remain imbedded in the soft, flabby granu- lations, and afterward become part of the abscess contents, or are eliminated with the discharges through fistulous tracts. At a little distance from the tubercular granulations the bone is osteoporotic, but immediately beneath it the cancelli contain young fibrous tissue, and it is here that thickening of the tra- beculae takes place. After the cartilage has disappeared the disease extends to the surface of the bone, which soon becomes covered with granulations, in which all of the histological elements of tubercle can be found. The tubercular process extends, step by step, into the bone, new areas becoming suc- cessively involved, while the older portions undergo cassation and liquefaction. Immediately beneath the infected tissues there is usually a narrow zone of plastic osteomyelitis, while more remote from the disease there may or may not be an osteoporotic condition of the bone, often in circumscribed patches. The destructive process takes place most rapidly at points subjected to greatest pressure. Thus, in coxitis, the rim of the acetabulum or upper segment of the head of the femur suffers the most from pressure of the head of the femur, and in tuberculosis of the knee-joint the articular ends show the great- est defects at points subjected to the greatest pressure. The detachment of fragments occurs by lacunar absorption of por- tions of the trabeculae. This interstitial absorption of bone is accomplished exclusively by living granulations, and can only BONE TUBERCULOSIS. 89 occur in places where these have not undergone caseation. Surface caries, as a rule, is always superficial, never involving more of the bone than a quarter of an inch in thickness* Caries sicca is a .form of caries which was first minutely described by Volkmann as a definite pathological variety of tubercular joint disease. The most characteristic features of this kind of caries are absence of suppuration, obliteration of the cavity of the joint, and sclerosis and concentric atrophy of the articular extremity of tJie bone. The yellow appearance of the sclerosed bone is due to fatty degeneration of the con- tents of the cancelli, and not to infiltration with tubercular material. Caries sicca is met with most frequently in the shoulder-joint, and is a form of joint tuberculosis which most frequently terminates in a spontaneous cure, without surgical interference. Tubercular Periostitis. Tubercular periostitis of the long bones is a comparatively rare affection, being far less frequent than syphilitic periostitis. This affection as a primary disease involves most frequently the vertebra?, ribs, cranium, and bones of the face. In the last locality it attacks the orbital border of the malar bone most frequently. As a secondary affection in tuberculosis of the long bones, it develops most frequently in connection with the diffuse infiltrating form of osteotuberculosis. In tuberculosis of the ribs the disease starts most frequently in the periosteum, and the bone is gradually destroyed from with- out inward. The compact layer of the ribs at points cor- responding to the disease in the periosteum shows, at first, minute circumscribed defects, which gradually enlarge, impart- ing to the bone a worm-eaten appearance. The disease often destroys the continuity of the bone, giving rise to a patho- logical fracture. It not only spreads in the direction of the bone, but also, by continuity, along the periosteum, terminating frequently only with the destruction of the entire periosteal envelope. The periosteum being the primary starting-point of the disease, extension of the process to the tissues outside of 90 TUBERCULOSIS OF THE BONES AND JOINTS. the periosteum is an early occurrence. In the adult, tuber- cular spondylitis is most commonly the result of an extension of the disease from the periosteum. A number of vertebrae are attacked simultaneously, or in rapid sucpession, and the forma- tion of a tubercular abscess must be expected. Curvature of the spine is frequently absent, and when present it is not as angular as when the disease attacks primarily the body of one or more of the bones. As a secondary disease in tuberculosis of the long bones it is rare, except in the diffuse variety. When the dry, granulating focus reaches the periosteum, a small, soft, elastic, limited granulation swelling forms, first under, later outside of it. It is characterized by slow growth, comparatively little pain, slight tenderness, and a tendency to remain stationary for a long time. If, however, the central focus has become cheesy, and the liquefied, cheesy material comes in contact with the periosteum and paraperiosteal tissues, a tubercular abscess forms in a short time. As soon as the periosteum has been perforated the cheesy material infects the connective tissue, which then takes an active part in the formation of the tubercular abscess ; the periosteum ruptures spontaneously, the skin overlying it becomes tubercular and presents subsequently, at the point of perforation, the appear- ance of lupus. In the differential diagnosis between a tuber- cular and syphilitic periostitis, the character of the swelling is of great importance. In the former, central softening is of frequent occurrence, and takes place earlier than in the latter ; at the same time, pain and tenderness are not as well marked as in syphilitic gumma of the periosteum. CHAPTER X. ETIOLOGY OF BONE TUBERCULOSIS. TUBERCULOSIS of bone occurs either as a primary or second- ary affection. In the former instance we understand that local- ization of the Bacillus of tuberculosis has not taken place in any other organ of the body, and that the tubercular lesion in bone presents itself as an isolated single affection. Little is known concerning the channels through which primary infection takes place. We have reason to believe that this occurs most fre- quently through the respiratory and digestive organs. Through these routes the bacilli of tuberculosis enter the general circu- lation and localize in the capillary vessels of those parts of the bones which are anatomically predisposed to localization of floating micro-organisms. The frequency with which pulmo- nary tuberculosis is met with in cases of bone tuberculosis, and the fact that the thoracic duct is also quite often the seat of tuberculosis, speak in favor of this assumption. We have no reliable evidence that infection rarely, if ever, takes place through a wound in a healthy person. Clinical experience tends to prove that primary tuberculosis of bones and joints is exceedingly rare, or, perhaps, does not occur at all. The tuber- cular lesions which give rise to metastatic tuberculosis may be very minute and elude detection, even on making a careful examination. A small cheesy deposit in the lungs, a hidden caseous lymphatic gland, may be sufficient, under certain con- ditions, to give rise to numerous metastatic foci. Carefully- made autopsies can only furnish additional reliable information on this subject. Buhl's assertion, that in tubercular affections of different organs without an old tubercular focus, this was not absent but overlooked, may yet receive corroboration by careful research in the future. Orth made 67 autopsies in the Gottin- gen clinic of patients that were the subjects of tuberculosis of bones and joints which had been subjected to operative treat- (91) 92 TUBERCULOSIS OF THE BONES AND JOINTS. ment. In 14 of these, caseous foci were found in other organs which could be regarded as the cause of the bone and joint affections, thus giving in only 21 per cent, caseous foci as the source for the metastatic bone and joint affections. The num- ber of those in which the post-mortem revealed only osseous foci were the following : Of 30 hip-joints, . 5 Of 17 knee-joints, 2 Of 8 ankle-joints, 1 Of 11 tuberculosis of vertebrae, 5 Of 1 multiple disease of bones, 1 The 67 autopsies showed 55 times, besides the bone and joint disease, older foci. Among these, the lungs were the seat 37 times; the lymphatic glands 21 times. Most frequently the bronchial glands were affected ; next in order came the mesen- teric and retro-peritoneal, and least frequently the glands of the neck and extremities. The genito-urinary organs were affected 9 times, as a rule complicated by pulmonary tuberculosis. Secondary tuberculosis of bones and joints is a common clin- ical occurrence. As has been previously stated, what is gen- erally regarded as a local bone tuberculosis (by which we mean the absence of recognizable tubercular lesions in other organs) is, in reality, in the majority of cases, a secondary disease, resulting from the introduction of bacilli through the respira- tory or alimentary tract into the circulating blood with localiza- tion in the bone, or the entrance of bacilli into the circulation from a pre-existing but undetectable tubercular product with secondary localization in bone. In this sense a primary, or, to use a more correct expression, a localized osseous or articular tuberculosis is, according to Kummer, found in about 40 per cent, of the cases ; in the remaining 60 per cent, depots are found at the same time in other organs : the lung comes first, with 25 per cent. ; then joints, 10 per cent. ; afterward bones, 10 per cent. ; lymphatic glands, 10 per cent. ; peritoneum, 3 per cent. ; pleura, 2 per cent. ; the usual history being in such cases something as follows : A patient has passed through an ETIOLOGY OF BONE TUBERCULOSIS. 93 attack of pleuritis, during which he has, perhaps, expectorated blood; but after awhile apparent recovery follows, but the patient has lost a great deal of flesh and does not gain in weight ; at the same time the appetite is impaired. Fre- quently, more or less cough remains ; a slight trauma lights up an inflammation of a joint ; a tubercular abscess forms, which communicates with an osseous focus. In persons advanced in years, a primary synovial tuberculosis is likely to develop under such circumstances. At other times an osseous or joint tuberculosis is preceded by a tubercular affection of the genitourinary organs. A correct diagnosis in such cases can usually be made without much difficulty. In persons the sub- jects of a cheesy deposit in some organ of the body a metas- tatic affection of bones or joints frequently follows a slight injury. In Konig's cases such a connection between an old tuber- cular process and a trauma causing bone tuberculosis was always established. Even in persons apparently in good health the subsequent history revealed the existence of a tubercular affection of long standing, and he relates a number of interesting cases which substantiate this statement. After a trauma, how- ever, the tubercular lesion can originate in the same manner as in acute osteomyelitis, in which a depot in the body does not invariably exist. In such cases we must take it for granted that the bacilli which have entered the circulation through the respiratory or digestive organs have not localized until the locus minoris resistentice is created by the. trauma. The trauma only serves as an exciting cause in the production of bone tuberculosis in persons already infected with the essential cause. Clinically, tuberculosis of the bones can be traced only in a small percentage of the cases to a traumatic origin. It is, as Volkmann asserted long ago, characteristic that the, traumatism is always slight, often quite insignificant; tuberculosis of bone, even in tubercular subjects, seldom, if ever, follows a fracture, as the injury in such cases is productive of such active cell-proliferation that it will hold in abeyance the pathogenic action of the bacilli which 94 TUBERCULOSIS OF THE BONES AND JOINTS. might reach the seat of injury with the extravasated blood. It is also possible that, in many cases at least, the attention of the patient or his friends is first accidentally called to an existing tubercular focus by the immediate effects of the injury, the latter having had no influence in the causation of the disease. Every child large enough to run around injures himself more or less almost daily, and yet tuberculosis of bones and joints follows as a consequence only in comparatively few; and in such cases the essential cause must be present in the blood or tissues at the time the injury is received. To show the influence of trauma in exciting tubercular disease of bone, Cheyne (British Medical Journal, April 25, 1891) made a study of 293 cases which came under Sir Joseph Lister's and his own observation during the course of several years. In 188 of these cases no definite cause was assigned, while in 105, or 38.8 per cent, of the whole, the trouble was directly ascribed to the injury. In these cases the males were considerably in excess of the females, namely, 194 : 99, or 66 per cent. : 34 per cent. Of the 194 males there was no history of injury in 113, and of the 99 females there was none in 75, or a percentage proportion of uninjured males and females of 66 : 40. This leaves 81 males and 24 females with a history of injury, or a percentage propor- tion of 77 : 23. The facts are more striking if we contrast the cases commencing before and after 10 years of age, in males and females respectively, as shown in the following table : Percentage Proportion of ' First Decade. Later. Uninjured and injured males, . . 67.1:32.9 53.2:46.8 Uninjured and injured females, . 68.8:31.2 81.5:18.5 Total males to total females, . 60.8:39.2 69.6:30.4 Uninjured males and uninjured females, . 60.2:39.8 60.0 : 40.0 Injured males to injured females, . 62.1 : 37.9 85.3:14.7 Uninjured males during the two periods, . . . . 41.6:584 Uninjured females during the two periods, 40.3:59.7 Injured males, . . 28.4 : 71.6 Injured females, 58.4:41.6 Before 10 years of age the liability in males and females is about the same, showing that the injuries to which males are ETIOLOGY OF BONE TUBERCULOSIS. 95 more subjected alter this time of life play an important part in the causation of tubercular affections of bone and joints, as after 60 years of age the proportion in both sexes is again about the same. The cases following an injury, as a rule, are of a graver form. Thus, of 301 cases of tubercular disease of joints collected by Cheyne, the bone was primarily affected in 94, or 31.2 per cent. ; of 193 uninjured cases, the bone was the primary seat of the disease in 41, or 37.9 per cent. Chronic inflammation is a local predisposing cause to tubercular inflammation. Suppu- ration aids in spreading the disease, which is best shown by the difference in the behavior of tubercular joints incised with and without antiseptic precautions. Tubercular meningitis more frequently develops in connection with septic than aseptic tuber- cular lesions. In reference to age as a predisposing factor, Cheyne gives the following table : 1-5 6-10 11-15 16-20 21-25 26-50 31-35 36-40 41-45 46-50 Above 50. Total .... 23.2 16.0 14.6 15.0 8.5 8.8 4.0 3.0 2.0 2.0 2.0 Males. . . . 11.3 9.5 9.5 9. -5 6.3 5.3 4.0 2.4 2.0 1.8 1.0 Females . . 8.8 6.5 ,0 5.8 2.0 3.3 0.8 0.4 1.0 It is also interesting to note that age predisposes to the localization^ of the tubercular process in certain joints. Cheyne gives the following table to illustrate that part of the etiology of tuberculosis of bones and joints : t,' g . QJ 3 B W