generally close to the articular surface, though sometimes farther away from this dangerous area. Here the importance of the disease is due mainly to the tendency there is to perforate into the joint cavity and to produce a "diffuse synovial thickening." A small softened area, with a patch of caries of small extent, and a little perforation through the cartilage, almost like the hole seen in worm eaten wood, is generally the picture presented. At times these small foci are the starting point of chronic abscess in bone with its characteristic symptoms, and at other times the tubercular process advancing does so laterally, instead of vertically towards the joint adjacent, and so the latter escapes unless, as in the hip, the whole epiphysis is intra-capsular.

A very instructive case has recently been under my care at the General Hospital. A boy 10 years old was admitted with a cold abscess of some duration over the front of the knee joint, and in addition there was a diffuse thickening obliterating the natural outline of the joint. On investigation, at the bottom of the abscess a small sinus led into the patella in which was a caseous area with a little soft bone, not larger than the tip of the little finger in all From this tubercular patch a tiny perforation had taken place through the cartilage covering the patella into the knee joint, and the whole synovial membrane was vascular and thickened, creeping over the margins of the cartilages and typically tubercular. The focus in the patella had found its way in both directions, giving rise to the cold abscess externally, and to the synovitis internally. Arthrectomy was followed by complete aseptic healing.

It only now remains to say a few words about that condition which I have spoken of as Caries Necrotica with sclerosis of the sequestrum. This comparatively rare form I have seen most commonly in the os calcis, but it occurs also in the extremities of long bones where there is much cancellous tissue. Here sequestra form, varying in size, but often as large as a pigeon's egg and of unusual density, the bone before dying and separating from its attachments having undergone sclerosis. In the ends of the long bones these sequestra often being wedge-shaped it has been suggested that they are due to emboli in the vessels

supplying these areas, but this would not accord with the sclerosis found in the sequestrum and it is probable that the embolic theory is not correct.

It will be noticed that I have said nothing of the condition known as "Caries Sicca." I have intentionally avoided speaking of this as a distinct variety, because I regard it as a mere accident, due to conditions unfavourable to the progress of the tubercular disease. I believe it may follow either the diffuse osteo-myelitis or the circumscribed caseous focus in the ends of long bones. The formation of a tubercular or cold abscess may occur in all forms of tubercular bone disease, especially in the periosteal, but like the condition last mentioned it must be regarded as an accident of the disease, but one that adds to its gravity.

It is impossible within the limits of this note to go fully into the question of the treatment of tubercular bones and joints; only an outline is possible. In tubercular, as in other forms of joint disease, rest holds the first position with regard to treatment, and if a word is to be said on this question, it is that the rest should be much more complete than is often the case. It is not rare to see children in bed with hip joint disease allowed to squirm about into any position they choose to take, and to give considerable mobility to the diseased joint, being only subject to such restraint as is produced by a weight and pulley extension; whilst when they are up, the Thomas' splint with which they are provided is almost a farce as a protection to the juint, simply from want of proper supervision and adjustment. Of all the means at the disposal of the surgeon absolute rest is still the most valuable in the treatment of tubercular joint disease.

Of the operative proceedings, excision and arthrectomy, each has its special place. For instance, in the hip, excision is necessary if an attempt is made to eradicate the disease, a complete arthrectomy being impossible; whilst in the knee joint complete arthrectomy is not only possible, but is more efficient than excision as usually performed, because it effectually removes all the disease, whilst the bone ends being but little interfered with,

Instead of complete

the operation is one of less severity.
arthrectomy, there is much to be done by partial operations if
the disease is circumscribed, and it is in this direction that
advance is to be looked for at present.

When the disease is located in bone, looking to the disaster it brings if it extends to a joint, if it can be attacked without exposing the patient to undue risk, this should certainly be done. It is especially important in those bones which enter into the composition of superficial joints, such as the knee, wrist, elbow, and ankle. One constantly sees cases where uncontrollable joint mischief has arisen from a small bone lesion, which in the early days of its existence might easily have been removed.

Cold abscess may be associated either with bone or joint mischief, or with the two combined. There is never justification for interference with these abscesses if they are not extending, unless the modern operation can be carried out with precision, for not a few of these collections remain quiescent and disappear with rest in bed. If they are extending, and even if quiet but not disappearing, the case is different, if the proper treatment of erasion, flushing, iodoformisation, and complete closure can be carried out with certain asepticity. So performed, this operation gives most admirable results. If the abscess is allowed to burst or is opened carelessly, its walls are invaded by the ordinary pus cocci, and in the walls thus rendered septic the tubercular process spreads rapidly often the tubercular and septic processes involve the tendon sheaths round the joint or bone and, what is worse, the planes of fascia between and around the muscles. There is no tubercular condition more difficult to extirpate than this; and to fascial invasion by the double infection we owe most of the hopeless cases of joint and bone tubercle we meet with doomed to die, or to part with a limb, despite any effort made to eradicate the disease by operation. To the prevention of septicity supervening on tubercular processes we must look for improvement in results, more than to any other development of











THE following case presents some points of interest. patient, æt. 40, was admitted on May 8th, 1893. Last period seen on October 1st. The record of the previous pregnancies and of their terminations was a remarkable one, and ran as follows-1st pregnancy, craniotomy at term; 2nd, premature labour induced at seventh month, boy now living; 3rd, 4th, 5th and 6th, craniotomy at term; 7th, labour induced at eighth month, child now living, but deaf and dumb; 8th, labour induced, child born dead; 9th and 10th, girls delivered alive at term, with forceps; 11th, labour induced at seventh month, child still-born.

Out of eleven labours we thus find that four were terminated by the induction of labour, with two children living; five were terminated by craniotomy, and two by the application of forceps at term, the latter being both girls and born alive. This, I venture to think, must, fortunately, be almost a unique record. The induction of labour in each case had been performed at a Lying-in Hospital, two at Queen Charlotte's, and two at the York Road Hospital.

The patient was now in the 31st week of her twelfth preg nancy. She stated that as a child she was very delicate, not being able to walk till six years old, but after her sixteenth year she became stronger and had enjoyed good health since. She was somewhat stunted in growth, but presented no obvious sign of rickets, and all her organs appeared to be in sound condition. The uterus reached two inches above the umbilicus. Foetal

movements were clearly perceptible, and the foetal heart could be distinctly heard on the left of the median line.

The induction of premature labour was resolved on, and treatment was commenced on May 12th, a vaginal douche of hot water being given every four hours.

On May 13th the os, which previously would not admit the finger, now allowed the tip of the finger to enter, and the membranes could be felt. The douching however had not excited any pains. At II a.m. on this day a large-sized gum elastic bougie, previously rendered aseptic, was carefully guided by the finger into the os and gently pushed along the posterior uterine wall until it passed into the uterus to the extent of seven inches. A sharp gush of bright blood occurred on the introduction of the bougie, but this soon stopped and did not recur.

May 14th. Patient experienced slight labour pains, and the bougie was partly expelled, but was easily replaced.

May 15th.


Bougie came out at 6 a.m. and was not re

May 16th. Slight pains at intervals.

May 17th.

Os dilating a little.

and walk about the ward.

Patient allowed to get up

May 18th. Pains during the day gradually increasing in strength, and at 5-30 p.m. child born. Placenta shortly afterwards removed by hand. Slight post partum hæmorrhage, which was quickly checked by washing out uterus with hot water. The labour finished rather rapidly, as at 3 p.m. the os was not larger than a florin, and membranes had not ruptured.

The child, which was a male, lived 36 hours. The mother made an uneventful recovery, and left the hospital well on June 3rd.

Remarks on the case.--In a case such as this the history of the previous labours is a more valuable guide, in my opinion, to the amount of pelvic contraction and the best method of treatment than any results obtained from pelvimetry.

The true conjugate, as deduced from measurement of the diagonal conjugate by the hand (though this could not be very

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