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widely practiced, in preference to excision, in cases of osseous ankylosis of the knee-joint.
With regard to the mortality from amputations above and below the knee, this has been decidedly reduced during the past few years, so that at present no surgeon expects, after amputation of the leg with antiseptic precautions, a greater mortality than three or four per cent.
DR. E. M. MOORE inquired whether the statistics regarding amputation were confined to cases of disease, or whether amputations for accidents, etc., were included.
DR. SMITH replied that the cases were those of chronic dis
DR. MOORE said he had understood that Dr. Smith referred to cases in which there was a deposit between the articular surfaces, with the formation of gelatinous tissue, rather than to bony ankylosis. He supposed that in these cases Dr. Gross would always excise the joint.
DR. GROSS replied in the affirmative.
DR. MOORE said that he had always felt a certain degree of timidity with regard to operations upon the thigh-bone, this feeling having perhaps arisen chiefly from his experience in cases of compound fracture. Last year, a case of the kind spoken of by Dr. Gross came to him for treatment, in which there was complete ankylosis. The knee was bent at fully a right angle, and any attempt at locomotion was extremely difficult and painful. Under these circumstances, he concluded to use an osteoclast, fashioned after that of Robin, of Lyons, France, which he saw at the International Medical Congress at Copenhagen. He succeeded in breaking the thigh just at the desired point, three inches above the knee, and union took place at the angle best adapted to locomotion. The result of the operation could not have been more gratifying. mentioned the case more particularly because MacEwen advocated another mode of treatment, dividing the bone partially with a chisel and then fracturing. He employed this method upon young persons principally, in whom the bony tissue is not so firm as in adults. The operation was performed for knock-knee, and the bone was divided two or three inches from the joint. In his paper read before the International Medical Congress, MacEwen reported about eight hundred cases of his own operations, and about two
hundred more, of operations performed by other surgeons. Out of the whole number, there occurred but five deaths. Robin reported two hundred cases in which he had fractured the thigh just above the knee with the osteoclast, and there had been but one death. The objection which MacEwen brought against Robin's method was that he could not be perfectly sure of the point where the fracture would occur.
THE RELATIONS BETWEEN TUBERCULOUS JOINTDISEASE AND GENERAL TUBERCULOSIS.
By FREDERIC S. DENNIS, M. D., of New York County.
MR. PRESIDENT AND GENTLEMEN: The past few years have been marked by important changes in our views regarding the traumatic origin of joint-disease. Recently, pathologists have proved that joint-disease, in the great majority of cases, is primarily due to tuberculosis, and that traumatism is either only a secondary factor in the causation, or, if it be ever the primary cause, the cases in which this occurs are very few. The experiments and observations which have been made in pathological laboratories upon the lower animals appear to accord with what surgeons have found clinically to be the case in studying joint-disease in man; and all these instances in which jointdisease is produced artificially have been found to have counterparts in the human body. This radical change of opinion in regard to the etiology of joint-disease has not yet been accepted by some surgeons, and the occasion of the meeting of the New York State Medical Association is an appropriate one on which to discuss such an important topic in surgical pathology. My object, in the present paper, is to present some microscopical and pathological specimens which show beyond peradventure the tuberculous origin of joint-disease, and at the same time to avail myself of these specimens to discuss the relation between tuberculous joint-disease and general tuberculosis.
The time allotted to me does not permit a discussion of
the clinical history, diagnosis, prognosis, and treatment of tuberculous joint-disease. A discussion of these topics, which are of paramount importance in connection with the questions which I shall consider, will be deferred for the present, and will form in the future a subject for another paper.
Before entering upon a discussion of the relation between tuberculous joint-disease and general tuberculosis, it is well to attach some definite and precise meaning to these terms. This preliminary step seems necessary, not only on account of the confusion which has been caused by the recent introduction of these terms into surgery and their indiscriminate use by surgical writers, but also because a clear understanding of the nomenclature is indispensable, at the outset, to an intelligent discussion of the subject.
By a tuberculous joint is meant a joint in the different tissues of which the bacilli tuberculosis of Koch are present, although it does not always follow that they can be found; and by general tuberculosis is meant acute miliary tuberculosis. The bacilli tuberculosis, which are the infective agents, are developed in a central focus, and the focus, in the majority of the cases, consists of a broken-down, caseous lymphatic gland. From this focus, dissemination of bacilli proceeds and causes acute miliary tuberculosis. Another term applied to caseous lymphatic glands is scrofula; and hence it is apparent that scrofula acts by furnishing a suitable soil in which the infective agents develop. It does not come within the province of this paper to discuss the relation of scrofula to tuberculosis; but it will suffice to state that pathological experiments and clinical observation prove without doubt that an intimate relation exists between these two affections. The best proof of this statement lies in the fact that the appearance of scrofula is usually associated with the presence of tuberculosis, and that when one condition is present the other is almost invariably found. Tuberculous joint-disease, however, can develop primarily without the presence of scrofula; or the joint-disease may be secondary, as when metastasis occurs from an organ in which infective agents are present. Thus, as metastasis may occur in the lungs from a caseous degeneration of
the bronchial glands, so a tuberculous peritonitis may arise from caseous retro-peritoneal glands. In a case recently reported in "La France médicale," a tuberculous osteitis was developed by metastasis from a tuberculous pleurisy which antedated the osteitis by a year.
A knee-joint may become primarily attacked by tuberculosis without any other focus. This condition has been seen in autopsies, although it is rare as compared with the number of cases in which the joint-disease is the result of a metastasis. It has been shown, in quite a number of cases, that a primary source of tuberculous osteitis, in the vicinity of the knee, for example, has been a focus situated in the cancellated tissue of the lower epiphysis of the femur, and that the caseous products of the central focus have discharged themselves in a direction away from the knee-joint, the patient thus narrowly escaping local joint-infection. This important clinical fact teaches a practical lesson of great value; viz., that surgical interference can avert and ward off a general tuberculosis, if the caseous abscess be trephined, thoroughly gouged out, and carefully scraped with a Volkmann's spoon. Iodoform packed into the abscess-cavity and sulcus destroys any of the remaining infective agents, and general dissemination is thus prevented. My own clinical experience has illustrated this in tuberculous osteitis, in several cases where this method has been employed. In a recent contribution, Professor Volkmann made an analysis of two hundred and fifty cases of excision of the hip for joint-disease, and could find in the entire number only five or six cases which were not tuberculous. Koenig relates a case where a resection of the knee was performed for tuberculous joint-disease. The wound was aseptic, and, two weeks after the resection, symptoms of acute miliary tuberculosis were well pronounced. The patient died, and the autopsy revealed the presence of miliary tubercles in nearly all the organs of the body. The same author reports another case in which, three weeks after resection of the hip, symptoms of general infection supervened, such as headache, projectile vomiting, facial paralysis, and coma. The patient died, and the autopsy showed the cause of death to be acute miliary