Part 8

In the beginning even the examining physician finds no symptoms of disease in the joint. No swelling, no abnormal position, no restriction of the freedom of motion, no pain from pressure or while moving, in short nothing can be found that would otherwise indicate the beginning of an inflammation of the joints.

Yet lameness only is sufficient data from which we may infer the probable beginning of hip-joint inflammation. It is much better to overestimate the significance of this symptom than to miss the proper time for calling in the aid of a physician by placing too little confidence on it.

The second symptom, pain, rarely attends the beginning of lameness, generally it comes several weeks later and in the case of very slow development of tubercularly inflamed hip-joint several months later. In very small children the attendance of pain is manifested by the fact that they will not play and they often wake up in the night and begin to cry.

Children from the fourth and fifth year upward definitely point out the hip as the seat of pain, sometimes, however, the knee-joint on the diseased side is designated with great determination. This pain in the knee has often been the cause of mistakes.

Later on painfulness of the hip-joint is experienced from pressure and at about the same time the movements are impeded.

Then the leg takes a peculiar position. The thigh is slightly bent and rolls outward. For convenience the child drops the half of the pelvis corresponding to the diseased hip-joint, and naturally raises the other half. From this apparently a curvature of the spinal column results in the lumbar region. Apparently only, for when the child is laid down and the morbid position of the thigh is restored the curvature of the lumbar column disappears.

During the further progress of the disease the pain is increased, and the sensibility may become so acute that the slightest movement of the limb, even a shaking of the bed in which the patient lies will cause the most intense pain. In the previous stage walking could only be done for short distances and then awkwardly, now it is entirely impossible. Children are obliged to lie in bed night and day, and under these altered conditions there is a change of the position of the extremity. The increased sensibility induces the child to seek the medium position, the leg is bent more than in the position mentioned above, it is halfway straightened.

To this is added, that the child can not lie well on the sensitive and swollen hip; with right side hip-joint inflammation it turns on the left. As the diseased and bent thigh does not then rest on the mattress the same is placed on the healthy limb for support and for protection from movements, in the same manner as we lay one leg on the other in a healthy condition when we sleep on our side.

The actual danger to life in tuberculous hip-joint inflammation begins with the time when the child takes to his bed. The fatal end comes almost without exception after suppuration has commenced, very rarely before that time. Total suppuration of the hip-joint is an almost absolutely fatal process. If this suppuration sets in suddenly, it may result in an early death with attendance of acute fever. In other cases several weeks may elapse from beginning suppuration till death.

A complete cure of tuberculous hip-joint inflammation may come about spontaneously. But often the knee remains bent and unserviceable for walking, so that crutches or machines must be used.

Even before this the beginning stages were treated with fair prospects of success, and it is a lamentable fact that in many cases the import of these seemingly trivial symptoms has been underestimated.

Rest is of the greatest importance during the very first stages of the disease in which the attending symptoms are of so indefinite a character that it is almost impossible to know whether hip-joint inflammation will develop or not; the child must not be allowed to walk. Aside from this the application of brine-, malt- and sea-water baths is advised. An abundance of nourishing food is of just as great importance. All this will also retain its significance in the future.

Formerly recourse to surgery has been taken during the later stages of the disease in which suppuration of the internal parts of the joint has commenced and large parts of the diseased bones may have become mortified. An incision is made into the joint, the same is exposed and all diseased portions are carefully removed. In the future this operation must probably also be performed, although with the difference that the prospects of success are now much more certain than formerly when relapses only too often followed the operation.

Tuberculous inflammation of the knee-joint is, as said before, very frequent with children and is rather lingering in the beginning. Here also a slight dragging or limping of the diseased leg can be noticed. The child when asked about the limping, or of its own accord, complains of pain in the joint after walking or when the part is pressed; at first nothing abnormal can be seen on the knee by the layman.

On closer examination, however, by comparing the two knees it will be found that the grooves on each side of the patella, which give the healthy knee-joint the beautifully modeled shape, have nearly or quite disappeared; nothing more can be noticed.

The hinderance in motion may be so insignificant, that the children may slightly limp about for weeks and months and complain but little. Generally the physician is not called until the limb begins to hurt and swell after continued exertion.

The swelling which in the beginning is hardly noticeable is now more plainly visible, the knee-joint is evenly rounded and quite sensitive to pressure.

If the disease is not now properly treated, its further course will be as follows: the patient may perhaps linger for several months; then comes a period when he must keep to his bed uninterruptedly because moving results in too much pain; generally the limb becomes more and more bent.

Now particularly painful points appear on the joint, especially on the inner or outer side or in the bend of the knee; on one of these points a soft portion distinctly developes, the skin becomes reddened and finally suppurates from the internal parts outward and breaks after a few months; thin purulent matter mixed with flakes is discharged. The pains now cease, and the condition is improved; but this improvement does not last; soon another abscess is formed and thus it continues.

Meanwhile perhaps two or three years may have elapsed; the general condition becomes greatly reduced. The child, formerly strong and healthy, has now become lean, the discharges of matter have often been attended by acute febrile attacks; the patient becomes exhausted, loses his appetite and digestion becomes more impaired from week to week. Even now a spontaneous change for the better is possible, though this happens very rarely; more frequently the disease progresses and leads to death from exhaustion resulting from severe suppuration and continual attacks of fever.

Restoration to health is indicated by decreased suppurative discharges; the openings of the fistulae contract, the general condition is improved, the appetite is restored, etc. Finally the fistulae heal, the joint becomes fixed at an angle or bent or otherwise crippled, but painfulness disappears and the patient escapes with his life and a stiff leg. This is the most favorable result known to have been obtained in severe cases. The joint may become a solid bony immovable mass or may admit of slight movements. The whole process may last from two to four years.

The former treatment of tuberculous inflammation of the knee-joint was either of a general or a local nature. The general treatment was designed to strengthen and nourish, and will continue to be applied in the future.

The local treatment consisted in the application of salves, brushing with tincture of iodine, spanish fly plasters, wet and dry bandages. As with inflamed hip-joint absolute rest by lying in bed is of the greatest importance.

If after a certain period of rest and application of the above-named remedies no improvement in the state of health could be noticed, the diseased joint was laid in plaster or confined with splints.

If even then, after such treatment for months, no improvement could be noticed but rather that the general state of health was reduced, nothing remained to be done excepting an operation, by which all the diseased parts of the knee-joint were removed, or amputation, that is, the taking off of the diseased limb. The latter method was generally adopted in the case of feeble and emaciated individuals and those who had passed the age of early manhood, as with these the removal of the diseased parts did not, as a rule, result in an improvement of the general condition, which was especially intended.

Now tuberculous inflammation of the knee-joint will be treated by Koch's method and in extreme cases only will operation be necessary. At all rates, an absolute cure will be easily effected.

Aside from the hip- and knee-joint the spinal column is most frequently attacked by tuberculosis. Here also it is the youthful age, from the third year upward, that has to suffer most from this serious disease. Adults are rarely attacked by it and with them it generally appears in connection with general tuberculosis.

The tubercle-bacilli penetrate into the substance of the vertebrae, destroy the same and transform it into purulent matter. As a result the destroyed vertebrae sink or rather settle down and cause a curvature of the spine, in other words a humpback.