TUBEKCULOSIS OF THE BONES. 183 



bone. The most unfavorable conditions are created in cases in 

 which the tubercular focus becomes the seat of a secondary infec- 

 tion with pyogenic microbes, as the suppurative process opens up to 

 the bacillus of tuberculosis new areas for infection in which the 

 resistance of the tissues to tubercular infection has already been 

 greatly diminished. It is also during the suppurative stage that 

 joint complications are most likely to arise. The clinical history 

 of cases of tuberculosis of bone, as well as the macroscopical and 

 microscopical appearances of the lesion, are typical of tuberculosis 

 as found in other organs. The crucial test which proves the tuber- 

 cular character of most of the chronic inflammatory affections of 

 bone in children has been furnished by bacteriological investiga- 

 tions. Most of the investigators who have studied the subject 

 agree that in tubercular bone affections it is sometimes very diffi- 

 cult to find the bacillus, that it is not found in great abundance, 

 and that sometimes it has evaded even the most careful search. 



Schuchardt and Krause (" Ueber das Vorkommen der Tuberkel- 

 bacillen bei fungosen und scrophulosen Entziindungen," Fortschritte 

 der Meditin, B. i. No. 2, p. 277) examined a great variety of tuber- 

 cular lesions and came to the conclusion that tubercle bacilli are 

 present without exception, but, as a rule, few in number, and only 

 to be found after long and patient search. They found them 

 invariably present in cases of secondary and primary tuberculosis 

 of synovial membranes, tuberculosis of bone, in tubercular abscesses, 

 and in the latter cases not in the pus, but in the granulations of the 

 abscess- wall. 



Renken (Jahrbuchf. Kinderheilkunde, B. xxv.) found the bacillus 

 of tuberculosis in all cases of spina ventosa which he examined. 



Miiller (" Ueber den Befund von Tuberkel-bacillen bei fungosen 

 Knochen und Gelenk affection en," Centralblatt /. Chirurgie, 1884, 

 No. 3) studied carefully numerous specimens of synovial and bone 

 tuberculosis with special reference to the existence of the bacillus 

 of tuberculosis, and although the results in a number of cases were 

 negative, he believes that the most intimate and direct etiological 

 relations exist between the bacillus and all tubercular lesions ir 

 bones and joints. Among others who have shown the never-failing 

 presence of the bacillus of tuberculosis in different forms of surgi- 

 cal tuberculosis, including bones and joints, may be mentioned 

 Kanzler ( u Ueber das Vorkommen des Tuberkel -bacillus in scro- 

 phulosen Localerkrankungen," Berl. klin. Woehenschrift, 1884, pp. 

 23-41), Mogling (Ueber chirurgische Tuberculosen, Dissertation, 

 Tubingen, 1884), Bouilly (" Note sur la presence des bacilles dans 

 les lesions chirurgicales tuberculeuses," Revue de Ghirurgie, 1883, 

 No. 11), and Letulle (G-az. hebd. de Med. et Chir., 1884, 49, 51, 

 52). Kanzler wished to make a distinction between scrofulous 



