184 CLINICAL FORMS OF SURGICAL TUBERCULOSIS. 



affections and tuberculosis, as he found the bacilli not as constant 

 in the former, and observed that after implantation of tissue of 

 scrofulous affections in animals, the process was slower than after 

 inoculation with tubercular products. 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 in preference 

 the internal organs. The points made by the last two authors are 

 too unimportant in still maintaining a scientific, or even practical 

 distinction between scrofula and tuberculosis. The surgeon must 

 recognize every lesion as tubercular in its origin, nature, and course 

 in which the bacillus of tuberculosis can be constantly found, and 

 from which successful cultivations can be made, and with which 

 'the disease in animals can be produced by inoculation. 



7. Joints. 



Tuberculosis of joints is so closely related to the same disease in 

 bone, that it often follows the latter, and when it occurs as a pri- 

 mary lesion it not seldom extends to the subjacent bone. As 

 stated above, it occurs more frequently as a primary lesion in the 

 adult than in children. Primary infection is only possible through 

 a wound of a joint, as in the case referred to under the head of 

 inoculation-tuberculosis. Tubercular infection of an intact joint 

 presupposes the entrance of the bacillus of tuberculosis through 

 some infection-atrium into the systemic circulation, or, the diffu- 

 sion of bacilli through the same channel from some preexisting 

 tubercular focus, and the localization of floating bacilli in the 

 synovial membrane by capillary embolism, or mural implantation. 

 A single tubercular nodule on the surface of the synovial mem- 

 brane may lead in a comparatively short time to diffuse tubercu- 

 losis over the entire surface of the membrane by local diffusion of 

 the microbe, in which the movements of the joint play an impor- 

 tant part. When the synovial surface has become the seat of diffuse 

 tuberculosis, the tissues undergo the same pathological changes as 

 during the first stage of tuberculosis in other organs, and it is the 

 characteristic granulation tissue which has given to this form of 

 arthritis the name of fungous synovitis and synovitis hyperplastica 

 granulosa. During the early stages of the disease the surgeon meets 

 with two distinct classes; in one the tubercular infection produces 

 a pulpous condition of the entire synovial sac, with little or no effu- 

 sion into the joint, the swelling being due entirely to the presence of 

 a thick layer of granulation tissue, the true tumor albus of the older 

 writers. This form of tuberculosis gives rise at an early stage to 

 extensive deformity of the joint, flexion, rotation, and, in the case 



