TUBERCULOSIS OF THE JOINTS. 185 



of the knee-joint, partial dislocation of the tibia backward. lu the 

 other variety, the fungous granulations are less marked, but a 

 copious effusion into the knee-joint takes place, which simulates a 

 catarrhal synovitis until time and the effect of treatment enable 

 the surgeon to make a correct differential diagnosis. In this form 

 Konig assures us that he has never observed a tendency to flexion, 

 or any other form of displacement of the joint surfaces. If sup- 

 puration takes place, which is not very often the case, it begins in 

 the granulations which cover the synovial membrane, and the pus 

 accumulates in the cavity of the joint until perforation of the cap- 

 sule takes place. During the suppurative process, the superficial 

 granulations are destroyed, and the tubercular infection penetrates 

 deeper, and as, during the destructive process, bloodvessels are 

 destroyed the patient is exposed to the additional risks of general 

 infection. If such a joint opens spontaneously, or is not incised 

 under the strictest antiseptic precautions, the additional infection 

 from without leads to the most serious consequences, as under these 

 circumstances the pus-microbes are brought in contact with a surface 

 which has been admirably prepared for suppurative and septic 

 processes by the antecedent pathological changes. 



Tuberculosis of a joint may terminate in a spontaneous cure in 

 cases in which the intensity of the infection is slight, or the resist- 

 ance on the part of the patient is so great that the fungous granu- 

 lations do not undergo degenerative changes, but are converted into 

 connective tissue. A partial or complete synechia of the joint is 

 often one of the unavoidable results in such cases. This endeavor 

 on the part of the organism to limit extension of the disease is 

 often observed in cases in which the joint affection occurs in con- 

 nection with osteal tuberculosis. As soon as the joint is perforated 

 a wall of granulation tissue is thrown out around the seat of infec- 

 tion, and under favorable circumstances a partition of cicatricial 

 tissue is formed, which isolates the infected from the intact portion 

 of the joint. In such instances we have an illustration how the 

 tubercular process is retarded, and sometimes permanently arrested 

 by the transformation of granulation into connective tissue. For 

 such a favorable termination to take place it is necessary that the 

 tubercular virus should become attenuated by age, or want of a 

 proper nutrient medium, or that the pathogenic effect of the bacilli 

 should be neutralized by an adequate resistance on the part of the 

 tissues before degenerative changes have occurred in the granulation 

 tissue. An exceedingly practical observation has been recently 

 made by a number of surgeons in reference to the influence of 

 operative interference in tuberculous joints in the dissemination of 

 the disease. Kouig observed in his own practice sixteen cases of 

 miliary tuberculosis following shortly after resection of tuberculous 



