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The striking fact in this table is the frequency of severe deformity after excision of the knee,
and remembering, that all these children have still years of growth left, it will be seen that the deformity,
particularly the shortening, is certain to increase. In 9 of the 34 cases re-excision has already been
carried out, and will be required in many of the others. A German surgeon (Hofmeister) pointed out
some years ago that excision of the knee was not a justifiable operation before the age of nine, owing
to the great liability to subsequent deformity. English surgeons do not yet seem to have realised this.
No fewer than 25 of the excisions were done before this age and some were done as early as the fourth
year. Associated tuberculous disease was present in 8 cases, including 3 in the spine and 5 in the elbow.
(4) Tuberculous Disease of other Bones and Joints.—These cases were
distributed as follows :—
Ankle 13 (5 cases amputated)
Tarsus and metatarsus 4
Elbow 7
Shoulder 1
Wrist and forearm 2
Head of tibia1
Upper end of femur1
Sternum 1
The numbers are too small to justify deductions. In 11 cases the disease was present in more
than one region.
General Remarks on the Results of Tuberculous Bone Disease.—
These 500 cases emphasise the proportion left with serious deformity. Their treatment should
strive to (i.) cure the disease, (ii.) prevent deformity. Economically, failure in the second of these
objects is more serious to the community than a high death rate from the disease, tending to leave
a number of cured, but crippled, individuals handicapped by deformity in their struggle for livelihood,
and having to be supported by other members of the community. It might be objected that only
the worst cases, surgical failures, are collected in the physically defective centres, but this is not so.
Last year, it was shewn that only 16 cases of tuberculous bone or joint disease had been noted in
14,098 children in the ordinary schools in Islington; disease of the spine, hip, or knee only occurring
in 11 of them. Mr. Rowntree noted, too, that the disease was not active, but that the resulting
deformities were very marked. Most of the children are treated as patients at the large general
hospitals. There are Teasons, press of work, numbers waiting for admission, necessity for shewing
results apparently economical in short stay of patients, which indirectly lead to the treatment of these
cases being made as brief as possible, and often it is practically confined to taking them in when an
abscess has to be opened, and sending them home when the wound is healed, or even earlier. At
other times they are treated as out-patients, in some form of splint, or in plaster, and are seen at
irregular intervals depending to a great extent on the pecuniary circumstances of their parents. The
very bad results, following excision of joints such as the hip and knee, are almost to be regarded as
due to hospital exigencies. The advantages of such operations are that they effect rapid cure by
clearing out the disease, and shorten the necessary stay in hospital. The corresponding disadvantages
to the child are so great that it is doubtful whether these operations should be done on children of
school age. The usual hospital method of treating such cases can never be efficient. A prolonged
period of rest to the diseased part, procured by absolute fixation in splints, and necessitating recumbency
in most cases, is required for periods of months and even years. The best place for such children
is the country recovery school, which has been often referred to before. The few special hospitals,
which treat hip disease in this manner, shew very much better ultimate results than can be found
among the patients of the large general hospitals.