1. The follow-up reports of ninety-one joints affected by rheumatoid arthritis and treated by synovectomy showed that seventy-three joints remained free of pain. Forty-nine out of ninety-one joints retained useful function after a period averaging three and a half years. 2. The average duration of the disease before admission was eight and a half years. 3. The joints causing most distress were selected for operation. Better results might have been obtained if these patients had received constitutional treatment, splintage and synovectomy earlier. Many of these patients had advanced disease which was continuing to advance at the time of their admission, in spite of previous treatment. Many accepted a trial of treatment in a long stay hospital as a last hope. 4. The return of forty-eight out of sixty-two patients to unassisted or nearly unassisted activity and the maintenance of this state in thirty-nine out of fifty-four shows that the success of the pilot scheme conducted in cooperation with Dr W. S. Tegner and Dr R. M. Mason of the London Hospital has been confirmed by further experience.
The infrequency of serious cartilage destruction in the joints of children makes it probable that the majority will recover with antibiotic and constitutional treatment alone, especially if a joint biopsy is performed. Synovectomy for children should therefore be reserved for those whose knees remain swollen and warm, even after antibiotic therapy, or whose range of movement does not show signs of returning. Exploration of such joints may show that pannus is wholly or partly covering the cartilage and that it is soft and pitted. Removal of the pannus allows better nutrition of the cartilage. The number of children who require arthrodesis in the future should be very small. Adults who respond well to antibiotic and constitutional treatment may also recover without surgery, except biopsy, but for patients with more severe disease the need for an alternative to arthrodesis exists. The choice between synovectomy–better called joint clearance –can often only be made after the joint has been opened. The choice between the two operations has always been fully discussed with the patient before the operation. The results enumerated in this paper suggest that arthrodesis may only need to be performed for patients with severe disease, often involving the bony articular surfaces, and that joints may recover function even when there has been partial destruction of cartilage.
The records of these patients show that restitution of joint function is quite possible even after severe disease. These results have been obtained by a combination of three methods, constitutional, antibiotic and operative. The duration of treatment averaged ten months and the patients were discharged to full activities in a short time without splints. There was one immediate failure in a child who received full, early and adequate treatment. There were two late relapses in patients treated early in the series whose operation was inadequate. The results were more variable in adults. If it is conceded that the triple treatment is valuable for patients with bone necrosis or severe synovial disease with pus in the joint, eight patients in this series remain who might have got better without operation. Two of these had had a synovial biopsy before admission. Whether the remaining six would have done as well without operation is a matter for speculation. It is difficult to assess the condition inside the joint solely by radiographic examination. Cauchoix (1955) allows me to say that, at the Institut Calot, Berck Plage, he has used similar methods to those reported in this paper, and that he endorses my belief that good results can be obtained by them. He does not, however, open the joint when operating upon an iliac focus, and for patients with purely synovial disease he prefers repeated intra-articular injections of streptomycin to operation. For my part, I consider that a simple arthrotomy at the beginning of treatment is less disturbing, and that, even if it is only done for diagnosis, it may be of therapeutic benefit. To me it seems unjustifiable to delay intra-articular operation for a patient whose hip disease is not manifestly resolving: operation is especially indicated for patients who have necrotic bone lesions.
Streptomycin and iso-nicotinic acid hydrazide are two powerful drugs lethal to tubercle bacilli, when access to the infected tissues is free. For early disease, before ischaemia and necrosis become established, they are curative: afterwards they are not. In this paper the use of surgery to augment their action has been discussed. The development of such methods may well revolutionise the treatment of skeletal tuberculosis. Therein lies a danger because attempts to cure the patient by exterminating the tubercle bacilli in his lesion may lead to a precarious recovery: treatment directed against the bacilli may greatly facilitate a real cure if constitutional treatment is also applied to make the patient immune. Revolutionary though the change may become, it will not be so great as the revolution which occurred thirty years ago when open-air hospitals were first provided for patients with skeletal tuberculosis. The first patient ever seen on a surgical ward by the author, when he was a student, suffices still as an example. A child with tuberculosis of the cervical spine was admitted from out-patients with multiple discharging sinuses from the neck which was supported in a sodden plaster jacket. "Whoever," said the house surgeon dramatically, "removes that plaster, will kill that child." Most unfortunately his words were true. Many other such patients could, in those days, be seen in the wards of city hospitals. It was largely due to the work of Sir Robert Jones, friend of children, that the value of constitutional treatment became recognised. With the combination of the old knowledge and the development of the new, a new chapter in the treatment of skeletal tuberculosis has opened and rapid restoration of function and permanent cure can now take the place of long and sometimes crippling illness.
1. Experience in the treatment of tuberculous disease of the spine, hip and knee by combined constitutional, antibiotic and operative measures is described. 2. In patients with tuberculosis of the spine, especially in the thoracic region and when perispinal abscess formation is a prominent feature, the treatment helps to ensure stable ankylosis in the type of case in which it otherwise might not occur. 3. In children with tuberculosis of the hip and in adults and children with tuberculosis of the knee it is usually possible to save the joint and to restore function, provided the joint has not been destroyed before treatment is begun.
The case histories of these Black Notley patients show that no serious harmful effects have been caused by pregnancies going to full term. Most of the patients had normal confinements; Caesarian sections were few and were usually done for obstetric reasons, not for fear of reactivation of the disease. This experience bears out a remark made to me by Marcel Galland. When asked if Caesarian sections were required for women who became pregnant after treatment at Berck for skeletal tuberculosis, he replied: Two patients in the series had artificial abortions, and one aborted spontaneously. Two of these three patients did not do as well as other patients whose pregnancies went to full term. Quite another question is whether the onset of skeletal tuberculosis sooii after pregnancy may be attributed to the pregnancy. In a group of women of child-bearing age, it would be difficult to distinguish between Further, it may be argued that pregnancy increases resistance to tuberculosis. Such a belief was current from the time of Hippocrates until the middle of the nineteenth century, and clinical evidence can be quoted in favour of such a view. In America, Lyman (1943) followed up 1,818 women who had been treated for tuberculosis in a sanatorium; many had married despite medical advice to the contrary. Lyman found that the late results of treatment were four times as good in the married patients as in the single women. Lyman says, "When we consider that the married group established this record in spite of the fact that 192 out of 315 gave histories of pregnancies (averaging 2·25 children each), it is clear that some factor not yet accounted for has exerted a profound influence in their cases." I have speculated elsewhere as to what this factor may be (Wilkinson 1949). But it seems clear that increased sterol circulation in the body is associated with increased reticulo-endothelial activity (Fraser 1935). Thus reticulo-endothelial proliferation has been observed in the lesions of lupus following the administration of calciferol (Dowling, Gauvain and Macrae 1948). An increase of blood cholesterol is found during pregnancy. The sex hormones are sterols and might be expected to be raised in the marital state; it is perhaps significant that marital contacts form a group relatively immune to tuberculosis. There would appear to be good grounds for reassuring the married woman who has suffered from skeletal tuberculosis regarding the prospect of normal pregnancy. Many letters received from patients in a follow-up of this sort are poignant documents. There is no doubt that the majority of these women desire children as ardently as normal women, and that a safe confinement following skeletal tuberculosis is an excellent form of rehabilitation.
