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The pathological diagnosis of bone and joint tuberculosis
December, 1926J
DIAGNOSIS OF BONE AND JOINT TUBERCULOSIS
TUBERCLE. DEOEMBER, 1926.
The Pathological Diagnosis of Bone and Joint Tuberculosis.
123
Little reliance is therefore placed by pathologists in general either on this reaction or on the tuberculin test. Mr.Dakden shows that pathological confirmation of bone and joint tuberculosis has thus to rest on the detection of the tubercle bacillus in the affected tissues. Cultural methods, owing to the sluggish growth of the organism. are cumbersome, and direct microscopy or animal inoculation is tberefore indicated. Unfortunately most authorities appear to look on the pus of a cold abscess as unlikely to yield tubercle bacilli, as a reference to many of the standard textbooks will show. Tubby and others, however, have shown that " actively growing tubercles contain bacilli in relatively large num bers, that tuberculous synovial membrane and granuiationa yield bacilli in a high degree of frequency and in greater profusion than the pus bathing them. and that in bone the detection of bacilli is prejudiced by the act ion of the decalcifying fluid which in a. few days appears to interfere with the staining property of the bacilli. On a priori grounds, therefore, pus which is derived from the coalescence of caseating tubercles would he expected to contain tubercle bacilli, though perhaps in a lower concentration." Mr. Oakden suggests that all tuberculous abscesses contain bacilli in grea.ter or smaller numbers, the chance of detecting tbem by means of the microscope or by animal inoculation depending rather on their concentration than on their capacity to take stain or on their virulence. He describes certain measures designed to increase this concentration.
MOST physicians would agree that the diagnosis of pulmonary tuberculosis rests primarily on the presence of tubercle ba.cilli in the sputum, and that in their absence the diagnosis can rarely be said to be proved. The diaenoeis of bone and joint tuberculosis, on the other hand, rests mainly upon clinical and X-ray evidence, largely owing to a widespread belief that pathological confirmation can comparatively rarely be obtained . In a particularly interesting paper, published in the M.A.B. Annual Report for 1925-26, Me. W. M. Oakden, F.R.C.S., Medical Superintendent, St . Luke's llospital, Lowestoft, discusses the whole question of pathological diagn?sis in so-called .. surgical" tuberculosis, He begins by recalling that of all patbological diag~ostic. tests t~e m?st conclusive IS the isolation and identification of the causative organism, either by direct microscopy, by cultural characteristics, or by animal inoculation. Of equal value and of simpler performance in certain diseases are the indirect tests, of which the complementfixation and agglutination reaction are the best known. In tuberculosis in general, and especially in bone and joint tuberculosis, which is probably never primary, indirect tests are equivocal, possessing the iu~erent defect tha~ the When an abscess of large size is aspirated in condition responsible for a positive the case of a patient that has been kept ~n the reaction may be derived not from the recumbent position for some time, It IS fresuspected area of disease but from some quently noted that the first portion of pus withdrawn is of the clear serous type, whereas occult focus in another part of the body. the later portions are thick and creamy in The prevalence of unrecognised quies- consistence. The latter will consist of pus cent tuberculosis in the lungs or deeply- that has been lying in contact with, and has situated glands in otherwise healthy drained away from , the shaggy lining memand it will also contain bacilli and cells adults detracts from the value of the brane, that have sedimented to the most dependent complement-fixation test, and attempts part of the abacess, to refine the reaction by carrying iG out On the assumption that this final portion of in a quantitative manner so as to pus is the most heavily infected, and tberefore the most suitable for examination. the routine differentiate between such quiescent procedure in taking samples has been varied foci and a suspected active clinical in the last eight months in this hospital. The lesion have hitherto proved inadequate. result bas been an increase in the positive
124
TUBERCLE
microscopic findings from 7'9 to 44'9 per cent., with an increase in the total positives (com ' bined microscopic and inoculation) from 50'9 to 81'6 per cent. Not only so, the time spent on the microscope search has been markedly curtailed.
Tables are given from which it appears that in the earlier series nearly 50 per cent. of cases were completely negative, although some of these were undoubtedly tuberculous in nature. Conclusions drawn frQm these figures would support the general textbook Im pression as to the frequent abs olute sterility of tuberculous pus. H is suggested that the true explanation is that the concentration of organisms in the actual portion of pus examined was too low for detection. even by guinea-pig inoculation. The much lower percentage of complete negatives in the later series appears to confirm this. Of the six cases included in this category, two were definite Pott's disease , in which a single aspiration sufficed for the cure of the abscess, so that a second examination was not possible. One was a case of Iong-standing hip disease with a recurrent abscess which also required only one aspiration; the fourth was a case of polyarthritis of non-buberculous type; the fifth a re sidual lumbar abscess Infected with staphylococci arising from .. piece of retained shrapnel; while the sixth was from a.
[December, 1926
ca se of necrosis of the malar bone, proba.bly non -tuberculous. Thus for the purpose under discussion the last three cases might justifiably be ~x.cluded, in . which case the percentage of positive cases nses to 92 '3. As a further proof of the varying concentra_ tion of organisms in the first and last portions of pGS aspirated, comparative smears were made in a sm all serres of cases of ab scesses of large size; and the superiority of the fina.l portion was manifest. Whereas the first smea.r frequently contained bacilli in only two Or three fields out of 200 examined, the second smear yielded bacilli in ten , twenty or more fields ; and occa sionally in nearl y every field examined,
In order still further to concentratethe organisms by laboratory methods the antiformin method has been tried with very hopeful results, details of which will be published when more complete statistics are available. Mr. Oakden would seem, however already to have justified his conclusio~ that the reliability of the com bined microscopic and inoculation test in bone and joint tuberculosis should be in the neighbourhood of 90 per cent. or even higher.
BOOK NOTICES AND ABSTRACTS.
Book Notices. The Registrar General's Statistical Review, 1925. Part I. Medical. rr.xr, Stationery Office.
Pp. 520.
Price 15s.
Tbe salient features of this report are summarised as follows :The birth-rats, which since 1920 has sbown a continuous decline, was 18'3 per 1,000 persons living in the year 1925. This rate was 0'5 per 1,000 below that of 1924 and, excepting the war years 1917 and 1918, was the lowest recorded since the establishment of civil registration. The deathrate was 12'2 per 1-,000 and was equal to that recorded in: the previous year, but was 0·6 per 1,000 above the rate of 1923, which was the lowest on record. The infantile mortality rate was 75 per 1,000. births and also equalled that of
1924, but was 6 per 1.000 above the lowest rate recorded in 1923. The death-rate from tuberculosis showed a further decline and was the lowest yet recorded, while the mortality from cancer was the highest on record The mortality from influenza. showed a substantial decline compared with the previous year, while that from encepha., litis lethargica was slightly below the high rate of 1924. The death-rates from measles. scarlet fever, whooping cough and diphtheria were all, p.bove those of 1924. The mortality fro III ," enteric fever was the lowest on record and for the first time the mortality of the two sexes was equal. Trudeau Sanatorium. Forty-first An. nual Report. 1926. This report is a document of great
DIAGNOSIS OF BONE AND JOINT TUBERCULOSIS
TUBERCLE. DEOEMBER, 1926.
The Pathological Diagnosis of Bone and Joint Tuberculosis.
123
Little reliance is therefore placed by pathologists in general either on this reaction or on the tuberculin test. Mr.Dakden shows that pathological confirmation of bone and joint tuberculosis has thus to rest on the detection of the tubercle bacillus in the affected tissues. Cultural methods, owing to the sluggish growth of the organism. are cumbersome, and direct microscopy or animal inoculation is tberefore indicated. Unfortunately most authorities appear to look on the pus of a cold abscess as unlikely to yield tubercle bacilli, as a reference to many of the standard textbooks will show. Tubby and others, however, have shown that " actively growing tubercles contain bacilli in relatively large num bers, that tuberculous synovial membrane and granuiationa yield bacilli in a high degree of frequency and in greater profusion than the pus bathing them. and that in bone the detection of bacilli is prejudiced by the act ion of the decalcifying fluid which in a. few days appears to interfere with the staining property of the bacilli. On a priori grounds, therefore, pus which is derived from the coalescence of caseating tubercles would he expected to contain tubercle bacilli, though perhaps in a lower concentration." Mr. Oakden suggests that all tuberculous abscesses contain bacilli in grea.ter or smaller numbers, the chance of detecting tbem by means of the microscope or by animal inoculation depending rather on their concentration than on their capacity to take stain or on their virulence. He describes certain measures designed to increase this concentration.
MOST physicians would agree that the diagnosis of pulmonary tuberculosis rests primarily on the presence of tubercle ba.cilli in the sputum, and that in their absence the diagnosis can rarely be said to be proved. The diaenoeis of bone and joint tuberculosis, on the other hand, rests mainly upon clinical and X-ray evidence, largely owing to a widespread belief that pathological confirmation can comparatively rarely be obtained . In a particularly interesting paper, published in the M.A.B. Annual Report for 1925-26, Me. W. M. Oakden, F.R.C.S., Medical Superintendent, St . Luke's llospital, Lowestoft, discusses the whole question of pathological diagn?sis in so-called .. surgical" tuberculosis, He begins by recalling that of all patbological diag~ostic. tests t~e m?st conclusive IS the isolation and identification of the causative organism, either by direct microscopy, by cultural characteristics, or by animal inoculation. Of equal value and of simpler performance in certain diseases are the indirect tests, of which the complementfixation and agglutination reaction are the best known. In tuberculosis in general, and especially in bone and joint tuberculosis, which is probably never primary, indirect tests are equivocal, possessing the iu~erent defect tha~ the When an abscess of large size is aspirated in condition responsible for a positive the case of a patient that has been kept ~n the reaction may be derived not from the recumbent position for some time, It IS fresuspected area of disease but from some quently noted that the first portion of pus withdrawn is of the clear serous type, whereas occult focus in another part of the body. the later portions are thick and creamy in The prevalence of unrecognised quies- consistence. The latter will consist of pus cent tuberculosis in the lungs or deeply- that has been lying in contact with, and has situated glands in otherwise healthy drained away from , the shaggy lining memand it will also contain bacilli and cells adults detracts from the value of the brane, that have sedimented to the most dependent complement-fixation test, and attempts part of the abacess, to refine the reaction by carrying iG out On the assumption that this final portion of in a quantitative manner so as to pus is the most heavily infected, and tberefore the most suitable for examination. the routine differentiate between such quiescent procedure in taking samples has been varied foci and a suspected active clinical in the last eight months in this hospital. The lesion have hitherto proved inadequate. result bas been an increase in the positive
124
TUBERCLE
microscopic findings from 7'9 to 44'9 per cent., with an increase in the total positives (com ' bined microscopic and inoculation) from 50'9 to 81'6 per cent. Not only so, the time spent on the microscope search has been markedly curtailed.
Tables are given from which it appears that in the earlier series nearly 50 per cent. of cases were completely negative, although some of these were undoubtedly tuberculous in nature. Conclusions drawn frQm these figures would support the general textbook Im pression as to the frequent abs olute sterility of tuberculous pus. H is suggested that the true explanation is that the concentration of organisms in the actual portion of pus examined was too low for detection. even by guinea-pig inoculation. The much lower percentage of complete negatives in the later series appears to confirm this. Of the six cases included in this category, two were definite Pott's disease , in which a single aspiration sufficed for the cure of the abscess, so that a second examination was not possible. One was a case of Iong-standing hip disease with a recurrent abscess which also required only one aspiration; the fourth was a case of polyarthritis of non-buberculous type; the fifth a re sidual lumbar abscess Infected with staphylococci arising from .. piece of retained shrapnel; while the sixth was from a.
[December, 1926
ca se of necrosis of the malar bone, proba.bly non -tuberculous. Thus for the purpose under discussion the last three cases might justifiably be ~x.cluded, in . which case the percentage of positive cases nses to 92 '3. As a further proof of the varying concentra_ tion of organisms in the first and last portions of pGS aspirated, comparative smears were made in a sm all serres of cases of ab scesses of large size; and the superiority of the fina.l portion was manifest. Whereas the first smea.r frequently contained bacilli in only two Or three fields out of 200 examined, the second smear yielded bacilli in ten , twenty or more fields ; and occa sionally in nearl y every field examined,
In order still further to concentratethe organisms by laboratory methods the antiformin method has been tried with very hopeful results, details of which will be published when more complete statistics are available. Mr. Oakden would seem, however already to have justified his conclusio~ that the reliability of the com bined microscopic and inoculation test in bone and joint tuberculosis should be in the neighbourhood of 90 per cent. or even higher.
BOOK NOTICES AND ABSTRACTS.
Book Notices. The Registrar General's Statistical Review, 1925. Part I. Medical. rr.xr, Stationery Office.
Pp. 520.
Price 15s.
Tbe salient features of this report are summarised as follows :The birth-rats, which since 1920 has sbown a continuous decline, was 18'3 per 1,000 persons living in the year 1925. This rate was 0'5 per 1,000 below that of 1924 and, excepting the war years 1917 and 1918, was the lowest recorded since the establishment of civil registration. The deathrate was 12'2 per 1-,000 and was equal to that recorded in: the previous year, but was 0·6 per 1,000 above the rate of 1923, which was the lowest on record. The infantile mortality rate was 75 per 1,000. births and also equalled that of
1924, but was 6 per 1.000 above the lowest rate recorded in 1923. The death-rate from tuberculosis showed a further decline and was the lowest yet recorded, while the mortality from cancer was the highest on record The mortality from influenza. showed a substantial decline compared with the previous year, while that from encepha., litis lethargica was slightly below the high rate of 1924. The death-rates from measles. scarlet fever, whooping cough and diphtheria were all, p.bove those of 1924. The mortality fro III ," enteric fever was the lowest on record and for the first time the mortality of the two sexes was equal. Trudeau Sanatorium. Forty-first An. nual Report. 1926. This report is a document of great