A STUDY OF THE BLOOD IN SEVENTY-THREE 
CASES OF BONE TUBERCULOSIS IN 
CHILDREN WITH REFERENCE 
TO PROGNOSIS AND 
TREATMENT. 
BY 
PHILIP KING BROWN, A. 8., M. D., 
SAN FRANCISCO, CAL. 
Reprinted from the Transactions of the Medical Society of the State of California, 
Session of 1897. A STUDY OF THE BLOOD IN SEVENTY THREE 
CASES OF BONE TUBERCULOSIS IN 
CHILDREN WITH REFERENCE 
TO PROGNOSIS AND 
TREATMENT. 
PHILIP KING BROWN, M. D,, San Francisco. 
[Read before the Medical Society of the State of California, April 22, 1897.] 
Why mesoblastic tissue in children is peculiarly susceptible 
to tuberculosis and the epithelial structures are correspond- 
ingly free I do not know, but the fact remains that glands 
and large bones are the usual seat of the tuberculous proc- 
esses in children in contra-distinction to the commoner loca- 
tion in the lungs of adults. It is quite the rule to find enlarged 
cervical glands as the sole tubercular lesion in a child, pointing 
to a direct passage of the bacillus tuberculosis from the mucous 
surface to the gland. This is more clearly shown in the cases 
of tuberculosis of the mesenteric glands without primary 
tubercular ulceration of the intestines, which is rather the 
rule in children, while the condition occurs rarely if ever in 
adults. Attention has been called also to the infection of the 
bronchial and tracheal glands without a sign of pulmonary 
tuberculosis. The location of tubercular processes in children 
points therefore to infection through the blood and lymphatic 
circulation by the organisms taken up from the gastrointesti- 
nal and respiratory tracts. It is not unreasonable to consider 
that there exists in the blood of children a condition which 
renders it less destructive to organisms than is the blood of 
adults, and to infer that the element of the blood destructive 
to organisms does not have its origin directly through the 
lymphatic system. What the different condition in children’s 
blood is, and how it may account for the greater susceptibility 
of children to contagious diseases in general, I shall point out 
in a later paper, confining myself now to the changes in the 
blood caused by tubercular processes in bone and their chief 
complication, septicaemia. Secondary infection of the wound is 
almost unavoidable where a case comes to operation, so that it 
is necftssary to consider that we have the changes of a mild 
septicaemia to deal with in considering the cases examined in. 
the period following an operation. The Blood in Bone Tuberculosis. 
1 Case No. 
w 
n> 
M 
Age. 
Duration. 
Family History. 
location and Extent. 
Treatment. 
Date of Count. 
Haemoglobin 
Per cent. 
0 $ 
n> j-j* 
0 
Teucocytes. 
F. 
Negative. 
Tub. of R. hip, with large abscess 
Excision of hip in ’96. Presisting 
Sept, 22, 1896 
68 
4,750,000 
12,760 
opened several times. 
sinus, Sept., ’96. 
March 15, 1897 
87 
4,680,000 
9,375 
F. 
Father died phthi- 
Tub. of R. head of ulna with abscess 
Excision, etc., ’95. Sinus nearly 
Sept. 22, 1896 
55 
3,960,000 
12,500 
sis. 
healed April 1, ’97. 
April 1, 1897 
7b 
4,760,000 
5,94° 
F. 
6% 
Negative. 
Tub. of I,, hip, with abscess. 
Excision head of femur 1 yr. ago. 
Sept. 22, 1896 
50 
3,720,000 
14,15° 
Sinus nearly healed. 
March 26, 1897 
98 
4,400,000 
7,500 
6 
F. 
Twin sister had 
Tub. of hip, with psoas abscess. 
Abscess opened and curetted in 
Sept. 2?, 1896 
40 
3,960,000 
26,850 
hip disease. 
’92. Traction, sinus. 
March 25, 1897 
47 
4,360,000 
14,060 
8 
F. 
12 
yrs. 
Negative. 
Tub. of hip; sinuses lungs involved 
Curettings and excisions. 
(Died) 
15 
2,800,000 
9.650 
F. 
8J| yrs. 
Negative. 
Tub. of hip, with abscess. 
Excision of head of femur 4 yrs. 
Sept., 1896 
87 
5,140,000 
13.300 
ago. Curettings. Sinus dis- 
March 3, 1897 
85 
5,140,000 
15,625 
charging. 
F. 
%y2 yrs. 
Negative. 
Tub. abscess outside hip joint in 
Incision and curetting Oct., ’96. 
Jan., 1897 
66 
4,600,000 
31,250 
sac iliac syn. 
Sinus presisting. 
March 26, 1897 
95 
5,920,000 
14.075 
F. 
xiy2 
4 yrs. 
Pat. grandmother, 
Tub. R. hip & T. wrist; abscess op- 
Curetting. Traction. 
Jan., 1897 
38 
4.133.6°° 
6,650 
uncles and aunts 
ened 4 yrs. ago; curetted Jan., ’96. 
March 26, 1897 
68 
5,680,000 
6,595 
died of phthisis. 
F. 
Tub. of heads both femurs, with ab- 
Abscess opened and bone excised 
Feb., 1897 
55 
4,900,000 
16,650 
scesses. ' 
1 yr. ago, before entering Ch. 
March 29, 1897 
55 
4,480,000 
15,625 
hosp. Sinuses. 
F. 
7 
2 yrs. 
Mat. grandmother 
Tub. disease of R. hip, with abscess 
Abscess opened 1 yr. ago. 
Jan., 1897 
75 
4,200,000 
6,650 
died of phthisis. 
in R. lumbar region. 
March 30, 1897 
100 
5,040,000 
12,500 
M. 
7 
yrs. 
Aunt had phthisis. 
Tub. disease of hip-joint, with ab- 
Traction. Abscess opened Feb. 
Feb. 4, 1897 
68 
5,260,000 
11,250 
scess above and behind joint. 
13. ’97- 
Feb. 13, 1897 
12,185 
HIP - JOINT TUBERCULOSIS, WITH ABSCESS. 
A.—Operative Interference. The Blood in Bone Tuberculosis. 
3 
24 
M. 
8 
3yrs. 
Negative. 
Tub. of T. hip, with abscesses which 
opened spont. i year ago. 
Curetting. Traction. Abscesses 
now healed. 
80 
4,800,000 
8,780 
3° 
F. 
gyrs. 
Negative. 
Tub. of T. hip. 
Fxcision Dec.,’89. Curettingjan., 
’97. Healed March, ’97. 
March 3, 1897 
68 
4,480,000 
12,500 
33 
M. 
14 
3 yrs. 
Negative. 
Tub. of F. hip and elbow; multiple 
abscess. 
Amputation at thigh. 
Feb. 28, 1897 
54 
3,435,000 
11,850 
34 
M. 
9 
6 yrs. 
Negative. 
Tub- of R. hip-joint, with abscess. 
Fxcision and curetting ’92. Many 
curettings since. Wound healed 
March, ’97. 
Feb., 1897 
78 
4,125,000 
10,330 
36 
M. 
3 Y 
2 yrs. 
Negative. 
Tub. of. F. hip, with abscess in in- 
guinal region. 
Traction, etc. Abscess opened 
Dec., ’96. 
March 4, 1897 
April 6, 1897 
57 
68 
4,132,800 
4,500,000 
29-564 
19-365 
37 
M. 
73/i 
2 yrs. 
Negative. 
Tub. of hip, with abscess in joint. 
Fxcision May, ’96. Sinus pre- 
sists. 
March 6, 1897 
April 10, 1897 
58 
68 
5,328,000 
5,400,000 
12,185 
13,000 
38 
M. 
8 
6 yrs. 
Negative. 
Tub. of F. hip, with abscess which 
opened spont. 4 yrs. ago 
Discharging from 3 sinuses. 
March 6, 1897 
April 25, 1897 
48 
37 
5.120.000 
4.120.000 
0 0 
0 0 
0 
to to 
4i 
F. 
8 
i yr. 
Mat. gr. gr. mother 
died of phthisis. 
Tub. disease of joint, with abscess 
opened 4 mos. before. 
Head of bone excised March 14, 
’77. Sinuses, etc., curetted. 
Fxcision and curetting in ’95. Nu- 
merous curettings since; last on 
March 14, ’97. 
March 10, 1897 
54 
5,000,000 
10,937 
42 
M. 
7 
21/ yrs. 
Negative. 
Tub. of head of femur and acetab. 
abscess penetr’ingto pelvic cavity 
March 10, 1897 
68 
4,560,000 
9.357 
44 
F. 
7 
yrs. 
Maternal uncle had 
phthisis. 
Tub. of hip, with abscess. 
Fxsection in ’95, and abscess op- 
ened. Discharged in Jan., 97. 
Sinuses nearly healed. 
March xi, 1897 
(sinus not quite 
healed) 
85 
4,600,000 
9,062 
45 
F. 
21 
6 yrs. 
Negative. 
Tub of F. hip. 
Traction 3 mos.; 3 curettings in 
next 4 yrs. Fxcision of head of 
bone Feb., ’96. 
March 11, 1897 
(sinus nearly 
healed) 
92 
5,640,000 
9,062 
46 
F. 
15 
8 yrs. 
Negative. 
Fxtensive abscess of hip-joint; lum- 
bar abscess opened Aug., ’95. 
Fxcision Feb., ’95. Curetting 
Feb., ’96. 
March 11, 1897 
96 
4,440,000 
9,680 
54 
M. 
3% 
iVz yrs. 
N egative. 
Tub. of hip, 2nd stage, with abscess 
Opened Dec., ’96. Wound healed 
March 31, ’97. 
March 22, 1897 
67 
5,840,000 
8,595 
55 
M. 
yrs. 
Tub. of both hip-joints, with double 
psoas abscess. 
Double exsection. Sinus presist- 
ing-. 
March 24, 1897 
76 
5,600,000 
10,000 
57 
M. 
15 
6 yrs. 
Negative. 
Tub. of head of femur, with abscess 
which opened spont. 6 yrs. ago. 
Fxcision in Oct., ’92. Sinus pre- 
sisting. 
April 1, 1897 
(2 hrs. p. c.) 
81 
4,800,000 
10,250 4 
The Blood in Bone Tuberculosis. 
1 Case No. 
05 
H) 
M 
Oq 
n> 
Duration. 
Family History. 
Location and Fxtent. 
Treatment. 
Date of Count. 
|tIsemoglobin 
Per cent. 
ft 
9 
n> 
c 
0 
0 
0 
s 
II 
F. 
6 
3yrs. 
Negative. 
Tub. head of femur I,, abscess all 
around joint, increasing in size 
(Feb. 3.) Mar. 16, stationary since. 
Traction. 
Feb. 1, 1897 
March 29, 1897 
72 
85 
5.168.000 
4.640.000 
14,370 
9,685 
21 
M. 
21/ 
4 or 5 mo. 
Brother with hip 
disease. Case 31. 
Tub. of head of L. femur, with ab- 
scess all around trochanter. 
Traction. 
Feb. 4, 1897 
April 2, 1897 
84 
65 
4,937,600 
4,560,000 
13,000 
13,437 
23 
M. 
7 
1% yrs. 
Aunt has phthisis, 
otherwise neg. 
Tub. of hip-joint, with large abscess 
above and behind, gravitating 
down. 
Traction. 
i3> ’97- 
Abscess opened Feb. 
March 4, 1897 
March 6, 1897 
March 9, 1897 
March 10, 1897 
March 11, 1897 
67 
i°5 
5,100,000 
16,875 
15,450 
’.3,237 
22,250 
25,045 
26 
F. 
3^ 
7 mos. 
Negative. 
Second stage hip dis. with abscess 
which began to show April 3, ’97. 
Traction. 
March 4, 1877 
April 3, 1897 
65 
62 
4,852,800 
5,000,000 
18,800 
12,190 
29 
M. 
5/^ 
16 mos. 
A sister had white 
swelling. 
Tub. of head of L. femur, with large 
abscess (Pentroch.) 
Traction. 
March 3, 1897 
April 6, 1897 
80 
90 
5.200.000 
4.720.000 
10,000 
9,390 
64 
M. 
9^ 
ITA yrs. 
Negative. 
Tub. of head of L. femur, with ab- 
scess which opened spout. 24 hrs. 
before exam. 
Traction. 
April 3, 1897 
85 
4,804,000 
8,330 
HIP-JOINT TUBERCULOSIS, WITH ABSCESS. 
B.—No Operative Interference. The Blood in Bone Tuberculosis. 
5 
5 
F. 
7 
5 mos. 
Negative, 
Tub. R. hip, limited abduction; pain 
Traction. 
Sept. 22, 1897 
63 
4.260.000 
4.480.000 
20,000 
in knee, limited rotation inward. 
March 25, 1897 
90 
9,060 
H 
F. 
13 
5 wks. 
Mother died pul. 
Tub. of head of L,. femur; joint rigid 
Traction. 
Dec. 30, 1896 
73 
5,000,000 
7,250 
tub. 3 yrs ago. 
from spasm. 
Feb., 1897 
(Symp. of pul 
tub. develped.) 
March 29, 1897 
67 
4,120,000 
12,185 
(Died Ap. 6,’97, 
Tub. of I,, hip. 
of pul. tub.) 
25 
F. 
5 
yrs. 
Sister had vent. 
Tx-action. 
March 4, 1897 
84 
5,264,000 
6,875 
tub. 
28 
F. 
6 
14 mos. 
Negative. 
Tub. of head of R. femur. 
Traction. 
Feb. 28. 1897 
April 6, 1897 
78 
9i 
3.665.000 
4.560.000 
10,330 
9,687 
6l 
M. 
10 
1% yrs. 
Pat. uncle phthisis 
Tub. of head of R. femur. Abscess 
Traction. 
March 29, 1897 
75 
4,332,000 
6,250 
healed some months ago. 
62 
F. 
18 
4 yrs. 
Negative. 
Tub. of R. hip. 
Traction; splint. 
March 29, 1897 
55 
3,040,000 
9,375 
68 
F. 
2^ 
i yr. 
Tub. of R. hip, 1st stage. 
Traction. 
April 6, 1897 
66 
4,600,000 
15,000 
April 18, 1897 
62 
5,600,000 
12,400 
72 
F. 
3 
6 mos. 
Negative. 
Tub. of R. hip. 
Traction. 
April 12, 1897 
75 
4,700,000 
10,312 
73 
F. 
5 
2 yrs. 
Negative, 
Tub. of R. hip. 
Traction; splint. 
April 10, 1897 
63 
5,360,000 
8,545 
HIP-JOINT TUBERCULOSIS, WITHOUT ABSCESS. 
No Operative Interference. The Blood in Bone Tuberculosis. 
o 
p 
w 
n> 
% 
p 
w 
n> 
« 
Age. 
Duration. 
Family History. 
Eocation and Extent. 
Treatment. 
Date of Count. 
Haemoglobin 
Per Cent. 
I Erythro- 
cytes. 
n 
£ 
0 
<3 
S’ 
cn 
7 
F. 
4 
1 yr. 
Negative. 
Kyphosis nth and 12th D. V. Ab- 
Abscess incised and curetted Feb., 
Feb. 1, 1897 
55 
4,080,000 
12,500 
scess in R. iliac region. 
’96. Sinus presisting Feb., ’97. 
March 29, 1897 
72 
5,120,000 
10,310 
20 
F. 
3^4 
2 yrs. 
Negative. 
Tub. disease nth and 12th D. V. 
Jacket and traction to Feb., ’97. 
Feb. 3, 1897 
50 
4,400,000 
14,700 
Psoas abscess increasing in size, 
Abscess incised Feb. 15. 
Feb. 13, 1897 
55 
16,250 
Feb. 1, ’97. 
Feb. 27, 1897 
45 
4,160,000 
15,625 
March 4, 1897 
53 
23,248 
March 6, 1897 
25,030 
March 18, 1897 
47 
4,026,400 
n,8oo 
March 26, 1897 
5° 
4,200,000 
17,500 
56 
M. 
4 
yrs. 
Consumption in gr. 
Vert, tuberc,, with psoas abscess; 
Abscess opened Feb.’g6. Traction. 
March 24, 1897 
50 
4,440,000 
13.125 
mother, 2 aunts 
presisting sinus. 
April 16, 1897 
5« 
4,820,000 
n,6oo 
and father. 
59 
M. 
II 
5 yrs. 
Negative. 
Vert. tub. with psoas abscess, open- 
Abscess opened 3 times and curet- 
March 24 1897 
33 
4,040,000 
13,750 
ed in ’92 and ’95. Many presisting 
ted. Traction. 
April is, iSq? 
32 
4,040,000 
19,200 
sinuses. 
B.—No Operative Interference. 
19 
F. 
4 
1% yrs. 
Negative. 
Tub. of lower lumbar vert., with ab- 
Jacket; no traction. . 
Feb. 3, 1897 
55 
5,850,000 
8,125 
scess behind E- trochanter, in- 
March 16, 1897 
creasing in size. Noted 6 weeks 
(Abscess 
before Feb. 3. 
smaller.) 
March 30, 1897 
85 
5,520,000 
7,500 
20 
{See Case 20A.) 
Abscess incised & curetted Feb. 15, 
22 
M. 
8 % 
3 yrs. 
Negative. 
Scoliosis and kyphosis tub. of 9-12 
Traction. 
Feb. 4, 1897 
80 
4,640,000 
7,150 
D and 1st lumbar V. Abscess in E. 
April ■ 2, 1897 
85 
5,140,000 
8,905 
iliac region getting larger, Feb.’q?. 
66 
F. 
4 
2 yrs. 
Negative. 
Vert, tuberc., with large psoas ab- 
Traction. 
April 6, i8q? 
89 
5,280,000 
10,520 
scess. 
(12 hrs. p. c.) 
69 
F. 
1% 
10 mos. 
Negative. 
Kyphosis upper dorsal, with abscess 
Traction, 
April 10, 1897 
78 
5,120,000 
11,250 
in infrascapular region; 3 mos. 
April 20, 1897 
73 
5,600,000 
10,000 
duration. 
VERTEBRAL tuberculosis, with abscess. 
A.—Operative; Inter eerEnce. The Blood in Bone Tuberculosis. 
2 
F. 
10 
5 yrs. 
Aunt died of phthi- 
sis pulm. 
Tub. disease middle dorsal region. 
Splint traction. 
Sept. 22, 1896 
March 28, 1897 
70 
85 
3.145.000 
4.720.000 
10,812 
8,750 
17 
F. 
2^ 
i yr. 
Negative. 
Tub. disease middle dorsal region. 
Rest in bed; no traction. 
Jan. 2, 1897 
March 30, 1897 
72 
85 
4,900,000 
4.960,000 
15,600 
7,500 
i8 
F. 
4 
16 mos. 
Negative. 
Tub. disease 5th and 6th dorsal vert. 
Splint traction. 
Jan. 
April 
2, 1897 
2, 1897 
90 
75 
6.536.000 
4.280.000 
6,250 
5,625 
31 
M. 
3ZX 
Brother, Case 21. 
Tub. disease 5th dorsal vertebra. 
Tub. disease T. hip; incipient. 
Splint traction. 
March 
April 
6, 1897 
18, 1897 
43 
73 
5,040,000 
5,280,000 
13,125 
15,600 
35 
40 
F. 
M. 
6 
2% 
3 yrs. 
6 mos. 
Negative. 
Negative. 
Kyphosis 5th, 6th & 7th dorsal vert. 
No active disease now. 
Tub. disease nth & 12th dorsal vert. 
Brace and Jacket. 
Splint traction. 
March 
March 
April 
4, 1897 
8, 1897 
17, 1897 
76 
52 
62 
4,532,800 
5.080.000 
5.200.000 
7.500 
17,440 
12,400 
52 
M. 
7 
2]/z yrs. 
Negative. 
Tub. disease 7th & 12th dorsal vert. 
P. P. jacket and brace- 
March 23, 1897 
April 18, 1897 
57 
73 
5.600.000 
5.360.000 
14,375 
9,900 
65 
M. 
5 % 
Negative. 
Tub. disease lower dorsal vertebra. 
Rest in bed; no traction. 
April 
1, 1897 
82 
4,400,000 
10,625 
67 
M. 
2^ 
9 wks. 
Mother had pulm. 
tub. 
Tub. disease lower dorsal vertebra. 
Rest in bed; no traction. 
April 
6, 1897 
70 
3,800,000 
10,000 
TUBERCULOSIS AT ANKLE-JOINT. 
Abscess and Operation. 
47 
M. 
5 
Father died of pht. 
Tub. ofR. ankle joint; curetted. 
Curetted May, ’95; Feb.,’96. 
’97. Sinus presisting. 
Mar., 
March 25, 1897 
100 
5,160,000 
5,900 
TUBERCULOSIS OF HIP-JOINT AND VERTEBRAL COLUMN COMBINED. 
No Abscess. 
No Operation. 
49 
M. 
7 
5 yrs. 
Negative. 
Tub. of hip and kyphos. 
Traction, splint and jacket. 
March 23, 1897 
67 
5,040,000 
6,875 
Abscess and 
Operation. 
43 
M. 
6 
2 yrs. 
Negative. 
Spina-ventosa and osteo arthritis, 
hip. 
Abscess opened Jan, ,’96. Curetted 
March, ’97. 
March n, 1897 
April 15, 1897 
48 
47 
4,000,000 
4,280,000 
9,850 
9,200 
60 
M. 
14 
10 yrs. 
Negative. 
Tub. of middle dorsal vert, and hip. 
Numerous operations over 
Pat. died April 4, ’97. 
Cyrs. 
March 25, 1897 
47 
2,830,000 
5,100 
vertebral tuberculosis, without abscess. The Blood in Bone Tuberculosis. 
i Case No. 
Sex. 
Age. 
Duration. 
Family History. 
location and Fxtent. 
Treatment. 
Date of Count. 
(Haemoglobin 
( Per Cent. 
-s E? 
O 
M 
£ 
n 
0 
0 
S 
No Abscess. 
No Operation. 
15 
F. 
9/4 
20 mos. 
Negative. 
Tub. synovitis L,. knee, with elfu- 
Inclined plane and traction. 
Dec. 30, 1896 
75 
4,080,000 
11,350 
sion. 
March 25, 1897 
66 
4,360,000 
7,500 
58 
M. 
nJ4 
10 yrs. 
Negative. 
Flexion of knee from tub. disease. 
Traction; extension. 
March 23, 1897 
100 
5,200,000 
8,812 
70 
F. 
5% 
20 mos. 
Pat. aunt died of 
Tub. synovitis, both knees. 
Aspiration; rest in bed. 
April n 1897 
84 
4,920,000 
12,250 
phthisis. 
No Abscess. 
Operation. 
27 
F. 
I 
3 mos. 
Both mat. gr. par- 
Tub. R. knee and R. elbow (elbow 
March 4, 1897 
53 
4,600,000 
15,625 
ents died of pht. 
incised by quack) reason unknwu 
32 
V. 
2% 
7 mos. 
Aunt had hip dis- 
Tub. focus in upper epiphysis of T. 
Fpiph. removed Jan., ’97. Union 
March 6, 1897 
70 
5,162,200 
10,515 
ease. 
tibia. 
by 1st intention, Mar. 16. Despite 
April is. 1897 
73 
4,600,000 
12,200 
healing there is evident tub. of 
synovia! membrane. 
39 
M. 
4/4 
3*4 yrs. 
Negative. 
Slight kyphosis of 7th and 8th D. V. 
Condyles trephined and foci re- 
March 3, 1897 
70 
5,040,000 
12,500 
Tub of D. knee; very little motion, 
moved; no pus. 
April 18, 1897 
73 
s, 600,000 
6,200 
swelling aroundfemr’l epiphyses. 
63 
M. 
2 
3 mos. 
Negative. 
Timp, pain and tenderness in T. 
Trephining, 
March 29, 1897 
72 
5,200,000 
8,650 
knee; no marked enlargement. 
71 
M. 
8 
2 yrs. 
Negative. 
Tub of knee. 
Removal of tub. granulations from 
April ii, 1897 
82 
5,680,000 
11,875 
synovial membrane. Curetting. 
(17 hrs. p. c.J 
Abscess and 
Operation. 
48 
M. 
7 
4 yrs- 
Tub. of knee and fingers; enlarged 
Amputation above knee and of 
March 23, 1897 
46 
3,880,000 
11,875 
cervical glands. 
several fingers. Innumerable 
April 18. 1897 
5° 
s, 600,000 
14,800 
abscesses now. 
50 
M. 
7 
I % yrs. 
Negative. 
Tub. of knee, with abscess in epi- 
Curetting Jan., ’97. 
*March 21,1897 
100 
5,172,000 
14,155 
physis of femur & popliteal space. 
51 
M. 
2 yrs. 
Mat. grandfather 
Tub. synovitis of knee, with abscess. 
Tub. focus removed at op., May, 
March 21, 1897 
87 
4,680,000 
9,065 
died of phthisis. 
’96. Dischrgd Mar. 30/97, cured. 
53 
M 
10 
254 yrs. 
Tub. of knee, with abscess which 
Fpiphysiotomy in Apr.,’96. Sinus 
March 2.3, 1897 
68 
4,920,000 
7,500 
opened spontaneously 2 yrs. ago. 
discharging. 
* Child has been running very high temperature for some days; once subnormal (March 20); not much food for some days. 
TUBERCULOSIS AT OR NEAR KNEE-JOINT. The Blood in Bone Tuberculosis. 
9 
I have separated the 73 cases into groups according to the 
location of the process, the presence or not of a clinically 
demonstrable abscess, and the treatment. Two cases were 
studied carefully before and after operation where a large 
primary abscess was involved, and are therefore counted twice, 
making a total of 75, of which 42 came to operation. The 
cases are divided as follows; 
Hip-joint tuberculosis with abscess. 
(a) operative interference 26 
(b) no operative interference 6 
Hip-joint tuberculosis without abscess, no opera- 
tive interference 9 
Vertebral tuberculosis with abscess. 
(a) operative interference 4 
(b) no operative interference 5 
Vertebral tuberculosis without abscess, no inter- 
ference 9 
Vertebral and hip tuberculosis with abscess and 
operation 2 
Vertebral and hip tuberculosis, no abscess, no 
operation 1 
Ankle joint tuberculosis, abscess and operation.... 1 
Knee joint tuberculosis, j 
(a) abscess and operation 4 1 
(b) no abscess and no operation 3 f 
(c) no abscess but an operation ....5 j 
75 
The family history was obtained in full in 69 cases and 
showed (1) absolutely negative results in regard to tuberculo- 
sis in 47 cases or 68 per cent; (2) negative in regard to direct 
inheritance in 59 or 85 per cent; (3) direct family history in 
parent, grand- or great-grandparent in 10 or 15 per cent, of 
which only 2 cases showed a family history in more than one 
other generation, and in no case were both parents affected. 
The direct influence of heredity is certainly a very small one. 
From the distribution of the lesions and the varying his- 
tory of injuries, the small value which can be attached to 
injury as an etiological factor is shown. It is so easy to obtain 
the history of an injury to the child if stress be laid on the The Blood in Bone Tubercidosis. 
question, that only in exceptional cases have I been able to 
attach much import to any particular injury reported by the 
parent. The fact that in this list of cases the hip is attacked 
more than twice as often as the vertebral column and more than 
three times as often as the knee, which is eternally black and 
blue in a child from injury, and as the list shows no case of 
primary tuberculosis of wrist-, elbow- or shoulder-joints, it 
seems to me likely that too much stress has been laid on in- 
jury as an etiological factor. lam more inclined to the belief 
that anaemia from malnutrition and the accompanying lowered 
resistance of the blood to the invasion of the bacillus tubercu- 
losis, are the most important factors in the etiology of bone 
tuberculosis. A large proportion of these cases show abund- 
ant cause for a secondary anaemia in the history of having been 
bottle-fed as babies, of having had serious digestive disturb- 
ances and of having been delicate always. 
Of the technique in these examinations I shall 
say nothing further than to recount the methods employed and 
standards taken, so that comparisons with subsequent work in 
this line may be made accurately. The haemoglobin determin- 
ations were made with von Fleischl’s instrument, and the 
Thoma-Zeiss blood corpuscle counting apparatus was used for 
the counts—a dilution of twenty volumes with 3 per cent so- 
lution of common acetic acid being used for leucocytes and 
Heyeni’s solution to 200 volumes dilution for erythrocytes. 
The differential counts were made from coverslip preparations 
made at the time of examination and stained with Neusser’s 
modification of Khrlich’s triacid stain and eosin and haema- 
toxylin. 
The normal number of erythrocytes in male children I have 
taken at 5,000,000 per cubic millimeter of blood and in females 
at 4,500,000. Haemoglobin in males is normal at 90 to xoo 
per cent, and in females as low as 80 per cent is not incompati- 
ble with a perfectly healthy color appearance to the erythro- 
cytes. This great variation in the normal amount of haemo- 
globin is not so marked in childhood. 
leucocytes settle down to about 10,000 per c. cm. shortly 
after birth and slowly diminish until the sixth year when the 
constant point of 7,500 is reached. An increase of about 2,000 
per c. cm. is counted in my paper as leucocytosis. The counts The Blood in Bone Tuberculosis. 
were all made from three and a half to five and a half hours 
after meals, at which time the digestive leucocytosis has gen- 
erally subsided. In referring to abscess formation I mean a 
clinically demonstrable accumulation of pus. 
Daache, among his early observations upon cases of tuber- 
culosis in general, makes this statement: “Tuberculosis in 
itself in most cases gives no appearance of marked anaemia.” 
The pallor of the skin is in marked contrast to the redness of 
the mucous membranes and the number of erythrocytes is not 
diminished, and the haemoglobin is surprisingly high. The 
general statement is also made by different authorities that in 
pure tuberculosis of all organs there is an absence of change 
in the leucocyte conditions. Many observers fail to distinguish 
between simple tubercular infection and a combined infection 
with one of the pathogenic organisms, so that their deductions 
are valueless in this discussion. The work of Dane, of Bos- 
ton, on the blood in bone tuberculosis is the only extended 
observation on the subject that I know of, and it is an admira- 
ble effort to put the subject in shape to be of use, and to show 
that a careful study of the blood, in this form of tuberculosis 
at least, does show interesting and important changes. I shall 
make Dane’s conclusions a basis of criticism in presenting the 
results of the study of my cases. 
The degree of anaemia in purely tubercular bone disease 
seems to depend on (i) the age of the child, and (2) the dura- 
tion and extent of the process, young children showing effects 
much more markedly than older ones, and a long continuance 
of the process under unfavorable circumstances telling decidedly 
on the child. 
The resemblance of the secondary anaemia of tuberculosis to 
chlorosis has caused the Vienna school to adopt the name 
chloranaemia tuberculosa. Dane’s observation that “ the per- 
centage of haemoglobin in bone tuberculosis is generally dimin- 
ished, giving rise to mild chlorosis,” should be changed to 
giving rise to secondary anaemia, which may reach any grade 
of severity, for chlorosis belongs to the primary anaemias whose 
causal factor is unknown. The decrease in percentage of 
haemoglobin is best shown on the accompanying charts—the 
lowest line indicating the percentage present in each case. C—No abscess formation and no 
operative interference. 
Second leucocyte coynt. 
Haemoglobin percentage. 
HIP JOINT TUBERCULOSIS. 
A—Operative interference 
B—No operative interference. 
Erythrocytes, 
leucocytes. 
A | Abscess formation. HIP AND 
VERTEBRAL 
TUBERCULO- 
SIS (K. L.) 
Second leucocyte count. 
knee and ankle JOINT TUBERCULOSIS (G.H.1.J.) 
G—No abscess, no operative interference. 
H—No abscess, operative interference. 
I & J—Abscess and operative interference. 
Haemoglobin percentage. 
Erythrocytes. 
VERTEBRAL TUBERCULOSIS (D. E. F.. 
p—No abscess, no operative interference. 
E—Abscess, operative interference. 
F—Abscess, no operative interference. 
leucocytes. The Blood in Bone Tuberculosis. 
Cases 7, 19, 20, 40 and 56 are young children who have had 
a long continued process. 
Cases 27, 49, 52 and 59, long continued and extended pro- 
cess. 
Cases 6, 8, 12, 13, 33, 43, 48 and 60 are long-standing 
cases with extensive disease, and a complication of septicaemia. 
Case 27 is a baby one year old. 
The point in regard to the general absence of a decrease in 
the number of red blood corpuscles in most cases is illustrated 
in the cases presented. In Cases 8, 33 and 60 we have the low 
count explained by the presence of a septicaemia in cases of 
extensive bone disease. Cases 8 and 60 died, and in Case 33, 
a boy of 14 years, the leg was taken of at the hip owing to 
the wide extent of the disease. Cases 2 and 62 are of many 
years standing without proper treatment at the time of the first 
examination. 
I have referred already to the statement of most authorities 
that the leucocytes in pure tuberculosis of all forms present no 
very marked change in number, tuberculosis being one of the 
few pathological processes which do not show leucocytosis 
under ordinary conditions. The observations of Holmes, of 
Denver, published in the New York Medical Journal last fall, 
on the diagnosis of tuberculosis by blood examination, I have 
been unable to confirm in any respect. 
The appearance of a high leucocyte count especially in hip 
disease has been held by Dane to indicate the presence of an 
abscess, or that one is about to be formed, and he cites four 
cases to illustrate. The counts were 14,000, 15,000, 20,000 
and 30,000. In all but the third case abscess formed within 
seven months. Among my cases this point is not fully sub- 
stantiated. The observation is corroborated by Case 26 in the 
second stage of hip disease in which no abscess showed on 
March 4, 1897, when the leucocyte count was 18,800. On 
April 3rd it was definitely determined that an abscess was pre- 
sent, and the leucocyte count that day was 12,190. Pus as- 
pirated from the abscess was negative to culture and coverslip 
examination. Case 31 may also prove to illustrate Dane’s 
point. The leucocyte count has increased in six weeks from 
13,000 to 15,600, but as yet no abscess has formed. Six of my 
cases on the other hand have presented conditions which would The Blood in Bone Tuberculosis. 
15 
go to disprove Dane’s point. All of them presented a more 
or less marked leucocytosis at first examination, and at the 
second examination, from two weeks to six months later, no 
abscesses had developed, and in every case the count was less. 
Case No. Ist. Exam. 2nd. Exam. Interval. 
5 20,000 g,060 6 months 
17 15,600 7,500 3 months 
39 12,500 6*200 6 weeks 
40 17)44° 12,400 5 weeks 
52 14,375 9,900 1 month 
68 15,000 12,400 2 weeks. 
I should be inclined therefore to modify very much the con- 
clusion drawn by Dane by saying that a case may go on to 
abscess formation without any increase in the number of 
leucocytes, and give every appearance clinically, and through 
blood examination, of improvement (Cases 19, 22, 29). Un- 
doubtedly purely tubercular abscesses of considerable size may 
be formed and be absorbed without there ever having been a 
leucocytosis. When, however, such a case begins to show an 
increase in the number of leucocytes, one of two things has 
happened, either a secondary infection has occurred (Cases 20, 
23), or there is a considerably increased activity in the tuber- 
cular process (Cases 14, 21, 31, 32). 
Case 14.—Girl of 13, with tubercular disease of head of left 
femur; five weeks duration at time of first examination. Eeu- 
cocyte count January Ist, 7,250; March 29th, 12,185. In 
February pulmonary tuberculosis developed with hemorrhages 
from the start. Death early in April. 
Case 21.—Boy 2years; had tubercular disease of the 
head of the left femur, with an abscess. The process was of 
five months duration at the date of first count, February 4th, 
haemoglobin, 84 per cent; erythrocytes, 4,900,000; leucocytes, 
13,000. April 2nd, haemoglobin, 63 per cent; erythrocytes, 
4,500,000; leucocytes, 13,400. Attempts at cultures on blood 
serum from pus aspirated April Bth, and from coverslips, were 
negative. 
Case 31.—Boy of years, with tubercular disease of fifth 
dorsal vertebra, and left hip trouble beginning. March 6th, 
haemoglobin, 43 per cent; erythrocytes, 5,000,000; leucocytes, 
13,125. April 18th, haemoglobin, 73 per cent; erythrocytes, 
5,280,000; leucocytes, 15,600. Clinical note, “ Fever, appetite 
bad, local condition not improving.” The Blood in Bone Tuberculosis. 
CASE 32.—Girl 2y% years old, with a tubercular focus in 
upper epiphysis of left tibia of seven months duration. Focus 
removed January Ist, union by first intention. March 6th, 
haemoglobin, 70 per cent; erythrocytes, 5,162,000; leucocytes, 
10,5x5. April 18th, haemoglobin, 73 per cent ; erythrocytes, 
4,600,000; leucocytes, 12,200. March 16th.—Clinical note, 
“Despite healing there is evident an active tuberculosis of the 
synovial membranes.’’ 
Cases 20 and 23 showed abscesses at the time of first ex- 
amination, and showed leucocytosis, the counts being 14,700 
and 11,250 respectively on February 3rd. Ten days later the 
count twelve hours after a feeding stood, 16,250 and 12,185, 
an increase in each case. On the theory of Gage, of Worcester, 
that this was an indication of secondary infection, and that the 
time for opening had come, both abscesses were opened im- 
mediately. Cultures on nutrient gelatine and agar-agar, and 
coverslips were negative in both cases. Commenting on Gage’s 
statement (made in Boston Medical and Surgical Journal in 
1896), I would say simply it is a well known law that all 
secondary infections cause leucocytosis, but that a moderate 
leucocytosis in a case with tubercular abscess probably has its 
cause in the sudden activity of the tubercular process, as I have 
already pointed out. 
All the cases of primary tubercular abscess showing any de- 
gree of leucocytosis were examined most carefully in regard to 
this point. Pus was aspirated in every case but one and cul- 
tures on blood serum were attempted and coverslip prepara- 
tions examined. In every case, as in Cases 20 and 23, the 
result was negative. 
Case ii.—February Ist, 14,370; March 29, 9,685; abscess 
smaller, no aspiration. 
Case 21.—February 4, 13,000; April 2, 13,437; aspirated 
April 8; negative. 
Case 26.—March 4, 18,800; April 3, 12,190; aspirated April 
15; negative. 
Case 29.—March 3, 10,000; April 6, 9,390; aspirated April 
8; negative. 
Case 66.—April 6, 10,520; aspirated April 13; negative. 
Case 69.—April 10, 11,250; aspirated April 13; negative. 
This concerns also Dane’s statement that with abscess for- 
mation low leucocyte count indicates absence, and high count The Blood in Bone Tuberculosis. 
the presence of secondary infection with pyogenic organisms. 
It becomes a most important question to know what is meant 
by a high count. In Case 20 the pus at operation was negative, 
although just previous to operation- the count was 16,250, 
showing an increasing leucocytosis. Two weeks later the 
count was 15,600. One week after that it was 23,000 and agar- 
agar cultures showed the staphylococcus pyogenes aureus. 
Case 23, showing the same condition and operated on at the 
same time, showed an increase of 4,500 in the leucocyte count 
three weeks after operation, making the count 16,800, and cul- 
tures showed the same organism. The patient developed 
tubercular meningitis and died five weeks after operation. No 
autopsy obtained. Judging from these two cases it seems 
difficult to say what is the lowest count which may be said to 
constitute the leucocytosis of secondary infection, and I would 
clear the ground partly by saying that if the known causes of 
leucocytosis be excluded, a rapid increase of several thousand 
in the leucocyte count in a case with tubercular abscess is most 
significant of secondary infection, for Cases 14, 20, 21, 23, 31 
and 32 show that other causes—probably an activity in the 
tubercular process—make an increase in the leucocyte count. 
From the surgical point of view either cause of the increase 
might indicate the necessity of surgical interference. 
That the leucocyte count bears no direct relation to the 
temperature, another observation of Dane, I can fully corrob- 
orate. The only relation which exists is where the cause of 
a leucocytosis is also the cause of the fever as in a secondary 
infection. Even here there is no constant relation between the 
two. The absence of relation is perhaps best illustrated in the 
fever following a malarial chill, and in the continued high 
temperature of typhoid fever where there is a diminished 
rather than increased number of leucocytes. 
The leucocytosis which occurs from the infection of the 
large open wounds following operations on tubercular bone is 
fully illustrated by forty of the cases coming to operation. In- 
fection is bound to follow the long continued dressing of these 
wounds. The leucocytosis in nearly all cases is very high for 
a period after the infection, and then it gradually falls unless 
the sepsis is acute and threatens the life of the patient, in 
which case it may remain high until a crisis is reached. If 
the resistance of the patient is good and the case progresses The Blood in Bone Tuberculosis. 
favorably, the leucocytosis slowly disappears and the haemo- 
globin percentage increases. If the anaemia was of the second 
degree of severity and the erythrocytes had greatly decreased, 
there occurs also an increase in their number. (Cases i, 3, 4, 
16, etc.) 
The failure of the haemoglobin percentage to rise, and of 
number of red blood corpuscles to increase, provided they were 
diminished, is a certain warning of an unfavorable condition 
in spite of the diminution of the leucocytes to the normal or 
below (Cases 8, 60). Stating the case generally, marked leu- 
cocytosis follows secondary infection with a pyogenic organism 
in children where the recuperative power is good, and the 
leucocytosis disappears as the recuperation goes on, or as the 
pyogenic material overcomes the recuperative power. In the 
first case the anaemia disappears, and in the second case it re- 
mains stationary or grows worse. 
Before concluding I wish to state that all of the severity- 
three cases examined were from the clinic at the Children’s 
Hospital and the private practice of Dr. H. M. Sherman, and 
I wish to acknowledge my indebtedness to Dr. Sherman 
for his kindly help and many suggestions in carrying on this 
study. 
resume:. 
I. No decrease in erythrocytes except in secondary anaemias 
of second and third stages, which come (a) in long-standing 
and extensive cases, (b) in very young children, and (c) in septic 
infections. 
11. Haemoglobin is decreased in all cases, and in proportion 
to the same factors which influence the erythrocytes. 
HI. The return to health is indicated by the tendency of 
blood to return to the normal. 
IV. Abscess formation not necessarily accompanied by 
leucocytosis. Slowly developing leucocytosis points to activity 
in the tubercular process. Rapidly developing leucocytosis 
points to secondary infection with pyogenic bacteria. Abscess 
may be absorbed without a leucocytosis having developed. 
In septic infection of wounds, leucocytosis is marked at first 
and diminishes as the resistance of the child increases or de- 
creases. If the diminution is accompanied by an increased 
anaemia, it is a sign of the lowered vitality of the child. W. A. WOODWARD & CO., 12 SUTTER ST., S. F