Treatment.—In addition to the general treatment of tuberculosis, local measures are employed. These may be described under two heads—the conservative and the operative.
Conservative treatment is almost always to be employed in the first instance, as by it a larger proportion of cures is obtained with a smaller mortality and with better functional results than by operation.
Treatment by rest implies the immobilisation of the diseased limb until pain and tenderness have disappeared. The attitude in which the limb is immobilised should be that in which, in the event of subsequent stiffness, it will be most serviceable to the patient. Immobilisation may be secured by bandages, splints, extension, or other apparatus. Extension with weight and pulley is of value in securing rest, especially in disease of the hip or knee; it eliminates muscular spasm, relieves pain and startings at night, and prevents abnormal attitudes of the limb. If, when the patient first comes under observation, the limb is in a deformed attitude which does not readily yield to extension, the deformity should be corrected under an anæsthetic.
The induction of hyperæmia is often helpful, the rubber bandage or the hot-air chamber being employed for an hour or so morning and evening.
Injection of Iodoform.—This is carried out on the same lines as have been described for tuberculous abscess. After the fluid contents of the joint are withdrawn, the iodoform is injected; and this may require to be repeated in a month or six weeks.
After the injection of iodoform there is usually considerable reaction, attended with fever (101° F.), headache, and malaise, and considerable pain and swelling of the joint. In some cases there is sickness, and there may be blood pigment in the urine. The severity of these phenomena diminishes with each subsequent injection.
The use of Scott's dressing and of blisters and of the actual cautery has largely gone out of fashion, but the cautery may still be employed with benefit for the relief of pain in cases in which ulceration of cartilage is a prominent feature.
The application of the X-rays has proved beneficial in synovial lesions in superficial joints such as the wrist or elbow; prolonged exposures are made at fortnightly intervals, and on account of the cicatricial contraction which attends upon recovery, the joint must be kept in good position.
Conservative treatment is only abandoned if improvement does not show itself after a thorough trial, or if the disease relapses after apparent cure.
Operative Treatment.—Other things being equal, operation is more often indicated in adults than in children, because after the age of twenty there is less prospect of recovery under conservative treatment, there is more tendency for the disease to relapse and to invade the internal organs, and there is no fear of interfering with the growth of the bones. The state of the general health may necessitate operation as the most rapid method of removing the disease. The social status of the patient must also be taken into account; the bread-winner, under existing social conditions, may be unable to give up his work for a sufficient time to give conservative measures a fair trial.