On closer examination, however, by comparing the two knees it will be found that the grooves on each side of the patella, which give the healthy knee-joint the beautifully modeled shape, have nearly or quite disappeared; nothing more can be noticed.
The hinderance in motion may be so insignificant, that the children may slightly limp about for weeks and months and complain but little. Generally the physician is not called until the limb begins to hurt and swell after continued exertion.
The swelling which in the beginning is hardly noticeable is now more plainly visible, the knee-joint is evenly rounded and quite sensitive to pressure.
If the disease is not now properly treated, its further course will be as follows: the patient may perhaps linger for several months; then comes a period when he must keep to his bed uninterruptedly because moving results in too much pain; generally the limb becomes more and more bent.
Now particularly painful points appear on the joint, especially on the inner or outer side or in the bend of the knee; on one of these points a soft portion distinctly developes, the skin becomes reddened and finally suppurates from the internal parts outward and breaks after a few months; thin purulent matter mixed with flakes is discharged. The pains now cease, and the condition is improved; but this improvement does not last; soon another abscess is formed and thus it continues.
Meanwhile perhaps two or three years may have elapsed; the general condition becomes greatly reduced. The child, formerly strong and healthy, has now become lean, the discharges of matter have often been attended by acute febrile attacks; the patient becomes exhausted, loses his appetite and digestion becomes more impaired from week to week. Even now a spontaneous change for the better is possible, though this happens very rarely; more frequently the disease progresses and leads to death from exhaustion resulting from severe suppuration and continual attacks of fever.
Restoration to health is indicated by decreased suppurative discharges; the openings of the fistulae contract, the general condition is improved, the appetite is restored, etc. Finally the fistulae heal, the joint becomes fixed at an angle or bent or otherwise crippled, but painfulness disappears and the patient escapes with his life and a stiff leg. This is the most favorable result known to have been obtained in severe cases. The joint may become a solid bony immovable mass or may admit of slight movements. The whole process may last from two to four years.
The former treatment of tuberculous inflammation of the knee-joint was either of a general or a local nature. The general treatment was designed to strengthen and nourish, and will continue to be applied in the future.
The local treatment consisted in the application of salves, brushing with tincture of iodine, spanish fly plasters, wet and dry bandages. As with inflamed hip-joint absolute rest by lying in bed is of the greatest importance.
If after a certain period of rest and application of the above-named remedies no improvement in the state of health could be noticed, the diseased joint was laid in plaster or confined with splints.