Treatise on orthopedic surgery

Front matter

Class.

Book J Copyrights?

COPYRIGHT DEPOSIT.

Preface To The Third Edition

In preparing the third edition of this work it has been necessary to rewrite entirely several portions, to make extensive alterations in others, and to rearrange chapters and subjects. These changes have been made in the endeavor to offer to the reader a description of the present condition of orthopedic surgery with its notable progress since the publication of the second edition in 1899.

The most marked difference between the second and third editions will be found in the chapters treating of congenital dislocation of the hip, of scoliosis, of traumatic and non-traumatic coxa vara, and of non-tuberculous diseases of the joints, as it is in the study of these subjects that the greatest advances have been made. Many original illustrations have been added and many of the old ones have been improved, making them more illustrative of the subjects mentioned in the text.

A chapter giving the details of orthopedic apparatus, with descriptions and drawings of appliances found to be of practical efficiency, is added in the hope of giving to the general practitioner technical information which is of use in the treatment of orthopedic affections.

The authors are greatly indebted to friends and colleagues for many helpful suggestions and for their ready permission to make use of their illustrations and clinical material.

Boston, April 1st, 1905.

Chapter I. Tuberculous Disease Of The Joints

Pathology. — Etiology. — Prognosis. — Principles of Treatment.

Orthopedic surgery deals with the prevention and correction of deformity, and demands not only a study of the deformities of the human body, but also some knowledge of the affections which produce them. Of these the most important are the tuberculous diseases of the joints.

Bone tuberculosis has been called strumous, scrofulous, and fungus disease, caries of bone, etc., and various theories as to the predisposing cause have been presented. It is known to be the result of the invasion of the tubercle bacillus, which frequently finds a favorable soil for development in the spongy bone of the growing epiphyses.

PATHOLOGY.

Articular tuberculosis begins as an affection of the spongy tissue of the epiphysis, generally near its line of junction with the shaft, occasionally near the articular cartilage. It occurs usually as a localized disease, appearing in one or more distinct foci ; a simultaneous tuberculous infiltration of the whole epiphysis, however, rarely happens.

The common form of tuberculous infection of the epiphysis is the one spoken of as focal or encysted, when the first change is the formation of single or multiple foci of tuberculous degeneration. On section of the diseased epiphysis the first noticeable change consists in a local hyperemia of some part of the spongy tissue. There then appears in this hyperaemic area a small, grayish, translucent spot, almost as small as one can see, which grows more gray and increases in size, while a zone of hyperaemic tissue develops around it and the neighboring bone looks boggy from an excess of the transuded fluid. At first usually there is no synovitis ; it is purely a localized ostitis.

The tubercle bacilli, being lodged in the marrow of the bone, cause a multiplication of the surrounding cells, probably by the action of a toxin, and a typical tubercle is formed. Such an area consists of a central mass of giant and epithelioid cells surrounded by a zone of lym-

ORTHOPEDIC SURGERY.

phoid cells. As the tuberculous area increases by multiplication of the cells, the centre degenerates, forming a necrotic mass in which fat drops may be seen. Sometimes the tubercle bacillus can be found, usually in small numbers, in the giant cells, or in the epithelioid cells, or between them. The process extends by the formation of other tubercles, apparently due to the multiplication of the tubercle bacilli and their diffusion through the tissues. New necrotic areas like the first are found, which coalesce and form a mass of caseous material. Around the tuberculous area there appears a zone of non-tuberculous granulation tissue early in the process. During the later and reparative stages of the process this area becomes less vascular and is converted into denser fibrous tissue.

As the individual tubercles meet and coalesce, they form, in the marrow of the bone, irregular caseous masses.

In this way large areas of bone may be involved by peripheral enlargement of the tuberculous area. This area may soften and a tuberculous bone abscess may result, the purulent material containing bone fragments like sand.

Instead of forming a " bone abscess " the process may result in the formation of a sequestrum composed of necrotic trabecular retaining their shape and lying in a cavity in the bone. About the sequestrum is a layer of granulation tissue. The sequestrum may take the shape m

A* fill o vv ^:i:r

*enc

Fig,

-Section of Tuberculous Synovial Membrane. (Nichols.)

TUBERCULOUS DISEASE OF THE JOINTS.

of a wedge having its base toward the joint, in which case it is known as a " bone infarct."

As the diseased focus grows larger it looks more yellow in spots, and shows at its centre a tendency to cheesy degeneration, and later in the history of the affection one finds nodules, varying in size from that of a pea to a hazelnut, which are filled with a putty-like substance, such as the cheesy material found elsewhere in the body, except that it contains spicules of bone from the trabecular, and in the larger foci pieces of dead bone of considerable size are found.

Later in the history of the affection the tuberculous nodule may break down into purulent material.

Generally the original focus is surrounded by smaller tubercles, which aid in its extension; but the chief work is done by the erosive action of the granulations, which take the place of the progressively rarefied bone.

From the stage of tuberculous infiltration the process may follow any one of three courses : the diseased focus may be absorbed and so

Fig

Tumor Albus. Small focus in upper epiphyseal line of tibia.

Synovitis of joint, but no tuberculous process apart from focus as noted. Death from miliary tuberculosis, a, Epiphysis; &, primary focus; c, shaft. (Nichols.)

NJ I

Fig. 3. — Tuberculous Epiphysis. Vertical section through the head of the radius, a, Shaft of radius ; b, epiphyseal cartilage ; c, epiphysis ; d, joint surface ; cartilage ; e, tuberculous primary focus; /", perforation of joint cartilage and infection of joint; g; tuberculous "pannus" extending over joint cartilage. (Nichols.)

cured ; it may extend to the periphery of the bone and break through the periosteum and empty itself there ; or, lastly and probably most commonly, it may extend to the joint and infect that.

ORTHOPEDIC SURGERY.

1. The absorption of the diseased focus is theoretically possible up to a late stage in the process, so long as the disease remains strictly local and no sequestra of any size have formed; the pus may become cheesy and calcified.

2. The next most favorable termination to the disease is when the focus does not infect the joint, but breaks through the periosteum and discharges into the periarticular structure. This happens when the

focus is so situated that the line of least resistance takes it to another part of the bony surface away from the joint, there forming probably an abscess which must be evacuated externally or break. Sometimes this ends the disease; the granulation tissue becomes fibrous, and then osseous, and the disease is over. This, according to Krause, is most likely when the focus is in the upper or lower end of the tibia or in the olecranon. 1 It is not likely to occur in the hip on account of the extensive distribution of the capsule.

3. Probably the commonest course for this localized ostitis to pursue is to break into the joint cavity, and the ease with which infection of the joint from the epiphysis is produced will be readily understood by considering the pathological conditions.

The seat of the disease in the beginning is ordinarily not far from the cartilage. At first it excites no joint inflammation, but when it reaches a certain stage, even before it breaks into the joint, inflammatory reaction in the joint begins. 2 The inflammation of the joint at

1 Krause : " Tub. der K. und Gelenke," 1891.

2 Lannelongue : " Coxo-tuberculose," Paris, 1886.

Fig. 4. — Section of Tuberculous Synovial Membrane. Numerous tubercles with giant cells. Between these, oedematous granulation tissue with many lymphoid and plasma cells. (Nichols.)

first is non-tuberculous, the synovial membrane appearing thick and cedematous, the cavity of the joint being filled with a serous inflammatory exudate. This process may be very extensive.

Perforation of the joint by the tuberculous focus is the next step in the process. When the tuberculous focus underlies it, the cartilage of the joint begins to disintegrate and appears softened and yellow, and k

U- y

Fig. 5.— Tuberculous Knee, Process of Repair Advanced. Small focus persists, a, Tibia ; b, tuberculous softening ; c, femur ; d, patella. (Nichols.)

finally breaks through. The perforation frequently occurs near ligaments. The tubercle bacilli, having entered the joint, are quickly disseminated by movement of the articulation, and the synovial membrane becomes infected.

The synovial membrane then appears thick, smooth, and shining, and sometimes nodular ; the surface is studded with small specks not larger than the head of a pin. The yellow tuberculous areas increase and soften, and tuberculous ulcers of the synovial membrane form. The thickened synovial membrane extends as a pannus growth over the edge of the articular cartilage, sometimes covering the whole cartilage. At the same time the tuberculous process may extend between the cartilage and bone. The cartilage beneath the pannus layer is destroyed and disintegrated, while the free surface of the cartilage becomes fibrillated and ulcers appear in it also. When the tuberculous process extends beneath the cartilage the latter is eroded and destroyed.

Large areas of cartilage may be detached from the underlying bone, and sometimes the entire cartilage may be loosened, as in the hip-joint. Under these conditions the denuded end of the bone is seen to be covered with nodular granulation tissue filled with tubercles, caseous and otherwise. As the disease goes on the cartilage is destroyed or cast off in flakes, and the denuded bones are attacked by the tuberculous process and are eroded. As a result of this, articular cavities are enlarged and distorted, and distortions and subluxations may occur. The tonic muscular contraction accompanying joint disease tends in certain joints to crowd together the softened ends of the bones and hasten the wearing away.

Microscopical examination of the diseased area at any time before all structure is lost shows a typical granulating tuberculosis.

Thickening of the capsule, infiltration of the periarticular tissues, and thickening of the ends of the bones are clinical manifestations, and abscess formation and all the other complications are ready to follow.

About the affected joint is formed a layer of granulation tissue which may be converted into fibrous tissue. This process may be very extensive and accounts for such phenomena as the ovoid swelling in tumor albus and the thickening of the trochanter in hip disease. This fibrous tissue may be cedematous, and the spaces may contain a fluid reacting to stains like mucin.

Repair is brought about by the formation of fibrous tissue, probably arising from the layer of non-tuberculous granulation tissue which grows into and replaces the tuberculous material. Caseous material is largely absorbed, and the inspissated remainder is replaced by fibrous tissue or is calcified and encapsulated. Fibrous, cartilaginous, or bony ankylosis may result from the process of repair.

It is most important to note that the process of repair may be incomplete, and that small areas of tuberculous material encapsulated by fibrous tissue may persist for a long time and under favorable conditions may become active and cause a recurrence of the disease. This fact must always be borne in mind in forcibly manipulating convalescent tuberculous joints. Or the repair may be complete and the previously inflamed tissue be converted into cicatricial bone — usually more firm than the original structure.

Certain variations of this process must be described as other types of synovial affection from that described are found at times.

Arborescent tuberculous synovitis is the name given to a condition in which the synovial membrane is covered with branching arborescent tags frequently coated with fibrin. Sometimes a large amount of fatty tissue may be present, constituting the " lipoma arborescens."

Solitary tuberculous nodules of the synovial membrane are described. Nodular and even polypoid growths with little tendency to caseation

FlG. 6.— True Ankylosis of the Hip Joint. (Joachimsthal.)

project into the joint. Although at first the rest of the synovial membrane is but little affected, it becomes involved later.

Hydrops articulorum tuberculosus was a name given by Konig to a chronic effusion of joints said to be primarily synovial. In these there is said to be at first no marked thickening of the synovial membrane. Later the membrane assumes the typical character of tuberculous synovial inflammation. A similar condition of joints with a purulent effusion is described as "empyema tuberculosum."

It has always been asserted by writers on bone tuberculosis that primary disease of the synovial membrane occurred. Volkmann, however, as early as the writing of his classical monograph, said : " The fungous inflammations of the joints begin generally, and in children almost without exception, not at all as an arthropathy, but as a pure osteopathy, with a very circumscribed caseous or tuberculous ostitis." '

Nichols, 2 in one hundred and twenty tuberculous joints examined from children and adults, many from excisions, a considerable number from autopsies or amputations, did not see a joint in which, if all the bones entering into the joint were sawed open, one or more old bone foci were not found. Complete examination of a joint at operation is usually difficult and oftenest impossible, so that conclusions as to the absence of primary bone disease based upon such examinations must be accepted with caution.

Although primary tuberculosis of the synovial membrane is described by those whose statements carry great weight, the results of Nichols' investigations must be borne in mind, which are positive and not negative conclusions. And it may be assumed for clinical purposes, until the contrary is proved, that practically all tuberculous joint disease has its origin in bone.

Cold Abscesses of Joints. — If the tuberculous process in the bone reaches the surrounding tissues by perforation of the cortex and periosteum or by rupture of the joint capsule, an abscess is likely to occur. The area of tuberculous softening in the periarticular tissues is formed by the coalescence and caseation of tubercles. Surrounding the softened area is a layer of tuberculous tissue, about which is another layer of cedematous and vascular granulation tissue. This process may extend until a large cavity has been formed.

The contents of these abscesses are composed of caseous material from the degeneration of the tubercles and exuded serum with necrotic pieces of bone. In the fluid are polymorphonuclear leucocytes, often taking up little or no stain on cover slips. Pyogenic organisms are absent unless present by secondary infection. The fluid maybe like true pus ; it may be so thick that it will hardly flow ; it may be thin and watery and contain coagula, or it may be red or brownish from hemorrhage.

Microscopically tubercle bacilli may be found in the abscess, but they are to be identified, even after prolonged search, in only about one-third of the cases. In such cases inoculation experiments must be relied upon to establish their presence.

The wall of these abscess cavities is composed of an inner layer of tuberculous tissue, outside of which is a layer of secondary inflammatory tissue. The inner layer may be granular or necrotic and ulcerated. The abscess extends by peripheral enlargement in the line of least re-

-Nichols: Orth. Trans., vol. xi., p. 383.

sistance. The walls of tuberculous sinuses consist of an inner layer of tuberculous tissue, outside of which is a zone of cedematous granulation tissue.

Tubercle bacilli in the tissues are frequently found, though not invariably, as in the process of decalcification necessary to cut sections of bone for microscopic examination they may become so disorganized as to stain with difficulty or not to stain at all.

Inoculation of animals with tissue from bones and joints affected by this type of disease produces general tuberculosis, 1 and the disease may be experimentally produced in animals. 2

General miliary tuberculosis of bone occurs in connection with general miliary tuberculosis. The marrow is studded with miliary tubercles; necrosis and inflammatory reaction are slight or are absent. 3

ETIOLOGY.

Heredity. — That heredity is a factor in causing tuberculous joint disease has long been claimed. Whether the tuberculous virus can be directly transmitted as such from father or mother to the offspring must still be held open to question/ but that the surroundings of certain families weaken the resistance and favor tuberculous invasion appears not improbable.

Figures which attempt to show what proportion of children with joint disease inherit a tendency to these diseases are notoriously untrustworthy. In the class of hospital patients from whom most of these statistics come, anything approaching accurate information with regard to the diseases of which relatives have died cannot be expected. There is also an inclination on the part of parents to deny the existence of tuberculous disease in their parents and relatives. In this way parents of all classes are much more anxious to establish some traumatic cause for the affection of the joint than to have it supposed that the child inherited any constitutional taint. Again, it must be remembered that in a community in which approximately ten per cent of all deaths are from phthisis, phthisis must necessarily appear m the family histories of a certain proportion of any group of individuals whose antecedents are inquired into. For these reasons the statistics cannot be

1 Cheyne : British Med. Jour., April. 1891.

'-Deutsch. Zeit. f. Ch.. 1872. xi., 317.— Schiiller: "Exp. und histol. Untersuchungen." Stuttgart. 1SS0. — Cent. f. Ch.. 1SS6. No. 14.

:; Konig : Archiv f. klin. Chir.. 26, p. 822.— Caumont : Deutsch. Zeit. f. Chir., xx.. 137. — Krause : Deutsch. Chir.. Lief. 28a. — Deutsch. med. Woch., 1SS6. 9-13.— Cent. f. Chir.. 1SS7. p. 52.— Quoted by Barber: Brit. Med. Jour.. June 23d. 1888.— Pfeiffer: Fort, der Med.. 1888. No. 1, p. 33.— For further detail the reader is referred to the article of Nichols (Trans, Am. Orth. Assn.. vol. xi.), which has been freely used by the writers.

4 Cheyne : " Tuberculous Disease of Joints." p. 97.

io ORTHOPEDIC SURGERY.

regarded as other than inaccurate, and only approximating the truth, but the error is likely to lie always on one side, in making the proportion of inheritance too small. 1

Traumatism. — Experimentally it has been shown that trauma to the joint of a tuberculous' animal may cause tuberculous joint disease, but that it does not do so in the healthy animal. It has been established that contusions and wrenches cause the effusion of blood in the spongy tissue of the bone. Cases are seen in which tubercles develop directly from the clot, just as in a syphilitic individual a gumma may develop at the site of an injury to the bone. " There are cases in which the swelling from the fall merges into the tuberculous swelling." 2 It would therefore seem rational to assume that trauma caused tuberculous joint disease in children who inherited a constitutional taint. But it becomes evident at once that this is not all, for every surgeon of experience must have in his mind cases in which joint disease of a tuberculous type has followed injury in children whose family histories were exceptionally good.

From one-sixth to one-half of all cases would appear from the collected statistics to be traumatic.

In certain cases traumatism alone must be accepted as the causative factor, while in some cases no cause can be assigned.

The exanthemata must be mentioned as being the cause of tuberculous joint disease in a certain proportion of cases, probably a larger proportion than has been suspected. Measles and scarlet fever are the most common eruptive diseases to be followed by these sequelae. There are very few figures bearing upon the subject. The effect of the exanthemata in causing other forms of joint disease will be alluded to later.

The entrance of the bacilli is apparently most often through the respiratory and digestive tracts.

It is probable that whatever continuously diminishes the power of resistance and of repair in growing children increases what may be termed the vulnerability of the epiphyses, and furnishes the soil for the development of tubercle bacilli and the consequent results.

Age. — Tuberculous joint disease is pre-eminently a disease of childhood. It is not congenital, and under one year it is not common. The majority of cases occur between three and ten years of age. 3

1 Gibney : " Strumous Element in Joint Disease," N. Y. Med. Jour., July, 1877. ^-From preface of German translation of " The Mechanical Treatment of Pott's Disease."— Croft: Clin. Soc. Transactions, London, vol. xiii. — Nichols: Orth. Trans., xi., p. 358.

' 2 Konig : Deutsch. Zeit. fur Chir., 1879, xi.

3 N. M. Shaffer: "Am. Clin. Lectures," vol. Hi., 141; Sonnenberg: Arch. f. klin. Chir., 1881, xxvi., 789; Lannelongue : Loc. cit.— " Hip Disease in Childhood," p. 2. — L. A. Sayre : " Orthopedic Surgery and Diseases of Joints."

TUBERCULOUS DISEASE OE THE JOINTS. II

The liability of the aged to tuberculous joint disease must not be overlooked. 1 The patients may be seventy-five or ninety, and cases of hip disease present the same pathological appearances here as in young children. The course of the disease is more rapid and destructive than in the young, and its etiological relations are decidedly more obscure.

The reasons why tuberculous joint disease affects children to so great an extent are as follows :

In the active period of growth more change is going on and therefore more instability exists and consequently greater liability to disease. Children are more liable to falls and injuries, which are such a fertile source of joint and bone lesions. It is not till after puberty that the process of natural selection has eliminated the weaklings from the stock. Children are kept quiet less easily than adults, and a slight injury may develop into a formidable disease. Tuberculosis in general is common in childhood.

Sex is not a factor of any prominence, but there is a slightly larger proportion of tuberculous joint disease among boys than among girls.' 2

Distribution of Chronic Tuberculous Joint Disease. — The relative frequency with which tuberculosis attacks the various joints in children may be estimated from the following figures :

At the Children's Hospital, from 1869 to 1903 inclusive, 5,950 cases of tuberculosis of the joints were distributed as follows: spine, 2,867; hip, 2,281; knee, 375; ankle, 394; elbow, 33. These practically all occurred in children under the age of twelve.

In 211 cases of joint tuberculosis among the out-patients occurring in children under two years, there were 120 cases of Pott's disease, 61 of hip disease, and 29 of tuberculosis of the knee-joint. 3

Judson has called attention to the great preponderance of joint disease in the lower extremity as contrasted with the upper limb. Analyzing the reports of two orthopedic institutions in New York City, he found that in a single year the following number of cases of disease of the different joints were treated:

Hip-joint disease 577

Knee-joint disease 181

Shoulder disease 6

Elbow disease 8

or 758 patients had disease of the joints of the lower extremity, while in the same time there appeared only 14 cases of joint disease in the upper extremity.

In joint disease, when one or more articulations are involved, any

*" Clinical Lectures and Essays. Senile Scrofula," 2d ed., p. 345. -Gibney: Loc. cit., p. 206. 3 Thorndike: Orth. Trans., ix., p. 196.

combination may be found ; but the most common are hip disease and Pott's disease, knee disease and Pott's disease, and double hip disease. Disease of the knee- and hip-joint at the same time is not common, and double tumor albus is unusual.

DIAGNOSIS.

The recognition of tuberculous joint disease is to be based upon certain general phenomena modified by the anatomical conditions of the joint affected. These diagnostic signs are considered in connection with the individual joints.

The use of tuberculin as a means of diagnosis is open to the criticism that its results are attended with so much uncertainty that its value in the individual case is always open to question and cannot be assumed to be a reliable demonstration that tuberculosis is either present or absent in that case. 1 It has been demonstrated that in a certain per cent of well-marked cases of pulmonary or other tuberculosis, tuberculin gives a negative result, while in other cases, presumably non-tuberculous, a certain percentage of positive results is obtained. The great frequency of tuberculous invasion has been shown by the autopsies of Babes, 2 for example, who found lesions of the bronchial glands in more than one-half of his autopsies on children ; and those of Naegeli, 3 who found, in 508 consecutive autopsies, that 97 to 98 per cent showed evidences of tuberculosis. Under these circumstances tuberculin must necessarily be unreliable in demonstrating joint tuberculosis. 4

The inoculation of material from suspected joints into guinea-pigs forms a reliable means in the diagnosis of tuberculosis of the joints.

The x-ray is an aid in the diagnosis of joint tuberculosis where the process is sufficiently advanced to have caused the absorption of lime salts in the affected area or to have destroyed any part of the bony structure. In early cases the radiograph may be normal when disease is present.

PROGNOSIS.

The destructive process which is so prominent a feature of joint tuberculosis is almost from the first accompanied by a reparative process tending to limit the destruction, protect the surrounding tissues, and prevent generalization. The prognosis depends in the individual

1 F. W. White : Boston Med. and Surg. Journal, August 5th, 1898 (with bibliography). — Schliiter : Deutsch. med.Woch., 1904, viii.,30, p. 272 (with literature). Brit. Med. Journ., 1903, vol. ii., pp. 48, 96.

2 Babes, quoted by Burrell : " Surg. Tub. ," Trans. Mass. Med. Soc. , xix. , 1903. 3 Naegeli: Arch, fur path. Anat., vol. clx.

4 " Indirect Tuberculin Reaction." Bull, de lTnstitut Pasteur, t. ii., April 30,. 1904, P- 333- case upon which of these two processes prevails over the other. The former is favored by inefficient local treatment, bad inheritance, poor general condition, unfavorable surroundings, and, in general, what may be termed poor resistance to the tuberculous process. The reparative process is favored by the reverse of these conditions. In the majority of all cases of joint tuberculosis, properly treated at a fairly early stage, the outlook is favorable. The prognosis is more favorable in children than in adults.

TREATMENT.

Since bone tuberculosis has been shown to be one manifestation of tuberculous infection and not the result of an unknown evil, the principles of treatment are more clear.

Resistance to the infection by the tubercle bacillus is furnished when the individual is in a normal state. The antidotes to be relied upon to check its advance after it has found lodgment are not only good air and food, but such general activity as will promote normal metabolism. Tuberculosis is prevalent and fatal among caged animals — a fact which is to be borne in mind in the treatment of bone tuberculosis.

The treatment is both general and local. The general treatment consists in giving the patient the best possible environment and in furnishing such conditions that normal activity will cause the least possible injury to the part locally affected.

In tuberculosis of the lung the patient is in constant danger of selfinfection or increase of the process from the inhalation of infected material. In bone tuberculosis no such danger exists. Strong, well ossified bone does not offer suitable soil for the bacillus. Bone tissues when invaded resist the advance of tuberculous infection by surrounding the diseased area with a thick enveloping mass of tissue and by subsequently repairing the invaded region by the development of strong bone. Traumatism, which injures this bone construction and furnishes undeveloped cells instead of firm bony structure, favors the spread of the tuberculous process.

The treatment of bone tuberculosis, therefore, consists in promoting such general conditions as will favor repair (general treatment) and the protection of the parts from injury during the disease (local treatment).

General Treatment. — The patient should be placed in the most favorable environment available in the matter of food, home surroundings, air, sunlight, proper clothing, exercise, avoidance of fatigue, and similar requirements.

Outdoor Treatment. — Of these requirements outdoor air is of the utmost importance, and the open-air treatment of surgical tuberculosis ' is nowhere more beneficial than in joint disease. The outdoor

1 Burrell : Comm. Mass. Med. Soc, 1903, xix., 11, p. 303.

method recognized as of such value 1 in the treatment of pulmonary tuberculosis is advisable. 2 During the day the patient should be out of doors or in a room with one or more windows open. In winter proper protection against cold should be obtained by warm clothes rather than by heated rooms. Such patients should sleep out of doors in tents or well-aired sheds. During the summer this offers little difficulty, and in the winter such treatment is available even in a New England climate. From Christmas, 1903, through the winter, the patients at the Convalescent Home of the Children's Hospital at Wellesley, with Pott's disease and hip disease, lived and slept in an unheated shed with skylights or doors open. Properly protected by woollen caps and heavy blankets, they suffered no discomfort, and the beneficial effect on the local process was evident.