PLATE XXXIV
Normal Knee-joint. (Child, seven years old.)
Tuberculosis of Knee, with Partial Dislocation. (Child, seven years old.)
With a better appreciation of the pathology of the condition numerous methods were devised by which the germs should be attacked in loco. Thus various antiseptics have been injected in varying strengths, either into joint cavities or around them. Lannelongue devised a “sclerotic method,” by which zinc chloride solutions were injected into the peri-articular tissues, to so condense and harden them as to imprison and destroy their contained germs. The method, however, is an extremely painful one and has not found general favor. For a long time iodoform was employed for the same purpose, in emulsions of 10 per cent. and 20 per cent. strength, in sterilized glycerin or olive oil. It affords a curious paradox that the iodoform itself must be sterilized before being thus used. This emulsion has been injected into the peri-articular tissues or into joint cavities, which, when containing appreciable amounts of fluid, should be first emptied and washed out; all of which can be done through the same small trocar used for introduction of the iodoform. The verdict of surgeons today is rather against the employment of iodoform, since they have learned to not rely upon it because of disappointment so often following its use.
Bier, in 1891, advised the so-called congestion treatment of tuberculous joints, basing it upon the fact that tuberculosis does not develop in lungs which are the seat of venous stasis from valvular heart disease. He proposed to produce an artificial stasis, in the joint structures and about them, by which living germs should be destroyed and their disease products encapsulated, claiming that as the result of the hyperemia thus produced the alexins are thus brought into more complete contact with the bacilli. The method is applicable to the limbs below the shoulder and hip. It consists in the application of an Esmarch bandage above the affected joint, applied with sufficient firmness to obstruct the returning blood, but not to interfere with the arterial supply. If there be room the limb is also bandaged below the joint with an ordinary cotton roller. This congestion is kept up at daily intervals for increasing periods, beginning with perhaps half an hour and continuing until it is in operation at least half of the time. Meantime other methods of treatment are not interdicted. In the earlier stages of tuberculous joint disease this method has given very encouraging and pleasing results. (See [Fig. 208].)
Tuberculous hydrops may be treated by aspiration and elastic compression. Should fluid distend the joint it should be opened and thoroughly cleaned, then closed and perhaps drained.
The treatment of pyarthrosis and of peri-articular cold abscess has long been a mooted subject. The orthopedic surgeons still adhere to mildly or absolutely non-operative measures, whereas the general surgeon prefers to adopt more radical methods. Each case should be judged on its own merits, and these should include a careful estimation of the general condition of the patient. Should evidences of septic intoxication be present or the ordinary general signs of the presence of pus, then these collections should be opened and cleaned out. If hectic can be excluded, then other considerations will indicate what is best. At all events there will be seen many cases where a delay in operation will be advisable, in order to permit of improvement of the general condition by measures above described. To merely open up a tuberculous focus and leave at least two fresh raw surfaces exposed to contamination is rather to invite the spread of the disease than to correctly meet the indication. Every old focus will be lined or surrounded with a more or less dense membrane formerly called pyogenic, but now more correct knowledge shows it to be pyophylactic. (See [p. 113].) To leave this in situ is to leave germ-laden walls, while to dissect it thoroughly is to make a larger, fresh raw surface and to open up innumerable absorbent vessels. Thus, whether it be removed in whole or in part, or allowed to remain, some sufficiently strong caustic material should be promptly employed, by which both destruction of living residual germs and closure of the mouths of the absorbents shall be effected. This has been set forth more fully when dealing with cold abscesses in general, but is of so much importance that it may be reiterated here. Whether the actual cautery, pure carbolic acid, strong zinc chloride solution, or some other agent be used should depend upon circumstances, but every portion of the surface which it is proposed to leave more or less exposed to the possibility of infection should be thus protected. In proportion to the intensity of the caustic action there will be separation of more or less cauterized and sloughing material, for whose escape provision should be made; but it will be separated by the granulation process, aided by an active phagocytosis, and when removed will leave a granulating surface which is but slightly absorbent. These facts pertain to small incisions for drainage as well as to extensive arthrectomies.
The operative treatment, then, of tuberculous arthritis varies from tapping, with or without drainage, to complete arthrectomy or amputation. When the joints of the foot or ankle are extensively diseased, and the patient, as usually happens, is in poor condition, it may appear that amputation will afford the most complete relief, and that a stump with an artificial member will be of much more use to the individual than a mutilated, tender, and disabled foot.
Fig. 208