The principles and practice of modern surgery

by Roswell Park

The surgeon as such is perhaps the more concerned in the treatment of abscesses which frequently complicate these cases. Much that has been already said about psoas abscess will apply here. It is a question requiring considerable discrimination as to just how to treat a small, cold abscess about a diseased hip. Much will depend upon the environment of the patient, i. e., upon the attention and expert care which he may receive. Such abscess should be treated kindly, i. e., by nothing more severe than aspiration, until ready for more radical treatment. By the latter term is meant readiness for following it down to the joint cavity and exsecting the head of the bone, if need be, following this with extirpation of the capsule, etc. When there is actual pyarthrosis the condition of the patient is sufficiently serious to warrant radical measures. Extra-articular abscesses are apparently quite common, yet most of these, if carefully traced, will be found to lead through the periosteum at some point into the osseous structure beneath. Such abscesses are, moreover, multilocular, and have ramifications in even unsuspected directions which should be followed with the sharp spoon and the caustic, in order that absorbents may be seared and that no infectious material remain. Old and persistent fistulas should also be treated kindly until one is ready to be radical. Some long-standing cases will heal after absolute physiological rest of the joint, i. e., by fixation in plaster-of-Paris splint, with openings opposite the fistulas for dressing purposes. The general constitutional condition of patients with these lesions is a predominating factor in their improvement—a fact which should never be forgotten.

The deformity which has resulted from old, long-standing, and quiescent hip disease affords opportunity for the best of surgical judgment. It is possible to effect great improvement in position by subcutaneous osteotomy after ankylosis, but this should not be attempted during the active stages of the disease.

The question of excision of the hip-joint is one of importance. In few other instances do social surroundings or factors enter so largely into the question of surgical judgment. The wealthy can afford long-continued treatment, which to the poor is prohibited, and one may be tempted in one case to exsect early when, under other conditions, he would treat the case tentatively. Nevertheless certain indications make the operation expedient in all cases, as, for instance, when the destructive process is steadily progressing or so acute as to shorten not only the limb but life itself. It is necessary also when there is necrosis, and in most instances of suppuration extending into the joint cavity. In those cases where skiagrams confirm other indications to the effect that the disease is localized in the neck or head of the femur, Huntington’s suggestion may be adopted, after exposing the upper end of the femur, to drill or tunnel in the direction of the neck until its diseased focus is reached and thoroughly clean it out. In cases treated otherwise conservatively, yet accompanied by a great deal of pain, especially those of the femoral side of the joint, one may frequently get relief by exposing the upper end of the femur and making ignipuncture in the same direction as above.

In general it is impossible to lay down succinct rules for the treatment of hip disease. Cases differ so greatly in location, in severity, as well as in environment and their personal surroundings, that what is advisable in one case is not to be thought of in another. Of the mechanical features of treatment one may say that that is the best splint or apparatus which best meets the indication in each particular case, and that none will be effective in which the element of traction is neglected, nor that of physiological rest. No patient should be released from treatment whose hip is still sensitive or in whom there remains any muscle spasm. Rest and protection should be maintained for months and even years after apparent recovery, while the same attention should be given to diet and climatic surroundings as in any other case of well-marked tuberculous disease.

TUBERCULOUS DISEASE OF THE KNEE-JOINT; TUMOR ALBUS.

This subject deserves special consideration, mainly because of the peculiar deformity produced by the disease rather than any of distinctive peculiarity in its nature. Years ago it received the name of tumor albus, and is frequently called white swelling by the laity, because of the pallor of the surface and the increased dimensions of the limb due to thickening, always of soft parts, and usually of the bone itself. The disease may begin in either epiphysis, in the patella, or in the synovial membrane, oftener in the bone in the young and in the synovia in adult cases. Its most distinctive feature is the deformity produced by excess of muscle spasm, the hamstring muscles especially producing a backward subluxation which frequently fixes the knee, not only at a right angle, but with very much disturbed joint relations, so that the head of the tibia is in contact with the posterior surface of the condyle rather than with their proper terminal areas. The soft tissues outside of the bone are frequently very much thickened and infiltrated, often edematous, while the joint cavity may be more or less distended with seropus or with old pyoid material. The exterior surface is so anemic from deficient blood supply as to make it appear comparatively white, while the superficial veins are made much more prominent by their engorgement owing to obstruction of the deep circulation. The picture, then, of an advanced case of tumor albus is quite typical.

Here the joint cavity is so large that there is early effusion of fluid, in most cases, which is in this location easily recognizable; hence the distinctive symptoms consist of pain, tenderness, swelling, limp muscle spasm, with, finally, limitation of motion, deformity, and atrophy. In addition to these features there may be added those due to the formation and the escape of pus, i. e., one may have the signs of acute or old suppuration, while the parts about the joint may be riddled with old sinuses. The deformity of these cases is usually characterized by a certain amount of external rotation of the leg, while a species of knock-knee is not uncommon. Actual lengthening of the limb due to overactivity at the epiphyseal junctions may also be noted.

Treatment.

—The treatment of white swelling is based upon the principles already laid down for the treatment of spinal and hip caries, the underlying feature being traction to a degree sufficient to overcome muscle spasm, unless it be too late to permit a subsidence of active changes. When seen early a few weeks of confinement in bed, with effective traction, followed by fixation with plaster-of-Paris bandage, combined with the [Thomas splint] (see above) or with some other form of more elaborate apparatus, by which rest and traction can be continually maintained, will be needed. The presence of tuberculous disease about the knee permits of the application of the elastic bandage above the knee, by which the congestion treatment of Bier can be more or less effectually carried out. It would, however, be a mistake to rely entirely upon this to the neglect of traction and rest, nor should too much be expected of it in severe cases. It is a method to be used early rather than late.

The final resort is excision, which is practically adapted to cases of moderate type in young adults, where the bones have attained their full growth and where it will afford a prospect of cure in a minimum of time. It is undesirable in children because it is so often necessary to remove the epiphyses, and because of the arrest of development that follows such removal and the consequent shortening of the limb. Nevertheless even in children it may be demanded and may be considered as a resort superior to amputation, the latter being reserved usually for a life-saving measure or for desperate cases where destruction has been practically complete and the limb is hopelessly useless.