TUBERCULOSIS OF THE KNEE-JOINT AND OTHER CASES IN ORTHOPEDIC SURGERY.*

BY DANIEL W. MARSTON, M. D., NEW YORK CITY.

INSTRUCTOR IN ORThopedic SURGERY IN THE POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL; VISITING SURGEON TO THE DAISY FIELDS HOSPITAL FOR CRIPPLED CHILDREN.

[PUBLISHED IN Che Physician and Surgeon EXCLUSIVELY]

THE first patient this afternoon is a typical case of the suppurative stage of tuberculosis of the knee. It presents many clinical features that we do not often see, except in the neglected cases from the crowded tenement districts. This boy is ten years old and has a tuberculous family history. The story of his present illness dates back sixteen months, when, while playing ball with his schoolmates, he received a fall which caused more or less lameness in the left knee. At the time of the acci.dent the injury was regarded as trivial and the boy, although a little lame, was allowed to continue at school. In a few days, however, the symptoms increased in severity, the lameness was especially marked, and the little fellow complained of considerable pain, particularly at night. The usual routine treatment of blisters and poultices was then instituted, but without the least benefit to the patient. The knee gradually became much larger, the flexion more marked, and the boy was unable to straighten the limb. At this time he was taken to a clinic where the limb was enveloped in a plaster-of-Paris dressing and the mother instructed to bring the youngster back for further treatment in about two weeks. This dressing was continued intermittently for some months, but did not prevent the formation of an abscess in the joint, which was allowed to rupture spontaneously. The sinus that you now see has existed since the evacuation of the abscess cavity.

* Delivered at the New York Post-Graduate Medical School and Hospital, November, 18, 1900.

It is of the treatment of this kind of cases that I will speak particularly. The etiology and pathology is practically the same as that of hip disease about which I lectured last week. At first the treatment is of course largely prophylactic. If these cases are seen early in their history it is possible with proper care to avoid the extensive destructive changes present in this joint. The treatment is both constitutional and local, although too often one or the other of these is neglected. Constitutional treatment consists of plenty of good food, good air, cheerful environments and careful attention to the general health. Beefsteak, cream and eggs are better general tonics than cod-liver oil and creosote. These drugs, however, have their place in the treatment of these cases; too often to the exclusion of the more common dietetic agents. I have noticed in this hospital that after operations upon cases coming from the overcrowded sections of the city, if the little ones are returned to their tenement homes the disease often recurs and they are again seen at our dispensary, candidates for further operative treatment. If they are sent to our country hospital at Englewood they usually make a permanent recovery, which certainly proves the value of combining hygienic treatment with the mechanical and operative.

When a case of knee-joint disease comes to your office it is a good plan to first of all be sure of your diagnosis. The child's gait will teach you a great deal, as I have often showed you here. Having seen the patient walk, repeat to yourself mentally, at least, if not verbally, that magic combination of symptoms which will unlock the diagnosis of any case of joint disease. See how many there are present out of the eight: (1) Pain.

(2) Heat.

(3) Swelling.

(4) Pain upon joint pressure.

(5) Limited motion.

(6) Atrophy.

If you are able to detect any three of these symptoms you can rest assured of your diagnosis. Physiologic rest is an important factor in the treatment of these cases. Put the patient into bed. Apply extension to reduce the deformity caused by the muscular spasm. Direct your extension in the line of the deformity. You will recall what I said of. lateral traction in the axis of the neck of the femur in the hip cases last week. In the case like the one now on the table, wherein the knee is considerably flexed, do not apply your extension to the leg and then simply throw the weight over the foot of the bed. By so doing you will create extension, it is true, but the patient will bitterly complain of the pain caused thereby. This is because you are making a fulcrum of the contracted hamstring tendons and with the tibia as a lever are creating intraarticular pressure. To apply the extension in the direction of the deformity it is best to put a hook into the ceiling and from it run a wide bandage behind the head of the tibia. This will lift the head of the bone forward, and will prevent the longitudinal traction over the footboard from creating the painful and destructive intraarticular pressure. Place pillows around the limb to protect it from the slightest jar.

A leg like this one will take an extension weight of four pounds, possibly increased to seven, and will require two weeks time at least to

straighten. Apply the extension straps as in hip disease, but do not run them above the knee. When the deformity is overcome and there is present no muscular spasm, place the child on a large sheet of wrapping paper and trace an outline of the limb from the tuberosity of the ischium down along the inner side of the limb and around the sole of the foot and up the outer side of the leg to half an inch above the trochanter major. Take the circumferential measurements at the groin and just above and below the knee. Send these measurements here and a brace like the one my assistant will show you is made. This is known as the Thomas. knee-brace. THOMAS, of Liverpool, however, did not believe in extension, and that feature of this brace did not originate with him.

The measurements above and below the knee are important, for unless these bands are properly adjusted there may occur a tendency to subluxation of the tibia. These bands draw the head of the tibia forward and hold backward the lower end of the femur The shoe of the opposite side should have an elevation of two inches applied to the sole. This brace has several advantages over plaster-of-Paris. It is light and cool and provides extension that can be regulated by the attendant. In overcoming these deformities force is to be avoided, as by such methods it is possible to create a traumatic dissemination of the germ life which has caused all this disturbance. You will not see all cases in the incipient stage, and abscess formation may have already taken place when the patient comes under your care. In all such instances immediately evacuate the abscess cavity, with all antiseptic precautions, and remove all necrotic tissue either in the soft parts, or in the bone. In previous years many surgeons have objected to this radical treatment of these abscesses on the ground that free incision opened up fresh area for further septic inoculation. It is now our custom to forestall this possible complication by a method inaugurated in orthopedic work by DOCTOR PHELPS, and which consists of a literal baptism of the abscess cavity with pure carbolic acid, allowed to remain in contact with the tissues for exactly one minute. Absolute alcohol is then generously applied and neutralizes to some extent the caustic action of the acid. Bichlorid of mercury solutions are then used in irrigating the joint. I no longer use the old collapsible rubber drainage tubes, but am committed to the use of glass tubes not unlike the old Ferguson speculum. These I use in sizes proportionate to the width of the incision and allow them to remain as the wound heals from below.

Typical restriction of the knee-joint in children under fifteen years is not now recommended when any other treatment can be substituted, because of the subsequent shortening of the limb. A thorough scraping, operating, or arthrodesis is preferred which does not interfere with the development in the epiphyseal line. In patients of mature years, excision is performed. Following any such operation the joint should be protected for at least eighteen months or two years. The injection of iodoform emulsions I have entirely discarded, and this method is now never used in the hospitals with which I am connected. The aspiration of joints of this kind is worse than useless and a waste of valuable time. I wil: have this patient admitted to the hospital and will show him to you after a week's treatment.

HERE is a case of cured hip disease. This little woman came to our clinic some five years or more ago. A Phelps lateral traction hip-brace:

was applied, which she wore for four years. Neither did anyone move it for her. Both passive and active motion of the knee and hip were strictly forbidden, and, by the application of that brace, made impossible. Yet, here she walks with freely movable joints. She has no angular deformity. The limb is half an inch shorter than its healthy mate, but this is not noticed because the shoe is built up in the sole. With hip cases treated with this hip-brace no patient need recover with angular deformity. Such cases are not seen in this clinic unless they come from other institutions where they have been allowed to wear the old-fashioned "long traction brace" which does not immobilize the joint or afford it much protection.

THIS case just placed upon the table is one in which I show you another excellent case of knee-joint disease, presenting the characteristic deformity. As you see, a plaster-of-Paris dressing has been applied from the middle of the leg up to the groin. You wish to know, however, what is the pathologic condition present in the joint; it is not enough to know that there is disease in the knee-joint. You observe that the limb is flexed, the foot is rotated outward and that there is partial dislocation or subluxation of the tibia backward, which produces the outward rotation of the foot. The flexion is caused by the spasm of the flexor muscles, notably the biceps. She complains of pain, there is evident swelling, there is perceptible elevation of the temperature of the part, there is pain on joint pressure, there is marked atrophy, spasm of muscle and deformity.

It cannot be synovitis as there is no effusion. The disease is both intracapsular and extracapsular, because the pain on joint pressure shows that there is intracapsular disease, and the swelling indicates that there is extracapsular disease. The thickening of the bone and the atrophy of the limb indicate that the disease is in the bone. The pain is referred to the inner condyle, so I can locate the focus of disease. When I pull on the internal lateral ligament she says it hurts. She will be admitted to our orthopedic department and I will apply fixation and extension until the deformity is overcome. She will then be another candidate for the Thomas knee-brace.

OUR next patient is this case of flat-foot. The man tells us that the trouble with his foot is due to his slipping down stone steps. The foot at first became a little flattened, then a trifle everted, as you see it now. He has been wearing a shoe with the sole built up on the inner side after the manner advocated by THOMAS. His idea was that by this means the weight of the body would be taken off the scaphoid bone. If I draw a line from the spine of the tibia downward to the foot, you will see that it passes far to the inner side of the foot, whereas it should pass through the center of the tarsus. As a result of this deformity, the weight comes upon the os calcis, the cuboid bone and the ball of the great toe. The weight of the body should fall equally on these points. When from any cause the entire foot is swung outward and the arch is at the same time flattened, we have the condition found in this case. He complains of pain where the fibula presses on the os calcis and on the sole of the foot as the result of the tension of the fascia. The cause of this man's trouble was trauma. Another etiologic factor is paralysis of certain groups of

muscles. A third cause is stretching of the ligaments and fascia in the sole of the foot. An illustration sometimes mentioned by DOCTOR PHELPS in this connection is, that when an architect builds a bridge, he not only puts in a keystone, but places an anchorage on either side to prevent the sides of the arch from spreading. Of course a "stringer" can be used instead of these anchorages.

This "stringer" in the human foot is the plantar fascia. As soon as the arch spreads slightly, the keystone of the arch will be pressed upon its upper border, the keystone becomes crushed, and the integrity of the arch is destroyed. In the foot the arch is made up of the os calcis, scaphoid, astragalus, cuneiform and metatarsal bones on the inner side. The arch is held by the plantar fascia and deep ligaments. If these "stringers" become stretched from any cause, such as traumatism, or if in early life from any cause the arch becomes flattened, greater pressure is brought upon these parts and the keystone of the arch, the scaphoid bone, is subjected to unusual pressure. This results in inflammation of the mediotarsal articulation and spasm of muscle. The advantage of leverage is thus given to the peronei tendons, which pull harder, thus converting the foot later on into a valgus. As the foot turns outward the external malleolus impinges against the os calcis, and this causes the inflammation and pain.

This cannot be confounded with tuberculosis of the tarsus, for in that condition the disease is always located at the mediotarsal articulation. The swelling is located higher up and is associated with great tenderness. In flat-foot the pain and tenderness are located directly at the mediotarsal articulation. These cases frequently are treated for rheumatism by practitioners who are not familiar with flat-foot. There should, however, be no trouble in differentiating them.

The treatment of this condition is to place the foot in such a position that the weight of the body will be transmitted through the cuboid bone and not through the scaphoid. Support of the foot so as to hold up the anteroposterior arch, and also prevent the spreading of the transverse arch of the foot is also necessary, The best method of treatment is to etherize the patient, and then with the hands pull the foot around so as to relieve the injurious pressure and then apply plaster-of-Paris. If the peronei tendons resist too much they may be divided subcutaneously, This plaster dressing will be kept on for ten days. The rest thus secured for the foot will allay the inflammatory action. After this it will be proper to use for a support to the foot a certain form of flat-foot plate.

ROBERTS, of Philadelphia, devised a good plate, YOUNG, of the same city, modified the Roberts plate, making it less cumbersome. WHITMAN, of this city, has made a plate that I like very much, and one that I am accustomed to use in cases of this sort. The plate projects above the outer and inner side and extends from the ball of the foot to the heel. First put the foot up in plaster-of-Paris and procure an impression of it. Using this as a mold there is obtained a plaster cast of the foot. At the foundry an iron mold of the foot is made. The instrument maker uses this iron last for his pattern and over it hammers a thin light plate.

These plates, like all of our braces and the aluminum corset, are made in our orthopedic workshop in this building, where you may all witness the different stages of manufacture. Tomorrow I will take the impression of this patient's foot, and you will see the plates fitted to his foot here in about a week from this date. The operative treatment by Paquelin cau