The Conservative Treatment of Knee-Joint Infections BY HORACE J. WHITACRE, M. D., CINCÍNNATI The infections of the peritoneal cavity are well understood, and their treatment has been reduced to a condition of almost scientific, accuracy. A fair understanding of the principles of bacteriology and the surgical methods of circumscribing bacterial invasion have made it possible for the surgeon to open the peritoneal cavity with safety, and to promptly establish conditions favorable to the forces of vital resistance. These same principles of aseptic surgery that have made it possible for the surgeon to invade the peritoneal cavity have revolutionized the treatment of the joint cavities of the body. It is now an accepted fact that a joint can be opened with just as much safety as the peritoneal cavity. It has furthermore been demonstrated that the prompt and efficient operative treatment of infections of joints will give the same good results that have been obtained in the peritoneal cavity. These, I say, are accepted facts, yet they are not practiced facts. I am satisfied that a timidity still exists even among surgeons in the invasion of joints that their better judgment tells them should be opened. I am certain that the general practician too often postpones surgical consultation or exploratory puncture beyond the stage of joint destruction. The early treatment of joint infections by free irrigation or drainage will give results that are surprising,— it will give moveable joints,--and it will give useful joints. The curse of articular disease is that of phantom-rheumatism. More ignorance seeks shelter under the protecting haze of this magic and to the layman all satisfying word, and more life-long disability has resulted from such practice than can be placed to the credit of that other mantle of ignorance, a touch of malaria. There is scarcely a physician who does not know of some one or more cases of joint trouble which have been treated month after month for rheumatism, and until burrowing pockets of pus, tubercular or pyogenic, have riddled the surrounding tissues, and broken externally to form persistent sinuses. The cases of this sort that apply to a large surgical hospital for treatment are legions. The results of surgical treatment applied to joints that have reached this stage of destruction are disappointing to the patient, to the friends, and to the surgeon. Functional results are impossible to the surgical pathologist. It has seemed to the writer that this is a neglected subject in medical society work, and one that should be more often discussed in representative bodies of this sort. It is the purpose of this paper to present certain general principles of treatment in joint lesions which the writer believes to be valuable. In general, a conservative line of treatment would, according to the Century Dictionary, be one which is preservative; one having power or tendency to preserve in a safe or entire shape; one which protects from loss, waste or injury. The term conservative is too often employed in medicine as a synonym for the nonoperative treatment of surgical diseases, whereas it should in reality have the opposite application in a certain very large percentage of cases.. That which conserves most in a bleeding artery is to cut down and tie the vessel, in a felon to lay the finger wide open, in suppurative nephritis to expose and split the kidney from end to end. To the author's mind there is no one site in the human body which better illustrates the meaning of this word "conservative" than the joints. A joint is an anatomic structure which is arranged for the connection of the various bones of the skeleton. The knee-joint consists of the expanded ends of two bones accurately moulded to meet the requirements of a combined hinge and arthrodial joint. The surfaces of these bones are covered by beautifully moulded articular cartilages. The bones are held together by a most complex system of external and interna1 ligaments, and the entire interior of the joint is covered by a delicate, shining, synovial membrane which secretes the most perfect lubricating fluid. Every anatomic element in this complex mechanism is essential to the physiologic integrity of this joint and every anatomic element must be conserved to the very utmost when this joint becomes diseased. A single line of conservative treatment cannot be fixed upon for such an anatomic structure. The particular form of conservatism that must be practiced will be determined entirely by the nature of the pathologic lesion present. Conservatism will at one time mean "hands off"; again it will mean simple aspiration, sometimes aspiration and antiseptic irrigation through cannulas, or perhaps it will mean an incision from one condyle to the other which will lay widely open the joint and quadriceps bursa. The all-important consideration is to save the functional value of the joint, and we should study how best to accomplish this end. The question is at once reduced to a pathologic basis. We must first learn exactly what anatomic change to expect in a given lesion, then we must apply that method of treatment which will most promptly arrest this process. It will serve the purposes of this paper to divide the lesions of the knee-joint as follows: 1. Simple synovial inflammations that are usually not destructive. 2. Subacute infections by the gonococcus and tubercle bacillus. 3. Acute pyogenic infections of the closed joints. 4. Lacerated wounds opening into the knee-joint. SIMPLE SYNOVIAL INFLAMMATIONS The simple synovial inflammations result (1) from mechanic causes, such as a blow, a sprain or a floating cartilage. (2) From chemic causes, such as bacterial toxins in septicemia, diphtheria and scarlet fever. (3) From direct infections by bacteria which do not usually cause a destructive inflammation. When a floating cartilage is caught between the articular surfaces of the knee-joint a reaction occurs in the synovial membrane which is a pure example of a simple inflammation of mechanic origin. The synovial membrane alone is inflamed, yet perfectly intact, and more synovial fluid is secreted than is normal. The joint becomes distended with fluid, and gives the usual symptoms of inflammation. The removal of the cause in this as in any other form of mechanic inflammation will result in a complete cure of the condition. This can be done by placing the patient in bed and by immobilizing the joint. A plaster of Paris encasing the splint will usually give the most satisfactory immobilization unless it is thought wise to make hot or cold applications to the joint. In this event a well-padded and well-applied board splint, a posterior strapsplint of plaster of Paris, or an interrupted plaster encasing cast will serve the purpose. It seems unnecessary to do anything more for this type of synovitis. The pathology of the second variety of mild reactionary inflammations does not seem so clear. It is a well-known fact that patients suffering from septicemia, or septic intoxication, very often present symptoms of an acute inflammation in certain joints, which, however does not go on to suppuration. The joint becomes painful, reddened, sometimes much swollen and its functional value is impaired, or lost. This inflammation subsides promptly, and the joint returns to normal. It is possible to explain this lesion in two ways; either as a chemic inflammation resulting from the concentration of bacterial toxins in these particular tissues, or as a mild infection by the bacteria themselves which is overcome by the forces of vital resistance. It has seemed to the writer that a chemic irritation is the most rational explanation of the transient forms of joint inflammation, yet the possibility of bacterial infection and metastatic abscess should be constantly borne in mind. The treatment of such a joint will divide itself naturally into two parts, the local and the general. The joint must be completely immobilized, and hot or cold applications of aluminium acetate or other wet dressing applied. The general treatment will be directed to the primary source of infection and to the elimination of the toxin contained in the blood. The third variety of simple synovial inflammations are those that result from the infection of a joint by bacteria and which usually do not cause a destructive inflammation. Such inflammations occur in articular rheumatism and in the mild infections by the gonococcus. The gonorrheal form of infection alone will be considered. The author has repeatedly treated cases of monarticular "rheumatism," occurring during the course of a posterior urethritis, which begin with slight lameness, some pain, no redness and usually a joint effusion. The patient usually consults,his physician one, two or three days after the onset of the trouble. The application of a plaster of Paris splint, rest in bed and the administration of urotropin have regularly caused the joint inflammation to subside and these patients have regained a perfect knee-joint. The lesion in these cases is undoubtedly a serous synovitis which has resulted from a mild infection by the gonococcus and which the forces of vital resistance have been competent to overcome under favorable conditions. We have thus far considered three conditions,—traumatic synovitis, chemic synovitis and mild bacterial infection of certain forms, in which the rational and the conservative treatment is rest alone. SUBACUTE INFECTIONS BY THE GONOCOCCUS OR TUBERCLE BACILLUS A certain percentage of knee-joints that are infected by the gonococcus do not follow the mild course that has been described above. When an infection is more severe or the infecting diplococcus more virulent than in these mild cases, the effusion into the joint takes place more rapidly and this effusion becomes purulent. There is an involvement of the articular cartilages, and the periarticular tissues. All of the local symptoms become severe, and mild or severe constitutional |