ANNUAL ADDRESS OF THE 
ORATOR OF THE SEC- 
TION ON SURGERY. 
THE MODERN ANTI-BACILLARY TREAT- 
MENT OF TUBERCULAR 
JOINT-DISEASE. 
BY I / 
CHAS. B. NANCREDE, M. D., 
Ann Arbor, Mich. 
REPRINT OF TRANSACTIONS OF 
MICHIGAN STATE MEDICAL SOCIETY, 
1892, [Reprint from Proceedings of Michigan State Medical Society, 1892.] 
ANNUAL ADDRESS OF THE ORATOR OF 
THE SECTION ON SURGERY. 
THE MODERN ANTI-BACILLARY TREATMENT OF TUBERCULAR 
JOINT-DISEASE. 
CHAS. B. NANCREDE, M. D., 
Ann Arbor. 
The addresses before the various sections of this Society 
must of necessity, while dealing more especially with the surgi- 
cal, medical, or special aspects of their subjects, yet be of such 
a character as shall interest in some measure the general prac- 
titioner, as well as those who devote their attention almost 
exclusively to one branch of our art. 
Casting about in my mind for a theme which should fulfil 
these conditions, the subject of the modern anti-bacillary treat- 
ment of tubercular diseases of the joints has appeared to me one 
about which special interest clings, quite as much for the family 
attendant as for the surgeon, because it is the former who is 
first consulted; it is the general practitioner who usually deter- 
mines, by the initial treatment adopted, whether conservatism 
or destructive operative treatment must prevail; whether life? 
with a more or less useful limb, or life after mutilation shall 
perchance be secured, although too often the prolonged suffer- 
ings end only in death despite the attempt at conservative 
mutilation by erasion, excision, or amputation of the diseased 
member. I am confident that a wider appreciation of the possi- 
bilities and ease of application of modern conservative treatment 
by the family attendant is gradually diminishing the frequency 
with which the knife is now resorted to, and it is my hope that 
what I shall present for your consideration may in some wise 
further the same end. 
The time at my disposal will admit of my doing little more 
than contending for the applicability of certain general princi- 
ples of treatment to all cases, with the modifications requisite to 2 
STATE MEDICAL SOCIETY. 
meet the indications for special exceptional ones. An indispens- 
able preliminary, however, is a brief consideration of the 
pathology of tubercular joint-disease to ascertain how nature 
effects cures-for this she often does unaided, nay, in the teeth 
of so-called art. 
It is only requisite to state the well-known fact, that while 
tubercular joint-disease may originate primarily in the constit- 
uent bones or the synovial membrane of a joint, in advanced 
cases all the articular structures become involved, to demon- 
strate that therapeutic measures adapted to one class of cases 
or the earlier stages of the disease are not of equal value in all 
varieties, or the later stages. 
Study with me the natural history of tubercle wherever situ- 
ated. Whether caused by the growth of the tubercle bacillus 
itself, or the ptomaines produced by the development of these 
micro-organisms, a more or less modified granulation-tissue 
results, which, from its lack of proper blood supply, or the effects 
of the ptomaines, undergoes coagulation-necrosis, in whole or in 
part. 
What further changes are possible? And can we take a 
hint from them to guide us in our therapeutic measures? Under 
favorable circumstances, the bacilli being few in number or dying 
out early from increased resistance of the tissues, however 
induced, the caseated mass is removed by absorption for the 
most part, leaving behind only the inorganic portions, perhaps 
increased by some infiltration of lime salts, nothing but a 
cretaceous mass remaining encapsuled by connective tissue and 
of no further pathological moment. Under a still more favor- 
able environment, with the cessation of the cause, the granula- 
tion-tissue, in whole or in part, carries out what may be termed 
its normal function, being converted into scar-tissue, a healthy 
cicatrix taking the place of the tubercular tissue. The thera- 
peutic lesson to be learned will be specifically mentioned later on, 
but must be apparent to you without special explanation. 
If, however, the resistance of the surrounding tissues to the 
germs is not sufficient to destroy them, or the exhaustion of 
nutritive materials for their growth does not occur, the coagul- 
ation-necrosis is followed by a caseation which, instead of CHAS. B. NANCREDE. 
3 
becoming encapsulated by an environing growth of connective 
tissue, goes on to liquefaction, forming a so-called " cold abscess " 
-yet not containing one drop of pus unless secondary infection 
has taken place-its walls, however, consisting of a layer of 
more or less active tubercular tissue. Let secondary infection 
with the microbes of suppuration now ensue and this "cold 
abscess " will open, the tubercular matter will be evacuated, a 
sinus usually remaining lined with tubercular granulations; this 
is nature's eliminative treatment. In certain favorable cases 
the intensity of the inflammatory process is such that all the 
infected tissues are destroyed and evacuated; this is another 
method by which nature cures by the destruction of tubercular 
tissue, not by its organization into harmless, permanent tissue. 
It is important to recognize the fact that a tubercular in- 
fection of a joint must, in the nature of the event, practically 
always be secondary to tuberculosis elsewhere; the primary 
point of infection may be some trivial lesion through which the 
germs have gained access, the lesion itself remaining unaffected, 
but the germ-charged blood current too often deposits the 
morbific cause in the epiphyseal regions of the young bones, 
where the normal conditions incident to their growth are 
peculiarly favorable for the lodgment and multiplication of 
microbes, even in the absence of what is so common, viz., some 
trivial injury, which, by interfering with the proper rate of the 
circulation through the injured part, tends to promote the 
dropping out and accumulation of germs of all kinds. A second 
fact to keep clearly in mind is, that before puberty, in a large 
majority of cases, both epiphyses entering into the construction 
of the diseased joint are involved; the process is often recog- 
nizable as an embolic one, a minute mass of germ-laden 
granulation-tissue being found plugging the vessel, or by the 
mural implantation of a few germs a thrombus has formed 
blocking the lumen of an arteriole, producing those wedge- 
shaped sequestra so often found. Conversely, in the adult, 
tubercular joint trouble is primarily of the synovial form, the 
bones becoming secondarily involved. 
The most superficial clinical study of surgical tuberculosis 
demonstrates the truth of the deductions drawn from our brief 4 
STATE MEDICAL SOCIETY. 
pathological investigation of the subject, viz., that not only is 
tuberculosis a curable disease but that it is curable in more than 
one way. The surgical mind has arrived at the acceptance of 
this view only by the adoption of a series of tentative procedures: 
First, the limb formerly amputated for white-swelling, was 
treated by a resection of the articulation; then the lesser joint 
troubles for which resection had been unhesitatingly employed 
-with its destruction of all mobility, its frequent total arrest of 
growth from the removal of the only partially diseased epiphyses 
-began to be cured by atypical resections, then by erasion, and 
now, finally, the wisdom of a resort in all cases to the removal of 
the disease solely by mechanical measures is questioned, and the 
attempt is made to aid nature in her more successful methods 
of dealing with tuberculosis. 
The results achieved by these latter methods are those to 
which I desire now more especially to call your attention, 
although, later on, where these fail or are contra-indicated, I 
shall endeavor provisionally to indicate the classes of cases to 
which erasion, excision, or even amputation are still the only 
methods applicable; in other words, while a strong advocate of 
modern scientific and conservative measures, I am not bigot 
enough to fail to recognize that, owing to seeing cases late in 
the disease, or to the failure of the patients in continuing treat- 
ment for a sufficient length of time-even when skillfully initiated 
by the surgeon-many cases must still remain where the older, 
more radical methods will be demanded. 
Manifestly then, if my statements as to nature's methods of 
cure are correct, that one most desirable is the organization of 
the tubercular products, in whole or in part, into harmless scar- 
tissue. If then, early in the process, we can destroy or render 
inert the germ or its products which prevent the transformation 
of the granulation-tissue into a stable tissue, we shall secure all, 
and more, than can be effected by the most radical operation, 
and that, too, without danger to life, to parts, or functions which 
are only damaged, not utterly destroyed. 
What remedy shall be resorted to which theoretically, at 
least, can effect this? While many rivals have been proposed 
from time to time, iodine still holds the first place; but it must CHAS. B. NANCREDE. 
5 
be iodine, which is so slowly set free from its combination that 
it shall prove neither irritant to the tissues nor toxic. Iodoform 
best fulfils these requirements and was first suggested for this 
purpose by Billroth and Mikulicz in 1881. Soon after this, 
Verneuil called attention to its efficiency in certain cases of 
tubercular abscess, contending that it destroyed the germs of 
the disease, converting a specific into a simple disease-process. 
Since then Moorhof in 1885, Krause, Bruns, and a host of other 
noted observers, have recommended and successfully employed 
iodoform in tuberculosis of the joints. 
More than twenty years ago Barwell, when describing the 
natural history of tubercular arthritis, showed that among the 
masses of granulation-tissue into which ligaments, synovial 
membrane, and the other joint-structures had been converted, 
it was quite common to find numerous areas where transforma- 
tion into scar-tissue was occurring, and pointed out that in this 
way a cure was effected when unaided nature was able to cope 
with the disease. Until a more modern pathology demon- 
strated that this granulation-tissue was the result of a living, 
multiplying germ and its products, there was neither motive 
nor incentive to induce observers to seek for a remedy, which, 
by removing or neutralizing the cause, destroying this tuber- 
cular granulation-tissue, or preventing its conversion into a per- 
manent tissue, should enable nature to do what she was so often 
successfully striving to accomplish under the most adverse cir- 
cumstances. It is true that Bruns and Nauwerk, examining 
portions of the wall of tubercular abscesses treated by iodoform 
injections, have described certain microscopic appearances sug- 
gestive of the entire disappearance of the miliary tubercles by 
destruction of the bacilli, fatty degeneration, and liquefaction 
of the cells. While this may, and probably must, be true for 
the focus of the tubercular lesion, both clinically and pathologi- 
cally the condition of joints prove, I contend, that my descrip- 
tion of organization of the granulation-tissue which has not 
become devitalized by the ptomaines, is in the main correct. 
But will such measures avail when areas of caseation exist? 
Certainly, for in many instances have we not seen that the 
unaided efforts of the tissues are capable of either absorbing 6 
STATE MEDICAL SOCIETY. 
the liquefied portions, encapsulating what remains, or of remov- 
ing all but the harmless mineral salts? Morever, when studying 
the method of applying the remedy, it will be clear that, in many 
instances, most, if not all, of the liquefied caseated tubercle is 
actually evacuated before the introduction of the remedial agent, 
which then only has to deal with comparatively unaltered tuber- 
cle-tissue. A review of the nature and action of the various 
substances which have been employed, and the gradual evolu- 
tion of the present methods of treatment so well illustrate the 
manner in which modern science attacks and conquers difficul- 
ties, and so clearly demonstrates the fact that to no one man 
belongs the credit of this great therapeutic victory, that I can- 
not refrain from repeating in a condensed form Senn's admir- 
able resume of the subject. 
Many years ago Brainard of Chicago, after emptying the 
joint with a trocar and canula, injected either pure tincture of 
iodine or tincture of iodine variously diluted with a solution of 
iodide of potassium, but the local and general reaction were too 
great, the remedy failing to do good, and so frequently aggrav- 
ating the conditions as to rule it out for the future. A two to 
three per cent, solution of carbolic acid was next employed by 
Hueter, both as an intra-articular and parenchymatous injection, 
repeated every other day. This remedy served a better pur- 
pose than the former, but it, too, with arsenious acid and cor- 
rosive sublimate, both advocated by Cavagni, have now been 
abandoned. Kolischer in 1887 reported numerous cases suc- 
cessfully treated by parenchymatous and intra-articular injec- 
tions of an acidulated solution of calcium phosphate, employing 
for this purpose a Pravez syringe. Upon the other hand, E. 
Muller has reported negatively upon the action of this remedy 
from experience gained in the Tubingen clinic. 
Owing to the action of zinc chloride inducing marked fibroid 
changes in softened tissues, Lannelongue has quite recently 
employed parenchymatous injections of this agent at the peri- 
phery of the tubercular process, in order to effect encapsulation 
of the focus, imitating one of nature's methods of cure; thus, four 
or five injections are made of eight or ten drops of a ten per 
cent, solution around the periphery of the subquadricipital CHAS. B. NANCREDE. 
7 
synovial pouch of the knee-joint. Although L. Sayre ante- 
dated him by thirty years, Landerer published in 1888 the 
results obtained by the employment of balsam of Peru in tuber- 
cular affections; the good effected he attributes, not to any 
anti-tubercular power, but to its stimulating effect so increasing 
the vitality of the tissues as to render them proof against the 
tubercular bacillus. This balsam can be employed as a 20 per 
cent, ethereal solution for injecting into fistulas, but for paren- 
chymatous and intra-articular use a sterilized emulsion of one 
part in four of oil of sweet almonds, redered alkaline by a 0.07 
per cent, solution of sodic chloride, should be employed. Some 
caution is requisite in the use of this drug, as Bruns and others 
have called attention to its irritating effects on the genito-urinary 
tract. 
Naphthol-camphor was experimented with by Perier at the 
Lariboisiere Hospital and later highly vaunted by Reboul as very 
slightly toxic, decidedly antiseptic, and antibacillary; moreover 
the drug is absorbed and can be detected in the urine for eight 
days after ceasing to employ it, which fact seems to indicate 
that this remedy may serve to prevent relapses by its prolonged 
action. From 50 to 100 grams of naphthol-camphor have been 
employed as an injection in joint-tuberculosis and cold abscesses. 
Finally Billroth, Mikulicz, Verneuil, Moorhof and others 
introduced, as has already been said, iodoform as superior to all 
other remedies. We should anticipate this decision from the 
results of experimental research, because Troje and Tangl have 
demonstrated that iodoform destroys the bacilli if kept in con- 
tact with them in sufficient concentration for prolonged periods, 
while, when employed in less quantity, the virulence of the 
germs is diminished; Gosselin's experiments and observations 
tend to prove the same thing. 
How shall iodoform be employed? First and last, that 
which demands most care and is absolutely imperative, is asepsis. 
The best preparation of iodoform is a ten per cent, mixture of 
the drug in equal parts of glycerine and water, the whole care- 
fully sterilized by boiling for five minutes in a water bath; never 
use anything but a recently sterilized preparation. Olive oil 
will also serve as a menstruum, the same proportion of iodoform 8 
STATE MEDICAL SOCIETY. 
being employed and similar precautions taken in sterilizing the 
mixture by heat; but the first formula is the better. The field 
of operation must be carefully cleansed by the use of ether or 
turpentine one part, alcohol seven parts, followed by soap and 
hot water; a corrosive sublimate dressing should then be 
applied to remain some hours, preferably over night. If doubt 
exists as to the thoroughness of the asepsis, or when time does 
not suffice for the prolonged application of an antiseptic dress- 
ing, just before puncturing I prefer to again cleanse the parts 
with a solution of potassium permanganate followed by a satu- 
rated solution of oxalic acid, and, after this, by free douching 
with a mercuric solution. 
The trocar and canula having been sterilized by heat, the 
joint should be carefully punctured obliquely at a safe point, 
first drawing the skin to one side, then all fluid, if any such be 
present, is to be evacuated by pressure and the articulation 
repeatedly and thoroughly washed out with a recently boiled 3 
per cent, solution of boric acid until the fluid returns clear. 
When no fluid exists this preliminary washing should be omitted. 
From one to eight drachms of the iodoform mixture should then 
be slowly injected into the joint by means of a sterilized syringe, 
the canula withdrawn and the puncture sealed with aseptic 
cotton and collodion. An antiseptic gauze pad had better be 
placed over the collodion dressing and held in position by a 
bandage for a few days. Diffusion of the iodoform throughout 
the joint is to be secured by kneading the parts and by passive 
motion. No fixation of the articulation is necessary unless 
motion causes marked pain, although I am in the habit of 
keeping the joint quiet at first. 
How often should the injection be repeated? As the action 
of the iodoform must be continuous, the intervals must depend 
somewhat upon the probable extent of absorbing surface and 
the amount of iodoform used at each injection; sometimes the 
injections require repetition as often as once in every eight 
days, in other cases once in six weeks will suffice. 
Where intra-articular adhesions exist, cutting off a portion 
of the joint-cavity, the drug cannot of course reach all the dis- 
eased portions; again, when the broken down tubercular masses CHAS. B. NANCREDE. • 
9 
cannot be evacuated through a large canula, nothing can be 
effectually done unless free incision into the joint be made, its 
interior thoroughly curetted, cleansed by careful rubbing with 
iodoform gauze, the wound accurately sutured, and then the 
injection be made, as has been done with such great success by 
Billroth. 
It is hardly necessary to say that if abscess formation is 
imminent and the skin has become thinned, the puncture must 
be made at some point where the integument is perfectly sound. 
Having said that the trocar should be introduced into each 
articulation at a safe place, it will be proper here to specify 
these points: thus, for the wrist-joint, enter the trocar just be- 
low the styloid process of the radius or ulna; for the shoulder, 
access may be had by entering the joint either internally 
or externally to the coracoid process of the scapula, or 
better, behind, just where the scapular spine expands into the 
acromion process; for the hip-joint, enter the trocar just above 
the trochanter major with the limb adducted and inverted, carry 
the instrument a little forward as it is thrust onward until the 
head of the femur is reached, when, by forcibly adducting the 
limb, room can be made to pass the trocar into the articulation; 
the knee can be punctured upon either side of the patella; in 
case of the ankle, the trocar must be entered in front below 
either malleolus and then by directing its point upwards the 
joint will be reached. 
I shall not adduce extended statistics to prove the efficacy of 
the iodoform treatment, but shall merely give the results 
obtained by a few representative surgeons, such as Bruns, 
Krause and Trendelenburg abroad, and Senn, in America, add- 
ing my own hearty endorsement of the latter's opinions, 
although, so far as I can gather, I had employed the method 
before he had commenced its use himself, having been led to do 
so by having seen the results obtained in a patient of his prede- 
cessor, the late Chas. T. Parkes. 
Bruns cured eighty out of one hundred cases of tuber- 
cular abscess, while he had a similar success with fifty cases of 
tubercular arthritis, in the course of four years. Krause, in the 
course of two years, submitted to the iodoform treatment thirty- 10 
STATE MEDICAL SOCIETY. 
six cases of tuberculosis of the knee-joint, thirteen of the hip, 
six of the tarsus, five of the wrist and one of the elbow. When 
reported, the treatment had been completed and a cure had 
been effected in the following cases, viz., of the knee, fifteen; 
of the hip, four; of the tarsus, one; of the wrist, three. Of one 
hundred and thirty-five cases of all grades of severity treated 
by Trendelenburg, sixty-eight per cent, were stated to have 
been favorably effected. Senn has also reported some admir- 
able results, and my own experience has led me to repose an 
ever increasing confidence in the efficacy of iodoform in articular 
tuberculosis. 
Is this plan of treatment solely productive of good without 
any attendant risks, at the worst merely failing to effect a cure? 
Certainly not; but the risks are insignificant, compared with 
those of the ordinary operative interference, so commonly 
resorted to, while nearly all are avoidable by taking proper 
precautions, as is shown by the experience of Bruns, pres- 
ently to be quoted. Death, during the operation, occurred 
in a case of Boeckal's, where the abscess communicated 
with the subclavian artery. Severe hemorrhage followed the 
the injection in three cases of Kbnig's from arterial erosion, 
but was arrested by ligaturing respectively the gluteal, the 
deep femoral, and external plantar arteries. Lindner also had 
two fatal cases of hemorrage, the blood coming in one from the 
femoral artery and in the other from the iliac vein. All these 
accidents would have been equally noted if incision with scrap- 
ing, erasion, or excision had been practiced. Dollinger and 
Trendelenburg, as well as others, have observed gangrene of 
the superjacent parts and iodoform intoxication from the 
employment of the ethereal solution, but the first objection 
does not hold good for the glycerine or oil formulae; while with 
proper precautions the employment of the same menstrua prac- 
tically does away with the risks of intoxication, although 
Heusner reports this accident from an intra-articular injection 
in a child containing only o.i of a gram of the drug, and 
Bramann another from 0.2 of a gram, although later the same 
amount was employed with impunity. The lesson to be learned 
is clear enough, viz., never to employ any but an oily or gly- CHAS. B. NANCREDE. 
11 
cerine vehicle, and not to exceed thirty grains of iodoform for 
the first injection in an adult, with much less in the case of a 
child. That such precautions will prevent accidents is proved 
by the experience of Bruns, nothing unpleasant having occur- 
red in one hundred and eight cases treated by him. Of course, 
neglect of the strictest antiseptic precautions will often deter- 
mine true suppuration in, and destruction of, a joint, and per- 
haps the loss of a life, but that is an entirely preventable 
accident. 
But some will say, " Are operations never necessary? Will 
use of iodoform entirely supersede the knife?" Manifestly not, 
for, unless employed in the comparatively early stages of the 
disease, iodoform can do nothing more than possibly render the 
field of operation less tubercular and therefore make it more 
likely that all diseased tissues will be removed by the knife. 
Even if apparently seen at a stage when, efficiently employed, 
iodoform should effect a cure, certain cases will progress 
from bad to worse, requiring erasion, atypical resection, or 
typical resection according to the condition found after incision, 
the former two being probably more generally applicable to 
the cases developing in adults, which are usually primarily 
synovial, the osseous lesions being secondary and therefore 
more limited than in the case of children, where the reverse 
commonly obtains. When, then, a three months' faithful trial of 
iodoform fails to effect improvement, which in its incipiency 
should be indicated by shrinkage of the capsule, some opera- 
tion is probably indicated, this decision being arrived at upon 
the same grounds as in other cases where the more usual 
forms of treatment by rest, etc., have failed. Again where 
sinuses are present or form, with evidences of amyloid changes 
in the viscera, or where lung tuberculosis is present, is threat- 
ened, or developes during the course of treatment, in my 
judgment amputation, and amputation only, is indicated as a 
life saving measure, even in the face of decided local improve- 
ment from the treatment. 
In conclusion, let me beg all of you who have to treat such 
cases, to give this method a fair and impartial trial, and that, too, 
upon such an extended scale as will eliminate the chance of 12 
STATE MEDICAL SOCIETY. 
error, not despising any of the minute precautions upon which 
I have insisted, and I am convinced that you will, from the 
scepticism which I myself first felt, pass on to the firm faith I 
have attained to, that by a proper choice of cases, and by edu- 
cating the profession and the public, in the near future erasions 
and excisions for tuberculosis of the joints will be as rare as 
amputations for these maladies have already become.