ABSCESSES IN POTT’S DISEASE. 
BY 
HERBERT L. BURRELL, M.D., 
SURGEON TO THE CHILDREN’S HOSPITAL, THE CARNEY HOSPITAL, AND 
ASSISTANT VISITING SURGEON TO THE BOSTON CITY HOSPITAL; 
INSTRUCTOR IN CLINICAL SURGERY, HARVARD UNIVERSITY. 
FROM 
THE MEDICAL NEWS, 
December 12, 1891. [Reprinted from THE MEDICAL NEWS, December 12, 1891.] 
ABSCESSES IN POTT'S DISEASE. 
BY HERBERT L. BURRELL, M.D., 
SURGEON TO THE CHILDREN’S HOSPITAL, fHE CARNEY HOSPITAL, AND 
ASSISTANT VISITING SURGEON TO THE BOSTON CITY HOSPITAL ; 
INSTRUCTOR IN CLINICAL SURGERY, HARVARD UNIVERSITY. 
In this paper I shall limit myself to certain points 
in the course and treatment of Pott’s abscesses that 
have occurred to me. An abscess, appearing in the 
course of the treatment of a case of spinal caries, 
is one of those incidents that may be considered as 
a conservative act of Nature in ridding itself of the 
detritus of a destructive process in the bodies of the 
vertebrae. 
The symptoms vary according to the location of 
the abscess. With all cases there are at first asso- 
ciated a rise in temperature more or less persistent, 
loss of flesh, and particular individual symptoms ac- 
cording to the anatomical structures involved—for 
instance, dyspnea or dysphagia in retro-pharyngeal 
abscesses; respiratory symptoms in cervical abscess ; 
pulmonary symptoms in upper dorsal caries; and in 
lower dorsal and lumbar abscesses, symptoms are 
developed according to the viscera pressed upon or 
involved. For the early recognition of abscesses I 
have come to depend largely upon a continued loss 
of appetite, loss of flesh, and continued elevation 
of temperature ; in fact, when a child has been effi- 2 
BURRELL, 
ciently treated by mechanical support for the spinal 
caries, and for some reason is not gaining in gen- 
eral health, one may suspect that there is an abscess 
forming. In the adult, however, these symptoms 
are not common. Here the course of abscesses con- 
nected with spinal caries is quite different. One of 
the most remarkable things is the quantity of pus 
that may collect in a psoas abscess in an apparently 
healthy adult, who has but little intimation that there 
is spinal caries; perhaps all that has been noticed 
has been persistent lumbago until the patient is 
brought to the surgeon, who finds that the iliac fossa 
is filled with a resistant mass, the thigh slightly 
flexed and enlarged from the passage downward of 
the pus along the course of the psoas and iliacus 
muscles. 
I have, in fact, come to regard spinal caries in an 
adult as essentially a different disease from that which 
occurs in a child. In adults the following group 
of symptoms is not at all uncommon : For a few 
months the patient has noticed some slight, per- 
sistent, local pain in the back, which is thought to 
be rheumatism. He experiences a sensation of gen- 
eral debility; there is slight loss of appetite, but he 
continues about his occupation—frequently a very 
laborious one, with progressive loss of flesh and 
persistent elevation of temperature. On physical 
examination no deformity in the spine can be de- 
termined, and occasionally, especially in the lumbar 
region, there is only slight spasm of the erector 
spinse muscles; but in the iliac fossa, and down on 
the thigh, one may notice a large collection of pus. 
It is true that we may have spinal caries in a child ABSCESSES IN POTT’S DISEASE. 
3 
appear very insidiously; but in an adult it is the 
rule, rather than the exception. 
Although the appearance of an abscess in Pott’s 
disease may be considered simply an incident of the 
disease, yet it is a very serious affair unless it is 
properly treated, and in many of our patients, in 
spite of all our care, it is the beginning of the end ; 
for when an abscess opens, and sepsis occurs, unless 
great care is taken a fatal ending is inevitable. 
The pertinent question in regard to all abscesses 
connected with spinal caries is : What shall be done 
with them ? Shall they be left alone, and if so, 
how long? Shall they be opened, and if so, when? 
Formerly, as we know, these abscesses were left 
alone, because the mortality attending their open- 
ing was very great, but in later years we have come 
to regard the opening of abscesses in Pott’s disease 
as a proper procedure under certain circumstances— 
and these circumstances I shall attempt to define. 
The surgical axiom, that wherever pus is found it 
should be evacuated, is not in this instance literally 
true, since we are all familiar with cases of abscesses 
in Pott’s disease, that, left to themselves, and under 
careful mechanical and hygienic management, have 
in course of time become absorbed. It is true that 
reasoning from an individual case is, as a rule, dan- 
gerous, but I wish to relate one case that illustrates 
the expectant treatment of an abscess. 
In 1884, an adult, J. D., twenty-four years of age, 
a bank-clerk in Somerville, was seen ; he had been 
treated for a year or more for lumbago and rheu- 
matism, but a few weeks previously he had noticed 
that his right thigh was enlarged and the limb 4 
BURRELL, 
flexed. He called the attention of his family phy- 
sician to this, and I was asked to see the patient. 
On examination I found slight tenderness over the 
last dorsal and first lumbar vertebrae. The con- 
cavity of the right iliac fossa was filled with a dense, 
indistinctly fluctuating tumor. The right thigh, an 
inch below the groin, was six inches larger than the 
left, and was occupied by a fluctuating tumor. The 
patient had lost some flesh, though his appetite was 
excellent, but he had been progressively growing 
worse. His condition having been explained to him, 
he concluded to try an efficient mechanical support 
for his back, and to temporize in the treatment of 
the abscess. A Taylor back-brace was adjusted, and 
the patient was instructed how to bandage the thigh 
with a flannel bandage to prevent the extension of 
the pus. 
I saw this patient at various intervals during the 
next two years, and at the end of that time I could 
not detect any perceptible enlargement of the right 
thigh. Four years later there remained some thick- 
ening in the right iliac fossa, but the abscess had 
apparently been completely absorbed. At the pres- 
ent time he is engaged in his occupation, strong, 
and apparently perfectly well. 
This is a case showing what can be done by ex- 
pectancy. I could cite numerous instances of con- 
ditions practically similar in children that were 
strong and healthy, and not of a marked tubercu- 
lous diathesis, in which absorption of the abscess 
had occurred. 
Bearing upon expectancy is the fact that these 
abscesses are often of long standing—that is, five, 
six or seven years may have elapsed since the begin- 
ning of the carious process ; and the more quiescent ABSCESSES IN POTT’S DISEASE. 
5 
the carious process, the better the result that may be 
expected from an operation. 
Efficient mechanical support of the spine will in 
a great many cases unquestionably avoid the neces- 
sity for operative interference. My own feeling in 
regard to the matter is, that, until some failure be- 
gins in the patient’s general condition, no operation 
should be thought of just so long as the patient is 
improving under efficient mechanical support to the 
spine, unless the abscess is extending in such a way 
that it is involving important parts—for instance, in 
the spine, the cord ; in the thorax, the lung. 
It seems far better to me to temporize until we feel 
assured that the abscess will not be cared for by ab- 
sorption ; and, again, when we do interfere, I be- 
lieve in interfering most radically and efficiently; 
for the danger of interference in psoas abscesses is 
unquestionably from sepsis, and if we drain effi- 
ciently and thoroughly, and keep our wound free 
from septic contamination, we shall in the vast 
majority of cases have favorable results. 
Aspiration of the abscess is an uncertain measure, 
for it rarely evacuates the abscess completely, be- 
cause of plugging of the needle. It should be re- 
served for those few instances in which temporizing 
is being carried out, and relief to tension of the 
abscess is thought necessary. 
The treatment by injection of the abscess-cavity 
after aspiration is uncertain, and when active germi- 
cides are used there is danger of systemic poisoning. 
The ordinary psoas abscess, as it presents itself, 
forms a tumor in the iliac fossa and in the upper 
part of the thigh, and when expectancy has been 6 
BURRELL, 
tried and is of no further avail, I carefully prepare the 
patient for operation by accurately fitting a Taylor 
brace, or by recumbency in bed for a week or ten 
days. This, I have found, tends to limit the size of 
the abscess and to render it more readily drainable. 
After aspiration, to exclude the possibility of aneur- 
ism or solid tumor, a free incision, just external to the 
femoral vessels, is made into the substance of the 
presenting tumor. This is usually associated with 
the discharge of a large quantity of pus. An in- 
cision is then made into the most prominent portion 
of the swelling in the iliac fossa, care being taken 
that the peritoneum is avoided when one reaches the 
transversalis fascia and the subperitoneal fat. From 
this point a block-tin sound is passed as far as may 
be up into the abscess-track toward the spine. Di- 
rect drainage is then obtained by carefully dissect- 
ing down on the outer edge of the quadratus lum- 
borum to the distended psoas and iliacus sheath. 
Usually these three openings are necessary in order 
to efficiently deal with the tuberculous material lin- 
ing the abscess-wall. A curette and flushing are 
used freely, and large drainage-tubes are placed in 
such positions that they will efficiently drain the 
cavity. The incision in the iliac fossa is frequently 
closed by suture. Occasionally the incision into 
the anterior upper portion of the thigh is closed by 
suture, but rarely have I diminished the size of the 
opening which is made in the loin, from the fact 
that from this opening I hope to obtain direct drain- 
age of the abscess from as near its source as is 
practicable. Of course, the fingers are introduced 
into the opening through the loin, and if any loose ABSCESSES IN POT'1'’s DISEASE. 
7 
fragments of necrotic bone can be felt they are 
removed. 
If the patient has a double psoas abscess I deal with 
both in the same manner, especially if they occur in 
an adult; because I have found that with double 
psoas abscesses it is better to drain both sides effi- 
ciently than to attempt to drain one side and then 
to drain the other; for, if only one side is drained, 
a large reservoir of pus may be left, which com- 
municates through a small opening with the side 
drained, and this collection of pus is occasionally 
the source of systemic poisoning. If a psoas abscess 
is efficiently drained, the quantity of pus discharged 
will diminish from day to day, and, according to 
the size and extent of the spinal carious process, 
will gradually cease in a varying time. 
No more depressing picture can be presented to 
a surgeon than to see a psoas abscess that he has 
opened become septic, and the patient gradually 
develop septicemia and die from that cause. Hence, 
for success in dealing with these abscesses, the most 
rigid antisepsis is absolutely essential. 
Those unique abscesses, that for some reason do 
not follow the usual course, of descending in the 
sheath of the psoas muscle, but point posteriorly at 
some point on the back, are likewise dealt with by 
free incisions at their most prominent part, by effi- 
cient flushing, and thorough curetting. 
Retro-pharyngeal abscesses, which are rare, form 
a group by themselves. I have seen only six, and 
two have been fatal. In both instances death oc- 
curred from bursting of the abscess and flooding of 
the lungs. Usually on introducing the finger into the 8 
BURRELL, 
posterior wall of the pharynx one can feel an elastic 
swelling, which may be incised by a suitably guarded 
knife introduced into the median line of the pos- 
terior wall of the pharynx. The “ Roser position ” 
of the head, that is, the head dependent over the 
end of a table, is by all odds the best, as, with a 
suitable mouth-gag, it gives complete and efficient 
control of the mouth of the patient, and the dis- 
charge of pus that takes place. With the patient 
in this position and efficiently held by assistants, one 
does not have to make a plunge in the dark, so to 
speak, but can thoroughly open the mouth, and can 
make a free incision directly into the apex of the 
tumor, and the discharge of pus will take place 
through the mouth and nostrils, and there will be 
no danger of suffocation from the pus entering the 
respiratory tract. 
In the last two cases of retro-pharyngeal abscesses 
that I have had to deal with I made a direct incision 
just posterior to the right sterno-cleido-mastoid, dis- 
secting down deliberately until I came in contact 
with the sheath of the main vessels of the neck. 
Holding these anteriorly I then entered a director or 
blunt probe, carefully separating the structures until 
I tapped the abscess laterally. In this manner I was 
in one instance enabled to keep the abscess sweet 
from beginning to end ; in the other, unfortunately, 
the child was moribund at the time of attempting 
the operative interference, and my efforts were un- 
availing. This is a measure seemingly worthy of at- 
tention, and has been the subject of investigation 
by one Russian authority. 
It is true that the operation for a Pott’s abscess is ABSCESSES IN POTT’S DISEASE. 
9 
a matter of consequence, but the dressing is of equal 
importance. I have come to use baked gauze, the 
inner layers of which are saturated with i : 2000 so- 
lution of corrosive sublimate, applied directly in 
contact with the various incisions that have been 
made. Over this is placed a large quantity of dry 
baked gauze; and I have found that assistants err in 
putting on too small a dressing. If it is a psoas 
abscess it is held in position by an efficient gauze 
spica-bandage. In all children great care should be 
taken to protect the dressing by putting on a mack- 
intosh or oil-silk to prevent soiling by urine or feces. 
Usually, within twelve hours, this dressing must be 
changed; for from a cavity as large as the average 
psoas abscess an enormous quantity of sanious fluid 
drains away and saturates the dressing. When 
treated by this method the subsequent dressings re- 
main sweet and clean for from a week to ten days 
at a time. 
In abscesses that point in other regions than along 
the course of the psoas and iliac muscles, for in- 
stance on the back, where it is impossible to get di- 
rectly to the bottom of the channel of pus, the 
cavity is tamponed with antiseptic gauze. In a 
retro-pharyngeal abscess when an incision is made 
directly behind the sterno-mastoid muscle, and the 
abscess-cavity is drained through this channel, a 
suitably-sized drainage-tube is placed in the wound, 
the remainder being held open by antiseptic gauze. 
This wound should be dressed once in twelve hours, 
owing to the liability of pus to collect in small pock- 
ets, and to prevent any possibility of pressure being 10 
BURRELL, 
made on the important structures of the neck. This 
measure should be carried out for two or three days. 
In the prognosis of psoas abscesses there is an 
important distinction to be made between abscesses 
occurring early and late in the disease. In those 
early or acute abscesses that come on within the 
first few months of a caries of the spine, and that 
are associated with marked constitutional disturb- 
ance, the prognosis is not so favorable as in the late 
or chronic abscesses that occur in the disease, at the 
end of two, three, or more years, after the beginning 
of the carious process. 
In acute abscesses the patient frequently succumbs 
to the disease in spite of all our tentative or opera- 
tive efforts, whereas in chronic abscesses their evac- 
uation by efficient drainage is simply an incident 
in the course of the disease. 
Quite a large proportion of the cases that I have 
operated on for abscess in Pott’s disease have re- 
covered completely, but after a long period of 
time. There frequently persists for weeks and months, 
and in certain instances for years, a sinus, out of 
which is discharged a slight quantity of pus or straw- 
colored fluid. Frequently the mistake is made of 
leaving off the antiseptic dressing when the wound 
is reduced to this sinus, but it should be continued 
until all discharge has ceased. The drainage tube 
should be retained until practically all of the tuber- 
culous material has been discharged, although oc- 
casionally I feel that the tube is retained too long. 
From my personal experience the following con- 
clusions are warranted : 
i. That efficient mechanical support of the spine ABSCESSES IN POTT’S DISEASE. 
11 
is the prime factor in the treatment of caries of the 
spine associated with an abscess. 
2. That under an expectant plan of treatment, 
the abscess will in many cases disappear. 
3. That the indication for operative interference 
is a steady or rapid decline in the patient’s general 
condition. 
4. That the operation should consist in thorough 
evacuation of the abscess, and the establishment of 
drainage from as near the seat of the disease as is 
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