[Reprint from Journal of Materia Medica.} 
The Early Removal of Tubercular 
Foci of the Bone. 
BY B. MERRILL RICKETTS, M. D. 
Read before Mitchell District Medical Association. 
Baden Springs,^Ind., July 13, 1893 
It is not my intention to address you at 
any very great length, or present to you a 
subject upon which no thought has been 
given by the surgeons in general. My in- 
tention is to present some thought and evi- 
dence that may lead us to make an earlier 
diagnosis and to adopt more prompt and 
radical measures in tuberculosis of the bone 
than are generally adopted. Tuberculosis 
is one of the greatest enemies which the 
human body encounters. It is surely the 
greatest destroyer of bone anatomy. When 
once the frame, or any part thereof becomes 
diseased, the interest of all that is dependent 
upon it becomes jeopardized. What greater 
example can we have of this than in the de- 
struction of a part or all of one of the spinal 
1 vertebne. Whatcanbemore deplorable than 
the various forms of spinal curvature, or.de- 
struction of the head of the femur, the meta 
tarsel or meta carpel bones? What feature 
is there more prominent than in the various 
causes of deafness, than that of tuberculosis? 
Syphilis has been accredited as the great de- 
stroyer of not only one, but of all kinds of 
tissue. It is a blessing compared to the 
ravages which tuberculosis produces, for in 
syphilis we have a remedy without much 
surgical interference. In tuberculosis our 
hands seem to have been tied, and the wheel 
of progress in its treatment made to stand still. 
There seems to be no constitutional treat- 
ment whatever ofthe least benefit in tubercu- 
lar disease of the bone. It is not because 
there has been no effort, for medical literature 
has been flooded with the various remedies 
suggested for its cure. It seems now that 
tuberculin has fallen short of our expecta- 
tions, failing in every particular, and giving 
no good results whatever. It seems to my 
mind, that the good to be obtained is through 
surgical interference only, and that it then 
depends upon early operative procedures. 
2 Aseptic surgery has been the greatest boon 
to this class of work, and we-must necessarily 
rely to a great degree upon cleanliness. 
However, we see how difficult it is to secure 
primary union even in the extirpation of 
tubercular glands. Seeing how hard it is to 
overcome these obstacles and to secure 
primary union in operation upon the soft 
tissue, we must necessarily shrug our shoul- 
ders when we come to the extirpation of 
tubercular disease of the bones and joints. 
However, much I might be gratified to 
present this subject to you voluminously, I 
must confine myself to the early extirpation 
of the tubercular foci of the bone. I believe 
that surgeons in general are responsible for 
a large per cent, of the cripples as the result 
of tubercular disease. I am thoroughly 
satisfied that there has been too much delay, 
that we have expected nature to do what we 
ourselves should have done. How natural 
it is for us to shirk responsibility? My own 
plan has been to act promptly and radically 
where 1 have evidence of tubercular disease 
in either the shaft or epiphysis. Possibly I 
have at times been hasty, but I would rather 
3 be accused of that than of procrastination, 
for surely the latter is the most dangerous. 
Even where there is a question as to the 
identity, it is best to give the patient the 
benefit of a doubt and operate promptly. In 
nearly all of the cases where the periosteum 
is thickened and tender, we have reason to 
suspect the presence of tuberculosis. Even 
in cases of trauma, tubercular bacilli seem 
to find their way and develop rapidly in the 
injured tissue. When once they are im- 
planted, they are not long in manifesting 
themselves and giving evidence of their 
presence. It is in just such cases as these, 
especially of the long bones, that an ex- 
ploratory incision and early extirpation give 
such excellent results. It is a matter of 
course that one should hesitate to open a 
joint as promptly as he would a shaft, but 
unfortunately the shafts are not so frequently 
attacked as the epiphysis. It is a great 
question, and one which must be considered 
greatly from the light of experience, as to a 
time when a joint should be opened. How- 
ever, I am safe in saying that the disease 
should be removed earlier when it attacks 
4 the epiphysis than when the shaft alone is 
involved. If the foci are.thoroughly removed 
let them be upon the surface or in the body 
of the epiphysis, then the destruction of 
bone is much less and its ability to repair 
itself much greater. Then too, when early 
extirpated the possibility of the other bones 
being involved is lessened. The disease 
when confined to one foci, is not so rapid in 
its progress as where several are to be found, 
although the single one may be as large as 
several of the smaller ones combined. Then 
too, the greatest number of tubercular foci 
are found in the epiphysis because of its 
spongy nature. There is not much likli- 
hood of the foci being multiple in the shafts, 
because they are more compact. 
I do not believe that there is one loci in 
a thousand that undergoes spontaneous re- 
covery, let it be in the shaft or epiphysis, 
much less is it likely to recover if found in 
the epiphysis. Even rest, which has been 
so long considered a cure for tubercular 
joints, is of little avail, giving, to my mind, 
no evidence whatever of the reparative pro- 
cess as the result. When once an area has 
5 become attacked by the bacilli, there seems 
to be no limit to the destruction which it 
may produce. If they do not become mul- 
tiple, the one will, in the course of time, 
destroy all the adjacent tissues. Tubercu- 
losis of the epiphysis is what epithelioma 
is to the skin, and should be looked upon 
with as great consideration, and the treat- 
ment made as radical. The earlier an 
epithelioma is removed the greater the 
chances for permanent relief. Just so with 
a tuberculous area within the bone. The 
influence of the diseased area seems to be 
nothing more than that of a foreign body, 
except the disease is more rapid and pro- 
gressive. The opening of a joint free from 
any disease could result in nothing more 
than ankylosis, to a greater or less degree. 
A joint affected with tuberculosis, neces- 
sarily results in ankylosis to a greater or 
less degree. Now, is it not better in cases 
where there is every indication of tuber- 
cular deposit, to give the patient the benefit 
of a doubt in exploratory incisions, followed, 
if necessary, by the removal of tuberculous 
matter? Until recently it was almost a 
6 crime to open the abdominal cavity. Now 
it has become quite a common occurence, 
even though doubt exists as to what is to 
be found in that cavity. Just so with 
tuberculosis of shafts, and especially joints. 
What can we expect from any other than 
radical treatment? The development of 
large ovarian tumors does not now occur, 
simply because the gynecologists have be- 
come so skilled in making early diagnosis 
that procrastination can no longer be attrib- 
uted to them. It is to be hoped that surgeons 
who are called upon to treat the various 
forms of tuberculosis, especially of joints, 
will not delay radical operative procedures 
until there is great destruction of bone, 
accompanied by the formation of fistula. 
This is deplorable, and I think is largely 
due to the surgeon himself. Perhaps he 
does not early recognize the disease, or it 
may be due to his inclination to procras- 
tinate, or his fear in assuming responsillity. 
It is as unscientific to allow the head of the 
femur to become destroyed from tubercu- 
losis as it is to allow an ovarian tumor to 
grow until it weighs 50 to 75 pounds. It is 
7 one thing for the patient or other influences 
to be responsible for such a state of affairs, 
and it is another for the responsibility to 
rest upon the attending physician. Just 
how much of the adjacent bone should be 
removed with tubercular foci, is a question 
for the operator himself to decide. I have 
no doubt but that in the majority of hip 
joint cases, the disease has progressed to a 
greater degree than is generally supposed at 
the time it is presented for treatment. We 
must expect all degrees of progress in the 
destruction of bony tissue as long as the 
people are isolated and out of reach of sur- 
gical aid. Poverty and indifference are 
prominent factors in the delay of treating 
all classes of diseases. But this should not 
be of any influence in establishing laws. 
Let the rules be established, and the good 
results made known, and there can be no 
plausible reason why the application should 
not become general. 
The Trinidad No. 137 Broadway, July 13, 1893. 
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