THE TREATMENT OF 
TUBERCULOSIS 
OF * 
BONES AND JOINTS 
BY 
PARENCHYMATOUS AND INTRA-ARTICULAR 
ITSTCTEOTIOTSrS. 
BY 
NICHOLAS SENN, M.D., Ph.D.,' 
OF CHICAGO, JLL., 
Professor of the Practice of Surgery and Clinical Surgery in Rush Medical 
College; Attending Surgeon to the Presbyterian Hospital; Surgeon- 
in-Chief St. Joseph's Hospital. 
Reprint from Annals of Surgery, January, 1892. THE TREATMENT OF TUBERCULOSIS OF BONES 
AND JOINTS BY PARENCHYMATOUS AND 
INTRA ARTICULAR INJECTIONS. 
By NICHOLAS SENN, M.D., Ph.D., 
OF CHICAGO, ILL. 
PROFESSOR OF THE PRACTICE OF SURGERY AND CLINICAL SURGERY IN RUSH MED- 
ICAL COLLEGt ; ATTENDING SURGEON TO THE PRESBYTERIAN HOSPITAL, 
SURGEON IN CHIEF ST. JOSEPH'S HOSPITAL. 
THE successful treatment in some cases of bone and joint 
tuberculosis by parenchymatous and intra-articular in- 
jections is one of the important achievements of modern sur- 
gery. Attempts in this direction were made long before the 
bacillus of tuberculosis was discovered, and before the true 
pathology of tubercular inflammation was understood. It is, 
however, since the true nature of the tubercular process has 
been revealed, and since the anti-bacterial action of a number 
of antiseptic substances has been carefully studied experimen- 
tally and clinically, that this method of treatment has been 
placed upon a scientific basis and has yielded satisfactory re- 
sults. It is reasonable to assume that if by a harmless proced- 
ure safe and efficient chemical substances can be brought in 
contact with the affected tissues within diseased bones and 
joints that exercise a direct curative effect, it would constitute 
a decided improvement over former methods of treatment by 
internal administration or external application of the same 
remedies. The remedies which have been used for this pur- 
pose possess potent antiseptic and stimulating properties, and 
have been employed with a view to destroy the microbic cause 
of the disease, and to aid and expedite the process of repair. 2 
N. SENN. 
The first attempts at intra-articular medication were made 
with a Pravaz syringe, the solution being thrown into the joint 
without previous evacuation of its fluid contents. At the pres- 
ent time the joint is punctured with a larger instrument, and if 
it contains fluid this is evacuated before the injection is made. 
If the joint contains tubercular pus, the intra-articular injec- 
tion is preceded by irrigation of the joint with a mild antisep- 
tic solution. The best instrument for puncturing a joint is a 
small trocar, through the canula of which the joint can be 
emptied, irrigated and injected. The puncture is to be made 
under strictest antiseptic precautions, and in accordance with 
the rules laid down elsewhere. In tubercular empyaema 
of a joint, irrigation should never be neglected as a pre- 
liminary step to the intra-articular injection. The simplest 
method of irrigating a joint is to connect the canula with a 
rubber tube attached to an irrigator holding the antiseptic so- 
lution. A2%> solution of boracic acid or a one-third of i% 
solution of salicylic acid in sterilized water should be used for 
this purpose. The connection between canula and rubber 
tube should only be made after the surgeon has been satisfied 
that neither of them contain atmospheric air. By elevating 
the irrigator the fluid enters the joint, and the infusion should 
be continued until the capsule is thoroughly distended, when 
the rubber tube is detached and the fluid evacuated through 
the canula by compressing the joint. This procedure is re- 
peated until the fluid returns perfectly clear. The intra-artic- 
ular injection is made with an ordinary one ounce glass syringe, 
to the nozzle of which a piece of aseptic rubber tubing is at- 
tached, Vvhich is fastened to the end of the canula with the 
same care as in making the irrigation. The quantity of fluid 
which is to be injected should never be large enough to cause 
painful distension. After the canula is withdrawn the punc- 
ture should be sealed with a pledget of aseptic cotton and col- 
lodium. 
Among the many substances which have been used for pa- 
renchymatous and intra-articular medication, I will only make 
mention of such that have received the most attention, and 
which experience has shown to be of some value. 
Tincture of iodine.-This preparation of iodine, pure or di- TUBERCULOSIS OF BONES AND JOINTS. 
3 
luted, with a solution of potassic iodide, was one of the first 
substances employed for intra-articular medication. The late 
Prof. Brainard, of Chicago, made extensive use of it in the 
treatment of chronic hydrops of joints. Usually the injection 
was made through the canula of a trocar after the joint had 
been emptied of its contents. The violent local and general 
reaction which sometimes followed the injection was in the 
way of a more general adoption of this method of treating dis- 
eased joints. It has yielded satisfactory results in the treat- 
ment of catarrhal synovitis as the vaso motor irritation which 
the iodine produces upon the inner surface of the cavity 
of the joint and the vascular changes connected with 
it bring about speedy retrograde metamorphosis of the inflam- 
matory product, and hasten the process of absorption. It is 
never safe, even in such cases, to allow the tincture to remain 
in the joint, as the desired therapeutic effect can be obtained 
by injecting through the canula of the trocar from two to four 
drachms of the tincture, and after bringing it in contact with 
the entire surface of the joint by flexion and extension, friction 
and compression of the joint allow it to escape. 
In the treatment of tubercular joints this remedy has not 
only proved a failure, but has often been followed by aggrava- 
tion of the local conditions, and should be stricken from the 
list of therapeutic resources in the treatment of these af- 
fections. 
Carbolic Acid.-Soon after carbolic acid was introduced into 
surgical practice as an antiseptic agent, it was also employed 
in the treatment of chronic inflammation of joints as an intra- 
articular injection. Hueter1 resorted to parenchymatous and 
intra-articular injections of a 2 to 3 % solution of carbolic acid 
in the treatment of chronic inflammation of bones and joints, 
upon the supposition that the carbolic acid when brought in 
direct contact with the diseased tissues would destroy the mi- 
crobic cause of the inflammation. The injections were made 
with a Pravaz syringe every other day. In a case of osteomy- 
JDie Wirkungen der parenchymatbsen Carbolinjectionen bei Entziidengen der 
Gelenke und Knochen. Deutsche Zeitschrift f. Chirurgie, Bd. IV., p. 526, B. V., 
p. 120 4 
N. SENN. 
elitis granulosa hyperplastica, the favorable effect of the injec- 
tions became apparent soon after the treatment was com- 
menced. Twenty injections in the course of five weeks resulted 
in a permanent cure. 
Hueter's Treatment was quite generally adopted in Germany 
but the res; .Its, on the whole, were so unsatisfactory that it 
was soon abandoned. The results have not been more en- 
couraging by puncture and irrigation of the joint with solu- 
tions of carbolic acid, and at the present time carbolic acid 
has been given up almost completely as an anti-tubercular 
remedy. The same late has met the following two substances: 
Arsenious Acid.-Cavagnis,2 of Venice, made a number of 
experiments on rabbits and guinea pigs to determine the ther- 
apeutic value of arsenic in the treatment of tuberculosis. 
On April 17, 1881, four rabbits, two gray and two black 
weighing respectively 1,580, 1,590, 1,660 and 1,680 grammes, 
and four guinea pigs, weighing 370, 500, 5 10 and 610 grammes, 
were inoculated with tubercular material by subcutaneous in- 
jection. From the date of inoculation until May 28, the gray 
rabbits received one drop of Fowler's solution, diluted with 
distilled water, daily; the medicine was injected into the back 
part of the mouth with a Pravaz syringe; the black rabbits 
were given two drops daily in the same manner, while the 
guinea pigs received only half a drop. The smallest guinea 
pig was killed May 21, all the other animals June 6. One of the 
rabbits and all guinea pigs were tubercular, a tubercular ulcer 
at the point of inoculation had developed, the tissues of which 
contained numerous bacilli; cheesy foci in the vicinity of the 
ulcer, lumbar and prehepatic glands enlarged and partly 
cheesy, spleen enlarged, containing numerous tubercles; liver 
also the seat of tuberculosis. One of the guinea pigs had nine 
small tubercles in the lungs. 
The other three rabbits presented an encapsulated abscess 
at site of inoculation, and one or two small cheesy masses in 
the vicinity, but aside of this, no evidences of tuberculosis 
could be detected. Inoculations made with the contents of 
the abscesses yielded negative results. 
2Etudes de la Tuberculose, p. 462. TUBERCULOSIS OF BONES AND JOINTS. 
5 
Landerer used this substance dissolved in distilled water in 
the proportion of 1:1000, and of this he injected from one to 
two syringefuls at intervals of a few days into the affected joint. 
The results must have been decidedly unfavorable, as it does 
not appear that this remedy was used for the same purpose by 
others. 
Corrosive Stiblimate.-Next to carbolic acid corrosive sub- 
limate has been used more extensively as an antiseptic in the 
treatment of wounds than any other substance, but has never 
been popular as an anti-tubercular remedy. Experiments made 
by Cavagnis3 to test its anti bacillary action yielded very fav- 
orable results as far as its action is concerned in preventing 
the growth of tubercle bacilli in the tissues of the rabbits. 
On April 17, 1887, he inoculated three rabbits and three 
guinea pigs with tubercular material, and subjected these ani- 
mals at once to a thorough treatment with corrosive sublimate, 
which was administered in doses of four drops of a solution of 
one part in hundred of distilled water, while the guinea pigs 
receive only one-fourth of this quantity. May 1, one rabbit 
died; another May 10; the animals were very much emaciated, 
and the necropsy revealed a small mass of cheesy appearance 
at the point of injection; no bacilli could be found in the case- 
ous material, and the internal organs showed no trace of tu- 
berculosis. The third rabbit became so emaciated that treat- 
ment was suspended May 10, and ten days later the animal 
died. A large abscess containing non-tubercular pus was 
found where the injection was made. Internal organs and 
lymphatic glands healthy. The guinea pigs were killed June 
7. These animals presented a tubercular ulcer at the site of in- 
jection, extensive tuberculosis of the lymphatic glands, spleen 
and liver. 
Vogt injected from three to five syringefuls into tubercular 
joints of the following solution: Corrosive sublimate O.l, sodic 
chloride i.O, distilled water, 50.0, but evidently without success, 
as Vogt himself soon suspended its use. 
Another remedy that seems to have been used only by the 
one who suggested it and a few others is 
30p. cit. 6 
N. SENN. 
Phosphate of Lime.- Kolischer4 used an acidulated solution 
of phosphate of lime for parenchymatous and intra-articular 
injections in tuberculosis of bones and joints. The injections 
were made with an ordinary Pravaz syringe. Pain and other 
symptoms of local reaction always followed the injection and 
continued for five to six days, after which the limb was im- 
mobilized. After this the swelling diminished in size, and the 
tissues became firmer, showing that healing by cicatrization 
was progressing in a satisfactory manner. 
E. Freund5 gives full directions for the preparation of the so- 
lution and gauze of acid phosphate of lime. 
In another publication Kolischer6 reports 500 cases treated 
by his method, and admits that while tubercular joint affections 
were benefited by the treatment, it had no such influence in 
cases of central foci in bone and the sequestrating form of bone 
tuberculosis. This treatment was faithfully tried in the Klinik 
at Tubingen, but with negative results as we learn from the 
paper published by E. Miiller.7 It is not probable that the 
use of this remedy will-be revived in the future in the treat- 
ment of tubercular affections of bones and joints. 
Chloride of Zinc.-Lannelongue made an important contri- 
bution to the Academy of Medicine of Paris concerning the 
local treatment of tuberculosis by injections of solutions of 
chloride of zinc. His attention was called to this remedy 
during the treatment of a case of lymph-angioma. He noticed 
that one of its effects was its power of changing softened tis- 
sues into hard fibrous structures. During the last few months 
he treated 20 cases of surgical tuberculosis by parenchymatous 
injections of a solution of chloride of zinc. The injection is 
made into the periphery of the tubercular lesions, so as to 
stimulate the surrounding healthy tissue to active proliferation, 
4Ein neues Heilverfahren bei lokalisirten Tuberculosen Processen. Wiener Med. 
Presse B. XXVIII, No. 22, 1887. 
5Ueber die bei Kalkbehandlung der Local tuberculose zur Verwendung gelang- 
ender Lbsungen. Wiener Med. Presse B. XXVIII, No. 24, 1887. 
6Erahrungen uber die Kalkbehandlung bei Local tuberkulose, Wiener Med. 
Presse, B. XXVII, No. 29. 
7Ueber die Kalkbehandlung der localisirten tuberculosen Processe. Central- 
blatt f. Chirurgie, No. 15, 18S8. TUBERCULOSIS OF.BONES AND JOINTS. 
7 
by which the focus is encapsulated. For tubercular disease 
of the knee four or five injections are usually made around the 
circumference of the superior cul-de-sac. From eight to ten 
drops of the solution (lO%) suffice for the knee of a child, set. 
io. He claims excellent results in the treatment of tubercu- 
losis of the lymphatic glands, and reports a few joint cases 
similarly benefited. 
Balsam of Peru.-More than 30 years ago Sayre employed 
balsam of Peru in dressing wounds after resection of joints for 
tubercular affections. The results following his operations 
were much better than the average in the hands of other sur- 
geons at that time, and we must attribute them, at least in 
part, to the use of this substance as a wound dressing. 
Quite recently Landerer8 has again called attention to the 
utility of the action of this antiseptic in arresting tubercular in- 
flammation. As the result of his experiments on animals and 
from clinical experience with this remedy, he has come to the 
conclusion that its therapeutic action is owing to its stimulating 
effect on rhe tissues which brings the parts in such a condition 
as to render the pathogenic action of tubercle bacilli harmless. 
He ascertained by his experiments on rabbits that had been 
rendered tubercular by inoculation that the disease was 
favorably influenced by innocuous injections of an alkaline 
emulsion of this drug. In the treatment of fistulas and deep- 
seated tubercular processes he uses a solution of the balsam in 
sulphuric ether 1-5 for injection. 
For parenchymatous injections he employs an emulsion of 
the strength of 1:4 composed of oil of sweet almonds and a 
.07% solution of sodic chloride. 
He reports 25 cases of tuberculosis of bone, generally im- 
plicating joints, greatly improved by injections of an emulsion 
of balsam of Peru combined in some cases with minor opera- 
tive procedures, and in some of these cases the joint affections 
were so serious that amputation was proposed, but the opera- 
tion was refused by the patients. 
8Eine neue Behandlungsweise tuberculoser Processe. Munch. Med. Wochen- 
schrift, No. 40, 1888 8 
N. SENN. 
Vamossy9 has made extensive use of gauze prepared with 
balsam of Peru in the treatment of open wounds after the re^ 
moval of tubercular products with signal success. He reports 
28 cases treated according to Landerer's method and expresses 
himself as satisfied with the results. Among these cases he 
observed albuminuria three times, cystitis twice, and acute 
nephritis once, affections of the genito-urinary organs which 
he believes were cured by the balsam. 
Binz10 also calls attention to the irritating effect of this drug 
on the urinary apparatus. 
Landerer thinks the danger in the use of the balsam has 
been greatly overestimated, and that it can be avoided by 
proper care in its use. 
Although balsam of Peru does not appear to possess any 
direct anti-bacillary properties there can be no doubt that it 
can be applied with great benefit in the treatment of tubercu- 
losis of bones and joints, especially after fistulous openings 
and open ulcerating surfaces have formed, as well as a dressing 
after resection of joints and the treatment of tubercular ab- 
scesses by incision and curetting. 
Camphorated Naphthol.-Camphorated naphthol was first 
prepared by Desesquelle in 1888, and was first used in the 
surgical service of Percer, at the Hopital Lariboisiere. It is a 
liquid prepared by taking b. naphthol 100 grammes, camphor 
200 grammes, pulverizing each substance finely, gently heating 
the mixture until complete fusion; filter and preserve the 
liquid obtained in yellow glass bottles well corked. It pos- 
sesses valuable antiseptic properties and is strongly recom- 
mended by Reboul11 in the treatment of tuberculosis of bones 
and joints. He believes that in the local treatment of these 
affections the employment of potent antiseptic remedies is in- 
dicated, and such substances should be selected which, of 
equal therapeutic value, are non-toxic, so that they can be 
9Zur Therapie der Localtuberculose mit Perubalsam. Wiener Med. Presse, 
B. xxx, No. 17-20, 1889. 
iaUeber den Perubalsam. Centralblatt f. klin. Medicin., B. x, 1889. 
Contribution a 1' etude du Traitement de la tuberculose des os, des articulations 
et des Synovialis tendineuses de 1'emploi du Naphthol Camphre. Etudes experimen- 
t ales et cliniques sur la Tuberculose, Paris, 1888-1890, p. 60S. TUBERCULOSIS OF BONES AND JOINTS. 
9 
used freely and for a long time. According to his estimation 
camphorated naphthol fills these two conditions, being only 
slightly toxic, an efficient antiseptic, and destructive to the 
tubercle bacillus. As naphthol camphor dissolves iodine, the 
following mixture can be used. 
Naphthol camphor, - 90.0. 
Iodine, ------ 10.0. 
The antiseptic properties of camphor naphthol have been 
demonstrated experimentally by Maximowitch, Park, Burrel 
and Edington, and corroborated by the clinical results of 
Nicaise, Fernet, Schwartz, Peyrot, Reboul and others. The 
successful treatment of local tubercular foci by camphor 
naphthol has been established by the results obtained; but the 
action of this drug seems to be general as well, since the 
naphthol is absorbed and has been found in the urine, in a free 
state, of persons dressed with camphorated naphthol (Deses- 
quelle). 
If a wound after operations for tubercular affections is 
dressed with camphorated naphthol the urine shows the pres- 
ence of naphthol for eight days, showing that its local and gen- 
eral action is prolonged, and may prevent relapses, secondary 
inoculations, complications following so frequently operations 
for local tuberculosis. 
Perier and Reboul have employed camphorated naphthol 
extensively as an injection in doses varying from 50 to 100 
grammes in the treatment of articular tuberculosis and tuber- 
cular abscesses with favorable results. The injections did not 
produce pain and were never followed by violent local reac- 
tion or symptoms of intoxication. 
Parenchymatous injections made with an ordinary Pravaz 
syringe proved equally successful in the different forms of 
local tuberculosis. The injections were repeated every eight 
days. 
Reboul reports a large number of cases of tuberculosis of 
bones and joints treated by incision, scraping and injections and 
dressings of naphthol camphor in which the results were all 
that could be desired, speedy healing of the wound and free- 
dom of relapse. In a number of cases of spina ventosa, punc- 
ture and parenchymatous injections of camphor naphthol re- 10 
N SENN. 
peated weekly resulted in a permanent cure within three 
months. He believes that the curative effect of camphor 
naphthol like other anti-tubercular remedies, when applied 
locally, consists mainly in the production of an irritative ostitis, 
and supports this opinion by citing the case of a patient 
treated for a tubercular lesion of the great trochanter with 
camphorated naphthol, who died of pulmonary tuberculosis. 
Around the tubercular focus which had been treated the bone 
presented the characteristic appearances of plastic osteo- 
myelitis, and no bacilli or miliary tubercles could be found. The 
action of the remedy substitutes for the tubercular a plastic 
osteomyelitis. 
Reboul has great faith in the conscientious use of camphor 
naphthol as a local application and dressing in resection of 
tubercular joints in securing an aseptic healing of the wound 
and guarding against local relapses and general miliary tuber- 
culosis. He cites a number of operations of this kind on the 
larger joints in which this remedy was relied upon exclusively 
as an antiseptic, and the results certainly appear to corroborate 
the claims made for it. 
He has also been satisfied with the results of interstitial in- 
jections with camphor naphthol in the treatment of fungous 
disease of joints. 
Iodoform.-Injections of iodoform in the treatment of tuber- 
culosis of bones and joints and tubercular abscesses were ad- 
vised by Billroth and Mikulicz12 ten years ago, and the latter 
published another paper on this subject a year later,13 but it 
was not until a few years later that it came into more general 
use through the teachings and writings of Mosetig v. Moorhof.14 
Mazzoni15 believes that iodol. ether glycerin injections into the 
tissues or joints has a favorable effect on tubercular lesions not 
only in arresting the disease, but also in expediting the subse- 
quent reparative process. 
l2Beiliner klin. Wochenschrift, 1881. 
I3D e Verwendung des Iodoforms in dvr Chirurgie. Archiv. f. klinische Chirurgie, 
P. Xvii, p. 3, 1882). 
14Zur lodoformfrage. Wiener Vedicinische Blatttr, B. viii, No. 10-12, 1885. 
15Ueber die Amwcndung des Iodols in dvr chirurgischen Praxis. Btrl. klin. 
Wochenschiift, No. 41. 1886. TUBERCULOSIS OF BONES AND JOINTS. 
11 
At the present time the anti tubercular action of iodoform 
is generally recognized from a clinical standpoint, but the re- 
sults obtained by different experimenters on the lower animals 
concerning the same questions are at variance. 
Experimental Studies.-Troje and Tangl,16 to test the anti- 
bacillary action of iodoform, devised the following series of ex- 
periments: Iodoform vapor and powder were allowed to act on 
pure cultures, the powder was dusted on the culture medium 
in the neighborhood of cultures, and the vapor was allowed to 
accumulate in the culture chamber; animals were then inocu- 
lated with the growth and a series of "controls" was made. 
The vapor killed the bacilli only after fifty days, but then sup- 
puration was produced by the action of chemical products as 
pointed out by Koch. After the vapor had acted six days, 
however, the rapidity of the growth of the bacillus was dimin- 
ished, whilst it had quite ceased at the end of four weeks, and 
the bacilli at this stage were distinctly weakened. When 
strewed on the culture the drug so diminished the virulence of 
the bacillus that after sixteen days nothing but cold abscesses 
were formed after inoculation, many giant cells being present, 
and the course of the disease was very chronic. When mixed 
in the proportion of one part of the active culture to fifteen 
parts of iodoform, it was found that the bacilli were not always 
killed in fourteen days, although in one case they were quite 
innocuous at the end of eight days; at the end of three weeks 
they were dead, or at any rate harmless. The authors found 
also that they could obtain bacilli which would set up only 
chronic tubercle by means of the action of the iodoform out- 
side the body, for when inoculating tubercle bacilli so treated 
they obtained a disease which was identical with Perlsucht, 
both in its clinical and pathological characters. Mixed with 
olive oil or glycerine in proportions of one part of iodoform to 
ten of the vehicle, they found that the organism was killed in 
sixteen days, the oil and the iodoform being much more 
efficacious than the glycerine mixture. Virulent bacilli can 
grow in the the tissues whatever iodoform mixture be intro- 
16t'erl. klin. Wochenschiift, No. 20, 1891. Supplement to British Med. Journal 
July 18, 1891. 12 
A. SEEN. 
duced along with them, this being due to the fact that the tis- 
sues are such a good medium for the growth of the organism 
that the energy of the latter becomes very great, and the 
iodoform can exert little action on its growth, although out- 
side the body where the conditions for growth are not so 
favorable the iodoform has a decided inhibitory effect. In 
the case of cold abscesses the growth of the bacillus is not so 
active, and therefore the iodoform has a better chance of ex- 
erting its valuable therapeutic properties. The authors found 
that the iodoform must act directly on the bacilli, as they have 
been able to demonstrate that it has a deleterious irritant action 
on the tissues; they also find that the action is most satisfac- 
tory in those cases where the number of bacilli is comparar 
tively small, in which case the iodoform appears to prevent 
the growth of the bacilli. Their investigations have led them 
to the practical conclusion that iodoform is a true disinfecting 
agent as far as the tubercle bacillus is concerned; that it has a 
direct destructive effect upon the bacillus if left sufficiently 
long in contact. They have also shown that this drug dimin- 
ishes the virulence of the tubercle bacillus and that cultures 
thus treated produce a more benign form of tuberculosis in 
animals. 
Gosselin17 made a series of experiments on animals with 
mercurial preparations and iodoform in order to ascertain if 
any of these substances could so alter the tissues as to render 
them unfit as a soil for the tubercle bacillus. He reasoned 
that if such a condition could be brought about by the intro- 
duction of chemical substances otherwise harmless an existing 
tubercular focus would be harmless, as local and general dis- 
semination co dd no longer occur. Experiments with mercuric 
bichloride and biniodide had no effect in this direction. On 
the other hand these mercurial salts appeared to aggravate 
the tubercular process. Iodoform yielded better resuks. It 
was administered like the salts of mercury subcutaneously. It 
was his intention to render the animals refractory to the 
tubercle bacillus by saturating the tissues with iodoform prior 
17Sur l'attenuation du virus de la tuberculose, Etudes sur la tuuerculose, ler 
Juillet, 1887. TUBERCULOSIS OF BONES AND JOINTS. 
13 
to the inoculation. He used a solution of iodoform of 10:100. 
Six rabbits were selected, three of which were subjected to 
iodoform treatment, while the remaining three were not thus 
treated, but kept under exactly similar conditions. Three 
drops of the ethereal solution of iodoform were injected under 
the skin every day for two months. In the beginning the 
iodoform was badly borne, as it diminished the appetite and 
caused frequent attacks of diarrhoea and the animals cowered 
in a corner of the cage and showed no inclination to move 
about. These symptoms always disappeared with the sus- 
pension of the injections. After a few days all the secretions 
and the tissues in different parts of the body responded to the 
iodine test. 
The injections had to be made with great care as they were 
often followed by acute inflammation of the skin and subcu- 
taneous cellular tissue. Four months later all of the animals 
were inoculated. The three control animals died of tubercu- 
losis in from thirty to fifty days, the iodoformized animals 
showed a partial immunity and manifested no symptoms of 
tuberculosis until the expiration of fifty days, and death did 
not occur until from the seventieth to the ninetieth day after 
inoculation. 
The same experiments were repeated three times with 
identical results. In two instances the iodoformized animals 
were killed respectively on the twenty-fifth and thirtieth day 
after operation. 
Nothing further was found at the point of inoculation than a 
slight circumscribed peritonitis in one, and a limited area of 
adhesion between the peritoneal surfaces in the other. Ex- 
amination of specimens stained by Ehrlich's method showed 
numerous bacilli in the adherent parts, and a fragment of 
lymph deposited on the surface implanted into the peritoneal 
cavity of a guinea-pig caused death from tuberculosis in 
twenty-seven days. Iodoformized guinea-pigs proved more 
refractory to the tubercle bacillus than rabbits; in one instance 
the animal lived one hundred and two days after inoculation. 
In another very interesting series of experiments Gosselin 
reversed the experiments, rendering the animals first tubercular 14 
N. SENN. 
by inoculation and then resorting to treatment with iodoform. 
In these experiments rabbits and guinea pigs were used. 
Soon after the animals were inoculated with tubercular mat- 
ter, daily subcutaneous injections of two to three drops of iodo- 
form ether (i:io) were made, suspending the treatment as soon 
as iodoform intoxication set in and beginning anew when they 
disappeared, grading the absorption of iodoform so as to ob- 
tain the maximum impregnation of the organism with this 
drug compatible with life in the shortest possible space of 
time. 
The experiments showed that susceptibility to iodoform dif- 
fers not only in the same species of animals, but also in differ- 
ent members of the same family. If the animal is not closely 
watched, it will die quickly, poisoned by the combined action 
of ether and iodoform. 
Three rabbits and two guinea-pigs remained well ninety-five 
days after inoculation and were killed and the most careful 
search showed no trace of tuberculosis at the point of inocu- 
lation and all of the organs presented a perfectly healthy ap- 
pearance. 
Two rabbits and one guinea-pig were in good health one 
hundred and sixty days after inoculation. The two rabbits 
were considerably emaciated and their appetite somewhat di- 
minished. These symptoms were due to the iodoform, for as 
soon as the use of this remedy was suspended the animals 
were restored to perfect health. The dose of iodoform was 
diminished every five days for a fortnight. A third rabbit died 
from iodoform poisoning on the thirteenth day and a careful 
autopsy did not reveal a trace of tuberculosis. At the seat of 
injection there was a circumscribed inflammatory exudation 
apparently free from bacilli. Two guinea-pigs were inoculated 
with fragments of tissue from this place and these animals, 
with the exception of slight emaciation, remained in good 
health one hundred and sixty-one days later. 
These studies appear to prove that the prolonged use of 
iodoform by subcutaneous injection carried to the point of 
toxic symptoms prevents, or at least retards, the extension of 
the tubercular process. 
Thiery18 does not believe that iodoform possesses such di- TUBERCULOSIS OF BONES AND JOINTS. 
15 
rect antitubercular properties as expressed by Gosselin, but he 
is willing to admit that it has a potent influence in retarding 
the tubercular process. In opposition to the conclusions 
drawn by Gosselin he reminds his readers that it is well known 
that tuberculosis, under favorable circumstances, is occasion- 
ally spontaneously cured or curable. In 131 autopsies 
made at the Morgue Vibert he noticed evidences of a former 
tubercular process, which had become arrested spontaneously, 
and the patients succumbed to other diseases. In seventeen, 
out of the twenty-five cases, the former tubercular depot was 
indicated by a cicatrix or chalky deposit. As further proof that 
tuberculosis does not always manifest progressive tendencies 
and undergoes a cure unaided by medication may be men- 
tioned the writings of Leroux, Cruveilheir,19 Rogee, who in his 
work20 makes the statement that in fifty out of one hundred 
autopsies, which he made on old men, he found evidences of 
pulmonary phthisis, which had been completely cured. Boudet;21 
Gaucherstudied carefully the process of spontaneous cure of tu- 
bercle by cicatrization. Similar and other observations in the 
same direction were made by Grisolle, Guencon de Mussy, 
Lebert, Jaccoud, Herard, Cornil, Peter and lastly the work of 
Thavu23. 
Jeannel24 has made experimental investigation in the same 
direction concerning the curability of tuberculosis as Gosselin. 
He made the following four series of experiments: 
1. Local treatment alone. 
2. Local and general treatment combined. 
3. General treatment alone from the beginning of the dis- 
ease. 
4. General treatment alone from a period remote from the 
18De la Tuberculose Chirurgicale, etc., Paris, 1890, p. 485. 
19Anat. Path. Gen., T. 10, p. 616. 
20Arch. Path. Gen. de Med., 1829, T. v. 
2lTh£se de Pai is, 1843. 
22Archives de Physiologie, 1878. 
23Clinique Chir. des Mal. Chron., 1877. 
24Recherches sur la Generalisation de la Tuberculose Experimentale, Congres de 
la Tuberculose, Paris, p. 351. Nouvelles recherches experimentales sur la tubercu- 
lose et sa curabilite, Etudes sur la tuberculose, fasc., ii, p. 416. 16 
N. SENN. 
beginning of the disease, that is, from the time inoculation was 
made. 
On the whole, the results were not very encouraging. The lo- 
cal treatment alone or combined with general treatment did not 
prevent the development of tuberculosis, all of the inoculated 
rabbits died from well-marked tubercular affections and the 
treatment did not even retard the progress of the disease or post- 
pone the fatal termination. General treatment alone inaugur- 
ated at the time the inoculation was made proved also ineffica- 
cious and Jeannel even intimates that the treatment by iodo- 
form ether has neither the power to cure or to retard tubercu- 
losis in the rabbit. Finally, general treatment alone instituted 
at a period remote from the beginning of the disease was a 
complete failure in every respect. Remarking how these re- 
sults were so widely at variance with those claimed by Gosse- 
lin, the latter replied that he positively maintained the asser- 
tion previously made concerning the curability of local tuber- 
culosis by treatment with iodoform injections. He at the 
same time insisted that generalization of tuberculosis varies 
with the place where the inoculation is made. 
The discrepancy of the view entertained by these French 
investigators leaves the experimental field concerning the 
curability of tuberculosis by the local and subcutaneous use 
of iodoform open for future research to determine definitely 
the value of this remedy in the treatment of this disease. 
Clinical Results.-The clinical results have been more uni- 
formly in support of the anti-tubercular action of iodoform 
than the conclusions drawn from experimental work. The 
iodoform treatment of tubercular affections of bones and 
joints found an enthusiastic advocate in France in the person 
of Verneuil;25 through his example and influence it found 
ready adoption at once in different parts of that country by 
the most prominent surgeons. 
Verchere26 expresses himself as highly pleased with the re- 
sults obtained by injections of ethereal solutions of iodoform, 
"Injections d'ether-iodoforme dans les abces froids. Revue de Chirurgie, 1885, 
p. 428, et sequi. 
"Revue de Chirurgie, 1886, p. 476-502. TUBERCULOSIS OF BONES AND JOINTS. 
17 
as advised by Vereuil a year after the latter surgeon published 
his first paper on the subject. 
Segond27 restricts the use of the iodoform treatment to pa- 
tients greatly debilitated by the disease, and in cases in which 
the primary disease is inaccessible to radical measures. 
Barrette28 reports twenty-eight observation, of his own with 
very favorable results. Among these was a man, set. 33, with 
tubercnlar osteo-myelitis of the fourth rib, complicated by in- 
cipient pulmonary phthisis. The cold abscess which had de- 
veloped in connection with the rib was treated by iodoform 
injections and the local lesion was cured. 
Two cases of cold abscess originating from the spine were 
also cured. In one case in which an abscess started from a 
tubercular focus after resection of the elbow the injections 
were followed by death from iodoform intoxication. The ne- 
cropsy revealed an incurable chronic affection of the kidneys. 
Reclus29 in giving his results of this method of treating tubercu- 
lar affections reports only two complete failures, five improved, 
meanwhile two died of slow tubercular lung complications. 
Eight recovered in spite of large collections located where 
operation was practically impossible and in nine cases the 
final outcome could not be learned. He injects into large ab- 
scesses from 60 to 120 grammes of a 5 % solution of iodoform 
in ether. The injections to be repeated in from three to four 
weeks, and in some cases the injection has to be repeated a 
third and a fourth time; after the injections the abscess wall 
becomes greatly disturbed by the ether gas; if the vitality of 
the overlying skin is considerably impaired necrosis may take 
place from the pressure. In such cases the ether vapor is to 
be removed by inserting a small trocar. In a few cases this 
treatmerit was followed by suppuration and the formation of a 
fistula, which, however, soon healed. He is of the opinion 
that in all of the cases in which a cure followed the same re- 
2'Abscds Tuberculeux de la Cuisse, injections d' ether iodoforme on operation 
sanglante. Gazette des hopiteaux, No. 146, 1887. 
28Sur le traitement des manifestations externes de la tuberculose. Congres de la 
Tuberculose, p. 586. 
29Gazette Hebdomadaire, 1887. 18 
TV. SENN. 
suit could have been obtained by incision and curetting, but 
the latter treatment would have required more time and would 
have left unsightly scars. In favor of the iodoform treatment 
he also maintains that it is less likely to be followed by a re- 
lapse, and cites Trelat, Guyon, Bouilly, Nelaton, Richelot, 
Quenu, Peyrot and Bruns as entertaining the same opinion. 
Tilanus30 studied the antiseptic and antibacillary properties 
of iodoform, and concludes that it is a useful remedy in the 
treatment of tuberculosis. 
Villemin31 is of the opinion that iodoform is deserving of 
the confidence of the surgeons. The French surgeons have 
employed almost exclusively the ethereal solutions of iodoform 
(5.100) and we hear of cases in which,like in some of the ex- 
periments on animals, the injections caused a violent local in- 
flammation and even gangrene. The injection is also painful, 
as the temperature of the body is sufficiently high to vaporize 
the ether in a very short time after its injection, which causes 
painful and sometimes dangerous tension in the joint or ab- 
scess. It appears also that iodoform intoxication occurs more 
frequently when the ethereal solution is used than when the 
iodoform is injected in the form of an emulsion in glycerine, 
or in olive oil. A case of death from iodoform intoxication 
was alluded to above and another occurred in the practice of 
Barvis.32 
The patient was a soldier, aet. 24, the subject of a large cold 
abscess in the region of the left wall of the chest. This was 
punctured and after evacuation of its contents from 50 to 60 
grammes of a 5 % ethereal solution of iodoform were injected. 
Immediately after the injection the patient went into collapse, 
and it is possible that some ot the solution was injected into 
the pleural cavity. In explanation of the sudden death it may 
be suspected that a small quantity of the ether vapor was 
forced into the venous circulation and that the collapse was 
30Proprietes de 1'iodoforme. Revue de Chirurgie fevrier, 1890. 
3lEtude experimentale de 1' action de quelques agents chimiques sur le develop- 
ment du bacille de la tuberculose, J888. 
32Du traitement des Abscess froids, Intoxication iodoformique mortelle. Arch, 
de Med. et de Pharmacie, T. xvi, No. 8, 1890. TUBERCULOSIS OF BONES AND JOINTS 
19 
caused by ether vapor embolism, but Barvis attributes the 
death in this case to acute iodoform intoxication. In view of 
the fact that ether iodoform injections are always productive 
of pain, and not infrequently produce intense local reaction, 
and that the ether used may become a source of danger and 
that they are more liable to give rise to intoxication than when 
iodoform glycerine emulsion is used, the latter preparation 
should be used exclusively. In Germany the latter method 
of administration is used almost exclusively. 
Bruns uses a 10% mixture of iodoform in glycerine or olive 
oil, always taking the precaution to sterilize the mixture. 
Krause recommends the following mixture: 
Iodoform subt. pulveris, _ _ _ 50.0. 
Mucil. gummiArab, - 2.30. 
Glycerini, - - 83-0. 
Aq. distillat., q.s. ad., _ _ _ 500.0. 
S.: Ten per cent, iodoform mixture. To this mixture he 
adds one per cent of pure carbolic acid. 
Whatever formula for the solution is selected, not more 
than half a drachm of the iodoform should be injected at the 
first time, and in children even less. If this dose does not 
produce any unpleasant symptoms, it may be increased the 
next time the operation is repeated. If used in this manner 
the risk of iodoform intoxication appears to be nil or 
at least very remote as not a single instance was observed in 
108 cases treated in the Tubingen clinic by Bruns. The best 
results with iodoform injections come from the Halle and 
Tubingen clinics. This is undoubtedly owing to the fact that 
in these institutions this treatment has been very extensively 
used, and the large experience thus gained has enabled the 
surgeons to make a proper selection of cases, and apply the 
treatment in the most efficient manner. 
Bruns33 injects every two weeks a mixture composed of 10 
parts of iodoform, 50 of glycerine and 50 of distilled water. 
33Ueber die anti-tuberculose Wirkung des Iodoforms, Verh. der. Deutschen 
Gesellschaft, f. Chirurgie, 1877. 20 
N. SENN. 
In his first report he states that of 54 cases oi tubercular abscess, 
40 have recovered under this treatment. 
In a later publication the same author34 asserts that the 
anti-tubercular action of iodoform has been demonstrated. In 
order, however, for this drug to exert its specific action it is 
necessary that the whole interior surface of a joint or tubercu- 
lar abscess should be acted upon and the action should be un- 
interrupted and continued for a long time. The curative 
effect often only becomes apparent after three or four months, 
but from this time the abscess gradually disappears. Of 100 
cases of tubercular abscess treated in his clinic during the last 
five years 80% were cured, and during four years 50 cases of 
joint tuberculosis were also cured. He uses now a 10 to 20% 
mixture of iodoform in pure glycerine or olive oil prepared 
fresh and thoroughly sterilized before each injection. 
In the case of fungous joints he makes the injection not only 
into the cavity of the joint, but also into the thickened capsule, 
making the puncture at different points and injecting from 2 to 
6 cm. of the mixture. In tubercular hydrops and tubercular 
abscess the fluid or softened contents are first removed, where- 
upon 10 to 30 cm. of the mixture are injected. 
Neither pain nor symptoms of local irritation follow the 
procedure, but the temperature usually shows a rise from one 
to two degrees, which, however, disappears after a few days. 
He does not immobilize the injected joints. He has never met 
with cases of iodoform intoxication from the injections. 
Parenchymatous injections are to be repeated every eight 
days, intra-articular injections every two to four weeks. 
Symptoms of improvement seldom appear before the expira- 
tion of six to eight weeks, although the pain diminished at an 
earlier date. 
Shrinking of the fungous capsule is the surest indication of 
beginning improvement. In children suffering from tubercu- 
losis of joints the functional result is frequently perfect if the 
treatment is begun before the disease has resulted in extensive 
destruction of the soft structures of the joint. In adults the 
34Ueber de Behandlung tuberculoser Abscesse und Gelenkerkrankungen mit 
Iodoform injectionen. Beitrage zur klinischen Chirurgie, vi, 3, p. 639,1890. TUBERCULOSIS OF BONES AND JOINTS. 
21 
best results often consist in a useful but partially or completely 
anchylosed limb. 
Wendelstadt35 uses a mixture of iodoform in olive oil in the 
proportion of 5:25. He insists that the mixture should be pre- 
pared fresh every time, as in mixtures kept for some time free 
iodine is generated, the presence of which can be recognized 
by the mixture presenting a brownish red color. 
As a parenchymatous injection he throws from 2 to 3 cm. 
of this mixture into the tissues with an ordinary Pravaz syringe. 
The injection is* repeated every eight days; the puncture should 
always be made at a different point in order to reach succes- 
sively different parts of the focus. 
In several cases he observed a rise in the temperature to 
400 C. the same day, but the febrile reaction always subsided 
in a short time. This method was applied in 109 cases of 
local tuberculosis; of this number 28 were later treated by in- 
cisions and evidement. A permanent cure was obtained in 
36, improved 37, and not much benefited 12, and 24 remained 
under treatment. 
Andrassy36 gives the particulars of the 22 cases of cold ab- 
scesses treated by iodoform injection that were first reported 
from the Tubingen clinic by Bruns. Of this number 20 were 
perfectly and permanently cured. In one case the abscess had 
to be opened. The largest dose of iodoform used was 10 grms. 
No symptoms of intoxication were observed in any of these 
cases, but occasionally a considerable rise in temperature fol- 
lowed the procedure. In most cases the operation had to be 
repeated two or three times at intervals of two weeks. The 
healing process was generally completed in from one-half to 
two and one-half months. 
Billroth37 uses a 10% iodoform glycerine emulsion. The 
tubercular joint or abscess is evacuated and from 40 to 50 
35Zur Behandlung der tuberculosen Knochen und Gelenkerkrankungen durch 
parenchymatose Injectionen von lodoformol. Centralblatt f. Chirurgie, No. 38,1889. 
36Beitrage zur Behandlung der kalten Abscesse, insbesondere mittelst lodoform- 
injectionen. Bruns' Beitrage zur klinischen Chirurgie, li, 1887. 
37Ueber die Behandlung kalter Abscesse in tuberculoser Caries mit Iodoform 
Emulsion. N. SENN. 
grammes of the mixture are injected. The injection is not re- 
peated until the urine no longer reacts to the iodine test. 
During two years Krause38 treated tubercular affections of 
the following joints by intra-articular injections of iodoform: 
Knee-joint, ------ 36. 
Hip-joint, - - - - - - -13. 
Tarsal-joint, ------ 6. 
Wrist-joint, - - - - - 5. 
Elbow-joint, ------ 1. 
The treatment was not completed in all of these cases, but a 
cure had been effected in the following: 
Knee-joint, - - - - - - 15. 
Hip-joint, ----- 4. 
Tarsal-joint, - - - - - - 1. 
Wrist-joint, - - - - 3. 
Three of the cases that were cured were sent to the clinic to 
undergo an amputation. 
Although in the cases where the wrist-joint was involved the 
treatment failed in restoring motion, it made the fingers more 
movable and useful. In the hip-joint cases recovery usually 
resulted in almost total anchylosis. 
This was evidently due to the fact that the severest cases 
were subjected to this treatment, and much better functional 
results can be expected if this treatment is commenced during 
the early stages of the disease. 
Improvement was noted in nearly all cases that remained 
under treatment. The best results were realized from the 
treatment in tuberculosis of the knee and wrist-joints. He 
recommends that if the canula of a large trocar is not large 
enough through which the joint can be completely emptied of 
its contents that an incision should be made for this purpose, 
and the wound sutured before the injection is made. 
Of the cold abscesses which were subjected to treatment by 
38Ueber den beutigen Standpunkt in der Behandlung der tuberculosen Knochen 
und Gelenk Krankheiten. Berl. klin. Wochenschrift, No. 49, 1S90. 1 UBERCUL0S1S OF BONES AND JOINTS. 
23 
iodoform injection 50% were cured. He believes that intoxi- 
cation symptoms are not produced by using emulsion of 
iodoform because none of the iodoform is in solution 
and on this account absorption is very slow. He has 
injected the emulsion which he uses in doses varying 
from 5 to 80 grammes. The injections never caused much 
pain but were often followed by a rise of temperature for a 
short time. The first symptoms which denote that improve- 
ment is taking place are lessening of pain and diminution of 
swelling. Peri-aiticular abscesses recurred several times after 
they were apparently cured and required repetition of treat- 
ment. 
Trendelenburg has treated 135 cases of all grades of severity 
by the injection method, making one injection of five grammes 
every eight days. The most striking results were obtained in 
wrist-joint tuberculosis in adults-a disease which usually gives 
a bad prognosis and frequently necessitates amputation. In 
68% of all cases the treatment had a favorable effect. 
Immediate and Remote Dangers Attending Iodoform Injections. 
The dangers attending the treatment of tubercular affections 
of bones and joints by iodoform injections may arise from 
iodoform intoxication, the action of the menstruum employed, 
secondary infection, and injury of important parts by the instru- 
ment used in making the puncture. 
In a case of Boeckel's,39 the patient died during the opera- 
tion. It was found that the abscess communicated with the 
subclavian artery. In three of Konig's40 cases the puncture of 
the abscess was followed by profuse haemorrhage, due to 
arterial erosion. The arteries involved were the gluteal, the 
deep femoral, and the external plantar. These had to be 
ligated. A similar complication occurred in two cases under 
the care of Lindner,41 one of* fatal haemorrhage from the 
femoral, and the other from the iliac vein. 
Dollinger42 does not approve of the iodoform ether injec- 
39London Medical Record, 1889. 
40Centralblatt f. diegesammte Therapie, 1887. 
41Deut. Med. Woch., 1887. 
42Beittage zur lodoform-ether behandlung der tuberculbsen Knoclien entziindung. 
Centralblatt f. Chirurgie, May 18, 1889. 24 
N. SENN. 
tions as advised by Verneuil, as he has found in his experience 
that in children they did not induce recovery in a single case. 
He not only regards them useless, but harmful, as the injection 
of even small doses produced deafness, headache, and nausea, 
while larger quantities were followed by loss of consciousness, 
impaired respiration and acute cystitis. At the moment of in- 
jection some headache may be felt, and there may be an 
evening rise of temperature of 3 to 4 degrees. The rapid 
evaporation of the ether may cause necrosis of the abscess 
wall, and if, for example, psoas abscess from rapid over-disten- 
sion should rupture into the peritoneal cavity, death might re- 
sult from such injections from septic peritonitis. 
Heusner43 reports a case of iodoform intoxication caused by 
an intra-articular injection of o.I of iodoform in glycerine. 
Bramann observed quite grave symptoms of intoxication after 
an injection containing 2.0 of iodoform. The patient was a 
boy. Later, the injection of the same amount produced no 
untoward symptoms. 
Trendelenburg first used iodoform ether, but in a short time 
the injection produced gangrene of the overlying abscess 
wall in three cases, and after that he has used the emulsion 
exclusively and has not observed such a result since. Gan- 
grene of the overlying tissues and iodoform intoxication have 
only been observed after iodoform ether injections; the first is 
caused by the overdistension resulting from vaporization of the 
ether and the latter is due to rapid absorption of the iodoform 
kept in solution by the ether. Another possible remote source 
of danger attending the injection of the ethereal solution is 
the entrance of ether vapor into one of the veins causing 
death from ether-embolism. 
The dangers just enumerated do not belong to injections of 
iodoform held in suspension irf glycerine or olive oil. Acci- 
dental infection, which has occasionally occurred during or af- 
ter the injection, is, of course, caused by a faulty antisepsis, 
and has happened from the use of iodoform by parenchyma- 
tous and intra-articular injections irrespective of the menstruum 
used. If such an accident takes place, it will become neces- 
43Berl. klin. Woch , Oct.'s, 1891. TUBERCULOSIS OF BONES AND JOINTS. 
25 
sary to make a puncture with a large trocar and evacuate the 
pus through the canula and resort at once to irrigation-, with a 
3 % solution of boracic acid, or treatment by incision and 
drainage may be required. Dangerous haemorrhage is occa- 
sionally encountered in treating tubercular abscesses by inci- 
sion and scraping when a vessel of considerable size has be- 
come eroded and the possible occurrence of this accident 
does not militate against the treatment by iodoform injections. 
Action of lode form on Tubercular Tissue.-If iodoform in the 
form of an emulsion is injected into an empty tubercular joint 
or abscess, and an effort made to diffuse it over the whole in- 
terior surface, by passive motion, pressure and rubbing, the fine 
particles of iodoform will soon be equally distributed over the 
entire surface clinging to the granulations, fibrinous masses, 
or the cheesy material lining the cavity. The iodoform pro- 
duces no violent irritation, its action on the tissues is mildly 
stimulating. The re-accumulation of fluid in the joint or tuber- 
cular pus in the abscess is slow and if the procedure is repeated 
after eight days to two weeks the fluid withdrawn will contain 
particles of iodoform, showing that the absorption of this sub- 
stance, when not applied in solution, is very slow. At the same 
time the fluid will have changed its character somewhat, con- 
taining elements the presence of whiqh indicates that remnants 
of dead tissue products of coagulation necrosis are being 
thrown off and that a reparative process has been initiated. 
The first effect of the iodoform on the tissues lining the joint 
or cavity is to bring about rapid disintegration of the tubercu- 
lar product, which then is displaced by a layer of active and 
very vascular granulations. 
Bruns and Nauwerk44 incised tubercular abscesses treated by 
iodoform injections at different intervals after the injection and 
extirpated pieces of the abscess wall for microscopical ex- 
amination. A few weeks after injection they found that the 
tubercle bacilli had disappeared, the miliary tubercles softened 
by infiltration with round cells and oedematous inhibition of a 
serous fluid; further on the tubercles disappeared by fatty de- 
44Ueber die antituberculose Wirkung des Iodoforms, Klinische und Histologische 
(Jntersuchungen. Bcitrage zur Klinischen Chiiurgie, iii. Tubingen, 1887. 26 
N. SENN. 
generation of the cells and liquefaction of the cellular detri- 
tus. Hand in hand with the degeneration and liquefaction of 
the tubercular product could be witnessed in the adjacent tis- 
sues a process of repair in the shape of a wall of granulation 
tissue which formed a line of demarcation between the healthy 
and diseased tissue which consumed in part the dead sterile 
tubercular tissue and detached the balance. As soon as the dead 
tissue was disposed of by absorption the granulations began to 
cicatrize and were gradually converted into connective tissue, 
and with this change the process of the healing was com- 
pleted. Krause made similar examinations and corroborates 
the observations made by Bruns and Nauwerk. That the cura- 
tive effect of iodoform in the treatment of tubercular joints 
and abscesses is not owing to the mere puncture and evacuation, 
but is brought about by the specific action of iodoform on the 
tubercular products there can be no doubt as tapping for these 
conditions was employed long before iodoform was used in 
surgery, but this procedure seldom yielded more than tempo- 
rary relief. Stockma treated five tubercular abscesses by tap- 
ping alone but always with negative results. If he injected 
the contents of tubercular abscesses, treated by different 
methods, into the anterior chamber of the eye in rabbits, the 
result was always positive, except in the case of abscesses 
treated by iodoform injections, in which a sufficient time had 
elapsed for the iodoform to exert its specific anti-bacillary ef- 
fect. Iodoform exercises a double therapeutic action on tu- 
bercular tissue when used by parenchymatous or intra-articu- 
lar injections, it destroys the bacillus of tuberculosis and aids 
the removal of the dead sterile tissue and favors the subse- 
quent reparative ^process by its stimulating action on the sur- 
rounding healthy tissue, properties not possessed to the same 
degree by any other, as yet known, subst mce. 
Indications.-The curative power of iodoform injections has 
so far been most manifest in the treatment of heretofore most 
hopeless cases of surgical tuberculosis, tubercular abscess in 
connection with an inaccessible osseous focus. One of the 
most brilliant achievements of modern surgery is the success- 
ful treatment of tubercular abscesses developing in the course 
of tubercular spondylitis by iodoform injections. Statistics TUBERCULOSIS OF BONES AND JOINTS. 
27 
show that more than 50% of such cases are amenable to this 
method of treatment. In the successful cases not only the 
abscess but the primary bone lesion is also cured. 
One of the most striking illustrations of the efficiency of 
iodoform treatment in these grave cases recently came under 
my observation. The patient was a delicate girl, set. 8, who 
had suffered from a tubercular spondylitis at the junction of 
the last dorsal with the first lumbar vertebra for six months. 
Slight angular posterior curvature. Within two months an 
enormous abscess developed in the right lumbar and iliac re- 
gions. Below the abscess extended as far as Poupart's liga- 
ment, above to the last rib. The abscess was very prominent 
in the lumbar and inguinal regions. The child had a temper- 
ature of 1040 F. every evening. The abscess was punctured 
under strict antiseptic precautions in the lumbar region, 
and nearly two quarts of tubercular pus evacuated. The ab- 
scess cavity was irrigated with a 3% boracic acid solution un- 
til the fluid returned perfectly clear and two ounces of a 10% 
mixture of iodoform in glycerine injected. The puncture was 
sealed with a pledget of antiseptic cotton and iodoform coi- 
lodium. 
The first injection had no effect in reducing the temperature. 
At the end of a week it was repeated, and about half as much 
tubercular pus removed. The temperature in a few days after 
the second injection was normal. The third and last injection 
was made four weeks after the first. At this time only about 
6 ounces of a viscid fluid were removed. The child improved 
in general health, and after this time no reaccumulation of 
fluid occurred. At the present time, six months after treat- 
ment was commenced, the child is wearing a plaster-of-Paris 
corset, and appears to be in perfect health. 
No one who is familiar with the efficacy of iodoform injec- 
tions in the treatment of tubercular abscesses would or should 
neglect to resort to it when called upon to treat tubercular ab- 
scess in communication with an inaccessible primary tubercu- 
lar focus. This applies with special force to abscesses devel- 
oping in connection with tuberculosis of the vertebrae and 
some of the pelvic bones. 
This treatment is again applicable and has yielded excellent 28 
N. SENN. 
results in tuberculosis of the knee and other readily accessible 
joints with or without the formation of para-articular abscesses. 
The treatment is most useful if the joint is distended with 
fluid, as under such circumstances, after the removal of the 
fluid the iodoform can be brought in contact with the entire 
surface of the cavity. This is often impossible if portions of 
the joint have been shut out by intra-articular adhesions. Ir- 
rigation of the joint should never be omitted if it contains pus, 
flakes of lymph, or detached broken down fragments of tuber- 
cular tissue, and it is in such cases that the canula of even a 
large trocar is often not of sufficient size to evacuate the joint 
or abscess properly, and that the puncture has to be followed 
by an incision large enough to meet the requirements. 
If the joint contains no fluid it is difficult and usually im- 
possible to reach all of the infected tissues by an intra-articu- 
lar injection, and it is in such cases that it must be combined 
with parenchymatous injections, and the site of puncture 
changed at each operation. As no fluid is to be removed, and 
no irrigation to be made under such circumstances, the neces- 
sary amount of iodoform emulsion is thrown into the joint and 
into the thickened fungous capsule with an ordinary Pravaz 
syringe, supplied with a large needle. The puncture is made 
at different points every time the procedure is repeated. It 
cannot be expected that a cure ean be effected by this method 
of treatment if the primary focus contains large masses of 
cheesy material, or a sequestrum of considerable size. But 
even in such cases, if the injections are made with the requis- 
ite degree of care, the treatment is harmless and results in 
great benefit in preparing the parts for subsequent surgical 
treatment by operation. 
Points to Be Remembered in Making Intra-Articular and Par- 
enchymatous Injections.-The strictest antiseptic precautions 
must be practiced in making the injections, as neglect in this 
direction would not only interfere with an ideal result of the 
treatment, but would expose the part and the patient to the 
risks and dangers incident to a suppurative inflammation with 
all its immediate and remote consequences. The surface 
where the puncture is to be made should be shaved and thor- 
oughly scrubbed with hot water and potash soap, and careful- TUBERCULOSIS OF BONES AND JOINTS. 
29 
ly disinfected by washing with an antiseptic solution, and 
lastly with pure alcohol. The trocar should be sterilized by 
boiling, or passing it slowly through the flame of an alcohol 
lamp. The emulsion must be prepared fresh, and sterilized. 
If a syringe is used for making the injection it should be one 
with an asbestos disc for the piston and kept in an aseptic 
condition. If a rubber bulb and rubber tubing is employed, 
these must be sterilized. The point where the puncture should 
be made in operating on the different large joints has already 
been described. The cardinal rule in all operations should be 
to select the shortest route from the surface into the different 
joints, and at a point where no important structures will come 
into the line of the proposed puncture. In injecting a tuber- 
cular abscess the puncture should not be made where the ab- 
scess wall is thinnest, but some distance from the most promi- 
nent point of the swelling, so that the puncture will be made 
through healthy skin, and not through tissues reduced in vi- 
tality from the long continued pressure from beneath. Before 
the puncture is made, the skin is drawn to one side, so that 
after the removal of the canula the puncture in the deep tis- 
sues may be subcutaneous. 
The ethereal solution of iodoform should never be em- 
ployed, as its use is attended by greater immediate and remote 
risks than if the iodoform is used in suspension in a non- 
volatile menstruum. 
The best method of using the iodoform is a 10% mixture in 
glycerine or olive oil. The quantity of the mixture to be in- 
jected must vary somewhat according to the age of the patient 
and the size of the tubercular focus. From three drachms to 
an ounce is the average dose. In injecting a tubercular joint 
which contains fluid or a tubercular abscess, irrigation with a 
3% solution of boracic acid should be employed until the fluid 
returns perfectly clear before the iodoform injection is made. 
If the joint dr abscess cavity contains broken down tubercular 
products which can not be removed through a large canula, 
the joint or abscess should be freely incised, the interior 
scraped and rubbed out with iodoform gauze, wound sutured 
and then the injection made, a plan of treatment practiced 
with great success by Billroth. 30 
N. SENN. 
In making parenchymatous injections the needle should be 
inserted in different directions without removing it completely, 
and the injection made at as many points as possible in order 
to saturate as large a territory as possible of the infected tis- 
sues. If the procedure is to be repeated the puncture is made 
some distance from the first so as to medicate a new area of 
tubercular tissue. 
After the canula is withdrawn the puncture in the skin 
should be carefully sealed with a pledget of aseptic cotton and 
iodoform coilodium. Mechanical diffusion of the injected ma- 
terial should be secured after the injection by kneading, com- 
pressing and rubbing the parts, and by making passive motion. 
The injection is not to be repeated oftener than every eight 
days to two weeks, and the treatment continued until the tu- 
bercular material has been removed and healing by cicatriza- 
tion is in progress. 
In the treatment of tubercular joints by iodoform injections, 
immobilization is only necessary if-active motion of the joint 
is productive of great pain. In tubercular spondylitis with 
abscess, the iodoform treatment should be combined with the 
necessary orthopoedic treatment. In tuberculosis of bones 
and joints, with a large caseous mass or a sequestration of con- 
siderable size at the primary focus the iodoform treatment can 
not take the place of mechanical removal of the infected and 
dead tissue, but is often of great value as a preliminary meas- 
ure to prepare the way for a radical operation. 
Cases of Tubercidosis of Bones and Joints Recently Treated 
by Iodoform Injections in the Surgical Clinic of Rush Medical 
College.-The most brilliant result of treatment by iodoform 
injections that came under my own personal observation was 
the case of tubercular spondylitis reported above. The local 
and general improvement was manifest after the second injec- 
tion, and complete cure, not only of the enormous abscess, but 
also of the primary bone lesion, was realized in less than three 
months. 
The cases reported below were treated in the clinic of Rush 
Medical College since April, 1891. In some of the cases the 
ultimate result of the treatment could not be ascertained, 
as the patients failed to report. A 10% emulsion of iodoform TUBERCULOSIS OF BONES AND JOINTS. 
31 
in glycerine was the preparation used exclusively. The intra- 
articular injections were made with a two ounce glass syringe, 
which was connected with the canula, after withdrawal of fluid, 
or, in case the joint was irrigated with a solution of boracic 
acid after completion of this procedure, by a piece of aseptic 
rubber tubing which was tied firmly over the distal end of the 
canula and the nozzle of the syringe. Special care was exer- 
cised to prevent the entrance of air into the joint. As a rule, 
the patients were permitted to use the limb moderately during 
the entire treatment. An exception to this rule was made in 
the cases of tuberculosis of the hip joint and in affections of 
the knee joint when the joint was much contracted. 
In no case was the injection followed by suppuration, in- 
toxication or any other immediate or remote untoward symp- 
toms. As a rule, the pain following the injection was slight 
and of short duration. The injection was always followed by 
some swelling, which reached its maximum about the second 
day. Improvement of the joint lesion was always announced 
by a change in the character of the effusion in the cases in 
which this condition of the joint existed. If the joint or ab- 
scess contained tubercular pus, the first change noticed was 
gradual disappearance of the solid portion of the fluid, such as 
shreds of lymph and fragments of tubercular tissue, at the 
same time the fluid became more viscid, bearing a strong re- 
semblance to thin mucus. As soon as this stage was reached 
the effusion disappeared speedily and permanently with con- 
temporaneous improvement of all the remaining symptoms. 
Case I. Laboring man, set. 27; has inherited a rheumatic tendency; 
presented himself for the first time in the clinic April 23, 1891; general 
health unimpaired; no signs or symptoms of pulmonary tuberculosis. 
Nine months ago he experienced pain on the inner side of the right 
knee joint. This pain was not constant, but was always aggravated 
by active exercise. Five months later the joint became swollen. When 
first examined, the joint was uniformly swollen, movements of limb un- 
impaired; upper recess of synovial sac quite prominent, fluctuation 
distinct; no tender points over condyles of femur or head of tibia- 
Primary synovial tuberculosis with hydrops was the diagnosis made at 
the time. 32 
N. SENN 
The joint was punctured with a medium sized trocar and about four 
ounces of a turbid synovial fluid, in which small flakes of lymph were 
suspended, were removed. The tapping was followed by irrigation of 
the joint with a 3% solution of boracic acid until the fluid injected re- 
turned perfectly clear. One ounce of iodoform emulsion was injected. 
The patient was advised to use the limb moderatelv. During five 
weeks the same procedure was repeated three times, and at each suc- 
cessive tapping the fluid removed was less in quantity and more vis- 
cid. When the patient was seen again after the fourth injection the 
joint presented a normal appearance, no effusion, and thickening of 
capsule nearly disappeared; motion of joint nearly normal. As the 
patient has not reported since that time it is fair to assume that he has 
completely recovered. 
Case II. Boy, set. 8, with good family history, entered the Presby- 
terian Hospital Oct. 25, 1890, suffering with hip disease. The disease 
commenced soon after an injury which he received in April, 1889. 
Rest in bed and extension by weight and pulley was the treatment em- 
ployed. Under this treatment the pain subsided, but the swelling and 
tenderness remained statiomry. During the month of May three in- 
jections, from two drachms to half an ounce of the emulsion each time, 
were made into the joint. As it was almost certain that the head and 
neck of the femur were the primary seat of the inflammation in this 
case, I made it a point to penetrate the neck of the femur deeply 
with the small trocar in order to attack existing osseous foci by the 
same treatment. The emulsion was first thrown into the substance of 
the bone, and later, after withdrawing the canula as far as the surface 
of the bone, into the joint. 
Several days after the last injection the pain became suddenly ag- 
gravated and the limb shortened in spite that extension was kept up 
uninterruptedly, at the same time the limb was rotated inward. It was 
now decided to resect the joint. The operation was performed June 
7. Tne great trochanter with the muscles attached to it was cut away 
from the shaft at the base of the neck of the femur with a chisel, and 
after the resection of the joint was replaced and fastened to the shaft 
with two catgut sutures. Inspection of the joint now explained the 
symptoms which had developed recently so suddenly. 
The head of the femur, partially destroyed, had slipped out of the 
acetabulum and was resting upon its upper brim. A number of foci 
were found in the neck of the femur in close proximity to the head, the 
joint was filled with granulations. No signs of caseation. The 
granulations were firm and of a bright red color, and 1 have no doubt TUBERCULOSIS OF BONES AND JOINTS. 
33 
had this accident not occurred the parenchymatous and intra-articular 
injections would have resulted finally in a cure. The neck of the 
femur was divided at its junction with the shaft with a broad chisel 
and removed with the head. The capsule was extirpated, and the 
granulations lining the acetabulum scooped out with a sharp spoon. 
Extension in abducted position was continued for several weeks. 
Primary healing of the wound and only very slight shortening, with leg 
in excellent position. 
Case III.-Farmer, set. 53, with a family history of tuberculosis, 
came to the clinic to be treated for tuberculosis of the wrist joint of 
three years' standing. General health fair; muscles of arm atrophied; 
hand slightly flexed; arm in position half way between pronation and 
supination. Swelling extended over the entire wrist joint, and pre- 
sented all the characteristic clinical features of tuberculosis of this 
joint. During the course of five weeks he received three iodoform in- 
jections, the quantity of emulsion used each time being sufficient to 
distend the joint fully. After the second injection the swelling and 
pain began to subside, and four weeks later the joint was practically 
cured. The injections were always made below the styloid process of 
the ulna or radius, from which point the trocar was made to traverse 
the entire joint from side to side; the injection was made slowly and 
at different points, as the canula was withdrawn. 
Case IV, Girl, set. 4, with good family history, was brought to the 
clinic June 25, suffering from typical tuberculosis of the right knee- 
joint. The disease commenced five weeks ago with pain and lame- 
ness. No evidences of tuberculosis in any other organ; general health 
fair; knee-joint slightly flexed, but only moderately swollen; no effusion 
in joint; capsule thickened, and upper recess of synovial sac evidently 
the seat of fungous granulations. Tenderness over the internal con- 
dyle of the femur suggested an osseous origin of the intra-articular in- 
flammation. The knee-joint was punctured but no fluid escaped. In 
order to ascertain whether the whole knee-joint could be medicated by 
intra-articular injection, boracic acid solution was forced into it from 
a fountain syringe until the whole joint was fully distended; it held 
about two ounces. Half an ounce of iodoform emulsion was then in- 
jected. The joint became more swollen, painful and tender after the 
first injection. The same quantity was injected July 11, August 4, 
and September 1. 
At the present time the position of the limb is normal, motion of 
joint fair, thickening of capsule greatly diminished and tenderness 
over condyle less. 34 
N. SENN. 
Case V. Girl, set. 7, was admitted into the Presbyterian Hospital, 
March 24, 1891, with well-marked advanced tubercular disease of hip- 
joint, of two years' duration. The little patient is anaemic and ema- 
ciated. Treatment by extension and parenchymatous and intra-artic- 
ular injections of iodoform. March 24, April 28 and May 28, half an 
ounce of iodoform emulsion was injected into the neck of the femur 
and hip-joint. At first the patient appeared to improve, but later her 
general condition became gradually worse, and an abscess formed. 
Resection of the hip-joint was made July 16. September 9 the wound 
was nearly healed, and the general condition much improved. The 
resected specimen contained a number of caseous foci which at least 
in part would explain the failure of the iodoform treatment. 
Case VI. Girl. aet. 7, child of healthy parents, has been suffering 
for two months from chronic inflammation of the knee-joint. Swell- 
ing has only recently appeared; limb is flexed at an angle of 1400; 
pain aggravated on motion of the joint; no fluctuation; tenderness 
over condyles of femur. 
Diagnosis.-Dry fungous synovitis with osseous foci in condyles of 
femur. Half an ounce of iodoform emulsion was injected into the 
joint and the thickened capsule at six different times from March 18 
to July 28. 
August 13, the joint was carefully examined, and the appearances 
were such as to warrant the assumption that the joint lesion was 
cured. Pain and tenderness on moving the joint, as well as in the 
condyles of the femur, had disappeared. The limb was now easily 
straightened, while the patient was under the influence of an anaes- 
thetic, and immobilized in a plaster-of-Paris dressing. 
September n, splint removed; position of limb satisfactory; further 
treatment, consisting of massage, passive motion, directed. Patient 
can walk without the aid of mechanical support. Pain, tenderness 
and swelling have disappeared completely. 
Case VIL Laborer, set, 19, good family history. Two years ago 
had an attack of peritonitis, which was followed by pain and swelling 
of one of the wrist joints. An abscess formed, and was opened four 
months after commencement of joint affection An operation was 
made a year ago. When patient was presented for the first time in 
the clinic, the wrist joint was very much swollen, and skin over it for 
some distance cedematous. Hand flexed and forearm pronated. Fis- 
tulous openings led to carious bone; lower end of radius and ulna en- 
veloped; suppuration slight; general health materially impaired. 
Evidement of joint; wound packed with iodoform gauze, and forearm, TUBERCULOSIS OF BONES AND JOINTS. 
35 
as far as base of fingers, supported by a well padded anterior splint. 
The sinuses were injected with iodoform emulsion twice a week for 
two months. At this time the wound was healed completely, and the 
patient has secured good use of hand, being able to perform manual 
labor. 
Case VIII. Laborer, set. 20; family history good. For a number 
of weeks patient has experienced pain in left knee joint, which was 
followed by swelling four weeks ago, since which time he has not been 
able to follow his occupation. At the time treatment was commenced, 
August 11, the knee-joint was distended with fluid, patella raised at 
least half an inch from anterior surface of condyles, upper recess of 
joint very prominent, and conspicuous bulging on each side of patella. 
Diagnosis: Primary synovial tuberculosis with hydrops of joint. Gen- 
eral health not much impaired. Joint was tapped, and ten ounces of 
turbid synovial fluid, mixed with shreds of lymph, removed. The joint 
was washed out repeatedly with a 2% solution of boracic acid, until 
the fluid returned perfectly clear, when, by compression, the joint was 
completely emptied and an ounce of iodoform emulsion was injected. 
Next day the joint was swollen as much as before the tapping. The 
patient returned August 25, and stated that the treatment had proved 
beneficial to him. The joint was again tapped, but only half the quan- 
tity of fluid removed as the first time. The fluid removed contained 
no shreds, and was clearer and more viscid than at the first tapping. 
The second injection produced less swelling and pain than the first. 
Two weeks later the swelling had completely disappeared, thickening 
of capsule less, and the patient has since recovered almost perfect use 
of limb. 
Case IX. Brakeman, set. 22, was admitted into Presbyterian Hos- 
pital April 15, 1891; tuberculosis not hereditary in his family. About 
five years ago patient experienced a sudden pain in left knee, which 
was followed very soon by swelling and local heat. Since that time 
the knee has been injured on three different occasions, and each acci- 
dent was always followed by aggravation of symptoms. About 18 
months ago the pain diminished, but patient was unable to walk with 
out the aid of crutches. The patient is anaemic and considerably ema- 
ciated; knee-joint swollen and flexed; no effusion in joint, but capsule 
thickened throughout; circumscribed point of tenderness over inner 
tuberosity of tibia. Careful search reveals absence of tuberculosis in 
other organs. Diagnosis: Tubercular osteo-arthritis with a probable 
focus in the inner tuberosity of tibia. Two iodoform injections were 
made two weeks apart, but as no improvement followed typical resec- 36 
N. SENN. 
tion of knee-joint with preservation of patella was made May 3, 1891. 
The whole synovial membrane was found converted into a granulation 
mass, and capsule of joint much thickened. The base of two triangu- 
lar sequestra in the head of the tibia projected into the joint. The ar- 
ticular surface of the two fragments of necrosed bone was much worn, 
and presented a polished surface. Primary union of wound and bony 
consolidation of resected ends in six weeks. The inefficacy of iodo- 
form treatment was explained by the pathological conditions revealed 
at the operation. Secondary tubercular synovitis following extensive 
necrosis from occlusion of an artery by a tubercular thrombus or em- 
bolus is not amenable to this kind of treatment. If in such cases 
this treatment is not followed by improvement after the second or third 
injection, resection is indicated and the operation should not be post- 
poned. 
It is my opinion that even in such cases the preliminary treatment 
by iodoform injections is of great value, as it brings the intra-articular 
structures in better condition for successful operative treatment. I 
regard intra-articular and parenchymatous injections of iodoform as 
the best preparatory treatment for the resection of tubercular joints in 
which this treatment does not meet the pathological indications. 
Case X. Boy, set. 17, with a tubercular family history, applied for 
treatment in the college clinic, June 18, 1891. When 2 years old, 
symptoms of tubercular spondylitis in the dorsal region first developed 
In spite of the usual treatment made use of for this affection an exten- 
sive posterior curvature formed. The patient, although 17 years of 
age, is not taller than a boy of 7 or 8 years. About 6 months ago a 
swelling was detected in the left iliac region which rapidly increased 
in size. The patient is very ansemic, and greatly emaciated. The 
curve involves at least eight or nine of the upper dorsal vertebrse. A 
fluctuating swelling reaching from Poupart's ligament to the costal 
arch, and extending to near the median line, was found on the left 
side. Diagnosis: Tubercular spondylitis of upper dorsal vertebrse, 
which has resulted in the formation of an immense lumbar abscess, 
which in all probability still communicates with the primary osseous 
lesion. The abscess was tapped in the lumbar region immediately 
below the last rib and six pints of characteristic tubercular pus were 
evacuated. The abscess was washed out repeatedly with a solution of 
boracic acid until the fluid returned perfectly clear, after which an 
ounce of iodoform emulsion was injected. 
Between June 18 and August 5, tapping, irrigation and injection 
was repeated four times. At each tapping the quantity of fluid re- TUBERCULOSIS OR BONES AND JOINTS. 
37 
moved was less, so that the last time not more than four ounces of a 
viscid opaque fluid were removed. Since then there has been no 
reaccumulation of fluid, and the general condition of the patient has 
very much improved. In its result the treatment in this case has 
proved equally satisfactory, as in the case of tubercular spondylitis de- 
scribed above. These two cases have satisfied me that the iodoform 
treatment will prove most beneficial in the treatment of chronic ab- 
scesses which develop in the course of tubercular spondylitis. The 
value of this method of treatment in such cases cannot be over-esti- 
mated inasmuch as little can be expected from operative treatment in 
tuberculosis of the vertebrae. 
Dr. Ochsner, assistant to the chair of surgery in Rush Medical Col- 
lege, has kindly consented to follow these cases in the future, and 
make later a supplementary report. It is only by keeping such cases 
under observation for months and years that reliable statistics as to 
the ultimate results of this as well as any other method of treatment 
for tubercular affection of bones and jointscan be obtained. The 
immediate effect of the treatment has proven highly satisfactory in my 
hands, and in conclusion, I can only urge its more general adoption 
by American surgeons. 
Conclusions. 
I. Parenchymatous and intra-articular injections of safe 
anti-bacillary substances are indicated in all subcutaneous 
tubercular lesions of bones and joints accessible to this treat- 
ment. 
2. Of all substances so far employed in this method of 
treatment iodoform has yielded the best results. 
3. The curative effect of iodoform in the treatment of local 
tuberculosis is due to its anti-bacillary effect and its stimulat- 
ing action on the healthy tissue adjacent to the tubercular 
product. 
4. A 10% emulsion in glycerin or pure olive oil is the best 
form in which this remedy should be administered subcu- 
taneously. 
5. The ethereal solution should never be employed, as it is 
liable to cause necrosis of the tissues overlying the abscess and 
iodoform intoxication. 
6. Tubercular abscesses and joints containing synovial 38 
N. SENN. 
fluid or tubercular pus should always be washed out thoroughly 
with a 3 to 5 % solution of boracic acid before the injection is 
made. 
7. Injections should be made at intervals of one or two 
weeks, and their use persisted in until the indications point to 
the cessation of tubercular inflammation and the substitution 
for it of a satisfactory process of repair, or until the result of 
this treatment has shown its inefficacy and indications present 
themselves of the necessity of resorting to operative interfer- 
ence. 
8. If the treatment promises to be successful, symptoms 
pointing to improvement manifest themselves not later than 
after the second or third injection. 
9. In tubercular empyema of joints and tubercular abscesses 
gradual diminution of the contents of the joint or abscess at 
each successive tapping, lessening of the solid contents of the 
fluid and increase of its viscidity are the conditions which in- 
dicate unerringly that the injections are proving useful and 
that in all probability a cure will result from their further use. 
10. Moderate use of limb is compatible with this method of 
treatment provided the disease has not resulted in deformities 
which would be aggravated by further use of the limb; in such 
cases correction of the deformity should be postponed until 
the primary joint affection has been cured by the injection. 
11. Parenchymatous and intra-articular medication with 
anti-bacillary remedies has yielded the best results in tubercular 
spondylitis attended by abscess formation and tuberculosis of 
the knee and wrist-joints. 
12. This treatment may prove successful in primary osseous 
tuberculosis followed by involvement of the joint, provided the 
osseous foci are small. 
13. Extensive sequestration of articular ends with secondary 
tubercular synovitis always necessitates resection, but pre- 
liminary treatment by iodoform injections into the affected 
joints constitutes a valuable preparatory treatment to the op- 
eration and adds to the certainty of a favorable result. 
14. In open tubercular affections of joints, incision, scraping, 
disinfection, iodoformization, iodoform gauze tampon, suturing, 
and subsequent injections of iodoform emulsion as advised by TUBERCULOSIS OF BONES AND JOINTS. 
39 
Billroth yields excellent results, and should be employed in 
all cases in which a more formidable operation can be avoided. 
15. Balsam of Peru ranks next to iodoform in the treatment 
of tubercular affections of bones and joints and if the latter 
remedy for any reason cannot be employed or has failed in 
effecting the desired result, it should be given a fair trial if 
operative treatment is not urgently indicated.