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A CLINICAL STUDY OF INJECTIONS OF IODOFORMGLYCERIN IN T[IBERCULOUS OSTEOMYELITIS.

B@ HARRY M. SHERMAN, AM., M.D.,SAN FRANCISCO,

AND

AGNES WALKER, M.D.,SAN RAFAEL.

ITis natural for man to indulge in the illusions of hope,andimpelledby a hopethatI might find,in my own experience,something to substantiate the statements of some others regarding thevalue of iodoform in tuberculosis of bones and joints, I began thelittleseriesof treatmentshere reported.It is true that I ammaking a somewhat tardyreport,tardyinthatthemajorityof youhave long had well-definedopinions,basedon experience,in thematter. But beforebeginningmy own systematictrialsof themethod,I had patientlywaitedfora definitestatementfrom anAmericansource,and inwaitingI had losttime. I do notmean tosaythatAmericanjournalscontainednothingconcerningthematter;on thecontrary,therewas a good deal;butmost ofitwas ina formthatledme to rejectitas an authoritativeenunciation,and theclaimsof therest,inthefirstplace,seemedtome extravagant,and,in the secondplace,theyinducedin me a desireto know iftheymight possiblybe true,and a hope thatenoughof them might betruetowarranttheuseof themethod incertaincases.

The casessubmittedtothetreatmentwere patientsin theChildren's Hospital, in San Francisco. The time covered in the trialwas the three years beginning January, 1893. The number ofcases submitted to the treatment was 20, and these represented15 hips,2 knees,2 ankles,and 1 elbow. Up to the middleof1894, thatis,forthe firsthalfof the threeyears,the intention

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and effortalwayswas todepositthe iodoformin thejointcavity,or the intimateperiarticulartissues.After the middleof 1894theinjectionshave been intothe diseasedbone [email protected] a totalof 81 intra-or penarticular injections given, and a total, likewise, of 81 intraosseousinjections,and 2 injectionsintotheevacuatedcavitiesof thetuberculousabscesses,making theentirenumber of injections164. Ineach case,and at each injection,notewas made of the followingpoints:1. The locationand directionofthepunctureoftheneedle,thedepthofitspenetration,and thecharacterofthetissuesthroughwhichitpassed,sofarasthiscouldbeestimated.2.The amount oftheiodoform-glycerininjected.3. Whether therewas orwas notarefluxof theiodoform-glycerinthroughthepunctureholeaftertheremovalof tileneedle. 4. Whether therewas or was not painfollowingthe injection,and the locationof it. 5. Whether therewas orwas nota generalreactionfollowingtheinjection.In alla uniformmixtureof iodoformand glycerin,10 percent.

of theformerto90 percent.ofthelatter,bothby weight,hasbeenused. In the firstseriesof treatments,theintra-and periarticularcases,no specialeffortwas made to havethemixturesterile,butIwas fortunate enough to have no pyogenic accident, all abscessesthatdevelopedbeingchronicand tuberculous.For theintraosseouscasesI had the iodoform-glycerinalwayssterilizedby exposuretothe temperature of a boiling-water bath for two hours, and as iodoform does not volatilizebelow 239F., nor glycerinboilbelow554F., I neverhad any decompositionof either.No bacterioscopic examinations of the product were made, but clinically themixturewas alwayssterile.In the intra-and periarticularcasesan ordinarysyringe,similartoa hypodermicsyringe,and withanordinaryleatherpacking,was used. The syringeheldhalfan ounce.When itcame totheintraosseouscasesI founditnecessarytohavespecial apparatus. I had a needle made similar to that described bySchller. It is of very strong steel and has a canula fitting thebore closelyand ground flushwith the bevelof the needle-point.The syringewas made withan extraheavycylinderofglass,toholdtwo ounces,and I was obligedtofita ratcheton the pistonrod,anda pinion-wirekey todevelopthe forcenecessaryto drivetheiodoform-glycerin through the cancellous bone. In the intra- and pen

1

HARRY M. SHERMAN AND AGNES WALKER. 49

articular cases it was not difficult to imagine the location and distribution of the mixture in the tissues, but in the intraosseous casesa littleinvestigationwas necessary.It is a very easy mattertothrust the needle through tuberculous bone, for there is absolutelyno resistancefrom thewastedskeletonof the bone itself.Ifthebonebe removedfromthe body immediatelyaftertheinjection,andsawn soastolayopenthe puncturetrack,itremindsone somewhatof thetrackofa bulletthroughwood. The osseoustrabeculsearebroken,upset,and pushedaside,and the trackdoesnotcollapseonwithdrawalof theneedle. The iodoform-glycenin,forcedfrom theneedle-point,followsthe directionof leastresistance,and thatisbackwardalongthe sidesof the needle;but thereisa distributionof itthroughthe cancellitoa varyingdistanceon allsidesof thepuncture, the spongy tuberculous granulation tissue being partlycarriedbeforeit. I triedto seeifanythingof the kind couldbedone innormalbone,and useda sheep'sfemurforthepurpose.Thetextureof thecancelloustissueof sheep'sbone seemeda littlefinerthanthatof the human bone,but the bone itselfwas notsohard.The needlewas driveninwitha malletand withoutany difficulty.The injectionof even the minutestportionof iodoform-glycerinwas an absoluteimpossibility,the cancelliwere so fullof firm,adherent medulla that there was no room at all for any foreign substance, and the needle was held in its place as tightly as a nail in aboard.In theintra-and periarticularinjectionsthejointwasapproached

from differentsides,but in the hip cases,which were the largestnumber, the usualapproachwas by the method suggestedby vonBgner. A pointwas found on the innerborderof the sartoriusmuscle and on a levelwith the anteriorsuperioriliacspine. Aneedlepasseddirectlybackward here willpiercethe capsuleandimpingeon theneck. I modifiedthe plan slightlyby making thepunctureatthe outerborderof the sartorius,directingthe needlebackwardand a littleinwardsothatwhen itreachedbonethepointshouldbe under the von Bgnerpointof entry. Moreover,theneedlewas soheldthatthebevelon theend was nextthebone,thusendeavoring to have the opening in the end entirely within the capsule. If, after an injection made in this way there was no reflux,and therewas pain inthe knee,itwas arbitrarilyassumed thatan

OrthoSoc 4

50 TUBERCULO1JS OSTEOMYELITIS.

intra-articular injection had been made. In the intraosseous injections, too, the bone was punctured from different sides, but the usualroute was through the trochanter and up into the neck and head,that being the most common site of the primary focus of the infection in the bone. In these injections it was generally possible toappreciate whether the needle-point was passing through soft tissues,cartilage or bone, and also the firmness of the hone. In this way avery fair estimate could be made of the extent and severity of thelesion.

AJISTRACT OF THE RECORDS OF INDIVIDUAL CASES, BYAGNES WALKER, M.D.

Intra- and Periarticular Injections.CASE 1.Boy, aged eight years; hip-disease; second stage,

chronic type; abscess. Limb was in good position and boy in bedwith traction on. There were sixteen intra- or periarticular injections, each of .3j of tile iodoform-glycerin; in but four was thereany reflux; pain always followed and was located at the hip andknee; there was usually a slight reaction, but never above 103F.,and after five injections there was no reaction. Early in tile treatment an abscess developed near tile anterior superior iliac spine, butwas resorbed. After the resorption of the abscess he was gotten upon crutches and a traction splint. At the end of eighteen months hewas in excellent general condition, and this form of injection wassuspended. There had been much improvement, but no more thanmight have occurred under protective methods alone.

CAsE 11.Boy, aged four years; knee-disease, severe chronictype; no abscess. Limb was in a plaster-of-Paris splint. Therewere five intra-articular injections, each 3@. After none was therereflux; there was always pain in the knee, and there was always,but once, a slight reaction. At the end of eighteen months theswelling had diminished, and there was no pain when the limb wasat rest, but there was joint rigidity and tenderness, and this form ofinjection was suspended. Here, too, there had been improvement,but not an exceptional amount.

CASE 111.Girl, aged eight years; hip disease; second stage,mild type; no abscess. The joint permitted 97flexion, 170 cx

HARRY M SHERMAN AND AGNES WALKER. 51

tension, and 20abduction. There was one and a quarter inchesshortening. There were six intra-articular injections, each tq,l3j,extending over a period of eight months. There was no reflux,always pain in hip and knee, and never any reaction. At the endof the eight months there had been a gain in extension, a loss inflexion, 46as against 97,and a loss in abduction, 11as against20,and some gain in rotation. Tile child left the hospital oncrutches and wearing a splint.

CASE 1V.Girl, aged five and a half years; ankle-disease;severe type, but the lesion seemed to he confined to the astragalus.Motion was very limited. There were three intra-articular injections, each from 3j3jss, at intervals of five or six weeks. Therewas always pain after them, but no definite record of reaction. Therewas no therapeutic result, and this form of injection was suspended.

CASE V.Girl, aged eleven years; elbow-disease; chronic type.

Flexion permitted to 61, extension to 143, i e., about 25 ofmotion. Eleven intra- and periarticular injections, each fromntxl@j,were given, the joint being approached from all sides. Therewas little or no reflux, pain was in the elbow, and reaction wasalways slight. At the end of these there was some less swelling,but about the same amount of tenderness; flexion 74and extension 160,a small gain in each. This form of injection was heresuspended.

CASE V 1.Boy, aged five and a half years; hip-disease; secondstage, mild type; no abscess. He was kept in bed with traction on.Nine intra-articular injections were given, each about 3j. Therewas little or no refiux; pain was referred to the hip, once to theknee, and there was practically no reaction. The treatment coveredseven months, and shortly after the last injection he left the hospitalwalking on his traction splint. Two months later he was seen, wasstill on his splint, and in good condition. He is reported now, twoyears later, as being perfectly well, with a good joint and but threequatters of an inch shortening and very slight limp. This casecertainly ran rather a short course.

CASE VII.Boy, aged six years; hip-disease; second stage,severe type; no abscess. The boy was in bed and the limb was onan inclined plane with traction on. Eight intra-articular injectionswere given, each about 5j. There was but twice any reflux; pain

52 TIJBERCIJLOUS OSTEOMYELITIS.

was referredtothehip,oncetotheknee,and threetimestherewasmarked reaction, the temperature once reaching 104F. Duringtreatment an abscess developed anterior to the hip and opened spontaneously; it left sinuses which persisted, were followed up into thejoint and the bone found to be diseased and soft, and so an excisionwas done. Healingwas slowbut uneventful,and the boy isnowwell, but does not, as yet, use the limb. Here the type of the disease was severe and the injections useless if not harmful.

CASE VIII.Boy, aged six years; Ilip-disease; second stage,severe type. The limb was fixed in a position of 30flexion andcomplete external rotation. There was a fulness in the groin. Sixintra-articular injections were given, each about 3j. There was butonce reflux; there was pain in the hip only, and reaction but twice,and then slight. The condition of the hip gradually grew worsethe swelling proved to be an abscess which burrowed up into thepelvis, and excision was finally done. Healing was uneventful. Thechild is reported now, two years after leaving hospital, as being inexcellent condition, with a limb one and a quarter inches short, butone on which he can walk without stick or crutch.

CASE 1X.Boy, aged three and a half years; knee-disease. Thedisease was of a rather severe type, with a tuberculous abscess occupying the joint and burrowing down the front of the leg. Threeintra-articular injections were made, each of njxlv, and each timeafter a washing out of the joint with boric-acid solution. The effectof the treatment was to control pain and to slightly increase motion.Shortly after the last injection tuberculous meningitis developed andendedfatally.

CASE X.Boy, aged seven years; hip disease; second stage.The type was mild, but there was some intra-articular thickening.He was kept in bed with traction on. Nine intra-articular injectionswere given, two of @sseach, the others 3j. There was no reflux;pain was referred to hip and knee; twice he had severe reactions,and once the reaction temperature of 104ran up to 108, andvaricella, then epidemic in the hospital, developed. At the end ofthe treatment he left the hospital on splint and crutches, with thejoint quite firmly fixed in a position of 30flexion. In this casbthere had been apparently improvement. His present condition,two years after leaving the hospital, is exceptionally good, the joint

HARRY M. SHERMAN AND AGNES WALKER. 53

showing, on careful examination, practically no trace of having beenaffected.

Intraosseous Injections.Case I. of last series. Five injections were given, all into the

femoral neck and head, each of 3ij; there was no reflux; pain wasin hip and knee, and reaction was slight. In each instance the bonehad been easily penetrated by the needle, but was, at the same time,able to support the weight of the body. Two months after the lastinjection he left the hospital wearing no splint, with full extensionand 50flexion, and one-half inch shortening. The total amountof iodoforw used on this boy was grs. cliv. Every effort to tracehim and learn his present condition, a year and a half after leavingthe hospital, has failed.

Case II. of last series. Thirteen injections were given into thelower fetnoral epiphysis. Smallest amount @j,largest amount 3iij,average amount 5ij; there was slight reflux; pain was in knee, andreaction was slight. The bone was of varying consistency, butalways penetrable. Shortly after the last injection he was takenfrom the hospital wearing a leather knee-splint and a Thomaswalking-splint. The knee was quite but not entirely rigid. Thetotal amount of iodoform used on this boy was grs. clxxvj. It hasnot been possible to trace him since.

Case IV. of last series. Three injections into the astragalus weregiven, each of @j3jss;reflux was insignificant; pain usually severe,and reaction slight. Nothing was being gained by the treatment,tuberculous abscess formed, pointed and opened, and it was decidedto remove the astragalus, as that bone seemed to be the only one in@volved. The operation disclosed, however, such extensive disease ofthe foot and the medulla of the tibia, that amputation had to bedone.

Case V. of last series. Four injections into the bones at theelbow were made, each from 5j3ij. There was little i-eflux; painwas in tile elbow, and there was no reaction. The bone was alwayseasily penetrated. During the whole of tile treatment the arm hadbeen in a plaster-of-Paris splint, and at the end there was a slightrecognizable improvement, such as a gain of 13fiexion and 17extension. The total amount of iodoform used was grs. xcij. Shortly

54 TUBERCULOUS OSTEOMYELITIS.

after the last injection the parents took her from the hospital, andit has not been possible to find her since.

CASE X1.Girl, aged eight years. Old hip-disease with (uscharging sinuses. Two injections were given, each of 3ij, one intofemoralneckand one intowallof acetabulum. The resultwas notgood,and excisionwas done. At present,twenty months afteroperation, the child is dying of general tuberculosis.

CASE X1I.Boy, aged nine years; hip-disease; second stage;no abscess. Three injections were given: one of 5ij into femoralneck,findingboneveryilard;oneof3iv; and oneof @jintotuberculous bone in pelvis, anterior and inferior to acetabulum. Therewas no reflux;painwas inhipand knee,and therewas no reaction.Afterthelastinjectiontherewas an induratedand tenderswellingat the point of puncture. An incision disclosed the iodoform in thetrackof theneedle-puncture,butno pus. Much diseasedbonewasfound,and thiswas removed,theoperationbeing practicallyan excision.Healinghasbeen slow,butiscomplete. Use of thelimbhas not yet begun.

CASE X1II.Boy, aged five and a half years; hip-disease;second stage; no abscess. Five injections were given, penetratingthe femoral neck in various directions, four of 5ij each and one of

@iv. There was no reflux; pain is not recorded; reaction moderate,and onceabsententirely.At thebeginningtherehad beenlittleorno indurationor swellingof tissuesaroundthejoint. Two weeksafter the last injection a tuberculous abscess developed, though thereiladbeena slightgain in jointmotion. Excisionof the hipwasdone, and the boy died the following day. The bone removedshowed no evidence of any response to the action of the iodoform.

CASE XIV.Boy, aged five years; hip-disease; second stage;

no abscess;and alsoa vertebraltuberculosis.Nine injectionsweregiven into the femoral neck and head: six of 3ij, one of 3iij, andtwo of 5iv. The bone was hardinsome placesand softinothers.There was never reflux; pain was in hip and knee, and reaction wasslight or absent. His general condition rapidly deteriorated, andthe local condition as well. Hip-excision was done; the head ofthe femur was entirely disintegrated. There was perforation of thefloor of the acetabulum, and an abscess in the pelvis. The wound

HARRY M. SHERMAN AND AGNES WALKER. 55

hasjusthealeda yearaftertheoperation.The amount ofiodoformusedinthiscasewas grs.cxxxviij

CASE XV.Girl, aged eight years; hip-disease, with a discharging sinus which did not connect with the joint. Sinus was laid openand curetted and wound stitched. After firm union had taken placeeightinjectionswere givenintothe femoralneck and trochanter,five of 3ij and two of 3iv; the amount of the eighth injection wasnotnoted. A slightrefluxfollowedtwo oftheinjections;painwasfeltinthehiponly,and thereactionwas considerableon onlyoneoccasion. Several small tuberculous abscesses developed about bothhip and knee, and no benefit resulted from the injections. The abscesses were opened and curetted and the injections discontinued.The child is still wearing a splint, thirteen months after last injection. Over grs. cviij of iodoform were used in this case.

CASE XVI.Girl, aged six years; hip-disease; second stage;no abscess. Only two injections of 3ij each were given, as bothgeneral and local conditions commenced to deteriorate very rapidlyand hip excision became necessary. At the time of operation thefemoral ilead, neck, and trochanter were found to have been largelyabsorbedand almostdetachedfrom the shaftof the bone. Thewound healedfirmlyand thechildleftthehospitalon crutches.Atthe present time tile hip is somewhat flexed, and there is a slightdischarge from the site of the operation where the cicatrix has brokendown.

CASE XVII.Boy, aged five years; hip-disease; third stage;abscess.Thirteeninjectionswere given,elevenintothe femoralneck, the bone being quite soft, and two into the cavity of an abscess which formed about the joint and was evacuated twice. Asthis abscess was thought to be aggravated by the injections, theywere discontinued and the boy remained in bed for six months, thenleft the hospital on splint and crutches, which he is still wearing atthepresenttime. Over grs.ciof iodoformwereusedinthiscase.

CASE XV 111.Boy, aged four years; tarsal disease; small sinus.Two injections of 3@jwere given, and were followed by severe painand some reaction.The injectionsweremade intothecentreofthetarsus; they appeared to have little or no effect on the course of thedisease, and the foot finally healed after a year's rest in a plastersplint.

56 TUBERCULOUS OSTEOMYELITIS.

CASE XIX.Boy, aged six years; hip-disease; third stage; abscess. First injection was made through an aspirator into the cavityof an evacuatedabscess.The secondinjectionwas a doubleone,,3@being injectedinto the abscesscavityand 3ij into tile neckofthefemur. In allsixteeninjectionswere given,of which fourteenwere made intothe neck or trochanterof the femur. The usualamount injected was @j,but on two occasions ,3iv were given. Aslight reflux occurred once; pain was always felt in the hip and wasthrice complained of in the knee. The temperature only once rosetoabout102,and usuallywas under 100. The boy improvedslowly in general health, the abscess in the hip ceased to refill, andhe eventuallyleftthehospitalon asplintand crutches,thehipbeingquite firmly anchylosed.

CASE XX.Girl, aged seven years; hip-disease; second stage;no abscess. Only three injections were given in this case. Theywere made into the trochanter and neck of the femur, and wereeach .5ij. Slight reflux of injected material and synovial fluid followed one. No pain and little reaction resulted.

The following points may be recorded:The greatest number of injections given any one case was twenty

one.

The greatestamount of iodoformgiven any one casewas grs.cxcviij.

The greatest amount of iodoform given at one injection was grs.xxiv.

The higilest temperature of reaction following an injection was104F. Usually the height of a reaction was attained in a fewhours,butinsome casesnotfortwo days.

The usual interval between the injections was two weeks, butsometimes they would be suspended for two, three, or four months,to permit observation, and then be resumed.

In no case was there any iodoform-poisoning. In no case wasthere any suppuration sequent to the injections.

During the treatment 7 cases improved as if under protectivetreatment alone; 10 cases got worse, 5 having tuberculous abscessesdevelop,and 7 being submittedto operation,1 of whom died; 3caseswereunchanged;1 diedof tuberculousmeningitis.

HARRY M. SHERMAN AND AGNES WALKER. 57

I asked Dr. Walker to abstract these cases in these two series,because the mode of operation of the drugs must be different in each.In the periarticular method the drugs are deposited in or close tothe advancing line of infection, where bacillary life is most active,and where the iodoform could exercise its supposed germicidal effects,and alsoby itsirritativeaction,aidedin thislatterby themoreirritant property of the glycerin, stimulate the growth of the protective wail of fibrous tissue. But the absolute impossibility ofknowing just where the limits of the infected tissue were, and thegreatprobabilitythattheiodoforni-glycerinwas oftendepositedinsound tissues, where it was simply a foreign body, led me to abandon this plan. Intra-articular injections, reaching a point withinthe infected areas, gave a little more promise, theoretically, for theefficient action of the iodoform, but, again, it could affect only theparticular articular structuresthe synovial membrane, for instanceand left untouched the original foci in the bones, except in thosecaseswhere therehad been ulcerationof the articularcartilages,opening tile cancelli of the bone to the joint cavity.

In most of my excision cases I have found a diffuse tuberculosisof head,neck,and greatertrochnter,and the softenedbone thatthe needle of my syringe always discovered showed that this condition existed in these cases. It seemed an improvement, then, toadopt the intraosseous method. The idea of flooding the cancelliwith iodoform-glycerin is not quite practicable. Bone tissue, evenif infected with tuberculosis, is not elastic, and but so much iodoform-glycerin may be injected, as blood or other fluids may bedriven out. If the injection is made into a tuberculous focus veryearly in its history, I cannot help feeling that, under the forced flowof the iodoform-glycerin, some of the tuberculous tissue, or products, or the bacilli themselves, may be carried outside the originallimits of the focus into the surrounding healthy areas, and in viewof theveryfeeblegermicidalactionof thedrug,thiswould tendtothe extension of the lesion. In cases where the lesion is a diffusetuberculosis this danger is not so great, and, as most cases that cometo us have much more than a focus alone, the risk may be consideredto be principally theoretical.

Once the iodoform-glycerin is in the infected area the questionof itsmode of actiontherearises.The inabilityof tissueinfected

58 TUBERCULOUS OSTEOMYELITIS.

with tuberculosis to itself inaugurate, or be stimulated to, any reparative action limits the drugs to germicidal effects only; but ifthese could be accomplished, there should be left something thatcould, in a little time, be easily disintegrated, absorbed, and replaced with sound cicatrix. I did not see any such happy resultsin my cases. In general, it seemed that the course of the diseasewas practicallyunchanged by the treatment,exceptin two caseswhere the patients were made plainly worse. Of these cases thatcame to excision, examination of the specimens did not show themto be in any way different from the specimens of cases that had hadno injections, and almost always the iodoform itself had entirely disappeared, unless the operation followed closely on the injection. Inthose cases where operation was not necessary, the course of the disease, both as regards tissue cilanges and the time treatment wasnecessary, and the final results, did not vary markedly from casestreated by classical protective methods alone.

As regardsthevalueof iodoformin the dressingof tuberculouswounds,I am a littleindoubt. I havelongusediodoformdissolvedin ether as an application to such wounds in the dressings duringhealing,and havepackedthem withiodoform-gauze.At one timeIdropped the use of it entirely, and then came back to it, under the impression that my cases had not been doing quite so well as before; butitisnotuncommon tohavetuberculosistakerepossessionofa woundin spite of all the iodoform one can get into it. The drug has, ofcourse,an exceedinglylimitedrange of applicationoutsideof thetreatment of tuberculosis, and even here I believe it is of comparatively little therapeutic value. Each of the cases here reported,with perhaps two exceptions, had the potentiality of recovery if thedrug could act as a definite germicide, and yet, as you have seen,the result was in most instances disappointing.

The search for an agent that will destroy the bacillus of tuberculosis in the tissues must go on, and probably it will some day succeed; but the past and the present can record only a series of failures,failures that are meritorious so far as the efforts they terminatedwere well planned and well and persistently executed, but we wholive in the time of trial and failure cannot help feeling that whilewe must always hope and always try, still hopedeferred makeththe heart sick.

DISCUSSION. 59

DISCUSSION.

DR. RIDLON asked if, in any of the cases except those of hip-jointdisease, any immobilization of the joints was attempted during thetimetheinjectionswerebeingcarriedout.

DR. SHERMAN replied that in no case was the orthopedic treatment interrupted.

DR. ROSWELL PAIU, of Buffalo, said that he had employed intraarticular injections for a number of years, but had not seen muchimprovement from them. In two cases in which excision had beennecessitated later on he had found the iodoform packed into a masswhich had acted as a foreign body. Since then he had not used themetilod. He (lid not think it compared with the zinc chloride injections, or with the Beers method of treatment by congestion. Thegermicidal action of iodoform he believed to be very trifling andquite unreliable. He had found that tile ordinary pyogenic cocciwould grow luxuriantly on jelly containing iodoform. The surroundings in practice were nearly enough like those found in theseculture experiments to make such an investigation of some practicalvalue. He could not understand how some surgeons could speak soenthusiastically of the treatment by iodoform injections.

DR. J. E. MooRE said that the reader of the paper and the lastspeaker had expressed his own conclusions, derived from clinical investigation. He had been disappointed with the method in everycase, except in the treatment of psoas abscess. In the latter classof cases he had gotten better results from injecting the abscess cavitywith iodoform emulsion.

DR. H. L. TAYLOR said that the paper had been very carefullyprepared, and tile results agreed with what he would expect fromtheoretical considerations. In giving up any idea of benefit in these

cases, we should not forget that in discharging sinuses a solution ofiodoform in ether was sometimes very valuable. When the tuberculoustissuehad brokendown and therewas a dischargingsinuson

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tile surface, and if iodoform were finely deposited upon the tissues, theresults were often good. Where a drying effect was desired, it couldbe well secured by a solution of iodoform in ether. The bacilli mightbe killed by being dried out as well as by being poisoned.

DR. ROSWELL PARK said he believed that the alleged germicidalaction of iodoform was due to the liberation of free iodine. rpvo orthree times he had used a mixture of iodine and glycerin, believingthat iodine and otiler haloids were most excellent bactericidal agents.

Dn. MOORE asked how the glycerin would add to the virtues ofthe iodine. He had used iodine and water as an irrigating fluid intuberculous cases, and had been satisfied with the result.

Dn. PARK saidthathe didnotmean forirrigationpurposes,butfor the purposes of injections.

Dii. KETCH said that in studying tile effect of these injections weshouldtakeintoconsiderationwhetherornot mechanicaltreatmentwas alsoemployed. Itwas wellknown thattheGerman surgeonswereintilehabitof treatingmany of thesecasesby iodoforminjections without protective apparatus.

DR. RIDLON said that iodoform injections were quite generallyused by general surgeons in Chicago. Dr. Senn was a most enthusiastic advocate of this method, and in no instance did he use anyimmobilizing apparatus in connection with this treatment. If a caseof joint disease were immobilized during the time that the iodoforminjectionswere used itwould be impossibletotell,ifimprovementshould occur, whether it was due to the protective treatment or to theinjections.He now had under treatmentthreecases.One was acaseof hip-diseasewhich had been treatedby anothersurgeonforninemonthsby iodoforminjections,withno benefit,and withseverereactionaftereach injection.Accordingtothestatementsof thefamily, the child steadily grew worse during the treatment. Anothercaseone of incipient disease in a child of five yearshad beentreated by another surgeon with iodoform injections in the region ofthehip-joint,withoutimmobilizingapparatus,forfourmonths. The

DISCUSSION. 61

third case was tilat of a form of tuberculosis of the kneeformerlycalledhydropsarticuli.Ithad been treatedforseveralmonths byanothersurgeonwith intra-articularinjections,most of the timewithoutimmobilizingapparatus.The casehad steadilygrown worseunder thistreatment.Under immobilizationfora periodof tenweeks,the distentionof thejointhad been reducedfullyone-half.For these reasons we should draw well-defined distinctions betweenthose cases treated with immobilizing apparatus and those treatedwithout. He had treatedaboutthirtycasesby iodoforminjections,buthad had no experiencewiththeinterosseousinjections.Aboutone-thirdof thesecaseshad done satisfactorily,and had made,perhaps, a little more rapid progress than if the injections had notbeen used. About one-third had kept about the same, and theremaining one-third had seemed to grow worse under the treatment.

Dn. A. NI. PHELPS said that when this treatment by injectionwas new he had tried it, but with no results. Of course protectiveapparatus had also been used. He was in favor of using iodoformand glycerin in tubercular abscesses after thoroughly draining them.He thought the only portion of iodoform that did good was thatwhich was dissolved, and which was decomposed so as to set freethe iodine. He believed the glycerin was useful by its hygroscopicaction, for it caused a washing out of the cavity. He was decidedlyopposed to injection of a joint with io'loform and glycerin until thatjoint had been opened and washed out, and he based this statementon the experience already referred to.

DR. GOLDTHWAIT said that about four years ago a report hadappeared upon results of injections with cinnamic acid or cinnamateof soda. He had tried the cinnaniate of soda in quite a number ofcases with absolutely negative results.

DR. WHITMAN said that the general surgeon reported these wonderful immediate results of this or that remedy, because his standardwas often entirely different from that recognized by the orthopedicsurgeon. The general surgeon thought chiefly of pain and the directevidence of local disease, and cared but little comparatively for thedeformity. The other had this final functional result in mind, which

62 TUBERCULOUS OSTEOMYELITIS.

persisted, and often neglected, it might be, local treatment of thischaracter. In this country protection of a diseased joint assumedtile first place, and the other methods were used in conjunction withit. He had thought the use of iodoform might be of service in thetreatment of pelvic abscesses.

DR. ShERMAN, in closing the discussion, said that at the time theiodoform injections were being carried out another set of childrenwere being given internally increasing doses of creosote. One of thechildren took more than a drachm of creosote a day for some time,but this treatment did no good. Last summer he had inquired ofBioca, of the HSpital Trousseau in Paris, regarding the use of zincchloride injections, and had found that even Lannelongue, the fatherof this method, rarely employed it now. ile had also tried themethod of packing sinuses with sulphur, but with entirely negativeresults. He expected to begin a series of experiments in dressingtuberculous wounds with ether alone, for he felt that it was quiteprobable that the improvement in some of these cases might be dueto the ether, and not to the iodoform. He had never dared to treattuberculous joint cases without apparatus; hence the only way onecould determine whether or not the special method of treatment wasresponsible for the improvement was by obtaining marked improvement in a large proportion of the cases treated by this method.Glycerin was certainly useful, because of its hygroscopic as well asits scierogenic action.