Beruflich Dokumente
Kultur Dokumente
GLYCERIN
STUDY OF INJECTIONS
OF IODOFORM
IN T[IBERCULOUS
OSTEOMYELITIS.
B@ HARRY M. SHERMAN,
SAN
AM., M.D.,
FRANCISCO,
AND
RAFAEL.
48
TUBERCULOUS
OSTEOMYELITIS.
and effort
always was todepositthe iodoformin thejointcavity,
or the intimateperiarticular
tissues.After the middle of 1894
theinjections
have been intothe diseasedbone itself@
intraosseous
injections.
It chancesthattherewas a totalof 81 intraor pen
articular injections given, and a total, likewise, of 81 intraosseous
injections,
and 2 injections
intotheevacuatedcavities
of thetuber
culousabscesses,
making the entirenumber of injections
164. In
each case,and at each injection,
note was made of the following
points:1. The location
and direction
of thepunctureof theneedle,
thedepthofitspenetration,
and thecharacter
ofthetissues
through
which itpassed,
so faras thiscouldbe estimated.2. The amount of
theiodoform-glycerin
injected.3. Whether therewas or was nota
refluxof theiodoform-glycerin
throughthepunctureholeafterthe
removalof tileneedle. 4. Whether therewas or was not pain
followingthe injection,
and the location
of it. 5. Whether there
was or was nota generalreaction
following
theinjection.
In alla uniformmixtureof iodoformand glycerin,
10 per cent.
of theformerto90 per cent.of thelatter,
bothby weight,has been
used. In the first
series
of treatments,
theintraand periarticular
cases,
no specialeffort
was made to have themixturesterile,
but I
was fortunate enough to have no pyogenic accident, all abscesses
thatdevelopedbeingchronicand tuberculous.For theintraosseous
casesI had the iodoform-glycerin
always sterilized
by exposureto
the temperature of a boiling-water bath for two hours, and as iodo
form does not volatilize
below 239F., nor glycerinboilbelow
554F., I never had any decomposition
of either.No bacterio
scopic examinations of the product were made, but clinically the
mixturewas alwayssterile.In the intraand periarticular
cases
an ordinarysyringe,
similartoa hypodermicsyringe,
and withan
ordinaryleather
packing,was used. The syringeheldhalfan ounce.
When itcame to theintraosseous
casesI founditnecessary
tohave
special apparatus.
I had a needle made similar to that described by
Schller. It is of very strong steel and has a canula fitting the
bore closely
and ground flushwith the bevelof the needle-point.
The syringewas made withan extraheavycylinder
ofglass,
tohold
two ounces,
and I was obligedtofita ratcheton the pistonrod,and
a pinion-wire
key todevelopthe forcenecessary
to drivethe iodo
form-glycerin through the cancellous bone. In the intra- and pen
HARRY
M. SHERMAN
AND
AGNES
WALKER.
49
articular cases it was not difficult to imagine the location and dis
tribution of the mixture in the tissues, but in the intraosseous cases
a little
investigation
was necessary.It is a very easy matterto
thrust
the
needle
through
tuberculous
bone,
for
there
is absolutely
no resistance
from thewasted skeletonof the bone itself.If the
bone be removedfrom the body immediately
aftertheinjection,
and
sawn so as tolayopen the puncturetrack,itremindsone somewhat
of thetrackofa bulletthroughwood. The osseoustrabeculse
are
broken,upset,and pushedaside,
and the trackdoesnot collapse
on
withdrawalof theneedle. The iodoform-glycenin,
forcedfrom the
needle-point,
followsthe direction
of leastresistance,
and thatis
backwardalong the sidesof the needle;but thereisa distribution
of itthroughthe cancelli
toa varyingdistance
on allsidesof the
puncture, the spongy tuberculous granulation tissue being partly
carried
beforeit. I triedto seeifanythingof the kind couldbe
done in normalbone,and useda sheep's
femurforthepurpose.The
textureof thecancellous
tissue
of sheep'sbone seemeda little
finer
than thatof the human bone,but the bone itself
was not so hard.
The needlewas drivenin witha malletand withoutany difficulty.
The injection
of even the minutestportionof iodoform-glycerin
was an absoluteimpossibility,
the cancelli
were so fullof firm,ad
herent medulla that there was no room at all for any foreign sub
stance, and the needle was held in its place as tightly as a nail in a
board.
In theintraand periarticular
injections
thejointwas approached
from different
sides,
but in the hip cases,
which were the largest
number, the usualapproachwas by the method suggestedby von
Bgner. A pointwas found on the innerborderof the sartorius
muscle and on a levelwith the anteriorsuperioriliacspine. A
needlepasseddirectly
backward here willpiercethe capsuleand
impingeon theneck. I modifiedthe plan slightly
by making the
punctureatthe outerborderof the sartorius,
directing
the needle
backwardand a little
inwardso thatwhen itreachedbone thepoint
shouldbe under the von Bgnerpointof entry. Moreover,the
needlewas so heldthatthebevelon theend was nextthebone,thus
endeavoring to have the opening in the end entirely within the cap
sule. If, after an injection made in this way there was no reflux,
and therewas pain in the knee,itwas arbitrarily
assumed thatan
OrthoSoc
50
TUBERCULO1JS
OSTEOMYELITIS.
or bone,
and also
the firmness
of the hone.
In this
way
very fair estimate could be made of the extent and severity of the
lesion.
AJISTRACT
OF THE RECORDS
OF INDIVIDUAL
AGNES
M.D.
Intra-
WALKER,
and Periarticular
CASES,
BY
Injections.
each
of .3j of
tile
iodoform-glycerin;
in
but
four
was
there
any reflux; pain always followed and was located at the hip and
knee; there was usually a slight reaction, but never above 103F.,
and after
five
injections
there
was no reaction.
Early
in tile treat
ment an abscess developed near tile anterior superior iliac spine, but
was resorbed.
After the resorption of the abscess he was gotten up
on crutches and a traction splint. At the end of eighteen months he
was in excellent
general
condition,
and
this
form of injection
was
suspended.
There had been much improvement, but no more than
might have occurred under protective methods alone.
CAsE 11.Boy, aged four years; knee-disease, severe chronic
type; no abscess. Limb was in a plaster-of-Paris
splint.
There
were five intra-articular
injections, each 3@. After none was there
reflux; there was always pain in the knee, and there was always,
but once, a slight reaction.
At the end of eighteen months the
swelling had diminished, and there was no pain when the limb was
at rest, but there was joint rigidity and tenderness, and this form of
injection 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
SHERMAN
AND
AGNES
WALKER.
51
V.Girl,
aged
eleven
years;
elbow-disease;
chronic
type.
52
TIJBERCIJLOUS
OSTEOMYELITIS.
was referred
tothehip,oncetotheknee,and threetimestherewas
marked reaction, the temperature once reaching 104F. During
treatment an abscess developed anterior to the hip and opened spon
taneously; it left sinuses which persisted, were followed up into the
joint and the bone found to be diseased and soft, and so an excision
was done. Healing was slowbut uneventful,
and the boy isnow
HARRY
M. SHERMAN
AND
AGNES
practically
WALKER.
53
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 was
in hip and knee, and reaction was slight. In each instance the bone
had been easily penetrated by the needle, but was, at the same time,
able to support the weight of the body. Two months after the last
injection he left the hospital wearing no splint, with full extension
and 50flexion, and one-half inch shortening.
The total amount
of iodoforw used on this boy was grs. cliv. Every effort to trace
him and learn his present condition, a year and a half after leaving
the hospital, has failed.
Case II. of last series. Thirteen injections were given into the
lower fetnoral epiphysis.
Smallest amount @j,largest amount 3iij,
average amount 5ij; there was slight reflux; pain was in knee, and
reaction was slight.
The bone was of varying consistency, but
always penetrable.
Shortly after the last injection he was taken
from the hospital wearing a leather knee-splint and a Thomas
walking-splint.
The knee was quite but not entirely rigid. The
total amount of iodoform used on this boy was grs. clxxvj.
It has
not been possible to trace him since.
Case IV. of last series. Three injections into the astragalus were
given, 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 decided
to remove the astragalus, as that bone seemed to be the only one in@
volved. The operation disclosed, however, such extensive disease of
the foot and the medulla of the tibia, that amputation had to be
done.
Case V. of last series. Four injections into the bones at the
elbow were made, each from 5j3ij. There was little i-eflux; pain
was in tile elbow, and there was no reaction.
The bone was always
easily penetrated.
During the whole of tile treatment the arm had
been in a plaster-of-Paris
splint, and at the end there was a slight
recognizable improvement, such as a gain of 13fiexion and 17
extension. The total amount of iodoform used was grs. xcij. Shortly
54
TUBERCULOUS
OSTEOMYELITIS.
after the last injection the parents took her from the hospital, and
it has not been possible to find her since.
CASE X1.Girl, aged eight years.
Old hip-disease with (us
charging sinuses. Two injections were given, each of 3ij, one into
femoralneck and one intowallof acetabulum. The result
was not
good,and excisionwas done. At present,twenty months after
operation, 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 femoral
neck,finding
boneveryilard;one of3iv; and oneof @jintotuber
culous bone in pelvis, anterior and inferior to acetabulum.
There
was no reflux;painwas inhipand knee,and therewas no reaction.
Afterthelastinjection
therewas an indurated
and tenderswelling
at the point of puncture.
An incision disclosed the iodoform in the
trackof theneedle-puncture,
but no pus. Much diseased
bone was
found,and thiswas removed,theoperation
being practically
an ex
cision.Healinghasbeen slow,but is complete. Use of thelimb
has not yet begun.
CASE X1II.Boy, aged five and a half years; hip-disease;
second stage; no abscess. Five injections were given, penetrating
the 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 been little
or
no induration
or swellingof tissues
aroundthejoint. Two weeks
after the last injection a tuberculous abscess developed, though there
iladbeen a slightgain in jointmotion. Excisionof the hip was
done, and the boy died the following day. The bone removed
showed no evidence of any response to the action of the iodoform.
CASE
XIV.Boy,
aged
five
years;
hip-disease;
second
stage;
HARRY
M. SHERMAN
AND
AGNES
WALKER.
55
XVI.Girl,
aged
six
years;
hip-disease;
second
stage;
XVII.Boy,
aged
five
years;
hip-disease;
third
stage;
abscess.Thirteeninjections
were given,elevenintothe femoral
neck, the bone being quite soft, and two into the cavity of an ab
scess which formed about the joint and was evacuated twice. As
this abscess was thought to be aggravated by the injections, they
were discontinued and the boy remained in bed for six months, then
left the hospital on splint and crutches, which he is still wearing at
thepresenttime. Over grs.ciof iodoformwere usedin thiscase.
CASE XV 111.Boy,
aged
four
years;
tarsal
disease;
small
sinus.
56
TUBERCULOUS
OSTEOMYELITIS.
HARRY
M. SHERMAN
AND
AGNES
WALKER.
57
58
TUBERCULOUS
OSTEOMYELITIS.
result
was
in
most
instances
disappointing.
The search for an agent that will destroy the bacillus of tuber
culosis in the tissues must go on, and probably it will some day suc
ceed; but the past and the present can record only a series of failures,
failures that are meritorious so far as the efforts they terminated
were well planned and well and persistently executed, but we who
live in the time of trial and failure cannot help feeling that while
we must always hope and always try, still hopedeferred maketh
the heart sick.
DISCUSSION.
59
DISCUSSION.
DR. RIDLON asked if, in any of the cases except those of hip-joint
disease, any immobilization of the joints was attempted during the
timetheinjections
were beingcarriedout.
DR. SHERMAN replied that in no case was the orthopedic
ment interrupted.
treat
and
tile results
considerations.
agreed
In
with
giving
what
up
any
he would
idea
expect
of benefit
in
from
these
60
TUBERCULOUS
tile surface,
and
if iodoform
were
OSTEOMYELITIS.
finely
deposited
upon
the tissues,
the
results were often good. Where a drying effect was desired, it could
be well secured by a solution of iodoform in ether.
The bacilli might
be killed by being dried out as well as by being poisoned.
DR. ROSWELL PARK said he believed that the alleged germicidal
action of iodoform was due to the liberation of free iodine. rpvo or
three times he had used a mixture of iodine and glycerin, believing
that iodine and otiler haloids were most excellent bactericidal agents.
Dn. MOORE asked how the glycerin would add to the virtues of
the iodine.
He had used iodine and water as an irrigating fluid in
tuberculous cases, and had been satisfied with the result.
Dn. PARK saidthathe didnot mean forirrigation
purposes,
but
for the purposes of injections.
Dii. KETCH said that in studying tile effect of these injections we
shouldtakeintoconsideration
whetheror not mechanicaltreatment
was alsoemployed. Itwas wellknown thattheGerman surgeons
were intile
habitof treating
many of thesecasesby iodoforminjec
tions without protective apparatus.
DR. RIDLON said
that
iodoform
injections
were
quite
generally
disease
were
immobilized
during
the
time
that
the
iodoform
injections
were used itwould be impossible
totell,
ifimprovement
should occur, whether it was due to the protective treatment or to the
injections.
He now had under treatmentthreecases. One was a
caseof hip-disease
which had been treatedby anothersurgeonfor
ninemonths by iodoforminjections,
withno benefit,
and withsevere
reactionaftereach injection.According to thestatements
of the
family, the child steadily grew worse during the treatment.
Another
caseone
of incipient
disease
in
a child
of five
yearshad
been
DISCUSSION.
61
to injection
of a joint
with
io'loform
and
glycerin
until
that
joint had been opened and washed out, and he based this statement
on the experience already referred to.
DR. GOLDTHWAIT said
that
about
four
years
ago a report
had
surgeon
reported
these won
62
TUBERCULOUS
OSTEOMYELITIS.
place,
and
the
other
methods
were
used
in conjunction
with
He
expected
to begin
a series
of experiments
in
dressing
tuberculous wounds with ether alone, for he felt that it was quite
probable that the improvement in some of these cases might be due
to the ether, and not to the iodoform. He had never dared to treat
tuberculous joint cases without apparatus; hence the only way one
could determine whether or not the special method of treatment was
responsible for the improvement was by obtaining marked improve
ment in a large proportion of the cases treated by this method.
Glycerin was certainly useful, because of its hygroscopic as well as
its scierogenic action.