COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64052648 RD641 B38 Bismuth paste in chr RECAP .... JP ■ illllll lifJilli ■111 ■11 liiii I k JH III m J HliM lllBISli liliilil In IB "HI II! : ; ... ■■-;■: ; Eg If M -'-l'- ■■■■■■':■•' ■'■ H I ■ ■■ ' ■ ' ' mwifffi'V agg; ■ ■:.'..• :TiS*J? ji*,^^ 1 ^ ^>!< •->j« ■*'>''" '**.-ftv- "tt^'V.ii 1 ..'. Y^:. : i:-i.rf*-,'-j^-^. *rr t^r ,1^ •*, ~ »*^*" — »- -'i^^r^j^~^ ED641 D38 Columbia Umber£ttpe<>p-2. tntfjeCitpofJ^etol^orfe College of $fjt>gmang ano burgeon* Reference Htfcrarp Presented by ILLIAM J. GIES Jf library resources to holders 1 Example 1. Osteomyelitis of Femur Treated for Hip Joint Disease. — Mr. C, aged 26, farmer, gives the following history: at the age of 23 he developed a large abscess about his hip. An incision and drain- age left a discharging sinus. A year later an operation for hip joint disease was performed, which failed to produce a cure. Later the area of suppuration was increased, so that four sinuses resulted. These sinuses were repeatedly curetted, but without avail. The radiograph Fig. 7. Bismuth paste remaining in focus of disease four months after clo- sure. Hip shown to be normal. (Case shown in Fig. 6.) (Fig. 5), taken after injection of the paste for diagnostic purpose, re- vealed the fact that the hip joint was not affected at all, but that it was the shaft of the femur which was the original source of infection, and that at this source there was also a sequestrum, the removal of which produced a closure of three sinuses within a month. The fourth sinus kept on discharging some serous fluid, but otherwise caused no inconvenience. Patient gained forty-five pounds after the suppuration had ceased. 38 BISMUTH PASTE IN CHRONIC SUPPURATIONS. It is not surprising that this mistake in diagnosis was made by a number of competent physicians, because there existed severe lameness, and even some shortening of the affected limb, but our radiograph shows distinctly that the head of the femur and the acetabulum are in- tact, and no connection existed between the large abscess cavity and the hip joint. Fig. 8. Tuberculosis of sacrum, mistaken for hip joint disease. Example 2. Abscess at the Hip, Originating in the Sacrum. — R. K., aged 13, with a tubercular family history, was well until the age of 5, when a swelling in his left hip, posterior to the greater trochanter, appeared. An abscess ruptured spontaneously and a copious purulent discharge persisted for seven years, which greatly debilitated the boy. In July. 1908, he was given the first injection of bismuth paste by Dr. Dahl, with whom I saw the case. The radiograph (Fig. 6) disclosed the fact that the abscess did not originate in the hip joint, as one would suspect from the location of the sinus, but that it communicated DIAGNOSTIC EKKORS REVEALED. 39 with the original focus in the sacrum by a narrow channel. This case proved to be not only an interesting example of the diagnostic value of bismuth paste, but it likewise credited the therapeutic account with a cure of which both the doctor and patient are justly proud. A radio- graph (Fig. 7) taken a few months after closure shows a small Quan- tity of the paste still in the original focus. Example 3. Tuberculosis of Sacrum Mistaken for Hip Joint Disease. — J. F., aged 36, presented himself for treatment of a sinus about the trochanter of his right hip. This sinus had existed for several years, and had been treated with washes and cauterization, but no surgical Fig. 8 A. Diagrammatic illustration of Fig. 8. treatment. It was thought to originate from his hip joint. The radio- graph (Fig. 8) clearly demonstrates that the hip is entirely free from disease, and that the sinus originates in the sacrum. The shadow of the injected paste traces the tract to the focus of infection — namely. the sacrum; there it fills out the ring around the diseased section and traces another tract running to the hip on the opposite side, which terminates in a blind end. This case teaches its that a sinus opening- near the hip does not necessarily mean hip joint disease, but that it 40 BISMUTH PASTE IN CHRONIC SUPPURATIONS. may exist as a result of a disease in the sacrum or the spine. Example 4. Subphrenic Abscess Following Appendicitis. — A. L., a robust cab driver, aged 27, was suddenly attacked in July, 1909, with an acute appendicitis. An emergency operation consisted in removing a ruptured gangrenous appendix; diffuse peritonitis was present. With Pig. 9. Subphrenic abscess following appendicitis, suspected of being an empyema. good drainage, in Fowler's position, and with continuous (Murphy) irrigation, I succeeded in carrying him over the shock, and four weeks later he left the hospital with the abdominal wound closed. His tem- perature, however, still rose to 100° or 101° every day, and he com- plained of pain in his chest. This condition became much aggravated, and within a week he developed a cough and suddenly expectorated large quantities of green, very fetid pus. At this time the abdominal wound also reopened and discharged the same character of pus. An DIAGNOSTIC KKKOKS RKVKALKD. 41 injection of the paste at the appendix incision proved that the original abscess of the appendix communicated with a subphrenic abscess, and that the latter had evidently ruptured into a bronchus, as he expec- torated a portion of the injected paste. A radiograph (Fig. 9), taken a few days later, verified our diagnosis. The patient was treated with injections of the bismuth paste, of which he regularly coughed up a part. The lung is now entirely clear, cough has ceased, and the sinus is closed. The patient has gained thirty pounds. Aside from the favorable therapeutic result obtained, the diagnosis / opening Fig. 9 A. Diagrammatic illustration of Fig. 9. was greatly facilitated by the injection. The diagnosis rested between subphrenic abscess and empyema, but our radiograph removed all doubt as to the correctness of the diagnosis of subphrenic abscess. Example 5. Unsuspected Renal Sinus. — R. P., boy, aged 10, has a sinus in his left lumbar region, which has persisted in discharging pus for about two years following an operation of an abscess within the pelvis. The radiograph (Fig. 10) brings out the surprising fact that the sinus extends not only downward into the pelvis, but that another channel exists and extends upward into the kidney, and there the paste maps out the contour of the pelvis of the kidney. This cleared up the 42 BISMUTH PASTE IN CHRONIC SUPPURATIONS. diagnostic puzzle as to why the sinus secreted large quantities of wa- tery secretions (as much as 10 ounces a day) in addition to occasional discharges of pus. We could cite many similar examples, but these are sufficient to show the diagnostic possibilities of the paste in clearing for us diagnostic errors. Fig. 10. Unsuspected renal sinus diagnosed by bismuth paste injection. A, renal pelvis ; B, pelvic abscess ; C, sinus opening for both. In no other condition are the diagnostic errors more frequent than in rectal fistula. This will be elucidated in the chapter on treatment of that affection. DIAGNOSTIC ERKORS REVEALED. 43 Fig. 10 A. Diagrammatic illustration of Fig. 10. CHAPTER V. THERAPEUTIC EFFECTS OF BISMUTH PASTE. The teclmic employed in the therapeutic application of the paste is practically the same as that in the diag- nostic method. The paste, formula 1, which consists of 1 part of bismuth subnitrate and 2 parts of vaselin, is em- ployed in the first injection. Should it be desired to em- ploy a firmer paste for longer retention, the following formula may be employed: Fokmula No. 2. Bismuth subnitrate 30 percent. Vaselin 60 percent. Paraffin (120° melting point) 5 percent. White wax 5 percent. The minor details and rules for the frequency of injec- tions will be fully treated in the description of typical cases. Sufficient time has now elapsed, and an abundance of cases have been treated with bismuth paste in all parts of the world, to permit making an estimate of its thera- peutic value. Let us review the literature, analyze the statistics, and then, by proper classification of cases, de- termine how this method compares with other forms of treatment. The curative effects of bismuth paste were first observed in August, 1907, about one year after inception of its use for diagnostic purposes. The following case was the first in which the therapeutic effect was tested: M. Y., aged 14; born in Germany; lived there until 1903; family history negative. He was healthy until he was 7 years old, when 44 Til i:i;Ai'i;i tic ki< ikctk. 45 he developed a painful swelling in his right knee. A cast was put on by his family physician for the purpose of immobilization. In a short time an abscess ruptured; the boy was transferred to the hos- pital at Freiburg, in Germany, and an operation was performed for tuberculosis of the knee joint. He left the hospital seven weeks later, with a sinus extending from the knee joint into the middle of the tibia, and two smaller ones near the joint. Fig. 11. closure. Tuberculous knee joint, showing remnants of paste four months after A short time later he returned to the hospital for another opera- tion, which, however, failed to close the sinuses, and a third opera- tion was performed two months later, again with an unfavorable re- sult. The parents then took the boy to Tubingen, where Professor Bruns performed the fourth operation. No improvement, however, resulted; the three fistulas persisted as before. The family then moved to America, in June, 1903. They had abandoned all treatment; noth- ing more than daily dressing was done by the patient himself. On March 21, 1907, at the age of 13, six years after the commence- 46 BISMUTH PASTE IN CHRONIC SUPPURATIONS. ment of the fistulse, he came to me for treatment. A radiograph with- out bismuth injection was first taken. It shows the joint and the epiphyses of femur and tibia nearly destroyed, and a sequestrum is clearly visible in the tibia. I proposed the resection of the knee joint, which was refused, but the next best procedure, the removal of the sequestrum, was consented to. This was done March 29, 1907, but the three sinuses persisted. The first bismuth paste injection was made October 3, 1907, and sinuses at once showed a tendency toward healing. After three injec- tions, at intervals of one week, they nearly closed, and it was with diffi- culty that I made the fourth injection. Since that time all sinuses have remained healed, the boy has become stronger, and the pain entirely disappeared, so that he could discard his crutches, which he had used for seven years. He can now skip up and down stairs on the tuber- culous limb, and can take part in all the athletic sports of his play- mates. His weight and strength are those of a normal boy of his age. The radiograph (Fig. 11) presents the condition as it existed four months after closure of the sinuses, it showing a small portion of the paste still within the cavity which held the sequestrum, but the paste which had been in the epiphysis of the femur is nearly ab- sorbed; only a few specks of it are visible in the picture. Encouraged by this result, I tried the bismuth injec- tion in a case of empyema, and, to my surprise, the cavity, which had suppurated for eight months, closed within one week (case reported in chapter on Empyema). Similar cases, such as sinuses following hip joint disease, tuberculous kidney, rectal fistula?, and fecal fistula?, were put to the test, and the results were uniformly favorable. Thereupon I traced the four cases which in the previous year were injected for diagnostic purposes, and found that these cases also had in the meantime healed. Thus I was able to report, in January, 1908, before the Chicago Medical Society, 1 14 cases, 10 of which were then cured, 3 improved, and 1 unimproved. Ten of these cases were exhibited at the meeting. Now, after a lapse of two years, the present status of these 14 cases is as follows: 1 E. G. Beck: A New Method of Diagnosis and Treatment of Fistulous Tracts, Sinuses, and Abscess Cavities. — Journal American Medical Associa- tion, March 14, 1908. TIIKKAI'llliTKl I ;KH;< ITS. 47 No. of case. Number of sinuses. Disease. Dui-jiI Ion, years. Result. 1 1 Spondylitis •; < !losure, 1 years '> 18 Spondylitis If) Died, l year alter tre it int.' 8 1 Coxitis !l Closure, '■'•',-i years i 9 Coxitis [fi Closure, 2)4 years 5 8 Tuberculous knee 7 ( 'insure, ->y± years 6 1 Tuberculous os ilium :\ Closure, '■'> years 7 1 Tuberculous ulna % Closure, 2 years 8 1 Removal tubercu- lous kidney 1 Closure, \'A years 1 Rectal fistula ■j Closure, 214 years 10 1 Rectal fistula 1 Closure, 2'A years 11 1 Rectal fistula A Closure, 2 years 12 1 Abdominal fistula of the appendix l Closure, '_' years 13 1 Abdominal fistula after laparotomy y Closure, 2 years 14 1" Tuberculosis of metacarpal bone 1 Closure, 2 years Total, 11 cases; cured, 13; died, 1. Shortly after this first presentation the method was taken np by Drs. Ridlon and Blanchard at the Home for Crippled Children in Chicago. It was tested on 26 chil- dren, and after three months' treatment the following results were reported by them at the June, 1908, meet- ing of the American Orthopedic Association i 1 9 cases cured in which sinuses had existed from one to eight years. 4 cases cured in which an abscess was opened and only once injected. 7 cases were improved and were still under treatment in which the sinuses had existed from two to three years. 5 cases were only one week under treatment; result undeter- mined. 1 case unchanged; no deaths. Total, 26 cases. These cases were shown to the members of the associa- tion at the Home for Crippled Children. 1 Ridlon and Blanchard: A New Method of Treating Old Sinuses. — Journal of Orthopedic Surgery, September. 1908. 48 BISMUTH PASTE IN CHRONIC SUPPURATIONS. 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Wco«ide342o3c3 CDCDCDCD-rt^-rf-rfCDCDaCDCD X CO CO X O 'U 'O X CO ^ X' CO B p, p, aa^SSS aft42 p a O 05 B WWWWPnPHCLiPHMffif-iWW S- < O - CO bDc3 C75 CM CC CM »^T t^ — ' — ' t- 00 X — H ^ OS B Hi B p pq CD a o3 . .flaJgO«§d -^j ^WS.3.2?l^g" W 4?^ »C-f fi 2 S T< o K'n.n4: «43£ SflSSSflCflSS 0^|?S5c,PpqHP fc <*H . O CD . t/a -^riM^lOtONOOO O— ICMCO O 03 ^° THERAPEUTIC EFFECTS. 49 These 26 were not selected cases, but comprised prac tically the entire number of children who were thBD afflicted with sinuses at the institution; some of them had been inmates for years and many bedridden for mouths. A treatment which produced 50 percent of cures within a period of three months must certainly have been a welcome innovation in an institution of this character. Their report, corresponding in its favorable results with that of my own series, served as a stimulus to other surgeons for its further application, and soon after my first publication reports began to appear in medical jour- nals here and abroad. The usual conservatism with new methods was cast aside because the method was simple and appeared harmless, and, furthermore, material for testing it was willing and plentiful everywhere. To the unfortunate invalids who had nothing to lose and every- thing to gain, anything new in the way of treatment was welcome. Besides, there was no opposition to this treat- ment, no one having claimed any successful remedy for this class of cases. Thus in October, 1908, I was able to present before the International Congress on Tuberculosis 1 2 a collective re- port of 192 cases, which included histories of cases treated by such prominent men as Drs. Mayo, Ochsner, McGuire, Ridlon and Blanchard, and in two hospitals of the United States Navy. Of this number, 123 cases, or 64 percent, were cured. 55 cases, or 28.5 percent, were improved and still under treat- ment. 11 cases, or 6 percent, were unimproved and still under treat- ment. 3 cases, or 1.5 percent, died during the period of treatment. 1 E. G. Beck: Surgical Treatment of Tuberculous Sinuses and Their Pre- vention. — Transactions Sixth International Congress on Tuberculosis. 2 E. G. Beck: Diagnose. Chirurgische Behandlung. und Verhiitung von Fis- telgSngen und Abscess Hohlen. — Beitrage zur Klinischen Chirurgie. 1909, bd. 62, h. 2. 50 BISMUTH PASTE IN CHRONIC SUPPURATIONS. The. pathological classification of this series of cases is as follows: 143 cases were of tuberculous origin. 23 cases were of nontuberculous origin. 26 cases were of doubtful origin. Summary Report of 192 Cases Treated with Bismuth Paste Method. Disease. Total number treated. Healed. Im- proved. Un- changed Died. Tuberculous spondylitis with sinuses . Tuberculous hip joint with sinuses — Tuberculous sacrum a.nd iliac syn- 26 43 7 5 4 4 12 4 3 2 3 19 6 6 1 16 18 7 13 21 7 4 3 4 6 3 1 2 2 14 4 4 1 13 13 5 9 19 1 1 6 1 2 3 2 1 1 Tuberculous knee joint with sinuses.. Tuberculous wrist joint and Angers Osteomyelitis of femur with sinuses... Osteomyelitis humerus with sinuses.. Osteomyelitis ulna with sinuses Tuberculosis of fascia and muscle with 4 3 1 1 1 2 1 Empyema and tuberculous lung ab- Tuberculosis of ribs with sinuses Sinuses following tuberculous glands. Sinuses following abdominal opera- 1 5 2 1 1 Tuberculosis of kidney with sinuses... Total 192 123(1) 55 (2) 11(3) 3(4) 1 Or 64 percent. 2 Or 28% percent. 3 Or 6 percent. * Or 1% percent. In a review of the literature on the uses of bismuth paste, Dr. Baer, of Johns Hopkins University, makes a comparative study of percentages of cures obtained by different surgeons. His report is as follows: THERAPEUTIC EKKECTS. 51 Number of Name. cases. Ochsneri 20 Ridlon and Blanchard 2 17 Beck, E. G."- 4 192 Robitschek* Don (Edinburgh) 6 Rosenbach (Berlin)" 4 Dollinger (Budapest)* 16 Beck, Jos. C.o 319 Penningtonio 17 Baer (Baltimore) n 12 Disease. Percentage of cures. Tubercular sinuses 55 Tubercular sinuses 53 Collective report 64 Tubercular sinuses 55 Tubercular sinuses 17 Tubercular sinuses 50 Tubercular sinuses 12% Accessory sinuses 22 Rectal fistula? 70 Tubercular sinuses 331/., Since this review additional reports have appeared in the literature which show even larger percentages of cures : Number of Percentage Name. cases. Disease. of cures. Stern (Cleveland) 12 4 Tubercular sinuses 100 Steinmann (Miinchen)i" 5 Tubercular sinuses 20 Bogardusi 4 1 Tubercular sinuses 100 Vidakovich (Russia)is. .' 2 Empyema 100 Nemanoff (St. Petersburg) 1 c. . . 6 Empyema 100 Ochsner, A. J.17 14 Empyema 85 Beck, E. G. (Chicago)is 11 Empyema 82 Ely (New York) 19 14 Tubercular sinuses 43 Hines (Cincinnati)- 9 Tubercular sinuses 89 Cuthbertson (Chicago)-i 1 Intestinal fistulse 100 Sandor, Sag (Budapest) 22 2 Otologic 100 Heitz, Boyer, and Morens (Paris) 2 3 11 Renal sinuses 73 Zollinger (Zurich) 24 24 Tubercular sinuses 54 Schober (Philadelphia) 25 5 Tubercular sinuses 80 *A. J. Ochsner: Michigan State Medical Society. August, 190S. 2 Ridlon and Blanchard: A New Method of Treating Old Sinuses. — Journal of Orthopedic Surgery, September, 190S. 1 E. G. Beck: Surgical Treatment of Tuberculous Sinuses and Their Pre- vention. — Transactions Sixth International Congress on Tuberculosis. * E. G. Beck: Diagnose, Chirurgische Behandlung und Verhiitung von Fistelgangen und Abscess Hohlen. — Beitrage zur Klinischen Chirurgie. 1909. bd. 62, h. 2. B Robitschek: Beck's Bismuth Paste Treatment of Sinuses. — Northwestern Lancet, February 15, 1909. "Don: Edinburgh Medical Journal. February. 1909. 7 Fr. Rosenbach: Zur Wismutbehandlung nach Beck. — Berliner Klinische Wochenschrift, February 15, 1909. 8 Dollinger: Gumos Eredetu Talyogok es Sipolyok Bismuth Pastaval. E. G. Beck.— Orvosi Hetilap, 1908. B Jos. C. Beck: Bismuth Paste in the Treatment of Suppuration of the Ear, Nose, and Throat. — Journal American Medical Association. January 9, 1909. 10 Pennington: Bismuth Paste in the Treatment of Rectal Fistula. — Lancet Clinic, December 26, 1908. 52 BISMUTH PASTE IN CHRONIC SUPPURATIONS. The results obtained vary from 12V2 percent to 100 per- cent of cures in the hands of different surgeons. The majority, however, have obtained a cure in from 40 to 60 percent, except in empyema, where the average per- centage in 31 cases reported by Nemanoff, Ochsner, Vida- kovich, and Beck was 92 percent. These reports of results obtained with bismuth paste by surgeons from different parts of the world should con vince even the most skeptical that a remedy which cures such a large percentage of a class of cases formerly con- sidered virtually hopeless is of practical value. It is to be expected that, with the increasing experi- ence and perfection in our technic, the failures will be reduced to a minimum, and thus the results obtainable will be more uniform. In the chapter on Causes of Fail- ure I shall explain why some cases do not respond to this treatment. The following rules apply to all cases: A clear history of each case should be obtained, and a u Baer: Some Results of the Injection of Beck's Bismuth Paste in the Treatment of Tuberculous Sinuses. — Johns Hopkins Hospital Bulletin, Octo- ber, 1909. 12 Stern: Bismuth Injection for the Treatment of Old Sinuses. — Cleveland Medical Journal, April, 1909, No. 203. 13 Steinmann: Mlinchener Medizinische Wochenschrift, December, 1908, No. 49, s. 2537. 14 Bogardus : Tuberculosis of Os Sacrum Treated with Bismuth Paste. — Journal American Medical Association, vol. 54, p. 701, February 26, 1910. 15 Vidakovich: Centralblatt fur Chirurgie, 1908, No. 49, s. 1487. 18 N. J. Nemanoff: The Treatment of Fistulas and Drainage Passages. — Russki Vratch, No. 7, p. 1568. 17 A. J. Ochsner: Treatment of Fistulas of Old Empyema.- — Annals of Sur- gery, July, 1909, p. 151. 18 E. G. Beck: Surgical Treatment of Tuberculosis, Pleurisy, Lung Abscess, and Empyema. — Journal American Medical Association, December 18, 1909. 19 Leonard Ely: Results of the Use of Bismuth Paste in Tuberculous Si- nuses at the Sea Breeze Hospital, New York. — American Journal of Surgery, January, 1910. 20 Hines: Lancet Clinic, September 26, 1908. 21 Cuthbertson: Intestinal Fistula Closed by the Use of Bismuth Paste. — Illinois Medical Journal, 1909, p. 348. 22 Sag Sandor: Ueber den Heilwert der Bismuth Paste in Otochirurgischen Fallen. — Pester. Medizinische Chirurgische Presse, 1909, No. 12. 23 Heitz, Boyer, and Morens: Des Injectiones de Pate Bismuthee en Chirur- gie Urinaire. — Annales des Maladies des Organs Genito Urinaires, June 1, 1910. 2 * Zollinger: Beitrage zur Frage der Wismuthpastenbehandlung Tubercu- loser Fisteln nach Beck. — Schweizer Rundschau fur Medizin, No. 20, May 21, 1910. 25 Schober: Treatment of Chronic Tuberculous Sinuses by Beck's Bismuth Vaselin Paste Injections. — Annals of Surgery, No. 51, p. 716. THERAPEUTIC EFFECTS. 53 thorough physical examination— without any probing, however — of the sinuses should be made in order to de- termine whether the case is suitable for this treatment. All chronic suppurative sinuses, fistula;, or abscess cavi- ties, whether of tubercular or other infectious origin, with the exception of fistulas of the gall bladder, pan- creas, or those communicating with the cranium, are suitable for the bismuth paste treatment. Very acute inflammatory conditions are not suitable for the injections, and, while some good results have been reported, I have noted even aggravation after the treatment. After we have decided that a case is suitable for treat- ment, a culture and a smear of the pus should be made, and the sinuses are then injected in the same manner as described in the diagnostic method. When more than one sinus is present and the paste escapes from the various openings during the injection, it is best to press small pledgets of cotton against these openings and pre- vent the escape, and thus force the paste into all re- cesses of the fistulous tract. I have made it a rule to take a radiograph also before the injection, in order to determine whether a seques- trum is at the seat of the trouble. The dressings should be changed daily. If the dis- charge changes from a purulent to a serous, the injection need not be repeated, as this is an indication that the sinus has become sterile, and one may expect a closure without any further treatment. Should the discharge remain purulent, it is best to wait one week before giv- ing the second injection. The systematic examination of the secretion should be the guide for the frequency of injections. As long as the pus contains microorganisms, it is almost certain that 54 BISMUTH PASTE IN CHRONIC SUPPURATIONS. the focus of the disease has not been reached, and the in- jections should be continued for a reasonable length of time. If the case shows no tendency to healing, then the cause of failure must be determined. This will be treated in Chapter XIII. Whether the chemical or mechanical action of the paste is instrumental in bringing about these striking results has been discussed by many, and various theories have been advanced, but, aside from plausible sugges- tions, no exhaustive report of investigation of this sub- ject has as yet appeared in the literature. Eidlon and Blanchard have drawn their conclusion from clinical observations, and state that they believe the beneficial effects from the paste are due to purely mechanical action. Don, of Edinburgh, and Ryerson, of Chicago, made a suggestion similar to one advanced by Dr. Dunning, of Baltimore, which seems plausible. He says: "Is it not possible that, from the selective action of nitric acid on tuberculous and other pathological tissues, the subni- trate, when acted upon by organic acids, gives up its nitric acid, which attacks the tubercular wall of the cavity and forms a barrier to absorption, and to further growth of tubercle bacilli?" Dr. Dunning tested samples of bismuth subnitrate? from various manufacturers in order to determine whether there is any difference in the time they hydro- lyze at a given temperature. The results were striking; each preparation gave off a different quantity of nitric acid at the body temperature. Some preparations hydrolyzed from five to ten times as rapidly as others. Dr. Baer, in studying this matter, made the deduction from these experiments that the results obtained will THERAPEUTIC EFFECTS. 55 vary according to the amount of nitric acid given off from a certain preparation of the subnitrate, and thus could explain some of the failures. His own experience would bear out his assertion. He used the same technic, but bismuth from different manufacturers at two differ- ent hospitals, and the results were as follows: All his cured cases were at the Union Protestant In- firmary, while at the Johns Hopkins Hospital, in the service of Professor William Halsted, they could not obtain a single closure. Since then I have received per- sonal information from Professor Halsted that they have obtained satisfactory results at their clinic. From my personal observation and from the bacterio- logical studies of the secretions in over 500 cases we have formed an opinion as to which factors cause the rapid improvement following the injections of bismuth paste. I am ready, however, to change my opinion if more posi- tive facts are offered in the solution of this problem. We have noted that in most instances the secretions have changed after the first injection. The purulent, thick discharge assumes, as a rule, a seropurulent or a serous character. This is considered a favorable sign, since the sinuses usually close rapidly after this change in the secretion has taken place. In each case we have made a smear preparation, a cul- ture, and in some instances inoculated guinea pigs, to test the bactericidal action of the bismuth paste. Twenty- four hours after the first injection the secretions were again bacteriologically tested, and thereafter the test was made every third or fourth day. As a rule, the microorganisms disappeared in twenty-four hours after the first injection, but in a certain percentage of cases their number was only diminished, and cultures would grow a little slower. In many instances where the 56 BISMUTH PASTE IN CHRONIC SUPPURATIONS. growth was abundant prior to the injection we could obtain no growth subsequent to the first injection. Tubercle bacilli are no exception to this rule. This fact was discovered in a case of tuberculous empyema (reported in my series of cases at the International Con- gress on Tuberculosis), 1 in which tubercle bacilli were found abundantly in the pus from the pleural cavity previous to the injection of bismuth. After the injection their number gradually diminished, and in five weeks they could not be found by microscopical examination. For illustration I cite this interesting case: B. H., aged 23, law student, with negative family history as to tuber- culosis, developed a pleurisy with effusion in his right chest in Jan- uary, 1906. In May, 1906, the chest was aspirated three times in five days; each time a large quantity of clear fluid was withdrawn. His chest, however, continued to refill and was periodically aspirated. At the ninth aspiration 1,200 cubic centimeters of turbid fluid was re- moved. September 20, 1906, he went to Denver, where his chest was again aspirated three times by Dr. Bonney, who reported that tubercle bacilli were found in the fluid withdrawn. On his return to Chicago, in November, 1906, he consulted Dr. J. B. Herrick, his diagnosis like- wise being tuberculous pleurisy with effusion. On December 5, 1906, an operation was performed in Toledo, which consisted in the resection of five ribs, the removal of a large amount of fibrinous lymph, and establishment of drainage. The large cavity was irrigated daily with 0.5-percent iodin solution during his seven weeks' stay at the hospital, and thereafter continued at home. With the above history he was referred to me by Dr. Herrick for the bis- muth treatment. Physical examination revealed a hyperresonance over his entire right chest. A fistulous opening, discharging a dark-green pus, was in the center of an eczematous area, about two inches below the nipple. Smear preparations from the pus revealed the presence of tubercle bacilli, five to fifteen in each immersion field, and a moderate number of staphylococci. A radiograph clearly showed the size of the cavity when empty, and another when injected to its full capacity with 620 grams of 33- percent bismuth paste. The drainage tube was at once left out, and the patient allowed to be outdoors. Every day or two thereafter the accumulation of pus was withdrawn by means of a glass tube and 1 E. G. Beck: Surgical Treatment of Tuberculous Sinuses and their Pre- vention. — Transactions Sixth International Congress on Tuberculosis. THERAPEUTIC EFFECTS. 57 examined microscopically. Each time we noticed a diminution in the number of tubercle bacilli, and after eight weeks their final disap- pearance. The staphylococci had likewise disappeared. We also no- ticed that the tubercle bacilli which were found after the bismuth had been injected had lost their characteristic shape. They became granular, beaded, and took the fuchsin stain more readily. Microscopical slides were submitted at different periods to Dr. Maximilian Herzog and Dr. A. Gehrmann, bacteriologists, whose re- ports coincided with our findings. Eight guinea pigs were injected with the pus discharged during the period of treatment of this case. Animal No. 4 was injected April 24 with 10 drops of a 10-percent solution of the pus taken from the chest before the bismuth treatment was instituted. Animal developed general tuberculosis and died six weeks later, showing tuberculosis of all parenchymatous organs and glands. Animal No. 9 was injected May 1 exactly like No. 4; died June 24. Liver, lungs, and spleen tuberculous. Animal No. 13 injected May 15 same as No. 4; killed July 15. The report of findings by Dr. M. Herzog is as follows: "Post-mortem examination of guinea pig No. 13, received alive July 10 and killed July 15, 1908, showed caseous enlarged axillary lymph glands on both sides and caseous enlarged inguinal lymph glands of the right side; very small young tubercles in the liver and spleen. Smears from these organs showed numerous typical tubercle bacilli. "Animal No. 1G, baby guinea pig, weighing 240 grams, was in- jected June 7 with 150 drops of 10-percent solution of pus from chest cavity. The animal has grown steadily, weighing 360 grams, and is very lively, but developed two lymph glands under the right axilla, which drained the injected point. One of the glands was excised for examination, and report of same is as follows: "Sections of the gland of guinea pig No. 16, stained by various methods, show young, not very much degenerated, tubercles, with a moderate number of tubercle bacilli." To test the toxicity of the discharge, two guinea pigs were in- jected. Each received an injection of 15 cubic centimeters of the dis- charge (not diluted) intraperitoneally, and both appeared well for three days, but were found dead on the fourth day. Post-mortem revealed acute peritonitis in both animals. Animal No. 21 was injected with ten drops of a 10-percent dilution July 18, and kept for observation, and remained perfectly well for months. Post-mortem revealed no tuberculous disease. The patient was cured with bismuth injections. Another case quite similar to the one just quoted was subjected to the same experiment, and the results proved to be identical to those obtained in the former. 58 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Froin these experiments we conclude that, while the tubercle bacilli can not be detected by the microscope soon after the institution of the bismuth treatment, the discharge must still contain some to produce tuberculous disease in guinea pigs, but the development of the dis- ease is much slower and symptoms much milder in the animals last injected, which proves that the number of tubercle bacilli, as well as their virulence, diminishes as the treatment of the patient progresses. If the rapid diminution and disintegration of tubercle bacilli noted in these two cases is not accidental, this disclosure is certainly of far-reaching importance. Whether the bismuth destroys the bacilli by its chem- ical action, or whether its presence acts as a chemotactic, we have not yet determined, although the evidence pre- dominates that its chemotactic property accounts for the destruction of the microorganisms. Tubercle bacilli are not often found in the pus from tuberculous sinuses; more often, however, in tuberculous empyema. They lodge in the granulations and the walls of sinuses or abscess cavities in abundance. The bis- muth paste coming in contact with the walls of these sinuses containing the bacilli, and thus inducing chemo- taxis, is instrumental in the destruction of the bacilli. Whether the metallic bismuth or the liberation of the nitric acid from the subnitrate is the chemotactic factor, I do not know, but Baer's theory appeals to me as the most plausible. The chemotactic property of the paste is, then, considered the prime factor. The mechanical action of the paste — namely, the dis- tention of the collapsed sinuses, and filling them with a smooth, aseptic substance, instead of allowing acrid se- cretions to bathe their walls — is, no doubt, a favorable factor. The change in the granulating surfaces indi- THERAPEUTIC EFFECTS. 59 cates that the paste is an excellent aid for the formation of healthy granulations. It serves as a support for the formation of new granulations, which become so large that they bulge out from the sinus openings. The paste is displaced by the rapid growth of these granulations, and escapes through the external openings. Very often the granulations are covered with a whitish membrane similar to the diphtheritic membrane, which, when peeled off, leaves a perfectly clean surface under- neath. This coating is a deposit of fibrin which under- goes organization. "We have examined sections of this membrane and found it infiltrated with leucocytes and some elongated connective tissue cells. Another factor to which I have referred in my former publications is, no doubt, of some, but only secondary, importance. The exposure of tuberculous disease to the x-rays is known to be of great benefit, and many remark- able cures are recorded in the literature to support this. It is a known fact that bismuth subnitrate, as well as vaselin, when exposed to the x-rays, will become radio- active, and will retain this radioactivity for several hours. It seems reasonable to me that this property may accelerate the therapeutic action of the paste. 1 have taken advantage of this principle and exposed the most refractory cases to the action of the x-rays at intervals of three days, and am convinced that their action has beeu beneficial. It must be admitted that the exposure to the x-rays is not essential, since many surgeons have recorded excellent reports without them. At present I consider these three factors as the princi- pal agents in the therapeutic action of the paste: 1. The chemotactic quality of the paste, which induces the bactericidal action. 2. The mechanical action. 3. The exposure of the injected sinuses to the x-rays. CHAPTER VI. TREATMENT OF SINUSES DUE TO SPONDYLITIS. The extreme frequency of Pott's disease and its serious consequences make it imperative that the physi- cian should possess definite knowledge of its causes, de- velopment, and complications, and be also informed about the most advanced and safest methods of treat- ment. The physician's action in a given case of Pott's disease is of the utmost importance for the life of the patient. There is hardly another disease to which we can ascribe a larger percentage of therapeutic failures than spondylitis, in spite of the fact that we possess the means of saving nearly every case. This disease is essentially a tuberculosis. This in it- self relieves us of the task of searching for its cause. We know from the researches of many scientists (espe- cially Koch) that without the tubercle bacillus there can be no tuberculosis, and thus we are certain that this germ has somehow found its way into the body of the affected individual. The question must, however, be answered, Will the presence of the bacillus alone cause the disease in bony structures'? The impression predominates that it re- quires a trauma to precipitate a tuberculous disease with- in the bones or joints by producing a locus minoris re- sistentise, and thus permit the tubercle bacilli circulating in the blood to get a foothold. Clinical facts support this view, but the question is not fully answered. Was the injured part perfectly healthy before the injury? Is it not possible that through the trauma a preexisting 60 SINUSES DUE TO SPONDYLITIS. 61 latent, encapsulated tuberculous focus ruptured, and the bacilli thus liberated found in the traumatized bone a suitable soil for rapid development? This latter view was propounded by Friedrich 1 and Hansel, 2 and has many plausible facts to support it. The bones are, as a rule, infected through the hematog- enous route, unless the disease extends by continuity from a neighboring joint (Konig), but it is also possible to spread through the lymphatic channels. Usually the infection takes place through bacilli-carrying emboli, which lodge in the smallest branches of the arteries and there set up the tuberculous infection (Miiller). This, to a degree, explains why the disease selects for its victims small children. The rich and many-branched arrangement of the blood vessels in the young growing- bones favors the lodgment of emboli, and thus the be- ginning of the disease. The source of the bacilli is usu- ally a primary tuberculosis of the lymph glands, which in most cases can be clinically demonstrated. It is important to know whether in a given case the localized tuberculosis in the spine is the only part of the body affected. Is there such disease as primary tuberculosis of the osseous system? To this question Professor Konig" answers, "Yes." By very thorough investigation of 67 subjects who, during life, were af- flicted with joint tuberculosis, he found 14 of the 67, or 21 percent, had no other tuberculous infection than that of the joints. This indicates that osseous tuberculosis may be primary, but it likewise shows that 79 percent of cases have multiple foci, and thus we must suspect in at least four-fifths of all cases tuberculous foci in other parts of the body to coexist. x Friedrich: Experimentale Beitrage zur Tubereulose. — Deutsche Zeit- 6chrift fur Chirurgie, bd. 53, s. 512. 2 Hansel: Ueoer Trauma des Gelenke. — Beitrage zur Klinik der Tubercu- lose. bd. 28, s. 659. 3 Konig: Die Tubereulose der Menschlichen Gelenke. 1906. 62 BISMUTH PASTE IN CHRONIC SUPPURATIONS. This tuberculous infection within the bodies of the ver- tebrae causes a gradual destruction of the same, so that a gap on the anterior portion is soon established. What is the result I The body weight causes a collapse of the column at the weak point, and a more or less pointed pro- jection backwards results, which is called kyphus. If the body weight is not supported by artificial means, the continuous weight upon the diseased and friable ver- tebra will increase the deformity, and change the shape of not only the spine, but also the chest and the relation of its viscera. Fortunately, in all tuberculous infections there is a natural tendency to repair. The gap produced by the destruction of bone is soon filled with newly-formed bone tissue, although not of normal texture, but solid enough to establish a strong splint for the weight-bear- ing spine. The majority of surgeons consider the formation of a kyphus as a necessary evil essential to a cure. This view is hotly opposed by Calot, 1 who for years has advo- cated a method for its prevention, and, even when the kyphus has already formed, he claims the spinal column may be straightened by proper redressment. He demon- strates the feasibility and success of this treatment by most convincing illustrations. The complications of spondylitis are abscess, fistulae, paralysis, and deformities. In this chapter we shall con- sider only one of these complications — namely, the result- ing sinuses. We have already described the process of formation of sinuses. We know that they are the shriveled abscess walls leading to the original focus of disease. The cold abscesses following spondylitis have three favorable 1 Calot: Die Behandlung der Tuberculosen Wirbelentzundung, 1907. SINUSES DUE TO SPONDYLITIS. 63 locations for their rupture. In children they open most frequently into Scarpa's triangle, or above Poupart's ligament; in adults they usually select the lumbar region. The dorsal vertebrai are most frequently affected. Jn 538 cases, reported by Dollinger, 63 were in the cervical region, 321 in the dorsal, and 154 in the lumbar region. The disease is not frequent before the second year; 50 percent of all cases, however, occur between the third and sixth years, and the disease rarely starts after the twentieth year. Spondylitis occurs oftener in males than in females. In Hoffa's analysis of 3,795 cases, 1 2,045 were males and 1,750 females. Compared in frequency to tuberculosis of other joints, it stands first. At the Children's Hospi- tal in Boston, of a total of 5,950 cases of joint tubercu- losis, 2,867 affected the spine. For the purpose of elucidating the finer points in the treatment with bismuth paste, the following types are cited : Example 1. Spondylitis of Tenth Dorsal, with Supraclavicular and Lumbar Sinuses. — This case is cited to show that in extreme cases the sinuses may open at a great distance from their sources, in regions where their communication is not expected. This little girl, shown in Fig. 12, is 12 years old, and had, as a result of a spondylitis of five years' standing, three sinuses — one in the lumbar region, one near the eighth dorsal spinous process, and one in the supraclavicular region, all on the right side of her body. The suppuration was very profuse for years, with a varying daily temperature of from 98° to 102°, with ex- treme emaciation and amyloid degeneration of the organs. The supra- clavicular sinus was thought to be due to a broken-down tubercular gland of the neck until the first bismuth injection, in July, 1909, proved that all three sinuses communicated. The paste was injected in the dorsal sinus, and escaped through the other two openings, the lumbar as well as the supraclavicular. The sinus in the neck closed after the first injection, but the two others persisted in discharging. Although the quantity of pus was diminished and its character changed to a seropurulent fluid, the prognosis in this case is, in view of the extreme marasmus, very unfavorable. 1 Hoffa: Orthopedic Surgery, 5th edition, p. 239. 64 BISMUTH PASTE IN CHRONIC SUPPURATIONS The radiograph (Fig. 13) was taken after the sinus in the neck wa closed, and therefore shows the paste to reach only into the tenth dor- sal vertebra. Example 2. Spondylitis, Sixteen Years' Duration; Sinus Healed with Three Injections. — J. C, aged 18, with a tainted family history as to tuberculosis, was a strong baby until he had spinal meningitis when 18 months old. A year later a deformity of the spine, with all the symp- toms of tubercular spondylitis, developed. A psoas abscess formed and Fig. 12. Spondylitis of the tenth dorsal vertebra, with communicating sinuses in supraclavicular and lumbar region. opened in the right Scarpa's triangle. An irritating pus discharge has persisted for the past twelve years. I made the first injection of bis- muth paste in this case in May, 1909, and the radiograph taken (Fig. 14) disclosed a most tortuous fistula, the paste having reached the seat of the focus in the vertebra, and from there being forced into an existing channel on the opposite side, which had its blind end about two inches above the hip joint. There was not the slightest suspicion that this left sinus existed until it was discovered by means of the paste injections and radiography. SINUSES DUE TO SPONDYLITIS. 65 The most pleasing phase of this case, however, was the surprii Ing therapeutic effect resulting from the bismuth paste. With only two subsequent injections the sinus closed, the patient gaining fourteen pounds in weight in four weeks. Fig. 13. Spondylitis of tenth vertebra, showing course of sinus, opening in lumbar region at point of black dot, and then downward course into the pelvis. This case teaches several points: First, it illustrates the fact that sinuses are formed by contraction of the abscess cavity. Second, that even after twelve years' suppuration we may obtain a cure with a simple injection of the bismuth paste. Third, that the absorption of small quantities of paste 66 BISMUTH PASTE IN CHRONIC SUPPURATIONS. will not cause any symptoms of intoxication, case all of the injected paste was absorbed. In this Example 3. Bilateral Psoas Abscess Without Destruction of Ver- tebrae. — Miss M. K., aged 18, was in perfect health until two years ago. September, 1907, she fell and injured the tip of her coccyx. Thereafter she was constantly ill, and in December, 1908, an abscess developed Fig. 14. Sinus following psoas abscess, sixteen years' duration (since in- fancy). Closed after third injection of bismuth paste. above the right Poupart's ligament. Two weeks later the abscess was lanced by the attending physician and drainage established. In January, 1909, another abscess formed on the left side, in relatively the same region, and this was also incised and drained. Both result- ing sinuses persisted in discharging profusely, so much so that in order to maintain a semblance of cleanliness the dressings had to be changed two to three times daily. Radiographs of the spine failed to SINUSKS Dl! K TO SPONDYLITIS. 67 disclose any destruction of vertebrae, and a radiograph taken after an injection of bismuth paste furnished a remarkable picture. (Fig. 15.) The two abscess cavities are shown to be symmetrical, both tri- angular in form, having sharp borders, unlike those following psoas abscess. The diagnosis was for a time doubtful, but we have discov- ered that the intervertebral disc between the third and fourth lumbar vertebrae was missing, and in the absence of any other finding we concluded that in this space lay the focus of infection. The patient is still under treatment, and, while her condition is much improved, the discharge greatly diminished, and one sinus already closed, the final outcome is still uncertain. Fig. 15. Bilateral psoas < ing above Poupart's ligaments abscess without destruction of vertebrae. Each open- 3. The quantities of paste required for injection of the sinuses following spondylitis are usually very small, especially when the sinus has existed many years, such as example 2 here cited, which had existed twelve years, where only half an ounce of paste was sufficient to fill this long, narrow channel. In recent cases the abscess cavities have not yet shriveled down to narrow channels, 68 BISMUTH PASTE IN CHRONIC SUPPURATIONS. and thus may hold large quantities, and can, on account of the softness of their walls, be overdistended. For this reason I often use a 10-percent bismuth paste to prevent toxic effect from absorption. In our series of cases of spondylitis with sinuses, 60 percent have healed subsequent to the injections. The remarkable fact is that the cases in which we least ex- pected a cure — namely, those that had existed for the longest period — proved to be most favorable, and those of more recent origin were refractory. I have reported 1 a case of spondylitis in a lady, aged 51, with sinuses in right and left lumbar regions, in which rubber drains had been kept for thirteen and eight years respectively, and nevertheless it took only two months for their permanent closure. I must, however, warn against the premature declara- tion of a cure. There is no disease in which a cure is more often only apparent than tuberculous disease of the bones or joints. Recurrence or reopening of the sinuses, even after months, has taken place in a few cases, and thus we must be conservative and wait for a reasonable length of time before we assure our patient that he is permanently cured. It must, however, be stated that, in patients who lived through the complications of abscess and sinuses and were finally cured, recurrence was much less frequent than in the cases in which the disease was checked in its incipiency. !Beck: Eeitriige zur Klinisehe Chirurgie, 1909, bd. 62, h. 2. CHAPTER VII. TREATMENT OF SINUSES FOLLOWING OSTEO- MYELITIS AND JOINT DISEASES. Two principal varieties of osteomyelitis and arthritis are recognized — those of pyogenic and those of tubercu- lous origin. The pyogenic or nontuberculous osteomyelitis origi- nates in three different ways: first, in consequence of in- juries, such as fractures, in which the bones were ex- posed or denuded of their periosteum; second, by exten- sion of pyogenic infection from soft structures, such as phlegmon; and, third, through the circulation. All varieties of pus-producing microorganisms are liable to cause this form of infection. In ectogenous infections the staphylococcus pyogenes aureus and streptococcus are the usual invaders, while through the hematogenous route the mixed infections of the staphylococcus pyogenes albus and the streptococcus pyogenes lead in frequency, and next in frequency occur the pneumococcus, the gonococcus, the bacillus typhosus, the colon bacillus, and bacillus influenza?. If the infec- tion follows external injury, the periosteum is first at- tacked, it being lifted from the bone, and thus the dis- ease may reach the bone marrow. The nontubercular infection usually starts in the bone marrow of the long bones ; less frequently in the cortical substance or the periosteum. From this primary focus it may spread in all directions, and may even break through the epiphysis into a joint, but most frequently it spreads through the Haversian canals toward the peri- 69 70 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Pig. 16. Sinuses from nontuberculous osteomyelitis. SINUSES FOLLOWING OTHER DISEASES. 71 osteum, and causes a suppurative periostitis. The accu mulation of pus will separate the periosteum from the bone shaft, deprive the underlying section of bone of its nutrition, and lead to its necrosis. A sequestrum is thus formed. This necrotic bone, now entirely detached, acts as a foreign body. Nature tries to cither eliminate or en- capsulate it. A liquefaction or crumbling of this bone will take place until only the hardest of its structure — a mere shell, perforated, grooved, with edges sharp and ir- regular — will remain. Such is the characteristic seques- trum of pyogenic osteomyelitis. During the time of this destructive process a reactive osteoplastic inflammation takes place, in which the peri- osteum takes the principal part. This osteoplastic proc- ess surrounds the dead bone with a strong casing, and at the same time strengthens the shaft of the diseased bone. As a result of the disintegration of the bone and the suppuration of the tissues, an abscess is formed. At times the pressure of the pus breaks down the barriers, the abscess is ruptured toward the outside, and a sinus is formed. The following case is typical of the facts just men- tioned : Nontubercular Osteomyelitis of Humerus. — G. W., a boy, aged 13. was brought to Dr. Carl Beck for operation in August, 1909. He had suffered from a suppurating sinus of his arm for over a year. Two operations had failed to cure the condition. Examination revealed a very much thickened bone of irregular con- tour, extending from the head of the humerus to about the middle of the arm. On the external surface of the arm was a sinus, and a large scar as evidence of a former operation. (Fig. 16.) The first radiograph (Fig. 17) taken shows the presence of several large se- questra, imbedded in a mass of dense tissue. This skiagraph shows distinctly the darker shadows of the sequestra and a brighter zone around them, indicating a layer of granulations, in which they are imbedded. Another darker shadow outside of the light zone indicates the layers of reactive ostitis — new formation of bone. 72 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Fig. 17. Radiograph of humerus showing sequestra, (Case shown in Fig. 16.) SINUSES FOLLOWING OTHER DISEASES. Fig. 17 A. Diagrammatic illustration of Fig. 17. Fig. 18. Three of the sequestra removed from humerus. (Case shown in Fig. 16.) 74 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Fig. 19. Bismuth paste injected into cavity after sequestra were removed. (Case shown in Fig. 16.) SINUSES FOLLOWING OTHER DISEASES. 70 Fig. 19 A. Diagrammatic illustration of Fig. 19. 76 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Pig. 20. Bismuth, paste remaining after sinuses were closed. (Case shown in Fig. 16.) SINUSES FOLLOWING OTHER DISEASES. 77 Fig. 21. Complete closure of sinuses and perfect restoration of function of arm. (Case shown in Fig. 16.) 78 BISMUTH PASTE IN CHRONIC SUPPURATIONS. The accompanying tracings explain the various pathologic changes in the humerus shaft. An operation was performed by Dr. Carl Beck, seven sequestra (Fig. 18) being removed, and the cavity packed with gauze. Twenty- four hours later the gauze was removed and the cavity filled with bismuth paste. A second radiograph (Fig. 19) was taken, which shows Pig. 22. tic sclerosis. Typhoid osteomyelitis of tibia. A, granulating cavity ; B, hyperplas- that all sequestra had been removed, and that the entire cavity had been filled with the paste, leaving only the lighter zone of the granu- lation tissue. With few additional injections of the paste the cavity has entirely filled with healthy granulations and new formation of bone (Fig. 20) ; sinuses have closed within three weeks after the operation, and re- mained so. SINUSES FOLLOWING OTHER DISEASES. 79 The boy now has perfect motion of his arm, as shown in Fig. 21, and sufficient strength to do ordinary hard work. A typical case of typhoid osteomyelitis of the tibia is shown in a radiograph. (Fig. 22.) The disease in the bone appeared four months after the typhoid fever subsided. The pus contained typhoid bacilli. The small area of infection is filled with granulation tissue (A), and the entire diseased process is surrounded by a layer of hyperplastic sclerosis (B), which acted as a barrier against spreading. Pyogenic Arthritis. — The nontubercular infection of joints has the same etiology as that of the bones, and may likewise occur through the hematogenous route as a con- sequence of an acute general infection, such as scarlet fever, diphtheria, pneumonia, gonorrhea, erysipelas, and meningitis. The synovial membrane is the structure first attacked. In consequence of its infection an exudate will at once be thrown out into the joint cavity. This exudate may be serous, serofibrinous, or from the start purulent, de- pending upon the virulence or type of the infective organism. The serous or serofibrinous variety repre- sents the milder forms of infection, while the severer forms will, from the start, cause a suppuration within the joint, and may either destroy the same or cause a general septicemia or pyemia, unless proper surgical measures are taken. In either the acute or chronic pyogenic arthritis the ac- cumulation of pus within the joint may eventually lead to a sinus formation. The pus may reach the surface either by spontaneous rupture of the joint or through surgical intervention. Tuberculous Osteomyelitis. — Except for anatomical dif- ferences, the formation of sinuses from tuberculous osteo- myelitis is the same as that described in the chapter on spondylitis. The primary infection likewise takes place through the circulation or the lymphatics, and then ex- 80 BISMUTH PASTE IN CHRONIC SUPPURATIONS. tends to neighboring structures. The predominating opinion is that in the tuberculous type the epiphyses are in the vast majority of cases the primary focus of the in- Epiphysial / V V/.^fcWu,. arteries \^ff j££ Metaphysial /V \Awt Metaphysial arteries "~'i4 y-'j \\$ Epiphysial t/p^—c^ ' • t arteries [pC^-- *-£ Pig. 23. Figs. 23, 24. Blood supply in bones of infant, showing subdivisions of nutrient artery in metaphysial line. (Lexer.) Epiphysial arteries Fig. 24. fection, and that from there the disease extends into the joint proper. Professor Konig has, however, pointed out that primary synovial tuberculosis is far more fre- quent than is supposed, and his experience is supported SINUSES FOLLOWING OTJJ.KK DISEASES. 81 by Lexer, 1 who states that the synovial form is at least as often primary as the osseous form. In the osseous form the disease is, no doubt, of em- bolic origin. A study of the blood supply in the bones of growing children (Figs. 23, 24) teaches us why this disease selects the ends of the bones of young individuals. The smallest subdivisions of the nutrient artery take place at the metaphysial end, and the epiphysial arter- ies enter from all sides and meet in the center of the epiphysis. Small triangular infarcts, when present, are due to blocking of one of these end arteries with bacilli- carrying emboli, and from this focus the disease spreads into neighboring areas. This primary infection causes an inflammatory reac- tion, with an area of infiltration, gradual formation of tubercles, and finally a cheesy degeneration of its center. The cancellous bone tissue is gradually destroyed, and a sequestrum of the harder portions of the bone may re- main. The tuberculous sequestrum has certain charac- teristics. It is usually a small roundish or oblong body, resembling a rough gallstone, seldom reaching the size of a walnut, while the sequestrum in the nontuberculous form is usually flat and zigzag-edged. Surrounding this diseased area we find a zone of new bone formation (periostitis ossificans), which forms a capsule around the sequestrum and the broken-down bone (Knochensand — bone sand). The process is liable to heal spontaneously. If, however, the disease has a tendency to further invasion, the limiting pyogenic mem- brane, or the osteosclerosis, will not form, but instead a diffuse tuberculous ostitis will take place. In this pro- gressive form the tuberculous disease may spread up- ward and affect the entire shaft of the long bone, or it 1 Lexer: Allgemeine Chirurgie, 1910, bd. 2, s. 378. 82 BISMUTH PASTE IN dHRONIC SUPPURATIONS. may extend to and break into the joint, and also affect the para-articular soft tissues. An abscess will then usually result, which may undermine the tissues and break through the skin in one or more places, and thus the tuberculous sinuses are formed. Tuberculous Arthritis. — "When this disease starts in the joint, the tubercle bacilli are primarily deposited in the capillaries of the synovia, and form miliary tubercles in this lining membrane. Inflammatory reaction is mani- fested by a serous or serofibrinous exudate and the forma- tion of tuberculous granulations. In the milder forms or in the beginning the exudate is of serous character (hydrops articularis tuberculosis, Konig) or may contain white flakes, which indicate an addition of fibrin to the fluid (hydrops fibrinosus, Konig). In the former the fluid is gradually absorbed; in the lat- ter type the fibrin is deposited on the joint surfaces, and, through organization, causes their thickening, sometimes the formation of a villous growth (Fig. 25), or of free floating bodies. These free floating bodies, also called rice bodies (Fig. 26) (corpora oryzoidea), are always the result of a tuberculous infection, as they contain the tubercle bacilli, and when inoculated into guinea pigs will invariably produce tuberculosis. In the severe forms the disease may still be arrested and the granulations undergo cicatrization. If cicatriza- tion takes place, the synovia is studded with tubercles, which are covered by a pale, grayish-red, granular coat- ing; if the disease progresses, the synovia is covered with a spongy mass of soft and mushy granulation. This con- dition is called fungus (Gliedschwamm), and causes a pseudo-fluctuation, and is therefore often mistaken for an abscess. In this latter form the parasynovial struc- tures become edematous and swell, so as to put the over- SINUSES FOLLOWING OTHEK DISLASLS. 80 lying skin upon a tension, thus producing an anemic, "shining" swelling of the joint, which in the knee is familiarly known as tumor albus. In the most severe form the masses of granulations within the joint undergo cheesy degeneration and small Pig. 25. Villous growth of tuberculous knee joint. (Konig.) foci of suppuration. The latter are the forerunners of the abscess formation. Their number increases until they coalesce and form the "abscess." When the ab- scess is under great tension, the surrounding structures become undermined and pus will work its way toward the skin surface, and the abscess may finally rupture. 84 BISMUTH PASTE IN CHRONIC SUPPURATIONS. The disease may even lead to the destruction of the car- tilages and the underlying bone surfaces, so that the en- tire joint is transformed into a mass of debris. The clinical course of joint tuberculosis is variable, de- pending upon age of the patient, his resistance, and the joints affected. In general, the disease starts very in- sidiously, and the progress is gradual. Only in little Fig. 26. Rice bodies from tuberculous joint. (Beck.) babies do we encounter an acute onset of this disease. The diagnosis in its incipiency is very difficult, and many cases are treated weeks and months for rheumatism, sciatica, neuralgia, etc., before any characteristic symp- toms arise. The usual forerunners are weakness in the affected limb, frequent lancinating pains, until the signs of the joint affection are manifest. When the character- SINUSES FOLLOWING OTHER DISEASES. 85 istic swelling and fixation of the joint are jn'esent, the diagnosis is easily established. A radiograph in doubt- ful cases is a most valuable aid. The early diagnosis is, of course, the salvation of the individual, because we possess the means of checking the disease only in its be- ginning. Should an abscess form in spite of our efforts to pre- vent it, we may still prevent the formation of a sinus by proper conservative treatment, of which I shall speak in another chapter. When, however, the sinus is already present, then the treatment with bismuth paste will be of service. Sinuses Following Hip Joint Disease. Next in frequency to spondylitis, the hip is affected. Of 5,950 cases of joint tuberculosis treated at the Chil- dren's Hospital in Boston, 2,281 affected the hip and 2,867 the spine. In our series of cases, treated at the North Chicago Hospital during the past four years, the relative frequency of these two conditions was 41 cases of hip joint disease to 34 cases of spondylitis. These num- bers, however, include only the cases in which sinuses were present. In the cases without sinuses the relative proportion was equal, 11 cases of each having come under our care. In only three instances did spondylitis and hip joint disease coexist. In this series of 41 cases of hip joint disease with sinuses the right hip was affected in 26, the left in only 15 cases, none being bilateral. This disproportion seems to us more than accidental, as this same relative frequency has kept up each year since we first observed it. Shortening of the affected limb existed in practically all cases, since the head of the femur was destroyed in nearly every case where the disease was so extensive as 86 BISMUTH PASTE IN CHRONIC SUPPURATIONS. to progress to sinus formation. In one case the shorten- ing amounted to eight inches. In two cases there was no ankylosis, although the head of the femur was destroyed. It is easy to make a correct diagnosis of hip joint dis- ease when sinuses are already present. I have neverthe- less encountered and cited in Chapter IV cases where sacral tuberculosis was mistaken for hip joint disease because the abscess happened to open directly over the hip. Three principal complications result from hip joint dis- ease — the shortening, the ankylosis, and sinuses. I shall here consider only the latter. The number of sinuses which are liable to result from a tuberculous coxitis may vary extremely. In our series of 41 cases, 12 cases had 1 sinus. 8 cases had 2 sinuses. 9 cases had 3 sinuses. 1 case had 4 sinuses. 3 cases had 5 sinuses. 4 cases had 6 sinuses. 1 case had 8 sinuses. 2 cases had 16 sinuses. 1 case had 20 sinuses. The sinuses usually open near the trochanter or in the gluteal region, but in extensive cases they may open at a distance from the hip joint. Fig. 27 illustrates the type of hip joint disease in which the abscess formation resulted in numerous sinuses. In this case eight sinuses had existed for four years, three of these having recently closed. The open sinuses show the large, pouting granulations which fol- low the injections of the bismuth paste. Not infrequently the sinuses open near the anus or scrotum, and thus may be mistaken for rectal fistulae. In SINUSKN FOLLOWING OTHER DISEASES. 87 one of my cases the abscess had ruptured into the blad der and thus the existing sixteen sinuses kept on dis charging the urine for seven years. 1 At times the acetabulum is perforated and the abscess Fig. 27. Sinus openings showing large pouting granulations after bismuth in- jections. will rupture into the pelvis, undermine the pelvic fascia, and open above or below Poupart's ligament. This com- plication, which increases the difficulty of treatment, was present in 5 cases in my series of 38. The radiographs after the bismuth injections have in every instance 1 Beitrage zur Klinische Chirurgie, bd. 62. h. 2. s. 40. 88 BISMUTH PASTE IN CHRONIC SUPPURATIONS. cleared up the diagnosis as to the origin and distribution of these sinuses. We are all familiar with the extreme chronicity of the affection. In our series of cases, 15 cases had sinuses from 1 to 3 years. 9 cases had sinuses from 3 to 10 years. 10 cases had sinuses from 10 to 15 years. 5 cases had sinuses from 15 to 20 years. 1 case had sinuses for 22 years. 1 case had sinuses for 41 years. Most of these patients contracted their hip disease in early childhood, passed the acute stage of the disease, and after years of treatment, either operative or pallia- tive, remained uncured. The mortality in hip joint disease is probably lessened each year because of our improved methods and conserva- tive treatment. Statistics compiled some years ago show an appalling mortality. Konig placed the mortality at 40.3 percent. Alexandria Hospital (384 cases), 26 percent. Gibney reports 288 cases, with a mortality of 12.5 per- cent. The mortality is lower in children than in adults. A report of 100 cases from Kocher's clinic, by Lewiasch, gives the following mortality: In 25 cases which had abscesses, mortality of 65 per- cent. In 75 cases without abscesses, mortality of 13.3 per- cent. The extreme chronicity and the resistance to simple treatment have forced the surgeons to adopt radical and often desperate methods. The most extensive and dan- gerous operations — such as excision of the hip joint, or even amputations — have been performed, but past experi- ence has taught us that even these most radical proce- SINU8ES FOLLOWING OTHER DISEASES. 89 dures Lave in a Large measure resulted in failures. In the intervals between these operations the sinuses were irri gated with various antiseptic solutions, from the mildesl boric acid to the corroding pure carbolic. The favorite irrigating fluid was a weak solution of iodin or permanga- nate of potash. Some cases in our series have given a history of many years' daily irrigation without any bene- fit. Most surgeons have now abandoned the irrigation of abscess cavities, and substituted more modern and effect- ive methods. In the light of our present knowledge of the anatom- ical distribution of sinuses, the injection of any watery fluid, whether corrosive or mild, no matter how effective its bactericidal action, can be of only temporary benefit, because the solution will not reach all channels and crevices of the infected tract, and, if it does, it will not remain in contact with the infected walls sufficiently long- to exert a therapeutic action. The bismuth paste will accomplish this, and in this principle I believe lies the secret of its effectiveness. It possesses to a marked de- gree all the above requisite qualities. It is liquid when injected, so that it reaches all the branches of the sinuses, and on cooling becomes semi-solid, thus remaining in con- tact with every portion of the infected tract long enough to permit a slow chemical action. Following are illustrations of the treatment of various types of hip joint disease : Example 1. Hip Joint Disease, Sixteen Years' Duration; Fifteen Operations; Injection of Paste; Cure in Thirty Days. — Miss M. G., aged 21, developed a painful condition of her right knee and hip at the age of six. For one year she was treated symptomatically, and then a diagnosis of hip joint disease was made by aspirating pus from the hip. Incision and drainage (at that time considered the proper procedure) was made. Condition was thus aggravated, and after six months of extreme suffering, often requiring chloroformization dur- ing dressings, a radical operation was performed, consisting in the re- 90 BISMUTH PASTE IN CHRONIC SUPPURATIONS. section, of the head of the femur. This radical procedure, however, resulted in the formation of many sinuses and persistence of fever. During the following ten years she submitted to thirteen more or less Fig. 28. Radiograph showing sinuses within hip after sixteen years' suppura- tion. Closure in one month ; no recurrence. radical operations, at intervals of from six months to three years, all of which, however, were of no avail. The discharge and pain per- sisted. The last operation was performed by the late Professor Senn K1NUKKS FOLLOWING OTHER DISEASES. 91 in June, 1907. It was the most radical procedure thus far undertaken; hoth trochanters were removed and the acetabulum was thoroughly curetted. The five sinuses, however, kept on discharging pus. In December, 1907, the first injection of bismuth paste was made, and repeated every two or three days, and on January 15 the sinuses were closed, and have remained thus to date. The radiograph (Fig. 28) shows the extreme destruction of the joint, the end of the femur, in- Fig. 29. Radiograph showing path of sinus into hip joint. B, small abscess cavity. A, sinus opening eluding both trochanters, having been removed. The rim of the ace- tabulum is filled with the bismuth paste, showing distinctly a col- lateral sinus. Example 2. Hip Joint Disease, Six Years' Duration; One Sinus; Closure in Four Months. — Miss M. W., aged 13, was well until her seventh year, when she fell, striking her hip. No serious conse- quences were discovered until two years later. She was taken to 92 BISMUTH PASTE IN CHRONIC SUPPURATIONS. St. Joseph's Hospital in Chicago, where her case was diagnosed as tuberculosis of the hip; injected with a 10-percent iodoform-glycerin emulsion, and the limb put into a plaster of paris cast. Three months later the cast was removed, and from that time the injections of iodo- form were repeated until nine had been given. An abscess, neverthe- less, formed, which ruptured on the external side of her thigh, near the middle of the femur. The sinus resulting therefrom persisted in discharging large quantities of green, malodorous pus for three years, requiring daily dressing. She was unable to move about without the aid of crutches, owing to the tenderness in her hip. Fig. 30. Hip joint disease, nineteen years' duration, gluteal region ; S, S, S, sinus openings. C, incision of abscess in On February 28, 1908, when she first came for treatment, she was very much emaciated, pale, and weak, with a shortening of four inches of her left limb, and a sinus on the anterior surface of her left thigh, discharging pus. A radiograph taken demonstrated the destruction of the head of the femur. A second stereoscopic radiograph (Fig. 29), taken after the first bismuth paste injection, demonstrated that the sinus extended from the opening on her thigh upward, in front of the trochanter, winding its way backward toward the acetabulum, and there filling a small cavity in front of the ramus of the ischium. The discharge diminished after the first injection, and its character changed to a seropurulent fluid, resembling dish-water. After twenty SINUSES FOLLOWING OTHER DISEASES. 93 injections during a period of four months the sinus healed, and has re- mained so. Example 3. Hip Joint Disease, Nineteen Years' Duration; Required Curettage Before Injection. — (Fig 30.) The patient is 2G years of age, and has had since his sixth year a hip joint disease, which resulted in the entire destruction of the head of the femur, and four sinuses, which latter continued to discharge for nineteen years. The radio- graphic examinations proved that a large sequestrum was at the bot- tom of the suppurating focus and that its removal would be required before a cure could be accomplished. This was done in May, 1909. Two large sequestra were removed, and an abscess, undermining the entire left gluteal region, was discovered during the operation. A large counter-incision (C) was made, and through this the abscess was traced into the pelvic cavity. After a few' days' packing with gauze the cavities were filled with bismuth paste, and within four weeks all sinuses were closed. The temperature, which had con- stantly been high, became normal, and patient gained forty pounds in weight. Sinuses from Pyogenic Osteomyelitis of the Femur. The femur is the most frequent seat of nontnberculous osteomyelitis. During the past four years we have treated at the North Chicago Hospital 57 cases of non- tuberculous osteomyelitis, occurring in the following parts : 20 in the femur. 12 in the tibia. 1 in the fibula (syphilitic). 6 in the humerus. 4 in the radius (3 syphilitic). 4 in the ulna (3 syphilitic). 2 in the ribs. 8 in the fingers. Of the 20 femur cases, 9 occurred in the right and 11 in the left limb. 14 were males and 6 females. 15 were adults and 5 children. The lower half of the femur is most frequently affected, the disease having occurred nineteen times below and only once above the middle. The cause of this unequal 94 BISMUTH PASTE IN CHRONIC SUPPURATIONS. distribution has not been determined, but is likely due to the anatomical difference in structure, the lower end having a much wider medullary canal than the upper Fig. 31. Nontuberculous osteomyelitis of femur. A, density of bone ; B, se- questra after removal. portion of the femur, which predisposes the lower to the infection. Nontuberculous sinuses in this location are usually two in number — one external, in the groove between the biceps femoris and the vastus lateralis, and the other on SINUSES FOLLOWING OTHER DISEASES. 95 the interna] side, in the groove between the semi-tendi- nosus and semi-membranosus. Of our 20 cases, in only one instance lias a sinus existed in the popliteal space. In most cases there exists a marked hypertrophic sclerosis, as plainly shown in the radiographs, where the part af- fected is at times nearly twice its normal thickness, and so vitrified that the medullary canal is obliterated and the entire width of the shaft gives a shadow of uniform density. This hardening of the bone structure is a re- sult of chronic inflammation, and causes considerable difficulty during operations, it being almost impossible in some cases to cut the bone with a sharp chisel. At times there are foci of infection or small sequestra, en- capsulated in such a hard shell of bone, and their re- moval thus becomes extremely difficult. I cite a typical case of this variety for illustration. A. H., aged 29, was always well until February, 1907, when a swell- ing appeared above his left knee, accompanied by chills, fever, and pain. Physician lanced the swelling and removed a quart of pus. Ten days later he was operated, and four sequestra from the femur were removed and the wound drained. A sinus persisted in discharg- ing profusely an irritating pus. In August, 1908, he was again operated; a radical curettage was performed, but again without result. In November, 1908, I had a radiograph taken (Fig. 31), which ex- plains the failure. The lower portion of the shaft is very much thick- ened and the cancellous tissue is entirely replaced by hard bone. An- other sequestrum (A) is still in the femur. The four sequestra (B) previously removed are placed alongside the femur to show their rela- tive size and shape. After the removal of the last sequestrum the bismuth paste was injected, and rapid improvement and closure of sinus followed. Sinuses Resulting from Tuberculous Knee Joint. The same pathologic processes as described in hip joint disease lead to the sinus formation in knee joint tuber- culosis. Next to the hip, it is the most frequent seat of this disease. Young individuals are most frequently the 96 BISMUTH PASTE IN CHRONIC SUPPURATIONS. victims, one-third of all cases occurring before the tenth year. Men are more often affected than women. Konig's 1 series of 720 cases treated shows 60 percent were men. Fig. 32. Bilateral tuberculosis. Tibia in right and femur in left limb affected. In our own series of 24 cases, treated at the North Chicago Hospital during the past four years, 19 occurred in men and only 5 in women. Of these 24, 7 affected the right and 17 the left limb, just the reverse ratio to what 1 Konig: Die Tuberculose der Menschlichen Gelenke. WJNIISKS KOUjOWINU OTIIKI't DISKASKS. 97 occurs in tuberculosis of llic hip, where we encountered 26 cases affecting the right side against 15 the left. Konig states that at least one-half of the cases begin with a primary synovial tuberculosis, and from there spread to the adjacent bones, while other authors (Tay- Figs. 33, 34. in Pig. 32.) Fig. 33. Fig. 34. Radiographs demonstrating bilateral tuberculosis. (Case shown lor) assert that more frequently the disease starts in the bones and affects the joints secondarily. Any of the four bones which make up the knee joint may be the primary seat of the disease. The lower end of the femur leads in frequency and is closely followed 98 BISMUTH PASTE IN CHRONIC SUPPURATIONS. by the upper end of the tibia. Primary tuberculosis in the patella is not as rare as is generally believed; only two cases, however, occurred in our series. In Konig's 720 cases it occurred 50 times, in 33 of which the patella was the only bone involved. The fibula is rarely af- fected; not a single case has occurred in our series. Fig. 35. Demonstration of method of injection of bismuth paste into sinus of the knee. In one case the disease was bilateral. This case has so many interesting features that I desire to cite it: Example 1. Bilateral Knee Joint Tuberculosis. — A boy, aged 13, de- veloped bilateral tuberculosis (Fig. 32) at the age of 10. In both limbs the disease progressed until sinuses formed, which persisted in dis- charging purulent material, and also small spicula of bone. In the right limb only the tibia is affected, as shown by the large swelling below the SINUSES FOLLOWING OTHER DISEASES. 99 knee and the extreme atrophy above the knee. In the left limb the femur is diseased, the swelling being above and a contracting atrophy below the knee. The radiographs (Figs. 33, 34) demonstrate this con- dition most lucidly. It is remarkable that, in spite of this extensive destruction, neither the right nor the left joint is involved. The boy has no pain, can stand erect, walk fairly straight, and, moreover, he can bend both knees, as shown in Fig. 35, in which I demonstrate at the same time the method of injection of these sinuses with bismuth paste. I have carried out this treatment in this case for the past eight Fig. 36. Tuberculous knee joint with forty-two sinuses, sixteen years' duration. months, injections having been given at ten days' intervals, but the sinuses continue discharging. A radical operation — namely, a complete exenteration of the end of the femur and tibia — is the indication under those circumstances, but the knee joints should not be opened. For illustration as to what extent the soft structures may be undermined as a result of tuberculosis of the knee joint, I cite another case: 100 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Example 2. Knee Joint Tuberculosis, with Forty-two Sinuses. — In this the disease started when the patient was 6 years old, and sinuses began to form until the entire area from the middle of the thigh down to the middle of the leg was studded with profusely discharging sinuses Fig. 37. Network of sinuses of femur. (Case shown in Fig. 36.) (forty-two in number, Fig. 36). Multiple openings make it difficult of injection, as the paste escapes from the nearest counter-opening, thus failing to reach all portions of the network underneath. The patient's father, a physician, tried the bismuth paste, and, while it reduced the SINUSKS FOLLOWING OTIILK DISKASKS. 101 amount of discharge, it failed to produce the closure of the sinuses. He believed that this was duo to faulty technic, and brought his son to me for treatment. While the case seemed hopeless, on account of the extent of the disease and the failures in the previous surgical treatment, we never- theless decided to give it a trial. A stereoscopic radiograph of the knee joint was made, and demonstrates the causes of failure by showing a Fig. 38. Hopeless condition of old tuberculous knee joint, putation required. Eight sinuses. Ana- large sequestrum in the tibia. This sequestrum was removed, and then all the sinuses were injected and another radiograph was taken. This picture (Fig. 37) demonstrates the complex arrangement of channels. After this operation a rapid improvement followed, and the sinuses above the knee also began to close, indicating that the focus of the dis- ease in the tibia was the fountain of the constant discharge. The case is still under treatment and the final outcome yet undecided. 102 BISMUTH PASTE IN CHRONIC SUPPURATIONS. It is needless to say that there are some cases which will not yield to the bismuth paste treatment. In our own series we found that 6 percent could not benefited after a persistent treatment of at least one year's duration. In no case do we give up hope of an ultimate cure until after at least one year's treatment. Occasionally we encounter a case in which treatment is not even worth trying. The following case is an ex- ample : M. F., aged 26, developed at the age of 10 a tuberculous knee. In spite of the most skillful treatment, the joint had undergone abscess formation, leaving it ankylosed, with eight suppurating sinuses, for sixteen years. The entire limb had undergone extreme atrophy and a shortening of six and one-half inches, so that, even if there had been no sinuses, the limb would have remained useless. A radiograph, taken after an injection of the paste for diagnostic purposes (Fig. 38), discloses the hopelessness of a cure. I therefore amputated above the knee and had it replaced with a useful artificial limb. The discarding of crutches, a gain in general health, and a great improvement in appearance were the benefits derived from this procedure. Sinuses from Bone and Joint Disease of the Foot. The architecture of the foot is such that tuberculous disease rarely affects a solitary bone or joint. The os calcis is occasionally a solitary focus. The ankle joint is most frequently involved. In Fig. 39 we illustrate the typical shape of an advanced tuberculosis of the ankle. This case is of many years' duration, and was considered hopeless, an amputation having been advised by several surgeons after the radical operations had been of no avail. In 1908 the six sinuses were injected with bis- muth paste and the treatment kept up for one year, and during this period the foot was reduced in size, three sinuses closed, and the three remaining have discharged only a few drops of serous fluid. He can walk without crutches, and returned to his work, which he had aban- doned since the beginning of his disease. SINUSES FOLLOWING OTHEK DISEASES. 103 Even the most extensive destruction in the ankle joint may ultimately heal, and the limb may become strong enough to carry the body weight. The radiograph (Fig. 40) illustrates such a case. Tuberculous Ankle, Ten Years' Duration. — A young man, aged 19, developed at the age of 9 a typical tuberculosis of the ankle, in which Fig. 39. Typical tuberculous ankle joint with sinuses. the entire set of bones composing the ankle took part. The destruction of the joint was complete, abscess ruptured, and sinuses persisted for ten years, but the discharge became less profuse every year and the joint became small and painless. In April, 1909, I injected the sinuses three times, and within a month they closed and remained so. The patient can support his body weight on the healed limb. The radiograph (Fig. 40) has many instructive features. It shows 104 BISMUTH PASTE IN CHRONIC SUPPURATIONS. that after this extreme destruction of the joint nature has soldered the rough bony ends together, and produced a solid support. Callous deposits fill in all the gaps of missing bone. Another pathological feature is here lucidly illustrated. It has been observed that the bones in the vicinity of tuberculous disease are frequently deficient in lime salts, Fig. 40. Destruction of ankle joint, with ankylosis (closed). A, callus; B, B, absorption of calcium salts. and therefore give a much lighter shadow than normal bone. We note that in this case the os calcis, all the tarsal bones, and the ends of the metatarsals show this characteristic deficiency of lime salts, while the tibia and fibula and the distal parts of the metatarsals are per- fectly normal, and give a contrasted darker shadow. SINUSES FOLLOWING OTHER DISEASES. 105 Tuberculosis in the os calcis is not very rare. We illustrate a typical case in Fig. 41: A young man of 20 developed a painful swelling of his right heel in 1907. After two months an abscess was lanced, but, instead of the expected healing, a sinus remained. A radiograph disclosed a seques- trum of a round shape, lodged in a well-formed cavity in the os calcis. Sequestrum was removed and a drainage on both sides of the heel established. The sinuses persisted and the disease extended upward, involving the sheath of the tendo Achillis, with formation of two more sinuses. In this condition he came to me for treatment. The first Fig. 41. Tuberculosis of os calcis injected with bismuth paste. injection was made in March, 1909, and after three weeks' treatment the sinuses closed and remained so until January, 1910, when one of them reopened and a small amount of discharge returned. A few additional injections of the bismuth paste closed the last discharging sinus. Sinuses from Tuberculosis of the Elbow Joint. This disease shares the general characteristics of tuber- culous infection in other joints. It occurs, however, more frequently in young girls than in boys; affects the 106 BISMUTH PASTE IN CHRONIC SUPPURATIONS. right arm at least 10 percent more often than the left. All three bones comprising the joint may be affected, bnt the humerus most frequently. Of 128 cases cited by Konig the radius was only twice affected, while the olec- ranon process was affected in 36 cases. The disease is primary in the bones in about 70 percent of cases, and in- vades the joint secondarily. If not arrested in its initial stages, it will progress as usual to abscess formation and rupture, with the ultimate sinus formation. In Konig 's 128 cases 35 percent had abscesses, and in 53 percent sinuses were present. It must be remembered that his statistics comprise material of several decades, and therefore do not represent the proportion of sinuses of recent years. With the modern and conservative treat- ment introduced in the last few years, the formation of sinus has been reduced to a great extent, and, as will be shown in the chapter on the Conservative Treatment of Cold Abscesses, the sinus formation can be prevented in practically all cases. When, however, the sinuses al- ready exist, the bismuth treatment is indicated, no special technic being required for this class of cases. The wrist so resembles the ankle joint in architecture that the disease affects both in similar manner. The number of small bones and joint surfaces predispose to a rapid extension of the tuberculosis, and therefore it is rarely confined to one. In the wrist more than else- where the disease leads to abscess and sinuses, but these sinuses respond promptly to the bismuth paste treatment. Of 10 cases in our series, only 2 required curettage; the remainder healed after one or more injections without surgical interference. The smaller bones and joints of the hand and foot are subject to the same infections, pyogenic or tuberculous, and the resulting sinuses yield to the same treatment as those of other joints. SINUSES FOLLOWING OTHEK DISEASES. 107 Sinuses from Tuberculous Ribs and Sternum. Tuberculous abscesses on the thorax wall rarely origi- nate in the soft structures. Almost without exception they are the result of a bone tuberculosis. Leaving 1 out sinuses resulting from empyema and those from spon- Fig. 42. Sinuses supposed to have originated from ribs, found to be due to tuberculosis of sternum. dylitis, we may regard every sinus of the chest wall as that of a rib or sternum. The ribs furnish about five times as many cases as the sternum, and most of them are of tuberculous origin, only a small fraction originating from typhoid or pyo- genic infection. Men are more frequently affected than women, usually between 20 and 40 years of age. The 108 BISMUTH PASTE IN CHRONIC SUPPURATIONS. tuberculous foci are rarely larger than a cherry, usually affecting less than one inch of the rib. Their most favor- ite location is in the anterior curve of the third to the ninth rib. Tuberculosis of the ribs runs a very chronic Fig. 43. Patient of radiograph shown in Fig. 42. A, incision of first opera- tion ; B, incision of second operation ; C, incision for removal of sequestrum in sternum. Closure ef all sinuses after removal of sternal focus. course, often requiring months before an abscess forms, and the sinuses may open at quite a distance from the diseased focus. At times the disease originates in the sternum, and the abscess undermines the chest muscles SINUSES FOLLOWING OTHER DISEASES. J 09 and opens clear over at the side of the chest wall, produc- ing a sinus opening so far from the original focus as to mislead one in the diagnosis. The following case will illustrate this: Tuberculosis of the Sternum Mistaken for Tuberculosis of Ribs. — T. L., aged 21, developed when 1G multiple abscesses on the left side of his chest, below the nipple line. The same were drained, but, in- stead of spontaneous closure, they persisted discharging for a year. The diagnosis of tuberculosis of the rib was made and a part of the ninth rib was resected. This did not alter the condition, and a year later another radical operation was performed; the entire undermined area was curetted and a section of the fifth rib resected. Five sinuses remained after this operation, and persisted in discharging a purulent, very irritating pus for another three years. With this history he came to me in the spring of 1909. My sus- picion that this was a tuberculosis of the sternum and not of the ribs was verified by the radiograph (Fig. 42), in which it is shown that the sinuses led toward the sternum. Without opening any of the old sinuses, some of which were in the axillary line, I made an incision near the sternum, where I found some of the paste injected the day before. Following the tract of the paste toward the median line, I found a sequestrum the size of a silver quarter. This was removed and the cavity packed with gauze, followed by three injections of paste (33 percent). Subsequent to this operation, and without any surgical treatment to the other sinuses, the entire set of them closed within a month, as shown in Fig. 43, and remain so to date. CHAPTER VIII. POST-OPERATIVE SINUSES FOLLOWING ABDOMI- NAL AND KIDNEY OPERATIONS. A decade ago, when it was customary to drain the abdomen after nearly all laparotomies for suppurative conditions, post-operative fistulas were relatively fre- quent, especially when silk had been used for tying pedi- cles. At the present time of aseptic surgery, with our knowledge of the harmlessness of sterile pus and the acquired local immunity in chronic abscesses, we have been taught not to drain as frequently, and therefore post-operative fistulae are rather uncommon. Neverthe- less, there still exist quite a number of cases, carried over from the drainage period, some of which have lasted for many years. Another variety of abdominal fistulae are those result- ing from the worst forms of tuberculous peritonitis, or rupture of subphrenic or appendiceal abscesses. In these varieties of sinuses I have tested the efficacy of the bismuth paste treatment, and, while the number of cases is small, certain lessons can be drawn from my observations which may aid in the future treatment of this class of cases. Our experience is limited to thirteen abdominal cases, four of which were the results of tuber- culous peritonitis and nine cases of post-operative sinuses after laparotomies. Sinuses Following Tuberculous Peritonitis. Two of the four cases in which tuberculous peritonitis was the cause of the sinuses were not in the least bene- 110 SINUSES FOLLOWING CERTAIN OPERATIONS. 1 1 1 fited by the bismuth treatment, gradually wasted, and died. Both cases belonged to the most malignant type, and each had a fecal fistula besides the suppurating sinuses. The first case, shown in Fig. 44 (a young man aged 23), took from the beginning a most violent course, simulating acute suppurative ap- pendicitis, but a positive ophthalmo reaction and other symptoms con- vinced us that we had to deal with tul ^rculous peritonitis. Within six months the patient was emaciated to a skeleton, and a sinus Fig. 44. Sinus and fecal fistula in tuberculous peritonitis. formed just below the umbilicus, in the line of incision, and soon thereafter a fecal fistula complicated this condition. A violent eczema aggravated the already unbearable condition, and thus he succumbed to the disease. Six injections had been made into the sinuses without any effect. The second case was that of a young man who was referred to us by his physician after the abdominal sinuses and fecal fistula? had already existed for several weeks. Following the first few bismuth injections he seemed to improve and began to walk, but soon after relapsed and gradually wasted away and died. A post-mortem was obtained. It proved to us the futility of this or any other treatment 112 BISMUTH PASTE IN CHRONIC SUPPURATIONS. in cases which have reached this stage. The disease had invaded the entire abdominal cavity to such an extent as to convert the intestines into a firm mass, in which were locked up hundreds of abscesses. The paste was seen to have reached only one of these abscess sacs. The duodenum showed a perforated ulcer. The cecum was evidently the primary focus of the disease, it having been transformed to a mass of tuberculous tissue. With the experience in these two cases, I do not advise the use of the paste in tuberculous peritonitis when it has reached this malignant and hopeless stage. Whether the paste will be of value in the earlier stages or the less malignant forms of tuberculous perito- nitis is still a problem. There has always been some- thing mysterious about the spontaneous cures of tuber- culous peritonitis; nearly every remedy tried has been successful, and finally it was found that the simple open- ing of the abdominal cavity was all that was necessary to produce a cure. It has, however, been found that many of these mysterious cures were only apparent, and that recurrences took place. (Mayo. 1 ) In St. Mary's Hospital at Rochester, Minnesota, where in a period of ten years (1894-1904) 89 cases of tubercu- lous peritonitis were operated upon by simply removing the fluid, most of them improved. It was noted, how- ever, that a considerable percentage returned for further treatment, and thus it was shown that the improvement had been only temporary. Some were reoperated as many as four or five times without any permanent result. In 1902 Dr. J. B. Murphy called attention to the fact that when tuberculous peritonitis was present the mucosa of the fimbriated end of the Fallopian tube on one or both sides would usually be found everted and the tube con- siderably thickened. This fact was readily verified dur- ing the subsequent operations, and the majority of female iMayo: Surgical Tuberculosis in the Abdominal Cavity. — Journal American Medical Association, April 15, 1905. SINUSES FOLLOWING CERTAIN OPERATIONS. 113 patients with tuberculous peritonitis showed a thicken- ing of the tubes. On removal of these tubes, typical tubercular ulcers of the mucous membrane, with cheesy deposits, were discovered, and in many instances the tubercle bacilli could be stained. In the minority of cases the tubes were normal. This knowledge was at once taken advantage of, and in the subsequent laparotomies for tuberculous peri- tonitis the disease focus was radically removed whenever it could be located. Of 26 tubal resections for tubercu- lous peritonitis performed by Drs. Mayo, 25 recovered. Of these, 7 had been previously operated from one to four times. In not one single patient has a secondary operation been necessary thereafter. This striking example from such a reliable source teaches us the lesson that tuberculous peritonitis is prac- tically always secondary, and that by removing the primary focus the peritoneum will usually take care of itself and a permanent cure will be obtained. In other words, if the source of the constant reinfection could be eradicated, the peritoneum would undergo spontaneous healing. The primary sources of tuberculous peritonitis are the Fallopian tubes, the appendix, the mesenteric glands, and ulcerations of the intestines. Since we know that this peritonitis is practically always secondary to tuber- culous disease of other organs in the abdomen, it would be irrational to treat the peritonitis and ignore its source. Surgical treatment is the proper procedure, and. as shown by Mayo, the removal of the primary focus gives a splendid chance for permanent cure. This remarkable fact has its analogy in other tubercu- lous conditions. For instance, in tuberculosis of the kid- ney there is frequently a coexisting tuberculosis of the 114 BISMUTH PASTE IN CHRONIC SUPPURATIONS. bladder. As soon as the kidney is removed, the bladder will usually heal spontaneously. Again, the removal of a tuberculous tonsil will frequently cure an infected chain of lymph glands. A similar, but not so well-estab- lished, example of this principle is that observed by Brauer, Forlanini, Murphy, and others — that when one tuberculous lung is collapsed (nitrous oxide gas injec- tions into the pleural space), and healing has taken place, a coexisting focus in the other lung, when present, will also be favorably affected. The regularity with which this spontaneous healing occurs precludes the possibility of coincidence, and re- quires an explanation. Is it not possible that, through the removal of a large portion of the diseased tissue, our body, which has acquired such high degree of immunity during the gradual development of the disease, is suddenly relieved of the source of a large quantity of toxins, and the existing high degree of immunity is powerful enough to cope with the balance of microorganisms still operating in other parts of the body? In other ivords, is it not likely that during the development of the disease the degree of immunity keeps pace with the progress of the disease, and that the sudden removal of a part of the diseased tissue leaves the system a sufficient degree of immunity to combat the remaining quan- tity of disease in the body? I have undertaken a series of experiments on lower animals, such as swine and guinea pigs, to prove this theory, but it is too early to permit of the publication of the results. Surgical treatment, therefore, is the most rational in tuberculous peritonitis, and only when the removal of the original focus of the disease has failed to check the progress are other methods, such as injection of various oils and emulsions, to be employed. I desire to warn the practitioner against injecting large SINUSES FOLLOWING CERTAIN OPERATIONS. 115 quantities of the bismuth paste into the peritoneal cavity, because the extensive surface for absorption may lead to bismuth poisoning. It may be permissible to injecl a few drams of a 10-percent bismuth paste in the earlier stages, where the focus of the disease has already been removed. We have tried this in two cases, and, although we have obtained splendid results in both, I do not yet consider this a sufficient test for its advocacy. A brief history of these cases may be of service: Case 1. Tuberculous Peritonitis; Bismuth Treatment; Cure. — Miss L. M., aged 23, developed in 1907 symptoms of chronic appendicitis. An operation revealed a tuberculous peritonitis without adhesions, but the intestines and omentum were studded with tubercles. At the base of this was found a tuberculous appendix, which was removed. Instead of gaining, she continued to lose in weight and strength, and was sent to California, where she remained for six months. Not improving, the physicians there advised her to return, pronouncing her case hopeless. Upon her return to Chicago, in 1909, I proposed to try the injection of a small quantity of paste into the peritoneal cav- ity. The parents consented and the procedure was as follows: through a small incision in the abdominal wall above the left inguinal ring three drams of a 10-percent paste were injected and the incision closed in the usual way. With the purpose of spreading the paste over the surface of the intestines, a gentle massage of the abdomen was made. For three weeks following this procedure she was rather ill, running a temperature of 100° every day, and apparently losing ground, but after that period she began to improve in every way, so that after one year she regained her health and is able to attend general household duties. Locally, there are no symptoms of peritonitis. Case 2. Sinus Following Tuberculous Peritonitis; Bismuth Treat- ment; Cure. — Mrs. K. H. was treated in 1908 for tuberculosis of the glands of the neck. An extensive and radical operation was followed by a tedious process of suppuration, and deep-seated sinuses persisted until they healed with bismuth injections. Thereafter patient spent a year of perfect health in Colorado. Upon her return to Chicago she developed a large abdominal exudate and lost considerably in weight; ophthalmo reaction was positive. Exploratory laparotomy was per- formed by Dr. Carl Beck (my brother). The abdomen was studded with thousands of tubercles, and both Fallopian tubes were thick and tuberculous. He removed both tubes and closed the abdomen; pri- mary union took place. Six weeks later the scar reopened and dis- charged a quantity of cheesy material and pus. The sinuses showed no tendency to closure, and the bismuth injections were then instituted. 116 BISMUTH PASTE IN CHRONIC SUPPURATIONS. In the radiograph (Fig. 45) we can plainly trace the path of the sinus to the original focus in the region of the tubes. After one month's treatment with paste injections the sinus closed, and patient is now in good health. Although the final result in these last two cases is very satisfactory, I advise the most extreme conservatism in Pig. 45. Sinus following tuberculous peritonitis after removal of the adnexa. the use of the paste in this class of cases, and would limit its use to those cases in which a fistula remains after a radical operation, barring the hopeless cases, such as I have cited in the beginning of this chapter. SINUSES FOLLOWING CERTAIN OPERATIONS. 117 Post-Operative Abdominal Fistula of Pyogenic Origin. Nine cases of this variety were treated with bismuth paste. This series does not include post-operative fecal fistulae, which are considered separately in another chap- ter. The sinuses in the above nine cases were of from two months' to three years' duration, all resulting from drainage following abdominal operations. In eight of these nine cases the treatment was effective, requiring from one to thirty injections for their closure; in the re- maining case the bismuth treatment produced no effect. The usual technic was applied in their treatment. I shall cite the case in which the treatment failed, because we can learn more from the failures than from the suc- cessful cases. Case 9. This case, in which the bismuth treatment also failed, was a sinus occurring after a laparotomy performed two years ago. The radiograph shows a large cavity in the pelvis, and a tumor is present, which appears to be a pyosalpinx filling the left side of the pelvis. The abscess cavity evidently originates from a diseased tube, and thus we can not expect a closure of the sinus until the diseased mass is eradicated. The remaining eight cases responded promptly to the treatment, especially those which were of long duration. I am certain that many physicians have had cases similar to those just cited, and their ex- periences will probably tally with those of mine. I do not advise the use of the paste in recently operated cases in which a spontaneous healing may be expected in due time. Only in those cases where the healing is very much protracted, and where there is no tendency to spon- taneous closure, are we justified in using the paste. It must be remembered that the newly-formed ad- hesions of drainage channels are very thin and may tear at even moderate overdistention with the paste, and thus open fresh areas for infection. Moreover, we must bear in mind that fresh surfaces absorb the metallic bismuth much quicker than the hard fibrous walls of chronic 118 BISMUTH PASTE IN CHRONIC SUPPURATIONS. sinuses, and thus the excessive absorption may lead to bismuth intoxication. Again, I warn against the use of the paste when the abdominal wound is in a state of acute inflammation; here it may even aggravate the condition. Sinuses from Tuberculous Kidneys. Not all sinuses in the loin originate from the kidney. They may be the result of spondylitis or sacral tubercu- losis. The latter two have already been discussed in the respective chapters, and their mention here is necessary only to point out that every sinus in the region of the kidney is not necessarily a kidney sinus. The history of the case and the entirely different symptoms in these two affections leave very little chance for diagnostic error; nevertheless, under unfavorable conditions a sinus from tuberculous disease of the kidney may be mistaken for one of spinal origin. I cite such a case on page 122. When these sinuses lead from the bed of the kidney, they may have their origin in either the kidney substance or result from a perinephritic abscess — one which either ruptured spontaneously or had been incised and drained. Another variety is the post-operative sinus resulting from nephrotomy or nephrectomy. The results obtained in this form of sinuses by means of the bismuth paste treatment have been most gratify- ing, because the prospects for a cure seemed scant and the results were surprisingly good. The most recent re- port on the therapeutic effects of bismuth paste on sinuses following nephrectomies is that of Heitz, Boyer, and Morens. They treated 11 most refractory cases in a Paris hospital, with the result of 8 complete and 1 relative cures, the two remaining cases being improved and still under treatment. The cases are reported in detail and illustrated with splendid radiographs, thus adding an in- SINUSES FOLLOWING CERTAIN OPERATIONS. 1 19 structive chapter to renal surgery. 1 My experience is limited to seven cases, six of which were cured and the seventh died subsequent to a surgical operation. For illustration, I will cite four of these cases, including the fatal one: Case 1. Cystic Kidney with Calculi; Operation; Result, Fatal. — Mrs. H. J., aged about 50, mother of two healthy children, developed an abscess in the region of her left kidney when 35. The abscess was incised and suppurated for fifteen years. Besides the profuse, puru- lent, and malodorous discharge, she passed also a great deal of pus in the urine. December, 1907, she applied to me for treatment. At that time I had very little experience with the bismuth paste, but I decided to try it in this case. Following the injection, the discharge lessened, but the radiograph revealed the presence of calculi in the substance of the kidney. The patient was in many ways handicapped, having only one kidney, and was a poor subject for operation; never- theless, nephrectomy was decided on and performed. It was very dif- ficult to separate and remove this large sacculated kidney from its firm bed, which prolonged the operation. The kidney had been en- tirely destroyed and consisted of a large mass of multilocular abscesses studded with dark, irregular-shaped stones. The patient died on the fourth day from uremia. It is my belief that the ether anesthesia was partly responsible for the uremia. Bismuth paste treatment could have been of no value in this case on account of the infected calculi within the diseased tissue. Case 2. Tuberculous Kidney; Nephrectomy; Sinuses One Year; Bismuth Treatment; Closure. — Mrs. H. R., aged 26, was operated upon January 7, 1907, by Dr. Carl Beck for tubercular right kidney. A tuberculous involvement of the bladder and urethra made it impossible to determine before the operation whether the left kidney was func- tionating normally and whether it was free from tuberculosis. For this reason the following procedure was followed: The right kidney was brought forward and fixed outside of the body, split, and all the urine drained outward, whereupon the urine from the other kidney, which was voided through the bladder, was so clear that we could conclude that the nephrectomy could be performed with safety. ' It required a large incision, and the ragged cavity which remained after removal of the diseased kidney was packed with gauze. After long and tedious treatment, such as irrigation, the patient im- proved in general health, but the fistula showed no tendency to heal- ing, and the patient left the hospital May 22, nearly six months after operation, with very little hope that her fistula would ever close. 1 Heitz, Boyer, and Morens: Des Injectiones de PatS Bismuthee en Chirurgie Urinarie. — Annales des Maladies des Organs Genito Urinaries, June 1, 1910. 120 BISMUTH PASTE IN CHRONIC SUPPURATIONS. About three months later, when our experiments with bismuth injec- tions became encouraging, I sent for her, intending to try this method, with the view of closing her fistula. She returned September 3, 1907, and the first bismuth injection was made, of which we have a skia- graph. It shows that the fistula reaches up to the diaphragm, about Fig. 46. Tuberculous sinuses of kidney, nuses. Vertebral column unaffected. A, A (for tracing), openings of si- four and one-half inches in length. From September 3 until November 13 only five injections were made, and a decided improvement followed. The patient did not, however, wish to remain longer at the hospital, and returned once a week for bismuth injections. By February 1, 1908, the sinus was closed and remained so. The closure of the sinus js not quite so remarkable a feature in this case as the most visual SINUSES FOLLOWING CERTAIN OPERATIONS. 121 gain in weight. In her worst state, in September, 1907, she weighed ninety-one pounds, and within two years she has gained sixty-four pounds, and is in perfect health. Case 3. Nephrectomy; Sinus Nine Years; One Injection; Closure in Twenty-four Hours. — Joe L. G., aged 46, developed an abscess in his left lumbar region. Incision and evacuation of one quart of pus relieved the symptoms, but sinuses remained. Two years later a nephrectomy was performed, during which he nearly lost his life from hemorrhage. Fig. 4G A. Diagrammatic illustration of Fig. 46. A suppurating sinus remained, and the drainage was kept up for nine years. The opening of the sinus was on the anterior wall of the abdo- men, about three inches to the left of the umbilicus, but led subcuta- neously to the kidney region. In October, 1908. he came for examina- tion of the existing post-operative ventral hernia. I injected the sup- purating sinus, which had then been open for nine years, and asked the patient to return next day. Within these twenty-four hours the sinus closed and never reopened. Patient gained very much in weight and strength. 122 BISMUTH PASTE IN CHRONIC SUPPURATIONS. The following case is instructive for diagnostic as well as for therapeutic reasons: Case 4. Tuberculosis of Kidney; Sinus Treated Without Nephrec- tomy; Cure. — Miss C, aged 19, was well until 1907, when she fell from a buggy and slightly hurt her back. After two months' illness of fever, pain in the back, emaciation, an abscess formed in the lumbar region. The abscess was opened, whereupon secondary infection took place. For one year she was confined to bed, running a temperature from one Fig. 47. Fig. 48. Figs. 47, 48. Patient with tuberculous kidney. Fig. 47, patient in most emaci- ated state; weight, 68 pounds. Fig. 48, patient one year later; weight, 129 pounds. Kidney not removed. to three degrees every day, and thus was reduced to a mere skeleton, weighing only seventy-six pounds. July 16, 1908, she was brought to me in this pitiable condition. In the eczematous lumbar region were two sinuses, secreting quantities of greenish pus. These two sinuses communicated, as proven by the bismuth injections. On account of the painful condition, I could in- ject only small quantities of the paste. A radiograph proved that this case was a tuberculosis of the kidney, the vertebral column being per- fectly normal. SLNU&LS FOLLOWING CERTAIN OPERATIONS. 12.3 Between July 15 and September 9 the sinuses were injected sixteen times without the slightest effect upon the secretions or upon her gen- eral condition. The fever continued. On September 9 I used a lit- tle more force than usual during the injection, and felt as if something had given way, and I could inject three times the usual quantity. Another radiograph after this injection (Fig. 46) plainly shows that the paste reached into the kidney. From that day the temperature fell to normal, the secretion changed to a serous consistency, and after five subsequent injections the sinuses became entirely closed. The patient could be taken into the fresh air in a rolling-chair and began to gain rapidly. Fig. 47 shows her one week after closure of sinuses, when her weight was only sixty-eight pounds. Within one year her weight rose to one hundred and twenty-nine, which she has retained, and her perfect health can be discerned by her present pho- tograph in Fig. 48. Two cases similar to the one just cited were reported by Dr. A. J. Ochsner at the Chicago Medical Society, both recovering by this method of treatment. These cases show that sinuses which remain after spon- taneous rupture of kidney abscesses or after nephrec- tomy are not as hopeless a condition as formerly consid- ered, and that with the bismuth treatment the outlook for a cure is most promising. CHAPTER IX. RECTAL FISTULA— DIAGNOSIS AND TREAT- MENT WITH BISMUTH PASTE. The bismuth paste serves two purposes in rectal fis- tulae. First, it reveals diagnostic errors, and, second, it heals the majority of cases which have not responded to surgical treatment. I have encountered several cases in which the radiographs of the injected fistulae proved an incorrect diagnosis — they were sinuses resulting either from pelvic abscesses or tuberculous osteomyelitis of the hip or sacrum. These abscesses happened to rupture so near the anus that they were mistaken for a rectal fistula and operated upon, often with the disastrous result of adding an incontinence to the existing trouble, besides transposing the sinus opening from the skin into the rec- tum. Fig. 49 illustrates such a case. The therapeutic results depend in a great measure upon correct diagnosis and proper teclmic. A fistula which has its origin in a tuberculous focus in the sacrum and a sequestrum at its root can not be expected to heal by simply injecting the paste. The focus of the disease must first be eradicated. If the fistula has a counter- opening in the rectum, the paste will flow into the rectum by the shortest route, and miss side branches if such exist. The therapeutic possibilities of the paste in rectal fistulae are illustrated in the following case: Rectal Fistulae, Forty Years' Duration; One Injection; Closure. — J. P., aged 68, developed in 1868 a pararectal abscess. Being a cow- boy, and living in a rural district where a physician was not within 124 ltWJTAL FIST U LA K. 125 reach, he performed his own surgical operation by plunging a jackknife into the abscess with the aid of a mirror. Within one year he bad five sinuses around his anus, which discharged pus uninterruptedly for forty years. Although many times advised to undergo an operation, he refused, preferring daily dressing, to which he so accustomed him- self that he did not mind their inconvenience. In June, 1908, I first injected the fistulas with bismuth paste (for- mula 1), and found that the five sinuses communicated. To my sur- prise, the discharge ceased after this first injection, and one month later all sinuses were closed and have remained so (two years). 1 J5 H \ " 1 A ^j Pig. 49. Rectal fistula originating in coccyx, supposed to be of rectal origin. A, side branch ; B, highest point, near coccyx. The literature contains many scattered reports of cases of rectal fistula treated with bismuth paste, and the average results have been satisfactory. Failures in treat- ment could in nearly all cases referred to me be ac- counted for in two ways— first, faulty technic, and, second, incorrect anatomical diagnosis. The only special report on rectal cases is that of Pen- 126 BISMUTH PASTE IN CHRONIC SUPPURATIONS. nington, who tested the method shortly after he saw my cases, brought before the Chicago Medical Society in January, 1908. His report relates to 17 cases which he treated with bismuth paste, most of which had been pre- viously treated by other methods. After a period of four months he obtained a cure in 14 of the 17 cases (76.8 per- cent). Dr. Pennington modestly attributes this high average to his good fortune in having favorable cases. My explanation would be that his large percentage of cures was due to following out the technic. In my own series of 57 rectal cases 4 were given up as hopeless; 5 discontinued treatment, although improved; 48 were cured, 3 of which had recurrence and healed with resumed treatment. One patient died, three years after closure of the fistula, of a hemorrhage of his lung. There could be no relation established between the cause of his death and the former rectal trouble, except that the fistula had been of tuberculous nature. Technic in Rectal Fistulse. The patient should be placed in the knee-chest posi- tion, and the sinus opening cleansed with 95-percent alcohol. The metal syringe shown in Fig. 1, filled with the paste, is then immersed in hot water, so as to keep the paste liquid. The tip of the nozzle is placed against the opening, and with steady, gentle pressure the paste is injected into the sinuses until the patient feels some distention. No force should be used. In order to as- certain whether the external sinus communicates with the rectum, the finger should be introduced, and, if it shows traces of the paste, we may conclude that we are dealing with a complete fistula. Should this be the case, the treatment will be somewhat difficult. It is then nec- essary to occlude the internal opening of the fistula with KKCTAL FISTULAE. 127 the finger while the paste is being injected into the exter nal opening. Thus the escape of the paste into the rec- tum is prevented and it is forced into the other direction, where it will fill other existing channels. At times it becomes necessary to employ a rectoscope in order to in- ject the fistula through the opening within the rectum. Fig. 50. Method of injection of external rectal fistula. For this purpose the long nozzle of the metal syringe is used. It must be kept warm, so that the paste will not solidify and clog the narrow channel. "When the fistula has a very small opening and is in the puckering folds of the anus, the spear-shaped tip is to be inserted, while an assistant stretches the folds. Fig. 50 illustrates this pro- cedure. 128 BISMUTH PASTE IN CHRONIC SUPPURATIONS. After the injection is completed, a T-bandage is ap- plied and the dressing changed daily. If after one week the discharge continues to be purulent, the fistula should be reinjected. If the secretion becomes serous, it should not be reinjected, as it will usually close within a short period. Fig. 50 illustrates the procedure. Fig. 51. Dermoid cyst treated with bismuth paste. An infected dermoid cyst of the sacrum or coccyx may be mistaken for a rectal fistula. I illustrate such a case in Fig. 51. In this picture there is shown the procedure of injecting a sinus resulting from a dermoid cyst. The patient is only 23 years old and weighs two hundred and sixty pounds. For the past five years he has had a foul discharge from four little openings, one-half inch apart, in the fold above the anus. The first injection proved that they com- municated, because the paste injected in one at once escaped from KKCTAI, I' 1ST I ' I, A i;. 129 the mouths of the others. At one time a small quantity of jot-black hairs came out of one of the openings. This indicated that we had to deal with a dermoid cyst, and consequently an operation was ad- vised and performed, which consisted in the complete eradication of the cyst. The cavity was drained and four days later an injection of the paste was made. The purulent and foul discharge changed into a yellowish, clear serum within three days, and healing progressed rapidly. This picture shows that a greater part of the incision is healed, and that the paste injected through the upper opening escapes through the lower. Within a period of six weeks the sinuses were closed. Pig. 52. Supposed rectal fistula, shown to be a sinus resulting from disease of pelvic organs. A, fistulous opening in the rectum ; B, bi-paste in the pelvic cavity. The following case is typical of those in which incor- rect diagnosis led to futile operations: Rectal Fistula Originating in the Pelvis. — The patient, a lady, aged 30, has since 1900 undergone six operations for rectal fistula, all of which failed to stop the profuse and irritating pus discharge. The last operation was very extensive and produced incontinence of feces. In this condition the patient came to me in January. 1908. when I made the first bismuth paste injection. A radiograph (Fig. 52) disclosed that the fistula had its origin high up in the pelvis. Several sinuses as high as the sacral prominence are plainly shown, the early discovery of which could have saved the patient the six operations and nine years 130 BISMUTH TASTE IN CHRONIC SUPPURATIONS. of invalidism. This fact was corroborated further by the most satis- factory result, obtained from the bismuth paste injection. It required three months' treatment, but the sinuses healed. The sinus openings were intrarectal, and the large gaping rectal opening permitted their being easily reached and injected. A year after the cessation of dis- charge a plastic operation for the incontinence was tried, but was only partially successful. An abdominal operation six months later proved that the sinuses originated in the Fallopian tubes. Examples as the one cited above must guard us against assuming that every suppurating sinus near the rectum is necessarily a rectal fistula. In my collection of radiographs of bismuth-injected rectal fistulae there are a number of examples in which the supposed rectal fistula was in fact a sinus originating in some distant part of the body, such as the hip joint or spine. In not a single one of them have I seen a straight fistula, similar to the schematic drawings of our text books. In the radiograph shown in Fig. 53 I illustrate a sinus in which the passing of a probe indicated that we had to deal with one single, straight fistula, and, behold, a turtle-shaped sinus, so different from what we ex- pected, reveals itself. This demonstrates the fallacy of relying upon the probe as an anatomical diagnostic guide. We can not rely upon its accuracy in showing us the direction, depth, and extent of a fistula. The mere fact that the probe will pass readily into a fistula is no proof that it has reached its depth, or that the sinus has no branches; and, on the other hand, if the probe is arrested in some fold or curve, it likewise fails as a diagnostic aid. In many instances its use is very deceptive, and has led to errors which have caused many a useless operation. The diag- nostic method by means of the bismuth paste has, in my hands, entirely displaced the use of the probe for sound- ing fistulae. We must bear in mind the fact that a fistula is noth- RECTAL FISTULAE. 13] ing more than a shriveled old abscess cavity, and not, as is often supposed, a channel formed by an ulcerative process from the surface, burrowing into the depth of the tissues. At times the abscess is multil ocular and will Fig. 53. Turtle-shaped sinus in perineal region, thought to be a straight rectal fistula. undermine a large area in the perineum, and thus an irregular network of fistulous tracts may surround the rectum and form a number of sinus openings around the anus. • The stereoscopic radiographs, of which I have shown a number among my illustrations in Professor Kelly's Stereo-clinic, have shed a great deal of light upon the anatomical relations of the sinus tracts to the surround- ing structure, and have cleared up for me many fallacies in both diagnosis and treatment of rectal fistulae. CHAPTER X. BISMUTH PASTE IN FECAL FISTULA. Fecal fistulse, such as result from laparotomies, have the tendency to spontaneous closure. At times, however, their persistence causes the patient such misery that he is willing to submit to the most hazardous operations. It is, therefore, comforting to know that this class of fistulse can also be successfully treated with bismuth paste. Be- sides several successful cases reported in medical litera- ture by others, we have treated eight cases at the North Chicago Hospital, five of which were cured, one failed be- cause of a coexisting intra-abdominal tumor, and two died as a result of tuberculous peritonitis, which was the cause of the fecal fistula. The result obtained in the first case in which the paste was tried was so striking that I felt encouraged in its further application in similar cases. The history of this first case is as follows: Fecal Fistulae; Bismuth Injection; Closure. — M. A., aged 25; family history nontubercular. In the fall of 1905 he was operated upon for gangrenous appendicitis. Fecal fistula resulted and persisted for four months. A second operation failed to close the fistula. He was then treated for six months with silver nitrate cauterization, without im- provement. In August, 1906, we took a radiograph after an injection of bismuth paste. It demonstrated the uselessness of our silver nitrate treatment because of the existence of a cavity, which undermined the muscles to an area two inches in diameter. The first injection was sufficient to obliterate this fistula. Two years later finds the fistula still closed. A second case with almost the identical history, in which the fecal fistula had persisted for one year, reacted also most favorably to the bismuth treatment. 132 FECAL FISTULAE. 133 The following case gives an idea of the possibilities of the bismuth paste in fecal fistula?. Fecal Fistula; Discharging Entire Bowel Contents. — Mrs. J., aged 29, was operated on July 17, 1909, for double pyosalpinx. The diseased tubes were so adherent to the intestines that during their removal the large bowel was torn. The sutures did not heal, the bowel reopened, and for three months the entire fecal contents discharged through the abdominal wound, no fecal matter or gas passing through the rectum. There being no natural tendency to closure, it was decided to resect a portion of the bowel, to which the patient, who was tired of her mis- erable existence, gladly consented. Before, however, resorting to this dangerous operation I decided to try a few injections of bismuth paste, and, although I did not expect very much from its use, the change was most surprising. The large opening gradually contracted to a narrow channel, the patient began to have a small evacuation from the rectum, and within ten weeks the fistula was entirely closed. Ten days later a pin-hole opening appeared and small amount of gas escaped. At pres- ent sinus is closed. Patient gained forty pounds. This remarkable result in one case should not, how- ever, create the impression that every fecal fistula can be cured by this method. The anatomical conditions in themselves make the prospects of a cure uncertain. I believe that the percentage of cases suitable for the bis- muth treatment will be smaller than those of rectal fis- tula?. Dr. Cuthbertson, of Chicago, in reporting a case of post-operative fecal fistula cured with the paste, made a practical suggestion. He states: "It is absolutely neces- sary for the patient to remain in bed during the period of treatment. If he is allowed to walk about, the paste is immediately expelled either by the contraction of the ab- dominal muscles or the pressure of the bowel contents." Our experience in treating these fecal fistula? may be summed up as follows: 1. Where the fistula is the result of tuberculous peri- tonitis or intestinal tuberculosis, the bismuth treatment will be useless. 2. The post-operative fecal fistula? are best suited for 134 BISMUTH PASTE IN CHRONIC SUPPURATIONS. this treatment, but a reasonable length of time should be allowed for spontaneous closure, and in no instance should the paste be poured into the fresh wound in the abdomen. 3. The cases in which the channel leading to the intes- tine is long and narrow respond most favorably to this treatment, as the paste blocks up the fistula, keeps the fecal masses from soiling it, and thus a most favorable condition for healing is produced. The fecal contents will then be propelled through the intestinal tract. 4. When the channel between the bowel and the skin surface is short, or when the intestines protrude, the paste is absolutely useless, a surgical operation then be- ing the only means of producing a cure. CHAPTER XI. BISMUTH PASTE TREATMENT OF EMPYEMA AND LUNG ABSCESS. Without dwelling upon the usual methods of treatment of empyema and lung abscess, I desire to describe this new method which is applicable especially to those cases in which other surgical treatment has failed. The bismuth paste may be applied in chest cases for diagnostic and therapeutic purposes. As a diagnostic aid it has served most satisfactorily in outlining the con- tour and estimating the size of suppurative cavities with- in the pleural space. The radiographs showing the boundaries of these injected cavities aid in differentiat- ing between an empyema of pleural origin and one re- sulting from a rupture of a lung abscess into the pleura. As a therapeutic agent the paste has, in a certain class of cases, proven to be the remedy par excellence. Its chief value lies in producing rapid closure of old sinuses of empyema, some of which had persisted in discharging pus for many years in spite of the most radical surgical treatment, such as the Estlander or Schede operation. Ample time has now elapsed and a sufficient number of reports from reliable sources in Europe and America have appeared in medical literature to justify the con- clusions as to the real value of this new treatment. In December, 1907, I first instituted this form of treat- ment in empyema, an abstract of a report of the first case being here cited : Case 1. Empyema. — A. H., aged 19; family and personal history free from tuberculosis. January, 1907, attack of pleurisy with effusion. 135 136 BISMUTH PASTE IN CHRONIC SUPPURATIONS. soon changing into empyema. March 20, 1907, resection of two ribs, evacuation of pus, and drainage. A daily discharge of two or three ounces of fetid, green pus persisted in spite of all treatment. Decem- ber 20, 1907, the patient was brought to me for treatment. Bismuth Treatment. — Drainage tube was removed and 120 grams of bismuth-vaselin paste were injected into the suppurating cavity in the patient's chest. Two days later the injection was repeated, most of the previously injected paste having escaped with the discharging pus. After four days the discharge became serous, lost its foul odor, and greatly diminished in quantity. Injections were repeated daily, and on the twelfth day the sinus closed and has remained so. The patient has gained thirty pounds in weight and is in perfect health. Skiagraphs had been taken at intervals of two months, which demonstrated the gradual absorption of the bismuth paste and the slow expansion of the lung where the abscess had existed. This surprising result obtained by such simple means naturally encouraged its further application, and six months later I was able to include in my report to the Sixth International Congress on Tuberculosis nineteen cases of empyema and lung abscesses which had been treated by this method. Fourteen of these cases were then apparently cured, four improved and still under treatment, and one not improved — treatment discon- tinued. The sources of this report were perfectly reliable, such competent surgeons as Mayo, Ochsner, McGuire, and others having contributed, in addition to the cases treated by myself. Since the publication of these cases reports from many surgeons throughout this country and from abroad have convinced me that the application of the bismuth paste in the treatment of empyema surpasses even the good re- sults obtained in treating other suppurative conditions by the bismuth paste method. Nemanoff, for instance, reports from the clinic of Pro- fessor Kacljan, St. Petersburg, four cases of empyema in which one injection of bismuth paste in each case was sufficient to produce complete closure, whereas the same EMPYEMA AND LUNG ABSCESS. 137 patients had been treated at the clinic for six months by other methods without success. Vidakovich reports two cases of empyema, both with perfect result. Dr. A. J. Ochsner, Chicago, reported to the American Surgical Association on June 4, 1909, fourteen cases of empyema, all of which had been previously operated (two by Estlander's operation), with sinuses in all cases persisting nevertheless. He applied the bismuth paste in each of these cases with the result that twelve cases healed completely, and two were still under treatment and very much improved. My experience pertains to nineteen cases of empyema and eight cases of lung abscesses treated by the bismuth paste method. At first I employed the paste in cases of drained em- pyema only, but later its usefulness was extended to cases of empyema still unopened and to abscesses within the lung tissue proper. Of these cases I shall cite a few, such as will illustrate some special points in the technic not mentioned in the general rules and aid in the selec- tion of cases to which this form of treatment may be ap- plied advantageously. Technic in Chest Cases. The technic of bismuth injections employed in abscess cavities in the chest differs somewhat from that applied in the sinuses. In the chest we have to deal with an in- fected cavity which has a rigid chest wall on one side, and the retracted, but more or less resilient, lung on the other. A radiograph of the chest is first taken. The discharge should be examined microscopically, cultures made, and where tuberculosis is suspected a guinea pig should be inoculated. The cavity should then be filled by means 138 BISMUTH PASTE IN CHRONIC SUPPURATIONS. of a glass syringe with a 33-percent bismuth paste, but no drainage tube inserted, and then another radiograph taken, which will show the outline of the cavity. It is not advisable to leave more than 100 grams of a 33-percent paste in the cavity longer than three days. When more than 100 grams are required to fill the cavity, and none of the injected paste has escaped during the fol- lowing twenty-four hours, it is advisable to remove, either by suction or by flushing with olive oil, such quantity as will leave approximately 100 grams in the pleural cavity. In case the entire injected quantity has escaped into the dressings, a second injection should be made with a 10- percent bismuth paste in order to keep the hollow pleural space filled with a semi-solid sterile substance. Gauze dressing is changed daily until the sinus closes. Should the temperature rise above 101° F., or the patient complain of severe pressure, the accumulated fluid should be drained off. If the temperature remains normal, and the amount of paste injected is not more than 100 grains, it may be left in for absorption, provided no signs of bismuth intoxication arise. Repetition of the in- jection is necessary only when the microorganisms are still present in the secretions, and therefore a systematic examination of same is necessary. Negative Pressure for Re-expansion of the Lung". At the suggestion of Dr. Carl Beck I have recently em- ployed a means for reexpansion of contracted lung. The technic is here illustrated: M., aged 31, developed in 1900 acute pleurisy, terminating in em- pyema. After several tappings of fluid, drainage with a rubber tube was established. The empyema proved to be of tubercular origin, the bacilli having constantly been found in the pleural discharge. For the past nine years the cavity had been flushed daily with antiseptic solutions and drainage maintained. EMPYEMA AND LUNG ABSCESS. i:{9 On January 10, 1910, the first bismuth paste injection was made, but the cavity was not entirely filled, only 240 grams being injected. The secretion, which up to this time had been purulent, soon became serous and sterile, but there was no indication of reexpansion of lung. The following method was applied and found satisfac- tory (Fig. 54) : Fig, 54. Method of re-expansion of lung by suction pump. The rubber tube (A), which is fastened to a rubber nipple (B), is inserted into the sinus and this is covered by a Bier's cup. To the outlet of the Bier's cup is at- tached the connecting tube (C) of a large suction syringe which has a release valve. Moderate suction is produced 140 BISMUTH PASTE IN CHRONIC SUPPURATIONS. and released in the rhythm of the patient's breathing. During inspiration we produce suction; during expira- tion we release the valve and allow the lung to collapse. This treatment is carried on systematically every day for five or ten minutes. This is suitable in cases where the discharge is not pro- fuse or bloody. In some cases the granulating surface is very apt to bleed when strong suction is applied, which fact should always be borne in mind. In the case here illustrated we have watched the grad- ual expansion of the lung. When beginning the treat- ment the cavity would hold over 240 grams of the paste, while it now overflows when injecting but 45 grams. The physical signs and radiographs give evidence of the lung expansion. Large Cavity Remaining After Estlander Operation. In Fig. 55 we show the cavity left in the pleura after a secondary Estlander operation on a young man 26 years old. After two years of constant suppuration the bis- muth paste treatment was instituted. The secretion be- came sterile, but the lung remained retracted. I em- ployed the suction pump treatment described in this chapter, and within six weeks the cavity was reduced to half its size, holding only nine ounces at present. The following cases are cited to illustrate the bismuth paste treatment of chest cases: Case 4. Simple Empyema. — Chas. L., aged 18, had the grip in March, 1908; two weeks later pleurisy, with effusion; temperature, 105°. Four weeks later aspiration, resection of a rib, and evacuation of 2,000 cubic centimeters of pus, and drainage. For the next three months discharge profuse. July 20, 1908, 30 grams of bismuth paste were injected, and within twenty-four hours the discharge ceased and the sinus closed five days later. Patient gradually regained his health and sinus has not reopened. Case 6. Empyema of Spontaneous Rupture, Leaving Three Sinuses. EMPYEMA AND LUNG ABSCESS. 141 — Mary H., aged 8, at the age of 6 developed an empyema, which, after several months of expectant medical treatment, ruptured spontane- ously in two places on the anterior chest wall, leaving three sinui i discharging thick pus. Child was very much emaciated when brought to me in May, 1908. Fever rose to 101° or 102° daily. Patient, coughed Fig. 55. Cavity in pleura remaining after Estlander operation, bismuth paste. Injected with and had shortness in respiration (20 to 42). There was dullness over the entire left chest, radiograph distinctly showing the left side filled with fluid. Instead of the usual resection of ribs and drainage. I in- jected 60 grams of bismuth paste through one of the sinuses. Temper- ature and cough persisted in a milder form for three weeks; there- after all symptoms disappeared and all sinuses closed. Two years have 142 BISMUTH PASTE IN CHRONIC SUPPURATIONS. elapsed, .fluid has disappeared, child has gained thirty pounds, and is in perfect health. Bacteriologic examination of pus, carried out systematically, proved that the pus discharge became sterile twenty days after first injection. Case 7. Empyema; Two Years' Drainage; Permanent Closure After First Paste Injection. — Miriam D., a delicate child, aged 5%, at the age of 3 developed an acute lobar pneumonia. Empyema followed, and after aspiration of the pus two ribs were resected. Discharge of pus continued for one and one-half years, child gradually failing in health. As a last resort an Estlander operation was advised by the physician in charge, to which the parents did not consent. In October, 1908, the child was brought to me for treatment. Temperature from 99° to 101°. Extreme emaciation, cough with pain, as well as retrac- tion of the chest wall, were the principal symptoms. The small open- ing in the chest secreted daily about 30 grams of creamy pus. Through this sinus I injected 30 grams of bismuth paste. A radio- graph showed that the cavity contained a large quantity of pus, and that the paste merely floated therein. Although no further injections were made, I observed a gradual decrease in the fever and cough, cessation of the discharge, and closure of the sinus on the tenth day. The child gained four pounds in two weeks and now has regained per- fect health. This patient was presented by Dr. Hartford at the session of the American Medical Association, Atlantic City, June, 1909. The lesson learned from cases 6 and 7 is the following: 1. That it is not absolutely necessary to evacuate or drain off the pus from the pleural cavity before injecting the bismuth paste, and that small quantities (30 to 60 grams) are sufficient to produce the desired results. 2. Although the purulent exudate was not absorbed for several weeks after the bismuth injections, its pres- ence caused no elevation of temperature, and sinuses closed in a comparatively short time. 3. While the discharge retained its purulent character after the bismuth injections, it was nevertheless found to be sterile. Case 9. Empyema; Twenty-eight Years' Drainage; Closure with Bis- muth Paste. — G. T., aged 39; engineer; family history negative. In 1881 he suffered from an attack of pneumonia, followed by an accu- mulation of pus in the left pleura. Drainage was established by inter- costal incision (Dr. Favill, Sr., Madison, Wis.), and rubber tubing in- serted. The purulent discharge had persisted since 1881, with only a EMPYEMA AND LUNG AIJKGKSS. 14.5 few days' intermission, a drainage tube being kept in the discharging sinus for twenty-eight years. Various methods, except radical opera- tions, were tried in attempts to close the sinus, but all failed. In January, 1909, the patient was referred to me by Dr. H. B. Favill for treatment. His general health was very good, temperature and pulse Pig. 56. Empyema of twenty-eight years' duration, paste. Closure in sixty days. Injected with bismuth normal, right lung normal, left lung and chest cavity very much con- tracted; pus discharge thick and of dark-green color, containing staphylococci and a few streptococci. Bismuth Treatment. — Injection of bismuth paste (formula No. 1), 60 grams filling out the entire contracted pus cavity. Temperature re- 144 BISMUTH PASTE IN CHRONIC SUPPURATIONS. mained normal, and discharge became serous on fifth day. After sixty days the sinus closed, and patient returned to Arizona to resume his work. There is no recurrence. This case is very instructive, as it teaches that even after twenty-eight years' constant suppuration an em- pyema may be obliterated by injection of the paste. The radiograph (Fig. 56) shows the size and contour of the remaining pouch, and likewise illustrates the efforts of nature in her attempt to obliterate the pus cavity. The ribs are so much retracted that the intercostal spaces are nearly obliterated, the spinal column is markedly curved, with its convexity to the well side, the clavicle drawn downward and diaphragm drawn upward; all structure contracting toward one central point — the old suppurating cavity. Case 12. Empyema of Infant Injected with Bismuth Paste. — M., aged 2, had a severe attack of pneumonia April 16, 1909; temperature, 105°; pulse, 136; respiration, 48; after ten days developed into an em- pyema. Resection of rib by Dr. Carl Beck; drainage. Temperature still rising to 100° to 102° daily; respiration, 38 to 48. Bismuth Treatment. — On the eighth day after the operation an in- jection of 120 cubic centimeters of a 5-percent bismuth-vaselin paste was made, and two days later the same quantity was again injected. Temperature fell to 99.4° (rectal), respiration to 30. The pus became sterile after the first bismuth injection, but staphylococci reappeared a week later, and for this reason the opening was not allowed to close. The injections were continued for three weeks until the secretion be- came sterile. Sinus closed, and child is perfectly well. Tuberculous Empyema. It is noteworthy that the tuberculous empyema is far more resistent to any form of treatment than that of pneumococcus or other origin. Murphy states that a very large percentage of empyemas in adults is of the tuberculous form, and that these rarely undergo absorp- tion or break into a bronchus. From personal communication with Dr. Moore, medical EMPYEMA AND LOTG ABSCESS. 145 superintendent of the Dunning Hospital for Consump tives, an institution which takes care of an average of four hundred consumptives in the most advanced stages, I have the information that in the past four years he observed, in 5,000 cases treated, 25 cases of tuberculous empyema, and, whether operated on or not, all of the patients succumbed to the disease. These cases usually start with serofibrinous pleurisy, which, either from frequent tapping or spontaneously, become secondarily infected and result in empyema. Op- eration is usually resorted to, and as a rule the subse- quent treatment is very tedious and unsatisfactory. In my series of cases of empyema three proved to be of tuberculous origin, and, while I do not consider them per- fectly cured, they have regained their health sufficiently to permit of the resumption of their usual occupations. Empyemas in children, or those following acute pleu- ritis in adults, give a much brighter outlook for recovery. In children the expansion of the lung and spontaneous closure of the sinus is rapid, and the majority of cases of the nontuberculous type in adults will yield to the simple drainage. A small percentage of cases, however, resist all medical and surgical treatment, and sinuses will per- sist in discharging pus indefinitely. The failures may be explained as follows: 1. As long as the walls lining the abscess cavity are the seat of living microorganisms, especially tubercle bacilli. an obliteration of the space can not be expected. 2. After years of suppuration the pleura has become hard and leathery, binding down the cicatrized lung, and thus the expansion of the lung is not possible. The requirements, therefore, are: a cavity free from microorganisms and the lung still sufficiently resilient for expansion. 146 BISMUTH PASTE IN CHRONIC SUPPURATIONS. The method described and employed in my cases pos- sesses, I believe, to a marked degree the means essential to obliteration of empyema. The introduction of bismuth paste has as a rule produced, by a process of local leuco- cytosis, a sterilization of the cavity, and in most cases softened the indurated pleura sufficiently to allow mod- erate expansion of the lung and the obliteration of the space. Lung Abscess. It is needless to say that, in order to cure lung abscess, an operation is necessary. I suggest two valuable aids in the procedure — namely, the stereoradiograph for diagnosis, and the bismuth paste for the after-treatment. The stereoradiograph is a most valuable guide in the diagnosis. It will define, in plastic form, the boundaries of the abscess, thus enabling the surgeon to reach it by the shortest route. It will also locate foreign bodies, which, at times, are the cause of the abscess. The bismuth paste is a valuable adjunct in the after- treatment. Instead of draining the abscess for weeks or months, or flushing it with various antiseptic solu- tions, it is filled with the paste the second day after the operation. This promotes the sterilization of the cavity, the odor soon disappears, and the cavity tends toward contraction and final obliteration. It is noteworthy that such cases heal in a very short time, even when the cavity communicates with a bronchus. The following case illustrates this new method of treatment : Case 5. M. M., aged 42. One year ago, after a short illness of cough and fever, he suddenly felt a large quan- tity of fluid rising in his throat, which almost strangled him. It was the rupture of a lung abscess. From that EMPYEMA AND LUNG ABSCESS. 147 time on he continually expectorated from ten to twelve ounces of very offensive pus every morning. Diagnosis. — May 13, 1910. A stereoradiograph dem- onstrated the lung abscess to be located in the right lower lobe, corresponding to the posterior aspect of the eighth, ninth, and tenth ribs. The stereoscopic view showed plainly that the abscess was not superficial, and that at least a two-inch thickness of lung tissue existed between the pleura and the abscess wall. Physical examination by Professor Babcock corroborated the findings of the radiograph. New Method of Treatment. — The following surgical, two-step operation, which I had previously carried out in two similar cases, was employed. Under general anes- thesia, through a trap-door incision, three inches of each of the tenth and eleventh ribs in line with the abscess were resected. The costal pleura was cleared of all ad- herent tissue, so that a circular area three inches in diam- eter was exposed. Without incising the pleura, the ex- posed surface was swabbed with a small quantity of 95- percent carbolic acid. Into this cauterized area a flat coil of No. 14 red rubber tubing was placed, and the skin wound closed with temporary sutures. The object of the carbolic cauterization of the costal pleura was to produce its rapid adhesion to the opposite surface of the lung. By this procedure two important aims are attained: 1. The adhesion protects the pleural cavity from in- fection. 2. The inflammatory adhesion has the tendency to draw the lung abscess toward the surface, thus facili- tating approach to the abscess. The rubber coil was placed in for the purpose of preventing adhesions of the muscles of the flap to the cauterized pleura, and thus pre- serve a clean field for the second operation. 148 BISMUTH PASTE IN CHRONIC SUPPURATIONS. After this procedure a second radiograph was taken to show the location of the rubber coil in its relation to the lung abscess. It was shown to be one inch lower Fig. 57. Rubber coil showing against exposed pleura, demonstrating relation to lung abscess. than the abscess, and therefore served as a valuable guide in the second operation. (Fig. 57.) Four days after the first operation the patient was again anesthe- tized, the wound reopened, the rubber coil lifted from its EMPYEMA AND LUNCJ ABSCESS. 149 bed, and the clean costal pleura exposed. An incision one inch in length was made in the upper angle of the ex- posed pleura, and then, with the index finger, the lung tissue was penetrated and the abscess wall i in mediately felt. A blunt forceps was then pushed into the abscess wall and widely spread. The cavity was explored with the index finger and found to consist of several compart- Fig. 58. Lung abscess cavity, viewed with stereoscope, will show four bronchial openings. ments, which were separated by friable walls. These walls were broken up and two calcareous concretions re- moved. There was no hemorrhage. The procedure lasted only ten minutes. The cavity was packed with gauze for twenty-four hours, and then injected with 33- percent bismuth-vaselin paste, of which the patient coughed up a considerable quantity during the next few hours. Without reinjection, the pus secretion from the 150 BISMUTH PASTE IN CHRONIC SUPPURATIONS. abscess cavity disappeared within ten days, and only mucus could be forced out by intentional coughing. The depth of the abscess cavity could now be inspected by ordinary daylight, four bronchial openings being plainly Fig. 59. Multilocular lung abscess injected with bismuth paste. visible. (Fig. 58.) To insure the closure of the bron- chial openings, their mucous lining was destroyed with electric cautery. This procedure was painless, although the resulting smoke passing up through the bronchi and nostrils was irritating and disagreeable. EMPYEMA AND LUNG ABSCESS. 151 The cavity is now rapidly shrinking, and the indica- tions for permanent closure are evident. In two cases previously treated in this manner the cavities closed in from two to four weeks after the operation. Fig. 59 illustrates the multilocular condition of lung abscess in one of these cases treated in this same man- Fig. 59 A. Diagrammatic illustration of Fig. 59. ner. While this procedure is comparatively new, and to my knowledge has not as yet been tried by others, I have employed it successfully in three cases, and have in each instance located the abscess without any difficulty and without causing a hemorrhage, and therefore anticipate that the method will be tested by other surgeons. The task of definitely locating a lung abscess has al- 152 BISMUTH PASTE IN CHRONIC SUPPURATIONS. ways been considered rather difficult, and many an opera- tion lias had to be abandoned because of profuse hemor- rhage in searching for the abscess. With the aid of the stereoradiograph and the subsequent surgical procedure Fig. 60. Bronchial tree injected with bismuth paste for anatomical study. which I advocate, the locating of the abscess is compara- tively easy and almost certain, and the danger of the operation is reduced to a minimum. In the diagnosis of lung abscesses knowledge of the EMPYEMA AND LUNG ABSCESS. 153 anatomy of the bronchial tree is essential. To assist in the study of this subject I have produced a radiograph of a bronchial tree (Fig. 60) which I believe will aid in the locating of abscesses. This picture was produced by injecting into the trachea of a fresh cadaver a quantity of bismuth paste which penetrated the minutest ramifications of the bronchi, in some places even filling the alveoli and thus producing the cauliflower-like shadows. The division of the trachea takes place opposite the sixth dorsal vertebra. It is generally assumed that the right bronchus is a continuation of the trachea. Prac- tically this is the case, but our radiograph shows that the right bronchus deviates 17 degrees and the left 40 de- grees from the axis of the trachea. The number of sub- divisions in the bronchi vary from six to ten, those in the lower lobe having more subdivisions. The bronchioles appear somewhat beaded, due probably to overdistention by the paste. This picture also furnishes the true rela- tions of the bronchi to other structures within the chest, as they actually exist in life, before the chest cavity is opened and the lung collapsed. I trust that the employment of the stereoscopic radio- graph and the anatomical illustration of the bronchial tree will add much to our diagnostic ability, and that the introduction of the simple and effective surgical opera- tion here described will aid in simplifying the surgery of lung abscess. CHAPTER XII. BISMUTH PASTE IN THE CONSERVATIVE TREATMENT OF COLD ABSCESSES. Surgeons the world over are almost unanimous in their opinion that cold abscesses should neither be opened nor drained, but they have not yet agreed upon a method which would prevent the complications and dangers which usually follow the spontaneous rupture or incision of these abscesses. As long as a cold abscess is closed, it is comparatively harmless, but when opened it immedi- ately becomes a source of danger. Secondary infection is then the rule, and sepsis and death the frequent conse- quences. Calot says: "To open a spondylitic abscess or allow it to open spontaneously means to open the gate through which death nearly always enters. A physi- cian's viewpoint in the treatment of cold abscesses is, for the life of the patient, of the utmost importance." In 1858 Bouvier said: "It is common to see both adults and children in whom large abscesses cause little in- convenience, but, when these abscesses are opened, acute pain and extensive inflammation gradually exhaust and may even kill the patient." The last century has witnessed many changes in the treatment of cold abscesses, the methods in each period depending upon the prevailing opinions which were held at the time as to their pathology. Before Pasteur's great discovery, when surgeons had no conception of asepsis, the treatment was, of course, irrational. Dupuytren, Larrey, and others treated cold abscesses with wide incisions, but many surgeons were 154 COLD ABSCESSES. 155 decidedly opposed to such procedures. The mortality at that time, according to Follin's figures, ranged from 56 to 70 percent in hip diseases and spinal caries. In the light of our present knowledge of the disease this high mortal- ity was due to imperfect immobilization, bad hygiene, and the lack of knowledge regarding the necessity of steril- ization of instruments and care in dressings. With the introduction of asepsis and the modern teach- ings on tuberculosis of bones and joints by such men as Konig and Lannelongue, the treatment was radically changed. It was shown by Lannelongue that the cold abscess was the result of a primary tuberculous infection, and consequently he advocated the early radical removal of the primary focus. This certainly was rational treat- ment. The death rate, however, from shock in the ex- tensive resections of hips and vertebrae was enormous, and the final results in the cases which survived were deplorable because of the resulting deformities. For this reason this method soon lost its popularity, and a reaction to less radical methods took place. There- after the treatment was limited to the abscess, and the bony lesions from which it sprang were ignored. Cu- retment of the abscess lining or the excision of the ab- scess wall, under the most rigid aseptic precautions, were practiced apparently with favorable results. Wounds healed by primary union, and patients gained rapidly in health soon after the operations. The test of time, how- ever, shattered the hopes of the advocates of this method, it having been observed that the cures in most cases were not permanent. The reason for recurrences with this semiradical method is apparent when the following facts are considered: While it is true that the tuberculous debris within an abscess is usuallv sterile, we know that the wall itself is 156 BISMUTH PASTE IN CHRONIC SUPPURATIONS. the seat of living bacteria. At the same time the abscess wall furnishes the fortification against the spreading of the bacteria into neighboring tissues. Its connective tissue wall forms a barrier against further invasion. Would it, then, be rational to excise or scoop out these natural barriers, and thereby expose large surfaces to the implantation of the living bacteria, which were com- paratively harmless when imbedded in the connective tissue of the abscess wall? Moreover, by removing the lining or the entire abscess wall we still leave the primary lesion intact, which still retains its activity. Of what ad- vantage, then, is the excision of the abscess wall? Unless the primary focus is already extinguished, or the virulence of the bacilli so much attenuated as to be harmless, the curetment or excision of the abscess wall can be of little avail. Practically the final results confirm this assertion. The immediate effects in many of the operated cases seem excellent, and, no doubt, some lasting results are obtained, but most frequently the cavity refills with either tuberculous debris or purulent secretion; the wound reopens, and frequently secondary infection takes place. If the process is not so violent as to cause death, the condition becomes chronic and a sinus results. "While this semiradical procedure is still practiced in some countries, it has been largely supplanted by the conservative method. The most desirable treatment is the nonoperative one. It consists in allowing the abscess to become absorbed. This is accomplished by complete rest in bed, immobili- zation, and giving the patient all the hygienic advantages that reinforce the natural resistance against disease. The conservative orthopedic surgeons have a great deal more patience with these cases than some of the aggres- COLD ABSCESSES. 157 sive, restless, younger generation of surgeons, and, no doubt, have saved by their conservatism thousands of children; but, on the other hand, many a cripple with a discharging sinus hobbles from clinic to clinic who might have been spared much misery if his abscess had, at the proper moment, been treated by proper surgical method instead of having been permitted to rupture and to drain. The most effective and satisfactory method is that of aspiration of the abscess and injecting a modifying sub stance. Calot 1 prescribes the following rules for treating cold abscess: 1. "It is forbidden to touch abscesses when they are not easily reached. There is no danger that these will rupture spontaneously. ' ' 2. "It is permitted to treat abscesses when they are easily reached, even if they do not threaten to rupture spontaneously. ' ' 3. "It is our urgent duty to treat abscesses when they threaten to rupture. In this case they are easily access- ible. 'To treat them' means to aspirate and then inject some substance producing a healing effect." I subscribe most decidedly to rules 1 and 3, but can not subscribe to rule 2, as it is my belief that the non- operative treatment should be persisted in as long as possible. As long as the patient does not suffer extreme pain, and has very little fever, he should be given a chance of cure without surgical interference, but the abscess should be constantly watched, and as soon as signs of threaten- ing rupture appear it is of the utmost importance that surgical methods be employed. If, however, there ap- pear symptoms of pyrexia, or if the patient's health de- 1 Calot: Die Behandlung der Tubereulosen Wirbelsaulenentziindung. 158 BISMUTH PASTE IX CHRONIC SUPPURATIONS. clines steadily, then it may be assumed that the abscess contains true pus, and surgical interference is not only permissible, but is urgently required. The surgical pro- cedure should, however, not be too radical. It is not ju- dicious to use a curet, nor is irrigation of the abscess in- dicated. The abscess should be located, aspirated, and filled with a modifying substance. The aspiration and injection of modifying fluids is, at the present time, the most popular method in cases in which the abscess threatens to rupture. Various sub- stances have been used at different periods for the injec- tion of these cold abscesses, and it seems that nearly all of them have given satisfactory results. Silver nitrate, tincture of iodin, alcohol, corrosive sublimate, lactic acid, ether and iodoform, naphtolcamphor, trypsin, serums, guaiacol, formalin, and many others have been used at different periods of the development of this curative method, but in the last few years Calot's mixture — 01. olivarum 50 grams Ether sulf 50 grams Kreosot 2 grams Iodoform 5 grams — or naphtolcamphor (1 gram in 5 grams of glycerin), and lately the 2-percent formalin-glycerin mixture of Murphy, have been most in favor. Some surgeons do not employ modifying fluids, claim- ing good results with simple aspiration, repeating it as often as the abscess refills. (Gangolphe.) Simple aspiration may be compared to the tappings of pleural exudates in tuberculous pleurisy. They do not often cure the underlying disease, although they usually benefit the patient temporarily. The aspiration of an abscess is an incomplete procedure, since it can not re- move or disinfect the original focus of the disease, of (!(>U> AllNOKKKKN. 159 which the abscess is only a consequence. If the opening or aspiration of the abscess meant the eradication of the disease, the problem of curing spinal tuberculosis or hip joint disease would indeed be very simple. The neces sity of frequent repetition of the aspiration, furthermore, predisposes to secondary infection, which is practically avoided by using modifying substances. Fig. 61. rupture. Psoas abscess, pointing in the lumbar region. Ready for spontaneous In January, 1908, I tested the value of bismuth paste as a modifying substance in the conservative treatment of cold abscesses, and, finding it very effective, I have since employed it in a large number of cases. Now, after two years' experience, I have no hesitation in recom- mending it as a most valuable addition to other modify- ing fluids. 160 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Method of Application. — A cold abscess, when it lias reached the stage of spontaneous rupture (Fig. 61), should, with the most aseptic measures, be opened by an incision one-half inch in length, at the fluctuating spot, and the contents allowed to escape, but not squeezed out forcibly. Vigorous manipulation is harmful. Then, through this small incision, a quantity of not more than 100 grams of a 10-percent bismuth- vaselin paste is in- jected into the cavity, and the opening is not sealed or drained. Gentle massage over the abscess area should then be made in order to spread the injected paste into all the folds of the collapsed abscess. A sterile gauze dressing is placed over the incision and a five-yard sterile gauze bandage is snugly put on and securely pinned, so that the patient, usually a child, can not dis- place it and can not infect the wound. This method, properly carried out, will prevent secondary infection. The gradual contracting of the cavity forces small quan- tities of the thick paste from within through the small incision, thereby blocking the opening and preventing the introduction of any infectious material. Dressings are to be changed daily under the most scrupulous asepsis. Should the fluid reaccumulate, the incision may be reopened, and the fluid contents, which have by this time become serous, allowed to escape, but the injection need not be repeated. The first trial of this prophylactic method was made on January 17, 1908, at the North Chicago Hospital on a two-and-one-half -year-old boy, who had a tuberculous abscess about the middle of his tibia. I made only one injection, and the abscess was obliterated within one week and remained closed. This favorable result encouraged me to try the treat- ment in the following case of psoas abscess: (JO LI) AHSOKSKKS. 161 A boy, aged 4%, had a large psoas abscess pointing above Poupart's ligament, with a softened area at its summit. A quart of debris was evacuated and the cavity injected with 120 grams of a 10-percent bis- muth-vaselin paste. The temperature remained absolutely normal after this injection, whereas previously it had risen from 99° to 100° every Fig. 62, Abscess of trip joint injected with bismuth paste to prevent sinus. day. The incision closed in four days, and was intentionally reopened three days later and about three ounces of muddy, but sterile, liquid were removed, and 60 grams of a 33-percent bismuth-vaselin paste in- jected. The opening closed three days later, and the patient gained rapidly in general health. 162 BISMUTH PASTE IN CHRONIC SUPPURATIONS. This prophylactic method is applicable in treating cold abscesses in all parts of the body. Several cases are here cited for illustration : Pig. 63. Normal pelvis of same age, for comparison with Fig. 62. Hip-joint Abscess. — Master E. T., aged 7, at the age of 2% years fell and soon after developed an abscess in his hip. One year later his physician incised and drained the abscess, and purulent discharge con- tinued for two years. In April, 1908, I made the first injection of bismuth paste, whereupon the sinus closed. With the aid of a high shoe the boy could now run about as well as his healthy comrades, and was well until September, 1909 (sixteen months after closure), COLD ABSCKSSKS. ]<)/> when he fell downstairs, which accident was followed by chills and fever of 103°, and extreme tenderness of the hip. For three weeks his hip was treated with liniments, etc., without any relief, and a large abscess in the gluteal region appeared. In this condition he was again brought to me for treatment. On October 24, 1909, the prophylactic method of bismuth treatment was carried out as follows: An incision two inches long was made through the gluteal muscles, reaching a deep abscess. The pus was allowed to escape without any scooping or the introduction of gauze, and the resulting cavity was Fig. 64. Patient whose pelvis is shown in Fig. 62, standing on the diseased limb two weeks after injection of abscess. filled with a 10-percent bismuth paste. The radiograph (Fig. 62) illus- trates the size and shape of the cavity. The shadow of a buckshot represents the location of the opening of the sinus. This radiograph also illustrates the extreme tilting of the pelvis and the atrophy of the shaft of the femur, which occurs in some of the cases of hip joint disease. For comparison I show a radiograph (Fig. 63) of a normal pelvis of a child of the same age. Child has fully recovered and sup- ports his body weight on the tuberculous limb. (Fig. 64.) Tuberculosis of Elbow with Multiple Cold Abscesses. — L. R., aged 18, when 8 years old was operated upon for tuberculosis of the knee 164 BISMUTH PASTE IN CHRONIC SUPPURATIONS. joint. Result, primary union, with considerable shortening. Since then the patient remained apparently well until four months ago, when a swelling in his left elbow began to form, which was first diagnosed as rheumatism. This swelling enlarged and the elbow became entirely immovable. Fluctuation was distinct at three different points. The Fig. 65. Tuberculous elbow joint with three abscesses before injection treatment. Fig. 66. Reduction in size of arm shown in Fig. 65 after prophylactic, con- servative treatment. Secondary infection avoided. photograph of the arm (Pig. 65) shows the size of the swelling before the prophylactic treatment was instituted. March 1, 1910, the three abscesses were incised at their softest points, and, according to the method described, were injected with bismuth paste No. 1, this 33- percent paste being employed because the quantities used were small. The cloudy discharge changed within twenty-four hours to a clear COLD ABS0E88E8. 165 straw-colored fluid, which at first was very abundant, but gradually became scanty. The opening closed, and the elbow returned to its normal size. (Fig. GO.) Mobility was less impaired than we antici- pated. The radiograph (Fig. 67), which was taken after the abscesses were injected, shows distinctly the size of each abscess, and demonstrates the fact that these abscesses did not communicate, but all of them had their origin in one tuberculous focus in the external condyle of the humerus. During the past two years I have applied this method of treating cold abscesses in nearly all parts of the body, including suppurating lymph glands and pararectal ab- scesses, and not in a single instance have I experienced a secondary infection and high fever. I have not trusted to simple aspiration, and have employed it in every case of cold abscess treated during the past two years. Therapeutically the results have been all that could be desired; in fact, of twenty-six cases treated in this man- ner in only one did a sinus persist, and in this case a badly diseased hip joint was responsible for its failure to close. This method has already been tried by others. Ridlon and Blanchard made a report in June, 1909, to the Amer- ican Orthopedic Association of eight cases treated in this manner at the Home for Crippled Children, in Chicago, in which institution I had introduced this method a year previous to their report. Their results were as follows: Report of 8 Cases of Cold Abscess Treated by Ridlon and Blaxchabd with Bismuth Paste. aj c3 o Name. Age, years. Disease. a Is Abscess. Cured in 3 ~ 1 Elmer H. 5 Pott's disease 3% Psoas 21 days 9 Samuel J. 7 Hip disease •> Thigh 13 days 3 John B. !i Hip disease 3 Thigh 14 days 4 Joseph M. S Hip disease 2 Thigh lrt days 5 Josephine 5 Hip disease 2 Thigh 20 days 6 Hiram W. 17 Pott's disease 1 Lumbar 17 days 7 Maggie S. 10 Hip disease 2 Thigh lii days 8 George T. 9 Hip disease 2 Thigh 15 days 166 BISMUTH PASTE IN CHRONIC SUPPURATIONS. One might ask why surgeons have shifted from one to another of these modifying substances when nearly all of them have fulfilled their purpose. New modifying fluids Fig. 67. Radiograph showing the three distinct cavities communicating with the elbow joint. (Case shown in Fig. 65.) were introduced, not because the older ones failed, but, rather, they were added because they were just as effec- tive and, in addition, possessed other advantages, such as being less toxic, less irritating, or painless. COLD ABSCESSES. 167 Action of Bismuth Paste as a Modifying Substance. We have studied the effects of bismuth paste upon the secretions of these abscesses by cytologic tests in several hundred cases, and have made observations which, in a large measure, explain to us its favorable action upon the diseased abscess cavities and their contents. The con- Openinc/ o/ Gbscess Three dish'ncr abscesses, nor commumcorwg Fig. 67 A. Diagrammatic illustration of Fig. 67. tents of tuberculous abscesses are usually sterile, and consist of debris with a very few white blood corpuscles. Within twenty-four hours after an injection of the bis- muth paste the fluid will contain an abundance of poly- morphonuclear leucocytes. A fibrinous network, in which are entangled a large number of these leucocytes and some red corpuscles, will appear. All these facts in- 168 BISMUTH PASTE IN CHRONIC SUPPURATIONS. dicate that there is an inflammatory reaction. The same cytologic changes have been noted by other observers when other modifying substances have been applied. Coyon and Fiesenger {Journal des Practiciens, Octo- ber 20, 1909) have advanced a theory which places the action of the various fluids on a chemical basis. They have shown that, in the more acute form of abscess, there exists a proteolytic ferment analogous to the tryptic fer- ment of the pancreas, which coagulates albumins and changes them into peptones and amido-acids. This fer- ment is produced by the destruction of the polymorpho- nuclear leucocytes. In contradistinction, this ferment is not present in tuberculous abscesses because of the absence of the poly- morphonuclear leucocytes in cold abscess. The injection of any of the modifying fluids will cause the appearance of the leucocytes. Soon after the discovery of the tubercle bacillus it was believed that the curative action of modifying injections was due purely to their antiseptic power, but it was found that some of these substances exert very slight bac- tericidal power in vitro, while within an abscess their action upon bacteria is very powerful. Iodoform is a striking example. Its retarding action upon bacterial growth outside of the body is very weak, but within the living tissues it exerts a marked inhibition upon the growth of microorganisms, especially upon that of tuber- cle bacillus. The bactericidal action of the paste does not depend upon the antiseptic power of the bismuth, but upon an underlying principle which governs all these modifying substances — namely, the production of a local leucocy- tosis. The bismuth has a chemotactic action — it attracts the leucocytes to those tissues with which it comes in COLD ABSCESSES. 169 contact. Indirectly, then, the injection of the paste is re- sponsible for the phagocytic action. The following are the advantages of using bismuth paste instead of other modifying substances: 1. The paste is injected through a small incision in- stead of using a trocar, and thus the possibility of miss- ing the abscess is eliminated. 2. By discarding the aspirating needle the danger of injuring underlying vital organs or entering blood ves- sels is avoided. 3. Through an incision it is possible to evacuate the larger clumps of the tuberculous debris, which could not pass through the aspirating needle. 4. The thick paste within the cavity will allow the escape of secretions along the walls of the abscess, but will not permit the entrance of infectious material; thus secondary infection is prevented. 5. Injections of other modifying fluids must, as a rule, be repeated, while with the paste the first injection usu- ally attains the desired result. 6. The injection of bismuth paste is not painful or irritating. It is injected in a warm, semi-liquid state, and remains long enough in contact with the diseased tissues to produce its therapeutic effect. The vehicle (vaselin) does not macerate the walls of the abscess. Toxic effects from bismuth subnitrate can easily be pre- vented. 7. The therapeutic results are equal, if not superior, to those obtained by other modifying substances. These advantages and the practical results obtained with the paste in treating cold abscesses naturally sug- gest the question : "Why could it not be employed for the injection of tuberculous joints before abscess formation instead of iodoform emulsion, etc.? This question has 170 BISMUTH PASTE IN CHRONIC SUPPURATIONS. frequently been put to me. I have been reluctant in ad- vising it, although. I have employed it in several cases with success, but I encountered one failure which taught me the possibility of its producing harm. 1 In the past few months, however, I have renewed its application in tuberculous joints by a modified method, but the brief period which has elapsed does not permit drawing definite conclusions and its publication. I do not as yet advise the general use of the paste when abscess is not formed; at least not until the reports from large clinics have established the safety of its application and its advantage over the methods now in vogue. 1 Beck: Transactions of Sixth International Congress on Tuberculosis, vol. 2. CHAPTER XIII. LIMITATIONS AND CAUSES OF FAILURE. To one who has the opportunity of treating many cases with the bismuth paste, new possibilities for its applica- tion constantly suggest themselves. Its application in the accessory sinuses of the nose and ear is so extensive, and its possibilities so great, that a special chapter is de- voted to their consideration. In dentistry the paste has likewise found a place of usefulness. A publication by Dr. R. Beck, including a collective report from several hundred dentists of America and Europe who have made use of it in pyorrhea alveolaris and sinuses within the mouth, indicates that in dentistry there are also great possibilities for its appli- cation. A special chapter is written on this feature. There is no reason why the same beneficial results may not be obtained in lower animals affected with sinuses. In this branch of surgery the veterinaries have already taken advantage of its use. In the American Veterinary Review (February, 1910) Dr. C. A. Leslie published a report in which he gave histories of thirteen cases of various forms of fistula? in horses in which he used bismuth paste, with complete recovery in every case. Some of these cases had been operated upon as many as four times without success, and with this simple method a complete cure was obtained within ten days. Similar reports not yet published have been made to me by other veterinaries. Should these reports be verified in veteri- nary colleges, where I am informed this method is being 171 172 BISMUTH PASTE IN CHRONIC SUPPURATIONS. tested, this treatment will certainly prove to be of im- mense value. The wide range of application of bismuth paste must not, however, mislead to the belief that there are no limi- tations to its use. There are suppurative conditions in which it is of no benefit, and in some its application may even be harmful. First of all, it is contraindicated in acute inflammatory conditions, such as acute sinusitis, acute phlegmon, freshly opened acute abscesses, etc. Although some gratifying results have been reported also in acute con- ditions, we have been conservative in its application, having occasionally noted an aggravation of the symp- toms after its use in acute cases. For obvious reasons it should never be injected into a fistula of the gall-bladder or the pancreas, and great care should be exercised when making injections in the vicinity of the cranium, where there is a possibility of the paste finding its way into the subdural space, as it would cause a compression of the brain similar to that of a blood clot. A hypodermic needle should never be employed to make these injections, as it may enter a vein, and thus the paste may be injected into the circulation and cause death by blocking the branches of the pulmonary artery. Causes of Failure. "We have had many cases referred to us in which the method had been applied and for some reason the desired results had not been obtained. Thus we were afforded a good opportunity to study the causes of failure in quite a variety of most interesting cases. The citation of a few examples will be instructive in showing the causes of failure. LIMITATIONS AND CAUSES OK FA I MIRK. 173 Foreign Body. — W. W., aged 4. One month following an attack of croup, in December, 1907, became suddenly ill with chills and fever, and pain in the upper arm. Within two weeks of continued intermit- tent rise of temperature, up to 104.5°, a swelling midway between the shoulder and elbow appeared. Diagnosis: osteomyelitis. A half pint of pus was evacuated through three incisions from shoulder to elbow. The suppuration failed to cease within a reasonable time, and another operation was performed, in which a considerable amount of necrosed Pig. 68. 69. Figs. 68, 69. Tip of probe (Fig. 6S, F) within the shaft of humerus as a cause of failure of bismuth injections. Cavity filled with bismuth paste (Fig. 69) after removal of foreign body. bone was removed and the entire length of the medullary shaft of the humerus was curetted. Five weeks later the discharge still persisted. At this time the bismuth paste treatment was tried by the physician in charge, but with no benefit. Therefore another radical operation was undertaken and more necrosed bone removed. Bismuth paste was again injected, and after a sufficient trial it was discontinued. In July, 1908, the boy was brought to Chicago for the bismuth treat- ment. The radiographs here shown (Figs. 68, 69) explain the cause of failure. The tip of a probe, one and one-half inches long, was 174 BISMUTH PASTE IN CHRONIC SUPPURATIONS. lodged in the shaft of the humerus. After its removal the bismuth paste was injected and all sinuses promptly closed without a recur- rence. Foreign Body. — J. N., aged 14. Developed an osteomyelitis in the upper part of the humerus and the tibia four years ago. After the usual treatment at home, which included curettage and drainage of the bone cavities, there appeared to be no tendency to healing. The sinuses continued to discharge pus profusely. He was then brought to hie for the bismuth treatment. A radiograph of the humerus, taken before the injection of bis- muth paste, shows a shadow resembling a sequestrum. In the pres- ence of a sequestrum the paste would be -of no avail, and I therefore proposed a thorough curettage before injection. During the operation I noticed a dark striated object lying within the shaft of the humerus. It was resilient, like a large blood vessel, and upon extraction proved to be a piece of rubber tubing two and one-half inches long. Bis- muth paste would, no doubt, have been a failure had we not discovered the foreign body beforehand. These two cases, however, represent accidents, and can not be taken as examples of frequent causes of failure; but the disease itself very often leaves a foreign body at the seat of trouble — namely, the sequestrum. Sequestra are the most frequent causes of failure. Their diagnosis has been extensively studied by my brother, Dr. Carl Beck, who satisfied the members of the Surgical Society of Chicago that sequestra, when present, can be recognized by means of radiographs practically in all cases. 1 When a sequestrum is present we do not expect a cure until it has been removed. Nevertheless, a risky operation should be undertaken only as a last re- sort. I know of two instances in which sequestra have healed in during the bismuth treatment. Large Sequestrum of Ulna. — L. B., aged 12, with congenital syphilis, was treated by me for this condition the first three years of his life. For seven years thereafter he enjoyed comparatively good health and normal growth. At the age of 10 he developed a remittent fever, which lasted six months, and debilitated the boy very much. With antiluetic treatment he gradually recuperated until he reached his 1 Carl Beck, Chicago: Chronic Osteomyelitis— Diagnosis and Treatment. — Surgery, Gynecology and Obstetrics, February, 1910. LIMITATIONS AN)) CAUSES OF FAILURE. 175 11th year. Thereafter he was sickly i'or one year, and returned for treatment at the age of 12. He had a daily temperature of from LOO to 103°, was extremely anemic and emaciated. His legs helow the knees and his forearms were very much enlarged. Radiographs of these parts were taken, and it was found that suppurative osteitis had taken place in practically all of the bones of these parts, showing softened areas on the skin, which indicated the presence of abscesses. On the right forearm was a sinus, through the opening of which a portion of Fig. 70. Sequestrum of the ulna, requiring removal before bismuth injection. dead bone protruded. The radiograph (Fig. 70) of this arm shows enormous destruction of the ulna and elbow joint. The entire ulna was practically a sequestrum, and the futility of any conservative treatment was evident. The sequestrum was removed under anes- thesia, and its natural size and colors are shown in the colored plate. The cavity was packed with gauze, and the next day was filled with bis- muth paste. The abscesses on the left arm were incised and injected, and closed without secondary infection within three days. Temperature 176 BISMUTH PASTE IN CHRONIC SUPPURATIONS. ceased after first injection. The healing progressed rapidly, and three weeks after the operation the wound was practically closed, the boy had gained twelve pounds, and had practically normal motion in both arms. (Fig. 71.) It must, however, be stated that he had at the same time received antiluetic treatment, which may, to a certain degree, account for the rapid improvement, although the same treatment be- fore the operation did not have this effect. Fig. 71. Complete closure three weeks after operation and bismuth treatment. Removal of ulna from left arm. Faulty Technic. Faulty technic is, no doubt, the cause of many fail- ures. I have often been surprised to find that cases re- ferred to me, in which the paste had been used "faith- fully" for months without success, responded to my first injection and closed. The underlying principle must always be kept in mind that the bismuth paste must be soft enough to permit its flowing into the remotest parts of the channels and filling every one of them completely. In Fig. 72 we show a LIMITATION'S AND CAUSES OF FAILURE. 177 bone cavity which was injected, but not filled completely. If a small side-pocket or branch of a sinus is missed, the suppuration will continue and in time the entire tract of the sinus become reinfected. Fig. 72. Incomplete injection of abscess cavity, demonstrating cause of failure of bismuth treatment. Unexplained Causes of Failure. Empyema; Estlander Operation; Closure with Paste. — Miss L. E., aged 28. Her family and personal history are negative as to tuber- culosis. Four years ago she developed an acute pleurisy, with effu- sion. Two weeks later purulent fluid was aspirated, whereupon a resection of one rib was performed and drainage instituted. For eighteen months a copious, purulent discharge persisted. A second operation was performed for the purpose of establishing a counter- drainage, but this also failed to stop suppuration. As a last resort 178 BISMUTH PASTE IN CHRONIC SUPPURATIONS. an extensive Estlander operation was performed, but even this radical procedure did- not suffice to stop the discharge. The bismuth injec- tions were then tried at home, and, while the discharge became more scanty and less purulent, it did not cease. Retention, with fever, often occurred. With this history the patient arrived at our hospital Fig. 73. Injection of empyema after Estlander operation has failed to obliter- ate the cavity. in October, 1909. The radiograph here shown (Fig. 73) gives a vivid illustration of the true condition within the chest which existed after an Estlander operation. The paste occupies the remaining cavity. The upper part of the lung is perfect and functionating. The paste, which was in the chest cavity, was washed out with LIMITATIONS AND CAUSES OF FAILURE. 179 warm olive oil, and the following day a fresh injection of bismuth paste No. 1 was made. The secretion became sterile, and the sinus closed within one week and has remained so to date. There has been no elevation of temperature or discomfort, and a radiograph taken re- cently shows the absorption of the paste and the distention of the lung. These are signs most promising for the permanency of the cure, although recurrence is possible. We have noticed that there are two classes of cases — one class responds promptly to the bismuth treatment, while the other is very refractory. To which class a case belongs is usually decided after the first injection. If the purulent discharge changes into a serous one, a good result is to be anticipated, and a closure usually follows the first injection. If the discharge remains purulent, the outlook is not so promising. The injection is not, however, repeated for at least one week. Only the daily dressings, with frequent microscopical examinations, are continued. Thereafter the sinus is reinjected every three or four days for a reasonable length of time — about a month. If no improvement is noticed, the cause of fail- ure must be searched for, which in some cases remains inexplicable. The limitations here prescribed may seem too strict and unnecessarily conservative to surgeons who have already tried the bismuth paste and obtained good results even in cases where I do not recommend its use. Never- theless, I insist that it is far safer for the present to limit its use to such cases where our experience has assured us of its safety and usefulness. CHAPTER XIV. BISMUTH POISONING AND ITS PREVENTION. The introduction of new remedies is usually met with skepticism, and the failures and possible dangers are pointed out first. This is, of course, most desirable, since it helps to eliminate the objectionable features from otherwise useful methods. The x-ray received its first blow when the reports of x-ray burns began to pour into the literature, but after fourteen years of its employment, when its use has been increased a hundredfold, reports of burns are comparatively rare. Vaccination, antitoxins, and anesthetics passed through similar experiences until their true value was recognized. There is no remedy of any importance which has not some objectionable feature, and its true value depends only upon the relative amount of good to be accom- plished by it. Chloroform may cause death, but never- theless thousands of persons request anesthetics, know- ing their usefulness. Bismuth paste is no exception to the rule, and its objectionable features were brought forward shortly after the appearance of my first article on the subject. The objection advanced is the toxic effect following its administration. It is far safer to magnify this danger than to make too light of it, but an undue exaggeration of this complication may deter many from applying an otherwise useful method of treatment. Neither my brothers nor I have had a single case of poisoning in our experience with several hundred cases. I have, neverthe- 180 BISMUTH POISONING. 181 less, at every opportunity warned the profession againsl this possible danger. It must be admitted that in the application of bismuth paste toxic effects may be produced. The slow absorp- tion of the metallic bismuth from cavities where large quantities are retained for a long period causes symptoms of poisoning similar to those of mercurial intoxication. The first symptom, a slight lividity of the skin, ap- pears during the second or third week. Later we find small blue ulcerations of the gums and back of the wis- dom teeth, and a black discoloration underneath the tongue. Soon thereafter patient complains of nausea, headache, and, frequently, diarrhea. The urine contains epithelial casts and some albumin. If the progress is not checked, the ulcerations will enlarge, the teeth become loose, and the patient become cyanotic and begin to lose considerably in weight, and finally may succumb to the effects of poisoning. Administration of bismuth subnitrate in overdoses may produce two distinct varieties of poisoning: 1. The acute nitrite poisoning", which results from the rapid absorption of large quantities of nitrites liberated in the intestines from the bismuth subnitrate. 2. The slow but constant absorption of the metallic bismuth from either the intestinal tract or the serous cav- ities, or when injected into wounds — bismuth poisoning". The instances of toxic effects from the use of bismuth subnitrate in medicine and surgery have been so rare that, until recently, physicians have regarded its adminis- tration as perfectly harmless. Schuler 1 and Von Barde- leben 2 have pronounced its action as nontoxic, the latter 1 Schuler: Zeitschrift fur Chirurgie. 1885. 2 Von Bardeleben: Deutsche Medizinische Wochenschrift, 1901. No. 544. 182 BISMUTH PASTE IN CHRONIC SUPPURATIONS. having treated one hundred cases of extensive burns by dusting with bismuth subnitrate, and observed no un- pleasant symptoms therefrom. Professor Miihlig 1 ad- ministered 20 grams daily for a prolonged period with- out producing any poisonous effect. It was, therefore, not surprising, when radiographers began to use bismuth subnitrate for the purpose of obtaining radiographs of the stomach and intestines, that they had no hesitancy in administering large doses, and boasted of the safety with which as much as 40 grams in one dose could be administered. The subject of bismuth poisoning has been revived only within the past three years, during which time radiographers have employed the drug more extensively. Bismuth Poisoning- Due to Dusting" Powder. The first authentic report of bismuth poisoning was made by Theodor Kocher 2 in 1882, who observed that the insoluble bismuth preparation, when applied to large wound surfaces, is capable of yielding enough bismuth to absorption to produce poisonous effects. Similar cases were reported by Professor Peterson. 3 Thereafter the literature on the subject remained silent until 1901, when Professor Miihlig 4 reported the following two cases: Case 1. A man, aged 26, received burns on both arms, hand, and neck, which were dressed with oil for three days and the pure bismuth subnitrate applied. Two weeks later a black border around the teeth appeared, and within five more days the whole mouth and uvula were grayish-blue and slightly ulcerated. Urine remained normal; diges- tion normal. Recovery took place after wounds were curetted and freed from bismuth. Case 2. A man, aged 34, was burned on both legs. Treatment the same as in case 1. Twelve days after first bismuth dressing symp- toms identical with those in case 1 appeared. Urine and stool re- 1 Miihlig: Munchener Medizinische Wochenschrift, 1901, No. 13, p. 592. 3 Kocher: Volkmann's Klinische Vortrage, 1882, p. 224. 3 Peterson: Deutsche Medizinische Wochenschrift, June 20, 1883. * Miihlig: Munchener Medizinische Wochenschrift, 1901, No. 13, p. 592. BISMUTH POISONING. 183 mained normal. The curettage of the wounds resulted in prompt re- mission of the symptoms. The bismuth used in these cases was free from impurities. A similar case was reported by Dressman: 1 Case 3. A man, aged 30, received a burn of third degree. Five days later a 10-percent bismuth salve was applied. Three weeks later a black sediment was discovered in the urine. A severe stomatitis, with deglutition pains, followed. A bluish-green border around his teeth was noticed, and the mouth resembled the condition which exists after eating huckleberries. After the bismuth dressings were stopped the symptoms abated, but even six months later there were marks around the teeth. These cases prove that absorption of bismuth sub- nitrate, when applied as dusting powder on burns, may produce symptoms of bismuth poisoning, which, how- ever, subside as soon as the bismuth is removed. None of these cases were fatal. Nitrite Poisoning Due to Bismuth Subnitrate. The first fatal case directly traceable to the adminis- tration of bismuth subnitrate for diagnostic purposes is reported by Bennecke and Hoffman: 2 Case 4. A baby, aged 3 weeks, suffering from enteritis, weak and emaciated. A mixture of three grams of bismuth subnitrate in 100 cubic centimeters of buttermilk was administered by stomach in order to diagnosticate a pyloric stenosis by rontgenograph. Twelve hours afterward cyanosis developed, collapse followed, and the child died three hours later. Post-mortem examination revealed bismuth in the bowel, and small quantities in the liver and blood. Methemoglobine- mia was present. From the same clinic a similar case was reported by Bohme. 3 Case 5. A child, aged iy 2 , markedly rachitic, artificially fed. and marasmic, received a few grams of bismuth subnitrate by stomach for 1 Dressman: Miinchener Medizinische Wochenschrift. 1901. No. 6. p. 23S. 3 Bennecke and Hoffman: Miinchener Medizinische Wochenschrift. 1906, No. 19. 3 Bohme: Archives fiir Experimentelle Pathologie und Pharmakologie. p. 441, 1907. 184 BISMUTH PASTE IN CHRONIC SUPPURATIONS. radiographic purpose. Stomach was washed out, and no symptoms of poisoning appeared. Two days later a few grams of bismuth subnitrate were injected by rectum for the same purpose, and again the bismuth was washed out. Three hours later the child was suddenly seized with pain, became cyanotic, pale, skin cool, pulse small; it died in thirty minutes. Section. Distinct methemoglobinemia, all mucous membranes were brownish discolored, marked rachitis, dilatation of the stomach, with stenosis of pylorus. Colon contained large quantities of black and white bismuth. Professor Hefter suggested that death might have been caused by nitrite poisoning. The blood and peri- cardial fluids were tested, and in both nitrites were found. Bismuth could not be detected in the liver or blood. These chemical findings threw new light on both cases, and prompted Dr. Bohme to determine the true cause of bismuth subnitrate poisoning. The results of his experiments were as follows: A number of pure cultures of the bacterium coli were found to liberate nitrites in every case when added to bouillon to which some bismuth subnitrate had been added. The controls of bouillon — treated the same way, but without the addition of bismuth — remained free from nitrites. This experiment was repeated by using a solu- tion of children's stool instead of pure cultures, and in every instance the formation of nitrites was marked, while the same experiments with stools from grown per- sons showed nitrites absent in 40 percent, slight in 35 percent, and marked in only 25 percent of the cases. The character of food seemed not to influence the nitrite formation, as some of the adults received a milk diet. The next question Bohme determined was whether the formation of nitrites would occur in feeding lower ani- mals with bismuth subnitrate. Cats and rabbits were used for experiments, and, after finding their stools and urine free from nitric acid, they were given from three to BISMUTH POISONING. 185 five grams of bismuth subnitrate in milk. Nitrates ap- peared in the urine after a few hours, and did not cease to be eliminated from the kidney for twenty-four hours. Reaction to nitrites was absent in the rabbits and only faintly marked in the cats. To prove that children's feces mixed with bismuth subnitrate would liberate nitrites in the bowel of the rab- bit, Bohme injected a mixture of five grams of each into a part of the bowel by first ligating the loop. Nitrates and nitrites were found in the urine, but not in the blood taken from the hearts of the animals. In the feces of the ligated part of the bowel a large quantity of nitrates and nitrites was found. In trying larger quantities by the same method, and testing the urine hourly, the quantity of nitrates and nitrites increased, but not enough was absorbed to cause methemoglobinemia. By these experiments Bohme proved by test tube and animal experiments that the feces of children, when in contact with bismuth subnitrate, will liberate nitrites, which are quickly absorbed from the intestines and found in the urine. While methemoglobinemia was not pro- duced by the absorption, it must be assumed that the ab- sorption of larger quantities would produce methemo- globinemia. Experiments proved this to be a fact. Collishon 1 reports two cases of accidental nitrite poi- soning in which sodium nitrite instead of the sodium ni- trate was given. The symptoms were cyanosis, extreme weakness, and a grayish-blue discoloration of the mucous membrane and the tongue; they were so severe as to pro- duce collapse, but cleared up after the drug was discon- tinued. Routenberg 2 reported a case in which a methemoglobin- 1 Collishon: Deutsche Medizinische Wochenschrift, 1SS9. No. 41. 2 Routenberg: Berliner Klinische Wochenschrift. 1906. No. 43, p. 1397. 186 BISMUTH PASTE IN CHRONIC SUPPURATIONS. emia, with the usual symptoms of nitrite poisoning, fol- lowed the rectal injection of 50 grams of bismuth sub- nitrate in 400 cubic centimeters of oil of sesame, and, while the author ascribes the poisoning to the contami- nation of the oil, the analogy to other similar cases leads one to suspect that it was a case of nitrite poisoning. A recent report of fatal nitrite poisoning due to bis- muth subnitrate is published by Novak and Giitig. 1 Case 6. A man, aged 44, who, a year after a retrocolic gastro- enterostomy, suffered from symptoms of obstruction, received in July, 1908, a rectal injection of four tablespoonfuls of bismuth subnitrate suspended in two liters of water, to test the function of the anas- tomosis. Soon after the x-ray examination the bowels were washed out. He had a restless night. In the morning the nurse noticed a discoloration of the patient's skin. Gradually the patient became grayish-green, mucous membranes cyanotic, temperature 40° C, pulse 96, had stertorous breathing, and did not respond to treatment. Vene- section revealed the blood to be of a chocolate color, due to methemo- globinemia. Patient died eighteen hours after rectal injection of bis- muth subnitrate. Spectroscopic examination of the blood a few hours after death showed that it had returned to normal, the brown color having changed to red. Two days later the post-mortem examination proved that the methemoglobinemia, which was positive before death, had now disappeared and blood had assumed a normal color. This case also gave further impetus to investigation. "The administration of 100 grams of bismuth subnitrate by mouth, then by rectum, and through a fistula into the small and large bowels of dogs and rabbits, failed to pro- duce any symptoms of poisoning, while in cats much smaller quantities (20 grams) would cause death in ten hours. Seven hours after ingestion of this quantity the -cat vomited, her mucous membranes became bluish-gray, blood assumed a chocolate color, and spectroscopic ex- amination revealed the methemoglobin stripe in the red." This proves that certain animals are susceptible to 1 Novak und Giitig: Berliner Klinische Wochenschrift, 1908, No. 39, p. 1764. BISMUTH POISONING. 187 nitrite poisoning, while others are not. It is not yet fully determined to which class the human belongs. Maasen proved that certain bacteria in the bowel con- vert the nitrites into ammonia or into nitrogen. It is likely that the bismuth subnitrate ingested always causes a liberation of small quantities of nitrites, which are either absorbed (and owing to the small amount cause no toxic symptoms) or are changed in the intestine into am- monia or nitrogen. When, however, large quantities of bismuth subnitrate are given, and the liberation of nitrites is abundant and can not be neutralized quickly, typical symptoms of ni- trite poisoning will appear. Alcohol and glycerin accele- rate the formation of nitrites in the intestines. This sug- gests to us a practical point — namely, when we encounter a case of nitrite poisoning, to withhold alcoholics and glycerin from ingestion and administer some form of iodin. From these experiments and reports of fatal cases Ave must conclude that the poisonous effects of the bismuth subnitrate were not due to the absorption of the metallic bismuth, but to the absorption of nitrites, which caused the methemoglobinemia. This methemoglobinemia is the factor producing most of the clinical symptoms — the cyanosis, dyspnea, diarrhea, and cramps. The sudden change in the blood impairs the internal or tissue respi- ration, and the patient succumbs, with symptoms of suf- focation. It appears that the intestine, and especially the sig- moid and the rectum, are the laboratories for the libera- tion of nitrites. The bacteria in this part of the intes- tinal tract evidently are the nitrite-splitting factors, whereas those in the stomach and small intestines allow the bismuth subnitrate to pass into the large intestines 188 BISMUTH PASTE IN CHRONIC SUPPURATIONS. without liberation of quantities of nitrites sufficient to cause poisoning. The fatal cases thus far reported were all suffering from intestinal diseases, especially diarrhea or constipa- tion, which suggests that the intestinal putrefaction ac- celerated the nitrite formation and rapid poisoning. During the past three years the author 1 has employed bismuth subnitrate quite extensively in the treatment of empyema, sinus, and abscess cavities by injecting a mix- ture containing 33-percent bismuth subnitrate incorpo- rated in petrolatum into the cavities. The question as to what became of the bismuth paste after the injection arose. A study of the subject revealed the fact that if the paste did not discharge from the sinus soon after in- jection, but was retained, it became encapsulated and ab- sorbed. In nonresilient cavities, such as bone cavities, the mass is penetrated from all sides by fibroblasts and gradually replaced by connective tissue, while in col- lapsible cavities, such as the pleura, the expanding lung gradually replaces the slowly absorbing bismuth paste. This can be proven by taking radiographs at certain in- tervals of the region injected. This, then, proves that the bismuth paste is absorbed, and the question arises, How is the bismuth excreted, and is its absorption harm- ful? Harnack 2 states that bismuth subnitrate is slowly ab- sorbed and slowly eliminated. Orfilla found bismuth subnitrate in the liver. M. M. Bergeret 3 states that bis- muth subnitrate is found in the urine and in the serous exudates a few hours after administration. In rabbits the administration of a few grains could be detected in the spleen, muscles, and blood. Professor E. S. Wood 4 1 Beck: Illinois Medical Journal, April and July, 1908. 2 Harnack: Arzneilehre, 1883, p. 383. 3 Bergeret: Journal de l'Anatomie, 1873, p. 242. 4 Wood: Transactions of American Neurological Association, 1883, p. 23. BISMUTH POISONING. 189 has detected bismuth in the urine four weeks after ad- ministration, proving its slow absorption. We may, therefore, conclude that the bismuth is slowly absorbed and slowly eliminated. Before attempting to answer the question — Is the ab- sorption of bismuth paste harmful? — we must decide whether the harmful effects noted in the reported cases are due to the absorption of the liberated nitrites or of the bismuth itself. In my experience with the injection of bismuth petro- latum into sinus and abscess cavities I have not encoun- tered a single case in which the train of symptoms would correspond to that of an acute nitrite poisoning. I have, therefore, concluded that the injection of the paste does not produce a nitrite poisoning. The first case in which I observed symptoms of true bismuth intoxication as a result of bismuth paste was a case of empyema pleurae, in which I injected into the pleural cavity 720 grams of 33-percent bismuth paste, which was retained there for six weeks. "A desquama- tive nephritis developed, albuminuria was present, with rapid loss of previously gained weight, and the blue bor- der around the teeth appeared. As soon as the bismuth paste was withdrawn by means of olive oil all the symp- toms disappeared, and the patient regained his weight in a few weeks. I desire to cite a case which I saw in consultation, and reported in the New York Medical Journal, January 2, 1909, in which the bismuth injections had caused severe bismuth intoxication, and after this abated the patient died. Post-mortem examination and complete analysis throw some light on the pathology of this affection. Case 7. R., a lawyer, aged 57, for many years an invalid, had a tuberculosis of his hip since 1896. After extensive operations he re- 190 BISMUTH PASTE IN CHRONIC SUPPURATIONS. tained several sinuses, which discharged large quantities of foul pus. In March, 1908, his sinuses had been injected by the house physician twenty times in a period of sixty days with a 33-percent bismuth pet- rolatum paste, the total amount representing about 400 grams of pure bismuth subnitrate. While his general condition improved at first and his sinuses had healed up, all typical signs of bismuth intoxication gradually developed. The mucous membrane of the mouth and gums became bluish-black, with ulcerations; teeth became loose and lips edematous. He experienced great thirst, diarrhea, and had desquama- tive nephritis. The symptoms gradually abated, and he became well enough to resume his work as an attorney, and for two months was active in his vocation. A radiograph taken of his pelvis demonstrates that there were only small quantities of bismuth within the tissues. August 1, 1908, he fell, injured his wrist, and a large abscess formed, which was operated on by Dr. V. Verity. A large area of necrosis fol- lowed. From this time his temperature varied from 99° to 101.5° F. He lost in strength, his urine was loaded with casts and albumin, his heart became weaker and irregular, and he died August 16, 1908. Post-mortem examination, made by Dr. Gehrmann and myself, showed the following conditions: Abdominal Cavity. A small amount of fluid present. No adhe- sions or evidence of tumors or inflammatory exudates. Liver. Normal in size, dark-brownish in color. Section fails to show any noticeable changes. Spleen. Normal size, but unusually dark; quite soft. Pancreas. Negative. Intestines. Somewhat distended with gas, but otherwise negative. Vermiform Appendix. Negative. Mucous Membrane of Intestines. Shows dark color, very marked. Kidneys. Normal in size. External surface of both shows some evidence of beginning contraction, as the capsule is irregularly de- pressed. Sections show both kidneys to be of dark color, with the cortical markings not as distinct as in a normal organ. Pelvis and Ureters. Free. On the right side in the peivis the retroperitoneal tissue appears gelatinous, of a whitish, glistening ap- pearance, as if filled with a foreign substance. (No bismuth.) Chest. Pericardium negative. Heart about the size of subject's fist. Heart muscle rather softer than normal. Valves negative and coronary arteries negative. Lungs. Few adhesions about apices on both sides. Some hypos- tasis on both sides. Otherwise negative. Bones of Thorax and Spine. Inspection, as far as possible, fails to show fractures, tumors, or inflammatory changes. Head. Not posted. The microscopical examination of the tissues from the liver, spleen, kidneys, heart muscle, and intestine, and the chemical analysis of tis- sues, were made by Dr. Maximilian Herzog, and his report is as fol- lows: BLSM TIT rr POISONING. 191 Liver. The liver parenchyma cells in general do not show any marked pathological changes. Some cloudy swelling is noticeable here and there, but the process is not at all extensive; on the contrary, it is quite limited. There is very little fatty infiltration and fatty de- generation. Quite a number of parenchyma cells show bile granules in their paraplasm. Whether the latter also contain here and there bismuth is a question which can not be definitely decided, as we do not know of any microchemical reaction for bismuth. It appears, how- ever, that we find frequently in liver cells granules darker than the bile granules and that they are bismuth granules. The latter can first Pig. 74. Photomicrograph of section of liver about four niicra thick. In the center of an interlobular vein, to the right and above a sublobular vein. The intima of both lined with bismuth. Magnification, 210 diameters. be seen distinctly and beyond doubt in the interlobular capillaries. Here we see the dark granules in the lumen of the small vessels and crowded in fusiform cells, probably the star cells of Kupfer. In the interlobular veins bismuth is present to a large extent; it is found in the vascular endothelium and deposited in the form of fine granules on the free surface of the intima. Occasionally one sees in the inter- lobular connective tissue a vessel, apparently a sublobular vein, which likewise contains bismuth. (Fig. 74.) But this point is not clear be- yond doubt, as is the presence of bismuth in the portal system. Bile capillaries containing bismuth can be distinguished here and there between the liver cells; bismuth is also occasionally found in the 192 BISMUTH PASTE IN CHRONIC SUPPURATIONS. small interlobular bile ducts, but the biliary ducts and capillaries are generally collapsed and empty. Kidneys. The renal tissue shows chronic interstitial changes, with hyaline degeneration of a considerable number of glomeruli. A few of the degenerated hyaline spheres contain lime salts. Some tubules contain hyaline casts; besides, here and there the tubular epithelia show marked cloudy swelling. There is no bismuth present in the renal sections. Spleen. There is some thickening of the capsule and of the tra- becular noticeable. The pulp spaces are not very distinct — well crowded with erythrocytes and leucocytes. The Malpighian bodies are not well defined. Some bismuth is present in the shape of amorphous granules, and denser masses in the pulp spaces. Myocardium. Striation is not very distinct; there is here and there a fine vacuolation; also occasionally some cells which show the pig- mentation of brown atrophy. But these pathological changes are very moderate in degree. A few subpericardial round cells foci are present. Intestinal tissue. Nothing, except a very few thick, irregular sec- tions were accessible for examination. These show an extensive in- filtration of the mucosa with bismuth. The lymphoid tissue likewise shows bismuth, and much of the latter is found in the veins of the submucosa. The chemical examination resulted as follows: Heart Muscle. A faint trace of bismuth. Spleen. Very small piece. Distinct reaction for bismuth. Liver. Contained 0.13 percent of bismuth oxide. The tissue was pressed fairly dry between filter paper. Weight, 2,292 grams; total ash weight, 0.030 grams, in which bismuth weighed 0.003 grams. From the above microscopical examination it might appear that the bismuth was first absorbed into the lymphatics — that it was transported to and excreted into the intestines. Much was, however, reabsorbed by the portal circulation and transported to the liver, to be there excreted into the bile passages. There is no evidence that any of the bismuth was excreted by the kidneys. While this case presented the symptoms of bismuth intoxication, and its absorption was proven post-mortem by microscopical examination and chemical analysis, the question is still open as to whether the absorption and presence of metallic bismuth in the tissues was the direct cause of death. The pathological changes in the liver, BISMUTH POISONING. 193 spleen, and heart muscle did not indicate that a severe de- structive process, which would interfere with function, was going on. The interstitial nephritis was evidently not due to the bismuth absorption, as the renal tissue was free from deposits of the metal, and the pathological con- dition found could be expected in an old man who had for years suffered from a chronic suppurative disease. Dr. Verity reports that the patient was treated by him ten years ago for chronic nephritis. Dr. H. Eggenberger, 1 from the clinic of Professor Wilms, of Basel, reports a fatal case of bismuth intoxica- tion subsequent to the injection of a psoas abscess in a child 7 years old. Thirty grams of the paste were in- jected and retained for six weeks. Stomatitis developed, resembling mercurial intoxication; pulse rose to 130, and a picture of toxic cortex, such as is often observed in uremia, developed. The abscess cavity was evacuated, but the child died a few days later. Autopsy revealed no anatomical changes, except a hyperemic condition of the central nervous system and small hemorrhagic spots in the mucous membrane of the stomach. The intestinal follicles were red and swollen, and on the valvula Bauhini a greenish-brown ulceration, 2 to 3 centimeters in circumference, was found. In a resume, Eeich, 2 of Professor Bruns' clinic, has col- lected from the literature thirteen cases of bismuth in- toxication, of which six terminated fatally and seven re- covered. This series includes the three cases previously reported by me, which, however, occurred in the practice of other physicians who called me to see them. The re- maining three cases were those of Kaufmann (Cook County Hospital), Eggenberger, and Reich. 1 Eggenberger: Centralblatt fiir Chirurgie, 1908, No. 44. 3 Reich: Beitrage zur Klinische Chirurgie, 1909, bd. 65, h. 1. 194 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Since. then Matsuoka, 1 of Japan, reported three cases, of which two were fatal and one recovered. Most of these cases occurred in the early period of the Fig. 75. Large quantities of bismuth paste retained in pelvis, causing absorp- tion. Complete recovery after washing out with olive oil. development of the bismuth paste treatment, and usually in one of the first cases in which it was tried. Since the various warnings and my publications as to its preven- 1 Matsuoka: Deutsche Zeitschrift fur Chirurgie, bd. 102, s. 508. BISMUTH POISONING. 195 tion, the reports of bismuth poisoning- ceased to appear in the literature, in spite of the fact that its use has been extended into all parts of the world. This indicates that the paste is used more judiciously and the intoxication is avoided, thus eliminating- the one objectionable element. My brothers and I consider ourselves fortunate in not Pig. 75 A. Diagrammatic illustration of Fig. 75. A, bismuth paste in pelvic cavity ; B, sacrum ; C, greater trochanter ; D, intrapelvic abscess, cavity close to rectum ; E, symphysis pubis ; F, femur. having had a fatal case in our large series, especially so as we had no one to put us on our guard against such con- tingency. Fortunately I discovered the onset in the first- case, an empyema, early enough to prevent a fatality, and from this lesson we learned to anticipate and prevent its occurrence. 196 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Prevention of Bismuth Poisoning. The prevention consists of not allowing large quanti- ties of the paste to remain in the body for absorption. Should the symptoms appear, the paste must be removed by washing out the cavity with warm olive oil. The sterile oil is injected and retained for twelve to twenty- four hours, in order to produce an emulsion, which should be withdrawn by means of suction. After its removal all symptoms will promptly disappear. Scraping out the paste with a scoop is a dangerous procedure, because it opens fresh channels for absorption. The following case illustrates the prevention of bis- muth poisoning: R. W., aged 33, fell from a horse at the age of 15, injuring his left hip. Three months later an abscess developed, which ruptured spontaneously. Within a year the limb shortened four and one-half inches, and five sinuses about the hip developed and persisted in dis- charging pus for the next seventeen years. In the fall of 1908 the bismuth injections were begun at his home. The first few injections were made by his physician, and thereafter (he living in a rural dis- trict) the treatment had to be continued at home by the patient's wife. She "faithfully" injected every day, and after thirty days he developed typical signs of bismuth absorption — namely, blue ulcers of the gums, headache, loss of weight, etc. The radiograph (Fig. 75) demonstrates that enormous quantities of paste have accumulated in pelvic cavities, with no outlet for their return, and thus their absorp- tion. The sinuses were immediately washed out with warm olive oil, and within twenty-four hours nearly all the paste was withdrawn by means of a suction pump. Symptoms of bismuth poisoning subsided within four days, but the sinuses continued to discharge. Four weeks later I injected 30 grams of paste. The secretion changed from that of pus to serum, and two weeks later the sinuses closed. Another illustration is the following case of empyema: B. had pneumonia, followed by empyema, in the fall of 1909. A re- section of one rib was performed and drainage instituted. The sup- puration continued, however, for several months, when he was brought to me for treatment. After estimating the size of the cavity by radio- graph, I injected 16 ounces of the 33-percent bismuth-vaselin paste. Radiograph (Fig. 76) shows the size of the cavity. The paste was BISMUTH POISONING. 197 retained for ten days, and during this time the patient felt absolutely well, but thereafter he began to complain of lassitude and loss of appe- tite. An examination of the mouth showed the first symptoms of bis- muth absorption — i. e., a bluish discoloration at the margins of the gums and also bluish rings around the follicles of the tonsils. Within Fig. 76. Empyema filled with bismuth paste, causing symptoms of absorption in two weeks. Prompt removal of paste resulted in complete recovery and cure. the next twenty-four hours small ulcerations began to appear back of the wisdom teeth. The chest cavity was at once washed out with warm olive oil and the paste withdrawn with suction pump. (Fig. 77.) The cavity was refilled with sterile vaselin in order to prevent the entrance of air. The secretions in the meantime had become abso- 198 BISMUTH PASTE IN CHRONIC SUPPURATIONS. lutely sterile and reduced in quantity. The symptoms of bismuth absorption at once began to disappear, and within three weeks not a sign of them remained. The cavity was treated by repeated suction to expand the resilient lung. Two more injections of a 10-percent bis- muth paste were given at intervals of ten days. Finally all the paste was withdrawn, the cavity closed, and now the contracted lung has ex- Fig. 77. Method of withdrawing mixture of paste and olive oil twenty-four hours after injection of the latter. panded sufficiently to fill out the entire space first occupied by the bismuth paste. The sinus is closed, and the patient has gained greatly in weight and general health. We have shown that bismuth poisoning can be pre- vented, and when it does appear it can be checked. Thus we are able to eliminate the objectionable feature of the bismuth paste treatment. CHAPTER XV. BISMUTH PASTE IN THE TREATMENT OF CHRONIC SUPPURATIVE DISEASES OF THE NOSE, ACCESSORY SINUSES, EARS, AND MASTOID PROCESS. BY JOSEPH C. BECK, M. D. 1 One of the first cases of the head treated by means of bismuth paste, and subsequently reported by Dr. Emil Beck, was a tuberculous osteoperiostitis of the orbit, with abscess and fistulous formation, in a child, and so strik- ing was the therapeutic result that I from that time — January 24, 1908 — began to employ this method of treat- ment with great enthusiasm. In order to determine the value and limitations of bis- muth paste in chronic suppurations in the head and neck, I decided to experiment on every pathological condition in which the principles underlying the action of bismuth paste appeared to be indicated. In May, 1908, I made a preliminary report before the Chicago Otolaryngological Society on the injection of bismuth paste in antrum suppurations, and in October, 1908, I made a complete report before the Chicago Med- ical Society of 319 cases of the following conditions and results obtained. The results in this report were not final, as a large per- centage of these cases were at the time still under treat- ment. 1 Surgeon to the North Chicago Hospital and Cook County Hospital: Clinical. Professor of Otolaryngology. College of Physicians and Sur- geons, Chicago; Professor of Otolaryngology, Eye, Ear, Nose, and Throat College, Chicago. 199 200 BISMUTH PASTE IN CHRONIC SUPPURATIONS. CD CO c3 P4 +3 T3 CD o3 CD U H o CD S3 c3 cd CD CD PS o o as fca Mg a e 8 *§ IN H r-H i-H C6 p ?3 to n w R *d a.S Od +i Q) o o H5 a o 'A X IB M a O T c c, c aj r a -i f CD ' c/ S P 1. a a ® X t * CO cp CO S -d g,0 ^H ~* :c a 03 n t* | .2 «< .2 q a S S W o <1 ^ S o3 *= • a 6 ° « o3 rs ^ ■S3 w j-d ° q o q q m eg c3-h " o3 a 2* O ho o q ■q o g 03 o2 S o o o 3£ an SI oO P'o o f 3 ^ O ri ■- a 3 '- q M S 5 < a o on h rj ?|3 ,c q w • -q £ q q bD H 03 o 1 o ® D. * oS -* 0.2 o q ■d q 0* 2 33 o> 5, a" o © s: K 2 S3 75 S 7. 3 3S fl"H 3 =3 C q- q b 52 s q i - ill II! = X-3 i « - — — n §13 202 BISMUTH PASTE IX CHRONIC SUPPURATIONS. After more than one year of observation of these cases, treated for finding the limitations of the bismuth paste in nose and ear work, I came to the following conclusions : 1. That in atrophic rhinitis, while scab-forming and odor were controlled during the period of treatment, the curative effect upon the atrophic condition was negative, and, as the injections were more disagreeable than other methods of treatment, I have discontinued their use in this affection. 2. As a primary dressing- following submucous resec- tion of the septum, I have discontinued its use, owing to the possibility of some of the paste getting in between the mucoperichondrial flaps and thus preventing union. 3. In ethmoid suppurations I have found that injec- tions were of no avail, as the paste can not reach all the infected cells, and consequently I do not employ it in this affection; but as a primary dressing after exenteration I employ it regularly, as will be shown in this chapter. 4. In chronic lacunar tonsilitis I have come to the con- clusion that no permanent results could be obtained, and therefore it is of no greater value than any other pallia- tive treatment. 5. In chronic suppuration of the antrum of Highmore, and the frontal and sphenoidal sinuses, as a palliative treatment, I am convinced that the results are equally as good as from any other method of treatment. As a cura- tive method the paste has produced the best results in the radical obliteration of the frontal sinus and the an- trum, as will be shown later. 6. In chronic suppurations of the middle ear I continue to employ bismuth paste, and find that, while it does not cure more cases than other palliative means of treatment (the pathologic condition usually precluding such a pos- NOSE, EARS, MASTOID PROCESS. 203 sibility), I am nevertheless certain that in cases which are curable by nonoperative measures the paste treat- ment will stop the suppuration quicker and recurrences will be less frequent. 7. As a primary dressing (at the time of the opera- tion) in radical mastoid with plastic I have discontinued the employment of bismuth paste, owing to the fact that some of the paste may find its way underneath the flaps and delay healing. As a secondary dressing, however, just as soon as union has taken place, I know of no bet- ter dressing to control the suppuration and stench, which we are accustomed to see in these cases, than the applica- tion of bismuth paste. 8. As a framework for bone formation in the simple mastoid operation, with primary closure of the wound, I employ it only in the selected cases, where the bony walls of the mastoid are absolutely intact, and when the char- acter of the infection is not of a virulent type. 9. As a secondary dressing in the simple mastoid cases, I am certain there is no other method that will compare with the results in obtaining rapid and permanent clos- ure of the retroauricular wound. 10. In otitis externa eczematosa, filling the external auditory canal with the paste is preferable to other methods of local application. 11. The simplest means of controlling intranasal hemorrhage, especially when it originates from the an- terior or upper regions, is the injection of semi-solid bis- muth paste No. 2. The difficulty of controlling bleeding from the posterior and lower portions of the nasal cavity is due to the inability to retain sufficient quantity to plug that region, as it usually drops into the throat. 204 BISMUTH PASTE IN CHRONIC SUPPURATIONS. Treatment of Suppurations of the Nose and Its Accessory Sinuses. In considering the treatment of chronic suppurative diseases of the nose, I refer especially to the accessory sinuses, as suppuration of the cavity proper is usually secondary to the above-named structures, although ozena, atrophic rhinitis, and suppurations associated with foreign bodies are frequently met with. Before considering the treatment of the sinuses it will be well to mention some anatomical, physiological, and patho- logical points, so far as these bear relation to bismuth paste treatment. Anatomical Points. — The nasal accessory sinuses are solid-walled cavities, oftentimes divided by partial septa, and irregular in shape, the ethmoidal labyrinth being multicellular. They are neither compressible nor dis- tensible, and are lined by a modified mucous membrane. The openings leading into them from the nasal cavity are so located as to make the introduction of a cannula or sound somewhat difficult, and thus the treatment can be carried out advantageously only by those who are famil- iar with the technic and the use of reflected light. Physiological Points. — 1. These cavities are resonators to the voice. 2. They impart warmth and moisture to the inspired air. 3. An accessory function of the sense of smell is at- tributed to them. 4. Their hollow construction serves the purpose of mak- ing the bones of the head very light. 5. The large surface of mucous membrane has a power- ful absorptive function. Pathological Points. — There exists usually the myx- omatous degeneration of the mucous membrane with NOSE, EARS, MASTOID PROCESS. 205 polypoid formation. In very chronic cases there is fre- quently superficial osteitis, a necrosis with accompany- ing granulations. These points must all be borne in mind in the treat- ment. Without a perfect knowledge of them, one will scarcely be able to explain the difficulties in the treatment of these cavities compared with the treatment in other parts of the body. It must be stated at this time that only chronic sup- purative conditions should be treated with bismuth paste — never acute ones. The treatment is divided into two subdivisions — name- ly, (A) palliative and (B) radical, or obliterative. The formulae used in the treatment of the suppurative conditions of the nose and ear are the same as used in other parts of the body; the technic and instruments are, however, somewhat different. Instruments. — In Fig. 78 are shown the syringes and cannulas, the use of which is described in the technic of treating the various conditions. (A.) Palliative Method. Injection of Antrum of Highmore. Condition 1. — An antrum which has not previously been treated surgically. Position of patient — sitting. Cocaine anesthesia. By means of trocar the antrum is punctured in the usual manner, and without previously irrigating it the syringe proper is adjusted by its bayonet joint and the cavity injected to distention. The middle meatus is temporarily packed with cotton in order to prevent a too free escape of the paste while injecting. A small pad of cotton is placed against the opening created by the trocar, and the patient kept quiet 206 BISMUTH PASTE IN CHRONIC SUPPURATIONS. p* Sis a agS.. a; " Pi (h _, ■2^2 tn cu a o a d«^ %32 tn a O'S m >> - S is ™ d IB& QJ P. hSN to .by- *" .-S £ '> £<><> Hip, abscess at, originating in sa- crum, 38 joint abscess, cold, 162 disease, 89, 91 mortality in, 88 osteomyelitis mistaken for, 37 sinus following, 85 tuberculosis of sacrum mis- taken for, 39 Horses, fistula in, 171 Humerus, nontubercular osteomy- elitis of, 71 I Incising, danger of, cold abscess, 26 Indication for bismuth treatment, 177 for surgical treatment, 22 Infant, empyema of, 144 Infectious processes, fistula3 se- quelae of, 21 sinuses sequela? of, 21 Inferior turbinated body, applica- tion after cautery of, 214 turbinectomy, post - operative dressing in, 214 Inflammation, osteoplastic, 71 Injection in pyorrhea alveolaris, 220 of antrum of Highmore, 205 of ethmoidal labyrinth, 205 of frontal sinus, 208 of sphenoidal sinus, 208 syringes for, 28 technic of, 28 Instruments for ear, 206 for nose, 206 for throat, 206 Intoxication, bismuth, 193 avoidance of, 195 Intranasal hemorrhage, 203 Introduction, 17 Jaw, sinus of, due to cyst, 224 due to fracture, 224 Joint disease of foot, sinus from, 102 treatment of sinus following, 69 tuberculosis, clinical course of, 84 K Kidney abscess, sinus after, 123 cystic, with calculi, 119 Kidney— cont'd. operation, post-operative sinus following, 110 tuberculosis of, 122 tuberculous, 119 sinus from, 118 Knee joint disease, primary seat of, 97 tuberculosis, 100, 102 bilateral, 98 tuberculous, sinus resulting from, 95 Kyphus resulting from tubercu- lous infection, 62 Labyrinth, ethmoid, technic cf, 214 Lacunar tonsilitis, chronic, 202 Lime salts, deficiency in, 104 Limitation of bismuth paste, 171 in peritoneal cavity, 115 Limited value of peroxide of hy- drogen, 33 Lung abscess, 137, 146 bismuth paste in aftertreat- ment of, 135 multilocular condition of, 151 negative pressure for re-expan- sion of, 138 M Mastoid operation, primary dress- ing in radical, 203 primary dressing in simple, 215 secondary dressing in radical, 203,217 secondary dressing in simple, 203, 216 process, bismuth paste in chron- ic disease of, 199 bismuth paste in disease of, 215 Mechanical action of bismuth paste, 58 Mental influence as resisting fac- tor, 23 Methemoglobinemia, cause of, 1S7 Mixture, Calct's, formula for, 158 Murphy's formalin, formula for, 158 Modifying fluids, aspiration and injection of, 15S substance, action of bismuth paste as, 159, 167 Mortality in hip joint disease, 8S Mouth, bismuth paste in sinus of. 171 234 INDEX. Multilbcular condition of lung ab- scess,~151 Murphy's formalin mixture, for- mula for, 158 N Neck, table of cases of chronic suppurations about, 200 Negative pressure for re-expan- sion of lung, 138 Nephrectomy, 121 Nitrite poisoning, acute, 181 bismuth paste not cause of, 189 due to bismuth subnitrate, 183, 186 treatment of, 187 Nontoxicity of bismuth subnitrate, 181 Nontubercular osteomyelitis of humerus, 71 Nontuberculous osteomyelitis, 69, 93 Nose, bismuth paste in chronic suppurative disease of, 199 in, for other disease than si- nus, 214 in sinus of, 171 instruments for, 206 suppuration of, and accessory sinuses, 204 O Operation, empyema after Est- lander, 177 Estlander, cavity after, 140 frontal sinus, 209 post-operative sinus following abdominal, 110 following kidney, 110 radical mastoid, primary dress- ing in, 203 secondary dressing in, 203, 217 simple mastoid, primary dress- ing in, 215 secondary dressing in, 203, 216 Opsonins as protective factor, 22 Os calcis, tuberculosis in, 105 Osteomyelitis mistaken for hip joint disease, 37 nontubercular, of humerus, 71 nontuberculous, 69, 93 pyogenic, 69 sinus from, of the femur, 93 treatment of sinus following, CO tuberculous, 69, 79 Osteoplastic inflammation, 71 Ostitis, diffuse tuberculous, 81 Otitis externa eczematosa, 203, 215 media, suppurative, 215 Palliative method of bismuth paste treatment, 205 Paralysis as complication of spon- dylitis, 62 Pelvis, rectal fistula originating in the, 129 Peritoneal cavity, limitation of bismuth paste in, 115 Peritonitis, tuberculous, 115 primary source of, 113 sinus following, 110, 115 surgical treatment in, 114 Peroxide of hydrogen, limited value of, 33 Phagocytosis as protective factor, 22 Poisoning, acute nitrite, 181 bismuth, 180 due to dusting powder, 182 prevention of, 180, 196, 198 symptoms cf, 181 nitrite, bismuth paste not cause of, 189 due to bismuth subnitrate, 183, 186 treatment of, 187 Post-operative abdominal fistula of pyogenic origin, 117 dressing in inferior turbinec- tomy, 214 sinus following abdominal oper- ation, 110 kidney operation, 110 Powder, dusting, bismuth poison- ing due to, 182 Preparation cf bismuth paste, 28 Prevention of bismuth poisoning, 180, 196, 198 Primary dressing following sub- mucous resection, 202 in radical mastoid operation, 203 in simple mastoid operation, 215 seat of knee joint disease, 97 source of tuberculous peritoni- tis, 113 synovial tuberculosis, 80 Probe, bismuth paste displaces, 130 Protective factor, antitoxins as, 22 bacteriolysins as, 22 opsonins as, 22 phagocytosis as, 22 INDEX. 90 >•) Psoas abscess, cause of, 25 cold, 161 Pyogenic arthritis, 69, 79 osteomyelitis, 69 of the femur, sinus from, 93 Pyorrhea alveolaris, 219 bismuth paste in, 171 injections in, 220 R Radical mastoid operation, prima- ry dressing in, 203 secondary dressing in, 203, 217 method of bismuth paste treat- ment, 209 Radiographs, stereoscopic, in ana- tomical diagnosis, 31 Rectal fistula, 124 abscess mistaken for, 124 dermoid cyst of coccyx mistaken for, 128 originating in the pelvis, 129 technic in, 126 Re-expansion of lung, negative pressure for, 138 Reliability of bismuth paste, 33 Renal sinus, unsuspected, 41 Resection, primary dressing fol- lowing submucous, 202 Resisting factor, mental influence as, 23 Rhinitis, atrophic, 202 Ribs, sinus from tuberculous, 107 tuberculosis of sternum mis- taken for tuberculosis of, 109 Rice bodies, 82 Rules for application of bismuth paste, 52 Rupture, spontaneous, empyema of, 140 Sacrum, abscess at hip originating in, 38 tuberculosis of, mistaken for hip joint disease, 39 Secondary dressing in radical mastoid operation, 203, 217 in simple mastoid operation, 203, 216 Septal ulcer, application in, 214 Sequestrum, cause of, 71 cause of failure, 174 of ulna, 174 tuberculous, 81 Simple empyema, 140 mastoid operation, primary dressing in, 215 Simple; mastoid operation — cont'd, secondary dressing In, 203, 216 Sinus, accessory, bismuth paste in, 199 after kidney abscess, 123 bismuth paste in nose for other disease than, 214 bismuth subnitrate in, 188 cause of, 24, 26 due to spondylitis, treatment of, 60 following hip joint disease, 69 following joint disease, *reat- ment of, 69 following osteomyelitis, treat- ment of, 69 following tuberculous peritoni- tis, 110, 115 formed by contraction of ab- scess cavity, 65 from bone disease of foot, 102 from joint disease of foot, 102 from pyogenic osteomyelitis of the femur, 93 from tuberculosis of elbow joint, 105 from tuberculous kidney, 118 from tuberculous ribs, 107 from tuberculous sternum, 107 frontal, injection of, 208 technic in, 210 in spondylitis of tenth dorsal, 63 of ear, bismuth paste in, 171 of jaw due to cyst, 224 due to fracture, 224 of mouth, bismuth paste in, 171 of nose, bismuth paste in, 171 post-operative, following ab- dominal operation, 110 following kidney operation, 110 resulting from tuberculous knee joint, 95 sphenoidal, injection of, 20S technic of, 214 unsuspected renal, 41 Sinuses from tuberculous coxitis, table of cases of, 86 general consideration of, 21 sequelae of infectious processes, 21 Sphenoidal sinus, injection of, 20S technic of, 214 Spine, deformity of, in spondyli- tis, 64 Spondylitis a tuberculosis, 60 abscess as complication of, 62 deformity as complication of, 62 236 INDEX. Spondylitis — cont'd. deformity of spine in, 64 fistula as complication of, 62 mistaken for tuberculous adeni- tis, 25 of tenth dorsal, sinus in, 63 paralysis as complication of, 62 treatment of sinus due to, 60 Spontaneous rupture, empyema of, 140 Stereoradiograph as guide in ana- tomical diagnosis, 31, 146 Sternum, sinus from tuberculous, 107 tuberculosis of, mistaken for tu- berculosis of ribs, 109 Submucous resection, primary dressing following, 202 Subnitrate, bismuth, effect of, on animals, 184 in abscess cavities, 188 in empyema, 188 in sinus, 188 nitrite poisoning due to, 183, 186 nontoxicity of, 181 Subphrenic abscess following ap- pendicitis, 40 Suppuration, cause of, 24 chronic, of antrum of High- more, 202 of middle ear, 202 ethmoid, 202 of nose and accessory sinuses, 204 Suppurations, chronic, table of cases of, about head and neck, 200 Suppurative otitis media, 215 Surgical treatment, indication fcr, 22 in tuberculous peritonitis, 114 Symptoms of bismuth poisoning, 181 Syringes for injection, 28 Table of cases of chronic suppu- rations about head and neck, 200 of sinuses from tuberculous cox- itis, 86 treated, 47, 48, 49, 50, 51 of cold abscess cases treated, 165 Technic, faulty, cause of failure, 176 failure of bismuth paste due to faulty, 125 in antrum of Highmore, 211 Technic — cont'd, in chest cases, 137 in frontal sinus, 210 in rectal fistula, 126 of ethmoid labyrinth, 214 of injections, 28 of sphenoid sinus, 214 of therapeutic application, 44 Therapeutic action of bismuth paste, 54 agent, bismuth paste as, 135 application, technic of, 44 effects of bismuth paste, 44 Throat, instruments for, 206 . Tonsilitis, chronic lacunar, 202 Treatment, aid in, 20 bismuth paste, of empyema, 135 of lung abscess, 135 palliative method of, 205 radical method of, 209 of cold abscess, 157, 160 bismuth paste in, 154 of fecal fistula, 133 of nitrite poisoning, 187 of sinus due to spondylitis, 60 of sinus following joint disease, 69 of sinus following osteomyelitis, 69 Tubercle bacilli, effect of bismuth paste on, 56 Tuberculosis, bilateral knee joint, 98 in os calcis, 105 of ankle, 103 of elbow, 163 of elbow joint, sinus from, 105 of kidney, 122 of ribs, tuberculosis of sternum mistaken for, 109 of sacrum mistaken for hip joint disease, 39 of sternum mistaken for tuber- culosis of ribs, 109 primary synovial, 80 joint, clinical course of, 84 knee joint, 100, 102 spondylitis a, 60 Tuberculous adenitis, spondylitis mistaken for, 25 arthritis, 69, 82 empyema, 144 infection, kyphus resulting from, 62 kidney, 119 sinus from, 118 knee joint, sinus resulting from, 95 osteomyelitis, 69, 71 [NDEX. 2W1 Tuberculous — cont'd, ostitis, diffuse, 81 peritonitis, 115 primary source of, 113 sinus following, 110, 115 surgical treatment in, 114 ribs, sinus from, 107 sequestrum, 81 sternum, sinus from, 107 Turbinectomy, inferior, post-oper ative dressing in, 214 U Ulcer, septal, application in, 214 Ulna, sequestrum of, 174 Unexplained cause of failure, 177 Unreliability of colored fluids, 32 Unsuspected renal sinus, 41 Value of radiograph in diagnosis, 31 Vaselin, effect of x-rays on, 59 Veterinary cases, bismuth in, 171 W Wrist affected same as ankle joint, 106 X X-rays, effect of, on bismuth sub- nitrate, 59 on vaselin, 59 in chest cases, 137 COLUMBIA UNIVERSITY LIBRARIES | Rd 641 B38 C.2 Bismuth pH',tr: i!!.'.hro;iif ;,u| 2002098318 RD64-1 Beck B30 cop,