occurs and is rendered possible of detection by fluctuation, the abscess, however small, should be opened. The incision should be of no greater length than necessary to insure complete evacuation of the pus and subsequent drainage. In order to render the scar but slightly conspicuous, surgeons should open superficial abscesses, when possible, by a horizontal incision, thus insuring its concealment by the collar. The horizontal incision is also preferable to the longitudinal, for the reason that the resulting scar is less likely to be reddened and hypertrophied on account of the diminished traction incident to the frequent turning of the head. If the abscess is deep, the direction of the incision, however, must be determined with reference to the position and course of the blood-vessels, surgeons prefering an oblique downward and forward incision at the upper part of the neck, but a transverse one in the lower portion. Precaution should be taken not to insert the knife too far into the tissues of the neck. Either a pair of blunt-pointed scissors or a grooved director should penetrate the fascia in a search for the suppurating cavity. After the insertion of the scissors or forceps into the abscess, the fascia should be torn and stretched by withdrawing the instrument opened, thus avoiding the danger of injury to immediate structures.

Curetment is sometimes employed, especially in cases of large abscess formation, and is particularly applicable to gland sinuses with a probable mixed infection. When prolonged anesthesia and radical surgical intervention is precluded by the general condition, it is occasionally permissible to attempt the disintegration of glands by this process, the results varying according to the thoroughness with which the glandular tissue is scraped away. To remove this entirely without penetrating the adherent capsule is well-nigh impossible, while considerable traumatism may result, not only involving possible injury to immediate bloodvessels, but also producing a rapid extension of the tuberculous infection to other parts.

Mayo recommends the application of iodoform emulsion or tincture of iodin following incision and curetment, and an immediate closure of the incision in order to avoid prolonged drainage. Sinuses are stimulated with phenol in order to effect as complete sterilization as possible. Gould prefers the application of a solution of zinc chlorid, 40 grains to the ounce, as an efficient germicide. In many cases it is sufficient to pack lightly the cavity with iodoform gauze for a few days. The operation is simple, necessitates but a small incision, and leaves, as a rule, no disfiguring scar. There is but little danger of penetrating the capsule and injuring veins, arteries, or nerves, provided a blunt spoon curet is employed. The deficiencies of the operation relate to its unreliability and the possibility of further tuberculous extension.

Total excision of tuberculous glands is, in the majority of instances, the operation of choice. This time-honored procedure is said to have originated with Galen, and to have been employed by Paré. It is of some interest to note, however, that for several hundred years up to the latter part of the nineteenth century, the attempt to remove enlarged glands of the neck was quite uniformly deplored. Cooper, in 1815, objects to the practice "because the removal of a scrofulous gland can hardly be said to do much good to a patient whose whole system is under the influence of strumous enlargement." Druit, in his "Modern Surgery," published in 1841, states that "it is sometimes expedient to extirpate one or more glands," but deprecates such effort in nearly all cases. Miller, in his "Principles of Surgery," published in 1853, says:

"It is almost unnecessary to state that chronic enlargements of lymphatic glands by tuberculous deposit in the neck are not to be made the subject of severe operation, discussed, they may be, or by suppuration they may be broken down and extruded, but extirpation is, in truth, but reckless and unwarrantable cruelty, injurious to the patient, surgeon, and surgery." Erichsen and Ashhurst, in 1869, state that "excision of enlarged cervical glands is seldom necessary, and advise against undertaking the operation unless the disease has been of many years' standing and the glands very large." In 1873 Hamilton, in his "Practice of Surgery," says: Excision has in all cases been followed by a speedy return. After the most thorough extirpation, new glandular enlargements have soon been presented." He urges the limiting of operation to cases "in which only one or at most only a few adjacent glands are involved, and then not until the size and relation of the tumor immediately imperils life." In 1881 Savory and Roberts, in Holmes' "System of Surgery," state: "Should the tuberculous gland be removed by operation? Hardly ever. The operation can be justified only when the glands have remained for a very long time stationary in spite of all local measures and constitutional treatment, and when it is an unsightly deformity or not connected with diseased glands more deeply situated."

Such teaching in comparatively recent years, denying the rationale of complete excision of tuberculous glands, is somewhat startling in view of our present knowledge regarding the relation of lymphatic enlargements to pulmonary tuberculosis and general miliary infections. Groben, after an analysis of the statistics of several clinicians, reports that pulmonary tuberculosis developed in 75 per cent. of all non-operated cases, and in less than 15 per cent. of those undergoing excision. The conclusions of other observers hardly bear witness to these results, but the evidence remains irrefutable that the proportion of cases developing other foci of tuberculous infection is much larger in patients denied the benefit of active surgical interference. In this connection it is of much interest to read the remarkable words of John Browne, of whom mention has been previously made, apropos of healing by "royal touch," as quoted by Stoll. In the seventeenth century he says: "These tumors do require extirpation and extraction. to be so dexterously performed as that no part be left behind. Our greatest advice in the use of the knife is to have a particular and special care to the vessels bordering upon the parts, namely, the nerves, veins, and arteries, lest they be injured thereby. The glands are to be extracted with great care and caution, so as no vessel whatsoever be injured by the operation; and if any flux of blood may happen in this operation, it is presently to be stopped with restrictives, and this method is to be prosecuted till every part of the cystus or bags thereof are perfectly and thoroughly eradicated and extracted, the which being done and the part clean, mundifie the ulcer, digest, incarn and then induce a cicatrix."

It is scarcely within the province of this book to elaborate the technic of the operation. It is sufficient merely to call attention to several important considerations in connection with the principles of surgery as applied to glandular tuberculosis.

A large proportion of cases of cervical adenitis are suited to radical operation. The existence of a moderate pulmonary infection does not in itself offer any distinct contraindication for operative interference. If the pulmonary involvement is not far advanced, the indications for oper

ation are emphasized by the very fact of its existence. Added opportunities for recovery are offered by virtue of the removal of an important and often primary focus of infection. The supposed danger of anesthesia to the consumptive has been found by actual experience to be largely a myth. I do not recall a single instance of unfortunate results of chloroform or ether anesthesia among the many phthisical patients undergoing operation for various causes.

Complete extirpation of tuberculous glands is often one of the most difficult and tedious operations which the surgeon is called upon to perform. It should not be undertaken by other than those possessing an excellent technic and thorough familiarity with the anatomic relaA most important consideration is the complete and thorough removal of all affected glands. To this end search must be made patiently and carefully in the midst of highly important structures for almost innumerable glands not originally detected.

Much has been written about the advantages and disadvantages of the various forms of incision. Some surgeons recommend several small ones, either oblique or transverse; others urge large sweeping incisions, either of the letter Z or letter S shape, or conforming to a simple transverse curve across the upper portion of the neck. No conventional incision is applicable to all cases. The essential desideratum is to have plenty of room, and this demands a large opening, extending in many cases from the mastoid to the clavicle, regardless of subsequent deforming cicatrix. To avoid injury to important parts the dissection should be made as much as possible with a blunt instrument. Care should be taken to remove the glands intact without rupture of their capsule, in order to prevent all danger of disseminating the infection through contamination of the wound. This possibility, together with the danger of injury to nerves and blood-vessels, represents one of the disadvantages of the operation. Its thoroughness, however, more than offsets any objections incident to its severity. It is essential to remove with a wide excision all gland-bearing fascia. A subcuticular suture will lessen the prominence of the scar.

Further discussion of the surgical details is inappropriate in connection with a work devoted to pulmonary tuberculosis. It is permissible to allude briefly to the danger of wounding veins, arteries, and nerves.

The chief parts liable to injury are the jugular vein and the spinal accessory nerve, together with the pneumogastric, phrenic, laryngeal, sympathetic, and the facial.

He

A somewhat unique accident, occurring in the course of operation, came under my observation seven years ago. A young man consulted me in January, 1900, with reference to a tuberculous enlargement upon the right side of the neck the size of a hen's egg. had been operated upon in 1891 by Dr. W. T. Bull, who removed a large mass from the left side. I advised immediate operation for the right-sided involvement, and referred the patient to Dr. Powers. The patient, however, after some delay submitted to operation at the hands of a surgeon in another locality. I was not present at the operation, but was informed subsequently that there was profuse hemorrhage and that, by means of an aneurysm needle, the deep vessels were tied with heavy silk ligatures. It was found impossible to complete the operation after this on account of the collapse of the patient. Upon recovery from the anesthetic there were distressing spasmodic cough and aphonia. The severe cough was practically constant for several days, while the loss of

voice persisted for some weeks. After a gradual subsidence the cough was quickly excited at all times by gentle pressure in the region of the wound. About five weeks subsequent to the operation the patient again came under observation and the further management was directed by Dr. Powers, who reported the case at length. On account of the unsatisfactory condition of the patient, it was not thought wise to attempt any surgical interference until January of the following year. Powers reports: "The scar on the right side of the neck was exceedingly irritable, even slight pressure at any point in its upper third occasioned severe spasmodic coughing. Nearly a year following the previous operation the end of a heavy silk ligature presented at the upper end of the sinus. Traction with an artery clamp occasioned intense coughing, pain, shortness of breath, and vomiting." During the operation, which followed shortly, the loop of the ligature was found surrounding a large mass of granulation tissue, in the midst of which lay the pneumogastric nerve. "The slightest interference with this portion of the wound and the slightest traction of the ligature brought on alarming coughing and cyanosis." The patient made a good recovery. Some months after the operation the tendency to cough upon pressure at the site of the wound almost disappeared. During the last few years his recovery has seemed apparently complete, until a recent appearance of glandular enlargement, for which the bacilli emulsion is being administered at the present time.

The tendency to recurrence should always be borne in mind. Mayo has pointed out that the term recurrence is used improperly in that the enlargement is due to the growth of new glands, rather than to an impossible reappearance of glands once removed. It should be made clear to the patient and friends that the excision of enlarged glands offers no positive assurance that other glandular structures previously quiescent may not come to the front in due time, and present themselves in the neighborhood of the former site. The percentage of recurrences varies from about 25 to 70, as reported by several observers. Mayo reports that during the past four years there have been operated in Rochester 235 cases for primary tuberculous enlargement of the glands, and but 15 cases for secondary involvement.

The return of the trouble is not always due to a lack of skill or knowledge on the part of the operator at the time of the initial operation, nor is it dependent necessarily upon an impaired condition of the patient.

I recall the case of a young man who consulted me in 1896, immediately upon arrival in Colorado, on account of moderately enlarged tuberculous glands of the left side of the neck. There was no evidence of tuberculous lesion elsewhere, the general condition was unusually robust, the patient was plethoric, and nutrition was unimpaired. An operation which lasted several hours was performed very patiently and skilfully by Dr. Edmund J. A. Rogers. During the next few years four different operations were performed by the same surgeon for enlarged tuberculous glands upon each side of the neck, the general condition remaining unimpaired, with no evidence of tuberculous infection in other parts of the body. Enlarged glands continued to appear, however, with but little delay, following each operation, and there finally developed an acute miliary infection which terminated his suffering.

It is a reasonable assumption that had this case been observed after the discovery of the x-rays, better results might possibly have been obtained from their employment as a postoperative procedure.

SECTION V

TUBERCULOSIS OF BONES AND JOINTS

CHAPTER LXIII

ETIOLOGIC AND PATHOLOGIC CONSIDERATIONS

THE etiology of tuberculosis of the bones and joints is not especially different in its essential characteristics from the conditions giving rise to involvement of other parts of the body.

The pathologic condition is due primarily to the presence of the tubercle bacillus in the affected part, although the manner of its introduction to the seat of the disease is not always entirely clear. A somewhat obscure conception as to the precise method of infection, arises by virtue of the supposed protection of the parts from an anatomic standpoint, the dense structure, the frequent sharp localization of the diseased area, and the failure to discover a possible neighboring focus of tuberculous. infection. Further confusion results from the promulgation of the theory of a strong hereditary influence in determining the development of the disease. The acceptance of certain clinical data also affords ground for widely differing opinions regarding the etiology. It is well known that the great majority of cases of tuberculosis of bones and joints develop in early life.

Whitman

Billroth reports one-third of all cases to have occurred during the first ten years of life, and one-half before the twentieth year. reports, out of a total of 5461 cases of tuberculous disease under treatment at the Hospital for Ruptured and Crippled, that seven-eighths of the patients were under fourteen years of age and that 85 per cent. of those recently treated were in the first decade of life. The fact remains, however, that it not uncommonly develops among apparently strong and healthy individuals without any evidence of preëxisting tuberculous disease or other assignable cause. I have had occasion to note, in a rather surprising number of cases, the so-called idiopathic development of tuberculous processes in bones and joints among adult robust farmers and others accustomed to physical activity in the open air.

The rôle of trauma, with or without penetrating wounds, constitutes another etiologic phase susceptible perhaps of varying interpretations. Slight concussion without visible wound has been followed by distinct infective processes, while severe contused or penetrating injuries have often occasioned no evidence of tuberculous bone lesions despite the presence of apparently similar conditions.

Incised wounds have been known to heal promptly with the speedy subsequent appearance of a localized tuberculous process in individuals. presenting every external appearance of vigorous health. On the other hand, invalids with advanced pulmonary tuberculosis rarely develop bone or joint lesions. Further, the parts most frequently affected are those least liable to external injury. Tuberculous lesions of the lower