When sinuses are already present these should be opened up and scraped, and any diseased bone gouged out or sequestra removed, but as al] partial operations on tuberculous bone are liable to prove unsatis factory it is a good practice to first try the effect of injecting warm Bismuth Jelly into the open sinus, as often complete healing follows unless a sequestrum is present. Where there is evidence of carious or dead bone in the joint the gouge or chisel must be used after an open incision by Kocher's method. This gives much better results than excision of the head and neck of the femur, though when the head of the hone has become dislocated upon the dorsum ilii, and the acetabulum is extensively diseased and numerous infected sinuses are present, there may be no other choice but excision or amputation of the wasted limb to prevent lardaceous disease or death from exhaustion.
Much may be achieved in the treatment of this disease by the employ ment of the vaccine method, which will be described under Phthisis. Even when secondary infection by pus-forming organisms has taken place in the sinuses a vaccine may be prepared from cultivating the cocci, and this may be employed in addition to Human T.R. Tuberculin. In all operations about the diseased joint, the practice of the surgeon should be to avoid drainage so as to prevent this secondary infection; the cavity of the abscess or of the joint being thoroughly disinfected after curetting, the skin wound must be carefully sutured and sealed from the air, a quantity of Iodoform Emulsion having been left in it. (Though Bismuth jelly possesses such remarkable antiseptic action upon the open sinuses, it must not be injected into a sealed abscess cavity unless drainage is provided.) By resorting to vaccine treatment in apparently hopeless cases amputation may sometimes be avoided, but the worst cases should not be permitted to die without the chance being given to the patient of an operation. Nearly 4o years ago the writer operated for the late Dr. Newett upon a girl whose femur had spon taneously fractured in the upper third from extensive tuberculous dis ease; the neck, head and upper part of the shaft were destroyed by caries. After removal of the limb a large proportion of the ilium, ischium and the whole of the acetabulum were gouged away, exposing the pelvic fascia. The tissues composing the buttock were infiltrated with gela
tinous and caseating products and riddled with old sinuses. The ligature applied to the femoral artery cut through the diseased coats of the vessel, necessitating dissection of the external iliac, which he ligatured in the pelvis. Notwithstanding that the patient had suffered from night sweats and repeated hiemoptysis before the operation she made an excellent recovery and is still living and well. Bowlby has drawn attention to the remarkable fact that phthisis and scrofula very rarely develop in patients suffering from hip-joint disease.
Where complete recovery has occurred in neglected hip-joint disease with ankylosis of the joint in such a position as renders the limb useless and progression impossible or highly inconvenient, an osteotomy opera tion should be undertaken to correct the deformity, the section of the bone being made at the neck or below the lesser trochanter according to the requirements of the case. Kurphy's arthroplastic operation, which consists in transplanting between the ends of the hones a flap of fatty tissue, has proved useful in some cases by providing a movable joint.
The treatment of non-tuberculous or acute septic inflammation of the hip-joint is to he carried out on similar lines. Extension in these cases may be resorted to in order to diminish pain, but the acute abscesses which are sure to form will demand prompt incision and free evacuation of the pus, which differs materially from the secretion found in the tuberculous cases. These abscesses are liable to point in the pelvis or extend along the planes of deep areolar tissue in the thigh, and prxmia is apt to occur, hence the freest drainage is necessary after thoroughly flushing out the abscess cavity with Hydrochlorite solution. The joint will usually require to be explored by an anterior incision, and if the head or neck of the femur is found to be necrosed they must be excised and a counter-opening made for drainage through a large-sized tube.
The after-stages of the affection may be curtailed by the judicious employment of a vaccine prepared from cultures of the purulent fluid, provided that the infection keeps localised.