INJECTION WITH PURE CARBOLIC ACID.
DR. M. L. HARRIS presented a boy, seven years of age, who was admitted to the Children's Hospital, August To, 19oo, and discharged December 30. When admitted, he was greatly ema ciated, having hectic fever, pain, and the characteristic deformity of hip-joint trouble. There was a large abscess filling the left hip-joint and extending beneath the tensor vagina femoris mus cle almost to the knee. He was operated on August 29, the joint opened, and the tubercular focus, found on the upper sur face of the neck and inner surface of the great trochanter, re moved with the curette. The joint was filled with pus and tuber culous granulations, which were removed with the curette. The abscess, extending down the thigh, was opened in the same way, and posteriorly where an abscess had dissected backward. The joint was filled with pure carbolic (95 per cent.), and al lowed to remain one minute, when it was removed and alcohol used, as recommended by Phelps, of New York. All the cavities were filled in the same manner, and washed out with alcohol and dried thoroughly with gauze. A large drainage tube was used. and the wounds packed with gauze. A long anterior Thomas splint and plaster to fix the joint were used. Improvement was rapid ; the cavities closed up, and the joint is now well.
Dr. Harris presented a second patient, a boy, nine years of age, who was admitted to the hospital July 9, and operated upon July Is. The case was essentially the same as the first one. The joint was opened, the tuberculous focus found on the upper sur face of the neck extending into the joint, and was thoroughly removed with the curette. The joint was filled with carbolic acid and washed with alcohol in the same manner as in the first a large drainage tube being introduced, the joint packed, the wound dressed in the same manner with Thomas splint, and the boy is now running around.
Dr. Harris mentioned three more cases in the hospital which he had treated in the manner described, but they had been oper ated upon so recently that they were not well enough to be pre sented. In both the cases presented excellent motion in the joint was preserved.
DR. L. L. MCARTHUR stated that in large abscesses about the hip-joint, presenting the classical symptoms of hip-joint disease, the great temptation has been to make the classical incision down into the joint at once. The conservative surgeon should explore any sinus or abscess cavities that may be associated with apparent hip-joint disease, and see whether the tubercular focus lies in the fossa within the greater trochanter, or whether it be a tubercu losis of the margin of the acetabulum, for in 2 or 3 per cent. of the cases the hip-joint may be spared if these early operations be done, not incising the joint, but curetting the diseased area, which will be found in a number of cases to be outside the joint. He has twice cut into joints without finding disease, but found the disease either in the greater trochanter or on the margin of the acetabulum ; remembering that fact, he has called attention to it in his last term of service at his clinics in St. Luke's Hospital. In a typical hip-joint case he found tuberculosis of the margin of the acetabulum, but not involving the joint, thus obviating the need of opening the capsule.
DR. HARRIS said that he had not used this treatment in any case of primary synovial tuberculosis. He has used it in five cases of hip-joint trouble and in two of tuberculosis of the elbow-joints. In all cases he had to deal with primary osteal tuberculosis.
In regard to the incisions for the removal of the capsule, the capsule is not dissected out ; and it is not the intention to do so in this method. The tuberculous sequestra are removed always by means of the curette, and no bone is sacrificed except the tubercu lous area. The interior of the joint is curetted, so that the granu lations may be removed and the joint cavity filled with carbolic acid.
Replying to a question, he stated that scars, after the healing of tuberculous wounds, are always red and present the charac teristic appearance of these scars for some time. Furthermore, tuberculosis, when once lodged in bone, probably never entirely disappears. He has no doubt but that there is tuberculosis still in both of the cases, but, so long as there are no clinical manifes tations of the disease, the patients are said to be cured. The disease may remain dormant for a number of years and then develop again.
The point brought out by Dr. McArthur of following up sinuses he agrees with ; and in one of his cases, in which there was a large extra-articular abscess, it was opened first, and the abscess tract followed up until it was determined where it led to. It extended to the upper surface of the neck and from there into the joint. It is wise advice to follow sinuses, at present, to see if the joint is involved, rather than open into the joint and then find out whether it is involved or not.