Presented by Wallin W. King, D. 0, COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA THE JHIP AND ITS n DISEASES <^ * BT V7P. GIBNEY, A.M., M.D. PROFESSOR OF ORTHOPEDIC SURGERY IN THE NEW YORK POLICLINIC ; ASSISTANT SURGEON TO THE HOSPITAL FOR THE RUPTURED AND CRIPPLED; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE ; FELLOW OF THE AMERICAN ACADEMY OF MEDICINE ; MEMBER OF THE NEW YORK PATHOLOGICAL SOCIETY, OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK, OF THE NEW YORK CLINICAL SOCIETY, OF THE PRACTITIONERS' SOCIETY Of NEW YORK; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION, OF THE AMERICAN NEUROLOGICAL ASSOCIATION, ETC., ETC. BEBMINGHAM & COMPANY, 28 UNION SQUARE, EAST, NEW YORK. 20 KING WILMAH ST., STRAND, LONDON. 1884. 5" COPTKIGHT, 1883, BY BERMINGHAM & CO. OUT Of GRATITUDE TO A FRIEND AND ADMIRATION FOR AN HONORED MEMBER OP A PROFESSION WHICH RECOGNIZES HIM AS gin 2lutfjorfn> IN THREE DISTINCT BRANCHES OF MEDICINE, THE WRITER DEDICATES THIS VOLUME TO C. MACNAMARA, F.R.C.S., ENG. SURGEON TO AND LECTURER ON SURGERY AT THE WESTMINSTER HOSPITAL, SURGEON TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL SURGEON MAJOR H. M. INDIAN MEDICAL SERVICE. PREFACE. For nearly thirteen years I have resided in the Hospital for the Ruptured and Crippled, all of my time being devoted to daily service in both the in-door and the out-door de- partments. This hospital is well known for the large num- ber of orthopedic cases that come under observation and treatment. For instance, during my term of service the annual reports show that up to the present time 2048 cases of " hip-disease" alone have been treated, and a very large proportion of this number have been under my own ob- servation. The hospital is further known as an extremely conserva- tive institution. Dr. Jas. Knight, its founder and surgeon in-chief, has been led by his extensive experience to adopt a plan of treatment which coincides, in many respects, with the definition I have elsewhere given of the term expectant. It will therefore be readily seen that the writer of this book has enjoyed unusual facilities for the study of the clinical history of bone and joint diseases. A large num- ber of our cases in the wards are of this nature, and many remain in hospital for two or three years. The record of signs and symptoms as they occur has been made without any bias, and it is seldom that any interpreta- tion even, of these changes appears on the books. My aim, in other words, has been to picture every case from its beginning to its close. Our case books, which now number several volumes, will show how well we have succeeded, and they will show too that the notes have been made by or at the dictation of myself. My observations have not been confined especially to cases under the non-mechanical treatment. My relations with those gentlemen who are fully committed to mechani- cal therapeutics have been close enough to permit from time to time personal examination of their own cases ; and V PREFACE. many of these cases I have seen and recorded my diagnosis, with reasons therefor, before the splints have been applied. The privilege therefore has thus been afforded me of study- ing this disease under the various methods of treatment; and the fulness of my notes at different periods as the cases progress has made it quite unnecessary for me to rely on impressions not based on fact. For unusual facilities in the pursuit of my studies I am under many obligations to my very good friend Dr. Jas. Knight the distinguished surgeon-in-chief of the hospital. To the members of our house staff Drs. S. M. Taylor, H. P. Cooper, and H. J. Bogardus I am very much indebted for assistance in the preparation of this work for the press. With general surgeons I have likewise had many oppor- tunities of studying the results of operative procedures. It therefore gives me much pleasure to thus publicly thank Drs. Taylor, Judson, Shaffer, Yale, and Stillman for privileges extended me in examining their apparatus as well as cases under their care; Drs. W. T. Bull, C. T. Poore, Jno A. Wyeth, F. S. Dennis, and other surgeons for similar acts of kindness. I feel that I can thus present a pretty accurate picture of the clinical features of bony lesions of the hip, both under the expectant and the mechanical forms of treatment. That such a book is needed none will deny; that the writer of the present volume has succeeded in producing such a book my readers will decide. The limited time at my disposal, the hard work of hospi- tal life, the opportunities that city life affords for recrea- tion after a day of toil, mental and physical, must be my apologies for the many imperfections contained herein. V. P. GIBNEY. NEW YORK, November, 1883. CONTENTS. CHAPTER L INTRODUCTION. FAGS The present status of therapeutics^Classification Method of ex- amination Schedule for final results 18 CHAPTER II. THE ANATOMY OF THE HIP. Surface anatomy The muscles arranged according to function The fascia of the hip The bursae about the hip The ligaments Synovial membrane The articulation Centres of development. 30 CHAPTER III. SPRAINS AND CONTUSIONS OF THE HIP. Symptoms Diagnosis Cases illustrative Treatment. 50 CHAPTER IV. NEUROSES OF THE HIP. Definition Comparative frequency Case of neuromimesis Diffi^ culties of diagnosis Points in differentiation between neuroses and bone lesions Treatment. , . 59 CHAPTER V. I. RHEUMATISM OF THE HIP. Reasons for recognition in nosology Illustrative cases Elements in diagnosis Cases showing how easily error may arise Prog- nosis Treatment 74 II. CHRONIC RHEUMATIC ARTHRITIS (MALUM COXM SENILE). Pathology Cases illustrating clinical history Diagnosis Treat- ment 85 6 CONTENTS. CHAPTER VI. COXO-FEMORAL PERIARTHRITIS. PAGE Pathology Fibrous periarthritis not considered Course of disease, with cases The diagnosis and its importance Lesions from which differentiated Simplicity of treatment 94 CHAPTER VII. BURSITIS OF THE HlP. Bursse most frequently affected Causes Diagnosis Cases Danger of expectancy in ilio-psoas bursitis Treatment and prognosis Recapitulation no CHAPTER VIII. ACUTE PRIMARY SYNOVITIS. Symptoms illustrated by cases The synovial origin of bone diseases not established Blisters and poultices 121 CHAPTER IX. I. ACUTE EPIPHYSITIS OF THE HIP. The infrequent use of the term Its significance and value Analysis of cases reported as diastasis Diagnosis Its similarity to syphilitic lesions The incompleteness of cure Treatment. . . . 135 II. DIASTASIS OF THE HEAD OF THE FEMUR. Definition Signs and symptoms Traumatic as distinguished from pathological Rarity of the former Case illustrating difference of opinion Diseases and conditions from which differentiated Conclusions 146 CHAPTER X. I. PERIOSTITIS OF THE HIP. Definition Pathology Etiology Clinical history Cases illustra- tive Diagnosis A mode of origin of chronic ostitis Value of the probe Prognosis 153 II. MALIGNANT DISEASE OF THE HIP. The most common form Period of life for periosteal sarcoma Importance of early diagnosis Fatality. , . , , , , . jj CONTENTS. 7 CHAPTER XI. CHRONIC ARTICULAR OSTITIS OF THE HIP. PATHOLOGY. PAGE Different views The pathology as taught Cases to illustrate the bony nature of Disposition of several foci to become involved Distinction between terms in vogue Conclusions 170 CHAPTER XII. ETIOLOGY OF CHRONIC ARTICULAR OSTITIS. Opposing views Definition of struma Statistics to prove the strumous origin of Similarity of struma with syphilis The possibility of a non-strumous origin Is joint disease a cause of strumous diathesis ? Deductions 203 CHAPTER XIII. CLINICAL HISTORY AND COMPLICATIONS OF CHRONIC ARTICULAR OSTITIS. Division into stages The dependence of symptoms upon pathology Cause of atrophy The hip-limp Reflex muscular contrac- tion Symptoms and signs of first stage Second stage defined Third stage Complications Dislocation nearly always pathological Tubercular meningitis Lardaceous degeneration. 227 CHAPTER XIV. DIAGNOSIS OF CHRONIC ARTICULAR OSTITIS. PART I. THE FIRST STAGE. Possibility of determining initial lesions Diseases from which to be differentiated Detailed account of each Cases illustrating difficulty of 268 PART II, THE SECOND STAGE. Perinephritis Primary perityphlitis Caries of vertebrae Acute epiphysitis 306 PART III. THIRD STAGE. Traumatic dislocation Caries of pelvic bone Definition of rheu- matism 316 CHAPTER XV. THB TREATMENT OF CHRONIC ARTICULAR OSTITIS GENERAL CONSIDERATIONS. Modes of treatment Nature's cure Is it the best ? The expectant treatment Definition Typical cases Results Claims 32? 8 CONTENTS. CHAPTER XVI. TREATMENT OF CHRONIC ARTICULAR OSTITIS WITH CRUTCHES AND HIGH SHOE, WITH OR WITHOUT FIXATION. I. THE PHYSIOLOGICAL TREATMENT OF DR. HUTCHISON. PACK Its simplicity Difficulties of carrying it out Results Conclusion. 337 II. PHYSIOLOGICAL TREATMENT COMBINED WITH FIXATION SPLINTS. Hamilton's wire gauze Vance's leather splint Pattern for same The Liverpool method Hugh Owen Thomas's splint Mode of correcting deformity Analysis of cases 344 CHAPTER XVII. THE TREATMENT OF CHRONIC ARTICULAR OSTITIS BY EXTENSION APPARATUS WITH OR WITHOUT MOTION. Bauer's splint Washburn's splint Hutchison's splint Taylor's long-splint Taylor's modified splint Shaffer's lateral screw Sayre's long splint Judson's modification Mode of applying splints Willard's splint Sayre's short splint Chance's ap- paratus Stillman's sector splint Stillman's brace for hip and pelvic deformity Roberts' elastic tension splint Conclusions. . . 358 CHAPTER XVIII. OPERATIVE TREATMENT IN CHRONIC ARTICULAR OSTITIS OF HIP. Drilling trochanter for arrest of disease Macnamara's results Ex- cisions Incorrectness of statistics Indications for operation Mode of operating Operations for relief of deformity Barton's Volkmann's subtrochanteric osteotomy Conclusion 388 TABLE OF ILLUSTRATIONS. FIG. PACK 1. Bursae in Front of the Joint 37 2. Bursae at the Back of the Joint 38 3. Front View of Capsular Ligament 39 4. Back View of Capsular Ligament 40 5. Ligamentum Teres 43 6. Diagram showing the Course Pus takes in Perforation of Ace- tabulum 45 7. Plan of Development of the Femur by Five Centres 47 8. Vertical Section through Hip-Joint of an Adult 48 9. Vertical Section through H ip- Joint of a Child 49 10. Round-celled Periosteal Sarcoma 164 11. Acetabulum and Head of Femur, showing Discolored Spot on Latter 175 12. Specimen of Diaphyso-Epiphysitis 178 13. Vertical Section of Proximal End of Normal Femur 183 14. Vertical Section showing Foci of Disease 184 15. Section of Sound Femur in Fricke's Case 185 16. Section of Morbid Femur in Fricke's Case 185 17. Volkmann's Case 186 18. Showing Rapid Destruction of Bone in Barwell's Case 189 19. Mr. Holmes' Specimen to illustrate Caries of the Neck 190 20. From Volkmann's Colored Lithograph, showing Exfoliation of Articular Cartilage 191 21. Caseous Ostitis, Remnants of Head Neck and Acetabulum fused together in Attempt at Repair, Trochanter displaced upward 192 22. Section of the Sound Femur to compare with Fig. 21 193 23. Changes in Acetabulum in the Advanced Stages 195 24. Abscess from Acetabulum 196 25. Section of Femur 197 26. The Usual Deformity of the Third Stage 255 27. A Compensatory Lordosis of the Third Stage 256 28. The Real Deformity in a Case of Spontaneous Cure in Third Stage 257 29. A Goniometer 274 30. Mr. Thomas's Method of securing Fixation of the Body 275 31. Beginning of the Second Stage 308 32. End of the Second Stage 308 33. Articular Ostitis of Both Hips 335 IO TABLE OF ILLUSTRATIONS. 34. Hamilton's Splint Front View 345 35. Hamilton's Splint Rear View 345 36. Pattern for Leather Hip-Splint 346 37. Dr. Vance's Leather Splint 348 38. Wrenches for Orthopedic Practice 350 39. The Thomas Splint Front View 352 40. The Thomas Splint Rear View 353 41. Mode of Correcting Deformity with the Thomas Splint 354 42. Dr. Bauer's Splint 359 43. Dr. Washburn's Splint 359 44. Dr. Hutchison's Splint 360 45. Dr. Taylor's Mode of reducing Deformity 361 46. The Modified Taylor Splint 362 47. Long Splint used by Dr. Sayre 363 48. Dr. Shaffer's Lateral Screw 363 49. Dr. Shaffer's Lateral Screw attached to the Taylor Splint 364 50. Dr. Shaffer's Lateral Screw attached to the Taylor Splint 364 51. Dr. Judson's U-shaped Attachment 365 52. Adhesive Strips prepared for Splints 366 53. The Plaster applied 366 54. The Taylor Splint applied 368 55. Dr. Taylor's "Joint-Supporting" Splint 369 56. Dr. Willard's Splint 370 57. Dr. Sayre's Splint 371 58. Mr. Chance's Apparatus 372 59. Dr. Stillman's Sector Splint 373 60. Dr. Stillman's Splint applied 374 61. Dr. Stillman's Brace for Hip and Pelvic Deformity 376 62. Spring for Dr. Roberts' Splint 377 63. Dr. Roberts' Splint 378 64. Dr. Sayre's Wire-Breeches 399 THE HIP AND ITS DISEASES. CHAPTER I. THE INTRODUCTION. In studying any subject connected with the science of medicine necessary attention to detail should be the chief consideration. And in a subject like the present, when there is so much that is not clear, so much that is taken for granted, it seems to me that the diseases of the hip are certainly worthy of extended study. There are certain points about these diseases that I claim to have made myself familiar with ; there are certain facts that I have gathered here and there that enable me to speak with a positiveness that sometimes borders on dog- matism. In the whole range of surgery there is very little that is really positive on this subject. Year after year witnesses the introduction of new forms of apparatus, new methods of treatment, or revivals of the same principles in old ap- paratus, and year after year witnesses the failure of the same to meet the diseases set forth. Not that I am aiming to depreciate the progress in the treatment of joint diseases, but there are certain stubborn facts that cannot be overlooked. It is a fact that physicians, as a rule, still call all the lesions in or about the hip, whether they be acute or chronic, hip-disease. It is a fact that many children grow up to adult life with short limbs and stiff hips. 18 DISEASES OF THE HIP. It is a fact that an exceedingly small number of cases of what is looked upon as "genuine hip-disease" get well without deformity or lameness, let them come under the most approved mechanical treatment early or late. It is a fact that the lay public still looks with disfavor, or at least with apathy, on the mechanical treatment of dis- eases of the hip. On the other hand, it is a fact that the majority of chil- dren in the better walks of life receive mechanical treat- ment when their hips are diseased. It is also a fact that the orthopedic surgeons, with few exceptions, have discarded what is known as the old expec- tant method. My earnest endeavor in the pages of this book has been to contribute something toward the classification of dis- eases about this articulation. I shall feel that some good will have been accomplished if I can succeed in establish- ing at least two grand divisions ; if I can set on one side all those lesions of the soft parts, without and within the joint, many of which are of an acute nature ; and on the other side, that lesion which gives the results we all dread so much that lesion beginning in the bones, entering into the formation of the joint, and known as "true hip-disease." All orthopedists are working in this direction, and classi- fication is becoming nearer perfect as diagnosis and path- ology are more closely studied. Mr. Barwell has done much to simplify the study of joint diseases, and in his last edition such terms as ostitis, epiphysitis, chondritis, in connection with joints, encourages us to believe that the time has come, or is rapidly approaching, when we can recognize these various diseases and intelligently direct treatment. Diagnosis is, after all, one of the most im- portant steps in the management of joint diseases. The anatomy of the hip is stereotyped, and very little can be given that is not found in Gray, Quain, and Morris. Indeed, the chapter I have introduced is merely a compila- tion from text- books, and I lay no claim whatever to any originality. But for the need one always feels of anatomical knowledge in studying surgical diseases, I should not say anything about the anatomy of the hip. Much that is not found in the ordinary text-books is found in Morris, on the " Anatomy of the Joints," and as this valuable work is unfortunately not found in many American libraries THE INTRODUCTION. 19 I make no further apology for the reproductions to be found in the next chapter. In the chapter on Sprains and Contusions an effort has been made to render the diagnosis easy, and some suggestion as to prognosis I have ventered to make, although at variance with popular teachings. The impression prevails among the laity, and the profession as well, that a sprain or a contu- sion of a joint are serious accidents and far-reaching in their results. The introduction of a few cases from the large number that have come under my own observation clearly contradicts this impression, and I am sure they will suggest many similar cases in the practice of other physicians. If I do not make one point strong enough by way of excep- tion in this chapter, I want to emphasize the fact that I am not a disbeliever in the development of chronic joint dis- eases from slight injuries occurring at a time when the sys- tem is in a poor or vicious state of nutrition. Under such circumstances sprains and contusion often lead to grave joint lesions. During a convalescence from a continued fever or from any of the exanthemata, such conditions of the system may often be found to exist. When any injury, however trifling in appearance, occurs at such juncture an early diagnosis is of vital importance, and the treatment by rest during repair is equally important. Next in order we have a class of symptoms that are grouped under the term neuroses, and I have made a chapter on Neuroses of the Hip. It may seem that such lesions belong to neurology, but inasmuch as these cases come frequently under the observation of the orthopedist, and questions of differential diagnosis come up for settle- ment, I have deemed it highly important to class this ail- ment under the diseases of the hip. We hear much now of hysterical joints, of neuromimesis, and of the old Brodie-joint. These all depend on some altered condition of the spinal nerves, and their recognition saves much valu- able time to the patient. These are the cases that " go the rounds," see all physicians, and are finally cured either by heroic treatment or by the magic touch. It is quite true that neurological science is furnishing much that is of value to us in the study of joint diseases, and in no affection is the connection between the two specialties more marked than in neuroses. I have had the courage to introduce a chapter on Rheu- 20 DISEASES OF THE HIP. matism among the diseases of the hip. All of us are taught to look with a deep sense of pity on a man who calls a " hip-disease" " rheumatism," and we begin to think that this is one of the errors of the dark ages. My sense of pity is not so acute as it formerly was, and I have reached the conclusion from cases in actual practice that subacute and chronic rheumatism, both of the muscular and the arthritic varieties, do exist in the monarticular form in children. I have incorporated several cases that seem to me conclusive. In districts where damp weather prevails and where malaria abounds there are many cases of this nature; and while some clinical lecturer may occasion- ally find a child at his clinic in whom rheumatism has been diagnosticated where a true bone disease exists, there are many more in whom such a diagnosis has been made that do not come to the clinic. Still, this is a not uncommon error, and a chapter on the subject will serve to bring out the points in diagnosis all the more sharply. On the subject of chronic rheumatic arthritis themalutn coxae senile of some authors I fear I have not been suffi- ciently explicit. Many of these cases I have had an oppor- tunity of examining, and have made myself familiar with their clinical history; but I have not had the treatment of the same, because the hospital with which I am connected is exclusively for children. Still, from a study of a few that I have seen under treatment and reported in current literature, I have aimed to set forth principles in treatment that I feel convinced will lead to good results. These are a very unfortunate class of sufferers, and the lesion once being recognized, free passive motion of the joint under an anaesthetic sometimes affords decided relief. While the term periarthritis, as originally employed, desig- nated a subacute or chronic lesion limited to the fibrous structure in close proximity to the joint, I have found it very useful to designate by this term an acute cellulitis a little more remote from the joint, yet by contiguity often involving structures more closely related. This periarticular cellu- litis, then, I have been in the habit of calling a coxo-femo- ral periarthritis. The name seems to me a good one, and I cannot at present recall the name of the author to whom we are indebted for its introduction into our nosology. It is nearly always acute, and nearly always terminates without seriously impairing the joint functions. It is a comparatively THE INTRODUCTION. 21 trivial disease, with very alarming signs and symptoms; hence the importance of recognizing the lesion, and dis- tinguishing it from the chronic bone disease in the neigh- borhood of the hip. Its early recognition is also important, in view of advantage to be gained by early incision of puru- lent areas. These abscesses in children not suffering from any malnutrition are harmless; but, occurring in patients whose assimilative powers are poor, whose constitution is depraved, the effects at times are very disastrous. In my chapter I have sought to fully illustrate this condition by typical cases taken from our hospital records. If I have not insisted strongly enough in the context on the impor- tance of distinguishing these areas of infiltration from similar conditions occurring in connection with the second stage of a chronic articular ostitis very insidious in its approach, I take the present opportunity of calling atten- tion to the subject, and know of no better way of avoiding error than in the cultivation of a habit of securing reliable histories. One essential point in the history at all times is the existence or not of lameness long prior to the develop- ment of the acute symptoms. Another point in connection with this is the presence of the infiltration. The subject of Bursitis of the Hip has not heretofore, so far as my reading goes, been honored with a special chapter in works on joint disease. The impetus given to the study of the bursae by Mr. Henry Morris has enabled us to more easily recognize these simple lesions, and the separation of the same from bone diseases renders still simpler the study of the more serious affection. If one meets with a case of primary bursitis and has an opportunity of observing it throughout its course, he will be less disposed to call every swelling bursitis, that occurs in the vicinity of the bursa. The whole subject is to me an extremely interesting one, and the few cases I have had under treatment seemed worthy of collection into a separate chapter. The time may come, when their nature is the more fully understood, and their exact relationship to surrounding structuresthe better appre- ciated, that antiseptic surgery will enable us to effect more speedy cures, and thus add another laurel to the wreath that must adorn the brow of the immortal Lister. From the experience I have had I cannot help thinking that a few cases at least are subjected to mechanical treatment by the indiscriminate use of such means in the hands of those 22 DISEASES OF THE HIP. who belittle diagnosis at the expense of joint therapeu- tics. Another subject equally important with that of bursitis is acute primary coxo-femoral Synovitis. A case of this occurring in one's practice, and closely studied, will shake one's faith in the current pathology of joint disease. It will show that hip-disease, as popularly understood, does not, as a rule, begin in the synovial membrane. My hospital facil- ities have enabled me to make a somewhat extended study of this disease, and hence I recognize the importance of differentiating the lesion from the bone lesions the start- ing-point, as I believe, of the vast majority of cases of "hip-disease." In the chapter, however, devoted to this subject I have endeavored to avoid bias, and to recognize the fact that " hip-disease" does sometimes begin in this way. The sub- ject, therefore, has been elaborated as fully as my time would permit, and I trust it is made sufficiently clear to fur- nish the reader with some suggestions, at least, that will enable him to pursue the study in a satisfactory manner. It will be seen that I have not fully developed the subject of chronic synovitis of the hip, and my apology for not de- voting more attention to this lesion is, that I believe when such a lesion does occur its tendency is to involve the deeper tissues and make a genuine hip-disease. Still there are, I fancy, cases of chronic synovitis occurring in adult life where the bone does not become involved. We are prone to regard such as rheumatism, and, foraH practical purposes, the classification is not objectionable. Chapter IX., is devoted to a subject that is growing in im- portance, thanks to the researches of pathology. We are indebted to English observers for the light that has been thrown upon Epiphysitis, and the recent meeting of the British Medical Association brought out several papers on this subject that must prove of great value in the study of joint diseases. Many cases that we have been in the habit of classing among congenital luxation and among trau- matic separation of the epiphysis we can now look upon as due to acute inflammatory diseases occurring in very early life. Mr. Thomas Smith, in the St. Bartholomew Hospital Re- ports of 1874, describes quite minutely this affection as " acute arthritis of infants," and I find that my own cases THE INTRODUCTION. 23 correspond very closely with those he has reported. It is to him we owe our knowledge of the pathological processes. It is but fair, however, to my own chapter to say that I was not familiar with this contribution to our literature when I recorded my own cases. As remarked in that chap- ter, I was at a loss for a long while how to classify the ma- terial, and in my intercourse with my orthopedic confreres in this city I found very little to help me in my study. The cases seemed to have drifted into my hands, and I knew of only one that had come under the observation of another practitioner in this specialty, and that practitioner was Dr A. B. Judson. In the same hospital reports the fifteenth volume Mr. Eve deals with the pathological aspects of necrosis at the extremity of the diaphysis and in the epiphysis of growing bones, and contributes a valuable addition to the subject of epiphysitis. Mr. W. Morrant Baker, surgeon to St. Bar- tholomew's, at the last meeting of the British Medical As- sociation, threw out some valuable suggestions as to treat- ment in a paper on "epiphysal necrosis and its consequences.' A reference to these papers from that time-honored hos- pital will supplement the chapter I have here introduced. The second part of this chapter deals, in a negative way, with diastasis of traumatic origin, and I much regret my lack of clinical material to make this portion more at- tractive. Its close relationship, however, with acute epiphy- sitis and with diastasis, the result of slow pathological changes in chronic diaphyso-epiphysitis, is brought out by illustrative cases, and this relationship may enable us to bet- ter recognize those of traumatic origin. In this way then, I fain would believe, the chapter will prove a contribution, a'; least, to the diagnosis of chronic articular ostitis. Periostitis of the hip and malignant diseases are consid- ered in Chapter X. This brings us nearer to the lesion of the hard parts, and introduces us to diseases that are often of grave import. This is particularly true of malig- nant diseases. In selecting a caption for this chapter the term periarticular periostitis occurred to me; but, on reflec- tion, the qualifying adjective seemed to be entirely super- fluous. A periostitis is naturally periarticular, and the asso- ciation of this term with the joint locates the lesion at the hip. I have dealt, however, with the disease as a primary lesion; and while there are cases wherein pus dissects up 24 DISEASES OF THE HIP. the periosteum and where a peripheral ostitis induces a peri- ostitis, these cases would add nothing to the subject from a therapeutic standpoint. These conditions are found occa- sionally associated with ostitis beginning in the centres of ossification, the inflammation extending to the periphery. Again, we are all familiar with periosteal lesions of the femur, induced by spinal abscesses, but these are inter- esting only in a differential way. If I have not made myself sufficiently clear in tracing the development of an articular ostitis from a periostitis, it has been because of the lack of pathological data. I want it understood, how- ever, that I am not an unbeliever in this mode of production of a "hip-disease." In the second part of this chapter the only malignant disease that I have attempted to elaborate is the round-celled periosteal sarcoma. The other forms of malignant diseases are very infrequent, and indeed rarely ever occur in childhood. Once recognized the question of therapeutics admits of little discussion. This belongs more properly to the works on general surgery, and to such those interested in this subject can refer. The larger part of this work is devoted to chronic articu- lar ostitis, and this disease certainly demands a large space. It will be seen in the caption of the chapter on pathology that I make this name synonymous with morbus coxarius, morbus coxae, hip-joint disease, etc. The views as to the pathology are undergoing radical changes now, and we are gradually coming to recognize a central ostitis as the lesion, which will explain the more important features of the dis- ease in question. Once a clear idea of the pathogeny and the pathological changes is had the indications to be met can be more readily appreciated, and the case be better conducted to a successful issue. I have purposely devoted considerable space to the pathology, having learned to ap- preciate its value in all joint-diseases. Concerning the etiology much has been said in a clini- cal way, although a little statistical work has been inter- spersed. I have not collected the number of cases of disease affecting both joints and those affecting the spine as well. These would be interesting from an etiological point of view, but they scarcely merit, it seems to me, a distinct chapter, or even a portion of a chapter. For the benefit of those who believe that double "hip- disease" is an extremely rare affection, I would say that it THE INTRODUCTION. 2$ occurs with more frequency than one would imagine. I have seen quite a number of patients examined and treated, even for bone disease affecting one hip, while the same lesion in the other hip would be entirely overlooked, so insignificant did the signs appear by comparison. I have also seen cases with the monarticular form develop the bilateral form several months or a year or two later. I have in mind now two cases that I saw some two and a half years ago, and I am sure that the disease existed only on one side. When I saw them again one eight months and one two years afterward they were wearing hip splints for undoubted disease on both sides. I believe that some of us at least are deceived in this way: We examine a hip, and find signs of the first stage; we also find some obscure signs about the other hip, and delude ourselves into believing these to be sympathetic. I am growing very skeptical concerning sympathetic hips. Still I am free to say that I have never committed myself strongly to that belief. It has become a habit with me to place implicit reliance on certain signs found about a hip, even if all the joints are the seat of disease. I have not devoted any space in the body of the work to a consideration of hip lesions associated with similar lesions in other joints and in the spine. I have notes of a number of cases of spinal caries with bone lesions of the hip; in- deed it is sometimes difficult to tell which was the primary disease. I have under treatment at present a girl aged five years who has lumbar caries, ostitis of both hips, and ostitis of the carpal bones. These are interesting facts to know, in order that one may not set aside signs of diagnostic value because other joints are involved. All such cases would have been mentioned had I undertaken to write a statistical work. I have avoided statistics as far as was practicable in order to make the book more readable. The questions of trauma and struma have not been placed in antithesis, because I do not believe such a relationship should exist. In describing the etiology I have taken it for granted as settled that the bulk of the profession believe in a strumous diathesis; if not hereditary, then acquired. Given then this strumous diathesis, this cachexia, this evidence of malnutrition, it is very easy fora concussion to induce a hyperaemia of the centres of development, which hyper- aemia under certain conditions will result in inflammation. 26 DISEASES OF THE HIP. It is also well established that these foci of disease can originate without even a fall as exciting cause. I am willing, then, to admit that falls which induce a concussion in young children or sprain or contusion in older children are the exciting cause in a large number of cases; but I am not willing to admit that the individuals thus affected are free of a diathesis which we call strumous. The cases and the other facts all go to prove the above two propositions, and 1 am sure that all unbiased observers will arrive at the same or similar conclusions. I have deemed it necessary to fully illustrate the clinical history, for the reason that many good surgeons practising this specialty even seem to be at a loss to understand the nature of this disease. They seem to think that it gets well in six months or a year; that the subsidence of acute symp- toms means a cure; that an exacerbation yielding to treat- ment justifies them in applauding the particular means em- ployed. So that I have endeavored to make this chapter especially full. The material at hand encourages me to Delieve that I can certainly do justice to the clinical history. The subject of diagnosis too is dealt with at some length, the different stages being accorded special parts in the chap- ter; and, in view of the importance of a clear understanding, especially in the early stage, no apology is offered. In discussing treatment I have attempted to explain what is meant by the expectant treatment, giving cases by way of illustration. It does seem though that the time will come when all mechanical treatment will be considered as expec- tant. Extreme views may have found a place in this portion of the volume, but they are views based on solid experience and if they are not accepted I can well afford to let them take their course as facts. The physiological treatment is given a place. I feel entitled to speak at some length on this method, for I have had a large proportion of my out patients on crutches and a high shoe. The idea of leaving the hip unprotected save as the reflex spasm in the muscles protects the hip is peculiar to Dr. Hutchison, and there are cases occasionally met with that seem to do well with the shoe and crutches alone. In this country we are not disposed to accept the treat- ment advocated by Mr. Hugh Owen Thomas of Liverpool, but it certainly seems to possess advantages over the THE INTRODUCTION. 2? strictly physiological. The hip is well fixed, it would seem; though recent writers who have attempted to carry out Mr. Thomas's instructions are very loath to bear testimony to the facility of application of the apparatus. The weight of the steel, the disposition to turn, and various other minor points of detail, so simple to the inventor, are not by any means simple to the practitioner. The true value of the treatment is discussed at length. Concerning the subject of traction and extension appara- tus, there is much that is as yet unsettled. The object is, I take it, to bring about ankylosis in the best position. This is what many of the splints do, and it is immaterial what is claimed for them. The correction of deformity by screws is condemned by some who employ apparatus. The limb is left to take care of itself. If I have not given all the forms in common use it is because of my limited time in which to collect. Many splints I know are pictured in catalogues, but are no longer in use. The chapter on operative treatment has been devoted to drilling in the early stage, to excision in the latter stages, and to osteotomy for correction of deformity. There are many cases on record of what seem to be good results, but enough time has not elapsed to make them of any special value for statistical purposes. In concluding then this chapter let me insist again on the importance of a thorough examination in every case. The object, in the first place, should be to have a proper classification, and to bear this in mind when examining a patient. There are certain signs that can be discovered only when the patient is divested of all clothing. The tape-measure is an essential the goniometer is useful but above all things a practised eye and an unbiased mind are indispensable. In classifying cases for statistical pur- poses a few years ago the committee on surgical procedure in the Therapeutical Society met with many difficulties in the way of harmony. I drew up a schedule which was supplemented by several specialists, and the form we finally accepted is submitted for further use. I would premise by stating that some confusion yet exists concerning the measurement of angles. I have advised with a number of orthopedists, and I find that in recording angles the supplement of a right angle is used when the 28 DISEASES OF THE HIP. deformity is less than 90. The starting-point is taken from the direction of the head, and the limb is moved over the articulation with the plane of the body as the base. So that when the limb is on a line with the body we have 180, and not o as some estimate angles. It would be better I think, for the sake of unanimity in recording cases, to adopt this method. The following is the schedule in conformity with which cases may be reported for the use of statisticians : i. Sex. 2. Age when disease developed. 3. Side affected. 4. Date of first symptoms. 5. Symptoms at invasion. 6. Apparent seat of initial lesion : bone, including periosteum ; or, soft parts, including synovial membrane. 7. Exciting cause as stated by patient. 8. Interval between this and first symp- tom. 9. Date of first examination. 10. Detail the signs found ; as shortening, atrophy, angle of deformity, limitation of movements, usefulness of limb, abscess, pain, etc. n. Previous treatment: each method, and duration of same. 12. Sub- sequent treatment, with duration of same. 13. When did the opening take place leading to carious bone ? 14. When did the sinus or sinuses close permanently? 15. Extent of carious process. 16. Condition when treatment suspended, with date, (a) Shortening : real, practical. () Atrophy. (c] Mobility in angles: flexion, extension, abduction, adduction, rotation, (d] Position of limb, (e) usefulness of limb. We have aimed to make our examinations in conformity with these questions, and are accumulating some valuable material. To get the length of a limb there are several points from which to measure. The anterior-superior spinous process is the more usual point. This gives, if the limbs are sym- metrically placed, the real shortening. From the umbilicus the practical shortening is obtained, also from the perineum. To get the shortening from bone atrophy or arrest of development measure from the tip of the tro- chanter. The position of the trochanter and its relative distance from the basin of the acetabulum are certainly important points to note, and Nelaton's line enables one to decide whether the tip of trochanter is above or below the normal position. In concluding this introductory chapter let me insist upon the necessity of employing all the means at our dis- THE INTRODUCTION. 2Q posal for thorough examination. The family history, the personal history, the sequelae of the exanthemata, the sud- denness of invasion or the slow insidious invasion all these should be clearly understood to make physical signs of value in diagnosis and in prognosis. CHAPTER II. THE ANATOMY OF THE HIP. In general terms the word hip is employed to designate not only the immediate structure entering into the forma- tion of the joint, but the structures, both hard and soft, which contribute to the functions of the same. In popular parlance, the integumentary coverings go to complete the full group of tissues embodied in the term hip. If one bruises the skin in the neighborhood of the trochanters the hip is bruised; if a furuncle form in this neighborhood the boil is on the hip. Neither does the profession nor the laity draw a sharp distinction between the different struc- tures in and about the joint when casually discussing this subject. Webster defines the hip as " the projecting part of the trunk of an animal formed by the lateral parts of the pelvis and the hip-joint with the flesh covering them; the haunch." It is an Anglo-Saxon word. The term, then, hip-disease is a general one, and while many authorities endeavor to have it restricted to lesions primarily involving the immediate joint structures it is really applicable to lesions of any part of the hip. It is in this way that confusion arises. When one says he has cured a case of hip-disease you do not know just what meaning he intends to convey, and if you demand an ana- tomical diagnosis he will very often find it difficult to tell you just what he does mean. It is, therefore, very neces- sary to a proper understanding of the diseases in and about this joint that one bear in mind the various anatomical structures entering into its formation. It is well, too, to bear in mind that inflammatory diseases and neoplasms attacking particular structures in this vicinity deal with them just about as they deal with like structures in other vicinities. The early recognition of the tissues involved and the nature of the morbid process will naturally suggest appropriate efforts at least in preventing an extension of the disease to other parts, the involvement of which may or may not be of vital importance. THE ANATOMY OF THE HIP. 31 Looking, then, at a naturally formed hip one must learn by observation the contour of the parts, the appearance of the skin, the folds and dimples into which it is thrown, while the subject assumes different attitudes. Art students naturally become familiar with surface anatomy, and medi- cal men should by all means study the normal appearance, not only of the hip but of all the joints. Indeed, surface anatomy plays a very important part in orthopedic surgery. The prominence of the nates, of course, stands out most conspicuously as the erect position is assumed; the fulness or the flabbiness indicating health or the reverse. In the normal state we must find absolute symmetry in the pro- minences and the depressions. The eye then takes in the gluteal fold, which must not deflect to one or the other side; the supra-trochanteric dimples, or depressions, which vary in depth and area according to the leanness or obesity of the subject, preserving, however, in any instance, a sym- metrical appearance; the gluteo-femoral folds, marked by fissures or creases, indicating the junction posteriorly of the thigh with the trunk. These creases vary, too, according to the muscular or adipose development of the individual. As a rule the fissure is a bifurcated one, the upper curvilin- ear being the longer, and extending from the perineum to the junction of the posterior with the outer surface of the thigh, while the lower, nearly straight, being the shorter by one half, and leaving the upper about an inch from its femoral extremity, to extend an inch or two diagonally down the posterior aspect of the thigh. Often, however, we find a third division or fissure much shorter, and taking a course nearly vertical from the curvilinear above. We remember, too, that the law of symmetry must be recognized even in these fissures. Indeed, one cannot but help admire the symmetrical arrangement of the lines and prominences so exquisitely drawn by the hand of Nature in a pair of hips free from disease or deformity. One must not rest content with studying the parts already mentioned, but the eye will take in at a compara- tive glance the position of the trochanteric prominences the sacral region, the ilio-costal spaces, and their relation- ship to the crista ilii, the size of the thighs in the upper third and, indeed, all the regions immediately connected with the hip. Soon one learns to observe all this at a glance, and easily detects any departure, however slight, from the law of symmetry. 32 DISEASES OF THE HIP. To look through the integument and recognize the muscles and fascia and adipose tissue immediately under-lying, another step in anatomy- must be taken. The prominence of the nates we know is produced by an accumulation of fat lying over the gluteal muscles. It is by far the better plan to give the muscles which act upon the hip-joint a classification according to function, and it shall be my aim to enter as little as possible into anatomical details. THE FLEXORS. There are two sets ; one whose function is pure flexion, and another whose function is principally accessory to the first. The former are the psoas and the iliacus, practically forming a single muscle. Their attach- ments are extensive, and hence their importance. If disease involve the bodies of the lower vertebrae the psoas is involved, and if the ilium the sacrum or the capsule of the joint is implicated the iliacus is excited often into undue action. Both are inserted at and below the small trochanter. I have purposely omitted the psoas parvus because it has no action on the hip. The latter group of muscles which assist in flexion under certain circumstances are; the pectineus, the sartorius, and the rectus. The latter two can act only when their action on the leg is completed or prevented. The vastus externus is thought by some anatomists to assist in flexing the thigh through its attachment to the rectus, and the obtura- tor externus is occasionally a decided flexor. This is illustrated when you cross one thigh over the other. The flexor muscles all arise within, or along the margins of, the pelvis, the psoas alone excepted. THE EXTENSORS. The three glutei, and these are as- sisted by the obturator internus and the hamstring mus- cles, the latter acting when they have completed the flexion of the leg, or are prevented from so doing. Their action can, however, have little to do with disease at the hip, since they influence both joints simultaneonsly, as in the first act of rising from a seat. The extensors arise from the pelvic bones posteriorly one, the obturator internus taking the greater portion of its origin from the inner surface of the posterior wall. THE ADDUCTORS These pass between the os innominatum and the femur, and are the long, short, and great adductors, assisted by the pectineus and the graciis, and occasionally by the gluteus maximus, the obturator externus and the THE ANATOMY OF THE HIP. 33 quadratus femoris. If the limb be extended the gluteus assists in adduction, if flexed the external obturator assists, and if extreme outward rotation is completed or'prevented, then the quadratus acts as an adductor. THE ABDUCTORS. The muscles which support the pelvis on one thigh the gluteus medius and gluteus minimus are strong abductors, and their most powerful action is displayed when one limb becomes the basis of support. The gluteus maximus, with its upper fibres and the tensor vagina femoris are auxiliary to the above act. The sar- torius abducts while flexing both hip and knee. THE INWARD ROTATORS. The tensor vagina femoris and the anterior portions of the gluteus medius and gluteus minimus are the muscles here employed. THE OUTWARD ROTATORS. These muscles occupy places on both sides of the joint, and in front we have the psoas and iliacus the chief flexors. On the inner aspect the pec- tineus and the three adductors; on the inferior and posterior aspect the obturator externus. Posteriorly are the quad- ratus femoris, the gemelli, the obturator internus, the pyriformis, and the posterior portion of the gluteus minimus and gluteus medius. These are all assisted by the gluteus maximus. When the knee is extended the biceps femoris may serve as an outward rotator. It will be observed that the muscles whose function it is to execute the angular movements of the thigh, act also as outward rotators, and this double function gives a greater range of motion to the thigh, i.e., if one of the functions of a group of muscles is rendered unnecessary the whole force can be directed toward the other. Abduction, however, is an exception. To sum up, then, the muscles with their functions we have FLEXORS. {Pectineus. Obturator Externus Vastus Externus. Sartorius. Rectus. Nerve supply: The psoas is supplied by anterior branches 34 DISEASES OF THE HIP. of the lumbar nerves, and the iliacus by filaments from the deep branches of the anterior crural. The accessory obturator which is not always present the deep muscular branches from the anterior crural, and occasionally the anterior branches from the obturator, sup- ply the pectineus. Posterior branches of the obturator supply the obturator externus, while the sartorius gets filaments from the mid die, or internal cutaneous nerves, branches of the anterior- crural. The vastus externus derives its supply likewise from the anterior crural, and from the branch going to the muscles is given off a filament which is distributed to the articular surfaces of the knee. EXTENSORS. S Gluteus Maximus. Gluteus Medius. Gluteus Minimus. {The long head of the Biceps. Semitendinosus. Semimembranosus. Obturator internus. Nerve supply : The inferior gluteal, a branch of the small sciatic, is distributed liberally throughout the gluteus maxi- mus, and an additional supply comes from a branch of the sacral plexus. The superior gluteal of the sacral plexus supplies both the gluteus medius and gluteus minimus. The great sciatic furnishes muscular branches to the biceps, the semitendi- nosus and the Semimembranosus and the sacral plexus similar branches to the obturator internus. ADDUCTORS. ( Adductor Longus. Three Special. \ Adductor Magnus. ( Adductor Brevis. f Pectineus. I Gracilis. Five Accessory. 4 Gluteus Maximus (when limb is extended). Obturator Externus (when thigh is flexed). [Quadratus Femoris. Nerve supply; The obturator nerve supplies all the THE ANATOMY OF THE HIP. 35 muscles in this group except the quadratus femoris, while the adductor magnus gets additional branches from the great sciatic. The supply of the pectineus has already been given. The quadratus femoris gets its entire supply from the sacral plexus. ABDUCTORS. One Special. Tensor Vaginae Femoris. ( Gluteus Maximus. Three Accessory. \ Gluteus Medius. ( Sartorius. Nerve supply : The tensor vaginae femoris derives its sup- ply from the inferior branch of the superior gluteal, one of the important divisions of the sacral plexus. The sartorius, as before mentioned, gets filaments from the anterior crural, and the glutei from the small sciatic and the superior gluteal branch of the sacral plexus. OUTWARD ROTATORS. 'Quadratus Femoris. Gemellus Superior. c" CM. / ) Gemellus Inferior. Six Spectal.\ Obturator Intern us. Obturator Externus. Pyriformis. Ilio-psoas. The Three Adductors. Pectineus. Nine Accessory. \ Posterior Fibres of the Gluteus Medius. Posterior Fibres of the Gluteus Minimus. Gluteus Maximus. Biceps. Nerve supply: Branches from the sacral plexus supply all the special muscles in this group, with the exception of the obturator externus, which is supplied, as already stated, by posterior branches of the obturator. The accessory group has already been treated as to the nerve supply under their respective localities as special muscles, and a repetition is unnecessary. INWARD ROTATORS. One Special. Tensor Vaginae Femoris. Two Accuse \ Anterior Fibres of the Gluteus Medius. J. wo Accessory. 1 Gluteus Minimus. 36 DISEASES OF THE HIP. The nerves supplying this group have already been given as the superior gluteal. The blood supply of the muscles which control the action of the hip is from the profunda femoris chiefly. This is a large branch of the femoral. THE FASCIA OF THE HIP. There is a superficial fascia of the thigh described in the works on anatomy, but as this has no special connection with the diseases of the hip I pass to a consideration of the deep fascia the fascia lata. Deep abscess, acute and chronic, is rendered particularly dangerous by reason of this fascia which furnishes a uniform investment for the whole of the upper third of the thigh, receiving fibrous expansions from the gluteus maximus, the biceps, sartorius, gracilis, semi-tendinosus, and quadriceps, while the tensor vaginae femoris is inserted between its layers. It is attached above to Poupart's ligament and to the crest of the ilium; behind, to the margin of the sacrum and the coccyx. It is attached to the whole length of the thigh-bone, from the inter- trochanteric line to the widening of the linea aspera. The numerous smaller septa enclose individual muscles and are attached to the main fasciae. The saphenous open- ing is simply a large oval aperture in this tissue, and through it abscesses from the deep structures often find their way to the surface. In this locality the fascia is divided into an iliac and a pubic portion. The former includes all that portion on the outer side of the saphenous opening being attached exter- nally to the anterior superior spine, to Poupart's ligament, and to the pectineal line in connection with Gimbernat's ligament. It forms as it passes down from the spine to the pubis the outer boundary of this opening. The pubic portion lies on the inner side of the saphenous opening. It covers the surface of the pectineus, passing behind the sheath of the femoral vessels, being closely adherent thereto, and is continuous with the sheath of the psoas and iliacus muscles. It is lost finally in the capsule of the hip- joint. THE BURSJE ABOUT THE HIP. The synovial bursae in this region are nine in number, and subserve an important function. They consist of a thin wall of connective tissue partially covered by epithelium, THE ANATOMY OF THE HIP. 37 and contain a viscid fluid. Naturally they enhance the free- dom with which muscles move over bony prominences and tendons. One can readily see how imperfectly these muscles act when their underlying bursae are not in perfect con- dition. Figures i and 2 I have had copied from Morris. A large bursa (D, Fig. i) lies between the iliacus and the thin por- tion of capsular ligament di- rectly in front of the joint, and it often communicates with the synovial cavity. Its joint con- nection makes it a very im- portant element in the patho- geny of disease affecting this articulation. Between the gluteus medius and the upper and front por- tion of the trochanter major there is a small bursa (I, Fig. i). It extends quite a distance be- tween the tendon of this muscle nad that of the pyriformis. Occasionally two bursae in- stead of one are found ; one between the tendon and the bone and the other between the tendon and the pyriformis. A bursa (F, Fig. t.) of larger size than the preceding lies be- tween the tendon of the gluteus FIG. i. BURS^E IN FRONT OF THK JOINT. minimus and the front of the A. Bursa between pectineus and trnrhanter <;nmprirnp<; evrfnrl- femur; B. Adductor brevis; C. Pec- er > S tineus; D. The bursa between the ilio- ing between this muscle at Its psoasand the capsule of the hip, often in^prtinn anrl tVio vactiic PYtPr communicating with the joint; E. Ilia- _i Liou aiiu Liie VdbLUb exier- cus ; p_ Bursa between gluteus mini- nus at its attachment. Lying in front of the gluteUS bursa between maximus, and between it and ~ luteus maxi umus and vastus extends : the vastus CXternuS is a bursa K. Gluteus maximus; L. Vastus exter- (J, Fig. i) of larger size, over which rides the strong fascia of the buttock as it passes down the thigh towards the insertion of the first named muscle. At the base of the great trochanter is a large multi- locular bursa (A and B, Fig. 2), over which the dense fascia and the tendon of the gluteus maximus play. mus and trochanter; G. Gluteus mini- mus ; H. Gluteus medius; I. Small ;luteus medius and trochanter; J. Small bursa between luteus maxiumus and vastus externus ; :. G nus. DISEASES OF THE HIP. The remaining four bursae are at the back of the joint and are arranged in the following order: An unimportant bursa situated between the external obturator and the pos- terior portion of the neck of the femur. A large bursa be- tween the quadratus femoris and the pos- terior surface of the small trochanter. Frequently an elon- gated bursa is found between the internal obturator and the gemelli muscles, and capsule of the joint in its posterior portion. Then there are bur- sal inter-spaces con- taining the usual bursal fluid, between the quadratus femoris and the obturator externus, and the capsule pos- teriorly. THE LIGAMENTS. Fig. 2. BURSJE AT THE BACK OF JOINT. i. The Capsular, This A. and B. Two small bursse between the tendon .!,_ , T ^il, f fluteus maximus and bone; C. Large bursa be- IS the enveloping StrUC- wecn gluteus maximus and trochanter; D. Bursa ure of the hip-ioint between obturator internus and capsule of hip; 1. Bura between gluteus medius and pyriformis; V. Pyriformis; G. Gluteus minimus; H. Gemellus uperior; I. Bursa between obturator internus and ischium; J. Obturator internus cut across; K. Gtmellui inferior; L. and M. Small bursae in con- nection with hamstring muscles at their origin. at- ,. , , WHICH GCnVCS ItS + c>VimERiOSTITiS OF tHE Hit*; Could be found. My diagnosis was at this time a simple cellulitis. This area broke down into ulcers, and sinuses followed, which discharged more or less during the next two or three months. In December these closed, while a similar condition of degeneration presented itself on the outer side of the thigh; Repeated exacerbations with a mild grade of constitutional symptoms supervened, and in March the inner side of the thigh, in the old locality, began to behave badly again. Abcess formed here, and in May, a spicula of bone was exfoliated. This completed the cure, and I had myself to censure for taking fifteen months to recognize the true nature of the disease. But for the clini- cal features in the case it would be humiliating to place it on record. It teaches the value of the probe, if that lesson were necessary in this enlightened age of surgical science. I have seen far more abuse from neglect of this simple aid to diagnosis than damage done to healthy or diseased parts by its employment in the hands of the most reckless. I am aware that some honest surgeons of large experience condemn its use because of supposed in- juries done. Had I resorted to it in this case I should surely have been spared the error of diagnosticating a cellulitis on the boy's readmission. Remembering the influence of cold as a cause of periosteal inflammations, I had no difficulty in forming a correct opinion in the following case. This one is so interesting from a therapeutical point of view that I find it very serviceable at this juncture because I can illustrate what further remarks I have to make on diagno- sis, passing at the same time to the treatment. A lad, aged fifteen, was referred to me for "hip disease" by a medical friend, who had made only a cursory examin- ation, during the latter part of 1881. Two months before his appearance at the hospital he had taken a surf bath one cool day in August, and the next day without any chill pre- ceding he had a slight febrile exacerbation attended with headache. The next ten days found him confined to bed, complaining much of pain in the upper portion of the left thigh and in the hip. There was no pain referable to the knee or its coverings. In the upper third of the thigh was considerable tenderness. At the end of the ten days on getting out of bed he was able to walk only with the aid of two canes. The patient walked with a cane into my ex- amining room; he was anaemic; the limb was flexed at the hip and rotated inward; the deformity was not marked, 158 DISEASES OF THE HIP. yet suggestive. I could not discover any joint tenderness- but on measurement found the circumference of the thigh in its upper third one and a half inches greater than that of its fellow; the whole limb was apparently an inch longer than the right; really there was no difference. The indu- ration was confined to the outer aspect of the limb, and to my touch seemed unmistakably periosteal. There was no fluctuation, but there was extra heat and tenderness. I did not thoroughly test the joint movements, but found the articular surfaces quite smooth on moving the limb over small arcs. The diagnosis was made unhesitatingly of periostitis of the shaft in its upper portion, and I ordered a high shoe for the sound limb and a pair of crutches to correspond. An iodine liniment, cotton batting, cod-liver oil, and a tonic completed the order. This was followed faithfully, and the boy did well for a month, in so far as freedom from pain and comfort were con- cerned. Then the area of induration became more circum- scribed, and while I could get no fluctuation I felt quite sure that the disease was not receding. Hot fomentations were substituted for the cotton-batting, and when I saw the patient again a week later a spontaneous opening had occurred, and a sero-purulent discharge issued therefrom. Carbolic acid, in weak solution, was employed as an injec- tion, and at his next visit he brought me two spiculae of bone, less than a half-inch in length, which he had removed himself from the sinus the day before. By exploring freely I could not detect any more. The sinus was kept open, however, and within the next fortnight two more spiculae were exfoliated. In April he fell down a half-dozen steps, striking on the trochanter, and the sinus bled a little. A week's rest and a sojourn in the country proved highly beneficial. In October a good-sized shell of bone was removed from the sinus, and this proved to be the last exfoliations of any significance. The sinuses closed, the joint movements became more free, and the crutches were discontinued. He had no lameness, no shortening of the limb, and he was regarded as cured, until six months later, when the sac filled again, and quite an insignificant piece of bone was thrown off. He soon re- covered, and has been on the convalescent list now for a year, with instructions to call only on the recurrence of any symptoms. There came into my examining- room one morning in PERIOSTITIS OF THE HIP. 1 59 December, 1881, a boy, aged eight, whose case I looked upon as an excellent result from an old periostitis, with necrosis and exfoliation of bone. He had no atrophy of the thigh, only a half-inch of the calf, and no shortening of the limb. The joint-surfaces were smooth, and the functions normal. An old cicatrix existed about the trochanter, and he reported that spiculse of bone had been exfoliated through an abscess in this locality. I learned that he had been a patient of Dr. Schoenem'an's, of this city, and at my request the Doctor very kindly fur- nished me a copy of his notes of the case, an abstract of which I here present. He had first seen the boy in February, 1881, and had obtained a strumous history. The boy had a fever of some kind in the November preceding, and on convalescing, a few weeks later, complained of pain in the right hip, occasionally in the knee of the same side. There was some fulness around the hip-joint, and the only point of tenderness was below and anterior to the great trochanter. Movement in every direction was easy and normal in extent, though the boy complained a little when ab- and adduction were carried to extremes. The treatment to be employed was a long splint; but nothing was done prior to July pth, when it was recorded that he was not able to walk, and suf- fered from pain in hip, thigh and knee. The gluteal region presented much fulness, the fold was obliterated, and motion was limited and painful in every direction. On the outer side of the thigh, at its middle third, was a fluctuating tumor. The splint had been applied on July 14th, but very little extension was made. Warm fomentations were em- ployed. The splint soon gave relief, and on July 28th the abscess opened spontaneously. A probe reached bare bone over the trochanter. Carbolic acid injections of the usual stfength were ordered as a wash three times a day. A small piece of bone (size of a pea) was exfoliated on August 6th. The deformity of the limb had by this time disappeared. Later, abscesses forming about the sinus were opened and thorougly cleansed with carbolic acid solution. The dis- charge continued, more and less profusely, until November, when the sinuses closed. The splint was then removed, and the boy began to walk without assistance. The case which I had under my own observation had about the same history, progress, etc., as Dr. Schoeneman's had. The one was treated by the method known as that of ' physiological rest," the other by the long splint. Both 160 DISEASES OF THE HIP. made excellent recoveries, and the time required was about the same. The principles, then, which these cases teach are: the maintainance of good position of the fimb, a certain degree of rest to the parts, and general constitutional measures. Mr ; C. Madnamara, of the Westminster Hospital, Lon- don, thinks very highly of the extract of belladonna, freely applied, over the inflamed area, in conjunction with perfect rest to the parts, and his reported results are most excellent. He introduces a grooved needle when pus is suspected, presses the fluid contents out along the needle, and then places a firm compress over the parts. In view of one or two cases that have gone on to fatal results, I am convinced that early incisions, or needling, such as Mr. Macnamara practices, should command more attention. I have in mind now a case seen many years ago, where a sharply-defined diagnosis was made of subacute periostitis about the trochanter, where the progress of the case fully confirmed the diagnosis made, where constitutional treatment was alone employed, where abscess after abscess gradually in- vaded the joint, where amyloid degeneration super- vened, and where death by exhaustion has recently oc- curred. In chronic tibial periostitis, as well as in the acute form I have had, as have others, most gratifying results from free incisions down through the inflamed periosteum to the bone, even when pus was not even expected. Such treatment in the neighborhood of the hip must become popular when we begin to distinguish with tolerable accuracy between the various diseases prevalent about this articulation. The pre- vention of necrosis and ostitis by contiguity is especially to- be considered, and the protection to the joint structures aids materially in limiting the imflammatory process. There are other remedies which are sometimes resorted to with good result, such as blistering and other means of counter-irritation. Fomentations likewise are called for in the relief of pain when the knife is not employed. As regards medication the iodides are in good repute, but I doubt very much their great value unless a syphilitic element prevail. I should rather rely on tonics, cod-liver oil and a good hygiene. The last we cannot always com- mand. Indeed, the art of medicine is truly an art when it works good against all such obstacles. The prognosis is good if a correct diagnosis can be made MALIGNANT DISEASE OF THE HIP. l6l and if treatment can be carried out on strict surgical principles. A case of trochanteric periostistis, or iliac periostitis if allowed to pursue its own course, will do one of two things. If mild in type resolution will in all prob- ability take place within a few weeks; if it be of a more severe type and occur in an individual of cachectic habit, the march will be slow, yet undeviating, to a bony joint disease, the final outcome of which no man can predict. That many cases of so-called hip-joint disease originate in this way I have long since been convinced. Dangerous expectancy it is to overlook these periosteal contusions. In infants the enforced rest soon brings about a cure if in- herited syphilis be not an etiological factor. The prognosis of acute diffuse periostitis involving the shaft of the bone is -grave enough, though prompt thera- peutics have deprived this of much of its terror since the memoirs of Chassaignac in 1854, and the paper of Dr. Demme, of Berne, in 1862. The incisions that they recom- mended, and which were followed by such disastrous results, made now under antiseptic precautions, would seem to overcome the objections urged then against the pro- cedure. Their cases, however, were those of osteo-myelitis, in which, of course, a suppurative periostitis existed. II. MALIGNANT DISEASE OF THE HIP. Intimately associated with periostitis is a class of diseases whose beginning is obscure, whose termination is fatal, and whose early diagnosis is next to impossible. The most prevalent of the maglignant diseases are the sarcomas, and Bilroth believes that their subdivisions, made according to histological peculiarities, are of no great value during life. Dr. S. W. Gross believes differently, and in a paper showing careful elaboration, makes a very interesting study of sar- coma of the long bones, based upon an analysis of one hundred and sixty^five cases. He found that the most frequent were sarcoma. Osteomas, chondromas, osteoid chondromas, fibromas and myxomas prevail next in fre- quency in the order named. His paper has been published in the American Journal of the Medical Sciences for July and October, 1879. Tumors of the long bones begin either in the periosteum 162 DISEASES OF THE HIP. or in the medulla. Thus we have central sarcoma and periosteal sarcoma. The term osteo-sarcoma is an unfor- tunate one, as Dr. Gross has pointed out. It means one of two things : either a sarcoma in or on a bone, or a sar- coma in the soft parts containing osseous matter. Wilks and other English writers have designated the periosteal osteoids osteo-sarcomas, and some German pathologists apply this name to the myeloid tumors only. These are the giant-celled tumors, and are always central. The cen- tral tumors are as a rule enclosed in a bony capsule, i.e., the major portion is bony, while other portions may be mem- branous. The peripheral or periosteal sarcomas are covered by the outer fibrous layer of the periosteum, and if this tissue participates in the cell proliferation the capsule is composed of connective tissue. Osseous tissue is never found in the investing membrane. The periosteal are the malignant tumors one finds most frequently in the neighborhood of the hip, and are the growths that present for differential diagnosis. In Dr. Gross's tables, including all the bones involved, the femur was the seat of disease in sixty-seven cases out of the hundred and sixty-five. The central giant-celled tumors are not met with during childhood, so that in differ- entiating neoplasia in children we can eliminate this class. Even in adult life the upper epiphysis is seldom implicated. Thus, in seventy cases of the giant-celled variety the upper epiphysis was the seat of disease in only two instances, while the lower epiphysis was affected seventeen times. The round-celled sarcomas, which are periosteal, are the tumors which are the more apt to present in early life, and even these were found to occur not earlier than the seventh year in the tables above mentioned. Naturally, in the large clinical field to which I have had access I should find this disease in early life, if at all, and in the many hundred cases of disease in and about the hip, I have notes of only three or four. I seldom meet with cases where even the diagnosis seems at all probable. The clinical history is very important, and I gladly place on record the following, which will serve me as a text for remarks on pathology, diagnosis and therapeutics. On the zoth of July, 1881, I saw a boy aged three years, and diagnosticated chronic periostitis of the middle third of the right femur on the strength of pains in this vicinity a.nd a slight bony enlargement, which was quite smooth. . MALIGNANT DISEASE OF THE HIP. 163 He had been complaining of vague pains in the limb for several months, and had not rested well at night. There was no lameness and no impairment of joint function. He was in fine physical condition and the fulness had been observed only a few days. The swelling, or, enlarge- ment completely encircled the bone, yet there was no tenderness whatever. I could not learn any cause either predisposing or exciting. The symptoms yielded to lotions, etc., and it was not until September that my fears were aroused. I found then that the size of the limb had been rapidly increasing, and on measurement the thigh in its upper third was two inches larger than its fellow, in its middle third it was three and a quarter inches larger, and in its lower third one inch. In one or two points I got deep fluctuation, yet there was a bony hardness generally over the mass, and the boy was suffering much at night. The superficial veins were growing prominent. I now gave up the idea of a periostitis and felt quite sure that the growth was malignant. The shape was ovoid, the skin was unaffected and the tenderness was not marked. Dr. Weir saw the case in consultation, agreed with me that it was one of sarcoma of the femur and advised amputation. Dr. Ripley, after a microscopical examination of a bloody fluid removed from one of these fluctuating areas arrived, at the same diagnosis. He agreed with Dr. Frank Hamil- ton, who made the same diagnosis, in advising against operation. By the latter part of September there were four inches difference in the size of the two limbs and yet the boy was walking with very little inconvenience, and had not lost flesh. The parents would not consent to any operative procedure and I had the melancholy privilege of following the case to the end. Through the month of October the increase in size went on without marked deterioration of health. The growth extended from condyle to condyle by the latter part of November and the veins had become large and tortuous. Rest was obtained only under the influence of morphia. The circumference was seventeen and a half inches against eight and a half for the other limb. The lymphatic glands were not involved, the skin was normal and the joints of the hip and knee were smooth and as yet unaffected. In December emaciation was first apparent and he was unable longer to go about. Though January and February 164 DISEASES OF THE HIP. he dragged along, eking out a suffering existence, the limb looking like a vast appendage to a small body. In the early part of March a superficial vein on the anterior sur- face of the tumor ruptured and the boy lost considerable haemorrhage before assistance was rendered. The appear- ance of the parts on the ist of April is well represented by the accompanying sketch made for me by Dr. Crook. The skin did not slough, and there was no haemorrhage of any significance, but the boy became oedematous and gradually sank April 4th, dying by exhaustion. Per- mission was given to remove the tumor, and with the assistance of Dr. G. W. Ryan I made a dissection of the parts involved. The thigh was disarticulated at knee and hip, the former joint with the superficial parts of the lower epiphysis being found absolutely normal. The latter joint was filled with a gelatinous-looking fluid, although the acetabulum was smooth and the head of the femur seemed FIG. io. ROUND-CELLED PERIOSTEAL SARCOMA. normal. The greater portion of the thigh, inclusive of muscles and bone, was replaced by the neoplasm. The mass, deprived of the integument, weighed ten pounds, and the jelly-like appearance on longitudinal section, of blanc-mange ; no muscular tissue could be found. Here and there were a few cysts of varying size. The periosteum could be distinctly traced out in the mass, it being separa- ted from the bone in a crescentic manner, the greatest dis- tance of separation being one inch. Dr. William H. Welch made a microscopic examination and reported that "the tumor is composed of a mass of cells with little intercellular substance, and is quite rich in blood-vessels. The cells are for the most part small round MALIGNANT DISEASE OF THE HIP. 165 cells, but there are some larger round, as well as irregular cells. Here and there are a few giant-cells. There is no alveolar or other regular arrangement of the elements. To the naked eye it is clear that the tumor originated in the periosteum. Diagnosis : Round-celled sarcoma of the perios- teum." The earliest period of life at which the disease showed itself in the eleven cases analysed by Dr. Gross was seven years. In the case I have just reported the first symptoms appeared before the boy was three years of age. I saw a case last fall in a boy aged four and a half years wherein the disease had lasted for nearly three years. In this boy the pelvic bones were involved and the tumor filled the whole of the external iliac fossa, including the hip. The inguinal glands were much enlarged, but whe- ther from irritation or disease I could not tell. The first symptoms were noticed when he began to walk. The case was seen also by Dr. Yale, who felt no hesitancy in pro- nouncing it a sarcoma. This was much slower in its growth than the other case. Pain, in the case I have detailed at length, was a most persistent feature, especially after the tumor reached such dimension. There was never any pulsation, and fracture did not occur. Dr. L. E. Holt related to me, at the time I was so much interested in the above cases, the history of another that had come under his observation, and it was as follows: In the summer of 1881, he saw, with Dr. Denning, of Webster, New York, a girl nine and a half years of age, who had for a long time been suffering from what was re- garded as chronic hip-joint disease. The family history was good, and the patient's own health had been good. When five years of age she had for several days sharp neu- ralgic pains in the right knee without preceding lameness. The pains passed away, without treatment, and a year later returned with greater severity, lasting several weeks, and during this time she walked very lame. She soon got re- lief spontaneously, but for a few months only, as the pain, lameness and deformity returned and continued with very little remission. The girl attended school quite regularly, until nine years of age. About this time the parts took an -increased enlargement and pain at times became excruciat- ing. Her screams were sometimes heard a quarter of a mile distant. For three months prior to the date of Dr. Holt's examination opiates were used daily. Profuse night-sweats, without any chills, had of late appeared. He found the 166 DISEASES OF THE HIP. patient thin, but not emaciated; a pulse of 150, and a tem- perature of 102.5 The right thigh was flexed at 90 and adducted. The pelvis moved with every attempt at passive motion of the limb. An immense tumor occupied the region of the hip, extending vertically from the crest of the ilium to the middle third of the thigh, and transversely from the gluteal cleft to the labium majus. In the groin it extended above Poupart's ligament, but followed its direction. In this locality the surface was a little irregular, but everywhere else it was smooth and uniform. The skin was tense and glistening and over the nates a little discolored; the super- ficial veins were prominent. There was no tenderness on palpation, but there was a sense of deep fluctuation. Moderate concussion of the joint surfaces elicited no tenderness, but any efforts at pas- sive motion excited great pain, especially if rotation were at- tempted. The circumference of the limb over groin and trochanter was twenty inches against eleven for the opposite side. From the anterior superior spinous process to the gluteal cleft the measurement was eleven and a half inches, that between same points on left side six and a half. There was apparently no shortening of the limb. The rapid en- largement, the loss of flesh, and the hectic with the ap- pearance of the skin led the Doctor to believe that he had to deal with a deep-seated collection of pus. The patient was accordingly anaesthetized and a four-inch aspirator needle was introduced to the full length in several direc- tions, and in every instance only a few drops of blood were obtained. It was very evident that no abscess was present. While the girl was under ether a little motion was ob- tained over an arc of about twenty degrees. She grew steadily worse and in a few months died of exhaustion. An autopsy could not be secured. The character of these tumors in general appearance de- ceives many. When fluctuation is discovered no ill results can follow the introduction of a hypodermic needle. The appearance of blood when one explores for pus is always of the gravest significance. Little need be said upon the subject of treatment. Opin- ions are about evenly divided on the question of operation or palliation. Dr. Gross collected thirteen cases of periosteal round- celled sarcoma, and all were subjected to operation save one. MALIGNANT DISEASE OF THE HIP. 167 This one he could not compare with the remaining twelve because of the incompleteness of the history. Of the twelve that he analyzed ten underwent amputation and two ex- cision. The two that were excised involved the shoulder joint and in both cases the disease returned. There were four of the twelve that did not have a perfect history, so that in estimating the prognosis as regards duration of life he was confined to eight. The time from the first observa- tion of the disease to the close of life varied from two months and a half to five years and one third. The average was eighteen months. " Of the eight cases in two death was due directly to surgical measures; one recovered, but died from metastatic deposits at the expiration of thirty- two months; three recovered, but died subsequently from supposed systemic infection respectively at seven, eight, and nine months ; one was alive with local recurrence at the end of three weeks; and one remained well for forty months." In the case I have reported on page 162, it was the mother's regret that she had not consented to the operation. My own conviction, from my knowledge of the life the little sufferer led, is that operation should be done even if there is not a single chance of recovery. We know, how- ever, that life can be prolonged, and we know, furthermore, that suffering can be ameliorated by such procedure. I saw that child from time to time, and saw him in pain and in distress; saw that ponderous mass threatening haemorrhage and sudden destruction to life ; saw the emaciated body fading into insignificance beside the tumor, and saw the mother worn down by care and apprehension. I was con- vinced, I say, by all these circumstances, that amputation could have done nothing worse, and may have done muh better. An early diagnosis is all-important, and the points in dif- ferentiation from periostitis are the following: 1. In periostitis the area of thickening is more circum- scribed and more irregular in outline. In periosteal sarcoma the thickening soon embraces the whole circumference of the bone. 2. In periostitis the superficial parts present more signs of an acute inflammation. In sarcoma the superficial parts present little in the way of extra heat or other inflammatory signs. 3. The pain in periostitis diminishes in direct ratio with the growth of the tumor. 168 DISEASES OF THE HIP. In sarcoma the pain increases with the growth of the tumor. . 4. Suppuration is the rule in periostitis; the exception in sarcoma. The diagnosis in the advanced stages is not difficult. Of course the joint may be so enveloped, and the functions of the same may be thereby so much impaired, that chronic articular ostitis may be diagnosticated. In the early stage of central ostitis very few signs present that are in any way similar to those of a sarcoma. A differen- tial diagnosis here is rarely called for; but there are certain points in common between the two, where the diseases are more advanced. For instance, I saw a boy, four years of age, last spring, with a bony enlargement of the femur, and I am not yet fully decided as to whether it is a periosteal sarcoma, a chronic osteo-myelitis, or a chronic articular osti- tis in the second stage. When I first saw the case there was uniform thickening of periosteum, it seemed, in the whole circumference of femur in its middle and upper thirds. The trochanter was very prominent, yet the joint surfaces were smooth and in normal apposition. When I saw the case again, three months afterwards, the bony enlargement was the same, yet there was a large, fluctuating, movable tumor on the posterior surface of the thigh. I did not have an opportunity of exploring the tumor.* 1. In the second stage of a chronic articular ostitis, the tumor is either circumscribed or distinctly fluctuating over a large area. In a periosteal sarcoma the tumor, as a rule, takes in the whole circumference of the bone, and if fluctuation be pres- ent, it will be over a very limited area, and more than one of these areas will be found. 2. The superficial veins in the one are not prominent; in the other they get to be enormously distended. 3. As the tumor increases in the one, the general health does not suffer; as it increases in the other, cachexia and emaciation become the more marked. 4. In abscess from bone disease the pain is at no time very severe, and when it does occur it occurs during exacerbations. In sarcoma the pain is progressive, and, as a rule, constant and severe. * Dr. John A. Wyeth informs me that the abscess has been opened, and that the case now presents the features of a general ostitis gf the shaft, MALIGNANT DISEASE OF THE HIP. 169 5. The hypodermic needle, or the needle of the aspirator, will enable one to make a differential diagnosis when other means fail. To quote Dr. Gross: "Finally, a rapidly-increasing, pain- ful, lobulated, soft, elastic, non-pulsating, pyriform or fusi- form tumor, especially if seated on the shaft of a long bone, occurring at about the twenty-third year, and unaccompanied by fracture, but marked by discoloration of the skin, enlarge- ment of the subcutaneous veins, involvment of the lymphatic glands, and elevation of temperature, may be safely ranked among the periosteal round-celled sarcomas." CHAPTER XI. CHRONIC ARTICULAR OSTITIS OF THE HIP. (SYNONYMS: MORBUS COXARIUS ; MORBUS COX.E ; HIP- JOINT DISEASE; HIP DISEASE; TUBERCULOUS DISEASE OF THE HIP; CHRONIC EPIPHYSITIS OF THE HIP; MEDULLO- ARTHRITIS; COXALGIA; COXITIS). PATHOLOGY. Whatever name surgeons employ to represent the dis- ease in question, all recognize the fact that its essential feature sooner or later is a destruction by inflammatory process of the bones entering into the articulation. Its nature, at least in the advanced stages, is too well recog- nized to admit of any argument at this late day. I employ the term chronic articular ostitis, because I be- lieve it better represents the pathology. The time has come when Science demands a definition of the terms we employ. Hip-disease has too vague a mean- ing. Too many distinct diseases are included in this term. Men talk glibly about curing hip-disease, and we find that they can give no clear idea of just what they mean. So of morbus coxarius, and morbus coxae the Latin equivalents merely. All are objectionable, although popu- lar. Coxalgia means pain at the coxo-femoral articulation ; coxitis, inflammation without regard to the tissues prima- rily involved; chronic ephysitis answers very well if we can always rest satisfied that the epiphysis is the only bone in- volved in the initial lesion. We know too well that the diaphysis and the acetabulum are often simultaneously implicated. Hence my objection to the use of the term. Tu- berculous disease of the hip is formidable enough, and may convey the proper idea; but on this side the Atlantic we are unprepared as yet to accept the conclusions in full of our German co-workers in this field of pathology. Some of us may believe, and with good reason, too that all osseous le- sions in the neighborhood of this joint are'not tuberculous. The name I have chosen will, I think, more clearly accord CHRONIC ARTICULAR OSTITIS : PATHOLOGY. I/I with accepted views, and will not commit us absolutely to one form of inflammation. The time has also come, I think, when a careful examination, with a full understand- ing of a history, of signs, and of symptoms, will enable us to recognize the disease in its early stage, despite the ob- jections of the general surgeon. Errors will, of course, arise, yet they will be highly instructive to him who strives to make this branch of surgical science an art in the fullest sense of the term. When, then, I use the term chronic articular ostitis of the hip, I want my readers to understand that I mean a bony lesion to begin with, and a chronic process; hence an insidious disease and one difficult with which to grapple. I mean, too, to convey the idea that no one bone is always the seat of the initial lesion. To the pathology of this disease, then, I propose to de- vote a few pages, and I make no claim to any originality. To name the different views of writers would be tedious and unnecessary. /The text-books on general surgery supply this want, and every student is supposed to leave college with an understanding that there are two theories prevalent; one, that this disease begins as a simple inflammation in the soft parts, the ligamentum teres or capsular ligament pref- erably, or in the synovial membrane or cartilage, induced by a sprain, or wrench, or contusion, however slight; the other, that it begins as a chronic ostitis of a strumous nature in one or more of the centres of ossification in the immediate neighborhood of the articulation. It may be caused by sprain or concussion, but frequently arises without these factors, and is aggravated after the full development of the disease by trauma. For an excellent resume of the views held and facts furnished by different authors, see a paper by Dr. Judson, in New York Medical Journal and Obstetri- cal Review, for July, 1882, entitled, " Some Practical In- ferences from the Pathology of Hip Disease." The arguments employed in favor of an inflammation in the soft tissues of the joint being primary, and inducing, either by interference with the blood supply or by contigu- ity, a chronic ostitis in the acetabulum or head, have never been convincing to my mind, and hence this theory has not been accepted in my pathology. Pathological specimens, I am well aware, are adduced to prove that the initial lesion was in the round ligament. These instances are, with a single exception, in specimens where section of the bone \ DISEASES OF THE HIP. has not been made. The exception is in the case of Dr, Willard's. I shall present his conclusions, with comments, however, a little later. An epiphysitis, and especially a chronic epiphysitis, wherein the inflammatory exudations encroach upon the blood-vessels, must, of necessity, produce a hyperaemia of the ligamentum teres, which carries the blood in a great measure to said epiphysis, and this hyperaemia cannot long remain without the usual inflammatory changes. In his work on Diseases of the Joints, Mr. Barwell states emphatically: " In no case of ostitis about the epiphysis have I ever found the round ligament other than entirely absorbed, thinned and inflamed, or ulcerated and hanging in shreds;" and to this view he is my authority for stating that Mr. Aston Key gave the weight of his authority. Without entering into an elaborate argument, I think that thoughtful and practical surgeons, the world over, will agree with me when I assert that the injuries done this lig- ament in cases where a clear and unmistakable diagnosis can be made at the time of, or very soon after the occur- rence of the injury, in children at least, terminate in reso- lution, with or without the " absolute rest" so zealously insisted upon by the orthopedist. On the other hand, all men know that there are cases of disease at the hip-joint that do not make a perfect recovery, even if the most successful orthopedist gets them under treatment the moment the first white blood-corpuscle wanders from its channel to light up disease. That disease may begin in the synovial membrane and extend by contiguity to the bone I am as well convinced as symptomatology and clinical facts can convince one, but I am unable in my study of pathology to adduce a single case either from my own records or from literature that will prove beyond a doubt that such a process takes place. Still, it is my belief, based on clinical records and compar- ative pathology, that many of the bone diseases about the hip occurring in children over eight years of age are in- duced by synovitis or periostitis. Some I find myself that seem clear, and yet I cannot feel absolutely certain. An acute epiphysitis may in these very cases be the original disease, and the synovitic symptoms may be such as we find developing in the course of a chronic epiphysitis. Take the following case, in a boy ten years of age, in whom I diagnosticated, with a precautionary interrogation-mark CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 173 however, acute primary synovitis. He was admitted to the hospital in February, 1881, and was so excessively tender about his hip that it required the greatest amount of care to get him into the ward without pitiful shrieks. After much coaxing he was induced to stand. The left limb was rotated outward over a small arc, and the foot was everted. It was slightly flexed, and by reason of the pelvic accom- modation was apparently one and a half inches longer than its fellow, while careful measurements from the an- terior superior spine revealed nearly a half inch shortening. There was no atrophy, and while there was unmistakable joint tenderness, most of the soreness on moving the limb was periarticular. Along Poupart's ligament the glands were infiltrated quite distinctly, and along the inner side of the thigh the parts were apparently swelled, yet measure- ments failed to verify. The gluteal, the iliac, and the ilio- costal regions were free from any infiltration. While all movements were resisted, any attempt at passive motion excited pain which was referred to the distribution of the anterior crural and the obturator nerves. The adductors stood out prominently tense. There was some febrile re- action but it was not measured. One month previously, while apparently in good health, and without any provocation, he complained one morning of pain in his knee, but walked to school as usual though limping. The lameness and the pain increased during the day and next day, so that on the third day he was quite unable to walk. His sleep was not disturbed unless he moved in the bed. The symptoms, according to the father, had been growing steadily worse. With this history, then, with the liabilities to cold at that season of the year (Christmas time), and with those symptoms many of which were those of synovitis, I felt reasonably sure that here I had a genuine case of primary synovitis, and I made a favorable prognosis. The treatment adopted was such as I had used with success in others, viz., blistering, poulticing, and rest. He grew rapidly worse, and within a month the infiltration had extended throughout the upper portion of the thigh. By the last of Mayan immense abcess had formed and opened near the junction of the upper with the middle thirds of the thigh. The pus was brownish in color and had a fecal odor. The deformity had increased and the hip was prac- tically locked against any motion, active or passive. 174 DISEASES OF THE HIP. The boy was taken away, and I have heard that he died shortly after removal. I have reported already in the chapter on bursitis, page 115, a case wherein the disease of a bursa underlying the ilio-psoas was the cause, in my opinion, of the joint disease, the final results of which have not been reached. Under seven or eight years of age the vast majority of cases of so-called hip-disease begin as an ostitis. Beyond that age a certain proportion, not large as I have already stated, begins as a bursitis, a synovitis or a periostitis, while still a large number begin as a central bone disease. At all events, be the starting point what it may, the peculiar richness of the blood supply in the cancellous structure of the bone, the temporary hyperaemias in and about the centres of ossification, induced by over-use or external vio- lence, and the recognized existence of a diathesis, make the transition from health to disease at times extremely easy. The experiments of M. Oilier, in Number X. of the Revue de Chirurgie, 1881, showed how easily disturbing forces could affect the epiphysis, i.e., could induce hyper- ffimia the initial stage of inflammatory changes. Dr. Jno. Jas. Berry, formerly associated with me in hospital work has written during the past year in the New England Medical Monthly a very instructive paper entitled, " Juxta Epiphysal Congestion in its relations to Hip-Disease." He makes use of the following remark, which I can in a great measure confirm: "We must remember that, whereas, in adults, the liga- ments and cartilage suffer from the shock of injuries, in children, concussion affects the weakest portion of the articu- lation, which is the epiphysis. Added to such injury there is crushing of the dense enclosing layer and effusions of blood into the medullary spaces." The promptness of such injuries to resolve, I think, is well demonstrated, and when they do not thus terminate one naturally assumes a. cons- titutional diathesis. It does not always result in carious deposits even in strumous children, for there are various degrees of resistance. Hereditary qualities and conditions of health, hygienic surroundings and peculiar conditions of the atmosphere make the individual, and this tissue in particular, a fit receptacle for the lodgment of the bacillus which is found in strumous matter. Then, again, certain acute diseases increase this vascu- CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 17$ larity in structures wherein rapid developmental changes occur and bring about practically the same result as do concussions and other injuries. This is well illustrated in a case reported by Dr. Willard of Philadelphia, in the Boston Medical and Surgical Journal, 1880, and in which the microscopical work was done by Dr. Shakespeare of the same city. The article was entitled " Hip-Joint Disease: Death in Early Stage from Tubercular Meningitis." The child was five years of age, and phthisis and bad hygiene were found in the history. Lameness and other signs of joint disease began one year prior to Dr. Willard's observations in the case. From his examination he concluded that there was " presumptive evidence that the round ligament is the centre of the disease." The FlG. 10. ACKTABULUM AND HEAD OF FEMUR, SHOWING DISCOLORED SPOT ON LATTER. patient was confined to bed with weight and pully, and every facility utilized for securing good hygiene. Two months later tubercular meningitis developed, and after a very acute attack, lasting six days, the patient died. The specimen is of such great interest that I have reproduced it in its gross appearances. "There was not more than ten drops of effusion, but the synovial membrane was everywhere congested and soft- ened, and at the acetabular attachment of the ligamentum teres were decided evidences of inflammation and softening of tissues. Upon the head of the femur, on its posterior upper surface, was a discolored patch (Fig. 10) possibly 176 DISEASES OF THE HIP. caused by post-mortem contact against the acetabutum, although there was no corresponding spot in that cavity, and it had more the appearance of redness situated beneath the articular cartilage. The capsule was perfect, the round ligament intact, and while the membrane covering it was more reddened and softened than at any other part, yet there were no positive signs of ulceration to the naked eye." "After decalcification of the hard parts and harden- ing of the soft tissues," Dr. Shakespeare made a section of the acetabulum and head, at the same time cutting longi- tudinally the ligamentum teres. The epiphysis did not contain to the naked eye any ca- seous or other nodules, the cartilage was entire, there was nothing macroscopical in any of the tissues suggestive of miliary or confluent tubercles. Among the conclusions arrived at from microscopical ex- aminations of this specimen was that the bony structure of the neck of the femur, although hypersemic, was but slightly diseased and not tuberculous, and that a few caseous foci were found in the ligamentum teres, but these were not tuberculous. Indeed, about the only condition actually found was a somewhat exaggerated hypersemia throughout all the tissues. Pathologically, it was negative. Now, while the conclusions arrived at by the two gentle- men reporting the case are perfectly legitimate, I am con- strained to regard it as one in which the pathological pro- cesses that existed early in the disease (this had begun already a year before coming under Dr. W.'s treatment) were in that slow, inactive state, and under the favorable hygiene latterly provided, had undergone a cfertain degree of resolution, all to be disturbed again and provoked to renewed activity by the invasion of the acute tubercular meningitis. This disease, it will be seen, proved fatal in one week, and hence time had not been sufficient for any extensive lesions from original foci of the chronic disease. The centres of ossification are fertile soil for the develop- ment of strumous (tuberculous) processes. The resem- blance of this cancellous texture to the parenchyma of lung is very striking, and the clinical characters of tubercle in the two localities have been brought in close comparison within the past year by Mr. Scovell Savory, one of the sur- geons to St. Bartholomew's Hospital. He published his notes on page 737 of volume II. of the Lancet for 1882. The structure of the two tissues is sponge-like, yet the resem- CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 177 blance becomes, the stronger when a mass of yellow tuber- culous-looking matter occupies the substance. Mr. Savory speaks further of the halo of inflammation or increased vascularity by which each is surrounded, vary- ing in width. I have myself seen this so often in bone with caries and rarifying ostitis. This is very difficult to show without colored lithographs, and hence the ordinary plates seem tame and inconclusive. The author from whom I have just quoted goes still further in his comparison: "Just as pleurisy is so often set up by the disturbance of tubercle in the lung, so synovitis is often provoked by the disturbance of tubercle in adjacent bone; and just as em- pyema is sometimes produced by the perforation of the lung-wall and the escape of matter into the pleural cavity, so suppuration in a joint which is too often destructive is due to the perforation of the articular wall of bone and the escape of matter into the synovial cavity." The researches of Volkmann establish, so far as speci- mens from the joint and the bones entering into the forma- tion of the joint removed by excision at all stages of the disease can establish, the truth of the theory that the great proportion of all cases begin by small localized centres of disease at or near the centre of ossification. The nature of these, histologically, is tuberculous. My own studies lead me to the conclusion that the centres of disease are nearer the diaphyso-epiphysial line. In a case that I had for a time under observation with Dr. C. T. Poore of this city, and subsequently published by that gentleman in the Medical Record, this localized centre of disease is shown in the accompanying figure No. n. The patient was a girl aged five years, and began to com- plain of pain in her right lower limb in the early part of December, 1878. The family history was poor, and the hygiene had been wretched. There was no existing cause, so far as could be ascertained. The pain and lameness were synchronous, and the stiffness was especially marked in the morning. When I saw her first it was on the i4th of De- cember, and I found both lower limbs very hyperaesthetic, the right the more notably so. I saw her again nearly one month later. She seemed very helpless, and the report from the mother, who was herself exceedingly hysterical, was that the child had been screaming while asleep, and even waking out of sleep crying, as if suffering terribly, every night since I had seen her last; that the lamenessjiad. 1/8 DISEASES OF THE HIP. increased, and that she was losing flesh. I saw that she was much thinner than when I had examined her before. The left thigh now was advanced a little and the foot evert- ed. Extension to the normal limit was resisted, other movements were not. Two days later there was dulness in the left ilio-costal span, but in the absence of other signs was not significant. The lameness and pain on walking, and the morning stiffness were still present. Pain and re- sistance were encountered when the left thigh was rotated. Two days elapsed again and the right thigh was adducted, Fio. ii. SPECIMEN OF DIAPHYSO-EPIPHYSITIS FROM CASE REPORTED ON PAGE 177. the foot was inverted, and there was marked resistance to flexion beyond 90. The same resistance was present on the left side. As she stood, both limbs were in moderate genu-vulgum, and the right natis was flattened and crease lowered, while the lameness was marked in the left limb. Tenderness at either hip or at either sacro-iliac synchon- drosis was absent by any test employed. Indeed, there was no sign present on one side that was not present on the other, and this circumstance wai> duly recorded. In a couple of days she was again submitted to a thorough examination, and the greatest tenderness elicited was over the left sacro-iliac junction. Motion at the left hip caused no pain. Even the severe test of putting on and off the CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 179 stocking caused no pain, and forcibly percussing the heel with limb extended induced laughter. On attempting to stoop, pain was complained of at the left knee, and as she stood this limb was apparently longer. Next day Dr. Poore saw the case with me, and he noted that " nothing wrong could be detected about either hip-joint; motion free and painless in all directions, except that she complained of some pain in the knee when the left thigh was strongly flexed. When the left joint was moved patient made no complaint, but when the left ilium was pressed inward she cried out from pain. There was no swelling about the right or left hip-joint; no change in the crease of the natis. The right hip-joint seemed perfectly healthy. There was pain on pressing the crest of the ilium on the left side in- ward, referred to the left knee, or upon ?' -npting to com- municate motion to the sacro-iliac joint o~ ihatside. There was tenderness, or at least the patient complained, on pressure being made over the sacro-iliac synchondrosis of the left side, and there appeared to be some dulness on per- cussion over that joint; none on the right. In walking or standing she favored the left limb, but there was nothing characteristic in her attitude." On the 24th of February I saw her with Dr. P., and noted that motion at hip (left) was limited in flexion and exten- sion to smaller arcs than normal, and in abduction and ad- duction to scarcely appreciable arcs; that with the excep- tion of the tenseness of the adductors, the same signs were found at the right hip. I could not discover any atrophy or shortening. The joint surfaces on both sides were smooth, however, in the limited arcs of motion. During the latter half of Marcli there was much pain about the right knee, and the limb was held flexed as the child lay in bed. Adduction became a strongly-marked sign on each side. I assisted, one day early in April, the Doctor in making a pretty thorough examination under ether. The adductor contraction yielded with very little force, but in our man- ipulations the right hip was subluxated. While there was entire absence of articular roughening at either joint, this giving way of the ligamentum teres was the only sign we could discover. The urine, a few days subsequently, was ob- served to be dark and smoky. The patient died on the i6th, and after twenty hours post mortem, we found the limbs perfectly straight and equal in length. The parts on section I8O DISEASES OF THE HIP. down to the capsule, right side, were normal in appearance. The head could be easily slipped out of the socket, and as easily returned. The capsular ligament itself was intact, but on being opened was found to contain about two drachms of thick, inodorous pus. The ligamentum teres was softened, pretty thoroughly disorganized, and about two lines of it was attached to the head, while the proximal portion lay spread out on the floor of the acetabulum. On passing the finger over this portion of the acetabulum an area of bare, roughened bone, a half-inch in diameter, could be felt, and one blade of a small pair of forceps passed readily through without force, the point of the blade being felt by a finger inserted through the sacral foramen. The cartilage cover- ing the head was yellowish but nowhere eroded. Section of the head and neck was made, and nothing abnormal to the naked eye was observed. The left hip-joint was exposed, and its capsule was found normal in every respect. No fluid escaped when it was opened, and the head could only be turned out of the socket with considerable force and with the characteristic suction sound. Its complete dislocation was impossible, without dividing the ligamentum teres. This ligament was pale red in appearance on section, and seemed normal in size, strength and attachments. The articular cartilages were pearly white, and apparently normal. The same means with the finger and forceps were made to detect erosion or disease in the acetabulum, as were made on the right side, with absolutely negative results. On removing the capsular ligament at its femoral attach- ment, a worm-eaten hole was discovered on the upper border of the neck just at its junction with the head, and into this hole the point of a lead pencil could be inserted without force. On section of bone, a yellowish (caseous [?]) patch was seen involving the upper portion of the diaphysis, encroaching upon the diaphyso-epiphysial cartilage and even above this line within the medulla of the epiphysis there was a similar patch, the two only separated by the cartilage. This diaphysial patch communicated with the joint by means of the small hole above mentioned. There was no pus. A vascular areola existed about this patch, shading off into the normal bony tissue. (See Fig. n.) On opening the abdominal cavity, the bladder was seen above the pubis but not distended. Pressure upon this viscus was immediately followed by a discharge CHRONIC ARTICULAR OSTITIS : PATHOLOGY. l8l of at least a half ounce of whitish very fetid pus from the vagina. The bladder contained about an ounce of clear normal-looking urine, and its walls appeared normal. A pus-sac was found between the bladder and the vaginal wall opening into the latter. This sac had been cut away by the dissection, and its direct connection with the per- forated acetabulum could not be made. The whole inner surface of the pelvis was carefully exposed and no evidence of disease about the ramus of the pubis, the symphysis, or either sacro-iliac junction could be discovered. My own explanation of the source of the abscess is that the pus bur- rowed behind the obturator muscle, as it sometimes does. (See Fig. 6, arrow C), and found its way into the ischio- rectal fascia. In the female the vagina perforates the recto- vesical fascia and receives a prolongation from it. It would be just as easy, then, for the pus-sac to open into the vagina as in the rectum, between which there is no fascial layer. I have been thus particular in detailing this case, making it even fuller in some respects than it was when first pub- lished, because I find it so very instructive and so illustra- tive of the pathological processes that take place. In the first place the subject would pass anywhere for a strumous child, and yet no exciting cause could be found. Again, the ostitis developed in the acetabulum of one side, and in the diaphysis of the other side, very nearly about the same time. In other words, there was a multiple lesion, and the foci of disease were in close proximity to centres of ossification. From the acetabulum there were quite early, though not appreciated, signs of synovitis. Indeed, the process here was more acute than in the femur, and the inflammatory processes extended the more rapidly to neighboring parts, involving the synovial membrane on the one hand and the pelvic fascia on the other; a little later, the ligamentum teres. It will be observed, too and this fact I want to stand out in bold relief that although the ligamentum teres was thoroughly diseased and disorganized, the nutrition of the epiphysis suffered no appreciable change. The acetabulum was not the tissue to suffer from disease of this ligament, and yet it was perforated. The process going on in the left femur was much slower, and was what some might describe as a caries sicca. But how do we know that this would have been so had the process in the right acetabulum been less acute ? It is seldom that the ostitis pursues so rapid a course 1 82 DISEASES OF THE HIP. as it did in this particular case, yet cases have their counterpart in pulmonary tissues. Often the lesion seems arrested, and cases with long intermissions are not at all uncommon. Cases like the following come under observa- tion, and during the interval between exacerbations a cure is often pronounced. The boy was four years of age at the time of admission to the hospital in March, 1871. It is recorded that he had a brother suffering from caries of the hip, well advanced into the destructive stage. They re- port that a year prior to admission our patient fell from a velocipede about one year prior to admission, and a few months later complained of pain in the right knee. This became severe, and was referred to the hip, causing the usual night screens, the morning stiffness, etc. Condition on entrance to hospital as follows: plump, and well nourished; boy standing with the right lower ex- tremity semiflexed, everted, and resting on the toes, and walking with a very marked limp; nates on right side broadened, natural depressions effaced, crease raised, and cleft inclined to the left; thigh flexed on pelvis at an angle of 150, and held here by muscular action, though flexion can be carried to 90 without causing much pain. The diagnosis is made without reservation, and, under the usual treatment of the hospital, the case made good prog- ress; though in the month of May there occurs without known cause a suppurative middle-ear disease, left side. At the close of the first week in September it is noted that his condition is such as to justify his discharge, and a month later his general health seems excellent; he stands squarely on both feet, and walks without a trace of lame- ness; no atrophy exists, no tenderness or pain on complete flexion or extension, or on concussion of trochanter in fact, no sign of disease in or about the hip can be detected. His friends had deserted him, and no home could be found; hence, he remained in the hospital, different persons prom- ising to adopt him, until the beginning of 1875. During that period never a sign of disease was observed, and the cure was regarded as well established. The ear disease continued, however, after the usual manner. On the first day of January, 1875, note is made of an en- largement of cervical glands right side three months' stand- ing, coming on without any known cause, and steadily gaining ground despite, all treatment. Hip still free from any sign of disease. CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 183 Next day, after perfect immunity for three years and three months, the hip is the seat of great pain, and the boy is abed with a high temperature, and crying if any motion at the joint be attempted. The acute symptoms were relieved by the middle of the month, and the boy was walking around the ward, though joint still tender and glandular infiltration increasing. A general glandular enlargement, or, adenia, set in, the boy became emaciated to a skeleton, and death by asthenia occurred the last day of February. Autopsy twenty-four hours later, conducted by Dr. Ed- I FIG. 12. VERTICAL SECTION OF PROXIMAL END OF NORMAL FEMUR IN CASE ON PAGE 184. ward G. Janeway. Body greatly emaciated, and skin jaundiced about eyes, scrotum and right lower extremity; both lower limbs lie in complete extension, and motion at joints is free. Right lung slightly oedematous, otherwise normal, and old pleuritic adhesions are extensive; left lung and pleura normal, as also the heart. Peritoneal cavity contains about a pint of a yellowish jelly-like material; liver is one fourth larger than normal, and on the surface as well as on section there is a mottled appearance. In the gastro-hepatic omentum a gland the size of a walnut presses against the ductus-communis choledochus, 1 84 DISEASES OF THE HIP. the pyloric orifice of the stomach and the receptaculum chyli. The microscopic appearances of this gland are normal. Mesenteric glands enlarged, as likewise the cer- vical, from the mastoid process to the clavicle, varying in size from a hazel-nut to a walnut. A deeper gland sep- arates the deep jugular from the carotid, a space of one inch, and presses against the pneumogastric. Pus is found in the right middle ear, extending into the mastoid cells. The right hip-joint being opened, the capsular ligament is found intact; there is no fluid within the cavity, and suc- tion force is normal, while the ligamentum teres is easily detached. Head of bone presents a dirty yellowish aspect, with a groove extending from ligamentum teres towards FIG. 13. VERTICAL SECTION SHOWING Foci OF DISEASE IN CASE ON PAGE 184. trochanter minor, intersecting a similar groove about the insertion of capsular ligament. In this groove is new con- nective tissue. At one point the cartilage is completely eroded; head flattened. On vertical section there appear three yellowish spots, two above and one below the line of epiphysial union, which line of union is carried up one inch; cartilage is one half the normal thickness, and this, as well as the bone underlying, is, in the field of the micro- scope, seen to be in the process of fatty degeneration. The head and neck of the sound femur are also removed CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 185 and the above description is comparative. Blood exam- ined microscopically and found normal. The accompany- ing cuts show very strikingly the pathological changes, with the exception of the coloring. The whitish spots in the head and neck of Fig. 13 in the original sketch, as made by the artist at the post-mortem, are yellowish, showing the fatty metamorphosis to perfection. Fig. 12 is a section of the sound bone inserted for comparison. The case of Fricke's, of Hamburg, published in 1833, I take from Dr. Judson's paper, is of value in this connec- tion. The boy was four years of age and had been lame FIG. 14. SECTION OF SOUND FEMUR TO FRICKB'S CASE. COMPARB WITH FIG. 13. FIG. is. -SECTION OF FEMUR m FRICKK'I CASE. PAGE 185. four months, when he died of tubercular meningitis. Lon- gitudinal section was made of each femur and is repre- sented in the copies from colored lithographs. Fig. 14 the sound; Fig. 15 the diseased. He found the synovical mem- brane everywhere red and congested. The articular carti- lage was healthy in all its surfaces, whue the spongy tissue of the upper portion of the femur, throughout its whole extent, was much redder and more vascular than that of the sound femur. A firm yellowish or grayish-white mass was seen in the interior of the neck occupying the greater part of the medulla, and taking the place of the spongy tissue. 186 DISEASES OF THE HIP. At its upper portion it was retained in contact with the com- pact layer of the neck of the femur, but loosely enough for a probe to pass between; the lower portion of this mass was firmly adherent to the spongy tissue. The epiphysial car- tilage was greatly reduced in thickness. M. Larinelongue's case published in 1881, in the Bulletin Of the Surgical Society of Paris (vol. ii. No. i. pp. 9-11,) Illustrates the close connection between the diaphysial lesion and the fungous localized synovitis. This abstract I also take from Dr. Judson's paper. The patient, a girl, three and a half years of age, had been lame two and a half months and the hip was locked in the flexed and adducted position. Five months after the invasion of the joint disease she died of diphtheria, and the synovial membrane was found, post mortem, reddish, thickened, and fungoid in appearance, in certain places, especial- ly at its lower and posteri- or portion. The synovial changes appeared to M. Lannelongue to start from the neck of the femur near the head. The ligamen- tum teres was also red, vascular and slightly fun- gous. The surfaces of head and acetabulum presented no change, and the articular cartilages retained their normal condition, with the exception of a little thinning on cer- tain portions of the head. Section of head and neck revealed a marked redness in the centre of ossification of the head and large areolae in comparison with those of the opposite side. The promi- nent feature of the specimen was a cavity the size of a small bean lined with thin membrane and filled with a cheesy substance, situated immediately below the epiphysial carti- lage. The bony tissue around the cavity presented a red zone. From certain portions of this lining membrane of the cavity fungosities started and reached the surface of the bone, where they became continuous with the thick- ened synovial membrane. Volkman has published a case the specimen from which (Fig. 16) is similar to Fricke's. (See p. 1406, Saml. Klin. Vortrag. Nos. 168, 169, 1879.) It is described by the FIG. 16. VOLKMANN'S CASE. PAGE 186. CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 187 author as having a cavity in the neck of the femur immedi- ately under the epiphysial cartilage, which cavity is lined with smooth tuberculous membrane and filled with cheesy matter. The term ostitis malacissans is the term Billroth prefers for the early changes, and Volkman employs for the same the term rarefying ostitis. The chalky salts quickly dis- appear from the osseous tissue, and the medullary vessels increase; the medulla, being filled with wandering cells takes the place of the disappearing bony tissue (Billroth). This is directly the opposite of ostitis osteoplastica. In the one softening of the bone-substance occurs, and in the other the neoplastic tissue is transferred into compact bone. The form of inflammation with which we have to deal is not the osteoplastic ostitis, but the ulcerative and the fun- gous. Caries is only employed to represent the destructive stages of an ostitis. It represents the bony defects caused by the lacunar erosions. Caries begins as an ostitis, and is known as such by some authors, Billroth preferring to abandon the term altogether and modify the term ostitis to express the different kinds one meets both clinically and on the dissecting-table. If, then, a rarefying ostitis, which produces always a soft- ening of the bone substance, is characterized by proliferat- ing granulations, and does not go on to suppuration, we call this a caries sicca, or, an ostitis fungosa. If, on the other hand, the rarefying ostitis goes on to suppuration, the neo- plastic material disintegrating or undergoing carious meta- morphosis this we call caries atonica. Frequently masses of bone become separated, and the process is called caries necrotica. Indeed, as repair goes on, and these disinte- grated portions are exfoliated we have particles of necrotic bone coming away with the pus ; so that a really distinct caries is comparatively rare. Both clinical experience and post-mortem anatomy teach clearly that no one form is always present to the exclusion of the other. The forms of inflammation blend here as in other tissues. Billroth claims that the non-suppurating caries, the fung- ous ostitis, is the more common in childhood, while the atonic belongs especially to adult life. My own views are just the reverse of this. He states, argumentatively, " Path- ological anatomists, who only see caries on the dissecting- table, rarely know the fungous form accurately, or consider 188 DISEASES OF THE HIP. it the more rare ; but when one often examines pieces of carious bone, cut out during life, especially the resected joints of children, where the process is going on actively, he learns to judge differently from what he would in the anatomical museums where macerated bones almost exclu- sively are preserved" (p. 503, Hackley's Trans.). I would retort by asserting, with abundance of proof to sustain me in the assertion, that at least three-fourths of the cases of chronic articular ostitis of the hip in children do suppurate, and the reason why the distinguished Vienna surgeon, and other surgeons throughout Germany, do not meet with the atonic form of caries in these resected speci- mens is, that they, almost with one accord, operate early, and rarely wait for the suppurate stage. How can one de- termine whether the process he sees on resection would have remained as it is, or have gone on to caseous degene- ration and the formation of tubercle ? It is simply impossible to say in every given case of chronic bone disease affecting the hip-joint, and I might include the other large joints, that suppuration will not occur. In thirty cases of caries of the ankle in children that I have analyzed, twenty-five suppurated. (Am. Jour- nal of Obstetrics and Diseases of Women and Children, April, 1880.) The changes that take place in the medullary portions of the bone in the vicinity of the centres of ossification, even in the fungous ostitis, certainly cannot long resist the ten- dency to suppuration. Indeed, Virchow has shown that the boundary lines between the medullary cells and pus cells cannot be sharply defined. (Cellular Pathology.) The development from one to the other is, of course, hast- ened by septicaemic influences. So that I am forced to the conclusion that it is exceedingly difficult to differentiate from clinical evidence between a caries sicca, and a caries atonica. With this chronic disease marked by such slowly developing products in the medulla and at the centres of ossification a strumous basis the development of tuber- cles is an easy and a natural process. Dr. Henry H. Smith, of Philadelphia, has traced the con- nection, in a highly instructive paper, presented to the American Association in 1878 (Transactions for that year). He notes the influence of congestion of the medulla on the cell proliferation, and on the increased number of leuco- cytes ; also the defective elaboration of blood as a result of CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 189 perverted myeloid cell action : and arrives at the conclu- sion that struma and tubercle are so closely allied that dif- ferences cannot well be demonstrated. Such is now the accepted view of the nature of the strumous ostitis of the spongy portions of bone. In Germany, I am informed by Dr. Wm. H. Welch, the question is long since regarded as settled, and further inves- tigation is deemed useless. Given, then, the caseous degeneration, what becomes of the products, and how does the process extend ? Abscess forms, the cavity is lined with a membrane in which can be sometimes found tubercles. The caseous matter contains bone debris. Parts fall together, are fused, or still further destroyed. Harwell's case, in a boy who died of tuberculous meningi- tis two months after the appearance of the first symptoms of joint disease, is detailed on page 276 of the Wood's Li- FIG. 17. SHOWING RAPID DESTRUCTION OF BONE IN HARWELL'S CASK. brary Edition. The specimen, Fig. 17, is described as fol- lows : "What remains of the round ligament can barely be seen ; it was very thin, soft, and shreddy ; red, and infil- trated with a blood-stained serum. The epyphysial and diaphysial head of the bone, with a portion of the'neck, was, at its lower part, quite carious ; the excavation shown in the figure was, when fresh filled up with thick pus, mingled with bony detritus and soft granulation tissue. The carti- lage was intact though thinned, except around the caseous cavity, where it had in great part disappeared. It was de- tached in great part from the bone for a considerable dis- tance around the margins of that excavation." 1QO DISEASES OF THE HIP. Mr. Holmes, in " The Surgical Treatment of Children's Diseases," has a specimen figured which closely resembles Mr. Harwell's. The drawing was made from the bone as removed by excision from a girl eleven years of age who had been lame for two years. Mr. Holmes describes it as a case in which the disease was seated wholly within the neck. I have had the specimen reproduced in Fig. 18. The portion of bone which gave way is well shown, yet I am not convinced that the epiphysis did not contain a focus of caseous ostitis inasmuch as no mention is made of a section. It does not follow that because the "articular surface was quite healthy" a mass of carious bone did not lie beneath it ready to break through during an exacer- bation and complete the destruc- tion of the joint. The compact tissue of the neck giving way FIG. ,8.-MR. HOLMES' SPECIMEN TO first > this case g 6S n re< T rd aS . ILLUSTRATE CARIES OF THE NECK, one of the femoral Variety of VERTICAL SECTION NOT MADE. i . j- A. C. C. which being in- terpreted is: cathodal closure contraction is greater than anodal closure contraction. 4. The faradic reaction is lost in muscles paralyzed from an infantile spinal paralysis within the first week ; it is CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 289 merely diminished if at all impaired in the early stage of a chronic articular ostitis. This latter is the more available test for the general practitioner. V. PERIARTHRITIS. It is only in the very early stage of a periarthritis that one need experience much difficulty in making a diagnosis. After the infiltration has presented the signs become suffi- ciently clear. It must be remembered that I am now speak- ing of the phlegmonous inflammations around the joint. Children as a rule never have the fibrous form, but this oc- curs in the adult occasionally, and the diagnosis is made then by exclusion. Take as a very good illustration of the course a periar- thritis of childhood, the following, in a boy three years of age, who came under my observation in August, 1879. In the early part of July he had an attack of rubeola and was con- fined to bed for ten days. On leaving his bed no lameness was discovered, in fact he walked as well as he ever did, until a week had elapsed, when he began without known provocation, to favor the right side in walking. A few days later pain became a marked symptom, and the limb would not tolerate any handling. The father was referred to the hospital by his medical adviser to have the child treated for " hip-disease." I found an axillary temperature of 101.5, a pulse of 132, and an extreme degree of irritability in the patient. It was difficult to secure a satisfactory ex- amination on account of the apparent tenderness of the limb, yet by a little perseverance I learned that the thigh could not be completely extended, flexed or rotated, and that the position assumed in standing was that of the first stage at the height of an acute exacerbation. There was extensive infiltration about the hip and around the upper third of the thigh, though no fluctuation could be detected. The acuteness of the attack, the rapid development of signs, and the constitutional disturbance enabled me to diag- nosticate a periarthritis. The subsequent progress of the case fully confirmed the diagnosis made, and in less than two months a cure was fully established. In February, 1879, I saw a boy nine years of age, two months after his first lameness was observed. An exacer- bation had followed soon after the beginning of the lame- ness, and the second stage was already present at the time. DISEASES OF THE HIP. I made my examination. There was an apparent lengthen- ing of one inch, and the natis and thigh were very promi- nent by reason of extensive infiltration. I found it difficult, however, to flex the thigh to 90 or to extend to 135. All the other movements were resisted and the diagnosis was made without any hesitation of chronic articular ostitis of the hip. The case went rapidly through the various stages The temptation to cite further illustrative cases is very strong, but the chapter on the clinical history of bone lesion is already full enough to convince any one that while cer- tain cases may seem like acute processes, a little more study of details will bring out the chronic nature the slow pro- cesses of the same. It remains now to sum up the points, as my plan is, of differential diagnosis, premising, however a few points of similarity 1. Both plegmonous coxo-femoral periarthritis and chronic articular ostitis of the hip occur at about the same period of life. 2. Both occur in strumous subjects, yet the former is more frequent than the latter in non-strumous subjects. 3. Both may begin with lameness without accompanying pain. 4. The limp of the two may be identical. Differentially, we have : i. Pain and acute symptoms within the first few days in a periarthritis ; these are the exceptions in a chronic articular ostitis. 2. In the one there is extra heat and superficial tender- ness ; in the other these signs are so insignificant as not to be readily appreciable. 3. In the one tumefaction appears as a rule within the first fortnight ; in the other several weeks, and months even, elapse before any tumefaction presents. 4. In an early periarthritis those movements are li mited whose mechanical execution is interfered with by inflam- matory processes, and the explanation is comparatively easy: in an early ostitis the limitation is purely reflex there being no mechanical obstructions appreciable, and one is at a loss to explain why certain groups of muscles should be excited to spasm or resistance by attempts at passive motion. 5. Palpation will detect a lesion in the periarticular tissue in the one; in the other palpation will serve only a negative purpose. 6. In the one the constitutional symptoms are often very CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 2QI marked ; in the other there are, as a rule, no constitutional disturbances in the early stage. 7. In the one the sleep is disturbed by moaning and rest- lessness; in the other the characteristic night symptom is the ostitic cry. 8. In the one there is no atrophy of the limb; in the other this is an early sign. 9. Finally, if an immediate diagnosis be not required, re- peated observations, extending over a fortnight, will clear up all points of differentiation. VI. BURSITIS. The comparative infrequency of a simple uncomplicated bursitis, makes it very improbable that one will have occa- sion to differentiate between this lesion and a chronic articular ostitis. The mere fact, however, that such lesions do occur, and the fact that they yield so promptly to reme- dial measures, make it extremely important that one should be able to effect a differential diagnosis. The signs are usually well enough marked if one look over the case with an unbiased mind. The average prac- titioner is so prone to regard every case of lameness as one of " hip-disease," that he gets, not only the history, but the symptoms or signs of the disease without any difficulty. I remember with a good deal of chagrin a case of infantile spinal paralysis in which I got an excellent history, ten years ago, of chronic disease of the hip-joint ; and what was worse, I kept him under treatment for many months before I recognized my error. Ordinarily a bursitis presents very few signs of an exag- gerated type. The lameness is scarcely appreciable, even at any time during the progress of the disease, the exacer- bations are usually mild in character, and the constitutional disturbance is comparatively insignificant. Take, for in- stance, the case reported on page in of this work. The bursa involved lay under the gluteus maximus and over the trochanter major. At times separated by long inter- vals, the inconvenience was so slight even then, that the patient did not care much for treatment. He was naturally annoyed by the little pain on walking and feared an out- burst of joint-symptoms, yet as the years went by his fears became of less consequence and he gradually lost interest in his case, The lameness, it is true, was nearly always 292 DISEASES OF THE HIP. yuch as one would expect to find in a chronic bone disease whose evolution was exceedingly slow. During the exa- cerbation he complained only of a moderately severe pain, and was not sufficiently crippled as to think of giving up his work. Then, again, the girl whose case is reported on page 112 stood with limbs parallel and the lameness was so slight as to lose its significance. The symptoms were mild in type and the patient would scarcely be recognized as a patient. The presence of the sub-gluteal tumor was all that occa- sioned any anxiety. The ilio-psoas bursa, in the case of the girl reported on pages 117 and 118, proved in the end far more serious than any with which I have had to deal ; yet her acute and dis- tressing symptoms were not due to the bursitis as a bur- sitis. It was after repeated invasions of the articular cavity that the points in differential diagnosis proved of no avail. All the time prior to the establishment of the joint lesion, the signs and symptoms of the simple bursitis were clear enough for diagnosis. To differentiate, then, an uncompli- cated bursitis from a chronic bone lesion in the immediate Vicinity of the hip, it must be remembered that: 1. The exciting cause in a bursitis will be the sooner fol- lowed by visible effects in the soft parts about the hip. 2. The history of lameness in a bursitis is that of exa- cerbations with complete remissions ; while in a chronic ostitis the remission is never complete. 3. A primary bursitis seldom invades with inflammatory products adjacent tissues; while a bursitis induced by proximity to bone-disease, is surrounded by infiltrated tis- sues to such an extent that the bursa itself can with diffi- culty be appreciated. In other words, the one is easy of recognition by palpation, the other is a part of a general tumefaction. 4. In a bursitis the joint is never locked by reflex muscu- lar spasm; while in an ostitis this is a common condition. 5. A bursitis rarely occurs prior to the seventh year; a chronic ostitis more frequently occurs before this age. 6. A hypodermic needle will reveal the existence of serum in a bursal tumor, of sero-pus, or pus in a residual abscess. VII. ACUTE SYNOVITIS. In Chapter VIII. I have already shown that when the CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 293 synovial membrane of the hip is primarily inflamed the process is acute, and is the more common between the ages of eight and fifteen years. I have also combatted the theory that articular ostitis begins as a synovitis, and while I am prepared to admit that exceptionally such bone lesions be- gin in this way, I am all the more fully convinced that the initial synovitis can be easily recognized, and if promptly recognized, be controlled before destructive changes occur in the osseous tissue. Apart, however, from therapeutic con- siderations, the necessity for discrimination is still greater from a prognostic standpoint; for a synovitis, as a rule, will resolve, even if no treatment be employed, and this fact in connection with a chronic ostitis of the hip is but too clearly demonstrated as a fact, viz.: that resolution does not, as a rule, take place under the best form of treatment known to the profession. I shall be pardoned, then, if I insist strongly in detail on the points of difference. The following case, from the signs found, led me to re- gard it as one primarily of synovitis. It was in a girl aged ten years, who was fairly nourished, and whose limb as she stood, was in eversion and slight outward rotation. There seemed to be some tension of the nates and the joint ten- derness was very marked, the least pressure of the head into the acetabulum exciting sharp pains in the joint and in the knee branches of the obturator. On rotating the limb, pain was referred to the knee. The thigh could be flexed to the full extent and extended to the extreme normal limit with ease. On abduction she complained of pain and the move- ment was checked by reflex spasm of the adductors. There was no atrophy in any portion of the limb. There was con- siderable tenderness of the spine. I found a phthisical ele- ment in the family history, and the present disease began five weeks before with lameness and lordosis. It was nearly a fortnight before pain developed. She then began to scream at night. In other words, there could not have been a better history of a chronic ostitis, and the subse- quent history proved this to be a typical case. Her first exacerbation, as is common in patients of that age, came on early, and I chanced to examine her for the first time as the exacerbation was subsiding. In the early years of my hospital service I met with a case which puzzled me no little. It was in a girl seven or eight years of age who would come into the hospital in the most acute stage of " hip-disease/' and under a little ex- 294 DISEASES OF THE HIP. pectant treatment make a prompt recovery. This was re- peated twice to my knowledge. Here remissions were so complete that I could not regard it as true bone-disease. When she first came into hospital, it was in 1870, and her history, as I find it recorded, was that she had a severe fall six months before her admission, and began fourteen days afterwards to walk lame. Shortly after the beginning of the lameness she had severe pains attended with screaming at night and loss of flesh. All these acute symptoms had subsided on her admission, yet she had decided joint-ten- derness in response to the different tests. There was no resistance, or, at least very little to normal movements. No diagnosis was recorded; a simple liniment was employed and a month later a careful examination failed to detect any symptoms or signs of disease. A year and a half elapsed and she was readmitted totally unable to walk, and standing, when it \vas possible to in- duce her to stand, almost entirely on the left limb (the right was the one fromerly affected as well as now) while this was advanced and everted. The natis was broad yet free of infiltration, while the inguinal glands were enlarged. Flexion and adduction caused great pain, and the oppos- ing muscles were very tense. She seemed to be suffering very acutely, and her symptoms were only of about ten days' standing. She was blistered and poulticed quite freely, and within a week all acute symptoms had sub- sided, and seven weeks from the date of this readmission she was again discharged cured. I have seen the girl from time to time, growing up into womanhood, and she has never walked lame or shown any disposition to relapse since the date of last discharge. I cannot do other than regard this as a recurring synovitis from trauma, although my notes are not as full as I should like. Still, the course of the disease in the two instances strengthens me in the belief in my diagnosis. The cases reported in the chapter specially devoted to this subject are much more pertinent, and a study of them will give one a complete picture of this ailment. The differential diag- nosis can be made by remembering that: 1. In a synovitis the pain will be coincidental with the lameness, and the invasion will be sharp and clear; in an ostitis the lameness precedes the pain, and the invasion is seldom, if ever, sharply defined. 2. In synovitis the lameness speedily becomes so great CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 295 that locomotion is impossible; in ostitis the reverse is the rule. 3. Synovitis occurs after the eighth year of life; chronic ostitis before this age. 4. Joint-tenderness is found in synovitis; and is not found as a rule in chronic ostitis of the hip. 5. In synovitis there will be no periarticular infiltration or bone-tenderness; in ostitis the bone-tenderness is an early sign, and infiltration will be recognized as the second stage approaches. 6. In synovitis atrophy is the exception; in ostitis, the rule. ^. The position of the limb in synovitis is, as a rule, rota- tion outward, eversion and apparent elongation; in an early ostitis it is parallel, or nearly so, with its fellow. VIII. PERIOSTITIS OF THE HIP. Taking a simple periostitis and a periosteal sarcoma, a correct diagnosis become very important. The cases of periostitis generally make a good recovery even if suppura- tion takes place. The early history of a chronic periostitis does not differ materially from the history of a chronic ar- ticular ostitis. In both the lameness is the first notable sign; in both there is bone-tenderness, and in both the ex- citing cause may be a contusion. In addition to the cases of periostitis already reported, the following may be of interest: Take that of a girl aged ten years, whom I saw in the spring of 1876. A pretty clear history was given of a severe fall a year previously, and she walked lame immediately thereafter. Bye and bye the lameness grew less marked, yet the pain was a constant symptom, and this was referred to the periarticular tissues about the trochanter. She had always suffered more at night. She was well nourished, and my examination re- vealed the following points: Advancing of the limb and eversion of the foot as she stood; flattening of the natis, change in the crease, and a little thickening apparently of the periosteum over trochanter, with much tenderness on pressure in this locality; a marked limp, in which the toes and ball only came in contact with the floor; resistance to passive flexion beyond 135, to abduction and to rotation, but none to extension; no atrophy or shortening. At that 296 DISEASES OF THE HIP. time I was at a loss for a diagnosis. Here were many of the characteristic signs of a central ostitis, and then, on the other hand, there was the clear history of the fall, the localized tenderness, and the continuous pain, but especially the absence of shortening and atrophy after a year's dura- tion. The most plausible lesion was a periostitis, and the parts were blistered. Before a month had elapsed there was scarcely any sign of disease, and at the end of two months she was discharged cured. I found no pain, no limp, no change in natis, and no resistance to any normal movement of the hip. Jn the summer of 1882 a girl eight years of age presented with a lesion about the left hip, and a member of the staff, very good in diagnosis, regarded it, after a careful examina- tion, as a chronic articular ostitis. The limbs were of equal length, yet there was one inch atrophy of the thigh and a fluctuating tumor in the upper third. The joint was free as to movements and the articular surfaces were smooth. She limped quite characteristically, and the history was that she had been lame for nearly a year, that it followed a severe fall down seven or eight steps, and that the lameness was preceded by pain. An opportunity was not afforded for another examination until a year afterwards, when I got a clearer history of pain at first, and very gradual lameness subsequently. The abscess had opened spontaneously, and two or three open sinues lay around the trochanter. The atrophy was the same as at last observation, but I made out now a half-inch shortening. I could flex easily to 45 and extend to 180, while the other movements were very nearly perfect. The limbs were parallel, and the limp was very slight. In other words, no joint lesion could be dis- covered, and the diagnosis of a periostitis was confirmed. A reiteration in this connection of the clinical fact that in children over eight years of age articular ostitis often be- gins as a periostitis, cannot be out of place. In such cases, however, early symptoms and early signs are usually suffi- ciently clear to enable one to make a diagnosis of the in- itial lesion. To enumerate the points in differentiation: i. In the history of a periostitis pain and soreness pre- cede the limp, and the pain is confined to a distinct area without the joint; in the history of a chronic ostitis lame- ness precedes the pain by a distinct interval, and the pain when it does make itself manifest is not confined to any CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 297 special locality, but may be felt at the same time in the hip joint and in the knee. 2. In a periostitis the trauma is followed by clear and unmistakable signs; in an ostitis the signs are aught but clear and unmistakable. In other words, if one is told that the whole trouble came from a fall or a blow there will be no trouble in finding signs of the same if the lesion be a peri- ostitis, but one will have to search frequently in vain for any tangible signs if the lesion be a chronic ostitis. 3. In a periostitis the muscular resistance to passive move- ment will rarely be reflex, but purely mechanical, i.e., those muscles which are connected with the seat of disease will respond less freely to attempts at active or passive motion; in an ostitis the reflex muscular spasm in adductors and rotators is usually present early in the case. 4. Palpation in a periostitis will detect thickness and tenderness over a given area; palpation in an early ostitis will only exceptionally detect any thickening or tenderness, and if such does exist it will be found near the digital fossa. 5. The lameness in a periostitis is pretty uniform, and rarely reaches the point when walking is impossible; during the exacerbation of an ostitis the patient is frequently totally unable to walk. These are the chief points, and others will suggest them- selves in a doubtful case if the proper care be employed in an examination. In differentiating a periosteal sarcoma from a central ostitis about the hip, a few points are necessary, such as, i. The uniform periosteal enlargement in a sarcoma an enlargement that takes in the whole circumference of the bone; and 2, the freedom of joint movements. This subject has been treated at considerable length in that portion of Chapter X. which deals with malignant diseases of the hip. IX. OSTITIS OF THE ILIUM, INCLUDING SACRO-!LIAC DISEASE. The current pathology of joint diseases, viz., an initial lesion of the soft parts gradually extending to the hard tissues is responsible for " Sacro-iliac Disease." It would be infinitely better, I think, to discard the name from our nosology, and employ the term ostitis, or necrosis, or caries of the sacrum or ilium. This articulation never in my own experience suffers primarily, and it is so well protected, so well fixed by its very construction that when it does become diseased the gravity of the lesion is not enhanced, 298 DISEASES OF THE HIP. It has been my observation that many cases diagnosticated as primary sacro-iliac disease, have proved to be caries of the lower lumbar vertebrae and sacrum, ostitis of the ilium, or chronic articular ostitis of the hip. I have myself diagnos- ticated many such, and ultimately find just what I have stated. I have notes, too, of cases presented at clinics as typical of sacro-iliac disease that are now undoubted cases of bone disease of the hip in the advanced stage. It is difficult to place them on record without being personal, yet I am just as firmly convinced that the disease in question is one of the rarest of all the so-called joint diseases. Time and again I have followed up cases that have developed abscesses, and have been operated upon in the general hospitals with the idea of finding this articulation involved, and I can not now recall a single case where the operator was willing to put himself on record as finding the lesion he suspected. I am willing to go thus far in a statement, viz., that I have been often asked by the general surgeon whether sacro-iliac disease is a myth or not. In searching the records of nearly twelve hundred cases of disease in the neighborhood of the coxo-femoral articulation I have had the opportunity of examining, I am unable to find a single case that I should like to place on record as one by which I could stand. I trust that I shall not in these remarks be regarded in the light of disbeliever in the existence of a lesion at this joint. I am too well aware that the many excellent ob- servers, both in my own country and in other countries, have honestly reported cases wherein the evidence seems overwhelming. Only I am desirous of stating my convic- tions (simply for what they are worth) on the following points: 1. That a primary arthritis of the sacro-iliac synchon- drosis is, to my mind, unproven. 2. That the cases recorded, and in many instances well recorded, are secondary to inflammatory bone lesions within the vicinity of this articulation. 3. That a destructive bone lesion of the pelvis is not rendered any more grave as to prognosis by the co-existence of a sacro-iliac arthritis. 4. That for practical purposes and for diagnostic pur- poses, it makes little difference whether a lesion of this joint be recognized as a distinct entity or not. I am unprepared to accept the dictum of any man regard- CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 299 ing the existence of such cases unless he will so report the case in all its details that I can make my own diagnosis from the symptoms and signs the given case presents. We must remember that the acetabulum is occasionally perforated at an early stage of ostitis of the hip, and that the pus sometimes burrows along the internal iliac fossa, giving rise to symptoms that would point to disease 'at or near this articulation. We must further remember that a neurosis may give rise to symptoms of disease in this neigh- borhood. As above remarked, my own cases of supposed disease here leave me still looking for an unmistakable in- stance. Take the case, for instance, I have already reported in the chapter on Pathology (page 179) as one of diaphyso-epiphy- sial ostitis of one side and caries of the acetabulum of the other. This girl, it will be remembered, had " lameness" as a " constant" sign, had " tenderness over the sacro-iliac synchondrosis" on several examinations, had " motion at the hip-joint on the affected (?) side, free, smooth and painless when the pelvis was fixed, except when carried to extreme flexion and rotation," had " apparent lengthening of the limb." After several examinations, one of which I shall presently copy verbatim from my notes, I made out a diag- nosis unhesitatingly of sacro-ilia disease, left side. The quotation points above inserted are placed about symptoms given by Dr. Poore in a classical article published in the American Journal of the Medical Sciences for January, 1878. I shall take occasion again to refer to this article. In the case I am now analyzing I noted January 17, 1879, in my case-book the following: "The mother insisted on the pain being in the left gluteal region. Pressure here, especially over the left sacro-iliac junction, gives pain unmistakably. This, also, on crowding the alse of the pelvis together. No pain on motion at the left hip. As the child lay on the bed the stocking was pulled on easily without any pain or difficulty. The heel was struck hard, and the child only laughed. She could not be induced to stoop to pick up anything, complaining of pain at the left knee on the at- tempt. Motion of the spine above the sacrum, however, could be made without pain. As she stands the left limb was apparently lengthened; no real difference by measure- ment. A careful examinanation is made as to a possible rheumatic history in the family, but nothing is found on cither side." Dr. Poore saw the case next day with me, 300 DISEASES OF THE HIP. and after a thorough examination, without an anaesthetic, confirmed my diagnosis of sacro-iliac disease. The subse- quent course of the case and the lesions found post-mortem are already a part of history. Again, in the case of a boy, reported in the chapter on Periarthritis, pages 104 and 105, 1 fancied I had a sacro-iliac disease. I found decided tenderness on pressure in the neighborhood of the sacro-iliac synchondrosis, resistance to abduction and pain in groin and about gluteal region. Then fourteen months later I found the sac of an abscess in this locality. Dr. Bull found, on operation, a sequestrum of bone near the synchondrosis, but no sacro-iliac disease. On account of Dr. Poore's accuracy and honesty of ob- servation, I very much regret that in his elaborate paper he has only two cases of his own to analyze. I am by no means convinced that the first one he reports belongs to this category, as it passed from observation before the diagnosis could be confirmed either by clinical features or by post mortem examination. It is reported, however, so faithfully and with such detail that any one at all familiar with the normal and abnormal types of a chronic articular ostitis, on a careful reading, would be very prone to make a diagnosis of ostitis of the hip. The second case is more to the point, and corresponds closely with the clinical history of the disease. From the perforation of the pelvis, however, it would seem that the sacro-iliac arthritis was secondary to the bone lesion. He analyzes fifty-eight cases collected from foreign and domestic journals, including his own in the analysis. As I have already confessed, I have no clinical experience in this disease, and I shall only too gladly base my subsequent remarks on the conclusion Dr. Poore has reached. First, as to the pathology. In twenty-two cases examined post mortem thirteen seemed to have been cases in which the lesion was primary, and nine secondary. Of this nine, five were secondary to disease of the lumbar vertebrae; in three the disease was subsequent to a phlegmonous inflam- mation of the pelvic-fascia, and in one it was due to disease of the ilium. In making a differential diagnosis between sacro-iliac dis- ease and chronic ostitis of the hip, I select certain points from the paper to which I am already much indebted cer- tain points to which I can subscribe. i. The pain from sacro-iliac disease is behind the hip- CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 301 joint; in ostitis of the hip the pain is usually referred to the knee. 2. In the early stage of sacro-iliac disease there is no reflex spasm of any of the groups of muscles about the hip when passive motion is employed. This sign is well known in ostitis of the hip. 3. In sacro-iliac disease there is no pain on pressure, either below Poupart's ligment or behind the trochanter; in os- titis of the hip there is, as a rule, tenderness in one or both of those localities. - 4. Pressure on the ilium at right angles to the body or at- tempts to rotate this bone, always causes pain in sacro-iliac disease; not so in ostitis of the hip. 5. In sacro-iliac disease there is, as a rule, tenderness and periosteal thickening over the joint; in ostitis of the hip tenderness over the sacro-iliac joint is seldom present. 6. In sacro-iliac disease, as a patient stands, the body is thrown on to the sound side; while in ostitis of the hip the body inclines to the diseased side. 7. Greater relief is experienced from absolute rest in bed in sacro-iliac disease; not so in ostitis of the hip. X. VERTEBRAL OSTITIS. It was a long time before I could believe that an ostitis of the vertebrae in the first stage could give signs and symp- toms that would lead one to diagnosticate an ostitis of the hip in its early stage. It is no uncommon thing to con- found a caries of the vertebrae in which psoas abscess has formed with the second stage of a coxo-femoral os- titis. Some unwelcome facts, however, have forced them- selves upon me, and I feel that I shall not make the diag- nosis of chronic ostitis of the hip in its early stage complete without a differentiation from vertebral ostitis. I saw in the spring of 1879 a girl aged eight years who favored the left side in walking. The limp did not seem like a hip-limp, and yet I was unable to classify it. I tested the joint functions, and found them perfect in every re- spect. There was no shortening and no atrophy, and, in- deed, no pain. She simply walked lame, and the lameness had come on very insidiously six weeks before I saw the case. The mother was a typical rheumatic. A hip splint had already been advised by a specialist. I could not make a diagnosis, though I leaned toward rheumatism. Nearly Lc i 302 DISEASES OF THE HIP. two weeks elapsed, and I examined the case again without finding any bone or joint lesion. Two days after the last visit the lameness was gone, and now it had just returned, and with it a little pain in the front of the thigh. This pain soon disappeared under the sodium salicylate, but I found a decided halt in her gait nearly three months later. It was a paretic limp, and there was a half-inch atrophy of the calf. After much walking she referred the pain thereby induced to the posterior aspect of the thigh. I fancied, from a history of periodicity obtained, that there might be a malarial element in the case, and ordered quinine, but at the next visit, a week later, the pain was con- stant by day but entirely absent by night. The anterior crural branches were seemingly implicated. At this visit I found for the first time resistance and pain to flexion be- yond 90. I was puzzled more now than ever. A couple of months passed and I found a limp decidedly paretic. She threw her shoulders back unusually far, and there was an inclination also to the left. The resistance to flexion was not present, but adduction carried toward the extreme limit caused pain. , There was a half-inch atrophy of the thigh and a marked loss of power. It was a fact, too, that she was lamer and stiffer after sitting awhile, or on rising from bed in the morning. On general principles iodide of potassium was prescribed, and in a week or two she was much better. Then, again, the next month she walked as if there were some defect in the lumbar muscles, and I examined the spine very carefully with negative result. The column was flexible and normal in shape. A spinal brace, however, was ordered by way of precaution. A few weeks afterward I found an inch atrophy of the thigh, and the movements at hip-joint absolutely perfect. Symptoms had varied as the weather changed. At times there was no sign, no symptom of any kind. I lost track of the case early in 1880, and did not see it again until I traced it out in March, 1883, and then I found a well-marked kyphosis in the mid-dorsal region of three quarters of an inch on a chord of six inches. The deformity had come on very stealthily, and the exacerbations had been so insignificant that the parents thought nothing further of seeking any re- lief. The hip and thigh symptoms had long since disap- peared. Ankylosis of the diseased vertebrae seemed to be pretty well established, so that I did not consider a brace necessary. CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 303 It was certainly a peculiar case, and the early neuroses are readily explainable now on the theory of nerve-irritation at the foramina of exit. That her symptoms and signs, too, should all be referred to the extremities, though, is certainly very strange. While on a visit in one of the Western States late in the spring of 1879, I was asked by a medical friend to see a case in which no clear diagnosis had been reached. I naturally felt anxious to examine the patient because of the obscurity attached to the case, and I found a fairly nourished female child, aged four years, with an excellent paternal family history, but a rheumatic, maternal history. One day in October, 1877, the child was exposed to a severe wetting, and complained the next day of pains about the hips. She also walked awkwardly at that time. The pain soon subsided without disturbing the sleep, and the lameness passed away within a week without treatment. It was observed by the family that, for three or four months thereafter, whenever the weather changed the child would complain of pain about the hips, and be a little stiff in her gait. All these signs and symptoms had disappeared by the spring of 1878, and nothing further attracted atten- tion until October of that year, when, without apparent provocation, the old symptoms returned with increased severity. The left limb seemed to receive the full force of this attack, but in the course of a month or two both thighs became strongly adducted, and reflex muscular spasm would be very annoying, especially during sleep. Ap- paratus was employed for a rheumatic deformity. Such was the history, and while I aimed to get an unbiassed history I am convinced now that I was prejudiced in favor of rheumatism. The lameness was bilateral, but more marked on the left side. The spinal column was normal in every respect, and I omitted no test in my examination. The next signs were plain enough, but were thought to be due to the apparatus the child had been wearing. They were: flattening of the natis, resistance to flexion beyond 135; rotation could be made only over a very small arc; resistance offered when hyperextension was attempted. All this was true of the left side, but in addition to the apparatus theory there were some signs on the right side which com- plicated a diagnosis more than ever. These were resist- ance to flexion beyond 90, and rotation limited to one half the normal arc. 304 DISEASES OF THE HIP. There was no tenderness in either hip, no infiltration or periosteal thickening about either trochanter, and no difference in the size or the length of the limbs. For my diagnostic points, then, I had: 1. A rheumatic element in the family history. 2. As clear a history of exposure to cold water about the hips as one could possibly get. 3. Exacerbations extending over three or four months, closely connected with changes in the weather. 4. A complete (?) remission of all signs and symptoms for six months. 5. A recurrence of exacerbation when the cold weather approached. 6. Bilateral lameness and other bilateral signs. 7. A six months' constant wearing of apparatus that ex- tended from axillae to feet. 8. Absolutely negative results on seeking for spinal signs. With these points and the bias already mentioned, I made a diagnosis, with proper precautions, however, of chronic rheumatic arthritis, and advised the removal of the appa- ratus and employment of massage and passive motion- The precautions I took in stating this diagnosis, and in giving the advice I did, were: that it was very difficult in such a case to come to a definite conclusion at a single ex- amination, that the family physician should be consulted on the slightest recurrence of symptoms, and that the ap- paratus should be reapplied on any increase of deformity. Six or eight months later rumors came that the child had Pott's disease of the spine, and abscesses ; later still, that there was " hip-disease" also complicating the case. I began to seek for more definite information, and after much correspondence, lay and professional, I succeeded at last in realizing that I had made an error. I found, on examination, over three years after my first observation, a distinct kyphos in the lumbo-sacral region, with cicatrices in the gluteal region and a moderate deformity of the left hip from chronic articular ostitis, with cicatrices about the thigh. I am prepared now to state, after the above confessions, that a differential diagnosis between the early stage of a vertebral ostitis, even in the dorsal region, and the early stage of a chronic ostitis of the hip, is at times exceedingly hard to make. Few men, I think, are willing to admit that there can be any difficulty where the dorsal vertebrse are CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 305 involved, and I myself was not prepared to admit the diffi- culty until the above two cases came under my notice so conspicuously. In a conversation with Dr. Schoeneman of this city, recently, I learned that in his opinion, the early signs sometimes run closely together. As a resume, briefly, then, we have: 1. Lameness depending on diminution in nerve or mus- cular power, when it exists in connection with disease of the dorsal vertebrae ; the lameness of an ostitis of the hip lacks these elements, and is too well known to require further description. In disease of the lumbar vertebrae, the lame- ness, on close inspection, will be seen to depend on con- traction of the psoas, and there will be more lordosis than is seen in the lameness of an early ostitis of the hip. 2. A patient with vertebral ostitis can stand as well on the lame limb as on the other ; not so in coxo-femoral ostitis. 3. Reflex muscular spasm is never excited by employing passive motion of the hip in which lameness is present, the result of vertebral disease ; as a rule this sign is always present in articular bone disease. 4. It is the rule to get a history of complete remissions in the lameness of the one, the exception in the other. I have given only some important points when other and more valuable signs are absent. Very fortunately, we are not called upon for such close discrimination; for disease of the vertebra?, especially in childhood, has a pretty defi- nite clinical history, and rarely is it that the signs point to lesions about the joints of the lower extremity. Concluding this part of my chapter, I may incidentally mention that an exostosis sometimes exists in the neigh- borhood of the hip-joint, and gives rise to symptoms as well as signs, that may lead one into error. I have myself had such a case and was saved from error by finding exos- toses in other parts of the body. Once in a long while I find a case with certain suspicious signs in connection with the hip, that disappear promptly on the administration of quinine. Dr. John James Berry, of Norwalk, Conn., writes me that he has had a case in a child four years, with pain and resistance to movements at the hip. He used a cathar- tic, and quinia for three days, when the recovery was com- plete. Then, again, I have seen cases with signs of disease at the hip in which all signs yielded to the expulsion of lumbricoids. 306 DISEASES OF THEJIIP. PART II. THE DIAGNOSIS IN THE SECOND STAGE. It would seem presumptious to discuss this branch of my subject, inasmuch as the impression prevails that any one can diagnosticate an ostitis of the hip when the first stage is passed. To the orthopedist, however, it is very common to find cases wherein it is aught but easy to distinguish the deformity of an ostitis from that of a psoas abscess, an iliac abscess, a perinephritis, or a chronic articular rheumatism. Cases with the second stage signs make a decided impres- sion on the medical attendant, especially when a perfect cure takes place while some method of treatment is being employed, but on the laity the impression borders on the miraculous. I. PERINEPHRITIS. During the past six years I have reported so many cases of this affection that I am at no loss for illustrations. In the month of May, 1877, a boy aged twelve was admitted to the hospital, and the following is the record made of his case: With the exception of one or two of the diseases of in- fancy he had always been in good health. The father had been a drunkard, and had died phthisical; a paternal aunt had did of "hip-disease;" the mother gave a rheumatic his- tory. The disease for which the boy is now admitted was first manifest six weeks before, supposably originating in a " cold." Loss of flesh had been marked, and his appear- ance to-day is indicative of much recent suffering. Pulse 116, R. 28, T. ioif. He stands with body inclined to the right, the lower extremity of this side slightly flexed at hip and knee. The spinal column deviates to the same side, though there is no tenderness along the column, no angular curvature, no pain on per- or concussion; the natis is broadened. Lameness is marked, and very like to that of a patient with " hip disease," second stage. The thigh can- not be extended beyond an angle of 165 without pain, but can be flexed and rotated over normal arcs. Measurements of the two limbs identical. He complains of pain about the knee. In the left lumbar region the erector-spinal muscle is full and tense, giving quite a ridge-like prominence; yet there is no pain here, or in the right ilio-costal space; two and one half inches from the spinous processes of the verte- brae there is marked tenderness, which extends to the right in a horizontal plane to a point immediately above the an- CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 307 terior superior spinous process, where the tenderness be- comes more extensive in area. This area is triangular, ex- tending along Poupart's ligament. There is subintegumen- tary induration along and above the ligament, with extra heat and comparative dulness. Flexion of thigh relieves pain. There is and has been no intestinal derangement. Suffice it to say, we had no difficulty in diagnosticating a perinephritis. The progress of the case differed from the usual type. Suppuration came on in due time, a large abscess being opened just above Poupart's ligament. In August the case was discharged cured, all deformity and lameness having disappeared. In typical cases the disease generally begins with a rigor or two, febrile exacerbations more or less severe according to the acuteness of the attack, lancinating pains in lum- bar region, loss of appetite, and general indisposition. In fact, the invasion does not differ materially from that of other acute inflammatory lesions, unless perhaps the pain be more localized, and if the child be very young the lo- cality of the pain is not discovered. Constipation, I believe, is always present. Very soon we have preternatural immo- bility of the spine, a stooping forward with elevation of the shoulders. After a week or ten days, spasm of psoas muscle occurs, and the gait becomes characteristic of that so commonly regarded as the second stage of hip-joint disease. The urine is of high specific gravity, and is loaded with urates. The tumefaction appears and the pain be- comes excruciating. If an exit be given to the pus a speedy recovery follows; if this be delayed and the contents of the sac be really pus, it burrows along the cellular tissue, pro- ducing an immense abscess, a spontaneous opening is effected, and the convalescence is protracted. If, on the other hand, the inflammatory process has not resulted in suppuration, the contents are most likely serum, and reso- lution is effected. The position of the limb is more that of pure flexion, while in the second stage there is generally an element of outward rotation associated with the flexion. From Dr. Sayre's work I have taken the accompanying "cuts, which represent very finely a typical deformity of the second stage of an ostitis of the hip. Fig. 30 represents the earlier appearances, while Fig. 31 represents the more ad- vanced. When abscess appears during this stage the ap- pearances are still more unlike those of a .perinephritis. 308 DISEASES OF THE HIP. 1. In a perinephritis the characteristic deformity appears within a week after the first symptoms; in a chronic ostitis the deformity is very slow of development, and never ap- pears within the first week. 2. In perinephritis it is the rule to find a history of an initial chill and febrile reaction; in a chronic ostitis a chill is never present as a symptom. 3. In the one the tumefaction is found in the ilio-costal FIG. 30. THE BEGINNING OF THE SECOND STAGE. FIG. 31. SECOND STAGE WELL ADVANCED. space, or iliac fossa; in the other it is never found in the ilio-costal space, seldom in the iliac fossa, but as a rule in the vicinity of the trochanter major. 4. In the one, resistance to passive motion is offered only in extension, and traction on the limb increases the pain; in the other, all movements are resisted, especially flexion and rotation, while traction relieves pain. 5. In the one there is never any joint tenderness; in the other joint tenderness is the rule. CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 309 These constitute the chief points in differential diagnosis; but in conclusion I must insist on a careful examination, several times if need be, a history obtained without bias, an unalterable conviction that chronic ostitis is from the be- ginning a chronic disease, and a slowly progressing disease; I wish to insist, I say, on these, as points absolutely essen- tial in making diagnosis. I dislike to be hypercritical, but I firmly believe that ninety per cent yea, I am prepared to assert a much larger per cent, than ninety of the cases of ostitis of the hip reported as cured without lameness or de- formity, cured completely, are not and never have been cases of ostitis. II. PRIMARY PERITYPHLITIS AND ILIAC ABSCESS. Surgeons, I am well aware, are unaccustomed to look uponaperityphlitis as any thing but a lesion secondary to a typhlitis. They call an inflammation which involves the cel- lular tissue surrounding the vermiform appendix a subfas- cial or iliaccellulitis. Still surgical authorities do recognize a primary uncomplicated perityphlitis, and I have seen cases whose clinical histories were very sharply defined. It is immaterial, however, for purposes of differential diagnosis whether the cellulitis be on the right or the left side. In either event the signs closely resemble those of the second stage of a chronic articular ostitis of the hip. A case I saw in September, 1878, was in a boy aged six years, whose history was as follows: Absolutely free from hereditary diseases or the cachexia which often follows in the wake of infantile disorders. True, in the early spring of 1878 he had some fever which, to use the mother's expression, made him " deaf, dumb, and blind," yet he made an excellent recovery after six weeks, and was in good health until the beginning of September (three weeks prior to the day he presented at the hospital), when he came in from play reporting to his mother that he had had a fall. The child's sleep was disturbed the same night; he complained of general soreness, and was appa- rently quite feverish. No contusions could be found, yet he continued from that time forth to grow more lame and to sleep more uneasily; in fact it was difficult to get a posi- tion in bed that would be at all comfortable for any length of time. While quiet the little patient was free from pain, but any movement caused him to cry out sharply. He has 3IO DISEASES OF THE HIP. limped from the very beginning, favoring the righ limb; at times has been able to go about only on the hands and knees, and at other times he has walked comparatively erect. It was not ascertained whether the patient was con- stipated during this period, or whether he had vomited, or whether he had eaten anything that would be likely to lodge in the appendix. The mother insisted only on his high fever. The nurse soon discovered that he was obsti- nately constipated some days after admission. The case had been regarded as one of dislocation, and an attempt had been made at reduction under ether. This was three or four days previous to admission to hospital, and being sent to one of our consulting surgeons, he could find no evidence of dislocation, but reported it as one of severe strain of the hip-joint which would probably eventu- ate in disease of this articulation. The expectant treatment was employed in the hospital. It was recorded, however, that the boy was fairly nour- ished, could only stand when assisted, and could not walk at all; that the right thigh was flexed on the pelvis at an angle of nearly 90, extreme flexion being admissible while extension was resisted by muscular action; that there was some swelling about the hip and thigh obliterating the fold; and that further examination was postponed, so ex- cessive was the tenderness. His vital signs were not even recorded, but on the 26th, five days after admission, the pulse in the evening was 120, respiration 36, temperature ioif; and 'at the same time next day the record stood 124, 2 7> I0 3f- From this date until Oct. i6th the temperature ranged between 101 and 103! for the evening, while in the morning it was normal. Four days after admission it was observed that there was marked tenderness in the inguinal region, with well-defined induration above Poupart's ligament, that all the move- ments at the hip, save extension, could be made with care, and that the boy could easily bear his entire weight upon the limb. Joint disease was readily excluded, and the le- sion, an inflammatory one, definitely located in the iliac fossa. Within a fortnight a long, oval-shaped, fluctuating tumor presented above Poupart's ligament, was incised, pus evac- uated, and in another fortnight the case was discharged cured. It is not necessary always for suppuration to have taken CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 31! place in order that a diagnosis may be made. I have on my case-books several in which no suppuration occurred. One is noted in detail, and I shall present it in this connec- tion in order that the points in differential diagnosis may be the better illustrated. Early in the last week of October, 1879, a boy, six and a half years of age, was carried into the waiting-room of the hospital, and so tender was the little fellow that his cloth- ing could with great difficulty be removed for examination. He was in perfect health and sound in limb three weeks previously, and, with the exception of a slight attack of malarial fever two years ago, he had been uninteruptedly healthy. He is reported to have had a fall, no one saw him fall, to which his parents attributed the present lameness. His first symptom was pain about the right hip, the night of the day on which he reported his fall; next day he could scarcely walk, and four or five days later medical advice was sought, the surgeon (one in very good standing) pro- nouncing it "hip disease" (so the father stated) and apply- ing a weight and pulley, which had been employed constantly until the twenty-sixth, the day before this visit to the hospital. During this whole period the patient suf- fered much pain in the knee and groin, requiring anodynes one or two nights. The condition of his bowels during the first week could not be ascertained. His rectal tempera- ture on this date was ioif. The family history was nega- tive on father's side, neurotic on mother's, i.e., she was insane. The boy was greatly emaciated, and tongue was Boated. He was able to stand if assisted, bearing his entire weight on the left limb with the right semiflexed at hip and knee and rotated inward, yet he could not walk. While sitting on the side of the bed he voluntarily crosses the right leg over the left knee, and as he lies down there is nothing to be seen abnormal save a lateral deviation of the spinal column in the lumbar region to the left. In the dorsal decubitus he voluntarily flexes the thigh on the pelvis completely, can abduct and adduct, but cannot extend beyond 90 without pain, and if passive extension be attempted, the boy resists, crying aloud. Rotation can be easily made, if made with care. Nothing can be felt per rectum save a few scybalae. Pressure over the trochanter in the line of the neck gives no pain, nor does concussion of hip. No infiltration about the trochanter or below Pou- part's ligament. A cicatrix of recent vesication is seen over 312 DISEASES OF THE HIP. the gluteal region. The abdominal walls are a little re- tracted, and there is neither tenderness nor infiltration in either ilio-costal space, nor is there any in the left iliac fossa, but in the right tumefaction can be felt distinctly within a triangular area bounded above by a line extend- ing from the top of the crest of the ilium to the median line just below the navel, laterally by the median line and below by Poupart's ligament. There is dulness here and excessive tenderness, but no fluctuation, and no tumor present to the eye. The result was a resolution of the mass under blistering and hot fomentations. He was well in a couple of months, and the diagnosis was fully confirmed. From the foregoing histories and remarks the recognition of a case of iliac abscess should depend on a reasonably careful examination. To distinguish this from an ostitis of the hip in the second stage, one should remember that 1. The deformity is of too rapid development for a chronic ostitis. 2. The constitutional symptoms are too prominent. 3. That resistance to extension alone never occurs in the second sl.age of the disease. 4. That tumefaction in the iliac fossa alone rarely occurs. III. THE SUPPURATIVE STAGE OF CARIES OF THE DORSAL AND LUMBAR VERTEBRA. The natural delays in the appearance of abscess from caries of the vertebrae make one peculiarly liable to asso- ciate them with the hip or thigh. I have seen most excel- lent surgeons call a tumor in the gluteal region, for in- stance, a bursitis or a hip abscess, when a deformity of the lower dorsal or lumbar vertebrae was present, but regarded as perfectly innocuous and unconnected with the aforesaid tumor. Again, old fistulous openings on the hip or the thigh, with deformity of the limb, are time and again looked upon as associated with the nearest joint, and on being explored lead to diseased vertebrae. If one will look upon a caries sicca as an exceedingly rare lesion, and learn that an abscess from bone disease may appear at any time during a natural lifetime, many errors will be avoided. It is especially true of vertebral caries that a residual ab- scess will take one of several courses, and appear in the most unlooked-for localities. A very common site is CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 313 Scarpa's space; and another site nearly as common is the outer and posterior aspects of the thigh. Cases like the following come frequently under my observation. In the early part of January, 1878, a mother called to re- port her child, an out-patient of the hospital, as unable to attend, so helpless had he become by reason of the progress of the disease. She mentioned the name of her family phy- sician, whom I knew to be thoroughly competent, from his surgical experience in some of the best hospitals in the city, to take charge of any case, and to him I referred this pa- tient, a boy, aged eleven years, under our treatment since March, 1874, for caries of the lower dorsal. When I last saw the boy in August, 1877, there was a circumscribed tumor over the left hip, and I recognized this as a spinal abscess, ordering appropriate treatment therefor. I in- structed the mother to ask the physician to whom I had just referred the case to notify me as to present condition. I was informed by letter the seventeenth of January, that the child with caries of the spine had also hip-joint disease of over a year's standing, received from a fall; that the leg was flexed somewhat upon the thigh, and the thigh upon the abdomen, the usual position of the limb. I immediately requested a consultation, but the doctor was called out of town, and left word for me to examine at my convenience. A few days later I made a careful examination, and found a marked angular deformity of the spine, a soft, fluctuating tumor over upper and outer aspect of thigh, measuring three inches vertically, and an inch and a half transversely. The circumference of the limb at every point save over this tumor was identical with that of the other limb ; there was no shortening whatever, and the thigh could be moved in every direction without any pain in the hip or at the knee ; but when complete extension was made, the skin covering the tumor was put on stretch, and the boy com- plained of pain here. Rotation was easily accomplished, and I could find no disease at the hip by any of the recog- nized signs. In the absence of shortening, atrophy, and muscular contractions about the hip limiting motion, and in view of the position of the limb, I could not make out any hip-joint disease, and so reported to my friend the physician. Two years ago a case in a boy aged five was examined by a member of our staff, and pronounced to be lumbar caries with psoas abscess. The normal curve was lost, and 314 DISEASES OF THE HIP. the spine in this region was suspiciously stiff. The right limb was nearly in the position of the second stage. On palpation an elastic tumor could be recognized in the iliac fossa. Treatment for the spinal caries was promptly begun, and in the course of three months the case presented at another hospital, where, after a long examination, it was pronounced " hip-disease," and, with a look that combined egotism and pity, the diagnostician told the father that the spinal brace was of no service to the boy. When I saw the patient a month afterward there was a distinct kyphos in lumbar region, a well-marked tumor in iliac region, and resistance only to extension of the limb. Such cases are not rare, and I could illustrate at great length did it seem necessary. I shall content myself with recounting some of the more important points in the differ- ential diagnosis : 1. In residual abscess about the hip there will be either a history of spinal symptoms or the presence of the de- formity, if the abscess come from diseased vertebrae. In the second stage of a chronic ostitis at the hip, spinal symptoms and signs are wanting. 2. In a spinal caries with deformity at the hip, the resist- ance on passive movements of the thigh will be confined to the muscles in or about which the infiltration is mani- fest. In the second stage of a chronic articular ostitis the re- sistance, as a rule, is in all the periarticular muscles and the hip is often locked against any movement. In other words, the resistance in the one is from mechanical causes, in the other it is reflex. 3. In the one there is no tenderness at the hip-joint and the patient can easily bear all the weight on the limb; in the other, joint tenderness is usually present, and if not de- tected by manual examination, becomes quite apparentjwhen the patient makes an effort to stand alone on the limb. 4. The coexistence of a kyphos in lower dorsal or lum- bar regions with open sinuses about the upper third of the thigh, in a thigh either parallel with its fellow or at an angle of flexion, furnishes presumptive evidence against a secon .' stage of chronic ostitis of the hip. 5. Fi ally, a well-conducted physical examination, aided by the us ^ of the probe, will enable one to differentiate in cases, however doubtful they may be. I have nev ?r been able to satisfy myself of the existence CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 315 of a primary psoitis, and hence have not included this affec- tion among the lesions from which a chronic bone lesion of the hip in its second stage is to be differentiated. Admit- ting, however, the propriety of recognizing such a lesion, we should have the same points in differential diagnosis as have been enumerated in the foregoing diseases. IV. ACUTE EPIPHYSITIS. Inasmuch as our observations in acute epiphysitis are generally first made after the initial lesions have^been fully established, we rfaturally find the limb in a position that looks very much like that of a second stage of a chronic epiphysitis. Since I prepared my chapter on this acute articular disease of infancy, I have found a very instructive series of cases reported by Mr. Thomas Smith, in the Saint Bartholomew Hospital Reports for 1874. Mr. Smith writes his clinical paper on " The Acute Arthritis of Infants," and my attention was called to it by reading a report of some similar cases by Mr. Morrant Baker in the British Medical Journal for September i, 1883. His paper was presented at the last meeting of the British Medical Association, and is entitled " Epiphysal Necrosis and its Consequences." I very much regret that I did not see Mr. Smith's contri- bution earlier, for I should then have had a clearer idea of my own cases. Even in this connection I take pleasure in quoting from Mr. Smith the following paragraph, which will lay a most excellent basis for differential diagnosis. He says : " It occurs, so far as my own experience extends, within the first year of life, and is characterized by the sud- denness of its onset and the rapidity of its progress and termination, whether the latter be of a fatal or favorable kind. It is very dangerous to life, and intensely destruc- tive to the articular ends of the bones, which, of course, at this period of life are largely cartilaginous. Lastly, I would mention as a feature of the disease, that it rarely produces anchylosis, but leaves a child with a limb shortened, by loss of part of the articular end of some bone, and with a weak- ened, flail-like joint." Mr. Baker believes as I do, that the cases Mr. Smith has described had the epiphysis as probably the primary seat of disease. Indeed Mr. Smith stated himself that it seemed "that in many cases the formation of a subarticular ab- scess in the bone must have been the first step in the joint 3l6 DISEASES OF THE HIP. affection." Along with Mr. Baker and Mr. Macnamara, I believe that the disease is not exclusively confined to the first year of life. I have not had the experience Mr. Smith had in the mortality of such cases, and was not aware until I had read his reports that there was such destruction to life. However, I am digressing, and shall revert to the object for which I introduced this discussion, viz., differ- ential diagnosis. 1. Acute epiphysitis occurs at a much earlier period of life than does chronic articular ostitis. 2. The progress of the disease is much more rapid and the symptoms and signs are much more pronounced. One is an acute process, the other a chronic process. 3. The infiltration in the one is more of a phlegmonous nature, while that in the other presents the features of a cold abscess. 4. The joint movements in the one, despite the infiltra- tion, are less restricted than those in the other. Monafticular rheumatism presents many of the features of the second stage of a chronic ostitis of the hip. The signs are so similar that one must rely on the history and the existence of rheumatic signs in other organs. PART III. THE DIAGNOSIS IN THE THIRD STAGE. In this stage the signs are so well marked and so charac- teristic that the probabilities of error are reduced, it would seem, to a minimum. Yet in my experience there are several lesions which give deformities similar to the one under consideration. It must be remembered that real shortening is always present, that deformity is always present, and that, as a rule, sinuses and ulcers are present. The favorite position of the limb, it will also be remembered, is in flexion, adduc- tion, and rotation inward. By reason of the varieties in position, it often happens that a unilateral congenital dis- location is diagnosticated as the third stage of a chronic ostitis of the hip. It is frequently reported that a child has become suddenly lame, when on investigation it will be learned that the lameness has always existed. If no history be obtainable, then the diagnosis is often obscure. I do not see, however, how any one can fail to diagnosticate a congenital dislocation if an average amount of care be taken in the examination. CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 317 The limb is parallel with its fellow; is rotated outward over a small arc; is shorter, but can be made equal with its fellow by traction; has no abscess or previous signs of suppuration ; this freedom of motion, and above all the ovoid, or, globular tumor beneath the gluteal group of muscles, is very characteristic. All these signs, even without a history, are sufficient to exclude a chronic ostitis. From a traumatic dislocation the diagnosis is not always easy of differentiation. I saw October, 1880 a boy eight years of age, whose mother gave me the following history: Three and a half months before June 3oth he was on his way from school as active a boy as there was in the neigh- borhood, and one as free from lameness, when he passed a house in process of erection. As he passed a beam fell across his back and thigh, pinning him to the sidewalk. He was carried home, and the limb was treated for a frac- ture of the thigh. In two weeks he was out of bed and going about on crutches. He had been lame ever since the accident. The history was very clearly given, and without any suggestions. I found the limb adducted and rotated inward over a small arc; two inches shortening, both as measured from the anterior spinous process and the um- bilicus; the trochanter very prominent, and a rounded glob- ular body beneath the gluteal muscles, moving under my finger as I rotated the limb. There was no infiltration about the hip, but on the anterior surface of the thigh, at its middle third, was an irregular bony mass, about the size of a split walnut, hugging the former closely, and tender on handling. The movements at the hip were good in all directions save in abduction. I made out a dislocation on the dorsum, with possibly an old fracture of the thigh, and had my diagnosis confirmed by one eminent in this branch of surgery. On account of the bony tenderness about the callus, it was deemed inadvisable to make any attempts at reduction at that time. A few weeks later two of my assistants recognized the same patient at an orthopedic clinic, furnishing a text for a lecture on "hip-disease" in its third stage. The tension of the adductors was referred to as being specially diag- nostic. I confess that I was greatly surprised, and wondered how I could have come so wide of the mark, especially as I had examined the case so carefully, recording every step in the process. I have sought the boy in vain during the past few 318 DISEASES OF THE HIP. months, and hence am unable to give the final conclusion. The case, however, is interesting from the fact that two specialists differed so widely on points that should have been perfectly clear. There is one point on which I may have failed, viz., the early history. The clinical lecturer seems to have learned that the boy was lame prior to the accident. The mother to me asseverated that he was not lame prior to the accident. Caries of the pelvic bones, with much infiltration and ulceration of the soft parts, is sometimes mistaken for ar- ticular ostitis. I have notes of more than one case where such a diagnosis was made by very competent observers. The deformities of rheumatism are often regarded as those of the third stage of disease at the hip. Last summer a case was sent me from a suburban town by the local phy- sician, who wrote me that the patient had had a rheumatic inflammation resulting in deformity of the hip. Not caring particularly for the deformities of this disease in the adult, I accepted the case with some hesitation. In fact, when first written to about the case I referred the doctor to an- other hospital. Finally, the patient and a medical friend called to see me, asking at least for my diagnosis. My first impression, on looking at the patient, a man aged twenty-four years, was that I had here an old deformity from chronic articular ostitis of the hip. He was pale, cachectic-looking, and had a marked deformity of the right hip, the limb being in flexion at an angle of about 160 in inward rotation over a quadrant, and the foot touching the floor only by toes and ball. The rotation I desire to emphasize by stating, furthermore, was so great that the outer side of the knee rested against the popliteal space of the left side. There was an inch atrophy of the thigh, and the limb presented a practical shortening of two inches, though there was no real shortening. The trochanter was not above Nelaton's line, but was an inch and a quarter nearer the anterior superior process than was its fellow. I looked for cicatrices and could not find any, nor could I find any infiltration. The joint was absolutely immovable. It then occurred to me that I had better get a history, and I learned that he was perfectly well and free from lameness on the 22d of February, when he "caught cold;" that he overheated himself the next day running for a train; next was sore in "all his body and limbs." The same CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 319 evening he was decidedly feverish, and did not leave his bed the next day. The symptoms fixed themselves in the right hip, and he lay a sufferer for nine weeks, the limb assuming a position of flexion and adduction. I had no difficulty after so clear a history of diagnosticating a rheumatic periarthritis, and advised brisment force under ether. He entered St. Luke's Hospital, and Dr. Bull, confirming my diagnosis, carried out the treatment I had recommended. The result was all that we could desire; and at present writing the patient has a very useful limb, with a very fair amount of motion. In closing this chapter I can do no better than insist on the value of an early diagnosis in the first stage. The signs are clear enough, as a rule, when taken in connection with the history. Exceptional difficulties in diagnosis have been enumerated, and repetition is unnecessary. CHAPTER XV. THE TREATMENT OF CHRONIC ARTICULAR OSTITIS GEN- ERAL CONSIDERATIONS. The treatment best adapted to primary bony lesion of the hip is one of the most difficult problems in the whole range of surgery. Men may talk and men may write, yet the bony lesions of the hip, as a rule, advance to destruc- tive changes. There are many and varied forms of appa- ratus in use, and nearly all aim to meet the same indication for treatment. All aim to secure rest to the articular sur- faces. The therapeutics of chronic articular ostitis of the hip resolves itself into the following divisions: 1. The constitutional with the expectan^ for the early stages. 2. The expectant. 3. The mechanical. a. Pure fixation. b. Extension with and without motion. 4. Operative. While I have employed these divisions, I fully recogYiize the fact that hard and fast lines cannot be drawn; for nearly all surgeons recognize some hereditary vice as the predisposing cause, and hence see an indication for some internal medication. There are a few, however, who discard all mechanical appliances, especially in the first and second stages, adhering strictly to a constitutional treatment throughout. These, however, rely on topical treatment as well, and aim to relieve symptoms by the application of mild\ counter-irritants and of vesicants. This cannot be called the expectant plan of treatment, for it is only in the early stages that any effort is made to relieve symptoms. The deformity that arises seldom receives any attention, and certainly no mechanical efforts are made to prevent deform- ity. In diseases of the ankle, or the knee, or the spine, appliances are employed to prevent deformity; not so in TREATMENT OF CHRONIC ARTICULAR OSTITIS. 321 diseases of the hip. There is a certain angle of deformity that is best for an ankylosed knee, and perhaps it may be considered that the angle at which the disease leaves the hip is generally better than we can bring about by any treatment. This is the explanation I have adopted for the non-interfering method, and before proceeding further it would be well to define my terms. What do we understand by the term expectant ? Liter- ally it means to wait. Waiting for symptoms and signs to arise before treatment is instituted, and thus directing the treatment to these phenomena of disease; discontinuing as they disappear or are modified; resuming on their reappear- ance this is what is generally understood as expectant treatment. Physicians who adhere to the expectant treat- ment are known as conservatives; indeed, expectancy and conservatism have somehow become synonymous terms. If one treats a case expectantly then he is called upon to re- lieve the symptoms during the exacerbation in any way that he may find the most satisfactory. For instance, if he finds that rest in bed with weight and pulley gives relief the more promptly, he will employ this method; if he finds that local applications, such as cold-water dressings, hot fomentations, mild counter-irritants, or blistering and poul- ticing, if he finds that anyone of these serves him best he will employ that one, and still be treating the case after the expectant method; if, again, he finds that symptoms yield best to opiates he will employ opiates. When the second stage is reached, and deformity appears, it will be his duty to adopt such measures as will correct deformity and retain the limb either in normal position or in that position which will assist in bringing about the best possible result. Some employ the weight and pulley, some the crutches and high shoe, and some retentive apparatus. The aim in every instance is the same, and it all forms a part of the expectant plan. If abscess forms, it is his duty to manage this on what appears to him correct surgical principles. It will occur to one man to open early, thus avoiding the formation of a large sac with extensive suppuration; to another it will seem dangerous to touch the abscess so long as constitu- tional symptoms are absent. Both are aiming at the same object, viz., the minimum amount of suppuration. When it becomes clear that caries necrotica has advanced to such an extent that spiculae of loose bone are present in the 322 DISEASES OF THE HIP. joint cavity, then the expectant plan demands a removal of these, as it would a removal of any foreign body which militates against recovery. The minimum amount of cut- ting is of course expected. As a rule, no operative proce- dures are resorted to for the removal of such sequestra, as their presence is not known until they are seen projecting from a sinus. Thus a pair of forceps or one's fingers suf- fice to effect a removal. Again, when displacement and distortions have not been prevented, it is the duty of him who follows the expectant plan of treatment to reduce the deformity to the minimum. This is sometimes done with apparatus, and sometimes by means of the surgeon's knife. When resolution does not take place, and when the sup- puration continues to the production of lardaceous changes, a consistent expectancy would demand the removal of the cause, and the physician who follows the expectant plan might find himself some day excising a hip joint. It is certainly his duty to give his patient the best chance of life, and if he accepts the facts already indubitably established, he will most assuredly give his patient that which offers about the only chance of life. If, on the contrary, he does not accept the facts as recorded he will treat the symptoms as they arise; will administer diuretics, cathartics, etc., etc. Such then constitutes the expectant treatment, and it remains now to elaborate this method, and to ascertain whether this gives us the best cure. In a very instructive paper published in the Philadelphia Medical Times during the past year, Dr. Oscar Allis raises the question, "What is the best cure in hip-joint disease?" and proceeds to show that " nature's cure" is the best. He claims that ankylosis is a most fortunate termination, and that apparatus should be employed with this in view. Fur- thermore, the angle of deformity should be 135, as this will subject the patient to the least inconvenience in any voca- tion of life. The shortening of the limb, he further claims, is desirable, in that it necessitates the use of a high shoe. This is important, because with the loss of function we have arrest of development in the femur, and by this arrest of growth " the knee is made to approximate the trunk; and the ankle, by the elevation of the shoe, approximates the position of the knee." Now while Dr. Allis's views may seem extreme and while they give us an apparently gloomy outlook, they are just TREATMENT OF CHRONIC ARTICULAR OSTITIS. 323 the views that many a general surgeon comes to hold who follows his cases closely and who bases his opinions on final results. Dr. Allis, then, represents the surgeon; and while he admits the possibility and desirability of a cure without deformity or ankylosis, he confines his query to the cases that have advanced beyond the early stages, as the following quotation will show : " I shall have no reference in the following remarks to the early manifestations of the disease and its possible cure. An eminent surgeon has said that 'nine-tenths of the cases can be perfectly cured if taken in time.' Grant- ing this to be true, it is clinical experience that nine tenths of the cases are not brought to us in the early stage ; and the pertinence of my query still applies to the great ma- jority of cases that fall victims to this painful crippling dis- order." I shall, in the course of this chapter, aim to show what the expectant plan accomplishes, and whether we can ex- pect any better results than Dr. Allis accepts as the best, even if we "get our cases in time." And a few remarks on " getting our cases in time" may not be irrelevant. What does one mean by getting, for instance, a case of chronic articular ostitis of the hip in time ? Does he want it within the first week of the appearance of signs, or does he want it sooner ? Or will he be satisfied if he gets the case before the second stage is reached ? The fact is few men can agree on this point, and the anxious mother who feelingly asks, " Doctor, have I come to you in time with my child ?" knows too well by the guarded reply that it is a difficult question to answer. My own opinion of that conditional expression "if you had only come to me early enough," is that it is a mischiev- ous assumption. It is an assumption, because it assumes that the one using the expression is surely in possession of the means for bringing about a cure. It is mischievous, because it seriously reflects on the previous medical attend- ant and sows the seeds of dissatisfaction. Besides, it is a poor science that will not allow its devotees to accept the situation and get good results, however adverse the cir- cumstances. Let a man be honest to his brother practi- tioner, honest to his patient, honest to himself. 324 DISEASES OF THE HIP. THE EXPECTANT TREATMENT. With a knowledge of the clinical history of this disease the treatment will be directed to the exacerbations. The relief of the pain is the most important object, and this being accomplished the restlessness at night, the loss of appetite, etc., are of minor consideration. Rest in bed and a roller about the hips in the form of a spica bandage gen- erally suffice to relieve in a mild exacerbation. An opiate is seldom necessary. I have seen many cases yield promptly to the application of strong tincture iodine. At the hos- pital blisters are applied if these means fail, and it is the rule for a child to get speedy relief after such treatment, especially in an early exacerbation. By far the surest method is fixation and traction. The weight and pulley sometimes act like a charm. The spasm is overcome, the limb is supported, and the child falls asleep without fear. This exacerbation being passed, no further interference is called for until the next one ap- proaches. The interval is occasionally so long that a cure is pronounced, and one feels that he has really accomplished a good result by very simple means. It is scarcely necessary to mention the importance at- tached to cod-liver oil. This is used freely and forms the basis of all medication. Many employ an alterative tonic, such as the syrup of the iodide of iron, or the bichloride of mercury with the compound tincture of cinchona. In- deed one of the oldest prescriptions now employed in chronic bone and joint diseases is the twenty-fourth of a grain of the bichloride to a drachm of the compound tinc- ture of cinchona. When there is much lameness crutches form a valuable acquisition to our armamentarium. Whether we employ crutches in conjunction with a high shoe, or a patten, on the sound foot, or whether they are employed without the shoe, the aim is to rest the hip and at the same time to per- mit out-of-door exercise. Those who adopt what is known as the Hutchison method, viz., the crutches and high shoe, seldom persist in it longer than a few months. Reliei comes, i.e., an exacerbation is passed, in a short time the little patient becomes more confident in his powers, and the crutches are soon discarded; while the physician thinks too that they have served their purpose. The appearance of a cold abscess is the signal for a good TREATMENT OF CHRONIC ARTICULAR OSTITIS. 325 deal of alarm, and how to manage these pus sacs is often a serious problem in the course of an expectant treatment. Shall they be left severely alone, or shall they be opened early ? On former occasions I have quoted Billroth, in favor of leaving them to take care of themselves. For many years I have myself deemed it the part of wisdom to avoid surgical interference. The rule to-day among conserva- tives is to adopt this plan. The antiseptic system offers. I think, quite as good an outlook as does the process of nature. If the suppurative process in the bone be not ex- hausted it is thought that the opening of abscess is danger- ous, and many cases that seem to favor this view can be adduced. On close analysis, however, these cases fail to convince one that the incision has proven more detrimental than a spontaneous opening. Statistics for comparative study are wanting. An early incision, other things being equal, has the advantage of preventing the formation of an extensive pus sac. The rule holds good, however, as dis- tinctly enunciated by Billroth, that unless one is prepared to remove the diseased bone if suppuration be not checked the abscess should not be touched. If one can have all the conveniences of the antiseptic dressing and be familiar with all the details of the man- agement of the same, then I should strongly urge the early opening. Yet how few in private practice, and es- pecially among that class of people who are most frequently affected with chronic bone disease, can command the con- veniences a hospital affords. I am well aware of this fact, which should not be lost sight of. These abscesses are of trivial import to the orthopedist, whether he practise the expectant plan or the mechanical. His custom is to leave them alone until they get in his way or prove annoying or painful to the patient; then he makes a small incision or aspirates, applies a compress, and awaits the progress of events. When they refill he opens again. It is the prac- tice of some to make frequent aspirations removing only a small portion at each sitting. I know well that many cases have abscess after abscess, have a little hectic the fifth or sixth day after spontaneous opening, experience very little inconvenience, and that the treatment is followed without interruption. It has long been a question in my own mind not by any means original with me whether suppuration was not a good thing for an articular bone disease I believe that far better joints are secured, far 326 DISEASES OF THE HIP. less pain and tenderness and inconvenience are experienced in after life in those hips around which abscess scars can be found than in those that have gone on to ankylosis with- out any suppuration. So then I advise that cold abscesses be let alone until they begin to cause inconvenience. The management of the deformities shall be reserved for a discussion of the various forms of apparatus. Before leaving the expectant treatment I propose to introduce a few typical cases in order that its merits or demerits may be justly appreciated. The impression prevails that a certain class of cases can be so far relieved that no deformity will remain. I have the records of quite a number of such cases; but, when collecting them for publication, I find the notes so meagre on certain important points that I cannot assure myself even of the correctness of the diagnosis. Take, for in- stance, a case like the following : A frail cachectic child, two and a half years of age, was brought for treatment in March, 1877. A diagnosis of "hip-disease, left side?" was recorded, and the only other note made except the one relating to his delicate appear- ance, was that the disease was of seven weeks' standing. The treatment employed was a liniment and spica ban- dage, cod-liver oil and iron. Six weeks later it was recorded that there was no shortening, but apparent lengthening of the limb, and that the thigh was fixed on the pelvis and no motion was allowed at the hip. A month elapsed and there was no improvement. The same treatment was con- tinued, and in September (the last note was in May) I recorded a decided improvement in every respect. There was no fulness about the hip and he walked with ease, scarcely manifesting any lameness whatever. The motion at the hip was limited to an arc of only twelve degrees, and the limb was "still rotated outward a little," passive motion in rotation being resisted. In the latter part of October there was " no muscular contraction, no atrophy, and no evidence of disease." A cure was recorded, and I was at a loss to know to what I should attribute this good result. I somehow felt well convinced that I had a' true case of "hip-disease," and yet the only signs I had obtained were insufficient to qonvince one who had not seen the child. I traced the case at the end of three months and TREATMENT OF CHRONIC ARTICULAR OSTITIS. 327 found that no relapse had occurred. It was in the latter part of June, 1878, that the child was brought to me with the right limb advanced, semi-flexed, and everted. There was also much reflex muscular spasm at the hip and the boy was quite lame. All these signs had appeared within a week. The same treatment as before was ordered, and in ten days " the limb was straight, no contraction, motion at joint free in all directions, scarcely any lameness." A week or two later I could not detect by the most careful examination any sign of disease. Nothing further occurred until May, 1879, when he again showed decided stiffness at the right hip. It could not be flexed beyond 90 or be extended beyond 105. Indeed it seemed pretty well locked at this last-named angle. There was neither shortening nor atrophy, and no symptoms, such as pain at night, restlessness, loss of appetite, etc. These signs were of brief duration, and passed away as quickly under a liniment. I made it my duty to see the child every two or three months thereafter, and up to the begin- ning of the present year there has not been any relapse, and on the date of my last examination, January 27th, I could not find any sign of present or past disease. When I first saw this case I thought it hopeless, and taking together the hygienic surroundings, the apparent improvidence of the mother, and the frailty of the patient, I could not form any other opinion. I confess, now, that I am unable to make a diagnosis. The successive invasion of the two hips, the predominance of signs over symptoms, and the suddenness of the different'exacerbations leads me to regard it as a recurring rheumatism. I have searched diligently for any rheumatism in father or mother or rela- tives near and remote, have instituted the same search for tuberculosis, and get absolutely negative results. I could not help thinking, however, in a spirit, perhaps, of carping criticism, that had this patient been subjected to mechanical treatment a brilliant result would have been claimed, and no man could have disputed the claim. And yet this child never had a blister applied, never had any immobile apparatus, never any fixation or traction, never any rest to the joint other than the rest the contracted muscles gave to the joint. Compare this case now with the following : A boy aged six years, whom I saw in Jime, 1880, had resistence to flexion and to abduction as the extreme 328 DISEASES OF THE HIP. limits were reached. He had been lame for three months, with the characteristic hip limp, had an appreciable change in the ilio-femoral crease, and there was a half-inch atro- phy of the thigh. Following a varicella three months be- fore this date a swelling in the groin had presented, yet there was no history of any marked exacerbation. The diagnosis was recorded as articular ostitis of the hip, but an interrogation point followed the record. The boy did not come under hospital treatment, and, curious to know whether the diagnosis had been correct, I traced the patient and found him, February 22, 1883, walk- ing very easily; yet, on close inspection, I could trace a little inequality in his steps the space covered by the right was shorter than that covered by the left. There was still a half-inch atrophy of the thigh and the calf was now a half- inch smaller than its fellow. External rotation was cer- tainly less complete on this side than on the other, and I could not flex the limb or abduct it quite to the normal limit. The parents regarded the case as long since cured, and for all practical purposes he was as active as any boy in the neighborhood. I learned that he went under treatment shortly after I saw him in 1880, at a similar institution, wore a hip splint, continued its use under directions for nearly a year, and the splint was finally removed by the parents on their own re- sponsibility. I could not get a history of any exacerbations. Whether the disease has undergone permanent resolution, or whether there be an unusually long remission, it is diffi- cult to decide. At all e'vents the parents and the neighbors credit the splint with the cure. So, in the boy whose case is reported on page 230, the prayers of the priest got the credit for the cure. Cases like these, with such well-marked signs of bone disease, are extremely rare. I have seen very many in which I have felt just as hopeful of complete reso- lution, and have been congratulating myself or some of my surgical friends on the good result, when, on the slightest provocation, an acute exacerbation would declare itself, dissipating all my hopes. It may be pertinent to inquire what the expectant treat- ment will do for a chronic articular ostitis of the hip, if begun in the first stage. From my records I have selected some cases, a report of which will show what the method, in its popular acceptation, can accomplish. A girl, aged seven years, came under treatment near the TREATMENT OF CHRONIC ARTICULAR OSTITIS. 329 beginning of June, 1879, giving a tuberculous family history, and the history of a lameness of three months' standing. At the same time her lameness began, or shortly thereafter, she complained of pain in the groin and night pains soon developed; in other words, the first exacerbation appeared early and persisted at least two months. My notes of her condition are pretty full, and instead of giving them in de- tail, I shall simply state that there were present nearly all the signs of a typical bone lesion of the hip in the early stage. An error in diagnosis, I think, was out of the ques- tion. Under the hospital regimen, cod-liver oil and an alterative tonic, there were no further exacerbations of any significance during the year succeeding her admission. The signs gradually disappeared, and in August, 1881, I recorded an arrest of the disease because I could not de- tect any lameness, any reflex muscular spasm, any resist- ance to movements carried to normal limits, any atrophy, or any joint tenderness. I did find, however, a slight change in the contour of the nates, a little flattening, and a little enlargement, apparently of the trochanter. The lesion was probably confined to the diaphysis, and perhaps eventually encroached on the trochanteric centre of ossifi- cation. A case that came under my observation for the first time in the spring of 1878 was instructive for many reasons. The patient was of the same sex as the one just reported and was four years of age. In this case the lameness was more marked in the afternoon, in the other it was more marked in the forenoon. The father of this child was under my care for an osteo-sarcoma involving the knees, and of this he eventually died; In the beginning of the year, three months prior to her admission to the hospital, she began to walk lame, and it was very clearly reported that the lameness came on im- mediately after a fall. The signs found on my examina- tion were, slight eversion of the foot and advancing of the limb, a slight yet perceptible hip limp, a broadened natis, a crease shortened and lowered, a deformity at an angle of 150, with very little, if any, motion by reason of the re- flex contraction, and a half-inch atrophy of the thigh. Negatively I found an absence of effusion or infiltration about the trochanter, no shortening, no bone or joint ten- derness. When asked to locate the pain she placed hei hr.nd on the outer side of the knee. The treatment adopted 33O DISEASES OF THE HIP. was the same as in the other case, and in June, as she was convalescing from an attack of rubeola an exacerbation of pain, restlessness at night, etc., developed. Relief not coming promptly, a fly-blister was applied to the hip, and for a week subsequent to its application she rested much better. A month elapsing the symptoms returned, and it was noted that the parts about the hip were very tender. A second blister was applied, and the child was not allowed to move around unless by means of a rolling-chair. It was fully a month before any decided relief was ap- parent, and during the next eight months not an un- toward symptom developed. In June, 1879, a note was made that the thigh could be completely flexed without pain or resistance, and could be extended to 160 with equal facility. She had no pain, and walked with great ease. The medicines were discontinued. Nothing noteworthy occurred during the remainder of the year; only it was from time to time observed that the movements were becoming less free; indeed, on December 1 2th, I found the arc of motion only one half as great as it was in June. Again, in February of the following year the arc was much greater than it was in December. A cir- cumscribed fulness had appeared near the trochanter, and an abscess was thought inevitable. During the years 1 880-81 she had recurring attacks of naso-facial erysipelas, but no symptoms of any moment ref- erable to the hip. The tumor gradually diminished in size, and the final result of the case, as noted June loth, 1881, was as follows: a girl in apparently good health, able to walk with very little inconvenience, although the toes and ball of the foot served for the whole soie. There was an inch real, and an inch and a half practical shortening; an inch and a half atrophy of thigh, and an inch of the calf; joint surfaces smooth and free from tenderness; flexion perfect, and extension nearly perfect; a little resistance offered as the limb was abducted toward the normal limit; rotation permissible over about one half the normal arc; the abscess sac barely appreciable. It will be seen from the foregoing that the case presented a joint pretty completely locked in the early stage, that the exacerbations were few, that an abscess appeared and the contents of the same were probably removed by ab- sorption, and that a very mobile joint was obtained despite the shortening and atrophy of the limb. TREATMENT OF CHRONIC ARTICULAR OSTITIS. 331 I should like to have more such cases to report, but can- dor compels me to state that these results are exceptionally good. It is seldom that an abscess does not sooner or later appear, and it is seldom that it takes the same course as the one in the case reported. The following is an illustration of how poorly a certain number respond to the expectant treatment: In April, 1879, there came into the hospital a fairly-nourished boy four and a half years of age, who had been favoring the left limb for four months. The family history furnished nothing definite as to predisposition, yet it is fair to say that few facts were attainable. It was only two weeks before his admission that an exacerbation showed itself, so that when I first saw him the symptoms were very well marked. There were: a deformity approximating that characteristic of the second stage, a decided limp peculiar to chronic ostitis, a very limited amount of motion, and an angle of deformity at 135. The pain was referred to the groin, and the limb would not tolerate much handling. The usual treatment was adopted and the exacerbation soon passed off, to be followed three months later, however, by another. For his pains at night a cantharidal plaster was applied and the parts poulticed as is the custom. Ten days after- ward relief came, and the next exacerbation two months elapsing ended with an abscess which occupied the outer side of the thigh. This increased to a large size and opened spontaneously three months after its appearance. Hectic fever occurred on the sixth day, but did not continue longer than forty-eight hours. About this time another abscess could be recognized in the gluteal region, springing apparently from the digital fossa. The tumor spread rap- idly throughout this region, and opened near the sacro- iliac synchondrosis within a month. This was the third week in January, 1880, and on the eighth of February I re- corded the following note : "Is greatly emaciated, eyelids puffy, feet cedematous. Liver dulness extends four fingers' breadth below free border of the ribs; the abdomen is distended; an open sinus above Poupart's ligament is discharging quite freely, and there is another over the trochanter. The thigh is flexed at an angle of 90, and is strongly adducted." He died from exhaustion four and a half months after- ward, and on autopsy I found no ankylosis, but destruc- 332 DISEASES OF THE HIP. tion of the capsular ligament in its upper and lower fourths, where one's finger could be easily inserted, encountering eroded bone dark in color and foetid in odor. The iliac bone, including the acetabulum, exhibited no lesion what- ever, either superficially or on section. On vertical section of head, neck, and shaft the lesions found were, absence of articular cartilage, about one half of the necrotic head the remainder lying in fragments in the acetabulum, a little ir- regularity in the line of epiphysial union, and about a half inch below this line a yellowish spot in the centre of ossification of the neck. I could not find a vestige of the ligamentum teres. The liver was enormously enlarged and on section had a waxy appearance, the iodine test also fully confirming the diagnosis of lardaceous degeneration. This was an excellent case for early interference, and the lesion as shown post mortem was one for which the expectant treatment could do nothing. The evolution was unusually rapid, and the appearance of lardaceous changes came on very soon after the opening of the abscess. A single other case will illustrate some practical points in the management of this disease. It was in a boy twelve years of age, whom I saw first in December, 1880. The ma- ternal history was decidedly tuberculous. In the early part of the year the boy began to walk lame, and the lameness was uninterrupted by an exacerbation until five weeks before his admission to the hospital. The right limb was appar- ently lengthened, a little advanced, and rotated outward. The changes in nates, the lordosis, the inability to walk, the locking of the joint at an angle of 135, were salient points in enabling one to recognize this as the typical sec- ond stage. There was an extreme degree of tenderness in and about the joint. This was regarded as a fine case for blistering, and a blister was promptly applied. The relief was only temporary as an abscess made its appearance within three months on the outer aspect of the thigh lower third. It grew rapidly and was soon opened by incision. In spite of tonics and stimulants the boy rapidly lost flesh, and in less than two months another abscess involved the whole of the gluteal region, causing a vast deal of suffering. During the summer he had very few days without pain, he grew thin, and the limb assumed a very awkward position. In November, 1881, he was removed. The angle of de- formity was 120, and the case seemed hopeless. He was TREATMENT OF CHRONIC ARTICULAR OSTITIS. $33 taken to a home that was devoid of all hygienic qualifica- tions, a home where intemperance prevailed, and yet within a month the most marked improvement had taken place. In the following May I saw him and the sinuses were closed, his general health was excellent, and the disease seemed to be arrested. Tracing him out during the past spring I found that no exacerbation had occurred since he left the hospital. The deformity was about 135 and he was quite active. The point I wished to bring out is this, viz., that patients sometimes reach a stage in the progress of the disease where removal from a hospital offers the only hope of recovery. They become depressed, get homesick, and all remedies fail. Let the home be ever so humble, ever so unhealthy, the change often works wonders. The claims that are set up for the expectant treatment are, that 1. As good results are obtained as by other methods. 2. There is less expense and less inconvenience to the patient. 3. The nutrition of the limb is not impaired. With regard to the first claim, it is not proven. Regard- ing the second, I am aware that the expense of apparatus is a serious drawback in this specialty, and many patients do object to the cumbersomeness of these appliances, many of which are ill-fitting and fail to meet the indications. The extensive abuse of mechanical appliances has served to bring them into disrepute. So far as my own observation goes, well-fitting splints render the patients very comforta- ble, and the relief they experience from pain and muscular spasm is so great that it is difficult to bring about a sus- pension of their use. Concerning the third claim, the clinical history abun- dantly proves that the nutrition of the limb does suffer with or without the use of apparatus; indeed it is a clinical fact that atrophy is one of the most valuable signs in diagnosis. My own conclusion, after twelve years' daily experience with the commonly accepted expectant treatment, is, that 1. In a very few cases of chronic articular ostitis of the hip good results are obtained. 2. In the large majority of cases it is utterly inadequate either to arrest the disease or to secure the best possible re- sult, irrespective of the stage in which the treatment is begun. 3. Whenever one can feel assured that he has a genuine 334 DISEASES OF THE HIP. case of chronic articular ostitis of the hip, science demands, humanity demands, that the so-called expectant method should form no part of the treatment. The rule admits of few exceptions. 4. When one is in doubt as to the diagnosis, and the pre- ponderance of evidence seems to be against the lesion be- ing one in the bones entering into the articulation, the expectant method should be adopted pending the period of doubt. 5. If the evidence is in favor of a bone lesion, abandon the expectant treatment. I speak advisedly on this subject, and I speak fortified by a faithfully recorded experience. Cases like the following certainly make an impression. It made a painful impression on me, and I charged it up to the credit side of expectant treatment. The case has already been reported in the chapter on clinical history, and may be found on p. 244. The points are briefly these: He was six years of age, was admitted in January, 1873, had a poor family and a poor personal history, had been limping since June, 1872, had had one or two rather severe exacerbations ; on admission his limp was very slight scarcely perceptible the gluteal signs were slight yet sufficiently well marked, the deformity was nil, flexion could be made to 90 without pain or resist- ance, there was no joint tenderness, no atrophy, no short- ening. A diagnosis was easily reached, however, the dis- ease not having advanced beyond the first stage. A blister was ordered forthwith, but, on reflection, was postponed because he rested well at night. A liniment of iodine bella- donna and soap with a spica bandage was used. In February he began to sleep poorly, to walk with more difficulty, and Fowler's solution was administered. The symptoms sub- sided in a week, and in May the mother talked of remov- ing him. On examination then he stood squarely on both feet with limbs parallel, and scarcely favored the right hip in walking. There was no articular or periarticular tender- ness that I could elicit, and flexion of the thigh could easily be made beyond 90. In June it was thought that a cure had been effected so active had he become, still a careful examination would de- tect a few signs. Early in July he was climbing some scaf- folding, and fell striking the hip. He was scarcely able to walk the same day, and cold-water dressings and rest fail- TREATMENT OF CHRONIC ARTICULAR OSTITIS. 335 ing to give relief, a blister was applied a few evenings later : was poorly applied, and a week or two afterward a second one was applied, getting a good vesication. The poultices were used as is the custom a fresh one every six hours for three days. About this time two large boils appeared on the left hip but were considered the effect of the vesication. The left FIG. 33. ARTICULAR OSTITIS, BOTH HIPS. hip presented signs indicative of bone disease, and it was not long before the second stage was reached. In the mean- while the disease on the right side was advancing to the third. Abscess formed in gluteal region and on posterior surface of thigh, deformity became extreme, the boy be- came quite helpless fora long time, and was only able to get about in a rolling chair. Finally in February, 1875, he was able to leave the rolling-chair, and his mode of progression 336 DISEASES OF THE HIP. is well illustrated by a drawing from life. See Fig. 32, which represents very accurately the deformity of both hips. At this time the liver was found enlarged. After prolonged suppuration he was finally discharged as incurable in Sep- tember, 1876. My restrictions, I would have it understood, apply to the method as popularly understood. If the system were freely carried out, if not only the aim were to relieve the exacer- bation in the early stage, but to prevent and correct deform- ity, or to bring about that deformity, if deformity needs must come, which will secure the greatest usefulness of the limb, then I should say, By all means retain the treat- ment, yet never hesitate to abandon it in individual cases where it becomes clearly ineffectual. CHAPTER XVI. TREATMENT OF CHRONIC ARTICULAR OSTITIS, BY CRUTCHES AND HIGH SHOE WITH OR WITHOUT FIXATION. I. THE PHYSIOLOGICAL TREATMENT OF DR. HUTCHISON. II. COMBINATION OF THE PHYSIOLOGICAL TREATMENT WITH FIXATIVE SPLINTS. 1. The simplest form of mechanical treatment is that brought forward by Dr. Hutchison of Brooklyn, and is called by him the Physiological Method. The body is supported in walking by means of axillary crutches, and the limb diseased is allowed to swing, its own weight being relied upon to make the necessary amount of traction, while the peri-articular muscles by their reflex spasm serve to secure the necessary amount of fixation. The treatment is not complete, of course, without the high shoe, or patten, on the sound foot. I have not classed the weight and pulley known as Buck's extension as a separate form. This is employed now more as an adjuvant than as an independent mode. It is employed at times in connection with the various splints and appliances, and is used expectantly to relieve urgent symptoms or persisting signs. When the indications are met, it is discontinued. This would be more properly a step in the expectant plan of treatment. 2. Closely allied to the physiological method is the plan employed by Mr. Hugh Owen Thomas, of Liverpool,which is a combination of the physiological and the fixative methods. The principle involved is immobility, and this is best secured, Mr. Thomas claims, by limiting the movements of the joints immediately above and immediately below the hip-joint. 3. Fixative splints, whose sole object is to retain the limb in position, resisting thereby the muscular spasm that is so important an element in the production of deformity. These are called appliances for securing rest. 338 DISEASES OF THE HIP. 4. Splints whose object is not only to protect the joint but to make traction. These splints embody what the English choose to call the American idea. I. THE PHYSIOLOGICAL TREATMENT. In 1879, when Dr. Hutchison so zealously and so ably advocated this plan of managing hip-joint cases, many of us wondered why it had not occurred to us before, and many more of us fancied that we had at last been freed from the thraldom of splints. It seemed very simple and very useful. Somehow it has always been my misfortune to meet with cases that are grave from the beginning. I seem to meet with hip-disease which involves the bony structures; and, get the cases ever so early, I find them ex- ceedingly tedious, exceedingly slow, and so prone to re- lapses that I am rendered consequently slow myself in publishing cures. Since 1879 I have employed this method in quite a num- ber of cases, and I am not ready now to give an analysis of the same. Some of my best cases are still under treat- ment. I have seen enough, however, of its practical work- ing to form a very fair estimate, I think, of the value of the method. I look upon it, moreover, as but a part of the expectant plan, and, in so far as it gives protection to the joint, I am its warmest advocate. I am convinced, though, that it does not prevent deformity, and I have not had any- thing like the success that is recorded in Dr. Hutchison's book, published in 1880. Let me give one of my best cases; indeed, it is the only one out of a large number that has done well, and yet the the case is not complete. In July, 1878, I began treating a little girl whose case had advanced to the second stage. Her disease had lasted since March. When I saw her the limb was held rigidly flexed at an angle of 80, and the adduction was very great. She lived in the country, and as she had just passed an exacerbation, nothing was done further than to prescribe a liniment and an alterative tonic. I did not see the case again until March, 1879; it had been under another physi- cian, but the same prescription had been followed. The deformity was as great as when I saw it in July. The crutches and high shoe were now ordered; and, as her father was a man of much" mechanical ingenuity, he fully appreciated the idea, and had directions followed to the TREATMENT OF CHRONIC ARTICULAR OSTITIS. 339 letter. In May and in July I recorded an increase in the mobility of the joint. She found much relief from the treatment; had had only an insignificant exacerbation, and in December I found that the thigh could be easily flexed to an acute angle, could be extended to 135 before any resistance was encountered, and could be abducted and adducted over small arcs. I could rotate the limb, too, quite easily, and there was no apparent shortening, but a real shortening of a half-inch. In the following March I made a similar note. In September, 1881, the treatment having been continued the meanwhile, I found that I could extend the limb to 150, but I recognized in the iliac fossa a well-marked tumor, which I took to be an abscess. A week before this note was made she had fallen, striking the ilium near the anterior-superior spinous process, and next day complained of pain at the knee. I could not detect any joint tenderness, and could not perceive any diminution in the arcs of motion. I gave no attention to the tumor, and in January, 1882, it had reached the size of a hen's egg, and filled the groin. It had caused no pain or inconvenience, but the shortening of the limb was now one inch. For the tumor I ordered the hot douche twice a day. In March there was a practical shortening of three inches, and a real shortening of one inch. The tumor was as large as ever, and there was a marked tenderness of the joint. Over the trochanter a shade of fulness could be detected. She was crying in her sleep, and was generally indisposed. Hot fomentations at night were ordered, and the crutch and high shoe continued by day. In July the tumor was perceptibly smaller; otherwise there was no change. I did not see the case again until February of the present year, when the angle of deformity was 135. Flexion could be made to 45, rotation and ab- and adduction could be made over small arcs. As the child stood the limb was rotated outward. I looked long and diligently for the abscess, and had to record, " Not found." From the umbilicus to the lower border of the internal malleolus there were two and a half inches short- ening (practical), and from the anterior-superior spinous process one and a half inches (real). My last note was on the twenty-seventh of July. The limb hangs at angle of 150; is easily flexed to 45. There is no infiltration about the trochanter, in groin, or illiac fossa. The tip of the trochanter is one inch above N61a- 340 DISEASES OF THE HIP. ton's line, and the shortening is the same as measured in February. My impression is that I shall get a cure that will compare favorably with any case that can be shown. It will be seen that after three years' treatment the limb shortened one inch, abscess formed and disappeared, and a most excellent degree of mobility was obtained. And yet I cannot help contrasting this with other cases I have treated without crutches and high shoe. Take for in- stance the case on page 329 This girl, it will be seen, was in the hospital, not in the country; had a bad family his- tory and a bad personal history. She had a hip, in the early part of her hospital treatment, that was locked against movement. Later the movements were very good, an abscess appeared, disappeared. Finally came out, with an inch and a half shortening, and joint function nearly perfect. The duration of treatment was three years. Another girl I had under observation a number of years, with sinuses and abscesses, finally made a fair recovery, with the limb in a very serviceable position. The treat- ment had been constitutional, and in February, 1879, I made a note that the ulcers and sinuses were healed; that she had very little deformity, very fair motion, no pain or tenderness, and that she walked with much ease. At this time she was ten years of age, and her left hip had been the one about which the disease had spent itself. About the first of October, of the same year, she began to complain of pain about the right hip, and four or five days later I made an examination, finding it impossible to flex the thigh to a minimum extent, even without pain; considerable infiltration in the groin, and much joint ten- derness. Comparative measurements were unsatisfactory, because of the shortening in the other limb. The length of this limb, however, was twenty-six and a half inches. I decided upon the physiological treatment, but the exacer- bation was so acute, and the other limb was so insecure, that I waited a few days to devise ways and means. In the mean time a blister was ordered. A temporary relief followed its application, but ten days later she was con- fined to her bed, and all the symptoms were aggravated. Movements in all directions were resisted, and the limb was held flexed at an angle of 140. She fairly made night hideous with her shrieks, and had to be propped up with pillows to secure any rest at all. Another blister was ordered. This was the last of October, and three days TREATMENT OF CHRONIC ARTICULAR OSTITIS. 341 later I found her quite comfortable. She had slept quietly all night. With much care I could flex the limb to 120, and extend to 150. Abduction and rotation were resisted as soon as attempted. I could not detect any joint tenderness. Pathologically speaking, I regarded the case as one be- ginning as an acute coxo-femoral synovitis. It was not many days before I had her on a pair of crutches, with a six-inch high shoe on the foot of the left limb. It required two months to teach her how to get about on her apparatus, and before she was able to move around unassisted another exacerbation came on rendering her quite helpless. The sisters of the girl were very persevering in teaching her to walk, and by the following May I was surprised to find with what ease she moved about. The limb was apparently lengthened, the toe not clearing the floor well as she walked. In June I had twelve ounces of lead attached to the heel, with the desired result. The case progressed slowly, marked by frequent exacerbations, and it was not until December, 1881, that the treatment was discontinued. The right limb then measured twenty-seven and a quarter inches. The limb was very nearly straight, yet the move- ments were restricted to very small arcs. No suppuration had occurred, and there was no infiltration about the joint. At present writing she walks with comparative ease by reason of compensating deformities. The angle of deform- ity on the right side is 160, on the left 130. and movements on both sides are restricted in all directions. The joints are practically ankylosed. This certainly was a very fair result, if we consider the difficulties under which I labored. It was certainly better than the result obtained in that of a case I put under the same treatment in the summer of 1879. In May, 1878, I diagnosticated a chronic articular ostitis in a boy six years of age, after he had been walking lame for two weeks. I did not get the case to treat however until a year afterward. He wore a long splint the latter half of the intervening year, and when he came again under my observation the angle of deformity was 165 and the limb was only a halMnch short. The boy was so irritable that a satisfactory examination as to motion was out of the question. Suffice it to say, this seemed to me a very good case for the physiological treatment, and I forthwith put it into effect. It was at least two months before he learned to use the crutches well, and in January of the following 342 DISEASES OF THE HIP. year, as the deformity seemed to be increasing, I had a piece of lead attached to the heel of the shoe on the suspended limb. The joint became more securely locked, and about this time the first of a series of abscesses made its appear- ance, the locality being the space beneath the tensor vagi- nae femoris. It is unnecessary to follow the case, through these suc- cessive abscesses, through the pains and the increasing de- formity. It is enough to know that the treatment has been faithfully and persistently followed; that the disease has progressed from bad to worse without a reassuring interval; that lardaceous degeneration has declared itself by unmis- takable signs, and the limb is now ankylosed at an angle of about 130, is at least two inches shorter than its fellow; and that the inguinal region, the gluteal region, and the thigh on both lateral and posterior aspects presents one net- work of sloughing and burrowing ulcers, open sinuses and cicatrices. And yet this case does not present so melancholy a his- tory as that of a boy aet. nine years, who contracted disease of the bones entering into the formation of the hip in 1877. It had reached the second stage when I first saw the case in February, 1879. It was under the care of the family physician, and was sent to me simply for advice. I advised the crutches and high shoe. In May he was formally com- mitted to my care, and I recorded his angle of deformity, 135, his shortening, a quarter of an inch, the absence of joint tenderness, and the limitation of movements. The limb did not seem heavy enough to make the desired trac- tion, and ten ounces of lead was added. A month later the angle of deformity was 90 and the patient was in the height of a very acute exacerbation. The next note, a month afterward, records the subsidence of the exacerbation, but the deformity was unrelieved. It was a month before I recognized that a dislocation had taken place since the treatment had been employed, and he was admitted to the hospital, where a more careful ex- amination revealed the following interesting facts: four and a quarter inches shortening, the trochanter above Nela- ton's line, ability to flex the thigh to an acute angle, in- ability to extend beyond 90, an extreme degree of adduc- tion, the presence of what seems to be the head of the bone on dorsum ilii, and an absence of any signs pointing tc suppuration. TREATMENT OF CHRONIC ARTICULAR OSTITIS. 343 An anaesthetic was administered while the deformity and shortening were overcome. A leather splint was applied, and the weight and pully employed for a fortnight. He was then discharged from the hospital, but continued under treat- ment as an out-patient. The limbs were equal in length, and he was put on the crutches again, the high shoe com- pleting the outfit. He wore the leather splint three months, and then relied solely on the crutches and high shoe. From this time hence his suffering began anew. Night extension was employed, but abscess formed, the limb shortened, and the deformity came on slowly. He con- tinued to go about for nearly a year, but finally took to his bed, the suppuration became profuse, the deformity ex- treme, and later still the symptoms of lardaceous degenera- tion declared themselves. He lingered until the spring of the present year. I have notes of several cases under this form of treatment for a year or two, deriving no benefit, and finally coming under mechanical treatment. It is a clinical fact that pa- tients using the crutches and high shoe do feel encouraged during the first few months, and that they exhibit a certain temporary improvement. Many of us, no doubt, shared Dr. Hutchison's enthusiasm when the treatment was yet new, and we heartily subscribed to the peroration found on page 32 of his work on Orthopaedic Surgery: " What a boon it is to get rid of the paraphernalia with which the diseased limb was formerly encumbered the harness and the trappings, the weight and pulleys and ad- hesive plaster, the perineal bands and the iron splints, and all the discomforts which their use implies!" I was peculiarly impressed with that sentiment, and, in my own copy can be found a long mark of approval about the passage. Would that I could subscribe to it now! I had had no experience then; I have an experience now. In my interviews with various surgeons I have learned that the treatment has been disappointing. In Dr. Bradford's article on The Treatment of Hip-Disease, published in the Boston Medical and Surgical in November, 1880, his conclusions even at that time were that " it meets certain indications, but cannot be relied upon in all the phases of the disease. Patients treated according to this method illustrate that at some stages and in some cases the natural fixation is ap- parently sufficient, and that at times but little extension is ne.d.ed; but it is also clear that in many cases the weight 344 DISEASES OF THE HIP. of the limb is not enough to overcome muscular contrac- tion, prevent deformity, and give the patient the greatest amount of freedom from the discomfort due to disease at the hip-joint. As a means of extension it is imperfect, for the reason that it is efficient only when the patient is upright; for fixation, it does not perfectly guard against involun- tary motion occurring during sleep; it also is not cer- tain to protect the joint from jar, for in practice many chil- dren when not suffering from a painful joint will be found occasionally to kneel upon the affected limb, or take a step, unless watched more closely than is usually practicable." I have thus quoted Dr. Bradford at length, because all the points he makes are illustrated by cases; and were I to formulate my own conclusions, I should embody the same ideas. II. FIXATION SPLINTS ASSISTED BY THE PHYSIOLOGICAL METHOD. There are a number of splints that bear the names of the different surgeons, who have either invented them or em- ploy them, and while some are not expected to require any additional assistance, they all are meant to serve one special object, viz., fixation. All surgeons at the present day who employ such appliances have come to recognize the impor- tance of suspending the body on crutches so that the idea of fixation and rest may be all the more fully carried out. They all aim at immobility of the joint, with extension. There are really very few that are constructed with these two ends in view. These maybe enumerated in the follow- ing order: i. Dr. Hamilton's Wire-Gauze Splint. Closely allied to this is the wire-gauze splint of Mr. Barwell. The accompanying diagrams represent a front view and a rear view of the apparatus. It will be seen that it consists of an iron wire frame moulded to the pelvis and thigh. This frame is covered with wire gauze. The whole is kept in place by a pelvic band and a broad thigh band, both of which are secured by buckles. To secure exercise in the open air crutches are use'd. With a high shoe, the weight of the limb will thus prove an extending force. I have no personal knowledge of the value of this splint, do not even know of any cases that have been thus treated, hence can draw no conclusions as to its value. TREATMENT OF CHRONIC ARTICULAR OSTlTIS. 345 FIG. 34. HAMILTON'S SPLINT FRONT VIEW. FIG. 35. HAMILTON'S SPLINT REAR VIEW. 2. Dr. Vance s Leather Splint. On the same principle Dr. Ap M. Vance has constructed a splint of saddle leather. The Doctor selects the best saddle skirting, and with soft paper takes a pattern of the sound hip in the position it is desirable to fix the diseased hip. When this pattern is re- versed it will fit the other hip, and the leather when pre- pared for application will have somewhat the shape of the drawing in Fig. 35. The lettering represents the following parts : P. B. is the pelvic band, and is seen to be of good width ; T. B., is the thigh band; T., tongues of thinner leather and sewed to the splint after it has been moulded and fitted to the parts. These are applied in finishing up the splint; S. H., shoe hooks, also attached in the finishing process; R., copper rivets for securing the gusseted portion; A., a gusset to permit of adapting the splint to the pelvis. The limb is placed in the desired position in one of three ways, according to the exigencies of the case. i. If but little muscular spasm exists it can be easily forced into posi- 34* DISEASES OF tttE tion by the hand, and securely maintained pending the dry- ing of the leather. 2. If the spasm and contraction be too great for this procedure, the weight and pulley can be employed for a few days or weeks, as the case may be. 3. In the opinion of some surgeons it is better to administer an anaesthetic and bring the limb into position at once by e>~ . <3 : 'e. O; P.b, Q? O &al a/ 3 jt& e> e> f o FIG. 36. LEATHER SPLINT BEFORE IT is MOULDED TO THE HIP. force. By reason of our ignorance of the exact stage of the pathological process I deem this last process of reduc- ing deformity exceedingly hazardous. Of course there are periods when it can be done with impunity, but I have seen so many distressing symptoms, so many disastrous exacer- bations follow in the wake of these operations, that I always raise my voice against the practice, especially in the pre TREATMENT OF CHRONIC ARTICULAR OSTITIS. 347 suppurative stages. The leather is now immersed in very hot water long enough to make it thoroughly pliable. Then, while the hip is in that position we desire, mould the leather about pelvis and thigh, securing it with a roller. In from fifteen to twenty minutes it will " set," and be sufficiently hard to admit of removal without losing the shape. In order to give one time to dress and complete the splint the position of the !imb should be secured by weight and pul- ley. If there be no occasion for haste in completing the apparatus the leather can be left on the parts for twelve hours, and then, when removed for purposes of completion, the limb will be less likely to resume its original mal- position. The edges are pared down, thegusseted portion is riveted as desired, the hooks and tongues are attached, and, if one prefer a perforated splint, holes can be made with a belt- punch without weakening to any great extent the apparatus thus constructed. To guard against excoriation or undue pressure over the crista ilii fenestra are cut in these por- tions of the splint, and if it be necessary to take special precautions against the recurrence of deformity a strip of steel can be riveted in front, as seen in Fig. 36, which rep- resents the dressing in use. It will be seen also from this figure that the parts are protected by some soft material, such as the leg of a pair of closely-fitting drawers. If abscesses already exist, or form subsequent to the begin- ning of this treatment, openings in the leather are made when desirable. The special advantages claimed for this splint are, that it is easy of construction, easily fitted, and can be cleansed with soap and water without the least detri- ment to the material. Furthermore, if it be desirable to change the position of the limb, it can be done as in the first instance, the splint can be immersed again in hot water, and reset as before. This treatment in intelligent hands I know yields good results. The joint is protected, a good position of limb maintained, the patient is comfortable, and the disease is placed under the control of the surgeon. The objection that is urged against all short splints can be brought against this, viz., that it does not immobilize the joints above and below the hip. It is very easy, however, to make the bands wider, and thus meet this objection. For very young children who cannot be taught the use of crutches it does not fully protect against alterations in the position 34-8 DISEASES OF THE HIP. FIG. 37. DR. VANCE'S LEATHER SPIINT, TREATMENT OF CHRONiC ARTICULAR OSTlTIS. 349 of the neck of the femur. They will walk when not suffer- ing an exacerbation, and the weight is necessarily thrown on the limb. 3. The Liverpool Method. Mr. Hugh Owen Thomas, of Liverpool, England, has, for a number of years, employed a method of fixation that seems to secure this object better than most of the splints now in use. At the same time, while disavowing any attempt or desire even at extension, he uses in conjunction with his splint the high shoe and crutches. He certainly takes enough precaution to pro- tect the joint from injury, and the zeal with which he pur- sues his practice, and the favor it is meeting with through- out Great Britain, bespeak for it more consideration than the surgeons in our own country seem willing to give. In Chapter III. of the second edition of his work on " Diseases of the Hip, Knee, and Ankle Joints," he gives very explicit instructions about the making of the apparatus, and it would seem that any surgeon possessed sufficient mechanical tact to construct an instrument for himself. The patient is to stand with weight on the sound limb, while the foot of the side diseased rests on a block, or book, or cushion, sufficiently high to bring the spinal column perfectly straight. Ordinarily, in cases that have not advanced be- yond the first stage, the height of the foot-rest sufficient to secure this vertical bearing will be one inch. To secure the best fit, the whole of the posterior aspect of the body, including the lower limbs, must be divested of clothing. The materials necessary for work are: 1. A flat piece of malleable iron long enough to extend from the lower angle of the scapula to the junction of the middle with the lower third of the leg just where the calf begins. This should be an inch in width and a quarter of an inch in thickness, for an adult, and three quarters of an inch by three sixteenths, for children. 2. Three strips of hoop-iron: a, one for the chest an inch and a half in width by one eighth of an inch in thickness, and for its length about four inches less than the circum- ference of the thorax; b, another for the thigh, three quar- ters of an inch in width and one eighth of an inch in thickness, and its length two thirds the circumference of the limb in its upper third; c, another band of similar strength' for the calf, and equal in length to one half the circumference of the limb at this point. 3. A set of wrenches with which to shape the iron bars. DISEASES OF THE HIP. These are made by a smith, and properly tempered. Those marked i are enough for all practical purposes; 2 is an- other form, and may serve a better purpose at times than the other pair. To any one who makes any pretension to the practice of orthopedic surgery these or similar wren- ches are very valuable. This long iron bar now, with the patient in the position above-named, must be moulded over the buttock along the course of the sciatic nerve, through the popliteal space, and over the calf to the lower end. These precautions are FIG. 38. SERVICEABLE WRENCHES IN FITTING ORTHOPEDIC APPLIANCES. necessary to avoid excoriations. Indeed, one of the great secrets of success in all forms of apparatus is the extreme care one takes in the application of the same. The lumbar portion of this upright will be a plane surface, in fact, Mr. Thomas insists on it being " invariably almost a plane sur- face." It is necessary to rotate this baron its axis at a point just above the buttock curve, in order to adapt it to the individual patient, as some are more plump than others. This can be easily accomplished with the wrenches. The next step in the preparation of the splint is to mould this longer strip of hoop-iron into a chest-band. It is to be riveted to the top of the upright bar at a point one TREATMENT OF CHRONIC ARTICULAR OSTITIS. 35 1 third its length, measuring from the end corresponding with the side diseased. The shape will be oval, and this will be found necessary to prevent the splint from turning. The thigh strip is now fitted in the same manner as the one for the chest, and is to be secured to the upright at a point from one to two inches below the ilio fermoral crease. The third, or calf strip, is fitted in the same way, and riveted at the lower end. These three are called crescents, and are distinguished as chest, thigh, and calf crescents of the splint. If it be desirable to immobilize both hips when both are diseased, for instance, the other upright is con- nected to the first by a cross-bar in the lumbar portion. When the patient or friends do not object Mr. Thomas pre- fers this double splint, even in cases where only one joint is diseased, as he can then feel more certain of its efficacy. The crescents being riveted to the upright the instrument is ready to be padded and covered. For the padding a single thickness of No. i boiler felt is preferable, and for the covering basil leather as used by saddlers is preferable to any other material. A saddler can do this with very little inconvenience. The upper or chest crescent is secured to the body by a strap and buckle. Suspenders are used over the shoulders, as seen in Figs. 38 and 39 ; the lumbar portion is secured by a common roller bandage, and the limb por- tion in the same way. With the patten high enough to clear the foot of diseased limb and the crutches the outfit is complete, and Fig. 38 represents an anterior view of the patient ready for exercise. Even when the instrument has been carefully made and comes from the shop, more moulding and fitting is fre- quently required of the surgeon himself. The crescents may have to be shaped differently to get the upright in the proper line, and salient points will require a little more bending. Indeed, however lightly one may think of the apparatus as a therapeutic agent, he cannot but help ad- mire the great attention to details which Mr. Thomas ex- hibits in describing his plan. Some men may have the best instrument in the world and get the poorest results, and vice versa. The surgeon must not think his work done when the splint is applied. He must see it from day to day, for weeks perhaps, and aim to get the best possible fit. Inward and outward rotation of the limb, abduction, and adduction can be frequently corrected if not too exaggerated [- h \ LC 352 DISEASES OF THE HIP. by the uses of the wrenches while the instrument is on the patient. These little tendencies can easily be thus corrected. FIG. 39. FRONT VIEW OF MR. THOMAS'S SPLINT APPLIED. For bandages flannel rollers are the best, and should be employed by all means in young children. For the correction of deformity, the upright is bent in TREATMENT OF CHRONIC ARTICULAR OSTITS. 353 the buttock portion and the splint is applied in the deformed position. From time to time the curve of the upright is FIG. 40.-A POSTEROR VIEW OK THE THOMAS SPLINT. lessened by degrees at the point, A, indicated by the arrow in Fig. 40, 354 DISEASES OF THE HIP. Fio. 4i.-MoDE OF GRADUAL CORRECT.ON QF DEFORMITY WITH THE THOMAS SPLINT TREATMENT OF CHRONIC ARTICULAR OSTITIS. 355 I have thus given in considerable detail the construction and the mode of application of this instrument, and have confined myself pretty closely to Mr. Thomas's descrip- tion. For still more of detail, however, I must refer to the work itself. During the first three or four months after the applica- tion of the splint the patient is confined to the bed, and a change in the appliance is never made unless under the direct supervision of the surgeon. While any changes are being made the dorsal decubties must be maintained, and under no circumstances must the sitting posture ever be tolerated. While the patient is thus confined to bed during this period Mr. Thomas calls it his first stage of treatment. The second stage of treatment begins when the patient leaves the bed. Then the high shoe and the crutches are employed. There is no definite length of time for the con- tinuance of this stage, as it depends upon the rapidity of- atrophy. It must be " continued until the limb is well atrophied about the great trochanter." Considering the variableness of atrophy this seems to me a very uncertain guide. A better one in my opinion would be the length of time since the patient had had an exacerbation. The disappearance too of all inflammatory products in the neighborhood of the hip should also be an element in determining the duration of this stage. Splints that immo- bilize the joint surrounded by bone disease should be worn from one to two or three years. I am arguing now against contingencies; I am arguing in favor of giving the joint every possible chance. In the third stage of treatment the splint is removed at night, and replaced during the day, the patient still using the crutches and patten. The duration of this period is briefly given by the author as " a certain period." By ref- erence to a few reported cases it will be seen to extend over a period of from two to five months. The fourth stage of treatment begins with the removal of the splint altogether. The crutches and patten are still retained for a few weeks, or months, until the surgeon is satisfied that the cure is permanent. One naturally wishes to know what the results are. Do the results as obtained justify us in subjecting the child to so much apparent discomfort ? And again, is the discom- fort greater than that where perineal crutches are used? 356 DISEASES OF THE HIP. During the past summer a medical friend, who has for several years devoted his attention chiefly to orthopedic surgery, spent some weeks with Mr. Thomas, and he went over strongly prejudiced in favor of the "American method." This friend called to see me on his return, and I asked him particularly about the discomfort to which Mr. Thomas's patients were subjected. He replied by saying that he saw very few signs of any discomfort, that the patients seemed happy, and that good results were certainly the rule. Analyzing a few years ago the few reported cases Mr. Thomas has published, I found: one received in first stage, duration of disease and angle of flexion not specified, length of treatment twelve months, the first three months of which required the horizontal position in bed, with an ultimate "cure" for the result; four in second stage, two of which were of five months' standing, indicated by any given angle of flexion, say 150, the other two, three and four months standing respectively, not indicated by any given angle of flexion; three were "cured," one " recovered," one kept the bed three months, one five months, one nine months, and one twelve months; five were received in the third stage, and in three relief was afforded, one recovered in three years' time, and one died twenty days after an ex- cision. In Dr. Bradford's paper, to which allusion has before been made, the method is not warmly advocated. From a few cases he had under observation he reports that " one, an active child too young for crutches, visibly lost in general condition from the confinement of the splint. Another gained both locally and generally, but complained of the irksomeness of the apparatus. A third has improved and is free from active symptoms, but is inclined to lay aside his crutches and step on the affected limb." The following case is reported by Dr. Bradford as show- ing the value of extension over this fixation splint: "A boy aged five, with hip-disease, had been treated for several weeks by complete fixation in bed, and an extension by weight and pulley. The symptoms, which had been acute, had subsided. There was no swelling, pain, or ten- derness about the hip, and the case had been progressing favorably for some time. A Thomas splint was applied and accurately fitted. On the following night there was severe nocturnal pain, which increased on the next night. The next day the hip was found swollen and tender, and the TREATMENT OF CHRONIC ARTICULAR OSTITIS. 357 limb sensitive on jar. The symptoms all disappeared im- mediately on removal of the splint and the readjustment of the extension. The boy has since been progressing well, as before. The coincidence was so marked that there could be no doubt that the disease had been aggravated by the splint, and that this exacerbation was stopped by its re- moval. It should be said that in six other cases where Thomas splints were applied nothing of this sort has oc- curred." The objections urged against immobilization are, to my thinking, without ground, and I believe with Mr. Thomas that the closer one can come to securing perfect rest the better the final result will be. It seems a rational theory he advocates, viz., that the movements to which a joint are subjected by muscular irritation, by strain or by jar, by in- flammatory products excited by blistering, or by any other means, contribute largely to the ankylosis so common in this disease. In our treatment by the expectant method or by extension splints, we caution the patient against falls or strains of any kind, knowing that these little mishaps are often the direct cause of an exacerbation, and knowing that an exacerbation means the extension by contiguity of the inflammatory process to the joint and to the periarticu- lar tissues. If this plan will secure a movable joint the inconveni- ences are as nothing. At all events let American surgeons give it a trial. CHAPTER XVII. THE TREATMENT OF CHRONIC ARTICULAR OSTITIS BY EX- TENSION APPARATUS, WITH OR WITHOUT MOTION. This plan is almost exclusively American, and to Ameri- can surgeons we are indebted for a large number of appli- ances, all of which claim these same principles. The one practical idea, however, to which all these splints tend is immobilization or fixation, with the associated idea of motion if desirable. The aim of all is to transfer the weight of the body from the articulation to the perineum or the axillae. Nearly all the forms of mechanical appliances for the hip possess screws of some kind that will permit motion or arrest motion. In the preceding chapter the apparatus described is not constructed with this idea of motion in view. Extension and counter-extension, unremitting and invariable, is what some of those who have constructed splints insist upon; while others, more rational in their ideas, modify those ideas according to the indications. A history of the evolution of the extension treatment is not pertinent to this discussion, as all text-books and all papers lead us up the different steps. The original Davis splint is not used now I believe by any surgeons, and hence I have not represented it in these pages. It has no pelvic band, and is inferior as an ischiatic crutch to the splint de- vised by Dr. Andrews, of Chicago. As a means of exten- sion, however, it served a good purpose. Better splints followed. Similar in principle and not so extensively figured in the text-books is the Washburn splint. It has no screws or ratchets, and the lower end fits into a piece of steel attached to the shank of the shoe, while the extension is made by means of adhesive strips attached to the limb. The tabs pass through holes in the shoe, and are fastened to buckles connected with the foot-piece. It is represented in Fig. 41. Dr. Bauer, of St. Louis, employs a splint consisting of inside and outside bars, with attachment to shoe. There TREATMENT OF CHRONIC ARTICULAR OSTITIS. 359 is no pelvic band to this splint. It is represented in Fig. 42, and is practically a combination of Andrews' ischiatic crutch and Davis' original extension splint. The splint just represented is different from that em- ployed by Dr. Hutchison, of Brooklyn (Fig. 43), in that the latter has a pelvic band, and a joint at knee, which can be fixed as desired. Both have the single perineal strap condemned by nearly all orthopedists, and both are attached FIG. 42. DR. BAUER'S SPLINT. FIG. 43. DR. WASHBURN'S SPILHT. to the shoe, being used only by day. The weight and pul- ley are used by night, however. Since Dr. Hutchison began the treatment by " physiological rest he does not employ splints so much; in fact, he says in his book his occupation's [as an orthopedist] gone. Before proceeding further it may be interesting to record a few points concerning extension that seem to be settled. i Traction does not produce any appreciable separation pf the head 9f the bone from the acetabulum, DISEASES OF THE HIP. 2. It does induce fixation and prevents concussion. 3. It relaxes muscles by overcoming reflex spasm. 4. Fixation is considered of far more value than pure extension. 5. Traction to be efficacious must be in the line of the deformity. Those who hold most zealously to the treatment known as extension with motion insist in the acute stage on fixa- tion, or " absolute rest to the joint," and yet all or nearly all admit that it is quite impossible to get abso- lute rest at the hip-joint. What is known as the long splint at the present day is the splint which bears Dr. C. F. Taylor's name. He it was who made certain modi- fications of the Davis splint, and nearly all who make modifications aim to meet certain indications not met by the Taylor splint. And yet Dr. Taylor confines himself less than do any of his followers to one form of splint. In the Boston Medi- cal and Surgical Journal, for March 6th, 1879, may be found a very fair enunciation of this gentleman's principles concerning the " me- chanical treatment of disease of the hip-joint." The two following pro- positions form the key-notes to his practice : "First. All organs while in a state of disease require rest from the performance of their functions in the direct ratio of the amount, quality, and intensity of the abnor- mal movements. Second. What is rest for an organ in one condition is not necessarily rest for it in another condition; that is to say, an organ, in a certain degree of /regressive inflammation, presents conditions essentially different from the same organ in the same relative degree of inflammation in the retrogressive stage." What he understands by the "so-called mechanical treatment" is the working out to practical conclusions the FIG. 44. DR. HUTCHINSON'S SPLINT. TREATMENT OF CHRONIC ARTICULAR OSTITIS. 361 362 DISEASES OF THE HIP. indications which the above propositions furnish. He aims, in the first place, to overcome contracted muscles by extension and counter-extension. The splint is applied in the line of deformity, and with weight and pulley fastened to the lower end of the splint the traction is made. The patient, however, is placed on an inclined plane, with conveniences for adapting the angle to the amount of re- laxation gained. Fig. 44 represents the appliance, splint and all save the weight and pul- ley. The force exerted is the ex- tending power of the splint plus that of the weight, and varies ac- cording to the amount required to bring about relaxation usu- ally from ten to seventy pounds. The recumbent posture is main- tained from one to four or five weeks. In addition to the im- provement in posture gained this preliminary treatment, he claims, "relieves nervous de- pression, gives time for the pa- tient to accommodate himself to the novel situation, enables us to save the amount of his weight from the perineal straps, and by that amount increase extension and hasten the effects of treat- ment." Fig. 45 represents what is known in the shops as Taylor's splint with the abduction screw. It is not really the splint he em- ploys at present. The pelvic band is too long, and there will be seen other changes which cor- respond closely with the long splint represented in Fig. 46 and FIG. 46.-THEMoD.FTKD TAYLOR'S used by Dr. Taylor. Thismodi- SFLINT. fication is accredited to Mr. Reynders, and is described in Dr. Sayre's last edition as follows : " The improved parts are where the long rod is attached to the pelvic band. The long rod is attached at A to a re- volving plate, B, which is fastened to the pelvic band. TREATMENT OF CHRONIC ARTICULAR OSTITIS. 363 When the plate, B, is revolved (partly), the long rod moves forward and backward. From the point, A, the long rod moves from and toward the other leg, as shown by the dotted lines toward L. C is a screw terminating at D in a small square stem of steel, fitting to a key. This screw turns in and out of the revolving plate, B, and has at the end of its thread a little knob, which is a little larger than the perforation at the upper end of the long rod, so that, when the key is applied at D, and turned, the screw, C, will force the long rod in the direction toward L. In this manner abduction is made. At. F the long rod is divided into two parts; the lower part holds an endless FIG. 47. THE LONG SPLINT USED BY DR. SAYRB. FIG. 48. DR. SHAF- FER'S LATERAL SCREW. screw transversely, which is worked by a key, and rota- tion thus produced." . . Dr Shaffer has found the abduction screw insufficient for purposes of adduction, and has devised a modification, which is represented in Fig. 47- This "consists of two parts, A and B, joined by the lateral hinge, C. A, is fastened to the- pelvic band. The part, B, is attached DISEASES OF THE HIP, to the shaft of the splint. Through the everted lip, D, there passes a screw, S, which operates through a button (which revolves on a horizontal axis), and which is fastened into another button (also revolving on a horizontal pivot), in the part, A. By turning the screw, we can either ap- proximate the lip, D, toward the part, A (producing abduc- tion), or, by reversing the screw, we can separate D from A, and adduct. E, E, represent the screw-bolts by which \ FIGS, 49 ANB 50. D*. SHAFFER'S LATERAL SCRHW APPLIED TO THE TAYLOR SPLINT. the apparatus is attached to the hip band and shaft of the splint." In using this " screw to abduct, the ordinary perineal pads, which form the basis of the counter extension, will also be the point of resistance. When we use the screw to adduct, it will be necessary to supplement the perineal with shoulder straps, and to apply a little more extension than is re- quired, so that, as we use the 'lateral screw,' the extra force may be transferred to and lost upon the shoulder." Dr. Judson has aimed to correct certain defects in the splint, defects which many surgeons of large experience TREATMENT OF CHRONIC ARTICULAR OSTITIS. 365 have encountered. The principal defect is this, viz., " the straps which are fastened to the adhesive plasters at the lower part of the apparatus, for the purposes of extension, become relaxed whenever the patient assumes the erect position and throws his weight upon the limb" (Judson). He argues that the cause of this is due to a too lightly- constructed upright, a pelvic band on too high a plane, and perineal straps too flexible. The points are argued in detail in the Medical Gazette, for December 10, 1881, and seem to be well taken. The apparatus used by him has a stronger or less flexible upright and pel- vic band than is commonly found in the long hip splint, and also a bolt and nut connecting the two parts, by the use of which they can be fixed at any angle desired by the surgeon. It is provided with suspending straps, buckled to the pelvic band in front and behind and passing over the shoulders, by which the plasters and the affected limb are relieved of the weight of the splint in walking. It also has a U-shaped attachment, made of steel, at the level of the lower part of the thigh, by which motion is more fully arrested than by a flexible knee-pad, as it serves to retain the limb more closely in FlG SI- _ DR . J ODSON 'S a line parallel With the Upright Of the U-SHAPED ATTACHMENT FOR BETTER FIXATION. splint. Dr. Taylor does not use the abduction screw, but employs a different splint when much adduction exists, i.e., after the preliminary recumbent treatment is completed. The or- dinary splint is so modified as to throw the weight of the body on the opposite side of the pelvis, and is called the "jointed supporting splint." The mode of applying the splint is as follows: Two strips of adhesive plaster the entire length of the limb, about four or five inches wide at the upper end and one third that width at the lower, are prepared by cutting into five tails, as shown in Fig. 52. From the centre tail a piece from four to six inches long is cut and added to the lower end for additional strength. Buckles are sewed to the lower end of these strips, and the whole thus prepared are laid against the lateral aspects of the leg, 366 DISEASES OP THE HIP. the lower ends beginning about two inches above the malleoli. The centre tails reach the entire length of the limb, to the perineum on the inside and the trochanter on the outside. The lower strips, or, tails, are wound spirally about the leg, extending up to the pelvis, and then the other two pairs are wound about the thigh in the same FIG. 5*. ADHESIVE STRIP PREPARED FOR APPLICATION TO LIMB. FIG. 53. THB PLASTER AS APPLIED. manner. This network of plaster is represented in Fig. 53. It will be seen that the thigh has at least three fourths of the attachment, and that the force exerted will meet with the greatest resistance here. Over this a roller is applied and the buckled ends are left out for the straps TREATMENT OF CHRONIC ARTICULAR OSTITIS. 367 at the lower part of the splint. A legging of twilled muslin provided with eyelets and laced up the inner side of the limb is a convenient substitute for a roller band- age. The stockings have holes cut through which the buckles pass, and the top of the shoe is cut off. The pelvic band is then applied, with the perineal straps buckled short in order to keep the band in a low plane. The shaft is then shortened a little, and the tabs are secured by the buckles. Traction is then made by the key, and the proper adjustment secured, and finally the knee-pad or the U-shaped attachment is applied. Fre- quently a leather strap is buckled around the leg and splint above the ankle. Dr. Judson uses traction to fix the joint rather than to oppose muscular contraction, and is satisfied with a moderate degree of traction, such as may be obtained by two vertical strips of plaster extending up the leg and thigh. He finds that the deformity of the active stages of the disease is reduced without special attention by the unconscious efforts which the patient makes during loco- motion to place the limb in a useful position. He be- lieves that the fixation allays inflammation, encourages repair, and relieves pain, and yet is not so inflexible as to prevent reduction of deformity, "which takes place spontaneously while the patient uses the perineal straps as an ischiatic crutch in locomotion." (Judson.) A high shoe is worn on the sound foot, and very fre- quently crutches are employed. I have seen patients un- der Dr. Taylor's care going about with this " combination method." Indeed, this name was given by Dr. J. A. Wyeth to a plan of treatment which he reported in the Medical Gazette, April 17, 1880. He combined the extension splint with the " physiological treatment," and claimed for this "combination method" advantages superior to all others. Dr. Sayre uses the long splint in larger children, or when his short splint fails to afford the necessary protection to the joints. When it is desirable to have a joint at the knee, and when it is no longer necessary to immobilize the hip-joint or take such precautions against injury in other words, dur- ing convalescence Dr. Taylor uses a splint represented in Fig- 55- " Th e lower steel plate is riveted to the upright, but the upper one is fastened by three 'keepers,' which DISEASES OF THE HIP. FIG. 54. THE TAYLOR SPLINT APPLIED. TREATMENT OF CHRONIC ARTICULAR OSTITIS. 369 enable it to be raised or lowered in adapting the instrument to the length of the leg. B is a foot-piece intended to rest under the foot inside the shoe. The broad band of leather C, is cut down at the top where there is a firm pad F terminating in the strap, G, which, when the instrument is applied, fastens in the buckle, H. The leather, C, has the H FIG. 55. thin metal plate, E, riveted to it to give it more firmness." (Taylor.) With the exception of Mr. Harwell's splint, those I have named comprise all the more common long splints now in use. The splint known by Mr. Barwell's name is not a pro- tective apparatus, and hence has not been employed, so far as I know, in this country. The aim with American sur- geons is to get the patient out of doors. Mr. Thos. Bryant, of Guy's Hospital, has devised a splint for maintaining the 370 DISEASES OF THE HIP. parallelism of the limbs. This, however, requires that the patient shall be confined to bed. Two years since I saw it in use in one of Mr. Bryant's wards, at Guy's, and this dis- tinguished surgeon pointed out to me many advantages. The patient was very comfortable and the limbs were in good position. Many of the leading English surgeons at the present day speak highly of the splint and treatment advocated by Mr. Hugh Owen Thomas. When patients must keep their bed and none of these modes of making extension are at hand, the prone couch described by Mr. Hugman in his treatise on Hip-Joint Disease, in 1856, affords a very simple method of securing extension. This consists of a horizontal plane about two feet in width, the length being determined by the patient. It is made " to extend from the top of sternum to the bend of the hip, and upon the upper portion of this is placed a movable chest-board which slightly elevates the chest and shoulders, and the whole is covered with a soft hair mattress. Depending from the horizontal plane, at an obtuse angle, is an inclined plane about four feet in length, covered also with a similar mattress, but divided along the centre, so that one portion (that corresponding to the F IC . s6.-D*. w IL LAR D 's SPUNT. ^ ffected side ) can be made to extend by means of a sliding framework; the movable por- tion is furnished with a padded leathern strap placed at its lower part. The upper and horizontal part of the couch is supported by two legs, the height of which is determined by the length of the inclined plane, the lower end of which rests upon the ground." (Hugman, p. 17.) There are several short splints, the best known of which is the one used by Dr. Sayre, and the one in fact which has TREATMENT OF CHRONIC ARTICULAR OSTITIS. 3/1 his name. A splint, however, which scarcely bears the name of an extension splint, is one devised by Dr. Willard, of Philadelphia. It has a single joint opposite the articulation so that the patient can sit down with comfort. It is rep- resented in Fig. 56, and is made of leather over a cast. The principle on which it is made and fitted to the body is about the same as that of the Vance splint, on page 345. After it is moulded and has thoroughly dried the pelvic and thigh por- tions are separated, and connected again by a joint attached to two spreading steel arms, as seen in the figure. A mortise, or, slot is made in the thigh section, and into this slot fits a bolt with a knob or head, by means of which it can be worked through one's clothing. It is only a fixed apparatus when the patient is standing and when the bolt fits into the slot. Dr. Willard says it is applicable to a limited number of cases, i.e., those in which the inflammatory symptoms are not acute. It is always used in connection with crutches and a high shoe. The Sayre splint is applied by means of adKesive plaster and buckles in very nearly the same way as the long splint is applied. For many years there was no pelvic band and only a single perineal strap. The present one is a decided improvement on the one figured in Dr, Sayre's last edition. The one he now employs consists of a pelvic band partially encircling the body. The upright is attached by means of a ball-and-socket joint, and is divided into two sections, one running with the other and controlled by a ratchet and key. At the lower extremity of this inner bar are two projecting branches going over to the inner surface of the thigh. Cylindrical rollers with two buckles are at the lower en4 FIG. 57. DR. SAYRE'S SHORT SPLINT. 372 DISEASES OF THE HIP. and here the tabs of the plaster are fastened. My own objection to this short splint is, that it does not sufficiently protect the joint, and is not equal to the amount of ex- tension sometimes demanded of a splint. It is easily mis- applied, and I confess that I am far more familiar with its abuse than with its use. Dr. Sayre has borne testimony himself time and again to the failure on the part of practitioners at home and abroad, to fully understand its application; and until the in- troduction of the pelvic band and the two perineal straps ir- reparable damage to the joint could be done in a short time by its misapplication. Occasion- ally crutches are used. Noble Smith, in his work on the " Sur- gery of Deformities," speaks very highly of a short splint devised by Mr. E. J. Chance, of one of the London hospitals for hip- disease. Mr. Chance uses both the prone couch and the mechan- ical appliance. This appliance is so constructed that the joint can be fixed at any angle, and in case of deformity from muscularspasm the splint can be applied to cor- respond, while, by means of the controllable joint, the deformity can be overcome by degrees day by day. He appreciates the im- portance of fixing the pelvis and indeed the spinal column. To this end he employs an abdom- Fio.s8.-MR. CHANCE'S APPARATUS. j na j band wh j ch ig WQrn j fl CQn . junction with the splint, constructed as follows: " A pelvic belt, A, is adopted below the iliac crests. An upright bar, B, passes from this belt to the height of the shoulders, and terminates in a pad. From this pad pro- ceed straps, C, forming armlets, or, shoulder-straps. From the pelvic belt proceeds a stem, D, which is fixed by a leathern casing to the thigh, and the stem is movable by means of rack joints, E, in the direction of flexion and extension as well as abduction and adduction." See TREATMENT OF CHRONIC ARTICULAR OSTITIS. 373 Fig. 58. Mr. Smith speaks of Mr. Chance's treatment, in the same glowing terms that we Americans are familiar with. Indeed one would imagine Mr. Smith giving expres- sion to an opinion concerning some one of the splints that are constantly being devised or modified in our own coun- try. He speaks of " the almost immediate relief from pain which the patient experiences when the splint is ap- plied; and, above all, the good results which are ultimately obtained j have convinced the author of the excellence of Mr. Chance's plan of treating this disease." FIG. 59. DR. STILLMAN'S SECTOR SPLINT. Another short splint combining all the movements of the ball-and-socket joint, but with the movements under the control of the surgeon, has been devised by Dr. Chas F. Stillman, of New York. At my request he has furnished me with a description, a pretty full abstract of which I take pleasure in inserting. The aim of the apparatus is extension with or without motion and at any desired angle. It furthermore seeks to overcome the compensatory lor- dosis. This apparatus is very similar in construction and design to the apparatus last described. A sector splint (Fig. 59) is placed on the outer side of the 374 DISEASES OF THE HIP. thigh over the hip, and is employed either as a " bracket" or as a " brace," the difference being that the bracket is to be secured by plaster of Paris or some inflexible bandage which does not admit of removal, while the brace can be removed at pleasure. The sector splint, it will be seen from the figure, is com- FIG. 59. DR. STILLMAN'S SPLINT APPLIED. posed of two plates of perforated tin that partially encircle body and thigh; of two slotted arms connected at one end by means of a clamp, and each attached at the other end to one of the perforated plates, near which a sharp curve is seen to prevent undue pressure over prominent parts; and of a slotted sector attached to the slotted arms by three TREATMENT OF CHRONIC ARTICULAR OSTITIS. 375 clamps. This sector has been fully described by Dr. Still- man in the journals, and further description in these pages is unnecessary. To apply this bracket, first, several strips of moleskin adhesive plaster are wound tightly around the thigh just below the hip, and around the pelvis above the hip. Sec- ond, thigh, pelvis, and waist are encircled by the plaster-of- Paris bandage, which is allowed to partially set. Third, the bracket is applied over this plaster, the angle being fixed as desired, the clamps having been previously loosened and the slotted strips shortened as much as possible. Fourth, the bracket is now fastened by a few turns of the plaster bandage, and this is covered by a dry muslin roller to ensure cleanliness. When the plaster is set the whole constitutes the splint, and is represented in Fig. 59. Enough precautions have been taken to secure the desired amount of firmness, and the apparatus extends from axilla to knee, the underlying adhesive plaster preventing any slipping or sliding on thigh or trunk. To make extension the slotted strips are pushed away from the centre, thus increasing the distance between body and thigh attachments. The degree of extension gained is secured by the clamps on the slots. By means of the clamps on the sector fixation may be secured, or motion may be allowed and extension be main- tained at the same time. Dr. Stillman combines this plan with the crutches and high shoe. The advantages he claims for his splint are: i. Local extension of the joint diseased; 2. Fixation at any angle with or without extension; 3. Motion with or without extension; 4. Gradual reduction of the flexion; 5. Opportunity for local inspection and topical applications. When a brace is desirable and, by reason of the unclean- liness of plaster, it is desirable to do away with this mode of application whenever anything different can be afforded a removable apparatus has been constructed by Dr. Still- man, and is represented both in back and side views in Fig. 6 1. The back frame here represented is provided with abduction, rotation, and flexion clamps for overcoming the obliquity of the pelvis. A rotation joint on the side of the brace below the hip is also provided for the correction of inward and outward rotation. The apparatus is attached to the thigh and trunk in the usual manner by straps and girths, and if additional DISEASES OF THE HIP. extension is desired a perineal strap is attached above and an adhesive plaster noose below the joint is added. Still another short splint is used by Dr. M. Josiah Roberts, who has kindly placed a description of the same at my disposal. FIG. 61. DR. STILLMAN'S BRACE FOR HIP AND PELVIC DEFORMITY. The instrument consists of a pelvic and a femoral seg- ment. The former is made of very thin sheet steel covered with leather on the outside and thoroughly upholstered on the inside. It is broad, and to secure a good fit he moulds it over a plaster cast of the patient's pelvis. The latter TREATMENT OF CHRONIC ARTICULAR OSTITIS. 377 (the femoral segment) is composed of two compound side-bars, which extend down along the thigh upon the inner and outer aspects, and are constructed with special reference to exerting continuous elastic linear traction upon the thigh. The mechanism by means of which this is ac- complished can be understood by reference to Fig. 62. Two side-bars are here represented; one is provided with expanded margins which have been turned over so as to perform a shell through which the other slides. The upper or proximal end of the shell is converted into a rectangular loop which completely closes over the sliding bar, ,:-'., and upon this a brass pin, A, is soldered. The lower or distal end of the sliding bar is |j likewise provided with a brass pin, B. Any force which brings these two pins nearer together must of necessity lengthen the instrument, as shown by the dotted line in the figure. It must also as a consequence exert a traction force upon the limb to which it is attached. In order to make this traction force elastic, or, in other words, like manual traction a narrow strip of strong elastic webbing provided at one end with a buttonhole is slipped over the brass pin at A. To the pin B, which is screwed into the opposing end 'of the other bar a buckle is attached. The instrument having been applied and screwed into position, with the brass pins at the greatest possible distance apart, we can by means of this strip of webbing and the buckle exert any desired amount of elastic force. By doing this the op- posing ends of the two bars are approximated and the instrument is thus lengthened. It is in this way that the traction force is graduated. By substituting a non-elastic strip for the elastic one fixed or rigid traction could be maintained by the same mechanism. The distal ends of the side bars are fixed to a metallic band which en- circles the limb just above the knee. This band is secured in position by means of strips of strong adhesive plaster placed longitudinally around the thigh with their lower ends turned up over it (the band) and retained in position with a roller bandage. The lower ring is thus prevented from being pushed down over the knee when traction is made as above described. At X (Fig. 63) a simple hinge-joint connects the outer side 378 DISEASES OF THE HIP. Fia. 63. DR. ROBERTS'S SPLINT. TREATMENT OF CHRONIC ARTICULAR OSTITIS. 379 bar with the pelvic segment. A like joint is found at the prox- imal end of the inner side bar at its junction with the peri- nea.1 strap. These two joints permit, it is claimed, articular action at the hip during locomotion and in changing from the sitting to the standing posture or the reverse. By con- tinuously exerting elastic traction, it is further claimed, artic- ular motion becomes possible without inter-articular pres- sure or friction, and without giving rise to the slightest dis- comfort to the patient. Under these circumstances Dr. Roberts thinks it is evi- dent that the condition of the joint more nearly approxi- mates that which we find in health than it would were it fixed. The Doctor argues that in this way we avoid the depreciating influences which prolonged immobilization of an articulation necessarily has on the local nutrition, that the circulation through the limb is facilitated, that we get the maximum amount of nutrition in the joint through the agency of which a favorable temperature is sustained for the growth and development of adjacent parts, and that repair in decayed tissues can the more readily be promoted. Passing over the joint anteriorly at X is a semicircular rod upon which a coiled steel spring is placed, the action of which is to oppose flexion of the thigh on the abdomen. An adjustable nut on the curved rod furnishes the surgeon with the means of exercising his discretion as to how much motion at the joint shall be permitted. The splint as applied is represented in Fig. 63, and it will be seen that no other joints save the one diseased are restricted in their normal movements. The sustaining power of this apparatus lies in its elastic attachments, and not in the steel bars which compose the framework. The office of these bars is only to give direction to the force ex- erted by the elastic side-straps. This principle enables the Doctor to construct the splint of such light material that it is easily portable and equally durable with the heavier iron and steel appliances. Another advantage he claims is that it does not interfere with the impact of the foot upon the ground during locomotion, thus preserving the foot sense, which is of the greatest possible advantage to the patient in averting sudden jars and traumatisms. To still fur- ther reduce the effect of jar incident to locomotion he has his patients wear soft rubber heels in their shoes. To recapitulate the advantages claimed by its author for this splint. 380 DISEASES OF THE HIP. 1. It protects diseased areas from traumatism. 2. It furnishes sufficient artificial support to counterbal- ance the loss of power on the part of the affected member. 3. It places the movements of the diseased articulation absolutely under the control of the surgeon at all times. 4. It permits inter-articular pressure. 5. By its use we can maintain the general and local nu- trition at the highest possible standard for the purposes of carrying on the repair of the diseased tissues. 6. The nullification of reflex muscular spasm. 7. Its easy portability. 8. Its non-interference with the performance of the func- tions of healthy joints. I have given at some length many of the forms of appa- ratus now in use, their construction and their claims, and with so many in vogue one wonders why it is that we have any imperfect cures in our midst. The fact remains, how- ever, that children do get well with stiff and deformed joints, that many are subjected to various operations, and that many die of the disease, notwithstanding they have been subjected to both the mechanical and the expectant treatment. It is also a significant fact that go where you will some one tells you of a friend or an acquaintance who has had " hip-disease," and when you begin to inquire about the result, you will hear of a short limb, a stiff joint, or an enfeebled constitution. You will hear further- more that the patient was under Dr. A's care or Dr. B's care a number of years, but that Dr. C or Dr. D had the patient first and this accounts for the result. I am well aware that patients are neglectful, that they tire of this treatment or of that, and that they fall into the hands of charlatans both in and out of the profession. Still my claim is that we should know of more of those fine results claimed. In other branches of medicine men publish results of cases, publish statistics of cures, and yet one has to look through a vast field of orthopedic literature to find good cases, and when he does find them they are often so im- perfectly recorded as to be unfit for statistical purposes. What then does the treatment of chronic articular ostitis of the hip by splints accomplish? In the paper of Dr. Taylor's from which I have already quoted there occur some representative cases. One was in a boy four years of age who had a slight halt in his right leg. A history of a traumatism was obtained, and the first TREATMENT OF CHRONIC ARTICULAR OSTITIS. 381 exacerbation followed immediately on the accident. This subsided, and Dr. Taylor saw him some weeks afterward. The difference in the motion of the two joints was very slight. The case did not come under treatment, and three months later another exacerbation more severe than the first came on, and the Doctor was again consulted. Treat- ment was again postponed by the parents. The case was at that time advancing into the second stage. Three months later abscess had appeared, and the patient was harassed by another exacerbation still more acute and still more persist- ent. At this time the deformity in flexion was very great. Treatment was now accepted, the splint was applied, the recumbent position was assumed, and the weight and pulley were attached to the distal end of the splint over the inclined plane. The extension force employed was thirteen pounds. This stage of the treatment was persevered in for three months, the abscess being opened in the meanwhile and discharging copiously for two months. On leaving the bed the joint was well protected by the splint, and traction both day and night maintained. During the next five months the long splint was worn, the sinuses caused very little discomfort, the limb was held in good position, there was a tolerable mobility of the joint, and the general health of the patient was very good. Later the "joint-supporting" splint was applied, say twelve months after treatment was begun. At the end of another twelve months he was discharged cured, and the report reads: " He does not limp. There is a slight difference in the lengths of the lower extremities, but not enough to be noticeable in his locomotion. He is directed to return frequently during the next two years for examination." Another case is reported. This was in a girl seven years of age who had manifested the first signs of a bony lesion at the hip some nineteen months before coming under Dr. Taylor's care. The treatment during fifteen months of this time had been by weight and pulley, and there was no pain from the beginning nor any during the whole time she was confined to the bed. Her general health too had continued good during this long period ofconfinement. The deformity was very slight, yet there was limited movement at the joint. It required two weeks in bed with the extension splint to completely relax the muscles. Then the long splint was worn ten months, when the patient was discharged perfectly restored. Two years later he examined the girl, 382 DISEASES OF THE HIP. finding that " the child has been going about like other chil- dren; there is perfect motion at the affected joint, and no discoverable difference between the affected joints, and no discoverable difference between the functions of the two limbs. Both trochanters are on the same level." Still another case is reported with an equally good result. I have now under observation a case that came under the same treatment about eight years ago with such a deformity as the first one reported had. It seemed to have been a genuine case of bone disease that had not yet resulted in abscess. This patient had eight years of faithful treatment, going through all the stages of the same, and to-day the hip is stiff, the angle of deformity is about 150, there is one inch real and two and a quarter inches practical shortening, and the case would not make a good one by which to illus- trate any special form of treatment. The following statistics from Dr. Taylor's papers are in- teresting, and I incorporate his report with much pleasure: " Leaving out of consideration all cases whose histories, subsequently to their treatment, are unknown or in doubt, I find that there remain ninety-four private cases of hip- joint disease which were under personal observation and continuous treatment from the time they applied until they died or were cured, and whose present condition is now, or was very recently, a matter of personal knowledge, for no case whose ultimate fate is not positively known deserves a moment's consideration in any estimate of the probable value of treatment for the hip-joint. Of the ninety-four cases three died, two of the disease, and one was run over and killed. Among them there were twenty-four with suppurating joints and discharging abscesses, nearly all in that condition when first applying. Of these twenty- four with abscesses, two died, the same as stated above, and in five the discharge has not yet ceased. Deducting these seven, there remain seventeen fully recovered, or seventy per cent of the suppurating cases. Three of the seventeen recovered cases have ankylosis, and fourteen re- covered with practicable joints the majority with ample and some with perfect motion. The ratio of motion to ankylosis, in the cases recovering after suppuration more or less extensive, is as eighty-two to eighteen. In two of the cases still discharging ankylosis is progressing favor- ably, and in three there is excellent motion, and, except for the slight discharge remaining, they would be among our TREATMENT OK CHRONIC ARTICULAR OSTITIS. 383 best cases. The joint motions are nearly perfect, and the joints themselves are apparently well, the present discharge being supported undoubtedly, as it so often is, by eccentric periosteal excoriations. In such cases nothing so tends toward recovery as the action of the muscles contiguous to such eccentric implantations. " The above enumeration includes all cases of the class previously specified for the nine years preceding Novem- ber, 1877, but excludes the cases received since that date." In view of the fact that the term hip-joint disease with Dr. Taylor is not synonymous with chronic articular ostitis of the hip, these statistics are not as valuable as they might be if only cases of true bone disease were embraced in these ninety-four private patients. During the past year I have, through Dr. Judson's kind- ness, had an opportunity of examining with him three pa- tients whose cases he reported in the Illustrated Quarterly of Medicine and Surgery, No. 2, 1882. The cases are, I think, classical in the literature of mechanical surgery, and I feel justified in reproducing them, in abstract, in these pages. No. i was a boy aged six, and presented, when Dr. Judson saw him, an enormous abscess with all the usual signs of the third stage of the disease, which was of nineteen months du- ration. The abscess opened spontaneously the same day on which he was examined. The general condition was bad, the limb was strongly flexed and adducted, and the slightest at- tempts at motion elicited screams of pain. It was found that the same case had come under my own observation only a month before the above notes were made, and in my rec- ords I find my own notes corresponding very closely with Dr. Judson's. I find also this significant remark, that the boy had been under the splint treatment for twelve months by a distinguished orthopedic surgeon, in conjunction with the family physician, and that the parents were very much dissatisfied with the combination. Six days after Dr. Judson saw the case the long splint of Dr. Taylor's was applied and the patient was about the house daily from the very beginning of treatment. The de- formity disappeared in due course of time. The progress was slow, abscess followed abscess, until finally there were nine sinuses about the joint, all leading to carious bone. Five extended in a line down the outer side of the thigh from the trochanter to the middle third of the thigh, and from one of 384 DISEASES OF THE HIP. these a fragment of bone extended. There were well-marked exacerbations from time to time, but these were not of a very painful nature. Some of the sinuses closed in time, the adhesive straps were finally removed, and for several months the splint was suspended from the shoulder and he walked upon an ischiatic crutch. An elevated shoe on the sound limb was worn all the while. He was under treatment two years and five months, and his condition six months later was as follows: "The limb is in good position, neither abducted noradducted, and flexed at a slight angle sufficient to allow him to sit comfortably, and yet not to interfere with locomotion. The motions of the knee are perfect. He walks with firmness, runs rapidly, and never uses a cane .... an inch of shortening .... absence of motion at the joint The cicatrices are firm, deeply depressed, and in some instances attached to the bone beneath." Three years and six months afterward his condition was reported: A point of moisture simply, at the upper end of scar over tuberosity of ischium ; atrophy of thigh, two and three- quarter inches ; of knee, three-quarters of an inch ; of calf, only a half-inch. The position of the limb was 150 in flexion and about 15 in adduction. The real shortening was one and a quarter inches, the practical, two and a half inches, with no attempt at arranging the limbs symmetrically. The knees were equally flexible. No. 2 was a girl three years of age, with a tuberculous family history. The disease involved the right hip, and had existed at least one year. An immovable dressing of plaster of Paris and subsequently a long splint with a sin- gle perineal strap and applied without adhesive plaster, had been her previous treatment. When the patient came under treatment at the hands of Dr. Judson there was marked adduction and flexion of the thigh, characteristic of the third stage. For several weeks previously she had suffered from intense pain and suppuration was suspected. The treatment was the same as in No. i. The pain soon abated, the position of the limb improved, adduction giving place to abduction and the flexion being materially dimin- ished. Abscess formed, nevertheless, and was opened five months after the beginning of treatment. The sinus was followed in the ensuing eighteen months by five others, TREATMENT OF CHRONIC ARTICULAR OSTITIS. 385 variously located about the joint, and the pus secreted was abundant and offensive. The mechanical treatment was supplemented by cod-liver oil, wines, and chalybeates. Exacerbation marked the approach of new abscesses, and some were noted for their high febrile reaction and emacia- tion, threatening a fatal termination. Mechanical treatment was continued for two years and seven months. Strong traction was used during the first half of that time, and during the latter half the apparatus was applied more loosely, and for several months it was worn only in the day- time, as an ischiatic crutch merely. Eight months after the removal of the splint her condi- tion was reported as follows: Her health is perfect, and she is able to walk and run without assistance of any kind. The position of the femur is favorable both for walking and sitting, there being no abduction or adduction, but a moderate degree of flexion, and the shortening is only one fourth of an inch, evidently due to a diminution in all the measurements of the limb. When she walks slowly it is difficult to perceive any limp- ing, although the motions of the joint itself are so slight as to be of very little if any advantage in locomotion. It was two years and four months after the above note was made that I saw the child with Dr. Judson, and we found her still in good health and very active. Her short- ening as measured from the umbilicus with no attempt at symmetry was one and a half inches ; measured from the anterior-superior spinous processes it was a half-inch without, and a quarter of an inch with, an attempt to place the limbs symmetrically. We could not detect any motion at the hip, and her angle of deformity was 160 in flexion, with about 5 in adduction. She was not able to button and unbutton her shoes in the natural way. No. 3 was a boy who was seven years old at the time he came under treatment, and had suffered from the disease for four years. He had worn a light hip splint, and to this Dr. Judson attributed his lack of progress. The reporter states that the usual signs of the third stage were present, without stating the degree of the deformity and the con- sequent inconvenience in locomotion. An abscess was, however, already recognizable. He had the same line of treatment as was adopted in the two cases just reported. Suppuration progressed, however, and finally, after great distension of the parts, four sinuses were established, one of 386 DISEASES OF THE HIP. which was in the groin and one above Poupart's ligament. "The severity and persistence of the symptoms, the num- ber and position of the sinuses, the long continuance and often offensive nature of the discharge, and the character of the resulting cicavlices, of which two are attached to the bone, clearly show that the case was one of destructive ostitis and disorganization of the joint." And such was his history. At the end of a year repair began, and the fix- ation of the joint was no longer necessary. Up to this time he had persisted in the use of crutches. These were now laid aside, but the splint was worn for three years longer. Eighteen months after all treatment was dis- continued he was an active robust boy, taking long walks to and from school, was a good skater, and when he walked slowly there was no perceptible defect in his gait. There was a half-inch shortening, limb was in good position, /.