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• • • • 

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3(^1'^ 



4COPYRIOHT, 188S, 

Bt BERMINGHAM & CO. 



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OUT OP 

GRATITUDE TO A FRIEND 

AND 

ADMHUTIOM J^R AN lONORF.I) MEMBER OF A PBOrB88ION 

WHICH RECOGNIZEH HIM A8 

an 3(uti)0i4tp 

IN 

THREB DISTINCT BRANCHES OP MEDICINE, 

THE WRITER DEDICATKH THIS VOU'ME 

TO 

C. MACNAMAUA. IJU'.S., KXC. 

SURGEON TO AND LKCTrRKR ON Sl'ROKUY AT TIIK WKSTMIVSTEK H()SIMTAL>, 

SURGEON TO THE KOYAF. WESTMINSTER «»1»HTHAI-MIC HOSPITAL 

SURGEON MAJOR U. M. INDIAN MEDICAL SERVICE. 



5fcir 



iCopnuQBT, IS8S, 

Bt bebui.nghau a CO. 







SRATITUOE TO A FRIEND 

ran IH ^ONOHKH MEMBUI OF 
WBICH RKCOOMlZItS HIM t» 

an Slittt)oelts 




PREFACE. 



For nearly thirteen years I have resided in the Hospital 
lor the Ruptured and Crippled, all of my time beingdevoted 
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 
o( " hip-disease" alone have been treated, and a very large 
proportion of this number have been under my own ot> 
servalion. 

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 withont any bias, and it is seldom that any interpreta- 
tion even, of these ciianges 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 



I 



i 



iv 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. 

23 Park Avenue, New York, 
November, 1883. 



CONTENTS. 



CHAPTER I 

Introduction. 

PAOB 

The present status of therapeutics — Classification — Method of ex- 
amination — Schedule for final results i8 

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 — DiflS- 
• 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 CoXiE Senile). 

Pathology — Cases illustrating clinical history — Diagnosis — Treat- 
ment S5 



6 CONTENTS. 

CHAPTER VI. 
Coxo-Femoral Periarthritis. 

PAGS 

Pathology— -Fibrous periarthritis not considered — Coarse of disease, 
with cases — The diagnosis and its importance — Lesions from 
which differentiated — Simplicity of treatment 94 

CHAPTER Vn. 

Bursitis of the Hip. 

Bursae 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 curt — 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 o^ chronic ostitis — ^Value of 
Ae prbbii--Pi:ognosis 153 

II. Malignant Disease of the Hip. 

The ttost common form — Period of life for periosteal sarcoma- 
Importance of early diagnosis — Fatality 161 



CHAPTER XL 
QlKONIc Articulas. Ostitis o 



DiScrcDt views — The paiholof^ 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. 



Opposing views — Definiiion 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 f— Deductions » 



CHAPTER XIII. 



CuNiCAL HisTOsv Ji 



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 
patboloGical — Tubercular meningitis — Lardaceous degeneration. aa7 

CHAPTER XIV. 
Diagnosis of Chronic Articular Ostitis. 



Possibility of determining initial lesions — Diseases from which to be 
differentiated — Detailed account of each — Cases illustrating 
dlfficultyof 363 

PAST II.— THE SBCOND STACK. 

Perinephritis — Primary perityphlitis — Cariei of vertebra! — Acute 

epiphysitis 306 

Traumatic dislocation — Caries of pelvic bone — Definition of rheo- 

■n«li»n' 316 

CHAPTER XV. 

The Treatment of Chronic Articular Ostitis — General 
Considerations. 

Modes of treatment — Nature's cure — Is it the best ? — The expectant 

treatment — Definiiion — Typical cases — Results— Claims 339 



J 



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. 

PAGB 

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 — Siillman'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. 



PIG. PAGB 

1. Burss 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. Li^amentum 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 Hip- 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 

i^. 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 30S 

32. End of the Second Stage 30S 

33. Articular Ostitis of Both Hips 335 



lO TABLE OF ILLUSTRATIONS. 

PIG. PAGE 

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 39g 



• 



THE HIP AND ITS DISEASES. 



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 ihe 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- 
malism. 

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. 




J 



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 llicm 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 witii apathy, on the mechanical treatment of dis- 
eases of the hip. 

On the other hand, it is ;i 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. 1 shall feel that some good 
will have been accomplished if 1 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 wliich 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 
ivork is unfortnnatelv not found in many American libraries 



THE INTRODUCTION. I9 

I make no further apology for the reproductions lobe 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 s^'s- 
lem is in a poor or vicious state of nutrition. Under such 
circumstances sprains and contusion often lead to grave 
joint lesions. During a convalescence fi-om 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 nenro!ogj% 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 neuromimesjs, and of the old 
Brodie-joint. These all depend on some altered condition 
of the spinal nerves, and their recognition saves much valu- 
able lime to the patient. These are the cases that " go the 
rounds." sec all physicians, and aie finally cured either by 
heroic treatment or by the magic touch. 

It is quite true that neurological science is furnishing 
much thai 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- 




1 



20 



DISEASES OF THE HIP. 



matism among the diseases of the hip. All of us are 
taught to look with a (Jeep 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 — the malum 
coxae senile of some authors — 1 fear I have not been suffi- 
ciently explicit. Many of these cases I have had an oppor- 
tunity of examining, and have made myself fiftniliar with 
their clinical history; but I have not had the treatment of 
the same, because the iiospitai with which I am connected 
is exclusively for children. Still, from a study of a few 
that I have seen under treatmeut and reported in current 
literature, 1 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. tThe 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 clironic bone disease in tlie neigh- 
liorliood 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 oflameness long prior to the develop- 
ment of ihe^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 ray reading goes, been honored with a special chapter 
in works on joint disease. The impetus given to the study of 
the bursfe 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 buVsa, The 
whole subject is to me an extremely interesting one, and 
the few cases 1 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 struct uresthe 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 



I 
i 



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, for all 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 mv own cases 



THE INTRODUCTION. 23 

correspond very closely with those lie lias reported. It is 
to liim 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 
wlieti 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- 
lerial. and in my intercourse with my orthopedic confreres 
in this city I found very little to help me in my study 
The cases seemed lo have drifted into my hands, and I knew 
of only one that had come under the observation of another 
practitioner in this speciallv, 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 (2 
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 lo 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, at 
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 lo the lesion of 
llie 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 
lerm 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 



1 



24 



DISEASES OF THE HIP. 



slitis induces a. peri- 
3 ilie subject from a 



the periosteum and where a peripheral o 
ostitis, these cases would add nothing ti 

therapeutic standpoint. These conditions are lound 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 lo 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 rai-e affection, I would say that it 



THE INTRODUCTION. 



25 



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 
ihem 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 lis 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 

f rowing veryskeptical concerning sympathetic hips. Siill 
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 
astrumousdiathesis; if not hereditary, then acquired. Given 
then this strumous diathesis, this cachexia, this evidence 
of malnutrition, it is very easy for a concussion to induce a 
hypersemia of the centres of development, which hyper- 
aemia under certain conditions will result in infiammation. 



1 



DISEASES OF THE HIP. 

It is also well established that these foci of disease can 
originate wiilioiit even a fall as exciting cause. 1 am 
willing, then, to admit that falls which induce a concussion 
in young children or sprain or contusion in oldei- 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 
I am sure that all unbiased obser^'ers 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 
nelieve that I can certainly do justice to the clinical history. 

Thesilbject 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 
•s given a place. 1 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 
Jeaving 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 



I 




THE INTRODUCTION. 27 

Strictly physiological. The liip is well fixed, it would seem; 
though recent writers whi) 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 tiiat is as yet unsettled. The object is, 
[ take it, to bring about ankylosis in the best position. 
This is what many of the splints do, anti 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 1 have not given all the forms in common use it is 



becau: 
splints I ki 



of I 



limited tin 

e pictured in catalogues, but 



)llect. Many 
I longer 



The chapter 
drilling in the e 



n operative treatment has been devoted to 
_ irly 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 impoi-tance 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 tliat can be discovered 
only when the patient is divested of all clothing. The 
lape-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 lind that in recording 
angles the supplement of a right angle is used when the 



38 



DISEASES OF THE HIP. 



deformity is less than go". The starting-point is taken 
from the (iircction 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 : 

1. 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, usefulmss of limb, abscess, pain, etc. ii. Previous 
treatment: each method, and duration of same. la. 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, (b) Atrophy. 
((■) Mobility in angles: flexion, extension, abduction, adduction, 
rotation, (d) Position of limb, (e) usefulness of limb. 
We have aimed to make our exammations in conformity 
with these questions, and aj-e accumulating some valuable 
material. 

To gel 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 jy«- 
wrfrtVa//)' 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 N^laton'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. 



29 



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. 3I 

Looking, then, at a naturally formed hip one must learn 
by observation ihe contour of the parts, the appearance of 
the skin, the folds and dimples into which it is thrown, 
while the subject assumes different attitudes. An 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; Ihe supra-trochanteric dimples, or depressions, which 
varj- 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 
lo 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 
10 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 cur\-ilinear 
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 ihe parts 
already mentioned, but the eye will take in at a compara 
live glance the position of the trochanteric prominences — 
the sacral region, ihe ilio-costal spaces, and their relation- 
ship to the crista ilii, the size of the thighs in the upper 
third and, indeed, alt the regions immediately connecied 
with the hip. Soon one learns 10 observe all this at a 
glance, and easily detects any departure, however slight. 
from the law of symmetry. 



32 



DISEASES OF THE HTP. 



Tolooklhrough the inlegumcnt 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'gluteai 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, pracjically forming a single muscle. Their attach- 
ments are extensive, and hence their importance. If disease 
involve the bodies of the lower vertebrse 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 extcrnus 
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 siraultaneonsly, 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 



f 



quadratus femoris. If the iimb be extended the gluteus 
assists in adduction, if fJexed the exlernal obturator assists, 
and if extreme outward rotation is completed or'prevenied, 
then the quadratus acts as an adductor. 

The Abductors. — The muscles which support the pelvis 
on one thigh — the gluteus medius and ghueus minimus 
arc strong abductors, and their most powerful aclion is 
displayed when one limb becomes ihe 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- 
lineus and the three adductors; on the inferior and posterior 
aspect the obturator externus. Posteriorly are the quad- 
ratus femoris, the gemelli, the obturator intemus, Ihe 
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 



7^0 Special. 



Psbas Magnus. 

■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. 

( Gluteus Maximus. 

T/ir^c Special. \ Gluteus Medius. 

( Gluteus Minimus. 

" The long head of the Biceps. 

r, M Semitendinosus. 

Four Accessory. So- u 

■^ I 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. 

r Adductor Longus. 
Three Special, \ Adductor Magnus. 

( Adductor Brevis. 

r Pectineus. 
I Gracilis. 
Five Accessory, i 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 



tnuscles in this group except the quadratus femoris, while 
the adductor niiignus gets additional branches from the 
great sciatic. The supply of the pectineus has already been 
given. The quadralus femoris gets its entire supply from 
the sacral plexus. 



One Special. — Tensor Vaginae Femoris. 
( Gluteus Maximus. 
Three Accessory. \ Gluteus Medius. 
( Sartorius. 
Nerve supply : The tensor vagina femoris derives its sup- 
ply from the inferior branch of the superior gluteal, one of 
the important divisions of the sacral piexus. T!ie 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 ROT J 



Six Special. ■ 



rilio 



Pyriformis. 



E Addu. 



IThe Thre 
Pectineus. 
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. 

Oru Special. — Tensor Vaginte Femoris. 
Two Accessory. ] q j , 



Fibres ofthe Gluteus Medius. 

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 
ihe 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 lo 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, sarlorius, gracilis, 
semi-tendinosus, and quadriceps, while the tensor vagina: 
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 fascite. 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 Pouparfs 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 Anally in the capsule of the hip- 
joint. 

THE BURSiC ABOUT THE HIP. 

The synovial bursa in this region are nine in number, 
and subserve an important function. They consist of a thio 
wall of connective tissue partially covered by epithelium, 



I 



THE ANATOMY OF THE HIP. 



a viscid fluid. Naturally they enhance the free- 
dom with wliicii muscles move over bony prominences and 
tendons, One can readily see how imperfectly these muscles 
act when their underlying bursie are not in perfect con- 
dition. 

Figures t 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 from of thejoini, and 
it often communicates xvilh 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 frcmt por- 
tion of the trochanter rtiajor 
there isa small bursa (1, Fig. i). 
It extends quite a distance be- 
tween the tendon of tins muscle 
nad that of the pyriformis. 
Occasionally two bursse in- 
stead of one are founid ; one 
between the tendon and the 
hone and the other between 
the Icodon and the pyriforniis. 

A bursa {F, Fig. 1.) of larger 
size than the precedinglies be- 
tween the tendon of the gluteus no. 1, 
minimus and the front of the a. 
irochanter. sometimes extend- 
ing between this muscle at its 
insertion and the vastus 
Dus at its attachment. 

Lying in front of the gluteus I 
maximus, and between it and ) 
the vastus externus is a 
(J. Fig. 1) 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- 
(A and B, Fig. i), over which the dense fascia 
of the gluteus maximus play. 




us: D. TbcbiirutK 



. K. Glutcui muioigt; L, Vutiu (lur- 



Lcular bursa ( 
1 and the tcndoi 



38 DISEASES OF THE HIP. 

The remaining four bursEc are at the back of the joint \ 
and are arranged in the following order: 

An unimportant bursa situated between the external I 
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 la 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. 

1. TAe Capsular. This 

C™r'U''bu™1^ 's the enveloping struc- 

rM-SS'^^if-..^ t"/!^ of,^''^ hip-joint, 

nediui udprriicttmisi u'hich derives Its at- 

,ob!&S«mS^«"l tachmenis from the I 

Gs;ir™f...fiorrL;-„d-5"'s"'n«5?LSST;U^: V^^X.^^-^^^^tf'H 

DcciioQwiibhamMiinemutciHuthiirDrisia. Varying distance from 
the acetabulum, and 
from the femur about the junction of the neck with the 
shaft. 

a. The Cotyloid, a fibro-cartilaginous rim attached to the ' 
margin of the aceiabulutfi which it thereby deepens. 

3. The Teres, or round ligament, an inter-articular flat 
band extending from the acetabular notch, to (he dimple 
!n the head of the femur. 

4. Tht 7Va«jT^rj^, consisting of a strong flaliened band 




E. Buna bcLweeu elulei 

F. Pufifonni.; G. Gluts 

iac^um: J. Obiunisr 



THE ANATOMY OF THE HIP. 



of fibres crossing the notch at the lower part of the ace- 
tabulum, thus converting it into a foramen. 




... _ mujclw, strenatheninB 

MB«ile:B. lllB-feir— '" .<.-<' -^—^ .: ^ -.. . 

These ligaments are deserving of a more detailed descrip- 
tion, but they are quite fully described in the works on 
anatomy. 

The capsular (see Figs. 3 and 4) encloses the cotyloid, 
Ihe ligamentum-teres and the transverse, springing partially 
from the outer fibres of the last mentioned. The whole of 
ihe joint is within its folds and the varied movements at 
this articulation demand a large loose capsule. In its 
lower circumference it is attached in front to the spiral or 
anterior inter-trochanteric line, above to the base of the 
cervix femoris, and behind to the middle of the cervix, a 
lialf inch from iliif iiUf i--lioch;interic iine. Its great tliic .- 




40 DISEASES OF THE HIP. 

ness is in the upper and forepart of the joint where the 
greatest amount of resistance is required. Below it is thin, 
loose and longer than in any other part. The fibres run 
in two directions, a longitudinal and a circular. The cir- 
cular are collected into a band at the lower and posterior 
portion, where thev embrace the femoral neck, while in front i 




cspmie aiuchcd 



they expand and are interwoven with the deeper layers 
of the strongly developed longitudinal fibres and are by 
these concealed. The longitudinal are most distinct as 
thick bands, serving as accessory ligaments; for instance, on 
the anterior and superior aspects of the capsule, known as 
the Uioffmoral ligament (B. Fig. 3) while these fibres at ibe 
lower and posterior portion of the joint are known as the 
isthio-femgral (A. Fig. 4) passing from the furrow on the 



THE ANATOMY OF THE HIP. 



41 



ischium below the acetabulum to end in the circular band of 
fibres. In front likewise there is a band converging to the 
capsule from the ilio-pec lineal eminence to the margin of 
the obturator foramen and the obturator membrane, known 
as the pectineo-femoral ligament. 

The capsule is additionally strengthened by contact with 
muscles and tendons being thus supported on all sides. 
Some are closely connected with the ligament, and serve 
lo raise it during the movement of the joint, thus prevent- 
ing the ligament from being pushed against the edge of the 
acetabulum. 

The ilio-femoral band, {B. Fig. 3) traverses the joint in 
front, extending from the anterior superior spinous process 
of the ilium, to tlie anterior trochanteric line. This is 
called the Y-ligament of Bigelow, from its appearance on 
dissection. Near its centre is an aperture transmitting the 
transverse branch of the external circumflex artery as il 
passes to the joint. 

This accessory hgamenl or band limits extension and 
thus prevents the natural tendency of the trunk to roll 
backwards when in the erect posture, Muscular power for 
this purpose, then, is not required. 

Every position of extension, except when abduction is 
combined with it, renders the band tense- Adduction 
with complete extension, outward rotation even with flex- 
ure, and extension with outward rotation lender tense the 
whole ilio-femoral band. 

Very strong fibres make up the ischio-femoral band (A. 
Fig. 4) and pass in almost straight lines to their femoral 
attachment when the thigh is flexed; but when this mem- 
ber is extended the fibres wind upward in a zonular man- 
ner over the back of the head and neck of the femur. This 
portion of the capsular ligament does not limit simple 
flexion and is not made tight until adduction or rotation 
inwards is combined with flexion, otherwise it is quite re- 
laxed. 

The pectineo-femoral band — a narrow set of fibres pass- 
ing from ihe anterior border of the pectineal eminence lo 
the neck of the femur — is put upon the stretch in abduction, 
whether combined with flexion or extension, and is very 
taut both in abduction combined with rotation outward 
and flexion, and in abduction combined with simple flex- 
ion. 

A triangular space bounded by the ilio-femoral and the 



42 DISEASES OF THE HIP. 

pectineo-femoral bands and the pubic rim of the a^. 
tabiilum is the thinnest portion of the whole capsule, but 1 
is never tightly stretched in any position of the joint. The I 
ilio-psoas muscle, separated by a bursa which occasionally ' 
communicates with the synovial sac, passes over this space. | 

The cotyloid ligament is more properly called by Morris 
the cotyloid fibro-cartilage, varying in depth and thickness, 
nowhere more than a quarter of an inch from its attached 
to its free edge. It is yellowish-white, is convex on its 
outer surface, while its articular face is concave, contract- 
ing somewhat the aperture of the acetabulum, so that it 
retains the head within its grasp after the capsule and all 
the muscles have been completely divided. It is soclosely 
blended with the transverse ligament that it is difficult to ' 
speak of the two as distinct structures. 

In both of its aspects it is covered by the synovial mem- 
brane, which is reflected over its free edge from the cap- 
sule to the articular cai'tilage of the acetabulum. 

Mr. Henry Morris (Anatomy of the Joints, and Br. Md. 
Jour., Nov. 28,1882,) has given more study to the ligamentum 
teres (Fig. 5) than any one of the recent anatomists, and his 
observations certainly deprive this inter-articular band of 
much of the importance and mysleriousness with which it 
has heretofore been enveloped. 

The teres, at the acetabulum, has two bony attachments, 
one on each side of the notch, intermediate fibres springing 
from the under surface of the transverse ligament being 
continuous here with the capsular ligament and periosteum 
of the ischium. Its attachment to the caput femoris is in the 
anterior part (known as the pit) of the dimple of the head, 
and to the cartilage forming the margin of this part of the 
dimple. The ligament is from an inch and a-half to an 
inch and three-quarters in length, and varies a little in size 
in proportion to the thickness of the ischio-femorai band. 

The fatty tissue at the bottom o( the rough recess in the 
acetabulum forms a thick quadrangular cushion, occupying 
all the non-articular portion of the cavity, and projecting ■ 
outwards beneath the transverse ligament through the ' 
acetabular notch. The ligamentum teres receives the artic- 
ular nerves and arteries as they enter the cavity to be 
transmitted through the round ligament to the femur. ' 
The thickness of the synovial membrane in its reflection ., 
from this pad, or cushion, to the ligatnent, gives it the 
appearance of two triangular planes at right angles wltfi 



THE ANATOMY OF THE HIP. 



43 



each other. This interarticular band is shut out from the 
synovial cavity of the joint, and resembles in this relation- 
ship the lungs and the abdominal viscera. 

From Mr. Morris' experiments positive proof was ob- 
tained " that (i) the ligamentum teres is quite relaxed dur- 
ing extension of the thigh, and that, too, whether the body 
lies on its back, or is raised into the standing posture; {2) 
when abduction is combined with extension of the thigh 




^H on be 



there is no tension on the lound ligament; (3) the liga- 
ment is at its tightest when the limb is simultaneously 
flexed, adductcd, and rntated outwards, very nearly as 
light when the limb is fully flexed and rotated outwards 
without being addilcted, or fully flexed and adducted with- 
out being rotated outwards." 

He further concludes that it is not the prime function of 
this ligament to assist in supporting the weight of the 
body in the erect position, whether we stand on one leg or 
on both: and that it does not check jHlduction in the ex 



44 DISEASES OF THE HIP. 

tended or nearly extended position, as when standing at 
ease. 

It has been shown by the anatomist, Hyrtl, that the ves- 
sels which pass into the ligamen turn teres from without, vix., 
one from the obturator artery, and the other from the in- 
ternal circumflex, turn back in loops and do not enter the 
substance of the head at all. This observation has been 
confirmed by other anatomists, and we are led to doubt 
seriously whether it is the primary function of the round 
ligament to convey blood to the head of the femur. In the 
young subject, before the epiphysis is joined to the dia- 
physis, the head of the humerus and the extremities of the 
other long bones receive their blood-supply without any 
such round ligament, and in the adult the size 'and num- 
ber of the vessels entering the neck of the femur seem 
amply sufficient to nourish also the head of the bone. 

It is certainly not necessary to the perfection of the hip- 
joint in man, by reason of the perfect mobility and security 
of the joint in persons wlio have been born without tins 
ligament, and by the successful reduction of the iiip after 
dislocation. Its secondary importance as a controlling 
structure over the joint is further proven by the fact that it 
can be divided wit iiout causing the slightest jerk or change 
in the position of the limb so long as the ilio-femoral band 
is intact. Indeed, comparative anatomy teaches that this 
ligament is but the iijndon of the ambiens muscle. 

The SYNOVIAL MEMBRANE liues the capsule and encloses 
the ligamentum teres in the manner already described. 
Through an opening in the anterior wall of the capsule it 
sometimes communicates with the bursa lying beneath the 
psoas. This membrane is quite extensive, but is well pro- 
tected from injurv by reason of its folds and connection 
with the mass of fat in the basin of the acetabulum. The 
fluid contained within its cavity does not differ from 
synovial fluid in general, viz., either colorless, or of a pale 
yellowish tinge, so viscid that it is with difficulty poured 
from one vessel into another. Robin, as quoted by Flint, 
gives the composition as follows: water, 918. oo; synovine, 
(albumen) 64.00; principles of organib matter, not esti- 
mated; fatty matter. 0.60; chloride of sodium and carbon- 
ate of soda, 6.00; phosphate of lime, 1.50; ammonto-mag- 
nesian phosphate, traces. 

The Articclation.— The hip joint isa bftlt and socket 
joint, its class beinij iliartlKosis. and its peculiar subdivision 



THE ANATOMY OF THE HIP. 



45 



innominate 



being enarthrodki, 
ooiyloid cavity — tiie acetabulum — in whicli snugly fits the 
globular head of the femur. The articular poriion of the 
acetabulum is shaped like a horse-shoe, is covered with car- 
tiliigc, is broader above and behind than in front, and is 
occupied by adipose tissue covered with synovial mem- 
brane. The acetabulum is formed by the ilium, a little less 
than two fifths; the ischium, a little more than two lifths, 
and the pubis, the remaining one-fifth. The direction of 
this cavity is downward, outward, and forward, thus re- 
ceiving the head of the temur obliquely. At its deepest 
part the bone is so thin that light is transmitted, while the 
upper and posterior wall is very strong and very thick. 
The pelvic surface of the innominate bone corresponding 
to the floor of the acetabulum, presents a smooth triangular 
plane, from which the obtu- 
rator membrane and the 
internal obturator muscles 
arise. It is here that per- 
foration takes place inarticu- 
lar disease of the hip, and 
the course pus takes is well 
illustrated by the accom- 
panying diagram 1 have 
taken from Dr. Clipping- 
dale's essay on hip - joint 
disease, published in the 
Meiikal Fras and Circular, 
1882-1883. 

The circumference of the 
acetabulum is represented by 
a circle, the attachment of the 
obturator muscle by a dotted 
line. It is obvious that ;i per- 
foration of the acetabulum 
mustappearinternally inoneFio. 8.— Dijiamii BnnwiNG rm Coitmb 
of three positions: (a) On fj« Tutio* ..-. fhifuiutics otacet*!.!!- 
the obturator muscle; (b) in 

front of the muscle; (c) behind it. If the opening extend 
into the muscle the pus will pass along its substance and 
emerge with it at the small sciatic notch, and point upon 
the nates. A, in the figure, indicates iti course. If per- 
foration have occurred behind the obturator the matter 
will pass into the tschio-rectal fossa, and may be discharged 




I 
I 




46 DISEASES OF THE HIP. 

cither through the perineum or into the rectum. The arrow 
B, indicates the course taken. In most cases, however, ihe 
perforation takes place anterior to the origin of the muscle, 
and tlien the pus passes upwards through the slieath of 
the obturator vessels and makes its appearance in the 
groin. Arrow C, indiciiies tlie Lourse. 

The development of the innominate, as well as the de- 
velopment of :i]l bones entering into llie formation of 
joints, is of prime importance in the pathogeny of bony- 
diseases in the neighborhood of articulating surfaces. 

Ossification begins in the cartilage of the ilium just 
above the sciatic notch in the eighth or ninth week. Bone 
is deposited similarly in the thick part of the ischium be- 
low the acetabulum in the third month, and in the su- 
perior ramus of the pubis in the fourth or fifth month. The 
greater part of the acetabulum, the crest of the ilium, the 
tuberosity and ramus of the ischium, and the body and 
inferior ramus of the pubis are still cartilaginous at birth. 
Ossification from tlie three primary centres has, how- 
ever, extended into the margin of the acetabulum. It is 
not until the seventh or eighth year that the rami of the 
ischium and the pubis become completely united by bone. 
Then there is atriradiate strip of cartilage known as the 
cartilage in the floor of the acetabulum, which does not be- 
gin to be ossified until about the age of puberty. 

The head of the femur forms two thirds of a sphere, 
which is very smooth, being covered by articular cartilage. 
But for the slight bulging at a spot below the dimple for 
the round ligament it forms a part of a true sphere. The 
fossa for the ligamentum teres is below and behind the 
middle point of the articular .surface and it is only in the 
anterior part of the fossa — the pit — that the ligament is 
attached, while it lies in the posterior part — the groove, 
when in action, viz., flexion with outward rotation. The 
neck is cylindrical near ihe head, becoming flattened as it 
proceeds outwards. Its inclination to the shaft varies in 
the different periods of life. In aduit life the angle is 135" 
(Fig. 8). In early life it is about 135" (Fig. 9). The angle 
is not so obtuse in females as in males. As age advances 
it approximates a right angle. In bnoe disease there takes 
place also this change in the angle. The posterior and 
upper half of the great trochanter overhangs the neck and 
in the angle thus produced we have the digital fossa, 
into which the tendon of the external obturator is inserted. 





THE ANATOMY OF THE HIP. 



47 



Numerous large foramina for the passage of nutrient 
vessels are found on the upper surface of the neck. The 
length, about two and three-quarters inches behind, and 
three inches below, together with the obliquity, give great 
leverage to the muscles inserted into the trochanter, and 
make possible a wide range of movement. The thigh can 
be flexed so that its anterior surface rests on the anterior 
surface of the abdomen. Extension in a child can be car- 
ried about ten degrees beyond i8o°. 
Abduction is much more extensive a 
movement than adduction, the one 
being limited by the striking of the 
upper border of the neck of the femur 
against the upper part of the brim of 
the acetabulum, while the other is 
"stopped almost at the outset by the 
encounter of the femur, which is put 
in motion with the corresponding 
bone of the other side." (Ward's Out- 
lines of Human Anatomy, p. 264..) 

If the opposite hmb be flexed, how- 
ever, then adduction can be carried 
to 45°. Circumduction and rotation 
are important movements. 

The structure of the head and neck 
is peculiarly adapted to receive force. 
There are inverted arches converging 
towards each other and even decus- 
sating. 

The development of the femur 
is by (i) one principal ossific centre 
for the shaft, first appearing about the 
seventh week, and by one for each of 
the four epiphyses, in the folloiving 
order: (2) A single nucleus for the 
lower epiphysis appears shortly be- 
fore birth; (3) one for the head in the pig 
first year; (4) one for the great tro- cIhikk™ "'"'"'""'"" 
chanter in the fourth year, and (5) one 

for the small trochanter in the thirteenth or fourteenth 
year. 

The neck is formed by extension of the ossification from 
the shaft. The small trochanter is united to the shaft by 
bony union about the seventeenth year, the great trochan 




— PLAHDrTKl DBVItOt- 



43 DISEASES OF THE HIP. 

ter about the eighteenth, the head from the eighteenth to 
the nineteenth year, and the lower epiphysis soon after 
the twentieth. It will be seen, then, that at birth there is 
only a single epiphysis in which ossification had already 
begun, viz., the lower epiphysis. The physiological devel- 




AcuLT. (Aft» Mouus.) 



opment is very rapid in the upper epiphysis and ihe numer- 
ous large foramina in the neck for blood-vessels shows how 
rich must be the blood-supply. The accompanying figure 
{9) represenis, very faithfully, a section of a hip in a boy 
eight years of age. The angle of the neck and shaft is 
well shown by comparison with the adult femur in Fig. 8. 
The extent of cartilage tissue between the diaphysis and 



THE ANATOMY OF THE HIP. 49 

ihe epiphysis is likewise shown by comparison with the 
aduit section. 

In fresh specimens taken from young subjects it is inter- 
esting to note the physiological hypcraemia. The ossific 




Fic, «.— Vertical Sictioh 



mailer is not so hard, and the intercellular spaces are not so 
sharply defineil. Fig. 9 is modified from Morris" work, the 
changes being made from a specimen I have in my posses- 
sion. Fig. 8 is cooied from Morris, without change. 



CHAPTER ni. 

Spkains and Contusions of the Hip. 

The popular fallacy so prevalent in our own country that 
hip-disease, as it is called, is caused by a sprain or a contu- 
sion, induces me to devote some remarks to these mishaps, 
great and small, the more especially as my records are 
pretty wfcll supplied with cases which I propose to use by 
way of illustration. 

By sprain is understood a strain or wrench to some of 
the joint structures, the ligaments especially. The extreme 
freedom of movement of an enarthrodial joint, like that of 
the hip, diminishes the liability to sprains. There are certain 
sudden movements, however, which strain not only the 
capsular ligament but the ligamentum teres also, and these 
do occur at all periods of life. Extreme abduction com- 
bined with flexion renders the fibres of the capsular liga- 
ment tense, and falls or injuries sustained when such tension 
is brought to bear, may cause considerable laceration even 
of these structures. When sudden flexion, combined with 
adduclionand rotation outwards takes place the ligamentum 
teres is very liable to injury. It is most lax in abduction 
and hence cannot suffer sprain in the very common po- 
sition of the limb to which children are exposed while at 
play. 

The ligaments, however, are the least frequently injured 
in sprains at this articulation so far as my clinical experi- 
ence leaches. Generally, I find the muscles near or at 
their points of insertion involved, as shown by manipula- 
tion and Irani" i. It requires a very severe wrench to in- 
flict serious injury on the ligaments, so well are they pn>- 
tected by fascia, cellular tissue and muscles. " 
naturally suppose that the nerves would participate in the 
sjirain. but it is seldom, in my own practice, that I am able 
to hnd any symptoms of nerve lesion. Occasionally I meet 
with cases, yet they are rare. It is different in contusions, 
In the case of a boy, aged three years, whom I saw October 
1. iSSi, the obturator nerve was so involved that temper- 



I 






SPRAINS AND CONTUSIONS OF THE HIP. 



51 



ary paralysis ensued. He fell three days before Ihis date, 
from a window, a distance of twenty feet, striking on tlic 
right side. The parents searched for bruises on the skin am! 
could not find any. He walked a little stiffly the sair.- 
evening and was fretful during the night. Next day lio 
was unable, or, refused at least, to walk under any circum- 
stances. When he came under my observation, the limb 
was held in slight flexion at the hip, and on attempting 
outward rotation, resistance was encountcied. joint ten- 
derness was quite a marked feature, and on rotating the 
limb 1 detected a distinct grating, not albuminoid, be- 
tween the head of the femur and the acltabulum. There 
was veiy little muscular resistance, no atrophy, and no 
shortening of the limb. No paralysis was discovered at 
this lime. 

My diagnosis was a contusion of the joint, and the peri- 
articular tissues seemed to have escaped. The position of 
the limb was readily explained by reflex muscular aeliori. 

A spica bandage with cotton batting underneath was 
applied and tiie patient was ordered to bed. On the 
seventh, a "cek later, the reflex symptoms had subsided, 
and the ch,;.: was able to stand without difficulty. The 
treatment was continued, and on the elevenih he was walk' 
ing, but there was a marked limp in the gait and the 
reflex symptoms had recurred, although they were present 
only on movement of the joint, as in walking. Six days 
later I found the boy walking as if the limb were weak 
and the calf was nearly a half inch smaller than its fellow. 
llie tijub tottered as he stepped and there seemed to be 
paralysis in the muscles supplied by either llje obturator or 
the sacral. Faradism was employed for a few weeks and 
00 the nineteenth of January he was discharged cured. 
The gait was perfect and there was no joint tenderness. 1 
saw him again on the last day of the month, and there was 
no relapse. 

Now in this case, in the absence of fuller notes on 
the day I recorded an apparent paralysis, I am unable to 
decide whether the paralysis, or, paresis, was due reflexly to 
injury of the articular terminal fibres of the obturator, or 
branches of the sacral, or directly from contusion of the sci- 
atic as it passes behind the trochanter. The muscular 
spasm was certainly reflex and a sufficient cause is found 
therefor if we suppose that the articular nervc-Ici mlnals 
were injured. 




DISEASES OF THE HIP. 

The symptoms of sprain depend materially on the tissues 
injured, and frequently so many are implicated that a clini- 
cal picture is difficult to paint. Of course pain immediately, 
on the receipt of the fall or wrench is to be expected, yet 
sometimes a day elapses before this symptom arises. The 
fact that in chronic bone-disease of the hip lameness is 
often the only sign for several weeks furnishes a strong ar- 
gument against the traumatic theory in the etiology of the 
same. 

In young children the crying and fretting and disturbed 
sleep so common within the first twelve hours after a severe 
fall are too well known and must be construed as indicative 
of immediate pain. In adults this is distinctly complained 
of in the beginning. A carpenter, forty-two years of age, 
in 1881 fell a distance of twelve feet, the upper portion of 
his left thigh coming in contact with a ladder. He exper- 
ienced a sharp pain in the hip. and this, with a marked 
lameness, continued up to the time I saw him, six months 
afterwards. Indeed, he had r severe contusion of the 
hip which kept him confined to bed in a hospital a few 
weeks, and compelled him to resort to crutches after leav- 
ing the institution. He was on crutches when I first saw 
him, and I examined the limb with much care, finding only 
a half-inch atrophy, no shortening, and a smoothness of 
joint surfaces. The movements were not resisted unless 
carried to extremes, and then he winced. My impression 
was that he had strained some fibres of the capsular liga- 
ment, as well as contusing the joint. The one thing he 
complained of most was the persistent pain and deep sore- 
ncsr. in the groin. Under the hot douche by daj', and hot 
fomentations by night, he gave up his crutches at the end 
of two months and then faradism was employed daily. 
His improvement has been slow, yet he is now free from 
pain and moves aboutvery easily without artificial support. 

The signs which one finds often correspond closely with 
those found in the earlv stage of joint-disease, jnd adiffer- 
ential diagnosis sometimes becomes very hard to make. If, 
however, the history of the fall be clear and the symptoms 
immediately succeeding be unmistakable, the diagnosis is 
easily made. These are so often imperfectly remembered, 
and so often become insignificant under a rigid cross-exam- 
ination that one must rest conten. with a provisional diag- 
nosis, and keep [he case, for a while at least, under close 
observation. 




:t close ^m 



I'kAINS AND CONTUSIONS OF THE HIP. 



53 



A boy, five and a half years of age, was brought to the lios- 
, pitalon the eighteenth of July, walking quite lame, with len- 
I (lerness in the left gioin, but not behinii the trochanter. The 
I natiswaschcingedalittlein contour,and muscular resistance 
' was offered when flexion, extension and rotation both in- 
( ward and outward, were carried near the full normal limits. 
In other words, he gave many of the signs, on testing the 
functions of the limb, that one gets in the first stage of 
chronic articular ostitis. On inquiry it was learned that 
the boy was perfectly well and free from lameness on the 
twelfth, when he had a fall while at play. He walked 
lame immediately thereafter and complained of pain. In 
a day or two tiiese symptoms subsided, and he had an- 
other fall, spraining the same hip. A sprain was the diagno- 
sis, followed by an interrogation point, and a roller was ap- 
plied by way of assisting in securing ilie desirable rest. In 
' four days the pain had disappeared and the contour of the 
, nates was nijimal. Nearly two years afterwards I traced 
: case out ;>nd found that all symptoms had disappeared 
shortly after the >.ate of my last note, and that he remained 
free from pain or lameness for twelve months, wheu he 
received a contusion over tlic same hip. and was lame about 
three days. 

In 1878, the month of October, a .ittle girl, three and d 
I half years of age, a tliin, exceedingly cross-looking specimen 
of humanity, was brought presenting a marked degree of 
I lameness. In fact the child seemed unable to walk except 
I by the aid of a Jiair. The joint was fairly locked, so -reat 
ilie muscular resistencewhen movements were attempted in 
■ any direction. There was no Infiltration or signs of con- 
tusion in the soft parts. .\ veck before this she fell from 
I tlie hand-rail of a staircase, striking on the left side, and no 
bruises could be found, but she cried a little at the time. 
That night, and on subsequent nights, the sleep was undis- 
irbed. Putting on shoes and stockings caused no cries or 
wincing. Only she refused to ivalk. Rest and a liniment 
were ordered, a simple sprain having been diagnosticated. 
The patient did not i-eturn as directed, and fourteen months 
afterwards I found iier free from lameness and in excellent 
health. All symptoms had disappeared shortly after the 
visit to the liospital. These sprains assume vast propor- 
tions when the child injured is a few years older than these 
two, and prospects of damages from a landlord or a wealthy 
corporation are held out by some hungry member of thi.' 



54 DISEASES OF THE HIP. 

bar. The diagnosis then becomes extremely difficult aai 
prognostications signally fail. Take the following as an in- 
stance: In the month of February, 1880, a ihirteen-year-old 
lad, muscular and well developed, came from a neighboring 
county to the hospital with his parents, plain laboring peo- 
ple of foreign birth. My examination was made with 
much care. He stood with limbs parallel, the right fool 
however inclined to inversion, i.e., he would from lime to 
time assume this altitude, and as he walked the foot would 
be inverted although the lameness was scarcely percepti- 
ble. He could stand resting all of his weight on either limb 
without pain or inconvenience, but when questioned as to 
Kie locality of symptoms he would complain of soreness in 
the right groin and down the outer aide of the thigh as far 
as the lower third. There was no infiltration any where to 
be found; flexion, extension, abduction, adduction, and ro- 
tation were made to the extreme limits, without increase 
of soreness and without muscular resistance. The limbs 
were equal in size and length, and I could not by any test 
elicit joint-tenderness. There was tenderness along the 
iliac crest, and the superficial inguinal glands were a littl " 
enlarged. 

The history given was that one day — a month befon 
while riding in a cart over a rough road, by a sudden jolt 
was thrown against an iron bar in the cart, ihe right hip 
ceiving the shock of the concussion. He walked v " 
ting out, and did not complain of pain. Next day he coi 
plained of pain in the right foot and was unable to wear hii 
boot. There was a ceriain lameness present, too. with in- 
version of the fool, and these symptoms not subsiding by 
the end of a week a physician was consulted, who stated, so 
the motlier says, that the "hip was out of place," and after 
eSorts at reduction claimed to have succeeded. At all 
events he got relief from pain and lameness from ihi 
manipulations. A week elapsing, he had pain referred ta 
the hip and the knee, and the foot again became inverti 
as he walked. This last is the only constant symptoi 
Since the accident he has had a little nocturnal eneuresi 
I confessed my inability to make a diagnosis and as thi 
mother was desirous of getting the boy into ihe hospital hi 
was admitted. A fly-blister was applied in the inguinal 
region that night, poultices followed during the next three 
days, and by the end of February all soreness and inversi< 
<ii foot had disappeared. He was retained in the hospil 



M 



SPRAINS AND CONTUSIONS OF Tirii HIC. 



55 



Lsion at I 
no fraci 



ten days longer, when a careful examination failed to de- 
tect any symptoms whatever. Oo this date he walked 
about twenty blocks, after which he was lame again, thp 
lameness continuing two weeks, when he was readmitted to 
hospital in (he same condition as before, A liniment and 
a spica constituted the treatment, and March 39th I made 
a note thai his lameness differed from that on the formei 
occasion in that he walked on the loes and the ball without 
the inward rotation. 

He was to every appearance restored by April 2d, bui 
was under daily observation until the 30th, without a symp- 
tom. He was then discharged. It was reported on May 
8th that he had been lame for eight days, and in June I found 
the lameness and everslon still present. I sent him to see 
Dr. Frank Hamilton, who wrote me "I think the internal 
rotators are partialFy paralyzed; he can turn the leg in if he 
tries," It was about this time we learned that a suit had 
been instituted against the town corporation for damages 
sustained by virtue of the road being out of repair. In fact 1 
was asked to appearas witness in thecause. This suit Idis- 
couraged by stating I could not testify lo any specific lesion, 
and after a year's delay, I think, the cause was dismissed. 
During this lime, loo. under the delays and uncertainties of 
the law, the lameness gradually disappeared, and to mv 
mind these curious relapses became satisfactorily explained. 

Il is something remarkable, however, the heights from 
which a child can sometimes fall without sustaining cor- _ 
responding injury. Quite a number of such cases have 
come under my own observation and it has been rare to 
find any joint disease resulting. Severe contusions of th'" 
soft parts, and occasionally of the bone, have been about 
the only lesions I could detect. A girl, aged three and a 
half years, was brought lo me in July, 1877, with a contusion 
of the left thigh. It was stated that two days before this 
she fell from a third-story window of a tenement hous<; 
into the back yard, probably striking in her descent a 
clothes line which broke the fall. She was picked up uncon- 
scious, though she soon recovered from this state. The 
forehead had sustained a lacerated wound, No other in- 
juries were found, but the child refused to walk and com- 
plained of pain in the left loin. I found the ihigh one inch 
larger than its fellow and a resistance to complete exten- 
sion at the hip. There was no shortening, no discoloration 
fracture. 



56 DISEASES OF THE HtP. 

I did not see her again until the 4th March, 1883. 4 
interval of nearly six years having elapsed, and I found thj 
she had made a speedy and a perfect recovery. No traci 
of the former injury could be discovered. ' 

In the month of August, 1875, 1 saw a girl, aged fiv< 
■ who had fallen a few days before from the fourth-story 
window into a gutter, striking, as she fell, a shutter on a 
third-story window. The left limb, when I examined her, 
was rotated outward, and there was great prominence of 
the upper third of the femur. I could not detect any crepi- 
tus articular or periarticular, and there was no shortening. 
She walked with a marked limp, yet seemingly without 
pain. The different diagnoses I succeeded in getting from 
gentlemen who examined the case with me were: (1) prob- 
able fracture uf the neck, near trochanter, {2) hip-disease, 
(3) fracture of the pelvis, and (4) relaxation of the ligaments. 

The treatment was purely expectant, and I contented 
myself with examining the case from time to time and re- 
cording my observations. In January, 1876. I recorded the 
same signs as on the first date, with the exception that her 
gait had materially improved. Attacks of diphtheria (?) 
and scarlet fever in the spring of that year were followed 
by suppurating cervical glands, but the functions of the 
limb suffered no impairment. In the month of Januarj'. 
1883, after a lapse of nearly seven years, 1 mnde an exami- 
nation, finding the same prominence of the femur in its 
upper portion looking very much like the deformity of a 
<lislocation or a diastasis. Vei I could not detect any short- 
ening or any atrophy. The head of the bone was in the 
acetabulum, and there was normal smoothness of the articu- 
lar surfaces. The movements were perfect in all directions 
save in extreme outward rotation. The child was free 
from pain and walked without any lameness. The diag- 
nosis to which I was led was that she had sustained an in- 
complete fracture of the thigh in its upper fourtli and thajM 
a degree of tortion took place at the same time. ^9 

1 trust that by the narration of these cases the diagn<j|^| 
has been made sufficiently clear, and I pass now to ^| 

Treatment, which need not occupy much space. In re- 
cent sprains all recognize the value of rest, and Nature her- 
self seems to enforce this great principle. I have been in 
the habit of using a spica bandage with infrequent changes, 
;ind this simple measure assists much in securing the Jest 
d -si red. I discourage all attempts at walking, and insist nn 





SPRAINS AND CONTUSIONS OF THE HIP. 



57 



tile child being confined to bed or Che nurse's arms until the 
soreness has been removed. If the soft parts have been con- 
tused cold or hot dressings will naturally suggest them- 
selves, A nineteen-montli-old child came under treatment 
November 12th. 1879, with a history of a fall on the 6th, 
in tliC doorway, the foot turning under her as she fell. 
The cbild had been walking about five weeks only. She 
cried bitterly for about two hours ;ind then fell asleep. 
There has been no disposition to use ihe limb and move- 
ments at the hip aggravate the pain. She cries much dur- 
ing sleep and holds the thigh flexed. I fuund that tnotion 
at the hip was free and painless in flexion and rotation, but 
not so in complete extension. There was no shortening or 
atrophy or infiltration of the parts about the joint. One 
year previously a brother four years of age developed 
chronic articular ostitis of the hip, which was in the sup- 
purative stage. 

Notwithstanding this fact. 1 diagnosticated a sprain, and 
the mother was enjoined to move the limb as little as pos- 
sible. A snugly-fitting roller was applied, and was not re- 
moved until the 15th, the date of the next visit, when it was 
nole<l that the deformity was less marked. I refrained 
from any manipulations, but reapplied the roller with cot- 
ton batting beneath, and directed the same care in hand- 
ling as before. In foiir days more the case was considered 
cured. The motions at hip were perfect and the child stood 
without any deformity. The roller was to be continued a 
week longer. There was no further treatment, the case 
making a good recovery, as proven by examination in Janu- 
ary 1880. 

The treatment of contusions is practically the same as of 
sprains. Rest is the sine qua noii, and the diagnosis once 
established frequent examinations are to be discouraged. 

The necessity for breaking up stiff hip-joints that depend 
on ligamentous strain and periarticular adhesion, does not 
often arise, especially in childhood. In other joints, for 
instance, lying more superficiai and limited naturally less 
in movements than the hip, these adhesions form. It gen- 
erally happens, however, that stiff hip-joints in children. 
when broken up by force, done as a rule, under the im- 
pression that the lesion is a result of a sprain, do badiy and 
cause the surgeon a deal of regret. He has egregiously 
efred in diagnosis, and the original lesion has been hastened 
into an advanced stagp. 



ind acl^ 



58 DISEASES Of THE HIP. 

Not SO, however, in adults, who suffer seve 
this joint. The reparative pi-ocess is much sli 
hesions do somehow form, wherein brilliant results a 
attained by vigorous passive motion under an anesthetic 

I think I am stating a rule that every careful surgeon wtl] 
approveand that every careful surgeon observes when I state 
that brisement force is seldom or never indicated in the stjl 
hips seen in early life. If they depend on a sprain, lime am 
locomotion and play will accomplish all that is desired, and 
a prognosis as to the perfect restoration of function may in 
nine cases out of ten be safely made. If the limitation of 
function depend on a periarthritis the same natural means 
will operate to bring about a perfect recovery 

If, however, there be a bone lesion, cither central or peri- ^ 
pheral, undoubted damage will be done and the future \iS6*i 
fulness of the joint jeopardized. 

It is better to wait and allow enough time to elapse 
settle the question as to diagnosis. In chronic articular os^! 
titis, the intervals between the exacerbations are so harm- 
less in their symptoms and the lameness is so persistent 
that the temptation comes with great force sometimes to 
attempt relief under an anassthetic. Cases are sent to me, 
not infrequently with notes from the attending physician, 
asking whether it would not be good practice to make an 
attempt at overcoming this little stiffness left over from an 
ancient injury. The cases are nearly always in children 
whose parents have given so clear a history of trauma that 
the doctor really believes such to be the exciting cause, and^ 
invariably I find a chronic bone-disease, at or near the join^j 
in one of the stages of slow evolution. 



ot 
ns 

i 



I at leas 

^^1 suppo: 



CHAPTER IV. 

Nfatroses of the Hip. 

"Neuroses, .... a generic name (or diseases sup- 
posed to have their seat in the nervous system, and which 
are indicated by disordered sensation, volition, or men- 
ial manifestation : without any evident lesion in the struc- 
ture of the parts, and without any material agent pro- 
ducing them. Such is the usual definition. Broussais at- 
tributes them to a state of irritation of the brain and spinal 

Such is, I am well convinced, the recognized meaning of 
the term among neurologists, and clinicians generally have 
found it very useful and a very convenient name to employ. 
Formerly a neurosis carried with it a pathological signi- 
ficance of some kind not always understood, but latterly it 
has come to represent a class of functional disturbances of 
the nervous system, and the definition at the head of the 
chapter fairly expresses the sense it convey;. In addition 
to the indications specified in the quotation by which these 
nervous phenomena are manifested I would add reflex mits- 
cular spasm, chiefly Ionic. 

The term associated with the hip is intended to convey 
to the minds of my readers the fact that there are many 
pscudarthropathies of the hip ivherein the neural element 
is so prominent that we speak of them as neurotic. There 
are many cases purely hysterical, and we speak of these 
assuch, and again there arc instances in which llie symptoms 
are feigned or counterfeited so closely that we speak of 
such as cases of neuromimesis. Sir James Paget, in " Clin- 
ical Lectures and Essays," published in 1875, employed this 
latter term and illustrated the subject by some cases quite 
remarkable. Skey, in a series of lectures published in 1867, 
called these joint affections hysterical — as did Sir Benjamin 
Brodic years before. Indeed, Sir Benjamin says: "I do not 
hesitate to declare that among the higher classes of society 
at least four-fifths of the female patients who are commonly 
supposed to labor under rii':e;ise of the joints, labor undi-r 




DISEASES OF THE HIP. 

hysteria and nothing else," Esmarch, whose name is associ- 
ated with so much _that is grand and abiding in surgery, 
rode at one time the' hysterical hobby, and {Dr. Shaffer — Hy- 
sterical Elements in Orthopedic Surgery — is my authority 
for stating this.) fully indorsed this assertion of Brodie. 
Esmarch, however, adopted to my mind the more compre- 
hensive term — viz,, geUnkneurose, and liis publication at Kiel 
in 187a was entitled "Ucber Gelenkneurosen," M. Charcot 
and S. Weir Mitchell have embellished this subject, and in- 
deed the literature of neurology contains much that relates 
to the various disturbances in nutrition and sensation. 
Hysterical contractions are very common in neurological 
and gynecological medicine. The neurological specialist is 
too prone, I think, to attribute real arthropathies to neuroses, 
and the cases of tabes dorsalis with bone and joint lesions 
so well elaborated by Charcot, certainly furnish strong ana- 
logical evidence that someat least of the joint diseases with 
which the orthopedist comes in contact are neural in origin. 
The late Dr. Jno. K. Mitchell of Philadelphia and his illus- 
trious son, whose name 1 have already mentioned, have fur- 
nished many illustrations showing the connection between 
spinal lesions and joint lesions. 

The subject is a fascinating one to the orthopedist, and he 
eagerly grasps at any cause the knowledge of which will 
help him to so easily solve some of the harassing problems 
of this particular specialty. In the early part of the last 
decade I became exceedingly interested in nervous diseases, 
and I studied many cases that lay on the border-line of 
neurology and orthopedy. Many instances of apparently 
formidable joint affections I could trace to a spinal or neural 
origin, and I obtained speedy cures with this knowledge at 
hand. 

In 1877 I published a paper that I had presented to the 
AiJerican Neurological Association on the subject with 
which I am now dealing, and in it gave my conclusions 
based on a study of some forty cases of true and false ar-. 
thropatliies. The subject was brought prominently beforei 
the members of my own specialty at that time. In 1879 
Dr. Shaffer collected his own cases, read a paper on " Hys- 
terical Joint Affections," before the New York Neurological 
Society, and brought it out in the shape of a monograph ia 
1880. 

From a reported case or two in the volume one can ii 
that the author appreciated the danger of being carriedj 



I 




NEUROSES OF THE HIP. 



away by enthusiasm. My o 
over iny cases a 



i befoi 



■nihusiasm when ; 
e this period led i 



: work 



I 
I 



scquently i 

tical about the causative relationship between neuroses und 
true bony lesions of the hip joint; so that my present chapter 
on this subject will deal purely with the false arthropathies 
of neural origin. 

Dr. Shaffer has placed on record some valuable cases, 
which I shall take the liberty of using in connection with 
my own. It is difficult to discuss the pathological phases 
of this subject, for the reasons already given, and I propose 
now to illustrate the clinical history by means of cases. 
The following appeared in my paper in 1877, and was that 
of a boy aged eleven years, who was brought to ilie out- 
door department of the hospital in March, 1877, for sus- 
pected hip-disease. A hasty examination was made, and a 
day set for his admission as an in-patienl. The mother was 
assured that the lesion was spinal, and a fair prognosis was 
given. Wo history was recorded at the time, but this was 
deferred until his admission. The next day, however, by 
the unsought advice of a kindly disposed aunt, the child 
was taken to an orthopedic expert, a consultation was held, 
and double hip-disease was diagnosticated, (This was 
volunteered testimony on the part of the mother and the 
aforesaid aunt.) I simply make mention to illustrate a dif- 
ficulty in making a differential diagnosis. 

On the Z7th March, admitted to the hospital, when it was 
learned that the father, after a long illness had died of 
phthisis, and that two other children in the family had died 
of some acute intracranial disease — in fact, no better stru- 
mous history could have been obtained. The patient has 
ever been healthy, prior to the middle of the preceding 
month. TJien, without any known exciting cause, he com- 
plained of pain in the right knee; shortly afterward of pajn 
in both knees, and in back. To-day, as he walked, one 
limb for a while was favored, then the other. His chest 
was found somewhat rachitic, auscultation furnished ne- 
gative resuhii. At one time he stands so that a marked left 
skoliosis presents itself, at another iv« versa. In other 
words, one position quickly fatigues. Tenderness on pres- 
sure over spinous processes of sixth, seventh, and eighth 
dorsal vertebra;, more marked as that of the ninth is 
reached, becoming excessively so over those of the lumbar. 
Pressure over trochanters, lateral ligaments, and malleoli 



f)2 DISEASES OF THE HIP. 

■ ■( bolli lower extremities, gives pain. Flexion, ab- and ad- 
duction of cither thigh, is resisted by muscularspasm. Hy- 
persesthesia is a prominent symptom. No swelling or effu- 
sion of any kind is found, periarthritic, and when the limb 
is grasped firmly and motion made, no pain in any joint is 
perceived. There is no arthropatliy, and the former diag- 
nosis stands unamended. An emplastrum cantharidis 10 the 
spinal tenderness is all that is prescribed. 

Four days later very little tenderness remained. On the 
7th of April it was recorded that he walks with perfect case, 
no limp being discoverable. No spinal tenderness at any 
point; no tenderness anywhere. On the i6th he was cured 
and on the 17th discharged. 

The recurrence of symptoms after long remissions is not 
uncommon, and occasionally we have an opportunity of 
observing the case through two or more exacerbations. A 
boy, for instance, aged (our and a half years, came under 
my care in the spring of 1876, presenting a stiffness in the 
lumbar spine, without tenderness or deformity. There was 
a moderate contraction of the psoas, left side. The boy 
liad been resting poorly at night, and walking with a limp 
for three months, A history was given of a stepladder 
falling across his back a month before the symptoms ap- 
peared, A diagnosis was made of spinal caries and a brace 
was applied. Ten days later there was scarcely any resist- 
ance on the part of the psoas, yet the spinal stiffness re- 
Three years after the above note was made, the boy came 
under treatment again for a recurrence of the same symp- 
toms identically that had presented at first, and they were 
now of four days standing. 

The mother was quite sure that the boy had been pro- 
nounced cured shortly after the removal of the brace in 
1876, Now there could not be found any evidences that 
spinal caries had existed and the case was pronounced one 
of neurosis of the hip. A blister to the lumbar spine was 
ordered, and in addition to this, the fluid extract of ergot 
in drachm doses three times a day. The ergot was pre- 
scribed a week later, the blister not having been followed 
by prompt relief. Three days after the ergot treatment had 
been instituted, the symptoms subsided, the limb was 
straight and he was discharged cured. 

In March, 1883 — just four years having elapsed — he ap- 
peared again, complaining of the same group of symptoms. 



I 



NEUROSES OF THE HIP. 63 

The limb was advanced, natis flattened a little, the ilio- 
femoral crease lower, wliile the resistance to movement 
existed only in the thigh flexors. 

The symptoms promptly subsided under blistering, and 
the boy was soon discharged again. 

At no time was there any atrophy of the limb, and at no 
lime were there any signs about the hip save a lameness 
and spasm of the ilio-psiias. There was no evidence that 
this boy aimed at any mimicry, and the lesion, if any ex- 
isted, was, I think, a meningeal hyperjemia caused in the first 
instance by the direct blow, and the meninges being ren- 
dered thus vulnerable were easily excited to similar condi- 
tions. The theory I favored in my communication to the 
Neurological Association was the hypersemic rather than 
the anfctnic one, but I had no pathological facts at that time, 
nor have I any now. 

The hysterical clement is well illustrated in this case re- 
ported by Dr, Shaffer. It was that of 3 girl aged ten, com- 
ing under his observation in September, 1876. She suffered 
from all the important and many of the urgent symptoms 
of disease in the left hip. The family history was unsatis- 
factorily given. The symptoms had come on very insidi- 
ously, the limp coming before the pain, though the interval 
was very short. Deformity and sleepless nights had fol- 
lowed, and when Dr. S. saw her she was on crutches. The 
symptoms, 1 had almost forgotten to mention, followed 
closely upon a fall. The doctor had great difficulty in 
securing an examination, and it was only after many sug- 
gestions that " the putient was finally placed in the supine 
position, the mother in the meantime making what seemed 
to be manual traction with a degree of force that indicated 
long practice. The patient all this lime was shrieking with 
pain and grasping the furniture near at hand, apparently as 
a means of counter-traction, I imagined that the case was 
one of chronic ostitis of the hip-joint in the stage of ex- 
acerbation. After much persuasion, 1 at last induced the 
mother to permit me to make the traction and control the 
limb. I then commenced to gently test the condition of 
the joint, as regards motion. While manipulating in the 
mildest way I was startled by an urgent cry from the patient 
and imperative command, ' Hold it tighter,' two or three 
times repeated. 1 was already making all the traction pos- 
sible, and naturally asked an explanation. The mother hur- 
riedly said, 'You don't squeeze tightly enough.' This 




C4 DISEASES OF THE HIP. 

threw a new light on the symptoms. Desisting wholly from 
all efforts at traction, I merely compressed the ankle-joint, 
with all my power. While doing this I could place tho* 
thigh in any position, and could even press the articular 
surfaces together without resistance or complaint. 

" Still ' squeezing the ankle,* I was able to get the patient 
in the upright position with liltte or no trouble. Without 
any support but that afforded by her crutches, ihe thigh be- 
came flexed and adducted. The whole limb was visibly, 
though not markedly, atrophied. There were various hy-i 
perKsthetic areas on the affected limb — principally on the' 
inner aspect of the thigh — and over the crest of the ilium. 
Pain was produced by pressure through the trochanters, by 
crowding the sacro-iliac surfaces together, and by digital 
compression in the inguinal region. The patient Stated 
absolutely that she could not walk without support. There 
was normal faradic contractility of the leg and thigh mus' 
cles." 

The doctor informed the mother that the child did not 
have hip-disease, but his opinion was not well received. 
Some time later he saw the patient in his wards at St. Luke's, , 
still on crutches, and still with " hip-disease," The mother 
had sought other advice and the case pronounced one of 
"hip-disease." Under treatment for the neurosis she soon 
recovered and left the hospital. 

A letter to Dr. Shaffer from Dr. G. A. Spaulding, is so 
interesting a sequel to the case that I shall make no apology 
for quoting it. 

" On February 19, 1879, about two months after her dis-, 
charge, her mother again presented the patient for admis^l 
sion to the hospital, giving the following history : A fevF\ 
weeks previous she had been seized wilh convulsions., 
These convulsions, the mother stated, were becoming more 
and more frequent and alarming — as many as three or four. 
occurring in twenty-four hours. As the mother gave this 
history, she was occupied in unrollinga large bundle, which 
proved to be a blanket. This she spread carefully upon the 
floor, remarking that the hour for one of these attacks had 
arrived, and that it was her custom to put the blanket down 
as a protection. Precisely at 11 o'clock a.m. the patient 
composed herself carefully upon the blanket, and passed 
into one of the most characteristic hysterical convulsions I 
have ever witnessed. The subsequent history is very 
aod most satisfactory. The usual remedies lessened 



I 



very brief l^B 

J 



NEUROSES OF THE HIP. 65 

fi'eqiiency and shortened the duration of the attacks. But 
an absolute cure was not effected until later. I chanced lo 
be in the ward one day at the time the patient was seized 
with a convulsion, and happening lo see a siphon of carbonic 
acid water, I picked it up and holding the young girl firmly 
by the back hair, I discharged the contents of the syplion 
down her throat. Her convulsive movements were instantly 
checked, and she promised to avoid all such conduct in the 
future. She kept her word, and in a few weeks was dis- 
charged from the hospital. Duringall this time the patient 
had no recurrence of the hip-joint manifestations." 

It has been my experience, as it has been also that of other 
observers, to find genuine cases of bone disease of the hip 
with hysterical or neurotic symptoms complicating. 
These would be the cases where one finds much difficulty 
in differentiating one affection from the other. There are 
indeed, very many old cases of ankylosis of the hip from 
suppurative and non-suppurative disease, presenting most 
marked neurotic phenomena. In August, 1877, a girl 
twelve years of age came under treatment, presenting a 
marked deformity of the left hip — two inches shortening, two 
inches atrophy of the thigh, one of calf, a sesile fluctuating 
tumor about the trochanter without tenderness or extra heat 
thereover, muscular resistance to abduction and extension, 
while flexion was easily made. Her dorso-lunibar spine 
was excessively tender Three years antedating this ob- 
observation she began to walk lame and had pain three 
.months afterwards. With the invasion of pain she soon 
was unable to walk, and for four months her sufferings and 
constitutional symptoms, from the history given, were 
very great. A peculiar neurosis would manifest itself 
during the remissions of pain about the hip. viz,, a sensa- 
tion about head and right ear as if water were dripping. 
Eight months after her first symptoms of joint disease she 
took to crutches, and on these she has walked for over two 
years. In the family there is a distinct neurotic and a 
tuberculous historj'. A blister to the tender spine was 
ordered, and after a "terrible drawing" on the part of the 
aforesaid blister, she reported much improvement two weeks 
later. A hir;!i shoe which she had been wearing was dis- 
carded now, as the limb seemed to be longer, and the 
crutches were likewise of no further use. 

Belladonna in gradually increasing doses was ordered. 
The patient continued to improve, and one morning about 




four months after her first visit, and after a so-called mala- 
rial attack, my.atlention was called to a hyperaesihetic 
on the sole of the fool. For this the hot-water douche was 
advised, and relief promptly followed, soon after which 
she passed from under observation. Curious to learn the 
outcome. I traced out the case, and found March 16^ 
1883, that in the five years no neurotic symptoms had beea 
prei^ent, thai ihe fluctuating tumor had disappeared, that 
the disease about the hip had been free of any exacerba- 
tions, and that the result under expectant treatment was 
certainly very good. 

One of the most difficult problems is the differentiation 
of neuralgiae in and about the hip from true disease of the 
joint. In these cases we seldom have any reflex contrac- 
tions about the joint. There is the lameness, the pains 
overbony prominences, the insidious invasion, the exacerba- 
tions, and ihe atrophy. It is safe, I think, then, to exclude 
joint disease it the absence of reflex symptoms persist, and 
if the family history be predominenllv neurotic. Many and 
many a case have I seen wherein the family history alone 
was siiffi, inuly neurotic to enable me to reach a conclusion. 

One of ihc most interesting cases — in view of its neurotic 
phases — that I have had the opportunity of observing, was ia 
the person of a girl aged twelve, who came to me in 1876. 
A younger sister had died of tubercular meningitis, a 
brother aged nine subsequently came under treatment for 
talipes equinus depending on infantile paralysis, and an 
elder sister I have likewise had under treatment for lateral 
curvature associated with an anterior crural neuralgia. 

The girl herself came with a history of lameness " off and 
■ on" for two years, and unassociated, so far as I could learn, 
with any fall or injury. She simply began lo feci tired 
and to favor the right limb. The nalis on this side wa« 
flattened, the crease was shortened, there was one inch 
atrophy of the thirrh, and three-quarters of the calf, The^, 
joint-movemeiii.. were absolutely faultless, A diagnosis, 
however, was made of "morbus coxee," and she was ad-, 
mitted to hospital. 

Under expectant treatment she w^s soon so far relieved 
tli.ii she w.ls discharged. The pain and lameness had en- 
tirely disappeared. The symptoms returned in a month, 
and a blister was ordered. Very soon afterwards — ten days 
— she was entirely relieved. The subsequent notes are full 
of relapses, and finally a chorea developed in 1880, 



I 



:es are full ^H 
0, yield fnft^H 

J 



I 



NEUIiOSES UF THE IIII'. G7 

lo arsenical treatment in about three weeks. In January, 
18S1, she developed an acute articular rheumatism affecting; 
both knees and the left ankle. This took the usual course. 
Chorea minor developed a year afterwards. Last summer 
— 1882 — she had a sciatica. She frequently has precordial 
pains without any heart lesion. Her general health is ap- 
pai^ently good all the while. The lameness has not re- 
curred, and yet the thigh is two inches smaller than its 
firllow. The temptation to regard these phenomena 
malarial by reason of the fact that certain heart symp- 
toms yield frequently to quinine, has led me to employ 
that drug from time to time in toxic doses without 
material benefit. At present the actual cautery is being 
employed. 

The diagnosis furthermore is obscured by certain inflam 
matory signs seen in the distribution of nerves about tile 
gluteal region, and really it is very difficult to avoid com- 
mitting an error. In some instances there is distinct swel- 
ing about the hip, and this, associated witli the characteristic 
deformity and muscular contraction causes one to hesitate 
long before making a diagnosis. This became necessarj' in 
thefollowiii;^ i.aie, which has been reported to me during the 
past year, as continuing well and free from lameness. The 
girl, a strumous-looking child, aged ten years, was admitted 
to hospital in April, 1876, The family history is imper- 
fectly obtained, as no other members are present at date of 
admission, the child coming from an orphan asvlum. A 
liisUii V of the exanthemata is obtained, however, and of a 
tall in.m a bed six or eight weeks prior to Uiis date, and the 
appearance of signs pointing to some lesion about the hip 
two weeks thereafter. This, taken in connection with iier 
general appearance, a marked lameness typical of chronic 
bone-disease of the hip, the position of the right limb in 
standing, viz.; semiflexion, eversion, and rotation outward; 
u flattening of the nates, tenderness on pressure thereabout 
amounting to a hypersesthesia; resistance lo flexion beyond 
50°, to extension beyond 160°; a swelling near the crest of 
the ilium; an absence of real shortening, while there is an 
apparent shortening — the above history, I say, taken in con- 
nection with all these signs, positive and negative, leads to 
a diagnosis of " hip-disease" second stage ; though, on re- 
flection, it occurs to us that such an amount of hyperfesthcsia 
cannot be due to disease in the hip-joint, and that such 
deformity has come on too soon for true bone disease, and 




68 DISEASES OF THE HIP. 

hence we placed an interrogation point after the diagnosis, 
already recorded. The treatment is expectant. 

On the 9th May a distinct and well-marked fulness ov 
crest of right ilium was observed, extending from theanterl 
superior spinous process to the sacro-iliac junction, qui" 
tender to pressure. The hip-joint seems reeof anydise 

The fulness slowly increasing, a fly blister is applied 
evening of the twelfth, the usual poulticing to follow. 

Abed the forenoon of the i6th. but in the afternoon 
moves about the ward with great difficulty byaid of a ch 
the foot being raised some two inches from the floor, 
symptoms gradually subsided, and with the exception • 
pain in the lumbar region at times, nothing occurred until 
the middle of August, when the fulness seemed to have 
shifted from the ilium to the thigh, and the upper fourth of 
this member measured one inch more in circumference than 
the left. There were also heat tenderness and constitutional 
disturbance generally. A cathartic, evaporating lotion, and 
rest seemed to afford relief in a fortnight, though the ful- 
ness remained. With a few intervening notes of minor im. 
portance, it is noted a month later that the child standi 
with both limbs parallel, and scarcely a limp can be detecti 
in her gait. The changes subsequent to this depended 
the amount of exercise, and the treatment was purely 
pectant. At times, she was in great pain, unable to leave 
her bed, and the parts around the hip would become exquis- 
itely sensitive, then relief would come and she would gel 
alm'ost well. 

In one of these attacks, in May, 1877, there was discovered 
marked tenderness over and to either side of the spinous pro- 
cesses from the fifth dorsal vertebra to the sacrum. The, 
spine was thoroughly blistered and poulticed, with decid< 
benefit. Subsequently, ergot was administered, and J 
July 20th there was no pain or lameness or other si^ 
of disease. She was kept under daily observation untit- 
October 5t!i. up to which time not an untoward symptom 
had recurred, and she was discharged cured; no muscular 
rigidity, no tenderness — spinal or femora! — and no lame- 
ness whatever existing. 

To sum up, then, the points in diagnosis: 

There will in nearly every instance be a neurotic element 
in the family history. The history is all important, 
certain cases may furnish evidence wl 
nomic. 



m- 
idiX 



■he 

1 



2 



NEUROSES OF THE HIP. 6g 

In iieuromimesis certain tricks will sooner or latei* be 
discovered on examination, which, it is needless to say, 
should in all cases be most thoroughly made. The psychi- 
cid elemenl will predominate in this as in the liysterical 
joints. The absence of atrophy both in neiimniimcsis and 
hysteria, with electrical reactions to faradism preserved, ilie 
hyperseslhetic areas and occasionally parassthetic areas 
will "contribute largely to the exclusion oC joint-disease. 
There is a peculiarity of the gait that is indicative of pain 
or fear, and that is otherwise difficult to describe. If con- 
tractions exist other signs that will invalidate them as 
signs in joint-disease will surely be present and their sig- 
nificance will be manifest. 

Again, the age will, as a rule, be between ten and twenty. 
Many of the phenomena are absent about the beginning 
of menstruation. In nciir;ilgia as before meniioned the 
liislory will help one lo estimate the value of the atrophy, 
and the freedom from muscular resistance is significant. 

Spinal tenderness, though not invariably present, is a very 
strongdiagnostic point and this will be worthy of study. 

The lifalmtiit is simple in those cases of muscular con- 
traction, especially if the tender spine be present. Counter- 
irritation in ihe form of blistering, the actual cautery, or 
simpler means, such as liniments, and the administration of 
ergot or belladonna. 

In cases of hysterical contraction or of neuromimesis 
the treatment by fly-blisters in connection with moral 
suasion secures good results. The great benefit, in many 
instances, is in the revulsive effect of the blister, while in 
some cases the subsequent poulticing gives to the blister a 
derivative effect. Prompt relief very often follows and the 
recurrences are as promptly relieved. Take the following 
as illustrative of the relief afforded by blistering. 

A girl, aged nineteen, was admitted to the hospital in 
June, 1880. She came from one of the towns on the 
Hudson, and was on crutches when she appeared for treat- 
ment. The family history could not be obtained; the pa- 
tioncd reported that as a child she was delicate, but had 
been in fair health up to January, 1880, when she had a fall, 
which was soon followed by great pain in the knee. This 
shifted to the hip two weeks later, and she walked lame, 
suffering much from fatigue. For the past six weeks she 
lias not been able to walk unless wilh crutches. She has 
been very restless nights, and lias lost flesh. 




J 




She stands resting all of her weight on the right lim ^ 
the left foot not even touching the floor. The left limb is 
advanced and rotated outward, while the pelvis is lilted to 
this side. No infiltration about the joint; thighs equal in 
size. The pain is referred to the left loin, the spine, and 
anterior surface of the knee. Absence of joint-tenderness, 
but muscular tenderness, with pain on pressure along sciatic 
nerve. The thigh can be almost completely flexed without 
pain or resistance. Indeed all the movements are normal, 
save extension, which aggravates the pain. There is for- 
mication about the sole and ankle and a moderate degree 
of dorso-lumbar tenderness. 

Joint-disease was excluded in the diagnosis, and a fly- 
blister was applied to the spine the same night. There 
was a little relief after two cir three days, but nothing very 
marked until the morning of July the id — ten days 
after admission — when she got up from a rolling-chair and 
walked across the floor with very little lameness and very 
little exertion. The pain had completely subsided and the 
deformity no longer existed. She was then put upon cod- 
liver-oil and an iron mixture. 

By the ist of August all signs of disease had disappeared, 
and a month later she was discharged. No signs present, 
Hnd general health excellent. She continued free from 
lameness or any symptoms until about two or three months 
ago. She had become a little aniemic, and complained of 
pain about her hip again. She came to the hospital, had 
similar treatment, and returned to her home in two or three 
weeks fully restored. She had, in fact, no joint-symptoms 
at this last visit. 

And again, the following case, in a girl aged nine and a 
half, a robust, hearty-looking, child, who was admitted in 
the spring of 1877. Until eighteen months before, her 
health had been excellent, and the family histories on both 
sides represented as good, although during the past year 
a sister has been under treatment for infantile paralysis. 
The patient however, after a fall, one and a half years since, 
experienced a sense of weakness in right lower extremity, 
with pain in knee. This continued for three or four months, 
uncomplicated with any other functional disturbance. She 
has walked lame, and during the past three months the 
symptoms have been increasing in severity. On admission, 
a thorough examination delects only a marked hall in her 
v;.iit, a lengthening of the right natal fold, slight infiltration 




A 



NEUROSES OF THE HIP. 



71 



of the right inguinal ganglia, a furuncle 



I 



;lit, though decided ten- 

processess of the eighth, 

The negative points 

.nd transcription here is 



1 acumtnation, 
Ricient 
of the inguinal ganglia), and a slij 
derness on pressure over the spinous 
ninth, and tenth dorsal vertebrae, 
were all noted in the case-book, : 
unnecessary. 

A blister was applied to spine, and next day, poultices to 
the vesicated surface, while at the same lime the furuncle 
was subjected to appropriate treatment. 

Ten days after admission, there was no spinal tender- 
ness; inguinal enlargement was scarcely perceptible; fur- 
uncle has diappeared. 

Five days later she was discharged, cured, and returned 
to her home. 

Recent opportunity has presented for learning the final 
result in this case, and I find that she has never had any 
relapse. 

The belladonna treatment, in my opinion, is certainly to be 
recommended as I have witnessed some remarkably good 
results from its administration. Ergot holds a place therea- 
peuiically of somewhat questionable value and may serve a 
good end in properly selected cases. Aboi'e all, attention 
to the minor details of general health, cathartics judiciously 
employed, tonics and nutrients, changes of living, and rest 
arc agents that the successful practitioner cannot afford to 
overlook. Concerning electricity I have had no experience, 
and a priori should consider it contra-indicated except in 
the neuralgia which comes under this classification. 

It is my conviction that many of these neuroses depend 
on meningeal hyperaemia induced by malarial poisoning. 
I have a patient at present, a patient whom I see once in 
two or three months: he lives beyond the Harlem River, in 
a district notoriously malarial. Is ten years of age, a male, 
and is of a neurotic diathesis. 1 first saw him March 
nth, 1882. He had been screaming at night for a long 
time; had been favoring the right hip in walking for six or 
eight months, yet the limp was not constant; and he com- 
plained of pain in the course of the anterior crural. The 
night screamings, I learned, on further investigation, were 
what the mother called " night terrors," and he had been 
subject to these phenomena for many years. He did not 
have the ostitic cry. The anterior crural pain was not 
constant, was not pcrinriical. 'sometimes it was present in the 




morning, sometimes in the evening. They were i 
fluenced by change in the weather. I searched diligently for 
the usual symptoms of malarial poisoning with negative 
results. During the last summer he had a diarrhoea the 
course of which was marked by intermission. He now suf- 
fered from constipation. ! could not detect any atrophy of 
the limb, and did not encounter any mu:cular resistance in 
testing the functions of the joint. Theie was no joint-ten- 

On general principles I ordered five grains of quinine 
twice a day, and on the t.venlieth, nine days elapsing, he 
called to report. The report was thai his pain and lame- 
ness disappeared within a day or two. and thai he had 
been entirely well until the nineteenth, when, after a con- 
siderable running at play, he came in very lame and had 
much pain in the outer side of the thigh. His sleep during 
the night, however, was undisturbed, and in the morning 
he was "all right again." I still found the joint functions 
normal, The mother, in response to inquiries, admitted 
that a sewer-pipe near her house was open. The quinine 
was continued in the same doses, and on April ;6lh I ex- 
amined the boy again, to find nothing whatever in the way 
of sign or symptoms. The quinine had been continued 
two weeks after the date of the last visit, and there being 
no further indications for Its use the mother had discon- 
tinued it of her own accord. 

The patient was conditionally discharged, and on May 
9th he called again complaining of a sharp attack of pain 
the day before, during damp weather. There was also this 
morning a little stiffness at the joint, as he had considera- 
ble difficulty in getting the stocking on. Still no joint 
resistance. The quinine was ordered again, and the mother 
was instructed to renew it on the recurrence of symptoms. 
From this time to February 20. 1883, he had one light 
attack tif pain, which soon passed off. 

Then, again, there are cases of neuralgia, wherein both 
hips seem weak and the limbs unsteady. The first symp- 
toms here, perhaps, begin years before in the wake of an 
intermittent fever. A condition of chronic malarial poison- 
ing is present, and quinine will not meet the case. Arsenic 
in some of its preparations better fulfills the requirements. 

I have seen speedy relief follow the use of the cautery in 
contractions of the ham-string muscles. For instance, I 
have applied it in light strokes to the lumbar spine in a 



A 



NEUKOSE.S OF THE HIP. 



73 



case where the contraction had existed for six weeks, to 
find entire relief the following day. 

The prognosis is good in the contractions accompanied 
by spinal tenderness. This predicate I employ, however, 
when the nature of the affection is fully appreciated. The 
proneness to recur under like causal conditions is certainly 
well established. In the neuromimetic forms the prpgnosis 
is not so good. The symptoms may continue indefi- 
nitely. Sooner or later, however, some one makes a 
correct diagnosis and the case speedily terminates in 
recovery, or in other neuroses. The same difficulty is met 
with in the hysterical cases; and in the neuralgic symptoms 
may come and go for years. 




I. Rheumatism of the Hip, — II. Rheumatic Arthritis u 
THE Adult [Malum Cox^ Senile]. 



One of the most common errors with which the general 

practitioner is charged is that of ca:ling hip-disease (chronic 
ostitis of the hip) "' rheumatism," Scarcely a week passes 
but that a patient suffering from the disease well advanced 
is brought to the dispensary, the parents asserting, "my 
said it was 'rheumatism'.'" It is s ' " 



of disease at the hip is reported 
testimony of the friends is inserted 
the evidence with much allowance, 
I have felt no disposition to censu 
has made such a diagnosis. The 
often very like that of 



,vithout this 
I have always taken 

the gentleman who 
if this dreaded 
larticular rheu- 



matism, and for several days and weeks even the symptoms 
run along almost parallel one with the other. I have very 
little doubt but that the surgeon who prides himself on his 
diagnostic skill occasionally commits just as great an error 
{considered as an error) in calling cases of rheumatism 
■' hip-disease." I have now the history of a case spread 
out upon my books, in a male child two years of age, whose 
symptoms began with sharp pain in the left thigh one night 
at eleven o'clock, causing loud cries, and next day there 
was decided redness with a little swelling on the upper 
third of the leg, same side. This child was treated, so I am 
credibly informed, with weight and pullyfor "hip disease." 
When I saw the patient one month after the invasion of 
the disease there was effusion in with extra heat and ten- 
derness about both ankles and the left knee. The symptoms 
were subacute in character. The mother was herself typi- 
cally rheumatic. Under soda salicylate, vigorously cm- 
ployed, the symptoms soon subsided, and in a week he was 
walking quite easily. A few days latter I succeeded, for 
the first time, in making a thorough examination of the 



u k. 



A 



RHEUMATISM Or TllL HIP. 



75 



impairment of function and no 
n after all these changes for llic 
in chaige, (lie father reported. 
, and was willing to make affi- 



I 
I 



hip, finding absolutely no 
tenderness whatever Eve 
better, the physician first 
called in, examined again 
davit that the case was one ot " nip-oisease. ■ 

Wc have been educated up to a positive fear of making a 
diagnosis of rheumatism, especially muscular rheumatisiii. 
One dreads criticism, as do some malariapliobists. In 
some localities it requires much nerve .o call a disease 
malaria. Those wiseacres who love to talk learnedly 
about subacute gastritis, perisplenitis, etc., lie in wail for 
the malarial man. Now 1 am pretty firmly convinced that 
many cases are correctly diagnosticated rheumatism out- 
side of the large cities, and that good results follow. It 
has been my privilege as a specialist to come in contact 
with many rheumatic cases, and I have recorded a few that 
I shall refer to in ihis chapter. 

The term rheumatism, as applied to the muscles, is depre- 
cated by some authorities. They prefer lo speak of 
myalgia. Myalgia simply means pain in a muscle, and 
nothing more. Rheumatism carries with it not only pain, 
but pain on movement, tenderness, and a rise of lempera- 
lurc, frequently associated with other constitutional 
disturbances. It does not necessary mean a palpable 
myositis, as some clinicians would seem to intimate. 

Dr. Garrod, in Reynolds' System of Medicine, defines 
muscular rheumatism as "an affection of the voluntary 
muscles, of an inflammatory nature (?), but unaccompanied 
with swelling, heat, redness, or febrile disturbance," 

On October u, 1878, a medical friend asked me to see his' 
little daughter, two years of age, in whom the mother had 
observed, on the and, a manifest indisposition. The rectal 
temperature was 103°. The day previous the child had 
eaten grapes and had swallowed the pits. A cathartic was 
administered immediately thereafter, and the pits were 
passed, per rectum, the next evening (the and). All day 
the little patient complained of pain about the shoulder 
and in the arm, was restless the next night, her tempera- 
ture that day ranging from 102° to 103°. On the 4ih the 
symptoms had subsided, and she was well on the 5th. 
There was no lameness of any kind. 

On the morning of the 6lh, while the mother was dressing 
the child it complained of pain in the left thigh and in lln- 
left foot, crying if haniiled much. ;in.i was noticed walkinj^a 





76 DISEASES OF THE HIP. 

liitie ianie — jusl a mere hall it was. This lainene 
linued without change one way or the other duri 
7th. the 8tli, and the 9th, and during the night any 1 
in the crib would be accompanied by moaning and 
iloud. There was no pain at this time in the . 
shoulder. Whenever any one grasps tlie hip in lifting 
her au outcry is made. The father I knew to be a sufferer 
from occasional attacks of muscular rheumatism, and he 
regarded himself us a typical rheumatic. On my examina- 
tion I found the child walking with a decided limp, mor| 
correctly described as a halt. She stood on the limb with) 
out any evident tenderness, and there was nothing abnoi 
mal in the position. The naies were unchanged, and there 
was no muscular spasm or resistance of any kind when I 
executed with the thigh the various movements of the hip. 
The joint was not tender by any test employed; there was 
no atrophy, no swelling or induration at any point, and no 
spinal sign or symptoms could be disvovered. 

Four days later, in the evening, I made an examination 
with tiie same tare, and the lameness, as on the fust exam- 
ination, was absolutely the only sign I could discover. It 
occurred to me at this date tliat this lameness partook 
more of the nature of that due to paresis of the nnierior 
tibials, yet I could not appreciate any atrophy. I learn that 
in the morning whej) ihe child is set upon the chamber-pot 
it complains of pain in the left liip, and raises this side of 
the nates from the vessel. I had scarcely ventured on a 
diagnosis up to this time, but was gradually eliminating 
.bone oi' joint disease. A day or so later I employed the far- 
adic current diagnosticaliy and the result was negative. 
The lameness and morning tenderness continued, gradually 
growing less, however, until the z3th, when all disappeared, 
and the case was discharged cured. There has been no re- 
currence of symptoms, however light, up to the present 
date. 

It will be seen then that the occurrence of pain in a fleshy 
part preceding lameness, tenderness, or pressure over the 
muscles, constitutional disturbance more or less marked, 
and a family history in which rheumatism is present, con- 
stitute the chief symptoms by which one is to be guided. 
Then the perfect freedom of joint movements, together with 
a limp which is suggestive of loss of power rather than the 
stiffish limp of chronic ostitis, known to all orthopedists 
the "hip-iimp," these two signs are quite sign'* 



lopedists «^^ 



RHEUMATISM OF THE HIP. 77 

curious case, wljicli puzzled not only myself but several 
olher gentlemen to whose diagnostic skill I always pay 
humble tribute, came under my observation in 1S75, and I 
was unable to venture a diagnosis even until 1878, in Octo- 
ber, when an attack came on wliicli acted so much like an 
acute or subacute muscular rheumatism. The case in 1875 
was this: 

A female child, two and one third years of age, living in 
a malarial locality, and the daughter of a gentleman who 
combines the rheumatic and the strumous diailieses, with ' 
the rheumatic notably preponderating, was taken in Octo- 
ber of that year with pain near the left hip, chiefly confined 
to the gluteal region. Lameness came on simultaneously. 
There was no evidence of any tramuatism in the case. At 
times there was stiffness of the lower portion of the spine 
and tenderness about tlie crest of the ilium, suggesting to 
one expert a low vertebral ostitis. Another inclined to os- 
titis of the hip, although neither he nor any one of us could 
find any muscu lar resistance abotit this joint. The child was 
lame, however, for nearly five months, some days less, some 
days moie. some days not at all. There was no scream- 
ing or restlessness during sleep, and, indeed, there never 
was any pain that could be regarded as at all signifi- 
cant. The hip was blistered, moderate rest was maintained, 
and finally, just as I was coming to believe in an iliac perios- 
titis, all symptoms subsided and the child was well. 

It so continued until the second attack, which 1 studied 
more closely, and which was easier of diagnosis. 

In October. 1878, on the morning of the 17th, without 
any premonitory symptoms, the child cried on getting out 
of bed and could with difficulty be dressed, so great was the 
hyperesthesia about the hips. She was unable to walk, 
and was carefully carried down stairs. Remained sitting 
all day, unless she wanted anytliing not within reach; then 
she would hobble along by the aid of a cane, the left thigh 
being held all the while in flexion, so that the fcot would 
touch the floor only by the ball and toes. If anyone moved 
lier she cried. The weather on the i6tb — the day preceding 
the attack — changed from warm to cold, and it rained that 
night. 

On the evening of the 17th she seemed better, but was 
unable to walk upstairs, and cried this nigh: five or six 
limes while asleep. There was nothing to indicate 10 the 
lather any febrile condition. She had to be carried down 




ning of the i8th, and used the wa]king*T] 
slick in going about the floor. About the middle of the af- 
ternoon of this day I called to examine the patient and 
learned that she was playing in the yard. I could find on!v 
a irace of lameness, no swelling about the joint, no rise of 
temperature, and no resistance lo any of the movements of 
the hip carried to the normal extent. She had not taken 
any medicine. Next day she went to school, and has re- 
mained well and free from lameness tolhe ist of July, 1883, 
when she came in from school crying and complaining of 
pain in the left knee. In an hour all pain had subsided. 

Again, on the evening of the lath of August she xvas 
quite lame and suffered much from pain about the same knee. 
She could not get up stairs without assistance. All day 
long she played without any lameness or pain and seemed 
to be in excellent health. There was no restlessness or dis- 
turbance of any kind during the night, and by the morning 
ail signs and symptoms had vanished. 

Now whether the attack in 1875 was one of subacute 
muscular rheumatism, or not, I am not in a position to de- 
cide, yet my belief in that theory is very strong. The 
strumous diathesis which in her case was, and is now, SO 
well marked, stands in the way of my accepting any theory 
as to bone or joint-disease undergoing resolution. The 
parts must be without swelling, and yet the swelling may 
not be present when the examination is made. But for a cleaV 
history of this sign, and an uncertain history of a blow, I 
might have diagnosticated rheumatism in a boy aged nine, 
who came under observation in April, t88t. The family his- 
tory was exceptionally good, and he had been complaining 
only eleven days when he entered the hospital. The first 
symptom was pain referred to the left gluteal region, and 
this was on the 9th. It followed a kick on the hip by a 
playfellow, the boy reported. His sleep was disturbed by 
pain the same night, but he did not walk lame until the 
nth, when he had a chill, which was followed immediately 
by fever, and the next day there was swelling over the hip. 
He was treated, as report went, for rheumatic fever, being 
confined to his bed because of his inability to walk. Fin- 
ally he was sent to the hospital for supposed "hip-disease." 
On examination he was totally unable to walk, and it re- 
quired considerable effort on his part to stand. The spine 
was normal, and there was no infiltration or swelling about 
the hip. Flexion and extension, when carried lo extremes, 



A 




RHEUMATISM OF THE IMP. 79 

gave him pair. The left natis was flattened and the gluteal 
crease obliterated. As he lay, in tlie dorsal decubitus the 
thigh was flexed and adducled to a slight degree. Under 
expectant treatment he soon recovered, and was ready for 
discharge six weeks after admission. The slight resistance 
to movements, the position of ihe limb, the chill and fever 
followed so closely by ihe swelling, which the parents re- 
membered and described so well, and the present recovery, 
pointed to a traumatic cellulitis, which underwent resolu- 
tion. 

To diagnosticate, then, a muscular rheumatism in the 
vicinity of the hip, the following points are necessary if it 
occurs in a young child : 

1. A rheumatic history in one or the other of the parents, 

2. A sudden invasion, the first symptom being pain. 

3. Muscular hypersesthesia more or less pronounced, 

4. Absence of deformity. 

S- Absence of resistance to normal joint movements. In 
older children it seldom occurs, and in adults it sometimes 
occurs, but then it is more apt to be confounded with sci- 
atica ^nd to be associated with a lumbago. Difficulties in 
diagnosis will therefore seldom occur tn adult life. 

In the rheumatism which affects the immediate periar- 
ticular structures it so seldom affects this joint alone that 
one will have little or no occasion for differential diag- 
nosis. 

In youth, however, and in adult life we occasionally have 
articular rheumatism, affecting this joint, and the symptoms 
differ little from those of ordinary polyarticular rheuma- 
tism. In the subacute and chronic forms, it becomes diffi- 
cult in certain stages of the disease to distinguish between 
this and scrofulous arthritis. 

In May, 1880, I saw. with Dr. M. T. Scott, in Lexington, 
Ky., a case of joint disease in a girl fifteen years of age. 
There was the shortening, and the ati-ophy, and the defor- 
mity characteristic of strumous disease. Yet the amount 
of motion and the exceptionally clear hlstor)' Dr. Scolt gave 
me rendered the diagnosis comparatively easy. The de- 
formity was of two years' standing, and there was phthisis 
in both father and mother. This strumous diathesis, I 
judge, served to retard recovery, even in the case so clearly 
rheuiftatic. I neglected to add to the above report that I 
found joint roughening in the knee, and in the shoulder, 
the elbow, and the wrist. A year later the lighi hip becar-'- 




8o DISEASES OF THE HIP. 

similarly affected bu" a rest for a week or two and a 
rheumatic remedies served to avert any of the subsequeni 
results to which its fellow was subjected. ■ 

When the rheumatic inflammation is limited chiefly to thfl 
periosteal tissues in close proximity lo the capsulai '"_ 
ment, signs may present that will render diagnosis exceed- 
ingly difficult. I have only within a fewdays satisfactorily 
accounted for some signs' that I found in the fall of 1880 
which led me to record as belonging to neuromimesis 
some very positive signs in the winter of the same yeah 
which led me to diagnosticale a chronic articular ostilia 
peripheral and periarticular in origin. The case has be< 
very puzzling for the past two and a half years and 1 a.m 
just now firmly convinced that I have unconsciously ha^ 
under observation all the while a very interesting forn 
chronic periarticular rheumatism of the hip. The ( 
will certainly bear a detailed history, 

A boy eight years of age was transferred from the Hoi 
for the Friendless to the hospital in the latter part of Se[l| 
tember, 18S1, without a reliable history. It was reportoi 
that the father was intemperate and worthless, and tha| 
the mother was dead; cause not known. Six or'sevt 
weeks prior to admission, he was observed lo walk as iQ 
something ailed his ankles. The gait was unsteady. 
complained at the beginning of pain about these joints, yet 
had no febrile reaction, did not take his bed, and in fact 
was not regarded as a sick boy. These symptoms were 
followed within two or three weeks by pain and stiffness at 
the wrist joints. 

On examination nothing in the way of physical signs 
could be discovered save some rachitic changes the sternum, 
in the sterno-clavicular articulations and at the knees. 
While the gait was a Ultle unsteady there was no lameness, 
and no spinal tenderness could be elicited. There was no 
heart murmurthat 1 could discover. When asked to locate 
the pain he pointed to the knuckles and to the tibio-tarsal 
joints. It was supposed that the boy was auiemic, and 
nothing more. 

After a month's observation the case was still enveloped 
in obscurity, the gait was evidently that of an ankle-limp, 
and yet I could not detect any other signs of articular or, 
periarticular disease. The whole Hmb was hyperEcthcsic, 
the dorsal spine was quite tender, and the foot had beei^ 
frequently seen hanging in equino-varus. 




<t had beei^H 
eemed as ^H 



RHEUMATISM OF THE HIP. 



Si 



there was after all a neurosis of spinal origin — possibly only 
a neuromimesis. Topical treatment was directed to the 
spinal area of tenderness, and there was a decided improve- 
ment noted in less than a fortnight. The gait did not be- 
come perfect, however, and in the latter part of December I 
subjected him to a careful examination of the hip, especially 
as I fancied he was slowly acquiring the hip-limp. I 
selected a hard table, removed all the clothing and found 
the following signs: Rotation inward with the leg fully 
extended could not be made to the f^ame extent as could 
the fellow limb under the same circumstances, the limita- 
tion of motion was very marked; the thigh could be flexed 
and extended and abducted over as complete arcs as could 
corresponding movements be made in the other limb, 
Negatively, there was no atrophy, no infiltration, no signs 
in ilio-costal space or iliac-fossa. The diagnosis on the 
strength of the persistent lameness (so light that it could 
with difficulty at limes be recognized) and this resistance 
lo perfect rotation was recorded as chronic ostitis, prob- 
ably central, in the neighborhood of the hip-joint. By the 
middle of July, i88r, the lameness was more marked and 
was regarded as characteristic, yet the signs at the hip had 
After an intermittent form of dvsentery in 
irked. 



the 




and in December he complained of pain, referring it lo a 
small area just below the trochanter major. In the spring 
it became less marked, and the signs seemed so insignifi- 
cant, that in July even expectant treatment was suspended. 
He enjoyed perfect (?) immunity from symptoms and signs 
until the following September when the lameness returned. 
He complained much of pain in the hip, and there was 
found marked joint tenderness. A fly-blister wiis ordered. 
the symptoms subsided soon afterward, and in November, 
another was applied. He was worse the last week of 
December. Without any special treatment he recovered 
from this exacerbation, and has continued well to date. Still, 
liulding on to ilie diagnosis of bone disease, I wondered 
why the evolution was so slow, and on the last day of July 
1submitte<l him to a final examination, finding no lame- 
ness, no defr'rmiti', no shortening, no resistance to rotation 
or any of the joint movements. In fact, all that I did find 
was a little muscular atrophy back of the trochanter and a 
half inch atrophy of the thigh in its upper portion. While 
as above noted there is no lameness there is a certain 



82 



DISEASES OF THE HtP. 



peculiarity in his gait difficult to describe. He lias now I 
well-marked mitral regurgitant murmur, 

At all events, my final diagnosis, of his case is tli 
chronic rheumatic arthritis at first poly-articular, final^ 
monarticular, the lesions in the last joint being penartictfi 
lar with exacerbations, the joint becoming involved by c 
liguity at these times, giving rise to temporary synovitis, J 

Now I am prepared to state that the diagnosis of a let ' 
like the one in the case I have just reported ought tc 
easy., i.e.. with a knowledge of all the facts I had in my 
possession. The muscular element was not a part of this 
case, except in so far as the nerves affected the muscles. 
The same law holds good in chronic rheumatism, that 
holds good in other chronic diseases, viz., the law of ex- 
acerbation, and with this before our minds, the peculiar 
phenomena of this case are readily explained. At first 
we had the ankles affected, then the wrists, both perhaps in 
separate exacerbations. A little later came the hip symp- 
toms, and these continued with long remission for two and 
one half years. The spinal tenderness and hypeia;sthesia 
may have iieen due to a hyperasmia of the meninges and 
may thus have affected the nerves. With his heart lesion 
now fully developed, the final outcome of the case is a ques- 
tion of much interest. 

The disposition of a rheumatic periarthritis to invade 
after long intervals the joint is well known in the history 
of this disease. We have at present a boy, nine years of 
age, in the hospital, who came several years ago under 
treatment for chronic articular ostitis of the knee. There 
were all the signs, including the deformity, that go to make 
up the features of such a case, and under the usual treat- 
ment a surprisingly good result was had wilhin a few 
months. It seemed very odd that this boy, in the same 
ward with other boys who were even less deformed than 
he, should so far outstrip them in the race for health and 
soundness of limli, yet such was the fact, and 1 was com- 
pelled to think of his case as an anomalous one. After a 
year or two he was readmitted with similar symptoms, 
greater deformity, and in addition a marked distension of 
I 111- svnnviyl sac. Merely an unusually acute exacerbation, 
thought I, and sure enough it subsided promptly under 
rest and extension apparatus. Up to this time, bear in 
mind, he had not exhibited any signs in any of the other 
joints — but a few months later the other knee, after a con- 



A 



RHEUMATISM Ol' THE HIP. 83 

tusion of the shin, took un inflammatory action, and the 
synovial sac soon filled. A double ostitis now, it seemed to 
me, only in this instance the synovial membrane became 
quite early involved. The prognosis was gloomy and the 
case caused me considerable anxiety. However, these symp- 
toms subsided, contrary to expectations, and the deformity 
of both limbs was overcome. Later still, he began to com- 
plain of pain at his left tibio-tarsal joint, and in a few days 
redness and swelling followed. Then it dawned upon me 
thai this was a' case of chronic rheumatism, beginning as a 
monarticular variety, and subsequently involving other 
joints. Occasionally a case presents with an unmistakable 
rheumatic history, joint swellings, etc., and subsequently 
develops true bone disease. One is inclined to believe that 
even bone signs are but rheumatic signs until an abscess 
forms. 

I well remember in all the details, a case that came 
under my care in 1881. It was in a stout, robust-looking 
girl, eleven years of age, who came into the hospital on 
August 26th, and a history was given which ran about as 
follows: In October, 1880, she began one day, without pro- 
vocation, si. l";ir as the family could learn, to complain of 
pain in the right groin, and was feverish; two days later 
her ankles swelled, the febrile symptoms continuing, and 
among these symptoms profuse perspiration. In a week 
the wrists were puffy and painful. This attack kept her in 
bed for three months, and for two months longer she was 
unable to walk. Since March, however, she had been get- 
ting about, after a fashion, on crutches. 

I found on examination that she stood with her weight 
on the left limb, the right nearly parallel with this, but 
rotated outward over a small arc. She was not able to 
walk without crutches. The right natis was very broad 
and quite prominent, the crease lowered. This fulness at 
the nates extended along the thigh in its upper third. 
Resistance was offered to extension of the limb beyond 
165". flexion was very nearly perfect; on rotation, which 
was limited to a small arc, a distinct roughening could be 
felt within the joint. There was no joint tenderness 
elicited by examination. I could get no articular rough- 
ening at the knee, but at the ankle-joint the roughening was 
present and the movements were limited to very small arcs. 
The left ankle-joint presented limited movements, but it 
was not so with the knee and the hip of this side. There 




was very little airophy, and while the limb was really aa 
inch shorter, as measured from the anterior superior spii 
process the pelvic accommodation was such that there was 
no practical shortening. There was no heart murmur. 
After two and a half months an abscess developed on the 
outer side of the thigh in the middle third, and there was 
extensive infillraliun of the inguinal glands. A month 
later she passed from under my obser\'ation. I found be- 
fore she left that the thigh conlil not iie Hexed beyond 90" 
or extended beyond 150". The abscess had not opened. 
Now, one would naturally expect from this girl's history 
and from the signs recognized within the joint, that her hip 
lesion was rheumatic, and yet the suppuration coming oa 
later would dispel this opinion, and the natural inferen< 
would be that the bone disease, or, suppurative periarticulai 
disease was coincidental. The roughening within the ji ' 
was exactly like Ihiit found in the ankle-joints. It is no 
very rare to find periosteal suppuration about other joints 
that are rheumatic. 1 think, though, that if a careful ex- 
amination be made, with the proper interpretation of 
symptoms and signs, it will not be impossible to separate 
the one from the other. 

Now, a case like that of a boy whom I saw in the spring 
of 1881 is not so misleading. He came under treatment for 
chorea minor of seven weeks' standing. On the subsid- 
ence of this disease he developed a subacute polyarticular 
rheumatism. This was two months after he had come 
under treatment, and among the first symptoms were pains 
in the knee and thigh of the right side. About the same 
time he walked lame, favoring this side. It was not a 
characteristic hip-limp, yet my suspicions were aroused and 
I gave him a pretty thorough examination, getting nega- 
tive results, with this exception; I could not make normal 
abduction. Under salicylate of soda he walked perfectly 
well in less than a week. But during this week the other 
hip presented the same sign. I saw him a month after- 
ward and he had no relapse. Of course, with the absence 
of deformity at the hip and the pufRness at the ankle, one 
could not well arrive at any other diagnosis than that of, 
subacute rheumatism. 

Having illustrated the different phases of rheumatism 
it affects the hip.ljoth as an extra-articular and an tnti 
articular lesion. I feel th.-it one who understands the sym; 
tomatology of rlietimatism in its diffurcnt f 



icoJ 




RHEUMATISM OF THE HIP. 



85 



I 
I 
I 
I 



examines the case with the fulness of detail that an obscure 
case should always demand — 1 feel, 1 say, quite sure that 
no flagrant error will be committed in diagnosis. The 
prognosis is nearly always good, both as to life and as to 
perfect restoration of function. If death ever does occur, 
it occurs from the heart complication. If deformity per- 
sists it grows less marked in lime, and the ultimate result 
may be complete cure. The myalgic affections are very 
favorable as to prognosis. Even if recurrence of symp- 
toms come on the tendency is not, like bone-disease, to im- 
pair the tissues more and more after successive exacerba- 
tion, but to gradually wear itself out. The tendency is 
always toward recovery. 

The Treatment of rheumatism need not occupy our 
attention long, for this is well considered in all text-books 
in general medicine. Of course, if one makes ihe diagnosis 
of muscular rheumatism in a child there is no special treat- 
ment indicated. The treatment on general principles will 
yield good results. It is the deformity we are called upon 
to treat, and this sometimes becomes very difficult. The 
majority of cases of stiff, or partially stiff, rheumatic joints 
require passive motion under an anaesthetic. This treat- 
ment is the orthodox treatment, but many find that poul- 
ticing the parts for several weeks and then employing 
passive motion is very effective. This is the plan essentially 
of the " bone-setters." and the success with which they 
meet should induce us to make more frequent use of it. 
Passive motion without an aUEesthetic only induces muscu- 
lar resistance, and on each attempt the resistance is the 
greater. I am not speaking now of the plan wherein pre- 
vious poulticing forms an essential part of the trealmcnl. 
In studying cases of anchylosis of the hip, in which bone- 
setters have achieved success, 1 find that their most brilliant 
results have been in rheumatic cases. 

An important question in therapeutics is this : should 
the parts be put at rest for a week or two after a biisement 
forci under an anaesthetic, or should passive motion be con- 
tinued daily without the anaesthetic? In other words, how 
long should one wait to begin such daily motion. There 
is testimony on both sides, but I am very sure that I have 
seen the best results in cases where at least a week's rest 
followed the operation. 

I saw a case about a year and a half ago, in a young girl 
eighteen years of age. Bntii hips had become horribly 




deformed after an acute attack of rheumatism. She waS^ 
entirely helpless, and the ankylosis seemed almost com- 
plete. For raoiitlis she had not been out of an invalid 
chair. The patient came, on my recommendation, under 
the care of Dr. Jno. H. Ripley, in Si. Francis Hospital. 
He employed great force under an anaesthetic in freeing 
the right liip of its adhesions, and placed il, after a few 
movements in flexion and extension, at an angle of about 
150° and put the parts at rest. He did not repeat the ope- 
ration for several weeks, and then the force was very slight. 
Two operations on this limb served to bring it not only in 
good position, but to bring about a good arc of motion. 
Later he moved the left hip, and found the adhesions here 
much greater than those of the right side. The final out- 
come was a pair of limbs with which she could go about 
with comparative ease. 

Mr. Brodhurst very properly insists on complete flexion 
in these attempts. Extreme extension should be avoided 
for fear of surgical fracture. 

CHRONIC RHEUMATIC ARTHRITIS (mALUM COX^-SEMLB). 

We find a disease of the hip appearing In the latter 
of adult life, described by authors as malum coxa; se 
and while there are many cases in which no rheumatic his- 
tory can be found, the impression prevails, nevertheless, that 
there is a rheumatic diathesis present, called into action 
by traumatic influence. I have met with a large number 
of cases, and I must confess that I fail to find in the ma- 
jority any characteristic rheumatic element present. The 
inception is not marked by notable symptoms. Frequently 
it is not unlike that of a chronic articular ostitis. Bone 
changes do occur, yet they occur as a result of osteo- 
plastic inflammation, and then we have more properly an 
arthritis deformans. 

The pathological changes 
assign to the clinical feati 
based on morbid anatomy, 
within and without the joint 

tent, and resolution occurs to such a degree that one ap- 
preciates on late examination nothingmore than the char 
acteristic intra-articular grating of chronic rheumatism. 
Tn some cases, again, the tissues immediately involving the 
joint, such as the ligaments and periosteum, seem to be the 



fsfl 



not constant enough to 
of the disease a name 
Dme cases the structures 
uplicated to a large ex- 



A 



CHRONIC RHEUMATIC ARTHRITIS. 8/ 

only structures involved, and the resistance to movement 
in ihe convalescent period depends on periarticular adhe- 
sions. While in another and a more formidable class, 
bony changes take the form of osteophites, or stalactites. 
locking in a measure the articulation. If one looks over 
the pathological specimens in the different museums a feel- 
ing of therapeutical despair comes over him as he examines 
the old rheumatoid hips. The head of the bone has assumed 
all manner of shapes; osteophiies and stalactites encircle 
the rim in irregular arrangement, the cartilage has disap- 
peared, and one really wonders how any measures looking 
toward the restoration of the joint functions could have 
ever been sucsessful. 

It is a clinical fact, notwithstanding these cabinet curios- 
ities, that much in the way of relief, either through time 
or therapeutics, is accomplished. It is also a clinical fact 
that the ankylosis is in many cases far from complete, and 
that a patient with a limited amount of motion, and with 
the limb not deformed to any exaggerated degree, gets 
about quite comfortably. 

Before proceeding to the clinical history of these chronic 
forms of rheumatism occurring in persons beyond the age of 
forty or fifty, 1 shal! refer, at least, by way of illustration, 
to certain forms that begin as acute, or subacute inflamma- 
tions, and are found in adult life prior to the age of forty. 
,A very good case for study came under my observation 
in 1879, in the person of a vigorous looking man twenty- 
five years of age. His vocation for several years had t 
posed him much to cold and wet weather, and in the w 
tcr of 1876-77 he had an attack of what was called lumba(_ 
from which, however, he recovered in two or tiiree months. 
In the spring of 1877 he was thrown violently from a sleigh, 
striking upon the left hip. but was not bruised in the exter' 
nal parts so far as he could determine. Yet he was stifE 
and lame for a week or two thereafter and suffered a mod- 
erate amount of pain at the hip. Within two weeks the 
symptoms subsided and he was quite well again. 

A week later, after unusual exposure to wet weather, he 
" took cold," and this " seemed to settle in his joints," The 
hip, knee and ankle-joints were affected. The two last 
named were much swelled, very painful, and very tender. 
He suffered also from shooting pains in the thigh and groin, 
yet he did not give up work for a month. The symptoms 
and the signs became so severe that he finally had to de- 



88 DISEASES OF THE HIP. 

sist, and for a couple of months he was barely able to 
hobble about on crutches. Then the knee and the ankle 
symptoms subsided, while the hip was subjected to treat- 
ment by weight and pulley and a hip-splint for a year. At 
one time in the early part of the extension treatment there 
was very annoying reflex muscular spasm about this joint. 
On examination I find four inches atrophy of the thigh; 
resistance to flexion beyond an angle of 135°! lo extension 
beyond 165", to complete abduction, and to both adduction 
and rotation even to a limited degree. Pain is teU in 
the joint and in the distribution of the sciatic nerve on 
concussion and on pressure over the trochanter. The in. 
guinal glands are large, and the natis is flattened. There is 
moderate lordosis. Under ether the thigh was moved over 
a large arc, and adhesions apparently within the joint were 
pretty thoroughly broken up, but no bony grating could be 
recognized. The muscular resistance which before was so 
marked had now disappeared. There was some muscular 
resistance, however, to complete extension. I could not de- 
lect any real shortening of the limb, but there was an ap- 
parent shortening of a half inch. The circumference of 
the thigh measured four inches less than that of the right, 
and the calf measured one inch less. No rheumatic signs 
could be discovered at the knee or at the ankle. On com- 
ing out from llie anaesthetic the movements could be made 
quite as easily, though the muscles were so deficient in tone 
that he could not voluntarily flex and extend. In other 
words, there was found the remains of an arthritis and a 
marked loss of power in the periarticular muscles. The 
faradic reactions were good, thus eliminating a true paral- 
ysis. 

Now, while the man presented acase of true joint-disease, 
with the characteristic muscular atrophy, the process had 
been unusually acute, and yet 1 can not help believing that 
the same tissues were involved as are involved in older per- 
sons. Senile changes in tissues we know proportionately 
modify the inflammation. That this was a case of monar- 
ticular rheumatism, although apparently excited by trauma, 
I think there is abundant evidence. 

I had an opportunity of seeing a case in the active stage. 
The patient was a commercial traveler, and he was thirty- 
nine years of age. He was very helpless, and any attempt 
at passive movement of the right hip caused great pain. 
Tile whole groin and gluteal region were infiltrated to a 



I 

I 





CHRONIC RHEUMATIC ARTHRITIS. 89 

marked degree; the limb was lying nearly parallel with its 
fellow, but was in outward rotation. There was no real 
shortening, the position of the pelvis giving a shortened ap- 
pearance to the limb. 

The pans about the knee were the seat of pain and swel- 
ling. He had been suffering very acutely for two weeks or 
more and was much exhausted. Hence my examination 
was not very satisfactory. 

The first symptoms were a heavy dragging feeling and 
pain m the right thigh, three months before. He had been 
much exposed to damp weather while travelling in the 
West. The symptoms were aggravated by walking; in fact, 
it was not more than a week before he was confined to bed 
with the usual constitutional disturbance of an inflam- 
matory disease. The inguinal glands soon became infil- 
trated, and the physician in attendance found suppuration. 
After a six days' exacerbation, he had a remission lasting 
two or three weeks. The symptoms subsided, but the 
lameness and stiffness of the hip continued without abate- 
ment, A relapse followed. 

I saw him January 13d, and employed hot fomentations. 
He was able lo get about on crutches by the first of Febru- 
ary. Anti-rheumatics were administered, massaije em- 
ployed and later the (aradic current was used daifvfora 
couple of weeks. By April ist he was walking without 
any assistance, the limb presented very little deformity, and 
he went " on the road " again, pursuing his vocation. He 
made a very fair recoveiy. 

The case illustrates a clinical fact recognized throughout 
the whole range of medicine, viz., that acute diseases resolve 
with infinitely less impairment of function than those that 
are essentially chronic in nature. My prognosis in this in- 
stance had been gloomy enough. 

In the early part of the present year, a man fifty years of 
age. came under my care for a peripheral paralysis, and I 
saw in him a peculiar limp that led me to examine the hip, 
which was found ankylosed in the straight position. He 
claimed to have been perfectly well two years ago, and to 
have come of a family free from any rheumatic disease. 
Never in all his life had any other joints been affected. In 
1869, a man gave him a kick in the groin, and the superficial 
parts suffered contusion, which was followed by pain 
and lameness for six mimihs. He did not give up work and 
had no special line of ircMinirnt. hdt gradually got better. 



1 



DISEASES OF THE HIP. 



garded s 



1 less than i 
5 retuM 



year the functions of joint were r»M 



1 of symptoms or signs until the b««| 
ginning of iSSi, when liis attention was drawn to tlie limbfl 
again by a peculiar cramp-like feeling in the groin immedi- I 
ately before or after a storm. He found, too, that the 
this year was not so useful. He favoied it at firs 
finally a well-marked limp was manifest. At no tiir 
he been compelled to give up work, and at no time has he.j 
had any very acute exacerbation. The case, it would seei 
from the history, had progressed slowly and almost withoul 
an incident. What connection the lesion fourteen years a 
has with present one it is hard to determine. That the c: 
at present is one of senile joint-disease I am well sat-isfied; 

I knew a man fifty eight years of age who attributed I 
similar condition of the hip to the wearing of a truss, and a!| 
surgeon of world-wide reputation, after examining him on 
two different occasions, wrote me that he looked upon the 
truss as the cause of the chronic rheumatic arthritis ! The 
hernia first appeared at the age of fifty-five. A year later, 
he began to walk lame, and during the next twelve months 
the following signs slowly developed: limitation in the arc 
of motion, morning stifness, pain in hip after a storm, rota- 
tion outward, and apparent shortening. I could not elicit 
any facts pointing to a rheumatic element either in himself 
or in any member of the family. He walked when I first 
saw him (which was two years after the first symptom) with 
a very marked limp and was compelled to use a cane. 
From both the umbilicus and the anterior superior spine 
I made out an inch and a half shortening of the limb. The 
natis was very broad and while the trochanter stood out 
very conspicuously from the pelvis, it did not appear above 
N^laton's line. The position was slight flexion, and abduc- 
tion. The limit to extension was i6o°, to flexion 135°, and 
the arc of rotation was very small. Abduction was resisted , 
the moment the act was attempted. I could not recognize 
any joint grating, but there was a peculiar crackling sens^ 
tion imparted to my hand as 1 moved the hip. This I founq 
was in the periarticular tissue. The thigh was three inchol 

smaller than its fellow, and the k 

respe-tively. 

Now the two cases I have just n; 
the clinical history, and fiom these 




CHRONIC RHEUMATIC ARTHRITIS. 91 

1. The invasion is not marked by any distinct train of 
symptoms. 

a. Tlie progress is exceedingly slow, and marked by long 
remissions and sliort exacerbations. 

3. The signs arc. first, siifness; second, change in position 
of limb; tliird, shortening. 

4. That a clear rheumatic history is absent in the major- 
ity of cases. 

Exceptionally, however, we do get a well-marked rheu- 
matic history. My attention was called to a case while 
writing this chapter in which a chronic polyarticular rheu- 
matism began first in the right hip, slowly invad-ing the 
right knee, then the left hip and [he left knee. On examin- 
ation I find the left hip strongly adducted and the foot 
everted, while the other signs are further characteristic of 
joint-disease. The right is limited as to movement, and 
the knees on movement impart to one's hand the distinct 
rice-body sensation. 

The diagnosis is not always unattended with difficulty. 
t have eeen cases of sciatica with the peculiar deformity, 
pain on movement, and periarticular infiltration that belong 
to rheumatic hips. 

As a rule, the neural symptoms are sufficiently well marked 
to enable one to decide the question in a differential diag- 
nosis. Anterior crural neuralgia gives more of the neural 
signs that belong to rheumatic arthritis of the hip than does 
sciatica. 

A good point in differential diagnosis between sciatica 
and joint-disease is this: place the thumb of your hand cor- 
responding to the hip involved over the tuber ischii, the 
middle finger over the. trochanter, and the tip of the index 
finger fully extended, will fall over that part of the gluteal 
region along which the great sciatic passes. 

Pressure now with the index-finger will elicit pain in the 
terminal branches of the nerve. If painful sensations do 
not follow this procedure, take the other hand and place 
thumb and tip of middle finger over Irochanter and tuber 
ischii as above. The tip of the index-finger will fall over 
the capsular ligament, and deep pressure here will produce 
pain in the joint. This simple lest 1 have found very ser- 
viceable in practice. 

Fracture of the neck of the femur presents many signs 
in common with senile arthritis, and the difl^crential diag- 
nosis becomes very awkward if the fractures have been im 



92 



DISEASES UF THE HIP. 



pacted. The solution of the question will rest largely on 
the history of the invasion. If one learns that the patient 
within the first week following the injury was confined to 
bed, or was unable to walk, and that several weeks elapsed 
before the ability to walk was regained, presumptive evi- 
dence is furnished in favor of a fracture. And a fair amount 
of cross-examination in a patient, however stupid he may 
be, will enable one to judge whether the disease began in- 
sidiously ur not. The greatest obstacle in the way of mak- 
ing a diagnosis is incomplete examination. The ease with 
which one can glance at a hip, estimate measurements by 
the eye, and take for granted certain probabilities as facts, 
will always be a stumbling block in the way of correct 
diagnosis. 

The Treatment of chronic rheumatic arthritis of the 
hip is not so simple as one would imagine. It is not as easy 
to secure rest in the adult as it is in the child. Time is of 
more value to one than it is to the other. Naturally it 
would seem that counler-irriiution in a disease so sluggish 
is a very important factor in therapeutics. It is exceedingly 
hard, though, to carry out a thorough course of counter- 
irritation outside the wards of a hospital. The disease, too, 
will have made considerable progress before medical or 
surgical advice is sought. The family physician, \i may be. 
is asked in a casual way about this peculiar stifness, or this 
pain after exercise. A liniment may be ordered and direc- 
tions given the patient to " call in some time soon "" and 
submit to a thorough examination. Temporary relief may 
follow the application of the liniment; the case goes into a 
remission, and the thorough examination is not made. It 
is so easy, too, to tell the patient that this is simply a neu- 
ralgia, or a cold, or a strain, or an infirmity of age. Finally 
when the stage of shortening and deformity appears, the 
examination is made for the first time. So that treatment 
rarely begins until this period is reached. My own experi- 
ence in the use of the iodides and of the salicylates does not 
enable me to speak with any confidence as to the value of 
these remedies. If fibrous ankylosis exists, I favor break- 
ing up the adhesions under an anaesthetic and the subse- 
quent employment of faradism and massage to the muscles 
that have been so long in disuse. 1 have seen some deci- 
dedly good results follow this plan of treatment, I ha' 
already reported a case on page 87, in which the 1 
was very gralifying. 



CHRONIC RHEUMATIC ARTHRITIS. 



93 
s with 



I 



Dr. H. P. Geib, of Stumford, asked me to sec a 
him last spring, and as the clinical history is not only ^ 
illustrated, but also the value of thL> treatment I have just 
advised, I propose giving some of the more important de- 
tails. The patient was a gaidener of robust frame, forty- 
seven years of age, and had always been in good health 
prior to the beginning of his present infirmity. About a 
year ago, while much exposed to wet weather, he first ex- 
perienced a dull pain in the vicinity of the hip and at the 
knee. It did not cause him much annoyance until lameness 
came on a few weeks afterward. No interest was aroused 
in his case because he rarely made any complaint. Exacer- 
bations of pain and stifness were induced, he thought, by 
weather changes. Still he became more lame, the lameness 
increasing very slowly, yet even this did not occasion any 
alarm. I found him standing with the right limb ad- 
vanced, in slight flexion and outward rotation. He walked 
exactly like one who had made an unsatisfactory recovery 
from a fracture of the neck of the femur. There was a 
half-inch real, and an inch and a half practical, shortening 
of the limb, one inch atrophy of the tliigli and no atrophy 
of the calf. Tlie thigh was fixed on the pelvis at an angle 
of 165°: though if a little force were employed a small arc 
of motion was secured, and at the same time a crackling 
sensation was felt, as if adhesions in the joint were giving 
way. The changes in the appearance of nates were very 
marked and very characteristic. 

What pain he had was referred to the trochanter and in 
the course of the anterior crural. I could not get any evi- 
dences of rheumatism in the history, or any account of a fall 
or injury as exciting cause. Hlistersand an ti- rheumatics did 
not effect any good, and two months afterward, assisted by 
Drs, Geib and Hungerford, I broke up the adhesions very 
easily under ether. He was kept at rest in bed two weeks 
and the operation was repeated. Finally it could be done 
without an anaesthetic; the parts were soon quite free of any 
resisting bands and under friction and rubbing the recovery 
was nearly complete when 1 last heard from the patient. 

When the exacerbations arc present symptoms are to be 
treated, and for the pain hot fomentations yield the best 
results. Stimulating liniments naturally suggest them- 
selves, and pain disappears after a few applications. Anti- 
rheumatics internally certainly modify the duration, and 
whichever drug the practitioner is best pleased with is 
the drug in employ. 




I 



I 



CHAPTER VI. 

Coxo-Femoral Periarthritis. 

The abundance of cellular tissue about the hip, the ex- 
tent of the fascia superficial and deep, and the exposure of 
the parts to traumatism, render this region peculiarly 
liable lo inflammatory conditions, usually acute in char- 

The lesion, as a rale, is confined to the soft parts, and the 
inflammatory products are bound down by the dense fas- 
cia and the muscles thus restricting the joint movements lo 
small arcs. In rheumatism the seat of the disease is in the 
fibrous tissues, the joint, the aponeurses, the sheaths of the 
tendons, the neurilemma, the periosteum or the muscles 
and tendons. Hence, with so many tissues involved we can 
not with propriety speak of rheumatism as a periarthritis. 
The term is preferable, I think, to extra-capsular abscess 
because it does not commit us to a suppurative form of in- 
flammation. 

It is often phlegmonous; and when it involves the gluteal 
region we speak of it simply as a phlegmon. 

The exciting causes are varied, contusion and sprain be- 
ing the most frequent. Some cases follow in the wake of 
an exanthem. A few are glandular and are decidedly 
scrofulous. 

The pathology of periarthritis in adults differs from that 
in children. The term was first employed by M. Duplay 
to represent a condition about the scapulo-humeral ar- 
ticulation that had been long recognized, viz., a chronic or 
subacute inflammation of the fibrous structure immediately 
surrounding the joint, and dependent on trauma. M. Gos- 
selin described cases in which the tibio-femoral articula- 
tion was involved. The reason these authors gave for ex- 
cluding rheumatism was that the lesions were monarticular 
and were free from rheumatic history. The beha 
practically the same. Exacerbations arc followed by ad- 
hesions limiting the joint functions and inducing recurring 
attacks of an arthritis by contiguity. I do not know of 



I 




COXO-KEMOkAI. PtKlARTUUrilS. 



95 



any post-mortem observation demonstraiing a similar lesion 
at the hip. I have not had an opportunity of verifying my 
own diagnosis in such cases. In a few I have reached the 
diagnosis by exclusion, and I shouhl like to place them on 
record, but, then, on reflection ! do not see what service they 
can render to pathology. I have had under observation 
for seven or eight years, a girl now aged fifteen, and I am 
•unable lo decide upon anything further than a chronic 
fibrous periarthritis. I think a strong case could be made 
out but I shall await further developm 



When . 
is against injuri 
■uch lesion is re 

As I have no 

chronic ligamer 

self to the 



members how well protected tlie hip-joint 
;s of the fibrous tissues, the infrequency of 
adily explained. 

hing clinical to offer bearing upon these 
lous forms of inflammation, I have limited 
ule and chronic cellular periarthriils. 
The youngest patient I have had was a female aged five 
weeks, the cellulitis beginning when three weeks of age and 
terminating in resolution at the end of three weeks. In an 
Analysis of forty-seven cases of periarthritis of the different 
joints made a few years ago, I found twenty for the hip, 
sixteen for the knee, six for the ankle, three for the sacro- 
iliac junction, and two for the spine. 

""" symptoms vary according to the regions implicated. 
vasion is nearly always acute, the patient experiences 
«harp pain, increased heal of the skin and induration with 
'fluctuation if suppuration follows. As a rule, this is an acute 
jdisease and exceptions are rare. A case I have already 
ijilaccd on record in the Ameriean Journal cf the Medical 
■Seiences forms a notable exception and is as follows; 

A female, aged three years, to all appearances well nour- 
ished, was admitted to the hospital the middle of December, 
^875. The father and mother had good family histories, 
'hiie the child herself was reported as having enjoyed 
cculiar immunity from the diseases of infancy. Began to 
■alk lame one year prior to admission, and no cause could 
be assigned. This was the only sign observed, until within 
the last few weeks, when pain was complained of in the 
back, and this pain was increased by any jar or turning. 
The child was restless and wakeful at night. About one 
month ago a plaster of Paris jacket was applied by a phy- 
sician for suspected spinal disease. This proved very un- 
eomtorlable. and, failing to give support to which the child 
could accustom itself, was removed by the mother, withni" 



c6 



DISEASES OF THE HtP. 



consulting the physician, at the end of two weeks, when a 
swelling was observed over the left hip. 

This morning the child stands with left limb advanced, 
toes slightly inverted, and walks ([uite lame. The spinal 
column presents no deviation laterally or antero-posieriorly, 
and no tenderness on pressure, percussion, or concnssrion. 
! left natis is broader than its fellow, fold elongated. 



e to the 
: to the 
Thigh 



ilrophy 



I 
I 



Above the trochanter, a 

crest of the ilium, is a c 

touch, non-fluctuating, and painless on pressure. 

can be flexed to an angle of 90° without 'pair, a 

completely extended, though there is muscular 

to complete abduction. There is no shortening, 1 

of the limb, and no tenderness can be elicited at 

ifiac junction. The diagnosis is not positive, although hip- ] 

disease suspected. Treatment expectant, a compress with ! 

the roller being applied over the tumor for the present. 

On the 25th of January the gluteal tumor is perceptibly I 
stnalltfr, and the child walks with more ease. 

A few days later the nurse reports that the patient c 
plains of pain along the spine, but a thorough examination I 
is attended with negative results. 1 

By the last of March the tumor had extended below the | 
gluteal told; genera! health very good. 

Inimediately to the left of the sacro-iliac synchondrosis 
is a hardish movable tumor, the size of a half-walni 
the upper extremity of the thigh on a line with the fold of ] 
nates is a tumor larger in size, fluctuating, and painless. 
This note was made on the i6th of April. 

Both tumors increased in size, the veins thereover became ] 
very prominent, and an incision was made in June, at t 
most dependent portion, giving exit to about one pint 
pus, of fair consistence. 

Constitutional disturbance did not follow until ten days ^ 
later, when the patient became very feeble and indisposed 
to eat or make any exertion. The discharge was very pro- 
fuse and offensive. Brandy and tonics were given freely. 
while the usual disinfecting injections were employed. 
The notes from this time forward show a steady decline; 
emaciation became extreme, and all efforts, nutrient and j 
stimulant, proved unavailing. Finally an exhaustive diar- ] 
rhccaset in; this was followed by a dysentery, and in August, ' 
five days after the diarrhoea began, the patient died by 
asthenia. 



COXO-FEMORAL PERIARTHRITIS. 



97 



n examination, post-mortem, revealed the sac of an ab- 
scess about eight inches long by four wide. lying beneath 
ihe gluteal muscles, and a careful search failed most signally 
lo detect any connection with diseased bone. The hip- 
joint, the sacro-iliac joint, and the dorso-lumbar veriebree 
were carefully examined and found to be absolutely free 
from disease. 

Ordinarily, cases progress differently from the above and 
the explanation of this one must be found in the low vitality 
of ihe child. Take, on the contrary, the case of a boy aged 
ine, who was admitted to the hospital the first week in Sep- 
tember, 1877, with a history of lameness dating from the 19th 
of August, he having fallen through a cellar doorway the 
day before. He had been resting poorly for the past two 
nights. On admission, tongue is coated, pulse is 120 tem- 
perature 101.5°, and the boy is fairly nourished. He stands 
; with the right thigh advanced, knee semifiexed, and foot 
slightly everted; he walks decidedly lame, favoring the 
right side. The natis is enlarged, and presents to the 
touch an elastic feel just about the trochanter, \vhere there 
is also considerable tenderness. The surface temperature 
° lower over this region of fulness than at the corres- 
ponding point over the right hip. There is one inch in- 
crease in circumference; tenderness in the groin, but none 
in the hip, as tested by pressure over the trochanter in the 
line of the neck of the thigh-bone, and by pressing on the 
knee (flexed) and on the fool {leg extended) in the axis of 
the limb. The movements are limited in all directions — in 
8exion to 90°, and in extension to 150". There is no spinal 
tenderness, no ilio-costal fulness, no tenderness or indura- 
in the iliac fossa. On the following evening a fly- 
.blistcr was applied, and the usual after-treatment wilh 
puultices was adhered to; yet, by the middle of September, 
^^Tie infiltration had increased to such an extent that the 
loy could scarcely be moved, so extremely tender were the 
laris about the hip; the circumference had increased three 
tiches. From this lime forth it became evident that sup- 
luration would supervene, and the parts soon became 
freatly distended, the thigh assumed a dcgrre of flexion 
imounting ic .ilnnit 90". and on the ist of Oi tober there 
«fas seven inches difference between the two thighs at the 
Upper third. The boy had become greatly reduced. Ab- 
scess opened by incision, and two pints of pus evacuated. 
Tonics and stimulants were administered quite freely. The 



\ 



98 DISEASES OF THE HIP. 

case, without further detail, progressed to a cure by the J 
loth of November, the opening of the abscess having closed I 
two weeks after the incision. The boy was discharged in r 
December completely restored; no lameness, no deformity, L 
in good health. In Januarj', 1880, I sought him out, and | 
made an examination of the limb, finding a joint absolutely I 
perfect, so far as signs go. There was no atrophy of the 1 
limb, no loss of muscular power. The only sign of former 
disease was a cicatrix on the posterior surface of the thigh 
in the upper third. 

Such extensive suppuralion with so perfect a recovery is 
somewhat remarkable, did we not remember how capacious 
is the cellular tissue under the fascia of the thigh. The ' 
muscles are generally well protected against injury and I 
one often finds in bone disease, for instance, these immense J 
accumulations of pus with very little impairment of mus* i 
cular tissue. A not uncommon mode of termination, espe- I 
cially in cases of mild type, is by resolution. 

A girl, aged eight years, presented on admission a well- , 
marked swelling in the gluteal region, right side, with much '] 
pain, extra iieat and tenderness. Her axillary temperature I 
was 102.6°. She could with difficulty walk, and the joint, | 
while not tender, was limited in its movements by peri- 
articular infiltration. 

The adductors were likewise tense. Her symptoms fol- 
lowed a fall against the round of a chair fourteen days pre- I 
viously, the pain coming on the same night. Her nights | 
became restless, and the case was regarded, so the father 
reported, as one of hip-disease. The pain was chiefly re- 
ferred to the knee, and this, with the signs, made the diag- 
nosis an extremely plausible one. The direct contusion, J 
the speedy development of acute inHammation, the infiltra- 
lion, and the absence of any joint-tenderness enabled me to _ 
diagnosticate a periarthritis. Hot fomentations were cm* 
ployed, and on the 26tli of October, one month after admis- 
sion, resolution was progressing rapidly. On the lolh of 1 
December there was no lameness, no infiltration, no atrophy J 
— no pain. The patient was discharged, and two years 
afterwards I examined her again without finding a symptom 
iir sign of disease. 

Glandular suppuration in the inguinal region is of longer 
duration than when it involves the cellular tissue, but the 
symptoms otherwise differ only in severity. A girl, aged J 
five years, was admitted in July, 1876. There was entire ^k 1 





COXD-FEMORAL PERIARTHRITIS. 99 

c of any cause, predisposing or exciting, in the history. 
The first sign, a swelling, appeared in the left groin four 
nths before her admission. Lameness was first observed 
)ut the same lime. 

The patient on admission was quite anaemic. She stood 
h left limb a little advanced, and walked favoring this 
limb. When the child was placed in the dorsal decubitus so 
that the spinous processes were on the same horizonlal 
planes, the distance between popliteal space and floor was 
Ihree inches ; flexion could be made over the normal arc, 
and abduction and adduction wereeasily accomplished. The ^^^ 
thigh was one half inch smaller than its fellow in the CK) 
left groin^ about midway of Pouparl's ligament was an ^'"^ 
indolent ulcer three quarters of an inch long by one inch 
wide, edges smooth ; one inch below this lay a smaller ulcer 
in the bottom of which was a little pus. Suppurative 
lymphadenitis was diagnosticated, and the treatment con- 
sisted of simple dressings and an alterative tonic with cod- 
liver oil. These ulcers proved very obstinate, and did not 
oughly heal until March of the following year. She 
not gain sufficient strength, however, to warrant her re- 
moval from iieatmeiit ; but on April 2-jih, five weeks after 
the closing of the ulcers, the child was discharged cured, 
there being no halt whatever in her gait. 

Diagnosis. — To differentiate this from ostitis or from 
synovial diseases we must remember that bone-disease es- 
pecially, if it be tuberculous, is essentially chronic, and that 
the pain and lameness always precede the infiltrations of 
the soft parts. In this connection we recognize the import- 
ance of a clear history, for on this the facility of diagnosis 
depends. The deformity and the locality of the abscess 
furnish no diagnostic signs of importance. In this, as in 
many other joint-diseases, it is extremely difficult to diagnos- 
ticate the case at a single examination. 

A female child, aged six months, was brought to the dis- 
pensary department in June, 1881, There was a large 
amount of infiltration in the left groin and this exiendeii 
round the upper third of the thigh, the limb being rotated 
outward. I had difiiculty in getting any motion at the 
joint by reason of the apparent mechanical obstruction. 
After a little coaxing I did get smooth motion over limited 
arcs and succeeded in eliminating from my mind the ques- 
tion of a diastasis. True, I had not elicited any history of 
a fall or injury of any kind, yet the position of tjie limb, the 




DISEASES OF THE HIP. 

absence of redness of the integument naturally 
such an accident. The symptoms were iif three weeks' 
duration, ami the family histnry was anght but reassuring. 
The mother was one of iwentvone children, live of whom 
only were living. I could not find any condylomata, but 
my suspicions of syphilis were so strong lliat I 
diagnosis of hereditary syphilitic periartliritis and orderei 
one twelfth of a grain of calomel three times a day 

Seven days later the infiltration was much more circum- 
scribed, and fluctuation was discovered. Four days after- 
wards 1 made an incision, giving exit to a few ounces of 
pus, and the case progressed uninterruptedly to a good 
recovery. Within a fortnight the functions of the joint 
were normal, the deformity had disappeared, and a cure was 
recorded, I took the precaution to examine the parts a 
month later and found no relaxation of the capsular liga- 
ment and no impairment whatever to the joint. 

When there is an absence of infiltration, and when one gets 
a history of a strain or over-exertion and an insidious lame- 
ness, the diagnosis is much more difficult. In July, 1880, Dr. 
Ripley asked me to see with him a boy aged six years, who, 
three weeks before our visit, had an acute suppurative 
disease of the middle ear, with perforation of the drum. 
From this he had made a good temporary recovery. One 
week after the beginning of his ear-disease on a damp, dis- 
agreeable day, he had been taken for a sail on the East 
river, and on his return that night he cried frequently during 
sleep. In the morning there was febrile movement, with a 
disposition to flex the left thigh on pelvis. Any attempt to 
move the limb was attended with sharp cries and the 
mother fancied that the knee was swelled, but Dr. Ripley, 
who saw ths case next day, could not find any swelling. He 
did find a temperature of 104.5°, 3n<^ ^ corresponding de- 
gree of constitutional disturbance. The thigh could be 
extended quite easily, but there was resistance to abduction. 
The movements became less free in a few days, ant' 
found the limb extended, while the right was flexed 
adductcd, so that the sole of the foot pressed firmly again! 
the dorsum of the other foot, as if assisting in maintaining 
extension. There was a distinct area of induration in the 
iliac fossa glandular, perhaps, and pressure elicited tender- 
ness. The thigh could be easily extended, but flexion be- 
yond 90° met with resistance and caused pain.- Abductit 
and rotation were likewise resisted, while there was 



'iM 

n- ^ 



nstlH 



AbductitMIH 
was eotn^H 

J 



COXO-FEMORAL PERIARTHRITIS. 



101 



absence of joint tenderness. The fold of the nates was a 
Iit:lc lower on this side. Yet the gluteal region was free 
from any infittrattoD. It was difBcult to decide between a 
pcriai'thritis, and an acute bone lesion. Vet the history and 
the appreciable infiltration so speedily developed, pointed 
to the former, and ibis diagnosis was recorded. Counlcr 
irritation was advised, and on my next examination, eleven 
days afterwards, the signs were less marked and the diag- 
nosis was in a measure confirmed. 

Dr. Ripley informs me that the case terminated in a 



Pelvic cellutiti 



child is 



tof c 



1 signs, 



The 



I 



yet when it does occur the symptoi 
those of a periarthritis; indeed, it is a pen 
iliac fossa is the point of departure, and the ilio-psoas mus- 
cle is in spasm by reason of the infiltration thereabout. 

About the middle of September, 1882, a little girl, two 
and a half years o( age, was brought to me for a hip lesion 
of two weeks' standing. The process began acutely, and 
on the day I examined the case the right hip was held in 
sharp flexiim, and there was a perceptible amount of infil- 
tration in the groin and extra heat and tenderness along 
the inner side of the thigh. 1 made out a periarthritis, 
the lesion being chiefly confined to the internal iliac fossa, 
and the case subsequently came under the care of Dr. Shaf- 
fer, who confirmed the diagnosis I had made. The case 
went on to suppuration, and on the disappearance of the 
infiltration the deformity disappeared, and soon the pauent 
was discharged cured. 

On the right side one naturally thinks of a perityphlitis, 
and the signs of an idiopathic perityphlitis are not unlike 
those of a pure periarthritis wherein the psoas group is 
chiefly involved. 

A periarthritis uccurring in a neurotic subject is not 
always easily diagnosticated. The neuroses obscure symp- 
toms, and we can rely only on signs. And thus, too, if 
malarial symptoms enter as a complication the difficulty in 
arriving at a correct diagnosis is certainly very great. 1 
am reminded now of a case that puzzled me for two or 
three weeks, and it is only on a careful review of the symp- 
toms that I can" find any consolation in having erred so 
egregiously. The paiicut was a sickly, cadaveric-looking 
girl nine years of age from Westchester county, and came 
■ rvat'on in th latter part of March, i88t. She 



H under 1 



102 UlSEASES OF THE HIP. 

had always been the delicate one of a phthisical family In^ 
the preceding year she had suffered much from maisrial 
fever. Two weeks prior to my first record of her case, the 
eirl had a chill one niglu, and this was followed by fever. 
Next day she favored the left hip in walking, and Uic 
lameness continued without abatement; indeed, it had been 
steadily increasing. There was also much pain in the outer 
side of the thigh, and in the vicinity of the hip. The child 
was worse by night and comparatively well by day, and 
febrile movement had been quite marked at irregular inter^ 
vals. When 1 made my examination I found that I could 
not abduct the right hip to my satisfaction, and that rotar 
tion caused a little pain. Other movements were perfect, 
The same signs, identically, weie found on testing the ianoi 
tions of the left hip, and in addition there was marked ten.^ 
derness and a shade of fulness behind the trochanter 
The spinous processes were very tender, and in fact th< 
whole body was markedly hypera^slhetic. The pain was 
referred to the left lower extremity a few days later, and a 
thorough examination could not be had on account of thfl 
extreme tenderness. I was at a loss to make a diagnosis, 
but felt quite sure that a malarial element was present aoq 
that this might account for the spinal neuroses. 

Quinine was pushed to physiological effects, and within 
a week all spinal tenderness had disappeared. The tender! 
ness about the hip remained, however. Then I left off tha 
quinine for a week and the neuroses returned. On resmo.^ 
ing the quinine the complications gave place to the real h\ff 
symptoms, and by this lime, twenty days after admissioo, 
there was an unmistakable area of fluctuation over j 
above the trochanter. In less than a fortnight an imme 
abscess, involving the whole of the upper two thirds of the " 
thigfli was opened and the flow of pus was quite remarkable. 

It was not until the end of August that the case was pro- 
nounced cured. The neuroses by this time had long since 
ceased to annoy, the functions of the hip were perfect, and 
the girl had grown plump and hearty. Recently, two years 
from that date, I have seen my old patient, and have failed 
to find any traces, save the superficial cicatrices, of the for- 
mer disease. It all seems clear to me now, and my oalyt^ 
wonder is that I did not make out a pure neurosis of tlM 
hip. 

There was, then, the case as it stood, viz.: a penarticula 
ii-!ltilitis occurring in a neurotic subject in whom malari^ 



COXU-FEMORAL PERIARTHRITIS. 



103 



ber, then, in making 
lug points are to bu 



I 



poisoning was present. Let one reniem 
a dilTerential diagnosis, that the follow 
considered ; 

1. There may be simply a sprain or contusion. 

2. There may be a bursitis simply, and a knowledge of 
the locality of the bursa will assist materially in arriving 
at a conclusion. 

3. An exacerbation in a very slow and scarcely appreci- 
able case of chronic ostitis may closely resemble a periar- 
thritis. 

4. A neurosis from any cause, with muscular contraction, 
may be taken into consideration. 

5. A residual abscess from lumbar Pott's disease may 
present beneath the fascia. The spine should always be 

6. An acute epiphysitis may give rise to signs that will 
be very confusing. 

The diagnosis, as above remarked, becomes comparatively 
easy wben one takes into account the behavior of acute and 
chronic inflammation. 

The prognosis is good, that is, a cure can be predicted in 
from three weeks to six monihs. The deep abscess of [he 
thigh, however, is a more serious affection, and it is in such 
thai a fatal issue is sometimes to be expected. It is ex- 
tremely rare that joint-disease follows such an inflammation, 
and hence one can safely assui'e the patient that no injury 
to the articulation will ensue. I deem it my duty, however, 
to place on record this exceptional case. 

The patient was a boy aged three and a half years when 
I first saw him in March, 1882. He came with a history of 
a fall from a high chair six months previously, getting 
a sharp contusion over the upper and outer aspect of the 
right thigh. He suffered much the same night, and was 
confined to bed by order of the physician who had been 
called, for three weeks, the contusion slowly giving way to 
a circumscribed swelling. This soon terminated in abcess, 
which was opened and the discharge therefrom continued 
in varying degree up to the date of his appearance at the 
hospital. The lameness was very slight, in fact it was with 
difficulty recognized; the limbs were parallel ; there was no 
atrophy, no shortening. The joint surfaces were smooth 
and free from tenderness, and the movements were very 
slightly if at all limited in any direction. The sinus com- 
nuinirjited witii a siic lyii;^ beneath the fascia lata, but nu 




i 



I04 



DISEASES OF THE HIP. 



bone could be discovered by careful probing. A diagiiosUJ 
of periartliritis was made, and the case continued uiid 
the care of Dr. Mayer, with whom I had simply consultt 

Everytliing progressed to a wish until the latter end 
December, same year. Tlie doctor gave most encouragi; 
reports of the case ; the lameness was for months not pi 
ceptible, but the sac, which had been well cleansed froi 
time to lime, would occasionally refill, and on I 
sions the child would favor the limb. Finally Dr. Mayer 
lost sight of the case. The parents moved to another part 
of the city, the patient suffered from unavoidable ncgleci, 
and when I saw iiim again in February of this year the signs 
pointed to a well-marked case of chronic periosto-ostitis of 
the hip. Deformity had already become a prominent sign, 
and at the mother's request he was admitted to the hos- 
pital. Under a better hygiene and a modified rest he sooa 
showed decided improvement, but the separation was 
poorly borne by the mother that she insisted on reinoviaj 
him & few days after admission. 

Dr. Cheever, of Boston, in a very interesting paper 
the Boston . Medical aud Surgical Journal for April iz, 
1883, gives some cases in his own experience wherein in- 
flammation beneath the deep fascia of the thrgii led to un- 
pleasant consequences. I have myself seen cases of deep 
subfascial abscess both in front of and behind the hip, run- 
ning an extremely tedious course and leading one to suspect 
bone disease as the initial lesion. Careful exploration, 
however, fails to detect any necrotic bone. It is certainly 
the experience of many surgeons, whose field is large, Va 
find burrowing pus sacs with fungous lining membranes, 
to thoroughly open the same and to find no diseased bone. 

A well-developed lad, thirteen years of age, came under 
treatment in March, i88j, for what I regarded with some 
reservation a strain of the right hip. The only signs I 
could find on a pretty thorough examination were a Utile 
resistance on abduction, and when the thigh was forced in 
this direction, pain was complained of in the capsule (?) of 
the joint. After a long run on the first day of December, 
i88i, he felt stiff next morning, and walked lame. Pain at 
this time was referred to the groin, and gluteal region. 
These symptoms continued a fortnight, and after ten days 
of complete remission returned and were pretty constant 
ii|i to the date he presented for treatment. Ten days after 
liis first visit in March I found decided tenderness over 



oa _ 



I 




A 



cox U-l-E MORAL I'tKlARlHUlTlS. 



lOS 



[he pusierior superior spinous process of the ileum, and 
ordered a blister. 

Fourteen months elapsed before I had an opportunity ot 
seeing the case again. This was in May of the present 
year, and in March an abcess had appeared spontaneously 

under the gluteal muscles, and Jilling about all of the exter- 
nal iliac fossa, was explored with much care, and I could 
not find any evidences of diseased bone. 

There was no tentierness at either sacro-iliac or hip joint, 
the lameness was so slight as to be scarcely appreciable. 
The inguinal glands were enlarged, and there was addi- 
tional fullness in this locality without any fluctuation. 

The sac had been washed out daily, and the discharge had 
varied in quantity. The fullness in groin has increased, and 
has caused considerable uneasiness. In August 1 find a 
little fluctuation in Scarpa's space, with one or two points of 
redness and induration. The gluteal sac is discharging very 
Htile. Dr, Wm. T. Bull saw the case, explored the sac and 
failed to find diseased bone ; yet he is quite confident 
that such exists. There is very little doubt that the pus 
is burrowing down into Scarpa's space, and appropriate sur- 
gical measures have already been urged.* 

This case furnishes not only many points of interest to 



'the diagnostitian, but 
surgical interference, 
proximity to the joint, 
the sooner it can 
joint; the better il 
have groi 



s the importance 
This immense sac, in such close 
certainly a dangerous neighbor, and 
:d the better it will be for the 
I be for the health of the patient. I 
ly restive under chronic abscesses 
arising in tissues around the joint. It is dangerous con- 
servatism to let them alone. 

It is regarded by some of the more conspicuously con- 
servative dangerous to probe sinuses or explore sacs, I 
am convinced by overwhelming evidence thai is belter to 
make a diagnosis, even at the expense of injuring soft parts. 
Wounds will heal if properly treated, and they will heal it 
not treated, but sinuses will not heal where they must serve 
as tracks for the passage of pus thai is being continually 



" As Ihrsp shcct-i arc going lo preS3 Dr. Bull wril 
this day, .^u^usl 3ISI. at S(. Luke's, made free incisio 

- * )ecss. His prognosis is gocwl. 



io5 



DISEASES OF THE HIP. 



I 



manufaciured by a pyogenic membrane. The well is being 
fed all tlie while, and it must have an outlet. 

The following simple case laiight me, as a sad experience 
will always teach, the value of exploring sacs, and of omit- 
ting no recognized tests in arriving at a diagnosis. 

In the early spring of 1875, a female child, aged one and 
a half years, was brought into the office of the Out-patient 
Department, and the examination, which was very superfi- 
cial, resulted in a diagnosis of caries at the sacro-iliac 
junction. The child was feeble, and was with difficulty 
handled, on account of tenderness; the soft parts about 
the sacrum wcie extensively infiltrated, two or three ill- 
conditioned ulcers were present, and the skin around these 
was bluish, the veins were prominent, and there was a sero- 
purulent discharge which was rather abundant. I did not 
explore the ulcers and sinuses with a probe, nor did I go 
through with any of the recognized tests for the presence 
of disease at the sacro-iliac synchondrosis, I learned from 
the mother that this condition of the soft parts had existed 
for six weeks, and that the first sign she observed was a 
small point of redness and swelling, like an ordinary boil. 
She knew of no cause. I did not ask her anything about 
previous treatment — was hurried, and, as before stated, 
did not examine very closely into the case. It seemed clear 
enough to mc at that time, for I thought sacro-iliac disease 
of common occurrence. I had not seen any cases about 
which I had felt sure as to diagnosis, yet I attributed this 
to my ill-luck. Simple dressings, witli tonics and occasion- 
ally stimulants, made up the treatment for the next six 
months. I did not see the child often, yet there seemed to 
be no marked change in the signs presenting from time to 
time, and while the health was improving a little I felt 
no great uneasiness about the ultimate result. In September 
she suffered considerable pain, and there were tour sinuses, 
with targe openings, amounting lo ulcers. The mother 
calls September i8th with the child, and brings in her 
hand a piece of muslin, one inch square, which she found 
yesterday protuding from one of the ulcers. The muslin 
was far on the way to decay, and, on questioning the 
mother, she remembered well tliat, in the early part of 
February, seven months before, the doctor who opened the 
" bull" inserted a piece of muslin to keep the wound open. 
Slie did not see the doctor any more, and had forgotten 
allabuut the tent. All the sinuses closed within a week, 



COXO-FEMORAL PERIARTHRITIS. I07 

and the child soon recovered. I did not see the case 
anymore, but found the child in January, 1880. and made a 
careful examination. I did not find any impairment of the 
functions at either hip or sacro-iliac joint. There was no 
atrophy, save about the cicatrices which covered the sacral 
region. The mother reported that no relapse had ever oc- 
curred. 

With the cases I have recorded in connection with that 
part of my subject which treats of the pathologj' and 
clinical history, the transition to treatment is very easy. 

Treatment. — In no one of the inflammatory lesions in 
and about the hip is there greater call for the employment 
of correct surgical principles. We seldom have a cold ab- 
cess in periarthritis, and hence the inflammatory products 
can be treated without delay. In severe contusions rest 
and hot or cold applications are called for, as the physician's 
choice may be. My own preference is for hot fomentations, 
and by hot fomentations 1 do not mean the application of 
a bit of flannel wrung out of hot water: I mean more than 
this. The ordinary toweling orspread clnih used forcoun- 
terpanes, should be folded into several thicknesses, satu- 
rated with water heated to the boiling point, and deprived 
of its superfluous water by wringEng. Then apply immedi- 
ately the cloth thus prepared; quickly cover this with oil- 
silk or oil-muslin, and overall apply a bandage of dry cloth. 
Cloths, when properly applied, (and it will require several 
applications for one to gel familiar with all the details), 
will keep the parts hot for at least twelve hours. This re- 
peated, then, in twelve or twenty-four hours, serves to allay 
the pain very often in a remarkably short space of time. 
If abscess form, the pus should be promptly evacuated. I 
well remember a case in which this was delayed, until the 
sac grew to immense size. It was in a poorly nourished 
girl, four years of age, whom I saw first in August, 1881. 
She had never been in good health, having suffered not only 
from many of the exanthemata, but from many of their se- 
quelas- A week prior to this visit, the mother heard her 
complaining of the back. On examination, I found the 
little patient unable to walk without a stiffness of gait. The 
right natis was a little flattened, and deep beneath the glu- 
teal muscles could be fell a tumor filling the external iliac 
fossa, lenderand semi-elastic. In the dorsal decubitus, the 
left thigh could be extended completely, but abduction 
■vas resisted and painful. Roiaii'ui was perfect, and the 




any joinl-tendcrness was extremely doubtfu] 
Tiierc was no tenderness at the sacro-iliac junction, 

I made a diagnosis of periarthritis and advised an inci- 
sion. The advice was not accepted by the attending sur- 
geon. Two and a half months later I saw the case agatn,_ 
and at that time the abscess extended throughout the wholyJ 
of the gluteal region. It opened spontaneously; exteosiv^B 
sloughing followed, and the patient finally, in an extreme 
degree orcmaciation, found a home in one of the sea-side 
sanitariums. She died of exhaustion a year after the first 



appearance of the disease, 
of disease in spine, sacrum 
whole course of the illness. 

A case in an aduit excite 
two hospitals in the winter 

A woman, twenty-five ye, 
ber of that year, and pr« 



lite sure that no signs 
ip ever developed during the 



siderable interest in one or 



of age, came to me in Septem- 
d a glandular enlargement la 
the inguinal region, left side, and a small soft tumor near 
the sacro-iiiac synchondrosis, same side. There were also 
associated with this condition occasional neuralgic pains. 
The first symptoms began three years before this period as 
she was convalescing from a difficult labor. A fall nearly 
a year subsequently seemed to aggravate the symptoms. 
Tn other words, the whole history pointed toward a chronic 
cellulitis in the left side of the pelvis, and she had come to 
the hospital on account of some impairment to the func- 
tions of the hip. It did not require an extended examina- 
tion to exclude disease at this articulation, and I referred 
her to a general hospital. She was admitted and examined 
by the visiting physician, who referred her back to me for 
a truss. I certainly made out a tumor in Scarpa's space, 
and got an impulse, but it was the impulse of fluid, and I 
declined to apply a truss. The case was referred then to 
Dr. Ripley, who agreed with me in diagnosticating a pelvic 
abscess. Pressure on the sacral lumor would impart an 
impulse in the tumor in Scarpa's space. Under expectant 
treatment both of them increased rather rapidly in size, 
and Dr. Ripley admitted her into St. Francis Hospital in 
the early part of June, 1881, for operation. The aspirator 
was first employed, and shortly afterwards small ulcers 
formed. Then a free incision was made and the upper 
tumor collapsed. Through drainage was established and 
repair promptly followed. At no time was there any 
eroded bone found, and it was the general opinion that the 



A 



COXO-FEMORAL PERIARTHRITIS. IO9 

abscess did not depend on caries, or in fact on any bone 
lesion. 

When the periarthritis is glandular the surgical princi- 
ples apply here as well as in other tissues. Glandular ab- 
scesses, however, as a rule give very little cause for anxiety. 
The great danger in allowing any inflammatory tissues to 
remain long in contiguity to so important an articulation 
must be quite apparent. Orthopedic appliances are very 
seldom called for, and one need not attach any importance 
to the deformities which often arise during the progress of 
the disease. In closing this chapter I can name nothing 
more important in the treatment than a correct diagnosis. 



CHAPTER VIl. 

Bursitis of The Hip. 

From the anatomy of the hip one will tearn that severat 
burssc exist about this joint and contribute largely to the 
smoothness with which the muscles, in their action, pass 
over bony prominences. Their functions have already been 
discussed in the chapter on anatomy, and now we discuss, 
them in a stale of inflammation. Many believe that one of 
the modes of origin of hip-joint disease is through injury 
and consequent disease of the bursx, and a tumor pre- 
senting in the gluteal region, for instance, in the second 
stage of a chronic articular ostitis is often pointed out as 
simply a bursitis. Now this is very confusing, and in my 
own experience I have really come in contact with very 
few cases of unmistakable primary bursitis in connection 
with the hip-joint, and in the text-books I do not find any 
cases recorded with a generosity that will enable one to 
make the diagnosis for himself. The general praclilioner, 
it would seem, is in a position to recognize these lesions 
in the early stage by very simple methods, and this being 
done, many cases may not only be saved from joint-dis- 
ease, but from the prolonged treatment for a joint disease 
which has no existence in fact. 

Those most commonly the seat of inflammation are ; the 
bursa under the glutei lying over the pyriformis, the bursa 
in front of the gluteus maximus, and between it and the 
vastus externus, and the large bursa between the ilio-psoas 
and the capsule of the joint {see Figs, i and 2). Others may, 
and I presume do, become inflamed under the influence of 
pressure or blows, and yet they are so intimately associated 
with neighboring tissues that the recognition of them as 
individual pathological entities is next to impossible, and 
to define them as such would subject one to the charge of 
striving after "pathological refinements." The, cause is 
manifold. Bursitis frequently follows very closely a fall 
or a strain, is ofcen induced by exposure to cold, and occa- 



I 





BURSITIS OF THE HIP. 



tionally we have to adroit that it is idiopathic. It matters 
little, however, what the cause may be. It is sufficient to 
know that a strumous bursitis is not recognized. 

In 1874 there came under my observation a lad, aged 
fourteen years, with pains about his left hip and tender- 
; over the upper portion of the shaft. The case puz- 
zled me considerably then, and finally I concluded it must 
be a peculiar form of " hip-disease." 1 saw him from time 
to time, at long intervals, until 1877, when I made a diag- 
nosis of periostitis. At that time he was unable to lie on 
the left side, and yet I could not detect any lameness or 
any marked impairment of joint function. He gave the 
history of exacerbations of pain, confined chiefly to the 
upper portion of the thigh, and generally relieved by iodine 
topically employed. 

I could not find a record of any notes of his case in 1874, 
but I remembered liim very well, and remembered how 
barren of any tangible symptoms my observations had 
been. 

On the 5th of March, 1879, I saw him again, after a 
long absence, and I could detect no real difference between 
hip functions at that time and those in 1877. He re- 
ported that he had much pain — not enough, however, to 
prevent him from working — and had not been able to lie 
on his left side with any comfort for six months. The 
fulness and tenderness about the trochanter were still 
present; but it did not occur to me until December 
3d of that year (1879) that this must be a case of recur- 
ring bursitis, and on examining the parts more carefully, I 
could make out quite distinctly, by palpation, a small cyst 
occupying the proper site of the bursa which lies under the 
gluteus maximus and upon the trochanter (see Fig. 2, C), 

On the introduction of the needle of a hypodermic 
syringe a synovial like fluid was removed, and the cyst col- 
lapsed. The case seemed clear enough then, and the ex- 
acerbations of pain and tenderness he had had for the past 
five or six years were easily explained by the filling and 
refilling of the bursal sac, consequent on strains or bruises. 
A few days later my diagnosis was fully confirmed by Dr. 
1. H. Ripley. The contents were thoroughly removed by a 
nypodermic syringe, and a compress was applied. This 
ffave temporary relief, and he came under treatment again 
in March, 1880. 

The further progress of the case has been, on the whole, 



i 



112 



DISEASES OK THE HIP. 



thigh is an 
niiied him, i 
:of any dir 



satisfactory. The removal of the sac by operation was 
practicable and was not urged, because of his inabilit 
to spare the time, and because blisters would give i 
whenever a re-accumulation of serum look place. Hi 
experienced very little inconveniencesince the nature n 
disease has been recognized, 
in circumference than its felk 
and no pain. I have recently 
pretty well established. 

Here then, we have no account o 
strain to induce the bursitis in the 
does not seem fair to exclude such a cause, inasmut 
no history of the case, in the early part of lis course 
if obtained, ever recorded. 

Thi.s is unlike, in duration at least, [he case of a i'toUj 
hearty-looking girl, nine years of age, who was admitted 
the hospital on the 4lh of March, 1880, bearing from the 
family physician a written diagnosis of hip-disease. We 
could not detect any flaw in family or personal history, and 
could not trace her lameness — of four weeks" duration 
only — to any distinct trauma, although it was presumed 
that she had strained her hip while at play, as she was very 
active, and during her waking hours nearly all the ti 
her feet. 

With the lameness there came also an occasional pi 
in the knee, and an unusual sense of fatigue after playii 
all day. 

On examination I found that she stood squarely 
feet with limbs parallel, and that she walked with great ease, 
though favoring the right limb perceptibly. I could see 
a protrusion of the soft parts in the gluteal region, which 
on palpation could be made out as a cyst-like body about 
the shape and size of a hen's egg, lying deep under the 
)t tender on pretty rough handling, and 
.ny glandular enlargement in the ingui 
region. 

I could not detect any joint tenderness, or bony tend) 
ness, and could not find any resistance whatever to any 
the normal joint movements, unless, perhaps, there 1 
slight reflex muscular spasm on extreme abduction. Th 
was no atrophy of the limb, and no tenderness, para or 
ilio-costal space, 
tis was made without any resei 
be employed was blisteriag 



; is 

I 

Ii3 



^ 

Ot^ 



gluteal r 



tiltralion in iliac fossa o 

The diagnosis of bursi 
tion, and the treatment ti 





liURSlTIS OF THE HIP. 

poulticing. Three blisters were applied within the next 
two months, and there was no marked diminution in siite 
of the bursal tumor. In the absence of any acute svmp- 
the patient was discharged in June and continued 
under treatment in the out-door depariment. A compress 
and the spica bandage were used, and by September 3d it 
ely difficult to detect any fulness what 



no hip signs. 

i attended 
that the 



I 
I 



the gluteal region. There were absolutely n 
and the patient was discharged cured. 

Occasionally one finds a peculiar "click" 1 
ing joints, and the interpretation of this sig 
^'ith much difficulty. My own impressiin 
click is produced by the slipping of a muscle or tendoi 
over a bursa formerly the seat of inflammation and now 
roughened, more or less, by the resulting diminution in 
secretion. When it occurs within a joint its significance is 
easier of explanation. While examining a highly neurotic 
patient during the past winter, I met with this phenomenon, 
and it seemed to me that its location was within the pelvic 
cavity, or, at least, near the pubic rim. The case was one 
of sciatica, and in the absence of any joint symptoms, I 
concluded that the bursa under the ilio-pHoas was at fault 
as I invariably got the " click " when that muscle was sub- 
jected to traction. 

A case of very great interest, diagnosticaily considered, 
was brought to me by Dr. Martin, of Boston, a member 
of ray class at the Polyclinic, in April of the present 
year. It was a lady thirty years of age. who complained 
of a sense of fatigue and a peculiar " click," which she 
experienced on walking. It was felt near the insertion 
of the gluteus maximum, right side, and I tried in vain 
to get it by passive motion. In the recumbent or upright 
posture she was unable to produce it, no matter into 
what position she threw the limb, but let her walk across 
the floor, and with my hand over the region in question 
1 could appieciate 'the "click" quite distinctly. There 
was no arthropathy and no interference whatever with the 
nutrition of the limb. There was no swelling and no ten- 
derness. Three months before the date of mv examination 



had appeared quite 
given the Doctor, was t 
liad been impaired by i 
met with the " click " in a ca 
knee-joint, which he reports 



the bu 



bly. 

sa over the trochanter 
changes. Dr. Shaffer 
le neuromimesis of the 
nnnograph, and I infer 




DISEASES OF THE HIP. 

that it was periarticular from his explanation, viz.: It 
due to "the reduction of a temporarily displaced tendon, 
or perhaps to the reduction of a slight subluxation; in 
either event caused by muscular action," The tendon pass- 
ing over a bony prominence not covered by a bursa whose 
functions are normal, explains to my own mind ihi ^ 

dition of things. 

The symptoms, then, seem sufficiently pronounced to gil 
a clinical picture that should enable one to make a dia}^ 
nosis, and I need not dwell longer on this point than to 
refer to the difficulty of differentiating this disease from 
chronic articular ostitis of the hip, or synovitis, if the bursa 
under the ilio-psoas be the one implicated. The freedom of 
all the joint movements, save flexion in extremes, and the 
presence of the inguinal tumor, which increases and sub- 
sides under exercise and rest respectively, are the points on 
which a differential diagnosis can be made. This is more 
fully illustrated in a case which is reported on page 1 15. 

The Treatment will depend, in a measure, on the locality 
of the bursa inflamed, and upon the severity of the symp- 
toms. Blistering over the gluteal bursse "^eems to have 
given me good result in a single case, and this still is a very 
popular method. In one case it did no good whatever, and 
the tumor yielded to a compress and the roller. 

The removal of the contents by the hypodermic syringe 
and the injection of iodine into the sac has been employed 
with fair result in bursa; in other parts of the body, and I 
should certainly employ Iliis method in another case. 

The rupture of the sac by percussion or direct bloi 
when the tumor lies over a bony surface, as in the one ov 
the trochanter, would commend itself, but for the danger 
exciting inflammation in parts contiguous. 

Then this might be brought about by valvular puncti 
or incision. The fluid would escape into the soft parts ai 
be absorbed, A compress worn subset)uent to this pi 
cedure over tlir- |i irts will prevent the reaccumulation, t 
less this be one of those irritated bursse, such as the one 
my first case proved to be. 

I have no experience in the wearing of setons 
of any kind, and on general principles I should hesitate 
long before recommending this treatment in inflamed bur- 
sx about the hip. A suppuration is induced, and the drain- 
age being poor, the neighboring parts are almost sure to 
participate. Even this treatment for the prepatellary 



)se 




» 



BURSITIS OF THE HIP. 



"5 



\ 

^H whicl 



bursse is not looked upon with favor by many good sur- 
geons. 

In those sacs whicn show such a tendency to refill, I 
should prefer excision. Corresponding last year with Mr. 
Mitchell Banks of the Liverpool Ruyal Infirmary, that 
gentleman very kindly sent me an extract from the Liver- 
pool Medico-Chirurgical Journal entitled, " Notes on the 
Surgery of Burste," published January, i88z, and in these 
notes I find two cases which he reports as at present in 
his wards. The disease was confined to the bursa over the 
most prominent pan of the great trochanter, I take plea- 
sure in reproducing them in this connection. 

"The first patient, Lydia T., aged 20, told us that some 
four years ago she was sliding in the street, when she fell 
and struck her left hip against the wheel of a passing wag- 
gon. A lump followed, which burst in about a week. 
There remained a small sinus, which has continued to dis- 
charge slightly ever since, and in the neighborhood of 
which she has suffered pain at intervals. Some three weeks 
before admission the parts arounds the sinus became much 
swollen and very hard, so that her pain induced her to 
come to hnspital. The only point was whether there was 
any disease either of the joint or of the femur. All the 
ordinary tests indicated that the joint was quite sound, 
while the most careful probing failed to reach bone. 
Clearly the treatment was simple enough then, namely, to 
lay the sinus open to its uttermost end. Ether being 
given, this was done, and then a smooth cavity lined with 
granulations was reached, which was pretty evidently the 
sac of the trochanteric bursa reduced to the condition of a 
very chronic abscess cavity. A free crucial opening into 
this was made, and it was tightly packed with lint dipped 
in carbolized oil. It is now growing up to the surface, ami 
in two or three weeks will be quite healed over. Although 
I was pretty confident that the cavity reached here was th<.' 
sac of an old inHamcd bursa, I could not be absolutely cer- 
tain, as it was the first case I had seen. But the diagnosis 
was confirmed by the appearances presented by the case nl 
Mary H., aged 24, who was admitted about a fortnight 
after the previous case. 

Two years ago she fell down stairs, after which she had 

the outer and upper part of the right thigh, 

which was followed in the course of a week by a lump 

about the size of a hen's egg, when first she noticed it. It 



J 




diminish- 
made ihe 
rmincd to 

found 



has rctnaincd pretty station; 
thinks, increasing a little in size, anu someti 
ing. She had no distinct pain in it, but 
whole leg ache and feel so weak that she > 
have it removed. Over the trochanter 
smooth, globular, somewhat elastic tumor, quite free, and 
moving readily about. The skin over it was unaffected, 
and there was no pain on handling. Two of my col- 
leagues examining it without knowing the history, pro- 
nounced it a fatly tumor. At my first examination 1 did 
also; but a day or two after patient's admission her history 
was carefully taken, and the tumor again examined before 
Operation, chiefly as a pan of the ordinary clinical training 
of the students; and not for my own satisfaclioo. • - -■ ■ 
examination, however, the history attracted my attentioil«„ 
and a more careful handling convinced me that the tumor 
was fluid and not solid. So a fine trochar was brought 
and thrust into it, and through it came some dark-colored 
serum. We thereupon all rejoiced at having discovered a 
second trochanteric bursa, and the subsequent small opera- 
tion was watched with considerable interest. Under ether 
I made a free incision through skin and fat into the tumor. 
Some serum escaped, and then a considerable quantity of 
stuff which looked like semi-liquehed fat, but which turned 
out to be lymph floating in the serum. From being worked 
up and down in the sac, this lymph was evidently acquii 



ioivB 
mor^ 



r that after a while 
small bodies, whidi 
ir melon-seed sha] 
;ynovial bursa: con^ 
i simply to plug thi 
r granulate up; but 
s tempted to di: 



a definite form, and it was pretty ch 
it would have broken up into a mass of 
would in lime have acquired the pecull 
with which one is familiar in diseased 
necled with tendons. My first idea wa 
sac, and cause it either to slough out, i 
it seemed so tough and shining, that 1 

sect it out, and very easily so, the only surface to which k 
was intimately adherent being the fascia and periosteum 
over the trochanter. Thus the wound was reduced lo 4 
very simple matter, and it will probably heal before that o£l 
the fi. " ■ ■■ 

The cases Mr. Banks first reports are interesting from * 
therapeutical point. The method of operating employed 
by this surgeon is to make two incisions, and speaking of 
the objections to excising bursse, he makes the following 



i 



lark: 
" In performing an operatic 



which i: 



: necessary for J 




BURSITIS OF THE HIP. 



the saving of life {an operation of complaisance, as the 
old surgeons would have termed it), one has to balance 
against the annoyance produced by the complaint, the pain 
of the operation at the moment of doing It, and the subse- 
quent risk caused by it. With regard to pain, that is a 
thing of the past, as far as the work of the knife ts con- 
cerned. As for the subsequent riskj antiseptics have put 
such an operation as removal of the bursa patcllx almost 
on a level with the commoner surgical proceedings of 
paring one's corns and cutting one's nails^operations, by 
the way, which have both been followed by fatal results, 
but which, in spite of ihai, are universally practised." 

Prognosis. — If one can recognize a bursa about the hip 
under a primary inflammatory attack, the prognosis ought to 
be extremely favorable, not only for speedy recovery but per- 
fect result. If not recognized, however, until the sac has be- 
come irritable and thickened, then one cannot predict the 
time when a spontaneous cure will follow. When the ilio- 
psoas bursa is affected, the prognosis should be given with 
extreme caution. I am pretty well convinced that grave 
diseases of the hip-joint arise out of just such conditions. 

Take the following, which has been to me a most interest- 
ing case, not only of bursitis, but of subsequent joint dis- 
eases: 

I saw for the first time, in the latter part of April, 1880, 
a plump, fairly nourished girl, aged eight years, and while 
there was a tuberculous element in the father's family, the 
eliild herself had been in good health all her life. It was 
reported that two years before this date slie had been run 
over by a wagon and severely bruised. The effects soon 
passed off, it was believed, and nothing further was ob- 
served until she began to complain of pain just above the 
right knee, in February. 1880. She continued at school, 
though, and the pain was felt chiefly by night, when the 
|>arents would hear cries during her sleep. No other 
symptoms were discovered until I found a fulness in the 
right groin, below Poupart's ligament. This fulness did 
not extend into the iliac-fossa, and I could not find any re- 
sistance to the normal movements of the joint. There 
was a slight limp, right side, but it was not the "hip 
liiop." The naCis on this side was broadened a little, and 
the gluteo-femoral crease was lowered and shortened. The 
diagnosis lay between a glandular periarthritis, and an 
articular ostitis. Under expectant treatment the lameness 



I 
I 



I 
i 




1 grew less marked — scarcely appreciable — but the i _ 
gtiinal fulness remained about in stalu quo ante. The lame- 
ness disappearing, a discharge was granted for the zind of 
June. There was, however, on this, the day of her discharge, 
a slight yet appreciable resistance to flexion of the thigh 
beyond 90°. There was no atrophy, and no joint tender- 
ness. 

Believing this tumor to be glandular, I employed iodine 
internally and externally, and occasionally applied a blister 
over the parts. In Aagust, lameness was induced by going 
up stairs, and this slight exercise indicated pretty well 
the locality of the disease. In November she became lame 
again, though prior to this she had been very active. The 
inguinal tenderness was very marked, and this tumefaction, 
or, tumor, still existed. 

In January, iS3i, I was quite positive in finding an elastic 
or cystic element in this tumor, and I made a diagnosis of 
bursitis just beneath the illo-psoas, and in almost direct 
contact with the synovial membrane. The tumor was not 
painful on handling, and was t,he size of a pullet's egg. 
There was no lameness whatever, unless a transient lame- 
ness after risingfrom bed in the morning. In March, I was 
more confident of my diagnosis, and urged the use of the 
hypodermic as a means of diagnosis at least, but I could not 
get the consent of the surgeon in charge of the case. Other 
remedies were employed, liniment, for instance. She be- 
came better, and worse again throughout the summer, but 
always retained that fulness in the groin more or less 
prominent. 

Some days it would be quite large, and her symptoms 
would be aggravated. Then, again, it would be small, and 
scarce!)- any lameness could be detected, and the only sign 
present was resistance to complete flexion. 

In October, 1881, there appeared for the first time real 
symptoms of joint disease. The hip was nearly locked, 
and there was much joint tenderness. She was re-admitted, 
and under expectant treatment grew worse, so that by 
February she had passed, with a great deal of suffering, loo, 
through the first stage of joint disease, into the second, 
with impending abscess and great deformity. The father 
removed her at this time, and placed her under the care of 
anotner surgeon. He made out scrofulous ostitis of the 
hip, implicating the acetabular parts, and has Iter now ' 




ls bcr now I 



, BURSITIS OF THE HIP. 



119 



under treatment. An abscess formed, and was aspirated. 

Dr. T. M.Taylor, of our staff, very kindly traced the case 
out ih June, and found the girl in a Thomas' splint, limb 
straight and in good position. The girl had no pain, and 
was in a fair condition of health. The hip was fixed by the 
splint, which was not. removed ; the limb was atrophied 
nearly two inches in circumference, but seemed equal in 
length. 

Such cases as the one just recorded furnish texts for 
extended comment. Here was this tumor duly recognized 
long before any inflammatory mischief had been done the 
joint, and here was the knowledge of the disastrous effects 
of disease at this articulation. It would have been better 
to have removed the offending bursa, taking all the risks 
of so delicate an operation. In this day of antiseptic sur- 
gery, with such facilities for diminishing the danger of 
inflammatory processes, little fear need be entertained in 
making an operation wound, however large and however 
extensive, provided it is demanded by the exigencies of 
In an acute bursitis rational therapeautics de- 
mand rest and expectant measures ; but if the lesion gets to 
be a chronic and a recurring one, then excision of the 
tumor, or obliteration of it by surgical means is the only 
rational treatment to be considered. 

To recapitulate : 

I. The bursa about the hip are occasionally inflamed as 
a direct result of strain, contusion, or exposure to cold. 

J. Ordinarily they excite a very trifling amount of in- 
flammation in adjacent tissues ; occasionally, however, the 
joint is implicated, especially if the bursa beneath the ilio- 
psoas be the one diseased. 

3. In a certain number of cases of acute bursitis the ten- 
dency to recurrence is very great, and this is chiefly true 
of those wherein a diagnosis has not been made until two 
or more attacks have already appeared. 

,4. The diagnosis depends on the history, the knowledge 
of the anatomical locality of the norma! bursae, the pres- 
ence of a cystic tumor, and the exploration of the same 
and the exclusion of synovial, periarticular and bone 
diseases. 

5. The treatment in the first attack should be blistering, 
if the process be not acute ; hot fomentations if acute, rCst 
and compress. If recurrences have already taken plac^ 



1 



I20 DISEASES OF THE HIP. 

and the sac be an irritable or a sero- purulent one, the de- 
struction or the removal of the same is the only treatment 
that holds out any prospect of a cure. 

6. It is dangerous fo permit, for a long time, inflamma- 
tion of a bursa which communicates with the joint, or 
which lies directly upon the capsular ligament. 



CHAPTER VIII. 

Acute Primary Synovitis. 

The serous membrane which lines the capsule and is 
spread over a large surface of tlie articulation occasionally 
becomes the seat of a primary inflammation, marked by acute 
symptoms and running a comparatively brief course. The 
age at which children are thus affected is from eight to 
fifteen years. The invasion is acute and well-defined. The 
mother will be able to name the day, the hour frequently, 
when the first pain was experienced, and this is generally 
preceded a day or two by a little lameness, sometimes 
merely a sense of fatigue. The joint soon becomea ex- 
ceedingly tender, and the patient will be unable to walk 
during the first and second weeks. In chronic ostitis 
of the hip the inability to walk docs not, as a rule, 
come until several months after the invasion. Lameness, 
it must be remembered, is the first sign, but this is very 
slight, and it is a long time before the patient is actually 
unable to walk. Pain in the branches of the obturator — 
at the knee, for instance^will follow crowding of the artic- 
ular surfaces together. The intensity of the pain will, of 
course, be in proportion to the acuteness of the inflamma- 
tory process. 

The case of a boy, aged twelve years, who came into the 
hospital in October, 1879, furnishes a good clinical history 
of this disease. He came from a country town, and was a 
muscular-looking lad. There was a history of phthisis in 
both branches of the family, and the father was reported to 
be suffering at the time from sciatica. With the exception 
of a slight attack of what was regarded as malarial fever 
two years since, the boy himself had been in excellent 
health until one month before the date of admission, when 
he was seized with pain on the inner side of the right thigh 
He had been in bathing quite frequently during the latter. 

r part of the summer— three or four ti 

■ to exposure or fatigue that his pai 




was able to walk the first day, although he was decidedly 
lame. On the third day he took to bed, so tender had the"* 
parts in and about ihc hip become. There was consider- 
able febrile Histurbanfce, without constipation, and morphia 
had to be administered every night to allay the pain, The 
hip and the knee alternalely had been the seat of pain, and 
the iimb could with difficulty be moved at all. Recently he 
had suffered most in the distribution of that branch of the 
obturator which supplies the knee. He held the thigh 
acutely flexed while lying in bed. 

He was taken from his bed this morning and brougbtj 
into the hospital. Is able to sland, although the weight 
is borne on the left limb, while the right is a little ad^ 
vanced, the foot being everted. He remarks that thiKj 
is the first time he has been able to set his foot squarelyj 
upon the floor since the beginning of his illness. As fc 
attempts to turn, he does so by means of Ihe left foot. Ca 
walk only when well supported on each side. He is well^S 
developed, but has a face that is indicative of great suEfer-l 
ing. It is a painful expression he has. The thorax and theT] 
spinal column are examined, with negative results. There 
is much width to the nates on the right side, the fold is 
obliterated ; no tenderness over the sacro-iliac junction, 
and none elicited on crowding the alee of the pelvis together. 
No infiltration in the groin or in the gluteal'region, no tea-_ 
derness here on handling ihe parts. The superficial ingui»! 
nal glanils are a little enlarged. Light pressure in thai 
groin or over the trochanter gives rise to no pain ; no pain] 
on pressure along the shaft of the femur. If firm pressurefl 
be made over the trochanter in the line of the neck of thai 
bone, he winces very decidedly, and refers the pain to' th«j 
outer aspect of the thigh and about the knee. Conci 
of the joint gives rise to much pain. 

No dulness or tenderness in either the iliac fossa or ilw. 
ilio-costal space. The limbs are equal in siiie, except w 
their upper thirds, where the right one is one inch largeU 
than t!ie left. This may be the result of two fly-blisters ofl 
the inner side of the thigh, cicatrices of which now rematq, 
They were applied by order of the physician at his homc^^jj 

He cannot be induced to flex the ihigh beyond 135°, na| 
will he permit extension beyond t6o°. Abduction, adduT 
lion and rotation are quite impossible, so marked is tb 
reflex Vouscular action when these movements arc B^ 
tempted. The rectal temperature is ioj-s". 



ACUTE PRIMARY SYNOVITIS. 



123 



A counier-irritant is applied this evening over Ihe troch- 
anteric region. 

Two days after admission, he is walking witl 
port, and the improvement is at least fifty per ci 
blistered surface is being poulticed every six I 
though it has healed, and the contour of the nates is nearly 
restored. He walks with much facility, limping very little. 
No joint tenderness can be elicited. It is thought neces. 
sary, however, to repeat the vesication, and another plaster 
is applied this evening in the same region. 

Tins last vesicated surface was a long time healing, and 
there remained early in November many superficial ulcers 
in its neighborhood. During the last week in October he 
walked with a mere trace of a limp, and he had no pain 
until one night, when by accident another patient ran 
against him the wheel of a rolling chair, striking the gluteal 
region with considerable force. Consetjuentiy he was very 
lame next morning, and the soft parts, the inguinal glands 
especially, were extensively infiltrated. No joint tender- 
ness could be found, however, by the different tests, and 
the pain and tenderness were thus proven to be periartic- 
ular. It would seem, then, that the contusion had simply 
aggravated the periarthritic infiltration resulting from the 
second vesication, without injuring the joint. He went to 
bed for a few days, and the poultices were renewed. 

The ulcers were most obstinate, and the periarthritis of 
our own making after his admission to the hospital gave 
him much more trouble than did the synovitis. They (the 
ulcers) were finally scabbed over, and at the close of the 
first week in October the boy was submitted to a thorough 
examination regarding his joint functions, which were found 
to have been perfectly restored. 

Discharged, January 12, 1880. There were no signs of any 
disease, nor any remnants of disease, with the exception of 
the rougiiened skin at the sites of blisters. His general 
health was excellent. 

October 31st, the father writes me, in response to a 
letter of inquiry, that there has been no sign of any 
relapse, and that the boy is still free from pain and lame- 
ness. Late inquiries have been answered in the same way. 
It will be seen that febrile disturbance was a marked fea- 
ture in the early stage. 

Effusion into the capsule can generally be recognized 
when other symptoms are present which go to confii 



I 



4 




A degree of tension, with 
1 be easilj' recognized. A 
was admitted in August:, 1876. 

sion, without any known provocation, he suddenly c 
plained of weakness, tenderness and pain, which sympli 
have increased in severity. He stood on examination \ 
left ihigh advanced semi-flcKed and everted, and walked 
with a decided limp. The left natis was broad, quite lense, 
and there was marked tenderness on pressure over the tro- 
chanter. The superficial inguinal ganglia were enlarged. 
The thigh could be extended to an angle of 165° withi 
tilting the pelvis. There was limited motion at the joi 
but any attempt to fle\ was opposed by muscular res: 
ance, ad<and abduction being likewise opposed. Noshoi 
ening, and no atrophy. Pain was complained of whi 
articular surfaces were approximated, A diagno: 
synovitis was made, and on the day following he was sub^ 
milted to a more thorough examination. The surface-tem- 
perature on left side over the joint was two degrees imi-er 
than that at same point on right side. Measurement around 
groin and over trochanter for the right side was fifteen and 
a half inches, while on the left side it was seventeen and a 
half ; from coccyx to anterior superior spinous process, 
right side eight inches, left side nilie. The usual locaj 
treatment was begun without delay. 

The blistered surface was poulticed with Haxseed m\ 
on the following morning, and renewed every six hours I 
three days, then dressed with simpl^ressings until heah 
There was, ten days after admission, one and a half inchi 
difference in the size of the nates, as measured around groil 
and over trochanter. 

The decrease of the swelling continued ; the boy was free' 
from pain, and the iimb was almost straight at the end of 
ten days more. 

Near the close of the month there was only a very slight 
limp. No resistance to flexion, extension, ab- or adduction. 
There was no difference in size or in length of limbs. The 
measurements over trochanter and around groin on both 
sides were identical ; those from coccyx to anterior superior, 
spine, on both sides, likewise identical. The surface-ie 
perature over the right hip-joint is one half degree higl 
than that over left. There is still a shade of flattening. 

The contour of the nates was to all appe; 
stored bv the ist of October, There was no p: 



ise, 
iro- 





ACUTE PRIMARY SYNOVITIS. 



125 



and he was discharged cured 3 few days 



erness, no lir 
later. 

1 saw the boy after a lapse of four years, and no relapse 
had ever occurred. 

There are many good observers, I am well aware, who 
teach and firmly believe that most of the cases called " hip- 
disease" begin as a synovial inflammation ; and I am quite 
sure that this impression is often produced by a failure on 
their part to properly consider the prodromal signs, if I 
may so call them, that precede the first exacerbation which 
induced the parents or the friends to seek advice. Unless 
the surgeon cinsei;- cross-examines Ihc patient he will be 
led to regard this exacerbation as the beginning of the dis- 
ease. The parents insist on it and then they will say, after 
a while, apologetically, it would seem, "Yes. he did walk a 
little lame; but then the lameness was of no account." I 
have had cases come under observation a second time, after 
a lapse of many months, and the history of a recent invasion 
would be given, when I would remember ihe name, look 
over my records, and find the same case noted with similar 
signs. These had subsided to a great degree, and in the 
interval only an occasional limp after exercise would be ap- 
parent. Cases exactly like these I have had under observa- 
tion in the hospital, and the only signs 1 could delect, on 
repeated examinations at long intervals, would be a slight, 
yet appreciable amount of resistance to flexion when carried 
beyond eighty degrees, and to rotation or to abduction. A 
limp was not always recognized. 

The point, then, I endeavor to make is this: that an acute 
primary synovitis has a distinct period of invasion, and fur- 
nishes a clear and well-defined clinical history. 

The following case referred to me for hospital treatment 
by Dr. Wm. T. Bull, on September 19, 1879, illustrates a 
not very severe type of the disease. It was that of a girl, 
aged nine 

With the exception of intemperance in the father, the 
family history on both sides of the house was good; the 
hygienic surroundingfs had been poor, yet the child had 
been in good health up to the invasion of the present dis- 
ease, the first symptoms of which appeared on the morn- 
ing of the nth, without any assignable cause, unless per- 
haps exposure to cold may be regarded as a cause. The 
girl walked a little lame that morning, favoring the left 
side, and referring the pain to the knee; was not very lame, 



J 



126 DISEASES OF THE HIP. 

and, indeed, rested very well thai night; but the next moi 
ing. the i3lh, she was unable to walk at all, so tender the " 
joint, and so acute the pain. In the afternoon fever came 
on and persisted througout the entire night. She suffered 
very much every day and every night until the day of her 
admission. While asleep, the limb was flexed at the hip 
and at the knee. The pain had been paroxysmal, and had 
been referred alw.iys to the groin, the innei side of the thigh, 
and the knee. The appetite had been good and the bowels 
regular. The child was carried in with the greatest care, 
and considerable difficulty was experienced in preparing 
her for examination. • 

While the patient was quite anaemic, tlie muscular system 
was fairly developed. As she stood, the right limb bore the 
weight, while the left was slightly flexed at the knee, the 
foot being everted. She was able to walk a short distance 
in the room, yet the lameness was very marked. On ex- 
amination, the heart and lungs were found to be normal. 
Firm pressure over the trochanter, in the line of the axis of 
the neck of the bone, caused acute pain, which was referred 
to the inner side of the thigh and knee. Percussion of the 
flexed knee, in the axis of the femur, did not produce pain. 
There was no tenderness on firm pressure in the groin or 
in the iliac region or in Che ilio-costal space. There was no 
infiltration or swelling in any of the localities just enumer- 
ated. The nates on the left side was broadened, though 
there was no infiltration here The superficial inguinal 
glands were slightly enlarged on both sides. The ihigh 
could not be extended beyond 150° without tilting the pel- 
vis; it could be flexed to 90°, though she complained of 
pain in the groin when it was forced beyond this point. 
Abduction and adduction could be made over one half the 
normal arcs. Pulse 160; rectal temperature 101.5°, A 
blister was applied over the gluteal region the night of her 
admission, and cod-liver oil and iron mixtures were ordered 
as routine. 

September i8lh. — Most decided relief since admission. She 
is now free from pain, and walks quite easily, only a slight 
halt being perceptible. No tenderness in or about the joint. 
Another blister was applied on the evening of the 30th, and 
on October 17th it was recorded that she had grown com- 
paratively stout, and walked without an appreciable limp. 
The only change observed in the naiis was, that the supra- 
irochanteric dimple was a little shallower than that on the 




ACUTE PRIMARY SYNOVITIS. 



right side. The iimbs were equal in size, and movements 
at the joint were perfect and painless. Pressure over the 



mination, and 
No sign cr 

:, the parents 



trochanter, in the direction of the joi 
cussion gave none. The cure was compleK 
October J4ih.— Submitted to ^ thorough e 
the supra-Irochanteric dimple found normal, 
symptom of disease. Discharged this date, 
promising to report on the first sign of any relapse. 

The case of a girl, aged si^ years, who entered the hospi- 
tal February 19, 1874, differs materially from the one just 
narrated, and yet the difference is in the acuteness and the 
severity of the symptoms. In this "the invasion was almost 
instantaneous. When she was brought into the office the 
pain was so intense that an examination was impracticable, 
in fact it was deferred until she could be transferred to the 
ward. 

The family was found healthy and free from disease; the 
girl herself was an only child, and had always been in ex- 
cellent health. She was considered perfect in health and 
limb on the evening of the 16th — three days before — went to 
1 that condition, and was awakened suddenly during 
ght by acute pain referred to the right hip-joint. Her 
alarmed the household. Febrile movement was 
id in the morning the child was quite unable to 
I the limb. The pain and tenderness seemed to in- 
ind the loss of strength from sleeplessness and gen- 
stitutional disturbance soon became alarming. 
On examination this evening the tongue is coated, the 
patient cannot be induced to stand alone, much less to take 
a step, and after much persuasion she allows herself to be 
held in the standing posture, when the right lower extrem- 
ilv is suddenly adducted, advanced, and semi-flexed; little 
or no change has taken place in the nates, there is no atro- 
phy of the limb, and no shortening, Anyattempt at active 
or passive motion causes intense pain at thehip, though by 



bed i 



grasping the thigh carefully and firr 
the while, the muscles hitherto in torn 
relax, and a great sense of relief is ■ 
synovitis of the hip is diagnosticated, and a t 
plied to-night. 

March 1st. — Almost entirely free from pair 
lion is. much improved. 

March 21st. — A second blister applied on recurrence of pain. 
From this lime forward the case progressed as favorably ps 



mly, making traction 
rigidity gradu; " 



ind condi- 



J 



I., as 
n in- 

'1 



I2S DISEASES OF THE HIP. 

could have been desired, and in October it is reported thl 
little or no deformity exi^sts; the child walks with great 
facility. An examination is made August 4, 1875, no un- 
favorable symptom having occurred in the mean time, and 
the result is as follows: general health robust; stands with 
right limb slightly advanced, walks and runs freely, though 
favoring this side; contour of hip almost perfectly restored; 
flexion, extension, ab- and adduction easily accomplished; 
no pain or tenderness, no shortening or atrophy; with the, 
exception of a mere limp the cure is perfect. T' 
must be due to some loss of substance in thi 
tures — a theory very plausible in view of the severity c 
primary lesion. The girl was seen by me a year or so latei 
and this limp could scarcely be detected. 

This case began as some bone diseases do begin, viz., as 
an acute synovitis. Tlie acuteness of the inflammation in- 
duced by contiguity a like lesion (though . modified) in 
bony tissues. 

It is needless to cite further instances. I have cited I 
above because it is difficult to formulate symptoi 
toms, 1 mean, that are pathognomonic. One mustexamin 
the case willi care, testing the functions and sensitiveness 
of the joint thoroughly, employing such means as may sug- 
gest themselves. He must remember thai, if the joi 
tender, he should get referred pain in the obturator whej 
ever the jointsurfaces are approximated. There should a 
no infiltration in the periarticular tissues. Sometimes od 
can perceive an clastic fullness about the trochanter or M 
low the groin, if there be much distension of the capstltl 
ligament, Then, there must be a history of acute pain m 
great tenderness. The history will be very clear— tl, 
mother being able to name the day, and the hour frequert 
ly, as I have said before, when the first attack of pain wij 
experienced. 

T/ie Diagnosis must depend upon the symptoms and sig 
already enumerated. There are peculiar cases of bi 
disease with acute invasions, and with sudden remissio 
These are exceptional, however, and I am quite ! 
a careful study with opportunities for repealed t 
, lions, will enable one to arrive at a diagnosis. 

T/ie Prognosis is good, and the exceptions to a perfect i] 
covery are very few. The case last reported is an ex«' 
lion, and the case of a boy whom I saw several years lu 
and placed on record as illustrating an irregular tjp^^ 



^m The m 



ACUTI; TRIMARV SYNOVITIS. 129 

hip-disease, seems now, on rclrospection, to have been one 
wherein repeated attiicks terminated in bone disease and 
abscess. The report is laken from a paper on "The Diag- 
nosis of Hip-Disease," which I |>ublished in the American 
Journal of the Medical Sciences, in October, 1878. Since 
the publication of that paper, this case has been under the 
:are of an orthopedic surgeon of this city, wlio assures 
me that the patient is now in the third stage of "hip-joinl 
disease," and is iindei the extension treatment. The case 
is certainly very peculiar, and my history points, as I have 
intimated, to recurring attacks of synovitis, the final one, 
as in many instances of recurring disease, not resolving 
ivell. and, in addition to this, invading, contiguous tissues. 
At all events, I shall give it in detail, and at the same time 
with this regret, viz., that I do not feel that confidence in 
my notes of 1872-73 — the earlier years of my hospital ser- 
vice — thai I feel in those of later years. My records were 
more meagre and hence my "facts" were not well enough 
fortified against criticism. "No signs of disease" in 1873 
does not, for instance, carry with it that conviction that the 
same expression docs in 1877. 

In the month of July, 1877, a boy, aged eight years, was 
brought into the office, and I at once recognized him as an 
old patient long absent. I of course censured the mother 
for neglect, but she was positive in asserting that at her last 
visit three years ago the case was pronounced cured; so on 
referring to the books I found a record of the diagnosis April 
19, 1873, as" hip-disease; end of first stage, 'and a note July 
18th same year "no signs of disease." At this visit his left 
Ihigh is flexed on pelvis at an angle of 135", and is rotated 
outward; the limb is in fact in the typical position for the 
second stage of " hip-disease." He is very lame; screams 
at night, waking, as it were, out of sleep, and in the morn- 
ing has no recollection of having suffered or screamed 
during the night. Refers the pain by day to the parts on 
Fither side of ilie patella; there is noswelling or tenderness 
^iround hip oi- knee, both of which seem peculiarly free 
from disease so far as external appearances or handling 
are concerned. Flexion and abduction can be made with- 
out pain or resistance, but other molions are limited by 
muscular action: when passive motion is made he complains 
of pain at the knee. There is no spinal tenderness, no 
angultir (lefortnily. no reliable sign of vertebral disease. 
The motlipr dfclnres that the boy was well and iiriive on 



I 

I 

I 
J 



130 DISEASES OF THE HIP. 

ihe tsth, five days before, not resting well the night of tl 
9th: tliat he was out for a long walk on the 12th, slept well 
that nigliC, and on rising in ihe morning was lame, but was 
fj-ee from lameness on the i4lh and on the 15th; and that alt 
of the present signs date from the i6th. Last winter, she 
reports, he had very nearly the same irain of symptoms one 
day after a storm, and recovered spontaneously. The attack 
in 1873 had lasted two or three months prior lo his applica- 
tion here for treatment. With the single exception of the 
transient lameness of last winter, just mentioned, he is re- 
ported to have been absolutely free from anything like hip- 
disease since Julj'. 1873, One year ago he had j^rtussis 
without any recognizable sequel. 

There are nine children in the family, and this, the 
seventh, is the only one ever out of heakli, so claimed. He 
was always considered a delicate child prior to the spring 
of 1873. A severe dentition, with an occasional convulsion. 
a series of convulsions when two years of age, a scarlatina 
shortly thereafter, and rubeola next in turn, make up his 
personal history. He is now fairly nourished, though the 
four lower and the two upper incisors are distinctly notched 
and irregular, while two molars on the left side have each 
six distinct processes. The mother is of a temperament 
markedly nervous, and her appearance forcibly suggests 
struma, the maternal grandfather died of " rheumatic 
gout," the grandmother of "apoplexy." The father seems 
healthy, and gives agood family history. No specific taint 
is discovered, though strongly suspected in view of ttii" 
presence of notched teeth in the child. A blister and poi* 
tices were ordered to the dorso-lumbar spine. 

The deformity is much less July 27th, and the boy fe« 
better. A fourth of a grain of the extract of belladonna 
three times a day is ordered. The treatment now is direc- 
ted to the spine more as a solution to the diagnosis than as 
a therapeutical measure. It will be remembered that 1 
found no spiii;;l ii;nc!erness, and hence I had no good rea- 
son for considering this, a spinal arthropathy. The mother 
calls Angust 3d to report the child free from pain, and the 
limb perfectly straight, unless after exertion. 

On the 1 1 th he is examined ; no resistance to normal 
tion in any direction found, except on complete extensii 
'In view of a possible syphilitic element in the etiology, p 
ass. iodid. gr. iv. three times a day is ordered. There is 
scarcely any lameness perceptible; stands with limbs par- 



int 

1 







ACUTE PRIMARY SYNOVITIS. 



131 



allel; contour of nates normal; motion good in every di- 

:tion, though, wlien thigh is completely flexed on abdo- 
men, he complains of pain at ihe knee. 

On the 20th of September, flexion and extension could 
be made to extreme limit; rotation inward to extreme limit 
causes the boy to wince, though he protests against feeling 
my pain. The iodide is continued. 

On the 17th of October, 1 found a complete relapse, 
vhich the father attributes to a strain the boy received last 
.■isil on the way home. The iodide is discontinued, and 
the belladonna, in fourth-grain doses, ordered again. A 
liniment for the hip is likewise prescribed. 

He was improving again on the 7th of November, at 
samer ate as before. 

April 17, 1S78. — Is seen to-day, and the limb is found 
again in the position of second stage. The father reports 
that in November last he made a good recovery from that 
ittack, and has been straight and active until three weeks 
ago, when present relapse appeared. There is found also 
to-day, for the first time, dorsal tenderness. 

The Treatment with which I have been most familiar, 
andtowhic.li ihe symptoms yield with great promptness, 
is blistering, followed by poulticing. Tlie hospital cases 
respond well to this method, and hence I can recommend 
it with much confidence. In addition to the testimony in 
the cases above mentioned, take the following: 

A girl, aged six years, was admitted to hospital Septem- 
ber id, 1S70. The history was that the mothers family 
was consumptive, but that this child had been in perfect 
health up to the second week in August, two weeks before 
her admission, when, without any known cause, unless it 
may have been a fall three weeks before the first symptom, 
she began to limp and to complain of pain in right knee 
and liip. She soon became quite helpless, and suffered ex- 
cessively at night. The appetite failed, and she lost flesh 
rapidly. Her exact condition on admission is not recorded, 

t it is noted that a fly-blister was applied, and that on 
the 7lh, four days later, she was comfortable. On the 
8th she is reported as resting well nights', and on the 

;h '"very little pain " is noted. On the 13th it is slated 
that she "came in totally unable to walk, but can now 
walk, even without the aid of chair; right leg semiflexed 
and everted on standing; right hip broadened; fold of iiatis 
Huch lowered; very little tenderness either behind tro- 




ad ■ 



chanlcror in groin, but considerable on concussion of bip 
through trochanter; limbs equal in length, " On the 19th 
she is walking with a very slight limp. Two weeks later 
there is no tenderness anywhere. Is walking without 
lameness, and is growing fat. And again on November 
i4ih no tenderness could be elicited on pressure over, 
flexion or concussion of, the joint. She was under observa- 
tion until the zoth of the following March, and no 
signs of any disease in or about the hip manifested them- 
selves. I saw her early in November, 1880, nearly ten years 
later, and could find no evidence, so far as physical signs 
went, that she had ever had iiny disease. During all this 
period she had been free from pain, tenderness, and 
lameness. 

A word regarding blisters. The respected founder 
the Hospital for the Ruptured and Crippled, Dr. Jam^* 
Knight, attaches great importance to the poultices which 
we employ immediately after the blistering, and the mode 
of procedure is this; A plaster of cantharidal cerate, three 
inches by four or five, is applied over the trochanteric re- 
gion at night, and not removed until the follow! 
ing, when the blebs are pricked, giving vent to the sen 
beneath, and a large poultice of ftaxseed-meal is applied 
this surface, no cloth intervening. The poultice is renew) 
every six hours for two or three days, when ad. 
simple cerate, or other similar unguent, is employed for ft] 
few days longer, the healing process going on the mean- 
while. 

We do not find it necessary to enjoin any more rest than 
the patient will necessarily demand, yet I have a friend in 
Boston, Dr. E. H. Bradford, a recognized authority, who 
seemingly places much value on absolute rest, citing the 
following very instructive case in the Boston Medical and 
Surgical Journal for November 11, 1880: 

" A healthy girl, five years old, a patient of Dr. Tarbell's 
of Boston, was suddenly seized with extreme pain in one 
limb. There had been no prodromata, except that the 
child had been noticed to limp a few weeks before. The 
pain was intense, particularly severe at night, and the 
patient required opiates. The slightest jar caused violent 
pain. The pain increased for a week, and began to dimin- 
ish, but was aggravated by changing the sheets. On ex- 
amination the child was found lying with both thighs 
flexed and abducted. The patient could move the toes and 





ACUTE PRIMARY SYNOVITIS. 



ankles, and such slight motioF) of the knee (the paii«nt lay 
with the thighs spread apart and Che legs bent at the knee) 
as did not move the ihigh was piossible, but any motion 
disturbing the hip-joints caused intense pain. There was 
no fever, and none of the other joints were affected, but 
there was swelling and lendciness over both hip-joints. As 
the child was absolutely immobiliied by the disease, noth- 
ing mechanical for the purpose was tried. Extension was 
not used, as the pain had been decreasing. In a few days 
this had diminished greatly, and in a short time had dis- 
appeared. In a month the patient regained perfect motion 
at the left hip-joint, but some muscular resistance remained 
at the right hip, and a light extension By weight and pul- 
ley was applied. In three months the child walked about 
freely, and six months later she was considered perfectly 
well by her parents. There has up to this time been no 
relapse." 

There came a girl, thirteen years of age, into the hospital 
in September, 1873, with a history of two months' lameness 
and pain, which had been most of the time referred to the 
neighborhood of the patella. She walked with a ver^- 
marked limp, and the left limb, the lame one, was appar- 
ently much elongated. There was much flattening of the 
nates, and its normal contour was lost. Sudden pressure 
over the trochanter caused her to start as if electrified. 
There was no atrophy, and as she stood the limbs were 
nearly parallel. 

Her symptoms pointed to a synovial inflammation, with 
probably an increased joint secretion. A liniment and a 
spica bandage constituted the treatment, and rest was not 
enjoined. In less than six weeks the contour of the hip 
was restored, all lameness had disappeared, the functions 
of the joint were perfect, and the patient was discharged 
cured. A relapse has never occurred, to my knowledge, 
and I have had an opportunity of seeing the girl from time 
to time. 

The practical deductions from ihis chapter are that acute 
primary synovitis is a comparatively rare disease, that it 
is of easy management, and that the progress is toward 
recovery. The duration is from two to si.x or eight months, 
seldom greater than four months. 

In giving a prognosis, it must not be forgotten that bone 
liibcase does occasionally arise from extension of the inflam- 
'natiim from the synovial membrane. To demonstate tiiis 



J 



134 DISEASES OF THE HIP. 

proposition is hardly possible, yet the histories of some 
cases, especially in children between eight and twelve years 
of age, furnish strong evidence. We do not know, however, 
but that the bone lesion may have begun near the peri- 
phery and that an exacerbation was early induced. The 
pathological process is easy of explanation. It is well 
then, under these circumstances, to be cautious in the prog- 
nosis. 





CHAPTER rX. 



I. Acute Epiphysitis of the Hip. - 
Diastasis. 



-II. Traumatic 



1 that of dia 



In selecting the lerm epipliysitis rather thai 
physo-epiphysitis. I feel that I shall evoke some criticism, 
and in advance I wish to state that my reason for so doing 
is that while the primal lesion is at the diaphyso-epiphys- 
cal junction, the ostitis extends the more quickly and the 
more destructively to the epiphysis, so that a necrotic dias- 
tasis soon follows, and the force of the lesion is ihus practi- 
cally spent upon this portion of tlie femur. The few patho- 
logical specimens, to which I have had access, prove to my 
own mind that even where the diastasis has not ensued, tlie 
epiphysis is pretty thoroughly destroyed, and the clinical 
signs likewise, convince me that such has been the result 
of the inflammatory process. 

A class of cases coming under my observation during 
the past few years has been peculiarly puzzling, and occa- 
sionally a ray of light is shed upon individual cases. Some 
I have at first diagnosticated — long subsequent, however, 
to the inflammatory process — congenital unilateral disloca- 
tion; some acute suppurative periarthritis; some syphilitic 
arthritis, or epiphysitis, and some were absolute enigmas. 
To the lectures of a friend in London, Mr. C. Macnamara, 
I am indebted for my first venture at classification — not 
that I had not seen the term employed, yet cases were 
wanting that were sharply defined. Clinical pictures were 
not readily»attainable. They arc not abundant, yet I am 
convinced that many cases of what we are in the habit of 
calling acute hip-disease, cases which follow closely on 
distinct traumatism with acute symptoms, should be called 
acute epiphysitis. Occasionally one with large opportuni- 
ties (or clinical material comes in contact with just such 
instances of bone lesion, where not only the initial symp- 
toms are acute, but where the whole progress of the disease 



i 




is acute up to the point of destruction of the joint. Prac- ' 
lically, often the same results are reached, yet they are the 
more speedily reached, and all the so-called stages of a 
joint disease pass in rapid review. 

My own experience is confined almost exclusively to the 
disease as it affects young children and infants, but Mr. 
Macnamara, in the second edition of his lectures on Dis- 
eases of the Bones and Joints, states the following : 

"Acute epiphj'sitis, although most frequently met with 
among young children under two years of age, is not by any 
means confined to infant life, as we have seeu from the cases 
already detailed." The cases he has recorded, with one ex- 
ception, however, were those in which other epiphyses than 
the proximal epiphysis of the femur were involved. 

I remember seeing a few years ago a specimen of pecu- 
liar interest to the orthopedist. It was shown me by Dr. 
Judson, and he subsequently presented it lo the New Vork 
Pathological Society. "The patient was eighteen months 
old. The symptoms commenced suddenly, and ended in 
death from exhaustion in seven weeks. The child's foot 
was everted, but there was an absence of the reflex symp- 
toms usually found in liip-joint disease. An examination 
showed undue mobility, with crepitation. There was swell- 
ing in the iliac fossa, groin, and right labium, and upper part 
of the thigh. An incision was made over the great trochan- 
ter, when about six ounces of pus escaped. Tlie diagnosis 
made was separation, i)arlial or complete, of the upper 
epiphysis of the femur. In the specimen the cartilage 
was found to have disappeared, with the exception of a 
small scale, which was attached by its outer edge to the 
neck. This latter was a rounded fragment of cancellated 
tissue three eighths of an inch in diameter." The extract is 
taken from an unofficial report of ihe society's meeting in 
the New York Midical Journal December, 1878, p. 6z8. 
Unfortunately, a compk-le report has not appeared in the 
Society's Transactions, as the specimen was presented for 
a ca.ididale. The specimen appears to roe t* be one of 
acute epiphysitis going on lo rapid caries necrotica. Dr. 
Judson tells me that it was to him difficult of explanation. 
It certainly seems to have been the result of a rapid process 
and the clinical history, brief as it is, corresponds closely 
with one of a case that came under my own observation 
after the acute symptoms luul passed. 

It occurred in a femiili- cl:ild, who, when eight and a 




ACUTE EPIPUYsniS Oi I HE HIP. 



137 



lialf months o( age, was taken with a cold and suffertd a 
« conseqiieoce apparently from giave constitutional sym): 
tonib. The febrile reaction was very great, and the loss of 
flesh was extreme. The motlier got the impression that 
the child had "the 'harmonia' of the left lung," and at 
the end of the seconii or third week, just as a change 
for the belter had been observed. i,lie took it up into I 
arms one day, when the discovery was made that ihe hip 
was very tender, and that swelling in llie groin accom- 
panied this tenderness. This fullness of ihe groin in- 
creased for about three weeks ; ihe skin becoming red, 
while the thigh became more and more flexed. Then a 
physician was called, and he regarded it as abscess, order- 
ing poultices, which were continued for two or three weeks 
longer The abscess soon opened sponlaneously. giving 
exit to about a half teacupfnl of pus "yellowish" in ap- 
pearance. The parts soon healed ; the infiltration disap- 
peared, and ihe child began to walk around. It had been 
walking around the floor by the chairs nearly six weeks 
when the sickness appeared, and had not shown any lame- 
ness. The gait now was marked by a decided lameness, 
which continued up to the time I first saw the case eight 
months afterwards — August. 1879. 

1 found the limb from a half to three quarters of an 
inch shorter than its fellow, and perceived a distinct bony 
grating with upward subluxation. There was rotation 
outward, and the lameness was such as one would expect 
from a diastasis. The movements were pretty free and 
unattended with pain : a cicatrix in the groin remained. 
The teeth were irregular and decayed, while the incisors 
were notched, though not in the crescentic manner that 
Hutchinson describes. I naturally suspected a specific ele- 
ment in the case, and not getting satisfactory evidence in 
the family history obtained, took the patient to see Dr. 
R. W. Taylor, who, after a very thorough examination, 
could not get a history of syphilis in either father or 
mother {both were submitii-d to an examination), and no 
traces of it could be found ui other members of the family. 
The bony grating was fully recognized, and the up-and- 
down movement he stated quite positively was between 
the diaphysis and the epiphysis ; in other words, his diag- 
nosis was a diastasis due to an epiphysitis caused by 
cachexia. 
The case subsequently came under the care of Dr. Robert 



I 



138 DISEASES or THE HIP. 

Abbe, who recognized the same condition Dr. Taylor and I 
had recognized. His treatment consisted of an immovable 
apparatus to the hip, and cod-liver oil with iron. This 
grating grew less distinct, Dr. Abbe informs me; but the 
case passed out of his hands, and neither he nor I have 
beenable to trace it; hence my in^ibility 10 give final re- 
sults. 

In the cases just narrated, the facts elicited enable one 
to diagnosticate epipliysitis, remembering the case of Dr. 
Judson's. The grating I found in August, eight months 
after the beginning of the inflammatory process and about 
six months after the subsidence of the same, I found it 
again quite readily on two different occasions in November, 
while, after an attempt at immobilization, it was not so 
easily recognized — i.e., more pain was induced on employ- 
ing the mpvements necessary to its production. The case 
throws considerable light on some of those reported by 
Dr. Sayre in the second edition of his Lectures, as traumatic 
diastasis. For instance, on page 382 he records the case of 
a little girl (age and date of injury not given), in which he 
excluded hip-disease, although there was a large abscess in 
the gluteal region. There was shortening, the trochanter 
was above N^laton's line, while " the ordinary symptoms of 
luxation, inversion of the foot, etc., when tiie head of the 
femur is upon the dorsum of the ilium, were absent," The 
accident, we learn later, had occurred two years before (the 
date of Dr. S.'s examination), and the shortening, he now 
learned, had followed J>«w«i/'w«/)'- " The abscess [when it 
came and how long it lasted we are not informed] was 
caused by inflammation of the bursa over the great irochan- 
ler." On page 384 another case is recorded, the data of 
which are more exact. The child was three years old when 
Prof, Sayre saw it, and had been treated, we are informed, 
for eighteen months with soap liniment and a bandage for 
"a simple sprain, then six months in St. Luke's, with weight 
and pulley, for hip-disease, no improvement occurring in his 
hip." At the end of these two years the litilc patient came 
to Bellevue, and about eight months afterwards Dr. S. ob- 
tained thefollowing history: "When three months old the 
child rolled out of the cradle, and the mother, catching it by 
the leg while falling, felt something snap. Nothing partic- 
ular was noticed until about a week afterwards, when, the 
mother states the hip looked somewhat swollen," (The italics 
are my own.) Whether this swollen condition ever termi- 




ACUTE EPIPHYSITIS OF THE HIP. 139 

natcd in suppuration, or whelber a cicatrix was sought 
when che patient entered Beilevue, we do not know, 

I do not make this remark to be hypercritical, but I make 
it because, in my own case, a surgeon of fine diagnostic abil- 
ity had overlooked the cicatrix in the groin, had discounted 
the mother's clear testimony about the swelling and the 
suppuration, and had made out /reiwwfl/jV "diastasis of the 
head of the femur, unquestionably," an error he subse- 
quently very frankly admitted. The result of treatment in 
the two cases I have taken from Dr. Sayre is not given. " It 
was the same as if he had hip-disease" in the second; not 
given in the first. 

The third case the doctor reports is on pages 585 fise^. 
This was in a girl, aged four, seen January 5, 1873, and the 
history he obtained was that on Christmas, 1870, the child, 
already six months walking, was left by the mother for 
about two hours in charge of the nurse, and on the mother's 
return the little one was found lame in the left leg, which 
was shortened and slightly turned out. From that fatal 
hour to the fifth of January, 1873, the child was not "able 
to walk upon it or touch the floor." "The nurse insisted, 
with great positiveness, that she had received no fall or 
other accident during the mother's absence, and that she 
had not been out of her sight a single moment." In view 
of the mother's clear recollection of the signs of a diastasis 
(after the lapse of two years), the recorder of the history 
could make no other comment on the nurse's statement than 
he did, viz., "The child being too young to contradict this 
statement, it has to be received for what it is worth." This 
patient was then living in London, and had the benefit of 
the advice of the surgeons connected with the different hos- 
pitals. All of the surgeons who examined the patient pro- 
nounced the case one of hip-disease, and advised leeching, 
blistering and rest. "The limb gradually contracted; ad- 
ducted and rotated, until in the course of the year it assumed 
its present condition," which is shown by a photograph, and 



the deformity in flexio 



lion outward c 
lion on page 387. 
inconsistent with 



inchylosis had 
vilh some force, limit 
In this case, we are 



I quadra 
This pro, 
■straight 
c of dia; 
iulted, toe 



lis li 



be rectangulai 
Indeed, such is the descrip- 
isive deformity is certainly 
b," "spine vertical," signs 
page 382. A false 



foi* 



fMS V 



e obtained." 



nformed, there had been " 






1 



140 



DISEASES OF THE HIP. 



ation about the joint, abscesses, ( 

disease of this articulation." The resul 

(division of muscles and tendons aiming 

formity under chloroform, and subsequent use of apparatui 

is such as one would expect in a case of caries sicca of t* 

hip; and hence I, for one, am not convinced that this was even 

a case of diastasis, either from trauma or acute epiphysitis. 

It is far from my intention to deny the existence of a 
traumatic diastasis, or todetracl in the least from the honor 
due the distinguished Bellevue Professor in bringing thiljr' 
subject so prominently forward in surgical science. sT 
leaves, as he claims, one of t lie deformities to be differentiate^ 
fn>ni that of chronic ostitis of the hip. Only, my own studit| 
lead me to regard it as an extremely rare accident in eai^ 
childhood, and as resulting, when it does result, from morbi 
processes going on at the diaphyso-epiphysial junction. 

There is a very interesting case, with a pathological spec!-' 
men, on pages 389 and 390, valuable not so much on account 
of the specimen, which might be found in connection with 
a chronic ostitis wherein repair had taken place, but on 
account of the testimony of the physician who gave DrJ 
Sayre so clear a history of the case seen the day foilowinj^ 
the accident. There was something here that seemed tanL 
bic — the shortening, tiie adduction, and the outward roM 
lion. Yet the physician diagnosticating diastasis at thi 
time should, it seems to me, have made some mention, poi 
itive or negative, of crepitus, either bony or cartilaginous. 1 

Occasionally one meets with a case many months afW 
the subsidence of all inflammatory signs, and fails to find aM 
grating. This can be easily explained hy the repair whtd 
takes place, leaving the remnant of the epiphysis coverB ' 
with a smooth cartilaginous capsule moving in a ne^ 
cavity, such as Dr. Sayre's specimen showed, The presenef 
or absence of roughening will depend, of course, on thf 
kind of repair that has taken place. 

In the early summer of 187S, a male child ten motiths o 
age came under my care foracellulitis of the upper fourtt| 
of the left thigh. The infiltration was a notsbie feature 
the case, the skin being quite lense, yet presenting no* 
acumination. There was much febrile reaction and con- 
siderable anorexia. The child would make no attempt to 
creep, and would lie only on the right side. Four weeks 
isly the mother had observed one mornings euddesa 
of power" in the limb, and could 1 ' " ' 



e mornings suddeftH 
] not recall any *m 



ACUTE EPIPHYSITIS OF THE HIP. 



141 



3ury direct or indirect. Next day the fever appeared and 
■ilh it a " little swelling" about the thigh. This continued 
■without abatement to the date when 1 first saw the case. 

I ordered an anodyne and poultices. Four days later I 
saw the child and found ils contiiiion about the same. 
Seven days after tliis visit I found the infiltration, which 
had involved only one side of the thigh, filling both sides, 
id extending up to the crest of the ilium, the thigh circum- 
ference being thirteen and a half inches against eight for 
corresponding portion of the other limb. The superficial 
veins were large and tortuous, and I detected a small area 
rf deep flnctualinn. Fearing either a malignant or a 
Byphilitic disease I refrained from incising. The anodyne 
no longer gave relief, and I resorted to stimulants, as they 
seemed to be indicated, and concluded to wait a little 
longer. 

I did not have an opportunity of seeing the little patient 
Again until the last of July, five weeks having intervened. 
In this interval another physician had been consulted, and 
lie opened the abscess, tor such it proved clearly to be, in a 
week or two after I had last seen the case, giving exit, the 
ther states, to four glassfuls of pus. This gave the 
needed relief, and the child w:is now free of pain, although 
there was some tenderness on moving the hip. There was 
a certain amount of infiltration. A tonic was ordered, 
nine days later 1 found the inguinal glands much en- 
larged, the infiltration above mentioned presenting a boggy 
feel, while the motion at the hip was smooth, A firm roller 
'as applied, and as ihe patient was greatly emaciated I 
rged that it be taken out on the water frequently. I was 
much surprised to find a month afterwards one inch short- 
ening of the limb, and signs of a pathological dislocation. 
The case soon passed from under observation, and at the 
end of a year I succeeded in tracing it out, to find the limb 
everted to a slight degree, the trochanter on a higher plane 
than that of the opposite side — one inch above Nilaton's 
line — and nearer the anterior superior spine of the ilium, 
>unded body like that of the head of the bone lying on 
ihe dorsum, and no bony grating on active or passive 
lOtion, both of which could be made. There were three 
quarters of an inch shortening which could be easily over- 
tome by traction. This speedily recurred on desisting from 
the traction. There was only a half inch atrophy of the 
limb, and the infiltration was no longer present. Tl.c 




mother had been dead six months, dying from consun)P'_ 
lion of two years' duration. The father did not care for 
any further treatment, and hence none was ordered. I 
examined the case purely scientifically a year afterwards, to 
find this lime one inch shortening and one inch atrophy. 
The gait and deformity wen; the same on the occasion of 
my last examination, fourteen months having elapsed. The 
shortening was one and a quarter inches, and not overcome by 
tra<H9n. 

It will be seen, then, thatayear elapsed between the sup- 
purative period and my next observation. Whether there 
ever existed any bony grating I did not know, yet the pre- 
sumption is that such was present before the reparative 
process was fully established. If there is one thing more 
clearly demonstrated than another in bone diseases it is 
the wonderful success JJature meets with in reproducing 
osseous and cartilaginous material. Many of Dr. Sayre's 
cases of excision have demonstrated this most conclusively. 
In the frontispiece of his last edition is a specimen most 
remarkable in this respect. 

The diagnosis, then, of acute epiphysitis rests chiefly 
upon the following points: The age of the patient, viz.. 
under two years of age. {This is not absolute, only my own 
experience induces me to name this period. Other ob- 
servers have met with this lesion in older children.) The 
accuteness of the attack, coming on rather suddenly, and 
ushered in by marked constitutional disturbance. The 
history of exposure to cold or of a traumatism. The gravity 
of the symptoms during the first fortnight. The early 
signs of suppuration. The loss of function of the limb 
almost from the first symptom, with extreme tenderness of 
the joint and periarticular tissues. The resulting deformity, 
viz., that of a diastasis with grating felt in connection with 
the femur itself. This grating is not a constant sign, 
especially if repair has begun before examination is made. 
The lesion is to be differentiated from syphilitic periostitis 
of the epiphysis and diaphysis, from traumatic diastasis, 
from acute periarthritis, from acute synovitis, and from 
chronic articular ostitis with acute exacerbation. 

In syphilitic disease there is always the history, which, 
by the way, is not always easily obtained. The symptoms 
of hereditary syphilis are so changeable and so uncertain 
thai one cannot always decide the question. One group of 
symptoms will satisfy one authority in syphilography and 




ACUTE EPIPHYSITIS OF THE HIP. 143 

mere notching of the teeth is far 
There must be a regularly cres- 
centic notching for the Hutchinson teeth, and ihen even 
with this clean-cut sign some are unwilling to accept it as 
evidence unless the wedge-shaped teeth be present. 

The following case well illustrates the difficulty of a dif- 
ferential diagnosis: 

Dr. S. Hemingway referred to me in October, 1879, a 
female child, aged eighteen months, with marked infiltra- 
tion throughout tlie whole extent of the right thigh, the cir- 
cumference being ten inches against seven and a half for 
the opposite side. The limb was held flexed without any 
rotation either way, and on employing passive motion at 
the hip, a distinct bony grating could be felt in the joint. 
The upper incisors were notched, and seemed to me suf- 
ficiently crescentic in the notching ; the post-cervical glands 
were enlarged symmetrically, and the rectal temperature 
was 103°. I could not find any condylomata, but there 
was an eczema over the lobe »f the left ear. The child 
was very thin, and poorly nourished. I learned that one 
month previously the liltle girl was running about quite 
actively, and that within three weeks a lameness had ap- 
peared. Whether the lameness was sudden or was preceded 
or accompanied by pain I did not learn. At all events, 
the child now would not make any attempt to walk. 

Without making any attempt to get a specific history in 
the parents, I referred the case back to Dr. Hemingway, ad- 
vising an anlisyphiliiic treatment. Eleven days later Dr. 
H, sent the child lo me again, with a note stating that the 
patient failed to improve under the mixed treatment, and 
that then he had applied poultices to the paits with decided 
benefit. He further wrote that he could not get any spe- 
cific history. 

I somehow felt that there must be such an clement in the 
case, and made an appointment 10 meet tiie Doctor wilh 
Dr. R. W. Taylor. At this visit the grating was distinct, 
and twelve days afterward I could not detect it. Emacia- 
tion had now become extreme, and there was a wrinkled, 
aged appearance of the face. The infiltration had not de- 
veloped into abscess, but nevertheless seemed to have 
increased in extent. 

Next day we met Dr. Taylor in consultation, the parents 
being also present, and he failed, after a must exhaustive 
examination, to gel any evidence of syphilis in either pa- 



i 



144 



DISEASES OF THE HIP. 



rent, or in any of the other children. On the strength g 
this negative testimony he excluded syphilis, and made the 
lesion out a purely strumuous periarticular ostitis. The 
grating was not present at this examination, and hence his 
exclusion of joint lesion. Under syrup of the iodide of iron 
and cod-liver oil the patient improved so much that, at the 
end of six weeks the infillration had almost completely dis- 
appeared. 

Two months prior to this examination the right thigh 
was live and a quarter inches larger in circumference than 
the left. Now it was only one inch larger. The limbs now 
were equal in length, and the child was walking. In Feb- 
ruary, 1880, 1 saw the patient again and detected a limp not 
unlike that of chronic joint disease. While all movements 
were painless and unresisted, I felt the grating within the 
joint quite distinctly. The capsular ligament seemed ab- 
normally lax, and the great trochanter was more prominent 
than its fellow. A few days later I found a half-inch 
shortening, while the limbs were equal in size. 

I did not see the case again until October, i88a, when 
I found a practical dislocation of the hip with one inch 
atrophy of the thigh, one and a half inches shortening, 
and the grating still present on passive motion. Then 
again, in 1883, March 8th, I examined the Hmbs, finding 
them parallel as the child lay on ihe table, but the left one 
Was rotated outward over at least a quadrant. The lip of 
the trochanter was an inch above Nelaton's line, and was 
on a plane nearer the abdominal walls than its fellow. The 
motions were still good, save that of abduction. External 
and inlernal rotation were preternalurally free. The 
shortening was one and a quarter inches, and only a quar- 
ter of an inch could be gained by traction. What seemed 
to be the remains of the head of the bone (the body was 
small and irregular in shape) could be felt on the dorsum 
and without the acetabulum, though if sharp flexion were 
made this body seemed to slip into the acetabulum with 
a roughened thud-like sensation. No abscess has ever 

1 have detailed this case at considerable length, indeed 
all I have repeated have been thus extensively narrated in 
order that deductions as to the diagnosis and prognosis 
might be drawn. In this particular case, however, without 
a history even of syphilis, I am still strongly inclined 10 
the belief that the lesion was syphilitic. It will be seen, 







ACUTE EPIPHYSITIS OF THE HIP, 

ihough, that the presence of a clear history is nece^ary to 
(lie diSctentiation of epiphysitis from syphilitic diseases of 
the bone. 

In diastasis of traumatic origin the history is also llic 
one point on which a diagnosis can be based. Tliere 
must be sudden lamt^ness and deformity immediately fol- 
lowing the injury, and it thest; follow any acutely inflam- 
matory symptoms attended with suppuration, leading 
questions in securing the history should be avoided. lu 
diastasis the grating should also be recognized early, and 
of course, must not be expected after the lapse of many 
weeks. 

In acute periarthritis ihe infiltration can be recognizfd, 
.md the joint is fjee from teotlerness. The joint should be 
tested as to its functions from time to time. I am Cully 
aware that a satisfactory test of the joint or its functions, 
if an acute periarthritis be present, is exceedingly difficult, 
uud us the treatment is practically the same in either event, 
a diffeicuiial diagnosis ciin be deferred until the subsidence 
of the acute symptoms. 

From the acute exacerbation of a chronic articular ostitis 
the history will be all important, and in the absence of this 
the age of the child, the character of the infiltration, and 
the temperature wilt serve in all likelihood to effect the 
differentiation. 

Then there are iliac abscisses and perinephritic inflam- 
mations that may harass one. yet these have signs quite 
distinctive, and scarcely need be mentioned in this connec- 

The prognosis depends largely upon the cachexia of the 
child, and upon the gravity of ihe lesion. In a violently 
active inflammation, like that in the case of Dr. Judson'-. 
patient, the chances of life are small. Yet, in the majority 
of instances death docs not ensue. The deformity whicli 
results is pretty uniform, and one must expect from a half- 
inch to ao inch shortening. The extension to the surround- 
ing bones does not often occur, yet the diapliysis and the 
whole shaft may become involved in an osteo- myelitis, the 
prof^nosis of which is grave enough. A progressive defor- 
mity, such as one would expect in chronic nsiitis of the 
hip, is not to be expected. 

The treatment naturally divides itself into measures for 
controlling the inflammation of the early stage, and means 
fur preventing deformity and correcting the same. 



146 



DISEASES OF THE HIK 



The nature of the disease (to use an expression which caiq 
never become too hackneyed), once being recogniz 
limb should be placed at rest in the position whi 
secure the most comfort, and hot or cold applic 
ployed, according to the taste of the practitioner. As I hav| 
before remarked, when speaking of acute inflammation] 
my own preference is for hot fomentations. If absce! 
forms, it should be opened early iind destruction to t 
periarticular structures thus avoided. Undoubtedly much' 
valuable information can be gained by exploring with one's 
finger, the abscess sacs thus opened. Rest should still be 
continued, let the joint be well protected during Nature's 
efforts at repair, and by no means allow the patient to wallQ 
upon the Hmb, unless this precaution have been secure 
I am not giving the treatment as I practiced it, but I aill 
giving such as my cases teach should be employed. Thev 
did not have any protection to the joint except in one ii^ 
stance, and that seemed to do well. Though, in a caa 
reported by Mr. Macnamara on page 79 of his work, 
which reference has been made, all the precautions were 
taken, drainage tubes were inserted about the joint, and 
the limb was fixed to a Thomas' splint with subsequent ex- 
tension from the foot of the bed. The final report records 
shortening, and such other conditions as my own case) 
show. 

A plaster-of-Paris dressing or a well-moulded leathel 
splint could be easily managed, I should think, in a child 
so young. 

These need to be worn, too, for many months at lea: 
and then should not be removed until the joint is carefutl^ 
examined as to the repairs that have taken place. 



II. 



DIASTASIS OF 1 



F THE FEMUR. 



Diastasis is ;iii anglicized Greek term, and means sitnplw 
a separation, in connection with the proximal end of thfS^ 
femur. It means a separation of the epiphysis from tbft^ 
diaphysis, and corresponds closely enough for the practical ' 
purpose of a definition with an intracapsular fracture 
which occurs in the adult. It will be remembered that os- 
sification between the diaphysis and epiphysis is not com- 
plete before the twentieth year of life. By reference U, 
Fig, 7 on page 47 the line of cartilaginous union is seen, i 




DIASTASIS OF THE HEAD OF THE FEMUR. I47J 

Dr. Hamilton classifies epiphysial separation with frac- 
ures, and states, in speaking of them as applied to all the 
^ong bones, that they rarely occur after the twentieth year of 
life; and in speaking of this particular separation, on page 
374of " Fractures and Dislocations," he states that the tour 
cases he has collected, viz.; one reported by Mr South in 
3j7. in a boy ten years of age; one by Dr. Willard Parker 
n 1850, diagnosticated seven years after its occurrence, in a 
[irt eighteen years of age; one by Dr. Alfred C. Post in 1840, 
n a girl sixteen years old, and one by himself in a boy fifteen 
■ears old, "constitute the only examples of this accident 
which I find reported, or of which I have any knowledge, and 
although there mav be much reason to suppose that the 
diagnosis may be correct in each instance, I can not regard 
them as actually proven." And he further remarks, " nor 
can I admit the accident as fairly established, or the diag- 
nostic signs as being properly made out until these im- 
portant points have received the confirmation of at least one 
dissection." 

The signs given by Bauer are: eversion of the limb and 
shortening, yet the limb will be straight; a loose articula- 
tion, a straiglit pelvis, and crepitus in the early stage; the 
spine will be vertical, shoulders square, and the apex of the 
great trochanter above N^laton's tine. The deformity must 
also be produced suddenly. If one confines himself to these 
signs the diagnosis should be easily made, and no two ob- 
servers should disagree. For at least ten years I have been 
looking for a case of unmistakable diastasis, the direct result 
of trauma, and I must confess that I have met with only 
a single case that does not admit of doubt. This was in a 
boy eight years of age, whom I saw for the first time the 
3clh of August, 1881. He was able to walk, though he 
was quite lame, and the act gave much pain referred to the 
left hip. There was an inch shortening, and this yielded 
three quarters of an inch on strong traction, a marked bony 
irtpitatioi» accompanying this manceuvre. There was a 
distinct up'and-down movement. The limb as he stood 
Was very nearly on a line with the axis of the body, but 
was rotated outward over an arc of about 20°, the foot being 
in marked eversion. Most of the weight was thrown upon 
the right limb. The movements were very good. He 
complained, the father said, muci) of pain during the night. 
There did not seem to be any atrophy, though comparative 
measurements were omitted. 




DISEASES OF THE HIP. 

The history as given by both the patient and the fathefl 
was that three weeks before this date, while in perfect 
health and sound in limb, he fell a distance of fifteen feet, 
striking directly upon the left hip. His lameness and ap- 
parent shortening followed immediately. My diagnosis was 
diastasis iif traumatic origin, and the case whs referred to 
Bellevue Hospital for treatment. Dr. L. E. Hoii, who was 
house-surgeon to the fourth surgical division, reported to me 
that my diagnosis was confirmed at the hospital, that the 
deformity was reduced, and that the plaster- of- Paris dress- J 
ing had been employed. I 

He remained under treatment from September isl Um 
November 2d, when he was discharged cured. I traced the' 
case, and examined again on the toth of March, 1HS3, find- 
ing a little broadening of the hip, about the trochanter, on 
the left, [he affected side, perfect motion in all directions, a 
half-inch shortening as measured from both trochanter and 
timbilicus, a half-inch atrophy of the thigh, a quarter-inch 
of the calf, and a gait in which one could on close inspec- 
tion detect a slight limp. There was no grating or rough- 
ening of any kind within the joint. The recovery may be 
said to have been perfect. 

In Mr. South's case, as quoted by Dr. Hamilton, the limb, 
when first seen after the accident was slightly turned out, 
but scarcely at all shortened. If the thigh were Hexed and 
rotated outward a distinct " dummy" sensation was fell, as 
if one articular surface had slipped off another. By way 
of treatment the patient was placed on a double inclined 
plane, but so little inconvenience was experienced that he 
would frequently leave the bed and walk about. The fur- 
ther progress of the case has not been recorded. Dr. Parker, 
at his clinic, made out a case in a girl who had had abcess and 
fistulous discharge. The history of the fall on the curb- 
stone several years before, although in lime followed by sup- 
puration, shortening and eversion, and the fact that flexion 
and rotation could be made without inconvenience seemed 
to have convinced Dr. Parker of the correctness of his diag- 
nosis. There are so many cases of undoubted bone disease at 
the hip in which anchylosis is not present and in which 
flexion and rotation cause no inconvenience, that Dr. Hamil- 
ton was fully justified in not accepting this clinic < 
one of diastasis. 

Dr. Post's case presented the signs the day foHowia 
the injury, and Dr. Hamilton's case was equally well 1 ' 




DIASTASIS OF THE HEAD OF THE FEMUR. I49 

served. Still, the dissection was wanting, and hence the 
diagnosis has not been verified. 

It is very curious how much difficulty in diagnosis arises. 
Indeed it is no easy lesion to make out, and the following 
case illustrates veiy well the point I now maintain. 

On the 4th of December, t8So, a German lad, sixteen 
years of age, presented at my clinic, and there was found a 
peculiar deformity about the hip, which he said had imme- 
diately followed a Tall nine months before. The history 
was confusing a little and I saw the father a week later, who 
assured me that one day in March last the boy was walk- 
ing rapidly along the sidewalk, when he slipped and fell, 
making strong effort to save himself. On coming into the 
house "the boy found himself hurt so severely that he took 
to his bed, and was unable to walk for six weeks. During 
this period he was treated with a plaster-of-Paris dressing 
for a " fracture of the hip." On coming out of this treat- 
ment at the end of the six weeks, he hobbled about oTi acane 
for a few weeks longer. He had been slowly gaining from 
that time, and on examination there was found an inch and 
a half atrophy of the thigh, undue prominence of the tro- 
chanter, a moderate amount of limitation in all the joint 
movements, and at least an inch shortening of the limb. 
The limb was vcrj' nearly parallel with its fellow, and 
there was no in or evcrsion. I did not gel enough facts 
for a diagnosis, and I thought it a subluxation, a diastasis, 
Oran arthritis. Thecase was sent to Dr. Frank H. Hamilton, 
who wrote me that he thought it a "fracture of the neck, 
probably aseparation of the epiphysis." Dr. Holt, who was 
house-surgeon at Bellevue at the time, reported to me on 
Ihe evening of the 8th of December that Dr. Hamilton 
examined the case more carefully that dav in the hospital, 
in the presence of Dr. Yale and Dr L. H. Sayre, all three of 
"whom pronounced it an intracapsular fracture. Dr. Holt 
went over the case again and felt convinced that such was 
the lesion. 

A fortnight later Dr. Hamilton told me that he had 
changed his diagnosis and in the absence of a more satisfac- 
tory history could not believe it other than a "genuine case 
of hip disease." 

Now, I have given the above details in order to show 
how uncertain one can be on this subject, and how obscure 
signs may be after the lapse of a few months. 

Histories are very uncertain bits <A literature, and the 





facility with which a history to suit a case can be obtaim 
is a well-established fact in medicine. 

Two years ago I had a friendly correspondence with Dr. 
Sayre, about a patient he sent me for mechanical support. 
The patient was a girl fourteen years of age who brought 
a card from the Doctor, saying this was a very interesting 
case of dislocation of the hip of long standing I naturally 
felt curious to "look it over," and found her walking 
quite easily, though limping. The heel of the left foot 
lacked an inch of reaching the floor, and the foot was a 
little everted. The limb was very nearly parallel with its 
fellow; the trochanter could be felt at a point a little be- 
low the crest of the ilium, and near the anterior superior 
spinous process. Taking this as a bearing, I ran my fin- 
ger over it and encountered a globular body lying on the 
dorsum ilii. On rotating the limb, this body rolled under 
my finger. In the dorsal decubitus, the shortening by careful 
measurement was a little less than one and a half inches, 
and on firm traction downward this shortening was com- 
pletely overcome; the globular body above mentioned slip- 
ping over an irregular surface, where a distinct grating 
could be recognized. Abduction of the limb was impossible, 
as the member lay in its acquired position. As she stood. 
there was no deviation in the spinal column to the right or 
to the left. I could not find any cicatrices, and could get 
no history of suppuration. The girl told me that she had 
always walked lame, and furthermore that she hurt her hip 
when four years of age. Both father and mother had been 
dead several years, and I had no other one from whom io< 
formation could be obtained. 

I made out a congenital dislocation of the hip and eX' 
plained the roughened sensation on the theory of an irregu- 
lar cleft in the upper rim of the acetabulum. A note was 
sent Dr. Sayre asking whether he meant by " dislocation of 
long standing" a congenital dislocation; and I received a 
reply in which he stated " It is not a congenital dislocation, 
as she was perfectly well until she was/c«r years old, when 
she had a fall down stairs out of agirl's arms, and probably 
had a diastasis at the neck of the femur, although it may 
possibly have been a luxation; but my impression is, it was 
a diastasis." 

The crepitus, if crepitus it could be called, on making 
traction of the limb seemed to me to be the only sign 
iv'iich could be regarded as one of a diastasis, and yet, in 



i 





DIASTASIS OF THE HEAD OF THE FEMUR. 



I that it is very 
ivinced by a. careful 
istasis, and even the weight 
of Dr. Sayre did not con- 



len years time, crepitation ought certainly to have long 
since disappeared. Dr. Sayre relied on the history he got 
from the girl and I did not,' It v " ' 
easy to err in diagnosis, I was n 
examination that this \ 
of so great an authority as thai 

vince me. I have met with quite a number of cases of 
double congenita! dislocation in which a roughening on 
passive motion can be easily recognized. In a recent 
number of the Philadelphia Medical Times is a report of a 
case of epiphysial separation by Dr. J. M. Barton of Phila- 
delphia. The patient was a boy aged fifteen years, who, a 
(ew days before Dr. B. saw him, had received an injury to 
his hip in the following way: while crossing the yard bear- 
ing a large bundle, a companion pushed against him so 
that he let the bundle fall to the ground and rested his 
hands upon it to save himself from falling. While in this 
position, a second push turned him over and he came to 
the ground seated, supporting his weight by the hands. 
An inch shortening was found on examination, and the foot 
was everted, though not as fully as it is in senile intracapsu- 
lar fracture. The popliteal space and lumbar spine were in 
contact with the bed at the same lime. The periarticular 
muscles were free from spasm, the fascia-lata was relaxed. 
The trochanter was higher, more prominent, and nearer 
the anterior superior spinous process than its fellow. 

Under ether the limb was fully rotated and the trochan. 
ter described a large arc of a small circle, i.f., it rotated on 
its own centre and did not increase its distance trom the 
median line of the body. Traction reduced all deformity 
but shortening and prominence of trochanter returned 
immediately on suspending this act. Crepitation of an 
unusual kind was felt, during these manipulations, as if 
large surfaces of diseased bone were rubbed together. 

The patient was placed in bed with extension and the 
hip was additionally supported. At the end of five weeks 
there was less than a half inch of shortening and on re- 
moving the extension the original deformity returned, 
although under portable extension treatment for a year 
the shortening had increased to one and a half inches. 

Diastasis is to be differentiated from: 

I. An unusual form of traumatic dislocation. 

t. Congenital dislocation. 

3. Pathological separation in acute epiphysitis. 



1 



IS2 DISEASES OF THE HIP. 

4. Pathological separation in chronic articular ostitis. 

The treatment is simple and any one recognizing the 
lesion early would naturally resort to such means as would 
reduce the deformity and hold the fractured parts in appo- 
sition. It is very important lo fix the hip securely and 
maintain the immovaliie dressings for at least two months. 
The parts will readily enough unite after a fashion, but 
the hyperaemia induced in neighboring parts is apt, 
seems to me, to set up bone disease, especially if the child 
be permitted to use the limb while the neck of the femuri 
is unprotected. 

In those cases wherein deformity has already resulted, 
and the malposition of the limb is such as to occasion much 
impairment to locomotion, the treatment will be the same 
that is employed in the correction of the deformity from 
chronic bone disease of the hip. 

Reported cases are indeed very scarce wherein perfect, 
recovery has been obtained. The results seem lo be no' 
better, in fact, than those wherel he diaphyso-epiphysia!, 
lesion is an inflammatory process. 

The conclusions, then, to which my studies have led au 
are: 

1. Diastasis of the head of the femur of traumatic pre 
duction is an exceedingly rare accident. 

2. The diagnosis at the time of the injury even is mud. 
more difficult than one would infer from the signs given ift, 
the text-books. 

3. The diagnosis years after the occurrence of the de- 
formity depends altogether on the history, and as histories 
are so frequently biased by preconceived ideas as to the 
nature of the lesion, this is a very uncertain basis for an _ 
opinion. ^ 

4. Practically it makes no difference whether one at thi^ 
advanced stage diagnosticates traumatic or pathological 
diastasis, as the treatment for the two is identically t' 
same. 

5. The results with or without treatment, as far as on^ 
can judge from published reports of cases, are the same 1 
arc obtained in chronic articular ostitis of the hip, 

The treatment must extend over a longer period than isj 
required for fractures, in view of the nature of the bone iafl 
contiguity to the line of separation. 



4 



CHAPTER X, 

I. Periostitis of the Hip. — 11. Malignant Disease of 
THE Hip. 

By the terms periostitis of the hip I would call attention 
10 a class of cases coming frequently under observation 
and distinctly traceable to a specific cause, viz., traumatism 
in some one of its varied forms. It is the periosteum about 
the trochanter which is most frequently implicated, but 
sometimes pelvic bones are involved, and we have the same 
lesion to contend with. The shaft of the femur, when the 
subject of periostitis, does not occasion the anxiety that 
the extremities of the bone do when affected. 

With acute diffuse periostitis I am not personally famil- 
iar, and I have no clinical experience, consequently, to re- 
cord. To dissociate it from acute ostitis or acute osteo- 
myelitis is hardly practicable, however desirable. Such 
cases are fully detailed in works on surgery, and come more 
frequently under the eye of the general surgeon. 

The acute localized periostitis from trauma and the sub- 
acute and chronic forms occurring in the vicinity of joints 
are not usually recognized in works on surgery, except in 
their relationship to the etiology or pathology of arthro- 
pathies. 

Periostitis, secondary to an ostitis, is not an uncommon 
lesion, and then really it is not entitled to a distinct place 
in the nomenclature of joint diseases. To recognize the 
primary localized periostitis is certainly very important, 
while it matters little whether the secondary form is recog- 
nized or not. In one, a joint may be saved by prompt and 
judicious surgery ; in the other, the same surgery would 
be meddlesome. In no department is an early diagnosis so 
valuable as in the disease of which this chapter treats. 

Among the causes, a contusion is the more frequent. 
Exposure to cold, strains, and the like oftea act as direct 
exciting causes. 

The symptoms resemble closely those of chron 



1 



154 DISEASES OF THE Hlf. 

ular ostitis, and very often the progress of the case 
such as to puzzle one in defining the characteristics of t 
two. There will be the direct cause, in close proximity 
the date of the swelling, or, periosteal enlargement, ai 
hence the necessity of becoming familiar wilh the touch of' 
all the structures one can reach about a joint. These pains 
at times will be most acute, depending largely upon the 
severity of the inflammation. Take, as instance, the fol- 
lowing case, which will furnish likewise some useful points 
in Hiagnosis; ' 

On the 23d of October, i877,.thcre hobbled into the Outoj 
door Department, on crutches, a man aged iwenty-two, of 
fair build, yet not well nourished ; and his sufferings were 
so great, he said, that he had lost much flesh during the 
past fortnight. His lameness was of only four weeks' 
standing, and, in fact, none of his symptoms dated further 
back. He was a porter in a mercantile house, and fancied 
that he had strained himself while lifting. It seemed a 
plausible etiology, too, for his pain and soreness about the 
right hip began the day after a severe effort at lifting a case 
of goods. Swelling soon followed, and prior to the date of 
his visit to the hospital a blister had been applied. It was 
difficult to secure an examination at all satisfactory; yet 
there was found a marked degree of infiltration diffusely 
scattered throughout the gluteal and upper femoral regions, 
with tenderness on handling, and on attempted movements 
at the hip, A diagnosis was provisionally made of hip-dis- 
ease in its acute stage, and further vesication was ordered. 
October 27th. — Is able to walk now, and feels very much 
better. November sth. — Walks with a very slight limp, has 
no pain, the infiltration is much less, and the patient wants 
to return to work. After a week or two he ceased coining, 
and returned to his vocation, although the movements at 
the joint were not quite restored. He was able, however, 
to do only very light work, and then suffered much pain 
after exertion. 

March 20th, 1878. — Returns with a relapse — i.e., sveXWng^. 
pain, and tenderness about the trochanter major of two 
weeks' standing. The iiililtration this lime is phlegmonous 
in appearance, and the movements of the joints are very 
little, if at all impaired. He was blistered again, and iodide 
of potassium was administered. This treatment was con- 
tinued with temporary benefit, then acute symptoms r 
curred, and finally, on May 4tli, an abscess on Iheuppcrthii 



I 




PERIOSTITIS OF THE HIP. 



155 



of the thigh, outer aspect, was opened. May 21st. — A small 
spicula of bone from the shaft of the (emur exfoliated 
through the abscess opening. After this the discharge 
ceased, and the opening soon closed, June 5th. — Discharged 
cured: no lameness; no pain; no infill ration. Nothing 
further occurred until January 22, 1879, when he returned 
with a swelling and tenderness over the spine of the tibia 
on the same side, of ten days' standing. The circumfer- 
ence is one inch greater than that of the fellow limb at the 
corresponding point. Periostitis of the tibia is diagnosti- 
cated, and iodide of potassium, gr. x., t. i. d,, ordered. An 
incision was made lo the bone on the 13th of February, and 
more blood than pus evacuated. After a few days there 
was an increased flow of pus, and a few days later the 
wound closed. He was discharged cured on the 21st of 
February, Seen December 13th as a conductor on the 
Fourth Avenue Railroad, and declares that he has not suf- 
fered the slightest inconvenience since last spring. Con- 
siders himself perfectly restored. 

Within the past year 1 have seen the subject of the above 
history, and he has never had any return of symptoms. 

In some instances, especially in young children, the case 
becomes exceedingly chronic, and the abscesses open and 
discharge to close again, year in and year out. A bright girl, 
eleven years of age, was admitted to hospital in tlie spring 
of 1881. She seemed to be in excellent health, but was 
quite lame, and presented a marked degree of deformity at 
the right hip. The movements were limited to a small arc, 
although the joint-surfaces were smooth. Below, and in 
front of the trochanter, a sinus existed, while on the outer 
surface of the thigh were four cicatrices. There was an 
inch and a half shortening. A little over two years before 
her admission she had fallen, striking the hip ; pains about 
the thigh and knee speedily followed, and on the thigh a 
periosteal?) swelling appeared. This developed into an ab- 
scess and was soon opened. A high shoe was worn on the 
foot of the sound limb^ihc child going about on crutches. 
Extension by weight and pullev was not tolerated well, and 
she seemed to derive the greatest relief from the crutches 
and high shoe. For four years these sinuses would open 
and close, giving rise to deformity which would subside as 
the inflammation subsided. Finally, she recovered with 
an inch shortening, with scarcely an appreciable lameness, 
and with perfect motion at the joint. 



1 




DISEASES OF THE HIP. 

The fact that many of these patients sufler 
most intense pain is due to the locality of the mtlamma- 
lory process. The formation of pus sacs in contiguity 
with nerve-bundles of course induces pain. I have seen 
instances where the periosteum covering the pubis was in- 
flamed and the symptoms were referable to this region. 
The iliac-fossa and the cresl are occasionally injured, and 
the nates are altered, the inguinal glands are enlarged as 
the lesion extends, and the joint movements are more or 
less restricted. A boy, aged four and a half years, came 
under my observation October 5lh, of last year, with a hard- 
ish swelling under the gluteal muscles in close proximity 
lo the sacro-iliac junction, right side. He fell in July, 
striking against the rocker of a chair. The signs came on 
very slowly, and the thickening of the periosteum had only 
recently been observed. No sacro-iliac tenderness, and no 
hip-joint tenderness could be discovered. The subsequent 
progress of the case fully confirmed the diagnosis made, 
the neighboring joints remaining free. 

The diagnosis is made on the history and on the presence 
of a periosteal thickening, if the case comes under observa- 
tion early, and if later, then the extent of the sinuses and 
the absence of joint lesion. These are the chief points on 
which one can base an opinion, but ail surgeons know thai 
in very few instances can they get sufficient data for a 
sharply defined anatomical diagnosis. Between an ostitis 
and a periostitis there exist many symptoms in common, 
I remember a boy, aged ten years, who was admitted to lios- 
pital January s6, 1876, and in the absence of a history I 
made a diagnosis of "hip-disease " second stage, employ- 
ing the term to indicate an articular ostitis. I found htm 
with the limb advanced and foot everted, walking wil' 
slight limp. The natis was much broadened, fold lowei 
and while 1 could elicit no joint tenderness, the limit to 
tension was 150°, to flexion 130°, and there was a littl 
atrophy. Under a liniment, and hospital regime all symp- 
toms and signs disappeared by the following March. The 
functions of the joint being found normal, he was dis- 
charged cured, to be readmitted, however, on the nth of the 
following August, I found then a circumscribed indura- 
tion on the inner side of the thigh, without any fluctuation 
discoverable. The skin was pinkish in hue and deprived of 
its epidermis. No muscular spasm of a reflex nature exi 
ted about the hip, and no other evidence of a joint disi 



lu m 

tt^B 




PERIOSTITIS OF THE HIP. 



cuuM be found 

cellulitis. This 
followed, which d: 



My t 



157 

Tiple 



lagnosis was at this ti 
roke down into ulcers, and sinuses 
■ged more or less during the next 
two or three monlhs. In December these closed, while a 
similar condition of degeneration presented itself on the 
outer side of the thigh. Repealed 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 1 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. Il leaches 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 difliculty 
in forming a correct opinion in ihe following case. This 
one is so interesting from a therapeutical point of view 
thai 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 ihe upper third of the (high 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 anemic; the limb was flexed at 
Ihe hip and rotated inward; ihe deformity was not marked, 



I 




yet suggestive, I could not discover any joint tendemest 
bm on measurement found the circumference of the thigb 
in its upper third one and a half inches greater than that 
of its fellow; tiie whole limb was apparently an inch longer 
tlian 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 arc:;. 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 1 
correspond. An iodine liniment, cotton batting, cod-liv( 
oil, and a tonic completed the order. 

This was followed faithfully, and the boy did well for 
month, in so far as freedom from pain and comfort were cor 
cerned. Then the area of induration became more circum- 
scribed, and while 1 could get no fluctuation I felt quite 
sure that the disease was not receding. Hot fomentations 
were substituted for the cotton-batting, and when 1 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 spicul^e 
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 fi 
and the crutches were discontinued. He had no lameni 
no shortening of the limb, and he was regarded as ci 
until six months later, when the sac filled again, and quite- 
an insignificani 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 



ea 

I 



nee. 

i 



Zl 



I 



PERIOSTITIS OF THE liir. 



'59 



December, i88r,a boy.a] 
as an excellent result fr 
and exfoliation of bone, 
only a half-inch of the c. 
The joint-surfaces ■ 



eight, whose case I looked upon 
an old periostitis, with necrosis 
; had no atrophy of the thigh, 
ind no shortening of the limb. 
' 5 normal. 



An old cicatrix existed about the trochanter, and he reported 
that spiculas of bone had been exfoliated through an abscess 
in this locality. 

I learned that he had been a patient of Dr. Schoeneman'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 
wrhich 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 (ew weeks later, complained of pain in the 
Tight 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 9th, 
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 z8th the 
abscess opened spontaneously. A probe reached bare bone 
over the trochanter. Carbolic acid injections of the usual 
strength 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 
ihorougly 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. Bolli. 




1 



i6o 



DISEASES OF THE HIP. 



made excellent recoveries, and the lime required was about 
the same. The principles, then, which these cases teach are: 
the mainlainance of good position of the fimb, a certain 
degree of rest to the parts, and general constitutional 
measures. 

Mr. C. Macnamara, 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. 1 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 imflammalory 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 io 
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 coin< 
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 



I 




I-IGNANT DISEASE OF THE HII 



[6[ 



and if treatment can be carried out on strict surgical 
principles. A case of trochanteric periostislis, 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 (ew weeks; if it be of a more 
severe type and occur in an individual of cachectic habit, 
the march will be slow, yet undevialing, 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 
tliis way 1 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 
I memoirs of Chassaignac in 1854, and the paper of Dr. 

»I)emme. of Berne, in 1862. The incisions that they recom- 
mended, and which were followed by such disastrous 
s-c5uU3, made now under antiseptic precautions, would seem 
*o overcome the objections urged then against the pro- 
cedure. Their cases, however, were those of osteo-myelitis, 



II. 
Malignant Disease of the Hip. 



Intimately associated with periostitis is a class of diseases 
■^vhose beginning is obscure, whose termination is fatal, and 
Xvhose early diagnosis is next to impossible. The most 
prevalent of the maglignant diseases are the sarcomas, and 
fiilroth believes that their subdivisions, made according to 
>it5tological peculiarities, are of no great value during life. 
Xir. S. W. Gross believes differently, and in a paper showing 
^:areful elaboriitinn, makes a very interesting study of sar- 
«:;oma of the long bones, based upon an analysis of one 
liundred and sixty-five cases. He found that the most 
Irequent were sarcoma. Osteomas, chondromas, osteoid 
^rhondromas. tibromas 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 






l62 DISEASES OF THE HIP. 

or in the medulla. Thus we have central sarcoma and 
periosteal sarcoma. The term osteosarcoma 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>., thr 
major portion is bony, while other portions may be mem- 
branous. The peripheral or periosteal sarcomas are 
covered by theouter fibrous layerof the periosteum, andif 
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 (emiir 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 
itrmors which are the more apt to present in early life, and 
even these were found tooccurnot earlier than the seventh 
year in the tables above mentioned. Naturally, in the large 
clinical field to which 1 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 joth of July, i3Si, 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 
and a slight bony enlargement, which was quite smootlL 





I 
I 



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 growingprominent. 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 limbsand 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 



t 



i64 



DISEASES OF THE HIP. 



he dragged along, eking out a suffering existence, the li 
looking like a vast appendage to a smidl body. In 
early pari of Marcli a superficial vein on [lie anterior i 
face of the tumor ruptured and ihe boy lost considers 
hoemorrhage before assistance was rendered. The appt 
ance of the parts on tlie 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 hseniorrhage 
of any significance, but the boy became cedemalous am* 
gradually sank April 4ih, dying by exhaustion. P« 
mission was given to remove the tumor, and 
the assistance of Dr. G. W. Ryan I made a dissection of tl 
parts involved. The thigh was disarticulated at knee ai 
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 femurse 




.— ROUMD-CILLBI] PeBIOSTeaI. SaICOHA. 

normal. The greater portion of the thigh, inclusive I 
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 (. 
cells with little intercellular substance, and is quite rich i| 
blood-vessels. The cells are for the most part small r 





I 



L 



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 seer 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 3'ears 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. Abmu this time the parts look an 
increased enlargement and pain :it limes became excruciat- 
ing. Her screams were sometimes Inlaid a quarter of a mile 
distant. For three months prioi 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 



I 




paiicnt thin, but not emaciated; a pulse of 150, and a tem-i 
peralure of 101.5° The right thigh was flexed at 90" and 
adducled. The pelvis moved with every attempt at passive 
motion of the iimb. 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 
tliis locality thesurfacc was a little irregular, but everj'whert 
else it was smooth and uniform. The skin was tense an^' 
glistening and over the nates a little discolored; the sup< 
ficial veins were prominent. 

There was no tenderness on palpation, but there waad 
sense of deep fluctuation. Moderate concussion of tap 
joint surfaces elicited no tenderness, but any efforts at p 
sive motion excited great pain, especially if rotation were aSL 
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. Theie 
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 
lo 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 routid- 
celied sarcoma, and all were subjected to operation save one- 




I 



MALIGNANT DISEASE Of THE IlII'. l6/ 

This one he could not compare wiih 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 hisiorj% so 
that in estimating the prognosis as regards duration of life 
he was confined to eight. The timi- from the first observa- 
tion of the disease to ihe close of life varied from two 
months and a half lo 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 rteeks; 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 lo the operation. 
My own conviction, from my knowledge of the life the 
little suflerer 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 sufifering 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 liEemorrhage 
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 much 
better. 

An early diagnosis is all-important, and the points in dif- 
ferentiaiion from periostitis arc the following: 

1. In periostitis the area of thickening is more circum- 
scribed and more irregular in outline. 

In periosteal sarcoma the thickening soon emWaces the 
whole circumference of the bone. 

3. In periostitis the superficial parts present more signs of 
an acute inflammation. 

hi sarcoma the superficial parts present little io the way 
of extra heat or other inflammatory signs. 

3. The pain in periostitis diminishes in direct ratio with 
the growth of the tumor. 



I 

1 



loS DISEAbES OF THE HIP. 

In sarcoma the pain increases with the growth of tid 

lumor, f 

4. Suppuration is the nile in periostitis; the exception $ 



The diagnosis in the advanced stages is not difficult. 

iiiurse the joint may be so enveloped, and the functions 
ihe same may be thereby so much impaired, that chronj 
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 osleo-myelitis, or a chrpnic^articular osti- 
tis in the second stage. When 1 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 t 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.* 

I. In the second stage of a chronic articular ostitis, the 
tumor is either circumscribed or disiinctly 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. 

3. The superficial veins in the one are not prominent; 
the other they get to be enormously distended. 

3. As the tumor increases in the one, the general heal 
does not suffer; as it increases in the other, cachi 
emaciation become the more marked. 

4. In abscess from bone disease the pain is at no t 
severe, and when it does occur it occurs during exacerbations. 
In sarcoma the pain is progressive, and, as a rule, constant 
and severe. 



res- 
one 




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." 




i 

al 

ts 



(Synonyms: Morbus Coxarius : Morbus Co\m ; 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-^l 
case 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 I 
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 ihey mean. 

So of morbus coxarius, and morbus coxte — 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 oE 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-worl;ers 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. 171 



with accepted viewi 
one form of inflar 
think, wlien a caref 
ing of a liistory, of 



, and will not commit us absolutely to 
matton. The time has also come, I 
il examination, with a full understand- 
igns, and of symptoms, will enable us 
to recognize (he disease in its early stage, despite (he ob- 
jections of the general surgeon. Errors will, of course, 
arise, yet ihey will be highly instructive to him who strives 
to make this branch of surgical science an art in the fullest 
sense of ihe 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, ■ 



■ery 



,tudei 



mding thai 



the 
e begin! 



upposed to leave college with 
■e are two theories prevalent; 
as a simple inflammation in the 
eres or capsular ligament pref- 
mbrane or cartilage, induced by 



one, that this dis 
soft parts, the ligam 
erably, or in the synovial n 

a sprain, or wrench, or contusion, however slight; the oiner, 
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 resum^ of the views 
held and facts furnished by different authors, see a paper 
by Dr. Judson, in New York Medical Journal ;tnd Obstetri- 
cal Review, for July, iSBs, 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, 
eitlier 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 arc, with a 
single exception, in specimens ivlicre section of the bo'ti; 



I 



I 
I 

1 



172 



DISEASES OP THE HIP. 



has not been made. The exception is in the case of Dif 

Willard's. 1 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. Harwell 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 iind myself that 
seem clear, and yet 1 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, tn whon,' 
I diagnosticated, with a precautionary interrogation-mai* 




CHRONIC ARTICULAR OSTITIS : PATHOLOGY. 



173 



I 



I 



however, acute primary synovitis. He was admitted "o the 
hospital in February, 1881, and was so excessively lender 
about his hip thai it required the greatest amount of care 
to gel him into the ward without pitiful shrieks. After 
much coaxing he was induced to stand. The left limb was 
rotated outward over a small aro, 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 halt 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 primafy synovitis, and 1 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. 



^_ (.icaiiy lui 



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 liip-disease begin as an ostitis. Beyond 
that age a certain proportion, not large as 1 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 hyperffimias 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 
easv- 

fhc 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- 
emia — 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 li| 
ments and cartilage suffer from the shock of injuries, 
children, concussion affects the weakest portion of theartici^ 
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 arc 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 matt 

Then, again, certain acute di: 






increase this vascOtH 



CHRONIC ARTICULAR OSTITIS: PATHOLOGY. 175 

larity in structures wlierein rapid developmental changes 
occur and bring about practically tlie same result as do 
concussions and other injuries. 

This is wcl! illustrated in a case reported by Dr. WJllard 
of Philadelphia, in the Boston Medical and Surgical Journal, 
l88o, 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 
Ihe round ligament is the centre of the disease." The 




patient was confined to bed with weight and pully, and 
every facility utilized for securing good hygiene. Two 
ths 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 
' I its gross appearances. 
There was not more than ten drops of effusion, but the 
Gynovial membrane was everywliere congested and soft- 
ened, and at the acetabular al'lachment 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) possiblv 



i;fi DISEASES OF THE HIP. 

caused by post-mortem contact against the acetabulu: 
although there was no corresponding spot in that cavit; 
and it had more tlie appearance of redness situated beneai 
the articular cartilage. The capsule was perfect, the rour 
ligament intact, and while the membrane covering it wi 
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 hardi 
ing of the soft tissues," Dr. Shakespeare made a section of, 
the acetabulum and head, at the same time cutting lon| 
tudinally the ligamentum teres. 

The epiphysis did not contain to the naked eye any 
seous or other nodules, the cartilage was entire, there waS 
nothing macroscopica! in any of the tissues suggestive of 
miliary or confluent tubercles. 

Among the conclusions arrived at from microscopical ex- 
aminations of tliis specimen was that the bony structure of 
the neck of the femur, although hypersmic, 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 actuallj 
found was a somewhat exaggerated hyperemia throughoi 
all the tissues. Pathologically, it was negative. 

Now, while the conclusions arrived at by the two genti 
men reporting the case are perfectly legitimate, I am coi 
strained to regard it as one in which the pathological pn 
cesses that existed early in the disease (this had begui 
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 certain 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 aoy 
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 U. of the Lancet for 
structure of the two tissues is sponge-like, yet the resi 



'3| 



oci 
not.^_ 

i 




CHRONIC ARTICULAR OSTITIS: PATHOLOGY, 177 



mger when a 



•ellow tuber- 



blance becomes, the stn 
culous-lookitig matter oi 

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 dcstiuctive is 
due 10 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 Ihe bones enier-ing 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 I lie 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 Ihe Medical Record, this localized centre of disease is 
shown in the accompanying figure No. 11. 

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 14th of De- 
cember, and I found both lower limbs very hyperjesthetic, 
jht ilie mire notably so. I saw her again nearly one 
month later She seemed very helpless, anri the report 
'from the mother, who was herself exceedinsrly 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 lameness had 





178 DISEASES OF THE HIE'. 

increased, and thai she was losing flesli. I saw thai 
was much thinner than when I had examined her before. 
The left thigh now was advanced a little and the foot even- ' 
ed, Extension to the normal limit was resisted, other i 
movements were not. Twh days later there was dulness in 
the left ilio-cosiai span, but in the absence of other signs 
was not significant. The lameness and pain on walking, 
and the morning stilTness were still present. Pain and re- 
sistance were encountered when the left thigh was rotated. 
Two d^ys elapsed again and the right thigh was adducted. 




I 



the foot was inverted, and there was marked resistance to 
flexion beyond 90°. The same resistance was present on 
the /if// side. As she stood, both limbs were in moderate 
genu-vujgiim, ami the right nalis was flattened and crease 
lowered, while lln^ 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 sacroiliac junction. Motion at the left hip caused 
no pain. Even the severe test of putting on and off the 




I 

I 
I 



CHRONIC ARTICULAR OSTITIS: PATTinLOGY. 179 

stocking caused no pain, and forcibly percussing the hcei 
with limb extended induced laughter. On attempting to 
stoop, pain was complained of at tlie left knee, and as she 
stood this limb was apparently lunger. Next day Dr. Poort^ 
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 xvas 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 k-ft knee, or npoa attempting to com- 
municate motion to the sacro-iliac joint on that side. There 
was tenderness, or at least the patient complained, on 
pressure being made over the sacro-iliac synchondrosis of 
the left side, and thore appeared to be some dulness on per- 
q^ssion 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., ^nd 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 a] 

During the latter half of Mar<. 
about the right knee, and the hmt 
child lay in bed. Adduction bei 
sign on each side. 

I assisted, one day early in April, the Doctor in making a 
pretty thorough examination under ether. The adducioi 
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 16th, 
and after twenty hours post mortem, we found the limbs 
perfecUy straight and equal in length. The parts o 



-, held fle: 



[nuch pain 

«ed as the 

mgly-marked 



l80 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 
pasily returned. Thecapsularligament itself was intact, but 
on being opened was found to contain about two drachms 
(if thick, inodorous pus. The ligamentum teres was softened, 
pretty thoroughly disoi^anized, and about iwn 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. Seciion 
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. lis complete dislocation was Impossible, without 
dividing the ligamentum teres. This ligament was pale red 
in appearance on section, and seemed normal in si)!c, 
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 ihe 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. II.) 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 




/ 



CHKOSIC ARTICULAR OSTITIS: PATHOLOOY. 



sf at least a half ounce 
vagiaa. The bladder t 
normal-looking urine, a 
pus-sac was found bef 
wall opening into the 1; 
by the dissection, and i 



-alls appe. 



lal, A 



; bladdt 
tter. This sac had been cut away 
s 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 
cilher sacroiliac junction could be discovered. My own 
explanation of the source of the abscess is that the pus bur- 
rowed behind tiie 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 
he 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 thiscase, making 
it even fuller in some respects than it was when first pub- 
lished, because I find ii so very inslruclive 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 lime. 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 

the one hand and the pelvic fascia on the other; a little 
later, the Ugamentum teres. It will be observed, too — ^and 
this fact I want to stand out in bold relief— that although 
the Ugamentum teres was thoroughly diseased and disorganised. 
the nutrition of the epiphysis suffered no appreciaMe 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 



\ 



l82 DISEASES OF THE HIK 

as it did in this particular case, yet cases have ill 
counterpart in pulmonary tissues. Often the lesion see 
arrested, and cases with long intermissions are not at 
uncommon. Cases like the following come under obser 
tion, and during the interval between exacerbations a c 
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 hu liad a brother saffering from caries of 
ihe 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 scrcL.ns, 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 withoiil 
known cause a suppurative middle-ear disease, ? 

At the close of the first week in September 
that his condition is such as to justify his discharge, and 
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. Durii 
that period never a sign of disease was observed, and I* 
cure was regarded as well established. The ear disei 
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. 



■og- 
daV 



Dm> 

^ 




CURUXIC AKTICULAR OSTITIS: PATHOLOGY. I83 

Next day, after perfett immunity for tliree years and 
three montljs, the liip is the seat of great pain, and the boy 
is abed witli a liigh temperature, and crying if any motion 
at the joint be attempted. 

The acute symptoms were relieved by the middle of the 
onth, and tiie buy was walking around the ward, though 
int still tender and glandular infiltration increasing. A 
general glandular enlargement, or, adenia, set in, the boy 
' ;came emaciati'd to a skeleton, and death by asthenia 
icurred the last day of February. 
Autopsy twenty-four hours lau-r, r.>ii,jii,[,(i l.y Dr. Ed- 




Fig. I 

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 (edematous, 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-hepalic omentum a gland the size of a 
walnut presses against the ductus-communis choledochus, 



J 




DISEASES OF THE HIP. 

the pyloric orifice of the stomach and the receptaculum^ 
chyli. The microscopic appearances of this gtand at* 
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 d£ep 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 tif bone presents a dirty yellowish aspect, 
with n groove extending from ligamenium teres towards < 




Fic. 1].— VsHTiir^i. Sectioh Siiowinc Foci of Disiasb in Ca» ok Page iI*. 

trochanter minor, intersecting a similar groove about tfaft 
insertion of capsular ligament. In this groove is new con- 
nective tissut. 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 necic of the sound femur are also removed 




CHRONIC ARTICULAR OSTITIS: PATHOLOGY. 

end liic above description is comparative. Blood exam- 
ined microscopically and found normal. The accompany- 
ing cuts show verj- 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 yellonish, showing the 
f;iiiy metamorphosis to perfection. Fig. la is a section of 
the'sound bone insi-rted for comparison. 

The case of Fricke's, of Hamburg published in 1833, I 
take from Dr. Judson'a paper, is of value in this connec- 
tion. The boy was four years of age and had been lame 




0. II.— SucrrOH of Snuno Fimi n Fie. 15.— Sictioh op Fkhub m Puicsi 

l«ICK«-l CASt COHPAH WITH F.H. 15. CaSH. PsM 18). 

four months, when he died of tubercular meningili'- Lon- 
gitudinal section was m^de of each femur and is repre- 
sented in the copies from colored lithographs. Fig, 14 the 
sound; Fig. 15 the diseased. He found the synovJcal mem- 
brane everywhere red and congested. The articular carti- 
lage was healthy in all lis surfaces, whi/e 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 nf the spongy tissue 




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. TJie epiphysial car- 
tilage was greatly reduced in thickness. 

M, Lannelongue's case published in i88i, in the Bulletin 
of the Surgical Society of Paris (vol. ii. No. i, pp, 9-11,) 
illustrates the cIosr connection between (he 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 Rexed and adducted position. 
Five months after the invasion of the joint disease she died 
of diphtheria, and the synovial membrane was found, post 
mortem, reddjsh.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- 
lum teres was also red, 
vascular and slightly fun- 
Fio. 16 — Voi.KM.\NK-s c*sB i'At;E 1S6 gous. The surfaccs of hcad 
and acetabulum presented, 
no change, and the articular cartilages retained their normi ' 
condition, with the exception of a little thinning 
tain portions of the head. 

Section of head and neck revealed a marked redness 
the centre of ossification of the head and large areolas 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 ol 
the bone, where they became continuous with the thickj 
ened synovial membrane. 

Volkman has published a case the specimen from whii 
(Fig. 16) is similar to Fricfcc's. (See p, 1406, Saml. I'" 
Vortrag. Nos. 168, 169, 1879.) It is described by 




ted,_ 

3 




CHRONIC ARTICULAR OSTITIS: PATHOLOGY. 1S7 

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 

The term ostitis malacissans is the term Billroth prefers 
Jor the early changes, and Volitman employs for the same 
the term rarefying ostitis. The chalky salts quickiy dis- 
appear from the osseous tissue, and the medullary vessels 
increase; the medulla, being filled with wandering cells 
takes the place of ihc 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 
10 express the different kinds one meets both clinically and 
on the dissecting-tabte. 

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 aionlca. 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 leach 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 arc 
just the reverse of this. He states, argumentatively, " Path- 
ological anatomists, who only see caries on the dissectJng- 
table, rarely know the fungous (nrm iicciiralely, or consid'- 



« 




but when one often examines pieces ol 
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, Hacfcley's Trans.). 

I would retort by asserting, with abundance of proof 
sustain me in the assertion, that at least three-fourths ol 
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 
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 ofj 
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 1 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 
isis — the development of tuber- 



ot " 



ossification- 
cles is an easy and a 
Dr. Henry 'H. Smit 
nection, in a highly 



of Philadelphia, has traced the con- 
structive paper, presented to the 
American Association in 187S (Transactions for that year). 
He notes the influence of congestion of the medulla on the 
cell proliferation, and on the increased number of Ieu(H>^ 
cytes : also the defective elaboration of blood as a result O 



.^ 




CHRONIC ARTICULAR OSTITIS: PATHOLOGY. 189 

perverted myeloid cell action : and arrives at the conclu- 
sion tliat 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. 

Barwell'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- 







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." 



^^^^H Mr. Holmes, in "The Surgical Treatment of Children's 
^^^^B Diseases," has a specimen figured which closely resembles 
^^^^B Mr, B.irvveH's. The drawing was made from the bone as 
^^^^V removed by excision from a girl eleven years of age who 
^^^B had been lame for two years. Mr. Holmes describes 
^^^B it as a case in which the disease was seated wholly within 
^^H the neck. I have had the specimen reproduced in Fig. i8. 
^^H ^^^^^ The portion of bone which gave 

^^H ^^^^K^L way is well shown, yet I am not 

^^m ^^ .^^^^^m^^^ convinced that the epiphysis did 

^^m ^^B^^^^^^f ^^1 "'"'' ^ focus caseous 

^H ^W^H^^^^Bk ^B ^^''''^ inasmuch as no mention 

^B wnmaBrnftf^^P^^K >^ made a It does 

^B KMKaSBMR^iy not follow that because the 

B w^m. &0^^r^ "articular surface was quite 

H ^H^U^Hly healthy" a mass of carious bone 

■ ^IBHI^S^ '^''^ "°^ ''^ beneath it ready to 

■ ■I^^HHV break through during an exacer- 

■ ^^^^^V bation and complete the destruc- 
I H^^^F tion of the joint. The compact 
I ^^^^^ tissue of the neck giving way 

no. .b.-Mk. Hnu.»s- Spiciu» to 6"'- ^'^'^^ <^ase goes OH record as 
li.Lusii.ATm Caiik or tm« Neck. One of the femoral variety of 
MTicAL icnoii hot M»c». hip-joittt disease. The disease 

may be such that the whole articular cartilages may be 
shed. This occurs, however, in the acute and subacute form 
of an epiphysitis. Mr. Harwell has figured a fine specimen 
on page 278 of the American edition of his work. The accom- 
panying figure (ig) is from a colored lithograph published 
by Volkman in his lecture. Dr. Judson has adduced this 
as an example of the spread of the pathological process 
from the centre to the periphery rather than the reverse. 

The neck and head in their changes are altered materi- 
ally ; the angle the neck makes with the shaft becomes acute 
sometimes, often it becomes rectangular, and the tro- 
chanter is carried above N^laton's line, giving rise to the 
appearance of a dislocation. The acetabulum, if not prima- 
rily diseased, occasionally becomes involved from contact 
with the necrotic masses filling its cavity. 

Dr. Judson reports (page; of his pamphlet): " ll is a curi- 
ous fact, and one which has not received the attention it 
deserves, that the tcibles of exsection of the hip (or disease 
contain a large number of cases in which theacetabulum is 
reported as healthy." In Hodges' table of one hundred 



I 



CHRONIC ARTICULAR OSTITIS : PATHOLOGY, igl 

and eleven operations, there were sixteen cases wherein the 
acetabulum liad escaped disease. 

In a case the specimen from which is shown in Pig. 20, 
[he acetabulum and remnant of head were fused into one 
homogeneous mass. 

The boy, aged twelve, was admitted to hospital in June, 
1875. He had a diathesis typically strumous inherited 
and acquired, if the latter were necessary to complete the 
condition. Six or seven years before admission symptoms 




of bone disease at the hip developed. Abscesses formed, 
and when I examined him the joint was seemingly an- 
kylosed, the angle of deformity in flexion being about 135°. 
Several cicatrices existed, and below the trochanter there 
were two open sinuses. The shortening and atrophy were 
prominent signs. From the dale of his admission to 
August, 1S76, the case ran the usual course. Abscesses 
would refill, sloughing follow about the gluteal region, and 
at this time one had opened below the anterior superior 




192 



DISEASES OF THE HIP. 



process and above Pouparl's ligaineni. Later, ulc< 
formed over ihe coccyx and in the border of the perineum. 
Indeed, all the parts about the joint became the seat of 
ulcers or cicatrices or areas of infiltration. Head symptoms 
were frequently noted, and during the next two years the 
notes show many exacerbations, many remissions. Finally, 
in August, 1378, the area of hepatic dulaess increased. 




There was much pain in this region, the urine for two or 
three years of low specific gravity, 1008, now presented 
epithelium and blood, but no casts. In September he had 
considerable vomiting and diarrhcea, and in October he 
slowly sank, dying by asthenia on the aist. Dr. Janeway 
assisted me in the autopsy ten hours after death. Drs. 
Ripley and Putzel were present. The left femur 1 
posed and an attempt made to tear it from the pelvis, 1 



h 




CHRONIC ARTICULAR OSTITIS: PATHOLOGV. I9JJ 

seemed so intimately associated that this portion of the 
pelvis was removed with the upper portion of the femur. 
The inner surface of the ilium showed a tiack of abscess, 

e end connecting with the perforated acetabulum, the 
other with an ulcer above Poupart's ligament. The tro- 
chanter major was very prominent, and extended one and 
one half inches above the corresponding point on the right 
side. The shaft of the bone, even denuded of all the soft 
(issues, was held lirmly in adduction. On longitudinal 




section through shaft trochanter and portion of pelvis 
rctnoved. the neck was absent, and only about one half of 
the head could be seen, and this was fused with the 
Bcetabulum, the outlines of which were very indistinct, 
a yellowish border shading off into red, taking the place 
of the normal rim. On comparison with a like section of 
the parts on the sound side the difference between the two 
hips stood out in fine relief. 

The trochanter of the diseased femur seemed to be on 
the same plane with the head of the sound femur, thus 



194 DISEASES OF THE HIP. 

making a shortening of the limb of between two and thrt 
inches. The shaft and the trochanter were perfectly normw 
m ac ros CO pi call y. 

The colored sketch from which the drawing represented 
in Fig. so is taken, shows the osleopjiites scattered through- 
out the caseiius mass, and is a fine demonstration of the 
mode in which destruction and reproduction go on at the 
same time in even the atonic caries of bone. The stage 
had been reached in this case when the reproduction was 
in excess of the destruction. But for the development of 
amyloid disease the patient would have made a recovery, 
with a very useful limb. 

The spleen was normal in appearance, but the kidneys 
had adherent capsules, nodular surfaces, and on section a 
marked waxy appearance was shown in the cortex and 
pyramids. 

The liver filled the greater part of the abdominal cavity, 
and the right lobe, instead of presenting a very sharp bor- 
del', was markedly rounded. (Text-books make this point 
in differential diagnosis during life between waxy and fatly 
livers; the border is sharp in waxy, rounded in fatly. The 
explanation given is that the organ reaches the brim, or 
fossa of the pelvis, and not being able to get lower, the bor- 
der is turned, so to speak.) The border of the left lobe was 
sharp, it not having descended into the pelvis, The weight 
of the liver was five and a quarter pounds. The upper por- 
tion was strongly adherent to ihe diaphragm. On section 
amyloid changes were very apparent to the naked eye. 

The lungs and pleura were free from miliary tubercles, 
though in the middle lobe of (he right a half-dozen calcified 
nodules, varying in size from a pin's head lo a small mar- 
ble, could be felt, apparently plugging the bronchi. 

The cranial dura was lined by a membrane which could 
be easily removed, and which, on microscopical examination, 
was found lo consist of fully-organized tissue filled with 
capillary vessels. No tubercles were anywhere found. The 
bones were not examined microscopically.* 

The destruction of the acetabulum is well shown in the 
specimens represented in Fig. a, which I have taken from 
Baiwetl. 

• Thi» case was reported in (he Medical Record for November 3, 1877, 
Bj one of " Cure of Tubercular Meningitis by Ergot." and. now. Iwo 
year« later, the post mortem showed tbat the boy had had. Instead,* 
simple acute internal pacby-meniDgitU. 



. had. Instead, ^M 




CHRONIC ARTICULAR OSTITIS: PATHOLOGY. 

The specimen as shown in Fig, 33 represents what few of 
us have had an opportunity of seeing, viz., a pus sac hang- 
ing from the inner wall of the acetabulum. 




196 DISEASES OF THE HIP. 

myelilcs more frequenlly than one would be led to suspect. 
In a paper on excision of the hip-joint, published in the 
New Vork Medical Journal for May. 1S77. (his author re- 
ports two or three cases in which a grave osteo-myelitis 
existed. In one caie, while he attempted to throw the 
head of the bore out of the acetabulum, after the usual in- 
cision had been made, the femur was fractured at the junc- 
tioo of the diaphysis with the epiphysis, just above Ibe 




Pic- 13.— Aukih moH Aceta><ii.uh. 

knee-joint. The whole shaft was removed by drawing it 
through the original opening. Tlie cut end was soft and 
discolored. It happened wilh Dr. Poore. as it has happened 
with other surgeons whose experience in excisions is large, 
on making his section, in several cases, to find the medul- 
lary canal diseased. Lower sections reveal the same con- 
ditions not infrequently. 

Mr. Holmes found a femur in a case reported in St, 
George's Hospital Reports, Vol. I., soft and diseased at 
both ends. Dr. Sayre, in fifty-nine cases of excision, found 
the shaft diseased in two-fifths of that number. 

Dr. Poore significantly remarks, " I know of no means of 
ascertaining the condition of the shaft before commencing 



CHRONIC ARTICULAR OSTITIS: PATHOLOOV. ig/ 

to operate, excepl ihat cases nf disorganiKalifin of ihe joint 
of long standing should be locikefl upon ivllli suspicion." 

It occasionally hiippt-ns, also, lliut not only llie sliitfl but 
the pelvic bones arc diseased tin nugliout a greater part of 
their structure, Mr. Annandale, in a paper on Hip Disease, 




i 



states 


hat 


he 


has met H 


ith two t^ses in 


which 


femur 


the 


iliii 


tn,and pre 


bably other of th 


- bones 


cased 


h rough 


■jut tlieirw 


hole structure. 




The 


nal 


re of the ost 


tis is usuallv the 


same i 


lesions 


of 


he 


spongy bo 


nes. and the'acco 


mpanyi 


No. 1+ 


sho 


ws 


he lesion 


n ihehcadof the 





n muliple 
ng figure, 
learer the 



Tg8 DISLASES OF THE HIP. 

periplicrv t!ian I have usually found the initial prot 
The boy (rum whom this specimen was taken had, in a 
tion, a caseous vertebral ostitis, a similar disease of 1 
bones of the foot, and a tubercular meningitis from wh; 
he died. He was ten years of age when disease of the I 
appeared, and shortly afterwards the spinal symptoms de- 
veloped. The "knuckle" was not observt^d until he was 
twelve. Six or eight months later, signs of chronic articular 
ostitis of the left hip were recognized. In a few months 
abscess over the trochanter formed. Later still, cystitis 
appeared and yielded to treatment. At times the hip and 
the ankle would be distended with fluid; then, an exit be- 
ing found, they would seem normal. Reflex symptoms were 
never a marked feature of the c^ise. From February, 1878. 
to October, 1879, he led at his home a vegetative exis- 
tence. Then he developed a tubercular meningitis, and 
died in November, The wonder was with his prolonged 
emaciation, his ulcers in various localities, and his prolonged 
suppuration, that he did not contract amyloid degeneration. 
There was no phthisis, however, in the family history, so 
far as could be learned. '" 

The autopsy was conducted with much thoroughnej 
vet the full notes are unnecessary here, and a bare mei 
of the lesions in certain organs will suffice. The brain 
instance, contained the lesion both macrospical and micrt 
scopical of tubercular meningitis. 

True miliary tubercles were found in the pulmoiu 
pleura. 

The bodies of three or four of the middle and low^ 
dorsal vertebras were broken down and generaly disorgaq 
ized, and a caseous cyst connected therewith was in 
proximity. Over the liver were small granular bodie 
nounced by Dr. Janeway, to whom I referred all the speci- 
mens, miliary tubercles. 

The femur, left side, was denuded of periosteum at its 
middle third for a couple of inches, and this area connected 
with atistulous tract openingon the outer sideof the thigh. 
On careful dissection, the capsular ligament was found 
intact; but just above its insertion, and above the upper 
margin of the acetabulum, was an ofiening through ihc 
ilium, into the floor of the acetabulum, through which the 
eroded head of the femur could be distinctly seen, and 

through which 1 put my finger, and felt t 

move as I rotated the shaft. 




CHRONIC ARTICULAR OSTITIS: PATHOLOGV. igg 



Areas o 



n all i 



t 

I 



long ihe exienial 
fossa, and«ven up to (he sacro-iliac synchondrosis. 
No trace of the ligamentum ier«s could be found. Lying 
loose in the acetabulum were several small pieces of 
necrotic bone belonging apparently to the head. On cleans- 
ing the cavity of these fragments no erosion of Ihe acetabu- 
lar cartilage could be discovered save in the upper portion 
above mentioned. In the triangular space, however, for 
s of an inch in diameter, there was complete 
loss of bone substance, but no opening into the pelvis, 
internal periosteum was quite thick at this point. 
I There was no pus or other fluid in the joint cavity. 

of femur, a soft pulpy material 
i filled the centre of the trochanter, and a similar mass occu- 
pied the upper end of the shaft at the centre of ossification. 
In ihr remnant of the diaphyso-epiphysial head was a 
yellowish pulp with reddish areolae in both epiphysis and 
dtaphysis, the cartilage separating the two being irregular. 
The angle of the neck with shaft, was apparently un- 
changed. In this section one could easily sec the different 
stages of a rarefying ostitis. A portion of this pulp micro- 
scopically presented medulla cells, granular and fatty, 
with an occasional giant celt, but no nucleated blood cor- 
puscles. 

The tibiotarsal joint was intact; the medio-tarsal 
thoroughly disorganized; articular cartilages destroyed. 
The greater portion of the scaphoid remained, while the 
cuneiform bones were reduced to one half the normal size. 
These fragments were loose and easily picked out. The 
cuboid and the proximal ends of all ihe metatarsal bones, 
for at least one fourth of their length, were eroded, and 
lying in thick fetid pus. 

»The internal malleolus was enlarged, but not eroded, 
while on section all the cancellous tissue was replaced by 
pus, pulpy matter, and the debris of cariusnecrotica. There 
was no opening through the shell of compact tissue. 

It seems fair to assume that central ostitis developt-il in 
the tarsal and metatarsal bones, and in the bodies of the 
vertebrse about the same time. The inflammation in the 
bones of the foot extended by contiguity to the tibio-tarsal 
synovial membrane, inducing a-simple synovitis, which re- 
solved like any other simple inflammation. The facts I 
, have recorded in my complete notes. The opening stook 
^M place into the medio-tarsal joint, producing here a puru- 



200 



DISEASES OF THK HIP. 



lent synovitis with destruction of the joint. Pus likewii 
escaped into the periarticular tissues, and we had chi 
iihscess. The malleolar ostitis, while going on to caseous 
degeneration, did not perforate the outer shell. 

The femoral diaphyso-epiphysitis and the iliac ostitis, 
seem to me to have been undoubtedly priman,' 
curring, however, two orthree years subsequent to the f( 
and spinal diseases. The synovitis here was, I thii 
secondary, and was undoubtedly purulent. The boy hi 
certainly enough caseous foci for the development 
tubercle and ihe fatal tubercular meningitis, although 
such diathesis was traceable in the family. 

The further destructive changes secondary to these bonJ? 
lesions are direct and indirect. The anaemia is one of the 
direct, and many of the patients who die of this disease, 
die by asthenia after prolonged suppuration. 

Among the more prominent modes of termination are 
exhaustion, tubercular meningitis, amyloid degeneration, 
phthisis. In one hundred and fourteen deaths 1 have suc- 
.ceeded in tracing, my notes show that fifty patients die; 
from pure exhaustion after long suppuration, the ostil 
never having fully subsided. Twenty-six died from tubi 
cular meningitis, and generally before destructive chanL 
had taken place in the joint. Eighteen died of amyloi 
degeneration of the larger viscera, induced by prolonged 
suppuration. Thirteen died of intercurrent ailments not 
classified, and seven died of phthisis. Connection between 
tuberculous ostitis, and tuberculous meningitis, and between 
prolonged suppuration and amyloid degeneration I have 
attempted to give in a theoretical way in the chapter on 
Etiology. As a rule, amyloid changes are late in develop- 
ing, yet cases are on record in which they may appear in a 
few months. M. V. Odenius, in a Sweedish periodical, the 
Nordist Med. Arkiv. Bd. XI. No. 25, reports the following: 

" A case of traumatic lesion of the knee-joint in a mai 
twenty-one years of age, who had always before 
healthy; the injury was complicated by considerable h 
of blood and perforation of the synovial sack. 

"After having been treated for some time at his natii 
place, and not in the most rational manner, he was ad- 
milted in the hospital at Lund. He was excessively ema- 
ciated, and on the inner side of the right knee existed a 
wound of some size, which communicated with the arti< 
lation, and in Ihe latter was a hirgc ;ibscess filled with f< 



itis, 

1 




CHRONIC ARTICULAR OSTITIS: PATH' 



LOGY. 20I 



^H pus; he died soon after; about tivo months after receipt of 
^F th« injury. 

" AuTOPSv, — Advanced destruction of the articular cartil- 
■iges, caries of the bones and a large abscess along the 
femur and tibia; in the kidneys, amyloid degeneration of 
a portion of the corpora malpighiana and their vasa after- 
«ntia. Traces of the same degeneration were likewise 
found in the capillaries of the spleen and their immediate 
vicinity. The other organs exhibited no similar changes, 
so that it is to be assumed that the degeneration mentioned 
was directly dependent upon the osseous lesion, as in Cohn- 
hcim's celebrated case. The conclusion at which we 
arrive is that this degeneration can develop itself within 
a period of two months." 

It is not very uncommon to find tuberculous degeneration 
and amyloid degeneration exist in the same subject. The 
so-called amyloid, or, lardacine is closely allied to albumen, 
differing from this substance in its insolubility in acids 
containing pepsine (Billroth and Kuhne) 

When death does not ensue by any of these processes 
repair takes place by the elimination of the fluid contents 
of these caseous patches, by reproduction of bone in the 
form of osteophites, by condensation of periarticular 
tissues ligaments and periosteum, and by the fusing to- 
gether of the neoplasia, forming a synostosis, or, what is 
more common, a joint practically ankyiosed by fibrous 
tissues. 

The conclusions to which I have arrived are: 

ti. The large majority of cases of chronic articular ostisis 
occur in childhood prior to the eighth year. 
2. In these the initial lesion is an ostitis interna, the 
focus of disease being in, or in close connection with, the 
centres of ossification. 
3. The head and neck of the femur are more often in- 
volved than the acetabulum. 
4. It is rare for a single centre of ossification to be in- 
volved, but usually two or more are implicated at very 
nearly ihe same time. 
5, The ostitis is a rarifying ostitis, and may terminate in 
a caries atonica or a caries sicca, the former being the 
more frequent. 

6. Synovitis is secondary, and if developed by contiguity 
is simple, and if by the perforation of the cartilage or com- 
^L pact layer, is purulent. ' 



202 DISEASES OF THE HIP. 

7. In children beyond the age of eight years the init 
lesion is- about equally divided among a central osti 
a periostitis, a chondritis and a synovitis. 

8. The process, whether central or otherwise, is ezco 
ingly slow, and proceeds to the destruction of the joint a 
displacement of remaining portions of bone. 

9. If the patient inherit a tubercular diathesis he is 
danger of tubercular meningitis prior to the occurrei 
of suppuration and to amyloid degeneration subsequent 
this stage. 



CHAPTER XII. 

The Etiology of Chronic Articular Ostitis. 

The causation of chronic joint disease in childhood will 
always occupy an attitude of great importance in ortho- 
"" ■ ■ -e exists in all cases, or in the 



pedic surgery. Whei 
great majority of ""■■ 
scrofulous, which : 
this has no c 
question that 
these maladii 



there 



isposing cause ; or whether 
incidental one^this is the 
ry turn in connection with 
t be an exciting cause few 



will deny. That the exciting cause Is always trauma, and 
that a predisposing cause, even with this as a factor, is un- 
necessary, few their be rash enough to assert such a proposi- 
tion. Therehas been and thereconlinues to be much useless 
controversy in relation to this subject. One class arrays 
itself on the side of traumatism, the other on llie side of 
scrofula. The lines are not sharply defined — one does not 
know exactly how the other defines his terms. When the 
traumatist says that the majority of joint diseases come 
from a fall or an injury, the impression is given that a 
Strumous habit or a constitution otherwise vitiated has 
nothing specially to do in their deveiopment. 

When the adherent lo the scrofulous origin of joint 
diseases presents his views the impression is given that all 
spring from hereditary predisposition. 

It is curious to note the difTcrences of opinion on this 
very subject, and I am quite sure that these differences 
spring from an imperfect understanding of the terms. The 
terms strumous and scrofulous are considered lo hold a 
certain relationship to tuberculosis, and the relationship is by 
no means clearly understood. This subject has been handled 
in a masterly way by Mr. Frederick Treves, of London, in a 
work published in this series. From his work one gets. I 
think, a clear idea of what " tubercle" is, what is meant by 
" tuberculous," and what relationship "scrofula" holds to this 
condition. I shall therefore, without going into the details 




of the discussion, simply give the histology of tuberct^^ 
and then ihe conclusions reached by his investigations. 

Tubercle " is composed of a mass having a finely 
rounded outline, and made up principally of cells. These 
cells are so arranged as to form in typical specimens three 
zones. The central part is occupied by one or more giant- 
cells, round this is a zone of many so-called epithelial 
cells, and beyond this is a third zone of simple embryonic 
cells or leucocytes. All these cell elements arc supported 
by a fine retlculeum, which is generally concentrically ar- 
ranged at the periphery, and towards the centre is observed 
to be continuous with the processes that commonly come 
off from the giant-cells. Tlie affected district is non- 
vascular. Such is a typical Lubercie." And yet, from the 
modifications in this structure and from the fact that giant- 
cells may be met with under the most varied circumstances 
and conditions where we can in no way term them tuber- 
cular, the conclusion is reached that tubercle presents no 
distinctive specific anatomical element. 

The conformation of the mass, the grouping of its parts 
and its history, its tendency and evolutions — all these and 
more determine its individuality. 

To construct a brief definition of scrofula, or, as I prefer 
to call it, struma, Is exceedingly difficult. 1 believe 1 am 
safe in stating that all authors, with one or two exceptions, 
regard as synonymous the adjectives strumous and scroful- 
ous, i^slhetically, I prefer the former, and shall conse- 
quently use the term scrofulous as infrequently as possible. 
To understand what the term means is not difficult. We 
recognize it as a tendency, a diathesis, and when one speaks 
of a strumous diathesis we understand him as speaking of 
struma, which I shall proceed to define. 

Struma, then, is a diathesis in an individual either here- 
ditary or acquired, which renders its subject, especially 
in childhood, peculiarly vulnerable in certain tissues, 
viz., the mucuous membrane, the skin, the lymphatic 
system, and the bones, and the inflammation which is 
so easily induced in the tissues named, is remarkable for 
its great pertinacity and for products which are notably 
cellular in character, which present certain peculiar prop- 
erties when inoculated on animals, and wJiich, instead of 
terminating in resolution or suppuration, extend locally 
and infect adjacent parts, developing either into tubercleflj 
ur degenerating into caseation. 



;ilher into tuberclet U 



CHRONIC ARTICULAR OSTITIS: ETIOLOGY. 

Call this diathesis a tendency if you will ; it can scarcely 
be called a disease. Thai it is recognized by certain cha- 
racteristics all must admit. It is impossible fora physician 
to be long connected with a dispensary or hospital in a large 
city without coming to the conclusion that some vice, either 
hcredilarj' or acquired, must underlie the constitutions of 
the vast majority of ihe poor who seek medical assistance. 
In one instance, the shape and configuration of the head 
attract your attention ; in another, the peculiar expression 
of the eye, the hue of the face, the irregularity of the teeth; 
in another instance, the contour of the chest, the general 
carriage, etc., etc. It is difficult, in fact, to predicate 
strumous of one particular type of expression. Some chil- 
dren who are undoubted subjects of this diathesis have 
light hair, and some have dark hair; the skin in some is 
almost transparently light, in others it is very dark. 

The experimental inoculation of tubercular and strumous 
products have been conducted by such men as Villemin, 
Burdon Sanderson, Wilson Fox, Klein, Cohnheim, Hueler 
ScbUller, Klebs and Deutschman, and the results, so far as 
they affect the relationship of the two conditions, may be 
summed up (to quote from Mr. Treves) as follows: 

" I. That tubercular matter, when introduced into the 
bodies of certain animals, can produce at first a local disease 
not distinguishable from scrofula." 

M. Kiener, in "LTlnion Medicale" for 1881. p. 316, has 
shown thai the injection of tubercular matter into the testis 
can induce caseous inflammation uf that body, and into the 
knee joint, a chronic joint disease that fully accords with 
the common notions of while swellings. Cohnhelm's ex- 
periments have all ihe same bearing, although these 
observers may refrain from applying the term scrofulous 
to the results produced. 

" 3. That scrofulous matter when used as a vehicle for 
inoculation can produce general tuberculosis. 

" 3. That tubercular matter acts more vigorously in these 
experiments than does strictly scrofulous matter. 

" From these results it may be gathered that experimental 
inoculation maintains the identity of scrofula with tuber- 
culosis, and at the most can only show that the two condi- 
tions differ somewhat in inlensity and degree." 

If we conclude, then, as many observers seem to have es- 
tablished, that struma is the soil, tubercle the seed {and it 
is especially, many think, exclusively, upon the soil of 



I 
I 



i 



2o6 



DISEASES or THE HIP. 



struma that the infective tubercle can take root •indi 
develop), we must accept tlie conclusions Mr. Trcvol 
draws as to the relationsliip, viz : ■ 

" I. The manifestations of scrofula are commonly asso*J 
ciated with the appearance of tubercle ; or, if no fulljf^ 
formed tubercle be met wilIi, a condition of tissue obtain*! 
that is recognized as being preliminary to tubet 
iomkally, therelniL-, scrofula may be regarded as a tuber-^ 
culous, or tubercli^-forming process. 

" r. The form of tubercle met with in scrofulous dis 
is usually of an elementary and often of an immature cha- 
racter, whereas in disease called tuberculous in a strict 
clinical sense, a more perfect form of tubercle is met with 
in the form of the gray granulation, or adult tubercle 
(Grancher). 

" 3. Scrofula therefore indicates a milder form or Stage of 
tuberculosis, and the two processes are simply separated 
from one another by degree." 

There is no pathological outrage, then, in speaking of 
chronic hip-disease as tuberculous; and one cannot but 
admire the courage with which Dr. Gross adheres to his 
convictions on this subject. All men know that what this 
great surgical clinician has studied has been well studied. 

In 1877 I presented to the County Medical Society of 
New York, a paper, based on the analysis of 860 cases oCj 
loint disease, and the part that the strumous element playS^ 
"n the etiology of these diseases was the chief point raV 
igations aimed to determine. Much of chat paper I 
shall reproduce in this connection. 

Dr. L. E. Holt, of this city, has since been associated 
with me in the liospital, and from an inaugural thesis he 
83o I, have additional statistical data. 



The sex- 
presented. In i8j8 
males and 909 female 
at a later date from ll 
males and iijq fem 



boys suffer 
favor of tri 
to encourage them 
A word or two 
they have on the minds of both lay: 
men, may not be amiss in this com 
first question propounded by the 



ons of the hip are about equally 
ses I have analyzed, I found 

Dr. Holt, in 2307 cases coUecici 
same hospital records, found 1178 
;s. Those, then, who argue that 
ntlythan girls and that evidence in 
therefore furnished, can find little 
the statistics I have adduced. 
reference to falls and the influence 
and professional 



^ 



About the! 
parent when ■■ 




CHRONIC ARTICULAR OSTITIS: ETIOLOGY. 



207 



child with suspected 
h, "Doctor, do yoi 
question seems par 
wondered why the i 
[nportaiU 



joint-disease is brought to a physician 
think it came from a fall ?'" That 
imount to all others I have often 
lalernal instinct did not suggest the 
as to what will cure the child. 



Generally, by the time a physician has been consulted, the 
history as to traumatism has been thoroughly invesiigatcd 



-the child has be« 
admit the possibility of s 
ice, or down a flight of ! 
cannot remember such t 
neighbor calls in to volun 



iiher by fear or by love, to 
e fall on the sidewalk, on the 
rs, If the unfortunate victim 
occurrence, some Argus-eyed 
r lesiitnony on the subject, so 
mat there can be no excuse for a doctor omitting this item 
in getting a history. I think it will be fair to stale that 
most of the histories, the data from which form the basis of 
this chapter, have been taken by men who have graduated 
from colleges thoroughly imbued with the idea thai trau- 
matism produced a very large proportion of all the chronic 
arthropathies. 

1 have seen a great many paralytic children, have 
examined them with much care at various stages of the 
paralysis, and many have been under my observation for 
several years. I have seen them fall often, and frequently 
get severe bruises ; and I have seen the injuries neglected 
time and again. No class of children, I presume, (all and 
'i about more than these unfortunates. To see an 






arthropathy and 

same patient is 

been noted, 1 hai 

of the case, Thi 

lected a few figures which enabli 

degree of 

cases, embi 

not f am ill 



ifantile paralysis associated 
ne a raritv : and, where such have 
ke special record 
that I have col- 
speak with some 
paper, as read, I had 1440 
period of fourteen years ; but, a^ I am 
th those recorded prior to 1871, I have c 



eluded to refer only to those I have had an opportunity of 
myself observing. During six years (1871-1877), 845 cases 
of spinal paralysis in children under fourteen years of age 
have been examined at the hospital, and of that number I 
am able to find four complicated with joint-disease. In 
three the joint-disease followed the paralysis, in one it pre* 
ceded the paralytic attack. This one 1 have already re- 
ported in the Philadelphia Medical Times, for December, 
1876. 
Age t; a predisposing cause^that is, the disease o 



< 



208 



DISEASES OF THE HIP. 



more frequently at certain periods of life — and from this 1 
tact, arguments are constructed to militate against a 
strumous diathesis in Iheetiology. In 560 cases of chronic 
ostitis of the hip analyzed in 1880. it was learned ihal 
the disease began before the fifth year in 352, or sixty- 
three per cent ; 290, a little over fifty per cent of all, be- 
gan between the third and fifth years of life ; only 35(1 
developed after the tenth year, and only five after iha 
thirtieth, tliree being at the fourteenth, and one each a^ 
the fifteenth and the seventeenth years. Among the easel 
collected were a number over ten years, in which the prim- 
ary diagnosis made was chronic articular ostitis, while iha 
progress and result of many thus diagnosticated revcalerf 
an error, nearly ail proving to be periarthritis, monarticu 
lar rheumatism, a neurosis, or a simple synovitis. " The de 
velopraent of this disease after the fourteenth year of lif 
I feel fully justified, then, in declaring to be exceedingly 
rare. Sixty-one, of the 560 analyzed, commenced before tlM 
second year. It is most commonly developed, one t 
safely say, between the third and the fifth years. Tin 
disease is known to begin as early as the eighth month; bui 
statistics here are unreliable, for many bone diseases at thii 
period are unquestionably syphilitic. 

In an address delivered byDr.S.D. Gross, before the Amen 
ican Medical Association in iS74,he says,''It must be with; 
in the recollection of every one of the older members of thii 
association, that many of the diseases formerly designate* 
as scrofulous have, (thanks to the researches of moden 
laborers), been proved beyond the possibility *f doubt q 
cavil to be of a syphilitic nature." The differential diag< 
nosis, however, between syphilitic bone diseases and stn( 
mous bone diseases has been' ably set forth by rece» 
authors, notably Dr. R. W. Taylor, of this city. A stud 
of bone syphilis in young children would be barren indee 
without an intimate knowledge of Dr. Taylor's work— 
"Syphilitic Lesions of the Osseous System in Infants an<i 
Young Children." With the facts then concerning the early 
age at which the upper epiphysis is attacked by strumous 
inflammation, it becomes pertinent to ask why children ia. 
general are more frequently diseased than adults. 

For some valuable information on this point I am iii< 
debted to Dr. Jacobi, who entered into the discussioij] 
which "followed the reading of my paper. He raised thij 
very question, and proceeded tu apply the fact, that e 




I 



CHRONIC ARTICULAR OSTITIS: ETIOLOGY. 20g 

thing which had a rapid physiological development was 
apt to become pathological, to bone and joint diseases 
especially, claiming thai those parts of a bone whidi had 
a rapid circulation of blood were the most frequently dis- 
eased. The upper portion of tiic fernur was better sup- 
plied with blood-vessels than the lower portion, and it was 
a fact that, when we had to deai with disease of Ihe bone 
in young children, the epiphysis was almost always the seat 
of 'the inflammation. He referred to the anatomical fact, 
also, that when man was born there was only a single 
epiphysis in which there was a single point of ossification, 
and liiat was the lower epiphysis of the os femoris — all the 
others being soft tissues. In the same degree that the 
epiphysis ossified, the doctor continued, the tendency lo in- 
flammation and suppuration of the bone generally would 
be diminished. The lemarks of both Dr. Hamilton and 
Dr. Jacohi on the different periods of life at which struma 
manifests itself, tlie different tissues affected, etc., were 
very interesting and highly instruciive. As I have not 
space to incorporate the discussion fully in this chapter, I 
shall refer my readers to a vfrbatim report of the same to 
be found in the Medical Record for April z8, 1877. 

Without entering into the old discussions of heredity or 
transmission of disease from generation to generation, I wish 
to affirm my belief in the theory that a disease or diathesis 
in the parent may be transmitted lo the child, if not through 
the same tissue and by the same manifestations, at least 
through different tissues, preser\nng the factors, chronicity 
and pertinacity. 

Let me illustrate. Much has been said about spinal 
being essentially a tubercular disease, and men 
whose experience and judgment must be profoundly re- 
spected hold now tenaciously to this theory. They find 
often a tubercular family history, probably running 
through two or three generations; and where they do 
not find this history, they conclude that such a diathesis 
must exist and has escaped their search. The opponents 
of this theory claim that no tubercular deposit has been 
found in the vertebrie thus carious, and furthermore, in 
many instances no iiihercular deposits can be found in the 
lungs or other organs, and on these negative facts they 
stoutly deny any tubercular element in the etiology. Now, 
it seems to me that no question in general pathology rests 
on a firmer basis than this; that a (ubcrciilar diathesis, or 




DISEASES OF THE mP. 

any diathesis, io the parent, may be and is transmitted 
the child, manifesting itself not in the organs through 
which the diathesis manifests itself in the parent, but 
through other organs and tissues. The type of the lesion 
may change in many particulars. The diathesis may be 
masked, and good hygiene and a prophylactic course of 
treatment may prevent its development in any tangible 
form, yet there remains the vulnerability. Those who 
have had occasion to study the alcoholic diathesis (intl 
liansmitted lesions in the ner\'ous system. How fre- 
quently are we baffled in our efforts to relieve a seemingly 
trifling disease in a child, and how zealously do we resort 
to drug after drug, when, linally, our attention is called to 
a suspicion of a syphilitic diathesis in the parents, we be- 
gin our anti-sypliilitic medication, and a cure speedily 
follows' In one of the cases included in my analysis this 
fact is strikingly illustrated: 

A little girl, aged seven years, was brought to the out 
door department for a synovitis of the right knee. Thei 
were found the usual symptoms and signs accompanying 
a subacute arthritis, and, furthermore, the child seemed 
in an excellent condition of health. The mother had 
traced the disease to a fall some three months prior to her 
first visit to the hospital, which was during the early part 
of 1876. The appearance of the mother, it is true, aroused 
my suspicion as to the existence of syphilis in herself, yet I 
could at that time see no connection between her disease 
and the one for which she brought the child. In fact, I did 
not pursue an investigation even, but proceeded to treat the 
child after the usual manner. I made slow progress, and 
after a few months the mother grew naturally dissatisfied 
and discontinued her visits. 

During the early part of 1S77 she returned, after having 
visited in turn other dispensaries. I found the child still 
lame, and the knee in about the same condition as when I 
last saw the case. I instituted the same treatment, and 
proceeded to keep full notes of the progress of the Case. 
After two months' observation I found no improvement. 
I then obtained an accurate history of the family, and I 
found that this child had been born subsequent to the de- 
velopment of syphilis in both fatlier and mother, and t 
obtained a history of hereditary syphilitic manifestations 
in the earlier years of the child's life. I discarded aS 
f<irmer treatment, and ordered potassium iodide. 



lis 

4 

HE ■ 




CIIRUNIC ARTICULAR OSTITIS: ETIOLOGY. 

grain doses, thrice daily. Within ten days the improve- 
ment was most decided. In less than a month a perfect 
cure was accomplished, and up to the present time no re- 
lapse has occurred. 

Dr. Taylor has done more than any author, so far as my 
knowledge goes, to establish the differential points be- 
tween syphilitic osseous lesions and strumous osseous 
lesions. In the closing paragraphs of his excellent work, 
to which allusion has already been made, he justly depre- 
cates the readiness with which observers, ordinarily ex- 
tremely careful, attribute certain swellings about the dia- 
physo-epiphyseal junction of the long bones to syphilis 
when there is not the slightest evidence of the disease in 
the ancestors. These lesions differ in many characteristics 
from those of syphilitic origin. I can not do better than 
quote the following: 

"An important question here arises, namely : Are there 
any distinguishing characteristics in these osseous lesions 
which will enable the physician to promptly and correctly 
diagnosticate them from syphilis? It must be confessed 
that in the main they resemble in many particulars the 
lesion of syphilis, still tliere are certain quite distinct fea- 
tures which are important to know. As a rule the osseous 
lesions above alluded to [those of acquired struma] arc de- 
veloped rather rapidly, may be complicated early by d<^gen- 
eration, and for the most part, do not primarily affect the joints 
[the italics are my own]. There are usually a smaller num- 
ber of bones involved than in syphilis, and there is a^rm/c/ 
tendency to unsyvtmetrical development [italics again my own]. 
Pain is generally a constant symptom, [this I do not care 
to italicize] and, in short, there is usually a much more pro- 
nounced condition of inflammation than we find in syphilis. 
When degeneration occurs there may follow Minuses which 
have the typical scrofulous appearance [as a matter of course] 
which we have observed to be not constant in syphilis. Fi- 
nally, a point of some importance may be determined by the 
bone or bones involved; thus, in this condition, it is very prob- 
able that the cranial bones would be unaffected, [I do not 
remember ever to have seen a case of strumous ostitis of 
these bones]and that the lesion would be limited generally 
to the long bones, or perhaps to the phalanges, whereas, in 
syphilis we have found that a number of ditTerent classes 
of bones were often coincidently involved. Still, as 1 have 
said in the chapter on diagnosis, the distinction very often 



i 



DISEASES OF THE mP. 



rests upon the history of the case, and upon the coexis- 
tence of lesions which are undoubtedly syphilitic. ~ 



. but it may 
'■ (P'lKes 173 and 174). 
e lie did not believe in the ac- 
nfer, and yet the etiology of 
s correspond identically with 



ays afford c 
sometimes assist in a measiir 

At the lime Dr. Taylor wro 
quired struma, I am led to 
these lesions and the progre 
those of this diathesis. 

I am not, then, prepared with Dr. Gross to assign syphilis 
so prominent a place in the etiology of a strumous dia- 
thesis, nor am I prepared to speak so cautiously of it as 
does Dr. Taylor. In my studies I find just as much reason 
for naming this condition struma as 1 do for naming those 
conditions struma in which histories of hereditary disease 
are conspicuous. 

I tabulated two hundred and sixty-five cases of chronic 
ostitis at the hip with reference to an hereditary, and two 
hundred and seventy-one with reference to an acquired dia- 
thesis, including thediseases and conditions which seem to 
develop struma in a child even when the family record is 
clear of any transmissible diseases and tendencies. These 
I have found to be the exanthemata, particularly rubeola, 
pertussis with tardy convalescence, rachitis, a severe den- 
tition, prolonged cholera infantum, bad hygiene, etc. 

Sixty and one-fourth percent of the number analyzed^ 
from an hereditary point of view, gave unmistakable evi- 
dence of a diathesis thus transmissible, and evidences, in 
other children of the family, of the e 
thesis were found in twenty-five per c 
ber. 

In the two hundred and seventy-on 
ence to an acquired diathesis eighti 
veloped the diathesis in this way. 
causative relationship eight 



e analyzed with refcr- 
:en per cent had de- 
Periutsis stood in a 
in three instances 
3 hereditary influences traceable. Scarlatina 
seemed to cause the disease eight times, there being no 
evidence in six of the cases analyzed with regard to 



heredity. In fivt 
and In one only (tonr . 
evidence of heredity. 

Since the publicatioi 
studies in this directioi 



ting cause, 
lalyzed) was there found any 



1 of that paper, I have pursued my 
n, and am still further convinced that 

not only do measles (and whooping-cough and scarlatina) . 

often serve to bring out a strumous diathesis in a child by 




CHRONIC ARTICULAR OSTITIS: ETIOLOGY. 



redity entitled to the same, but also induce such j 
thesis even where the family records are void of any tra 



missible diseases. Take the folli 
thtee years, the picture of health, 
exceedingly healthy. The paren 
the opportunity of interviewing, pi 
both personal and family. The p 
the room, walking about the floor 
stiffly, the shoulders being apprec 
1 the head -■ ■ - 



A boy, aged 

ana always regarded as 
ts, both of whom I have 
eseni very good histories, 
atient, 1 find, on entering 
carrying his head a little 
lably raised. He will not 
body at ihe same time 



I 



; processes except a very 



There is no deformity of ;_ 
mild degree of lordosis in mid-doi 
standing the clear history thus far obtained, I strongly sus- 
pect vertebral ostitis, but on pushing my investigation still 
further I learn that these symptoms have not lasted a week; 
that, in fact, one week ago he was very active and was 
jumping from the sofa, when he fell, striking- his head di- 
rectly against the floor — the fall producing a little concus- 
sion of the brain, but that he rested well that night and did 
not manifest any symptoms whatever until the third morn- 
ing, whe'n he got out of bed holding the head awkwardly, 
and complaining of pain on moving about. Since that 
jnorning he has been resting poorly nights, and his cervical 
stiffness has rather increased. 

In view of this severe fall, then, with the above facts in 
■view, I am on the point of excluding any bone disease in 
making up my diagnosis, and of attributing the whole diffi- 
culty to a muscular or ligamentous strain, relief from which 
■will speedily follow after rest and counter-irritation; but 
on attempting, by way of routine, to explore the posterior 
-wall of the pharynx with my finger, the little fellow sets up 
■violent resistance, and begins coughing rather spasmodi- 
cally-. The father now informs me that he is just getting 
over whooping-cough, which has already lasted two 
months. With this additional fact, I interpret the fall as a 
concussion of one or more of the vertebral bodies, the 
nutrition of which has been impaired by tlie whooping- 
cough in such a way as lo render them peculiarly vulner- 
able. This was a most unfortunate lime for such a trau- 
matism, and I have little hesitency in predicting, for the 
little patient a bone disease with destructive changes. 

In the RA-ue de Chirurgie, No. to, iSSi, M. Oilier, of Paris, 
has very clearly shown how such strainsor concussions prt- 
duce cerebral and peripheral bone diseases, in an arlicli; 



I 



I 



1 des a 



DISEASES OF THE HIP. 



ntorse juxta-^piphysai 



pom 



:: de I'ii 



In 1876 a well-marked case of articular ostitis of the 
ill a boy aged two years came under my observat 
was Che second of two cliildren, was nursed by the mother 
until eighteen months old, she liersclf having been unwell 
during this whole period, i.e., had " falling of the womb" 
and considerable anxiety on that account. She nursed the 
first child two years; was in excellent health the mean- 
while, and the child is reported as being in good health. 
The maternal grandmother, they say, died of consumption 
(evidence not very clear)and with this exception the family 
history is believed to be very good. The subject of this 
record, to resume, had many signs of rachitis during the 
first year, and in the beginning of the second had a cholera 
infantum which "wore him away to a shadow." During 
[his illness, without the probability of any traumatism, the 
mother found his hip tender one morning while chajiging 
the diaper. This was the first of the train of hip symptoms 
which followed. 

Last fail, while seeking diligently in the presence of wA 
class at the Polyclinic for a predisposing cause in a case oS 
ostitis at the hip, I obtained the following history of a ro- 
bust-looking patient, a boy aged six. He had a family 
record clear of any diseases to which a diathesis might be 
attributed, and there was no evidence oi any fall or injury 
of any kind sustained. In the summer of 1881, toward 
the close of the season, he had, while living in the outskirts 
of Brooklyn, a six-weeks' attack of typho-malaria fever with 
a protracted dysentery. The convalescence was exceedingly 
tedious, and toward the close of this, one morning, without, 
any previous signs, he got out of bed a lame boy, and hi 
been lame ever since. Three months later he had a vei_ 
acute exacerbation which lasted only a week or two. Ttei 
mother naturally attributed his lameness to that long ill- 
ness, and there seems to ray mind good reason for her belief. 

I could illustrate at great length, did the occasion demand, 
the influence the exanthemata, and measles especially, have 
in the production and the evolution of a strumous diathi 
sis. From a still more extended study on this subject, 
arrived at the following conclusions * 



;ly 




CHRONIC ARTICULAR OSTITIS; ETIOLOGY. 



215 



f 

^H histot 



I. Measles is not by any means "a trivial disease." 

II. Measles, and indeed any of the exanthemata, with 
whooping-cough especially included, are to be dreaded in 
patients suffering from the chronic bone and joint diseases 
commonly known as scrofulous. 

III. Measles and whooping-cough take precedence among 
all the diseases of infancy and childhood in the evolution of 
ao hereditary strumous diathesis. 

IV. A strumous diathesis may be caused by an attack of 
measles or of whooping-cough in a child whose family his- 
tory, both paternal and maternal, is absolutely free from 
hereditary diseases. 

A word regarding histories for scientific purposes. Not 
infrequently do I read the notes of a case published in the 
journals or the text-books with which case I am perfectly fa- 
miliar. It is reported as havinga" good family history," and 
to my certain knowledge there is enough phthisis and bone 
disease in the family to convince the most skeptical. It 
is well enough to omit all reference to a family history in 
reporting a case, but to report the flippant reply of a parent 
to the question "Are you healthy?" and "Is there anything 
of this kind in your family?" as sealing a question of fact 
is a gross insult to Science. If one pretends to get a history, 
let nothing be set down as fact unless it can be established 
as facL Because the mother is robust- looking, it does not 
follow by any manner of means that her immediate family 
even, is a healthy one. There should be a careful cross- 
examination, conducted, however, in a gentlemanly way. 
If it is incomplete, let the fact be stated in the report. My 
faith has so often been shaken in family histories that I at- 
tach no importance whatever to the term., ■ good " and " ex- 
cellent" used in connection with the same. I have many 
letters on file in my case-books from physicians recommend- 
ing me cases of joint disease in which they state the family 
history is good, and in the same letter tell about some other 
member of the family in the last stage of consumption. 

One of the most rebellious cases of disease of the hip I 
have ever had under my observation, was in a girl aged five 
years, who came under treatment in 1875. Over the left 
sterno-mastoid muscle was a cicatrix of old glandular abscess, 
and there were eczemalous excoriations about the alae nasi. 
She had the typical strumous face, and while under treat- 
ment had recurring attacks of naso-facial erysipelas. The 
history as given was that her family history was good, and 



I 

i 




DISEASES OF THE HIP. 

ili;it [he two Other children were in fine health. Subse^J 
i|uently I learned on a personal examination into the history 
iliat the father was consumptive and when young had cer- 
vical abscesses; that tile mother was regarded as consump- 
tive (since died of this disease), had had several still births, 
and came herself of a family in which struma and tubercu- 
losis prevailed. She had a brother who had multiple cold 
abscasses when six years of age, continuing more or less up 
to the time of his death by consumption, at the age of nine- 
teen years. I learned, furthermore, that the eldest child in 
the family was delicate as a baby, suffering much from ab- 
scesses about the thigh; and that the patient herself had 
when young chronic cczema-capitis with cervical adenitis. 

The proneness in certain individuals to the development 
of multiple bone lesion in close proximity lo articular 
surfaces is one of the strongest arguments, I think, that can 
be adduced in favor of a strumous diathesis. I have 
seen many cases where only one hip was involved develop 
a similar lesion in the other hip while under treatment; 
and by treatment I mean both the expectant, so-called, and 
the best form of mechanical. To find a case of caries of the 
vertebrse with caseous ostitis of the hip and of the ankle is 
not an uncommon occurence. 

In 1875 1 presented to the New York Pathological Society 
a specimen of caseous ostitis of the head of the femur 
where multiple abscess of the lungs had followed. The 
patient had also caries of the ankle. The boy was seven 
years of age, was the second of three children, all of whom 
were in a slate of health far below the normal standard. 
His father died at the age of thirty-six of phthisis put- 
monalis, six months after a form of insanity for which he 
was confined in the Ftatbush Asylum. Both the insanity 
and the phthisis, it is fair to say, were developed two years 
subsequent to the birth of this child. A paternal aunt 
died of phthisis. The mother had been choreic from girl- 
hood. His maternal grandfather died in an insane asylum. 
A maternal aunt was insane at the lime I made my report. 

With the exception of a slight herpectic eruption about 
the nasal orifice, the child was considered healthy up to 
his third summer, when a colliquative diarrhoea set in, and 
for months following this a peculiar ackwardness in his 
gait was noticed. Finally he recovered completely, so 
report went, and during the summer of 1872, when only 
four years of age, he fell from a railing, and on the next d^ 




CHRONIC ARTICULAR OSTITIS: ETIOLOGY. 



217 



I 
I 



complained of a pain in the left knee. This pain soon sub- 
sided, and nothing save a slight limp on extra exertion was 
observed for the next six months. Then "the starting 
pains," the gradual change in the position of the limb, and 
tenderness, induced the mother to seek medical advice. 
An abscess formed five months later. 

In March, 1874. the right ankle quite suddenly, and 
without apparent cause, took on severe inflammation. 
Other abscesses formeil, but shortly after the invasion of 
the ankle, the scarlaliua was contracted, and this was fol- 
lowed by oedema of the lower extremities, and chorea fol- 
lowed also in the wake of the scarlatina. For a full report 
of this case see Trans. Path. Soc, vol. i., p. 72. 

Many instances, 1 know, can be found where a diathesis 
seems to be wanting when the case first comes under 
observation, and 1 have recorded many myself, but during 
the progress of the case other manifestations, notably 
strumous, will appear, and facts in connection with the 
family history will be brought out that can not be contro- 
verted. Time and again t have had this experience, and 
hence my convictions about the relationship of this 
diathesis to the bone disease of which I am treating have 
been forced upon me, nolens volens. 

Traumatism may and often does play an important part 
as an exciting cause, yet one would marvel why grave 
lesions do not follow the numerous cases of strains and con- 
tusions about the hip — many of them were of the most severe 
character and many very trival — that appear at the out-door 
department of the hospital with which I am connected. Let 
me give an extract from a lecture in Scguins' Clinical Series, 
1877, of a gentlemen who has had very large experience in 
these diseases, and one who has the reputation of being a 
careful observer. Dr. Newton M. Shaffer says; 

" Experience proves that traumatism excites acute lesions 
only, as a rule. In those constitutions strong enough to 
resist and repair the injury these acute troubles soon sub- 
side: underreversecircumstances they are apt to be followed 
by a chronic form of inflammation which may end in sup- 
puration. . , . Traumatic joint lesions (excluding incised 
wounds of the capsule) are not very frequently seen, unless 
we accept sprain and dislocation as being lesions of this 
character. When, however, these typical traumatic joint 
lesions occur, they present symptoms that are unmistak- 
able. Tiiey no more resemble the ordinary forms of 



f 

i 



2l8 DISEASES OF THE HIP. 

chronic joint disease in their course and history than t 
fracture resembies a chrome ostitis." 

In this same lecture there occurs a very inslructivc case 
in a boy, aged five years, of dislocation of the hip, which 
was reduced by Dr. Little fourteen days after the accident, 
and for ten days following this reduction the boy presented 
symptoms that some regard as diagnostic of chronic joint 
disease. Dr. Shaffer very clearly set forth the difference, 
however, and the subsequent history of ihe case was a 
gradual subsidence of all symptoms and a complete re- 
covery. The patient had a lypicul strumous history too, 
and was five years of age, so that here there was sufficient 
trauma of not only the ligamenlum teres, but the capsular 
also, to induce a chronic " hip disease." 

I have myself placed on record in the American Journal 
of the Medical Sciences, 1S69, a case of traumatic disloca- 
tion in a child, aged four years, in which I reduced the 
dislocation at the end of six weeks. There was perfect 
restoration. The efforts at reduction were very great, as 
will be seen by the subjoined notes. 

One evening of June, 1878, I had my frientl, Dr. Ripley, 
see the patient with me. He fully confirmed the diagnosis 
I had already made, and we proceeded at once to reduce 
the dislocation. Chloroform was administered and when 
anaesthesia was complete the limb was rotated, while the 
thumb and Bngers grasped the h^ad of the thigh bone, 
which could be felt to roll distinctly. The Doctor made 
out the same shortening that I had made out some days 
previously. With the aid of a towel one held the pelvis quite 
securely, while the other manipulated the limb. We flexed 



iward, then 1 
ed and abducted 

ined the same. 
o, and for fully 
whatever. 



the thigh acutely on abdomen, 1 

tended. This was no avail. We then 

and extended, and the deformity 

Every possible man<Euvre was resort 

one hour we worked without anj 

Finally, after a strong adduction and careful extension, 

the bone could be felt under one's fingers to slip into 

place. There was no noise made, and we were only 

assured of our final success by finding the limbs parallel, 

equalin length, and the movements at the joint normal. 

A double spica bandage was applied, the limbs bandaged 

together, straight splints having been bound 

space, and a pad having been placed be 

An opiate was ordered for the 



Dund in popliteal 
:tween the kneeaj 



CHRONIC ARTICULAR OSTITIS: ETIOLOGY. Sig 

On the second day I find child free from pain, and the 
mother reports that after the first right he rested very well. 
The bandages are removed to-day and the limbs remain 
quite straight; passive motion made with comparative case 
and the dressings rc-applicd. An enema is ordered. 

Five days later the mother brings the child to the dispen- 
sary and reports that he has rested well and been free from 
pain since I saw him last. The limbs are of equal length, and 
both lie straight and parallel, one with the other. There 
is a moderate degree of resistance to complete extension. 
flexion, and adduction, though ihe thigh can be moved i[i 
flexion over an arc of about 90° with case, and rotation can 
be made with the same degree of facility. Only a spka 
is worn at present. 

He continued to improve, occasionally having a "catch- 
ing pain" as he walked. 

Three weeks after the reduction flexion could be made 
over the normal arc; rotation not quite perfect, and a very 
slight halt was observable. 

At the end of a monlh he walked and ran quite freely, 
and I could not detect any halt in his gait. The mother 
said she could not tell by his walking which was the lame 
limb. Flexion and extension perfect and painless; rotation 
nearly so; a scarcely appreciable change in the nates; no 
atrophy; no shortening; geneal health good. 

In tracing out some cases in January, 1879, I called at 
ihe residence of this patient and found that he had been 
free from any pain or lameness si nee the date of his last visit. 
1 had liim stripped, and on a thorough examination I could 
find no symptom or sign of disease about the joint. His 
rotation was perfect. 

If this injury were not severe enough to induce an arthritis, 
then it is useless to talk of falls as "causing hip disease." 
It is fair lo assume that the ligamentum teres was either torn 
across or severely stretched, and ive must admit a certain 
amount of injury done the capsular ligament. Then, too, 
the bruising and pulling and tortion thut were incidental to 
the eiTorls at reduction were certainly sufficient to cause 
disease in the joint, even if it had already escaped per- 
manent injury. Dr. Sayre, on page 237 of his Lectures, says: 

"A pinch of the skin, producing a 'blood blister,' or 
slight extravasation of blood within the cellular tissue, is 
of common occurrence, and is of no great importance. If 
let alone it will soon be absorbed ; or at most if yuu let i!:e 



220 DISEASES OF THE HIP. 

fluid out and do not irritate the wound, it will soon get 
well. But suppose, even in this most trifling injury, that 
instead of giving it rest and lime to heal you constantly 
scratch it with a rusty nail ; you will produce a sore that 
will last as long as the irritation is continued. [My patient 
walked around six weeks irritating those joint structures, 
and they got no rest.] This is a parallel case with a joint 
that is exercised after concussion, or a blow or wrench that 
has produced an extravasation of blood from tufts of 
blood-vessels already referred to." 

Dr. Shaffer, in his lecture, says: "If we take, for ex- 
ample, a case of chronic joint disease at the earliest mani- 
festations of the local symptoms, and treat it locally, as n-e 
would a fracture or a dislocation, can we assure ourselves 
that we will arrest the disease? Can we feel certain that 
pus will not form ? I do not mean to disparage local treat- 
ment in joint disease when I say that we cannot." 

This leads to the question: 

Can Joint- Disease occur ill a Nen-struinous Child t — At the 
meeting of the New Vork County Medical Society, in 
March, 1877, in the discussion which followed the reading 
of my paper, Dr. Sayre propounded the above question, or 
what I take to be its equivalent, viz.: " Can Pott's disease 
of the spine, or hip-joint disease, develop from an injury in 
a child in perfect health and absolutely free from any here- 
ditary diathesis?" The question was propounded for Dr. 
Frank Hamilton, who had just spoken, or myself, to answer. 
Dr. Hamilton answered in the uffirmative. A remark of 
no less a distinguished surgeon than Prof. S. D. Gross was 
given by Dr, Sayre, which was that hip-joint disease could 
not occur in any man, woman, orchild, unless a tuberculous 
diathesis be present. Such a statement, I confess, caused 
some surprise, and induced me to conduct a more thorough 
analysis of such cases as I had hastily recorded in my 
paper, then incomplete, wherein "nothing found" was 
specified. 

Of 596 cases analyzed with reference lo hereditary.and 614 
with reference to an acquired, diathesis, I have succeeded in 
lindingonly o«^ case of which it can be surely said there was 
no struma complicating. The three cases of spinal disease 
which I had reported in my paper may be classed by some 
as non-strumous, but I feel sure others will differ in their 
opinion. 

I think I am prepared to answer the question now, as 



I 

I 

I 




CHRONIC AKIICULAR OSTITIS: ETIOLOGY. 221 ] 

propounded by Dr. Sayre. Whatever other observi 
have experienced, I feel warranted in stating, (roma careful ' 
study of the cases whose analysis is here recorded, that 
true chronic joint-disease catinet occur in a non-strumous 
child. I believe that a slight injury often develops or acts 
as exciting cause, but never induces the disease unless a 
predisposing cause be present. I am not prepared with Prof. 
Gross, to admit thai that predisposing cause is always a 
transmitted tubercular diathesis; but I am firmly convinced 
that it lies in a morbid condition, which is either hereditary 
and permanent, or acquired, whether temporary or per- 

Aie Chrome Joint- Diseases ever the Cause of the Strumous 
Diathesis i — Mr. T. Holmes, in his "Surgical Treatment of 
Children's Diseases," on pagps 337, 338, after speaking of . 
the causes of struma, makes the following observation: I 

"I believe, also, that protracted suppuration is an efficient ' 
cause of tuberculosis, and that many of the exhausting joint- 
diseases which prove fatal ultimately by phthisis, and are 
therefore set down as strumous, were really themselves the 
cause, and not the effect, of the tuberculous diathesis." 
From acareful readingof Mr. Holmes's remarks on struma, 
I came to the conclusion thai he made only a differente in 
degree between the strumous and the tuberculous diathesis. 

That a joint-disease long continuing does sometimes 
develop struma in a child already predisposed, I have not 
the slightest doubt ; but that it .-auses the diathesis de ito7'o, I 
as scarlatina causes it, or as rubeola or pertussis causes it, ^ 
I entertain grave doubts. As bearing on the question, I 
have selected such cases as have been under observation 
during a period varying between six months and six years, 
and have analyzed them closely, including in my table those 
wherein amyloid degeneration developed, wherein adenia, 
tuberculous meningitis, recurring naso-facial erysipelas, 
chronic recurring phlyctenular conjunctivitis, diseases of 
other joints and of the bones, and several types of vaccinia 
occurred. 

Three hundred and twenlycases were found for observa- 
tion, and of this number two hundred and ihirly-six gave 
no evidence of strumous disease in any other locality. 
Manifestations undoubtedly strumous were observed in 
eighty-two, while in fifty-two of the two hundred and 
thfrty-six there was exhaustion in its various degrees. 
Before giving the different types of struma as developed 



i 



222 DISEASES OF THE HIF. 

while the patients were under observation, 1 propose tol 
show what number of those wherein exhaustion was r 
prominent feature actually developed any strumous sign>4 
' 1 localities or tissues other than the joints ; also to show] 



3 the exhaustion, or i 
IS, which were pres- 

1 state, were cases in 
ppuration existed, and in which 
mple was the only sign noticed. 
in the hospital from six to twelve 
V twice a day during the whole of 
twenty-one were in the hospital 
£ them, likewise, I saw 



whether such developments were di 
to other well-known causes or condi 
ent, and which were noted in the hi 

Those fifty-two cases, I may as v 
which long-continued s 
exhaustion pure and s 
Seventeen of these were 
months, and fifteen I sa 
their hospital sojourn ; 
from one to two years, 
twice a day. Eight were under the same daily observation 
for periods ranging between two and three years. The 
remaining six were under observation from four to five 
years, one as an out-patient, the others as in-patients. 1 am 
thus specific lest some one may say that strumous mani- 
festations may have appeared, and soon disappeared, no 
note having been made. I have kept faithful records of the 
cases, and such can be found at any time on the hospital 
case-books. Furthermore, twenty-three of the fifty-two 
died from exhaustion induced by the long suppuration, and 
no struma in other localities occurred. I can with 
ance, then, state that in fifty-two cases of suppuratioj 
joint-disease this diathesis was not manifest extrarthritic. 

A further analysis of the fifty-two cases of exhaustion 
gives the following result: In sixteen no attempt was made 
by the historian to trace any hereditary diseases in either 
member of the family, or the connection of any of the dis- 
eases of infancy with the joint disease ; in thirty-six, a pre- 
disposing cause was found either in a transmitted or an 
acquired diathesis, or in both. Twenty-seven gave heredi- 
tary diseases in the parents, and evidence of acquired 
struma was found in twenty-five. The hereditary diseases 
were found more frequently in the father than in the 
mother in the proportion of about two to one. Evidences 
of strumous disease were found in other members of the 
family in fourteen instances. In every case, then, exclusive 
of the sixteen in which no attempt was made to ascertain 
the existence of a possible predisposition, a cause, in a 
greater or less degree adequate, was found for the severttjf 
of the disease ; in other words, a strumous diathesis, eithtf 



"1 




CHRONIC ARTICULAR OSTITIS: ETIOLOGY. 



223 



hereditary or acquired, could with reasonableoess be pre- 
dicted of every case. 

Of the eighteen cases affected with strumous disease of 
the lymphatic ganglia, such as I have classed as adenia, only 
one suffered from any exhaustion consequent on suppura- 
tion prior to the glandular infiltration. In the thirteen 
cases with recurring nasal and fascial er^'sipelas as the ex- 
ponent of the strumous diathesis, there was no suppuration 
in nine ; the suppuration was very slight and not at all ex- 
haustive in two, while in two there was prolonged sup- 
puration antedating the first appearance of the lesion under 
consideration, and in both of these two the family histories 
were sufficiently poor to account for a transmitted tubercular 
diathesis. Consumption was found on both sides, and an 
exanthem as an exciting cause of the joint disease in one ; 
while in the other the mother's family was decidedly con- 
sumptive, and an acute necrosis in three or four different 
localities was the exciting cause of the joint disease. 

There was no suppuration in five cases dying of tuber- 
cular meningitis, but there was some excitement from the 
pain incident to the disease of the joint in four of this 
number, while in one there was no severe pain at any time, 
In five, long-continued suppuration produced exhaustion. 
which was thought to have been the cause of the menin- 
geal disease; but in one of the five pertussis, severe in 
character, occurred just prior to the prodromal period of 
the fatal tubercular meningitis, and could with propriety 
have been considered the cause. 

Among the cases in which strumous disease developed 
as chronic and recurring phlyctenular conjunctivitis, four 
occurred prior to any suppuration, and in three there was 
no suppuration while under observation. Of the three 
who suffered from an unnecessarily severe and chronic 
vaccinia, two had been the subjects of suppurative disease 
of (he joints, while one of these even bore marks of struma 
about the cervical region and in the eyes, reported to have 
antedated the suppuration, and in the other consumption 
was found on the mother's side, rheumatism (chronic artic- 
ular) on the father's. 

Of the whole number of the cases of amyloid degenera- 
tion twenty-two suffered a more or less degree of exhaustion 
from prolonged suppuration. 

To resume, then. Of llie number analyzed with refer- 
ence to the question of exhaustion from prolonged suppur- 



I 



234 



DISEASES OF THE HIP. 



alion causing the strumous diathesis, eighty-four were foun<l^ 
to have been the subjects of exhaustion in various degrees of; 
severity. In fifty-two no strumous manifestations in other' 
portions of the body than the joint thus affected occurred, 
during the period of observation; in nine there was stru- 
mous disease elsewhere manifest, but the facts go to 
show that the predisposition existed prior to the suppura- 
tion and exhaustion, and liad actually shown itself in some 
instances, hence the disease, or diathesis, was simply de- 
veloped, and not caused de novo, by the exhaustion. 

In the twenty-two cases of amyloid degeneration of the 
liver and kidneys, exhaustion was the exciting cause in 
every one; but from the table it will he seen that in nine- 
teen out of the twenty-two an efficient predisposing cause 
was found, while in the remaining three no such predispos- 
ing cause was sought. If amyloid disease be sirui 
may be interesting to know why this peculiar type 
ma should occur — what factors are necessary to i 
duction. I have often wondered why some cases of joini 
disease could suppurate profusely for months, and for yean 
even, and no amyloid changes in liver and kidneys occur. 
We have only twenty-two of 'the eighty-four cases of ex- 
haustion, or about twenty-seven per cent, terminating in 
this lesion; and the suppuration in the twenty-two was not 
greater, and did not extend over a longer period, than that 
of the fifty-two of uncomplicated exhaustion. 

It is a significant fact, that in every case of amyloid 
disease where a family history was sought — twelve in 
number — an hereditary disease was found; and this heredi- 
tarj' disease — a fact still more significant — was found to 
be pulmonary consumption in ten out of the twelve. 
The consumption was in the father in five instances, in 
the mother in six, being found in both father and mother 
once. One history of the two remaining gave chronic 
rheumatism in the father and in the mother, while stru- 
mous diseases were found in other members of the family; 
the other gave habitual drunkenness in the father, and 
probable consumption in the mother, a wretched hygiene 
being found as an element of no little importance. lo 
seven no family history was obtained, but the personi 
history gave an exanlhem as causing or developifig a stn 
mous diathesis, associated with a bad hygiene in two, 
associated with a bad hygiene in one. Bad hygiene 
found to have existed in a highly probable causative re! 



;, It 
nC>^H 




CHRONIC ARTICULAR OSTITIS; ETIOLOGY. 



225 



tionship to the joint-disease, and its severity, in five cases, 
one of which was furnished with additional evidence of 
struma, by the existence of such diseases in other members 
of the family. In no one of these cases was even a per- 
sonal historj- oblained. Hence the data, for conclusions 
are very imperfect so far as the last five are concerned, in 
fact, the whole ten, where no family history was obtained, 
arc valuable only so far as their harmlessness to a theory 
is concerned. Amyloid changes have been observed in the 
glandular tissues almost exclusively. The theory to which 
I have referred is, "The lymphatic diathesis is in most 
cases congenital, and transmitted from generation to gcn- 
eretion." 

I believe that, if Billroth had asserted that such was the 
fact in evtry case, his assertion could not have been dis- 
proved. 

The question, then, raised at the beginning of this branch 
of my subject, " Are chronic joint-diseases ever the cause of 
the strumous diathesis?" cannot be answered affirmatively 
by the history of any one of the three hundred and twenty 
cases 1 have had under observation. That chronic joint- 
diseases sometimes develop strumous disease in other lo- 
calities in an individual in whom a predisposition already 
exists, twenty-two of njy cases abundantly prove. Yet, as 
my analysis furnishes proof incontestable that the joint- 
disease itself is strumous, it remains for other investigators 
to prove that chronic joint-diseases, by any amount of sup- 
puration, ever develop even, a strumous diathesis. I cannot 
prove the assertion. 

The conclusions, then, to be drawn from these extended 
remarks and statistics are that: 

1. A strumous diathesis, either hereditary or acquired, is 
the great predisposing cause of all chronic inflammatory 
bone lesions of the hip. 

2. That the disease may be excited by a fall or strain or 
wrench, exposure to cold, or by an acute disease, an exan- 
them, for instance, with a prolonged convalescence. 

3. That in many cases no exciting cause can be found. 

All this question of etioJogy, then, must have some prac- 
tical bearing. The successful treatment of these maladies, 
attended with so much suffering, productive of so much 
deformity, much of which is often irremediable, and the 
mortality^a lingering mortality, too — of which is between 
ten and twelve per cent — the successful treatment, I say, is 



I 



1 



226 DISEASES OF THE HIP. 

the prize to the attainment of which all our labors should 
tend. That many diseases essentially constitutional de- 
mand local treatment, no sane man will deny; and, with a 
proper understanding of t;he constitutional vice on which 
the local lesion depends for its existence, no sane man will 
assert that local treatment alone will meet all the indica- 
tions. 



m4» 



I 



CHAPTER XIIL 

ChrOHIC Articular Ostitis of the Hip. 

clinical history and complications. 

The nature of diseases that are chronic and marked by 
exacerbations is usually not duly appreciated, and this 
lack of appreciation renders both therapeutics and prog- 
nosis inexact and unreliable. 

In lecturing on this disease I have heard it reported that 
an old professor, a pioneer in orthopedic siirger)', was wont 
to say, that any one could get a reputation in the treatment 
of hip-disease provided the case was secured near the 
close of an exacerbation. He advised then that the patient 
be dismissed as soon as the temporary relief followed. 

To estimate the value of any plan of treatment in any 
given disease one must know the natural history of the 
disease itself. 

The division of this malady into stages, while it may ex- 
press an incorrect idea of the pathology, is very desirable; 
I shall hence retain the old nomenclature. By the first is 
meant the early stage, and it means to my mind the stage 
of ostitis. The symptoms arc not always the same, yet the 
signs are quite uniform. When a case present^ a lameness 
which points loa saving of the hip, however slight, a flatten- 
ing of the nates and a resistance lo passive movements, 
with the minimum amount of deformity, we call this the 
first stage, i.e., so far as signs go. The symptoms may be 
only an occasional pain when active or passive motion is 
made, or the most violent pain even when the limb is at 
rest. Again, there may not be a symptom present and the 
deformity may be scarcely appreciable. If we limit, then. 
this stage to the period between the initial lameness and thi^ 
establishment of deformity irrespective of the length of 
the interval, one can understand always what we mean when 
speaking of the early, or, first stage. 

It will fairly indicate, too, the first stage in the patho- 



I 




23S DISEASES OF THE HIP. 

logical piocess. Marked deformity rarely accompanies^ J 
pure ostitis o( thediaphyso-epiphysial centres of develon 
ment. So long as the inflammatory process does not i 
tend by contiguity or by actual rupture into the sync 
cavity, the symptoms and the signs are not apt to be ot 
than reflex. These may continue for months, scarcely" 
appreciable. At present we have in the hospital two cases 
of chronic bone disease in the neighborhood of the articu- 
lar surfaces of the knee-joint, and the present theory as 
to the pathogeny of chronic epiphysitis is most beautifully 
demonstrated. At times liie patients walk with a limp that 
can be detected only by the most careful observer, and the 
functions of the joints seem perfect when the knee is flexed ; 
the contour of the parts notably differs from the norma] 
and yet while extended the difference cannot be readil|_ 
appreciated. On palpation the extra heat, and the boii|| 
enlargment can be easily recognized, T 

Then, again, acute symptoms suddenly appear on trivial 
provocations, lameness is extreme, and the sign; 
tended synovia] sac are very marked, palpation detectin^_ 
the fluid without any doubt, A few days' rest seem to allay 
these acute symptoms, and the parts relapse again to the 
nearly normal condition. Such has been the course of events 
in these two cases for nearly a year, and the explanation is 
this : the inflammation extends occasionally to the articitj 
lar surface, rapidly spreading to the whole synovial men 
brane and a serous synovitis results. This soon siibstdea 
there being no purulent element, and the bone lesion' 
slowly progresses, as before. 

Now, nothing seems clearer to my mind than the identity 
between these processes and those going on in the vicinity 
of the hip.' 

It is a significant clinical fact that tissues once inflamed 
are rendered the more vulnerable, and recurring attacks 
making successive inroads finally induce destructive changes. 

The main point, however, I am endeavoring to make is 
this, viz., that the first stage of chronic articular ostitis has a 
symptomatology that is, like the pathological process, sub- 
ject to changes. When a synovitis by contiguity makes 
its appearance, the symptoms and signs become those of a 
synovitis, and one examining the hip at this juncture would 
find the sign of the second stage- So long as the synovitis 
is not fungous or purulent, resolution takes place and . 
then we have the clinical features of the ii 



!ed;, 
lon^H 

ting 
ill ay 
the 
ents 
>n is 
tici^fl 

id^ 



ion laKcs piacc ana ^ 
e first stage. ^H 



CHRONIC ARTICULAR OSTITIS; SYMPTOMATOLOGY. 229 

Take a case, for instance, in a female child three and a 
half years of age I saw in March, 1879. The child had for 
one year been limping a little, occasionally complaining of 
a little pain at the knee, and crying out sometimes during 
sleep. The mother had traced out a fall on the floor which oc- 
curred three weeks before the first sign, as a cause. This 
first sign was a mere awkwardness In gait, the right !imt> 
being favored. A few days later there was ephemeral pain. 
These were all the symptoms noted, and they would become 
so insignificant that advice was not sought until the date 
above mentioned. I had some difficulty myself in recogniz- 
ing the limp, could not discern any tenderness in or about 
the joint, and did not encounter any resistance in making 
passive motion except in flexion beyond ninety degrees and 
in abduction. There was no pain, and yet on the two signs 
obtained, and the history. 1 recorded a diagnosis of sus- 
pected bone-disease in the neighborhood of the hip. A few 
days later I was unable to arrive at anything more satisfac- 
tory, but determined to keep the case under observation. I 
did not have an opportunity of making another examina- 
tion until the beginning of October, and the reason the 
mother gave for not reporting sooner was that the child 
got " perfectly well " very soon after the first visit in March, 
and continued "well" until September, when she began to 
walk lame again and to rest poorly at night. She knew no 
exibling cause for this apparent relapse. I found exactly 
the same signs I found in March; nothing more. Ten 
days later the diagnosis was unquestionable. 

Now, this case illustrates the slow evolution not only of 
the pathological process, but of the symptoms. 

Take another. A girl, eight yeai-s of age, whose father had 
died of rheumatism, and mother of consumption, came 
imder observation in May, 1880, with the history of a slight 
lameness extending over a period of two months. It was 
reported that there had been also a little pain about hip 
and knee. She cried aloud, too, at times, during sleep. 
The limbs were parallel, the ilio-femoral crease was short- 
ened, there was limited rotalinn, a little fulness apparently 
;ib('ut the trochanter, and she walked without lameness. 
This was the middle of the month, and a fortnight laici 
there was an exacerbation, marked by great pain, great 
icndcrness, inability lo walk, or even to gel into any posi- 
tion at all comfortable. This subsided under rest and 
anodynes, and by midsummer the hip and limb were appa- 



J 



SJO DISEASES OF THE HIP. 

rently normal. On testing the functions, however, thei 
was found moderate yet marked resistance in all direction 
accompanied by pain, and one-inch atrophy of the thigh by 
measuiemcnt. Tlie atrophy did not exist in May prior to 
the exacerbation. This condition of apparent restoration 
continued until the latter part a( September, when she was 
decidedly lame, and complained of pain on the inner side tjf 
the knee. The day before she was trying to execute a fancy 
dance. Rest was enjoined, and in October, one, to see the 
girl walk and dance, would never suspect the slightest im- 
pediment; yet, on critical examination, would detect the 
muscular resistance as above recorded. Four months now 
elapsed before another sign developed, and this was a cir- 
cumscribed fulness below the trochanter, attended with a 
little pain. The query as to abscess was noted on the 
records, and these signs continued for a couple of months 
without becoming any more marked, fn a note two months 
later, I made mention of the insignificance of apparent and 
the significance of real signs. Quite an active sumimerwas 
passed, the completeness of her recovery being a subjectot 
frequent remark. 

The family, however, noted the slight lameness after 
much walking. In the latter part of August I found, on ex- 
amination, a little more resistance to movement than I had 
encountered in July. The atrophy remained as before. 

From this time to August, i88;, a period of eiei 
months, 1 saw her frequently and could not get any joh 
tenderness, or anything more than the slight, yet, to my 
mind, important signs on testing the joint functions. 
There was no exacerbation whatever during this period. 
The lameness, however, had become gradually more 
marked. One day in the latter half of August she sud- 
denly became very lame, and complained of pain in the hip 
and at the knee, all without known provocation. The 
symptoms grew gradually worse, and within a week the 
limb had assumed the characteristic deformity of the second 
stage. The most violently acute pains supervened, the ful- 
ness which had long since disappeared reappeared in May, 
1883, and to-day she has the shortening, the deformity and 
the residual abscess of the third stage. Furthermore, the 
abscess has opened, hectic has appeared, and emaciation i» 
a prominent sign. 

The number of cases similar to this is not small; and, 
there occur many examples of dissatisfaction on the part of' 



had 
QioS 



CHRONIC ARTICULAR OSTITIS: SVMPTOMATOLOGV. 231 

friends with any kind of treatment. Every year a few are 
brought to me by the parents recommended frequently by 
the family physician for diagnosis. The cases are already 
under orthopedic treatment; but because of the slow evolu- 
tioa of the disease and the remissions, it is believed that the 
specialist is prompted purely by mercenary motives. It h 
very seldom, too, that on examinition I find any ground for 
doubting the diagnosis already made, and for questioning 
the necessity of maintaining the same careful observation 
that has been begun. 

la my search last winter for old patients that had ceased 
to attend, I chanced to find in the fourth ward of the city a 
little fellow whose history, apart from the amusement it 
afforded, was very instructive. 

The case was in a boy aged four years, whom I saw first 
in the latter part of February, 1881. The office record 
showed that we had found him limping, favoring the left 



hip, and resistin 
degrees, as also abduc 
tion stood out in ma 
was perfect, and there 
learn whether he had s 
for one week only, and 
could be found. The 
hip was recorded without 



of t>'e 



lety 



-ophy. 



; difficult to 
He had been lame 
citing cause for this lameness 
osis of articular ostitis at the 
1 the mental reservation of an 



interrogation point, and by way of treatment rest was or- 
dered. When he returned eight days later for observation 
it was learned that he had been complaining of pain about 
the hip. The muscular resistance to movements was still 
more marked, and hyperextcnsion showed a beginning re- 
sistance to this function. There was also an appreciable (?) 
amount of atrophy of the thigh and calf. The diagnosis 
was confirmed, and the mother so informed. This was the 
last opportunity I had for examining him until the last day 



of February, 1883. two y 

On entering the i 
prised, and to my inquiries ( 
"Why, he's well this eighteen 1 
Doctor, but I'm a religious won 
so unfavorable opinion about the li 

aid of the parish priest, who offered six or eight prayers 
over him, and then he was soon well !" 

I commended he]' for her faith, and asked the privilege 
of examining my former patient, whom I saw crouched in 



rars having elapsed. 

, the mother seemed greatly 

■ning her boy. rep 

iths. You'll excuse 

I, and when you gavi 
little fellow, I sought 



232 



niSEABES OF THE HTP. 



a corner of the room. She consented rather grudgingly. 
and on getting all the clothing removed, I had him walk 
across the floor while Dr. George W. Ryan and I watched 
closely for any defect in gail. We both detected a slight 
degree of lameness, or rather a yielding merely to thai side 
as he quickened his pace. The ilio-femoral crease was 
shorter on this side than on the left, and in the groin was a 
litlle fulness not marked, yet clearly recognizable on com- 
parison. Flexion was not as complete in the hip formerly 
affected as in the other: but comparison was necessary to 
elicit any resistance. Abduction could be made to the 
normal extent without pain or resistance. The same was 
true of inward and outward rotation. Abduction was not 
so easily executed on this side as on the other. There was 
no atrophy in any part of the limb and no shortening. The 
mother averred that he had not had any pain since the 
latter part of the spring of i88(. 

Here, now, was a good reason for maintaining one of two 
propositions: i. That there had been an error in diagnosis. , 
2. That the case had been cured by miraculous intervention. 
In the first place, I am quite sure that the case is not an 
absolute cure, but that the boy is enjoying a long remission 
and will yet come to the exacerbation. It is quite rational, 
however, tt) suppose that the disease is arrested in this the 
first stage, and that the signs, as at present existing, arc 
the result of a periarticular lesion of an obscure nature, 
and will ultimately disappear. , In the second place. I do 
not believe tli.^ any power superhuman will bring about 
any such result in a future exacerbation. It will be observed 
that the atrophy followed in the case just preceding this 
one closely on the second exacerbation, and that its max- 
imum was reached within a short time. In the last case 
cited no atrophy has taken place. 

I measured a six-year old boy in December. 1880, in 
wliose case there were signs of disease at the hip, the signs 
admitting of no doubt whatever. His disease began rather 
acutely, i.e., the lameness was accompanied from the begin- 
ning with pain and the ostitic cry. There was not any 
atrophy. I measured the same limb one year later, just 
after a second exacerbation (neither of which was very 
acute), and found no atrophy whatever, yet he had favored 
the limb all the while, and it seemed a little longer, but in 
reality'was not. The family history contained a specific 



tained a specific ^^H 



CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 233 

It would seem that the atrophy was in direct ratio with 
the acuteness of the exacerbation, and depended on this 
clement in the disease. Occasionally one meets with a case, 
however, tliat would seem to disprove this theory. Take 
the following, in a girl six years of age. who was admitted 
to the hospital in August, 1S7S, with a history of symptoms 
dating from April. 1877. It was stated that she had sharp 
pain in the knee during the first few weeks after the inva- 
sion, and then this subsiding she went until December, onlv 
walking a little lame, when a severe attack of pain came on. 
rendering her quite helpless for several months. In look- 
ing over my out-door tpcords, I found the same patient 
entered under date of May 12, 1877, there being at that 
time an appreciable degree of atrophy and a history of eae 
year's lameness! The symptoms had been very insignific- 
ant; yet this atrophy had supervened. To estimate the 
importance of atrophy in diagnosis is very difficult. That 
it does exist clinically all admit. Indeed, it is one of the 
most common, if not the most common, of the signs in 
chronic articular ostitis. Dr. Shaffer believes that the 
atrophied muscles exhibit marked diminution in farad ic 
contractility, and published in 1877 a paper in demon- 
stration of this position. None, I believe, deny the dimin- 
ished faradic contractility of atrophied muscles, and hence 
few orthopedic surgeons have availed themselves of this 
faradic test in arriving at a diagnosis. 

Dr. John J, Berrj', while an interne of the Hospital for 
the Ruptured and Crippled, analyzed thirty cases of artic- 
ular ostitis of the knee, and many more with other affections 
of the knee with reference to this very point, and published 
his conclusions in the Medical Record. "The result of 
these examinations has been to impair our confidence as to 
its claims; for in those presenting all the other signs of os- 
titic disease, which was often far advanced, the contractility 
was diminished about in proportion to the muscular 
atrophy, the responses being equally good in those cases 
presenting the same condition of the muscles from other 
causes." This so well expresses my own impression that 1 
have given th« extract as above. 

Now, how shall we explain the existence of the atrophy ? 
Sir James Paget, in his " Clinical Lectures and Essays," calls 
it reflex atrophy; and according to this author it is " due to 
the disturbance of some nutritive nerve-centre irritated by 
the painful state of the sensitive nerve-fibre," I agree fully 



234 



DISEASES OF THE HIP. 



with Dr. Shaffer in regarding the " stale" as an inflamed one 
rather than a painful one. 

The lameness that shows itself as the earliest sign is 
the lameness peculiar to bone lesion. One soon recog- 
nizes the difference between this and the lameness of a 
paralysis, partial or complete. There is something about 
it that is often pathognomonic. In my notes I have come 
to speak of it as the "hip-limp." Throughout all the 
stages when the patient does walk the clement of stiffness 
is present. True, the degree varies. At first, and often 
for a long time, only those immediately concerned can de- 
tect any favoring of the limb at all. At limes it is a mere 
awkwardness; the child does not raise the foot so high as the 
other is raised, ihe step is shorter, and all the time the little 
one shows a degree of care that excites in the parent some 
apprehension. Weeks may elapse, and sometimes months, 
before any change is observed. During this period falls 
are more common, and after one of these accidents a well- 
marked limp is developed. Verj' frequently, in seeking the 
history of a case, have I found this peculiarity of gait ante- 
dating the fall, to which the disease is attributed, and often 
it is that a watchful mother, in looking back over the case, 
volunteers this testimony. Indeed, with Ihe pathology of 
the disease in mind, one can readily see how the central 
ostitis, while limited to a single small focus, would produce 
a sign so apparently insignificant. Later, the gait develops 
into an unmistakable limp, the body, as the step is takea, 
being thrown cautiously to the side on which the disease 
exists. There is not that confidence in the limb that shows 
itself in the other. The lameness, too, is more marked after 
sleep. The muscles seem stiff, and after a little while this 
wears off in a measure! Exceptionally, it is more exagger- 
ated toward the close of the day, if the child have been at 
all active. From ihe inception, then, to the close, it maybe 
laid down as a constant sign. And those remarks and 
statements about the child walking "perfectly well," and 
entirely free from lameness are to be taken with due allow- 
ance for the inexactness of speech and the natural lack of 
close obser\'ation in the laity, Few of such reports will bear 
the test of rigid cross-examination. I speak nowadvisedly, 
for my observation on this point has been very close. 

Pain of a reflex nature is the earliest symptom, and this 
is more frequently referred to the knee. The richness of 
the nerve-supply in and about the articular structure ren- 




CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY, 235 

ders the parts near and remote peculiarly susceptible to 
pain. The grosser lesions, however, do not cause so much 
pain of a neuralgic character as the more obscure lesions. 
One often wonders why it is that a child with only the most 
obscure signs about the hip has so much pain, and viVe 
versa. 

I have often found that children whose parents were neu- 
rotic suSered themselves from neuralgic pains on apparently 
slight provocation. 

Some writers on this subject maintain stoutly, and it 
seems to be done in order to establish a theory in pathology, 
that the reflex pains in the knee-branches of the obturator 
are present only in the early stage — the stage, according to 
their views, of synovitis. If there is one symptom more than 
another that will be present in paroxysms throughout every 
Stage it is this distressing knee pain. Time and again 1 find 
it here in the hospital wards in cases far advanced in the 
ilcerative and destructive stages. It Is not uncommon to 
see an emaciated boy, with the hip in extreme deformity 

id the thigh covered with ulcers, grasping the knee with 
both hands, conscious by long experience that pressure will 

The obturator, ihe anterior crural, and the sciatic are often 
riiaied, and give the symptoms of the same in their remote 
distribution. Of one thing I am convinced, viz., the unre- 
liability of patients in their statements concerning the 
dates and localities of pain. In the last case to which I 
have made reference, the history as obtained in August, 
1878, was that the disease first made itself manifest in April, 
1S77, by slighi pain at the knee, which gradually increased, 
etc. Then I find on my books, under May u, 1877, that 
she had been walking lame for a yeai*, and had suffered 
occasionally from pain in the knee and foot. In this history, 
taken so shortly after April, 1877, there is no mention made 
of the gradually increasing pain, which is reported a year 
later to have been present at this time. The only sign found, 
on testing the movements in 1877 was a little resistance to 
extreme flexion. My attention is just called, loo, as I am 
writing this, to some inconsistencies in the history of another 
case, and I make mention of tbem as illustrative of this very 
point. 

On our Case Books, there occurs, under date of May 18, 
1S70, the history of a boy eight years of age. It is staled, 
by ihe way. that there is no scrofulous taint discoverable. 



236 DISEASES OF THE HIP. 

It is also recorded that when four years of age he fell from 
his uncle's arms upon the ice, and that his "knee was im- 
paired;" that the knee was the seat of pain for some time; 
that all symptoms then subsided, and two years elapsed be- 
fore another exacerbation appeared. 

In another history of the case as published, this fall on the 
ice occurred when he was eight years of age — the very time 
when he entered the hospital well advanced into the second 
stage. This fall, too, at the age of eight, was "immediately 
followed by pain about the hip." On the ^sth of March, 
1883, I learned the following facts from the mother: i. That 
this patient died about two years ago; cause given, con- 
sumption and Bnght's disease; z, he has a brother with 
double hip disease, now in the Home for Incurables on 
Randall's Island; 3, he has a cousin (whom I saw), a 
daughter of the mother's sister, hideously deformed from 
carious disease at both hip-joints; 4, the father and all his 
family — mother, brothers and sisters — died consumptive at 
comparatively early ages. 

It may be safely asserted that pain is present in every 
case, especially during and immediately following the exa- 
cerbation. It is generally regarded as a clinical fact, how- 
ever, that, exceptionally, a case may go through the first 
stage, and even the second, without pain at hip, knee or 
ankle, but t am an unbeliever. I do believe thai the pain 
is often of little consequence and insufficient to excite any 
apprehension. Indeed, I have seen hips with 
about them and with shortening of the limb whereit 
pain and inconvenience have been so slight that a phvs 
had not even been called. 

The reflex muscular contractions make their appeal 
very early, frequently within the first week, and con 
with remissions through all the stages. It requires 
examination olten to recognize them, and a comparativi 
of all the muscles is necessary. The san 
duces the atrophy and the pain seems to operate ; 
ing about the muscular spasm. Resistance is offered when 
flexion is made beyond eighty degrees, when abduction is 
attempted and when external rotation is carried over a 
small arc. This is early shown by the efforts the patient 
makes to get the shoe and stocking on. Indeed, it is diffi- 
cult to find a severer test to a htp than this one shoe-and- 
stocking test. 

In some instances the flexors and extensors are not af- 



I 
I 



that i 



CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 237 

fecled. A boy sevt-n years of age was admitled lo ihe hos- 
pital in October, 1881, with a history of the ostitic cry and 
of lameness lasting four or five monllis. There was noth- 
ing iri his posture to excite any suspicion, yet the natis was 
broadened a little and the crease was shortened. Flexion 
was made to the full normal limit without the slightest re- 
sistance, and both extension and hyperextension were made 
with equal facility. No resistance was offered when ad- 
duction was attempted, but when abduction was made to 
extreme limits a perceptible amount of resistance was rec- 
ognized, and this became more marked when rotation was 
attempted. 

The thigh was one and a half inches smaller than its fel- 
low, the calf a half Inch, and yel there was not ihe least 
tenderness discoverable at the joint or in any of the tissues 
thereabout. It was difficult to account for so much atrophy 
and so little muscular resistance, and I went over the case 
again with much care, only 10 find the same signs. I had 
no hesitancy, however, in making a diagnosis of articular 
ostitis, and I kept him under <Iat!y observation for six 
months. I tested the hip from lime lo time, and the free- 
dom of flexion and of extension continued intact. The 
limb gained nearly three quarters of an inch in girth, and 
the lameness diminished perceptibly. While I did not con- 
sider the disease fully arrested, I yielded to the parents' 
request for his discharge, and recorded all the points in the 
examination the day of his Uepartuie. The limbs were 
parallel and he walked with barely a trace of lameness. 
The thigh could be flexed acutely on the abdomen without 
any tilting of the pelvis, and abduction could be made with- 
out any resistance. 

To hyperextension and to outward rotation .there was 
slight yet unmistakable resistance. There was no joint 
tenderness, no infiltration, and no bony enlargement. "In- 
deed, it is difficult to detect any bone lesion, yet there is 
strong suspicion that he has it and that ihis may some day 
explode." 

The mother brought him to me one month from the date 
of discharge with ihe report that he had fallen on the side- 
walk the day before, straining Ins hip. He rested poorly 
that night. I found considerable joint tenderness but no 
periarticular infiltration. A counter-irritant was ordered 
and d'Tections were given to keep the boy in bed for a few 
days. He was better in a week, and in June I found the 



-DISEASES OF THE HIP. 



and extension unresisted. Those in 
[| were resisted more than at date of 
les, the trochanter major was enlarged 
; farther from the body than did its 



'38 

movements in flexion 
abduction and rotatic 
his discharge. Besid 
and reached a plai 
fellow. 

The same signs prevailed in July, but shortening began 
then, and in August there was fully a half inch difference 
in the length of the limbs. The same freedom of extension 
and flexion was found in October after an examination, 
while abduction and rotation were resisted more markedly 
than before. 

In some cases abduction can be made with perfect ease 
while flexion is limited, but as a general rule all the arcs of 
motion are limited, and it is very often the case that the 
joint movements are completely locked and the muscular 
spasm can be easily proven by an anaesthetic. Under ether 
the spasm yields and no resistance is encountered since ad- 
hesions within or immediately surrounding the joint have 
not formed. One of the roost characteristic signs found on 
grasping a thigh in a case of bone disease at the hip, is the 
apparent ankylosis of the hip. !n whatever direction the 
the thigh is moved, resistance is encountered and the pelvis 
moves with the limb. This is often the deciding point in 
making a diagnosis. 

The change one finds in the contour of the nates, is 
a flattening not due entirely to muscular atrophy. The 
muscles are simply in a state of rest, the weight of the 
body is thrown on the other limb, and this limb falls na- 
turally at rest. This is one of the oldest signs, and is 
relied on with rouch faith at present by a class of men who 
deprecate passive movements, holding, as they do, the 
theory that the disease begins in the soft structure with- 
in the joint. With the pathological views 1 hold, however, 
1 have come to place very little reliance in the gluteal ap- 
pearances. These muscles do not participate in the reflex 
contraction so peculiar to the adductors and the itio-psoas. 
They are influenced more by the periarticular infiltration 
and by the position of the trochanter. At a later period, 
broadening takes place and the parts have such an appear- 
ance as one would expect to find when the acetabulum 
is filled by a foreign substance at the expense of the head. 
In the early stages, too, one sometimes findsa fullness in the 
gluteal region, imparted to it either by the extension of the 
inflammatory lesi<iu lo the bursa in the vicinity, or by the 



I 

I 



CHRONIC ARTICULAR OSTITIS: SVMPTOMATOLOGV. 239 

appearance of an abscess springing from the digital fossa. 
This sign means, of course, a very acute exacerbation, or an 
acute synovitis going on to suppuration. The latter, how- 
ever, is very improbable. 

The lengtli. shape, and position of the ilio-femoral crease 
depends much on the nature of the disease. Whether it be 
raised or shortened or lowered, it makes little difference as 
a clinical sign. In the first few weeks of a chronic ostitis, 
ny change ; possibly the crease will be 



there is scarcely < 
sltoriened. 

The ostitic cry c 
the changes ' 



ncs a little later than the lameness or 
_ ites. It is usually present when there 

is pain in the knee by day. The child will be sleeping very 
quietly and the parents will be startled by a shriek or a cry ; 
go 10 the crib and find the patient still asleep. The nerves 
arc irritated by the inflammatory process, reflex contrac- 
tions of the muscles take place, distorting the limb and per- 
haps crowding together parts of the articular surface that 
arc hyperEcmic, the cry is uttered unconsciously and ail is 
quiet again. Where the limb is held by extension appara- 
tus or compressing appliances, so that the muscular con- 
traction cannot take place, these cries are not made. A 
frequent repetition, however, of these nerve irritations 
. finally awaken the child, and then there is continuous cry- 
ing. These paroxysms continue generally every night for 
a week or two, when they spontaneously subside, or, rather 
they continue during the exacerbation. Many cases I have 
been on the point of blistering when I would be informed 
that the child had rested well during the past night or two. 
Many I have seen yield very promply to a fly blister, but. 
again, it is my observation that the cries do not cease until 
two or three nights after the blister has been applied. They 
cease very promptly, too, on the application of extension. 
Indeed it is one of the most common observations of sur- 
geons to find a child sleeping quietly almost immediately 
after traction on the limb has been made by the hand. 

One of the strongest arguments for traction is found in 
this very relief so instantaneously given. All men bear tes- 
timony to it. Traction with the hand necessarily implies 
an amount of fixation so that the good result may come, as 
Dr. Judson claims, from its fixative power. 

To enumerate, then, the symptoms of the first stage: 
Pain on rising in the morning, referred generally to the 
knee, but often to other points in the distribution of the 




J 



240 DISEASES OF THE HIP. 

obturator, the anterior crura! and the sciatic nerves, scream 
ing during sleep, and crying aloud, even after waking oij 
of sleep. Tliere is also associated with these pain; 
perKstliesia of other nerves in the neighborhood, a 
have a tender spine, and many of the neuroses belc 
to a spinal irritation, or a genital irritation. 

These symptoins are of an irregularly intermittent cliara 
ter, coming as the exacerbations come, and going as 
go. This is the rub; but the oslitic cries may be pre 
without any day pain or any apparent tenderness. 

The signs are in the order of their appearance; awkwai 
iiess in gall; lameness characterized by a certain degree a 
stiffness at the hip; this lameness persisting, differing, how- " 
ever at limes in degree; loss in contour of naies; reflex 
spasm of the adductors the rotators and the flexors aggra- 
vated by attempts at passive motion, and atrophy of the 
thigh muscles, frequently also of the calf group. Such are 
the usual and most common signs and symptoms in the 
early stage, and they may cover a space of time varying 
between one month and three or four years. Be it remem- 
bered that the intervals of apparent cure or arrest of the 
disease are longer far than the exacerbations, and that the 
intervals grow less frequent and shorter in proportion to 
the frequency and the acuteness of the exacerbations. 

There are irregular types presenting from time to time, 
and they seem to present phases not found in the regular 
types. My own Impression is that the early stage of this 
affection, given a correct diagnosis, presents a train of 
symptoms and signs that are pretty uniform. We are 
often intentionally or unintentionally deceived as to the 
symptoms, by the parents or friends bringing the patient, 
and we just as often fail to elicit all the signs actually 
present by hasty or imperfect examinations. Symptoms 
may differ in the degree of severity, and signs mav be 
more or less marked — and while, for instance, it may be 
honestly reported that a child, after going through one or 
two unmistakable exacerbations, does not walk the least 
lame for many months, and while in a r^ry/ttP cases this 
may be a fact, my convictions are that there is lameness 
all the while, however masked it may be by the fond 
wishes of a parent or the eagerness on the pari of the med- 
ical attendant to record the fulfillment of a prediction. 
Statistics are not necessary to the maintenance of the prop- 
osition just set forth; I speak after having made statistics, 



I 



I 



1 II RUNIC AUTICULAR OSTITIS; SYMPTOMATOLOGY. 24I 

ucid I am quite sure many of the careful observers who 
practice the same specially 1 do will bear me out with their 

So much for the first stage, and now a few remarks on 
the second. By the second 1 mean the stage that corres- 
ponds to the stage of pathological perforation either into 
the capsular ligament or the periarticular structures. It is 
quite true that often in an acute serous synovitis of the hip 
we have the same signs that accompany a purulent syno- 
vitis. The signs of an acute synovitis, however, soon sub- 
side, and if bone disease be the cause leaves us the signs of, 
the first, or, stage of ostitis. The most natural outlet for the 
pus within the diaphysis epiphysis or acetabulum, is into 
the capsular ligament; and the specimens, nearly all, show 
that such has been the case. Yet there are instances where the 
pus has found exit without the capsule, and the burrowing 
about the muscles has given rise to deformity such as we 
find in the second stage. The perfoialion, loo, of the ace- 
tabulum may take place where the greater portion of the 
caseous ostitis is concentrated, and tlie outlet for matter 
"here is either into tlie obturator muscle, appearing on the 
Tiates as it comes through the small sciatic notch, behind 
the muscle, the pus appearing near the perineum in the rec- 
tum or in the vaginal walls, or in front of the muscle, the 
jibscess presenting above Poupart's ligament. (See Fig. 6. 
page 45.) The symptoms and signs under tlie above circum- 
stance must differ according to the groups df muscles in- 
volved. The suppurative arthritis that most commonly 
.arises in the progress of this disease has certain distinctive 
signs at its inception which mark the beginning of the 
second stage, clinically speaking. 

It begins in an exacerbation, and the reflex pains, the mus- 
cular spasm and the atrophy that comes on at this juncture. 
differ, as above mentioned, very little from the synovitis by 
contiguity. The persistence of the signs, however, and the 
appearance of new signs more marked render the clinical 
group complete. The gradual passage from the first into 
the second stage may be illustrated by the case of a boy, 
aged five years, whom I saw in May, 1872. The strumous 
diathesis was very well marked, and he had begun, without 
any known cause, to cimplain of pain in ihe hip and the 
knee, having walked lame a few days before the beginning 
of these acute symptoms. This pain was attended witli 
very great tenderness in and about the hip, an increasing 



I 




242 



•DISEASES or THE IIIF. 



lameness, the ostitic cry, etc. The limbs were parallel 
he stood, and at this date the limp was very slight. The 
nalis was broadened and the crease lowered. No tender- 
ness on concussion or percussion could be elicited at the 
joint. Muscular resistance was offerpd to flexion beyond 
eighty degrees, but none to abduction or adduction over nor- 
mal arcs. There had not as yet been any atrophy. In accord- 
ance with the stereotyped hospital treatment he was blistered 
and poulticed, and being anxious myself at that time to test 
ihc efficacy of this method, in a case, too, of so recent dale, 
had all the details of the subsequent poulticing carried out 
to the letter. The blister, it was recorded, fourteen days 
after its application, had afforded temporary relief, and a 
second was applied. 

He did well, ix., had no acute symptoms until the first 
week in September, when tenderness again became mani- 
fest, the gait was more awkward, and his sleep was dis- 
turbed again. The second exacerbation was approaching, 
and being fully developed by the 14th. he was blistered a 
third time. Within ten days the acute symptoms began to 
subside, and by November he was in a comparatively good 
condition. In January he was still going around quiic 
actively and was free from pain. In February the inguinal 
glands were observed to be a little enlarged, and during 
the first two weeks of the month he grew lamer, the glands 
increasing in size. The muscular resistance became more 
marked, deformity now began to show itself, and this 
glandular infiltration, proved to be only a part of a more 
extensive infliltration, which by the ist April had devel- 
oped into an immense abscess. There was nothing more 
than the deformity to mark the difference between the 
stages; he went about the ward, and by the middle of Mai 
the abscess had reached huge proportions, hang! 
tween the thighs like a large scrotal hernia. It open< 
spontaneously, and on the third day he was confined to becli 
with hectic fever. Next day, however, he was up, and 
toward the last of June it was recorded that not an un- 
toward symptom had occurred since that one day's hectic. 
The abscess had resulted in a draining sinus and the de- 
formity had become less marked. In July it was apparent 
that another abscess was slowly seeking an exit on the 
outer aspect of the thigh in its upper third. !t increased 
to a great size without special inconvenience, certainly wJI 
p'lt ronstituiional disturbance, until the third week of ' 



the 

t>ed^ 




I 



CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 243 

cember, when it opened. This was not followed by hectic, 
and in July, 1874, another abscess opened, apparently spring 
ing from the thyroid foramen. In October still anothei 
and by this time the deformity was very great. The posi 
tionof the limb was that of sharp flexion and rotation out 
ward. The subsequent history is not pertinent to this 
chapter, and will be continued in another for the final re- 
sult. 

It will be seen that this case began with an exacerbation 
which subsided really within a week, for when the boy was 
admitted he had no symptoms, only a few signs by which a 
diagnosis could be made, A three months interval followed, 
■when acute symptoms and an accentuation of the signs 
marked the progress of the case. Within a fortnight he 
was better again, and five months now elapsed before the 
third exacerbation came on. This was less acute, indeed, 
than the other two, but marked the close of the first stage, 
«tnd the subsequent history of the case demonstrated quite 
«learly that this had been the beginning of the second, or, 
«x Ira-osseous abscess, stage. 

The case of a boy aged six years who entered hospital 
September ust. 1878, was extremely instructive from the 
interrupted progress to the second stage. Four weeks prior 
to his admission, while at play he stepped into a hole in 
the floor and is thought to have wrenched the hip. but he 
Twas well in less than a week. A week subsequent to this 
Apparent recovery he was quite lame, and the mother de- 
tected a difference in the nates. Symptoms developed, such 
as pain, restless nights, loss of appetite, and loss of flesh. 
"When I examined him, the right limb as he stood was ab- 
ducted a little and advanced, while the foot was inverted; 
lameness was very marked. The thigh was flexed at an 
«ngle of 150°, and extension beyond this angle, as well as 
abduction, were much resisted. Flexion was resisted beyond 
ninety degrees. Indeed, all the signs went to show that 
this was a case in an acute exacerbation, A liniment and 
a roller were applied, and by the ad of October the re- 
lief was so great that serious doubts were recorded as to its 
being a case of articular ostitis. Improvement was unin- 
terrupted, and on November 9th he was removed. It re- 
<]uired a very thorough examination then to convince me 
that there was a chronic ostitis still present. 

He returned in the following March, and while the limp 
and the other signs pointed unmistakably to the disease 



344 DISEASES OF THE HIP. 

originally diagnosticated, there were no symptoms, 
little fellow had just passed through an exacerbati 
home. During the first week of April be began to complain 
of pain, to walk lamer, and to rest poorly at night. A blister 
was applied the evening of the 7th, and on the loth it is re- 
corded that he had derived no benefit therefrom. This, in 
fact, was the beginning of the second stage, and instead of 
gaining, as he had done on former occasions, he grew rapidly 
worse. A day or two later it was observed that he lay abed, 
on the left side with the right ihigh flexed and at an'ang] 
of ninety degrees, and he cried aloud if the least mov« 
ment was attempted. In a few days he was induced to t 
cupy a rolling chair, and it was noted, near the close 
September, as he stood by a chair, that the limb was everted 
rotated outward, and flexed at an angle of about ninety 
degrees. The superficial and deep inguinal glands were 
infiltrated, and for the first time now could any atrophy " 
the thigh be detected. 

It not infrequently happens that a case is doing remarkal 
well and indications seem to point strongly to an arr« 
of the disease in the first stage when a fall or injury will be 
speedily followed by the most acute symptoms ushering 
in the second stage. I well remember the congratulations 
with which I was indulging myself on the rapid strides 
toward recovery of a boy who was in the hospital 
in 1873. He was only six years of age, and had been ad- 
mitted in the beginning of the year with pretty well marked 
signs and a few subacute symptoms of disease at the hip. 
A few reflex symptoms not in the nature of an exacerbation 
were present at odd intervals during the first six months of 
his stay, and in June he was the most active boy on the 
ward. On superficial observation no disease could be rec- 
cognized. In the early part of July some carpenters were 
at work and this boy climbed the scaffolding one day and 
fell a distance of six or eight feet, his hip coming in con- 
tact with the hard floor. On getting up he could scarcely 
walk and there was much extra heat in the soft parts. He 
was kept in bed with cold-water dressings, but al the end 
of a week the symptoms were more acute, deformity had 
followed quite rapidly, and despite repeated blisterings the 
case went on to auacess. The final result, with sketch of 
patient, can be seen on page 335 I had under observa- 
tion in 1S77 a case with many obscure neuroses in a bo] 
ten years nf ape. He had been complaining of pains "' 



'ere 




CHUONIC ARTICULAR OSTITIS : SYMPTOMATOLOGY. 245 

his right thigh for a year when I first saw him in June. 

iths, I could get 

that 



1877, and had been limping for ! 



inly spinal symptom 



ind directed 1 



I 



treatment 1 
of the hip. It was 
iny signs, s 



He cuntinued under treat- 
til April, 1878, attend- 



_ thinking it might 
fully two months before I 1 
lameness, of disease at the hip. 
ment in the out-door departmen 

ing very regularly and exciting a vast amount of interest 
by reason of the shifting of the symptoms from spine to 
hip, and vke vetsa. My notes show a pretty clear history, 
though, of progressive chronic ostitis confined more exclu- 
sively to the diaphysis. 

He came into the hospital the middle of April, and the case 
was still very obscure. I had from the beginning placed my- 
self on record as diagnosticating boncdisease. and although 
the signs were few they were sufficiently well marked to be 
diagnostic. A month subsequently it is recorded that three 
or four days ago he received a kick from a playfellow just 
below the knee while sitting in a chair.and since that acci- 
dent he has been crying out during sleep, and even awaking 
out of sleep, crying out with pain in hip and knee. At this 
time he was scarcely able to walk and he moved about in a 
rolling chair. No contusion can be found superficially, and 
the hip joint must have suffered a concussion resulting in 
■"uplure of the cartilage of incrustation at some point per- 
xnitting escape of pus into the articular cavity. Ppssibty 
this, and possibly only a serous syno\'iiis by contiguity. At 
^11 events, acute symptoms remitted in a few days only to 
appear again shortly afterwards, and his limb from this 
lime forward gradually assumed the flexed position, while 
V:he pelvis assumed a higher plane. The trochanter became 
*nore prominent and the joint movements were to all in- 
tents locked. 

I could not help but regard this as a rather extraordinary 
case in the lateness of the development of tlie bone disease 
^nd in its exceedingly slow evolution ; for it will be remem- 
Ijered that the boy was fully eight years of age when the first 
svmptoms, such as pain and hyper^esthesia, appeared. Then 
a period of six months elapsed before the mother recognized 
any lameness. Still more curiously, for two or three months 
after coming under my own observation, no resistance to 
movementsinany direction or to any normal extent could be 
detected. Vet he had the undoubted hip-limp, and on this 
I based my diagnosis. The mode of passing into the second 



H^ 1 based my < 



I 



1 




stage was verjr nearly according to rule. It is seldom that n 
genuine central ostitis, unless acute in character, goes rapid- 
ly into the second stage. I have searched my notes rather 
diligently and I am able to find only a few. Be it under- 
stood, however, that I am not referring to cases occurring in 
children beyond the tenth year, when the probabilities are 
that the disease began either as a synovitis or as a periostitis. 
Must cases pass almost insidiously from the first into the 
second stage, and the line cannot be drawn. In out-patients 
one can very often see them at one date presenting the 
signs peculiar to the first stage, and at the next visit signs 
of the second stage will be present. In hospital, however, 
where you see cases day after day, you can only record in 
the vast majority " gradually passing into the second stage. " 
A little girl live years of age was admitted to the hospital 
irly part of 1873, and the family history was de- 
trumous. The child, two years prior to date 
I, had begun to walk lame and to complain of paii 
I the hip. Although she had passi 
) exacerbations, one of which was un- 
:ute, she still presented the signs of the first stage, 
ny atrophy even. The lameness and the reflex 
spasm, on movement, were very characteristic. During the 
months of March, May and June I had nothing to record 
in the way of changeexcept an occasional sign of pain, which 
would pass away as it came. The deformity imperceptibly 
increased all the while, and the spasm grew more marked. 
By November the second stage signs were well established, 
and these continued with progressive steps until an attack 
of pertussis, six months later, reduced her to such a degree 
that the displacements of the third stage began to make 
their appearance. 

■ progress in another girl, 



cidcdiy s 
admissioi 
in the km 
through i 
usually ac 



ie- 



was in the hospits 
was very similar to that 
a slight exacerbation \ 
months before her adm 
a second exacerbation 



April to the following September, 
e just narrated. She hi " 
after her first sigi 
[ was fairly established 
le she came into the hi 
pilal. She seemed to rally from this with very little diffi-' 
cuity, but it was only a faint remission. The symptoms re- 
sumed their severity, and in June a fulness appeared — the 
first sign of abscess — and the deformity slowly increased, 
so that in August the case was well advanced into ' ' 
second stage. 






^ 




I 



;sted before 



■ender such 
- begin 



CHRONIC ARTICULAR OSTITIS : SVMPTOMATOLOGV. 247 

The tluradon of this stage is variable, yet, as a rule, not 
so long as the first. The disease may be arr 
(he third is reached, but this is not, as some woi 
a termination. Treatment may and often does 
protection to the joint that the processes of 1 
before any bony displacements take place. It is very s 
however, to predict that a limb will shorten from bony 
changes al the upper end, in a case where the weight of the 
body is constantly brought to bear upon the repairing pro- 
cess at so great a disadvantage as takes place in a limping 
patient. The angle al which the neck meets the shaft will 
most assuredly change, and the trochanter will rise above 
N^laton's line, even though the articular extremity remains 
undestroyed. 

It is my custom to designate that as the second stage 
when the iimb presents a well-marked though not exagger- 
ated deformity, with either apparent lengthening or appar- 
ent shortening of the limb. The patient usually bears ihb 
entire weight on the sound limb standing, while the limb 
of the diseased side hangs in flexion and outward rotation. 
Some authors regard this position of the limb as caused by 
distention of the capsular ligament. So far as my own ob- 
servations go, and so far as my study of the arguments //o 
and CCA go, I must dissent from this as the cause. In many 
cases where one can detect by palpation the abscess as it 
springs from the digital fossa, the limb is not in this posi- 
tion. The amount of rotation varies, and the amount of 
flexion varies. Often the limb is not rotated either way. 
but is held rigidly in flexion. The nerve-supply to the joint 
is in intimate connection with al! the periarticular muscles, 
and especially those concerned in adduction and flexion. 
The ilio-psoas is an outward rotator, as well as a flexor, and 
it is an anatomical fact that the muscles concerned in the 
different angular movements act as outward rotators. Thus 
we have the chief flexors — the ilio-psoas, all the adductors, 
the two chief adductors, and the great extensor [Morris]. 
It is not rational to suppose that the whole cavity is filled 
with pus as soon as the perforation takes place into the joint, 
either through the cartilage of the head or the cartilage of 
the acetabulum. Even if it did, the muscles would not 
yield so promptly to the efforts of the limb to assume the 
position it would naturally assume when divested of these 
surrounding structures. By the time, too, that this stage 
in the pathological process is reached inflammatory pro- 



24S DISEASES OF THE HIP. 

cesses have extended to the intra- and extra-articular t 
sues, thus limiting the movements as well by inflammatoH 
neoplasia as by additional irritation of nerve-filamenqj 
traversing these products. i 

To be more explicit, then. The clinical second stage of a' 
chronic articular ostitis of the hip begins with the establish- 
ment of permanent deformity, due to muscular contraction, 
and ends with the establishment of the deformity dependent 
upon bony changes and displacements. There is no short- 
ening in this stage, although tt may be apparent; there is 
no lengthening, although this is called the stage of elonga- 
tion. Not that any orthopedists or any general surgeons 
really believe that there is any elongation; but theories have 
declared such lo be the case, and for this reason the name 
is sometimes retained. The tilting of the pelvis, and not 
the capsular distension, is now generally recognized as 
the cause of the apparent lengthening. The tilting upward 
of the alfected side of the pelvis not infrequently occurs, and 
then we have apparent shortening, although the capsular 
ligament may be fully as much distended. 

The escape of the pus into the periarticular structures 
occurs first during the second stage, and the suppurative 
process becomes fully established; so that one naturally be- 
gins to look for abscess, and if the symptoms are unusually 
acute and unusually persistent, the anxiety is all the greater. 
I would not for an instant be understood as saying that the 
approach of abscess is always accompanied by acute or es- 
pecially painful symptoms. Far from it; for these pus sacs 
present, very often without any premonitory symptoms, if 
we can rely on histories; but I am prepared to state from 
my daily hospital experience that there are premonitory 
symptoms in nearly every case. I think if I were to search 
my records closely I should be at a loss to find a single 
case in which the abscess was not preceded by several 
weeks, it may be, by certain vague pains about knee or 
hip called neuralgia, a certain amount of restlessness at 
night, attributed to indigestion or constipation. 

I have in mind now the case of a little girl who came un- 
der observation in July, 1878, She was at that time four 
years of age, and the initial lameness began nearly a year 
previously in the wake of an intermittent fever. The second 
stage was ushered in by a very severe exacerbation a few 
months before admission. She entered, therefore, with 
deformity, and the angle at which the limb was held was 





CHRONrC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 249 

lao". There was no shortening, but three-quarters of an 
inch atrophy of thigh. This child had also what is quite 
cominon in this stage, as well as in the third, viz., a com- 
pensating lordosis in the lumbar region. 

On admission, she was in the midst of an exacerbation of 
a mild type, and counler-irritalion was followed by relief. 
Nothing further occurred worthy of any note until the 
latter part of March, 1S79, when she had a recurrence of 
some malarial symptoms, which continued with remissions 
for a couple of months. No other note occurs again until 
August, 1880, when it was simply recorded that the de- 
formity without any pains or other symptoms had reached 
ninety degrees. Her case was considered a cure in the 
second.stage, and it was thought also that it furnished a 
fine example of a caries sicca. Circumstances were such 
that she remained in the hospital, and she has been as 
closely observed as if she were a patient. Her gait has 
been remarkably good, and even graceful withal. 

One day in April of the present year the nurse called my 
attention to a soft tumor al ihe junction of the upper with 
the middle thirds of the thigh, outer aspect. I said, here is 
a case in which the abscess appeared without premonition of 
any kind. I remembered, however, that she had been com- 
plaining during the past winter at odd intervals, and on 
reverting to my notes found thai in March, 1882, she had an 
exacerbation lasting a few days and subsiding spontane- 
ously. Similar attacks occurred in October and November, 
and she was blistered once or twice. 

The locality of abscess is most frequently under the ten- 
sor vagina; femoris, or in this immediate neighborhood. 
Another favorite site is on the outer side of the thigh near 
th^ junction of the upper with the middle thirds, and from 
this, as a starting-point, the pus dissects up the fascia, and 
we find not infrequently an abscess extending from tro- 
chanter to condyle. 

It must not be forgotten that this stage, like the first, is 
marked by exacerbations. At times when acute symptoms 
prevail the deformity may be very great, and the reflex con- 
tractions may arrest any movement, however slight. A 
little later, in the intervals, one may find smooth motion 
over an arc of seventy or eighty degrees. 

The changes in the nates are even more exaggerated than 
in the first stage. We find a very broad natis, and if ab- 
scess underlies, the contour differs still more markedly 



I 
I 

J 




from the normal. The spine begins to adapt itself to thft' 
joint deformity, and the lumbar region presents an antero- 
lateral curve, the convexity forward and to the side oppo- 
site the bone diseased. This is purely compensatorj', and 
changes as liie angle of flexion at ihe hip changes. (Sec 
Figs. 25, 26 and 27.) By suspending the patient or by 
having him sil upon a level surface the curve will disap- 
pear. So likewise this can be accomplished by lying on the 
back with the limb held in its abnormal position. 

The third stage presents clinical signs in accordance w 
the bone changes. The steps from the second to the thi 
are sometimes as gradual as those from the first to tho 
second; sometimes they are very abrupt. This stage may 
be defined in clinical terms as the stage wherein real short- 
ening of the limb makes its appearanee — pathological 
shortening — and wherein the deformity is dependent mainl]^ 
on the bone changes, the limb assuming positions consQ^ 
nant with the portions of head, neck or acetabultisl 
destroyed. 1 

For instance, if the upper rim of the acetabulum is c»*' 
rious, and hence insubstantial as a border against which the 
head rests, the limb would naturally be adducted and ro- 
tated either inwards or outwards. Inwards, it the anterior 
part of the head had broken down first; outwards, if the 
posterior portion had been the first to give way. There are 
cases where the limbs preserve their parallelism, and the 
deformity is most marked in the gluteal region when the 
projecting trochanter gives the appearance of a dorsal dislo- 
cation. When the lower portion of the acetabulum has 
been the seat of disease, and the limb during the second 
stage has been in flexion and outward rotation, fusion is apt, 
to take place between the necrotic head and the cariov 
acetabulum. Then the deformity differs very little froi 
that of the second stage. The most common position f( 
the limb to assume, however, in this stage is flexion, r 
tation inwards and adduction. In this position most of tl 
limbs can be found, and in this position most of the liml 
are left after expectant treatment. 

We have now in hospital a boy who was admitted early 
in 1881. He was then seven years of age and had begui 

favor the limb in walking threi '■' ^-' — '-■ ' ' 

He did not complain of any p: 
only evidence that thi 
joint. In fact, I saw hi 



; weeks before his admission, 
lin, and his lameness was the_ 
. any tenderness about I 
1 he had been limping onI]r^ 




I 
I 



CHRONIC ARTICULAR OSTITIS; SYMPTOMATOLOGY. 25 1 

week, and could not elicit any tenderness by a pretty careful 
examination. The maternal history was tuberculous. 

On the day of his admission I found it quite easy to flex 
the left thigh — the one he favored — to an acute angle. By 
comparison the angle was equal with that on right side; 
but when the extreme limit was reached the boy winced. I 
could extend the thigh to the normal degree without any 
tenderness. Abduction was very nearly perfect and quite 
painless, adduction perfect, though causing a little pain. 
Rotation inward and outward was not only resisted a trifle, 
but caused pain. He referred what pain he had experienced 
to the trochanter and to the front of the right knee. There 
was a little change in the contour of the natis, and the ilio- 
femoral crease was a shade shorter than that of the opposite 
side. Atrophy, shortening, and tenderness at the articular 
surfaces had not yet presented. The treatment employed 
was purely expectant, in accordance with the hospital rules; 
and while his lameness progressively advanced, there was 
no symptom until the beginning of February, when the 
parts about the hip seemed unusually tender and were sub- 
jected to the usual local treatment, during which he was not 
allowed to walk about the ward. This exacerbation ran its 
course in a week, and he then moved around very easily until 
the third week in April, when he had pain, and was able no 
longer to walk. Furthermore, he cried out during sleep, 
notwithstanding the details of treatment had been fully 
carried out, and by the last of the month his symptoms and 
signs were those of the second stage. 

About the middle of May tlie inguinal glands were infiltra- 
ted and the gluteal region presented, on palpation, a similar 
condition. He became ansemic, and one month later I dis- 
covered a small fluctuating tumor on the anterior and outer 
aspect of the thigh lying beneath the tensor vaginae femoris. 
Within ten days this tumor had become quite distinct to the 
eye, and above the trochanter springing apparentlj' from the 
digital fossa another tumor was recognized, cystic in nature. 
At this time he was not suffering to any great extent from 
pain, but was comparatively comfortable. From this date to 
the beginning of July, 1882, the case progressed slowly with- 
out notable changes. The gluteal tumor had by this time 
become a large, fluctuating mass without acute symptoms. 
The deformity of the thigh was in fle.xion at about 135°, and 
rotation outward over a small arc. Late in September this 
abscess opened spontaneously, and in ten days he was suf- 




Z 



252 DISEASES OF THE HIP. 

fering from hectic, was losing ground, and lie had a laryi 
gea! cough. These symptoms did not continue long, 
the next note I have, records extensive ulceration of 
skin around the opening. This was in January of ll 
present year. In February another abscess appeared 
the inner side of the thigh near the perineum, and in a few 
weeks this opened, the skin sloughing. During this period 
he rested well nights and was comparatively free from pain. 
The rotation outward became less marked, and by the first 
of June there was a slight amount of inward rotation. 
About this time he began to suffer from great pain about 
the knee, and it yielded very imperfectly to anodynes, 
present his gluteal region presents one boggy mass of inflatn.- 
matory products, and the thigh is pretty well covered wil 
ulcers and necrotic bits of integument. He is thin ev( 
to emaciation, yet goes about on crutches with more easi. 
than one would imagine. The hip is practically locked 
against any movement, and his shortening is about an inch 
and a half. 

This history I have narrated without abridgment. It 
records a bad case and gives the steps from the first to 
the second stage, and then from the second to the third. 
I have not had occasion to suspect any amyloid changes as 
yet. I should not give vent to any words of surprise did 
these changes manifest themselves before the close of the 
present year. The family history predisposes to this com- 
plication, and yet I have the records of many who have 
passed through just such stages, and have suppurated i 
freely, emerging from it all with bony ankylosis, and wil 
useful limbs. We have at present in the female wards 
child now ten years of age, the skin and soft parts oi 
whose hip and thigh present one net work of cicatrid 
tissue, whose angle of deformity is 135° and whose shorU 
ing is two inches. She has a very useful limb and yet hi 
face indicates the highest type of the strumous diathesis. 

It is difficult to find patients, especially in the early years 
of life, wherein such extensive ulceration occurs. In those 
cases where the bone lesion seems to start from the peri- 
phery, the passage from the second to the third stage is more 
acute — the abscesses when they do present are more numer- 
ous and the sloughing is more extensive. A good many 
run a course like that in a hearty-looking girl aged seven 
years, who came into the hospital early in the autunoD 
1S80. The family had observed her limping about 







CHRONIC ARTICULAR OSTITIS : SYMPTOMATOLOGY. 253 



ed fur adi 
imchangin 



_ distances \vi 
itie patient stood for examination lherij;lil 
everted. The usualchangesin theconlo 
ed, and on passive motion some resislan 
at ijo^in extension, and ijs"!!! flexion. 



s before slie presented fur admission. The 1 
had been \ 
twinge of 1 _ 

" ■ I tiring. As 

) wasa little 
of Lhe nates exist- 
ce was encountered 
The other move- 
ments, viz., abduction, adduction, and rotation, were limited 
lo very small arcs. I failed on several tests, concussion espe- 
cially, to elicit any tenderness in or about the joint. The 
atrophy of the ihigh was three quarters of an inch, and 
that of the calf a half inch. The diagnosis was made with- 
out any hesitation and the lesion was located in the upper 
epiphysis of the femur. During the first week of Novem- 
ber she became very lame and began to cry out at night 
without waking. The symptoms did not yield to the treat- 
ment employed, and a month afterwards a little thickening 
about the trochanter was observed, while the limb was as- 
suming a degree of permanent flexion. In other words, this 
case was passing into the second stage at the close of what 
seemed to be the first exacerbation, This is contrary to 
rule. 

This thickening around the trochanter proved to be the 
early appearance of an abscess which was quite large in 
February, and which increased to a great size by the latter 
part of May, when it opened spontaneously. 

The opening of the abscess was not followed by any con- 
stitutional reaction, and it soon closed down to an inoffen- 
sive sinus, which itself closed in the early part of August, 
to reopen again, however, at the end of a week. The gen- 
eral health continued good all the while, and the joint sur- 
faces prior to this time had not suffered from the disease. 
There was a certain outward rotation combined with the 
flexion, giving to the case the clinical features of the second 
stage. The subsequent changes were slow in evolution. 
The sinus continued to discharge, and in November, a year 
having now elapsed since the first signs of abscess, there 
were two openings, and the child was suffering more or less 
from pain in the knee. These keen pains were the first she 
had ever had, and they were peculiarly distressing and did 
not subside until the first week in December. 

In the following spring, an improvement was apparent, 
the sinus closed, and when she was discharged the right 




limb was flexefi at an angle of about 140° and rotated i 
warJ over a small arc. There were two inches shortening™ 
and (he limb bore the weight of [he body without evidence 
of tenderness. 

It lias been asserted with considerable emphasis by some 
writers that the knee pain is not present in this stage of the 
disease. My own experience flatly contradicts the state- 
ment. I have at this writing under treatment one of the 
most obstinate cases of ill-defined neuralgia in ayounglady^^ 
the subject of disease at the hip many years ago, that I havtf 
ever encountered. The deformity is characteristic, and th^ 
shortening is about three inches, yet she walks with grt 
case when in the intervals of the paroxysms. The anlr 
losis seems bony, and there are no acute symptoms at a 
lime save these frightful neuralgias. This, however, 
exceptional case as regards the acuteness of the 
Many patients who go for years with profuse suppuraticn 
have much pain on the appearance of a new abscess. 

The text-books illustrate very acurately the condition t 
these sufEerers in this stage, and the graphic accounts of e 
cision from time to time picture but too faithfully the j 
tient prior to the operation. Figures Nos. 25, 26, £ 
represent the resulting deformity in a certain type of casei 

This boy, from whom the photographs were taken, 1 sa«l 
first in May, 1873. He was at that time five years of age, 
and the disease had already advanced into the second stage. 
Ten years elapsed before I saw him again. Abscess had 
formed in 1874, but had not caused much annoyance, 
draining sinus a few months, a gradual change in tiM 
position of the limb, and an occasional pain were all thl' 
data Icould getout of his history. For eight years he hai 
been on his feet every day, it was stated to me, : 
he only thought of seeking advice now because of p 
about his hip sufUcienily sharp to keep him awake a^ 
night. His position in standing can well be seen in Fig. : _ 
While the gait is aught but graceful, it is an easy one. 
The shortening as measured from the anterior superior 
process is only three quarters of an inch, from the umbilicus 
it is three and a quarter inciies, while there is none 
as measured from the tip of the trochanter to the external 
malleolus. That is to say, the shaft of the bone has kept 
pace in growth with that of its fellow. The thigh in cir- 
cumference is three inches less than the right, the knee only 
a half inch, and the caif an inch. The lordosis is ' 




CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 2SS 

shown in Figs. ^5 
and 36, and the an- 
gle of deformity, in 
flexion at least, in 
Fig. 27. I cannot 
get any motion at 
the hip. The photo- 
graphs were taken 
inApril, andin May 
the cicatrix on the 
outer side of the 
thigh broke down 
in the centre, and a 
disc ha rge there- 
from continued un- 
til the latter part 
of Jnly. ■ 



;nt 



ing the 



sinus has closed. 
In a large number 
of cases the anky- 
losis is not bony, 
and in time there is 
indeed an astonish- 
ing degree of mo- 
tion. One tinds at 
an early examina- 
tion the hip to all 
appearance firmly 
ankytosed. and at a 
subsequent exami- 
nation, especially if 
several years have 
elapsed, an arc of 
tootion that is sur- 
prising. I have had 
such experience 
time and again, and 
I have knowledge of t:^ ~" 
like experience with ~~' " 

other surgeons. 

To recount, then, ^_ _ _ 

the clinical feature -^^^^—^^^^ 
of the third stage. 
One patient w i 1 1 f^' 
iMss almost impc-r- 




MS* 



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SYMPTOMATOLOGY. 257 ^| 


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aSS DISEASES OF THE HIP. 

ceptibly from the second to the third, and the exacerbatiooi 
will be infrequent and far from severe. Abscess ma 
and in some instances it will not ope4i, but the sac wil|| 
collapse, the fluid contents disappear, and the caseous de^, 
tritus remain an encapsulated and an inoffensive product. 

This case is one of many whose details are not only fainit- 
lar to me, but whose notes are in my possession. A little 
girl six years of age was admitted to hospital about Christ- 
mas. 1875; her sign of disease appeared five months before, 
and she had passed through one or two exacerbations. The 
case was slowly passing from the first into the second stage. 
A few pains at odd intervals were all the symptoms noted 
between her admission and the middle of October, 1S76, 
when record is made of a diffuse swelling in the upper third 
of the thigh, outer aspect. Her lameness was much more 
marked. The fulness did not develop into a well-defined 
tumor with marked fluctuation until the latter part of May, 
1877. ll did not go on to suppuration, but remained in statu 
guo for about a year, and then began to disappear. Id July. 
1879, the remark was made on the records that there had 
been for many months no changes worthy of note. The 
tumor had collapsed, the lordosis was very marked, the tro- 
chanter was prominent, the thigh was limited in extension 
to 140°, and was rotated outward over a small arc. There 
was motion over an arc of twenty degrees, and while mov- 
ing the thigh a grating sensation in the joint was imparted 
to my hand as it rested over the hip. Abduction and rota- 
tion were not permitted, and the limb was shortened one 
inch really, one and a half inches practically. In other 
words, the abscess sac had formed and had disappeared 
without external opening, and the limb was shortened by 
bony changes, and was rotated outwards. She had long 
since been discharged from the hospital, as she walked very 
easily and was free from pain. 

In August, t88i, she had an exacerbation lasting about 
two weeks, but the abscess sac did not refill. I traced out 
the case in March of present year, and found the signs as 
follows: the angle of flexion was 120°, and the limb was 
rotated inward a little; the real shortening was the same. 
while the practical was two and a half inches greater (four 
inches now); the arc of motion was scarcely appreciable, 
but thelumbarspinewasvcry flexible, and hence her facility 
in getting about; the sac was still in a state of collapse, and f 
it had never refilled. ' 




CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 259 

It need not be a necessary part of the clinical history to 
have external suppuration, even if a residual abscess do 
appear. 

There is another patient whose hip suppurates freely, 
hectic comes on from time to time, regulated very accurately 
by the invasion of pus tracks into fresh tissues, the health 
fails rapidly, and locomotion is impossible. By day the 
sufferer sits in a chair with the diseased limb swinging 
scissors-like over the other, ready with the hand to steady 
Ihe member when it is necessary to move about or to grasp 
it on the recurrence of any pain. The knowledge has come 
by experience that fixation of the hip or pressure over the 
neuralgic areas will relieve pain. Day in and day out the 
child will sit in this position nursing the limb, and yet 
showing a patience that would bring the blush to a martyr. 
In bed the dorsal decubitus is assumed for a while with 
both thighs flexed; the sound one at a right angle acting 
as a frame for the bed-clothing, the diseased one at an 
acute angle and generally rotated inward, the hands clasp- 
ing the thigh or tlie leg, zealously guarding the crippled 
member. Frequently a pillow will have been placed be- 
tween the knees, so that when the weary one dozes off to 
sleep fear of a fall need not be entertained. The hands re- 
lax their grasp then, and the pillow suffices. A little later 
he manages to get over on the sound side, while thu dis- 
eased limb rests in flexion and inward rotation on a pillow 
or an air-cushion which lies upon the fellow-limb. Ulcers 
are raw, surrounding parts are tense and painful, the sleep 
is broken often through the night, and the morning comes 
with a sense of relief; and so it goes through one ex- 
acerbation and then the interval of comparative comfort. 
It is true here, as in the other stages, that every exacer- 
bation leaves the patient a little worse. Finally, these run 
one into the other as the end draws nigh, the emaciation 
reaches its limit, so that one can truthfully say there's noth- 
ing here but skin and bones and impending death. 

Some, as I had occasion to remark in another part of this 
chapter, get well after such suffering and such profuse sup- 
puration. 

The duration of the third stage varies between a few 
months and a number of years. The majority of cases 
terminating In a useful limb will average about three years, 
i.e., the sinuses close, the exacerbations seem to be at an end, 
and the patient is able to walk without supporL I would 



I 



2tXt DISEASES OF THE HIP. 

have it understood lliat I am not speaktiig now fioi 
tics. This is not a statistical chapter. The pionencss of 
sinuses to reopen, the difficulty attending the elimination 
of necrotic pieces of bone, and the interference with repair- 
ing bone tissue by attempts at walking, render statistics of 
cured cases vciy difficult to obtain. 

Concerning the duration of the third stage, we can draw 
conclusions that merely approximate the reliable, from 
patients that are still living. In looking over the names of 
patients whose cases I analyzed for publication in 1878, I 
find that some have relapsed, others I have not seen. One 
relapsed after ten years' immunity from abscesses or incon- 
venience of any kind. He is now in feeble health and has 
one or two open sinuses, with pains tn the thigh and at tl 
knee. 

One frequently takes it for granted that, because 
patient does not return for treatment, he has continued 
well. Patients with chronic disease as a rule do not remain 
long under the same surgeon. It matters little how much 
they may be impressed with the skill of their medical at- 
tendant, they are easily induced by friends to seek other 
advice. 

I have, therefore, in the present volume, been unable to 
secure reliable data of a sufficiently large number of cases 
to make statistics on this head of any positive value. [ have 
learned that it is very unsafe to prognosticate that there 
will be no recurrence of symptoms, no re-opening of 
sinuses, no future abcess in cases that seem to be examples 
even, of a caries sicca. 

This is true, however, that in many instances the late ex- 
cerbations are induced by some traumatic influence and per- 
tain purely to the periarticular structures. They are 
necessarily mild, subside without treatment, and often do 
not come under medical or surgical inspection. I have seen 
very frequently such cases come tinder a surgeon's care and 
be subject to all the paraphernalia of joint therapeutics 
that a case in the early stages would demand. Treatment 
seems to begin really at this late day, and then the patient 
must go through the stereotyped course, the early subsi- 
dence of symptoms being attributed to the measures 
employed. 

Com PLICATIONS. — Among the direct complications in the 
early stage is a dorsal dislocation This is not of comraoa 
i have seen two cases, and have placed one 



n 




RONIC ARTICULAR OSTITIS i SYMPTOMATOLOGY. 261 

record in the American Journal of the Medical Sciences. It 
was in a girl who began to walk lame in the spring of 1877. 
Her lameness was followed within a month by the first ex- 
acerbation of pain. This subsided spontaneously, and the 
relief was so complete that in October of the same year 
not even a limp could be detected. The signs in the iyter- 
val between August and October had been unequivocal In 
the beginning of the next February she had scarlatina, 
followed byenlargmcnt of the cervical glands, and in March 
a second exacerbation of hip symptoms appeared. These 
were soacule that the signs at tiie close of the second week 
in March were those of the second stage. The thigh was 
held flexed at 90", and in marked outward rotation. The 
promptness with which relief followed made it clear that 
the second stage had not been reached. The signs in the 
next fortnight became those of the first stage, and while this 
remission was of longer duration than the preceeding it 
was not so complete; for the resistance to flexion persisted, 
and the child was never without a trace, at least, of lameness. 

In March of the following year {1879), she, with her play- 
fellows, caught the " walking fever " (it was very prevalent 
at this time), and after one of these feats she grew suddenly 
very lame, and the third exacerbation, milder in type than 
the second, declared itself; but the symptoms disappeared 
under rest within a week. From general appearances in 
May, two months subsequently, one would declare that she 
had no disease, so actively did she move about. One day 
during the last week of this month a member of the staff 
observed a shortening of the limb, and a refusal on the part 
of the child to walk. Dr. Knight's attention was called to 
the case, and an examination revealed an unmistakable dis- 
location on the dorsum ilii. The limb was shortened one 
inch, was apparently much shorter than this, the thigh was 
semi-flexed, rotated inward, and adducted, A few days be- 
fore this the limbs were of equal lengtli, and were free from 
any deformity. The child reported that she fell out of her 
bed a night or two previously, but on a careful investiga- 
tion, this was found improbable: the beds in the dormitory 
are so close one to the other, that a child could not fall be- 
tween them. Furthermore, on questioning both the day 
nurse and the night nurse, as well as the children who sleep 
contiguous, no onesaw her fall from the bed, and all are 
positive that she did not. 

I was in the country at this time, and as I was expected 



262 DISEASES OF THE HIP. 

home every day the reduction was' postponed until ray re-J 

Cliloroform was administered four days after the accidend 
and the diagnosis was fully contirmed. After a few minute^ 
manipulation, the head o( the femur slipped into place with- 
out ^jty "click." Measurement was made, and limbs found 
equal in length. While applying a roller about the hips, 
the head of the bone slipped again but was easily replaced. 
No grating could be felt, Extension by weight was made,— 
and during the day she suffered considerable pain in par^ 
oxysms. , 

The limb remained in position next day, though the chil^ 
required an opiate to secure rest through the night. 

Extension was removed two days later and a firn 
was applied with a pad above the trochanter, and child waq 
carefully placed in a rolling chair. 

The following record was made two weeks after there 
duction of ihc deformity: Since date of last note the case 
has progressed as well as we could expect. The dressings 
have been carefully removed and reapplied every other day 
to avoid excoriations. Any movements at the joint have 
caused the child to scream aloud. This noon while passing 
through the ward, I observed the limb sharply flexed, ad- 
ducted, and rotated inward, along with a marked degree o' 
shortening. An anaesthetic was administered, and Ic 
feel the head of the bone distinctly on the dorsum 
made out one and a half inches shortening. It was easily r 
duced and child placed in bed with usual precautions. 

Next morning the hip was dislocated again. Dr. Ap. 1 
Vance, a member of the staff, made a splint of ManitI 
paper and glue in the same manner as he makes his spin 
jackets. He procured his cast from a boy whose limb wai 
equal in length and size to our patient's, and the wl 
dressing dried and was ready for application next day. 

After reduction had been made it grasped the pelvi; 
a broad band, and completely encased thigh an ' 
was held securely by a lacing in front throughout the wholcj 
length. 

We had no difficulty with the limb after the paper splic 
was applied. The child moved about now quite freely I 
aid of a chair. 

A month elapsed and it was noted that the limb ' 
equal in length with its fellow. No deformity, child fre 
l.-om pain, and case in every way doing well. 



CHRONIC ARTICULAR OSTITIS : SYMPTOM ATOLOGV. 263 

In August a leather splint was substituted for the paper, 
and on testing the joint as to motion, muscular resistance 
was offered at every turn. The disease was slowly passing 
into the second stage without the pretext of an exacerba- 
tion. In December I was sanguine enough to hope that 
the removal of the splint and the employment of passive 
niotioti would restore the joint functions. The pelvis was 
raised on the left, the diseased side, and comparative 
measurements from the anterior superior spinous process 
to the lower border of the internal malleolus showed 
there was no real shortening, while from the umbillicus to 
the malleoli they showed a practical shortening of one inch. 
The thigh in its upper third was one and a half inches 
smaller than its fellow, and the calf three quarters of an 
inch smaller than the right. It was difficult to satisfy my- 
self that any motion at the joint existed. 

I soon had to abandon the idea that this was an ordinary 
dislocation, and to accept the situation, viz., that I had a 
well-marlced case of progressive chronic articular ostitis to 
deal with, and that the dislocation was but an incident in its 
march, permitted by a ligamentum teres that had suffered in 
nutrition from a caseous ostitis in close proximity to one 
or the other extremity. I could not get any passive motion, 
and soon desisted. The atrophy reached two inches in 
thigh circumference by the following April, and since then 
has remained in statu quo. The real shortening at this time 
was a half-inch, and was three quarters of an inch a year later. 
In April, and in November, 1883, it was one inch, while the 
practical shortcningwas two inches. There was anabscess 
of three or four weeks' standing on the anterior surface of 
the thigh outer aspect. In December she was scarcely able 
to walk. Quite recently I have found the patient walking 
very fairly. The shortening has increased, and the abscess 
sac has collapsed. 

Mr. Hilton {LaactI vol. ii, 1868, p. 2) reports a case where- 
in the dislocation occurred just as the patient was falling 
asleep; and, commenting on this, he says (" Lectures on 
Rest and Pain"): "Here I think it worthy of a passing con- 
sideration to inquire why it is that these dislocations almost 
always occur just as the patient is falling off to sleep. It 
is then that volition has withdrawn its influence from the 
nervous system generally, and the excito-motor function of 
the spinal cord seems to obtain an exclusive authority over 



264 DISEASES OF THE lllP. 

the limbs, and produces the involuntary spasmodic conditioOi 
of the muscles which causes these displacements." 

In the spring of 1879 I found, on examining a child 
fhmnic ostitis of the acetabulum, that ihe head of the bom 
slipped out of the cavity very readily, and the 
days previous!)-, in dressing the patient one mc 
peculiar slipping at the joint, and feared that the ^ip hi 
become dislocated. The autopsy, a few weeks later, 
vealed a carious condition of [he floor of the acetabulum 
and the destruction of tlie ligamentum teres. The infre- 
quency of such dislocations in the early stage, taken in con- 
nection wiih the frequency of examinations, with and with- 
out anaesthetic, furnishes, to my mind, strong evidence 
against the pathology as taught by Dr. Sayre and htel 
followers. | 

In the third stage dislocations are occasionally found, but 
they do not occur with nearly the frequency they were sup- 
posed to occur prior to 1853, when Dr. March presented a. 
paper before the American Medical Association, protesting 
against calling such those cases in which pathologic^ 
changes had taken place between the diaphysis and the 
epiphysis, or in which the head and neck were destroyed, 
while the trochanter occupied a position above Nelaton's 
line. 

The frequency with which tubercular meningitis develo] 
in the early stages of this disease suggests at times a po 
sible connection as a complication, yet it is only necessary 
to mention the fact that it does occur, and the relationship 
I have regarded as more of the nature of cause and effect. 
That is to say, I am of the opinion (the opinion is not forti- 
fied, however, by strong evidence) that the meningitis is 
caused by either the irritation induced by the frequent! 
recurring paroxysms of pain, or by the suppurating foci 
the well-known manner. It must'be understood, thougl 
that I am speaking now of exciting causes, and Ihal an h( 
ditary tuberculous diathesis must be present. And I 
not wish to go on record as asserting that tubercuh 
meningitis occurs only in the early stage of chronic articuh 
ostitis. It does arise in the advanced stages; but my owi 
observation leads me to infer that it is a more frequent 
companiment of the early stage. 

The displacements that occur in the third stage are vj 
ried. The disintegration of the head and the fusion of if 
eroded proximal end of the femur with a carious rira of tl 



i 



:lopJ 
poswH 
■sarjm 



n here^ 



CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 265 

acetabulum serve to perpetuate a very awkward deformity 
unless corrected by surgical means. 

Dislocation on the dorsum is seldom a dislocation with 
the head and neck intact. There is nearly always change 
in the angle with which the neck is joined to the shaft, and 
in proportion to the amount of bone left in the epiphysis, 
so much the greater will be tlie deformity. Last spring, 
while tracing out cases of interest, I found a boy in the 
fourth ward, seventeen years of age, with a most ungainly 
deformity of the hip. The angle at which the thigh was 
held flexed was 110°, the adduction was very sharp, and 
the trochanter stood out on a plane of two inches, ai least, 
from the plane of the body. At the same time an irregular 
bony mass could be felt lying above the acetabulum or in 
close proximity with its rim, and connected with the shaft 
below the trochanter. Abduction and outward rotation 
were quite impossible. There were two and a half inches 
real shortening and three inches practical. It was very evi- 
dent from the condition of the cicatrices and from the 
absence of inflammatory products in the soft parts, that the 
disease was fully arrested. He had motion over an arc of 
ten or fifteen degrees, the lumbar spine was exceeding 
flexible, and his gait, though awkward, was really a good 
one. The abdomen was not enlarged, and the boy seemed 
to be in good health. 'The Hmb was not oedematous. 

When J had last seen him it was in October. : " " 



ind oedema of the 
fat and hyaline 

t contained about 
extensive ulcera- 

, was 



had then a moderate hydro- peritonei 
scrotum; the urine contained granula 
casts, its specific gravitv was 1013, and 
twenty per cent ol albumen. There wi 
tion about the hip, and the prognosis, ^ 
very grave, especially as the last abscess opened in the peri- 
neum. There was no dislocation at this time. In this long 
interval he had not received any treatment, but had simply 
led a vegetative kind of existence in the upper rooms of a 
huge tenement-house, and Nature had succeeded in effect- 
ing a recovery by thus removing the head from the aceta- 
bulum. That this portion of the pelvis had been perforated 
the perineal abscess attested; and the evidences, although 
I could not make oul an enlarged liver in 1878. were 
strongly in favor of lardaceous degeneration having already 
begun. 

With such extensive suppuration as one often encounters, 
it would naturally be supposed that ulceration of the walls 



2C6 



DISEASES OF THE HIP. 



of arteries in the vicinity of the hip would often occur,l 
Such cases are on record, but this complication is of very 
infrequent occurrence. I find only one case among my 
notes, and this was in a boy who contracted disease at his 
hip when three years of age. He was five when the second 
stage was reached, and six when signs of the third were re- 
cognized. The suppuration in the early part of the third 
stage was very profuse, and he made a narrow escap)e with 
his life. After a year or two he was in such condition that 
a good limb was prognosticated. Three years then elapsed, 
in which interval he was regarded as cured. The deformity 
was very objectionable, however, and finally means were 
employed lo reduce this to the minimum. He wore appa- 
ratus six months, when an exacerbation came on, the old 
abscess sac refilled, other abscesses followed, and suppura- 
tion continued uninterruptedly for sixteen months, when be 
died of exhaustion. Five days before death, violent arterial 
haemorrhage from the bottom of a deep ulcer on the inner 
side of the thigh came on suddenly one evening, and it was 
necessary to apply a tourniquet to control it. The vessel 
from whence the blood came was a branch of the profunda 
artery, and on the following day a second haemorrhage 
occurred, more difficult to control. Two hours later a third, 
which ceased on the application of a compress. 

One of the most formidable complicallons, or rather 
sequels, is lardaceous degeneration. The first symptom of 
this is pain in the right hypogastrium. The seat of pain is 
presumably the liver; and this is a very constant ^ymptoin. 
Whenever I find a child with a suppurating bone-disease 
locating the pain under the border of the free-ribs, I forth- 
with examine the urine and find invariably a low specific 
gravity and a pale color. Albumen may not appear for 
several months. 

In the case of a boy, who died in April last, I began « 
amining his urine in' October, 1881, finding the specifH 
gravity at that time 1004, and not finding a trace of albi ' 
men. In November of the same year it was 1003, I 
1882, it was 1007, and although the liver dutness extended 
full five fingers" breadth below the free-ribs, there was 1 
albumen. It was not until the month of July, two mond 
later, that I succeeded in getting the first trace of albuma 
It will thus be seen that fully seven months elapsed betwct 
the first symptoms of lardaceous disease and the preseoce a 
albumen in the urine. 




CHRONIC ARTICULAR OSTITIS: SYMPTOMATOLOGY. 267 

I have long since reached the conclusion that lardaceous 
disease need not be /eared in children whose family histories 
are free of tuberculosis. 1 am unwilling, as yet, to change 
niy views on this subject, inasmuch as in several of my 
cases 1 have not been able to get any data in connection 
with the family history. Dr. Poore (Medical Record, vol. 
XV., p. lot) has reached, practically, the same conclusion. 
The last case but two that I have reported furnishes testi- 
mony to a very interesting point in connection with this 
subject, viz., the curability of this constitutional disease. 
This is the first case I have found in my clinical researches 
wherein lardaceous disease has presumptively undergone re- 
solution without surgical interference with the bone-disease. 
I knowas a fact that it does subside in a few cases in which 
removal of ihc diseased bone has been effected. 

From the beginning of these chances to the final termin- 
ation in death, the time varies remarkably — often il extends 
over a number of years. I saw, only this last spring, a boy 
die from lardaceous disease who had been a victim, to my 
positive knowledge, for ten years. Year after year I have 
treated him in exacerbation, of chronic nephritis during 
that whole period. 

The course of this disease, like that of the disease which 
it follows, is marked by exacerbations. The deformities of 
Vhe spine are generally compensatory, and I do not attach 
much importance to the lumbar lordosis, I do not recall 
any case of permanent lateral curvature or any rotary cur- 
vature developing out of this compensatory curve. The 
pelvic deformities are the more annoying when they do 
occur, and the interference with sexual relations becomes a 
serious complication, which calls the more strenuously for 
measures preventive of such deformity. I have seen a case 
in a woman with the deformity of the thigh so strongly 
adducted that laparotomy was performed to effect delivery 
of a fetus. 

The influence of the exanthemata in this disease is well 
recognized, and 1 have already dwelt upon these sufficiently 
long in Chapter IX. 



CHAPTER XIV. 

Chronic Articular Ostitis of the Hip. 

diagnosis. 

Past I.— Thh First Stage. 

There is a large class of men both in the profession and 
out of the profession that cares little, as a rule, for the diag- 
nosis of disease. Such men are saying all the while, " Tell 
us how to cure diseases; we don't care any thing about diag- 
nosis." In the ordinary ills of life, especially those whose 
course is rapid, it sometimes docs seem that diagnosis is 
of no value. And even in chronic diseases it seems some- 
times that treatment is the only thing worth knowing. 

It has been my pleasure during the past decade to note 
the interest nearly all men take in the diagnosis of diseases 
in the neighborhood of the hip. The first thing, as a rule, 
the parent wants to know about a limping child is whether 
it has "the hip-disease" or not, and it is seldom that the 
parent will rest satisfied with the opinion of a single prac- 
titioner. More advice is sought, and this question must be 
settled. The next qustion is, What was the cause of it? 

Somehow the impression is deeply rooted in the mind 
of the laity that "hip-disease" and "white-swelling," and 
" Pott's disease," are practically incurable diseases, and it 
makes little difference how many flaming circulars arc sent 
about the country by travelling quack combinations, certi- 
fying to marvellous cures; how many shrines exist at home 
and abroad where the magic touch heals by miracle; how 
many '■ natural bone-setters," native and foreign, fasten 
themselves on a community; how many scientific pamphlets 
setting forth the value of certain splints and modifications of 
splints are scattered broadcast over the medical world — it 
matters little, I say, how much of such testimony is furnished 
in favor of perfect cures, the impression still remains 
that these diseases rarely leave one perfect in body and 
limb. The lay mind soon settles down to the acceptance of 
the inevitable, and it wants to find that treatment which 
will bring about the best possible results. 



CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 269 

Above all things it wants to know what is the matter. 
Not only does the layman desire this knowledge, but the 
medical man hungers after diagnosis in diseases about the 
large joints. To him who " invariably gets good results" 
diagnosis is the last knowledge that is desirable, He likes 
such vague terms as "hip-disease," "morbus coxa," etc, 
He can call most any lesion in the neighborhood of the hip 
by those names, and in many cases will get fair results. 
But to him who signally fails time and again in getting the 
good results claimed for this treatment and that, who finds 
some of his cases going on to deformity and shortening, to 
profuse suppuration and lardaceous degeneration, to that 
man diagnosis is valuable, and he grows weary of and dis- 
gusted with the terms whose import is so vague, and strives 
after refinements. He is keen to know what tissues are pri- 
marily involved; he wants to put his finger on the initial 
pathological process. 

Orthopedic surgery has certainly made rapid strides in 
therapeutics, and while much of the value of any therapeu- 
tical measure depends on the diagnosis made, there is still 
'that uncertainty overhanging this subject that must be re- 
moved. The general surgeon who gets the cise late gets 
it when all the tissues, intra- and extra-articular, are involved 
mnd places little value on an anatomical diagvosis. He 
rightly says it makes little difference whether the disease was 
central or peripheral, whether it was synovial or osseous: the 
facts as shown under his scalpel are that all the structures 
are involved. Let him. however, get the case early, when 
he dares not employ his knife, then he would like to know 

{'list what tissues are involved. He doesn't find the whole 
lip infiltrated and disorganized, but finds the soft parts 
around the joint free of any inflammatory products. It is 
certainly valuable to know whether, in a given case, when 
the signs are yet obscure and of recent date, the lesion is in 
the centre of the epiphysis, in the acetabulum, in the syn- 
ovial membrane, in the periosteum, in the periarticular soft 
Structures. Is this knowledge attainable? Has a central 
is of the proximal end of the femur symptoms and 
> peculiar to itself; has an ostitis of the acetabulum its 
signs and symptoms; and is the same true of a syno- 
vitis ? 

le importance and the possibility of determining the 
arj' lesion in joint disease are receiving much con- 
^deration in England. At the last meeting of the British 



zyo 



DtSEASES OF THE HIP. 



Medical Association several valuable papers were presented 
bearing directly on these points. Mr. George Arthur. 
Wright, in an exceedingly interesting paper, published in 
the British Medical Journal for September ist, 1883, use* 
the following language, and I am quite sure it reflects the 
views of the majority of British and Continental observers: 

" I would further suggest that this question of the seal 
of the primary lesion is not given the prominence it deserves, 
Considerfng its importance as a guide to treatment. There 
is, I cannot help thinking, too much tendency to lumi 
diseases together as chronic arthritis of this or thai joint. 

Frequently I have heard good diagnosticians after ana^^ 
lyzing a case, thus express themselves, "'This is bone- 
disease." I do not remember to have heard any one con- 
vinced himself as to whether the ostitis is in the epiphysis 
solely, or in the diaphysis, or in the acetabulum. 

The truth is that the centres of ossification in the diaphy- 
so-epiphysial portion of the femur are so intimately asso- 
ciated, anatomically and physiologically, that lasions are 
very prone to develop in two or more of these centers at 
very nearly the same time. It is furthermore true that for 
clinical purposes a differentiation is undesirable. 

If one could feel reasonably sure that the inflammatory 
process extended ihiough the lines of cartilaginous union 
even, it would be just as easy to reach the parts through 
the trochanter as if the process were limited to one 
other side of the line. In a chronic ostitis symptoms ai 
very scarce in the early stages. We must rely more on eel 
tain signs, which are quite constant. Acute synovitis 
markedby acute symptoms almost from the very beginnii_ 
such as pain, extreme tenderness and constitutional disturK^ 
ances generally. The signs, too, accompany the symptoms, 
and become quite characteristic, provided the lesion be 

The symptoms, then, on which one can rely in diagnosti- 
cating a chronic articular ostitis of the hip make their ap- 
pearance, as a rule, in the following order: The child will 
complain of a sense of stiffness on rising from bed in the 
morning, and will show a tenderness, however slight, in the 
vicinity of one or the other hip by an awkwardni 
a disposition to fall on the most trivial provocation. 
condition may last several days or several weeks; but n 
while, or perhaps following it, there will come a sense 1 
fatigue after play or a short walk. Occasionally, when thui 



re 

m 



on ^^^ 

I 





'STITIR : I3IAGNOSIS. 



271 



I 



complaining, the child will refer pain to the region of the hip, 
and a little later llie pain will be referred to the knee, usually 
jusi above the patella. This site is not constant, for the 
sides of the knee and the popliteal space come in for their 
•hare quite frequently. 

When these iliifiing pains attract notice an exacerbation 
is approachini?, and ihc symptoms will soon become more 
acute. At thi; same time there will be restlessness during 
sleeping hours, and screaming while asleep. This latter 
partakes more of a shriek — one or too — and then an interval, 
followed by others. It is known as the ostitU rry, being re- 
garded by some as peculiar to bone lesiuns in the vicinity 
of joints. In seeking for 3 history of this cry, however, 
one must not expect to hear that the child invariably cries 
aloud without waking. It very often happens that two or 
three long cries in sleep will be fallowed by a waking and 
continuous crying. Then the little one will go to sleep 
io, and the same procedures will recur. 

loss of sleep and the harassing pain by day will 

lly, in many children, induce a loss of appetite an 

Ired digestion and an irritability of temper. These 

implete the symptoms in the first stage. 

The signs furnish, after all, the important points in diag- 

sis, and for convenience and system I shall arrange them 
in the order of observation. 

Inspection. — The lameness is the first sign that attracts 
one's attention, and this comes as near to being diagnostic 
as any other sign that presents. As described in the 
chapter on clinical history the limp is peculiarly a "hip- 
limp." Every effort the child makes in walking is directed 
toward the saving of the limb. The periarticular muscles 
seem to lock the joint, and the motion takes place chiefly 
at the knee and in the lumbar spine. The step is short, 
yet firmly taken, and differs materially from the limp of a 
paretic limb. During the first few days there may be an 
exception to this, as the foot appears to be unsteadily placed 
upon the floor, and as the weight is thrown upon it there is 
a slight swaggering from side to side. This, however, is 
an exceptional limp, and serves to bring out the rule in 
stronger relief. 

Bpth in standingand in walking the limb will vary a little 
between the horizontal line and outward rotation. In 
furthermore, the limb is advanced a little in order 
be thrown upon th'^ 




that the bulk of the weight 1 



^ mai ine uv. 




sound liinb, and the foot is either on a parallel plane ' 
its fellow, or is a little evened. In my own experience T 
have seldom found the inversion described as belonging to 
the first stage. The most common position is a position 
without inversion or eversion. If, however, the examination 
be made in the midst of an exacerbation the limb will be 
well advanced, and the foot in- or everted in accordance 
with the muscles or tissues about the joint implicated. 
- The change in the nates next attracts one's attention, and 
here is found a loss of the normal depressions — the expres- 
sion, so to speak, is gone. It is like looking at a face in 
which one side is partially paralyzed, and the difference 
can only be appreciated by comparison. The ilio-femoral 
creases are shorter, and are on a lower plane: frequently 
one only will remain. True, this appearance is present in 
certain forms of paralysis or in periarthritic lesions, yet the 
signs are valuable in connection with symptoms and a 
history. In some cases the creases will be like those on 
the sound side, but the parts about the crest will be more 
prominent, and the whole of one side of the nates will seem 
to be raised, the limbs being parallel. The size of the thigh 
is less than that of its fellow, and this difference will be 
early appreciated by comparison. It is a clinical fact — 
sufficiently elaborated in the preccdingchapter, that atrophy 
begins early in an ostitis affecting the centres of develop- 
ment, and with a knowledge of this fact (he observer will 
look for the signs of the same. 

Palpation. — TAe facfus eruiiitus does not help one much 
in the diagnosis of this disease. It is of more value in a 
negative than in a positive way. If the pathological pro- 
cess have advanced to such a degree that periosteal thick- 
ening has been induced, then this can be recognized by pal- 
pation; but it must be borne in mind always that every 
step of the examination should be conducted by com- 
parison. With flabby muscles the size of the trochanter 
will look and feel larger than normal, provided the other 
is not grasped at the same lime. Pressure over the bony 
prominence with this periosteal thickening will elicit bone, 
tenderness, which is a sign of questionable value. The in- 
guinal glands may be enlarged, yet it frequently happens 
thai the glands are not enlarged even when the diseqse is 
far advanced; so thai very little reliance can be placed on 
the conditions these structures present. 

Functions of the Joint. — By far the more importai 




CHUONIC ARTICULAR OSTITIS: DIAGNOSIS. 273 

[o diagnosis is obtained from a test of the joint functions, in- 
cluding not only the condition of the articular surfaces (so 
far as external examination can determine), but the condi- 
tion of the surrounding muscles, the extensors and the ad- 
ductors especially. If one have any feais about employing 
passive motion, the child can, while balancing on the sound 
limb, be induced to ntlempt active motion. On many oc- 
casions when I have been debarred the privilege of moving 
[he thigh myself, I have gained much positive knowledge by 
indiicin>: the patient to execute various movements with the 
limb. With the present views I hold concerning the lesions 
in and near the hip-joint, I entertain no fear whatever of 
doing the least amount of harm to the parts by passive 
movements, no matter what the lesion may be, prmnded 
they be made without an anjesthetic. 1 have never found 
it necessary to employ an ansesthetic in conducting an ex- 
amination except on one or two occasions. These excep- 
tions were in a patient with a few female relatives in the 
room, and I could not execute a single movement without 
the premonition of a sympathetic shriek. The very si^ns 
on which one is to rely in diagnosticating an early ostitis 
are obscured by the anesthetic. 

There is no necessity for being rough or in any way violent 
in the manipulations. Secure, if possible, a table for this part 
of the examination, and let it be covered with a blanket or 
other soft material. Never lest the joint function with the 
patient lying on the bed if it can be helped. Let the patient 
be divested of all ehthing below the waist. It is better still 
to remove every thing, save perhaps, the shirt worn next 
the skin. Now let the dorsal decubitus be taken on the 
table thus prepared, and get the child'sconfidence by manip- 
ulating the sound limb. Put the thigh through all the 
normal movements: flexion, extension, abduction, adduc- 
tion, inward rotation and outward rotation — all to their ex- 
treme limits. This will refresh our knowledge as to the 
normal movements both in kind and degree, and at the 
same time the patient will be prepared for an examination 
of the limb of the side diseased. 

As soon as the thigh is grasped with the hand of the ex- 
aminer the least resistance will be appreciated, and one can 
often tell in an instant what movements will be limited. 
Carry, without the employment of force, the thigh over the 
full extent to which flexion can be made, noting the while 
any reflex resistance that may present. It will be found 



274 DISEASES OF THE HIP. 

that the resistance point will be between ninety and forty- 
five degrees. The other thigh can be easily flexed to its 
limit by way of comparison. For purposes of record the 
goniometer, as represented in Fig. 28, is a very useful 
instrument. The one I have represented is taken from Dr. 
Knight's "Orthopoedia/* though modified in the marking. 
The fixed arm when in use rests with the graduated arc 
against the side of the body, the joint over the joint whose 
deformity is to be measured, while the movable arm rests 
against the limb parallel with its longitudinal axis. The 
angles can then be read off on the graduated arc. A 
little practice with the goniometer will enable one to esti- 
mate quite closely any given deformity, even without em- 
ploying the instrument. 
All orthopedists insist more or less on the position of 




Pig. «K.~A 



the body and the relationship of the spinal column to the 
table or bed on which the examination is conducted. All 
the spinous processes should be in contact with the under- 
lying surface, and in moving the limb this relationship 
should be maintained. I have been much pleased with the 
method Mr. Tht>n^as, of Liverpool, adopts for securing this 
fixation of the bo<l\. The accompanying figure (No. 29) well 
represents the method. The arm of the sound side thus 
placed in the popliteal space retains the corresponding 
thigh acutely flexed on the abdomen, thus preventing 
tilting of the pelvis during movements of the diseased 
member. 

Given now the arc of motion in the different directions, 
what significance shall we attach to the various degrees of 



CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 



275 



be resisted, however 
ts be perfect, we 



resistance encountered ? If flexioi 

little, even though all the other 1 

have one of the early signs of a chronic ostitis. If to this 

be added a limited arc of abduction and of rotation, the 

signs are thus rendered more significant. As a rule these 

three signs, viz., resistance to flexion beyond sixty degrees, 




RB Body whilb Tonwi! 

Pto abduction, and to rotation, are among the earliest, if not 
the earliest, one finds in a thorough examination. Indeed, 
with thes.c three present a diagnosis can be made. It is 
very seldom that one of these signs is present without 
the others. Exceptionally, the flexion sign is the only one 
that a careful test will discover, but when the adductors 



^ lliai a cc 




276 DISEASES OF THE HIP. 

are in reflex contraction there is a limit to full flexiot 
Exceptionally, too, an articular ostitis may be present antf 
the joint functions in every way perfect, but the exceptions 
art? so rare that ihe average practitioner will never, in my 
opinion, have occasion to think of such a contigency during 
a natural life-time. Very many cases on their first examin- 
ation give a hip in which all the surrounding muscles are 
in a state of reflex spasm^no movement whatever is 
allowed. 

Sensitiveness of Bone and Joint. — To determine the 
tenderness of the joint the most common method is to 
sharply strike the heel or ihe knee in the direction of the 
longaxisof thelimb. This has tome been a very unsatisfac- 
tory test. In the first place, the periarticular muscles are 
in such a state of reflex spasm that the joint is practically 
immobilized, and thus protected from concussion. In the 
second place one has to strike with such force to get 
any response, that not only is there danger of fatal injury 
to the joint by breaking down the articular cartilage in some 
weak point, but the impression conveyed to the patient and 
friends present is one of extreme roughness in examina- 
tion. At all times and under all circumstances rough 
methods should be avoided. A plan that I have adopted 
is free, I think, from this objection, and certainly I can gel 
much more information about the condition of the joint 
than I can by the concussion method. I make a lever of 
the patient's thigh, having for the weight or resistance the 
acetabulum, for the fulcrum the palm of my hand, and for 
the power the other hand. Bony tenderness if present will 
generally be found over the trochanter or shaft. As a 
rule, however, one will rarely find any joint-tenderness in 
the early stage of this disease, unless perhaps the examina- 
tion be made in the midst of an exacerbation. The greatest 
tenderness will be in the fibrous structures enclosing the 
joint, and these can be the more easily reached just over 
the digital fossa and in the groin. 

While the above examination is conducted, imformation 
will be gathered concerning the mode of invasion and the 
behavior of the patient by day and by night. The family 
history must be obtained, and it must be remembered that 
due tact is to be employed in eliciting facts in thi^ connec- 
tion. The personal history must not be forgotten, for oa 
this the existence frequently of a strumous diathesis t 
pends. 





CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 



277 




Studying the behavior of the patient at home it will be 
learned that every care has been made to protect the joint. 
The first thing the mother will have noticed is the difficulty 
the child experiences in getting on the shoe and stocking. 
There is no severer test to the functions of the hip, and all 
through the course of the disease this serves as a petty 
annoyance. Mention has already been made of the peculi- 
arity of gait, the restlessness ai night, the peevishness, the 
loss of appetite, etc. 

I have endeavoured to give the history, the symptoms, 
and the signs by which a diagnosis can be easily made in 
a typical case of chronic articular ostitis of the hip. The 
first exacerbation is usually delayed some weeks or months, 
but occasionally it appears very early, and the diagnosis is 
thus rendered very difficult. In young children, however. 
I do not believe in very early exacerbations. 

Three years ago a little girl of five years was brought to 
me complaining of pain in thigh and knee, left side. She 
had been ailing only three days, and there was no signs 
such as lameness or stiffness or awkwardness in gait even 
prior to ihal time, I could get no history of a fall or 
injury otherwise sustained, and the mother insisted that 
the family history on both sides was good. I found ihal 
the little patient kept lier thigh flexed, yet on attempts at 
passive motion I met with no resistance whatever in making 
flexion and extension to extreme limits. Rotation, ab- and 
adduction were limited to a readily perceptible degree. On 
the strength of these three signs 1 recorded an interrogated 
diagnosis of chronic articular ostitis, and reserved a 
positive diagnosis for a future visit. A week later she was 
"free from lameness, the thighs equal in size and limits 
equal in length, movements perfect, and child rests well 
nights." A fortnight afterwards 1 recorded ■' no resistance 
at all in movements, child cured and no disease at the hip," 

In this case I should not have placed any confidence in 
the symptoms developing coincidently with the signs. In 
another case I saw a few days before this one came under my 
observation there was a history of symptoms coming on 
one week after the first sign. The patient was a female, 
aged eleven months only, and the mother gave a history 
of a fall six weeks prior to the dale of mv first cxamina- 
rion. The child (ell on ihe hip, and cried' a iitilc at the 
time, but soon became quiet and did not complain any for 
a week. Then quite suddenly the limb became quire 



I 
I 
I 

I 





urbed. 



I the child would cry bitterly it the joint wertl 
A week afterward exstensJon was applied, but^ 
this seemed to add to the discomfort. I could find neither 
shortening nor atrophy. The adductor muscles were in 
slight reflex spasm. There was resistance and pain tn 
flexion beyond ninety degrees in the extremes of exten. 
sion, of rotation, and of adduction an appreciable resist- 
ance was encountered. At the end of a week the signs 
were less marked, yet I felt satisfied that I had here 
to deal with a case of bone disease. An exacerbation a 
month later ushered in the second stage, and the diagnosis 
was settled beyond question. 

In ditTerentiating this disease in its early stage the^ _ 
following affections present for consideration: ' ' 

I. Contusions and Sprains. 
II. Muscular Rheumatism. 

III. Neuroses of the Hip. 

IV. Infantile Spinal Paralysis (Poliomyelitis). 
V. Periarthritis. 

VI. Bursitis. 
VII. Acute Synovitis. 
VIII. Periostitis of the Hip. 
IX. Ostitis of the Ilium, including Sacro-iliac Diseas 
X. Vertebral Ostitis. 

I. Contusions and Sprains, 

The clinical features of these simple lesions have been 
discussed in Chapter III, The diagnosis is quite readily 
made when violence has been done to the external parts 
arid when the date of the injury is well known. It bC' 
comes more obscure, however, when nothing can be seen 
externally and when the accident is questionable. Wi' 
must then make a diagnosis chiefly ^y exclusion. 

Take, for instance, the following case I saw last spring: JC 
well-developed boy, aged five years, had a peculiar gait. 
It could scarcely be described as a limp, yet he favored the 
right hip and had been walking this way for eight days. The 
day before this sign was observed he fell while at play, the 
limbs being thrown into complete abduction. The mother 
saw him fall but he got up immediately and ran off to play 
without showing any evidences of sprain. He passed a good 
night, and next day toward the evening it was noticed that 
]i-: favored the right limb a little. From that lime he rest 



i 




CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 379 

well at night, but was more stiff in the morning than in the 
Utter part of the day. At no time did he complain of pain 
in any part of the limb. Here, now, was the morning stiff- 
ness, the lameness without symptoms, and eight days had 
passed without improvemenl. I was prepared to find some 
resistance on manipulating; the thigh, although I could 
detect no loss in contour of the nates. I did not find any 
impairment of [he joint functions on pretty thorough ex- 
amination, and recorded as diagnosis a sprain, enjoining 
rest for a few days. Within a month all this peculiarity 
of gait disappeared and the boy was perfectly well. 

It was not so in the case of a girl aged two years whom 
I saw last fall. There was a history of a sprain while at 
play two weeks before she came under observation. A 
playfellow had pulled the right leg, causing a little pain 
apparently at the time. She rested well the same night 
but next morning was stiff and walked lame. The limb, 
as she stood and walked, was markedly abducted. The 
lameness persisted and the limb had become quiie tender, 
so that she cried if any one moved it. With a little care, 
however, the thigh could be moved over normal arcs, the 
resistance readily giving way. She had begun tocry aloud 
during sleep and lo manifest an amount of tenderness that 
led me to regard this as an early exacerbation in bone 
disease. A week later she was walking more easily, but I 
found for the first time marked resistance lo rotation and 
abduction. The subsequent notes of the case show a 
gradual progress to the second stage, with abscess, etc. 

A girl aged five came under my observation in the early 
part of August with a lameness of nine days' standing. I 
found a slight resistance to outward rotation while all the 
other movements were free and painless. The child had 
fallen over the railing of a stoop on the day before the 
lameness came on and had bruised both the shoulder and 
the hip. Ecchymosis over trochanter remaineil up to the 
date of my examination; there were no acute symptoms 
and there was no sign save the ecchymosis, the lameness 
and the resistance to outward rotation; hence I made out 
a contusion of the hip and enjoined rest for a week, when 
I found the resistance to rotation gone, but the child was 
lamer. Then I waited a week longer and the mother re- 
ported that the lameness was not so marked, yet the child 
had more difliculty in going up and down stairs. All these 
signs passed away in the course of two months without any 



28o DISEASES OF THE HIP. 

esacerbalion, and six monlhs afterward I examined th< 

case again quite carefully, to 6nd nothing in the way of si{ 

or symptom. 

The points in difTerential diagnosis arc: 

I. Sprains and contusions are always the direct result 

trauma. 

Chronic articular ostitis is seldom the direct result ol 

s. Sprains and contusions give signs within tweniy-four 
hours of the accident. Symptoms usually follow imme- 
diately. 

Chronic articular ostitis may not show any signs until 
two or three weeks after the accident supposed to have^ 
stood in causative relationship. The symptoms will not 
appear until after the establishment of the signs. 

3. In the one there is, as a rule, no resistance to the joint 
movements. In the other, reHex muscular contractions, 
causing resistance to passive motion, as a rule, are present 
within the first fortnight after the initial lameness. 

4. In the one the signs are so pronounced that medical 
advice is sought within the first week. In the other thar 
signs are so obscure that medical advice is rarely soug-ht 
within a month. 

5. Sprains and contusions are more common in adult life^, 
chronic articular ostitis in early life. 

ti. In doubtful cases time wifl elTect a cure in the formi 
and will have no influence on the latter. 



II. Muscular Rheumatism OF the Hip. 

Muscular rheumatism, or, myalgia, from cold or expo* 
sure, gives certain symptoms that are very like those 
finds in the early exacerbation of a chronic bone disease, 
.ind the lameness, too, of the former, is sometimes diffii ' 
lodissociate from that of the latter. The "growing pains" 
that children complain of are generally rheumatic, and 
their relationship to certain signs of articular ostitis are 
not treated with sufficient consideration, so that in the ma- 
jority of cases these " growing pains" are but the symptoms 
of the more formidable disease we are now discussing. 

A case in a boy aged twelve years, whom I saw in May, 
1879, and one in a boy of the same age, seen first in Jutu 
1879, will illustrate the difficulty in differentiating the ti 




CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 28r 

ofTections. The first was reported to have been troubled 
much with " rheumatic" pains for two years, but the family 
history was free from rheumatism. When he first presented 
for examination it was for a lameness [hat had lasted only 
five days. He had been at school, and had been perfect in 
limb, so far as I could learn, when one day, without known 
exciting cause, he was seized with severe pain in the an- 
terior and inner surface of the right ihigh. It gradually 
diminished in severity during the day, and during the fol- 
lowing night he had no pain, but next day he was quite 
lame. On walking the pain was excited again, and it was 
further called into action by sitting a long while. The 
same region was always affected and yet he was not troubled 
any during the night. The natis presented a moderate 
flattening and the crease was ohlitenited. Resistance was 
offered when the limb was completely extended. A coun- 
ter-irritant was employed and within less than a month all 
symptoms had disappeiired, all signs had disappeared. I 
times during the following year and always 
with negative results on cxaminalion. 

The oiher boy was also twelve years of age and had been 
lame a few weeks three years before. He made a perfect 
recovery, it seemed from the history, and then, during the 
early months of 1879. two and a half years later, the lame- 
ness, accompanied by pain, returned, affecting the same 
limb. The pain was so great that he did not leave his bed 
for two months. Since he left his bed the pain had been 
veiy insignificant, unless after much exercise. It seldom 
caused any loss of sleep. When I examined, three months 
ment to bed, I could detect no change in the 
exaggeration of the dimple above trochanter 
of the side affected. The limbs were parallel and he could 
stand on either limb wifh equal facility. There was, how- 
ever, a half-inch atrophy of the thigh and of the calf, and 
a little resistance offered as the extreme limits of abduction 
and outward rotation were made. The joint was free of 
tenderness and the thigh could be flexed and extended to 
extreme limits without the least resistance. This case re- 
mained in hospital under daily observation for three weeks 
and at the end of that time there could not bedetecteH any 
lameness, while the movements were perfect in kind and 
degree. Notwithstanding this change, I had some mis- 
givings about discharging the boy. and he was allowed 
Home for a few days. He failed to return, and six months- 




282 DISEASES OF THE HIP. 

afterward I learned that he was on crutches, and was is 
another exacerbation of joint-and-bone disease. 

Now, wherein did these two cases differ? Let me state 
that the first was -diagnosticated bone disease and the latter 
rheumatism. The first proved to have been rheumatism 
and the second proved to be bone disease. With the 
history of each before me, and willi my mind divested of all 
bias I can readily note the points of difference. In the first 
there was a brief lameness, in the second there was a six 
months' lameness at least; in the first there wasa rheumatic 
history, in the second there was none; in the first the acute 
period lasted twelve hours, in the second nearly two months; 
in the first there was no clear history of any preceding lame- 
ness, in the second there was such history; in the first there 
was no pain at night, in the second there was occasional 
pain at night; in the first there were no signs save resist- 
ance to extension, in the second the limb could not be ro- 
tated well, or abducted or adducted; in the one there was 
no atrophy, in the other there was atrophy. Instead of in- 
terpreting that confinement to bed two months as due to 
rheumatism, I should have interpreted it as the second ex*i 
accrbation of chronic articular ostitis. 

The first case was not so clear as that of a little girl three] 
and a half years of age, who was brought to me in the win- 
ter of 1878 complaining of pain about the crest of the left 
ilium and in the gluteal region of samesidc. She had been 
complaining of pain and had been resting poorly at night for 
three weeks. There was no lameness, and a careful test of 
the functions of both hip and spine was attended with ab- 
solutely negative results. 1 had under treatment at the 
time a sister, a few years her senior, for chronic rheumatism 
affecting the knee, and I knew her father to be the subject 
of crippling rheumatism. I had, therefore, no difficulty in 
diagnosticating rheumatic neuralgia in this case, and put 
her on treatment for the same. She made a perfect re- 
covery in less than a fortnight, and 1 learned four and a half 
years later that she had never had any relapse. 

It is unnecessary to cite cases in adults, because these as 
a rule oflfer no difficulties in diagnosis, especially in the 
early stages. The articular varieties are usually associated 
with similar lesions in other joints, and hence do not offer 
any obstacles until deformity has arisen. When I come to 
speak of the diagnosis of the second and the third staga 
these lesions will come up for differentiation. 



I 



1 tne tnira staga b 

J 



ClIRUMC ARTICULAR OSTITIS: DIAGNOSIS. 283 

To sum up, then, the points in differential diagnosis be- 
tween the first stage of a chronic articular ostitis of the hip 
and a rheumatism of the hip, 

1. In the one the lameness precedes the pain, in the other 
the pain comes first, and frequently lameness is not present. 

2. In the one there is no hypertesthesia, in the other 
muscular hypcraesihesia is a prominent feature. 

3. In the one there is as a rule no resistance to joint 
movements and no reflex muscular spasms in the adduc- 
tors or flexors; in the other this resistance occurs early and 
the spasm is easily excited, 

4. In the one there is a rheumatic family history, in the 
other there is often a tuberculous history. 



III. Neuroses of the Hip. 



The prevalence of nervous diseases in large cities brings 
us more and more in contact with the true and false 
arthropathies of neurotic origin. I was formerly under 
the impression that these phenomena were limited to the 
period of adolescence, but latterly I have seen them in 
young children, and hence find it important to differen- 
tiate the more closely between these neuroses of the hip 
and chronic bone disease. It is necessary to fully ap- 
preciate this fact, viz., that because a child comes of a neu- 
rotic family and even has a decidedly' neurotic tempera- 
ment itself, it does not (ollow that a true bone disease 
about the epiphyses is at all improbable. In other words, 
the neurotic diathesis does not protect against the develop- 
ment of strumous diseases. The two diatheses sometimes 
run hand in hand. Some of the most destructive cases of 
boneand joint disease I have everseen have occurred in pa- 
tients who ivere typically neurotic. It must be constantly 
borne in mind that chronic articular ostitis has its own pe- 
culiar clinical expression, and however masked this may be . 
by nervous phenomena this expression should always be 
recognized. Neuroses, like bone diseases, have their exacer- 
bations, and but for the thoroughness of the remissions, the 
differential diagnosis would become extremely harassing. 
Take, for instance, a case I have reported on page 62. This 
boy had an exacerbation in 1876. Three years afterward 
he had another, and again after the lapse of four years he 
was similarly affected. Pjompt recoveries were effected nn 



2S4 



DISEASES OF THE HIP. 



every occasion, and a Hmp was not left over. Exceptioi 
ally, though, the lameness does persist, and its explanatii 
is possibly in a lesion of the anterior columns of '' 
cord. 

I saw, for the first time, a girl eight years of age, 
the summer of 1880. The family history was decidedly 
tuberculous, and the patient was a feeble, poorly nourished 
child. While she walked with ease there was a marked 
limp in her gait, and the left hip was favored. I could not 
elicit any joint-tenderness, and could not detect any atrophy. 
Considerable muscular resistance was offered to passive 
flexion of 90° even, and beyond this angle the thigh could 
not be moved. The other movements were made with ease. 
I found the dorso-tumbar spine and the limb itself very hy- 
peraesthetic. Fourweeks before she came under my obser- 
vation she fell on the side-walk, but did not seem to sustain 
any injury. It was two weeks before she began to walk 
lame and to complain of any pain. Her sleep had not been 
disturbed. Under a placebo the lameness and the pain dis- 
appeared in a month, and I examined her a month after- 
ward with negative result. In tracing out the case thi 
years afterward, I found that the lameness had soon 
turned, and while I could not discover any symptoms 
disease I found this favoring of the limb still present. 

In some cases, indeed in nearly all cases of contraction the 
result of nerve-irritation a little force is all that is necessary 
to overcome this completely. Last spring a girl twelve 
years of age came limping into my office, and I learned that 
all her symptoms and signs came on quite suddenly four 
days preceeding this visit. The mother knew of no cause, 
and I could not find any. The right ihigh was locked, as 
it were, on the pelvis, at an angle of 135°, and there was an 
apparent shortening of one and a quarter inches. The girl 
seemed generally hyperiesthetic, and I at once made up my 
mind that this was a case of hysterical contraction — a neu- 
rosis of the hip. With a little coaxing 1 succeeded in mov- 
ing the thigh over a small arc, and then, finding the con- 
traction give way, I rapidly and with considerable force 
moved it in all directions over the full extent, immediately, 
after which I made her walk across the floor. This she "'* 
with scarcely a trace of lameness. 

The signs of bone disease have been sufficiently elabi 
ated to make the introduction of further cases in this coi 
nection unnecessary, and I shall content myself with 



ter- 

1 




CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 



285 



. In a neurosis of the hip a neurotic element in the 



family history will, i 
ostitis of the hip the 
family history. This 
be found either hei 
patient. Furthcrr 



ule, be easily obtained; in chronic 
imous element will appear in the 
/ not be found, however, but it wUl 
e or as an acquired diathesis in the 
re, the neurotic and the strumous ele- 
ments may be combined in the family history, and the for- 
mer may even stand out more conspicuously than the 
latter. 

z. In both, the exciting cause, viz., trauma, may be the 
same, only tn a neurosis the cfFect will, as a rule, follow the 
more speedily. 

3. In a neurosis pain and the initial lameness appear 
simultaneously, and the exacerbation will be the more acute; 
in chronic ostitis the lameness appears first, and may con- 
tinue a long time before an exacerbation appears. 

4. In a neurosis there will be areas of hypersesthesia and 
paraesthesia in the distribution of certain nerve-branches, 
and the spine will also, as a rule, be tender in the region 
whence the nerves are given ofi ; in a chronic bone-disease 
there is seldom any hyperesthesia and seldom any spinal 
tenderness, while the pain is usually in the distribution of 
the articular branches of the obturator. 

5. In a neurosis the muscular spasm about the joint will 
yield readily to forced movements; while in a clironic bone- 
disease the contraction becfimes the greater on forced 
movement of the limb. In other words, the reflex spasm in 
the one yields promptly to force; in the other it is increased 
by force. 

6. In obscure cases a brisk counter-irritant to the lumbar 
spine will promptly relieve a neurosis, and will have very 
little effect on a chronic bone-disease of the hip. 

IV. Infantile Spinal Paralysis. 

One would never think of confounding an infantile 
spinal paralysis with the first stage of a chronic articular 
ostitis, yet it has been done by men who pride themselves, 
too. on their diagnostic ability. And then, when the two 
diseases are compared as to initial symptoms, it does not 
seem so unpardonable an error to mistake the one for the 
other. The ages closely correspond; the child, in a sub* 



2S6 DISEASES OF THE HIP. 

acute spinal paralysis, totters around sometimes two or 
three days before it actually gives up walking — there can 
for both be obtained a history- of a fall; with the sudden 
loss of power comes an accentuation of the pains and hyper- 
esthesia that belong to a poliomyelitis in its active stage; 
the constitutional disturbance is not any greater frequently 
than it is in a sharp exacerbation of a bone-disease of the 
hip. I must confess that a differential diagnosis 
always easy to make. 

In the fall of 1874 a male child two and a half years of 
age was brought to me for examination. He seemed to be 
in good heallh, biit was cross and hard to control. As he 
stood in a state of nudity the left nalis was flattened a little 
and the crease was lower than its fellow. Pressure over the 
trochanter elicited tenderness, and the least passive motion 
of the limb caused the child to cry aloud as if in great pain. 
On measurement there was only a shade of atrophy. The 
skin felt cold and the surface thermometer indicated a 
slight diminution in temperature. There was lameness, 
but as the child walked one could see that this was not due 
to the action of the muscles in protecting the hip; the gait 
was unsteady; a tottering at the knee was observed, and 
after walking a few steps the limb gave way, and a fall was 
the result. The electrical examination was unsatisfactory, 
though there seemed to be a diminution in the force of the 
faradic contractions. The mother, in giving the history, 
stated that seven nights before, without any provocation, 
so far as she knew, the child became a little peevish and 
rested badly; slept late, however, the morning following, 
and walked on rising; but that in a few hours she noticed. 
the child fall, get up, and after awhile fall again; that he 
cried and moaned the second night, crying the more if the 
limb was moved; that he was verj' lame on the second day; 
that she took him to a surgeon of acknowledged ability— a 
man whose diagnosis it would be arrogance to question; 
that after a long examination shi- was told a hip-splint 
must be procured as early as possible, that she could not 
meet the expense of the apparatus, and that she comes to 
me now two days later hoping to get the needed splint free 
of charge. 

In the family history a maternal aunt is reported to 
have died of hydrocephalus at the age of eleven years. 
The history of the invasion, the unsteadiness of the gait, 
the age of the child, suggested to my mind a paralysis of a 



I 
I 





CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 28/ 

group of muscles of the limb, and to this diagnosis I ad- 
hered, especially afier an examination on the day following. 
Santonins was prescribed in order to remove any causes 
acting reflexly in the intestinal canal. No results were ob- 
tained from this, and after one or two more visits the 
child was lost sight of for nearly a year, when the mother 
brought him back to be treated for a calcaneo-valgus, par- 
alytic in origin. The usual electrical treatment with the 
use of apparatus was employed, and' the deformity alto- 
gether has proven most intractable. This is no isolated 

Here is one differing a little, yet the result is the 
same. I have them both under treatment at present for 
obstinate calcaneus. This one was in a girl two years of 
age. seen in October, 1877. She was seized with a slight 
febrile attack five weeks before coming under my care. 
This continued five days, and at night the child was worse. 
During that period, and (or a week later, the patient refused 
lo walk, and, if placed on feet, would cry as if in severe 
pain. Gradually improved for a week, but for the past 
two weeks the improvement had been less marked. Lat- 
terly has had no pain whatever even when walking freely. 
Patient seen twice during the fourth week by a surgeon 
whom the profession regards as an expert in this specialty, 
and this gentleman writes that, after careful examinations, 
he locates the disease within the hip-joint, as he finds un- 
mistakable muscular rigidity about the hip. He makes a 
differential diagnosis, tiowever, from infantile paralysis. 

i found the nates on the left side flattened perceptibly, the 
calf one-half inch small; motion at the hip joint could be 
made to the normal extent in all directions without pain, 
though there seemed tu be a little resistance to complete 
abduction; there was marked diminution of the tibialis an- 
ticui in reaction to the faradic current. There was lame- 
ness, but this was not like that due to disease of the joint, 
My diagnosis was infantile spinal paralysis confined to a 
single muscle or group of muscles, and treatment instituted 
therefor. There was in April. 1878, a slight degree of varus, 
Ihc limb was colder than its fellow, there was atrophy, and 
the child would become lame after moderate exertion — tires 
easily. Neither had then, nor had had since October, any 
pain whatever, diurnal or nocturnal, and Ilie limb could be 
bandied without any discomfort. 

Unless cases like these two be carefully studied, one can- 





288 DISEASES OF THE HIP. 

not see the difference between such and achronic articul 
ostitis of the hip. 

One afternoon in July, i88i, a case was sent from one of 
the general hospitals, and although I had little time for 
making an examination, the child seemed to be suffering 
so much and so helpless wilhal, that I did go over the case 
rather hastily, finding what I took to be an early and an 
uniistially acute exacerbation in a chronic bone disease ot 
the hip. The patient was a boy three years of age, and had 
been four days lame ; in fact, on this day he was quite un- 
able to walk. The child stood like one very weak from aD 
acute illness. There was limitation to complete joint move- 
ments ill abduction and in rotation. These were all the 
signs I recorded, and while I placed an interrogation point 
after the diagnosis, I somehow felt that the case must develop 
into one of bone disease. The patient did not remain in 
hospital, and the next time I had an opportunity of exam- 
ining the case — two months later— I found paralysis of the 
quadriceps femoris, and anterior and posterior tibial groups. 

It will be seen that there are certain well-defined differ- 
ences, notwithstanding the close similarity — 

1. The limp in a spinal paralysis is not a limp that is as- 
sumed to protect the joint. The child is lame because of 
the weakness of the support; in bone disease the muscles 
contract to protect the joint and every step is taken with 
this protection in view. One is a tottering gait, the other 
is a stiff gait. 

2. In one there is no reflex muscular spasm about the 
joint; in the other a careful search will find one or more 
groups contracting on passive movement when carried near 
extreme limits. 

3. The galvanic current, after the first week at least, will 
give the degeneration reaction in a spinal paralysis ; in the 
other the galvanic current will give the normal formula. 
The degeneration reaction is the reversal of the normal 
formula. When the more vigorous contraction of a muscle 
or group of muscles takes place at the time the current is 
closed by placing over the same the electrode from the 
negative pole — this is called the normal formula— and is 
expressed by the signs C. C. C. > 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 
;in infantile spinal paralysis within the first week; '" ' 




CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 28g 



test for the general practitioner. 

V. Periarthritis. 



It is only in the very early stage of a periarthritis thai 



After the infiltrati. 

cicntly clear. It m 

; of the phlegm 



I has I 
*t ber 



nied the signs become 
■nbered that 1 am n 



emembered that 1 am now speak 
■nous 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- 
I thrilisof childhood, the following, in a boy three years of 
I age, who came under my observation in August, 1879. In the 
early pari 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 
Inospiial by his medical adviser to have the child treated 
ffor "hip-disease." I found an axillary temperature of 
E ■aoi.s", a pulse of 131, and an extreme degree of irritability 
I ■Sn the patient. It w.is 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 
^:ould not be completely extended, flexed or rotated, and 
•hat 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 
«igns, and the constitutional disturbance enabled me to diag- 
nosticate a periarthritis. The subsequent progress of the 
ose fully confirmed the diagnosis made, and in less than 
two months 1 cure was fully established. 
L In February, 1S79, 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 tfie lame- 
ness, and the second stage was already present at the time 





7)T?!EASES OF TIIE HIP. 

my examination. There was an apparent lenglhi 
ing of one inch, and the natis and thigh were ven- protnl 
nent by reason of extensive infillralion. I found it difficult, 
however, to (!ex the thigh to 90" or to extend to 135.° AH 
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 thai 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 diflferentia! 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 accompany! 
pain. 

4. The limp of the two may be identical. 
Differentially, we have : i. Pain and acute symptoi 

within the first few days in a periarthritis ; these are the 
exceptions in a chronic articular ostitis. 

1. 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 
n loss to explain why certain groups of muscles should 
be excited to spasm or resistance by attempts at passive 
motion. 

;, Palpation will delect 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 vM 



1 




I 

I 

I 



CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 291 

marked ; tn the other there are, as a rule, no constitutional 
disturbances in the early stage. 

7. In the one ;he 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 
<io 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 11 1 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 
patientdid 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 






DISEASES OF THE HIP. 



.■uch as one would expect to find in a chronic bone di 
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 
his work. 

Then, again, the girl whose case is reported on page 
stood with limbs parallel and the lameness was so slighi 
to lose its significance. The symptoms were mild in lyj 
and the patient would scarcely be recognized as a pat; 
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 lier acute and dis- 
tressing symptoms were not due to the bursitis as a bur- 
tealed invasions of the articular cavitv 



i 



differential diagnosis proved of no 
r to the establishment of the joint ]< 
ptoms of the simple bursitis were 
>sis. To differentiate, then, an uncompli- 

chronic bone lesion in the immediate^ 

must be remembered th, 

ill be the sooner f< 



the signs and sy 
enough for diagi 
cated bursitis fron 
vicinity of the hip, 

1. The exciting ■ 
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. 



>li- 



3. A primary bursiti 
products adjacent tis 

proximity to bone-disi 
sues to such an extent 
culty be appreciated. 



: seldom Invades with inflammatory 
ues; while a bursitis induced by 
ase, is surrounded by infiltrated tis- 
that the bursa itself can with diS- 
other words, the one is easy offl 



recognition by palpation, the other is a part of a gcnew 
tumefaction. 

4. In a bursitis the joint is never locked by reflex muscid 
lar spasm; while in an ostitis this is a common conditioa 

5. A bursitis rarely occurs prior to the seventh year; 
chronic ostitis more frequently occurs before this age. 

6. A hypodermic needle will reveal the existence of serui| 
in a bursal tumor, of sero-pus, or pus in a residual abscei 

VII. Acute Synovitis, 
In Chapter VIIT. T have already shown that when I 



CHRONIC ARTICULAR OSTITIS: DIAGNOSIS 



293 



synovial membrane Qf the hip is primarily inflamed ihe 
process is acute, and is the more common between the ages 
of eight and fifteen years. I have also eombatted 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 ! 
insist strongly in detail on the points of ditierence. 

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 verj- marked, the least pressure of the head into 
Ihe acetabulum exciting sharp pains in the joint and in the 
Icnee branchesof iheoblurator. On rotating the limb, pain 
was referred to the knee. Tile thigh could he flexed to the 
full extent and extended to tlie extreme normal limit with 
ease. On abduction shecomplained of painand 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. 1 found a phthisical ele- 
ment in the family history, and the present disease began 
five weeks before with lameness and lordosis. Ti 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 1 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 
rase which puzzled me no little. It was in a girl seven or 
fight years of age who would come into the hospital in the 
most acute staqe of ■■ hi:-'-ilisease." and under a little ex- 



* 




DISEASES OF THE HIP. 

pectaot treatment make a prompt recovery. This was re-1 
peated Iwice to my knowledge. Here remissions were so 

complete tlial 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 Iier 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. AM these acute symptoms had 
subsided on her admission, yet she had decided joint-ten-X 
derness in response to the different tests. There was am 
resistance, or, at least very little to normal movements. Nw 
diagnosis was recorded; a simple liniment was employe^ 
and a month later a careful examination failed to detect anjg 
symptoms or signs of disease. 

A year and a half elapsed and she was readmitted totaliyi 
unable to walk, :ind standing, when it was possible to in- 
duce her to stand, almost entirely on the left limb (the 
right was the one frotnerly 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 qulU 
freely, and within a week all acute symptoms had sub* 
sided, and seven weeks from the date of this readmtssioi 
she was again discharged cured. 

I have seen the girl from time to time, growing up intol 
womanhood, and she has never walked lame or shown ai 
disposition to relapse since the dale of last discharge. 
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 ihe 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 thai: 

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 become; 



J 



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 liip. 

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. 

7. 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 diSer materially from the history of a chronic ar- 
ticular ostitis. In both ihe 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 prelty 
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 r.otalion, 
none to extension; no atrophy or shortening. At that 




3gb DISEASES OF THE Ulf. 

lime I was at a loss for a diagnosis. Here were 
ihe characteristic signs of a central ostitis, and thi 
other hand, there was the clear history of the fall, lli 
localized tenderness, and the continuous pain, but especiali] 
the absence of shortening and atrophy after a year's dui 
lion. The most plausible lesion was a periostitis, and t1 
parts were blistered. Beforea month had elapsed there w 
scarcely any sign of disease, and at the end of two montl 
she was discharged cured. I found no pain, no iimp, no 
change in natis, and no resistance to any normal movement 
of the hip 

In the summer of 1882 a girl eight years of age presented 
with a lesion about the left hip, and a member of the staffs 
very good in diagnosis, regarded it, after a carefulexi 
lion, as a chronic articular ostitis. The limbs were of 
length, yet there was one inch atrophy of the thigh 
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 sevei 
fall down seven or eight steps, and that the lameness wi 
preceded by pain. An opportunity was not afforded f< 
another esamination until a year afterwards, when I got 
clearer history of pain at first, and very gradual lamene: 
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 e.ttend to iSo°, 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 he- 
gins as a periostitis, cannot be orit of place. In such cases,-| 
however, early symptoms and early signs are usually suf~~ 
cienlly clear to enable one lo make a diagnosis of the 
itial lesion. 

To enumerate the points in differentiation: 

I. In the history of a periostitis pain and soreness pi 
cede the limp, and the pain is confined to a distinct ar 
without the joint; in the history of a chronic ostitis lami 
ness precedes the pain by a distinct interval, and the pain 
when it does make itself manifest is not confined to any 



ited 

e as 
She 
she 

DtaS 

sly. 

:er. 

^de 

45° 

ery 

vas 

lis- 

[. 

t in 

he- 

I 




CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 

special locality, but may be felt at the same time in the hip 
joint and in the knee. 

a. In a periostitis the trauma is followed by clear and 
unmistakable signs; in an ostitis the signs are aught but clear 
jind 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, bnt 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. 

, The lameness in a periostitis is pretty uniform, and 



rarely reaches the point when walkin: 
the exacerbation of an ostitis the 
totally unable to walk. 

These are the chief points, and olh 
selves in a doubtful case if the 






.ible; 






per 



; frequently 



ill suggest them- 
s be employed in 



from a central 
necessary, such as. 



In differentiating a periosteal : 
ostitis about the hip, a few points ; 
1. The uniform periosteal enlargem 
enlargement that lakes in the whole circumference of the 
hone; 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-Iliac Disease. 
The current pathology of joint diseases, viz., an initial 
lesion of the soft parts gradually extending to (he 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. 



I 



b^ 




Ithas been my observation that maay cases diagnostic 
as primary sacro-iliac disease, have proved to be caries of the " 
lower lumbar vertebras and sacrum, ostitis of the ilium, or 
chronic articular ostitis of the hip. I have myself diagaos- 
licated many such, and ultimately lind 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 1 am just as firmly convinced that the disease in question 
is one of the rarest of all the so-called joint diseases. Timje 
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., tliat 1 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 1 am desirous of stating my convic- 
tions (simply for what they are worth) on the following 



> of the sacro-ilia 



ichon- 



pomts; 

I. That a primary j 
drosis is, to my mind, unproven, 

z. That the cases recorded, and in many instances well 
recorded, are secondary to inflammatory bone lesion 
within the vicinity of this articulation. 

3- That a destructive bone lesion of the pelvis is no) 
rendered any more grave as to prognosis by the co-existenci 
of a sacro-iliac arthritis. 

4. That tor practical purposes and for diagnostic |_ 
poses, it makes little difference whether a lesion of 
joint be recognized as a distinct entity or n 

I am unprepared to accept the dictum of any man regp 





ClIROMC ARTICULAR OSTITIS: DIAGNOSIS. ^59 

ing the existence of such cases unless he will so report tha 
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 exam inalions, had '' motion at the 
flip-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 
<}Liotation 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, (878. 
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 paih 
being in the left gluteal region. Pressure here, especially 
over the left sacro-iliac junction, gives pain unmistakably. 
This, also, on crowding the alae of the pelvis together. No 
pain on motion at the left hip. As the child lay on the bed 
the Slocking 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- 
nient. A careful examinanation is made as to a possible 
rheumatic history in the family, but nothing is found on 
either side." Dr. Poore saw the case next day with me. 



I 




300 DISEASES OF THE HIP. 

and after a thorough examination, without an anEesthetic^ ^ 
confirmed my diagnosis of sacro-iliac disease. The subse- 
quent course of tlie case and the lesions found post-morlcm 
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-itiac 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 
sccondaiy to the bone lesion. 

He analyies 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 cfais 
disease, and 1 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 secondari,-. Of this nine, 
five were secondarj- to disease of the lumbar vertebrae; in 
three the disease was subsequent to a phlegmonous inftam'- 
mation of the pelvic-fascia, and in one it was due to disease 
of the ilium. 

In makinga 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 p«in from sacro-iliac disease is behind the hiji 




CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 



301 



Joint; in ostitis of the hip the pain is usually referred to 
the knee. 

). In the early stage of sacro-iliac disease there is no reflex 
spasm of any of the groups of muscles about ihe 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 bonCj 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 jvas a long time before I could believe that an ostitis 
of the vertebrse 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 vcrtebrte in which psoas abscess has 
formed with the second stage of a coxo-femorat 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 s:de in walking. The limp did not seem 
like a hip-limp, and yet I was unable to classify iL 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 



I 
I 



H a diagn 



302 DISEASES or THE HIP. 

two weeks elapsed, and I examined the case again wfthoq) 
finding any bone or joint lesion. Two days after th! 
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 hall 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 1 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. 1 lost track of the case 
early in 18S0, and did not see it again until 1 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 verj* 
stealthily, and the exacerbations had been so insignificai " 
thai the parents thought nothing furthernf seeking any r 
lief. The hip and thigh symptoms had long since disai 
peared. Ankylosis of the diseased vertebrae seemed to B 
pretty well established, so that I did not consider a bra ' 
necessary. 



CHRONIC ARTICULAR OSTITIS: DIAGNOSIS.. 3O3 

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 ail be referred to the extremities, though, is certainly 
very strange. 

While on a visit in one of the Western States late in the 
spring ot 1879, I was asked by a medical friend lo see i 



case in which 1 
naturally fell anxious t 
obscurity attached to ih 
female child, aged foui 
family historj', but a 
day in October, 1877 



had been reached. 

ne the patient because of the 

nd I found a fairlv nourished 



ye; 



p;;te 



lal 



maternal history. 
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 aweck 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 symptomshad 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 wiih 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 r.m 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 go°, and rotation limited to one half 
the normal arc. 



I 
I 




J 



304 



DISEASES OF THE HIP. 



There was no tenderness in either hip, no infiltration ( 
periosteal thickening about cither trochanter, and 
difference in the size or the length of the limbs. For n 
diagnostic points, then, I had: 

I. A rheumatic element in the family history. 

a. As clear a history of exposure to cold water about t! 
hips as one could possibly get. 

3. Exacerbations extending over three or four monthi 
closely connected with changes in the weather. 



4. A . 



fors 



approached. 
6. Bilat ■ 



e (?) remission of all signs and symptoms 
ce of exacerbation when the cold weather 



nd other bilateral signs. 

ing of apparatus that 



-I 

'UK 

de 
lie 
)a- 

1 



tended from axillse to feei 

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 molioi 
The precautions I took in stating this diagnosis, and 
giving the advice I did, were: that it was very difficult 
such a case to come to a definite conclusion at a single C3 
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. 
1 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 cicai 
in the gluteal region and a moderate deformity of th 
hip from chronic articular ostitis, 
thigh. 

I am prepared now to state, after the above confession! , 
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, 1 think, are willing toadmit that 
there can be any difficulty where the dorsal vertebrae are 



ices 
)n^B 




:llRONIC ARTICULAR OSTITIS: DIAGNOSIS. 



305 



involved, and I myself was not prepared to admit the difli- 
Lully until the above two cases came under my notice so 
conspicuously. In a conversation witli Dr. Schoencman of 
ihis city, recently, I learned that in his opinion, the early 
signs sometimes run closely together. 

As a resum^. briefly, then, we have: 

t. 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 tiie hip lacks 
these elements, and is too well known to require further 
description. In disease of the lumbar vertebrse, 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 1 
find a case with certain suspicious signs in connection with 
the hip, that disappear promptly on the administration uf 
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. 



d 



3o6 



DISEASES OF THE HIP. 



Pabt II.— The DiACNosrs i 



E Skond Staok. 



n the 



It would seem presumptious to discuss this branch of 
subject, inasmuch as the impression prevails that any ' 
can diagnosticate an ostitis of the hip when the first st 
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 
of this afiectton 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 

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 indicalive of much recent suffering. Puis ~ 
116, R. 18, T. loi}". He stands with body inclined U 
the right, the loyer extremity of this side slightly flexed jj 
hip and knee. The spinal column deviates to the sain 
side, though there is no tenderness along the column, li 
angular curvature, no pain on per- or coucussion; the nat. 
is broadened. Lameness is marked, and very like to that of fl 
patient with " hip disease," second stage. The thigh caiK 
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 tlio-costai space; two 
and one half inches from the spinous processes of the verte- 
brae there is marked tenderness, which extends to the rigf ' 
in a horizontal plane to a point immediately above the « 




^^m pea ran 



CHRONIC ARTICULAR OSTITIS; DIAGNOSIS. 307 

tenor superior spinous process, where the tenderness be- 
comes more extensive in area. This area is triangular, ex- 
tending along Poupart's ligament. There issubintegumen- 
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 liad 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 
lo the acutcness 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 tiie 
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. 

I. In a perinephritis the characteristic deformity appeal 

within a week after the first sympioms; in a chronic ostitis" 

the deformity is very slow of development, and never ap- 



peal 



viihin the 



lephritis it is the rule to find a history of an 
initial chill and febrile reaction; in a chronic ostitis a chi 
is never present as a symptom. 
5. In the one the tumefaction is found in the ilio-co: 




:| 




no. 



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 onljj_ 
in extension, and traction on the limb increases the paii^ 
in the other, all movements are resisted, especially flesiOl 
and rotation, while traction relieves pain. 

5. In the one there is never any joint tenderness; 10 t 
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 percent — 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 i 



JD Ili 



; Abscess. 



Surgeons, I am well aware, are unaccustomed to look 
upon a perityphlitis as anything 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 
aprimarj- 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," vet 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 became 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 
lie 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 lime. While quiet the little patient was free from pain; 
but any movement caused him to cry out sharply, He has 




DISEASES OF THE HIP. 

limped from the very beginning, favoring the righ lii 
fit times has been able to go about only on the hands ; 
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 hkeiy 
lodge in the appendix. The moliier insisted only on I 
high fever. The nurse soon discovered that he was obs) 
natL'ly 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 lo 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- 

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 z6th, five days after admission, the 
pulse in the evening was lao, respiration 36, temperature 
loif; and at the same time next day the record stood 114, 
B7, 1031°. 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 
marked tenderness in the inguinal region, with well-defini 
induration above Poupart's ligament, that all the mov 
ments at the hip, save extension, could be made with cai 
and that the boy could easily bear his entire weight ui 
the limb. Joint disease was readily excluded, and the 
sion, an inflammatory one, definitely located in the ili 
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 



4 




^ 



CHRONIC ARTICULAR OSTITIS: DIAGNOSIS. 

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- 
tinn 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 forexamination. 
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 uninieruptedly 
healthy. He is reported to have had a tall, — no one saw him 
fall. — to which his parentsattributed 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- 
ing it " hip disease" (so the father stated) and apply- 
and pulley, which had been employed 
constantly until the twenty-sixth, the day before this visit 
10 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 
■uld not be ascertained. His rectal tempera- 
ture on this date was loij". Tlie family history was nega- 
I father's side, neurotic on mother's, i.e., she was 
The boy was greatly emaciated, and tongue was 
%oated. He was able to stand if assisted, bearing his entire 
veight 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, crj-ing aloud. Rotation can 
he easily made, if made with care. Nothing can be felt per 
rectum save a few scybala. Pressure over the trochanter 
in the line of the neck gives no pain, nor does concussion 
of hip No infiltration about the trochanteror below Pou- 
part's ligament. A cicatrix of recent vesication is seen over 




DISEASES OF THE HIP. 

the gluteal region. The abdominal walls are a liule 
traded, and tliere is neither tenderness nor infiltratioi 
cither ilio-costal space, nor is there any in the left iliac 
fossa, but in the right tumefaction can be felt distinctty 
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— -J 

I. The deformity is of too rapid development for i 
chronic ostitis. 

I. The constitutional symptoms are too prominent. 

3. That resistance to extension alone never occurs in the 
second stage of the disease. 

4. That tumefaction in the iliac fossaalone rarely occurs. 



i 

le 
s. 

SAW 



III. The Suppurative Stage of Caries of the Dors 
AND Lumbar Vertebrae. 

The natural delays in the appearance of abscess from 
caries of the vertebrse make one peculiarly liable to asso- 
ciate them with the hip or ihigh. 1 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 vertebra 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 lime and again 



looked upon as associated with tli 
being explored lead to diseased vertebrfe. 
upon a caries sicca as an exceedingly 



If o 



joint, : 



that an abscess from boi 
ring a natural lifetime, 



appear at any time 
s will be avoided, 
residual ab> 



It is especially true of vertebral carii 

scess will tahe one of several courses, and appear in tl 

most iinlnokcd-for localities. A very common site 




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 lake 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 1 recognized this as a spinal 
abscess, ordering appropriate treatment therefor. I in- 
structed the mother to ask the physician to whom I liad 
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, 1 could not mal"; out 
any hip-joint disease, and so reported to my frie ,1 the 
physician. 

Two years ago a case in a boy aged five was examined 
by a member of our staff, and pronounced tc be lumbar 
caries with psoas abscess. The normal curv^ was lost, and 





DISEASES OF THE HIP. 

ttie spine in this region was suspiciously stiff. The i 
limb was nearly in the position of tlie 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 ^1 
distinct kyphos in lumbar region, a well-marked tumor i^B 
iliac region, and resistance only to extension of the limb. ^ 

Such cases are not rare, and 1 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 hisiorj' 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 maoi-^ 
fest. 

In the second stage of a chronic articular ostitis the r 
sistance, as a rule, is in all the periarticular muscles 
hip is often locked against any movement. In othei 
the resistance in the one is from mechanical causes 
other it is reflex. 

3. In the one there is no tenderness at the hip-jornt aiu 
the patient can easily bear all the weight on the limb; 1 
theother, joint tenderness is usually present, and if not dM 
tectcd by manual examination, becomesquite apparent'whei 
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 
stcon.' stage of chronic ostitis of the hip. 

5. Fi illy, a well-conduclcd physical examination, aided 
by the us ■ of the probe, will enable one to differentiate ii 
cases, howtver doubtful they may be. 

1 have ne\ "r been able to satisfy myself of the existent 



L 




CHRONIC ARTICULAR OSTITIS : DIAGNOSIS. 



315 



c have not included thisaffec- 

hich a chronic bone lesion of 

to be differentiated. Admit- 

recognizing sucli a lesioi 



of a primary psoitis, and her 

tion among the lesions from 

the hip in its second stage i 

ting, however, the propriety ^ _ 

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 naturally 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 acuie 
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 1S74. 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 



I 





DISEASES OF THE HIP. 

affection. '■ Along with Mr. Baker and Mr. Macnamara,I_ 
believe that the disease is not exclusively confined tn 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. 

J. The infiltration in the one is more of a phlegmonouj 
nature, while that in the other presents the features of i 
cold abscess. 

4. The joint movements in the one, despite the iafiltrft< 
tion, are less restricted than those in the other. 

Monarticular rheumatism presents many of the featuri 
of the second stage of a chronic ostitis of the hip. Th< 
signs are so similar that one must rely on the history aiH 
the existence of rheumatic signs in other organs. 



Part III. — tkb 



E Third Stack 



In this stage the signs are so well marked and so charao> 
teristic that the probabilities of error are reduced, it would] 
seem, to a minimum. Yet in my experience there 
several lesions which give deformities similar to the 
under consideration. 

It must be remembered that real shortening is alwayi 
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 J 
in tbc examination. 




I 



CHRONIC ARTICULAR OSTITIS: PATHOLOGY. 3I7 

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 iraciion; has no abscess or previous signs of 
suppuration; this freedom of motion, and above all ihe ovoid, 
or, globular tumor bencalh 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 3olh — 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 
bouse 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 ami 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 
reduciion 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 




and hence am unable to give the final concluslo 
The case, however, is interesting from the fact thai 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 ilie accident. 

Caries of the pelvic bones, with much infiltration and 
ulceration of the soft parts, is sometimes mistaken for ar- 
ticular ostitis. 1 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 

farticularly for the deformities of this disease in the adult, 
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 mv 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 
ihigh, and the limb presented a practical shortening of two 
inches, though there was no real shortening. 

The trochanter was not above N61aton's line, but was ai^ 
inch and a quarter nearer the anterior superior process tin 
was its fellow. 

I looked for cicatrices and could not find any, nor could i 
find any infiltration. The joint was absolutely immovablfl 
It then occurred to me that I had better get a history, aM 
I learned that he was perfectly well and free from lamencT 
on the 33d of February, when he "caught cold;" thai ! 
overheated himself the next day running for a train; ne 
morning was sore in "all his body and limbs." The sai 




CHRONIC ARTICULAR OSTITIS: PATHOLOGY. 319 

cvcninghe 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 ofan 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. 




The Treatment of Chronic Articular Ostitis — Gbi 
AL Considerations. 



The treatment best adapted lo primary bony lesion 
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- 
face- 

Tlie therapeutics of chronic articular ostitis of the hip 
resolves itself into the follow! 



I. The < 

stages. 



mional with the expectant for the 



. The 



1 



expectant. 

3, 1 ne mechanical. 
't. Pure fixation. 
/: Extension with and without motion. 

4. Operative. 
While 1 have employed these divisions, I fully recognize 

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, especiajjy in the first and second 
stages, adhering strictly to a constitutional treatment 
throughout. These, however, rely on topical treatment as 
well, and aim to lelieve 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 blisteringand 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 bringingabout 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 o( 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 suppuraiion. When 
it becomes clear that caries necrotica has advanced to such 
an extent that spicule of loose bone are present is the 



J 



322 DISEASES OF THE HIP. 

joint cavity, then the expectant plan demands a removal t 
these, as it would a removal o( any foreign body whicl 
militates against recovery. The minimum amount of cm- 
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 lingers 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 
p!an 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 lo 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 AUis 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 
tliat 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 irui 
the ankle, by the elevation of the shoe, approximates tbi 
position of the knee." 

Now while Dr. Allis's views may seem exi 
they give us an apparently gloomy outlook, they are jui 




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. AUis, 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 
docs 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. 




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 hxation and traction. Tl 
weight and pulley sometimes act like a charm. The spasi 
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 ia 
chronic bone and joint diseases is the twenty-fourth of 
grain of the bichloride to a drachm of the compound tin) 
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. Reliel 
comes, !>., 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 tor a goi 



4 

I!b ■ 



4 




TREATMENT. OF CHRONIC ARTICULAR OSTITIS. 325 

dcaJ of alarm, and how lo 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 1 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 --ecm 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, thai 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. 1 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 



I 

1 




DISEASES OF THE HIP. 

less pain and tenderness and inconvenience are experienced 
in after lite in those hips around which abscess scars 
be found than in those that have gone on to ankylosis w 
out any suppuration. 

So then I adyise that cold abscesses be let alone until 
they begin to cause inconvenience. 

The management of the deformities shall be reserved foi 
a discussion of the various forms of apparatus. Befort 
leaving the expectant treatment I propose to inti-oduce a 
few typical cases in order thai 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 ii 
stance, a case like the following : 

A frail cachectic child, two and a half years of age, ws 
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 hxed 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) 1 
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 tatter part of 
October there was " no muscular contraction, no atrophy, 
and no evidence of disease." A cure was recorded, and 1 
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 convince one who had not seen the 
rhild. 

! traced the case at the end of three months 



elf 



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 al the hip and the 
boy was quite lame. All these signs had appeared within 
a week. The same treatment as beEore 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 ^^^^^, I 
could not find any sign of piesent or past disease. 

When I first saw this easel thought it hopeless, and 
taking together the hygienic surroundings, the apparent 
improvidence of the mother, and the frailly 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, 

1 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 June, 1880. had 
re-iistence to flexion and to abduction as the extreme 




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-fcmoral 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 12. 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 cei 
tainly less complete on this side than on the other, and 
could not flex the limb or abduct it quite to the normj 
limit. The parents regarded the case as long since cured,^ 
and for all practical purposes he was as active as any boy 
in [he neighborhood. 

1 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 events the parents and the neighbors 
credit the splint with the cure. So, in the boy whose case 
is reported on page 130. the prayers of the priest goi the 
credit for the cure. Cases like these, with such well-marked 
signs of bone disease, are extremely rare. 1 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 tl 






TREATMENT OF CHRONIC ARTICULAR OSTITIS. 329 

beginning of June, 1879, giving a tuberculous family history, 
Bud the history of a lameness of three months' standing. 
At the same time her lameness began, or shortly (hereafter, 
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 slate that there were present nearly all 
the signs of a typical bone lesion of the hip in ihe early 
stage. An error in diagnosis, I think, was out of the ques- 
tion. Under the hospital regimen, cod-liver oil and an 
alteratix'e tonic, there were no further exacerbations of any 
significance during (he 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 thespringof 1878 wasinstructiveformany 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 
hand on the outer side of the knee. The treatment adopted 



330 



DISEASES OF THE HIP. 



was the same as in the other case, and in June, as she v 
convalescing from an attack of rubeola an exacerbation 
pain, restlessness at night, etc., developed. Relief not 
coming promptly, a fly-blisier was applied to the liip. 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 tin- 
loward 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 
lath, 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 liad appeared near the trochanter, and 
an abscess was thought inevitable. 

During the years 1880-81 she had recurring attacks of 
naso-facial erysipelas, but no symptoms of any moment ref-^ 
crable 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 sole. 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. 



4 




I 



I 



I 



L 



TREATMENT OF CHRONIC ARTICULAR OSTITIS. 3JI 

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 thai 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 tile expectant tieatment; In April, 1879,1 
there came into the hospital a faidy-nourished boy four 
and a half years of age, who had been favoring the Icfi 
limb for four months. The family history furnished nothing 
definite as to predisposition, yet it is fair to say that few 
facts were attainable, II 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 
ol 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 tlie 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 
abscesscould 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 tlie third 
week in January, 1880, and on the eighth of Februarj- I re- 
corded the following note : 

"Is greatly emaciated, eyelids puffy, feet oedematous. 
Liver dulness exiends 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 ftetid 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 ccr 
ossification of the neck. 

I could not find a vestige of the ligamentum teres, 
liver was enormously enlarged and on section had 
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 sufiering. 
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 di 
formity was 120°, and the case seemed hopeless. He 



, a 




TREATMENT OF CHRONIC ARTICULAR OSTITIS. 333 

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 encellent, and the disease seemed 10 
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 

r. As good results are obtained as by other methods. 

1. 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. 1 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 
1 extensive abuse of mechanical appliances has served to 
I 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 

I. In a very few cases of chronic articular ostitis of the 
hip good results are obtained. 

1. 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 arlicular ostitis of the hip, science demaai 
humanity demands, that the so-called expectant mcthi 
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, aband* 
the expectant treatment. 

I speak advisedly on this subject, and I speak fortified 
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 rathi 
severe exacerbations; on admission his limp was vei 
si ig!ir ^scarcely perceptible — ^the gluteal signs were sligl 
yet sufficiently well marked, the deformity was ni 
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 dlRiculty, 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 Juty he was climbing some scaf- 
folding, and fell striking the hip. He was scarcely able 
walk the same day, and cold-water dressings and 



4 



en 

i 




TREATMENT OF CHRONIC ARTICULAR OSTITIS. 33$ 

ing to give relief, a blister was applied a few evenings later. 
It was poorly applied, and a week or two afterward a 
second one was applied, getting a good vesication. Tht 
poultices were used as is the custom — a fresh one every 
six hours for three daj*s. 

About this time two large boils appeared on the left hip, 
but were considered the effect of the vesication. The left 




p 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 riglit 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 for a 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 inefifectual. 



CHAPTER XVI. 

Tmatment of Chronic Articular Ostitis, bv Ckutchss 
AND High Shoe with or without Fixation. 

I. The Physiological Treatment of Dr. Hutchison. 
n. Combination of the Phvsiological 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 necessarj' amount of fixation. The treatment is 

plete, 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 indepentjent mode. It 
is employed at times in connection with the various splints 
and appliances, and is used expeciantly to relieve urgent 
symptoms or persisting signs. When the indications arc 
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 

red, 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 joif 
but to make traction. These splints embody what I' 
English choose to call the American idea, 

I. The Physiological Treatment, 

In 1879, when Dr. Hutchison 50 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. 1 
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. 1 have seen enough, however, of its practical work- 
ing to form a very fair estimate, 1 think, of the value of the 
method. 1 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 1 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. 187S, 1 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. 1 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 fuU; 
apprcriittpd ihc idea, and had directions followed to I' 





I 



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, 1S81, the treatment 
having been continued the meanwhile, 1 found that 1 could 
extend the limb to 150°. but I recognized in the iliac fossa 
a well-marked lumor, 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, i88z, 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 tendernt-ss 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 lumor 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- 
.1), and from the anterior-superior spinous 

half inches (real). 

s on the twenty-seventh of July. The 

angle of 150°; is easily flexed to 45°. There 

ion about the trochanter, in groin, or iltiac 

fossa. The tip of the trochanter is one inch above N^Ia- 





ton's line, 
February. 



and the shortening is the same as measured 
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 hav< 
treated without crutches and high shoe. Take fo 
stance the case on page 329 This girl, it wili be seen, 
in the hospital, not in the country; had a bad family hti 
tory and a bad personal history. She had a " * 
early part of her hospital treatment, that was lock< 
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 si 
that I waited a few days to devise ways and 1 
the mean time a blister was ordered. A temporary reli) 
followed its application, but ten days later shi 
fined to her bed. and all the symptoms were aggravati 
Movements in all directions were resisted, and the limb 
was held flexed at an angle of 140°. She fairly made nighi 
hideous with her shrieks, and had to be propped up with 
pillows to secure any rest at all. Another blister 
ordered. This was the last of October, and three da] 



ire. 




I 
I 



fed to find 

apparently 

she walked. 

the heel, 



TKEATMENT OF CHRONIC ARTICULAR OSTITIS. 34I 

later 1 found her quite comfortable. She had slept quietly 
alt night. With much care I could flex the limb to iio , 
and extend to 150°. Abduction and rotation were resisted as 
soonasattempted. Icouldnot detect any joint tenderness. 

Pathologically speaking, I regarded the case as one be- 
ginning as an acute coxo-femorai 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 hcrapparatus, 
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 tei ' ' 
walk, and by the following May 1 was surpi 
with what ease she moved about. The limb wa 
lengthened, the toe not clearing the floor well a 
Jn June I had twelve ounces of lead attached 
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 
liad 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 
«re practically ankylosed. 

This certainly was a very fair result, if we consider the 
^difficulties under which 1 labored. It was certainly better 
Chan 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 
*or two weeks. I did not get the case to treat however 
Ujntil a year afterward. He wore a long splint the latter 
half of the intervening year, and when he came again under 
«ny observation the angle of deformity was 165° and the 
limb was only a half-inch short. The boy was so irritable 
that a satisfactory examination as to motion was out of the 
tquestion. Suffice it to say, this seemed to me a very good 
^ase for the physiological treatment, and I forthwith put it 
into effect. It was at least two months before he learned 
<o use the crutches well, and in January of the following 



I 



ecrf" 



342 DISEASES OF THE HIP. 

year.as ilie deformity seemed to be increasing, 1 hada pii 
of lead attached to the htd 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; 
me femoris. 

ll is unnecessary to follow the Case, through these si 
cessive abscesses, through the pains and the increasing d4 
formity. It is enough to know thai the treatment has beci 
faithfully and persistently followed; that the disease has 
progressed from bad 10 worse without a reassuring interval; 
that lardaceous degeneration has declared ilself 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 lateraland 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 ;et. 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 6rst 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 N^la- 
ton's line, ability to flex the thigh lo an acute angle, in- 
nbilily 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 " 
suppuration. 





TREATMENT OF CHRONIC ARTICULAR OSTITIS. 343 

An anaesthetic was administered while the deformityantl 
shortening were overcome. A leather splint was applied, 
and the weight and pully employed for a fortnight. He was 
then discharged from the hospital, butcontinued 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 Orthopcedic 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 toil 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 sufGcient, and that at times but little extension is 
needed; 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 c 
tion, prevent deformity, and give the patient the greatd 
amount of freedom from the discomfort due lo disease I 
the hip-joint. As a means of extension it is imperfect, (( 
the reason that it is efficient only when the patient is i 
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- 
dien when nol suffering from a painful joint will be found 
occasionally to kneel upon the affected limb, or lake 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, 1 should embody the samCH 
ideas. 



II. Fixation Splints Assisted by the Phvsiolocicjh 
Method. 

There are a number of splints that bear the names of i _ 
different surgeons, who have either invented them or ena 
ploy them, and while some are not expected to requir 
additional assistance, they all are meant to serve one specifl 
object, viz., fixation. All surgeons at the present day wh3 
employ such appliances have come to recognize the impor- 
tance of suspending the body on crutches so thai the idea 
of fixation and rest may be all the more fully carried 
out. They all aim at immobility of the joint, with extensioi 
There are really very few that are constructed with ihea 
' ' " . These maybe enumerated in the follonf 






to this 



Hamilton's 



e-Gauie Splint. — Closely allic 
ire-gauze splint of Mr. Barwell. Tl. 
accompanying diagrams represent a front view and i 
rear view of ihe apparatus. It will be seen thai 
consists of an iron wire frame moulded to Ihe pelvis and 
thigh. This frame is covered with wire gauvte. 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 used. 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 treatedij' 
hence can draw no conclusions as to its value. 





I. Dr. Vance's Leather Splint. — On ihc 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 liip 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 
I permit of adapting the splint to the pelvis. 

The limb is placed in the desired position in one of three 
I ways, according to the exigencies of the case. i. If but 
llittle muscular spasm exists it can be easily forced into posi- 



% 




DISEASES OK THE 1IH'. 

;cui-ely maintained pending ilie dry- 
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 






p.b 




^ 


•a; 


r 








; 






«^ 






0; 






«• 













1* 






f 


Li 


_J 




Fta. )t.— LUTHU StLort ■■ 



force. By reason of our ignorance of the exact stage < _ 
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 1 alwaysil 
raise my voice against the practice, especially in the pre'F 




TREATMENT OF CHRONIC ARTICULAR OSTITIS. 547 1 

suppurative stages. The leather is now immersed in very 
het 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 sufiSciently 
hard to admit of removal without losing the shape. ' 
order to give one time to dress and complete the splint 
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 twelv< 
hours, and then, when removed tor purposes of completion, 
the limb will be less likely to resume its original mal- 
position. 

The edges are pared down, the gusscted 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 undui 
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 
tirst instance, the splint can be immersed again in hot water, 
and reset as before. 

Thb 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 tliis objection. For very 
young children who cannot be taught the use of crutches 
it does not fully protect a^iiiust alterations in the positiu.T 



TREATMENT OF CHRONIC ARTICULAR OSTITIS. 349 

of tl-.e neck of t'tie femur. They will walk when noB-Suffer- 
ing an exacerbation, and the weight is necessarily thrown 
on the limb. 

3. The Liverpeel 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 favnr 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 Jiis 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 
lact 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; 

I. 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 adiilt, and three quarters of an 
inch by three sixteenths, for children. 

!. 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 
ihickness, and its length two thirds the circumference of 
ihe 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 ban. 



I 




350 DISEASES OP THE HIP. 

These arc made by a smith, and properly tempered. Tliosa 
marked i are enough for all practical purposes; 2 is an- 
other form, and may serve a better purpose at limes than 
the oiher pair. To any one who makes any pretension 10 
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 caif to" the lower end. These precautions 1 '" 



i 



L 



li 



Fic jS.— Snviau>LE " 






y to avoid excoriations. Indeed, one of the great 
secrets of success in all forms of apparatus is the extreme 
care one lakes 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 




rresponeling 

I be oval, and this 



TREATMENT OF CHRONIC ARTICULAR OSTITIS. 351 

Ihird its length, measuring from ihe « 
with the side diseased. The shape 

will be found necessarj- to prevent tlie splint irom 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 arc called crescents, and are 
distinguished as chest, thigh, and calf crescents of the 
splint. IE 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 

I shoulders, as seen in Figs. 38 and 39; the lumbar portion 
is secured by a common roller bandage, and the limb por- 
ion 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 beei ' " 

comes from the shop, more mouldi 

I quently required of the surgeon hi 
may have to be shaped differently I 
the proper line, and salient points wi 
bending. Indeed, however lightly 1 
apparatus as a therapeutic agent, he 
mire the great attention to details v 

hibits in describing his plan. Some men may have the best 
instrument in the world and get the poorest results, and 

The surgeon must not think his work done when the 
j. 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 
I adduction can he frequently corrected if not loo exaggerated 



fully made and 
ig and fitting is fre- 
uself. The crescents 
o get the upright in 

me may think of the 
cannot but help ad- 
hich Mr. Thomas ex- 






Fio. jg FiiOKT View of Hi. Thom*?' 

For bandages flannel rollers are the best, and should 1 

employed by all means in young children. 

For the correction of deformity, the upright is bent i 



TREATMENI OF CHROXIC ARTICULAR OSTl'l S. 353 

ihe buttock portion and the splint is applied in the deformed 
position. From time to time the curve of the upright is 




DISEASES OF THE HIP. 




TREATMENT OF CHRONIC ARTICULAR OSTITIS. 355 

I have thus given in considerable detail the construction 
and the mtide of application of this instrument, and have 
" . Thomas's descrip- 



onths after the applica- 
inftned to the bed, and a 
■ macle unless under the 
While any changes 
aintained. 



confined myself pretty closely I 
tion. For still more of detail, 
the work itself. 

During the first three or four i 
tion of the splint the patient is c 
change in the appliance is nev< 
direct supervision of the surgeon. 
are being made the dorsal decubties 1 

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 sfcond 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 erf this period is 
briefly given by the author as " a certain period." By ref- 
erence to a few repiirted cases it will be seen to extend 
over a period of from two to five months. 

The/c«rM stage of frcaiment begins with the removal ot 
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 M 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 usedf 



DISEASES OF THE HIP. 



ummer a medical friend, who h; 

ted his attention chiefly to orthopedic 



3S6 

During the past : 
several years devt 

surgery, spenl some weeks with Mr. Thomai 
went over strongly prejudiced in favor of the " Americaaj 
melhod." This friend called to see me on his 
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 c " 

Mr. Thomas has published,! found: one received in 
stage, duration of disease and angle of flexion not specified, 
length of treatmenl twelve months, the first three monttiq 
of which required the horizontal position in bed, ' 
ultimate "cure" for the result; four in second stage, two o 
which were of five months' standing, indicated by ani^ 
given angle of flexion, say 150°, the other two, three ana 
four months standing respectively, not indicated by anfl 
given angle of flexion; three were "cured," one " recovered.^^ 
one kept the bed thiee 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, lo 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, pai 
derness about the hip, and the case had been progrt 
favorably for some time. A Thomas splint was appliec 
and accurately fitted. On the following night there wan 
severe nocturnal pain, which increased on the next night/ 
The next day the hip was found swollen and lender, and ttu 




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 
lie 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 
arc often the direct cause of an exacerbation, and knowing 
that an exacerbation means *he extension by contiguity of 
the inflammatory process to the joint and to the periarticu- 
lar tissues. 

If this plan wi!i secure a movable joint the inconveni- 
ences are as nothing. At all events let American surgeons 
g^ve it a trial. 




CHAPTER XVIt 

The Treatment of Chronic Articular Ostitis bv EXi 

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, lo which all these splints 
lend 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 lo 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 
1 have not represented it in these pages. It has no pelvic 
band, and is inferior as an ischiatic crutch lo the splint de- 
vised by Dr. Andrews, of Chicago. As a means of exten- 
sion, however, it served a good purpose. Belter 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, ehiploys a splint consisting (" 
irivide and outside bars, with attachment to shoe. Thei 




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 





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 
of the head of the bone from the acetabulum. 




36o 



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 10 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 acuie stage on^xa- 
tion, or " absolute rest to thi 
and yet all or nearly all admit thi 
it is quite impossible to get abj 
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 niiido 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 tlie Boston Medi- 
cal and Surgical Joitniiil, for March 
6lh, 1S79, 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 : 

"Fir.si. 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; 
thai is to say, an organ, in a certain degree of //-ugressive 
inflammation, presents conditions essentially different from 
the same organ in the same relative degree of inflammation 
in the frfi-ogressive stage," 

What he understands by the "so-called mechanical 
treatment" is the working out to practical conclusions 




hafJ 






TREATMENT OF CHRONIC ARTICULAR OSTITIS. 361 




362 DISEASES OK THE HIP. 

indications which the above propositions furnish. Hi, 
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, spli 

and all save the weight and pul- 
ley. The force exerted is the ej 
tending power of the splint pli 
that of the weight, a 
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- 
|)i-ovement in posture gained 
this preliminary treatment, he, 
claims, "relieves nervous de< 
pression, gives time for the pi 
tient to accommodate himself tl 
he novel situation, enables us' 
J save the amount of his weight 
rom the perineal straps, and by 
that amount increase extension 
and hasten the effects of treat- 
ment." Fig. 45 represents 
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 otherchanges which cor- 
respond closely with the long 
splint represented in Fig. 46 and 
J used by Dr. Taylor. This modi 
fication is accredited to Mi 
Reynders, and is described in Dr Sayre's last edition 
follows : 

" The improved parts are where the long rod is atlachi 
to the pelvic band. The long rod is attached at A to a - 
volving plate, B, which is fastened to the pelvic bai 




i 

•u- 
Is. 

cd 

f 11^ 

ght 

by 

ion 
reat- H 
whaM 
lor^H 
rrewT^l 



F1a.4s.-T1n 



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 
•*> H \\ 'na'Je. At F the long rod i 

J K *\ divided into two parts; 

gi^^^ 1^ ^ lower part holds an endless 




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. The part, 
A, is fastened to the pelvic band. The part, B, is attached 





DISEASES OK THE Hll-. 

lo 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),aDd 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 abiiiu- 
tion), or. by reversing the screw, we can separate D from 
A, and aJduct. E, E, represent the screw-bolts by which 




iched to the hip band and shaft of 



the apparati 
splint." 

In using this " screw to abduct, the ordinary perineal pai 
which form the basis of the counter extension, will also 
the poinl of resistance. When we use the screw la ada 
it will be necessary lo supplement the /m«cij/withjA*K/li 
straps, and to apply a little moic 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 correcl certain defects in the 
splint, defects which many surgeuns of large experience 



lO t^^l 



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 weigiit 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 Detember to, 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 'o 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 ^ 
a line parallel with the upright of the 
splint. ■"■■ """■ MXAT,o». 

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, arc 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, 





DISEASES OF THE HIP. 

the lower ends beginning about two inches above thr 
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 ihe pelvis, and then the 
other two pairs are wound about ihc ihigh in t' " 





manner. This network of plaster is r 
53. It will be seen (hat the thigh has b 



;sented in Fig- 
st 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 
and laced up the inner side 
iubstitute for a roller band- 



muslin provided with eyelets and laced up the i; 
of the limb is a convi 



I 



I 



I 



The stockings 
buckles pass, and the top of the shoe is cut off. 

The pelvic band is then applied, with the perineal scraps 
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-sliapcd attachment is applied. Fre- 
quently a leather strap is buckled around tlie 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 ischialic 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 treatmeni," and claimed for 
this "combination method" adivaiitug'-s superior to all 
others. 

Dr. Sayrc uses the long splint in larger children, or when 
his short splint fails to afford the necessary protection to 



Its. 



the joi 

When it 
when it is m 
take such precauiiom 
ing convalescence — I 
^'g- 55- "The lowei 



have a j 
y to imm 
gainst injury- 
Taylor uses 
^1 pL ■ 



int at the knee, and 
ibitize the hip-joint or 



splint represented in 
eted to the upright. 



but the upper one is fastened by three 'keepers,' which 





TREATMENT OK CHRONIC ARTICULAR OSTITIS. 369 

enable it to be raised or lowered in adapling 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 
is 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 




\ thin metal plate, E, riveted to it to give it more firmness." 
■ (T.ylor.) 

With the exception of Mr. Barweli's splint, those I have 
I named comprise all the more common long splints now in 
I use. The splint known by Mr. Harwell's name is not a pro- 
tective apparatus, and hence has nr.t been employed, so far 
as 1 know, in this country. The aim with American sur- 
[ geons is to get the patient out of tloms. Mr. Thos. Bryant, 
f Guy's Hospital, has devised a splint for maintaining the 



370 DISEASES OF THE HIP. 

parallelism of the limbs. This, however, requires that the I 
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. afiords 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 J 
bend of the hip, and upon I 
the upper portion of this ts 1 
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 
planeabout four feet in length, 
covered also with a similar J 
mattress, but divided along I 
the centre, so that one portioi^ I 
(that corresponding to the 
affected side) can be made to 
g framework; the movable por- 
tion is furnished with a padded leathern strap placed at 
its lower part, The upperand 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 




extend by meai 



WlLLARD't SrLMT. 

stidini 




TREATMENT Of CHRONIC ARTICULAR OSTITIS. 371 

his name. A splint, however, which scarcely bears the name 
uf an extension splint. Is one devised by Dr. Willard, of 
P!:iladelphia. 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 ihe 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. 
U 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 adiiesive 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 ihe 
one figured in Dr. Sayre's last Fic. 57.— Dw. Say 
edition. The one he now employs srum. 

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 arc at the lower end 





372 



DISEASES OF THE HIP. 



and here the tabs of the plaster are .fastened. My own 
objection to this short splint is, thai it does not sufiicicntly 
protecl the joint, and is not tqual to the amount of ex- 
tension sometimes demanded of a splint. It is easily mis- 
applied, and I confess that 1 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 pari 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. NoMe 
Smith, in his work on the " Sur- 
gery of Deformities," speaks verj" 
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 dcformityfrom muscular spasm 
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- 
'" inal band which is worn in con- 
splint, consirncled as follows: 
" A pelvic belt, A, is adopted below the iliac crests, 
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 




FlC. s'-— Mb. 

junction with the 



J 



TREATMENT OF CHRONIC ARTICULAR OSTITIS. 373 

Fig. s^- Mr. Smith speaks of Mr. Chance's irealment, 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, have convinced the author of the excellence o£ 
Mr. Chance's plan of treating this disease." 




Another short sjllint c. 
I the ball-and-socket joint, 
I the control of the surgeor 
f F. Stillman, of New York. 
[ me with a description, a 
] lake pleasure in insertin) 
I extension with or without 
I It furthermore seeks to ( 
I dosis. This apparatus is 
I design to the apparatus la 

A sector splint (Fig. 59) 



ombining all the movements of 
but with the movements under 
1, has been devised by Dr. Chas. 
At my request he has furnished 
pretty full abstract of which I 
5. The aim of the apparatus is 
motion and at any desired angle, 
overcome the compensatory lor- 
verv similar in construction and 

ibed. 
is placed on the outer side of the 



374 



DISEASES OF THE HIP. 



thigb over the hip, and iscmployed eiiher as a "bracket" 
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 con ~ 




posed of two plates of perforated tin that partially encircle I 
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; i 
and of a slotted sector attached to the slotted arms by three J 



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 arc 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 he 
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: 1. Local extension of the joint diseased; 
3. 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 unclcan- 
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. 61, 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 



376 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. Joslab 
Roberts, who has kindly placed a description of the same 
at my disposal. 







The instrument consists o( a pelvic and a femoral seg- 
ment. The former is made of very thin sheet steel coverMl 

ith leather on the outside and thoroughly upholstered on 

the inside. It is broad, and to secure a good fit he moulds 

plaster cast of the patient's pelvis. The latter 




TREATMENT OF CHRONIC ARTICULAR OSTITIS. 



171 



I 



ihe femoral segment) is composed of two compound 
:tide-bars, which exlend down along the thigh upon the 
inner and outer aspects, and are constructed with special 
reference lo exerting continuous elastic linear Iradion 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. ji 1 

The lower or distal end of the sliding bar is 1."] 
likewise provided with a brass pin, B. Any force 
which brings these two pins nearer together 
must of necessity lengthen the instrument, ; 
shown by the doited line in the figure. It niu; 
also as a consequence exert a traction force upo 
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 f 
Strip of webbing and the buckle exert any desired V 
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 
mn-elastie 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 iheir 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 




TREATMENT OF CHRONIC ARTICULAR OSTITIS. 379 

barwith the pelvic segment. Alike joint is found at the prox- 
imal end of the inner side bar at its junction with the peri- 
neal 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 llie 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 (hat 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 fiirnishes 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 sucli light materia! 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- 
|>erfectly 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. 38 1 

exacerbation followed immediately on the accident. This 
subsided, and Dr. Taylor saw him some weeks afterward. 
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 
ftrsl 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 montlis 
later abscess had appeared, and the patient was harassed by 
another exacerbation still more acute and still more pcrslst- 
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 weightaiid 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. 

"n 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 aslight difference in the lengths of 
the lower extremities, but not enough Co 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 of*;onfinement. 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 
splintwas worn ten months, when the patient was discharged 
perfectly restored. Two years later he examined the girl, 





DISEASES OF THE HIP. 

finding clial " the child has been going about like other chil- 
dren; there is perfect motion at the affected joint, and no 
discoverable difference between ihe affected joints, and no 
discoverable difference between the functions of the two 
liiTibs, Both trochanters are on the same level." 

Stili another case is reported with an equally good rcsiilL 
I have now under observation a case that came under the 
same treatment abnu I 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. Tiiis patient had eight years of faithful treatment, 
going through ail 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, ejtcept fi 
the slight discharge remaining, they would be among 01 



I 



TREATMENT OF CHRONIC ARTICULAR OSTITIS, 383 

KSt cases. The joint motions are nearly perfect, and the 
oints themselves are apparently well, the present discharge 
>eing supported undoubtedly, as it so often is, by eccentric 
Kriosteal excoriations. In such cases nothing so tends 
owartl recovery as the action of the muscles contiguous to 
tuch eccentric implantations. 

The above enumeration includes all cases of the class 

previously specified for the nine years preceding Novem- 

:r, 1877, but excludes the cases received since that date," 

In view of the (act that the term hip-joint disease with 

r. 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 

ty-tour private patients. 

uring the past year I have, through Dr. Judson's kind- 
, had an opportunity of examining with him three pa- 
tients whose cases he reported in the Illustrated Quarterly 
of Medicine and Surgery, No. 3. 1881. The cases are, I 
think, classical in the literature of mechanical surgery, and 
feel juslitied in reproducing them, in abstract, in these 
pages. 

No. I was a boy aged six, and presented, when Dr. Judsoa 
saw him. an enormous abscess with all the usual signs of the 
third stage of the disease, which was of nineteen months du- 
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 
le 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 verv closely with 
Dr. Judson's. I find also this significant remark, that the 
had been under the splint treatment for twelve months 
a distinguished orthopedic surgeon, in conjunction with 
ihc family physician, and that the parents were very much 
lissatisfied with the combination. 
Six days after Dr. Judson saw the case the long splint of 
Ir. Taylor's was applied and the patient was about the 
Duse daily from the very beginning of treatment. Thede- 
jrmlty disappeared in due course of time. The progress 
as slow, abscess followed abscess, until finally there were 
ine sinuses about the joint, all leading to carious bone. Five 
Ktended in a line down the outer side of the thigh from the 
'ochunter to the middle third of the thigh, and from one of 



j84 DISEASES OF THE HIP. 

these a fragment of bone extended. There were well-marked' 
exacLTbations 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'l 
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 wilh 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 Thtf cicatrices arc 

firm, deeply depressed, and in some instances attached to 
the bone beneath." 

Three years and six months afterward his condi 
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 plastei^ 
had been her previous tieaiment. When the patient cami ' 
under treatment at the hands of Dr. Judsun there wa 
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 Ilie 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, 



Of 

tic I 




■plbi 



tki:atment of chronic articular ostitis. 



varlouslv located about the joint, and the pus secreted was 
abimdajll and offensive. The mechanical treatment ivas 
supplemented by cod-liver oil, wines, and chalybeaies. 
Exacerbation marked the approach of new abscesses, and 
some were noted for their high febrile reaction and emacia- 
tion, ihreatening a fatal termination. Mechanical treatment 
was continued for two years and seven months. Strong 
traction was used during ihe 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 tor 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 
'as made that I saw the child with Dr. Judson, and we 
JUnd her still in good health and very active. Her short- 
lenlng 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 llie hip, and her angle of deformity was i6o" 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. lie had worn a light hip splint, and to this 
Dr. Judson attributed his lack of progress. The reporter 
stales that the usual signs of the third stage were present, 
without staling 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, i.e., 
the angle at a useful degree of flexion, and there was no 
motion at the joint. 

Three years after the above condition was found I examin- 
ed him with Dr. Judson, and we found the boy still as active 
and still as healthy. There was a shortening of one and a 
quarter inches as measured from the umbilicus (practical 
shortening), and an actual lengthening of a half-inch as meas- 
sured from the anterior-superior spinous process, with the 
limbs symmetrically placed. There was an arc of motion of 
at least io° in flexion, and a slight amount of abduction, ad- 
duction, and rotation was possible. The trochanter was 
not above Nelaton's line. 

Now these cases are very instructive, and they were re- 
ported just as they were. I have notes of many that arc 
now under the long-splint treatment, and while they are 
not ready for a final report I can at least report prog^ss. 
All are comfortable, in all the limbs are in good position, 
and all are out of doors most of the time. 

I have notes of a few that have been under the short-splint 
treatment, and nearly all have done badly. Two that I 
now recall went on to distressing deformity. 

From a study, then, of the mechanical treatment of this 
disease, I am persuaded that 

1. The short extension splints which permit motion 
exert very little if any influence on the average case of 
chronic articular ostitis of the hip. 

2. The long splint in competent hands secures for us 
better results than does any of the splints in general use. 



TREATMENT OF CHRONIC ARTICULAR OSTITIS. 387 

3. It is better to combine the extension splint with the 
crutches and high shoe. 

4. An intelligent use of the splint is but a very import- 
ant part of a true expectant treatment. 

I am indebted to Dr. Judson's paper for the following: 
" If we recall the morbid anatomy of this disease, in which 
the integrity of the central portion of the bone is invariably 
assailed, we can better understand the comparison of hip- 
disease to a fracture of the bone, and the more readily 
recognize the propriety of treating it by fixation. If hip- 
disease were synovitis, invading, under the pressure of re- 
flex muscular contraction, first the cartilage and then th^ 
bony tissue, it would be right to try to diminish this pres- 
sure by traction, or any other method believed to be prac- 
ticable. We might even attempt the difficult combination 
of traction with mobility, in the hope that motion without 
friction would perhaps assist the process of repair and 
secure a recovery without impairment of mobility. But 
the disease is not synovitis. It is ostitis, beginning in the 
cancellous tissue, or at the epiphysal junction, excavating 
the bone, undermining its strength, progressing from with- 
in outward, and involving in time all the structures of the 
joint. In this view it is clear that the proper local treat- 
ment is protection from the pressure and concussion in- 
cident to walking, and the prevention of motion in the 
joint. As in a fracture, so in hip-disease, the part should 
be placed in a favorable position for the action of the 
natural reparative processes which, aided by appropriate 
general treatment, are, as a rule, able to limit this morbid 
process when it occurs in parts which, like the ankle, are 
more easily protected from disturbance and violence by the 
voluntary efforts of the patient." 




For ihe arrest of disease in its incipiency surgery is not 
to be credited with any brilliant results. It has often oc- 
curred to me iliat much might be done by the judicious 
use of th. drill. This instrument has not been used to any 
great extent in this country, i.t., I am not familiar with any 
cases published in which It has been employed. If one 
can feel reasonably sure that the disease is confined to the 
femur, then the joint might be saved by establishing a 
drainage on the distal side of the capsular ligament. The 
question forces itself on one, whether even this procedure 
would prevent ilie extension of the lesion by contiguity lo-i 
the articular surfaces. 

I was aware that Mr. Macnamara had drilled the head 
and neck of the femur in cases of serous synovitis of the 
hip, and in a conversation with this surgeon some two 
years ago I learned that he had also employed this treat- 
ment in chronic articular ostitis of the hip. The results in 
his synovitic cases were very encouraging, and are recorded 
in his "Diseases of the Joints." Recently I received from 
him a summary of the cases treated, and 1 take pleasure in. 
giving the substance of his communication. 

During the three years ending in i88z, he had drilled the 
trochanter neck and head of the femur twenty-seven times 
for the relief of " hip-joint disease," and of this number be 
is convinced that twenty-four have made good recoveries, 
"Several," he says, "have grown up into strong healthy 
children with an amount of compensatory movement in the 
spine which enables them to go about like other healthy 
children." One case, a girl aged twelve years, died three 
months after the operation, and it was found that the drill 
had passed into the middle of the head of the bone, and 
not into the joint. The passage taken by the instrument, 
was filled with a comparatively soft fibro-cellular substance 
with islands of cartilage in which calcification of the car- 
tilage was in progress. A layer of newly-formed articular- 



I 




w 



TREATMENT IN CHRONIC ARTICULAR OSTITES. 389 

rcilage covered the head of the femur, and a very thin 
lyer of what seemed to be the original articular cartilage 
lay loose in the joint. 

In two other cases of the twenty-seven, at periods vary- 
:ing from four to seven months, the disease was not checked 
1)y the operation, and he was compelled to excise the head 
of the femur. 

His conclusion is that he does not now think drilling 
should be performed for osteo-myelitis in this locality 
until other treatment has failed. His management of a 
case at present is this: 

When it is clear that well-marked symptoms have de- 
veloped the patient is put under the care of an experienced 
nurse in such a locality that the best possible hygiene can 
be maintained, plenty of fresh air and light, proper food, 
principally fresh milk. At night the limb is secured by 
weight and pulley, and by day a Thomas splint is applied, 
while the child is encouraged to go about as much as pos- 
sible, aided by crutches and high shoe. If, at the end of 
from (our to six months no improvement follows this treat- 
ment, he resorts to the drill, dividing at the same time 
the adductor muscles, and it may be the tensor vaginae 
femoris. A modified Bryant's splint is applied immedi- 
ately after the operation, and secured to both limbs and 
pelvis by means of plaster-of-Paris bandages. No exten- 
lion or traction is made, the necessity for this being obvi- 
iled by the division of the muscles. 
I have thus been e-xplicit in the details of the treatment 
'■employed by Mr. Macnamara, because I believe him to com- 
bine very happily the conservative and the advanced surgical 
ideas of our British cousins. The question, as I remarked 
before, occurs to us whether with the means he employs 
for fixation at the time the exacerbations are at the height 
would not accomplish all that he gains by the additional 
drilling? 

I can see how an early drilling with the limb secured in 
the best fixation would act as an issue, would change the 
character of the inflammation, and would thus bring about 
a more speedy recovery. One reason I fancy why Mr. 
Macnamara gets stiff joints is that he permits too much 
freedom of motion; for instance, in removing (he splint at 
.sight and substituting therefor the weight and pulley. 
Then, again, I think his drilling would serve a belter pur- 
pose in the early stage of the disease. 



390 



DISEASES OF THE HIP. 



U will be seen that mj' object now is to save the articuli 
surfaces, and I am not convinced that any plan of treatment 
at present employed will accomplish this object in the 
majority of instances. One needs to know this fact when- 
ever a case presents in its incipiency. An anatomical 
diagnosis is essential above all things. Drilling is the 
only operation, except an early excision. Early excisions 
will never be popular, for the reason that the operation 
ie [oo grave in appearance for so apparently simple a lesion. 
Free incision and drainage may be resorted to, but even 
this is not advised unless there exist epiphysial necrosis. 

Operations fur the arrest of disease, where ii has already 
advanced to the destructive stages, consist of free incision 
gouging, and excision. The latter is by far the more 
common, and has become a very popular operation among 
general surgeons. The orthopedist who relies strictly on 
mechanical contrivances, seldom advises such extreme 
measures. He can afford to await tlic slow processes of 
Nature in her efforts to throw off the effete products. He 
waits occasionally until amyloid degeneration, or, as Mr 
Barwell prefers to call it, lardaceous degeneration, is far 
advanced, and then the case is considered hopeless. 

The question of excision no longer turns on the mortality 
of the operation. True, the danger in all surgical proce- 
dures is to be considered, yet antiseptic surgery has con- 
tributed largely toward removing this clement. When I 
say antiseptic surgery has done this, I mean that it has 
done so directly and indirectly. Those surgeons who o] 
pose Listerism have, in order to maintain their positii 
grown more cleanly in their operations, more careful, ai 
more discreet. It is seldom now that a patient dies 
shock from an operation, and especially from an excision. 
The objections that the extreme conservatives bring up 
against the operation are, that it does not always arrest 
the disease, and that it does not leave the limb so use- 
ful as when a cure takes place in the natural way. These 
really are the only arguments worth considering, and the 
first has no weight as an argument. When one decides 
that there is no hope left the patient — that he must surely 
die by exhaustion, either from the suppuration or the 
lardaceous disease, the operation of excision or of amputa- 
tion becomes as imperative as does tracheotomy when a 
child is dying from laryngeal stenosis. No man — even its 
greatest champion. Dr. Sayre — ever claimed that excision 



TREATMENT IN CHRONIC ARTICULAR OSTITIS. 39I 

I always arrest the disease and save life. It gives the 
L patient, even in extremis, the last hope, and, as Dr. Yate 
[.remarked in an interesting paper before the Academy of 
I Medicine, a few years ago, it is often the best febrifuge wc 
n command. Indiscreet enthusiasts have done as much 
I as the extreme conservatives have in bringing the operation 
I into disrepute, by claiming too much. When one looks 
Lover statistical tables, and sees the names of patients re- 
I ported as cured, patients whom he knows have long since 
[ gaccumbed to the disease for which the operation was per- 
f formed; when he sees other names, with the result given 

ter of an inch shortening and a very useful limb, . 
t patients whom he knows have from one to three inches 
\ shortening, and who use a cane or a crutch; when he sees 
mes of patients who are reported as free from disease, 
[■.patients whom he knows to be suffering from draining 
1; sinuses and exacerbations as of old — when one, I say, has 
\ an experience of this kind, he is apt to condemn the opera- 
I tion rather than the statistician. The time has certainly 
\ Come when excision can rest on its merits. Statistics are 
.0 it as a fond mother is to her favorite child. 

Apart from the unquestionable relief it affords to suppu- 
rating joints, it has been conclusively proven during the 
last decade that lardaceous degeneration may be arrested by 
this means. Cases that cannot be disputed are tnultiply- 
Ling, and before long the evidence will be overwhelming. 
I Take a single case, one among several that have eom- 
Funder my own observation: 

' In 1871 a boy, aged eleven years, was admitted to the 
hospital. The family history was tuberculous. The his- 
tory states that when he was two years of age he was lame 
in the right hip for one month, but, under the use of lini- 
ments, made a perfect recovery, and was active and free 
from lameness until three months prior to admission to 
hospital. When I examined him I found as he stood the 
right limb slightly advanced, and the foot everted. The 
weight was borne chiefly on the left limb. The limp, 
while characteristic, was very slight. There were the 
usual changes in the nates; the joint and trochanter 

C tender; the joint movements were limited only a 
little, and there was neither shortening nor atrophy, 
her words, the disease was in the 6rst stage and the 
nosis was good, i.e., from the views I then held con- 
I^ 






392 DISEASES OF THE HIP. 

The tenderness subsided within a month, the usual hos- 
pital treatment having been employed. During the winter 
— three or four months after admission — he was thin and 
poorly nourished, but the hip gave no annoyance until the 
following summer, when after an exacerbation the second 
stage was fully at hand. A year from the date of admission 
an abscess occupied the whole of the gluteal region, and a 
month later opened spontaneously over the coccyx. The 
usual hectic followed, but it was not severe, and he had 
comparative immunity from pain until the approach of 
another exacerbation, two months later, more acute and 
more distressing than any he had experienced. At this 
time two openings existed, and through one a spicula of 
necrotic bone was exfoliated. 

At the end of the second year the patient was feeble in 
health, the limb was in the position of third stage. The 
soft parts were dotted with ulcers and the openings of 
sinuses. His lungs at this time were the subject of much 
apprehension, physical signs revealing bronchial changes, 
and altogether the case was aught but hopeful. During 
the winter no marked changes occurred, but in the sum- 
mer — three years now from admission — the urine was light 
in color, gave on standing awhile a whitish flocculent de- 
posit, and, on the addition of the usual test, five per cent of 
albumen. In the field of the microscope it furnished an 
abundance of granular and hyaline renal tests. This par- 
ticular examination was made July 9, 1875. The notes for 
next day read: "Little or no oedema present. For past 
week has complained of some headache, nausea, and con- 
stipation, the significance of which is manifest by the 
urinarv examination." 

Another examination of the urine was made a fortnight 
later, and the specific gravity was 1020, while the specimen 
was loaded with albumen. I found also on examination 
hepatic dulness three fingers* breadth below the free border 
of the ribs. A month afterward he was discharged, larda- 
ceous degeneration being fully established and the suppura- 
tion being unchecked. The prognosis, as recorded, was, 
" death from amyloid degeneration within three years." 

The boy was admitted to St. Mary's Hospital, I learned, 
shortly afterward, and the hip was there excised by Dr. 
Poore, who has already placed the case on record. 

In December, 1879, — four years after the operation — I had 
an opportunity of examining the boy, and I found his 



TREATMENT IN CHRONIC ARTICULAR OSTITIS. 393 

general appearance excellent. He walked without any sup- 
port save a high shoe. Without this he used a crutch, 
although he could bear his entire weight on the limb with- 
out difficulty. He could actively flex the thigh beyond 90® 
with about one half the normal force ; could extend, abduct, 
and adduct over normal arcs, and with a little less than one 
half the normal force. The cicatrices all seemed old, and 
there were no open sinuses anywhere to be seen. The 
measurements, as I found them at that time, were as fol- 
lows: 

Right side: Thigh, 12^ in.; knee, 11 in.; calf, lo-J- in.; in- 
step, %\ in. 

Left side: Thigh, 17 in.; knee, 13 in.; calf, 12^^ in.; instep, 
9|in. 

The right limb in length was 25 J in., the left, 32-J- in.; the 
right tibia, 12^ in.; the left, 14 in.; the right foot, 8; the 
left, 9. He had no cough and his lungs were in an excellent 
condition. Dr. Ripley examined the lungs after I did and 
fully confirmed the result I had obtained. 

The condition, as described by Dr. Poore at time of 
operation, was as follows: 

"At the time of his admission the right thigh is flexed, 
shortened, and inverted; the knee-joint is also flexed and 
stifif. He suffers much pain, so that he is confined to 
the bed most of the time; he lies in bed, propped up with 
pillows; he has not been able to lie down for two years. [?] 
There are four sinuses about the joint, through most of which 
dead bone can be felt. There is considerable discharge. 
Patient is thin and pale; appetite poor; liver enlarged. 
There is some albumen in his urine, but no casts can be 
found. 

" On May 21st the joint was excised — present, Drs. Peters 
and Watts. The head of the bone was found lying in the 
cavity of the acetabulum in pieces; the neck was also splin- 
tered; the bone was divided below the trochanter minor; 
the shaft was found extensively diseased; the bone was 
soft, thin, dark-colored, and the medullary cavity enlarged, so 
as to easily admit the finger for two or more inches; the shaft 
was divided again lower down; the periosteum was loose; 
the condition of the bone at the point of second section 
showed the same diseased condition. The acetabulum was 
not perforated, and but slightly diseased. 

" Wound brought together in part, and patient placed in 
a cuirass, with extension so as to bring the knee down." 



394 DISEASES OF THE HIP. 

The important poiot about my examination was, that 
found the liver dulness normal — it did not extend below Ib< 
free border of the ribs. I had him pass a specimen of 
urine, and I found it of a specific gravity of loia, and con- 
taining the faintest trace of albumen. In four specimens 
examiiip'! microscopically 1 could not, after prolonged 
search, liiid any cast£ or epithelium. 

I have since seen the boy about the streets, and he 
seemed to be gaining in every respect. 

There are many cases where the lardaceous degeneration 
is not arrested by the excision, but subsequent amputation 
succeeds in arrestingthis process. There are cases wherein 
the excision has failed to remove all the disease and where 
the suppuration continues. 

Mr. Barwell reports a very instructive case of this kin( 
on page 39; of tlie American edition of his work on " Dis*' 
eases of the Joints." The patient was seven years of age, and 
Mr. Hancock had perfoimed excision twenty-two months 
before. When amputation was performed, " the liver filled 
the whole right side of the abdomen, its lower edge being 
lost within the crista ilii; it extended far to the left of 
the middle lint", the spleen was large. The urine was 
sufRcient in quantity; it contained albumen and some 
hyaline casts, nunc of which, however, were of the smaller 
size, and were mixed with endothelial cells." The ampu- 
tation was on November id, 187a "She made a rapid 
recovery; the wound did not suppurate; the liver and spleen 
were rapidly diminished in size, the albuminuria ceased, 
and she left the hospital fat and strong, 00 February i, 
1873" 

In September, 1880, he made this note: 
girl twice since the amputation. She g; 
and was remarkably strong and large. D 
above named I heard of her, that she was a large, strongs, 
and remarkably healthy woman." 

In the Medical Times and Gazette for August is, 1883, 
Mr. R. W. Parker details a case that is full of interest in this 
connection. The child was two and a half years of age in 
April, 1879, when admitted to the East London Children's 
Hospital. It had never been a strong child, and during 
few months preceding admission to hospital it had sevi 
"small abscesses" in different parts of the Iwdy, for instani 
on scalp, back axilla, and wrisi. Eleven days before admi 
sion the right buttock was similnly affected, and when Ml 



id^^ 



" I have seen this 

ew very rapidly, 

ing the monUi 



I 



TREATMENT IN CHRONIC ARTICULAR OSTITIS. 395 

Parker saw the case he found "a large fluctuating swcUing 
around and behind the trochanter, the skin over which is 
normal," The thigh was held in slight flexion and out- 
ward rotation, but there was " tw pain in, or fixation of, Ifie 
kip-jot Ht." 

The abscess was very promptly opened in its most de- 
pendent part, and a drainage tube inserted. The limbs 
were fixed in the extended position by weight, more with the 
idea of correcting rachitic curves that were very marked. 
A month later pain was complained of about the hip, and 
after another month moving of the limb caused considetahlc 
pain. The abscess cavity had contracted, and a probe in- 
troduced did not come in contact with any bare bone. 
Disease slowly invaded the diaphysis and the epiphysis, 
the ordinary signs and symptoms accompanied, and two 
months after it had been fully recognized excision was per- 
formed. The head of the bone was in part absorbed, wliih: 
the remainder was necrotic, " The neck was extensively 
carious, soft, and fatty." The recovery was slow, and ihe 
child was sent into the country during convalescence. The 
sinuses gradually closed, the boy grew (at and looked well. 
In February, i88_^— fully three years having elapsed since 
the wounds healed — he came under observation again for 
" dropsy." The wounds were still healed, but the cicatrices 
were white and supple. There did not seem to be any 
evidence of local disease. The urine was loaded with albu- 
men, was acid, and had a jpecific gravity of 1019. Reme- 
dies were administered for the kidney lesion — which, by the 
way, was supposed to be scarlatinal nephritis. Two weeks 
later the urine was more copious and the stools were watei-y. 
Vomiting had become an annoying symptom. Another 
week elapsed and the examination of the urine showed it 
to be pale straw-colored, scanty, and almost solid on boil- 
ing. No casts were found, and no blood-corpuscles. The 
stools became more frequent, and he died twenty-two days 
after coming under observation for his "dropsy." 

There was no fluid in the abdomen, in the pleura, or in the 
pericardium: the lungs were osdematous. " The liver was 
waxy, and weighed twenty-seven ounces and a half; the kid- 
neys each weighed seven ounces and a half, their capsules 
readily peeled off; the cortical substance was swollen and 
the whole organ pale. The joint was examined carefully; 
it was at first hoped that a specimen of repair after exci- 
sion would have been found. On the contrary, a process 



396 DISEASES OF THE HIP. 

of slow caries was going on in the iliac bone; it was sur- 
rounded by thick inspissated pus which had raised the 
periosteum from the pelvic surface of the bone, leaving it 
finely eroded. The upper part of the femur was connected 
to the remnants of the old capsular, ligament by firm, un- 
yielding, gristly connective tissue." 

Mr. Parker very properly heads his report, ^^ Peri-tro^ 
chanteric Abscess — Subsequent Coxitis — Excision— Apparent Re- 
covery — Lardaceous Disease three years later — Death — Autopsy** 

The other objection to the operation, viz., that the limb 
is left insufficiently strong as a support, is certainly an ob- 
jection worthy of consideration. Still this is of insignifi- 
cant importance when compared with death by slow, tor- 
turing suppuration. 

The questions then are reached: 

1. Shall we ever excise ? Yes. 

2. In what cases shall we excise ? 

To answer this question let me cite an hypothetical case 
or two. 

Suppose one gets a case in the early stage, and learns at 
that time or subsequently that a tuberculous element exists 
in some member of father's or mother's family, near or 
remote. Let this point be always borne in mind for prog- 
nostic purposes. Suppose, furthermore, that the treatment 
adopted is treatment that is known to be attended usually 
with a fair amount of success. Suppose resolution does 
not take place, but that the disease goes into the second 
and then into the third stages. Suppose the suppurative 
process is unusually severe and unusually prolonged, and 
that the patient is losing ground steadily despite treatment; 
suppose that the urine is of low specific gravity, and that 
this low specific gravity persists until the child begins to 
complain of pain in the hepatic region. Given now a case 
like the above, whether the evolution have been slow or 
rapid, no time should be lost, when these urinary changes 
have thus advanced, in removing every particle of diseased 
bone. If excision will not do it, resort to amputation. Lard- 
aceous disease is impending, and life is at stake. 

Suppose, again, in this same patient you can get no evi- 
dence at any time of a tuberculous element, but that sup- 
puration has existed long enough to induce an exceedingly 
low vitality and is accompanied by unexplained attacks of 
diarrhoea; the operation should then be done. These cases 
die by exhaustion, and these little disorders of the intesti- 



TREATMENT IN CHRONIC ARTICULAR OSTITIS. 397 

nal tract are but the precursors of a general dissolu- 

Suppose, still again, that you get a case that has reached 
the advanced stages without treatment, and that the above 
conditions exist; it is useless to waste time with any forms 



of r 



ichanical treat nn 



that I have placed the operation on the 
basis of a necessity^a last resort. If time be an important 
enough element in the case it may be performed even be- 
fore tlie third stage is reached. I do not know hut that the 
remarks of Mr. Holmes fairly represent my own views, and 
I take pleasure in quoting them, as does Mr. Macnamara: 

" I would sum up what I have to say about excision of 
the hip in a very few words, by the simple statement that 
it ought to be very rarely indeed required if the disease 
were treated properly at its commencement. Incases seen 
at an advanced stage of the disease, it is chiefly when se- 
questra exist that the operation is nfcfssary; though it may 
be advisable as a means of shortening ihe treatment in other 
cases, also, when the patient cannot obtain the prolonged 
surgical care which is essential to natural recovery." 

There are many cases, be it understood, that go the same 
way after excision, and if lardaceous disease be still present 
amputation should be performed. After all, this question 
must be left to the good sense of the intelligent practitioner, 
and he must be guided in addition by correct surgical 
principles. The chances of life and death, of prolonged 
suffering and relief from suffering, must be carefully 
weighed, and judgment be rendered accordingly. 

Given [hen the cases, how shall the operation be per- 
formed? There are several incisions, the semilunar, the 
vertical, the transverse, and the T. The mode of operating, 
as practised by Dr, Sayre, seems to be the most generally 
accepted, and, with antiseptic precautions, this should be 
done as follows: 

" Select a strong knife, and drive it home to the bone at a 
point midway between the anterior-superior spinous pro- 
cess of the ilium and the top of Ihe trochanter ; then, draw- 
ing it in a curved line over the ilium, and the top of the 
great trochanter, extending it, not directly over the top of 
the trochanter, but midway between the centre and its pos- 
terior border, and complete it by carrying the knife forward 
and inward, making the whole length of the incision from 
four to six inches, according to the size of the thigh. In 



DISEASES OF THE HIP. 



r a curved incision is made through all tht soft 
parts down to the bone and through the periostfum. If you do 
not feel certain that the periosteuon has been divided over the 
feinur by (he first incision, carr^- the point of the knife 
along the same line a second and, if need be. a third time." 

Dr. Wyeth has, by anatomical research, demonstrated that 
in the above mode of making the incision no hemorrhage 
of any significance is encountered. 

The parts being held aside by retractors, the. operator 
is in view of the trochanter. A narrow thick knife is now 
used for a " second incision through the periosteum, only at 
right angles with the first, at a point an inch or an inch and 
a half below ihe top of the great trochanter, as the case may 
be, just opposite the lesser trochanter or a little above It, 
and extend it as far as possible around the bone." The 
periosteum is detached by means of a periosteal elevator 
separating the attachments up to the digital fossa. The 
rotators of the thigh at this point are usually divided with 
the knife. Dr. Sayre lays special stress on the smaltness 
of the incision in this locality, and upon the necessity of 
elevating enough periosteum in order that the muscular 
attachments may be preserved. 

With a slight adduction movement the head or what re- 
mains of it can be thrown out of the acetabulum, the sec- 
tion being made with a saw. Some prefer the chain, some 
the finger. Bone forceps are undesirable. With a proper 
base a chisel would be preferable, as no sawdust would be 
left as an irritating substance. 

The place of section should now be subjected to careful 
inspection for disease of the shaft, and if any is found sec- 
tion must be made at a lower point. It will naturally sug- 
gest itself to the operator that the acetabulum should be 
carefully explored and all necrotic bone, so far as practi- 
cable, removed. Thorough cleansing aniiseptically, recti- 
fication of deformity, drainage tubes, and appropriate dress- 
ings comes next in order. 

Dr. Sayre again lays stress on the avoidance of cotton or 
lint as plugs. He uses oakum soaked in balsam Peru. 

As a splint for securing immobility, the most convenient 
is the modification of Bonnet's ^rand appareil (figured ■ 
as No. 64). This is well padded, and the patient is placed 
in the apparatus the sound limb being strengthened and 
secured by making the foot fast to the foot-piece, which 
moves by an adjustable screw. The diseased limb is se- 



TREATMENT IN CHRONIC ARTICULAR OSTITIS. 399 

cured with pads about salient points to prevent excoriation. 
This can be worn continuously for a month if the full 
Lister dressing Ijc employed; otherwise it will be necessary 
to change the dressing in from twenty-four to forty-eight 
hours. At the end of a month or six weeks the apparatus 
can be removed and other splints substituted. 

In England the Bryant splint is used, with modifications. 
Indeed splints which preserve the parallelism and secure 
immobility may be extemporized 
and the cuirass can be dispensed 
with. Works on surgery give 
the dressings and appliances in 
detail; but, for a complete de- 
scription, Dr. Sayre's work on 
Orthopedic Surgery is the best 
for reference. This operation 
is successful in proportion to 
the care in execution and subse- 
quent nursing given (he patient. 

Some surgeons obtain pei- 



before at ten 
in case the 



the limb, 
ipling the operation, 
disease is found so 
s to make the re- 



moval of all portions imprac- 
ticable. One never knows just 
how much caries he will meet. 
Sometimes, as in one or two of 
Dr. Poore's cases, the whole 
shaft is diseased. 

The remaining operations are 
for the correction of deformity, 
and to Dr. W. T. Bull I am in- 
debted for assistance in the pre- 
paration of the remaining por- 
tion of this chapter. Ftct*, 

The operation for bony ankylosis consists in division of 
the neck of the femur with a saw suhcutaneously, and it 
has been done, without question, with good results. 

It has also been done with a chisel by Volkmann, Maun- 
der and Macewen. It makes very little difference whether 
the bone is divided with a saw or chisel. Of late years 
most surgeons prefer the chisel to the saw. In either case 
the operation is practically the same: sink the knife right 




400 DISEASES OF THE HIP.. 

down to the bone above the upper border of the great tro- 
chanter, and then either pass a saw or a chisel through this 
opening and divide the bone. 

Theoretically, the saw is open to the objection of leaving 
sawdust behind, but both means give uniformly good re- 
sults. The wound generally heals perfectly, or with very 
moderate suppuration. Some wounds, when the bone is 
divided with the saw, heal subcutaneously. It is desirable 
to do such operations antiseptically as far as possible. 

Adams's operation is only practicable in cases of bony 
ankylosis where the head of the bone is in its place, and 
these are cases of ankylosis from rheumatism or rheumatic 
arthritis, ankylosis from long-continued rest, and Adams 
includes pyaBmic inflammation of the hip-joint — in fact any 
inflammation where the head of the bone remains in place; 
as long as the head is there, the operation is feasible. 

But cases of hip-joint disease where the head of the 
bone has been absorbed, where there is a high position 
of the trochanter above N61aton*s line are not amenable 
to Adams*s operation. 

Such cases require an operation first performed by Barton, 
but which should be done nowadays after the manner 
made more precise by Volkmann. 

Barton's operation consisted in cutting through the 
femur below the trochanter minor. An incision was made 
sufficiently large to separate the*periosteum from the bone, 
and then a chain-saw was passed around the bone, thus 
dividing it. Several American surgeons repeated this 
operation. Sayre modified it by making one end of the 
bone conve^x and the other concave, and claimed to obtain 
motion by this artificial joint, which persisted for two 
years (reported on page 420 of his work). There is an 
objection to this operation proposed by Barton, from the 
fact that the bone is cut completely across, and when the 
effort is made to straighten the limb, it is likely to throw 
upward or forward the upper end of the lower fragment. 
One case occurred in the practice of a surgeon in this city, 
in which the femoral artery was pressed upon and gan- 
grene took place. 

The Volkmann operation is the one Dr. Bull performs. 
In this the bone is not sawn or chiselled entirely through, 
but a wedge-shaped piece is removed from the outer sur- 
face of the bone, the apex of which extends nearly to the 
compact tissue on the inner surface of the bone. This 



TREATMENT IN CHRONIC ARTICULAR OSTITIS. 4OI 

leaves a thin layer of compact tissue on the inner surface to 
be fractured through in the effort to straighten the limb, 
and serves to hold the lower fragment in place. 

In addition to removing the wedge-shaped piece of bone, 
it is generally necessary to divide the sartorius, tensor 
vaginae femoris, and sometimes the rectus where the 
thigh is strongly flexed; and in addition to these muscles 
the adductors also should be divided when the limb is 
adducted as well as flexed. 

The operation to which Volkmann gave the name " Sub- 
trochanteric Osteotomy," is performed as follows: An in- 
cision is made directly over the long axis of the femur on 
its outer side, about one and a half inches in length, di- 
rectly down to the bone. The middle point of this incision 
should be from one to one and a half inches below the top 
of the great trochanter. The periosteum is separated from 
the bone over the outer and posterior surface, and with the 
chisel a wedge-shaped piece is removed embracing the 
whole thickness of the bone, with the exception of the inner 
layer of compact tissue. The width of the base of the 
wedge should be greater or less according to the amount 
of flexion, and the base of the wedge must be sufficiently 
large to permit the cut surfaces of the bone to come in 
contact when the limb is straightened. This varies from 
one half to one inch. 

After removing the wedge of bone, the pelvis should be 
steadied bv an assistant, and the limb brought down to a 
straight position by fracturing the layer of bone which has 
not been cut through, and before the limb can be perfectly 
straightened it may be found that division of the adduc- 
tors sartorius and, sometimes, the tensor vaginae femoris 
is required. This may be done by subcutaneous incision 
or by an open wound; probably the former method will 
suffice in the majority of cases, and is to be preferred on 
account of the smaller or insignificant character of the 
wound. If, however, extensive division of these muscles 
should be found necessary, some surgeons prefer to accom- 
plish this by the open method. 

The subcutaneous tenotomy (myotomy ?) is easily per- 
formed, by putting the muscles on the stretch by straight- 
ening the limb, entering the skin close to their origin 
with a sharp-pointed tenotome, then passing a blunt- 
pointed tenotome underneath the muscle, taking care to 
keep close to the point of insertion in the bone and cut- 



402 



DISEASES OF THE HIP. 



ling toward the skin while the iibres are kept upon the 
stretch. 

The wounds should be kept open and covered merely 
with a Lister dressing, which should reach from the 
lower third of the thigh to the crest of the ilium. Over 
this a plaster-of- Paris bandage should be applied from 
above the knee, embracing the pelvis, and a weight-and- 
pulley extension applied to the limb, a weight of five or ten 
pounds being sufficient. In place of the extension and 
plasler-of-Paris, a long external splint, reaching from the 
axilla to below the sole, should be used in young children. 

This operation has yielded perfectly satisfactory results 
only where antiseptic details have been strictly carried out; 
and while it is no longer considered necessary to use the 
spray upon a wound during operations, it is certainly de- 
sirable that the parts to be operated on, the instruments, 
and hands uf the operator and his assistants, should be 
carefully disinfected, and a typical Lister dressing should 
be used. In view, however, of carbolic-acid poisoning In 
children, especially those of a strumous diathesis, it seems 
to Dr. Bull at least preferable lo substitute for carbolic acid 
in the wound a solution of bichlorde of mercury, of the 
strength of one part to one thousand. 

The dressing need not be removed unless a discharge 
appear at its edge, or there be some constitutional distur- 
bance. 

At the end of six weeks union will have occurred at the 
point of section of the bone, and a week or two later the 
patient may be allowed to go around on crutches. In 
many cases the wound in the soft parts will be reduced to 
a mere granulating surface, or entirely cicatrized at the 
end of three weeks, and a more simple dressing may be 
substituted for the Lister gauze. 




INDEX. 



Abscpas above Poupan's ligament, 
46 

— in articular ostitis and lumbar, 
Poll-j, JII 

— . exlracapsular. 94 

— , disappearance of, 258 

— , iscbio- rectal, significanee o(, 45 

— . premonitions o(. 241 

— , perineal, significance of. 46 

— , rectal, sif^nificance of. 46 

— , residual, how managed, 335 

Acelabulum, points of perforation 
of, 45 

Acquired simma. 313 

Adams, Mr. Wm,, operation (or 
ankylosis, 400 

Adductors of hip, 34 

Age as a predisposing cause In ar- 
ticular ostitis, 207 

Allis, Dr. Oicar. on nature's rare. 
333 

American method of treating joint- 
diseases, 358 

Amputation at hip-joint (or larda- 
ceous degeneration. 3^ 

Amyloid disease (see Lardaceous 
disease) 

Amyloid degeneration after sappu- 

, relieved by dislocation. 365 

Anatomy of hip, 30 

Andrews, Dr.. the iscbiatic crutch, 
35B 

Angle of deformity, mode of meas- 
urement of, 27 

Annandalc, Prof.. on osteo-myebilii, 
"97 

Aiticulation, the, 44 



Arthritis, acute, of infants, aa 

— rheumatic, 80 

— chronic rheumatic in the adult, 

a& 

Articular ostitis of the hip, chronic, 
pathology of. 170 

, chronic, diagnosis of. 268 

, treatment by drilling tro- 
chanter, 3BS 

.incompleteness of cure of, 2^3 

Baker. Mr. W. Morrant, on Epi- 
physal Necrosis. 23 

Banks. Mr, Mitchell, on operative 
procedures in Bursitis, 117 

Barton, Dr. J. M.. case of irau- 

Barlon's operalion for dcforraily, 

Barwell. Mr., case of lardaceous 
degeneration arrested by ampu- 

Ulion, 394 

— hip-splint, 369 
Bauer. Dr., on the diagnosis of 



dias 



■>. 147 



hip splint. 359 
Belladonna in periostitis, 160 
Berry, Dr. John James, on the far«- 

— . on juxtaepiphysial congestion, 

174 
Billrolh. Prof, , on residual ab- 



n the V 






187 

Blisters followed by poultices, 133 
Blood supply to muscles of hip. 36 
Bradford, Dr., on the physiological 

method, 343 
— , on the Thomas method. 356 
Brisement torc6 in chronic ostili* 

dangerous, 58 



404 



INDEX. 



Brisement forc6 in rheumatic peri- 
arthritis, 85 

Brodhurst. Mr., mode of treating 
ankylosis, 86 

Brodie. Sir Benj., on hysterical 
joints, 59 

Bryant, Mr. Thomas, splint for 
maintaining parallelism, 370 

Bull, Dr. Wm. T., case of necrosis 
of Ilium, operation, 105 

— case of acute synovitis, 125 
Bursse about the hip, 36 
Bursitis of the hip. no 
— , etiology of, 1 10 

— producing articular ostitis, 117 
— , treatment of, 114 
— , prognosis of, 1 17 
Cases (see Supplementary Case In- 
dex) 

Cautery, the actual, in neuroses, 

72 
Centres of ossification of femur, 47 

of pelvis, 46 

Chance, Mr. E. J., apparatus for 

the hip, 372 
Cheever, Dr., on inflammation of 

deep fascia of thigh, 104 
Chronic articular ostitis, clinical 

history, 22C 

, etiology of, 203 

, methods of treatment, 320 

of the hip, pathology of, 170 

, the physiological treatment 

of. 338 
Chronic rheumatic arthritis, diag- 
nosis of, 91 

, treatment of, 92 

"Click,** a peculiar in Bursitis, 113 
— , a peculiar in neuromimesis, 113 
Clinical history of chronic articular 

ostitis, 226 
Clinical picture of the third stage, 

259 

Clippingdale, Dr., "On Hip Dis- 
ease,'* 45 

Complications of articular ostitis, 
260 

Contusions, 50 

Crease, Ilio-femoral, 31 

Cry, ostitic, 238 ' 

Cure, difficulty of establishing, 
260 

— -» the incompleteness of, in ar- 
ticular ostitis, 268 



Danger of passive motion in adhe- 
sions from chronic ostitis, 58 
Definition of hip, 30 

— of first stage of articular ostitis, 
226 

— of a neurosis, 59 
Deformity, correction of by the 

Thomas splint, 354 
— , mode of reducing by the long 

splint plus weight and pulley, 

361 
— , measurement of angle of, 27 
Diagnosis, the importance of, in 

orthopedic surgery, 269 

— of articular ostitis, 268 

— of articular ostitis, cases illustra- 
tive of, 277 

— of articular ostitis first stage 
functions of the joint, 272 

— of articular ostitis, table of dis- 
eases from which differentiated, 
278 

— of articular ostitis first stage, 
signs on inspection, 271 

— of articular ostitis first stage, 
signs on palpation, 272 

— between articular ostitis and 
bursitis, 291 

— between articular ostitis and 
exostosis, 305 

— between articular ostitis and in- 
fantile spinal paralysis, 285 

— of articular ostitis — points be- 
tween this and neuroses. 285 

— between articular ostitis and 
ostitis of Ilium, 297 

— between articular ostitis and 
periarthritis, 289 

— between articular ostitis and 
periostitis, 295, 296 

— of articular ostitis, cases of peri- 
ostitis, 295 

— of articular ostitis — ^points be- 
tween this and rheumatism, 283 

— between articular ostitis and 
sacro-iliac disease, 298-300 

— of articular ostitis, tabular state- 
ment regarding sprains, 280 

— of articular ostitis, from acute 
synovitis, 292, 294 

— of articular ostitis, case of recur- 
ring synovitis, 293 

^ between artictilar ostitis and 
vertebral ostitis, 30Z, 305 



^^^^^^^^^^H^^^H 


^^^^^^^^^^^^^^^^^^^^^^^l^^^l ^^^^^^^1 


^^^^/r ^H 


Dianiosis of articular ostitis, cases 
of Pott's disease. 301 


Duplay, M., on scapulohumeral 


periarthritis, 94 


— betwnn articular ostitis and 


Duration of second stage, 347 


lumbar Pott's disease, 311 


— of third stage. 3$q 


— ol the secnnd stage oi anieular 


— at synovitis, 133 


ostitis, 306 


Epiphysial uecrosis. 33 


— between second stage of articu- 


Epiphysitis of the hip, acute. 135 


lar ostitis and acute epiphysitis. 




SIS 


— versus Diastasis, 140 


— of articular ostitis, from the fe- 


— . lesions from which difteren- 


moral abscess of Pott"s disease, 


tiated. 14s 


313 


— , palholDgyof. 135 


— belvreen articular ostitis and 




Iliac alMcess. 309 




— of articular ostitis, cases of per- 


— , treatment of, 146 


inephritis. 306, 308 


Esmarch on neuroses. 60 


— between second stage of articu- 


Etiology of chronic articular ostitis. 


lar ostitis and perityphlitis, 30g 


303 


— of artieuiar ostitis, cases of peri- 




typhlitis. 3«) 


3*5 


— between second stage of anieu- 


— of bursitis. 110 


lar ostitis and Pott's disease ; 


— of joint-disease. sUtistics, aia 




Eve. Mr., on epiphysial necrosis, 


— ol articular ostitis, third stage. 


33 


3i6 


Exacerbations induced by trauma- 


— ol articular ostitis third stage. 


tism. a44 




— in neuroses. 2S3 


3.3 


— , signs indicating approach of, 371 


— of articular ostitis, third stage. 


— , significance of. 341 


case of traumatic dislocation, 


Ejtaminalion, danger in rough, 373 


317 


Exanthemata developing struma. 






— of muscular rheumatism, 75 


Excision, 390 


- of neuroses. 63 


— , lardaceous disease three years 


— of periarthritis, ijg. 103 


later. 394 


— of rheumatic arthriiis. 84 


— , when shall the operation be per- 


— of chronic rheumatic arthritis, 91 


formed. 396 1 


— of periostitis. 156 


— , the wire cuirass after, 396 


— of periosteal sarcoma. 167 


Expectant- treatment in chronic ar- 


— of sprains. 54 


ticular, 324 


— of synovitis, ia8 


, debnition of, 331 ^H 


Diastasis of the head ol the femur. 


, claims of, 333 ^M 


146 


, conclusions. 333 ^^M 


— versus Epiphysitis, 140 


Extensors of hip. 34 ^M 


— . traumatic, lesions from which 


Faradic current in diagnosis of os- ^^M 


differentiated, 151 


331 ^H 




Fasciie of hip. 36 ^^M 


ot. 140 


Family history in neuroses, value ^^M 


— , ire mm en I of. 151 


of. 66 ^H 


Dislocation, spontaneous, Mr. Hil- 


Flexion, resistance to, as diagnos- ^H 


ton on, 263 


337 ^H 




Flexors of hip. 33 ^H 


Double aniculM ostitis, frequency 


Fricke-s case of osUtit of the hip, ^M 


of. 34 


A 


— ^ _ ^ , 


.__■ 



406 

GaiTOd. Dr., 



1.75 









Geib. Dr. H. P., CMC of chronic 
rlieumatic arthrilis. 93 

GonjuDieter. Dr. Knigtii's, 374 

Gossclin, M., on Ti bio-femoral pe- 
riarthritis. 94 

Gross. Dr. S. W., on sarcoma of 
ihc long bones, 163 

Gross, Dr. S, D., syphilis as a pre- 
disposing cause of bone-disease. 
ioS 

Hugroan. Mr., the inclined plane 
(or " hip disease." 370 

Hamilton. Dr. Frank, on diastasis, 
147 

— , wire-gauze splint, 344 

Hemingway, Dr. S., case of epi- 
physitis, 143 

Heredity, phases of, aog 

Hilton on spontaneous dislocation. 

Hip. definition of, 30 

■'Hiplimp,"a33 
" Kip disease." double, 24 
Hip-splints, the abuse of. 373 
Hip-splint, Dr. Roberts', 376 
History of cases, mode of obuin- 

ing. 214 
History and record of case, sched> 

ule for, a% 
Histories, worthlesseess of many, 

234 
Holmes, Mr. T.. 00 excisiur, 397 
— . on chronic joint disease de- 
veloping struma, at 
Holt, Dr. L. E., case of sarcoma of 

the hip, 165 
Hot fomentations in periarthritis, 
107 



■r douche 

Hutchison, Dr. Jos., hip-splint. 360 

— , on (he physiological ~ 
of articular ostitis, 33B 

Hysterical elemei 

Immobiliiaiioo in articular ostitis, 
357 

Infantile spinal paralysis, diagnos- 
ticated from articular ostitis first 
stage. 28s 

Inspection in diagnosis, 271 

Inward roUtors ol hip, 35 

Iliac abscess, differentiated from 
articular ostitis, 309 



I!io-feraor^ crease, 31 
Irregular type of ostitis, 
Ischio-recta! abscess, significance 

of, 45 
Jacobi, Dr. A..on tbedevelopmenc 

of bone. Jog 
Janeway. Dr. E. G.. report on cases 

of ostitis. 183, 193 
Joint functions in diagnosis. 37s 
— lesions, multiple, ' 



Judson, Dr. A. B.. case and speci- 
men of epiphysitis, 136 
— , on pathology of " hip-diaeaae," 

171 
— , the U-shaped attachment for ' 

better fixation, 365 
Knee-pain, not confined to firM I 

stage. 254 
Knight. Dr. James, a goniometer, 

274 
— . on the mode of emplojring 

blisters. 13Z 
Lardaceous degeneration after mp- 

miration. statistics of, 934 ■ 

dependent on tubercular diiu | 



tbe: 



i. 267 



394 

Leather splint. Dr. Vance's, 34s 
Ligaments of hip, 

— , capsular, 3S 
— , cotyloid, 38 
— , teres, or, round, 38 



— , Ilio-femoral, 40 
— , I schiO' femoral, 40 
Ligamenitim teres, as primarily af- 

Liver, the tiorder of, in lardBceoiis ' 

changes, 194 
Long splint used by Dr. Sayre. 363 
Long splint, mode of applying, 365 
Lordosis complicating articular os- 

Macnamara. Mr. C. results of 
drilling trochanter for utictilar ' 
ostitis, 3SS 

— , on epiphysitis, 136 

Malaria as a cause of neuroMs, 71 

Malignant disease of the liip, t6l 

Malum coxx senile, B6 



^^^■■_^^^^M^^H 


^^^^^H^^^^^^^l^^^^^^^^^^^^^l ^^^1 


^^^^^^ 40fi ^^H 


^H Haluin coxK Mnile. rarely com- 


OMifiodon. centres of. 46 ^H 


H pleleankrlosislD, S7 




^M March, Dr. Aldcn. on pathological 


— of pelvis. 4b ^^^1 


^H dislocalion, 164 


Ostitic cry, 33S ^^H 


^H Martin, Dr.. case ol bursitis, 113 




^H Mayer, Dr. E., case of osteo-peri- 


bursitis, 117 ^^H 


■ ostitis. 104 


— , chronic, articular doable, fre- ^^H 


^H MeasutEmcnl for kngih of limb, 38 


quency of. 34 ^^^| 


^H Heningical byperBmia. a cause of 


— of hip with neurotic symptoms, ^^H 


^H neurosct, 63 


^M 




— of Ilium. diagnoBlicaled from ^^^| 


^H ing articular ostitis. 364 


articular ostitis, 397 ^^^| 


^B Mitchell, S. Weir, on spinal arthro- 


— . peripheral. 34 ^^^| 


^H palbies, 60 


Osteotomy, sublrochanteric. 400 ^^H 


^H Morris. Mr, Henry, on anatomy of 


Osteo-myetilis. ilarelalionshipwilh ^^H 


^H [he joint. 37 


articular ostitis, 196 ^^H 


^^M , on function of round liga' 


Outward routors of hip, 35 ^^H 


^H mem, 43 


Paget. Sir James, on the cause of ^H 


^H Movements of hip. normal, 46 


atrophy. 333 ^M 


^H Multiple joint lesions, 95 




^H Muscles of hip. classiGcalion. 33 


Pain in knee, not limited to Qrat ^^H 


^H Muscular rheumatism of the hip. 


254 ^H 


^H 


Pain in ostitis. 334 ^H 




Palpation in diagnosis, 373 ^^H 


^H Nates, changes in, value of. 237 


Parker, Mr. R. W., case of ariieu- ^H 


^H Nerve supply to abductors, 35 


lar ostitis; excised— subsequent ^^1 


^H to adductors. 34 


development of lardaceous dls- ^^^| 


^m lo extensors. 34 


ease; death: autopsy, 394 ^^H 


^M to fleiOTS. 33 


Parker. Dr. Willard, case of Dias- ^^M 


^^H to inward rotators. 36 


lasis. 14S ^^H 


^H~ to outward rotators, 35 


Passive motion under ether in Ad- ^^1 


^H Neuroses, 59 


hcsions folloning sprains and ^^H 


^H — , [be actual cautery in, 73 




^H — . complicating chronic articular 


Pathology of chronic articular M- ^^H 


^M ostitis. 6> 


titis, summary, 301 ^^H 


^H — , diagnosis of. 68 


— of chronic articular ostitis of the ^^H 


H - malaria as a cause of. 71 


170 ^M 


^H — , meningeal hypcixmia. tbe pa- 


— o( epiphysitis, 135 ^^H 


^H tbology of. 63 


Pattern tor Dr. Vance's splint. 346 ^^H 


^H — , prognosis in, 73 


Perforation of acetabulum, points ^^H 


^^H — , relapses in. 63. 69 


■IS ^M 


^H — , [reaicnent of, 6g 


Periarthritis, coxo-femoral. 94 ^^^H 


^H Neuromimesis, a case of Dr. Shaf- 


— , diagnosis of, 99 ^^H 


^M 63 


— , fibrinous, qt ^^H 


^M Normal movements of hip. 46 


~. points in diflerential diagnosis ^^H 


^H Obturator internus. its relation to 


103 ^^H 


^H pus-tracts. 4; 


— , rheumatic. 80-83 ^^H 


^M OIHer. M., on epiphysial byper- 


— . prognosis of. 103 ^^H 


^H xmia from traumatism, 174 


— , statistics of. 93 ^^M 


^H Operations for the arrest of articu- 




^m lar ostitis. 390 




^^H Operation for delormity. Barion s. 




^H 


Periosteal Sarcoma, diagnosis of. ^^H 


^H , Volkman's. 400 


167 ^^B 



4o8 



INDEX. 



Periosteal Sarcoma, statistics of, 167 

Periostitis of the hip, 153 

— , acute diffuse, 161 

— , diagnosis of, 156 

-:-, period of life when most fre- 
quent, 153 

— , causes of, 153 

— » prognosis of, 161 

— , treatment of, 160 

Perinephritis, differentiated from 
second stage of articular ostitis, 
306 

Physiological treatment of chronic 
articular ostitis, 338 

Poore, Dr. C. T., on osteo-myelitis, 
196 

, cases of sacro-iliac disease, 

299 

Post, Dr. Alfred C, case of dias- 
tasis, 148 

Position of limb, best, for locomo- 
tion when ankylosed, 322 

Pott's disease differentiated from 
articular ostitis, 301 

Poultices, following blisters, 132 

Practical shortening, 28 

Probe, the value of, 105 

Prognosis of bursitis, 117 

— of epiphysitis, 145 

— in neuroses, 73 

— of periarthritis, 103 

— of periostitis, 161 

— of synovitis, 128 
Real shortening, 28 

Record of case, schedule for, 28 
Reflex spasm in ostitis, 235 
Relapses in neuroses, 62, 69 
Rest in the treatment of contusions, 

57 
Result, best attainable, in chronic 

articular ostitis, 322 
Results of treatment by the long 

splint, 380 
Results of treatment by the Thomas 

method, 356 
Rheumatism of the hip. 74 
— , muscular, diagnosis of, 79 
— , treatment of, 85 
— , scientific dread of term, 74 

— following traumatic cellulitis, 78 
Rheumatic arthritis, diagnosis of,84 

. chronic, symptoms of, 91 

Rheumatic periarthritis, brisement 

force in, 85 



Ripley, Dr. J. H., case of rheuma* 
tic arthritis treated bj free pas- 
sive motion. 66 

Roberts, Dr. M. Josiah, hip splint, 
376 

Rotators of hip inward, 35 

outward, 35 

Round ligament^ function of, 42 

Round-celled periosteal sarcoma, 
162 

Sacro -iliac disease diagnosticated 
from articular ostitis, 298 

, cases of, 299 

Savory, Mr. Scovell, on analogy 
between pulmonary and epiphy- 
sial tissue, 176 

Sayre, Dr. Lewis A., cases of 
diastasis, 138 

— , operation for excision, 397 

— , short splint, 371 

Sciatica, a point in differentiating 
from joint disease, 91 

Schoeneman, Dr., case of perios- 
titis, 159 

Schedule for history and record of 
case, 28 

Scott, Dr. M. T., case of articular 
rheumatism, 79 

Sector splint, 373 

Sensitiveness of bone and joint in 
diagnosis, 276 

Shaffer, Dr. Newton M., on a case 
of neuromimesis, 63 

— , on traumatism, 217 

— , on the faradic current in diag- 
nosis. 232 

Shortening, real and practical, 28 

Short splint of Dr. Sayre, 371 

Smith, Mr. Noble, on hip-spUnts, 
372 

Smith, Dr., Henry H., on the me- 
dulla of bones, 188 

Smith, Mr. Thomas, on the diag- 
nosis of acute epiphysitis, 315 

Spaulding, Dr. G. A., on the sequel 
of a case of neuromimesis. 64 

Spinal deformities complicating 
articular ostitis, 267 

Sprains, diagnosis of, 54 

— , treatment of, 56 

— , 50 

Sprain, symptoms of, 52 
Stage, first, of articular ostitis de« 
fined, 226 



^^BC^^^^^^^V 


^I^^^^^H^^h^^^^^^^^^^^^l ^^^1 


^^^^^^r 409 ^^M 


Stage, firsl. sj-itiptoms t,'. 139 


Taylor. Dr. R. W., on syphilittc ^H 


SUgcs. ihe insidious pauaee Irom 


ostitis, 143. ^H 


first 10 second. 346 


— , syphilis as related to bone-dl*- ^^H 


— of ireaiincnt by the Thomas 


ease, 308, 3M ^M 


inelhod, 355 


Thomas. Mr. Hugh Owen, splint ^^M 


, oFarlicuIaT ostitis, diagnosis 


for "hip-disease," 349 ^^H 


of, 306 


— . method of examination, 37; -^^H 


Stage, second, deformity of, 349 


Traction in articular ostitis, some ^^™ 


. definiiioo of. a40. 347 


facts concerning. 359 


. symptoms 0/, 348 


TraumatlEm, its influence in induc- 


, duration o(. n? 


ing exacerbations, 344 




— , lis relation 10 bone disease. 307 


of, 350 


Traumatic diastasis, infrequencr ^^H 


, clinical picture of. 359 


of. 140 ^M 


, duration. 359 


Treatment of articular ostitis, re- ^^H 


Statistics of periarthritis, g; 


suits of. by the Thomas method, ^^H 


— in joini disease, as t© etiology, 


^H 




— oF chronic articular ostitis by ^^H 


— . Dr. C. F. Taylor's, 38a 




Struma as related to tubercle. 304 


— of articular ostitis, conclusioni, ^^H 


— as developed by suppuration, 


3S6 ^M 




— of bursitis. 114 ^^^M 


— developed by the exanthemata. 






— of epiphysitis, 146 ^^H 


Strumous elcmcni in etiology. 306 


— of neuroses, 69 ^^^H 


Stillmao, Dr. C. F.. sector splint. 


— of periostitis, 160 ^^^| 


373 


— of periarthritis. 107 ^^H 


— , brace for hip and pelvic de- 




tormitles. 375 


— , results of, by the long ipllnu. ^^H 


Subirochatiicric ostcoioray, 400 


^^M 


Sympathetic hips, 25 




Symplomsof sprain. 53 


— of sprains, 56 ^^H 


— of second stage, 248 


— of synovitis. 131 ^^H 


— of chronic rheumatic arthritis, 


Treves. Mr. Frederick, on the rela- ^^H 


9' 


tionship between struma and tu- ^^H 


— of first stage, 239 


bercic, 304 ^^H 




Trochanter, drilling of, 333 ^^1 


Synovial membrane. 44 


Tubercle as related lo struma. 304 ^^1 


— fluid. 44 


Types, irregular, Intrequency of, ^^H 


— membrane, as primarily affected 


139 ^^1 


in ostitis, 173 


Ulceration of arteries complicating ^^M 


Synovitis, acute primary. t3i 


articular oMiiis. z66 ^H 


— , diagnosis of, isS 


Vance, Dr. Ap M., leather splint, ^H 


— , duration of. 133 


34$ ^^1 


— , symptoms of. lai 


Volkman's case of ostitis of the hip, ^^H 


-, treatment of. 131 


186 ^H 


— , prognosis of. 138 


— case of ostitis with exfoliation of ^^1 


— , rarely ends in chronic joint- 




disease, 135 


— subtrochanteric osieoiomy, 400 ^^H 


Syphilis as related to bone-disease. 


Washburn, Dr., hip-sptln(. 359 ^^H 


20S 


Welch. Dr. Vfm. H.. on (he pathol- ^^1 




oicy of strumous osiills. T8g ^^1 


8-^ 


Welch. Dr. Wm. H,. report on ^^M 


— , practice of, 360 


round-celled sarcoma, 164 ^^H 

i 



4tO SUPPLEMENTARY INDEX FOR CASES. ^^H 


WiTlanl. Dr. de T.. cm* of "hip- 


Wright, Mr. Geo. Arthur, on Mtt ^^H 


joinl disease," death in earlv 


ImporUnce of recognizing lb« ^^^H 


sl»BC. I7S 


initial lesion. 37a ^^H 


Wire-cuirass after excision. 396 


Wyetta. Dr. John A., the comUna. ^^M 


Wire-gatue spUni of Dr. Hamilton. 


lion method, 367 ^^H 


344 


Yale. Dr. Lcroy H,. od exci(i«a«, ,^^H 


Wrenclies for orthopedic appli- 


.^H 


anCM. 350 


■ 


SUPPLEMENTARY 


INDEX FOR CASES. H 


Articular Ostliis with arterial bem- 




orrbage complicating, 266 


ly; good result. 339 ^^^1 


diagnosticaled as synovitis. 




ags 


»utopsy. 331 ^^m 


and Pott s disease, diagnosti- 


treated expectantly : fair re- 1 




suit. 339 


illustrating diagnosis of, 177 


treated by physiological 


simulating sprain, 279 


method : result dislocation and 


with a rheumatic history, 281 


death, 34» 




with lardaceous degenera- 


topsy, l3l 


tion; excised; recovery, jgi 


responding to faith-cure (?). 


, excision; lardaceous degen- 


83' 


eration three years later; death; ^^1 


, multiple. 19S 


autopsy, 394 ^^H 


illustrating slow evolution, 


Amyloid or. Lardaceous Degenerft- ^^M 


338 


tioo, cured by dislocation, 365 ^^^1 


with two and a half years' 


Bursitis long regarded as "hip. ^^^H 


interval between invasion and 


disease." Ill ^H 


second stage, saS 


— with a peculiar click, 113 ^^H 


after typho- malarial fever. 


— , gluteal; recovery, II3 ^^^H 


314 




from acquired slnima, 314 


of articular ostitis, 379 ^^^1 


in a family of hip cases, 33s 




treated ejtpcclanlly;«edlent 


recovery, 51 


result. 3^6 


— , result of fall from grealheight; 


treated bv a long sptloi; ex- 


perfect recovery, 55 


cellent tesult, 32B 


Caseous Ostitis, illustrating in. 


treated expectantly; poor re- 


tluence of heredity, 316 


sult. 333 


, specimen showing third sloce 


treated by the pbysiotopcal 


changes. 19a 


method: lair result, 33B 




— ~ double, treated expectantly ; 


as synovitis, 173 ^^m 


bad result, 334 




treated by physiological 


^H 


method ; result, lardaceous de- 


Diastasis (7). 138-9 ^^^1 


generation, 341 


.47 ^M 


^.— double, treated by physio- 


Dislocairon, diagnosucaced aa ok ^^^M 


logical method ; fair result, 340 


3iS ^^M 



^^I^^l ■ 




SUPl'LEMENTARV INDEX FOR CASES. 41I ^H 


OUIocalion, congeniul. 150 


Ostitis, second stage, precipitated ^^| 


— . traumatic, diagnoslkated as 


by trauma, 144 ^H 


■'hip-disca»e," 317 


— , illustrating passage (mm first to ^^^M 


Epiphysitis, acute, with specimen. 


second sta^c, 346 ^^H 


136 


— , progress interrupted, 243 ^^H 


— at syphilitic (?) origin. 137 


— of the hip to illustrate Second ^^H 


— with bony tepajr and shorten- 


Stage, :4o ^^M 


ing. 141 


— with abscess, disappearing, ajB ^^^H 


Fracmre ol thigh, Incomplete, upper 


— speedily reaching second stage, ^^H 


fourth, joint unimpaired, j6 


^H 


Femoral disease in one hip, aceta- 


— reaching second stage after first ^^H 


bular in the other, 177 


exacerbation. a;3 ^^M 


Femoral abscess from Pott's dis- 


— with progress very nearly pain- ^^H 


ease, diagnosticated as " bipdis- 


less, 348 '^H 


ease." 313 


— cured in third stage, aja ^^1 


Iliac abscess, loi . 


— illustrating third stage, aja ^^1 


Uio- psoas Bursitis, ending in joint- 


Periosliiis. i;3 ^^1 


disease, tJ7 


— , closely simulating " hip-dl>- ^H 


Infantile Paralysis, diagnosticated 


ease," 158 ^M 


aa articular ostitis, 336 


— near sacroiliac )unciion, tj6 ^^H 


ludson. Dr., three cures reported. 


— illustrating diagnosis. Ij6 ^^H 


383 


— following a cellulitis, 156 ^^H 




— with necrosis. 154 ^H 


sunding, 367 




predicted by specific gravitj 




of urine, 866 


lar ostitis, 29; ^^^| 


arrested by amputation, 394 


Perityphlitis, 309 ^^H 


Neurosis to illustrate diagnosis of 


Periarthritis suppurative with fatal ^^H 


articular ostitis. 384 


result: autopsy, OS ^^^H 


— simulating spinal caries, long 






^m 


— of both hips, diagnosticated aa 


— . with glandular suppuration, 99 ^^H 


bone-disease. 61 


— . with extensive suppuration; re- ^^H 




covery. 97 ^^H 


bt 


— . chronic rheumatic, nith exacer- ^^^H 


— complicated by periarticular 


balions. So ^^H 


swelling, 67 


— Coxo-femoral. 94 ^^H 


— complicated by inguinal aden- 




itis. 70 


— illustrating diagnosis, 99 ^^H 


— of long standing promptly 


— with complicating neurosis, 101 ^^H 


eured by blistering and poultic- 


— , fatal: exhaustion, 108 ^^H 


ing. 69 


— resulting in bone disease, 103 ^^H 


Necrosis of Ilium. 104 


— with signs of ostitis, 100 ^^^| 


Ostitis or Diastasis, 149 


— diagnosticated as"bip-disease," ^^^| 


— , syphilitic, 210 


aS9 ^M 


— . chronic articular without at- 


Perinephritis. 306 ^^H 


rophy, aja 


Pott's disease diagnosticated ax ^^H 


— of the hip with recurring naso- 


articular ostitis, 301 ^^H 


facial erysipelas, 215 


Reported by Dr. C. F. Taylor, 381 ^H 


— in the wake of pertussis. 113 


Rheumatism diagnosticated from ^^H 


— with spontaneous dislocation. 


family history. aSi ^^H 


a6a 




— with rcslsunce only to abduc- 




tion and rotation. 336 

to 


lar ostitis, aSi ^^H 



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