•^■ 0m^t^m'^h .m. H\^Q^^^. CoIutttWa ^mbet^ttp h-. E^ • r:^^: ^^!^ ^SM Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/etiologypathologOOIove FiSKE Prize Fund Dissertation, No. XLII. THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF Diseases of the Hip Joint, ROBERT W. LOVETT, M.D., ' OUT-PATIENT SURGEON TO THE BOSTON CITY HOSPITAL; ASSISTANT SURGEON TO OUT-PATIENTS AT THE CHILDREN'S HOSPITAL, BOSTON ; MEMBER OF THE AMERICAN ORTHOPEDIC ASSOCIATION. " I knew the mass of men conceal'd Their thoughts, for fear that if reveal'd, They would by other men be met With blank indifference, or with blame reproved." Matthew Arnold, "The Buried Life. ^'' BOSTON: Press of Geo. H. Ellis, 141 Franklin Street. 1891. THE Trustees of the Fiske Fund, at the annual meetmg of the Rhode Island Medical Society, held June ii, 1891, announced that they had awarded a premium of three hundred dollars for the best essay on " The Etiology, Pa- thology, and Treatment of Diseases of the Hip Joint " to an essay bearing the motto, — " I knew the mass of men conceal'd Their thoughts, for fear that if reveal 'd. They would by other men be met With blank indifference, or with blarae reproved." The author was found to be Dr. Robert W. Lovett, of Boston, Mass. WILLIAM H. PALMER, M.D., Providence, ROBERT F. NOYES, M.D., Providence, ELISHA P. CLARKE, M.D., Hop Valley, Tricstees. GEORGE L. COLLINS, M.D., Providence, Secretary of the Trustees. CONTENTS. PACE. I. Introduction and Classification 9 II. Acute Arthritis 14 III. Acute Synovitis 27 IV. Chronic Serous Synovitis 39 V. Tuberculous Ostitis (Hip Disease): Pathology and Etiology, including Chronic Purulent Synovitis ... 44 VI. Tuberculous Ostitis (Hip Disease): Treatment . . 70 VII. Gummatous Ostitis 145 VIII. Arthritis Deformans 148 IX. Charcot's Disease 166 X. Malignant and Other Tumors 171 XI. Loose Bodies 179 XII. Congenital Dislocation , . . 182 XIII. Hysterical Affections 215 Chapter I. INTRODUCTION AND CLASSIFICATION. In the present state of Pathology it is impossible to present any classification of diseases of the hip joint which shall be exact, or which shall be sanctioned by authority weighty enough to give it pre-eminence. It is essentially a time of transition in the history of the pathology of bone and joint disease, a time when tuberculosis has sprung into such prominence that the tendency is to refer to it the great mass of all chronic bone and joint disease. Coming as it did upon a pathology in which tuberculosis played a minor part, this change has disturbed the former arrangement; and enough time has not yet elapsed for the evolution of a new and permanent basis of classification. Consequently, each one who deals with these subjects has to formulate for him- self, as best he can under the existing conditions, the phe- nomena occurring in diseased joints. The classification given here is merely a scheme of abnor- mal conditions, which are to be clearly recognized in the hip joint, and which, it is hoped, has at least the merit of being practical. It follows no authority, because there is none to follow ; and it must stand on its own merits as a practical working classification. It does not enter into the refine- ments of subdivision, and so far as is practicable it rests upon a pathological basis. It has not been possible, for obvious reasons, to follow this out rigidly ; but, so far as possible, a pathological rather than an etiological basis has been adopted. 10 DISEASES OF THE HIP JOINT Acute Diseases of the Hip Joint. Acute Arthritis. « , e •*• ( Serous. Acute Synovitis. ^ ^^ , . { Purulent. Chronic Diseases of the Hip Joint. ^, . c •<-• *^ Serous. Chronic Synovitis.- -p, i ^« ( Purulent.* Chronic Ostitis (Tubercular). Chronic Ostitis (Gummatous). Arthritis Deformans. Charcot's Disease. Malignant and other Tumors. Loose Bodies. Miscellaneous Conditions. Congenital Dislocations. Functional Affections. * Chronic purulent synovitis is considered together with chronic ostitis. The discussion of the subject has been confined strictly and entirely to the subjects of Pathology, Etiology, and Treatment, as prescribed by the Trustees of the Fiske Fund. Each affection has been considered separately, and the pa- thology, etiology, and treatment of each are discussed individ- ually in the order designated. Inasmuch as in so extensive a subject as this it is manifestly impracticable to treat all parts with equal thoroughness, it has been the aim of the writer, so far as possible, to present the more practical side of the question, and to lay particular stress upon the dis- cussion of the treatment of the various affections, and par- ticularly the treatment of that most common of all affections of the hip described under the name of hip disease. Where it has been possible, the writer has endeavored to give the scientific reasons for the different modes of treatment. The consideration of the pathology and etiology was of necessity of the nature of a compilation ; but, in discussing the treat- ment of the various affections, it has been the aim of the writer to make it, to a certain extent, individual, by giving INTRODUCTION AND CLASSIFICATION II the results of his own experience in addition to that of other authors. It was a question in the mind of the writer whether congenital dislocation of the hip should be considered in this connection. It seems, however, that any consideration of diseases of the hip would sadly lack completeness that failed to include so important and so comparatively common a condition as this, and on this ground that deformity has been placed upon an equal footing with the other conditions. A few words should be said with regard to the anatomical relations of the hip joint. The joint lies so deeply buried in the soft parts that it possesses a remoteness that is not a condition in any other joint. As a result of this, in hip joint inflammations the seat of the disease itself is not accessi- ble to examination and observation, as is the case in the more exposed joints. One must depend more upon the re- mote symptoms, such as muscular spasm and the various malpositions, than on the direct evidences furnished by pal- pation and direct examination of the hip joint cavity. This adds an unfortunate complication to .the study of diseases of the hip, because nowhere is the early diagnosis more important than here, and nowhere are the disastrous results of overlooking the disease more distressing. On account of its remoteness and its firm protection by the strongest muscles and ligaments of the body, the joint is not one which is liable to traumatic affections, as any force exerted upon the leg is more likely to find its expression in traumatic inflammation of the less protected knee and ankle. The development of the femur is by one centre of ossifi- cation for the shaft, and one for each of the four epiphyses. A single centre for the lower epiphysis appears shortly be- fore birth, one for the head of the femur in the first year, one for the great trochanter in the fourth year, and one for the trochanter minor in the thirteenth or fourteenth year. A neck is formed by extension of the ossification from the shaft, and the head is not united to the shaft by bony union until the eighteenth or nineteenth year. The physiological 12 DISEASES OF THE HIP JOINT development is most rapid and most marked in the upper epiphysis, and especially in the neighborhood of the epiphys- eal cartilage. Certain points are of practical interest as considered in Mr. Morris's "Anatomy of the Joints." 1. The head of the bone is completely included in the acetabulum. 2. The whole upper epiphysis of the femur is within the joint. 3. The direction of the axis of the neck of the bone is such that a force applied to the trochanter will tend to oblit- erate the angle between the neck and the shaft of the bone, and consequently will be largely expended upon the inner aspect of the neck. 4. The main vessels of supply to the bone enter upon the upper surface of the neck. 5. The fact that the nerve supply is derived from the an- terior crural, the obturator, and accessory obturator nerves, along with the sacral plexus, and that these are to a large extent the same nerves which supply the important muscles controlling the hip joint. 6. That the psoas bursa frequently communicates with the joint through the thin triangular space between the ilio- pectineo-femoral band. 7. The cartilage covering the head of the femur is not all articular, in the sense that it forms a part of the bearing surface of the joint. A considerable zone, which may be designated "marginal," extends around the rest, and is more or less provided with synovial membrane. This cartilage often persists after destruction of the articular surface, and through this zone numerous vessels pass, which in disease are often enlarged. These vessels are apparently derived from synovial membrane ; and in most cases, no doubt, in- flammation reaches the synovial tissue through their agency. 8. The ligamentum teres forms, as it were, a channel through the articular cartilage to the bone, — a fact of impor- INTRODUCTION AND CLASSIFICATION 1 3 tance in determining the extension of disease from the bone into the joint. 9. The normal range of movement of the joint is through 145-150 degrees. Flexion is checked by contact of the thigh with the abdo- men and hyper-extension by the Y-ligament. Finally, it is important once more to call attention to the very active physiological hyperaemia which exists in the neighborhood of the epiphyseal cartilage, and which is an important factor in determining the location of tuberculosis ostitis. 14 DISEASES OF THE HIP JUlXT Chapter II. ACUTE ARTHRITIS OF THE HIP JOINT. BEING A FORM OF THE ACUTE ARTHRITIS OF INFANTS. The affection has also been described as Pcraciite Articu- lar Ostitis, or Epiphysitis (Barwell and Stromeyer *), Acute Epiphysitis and Suppurative Ostitis (MacNamara f), Meniugo- osteo-pJdebitis and EpipJiysentrennuug (Klose |), Acute Osteo- myelitis and Necrosis of Epiphyses (Jones §). Earlier writers describe what appears to have been this affection under a multiplicity of names, which it seems of little use to catalogue. A complete list of them is given in Townsend's article upon the subject. || The many different names applied to this condition point to an obscure pathological process, which is differently in- terpreted. Later usage has adopted the "name of Acute Arthritis of Infants for the particular condition under dis- cussion, which describes accurately enough the disease, and does not postulate any definite pathological theory. The term was first used byTerisse^ in an inaugural thesis in 1833 ; but its present use is due to the classical article of Mr. Thomas Smith in 1874, which was the first clear description of the affection and from which dates its modern recogni- tion.** * Diseases of Joints. R. Barwell. Americaa Ed. 1881. t Diseases of the Bones and Joints. MacNamara. London, 1SS7. $ Prager Vierteljahrschaft. 1S5S. § Diseases of the Bones. Thomas Jones. London, 1887. II Acute Arthritis of Infants, American Journal of Medical Sciences. Januars*, 1S90. IT Observations d'Arthrites aigues chez r Enfant nouveau ne. Paris. **St. Barth. Hosp. Rep. 1874, vol. x. acute arthritis of the hip joint 1 5 Pathology. It is not probable that the term acute arthritis of infants represents any pathological entity, as was first considered to be the case by those who described it. Rather it is to be considered as an acute joint destruction, in most cases pyemic, but also to be attributed to other causes. Clinically, all these cases are described as acute arthritis of infants. Pathologically, this affection may be the result of (i) a syphilitic osteo-chondritis, (2) a catarrhal synovitis passing on to ostitis, (3) a tuberculous ostitis running a rapid course, (4) a juxta-epiphyseal osteomyelitis of a septic character. The first three divisions will be described under their ap- propriate headings in other parts of the essay, and here will be considered only the last named, originally supposed to be the sole condition found in acute arthritis, and which consti- tutes the bulk of all cases of arthritis of the hip occurring in children less than a year old. Acute arthritis of infants in most cases is, then, an acute infectious osteomyelitis of the upper epiphysis of the femur. This was the view of Mr. Smith in his original article, and later investigations have borne out this idea. In most cases, therefore, the disease is to be considered as an affection primarily osseous. The great formative ac- tivity which exists at the upper epiphyseal cartilage of the femur in the early years of life is an explanation of many of the phenomena of this disease. Bone disease of all sorts is more likely to originate on the diaphyseal side of the epiphyseal cartilage than on the articular side. Fourteen-fifteenths of the length of the bone are due to the growth on this diaphyseal side, if we may accept Ollier's estimate ; and this great formative activity, of course, means a state of physiological congestion. On the diaphyseal side of the cartilage one finds a dense capillary network, surrounded by a venous plexus ; a spongy tissue, in short, predisposed by its structure and its function to acute l6 DISEASES OF THE HIP JOINT congestion, venous stasis, and rapid disintegration Moreover, it is easy to see, as ]\Ir. Neve * explains, why external causes tend to locate disease of the bone in this region. When a child is exposed to a sudden jar or a traumatism of any sort, much of the force will be transmitted to the cartilage and modified by its elasticity. But the maximum effect of the injury will be manifested, for mechanical reasons, at the junction of the rigid bone and yielding cartilage. [Moreover, the fine capillary network above alluded to will act as a filter for infectious material and pathogenic or- ganisms. For these reasons infection and traumatism in predisposed subjects favor a juxta-epiphyseal location of the disease, and this explanation serves equally well to explain why chronic articular ostitis is located so often in the same region. The first stage of the process is an increased hypersemia of the vessels in the neighborhood of the epiphyseal cartilage. Stasis and cellular infiltration follow, and with the distention of the vessels the nutritive supply is cut off over large or small areas, because swelling is impossible on account of the rigid cortical layer, and strangulation follows, causing the necrosis of larger or smaller areas of spongy tissue. An acute purulent inflammation being present under such conditions, the destruction of bone is rapid. Melted down by the pus or shut off from its blood supply, it disintegrates, and the process extends, most often in the direction of the joint. At an early stage the naked eye sees on section an area of spongy tissue of considerable extent, which is bright red or dusky; and the marrow is transformed into a semi-fluid mass of pus and melted fat, often offensive in odor, colored more or less red b}' extravasated blood. The periosteum is generally thickened, and purulent periostitis may be present secondarily. The cancellous tissue is pink and somewhat thickened. If the detritus is washed away, the spongy tissue ♦Arthur Xeve, Practitioner, January, iSgi. ACUTE ARTHRITIS OF THE HIP JOINT IJ appears red and softened, with, perhaps, spots of disintegra- tion or bits of necrosis. In some cases, the necrosis may have been sufficient to show a sequestrum of considerable size. At times the pus may be dark and thin, or it may be profuse, and resemble laudable pus. In most cases, the process tends to involve the joint. Commonly, the inflammation extends by the spongy tissue to the articular surface, and destroys the cartilage over a larger or smaller area, entering the joint to start up an acute puru- lent synovitis. In other instances, it may burrow under the periosteum, having started as a subperiosteal abscess at some more remote point, and enter the joint in that way. In still rarer instances, it may seek the surface of the bone, and, dis- charging into the soft parts, come to the surface and be evacuated without infecting the joint. The relations of the epiphysis and the joint capsule in young children are such that a focus of disease beginning in the epiphysis is practically within the joint from the begin- ning, as the epiphyseal cartilage is indistinguishable from the articular cartilage, and is in immediate relation with the capsule of the joint. When the joint is infected, destruction is rapid. The carti- lages and the articular ends of the bones melt down into pus, the capsule bursts, and, if the process continues, the ligaments and the capsule melt away. Sinuses form to drain away the products of destruction, and it seems difficult to set a limit to the process. The destruction about the epiphyseal cartilage may be so much that it is loosened from the diaphysis and lies loose, as if a section of the neck of the femur had been made. This results in a flail-like joint, and simulates very closely in walk- ing and manipulation the condition known as congenital dislocation of the hip. This is a common ending in cases of acute arthritis which recover. In other cases, an extensive sequestrum may remain. In young children however, the usual victims of this affection, 1 8 DISEASES OF THE HIP JOINT the process is of such virulence that necrosis is of little account compared with the rapid and extensive destruction of the bone and soft parts and the general sepsis, which is most marked. The character of pyogenic germs in the pus of acute ar- thritis is a matter of much interest. In the pus one finds various forms of the staphylococci, notably the S. aureus. Exceptionally, the streptococci may be present as the cause of suppuration ; and Volkmann found a coccus resembling the diphtheritic coccus of Loeffler. Metastatic abscesses may be found present, and the other pathological signs of general pyasmia are common in the cases of longer duration. In cases which have successfully withstood the acute at- tack of the disease, several conditions may be found which speak for the virulence and destructiveness of the affection. As has been said, (i) the epiphysis may be separated from the femur and a fiail-like joint be the result, (2) the head of the femur may be so eroded and the capsule so disinte- grated that dislocation may have occurred, (3) the articu- lar ends of the bone may be roughened and destitute of car- tilage, so that joint movement is accompanied by grating, (4) or, finally, more or less complete fibrous or bony anchylosis may be present ; but this is not so common as the other ter- minations. Etiology. The etiology of this form of joint disease is obscure; and, in the -present state of knowledge regarding it, the question can only be briefly discussed, and dismissed as unsettled. The pathological knowledge is imperfect, as it must have already appeared, largely because the data are insufficient, and, from the etiological side, the data are even more unsatis- factory. Traumatism is, of course, assigned a place in the etiology, and certain cases seem clearly traumatic in origin, as in one ACUTE ARTHRITIS OF THE HIP JOINT IQ of Mr. Smith's cases, where rough handling at birth seemed to have been the cause of the subsequent joint trouble. But for a simple traumatism to cause so violent and destructive a process seems unlikely and not reasonable. Rosenbach * demonstrated by experiments upon animals that neither mechanical injuries nor comminution of the mar- row by violence were sufficient to cause suppuration at the seat of injury. He showed, further, that the marrow was ex- tremely sensitive to the influence of septic substances, such as rancid butter, or the products of decomposition in general. Krause'sf experiments form a very interesting complement to these. He showed that in animals who had been infected by the injection of 6". auretis and albus cultivated from osteo- myelitic pus the fracture of the bones was followed by sup- puration at the seat of the injury, which was like an ordinary septic infection occurring there, except that the marrow was more extensively involved. These experiments would lead one to infer that traumatism alone was not enough to cause so great a destruction as oc- curs in these cases, but that, in connection with infection, either general or local, it might serve as the exciting and de- termining cause of the affection. Such a state of affairs is quite parallel to what will be observed later in speaking of the etiology of tuberculous disease. Pure cultivations have been made from the cocci of acute osteomyelitis, J and, as has been said, it was found that, if they were injected into the blood, bone injuries and fract- ures suppurated. § By their injection into joints, purulent arthritis was started up, and great quantities in the circula- tion killed rabbits and guinea pigs. Rosenbach found the same coccus in furuncles, empyaema, abscesses, and pyaemia. The place of traumatism, then, in the etiology becomes- *Cent. f. Chir., 1S84, No. 5; 1877, p. 289. t Fortsch. der Medicin, 1884, Nos. 7 and 8 + Rosenbach, Mikro-organismen b. d. Wundinfectionskrank. Wiesbaden, 1884.. § Krause, Fortsch. der Med., ii. 1884. 20 DISEASES OF THE HIP JOINT subordinate to that of infection of the general system from some source. An injury may be enough to locate a de- structive process in some one joint, or, on the other hand, so far as can be told, the disease may originate without trauma. The obscure question arises, when one asks, Why children under one year are the ones particularly liable to this affec tion, and how do apparently healthy children become sud- denly infected, and by what channels ? In this connection the statement of Escherich is of particu- lar interest, who found in all children at the breast, whether well or ill, the Staphylococcus aureus and albiis in the liver and the superficial layers of the skin. In the acute infectious diseases, pyemic affections are not uncommon, and acute destructive joint disease occurs in older and in vounger children. The acute arthritis of infants is one of the forms of this manifestation, and the pyemic infection after the exanthemata is one of the most common and the most satisfactory of explanations for the presence of the pathogenic germs in this disease. Of a comparatively small number (about 75) of these cases on record, a larger proportion are to be traced to the exan- themata than to any one cause. Cases have been reported due to chicken-pox,* and to va- riola,! measles, and scarlatina,t and, finally, pertussis, § and typhoid fever. The definite etiological character of the joint affections following the exanthemata has not been formulated further than to class them as pyemic. The frequency of such affections requires no comment. As an instance of a direct source for purulent infection may be mentioned cases of suppurating umbilicus. Such cases came under the observation of Townsend. In one case, empyasma seemed to be the cause. Again, a wound * Holmes, Surg. Treat, of Dis. of Inf. and Childhood. tMcLeod, Indian Med. Gazette, 1SS3, p. 232; Ancell, Archives of Medicine. 1S30, vol. iv. p. 491. {Eustace Smith and Ashby and Wright, in their Diseases of Children. § Ashb}- and Wright, Diseases of Children. ACUTE ARTHRITIS OF THE HIP JOINT 21 may appear to be the site of the infection ; but, in most cases, one must fall back necessarily upon a theoretical ex- planation of the entrance of the germs, and assume "that the infection may occur through the ears, eyes, nose, mouth, pharynx, respiratory passages, mucosa of the alimentary canal, or skin ; . . . furthermore, from any subcutaneous phlegmon, however small." * In this connection, one passes to the question of the patho- genic germs which are to be found, and the role which they play. Oilier quoted Rodet f as stating that all the varieties of juxta-epiphyseal ostitis might be produced by the inocula- tion of the Staphylococcus aureus. And no form of coccus has yet been discovered in the acute arthritis of infants which is different from those found in acute osteomyelitis, so that the conclusions of Park may be stated as defining the character of the pathogenic germs present in the affection under consideration. " It is a manifestation of the pathogenic properties of several micro-organisms possessing common specific pyo- genic activities. It is a phlegmon of bone or local pyaemia." To quote further, his conclusions are : (i) that there is no specific microbe for the production of acute infectious proc- esses in bone; (2) most of the staphylococci can cause them, and exceptionally the streptococci ; (3) of all the forms the Staphylococcus aureus is the most pernicious, and of the general causes which favor the entrance and influence of these germs the tubercular, syphilitic, and post-febrile condi- tions are the most prominent. In short, the affection is to be considered as a form of pyaemia. It is not so much that the arthritis is the cause of pyaemia as that the joint disease is pyaemia from the begin- ning, and that traumatism operates chiefly as an exciting cause rather than as the real originator of the affection. The relation of tuberculosis to this affection is very ob- *R. Park, Am. Jouni. Med. Sci., July, 1889. t Revue de Chir., 1885 ; Ann. de Gyn. et d'Obstet., 1S8S, p. 81. 22 DISEASES OF THE HIP JOINT scure. Acute arthritis occurs most often in feeble children, perhaps the offspring of tuberculous parents; but a tuber- culous history is not constantly or commonly present. The affection is not one which has attracted much attention of late years, since the range of tuberculosis in joint disease has been better understood; and pathological data are want- ing to establish the proportion of cases where the bone inflammation is tuberculous in character. It would seem reasonable to suppose that some of the cases were of that nature, and that in these the tuberculous process was of ex- ceptional virulence and rapidity, although following the same course, pathologically, as in the chronic affections of older children. A careful search of recent literature has not en- abled the writer to present any more definite conclusions than these with regard to the role of tuberculosis in the etiology of this affection. The same may be said with regard to inherited syphilis. It is not recognized as a cause of the affection, nor is it known what influence it has. On general principles, it might be classed as a predisposing cause, inasmuch as it would tend to depress the general condition of the patient. Dismissing, then, for the moment the more theoretical considerations, one finds that practically this affection at- tacks most commonly children in the first year who are not as healthy as they should be. Of the 71 cases analyzed by Townsend, 20 were less than four weeks old, and several were in their first week, 10 were less than two months old, and 6 were in their third month, making half of all the cases which occurred in the first 12 weeks of life. It can be seen from this that one is dealing in most cases with a well-marked joint affection, which stands off clearly enough from the usual forms of the affection and which merits its separate name and justifies its individual consider- ation. One point, however, deserves comment. The cases of this affection, so called, which occur in older children, ACUTE ARTHRITIS OF THE HIP JOINT 23 are open to the suspicion of being the ordinary forms of tubercular joint disease which are running a rapid course. Tubercular joint disease in young children is, as a rule, acute and rapid, and would closely resemble the affection under consideration. To sum up in a word the results of this consideration of the etiology, one would be justified in stating that the dis- ease was a pyaemic affection of bone, occurring in very young children ; that the role played by syphilis and tuber- culosis in the causation of the affection was not, as yet, understood on account of insufficient pathological findings, and that in older children the affection closely resembled, and was likely to be confused with, typical but rapid cases of bone tuberculosis ; that, however, acute arthritis occurred in young children as the result of syphilis, and probably as a distinctly tubercular affection, which will be considered under the proper divisions of the subject. Treatment. The acute sepsis which is so prominent a feature in this disease is, as a rule, the point against which the first attack must be made m the treatment of the affection. It is this which threatens life, and which kills the patient in fatal cases. Consequently, a strongly supporting treatment must be entered upon, as in the treatment of pyaemia in general ; and it is of course more difficult to carry out such treatment in the case of such young children than in adults. The use of alcoholic stimulants in appropriate doses is indicated from the first, with the administration of quinine ; and much dependence must be placed on frequent feeding with appropriate and easily assimilated food, preferably, of course, the mother's milk. In the older children, the use of beef juice and meat extracts is of much benefit from their stimulant properties. In the more asthenic cases, digitalis and ammonia might prove to be of use. Iron should be ad- 24 DISEASES OF THE HIP JOINT ministered as the syrup of the iodide, and is of much benefit in the convalescence. The local treatment is often of greater importance than the general, and in the milder cases it is the chief interest. Rest to the joint and free incision are the aims of local treat- ment. Acute sensitiveness of the diseased joint is a con- stant accompaniment of the affection, and mechanical fixation of the joint should be directed to the relief of that symptom. Inasmuch as the hip is almost invariably flexed in acute arthritis (and perhaps adducted as well), it must be fixed and held in the position of deformity without any attempt to straighten or correct it, which would cause very much pain. Fixation of the joint in its deformed position can be obtained by Qa) a wire frame, (^b') a plaster of Paris spica bandage, (<:) by bed extension with the leg on an inclined plane. The posterior wire frame known as the Cabot frame is the most convenient apparatus for use in such young children. Plaster of Paris becomes soaked with urine, and softens and irritates the skin so that it becomes a foul and irritating dressing ; and rest in a recumbent position is almost impossi- ble to enforce in children of this age. So that in all cases of acute arthritis of the hip, before and after operation and v/here no operation is indicated, a fixative appliance is an essential; and this is furnished in the Cabot frame. It is made of copper washed iron wire, one-fourth inch in diameter ; and it reaches from the angle of the scapula to the bottom of the calf. Above it should be as broad as the body, and at the level of the sacrum it should turn at a right angle, and below that consist only of one leg piece, which should be as wide as "the leg. It is a posterior wire splint for the body and for one leg. The leg piece can be bent to suit the flexion. So far as possible, the wire should follow the curves and outline of the trunk. The body piece should be padded and provided with a Canton flannel body swathe, and the leg piece padded with Canton flannel. At the junction of the leg piece and the ACUTE ARTHRITIS OF THE HIP JOINT 25 body piece the wire should be protected by rubber tubing, and the padding should be omitted here. The leg piece should be bent as much as desired, and the child laid on the frame. The swathe is pinned about the trunk and the leg bandaged to the leg piece. The child can then be handled without jarring the diseased joint. Fig. I. — cabot's posterior wire frame for fixation of the hip. Where the disease is seen in an early stage, and especially after operation, this splint is of the greatest use. Traction is not necessary, but it may be of relief in quieting the pain. It is, however, exceedingly hard to apply traction to children under one year of age. If anchylosis is to occur, it is desirable that the joint should be in a good position, and not with a flexed or ad- 26 DISEASES OF THE HIP JOINT ducted limb. Hence the importance of early and accurate fixation to soothe the joint and reduce the muscular irritabil- ity to the minimum. If anchylosis in a faulty position occurs, the treatment is the same as in the case of older children with hip joint disease. Incision of the joint, free and deep, should be made as soon as fluctuation or cellulitis becomes evident. It should follow the line of incision adopted for resection of the joint, where practicable, entering the joint back of the femur. The incision should be so free that the question of drainage tubes should not be discussed, and everything should be left open, while an antiseptic poultice or a simple linseed meal poultice should be applied. Children under a year bear cor- rosive dressings particularly well. An incision cannot be made too early in these affections if cellulitis be adopted as the indication for it. Any attempt to do more than incise and irrigate the joint must be left to the judgment in each case. It would seem more thorough at least to scrape away diseased bone ; but, if it is remembered that the epiphysis is diseased and that the removal of part or whole of it is likely to be attended by much deformity and retardation of growth, it will seem wiser in most instances to attempt nothing more than the most superficial removal of diseased and disinte- grated bone. The treatment can be summed up very briefly : general, supporting and stimulating measures ; local, fixation of the diseased joint and early free incision. The bibliography is given and the reported cases are tabu- lated in the article of Townsend already referred to. ACUTE SYNOVITIS OF THE HIP 2/ Chapter III. ACUTE SYNOVITIS OF THE HIP. Inflammation of the synovial membrane is also spoken of as arthromeningitis, hydrops articulorum acutus, sero- synovitis, and acute serous or purulent synovitis, vi^hile puru- lent affections are spoken of as empyaema articulorum and pyarthrosis. It may be permissible to allude to the limits and functions of the synovial membrane, in so far as the question affects in- flammatory affections of this structure. The synovial mem- brane is structurally much the same as serous membrane ; but it differs from serous membrane in secreting a peculiar lubricating fluid, — synovia, — from vi^hich it derives its name. All diarthrodial joints are lined -with synovial membrane, ex- cept where the articular surfaces are in contact, w^here the cartilage is bare. The ligaments and folds of the capsule are all invested with a synovial covering. The synovial fringes diversify the otherwise smooth surface of the mem- brane, appearing as tufts or folds, which are reduplications of the membrane richly supplied with blood, or else protru- sions of periarticular tissues into the joint. It is an important fact that the nerves supplying the joint surface are the same as those which control the muscles of the limb. Acute synovitis is to be classified according to the char- acter of the effusion, as either serous or purulent. The latter is at times the outcome of the former, but either may begin independently, and continue as it began throughout its course. Acute synovitis of the hip is classified, according to the character of the effusion, as serous and purulent. 28 diseases of the hip joint Acute Serous Synovitis of the Hip. Pathology. This affection first manifests itself as a hypersemia of tlie vessels of the synovial membrane, which is followed by stasis of the blood current and dilatation of the capillaries. The ordinary phenomena of inflammation follow in regular se- quence, and migration of white blood corpuscles occurs, with a profuse outpouring of fluid from the dilated vessels. The surface cells of the membrane are cast off with undue rapid- ity, and often give a flaky appearance to the effusion. The effusion may be slightly discolored with extravasated blood, especially in traumatic cases. The membrane at this stage looks bright red and soaked and boggy. This latter appearance increases as time goes on. When the contact with the fluid has been longer, this appearance is more to be noticed in the synovial fringes than elsewhere. The ligamentum teres appears swollen and soft. The cartilage is not changed in appearance, but continues bluish-white, and shows sharply in contrast to the bright red and sharply defined border of the synovial membrane. The effusion which is poured out and distends the joint capsule is at first thinner than normal synovia, but later it may become very rich in fibrine and more scanty, in some cases being deposited as a fibrinous layer on the joint sur- faces, being then classed as a dry synovitis. Distinct flocculi may be formed from the cast-off endothelial cells, which may be enough to render the fluid opalescent. There may be much periarticular swelling. This is briefly the state of affairs to be found at the height of an acute synovitis of the hip joint. Two courses are now possible : resolution may take place, or the affection may pass into the purulent form. If resolution is to occur, the inflammatory process subsides ACUTE SYNOVITIS OF THE HIP 29 and the distended capillaries in the synovial fringes resume their normal calibre, while the newly formed blood-vessels in the membrane and its fringes become obliterated and retrograde to connective tissue. The undue activity in the formation of endothelial cells is checked, and those al- ready cast off furnish mucin to the synovial fluid. With all this the effusion is gradually absorbed, and a continuance of these processes leads to a cure of the synovitis ; and in simple cases the joint should return to its normal state without hav- ing suffered permanent injury. If, however, the effusion has been one very rich in fibrine, it is likely that a certain amount of connective tissue formation will have resulted, which is likely to cause adhesions between the folds of the capsule, and even a fibrous connection between the joint surfaces them- selves. This, of course, results in impaired motion of the joint. Fortunately, it is an occurrence which rarely takes place in simple acute synovitis. It seems proper to speak of the atrophy of the muscles which occurs in connection with acute inflammation of the joints, and which seems to arise not so much from disuse of the affected limb as from an active trophic disturbance of those muscles. The work of Valtat* did much to eluci- date the matter, who found experimentally that acute syno- vitis in animals induced a rapid and progressive atrophy of the muscles controlling the inflamed joint, which was more than the atrophy of disuse. He found incidentally that the extensor muscles wasted more rapidly than the flexors. The question of the origin and reason of this muscular atrophy has been much discussed, but is still to be explained satisfactorily.! *Emile Valtat, L'Atrophie Muse, dans les Mai. Artie. Paris, 1877. t Paget, Clinical Lectures and Essays, p. 209; Hilton, The Therapeutic Influences of Rest, p. 156- 30 diseases of the hip joint Acute Purulent Synovitis of the Hip. PatJiology. If, however, an acute serous synovitis does not undergo resolution, it goes through a series of changes which make it a purulent synovitis. These changes are practically only a continuation of the processes already alluded to as leading up to acute serous s3'novitis. The cell migration goes on unchecked and to a greater degree, and the cell proliferation from the surface becomes more active. The synovial surface becomes glazed, and then red and velvety, and the fringes seem to take the most active part in the process. From the admixture of cellular elements the fluid in the joint becomes turbid or purulent, although merely by a continuation of the same processes which led to a serous. effusion. The process may not go beyond this stage, and from this point undergo resolution. It is this degree of the affection which is described by Volkmann* as " catarrhal inflamma- tion," which he speaks of as "rather a perversion of exces- sive secretion than an inflammatory tissue degeneration." It should also be noted that the same end may be reached by the infection of a serous inflammation. A resolving or quiescent serous inflammation may rapidly pass over into the purulent stage if pyogenic germs are introduced, as is sometimes done by tapping. Or the purulent character of the inflammation may be determined in the beginning by the entra'nce of germs through a Avound. Yet, however powerful this element is, it should be noted that outside in- fection is in no wise necessary for the establishment of a purulent synovitis of a catarrhal or a more destructive char- acter. If the svnovial inflammation is to go on still further than *Pitlia and Billroth. Hdbch. der Chir., Bd. ii. 2. ACUTE SYNOVITIS OF THE HIP 3 1 the stage already described, the same processes merely con- tinue and increase. The cartilages become yellow and opaque, and are the seat of cell proliferation and fibrillary degeneration, to be considered in detail in the next chapter. Spots of erosion form, and bone may be more or less bared ; but these extreme changes belong rather to the domain of chronic synovitis, as do those more advanced conditions of the synovial membrane where the membrane becomes one general granulating surface, secreting pus in great quantities. The capsule may burst from distention and softening, and the pus pour into the periarticular tissues, where it reaches the surface as an abscess ; but these and the other more de- structive changes will be considered in the following section. At any stage of the process resolution may occur, and the amount of limitation of the joint motion will be determined by the amount of granulation tissue which has occurred in the synovial membrane. It must of course retrograde to fibrous tissue, and, if this is present to any large extent, a certain cicatricial contraction of the capsule will result, which means necessarily impaired motion. In the simple catarrhal variety, however, perfect restoration of motion is not unlikely to occur. If the cartilages should be destroyed and eroded, however, it is a more serious matter. Hydrops articulormn ttiberailosjis, as described by Konig,* should be described here, although, perhaps, partaking as much of the character of a chronic as of acute inflamma- tion. It is found as a diffuse inflammation of the synovial mem- brane, which is found to be studded with tubercles, and the membrane in which they lie imbedded is succulent and boggy. The effusion may be serous, sero-purulent, or puru- lent ; and it may be fibrinous in character, perhaps even leading to the formation of foreign bodies. This form of synovial tuberculosis, generally, although not *Die Tuberculosis der Knochen u. Gelenke. Berlin, 1SS4. 32 DISEASES OF THE HIP JOINT necessarily, coexists with tuberculosis of the neighboring bone. Etiology. Acute synovitis is due to many and differing causes. (i) Traumatism is one of the most frequent and definite causes. It is ordinarily a serous synovitis which is caused in this way, unless the joint be opened by a penetrating wound, in which case the synovitis will probably be purulent. In the hip joint, of course, penetrating wounds are very rare, and traumatic synovitis here is generally a simple serous one. It is likely to be caused by falls and wrenches of the leg, by blows or falls upon the trochanter and the like ; but it is much less likely to occur than synovitis of the other leg joints, — the ankle and the knee. The hip is such a deep- seated and firmly protected joint, and so thoroughly con- trolled by the strongest muscles and ligaments in the body, that any moderate grade of injury is much more likely, for obvious mechanical reasons, to take effect upon either of the more exposed and less protected joints of the leg, so that sprained knees and ankles are vastly more common than sprained hips. It should be remembered that synovitis of the hip follows all forms of dislocation of that joint. (2) Over-exertion is sometimes followed by synovitis, but, here again, much more commonly by synovitis of the knee than of the hip. (3) Exposure to cold or wet, although a frequent cause of synovitis of the knee, can hardly be classed as more than a possible cause of hip synovitis. (4) Acute articular rheumatism is at times a cause, and one of the most frequent causes of synovitis of the hip. In a series of cases of joint affections occurring in acute rheuma- tism (compiled from series of cases by Haygarth,* Hersch,t Monneret,t and St. Bartholomew's Hospital), the relative *Clin. Hist, of Acute Rheumatism. 1S05. t Mittheilungen aus der Med. Klin, zu Wiirzburg, 18S6, ii. p. 277. JLa Goutte et la Rhumatisme. These de Concours. Paris, 1851. ACUTE SYNOVITIS OF THE HIP 33 frequency of hip synovitis is shown by comparison with the other articulations. The knee was affected 357 f The ankle was affected 28. The wrist was affected 249 t The shoulder was affected 229 t The elbow was affected 148 t The hip was affected 103 t The fingers were affected 81 t The feet were affected 45 t The hands were affected 44 t The toes were affected 29 t The spine was affected 16 t Miscellaneous joints 8 t Total joints affected 1,593 t mes mes mes mes mes mes mes mes mes mes mes mes mes Senator* has found the fluid from joints affected by acute articular rheumatism to be alkaline in reaction and rich in albumen and fibrine ; but Bouchard f reported cases where it was acid, so that nothing definite can be stated in this re- gard. In this form of synovitis the development is very rapid, and there is no tendency to pus formation. It is essentially a multiple form of synovitis, and spreads with much rapidity from joint to joint. It is suggested by Monneret that the arthritis is a phenomenon much like the cutaneous ery- themata of the disease ; but beyond this, little is known about it beside the fact that the great majority of all pa- tients affected by rheumatism suffer from joint symptoms. (5) Gout is the cause of a certain very small number of attacks of acute synovitis of the hip. The joint is attacked by an acute synovitis of the ordinary type, which tends to pass on into a chronic form, characterized by the deposit of urate of soda in the synovial membrane, the capsule, and the periarticular structures. *Ziemssen, Hdbch., 1879; 2d ed., vol. xiii. t Bouchard, Mai. par Raltntissement de la Nutrition, 1882, p. 318. 34 DISEASES OF THE HIP JOINT The attacks are, in the great majority of all cases, located in the great toe, and the hip is but rarely affected. In 198 cases reported by Scudamore, 140 had the disease in the great toe joint. (6) Syphilis is an uncommon, but still a recognized cause of acute synovitis. As a cause of chronic inflammation, it is more frequently met. Acute synovitis occurs at times {a) in connection with the secondary symptoms, such as the iritis, the eruption, and the pharyngitis. Na post-mortem reports of this condition have been reported, and the hip is not commonly affected, {b) A simple serous joint inflam- mation, with rather a chronic tendency, occurs in connection with some cases of hereditary syphilis. The joints are affected in syphilitic disease in the order named below, from which it will be seen that the hip is not often diseased from this cause. The knee, the elbow, the fingers, the toes, the metacarpo- and metatarso-phalangeal joints, the wrist, the hip, and the ankle are affected in the order named. (7) Infections diseases as a cause of acute synovitis are well recognized ; and, although no very satisfactory explana- tion of their action can be given, they must be regarded as a comparatively frequent cause of acute serous or purulent synovitis of the hip, — unfortunately, most often the latter. In general, it may be said that the affection most closely re- sembles a pyaemic process ; such infection of the joints being, in fact, a classical symptom of pyaemia. The diseases in which such joint inflammations occur are as follows ; diphtheria, dysentery, erysipelas, malaria, measles, meningitis, pneumonia, pertussis, parotitis, pyaemia, puer- peral fever, scarlet fever, septicaemia, small-pox, typhus and typhoid fevers, and varicella. Gonorrhoea and the use of catheters are probably to be grouped with these diseases as possible causes of synovitis. The joint complication in gonorrhoea most often occurs during or after the convalescence from the acute attack, ACUTE SYNOVITIS OF THE HIP 35 generally after the second week. These attacks may be serous or purulent. If the former, they tend easily to sup- puration. The joint infection in these diseases is attributed to the presence of micro-organisms in the circulation, and in the fluid from such joints micro-organisms are to be found. In the purulent and more severe cases one finds staphylo- coccus and streptococcus pyogenes in enormous numbers, and in the serous cases, milder forms, so that it seems as if whether the synovitis were serous or purulent were deter- mined by the character of the micro-organisms reaching the joint rather than by any other factor.* In most cases, the organisms reach the joint without doubt through the circulation ; but they may at times, as in puer- peral fever or erysipelas, reach the hip by the lymphatics or by direct extension.! The character of gonorrhoeal synovitis has been much dis- puted, but its proper place seems to the writer to be here. The theory of William Ord that it is the result of a reflex nervous disturbance does not seem tenable. Gonococci have been found in the joint fluid, J and the clinical character of the affection tends to make it seem like the synovitis of the other infectious diseases. Gonorrhoeal synovitis affects the knee most often and the hip infrequently. The joints are affected as follows in the order named : Of 308 cases, § 86 attacked the knee, 52 the foot, 29 the shoulder, 26 the hand, 17 the fingers and toes, 16 the metatarso-phalangeal joints, 15 the hip. Many of these infectious diseases also are the cause of tuberculous ostitis of the hip in children and of the acute arthritis of the hip in infants. In some instances, this is undoubtedly at first a synovitis ; but in most cases, it will be ♦Arch. f. Klin. Chir., xxxi., Heft 2 ; Ziemssen's Hdbch., 2 Auflage, ii. p. 546; Cent, f Chir.^ Sitzberichte d. Cong. f. Chir. , 1884. t Bradford and Lovett, Treat, on Orth. Surgery. iSgo. t Petrone, Revista Clinica, 1883, No. 2 ; Cent. f. Chir., 1884, No. 4. §Nolen, Archiv f. Klin. Med., 18S2, xxxii. p. 120. 36 DISEASES OF THE HIP JOINT seen, there is reason to believe that the original lesion is an osteomyelitis. Acute purulent synovitis, when secondary to a lesion of the bone, will be considered under the heading of diseases primarily osseous. Treatment. Simple acute synovitis of the hip is to be treated by rest and counter-irritation. Rest to the joint is most readily to be obtained in bed, with the hip controlled by a long outside splint or a plaster of Paris spica bandage. If there is much pain and muscular irritability, traction will add much com- fort, exerted by means of a weight and pulley drawing down upon the leg by means of adhesive plaster straps. Rest to the joint should be insisted upon until motion is free and painless. The hip joint is so deeply seated that it is not accessible to compression, so useful in the synovitis of other joints, and counter-irritation must take its place. This is most readily obtained by a fly blister back of the trochanter or by hot stimulating applications to the flank. If an abscess forms, it must be opened freely, most con- veniently by the conventional cut for hip excision. In the more rapid forms of acute infectious purulent synovitis, a free incision is to be made so soon as fluctuation is detected. Ordinarily, it will be better to wait until the collection of pus reaches the surface. The T'eatjnejit of Acute Synovitis of the Hip in Children. To the writer's mind this section of the subject is worthy of the most careful consideration. Children are not prone to suffer from simple acute synovitis : it is not the way in which their joints commonly react to an irritant or an injury. The tendency is to ostitis and to chronic degenerative synovitis. Nowhere is this more true than at the hip. Practical experi- ACUTE SYNOVITIS OF THE HIP 37 ence shows that simple acute synovitis of the hip which clears up and leaves a healthy joint in children is very rare. The fact is not altogether to be explained, but it must rest on the basis of experience. On the other hand, let it be remem- bered that hip disease very often is noted as beginning acutely. In a large numerical proportion of all cases it is attributed directly to some injury, as is well known ; and in most cases the symptoms after the injury are those of acute synovitis. Now, the practical outcome of the matter is that these cases of apparent acute synovitis are really beginning hip disease, which may have been excited by the injury or may not. The fact remains the same, that the surgeon who makes the diagnosis of simple acute synovitis in these cases lays himself open to a very great chance of error, as must be manifest. How common such cases are must be a matter of experience to every surgeon who sees much of children. Remissions in hip disease, in which the symptoms practi- cally disappear and the signs improve radically, are so com- mon that they require no comment. This simply adds to the obscurity in making the resemblance of early hip disease and acute synovitis the more close, in their clinical history as well as their symptoms. Therefore, not only should the diagnosis of simple hip synovitis be made with much reserve in young children, but also the treatment should be con- ducted with great care, and not be discontinued so long as any suspicion of hip disease remains. If the writer may allude once more to his own experience, it has led him never to make a diagnosis of acute synovitis of the hip in a child until some time after its complete and speedy recovery from all symptoms. This is, perhaps, a matter which belongs more to the diagnosis than to the treatment ; but its extreme practical importance makes it justifiable to allude to it here. The treatment should, of course, be the same as that de- 38 DISEASES OF THE HIP JOINT scribed above, except that, if at the end of a week the condi- tion is not decidedly improved, traction should always be added, and the child should not be allozved to walk 07i the affected leg until some time after all symptoms have disap- peared. If the symptoms persist, the child should be treated for hip disease without delay. CHRONIC SEROUS SYNOVITIS OF THE HIP JOINT 39 Chapter IV. CHRONIC SEROUS SYNOVITIS OF THE HIP JOINT. Forms of chronic serous synovitis of the hip which are not associated with the occurrence of tubercles or included in the manifestations of that affection known as arthritis defor- mans or rheumatoid arthritis, are so uncommon that they need not receive extended consideration. Tuberculous syno- vitis and arthritis deformans will be considered under their own divisions. Pathology. Chronic synovitis of the hip may, however, succeed an acute synovitis. It may start de novo as a dropsy of the joint, so called, or it may appear as a low-grade inflamma- tion with a scanty effusion, and associated with a strong ten- dency toward connective-tissue degeneration of the cartilage and obliteration of the joint by fibrous anchylosis. Succeeding an attack of acute synovitis, one finds that an increased vascularity of the synovial membrane is followed by a thickening and bogginess of it, which is increased by its contact with the joint effusion. The capsule becomes thickened and softened, and the ligamentura teres swollen and soft. The subsynovial tissues become swollen and the ligaments thickened and less firm. In a joint less protected structurally it would lead to abnormal mobility. The slight synovial fringes which exist in the hip become hypertro- phied, and appear papillomatous, but not to such an extent as occurs in the knee. 40 DISEASES OF THE HIP JOINT On the other hand, considerable effusion may rarely be found in the hip joint, as is so much more frequently the case in the knee, where the pathological changes are but slight. It is to such cases that the names dropsy of the joint, hy- drarthron, etc., are given. Although it was originally con- sidered to be an affection which was non-inflammatory, the weight of modern opinion inclines to class it as a low-grade inflammatory affection, accompanied by a copious effusion,* with slight structural changes in the synovial membrane. Finally, there may be found in the hip joint the third affection spoken of above, which was formerly classed as a "dry synovitis," but which is now spoken of more commonly as arthrite plastiqiie ankylosante, or arthritis chronica an- kylopoctica. The former idea was that a scanty effusion rich in fibrine was poured out, which led to a gluing together of the joint surfaces. This may occur in acute cases ; but in the chronic form of the affection modern pathology has gone on to the observation of more extended and significant changes, and allows but little importance to the plastic power of the effu- sion in itself. These changes differ from those found in arthritis defor- mans only in a slight degree, but chiefly in the cartilaginous part of the joint. In arthritis ankylopoetica, or ankylosing arthritis, proliferation of the cartilage exists only in a slight degree; and the changes on the cartilaginous surface partake less of the nature of a disintegration, being rather a change to connective tissue. In the earlier stages of the affection the synovial mem- brane appears thickened and more injected than it should be normally, while the slight fringes tend to hypertrophy. In addition to these changes, however, and more significant, one finds that the cartilaginous surface is roughened, with * Diet, de Med. et Chir. Prat., viii. 89; Bonnet, Malad. des Artie, Paris, 1 84 5 ; Billroth, Surg. Path., Am. Ed., 1883, p. 578; Billroth, Arch. f. Klin. Chir., ii. 408; Cornil and Ranvier, Histology; H. Marsh, Dis. of Jts. CHRONIC SEROUS SYNOVITIS OF THE HIP JOINT 4I a tendency toward fibrillary degeneration, and that certain parts have hypertrophied or have been made thicker by the deposition of layers of fibrine on the surface. In the deeper layers of the cartilage, next to the articular end of the bone, there is a tendency toward increased vascularity and change to osteoid tissue. A very important factor in the joint obliteration is now to be noticed ; namely, a vascularization of the cartilage. Blood- vessels are to be seen here and there in the stage subse- quent to the one just described, which play an important role. In part they are derived from the synovial membrane and in part from the subsynovial tissue, as well as from the syno- vial fringes. In proportion to the number and size of these is to be estimated the rapidity of the joint change, which is essentially a fibrinous gluing together of the surfaces along with a fibrillary degeneration of the cartilage. The first ad- hesions form in the neighborhood of these vessels, and these bands grow larger and firmer and shut off more and more of the joint. This condition of fibrous anchylosis is, in most cases, suc- ceeded by a deposition of bone in the fibrous tissue, resulting in a bony anchylosis and complete obliteration of the affected joint. It may seem a distinction of unnecessary accuracy to de- scribe this affection separately from arthritis deformans, but in doing so the writer only follows the example of Ziegler and the best modern pathologists. Etiology. Aside from the forms of hip synovitis associated with tuberculosis and arthritis deformans there is little to be said in considering the etiology of this affection. Certain cases are the outcome of attacks of acute syno- vitis, the result either of .traumatism or rheumatism, or in those instances where no cause can reasonably be assigned 42 DISEASES OF THE HIP JOINT for the attack. Cases which begin de novo as chronic serous synovitis are rare. For the most part, this form occurs in young adults, and is apt to be associated with rheumatism, in which case it is most often polyarticular. Gonorrhoea should also be mentioned as a possible cause of chronic serous synovitis, although occurring most often in connection with an acute or chronic purulent form, Gont, by a succession of acute attacks, induces a condition of practically chronic synovitis, in which the synovial mem- brane is the seat of urate of soda deposit, and stiffness of the joint ensues. Syphilis affects the hip joint sometimes during the sec- ondary stage of the disease, occurring as a subacute serous synovitis, accompanied by much swelling. It appears as a cause of joint inflammation more often at a later period, when the disease is well advanced into its tertiary stage, and appears generally in a chronic monarticular type. It is char- acterized by marked effusion, accompanied by much thicken- ing of the capsule and papillary hypertrophy of the synovial fringes. Gummata often appear in the synovial membrane, the cap- sule or the ligaments; and there is but slight tendency toward the formation of pus. Where resolution takes place, it is generally accompanied by contraction of the thickened capsule. Chronic ankylosing arthritis is also spoken of as artki'itis pajipej'um, which explains very succinctly the chief class affected by it. Associated in most instances with chronic rheumatic changes in the other joints, it is to be accounted the outcome of unfavorable conditions, such as damp dwell- ings, poor and insufficient food, exposure, and the like. It affects old persons, and mostly those in poor general con- dition otherwise. Practically, it is not always to be differentiated from the similar condition of arthritis deformans. chronic serous synovitis of the hip joint 43 Treatment. The treatment of chronic serous synovitis of the hip, apart from the two varieties which are not under consideration here, is a question which comes up but rarely in practice. A long continuance of symptoms of chronic hip synovitis would lead to the suspicion of the existence of tubercular disease, and to the adoption of the treatment for that affec- tion. Before that the measures most likely to be of use would be the administration of anti-rheumatic remedies and a building up of the general health. Locally, compression is not available ; and one must depend upon counter-irritation by blisters or the Pacquelin cautery, with protection and rest to the affected limb, most easily to be obtained by the use of a high shoe on the well leg, with crutches, so that the affected leg would swing in walking. Massage should be tried to assist in the absorption of the fluid. The treatment of chronic ankylosing arthritis is identical with that of arthri- tis deformans, and will be discussed under that heading. Chronic Purulent Synovitis of the Hip Joint. The changes here are so inextricably associated with the osseous changes that a consideration of the synovial changes by themselves would involve much repetition and lead to obscurity. It seems best, therefore, to consider the changes in chronic purulent synovitis in the next chapter. 44 DISEASES OF THE HIP JOINT Chapter V. TUBERCULOUS OSTITIS OF THE HIP {Hip Disease). INCLUDING CHRONIC PURULENT SYNOVITIS. There are two well-recognized forms of degenerative ostitis, the one characterized by the formation of tubercles, the other by the presence of guramata in the diseased tissue. The bone changes occurring in arthritis deformans will be discussed separately. The divisions of the subject are : — {a) Tuberculous ostitis. {b) Gummatous ostitis. {a) Tnberciiloiis Ostitis (including chronic purulent syno- vitis). The great bulk of all cases of disease of the hip joint is made up by a chronic degenerative process, characterized by the formation of tubercles, a process which sometimes begins in the bone and sometimes in the synovial membrane. The result is the same, and practically the diagnosis cannot be made between the two conditions. It seems best, there- fore, to speak of the whole affection by its accepted name of hip disease, and to discuss in one place the synovial, cartilaginous, and osseous changes, which go hand in hand in chronic tuberculous ostitis of the hip, commonly called " hip disease." TUBERCULOUS OSTITIS OF THE HIP 45 Hip Disease : Pathology. The affection is known more exactly as hip joint disease. Also it is called Coxalgia, Morbus Coxae, Morbus Coxarius, Caries of the Hip, Coxotuberculose, Coxalgie, Huftgelenk- krankheit, etc. Chronic articular ostitis of the hip is a more exact patho- logical name sometimes used. It belongs to the class of joint disease spoken of in other joints (as well as in the hip) as fungous joint disease, stru- mous arthritis, scrofulous joint disease, etc. In German similar names are fungdse Gelenkentziindung, die granulirend tuberculose Gelenkentziindung, and Glied- schwamm ; and, in French, Tuberculose articulaire. Osteite aigue, etc. The affection begins primarily either in the synovial mem- brane or in the spongy tissue of the bone, and, secondarily, affects the other in most cases. The cartilage plays only a passive role. Synovial Changes. An affection of the synovial membrane has been described by Konig which he has called Hydi^ops Articiilorum Tuber- culosus. This form of disease is found most often in connec- tion with the tuberculosis of neighboring bone, although not necessarily so. The synovial membrane is thickened and succulent most often, and studded with tubercles which extend even into the subsynovial tissue. On the other hand, the tubercles may be present in a synovial membrane, almost unchanged by in- flammation. The effusion is generally copious and serous or sero-purulent, and the synovial tissue tends to granula- tion, and the affection shades into the common form of fungous synovitis about to be described. 46 DISEASES OF THE HIP JOINT It exists, however, often enough alone to be described as an individual affection* pathologically. It should be men- tioned, in connection with it, that the effusion in some cases is very fibrinous, and shows a strong tendency toward co- agulation and the formation of loose bodies in the joints. f It is not, however, the usual form of tuberculosis of the synovial membrane. Konig finds an explanation for this particular form of joint disease in assuming that the irrita- tion caused by the growth of the tubercles in these cases is not enough to cause the ordinary manifestation as fungous granulations. The common form of tuberculosis of the synovial mem- brane results in changes in the membrane which lead to a purulent effusion. The affection may be the outcome of an acute synovitis which has passed into the chronic state or it may begin merely as a chronic affection at the first. If the affection was originally an acute purulent synovitis, a persistence of the condition described in speaking of that would lead to a chronic synovial disease. If it was originally an acute serous synovitis, certain transitional stages are to be noticed. The injection of the synovial membrane con- tinues, and leads to its hypertrophy and thickening. The increased blood supply and contact with the effusion make the membrane succulent and boggy. At the edges of the cartilages it encroaches upon them and corrodes them. The increased activity leads to the formation of white blood corpuscles, and their accumulation as granulation tissue, which causes a change in the effusion from a serous to a sero-purulent or purulent one. The first stage of inflammation in a synovial membrane infected by tubercle bacilli consists, then, in increased vas- cularity, thickening and succulency of the synovial mem- brane, accompanied by a serous or sero-purulent effusion. * Konig, Die Tuberc. der Knochen und Gelenke, Berlin, 1SS4, p 22. tRiedel, Deutsch. Zcitsch. f. Chir., Bd. xx. TUBERCULOUS OSTITIS OF THE HIP 47 This condition gradually merges into the formation of a low- grade granulation tissue, which occupies the surface of the membrane and which is best described by the term gelati- nous. In the hip joint this gelatinous degeneration is not so common as in the knee, for instance, and more commonly one finds a swollen and reddened membrane with comparatively firm granulation tissue. During this process the synovial membrane grows over on to the cartilage, and, where it covers it, it becomes adher- ent, and, if peeled off, it shows that the underlying cartilage has been eroded. Such synovial fringes as there are in the hip joint hypertrophy and take an active part in the process. Imbedded in the granulation masses are small white specks, just visible to the naked eye, which are to be identified as tubercles. Later they appear in larger masses, and perhaps tend to cheesy degeneration in the larger nodules. The secretion from these granulating synovial surfaces, as a rule, is small in the hip. When one considers how little effusion can be contained in this joint, and considers how comparatively uncommon hip abscess is in well-treated cases of hip disease, it must be evident that excessive secretion of pus is not the rule. In some instances, little or no effusion is present in the joint (Lannelongue), even when the disease is well advanced. Microscopically, the granulations are seen to consist of typical granulation tissue, interspersed with the white specks already alluded to, which are of the greatest significance. For a long time their importance was overlooked, and they were first recognized as tubercles by Koster.* Their struct- ure in the early stages is typical of that pathological condi- tion known as tubercle. Later, as they become cheesy and disintegrated, the section shows less characteristic appear- ances ; but even then the freshly forming tubercles can be identified. It would seem as if the identity of these struct- ures would be admitted by common consent, supported as *Kbster, Virch. Archiv., Bd. xlviii. ; Arch, de Phys., 1800, p. 325. 48 DISEASES OF THE HIP JOINT it is by the weightiest pathological authority ; * but so high an authority as Barwell f finds cause to argue that these structures are the result of fatty and suppurative degenera- tion. His views, however, find no acceptance whatever. Similar masses of inspissated mucus may, however, be found imbedded in the granulations. Tubercle bacilli are found in a certain proportion of these cases, and physiological evidence of their pathological iden- tity is abundant. These matters will be discussed later, and for the present it must be accepted that the nature of these minute bodies occurring in the gelatinous granulations is abundantly proven to be tuberculous. Synovial membrane which has reached such a degree of purulent inflammation as this pursues one of two courses. If matters go badly, the granulations melt down rapidly into pus and take on an erosive action. In their rapid career the synovial membrane is destroyed, and the capsule becomes thickened and softened, and probably bursts, letting out the pus into the periarticular structures, constituting the com- monest form of joint abscess. The cartilage becomes degen- erated and disintegrates, exposing the hyperaemic articular surfaces of the bones, which are at once attacked by the pus and take on a destructive activity themselves. Finally, what was formerly a joint is now amass of granulating and degen- erated tissue, in which the bare and eroded ends of the bone are loosely imbedded, while sinuses drain off the pus. It can be seen that it is not easy to set a limit to the destruc- tive activity of such a process as this. If, on the other hand, resolution is to take place in such a purulent synovitis as that described, the granulations be- come firmer and less pale, the tubercles cease to extend and become less frequent. In the granulation masses the connective tissue can be seen by the microscope to predomi- *Bnssaud, Rev. Mens, de Med. et de Chir., 1879, June 10; Kbnig, Deutsch. Arch. f. Chir., xi. pp. 317 and 350. t Dis. of Joints, 1881 ; and Lancet, Aug. 2, 188.^. TUBERCULOUS OSTITIS OF THE HIP 49 nate over the cellular elements, and the secretion of pus diminishes in proportion to this change. This is merely the first stage in the change to fibrous tissue. This will, in cases where the change has been at all extensive, lead to fibrous contractions of the capsule, and to adhesions between the joint surfaces, impairing or obliterating the joint move- ment. Recovery from chronic purulent synovitis with per- fect joint mobility is only likely to occur where the syno- vial membrane has been but slightly affected, because, if granulations have once formed, they can only be replaced by scar tissue, and contraction of the surrounding tissues follows necessarily. Such, in brief, are the changes which occur in the synovial membrane in chronic joint tuberculosis. It matters very little whether the changes originated in the bone or the sy- novial membrane, the pathological appearances in the latter are much the same, and the results are similar. Cartilaginous Changes. But no marked degree of change in the synovial mem- brane will have been reached without affecting the cartilage of the hip joint and the articular surfaces of the bones. First, as to the changes in the cartilage. Primary inflam- mation of cartilage is not an affection which is believed to exist in tuberculous joint disease ; and, although cases have been reported of so-called primary disease of the interverte- bral discs,* and of the cartilage of the knee f joint in one in- stance, there is not, so far as the writer has searched, a single authenticated instance of primary disease of the cartilages of the hip, except in the writings of twenty years ago recording changes which are now known to be secondary to inflamma- tion elsewhere. *Ogle, Path. Soc. Trans., xv., 1S63 ; Broca, Gaz., Hebdom., 1864, p. 298; Chassaignac, Gaz. des Hop., 1858, p. 156. t Kocher, Cent. f. Chir., Nov. 5, 1S81. 50 DISEASES OF THE HIP JOINT To the eye the appearances which occur in the cartilage in chronic purulent synovitis are manifested by a loss of the blue-white opalescent look which healthy hyaline carti- lage possesses. It becomes yellowish, and looks softer and more succulent than it should normally. The synovial mem- brane has crept over on to it in places at the edges ; and, if an attempt is made to detach it, it is found adherent, and, if pulled off, may leave a red and eroded surface of cartilage behind it. In some places it may tend to disintegrate, and to be replaced by granulations ; while in others it is cast off in flakes or large masses loose into the joint. Sometimes the whole cartilage of the head of the femur may be thrown off, or it may hang in tags, or look worm-eaten, or be under- mined by granulations. With the destruction of the carti- lage, the ends of the bones are exposed to the destructive processes going on in the joint. Microscopically, the cartilaginous changes are those by which cartilage always responds in inflammatory conditions. The nuclei and the cells both multiply very fast, and the hya- line substance tends to become fibrillated. Fatty degenera- tion ' of the cells ensues; and with it come softening and further fibrillation of the cartilage, which lead to its disinte- gration. The casting off of large surfaces of cartilage occurs chiefly in cases where the disease is primarily osseous and shuts off the nourishment supply of the articular cartilage. Osseous CJianges. The changes which occur in the bones are the most im- portant and the most significant. It will be shown later that the most frequent origin of hip disease is in the epiphysis of the head of the femur. Specimens of beginning hip disease are very rare, so that the earliest changes are more a matter of inference than of observation. A hyperasmia takes place in the spongy tissue TUBERCULOUS OSTITIS OF THE HIP 5 1 about the epiphysis, which is followed by the appearance in the centre of this byperasmic area of a small grayish, translu- cent spot, which increases in size and is surrounded by a zone of hypercemia. Cases little more advanced than this have been reported by Lannelongue.* It is probable that this stage of the disease is caused by an infection through the blood-vessels, that bacilli or mi- crococci become heaped up in the capillary of an Haversian canal and start up an endarteritis, which results in a tuber- cle. The irritation of this process causes and keeps up the hyperasmia which results in the processes described as rare- fying ostitis. That is, the trabeculae are absorbed in the hyperaemic area surrounding the tubercle, enlarged bone spaces are formed, and fatty degeneration of the bone cells occurs with the transformation of their contents to embryo- nal or granulation tissue. The earliest stage, then, seems to consist of a tubercle situated in an area of hyperaemic, spongy bone tissue which is undergoing the absorption and degeneration which result from prolonged hyperaemia. The gray spot continues to increase, and in its centre be- comes yellowish, and around it appear other small gray spots, which merge into it and hasten its destructive career. Most often the centre softens and breaks down into pus ; but before that it oftenest goes through a stage when it is filled with a semi-solid, cheesy mass, consisting of detritus, spicules of bone, amorphous matter, and fat. The active destruction goes on at the periphery of this nodule, and its growth takes place in the direction of least resistance. Sequestra of varying size may be found in con- nection with these foci of disease. These are caused by the cutting off of the vascular supply from some area of bone, due to the growth of the tubercles. At the hip they are likely to be more extensive than elsewhere, owing to the fact that the whole upper epiphysis of the femur lies zvithin * Coxotuberculose. Paris, 1886. 52 DISEASES OF THE HIP JOINT the joint, and that the main vessels enter on the upper sur- face of the neck. It thus happens that the blood supply of a large area may be easily shut off, and this accounts for the comparative frequency of necrosis of whole or part of the femoral epiphysis. This cannot be spoken of as a common condition, but it occurs often enough to have attracted con- siderable attention.* Mr. Parker found this condition in 5 out of 8 cases, and ]^Ir. Morrant Baker in 1 1 out of 24. Air. Wright,! who quotes them, finds this too high a percent- age, and reports only seventeen sequestra of the femur in 100 cases. Occasionally, the necrosis extends for a short distance into the diaphysis. To return to the focus of disease, which exists as a puru- lent or cheesy mass in the epiphysis, it may at this stage be absorbed, it mav grow toward the periosteum and be dis- charged outside of the joint, or lastl}^ it may break into the joint (which is probably the commonest course), and infect that with a purulent inflammation. If the conditions are favorable for its absorption, it be- comes more cheesy and dry, and remains as a cheesy mass latent in the bone, still infected with the bacilli, but quies- cent until some general or local cause calls it into activity; or, after becoming dry and cheesy, it is the seat of the de- posit of lime salts, becoming calcified ; or, lastly and most uncommonly, the pus ma}' be absorbed, leaving a cavity filled with clear serum. It is not likely that absorption occurs where the focus contains sequestra of any size. It can be seen from the anatomical conditions of the hip joint that a focus of disease in the neighborhood of the epiphysis of the femur is much more likely to invade the joint in its growth than to travel toward the surface of the bone outside of the capsule. It may be mentioned once more that the epiphysis lies wholly within the joint. Never- theless, it does occur that the enlargement of the tuber- *R. W. Parker. CKn. Soc. Trans. iS8o. t G. A. Wright, Hip Disease, Loudon, JSS7, p. 30. TUBERCULOUS OSTITIS OF THE HIP 53 culous disease takes place at times away from the joint sur- face, and the contents of the diseased area are discharged externally, and the cavity heals. This is, of course, much more likely to happen where the origin of the trouble is in the diaphysis and in those uncommon cases where the epiphysis of the great trochanter is the one involved. When the disease travels toward the surface of the bone, the periosteum over it becomes thickened and soft, and a slight or severe cellulitis of the neighboring tissues occurs. This termination of joint disease explains those cases where slight hip disease is followed by an abscess, after which the symptoms quickly subside. Finally, the most common course of the three is when the tuberculous focus advances toward the joint cavity. The original tuberculous focus has broken down into pus, and is surrounded by smaller tubercles, which aid in its destructive work in melting down the bone. There is no joint disease at first. Volkmann says that " the danger to the joint begins with the softening of the cheesy mass." As the inflamma- tion of the bone approaches the articular cartilage, inflamma- tion of the joint begins before direct infection of the joint from the tuberculous pus has occurred. From the early resections of Volkmann* and from the autopsies of Lannelongue, it would seem as if the joint in- flammation originated by sympathy as well as by direct in- fection. Certainly, it has not been uncommon to find a degree of purulent synovitis accompanying an osseous focus which has not broken into the joint and which could only have caused it in some indirect way. The synovial membrane becomes inflamed and undergoes the changes described above, especially in the neighborhood of the bone disease. The cartilage becomes secondarily in- flamed and softened over the approaching focus, and the way is prepared for the entrance of the pus into the joint. Generally, a small hole exists at first, which becomes larger as the disease advances. * Samml. Klin. Vort., No. 52. 54 DISEASES OF THE HIP JOINT When this stage is reached, it is evident that it matters little whether the disease began in the bone, the cartilage, or the synovial membrane, since all are involved in the destructive inflammation. The mechanism is at hand for an extensive and destructive inflammation. In cases of femoral disease the acetabulum becomes secondarily involved, and with that one finds a periosteal and fibrous thickening on the inner side of the pelvis under it, which is Nature's effort to prevent perforation. Perforation of the acetabulum, however, occurs in a cer- tain proportion of the more serious cases ; and the head of the femur may be forced through the bottom of the socket into the pelvis, or, more commonly, the opening is only large enough to cause the formation of an intra-pelvic abscess, the pus from which may be found discharging into the rectum or involving the other pelvic viscera. ]More commonly it points in the buttock or under the adductor tendons. An important element to be taken into account is found in the constant muscular contraction accompanying hip disease, which crowds the head of the femur against the upper edge of the acetabulum, causing not only wearing away of the softened bone composing the head of the femur (spoken of as absorption of the head), but also wearing away the upper edge of the acetabulum and causing an upward elongation of that cavity (spoken of often as migration of the acetabulum). This results in the malposition upward of the head of the femur, and the consequent shortening of the leg from the al- tered relation of the femur to the pelvis. Real shortening and atrophy, as well as retardation of growth, are to be found in the affected limb, which is another element in the produc- tion of the short leg of hip disease. True dislocation of the hip is very uncommon in hip dis- ease, occurring only when the changes affect the capsule very extensively. Accompanying the changes in the spongy tissue of the epiphysis, the periosteum of the neck of the femur and the TUBERCULOUS OSTITIS OF THE HIP 55 trochanter becomes secondarily involved and thickened ; and the capsule of the joint becomes softened and often dis- tended by the purulent effusion. Finally, it gives way, and the pus finds its way into the periarticular tissues to form a hip abscess. Another source of hip abscess'is to be found in the formation and degeneration of an independent focus of tubercle outside of the capsule. Even in the milder cases of hip disease without abscess formation there are to be found a condensation and infiltra- tion of the superficial tissues, which are rarely mentioned. Even at the stage of joint inflammation just described, ab- sorption may occur and a cure result. This comes about by the evacuation or absorption of the purulent effusion and the consolidation of the granulations, with their change to con- nective tissue, forming a fibrous anchylosis, which may later be the seat of a bony deposit. On the other hand, the tuberculous process may continue to spread and invade the more superficial tissues until they have the consistency of pork. Many sinuses form, and the destruction of the joint goes on, until the patient dies of exhaustion or some intercurrent affection. Tuberculosis of the other organs may be found in connec- tion with hip disease, especially tuberculosis of the meninges and of the lungs. In cases where the suppuration has been long continued, amyloid changes may be found in the liver and intestines. It should be said, in closing this section of the pathology, that the origin of the disease may be in single or multiple foci, beginning in the cancellous tissue. There is, moreover, a second form of tuberculous disease of bone, which has been left to the end, to prevent confusion ; namely, the infiltration of a whole or part of an epiphysis with a tuberculous deposit. A grayish substance, soft and semi-translucent, first appears in the tissue of the epiphysis, in appearance like the single focus of disease spoken of above. This degenerates in spots into yellowish, purulent material, 56 DISEASES OF THE HIP JOINT and soon pus forms everywhere, and the tissue is bathed in pus. This process is more rapid and more destructive than the focal form mentioned above. This latter form was first described by Xelaton under the name of " infiltrated tu- bercle," while the common form was called by him "encysted tubercle." To return to the microscopical characteristics of the affec- tion, and to ask what evidence we have that the process is a tuberculous one, the evidence is threefold,^ (a) physiological (inoculation experiments), {b) histological, {c) bacteriological. (a) Inoculation experiments will be discussed in speaking of the etiology. {b) The microscopical appearances are those of a typical granulating tuberculosis. In the later stages the type of the characteristic structures is obscured by cheesy degener- ation, but earlier one finds that typical tubercles with epi- thelioid and giant cells lie in the granulation tissue. Later thev lie in an amorphous mass, composed of bone spicules, fat, and detritus of all sorts. Outside of this area is still a zone of hyperaemic bone, the pathological appearances of which have been already described. In short, so far as structure can establish the identity of tubercles, they are present here. (. 193. 84 DISEASES OF THE HIP JOINT doLibtedly results in distraction of the joint surfaces. This furnishes a rational and scientific explanation for the use of traction. It is not likely, however, that traction necessarily pro- duces separation of the joint surfaces before it affords relief. On the other hand, even mild traction made with the hand is very often enough to control muscular irritability and relieve much discomfort. In these cases, it seems to act as a sedative to the muscles, probably by slightly stretching them, and to have its beneficial effect on that account rather than because any notable joint separation has oc- curred. Traction is used in two ways in hip disease, — during re- cumbency and by means of portative appliances. Traction during Recumbency. This older method of treatment is exerted by means of the weight and pulley, and, to be of use, must be rationally applied. It is of use where malposition of the limb or a sensitive condition of the joint is present, and in cases where apparatus is not to be obtained. On general principles pro- longed recumbency is to be avoided during hip disease. Exercise within certain restricted limits and fresh air are all therapeutic measures which are of the greatest value in con- trolling the disease and keeping the general condition as good as possible. During certain complications recumbency is indicated ; but, as a rule, it should only be resorted to when ambulatory treatment proves impracticable. It should be added that this is not in accord with the ideas of many eminent English surgeons, notably Mr. How- ard Marsh. During recumbency the patient's body should be secured and kept quiet. Without this, one loses half of the efficiency of the method. The best means of securing the patient is by means of a light bed-frame, to which the patient is THE TREATMENT OF HIP DISEASE 85 Strapped. An oblong frame, a little wider and a little longer than the patient, is made of ^-inch gas-pipe, being joined at the four corners by common gas-pipe "shoulders." It can ^ w .... n tic Jll/I \\'.tt\ n9 Fig. 13. — BRADFORD BED-FRAME. be covered with stout cloth, which should be tightly stretched over the bars, and over the buttocks it should be omitted, to al- low for the use of the bed- pan. The patient is secured to this by straps passing over the chest and by a band around the pelvis. This makes it impossible for the patient to sit up or roll over, which he is sure to do if left free in bed ; and it insures quiet to the joint. Traction is applied by means of a weight pull- ing upon adhesive plaster attached to the leg. Two strips of surgical adhesive plaster are sewed to web- bing, which should project below the foot. These plaster strips run upward from the malleoli inside and out- side of the leg and thigh ; and they are further secured in Fig. 14. — A PLASTER HIP EXTENSION APPLIED. 86 DISEASE OF THE HIP JOINT place by a basket-work made by two other strips of plas- ter running around the leg and thigh. This gives a firm hold upon the skin of the leg to the webbing which pro- jects below the foot. This is buckled to a crosspiece of wood from which runs a cord over a pulley at the bottom Fig. 15. — WEIGHT AXD PULLEY APPARATUS FOR BED TRACTION'. of the bed. To this cord a weight of from 3 to 5 pounds is attached. In acutely painful cases a heavier weight may be temporarily required. The foot of the bed should be elevated to provide for THE TREATMENT OF HIP DISEASE 8/ counter-traction, else the child will be continually pulled down by the weight. Tractioji should always be made in the line taken by the leg when the pelvis is made square, otherwise it is likely to prove painful. Traction thus made is a sedative measure, and tends to quiet muscular irritability and to reduce deformity. The use of a long outside splint or any other appliance, except in cases of deformity (when it may be necessary to elevate the leg on an inclined plane), is wholly unnecessary. Traction may, however, be made in bed, when deformity is present, without the use of the weight and pulley, by applying a long traction splint to the limb, and then placing the limb in the deformed position. Traction in bed is only indicated in acutely painful cases, in cases where deformity is present, and where apparatus is not to be obtained. Traction by Means of Splints. Any traction splint consists of an upright furnished below with some appliance to pull down upon the leg straps, while above it terminates in an arm or band to take a hold upon the pelvis and furnish a point of counter-extension by means of straps passing under the perineum. The conventional long traction splint consists of a steel pelvic band, made either straight, or curved in the manner shown which enables it to fit more closely to the crest of the ilium and take a firmer hold on the pelvis. This arm may be long or short, curved or straight. The pelvic band should be riveted to the upright at an angle with the anterior arm lower. The upright should reach from the pelvic band (which should be at a level with the anterior superior iliac spines) to two inches below the sole of the foot, and should be curved out a little at the top to avoid the fulness of the thigh. This, however, is not essential. Below, it should terminate in an arm with a DISEASES OF THE HIP JOINT windlass provided with pins, upon which the extension straps can be wound up. This is the cheapest form of apparatus. Fia;. i6. Fig. 17. Fig. 16. — SPLINT WITH CUR\"ED BAND. FigS. 17 and iS. — SPLINT WITH STRAIGHT BAND FOR LEFT LEG. A more expensive and more convenient one can be made by having the lower part of the splint slip inside of the upper part, at a point one-third of the way up the leg, where the inner piece is controlled by a ratchet cut into it, and the whole upright can be lengthened or shortened by means of a cogged key. In this way no windlass is needed on the foot piece, which requires only buckles ; and the traction is ob- tained by lengthening the upright by means of the ratchet and key. THE TREATMENT OF HIP DISEASE 89 Fig. 2o.- ■RATCHET AND SIGN. CE^• rXTEN- Fig. 19 — WINDLASS AND EXTENSION AS USED IN THE LONG TRACTION SPLINT. The splint is provided with an anterior pad over the thigh and a posterior arm behind the calf. If the windlass pattern is used, some provision should be made for increasing the length of the splint as the child grows. This is done by having the two pieces overlap and screwed together. The pelvic band should buckle around the waist and be padded with leather, as should also be done to the plate and arm. The splint should be made as light as is consistent with strength. Perineal bands are attached to the pelvic band, so as to pass under the tuberosity of the ischium as nearly as may be. They can be made of webbing, covered with Canton flannel, or of leather moulded over a leather strap. The care of the perineum is an important matter in hip disease, and it should be hardened by alcohol and kept dry by some dusting powder. If sloughs form, the splint should 90 DISEASE OF THE HIP JOINT be removed, and they should be dressed with some simple ointment. Traction splints may be made with one anterior and one posterior horn instead of a band, and be provided with only one perineal band. These furnish much less fixation than the others, and are not suited to severe cases, especially in hospital practice. '' Fig. 22. — CURVED TWO-BAND HIP SPLINT APPLIED (which follows more closely the outline of the crest of the ilium). Fig. 21. — STRAIGHT TWO-BAND HIP SPLINT APPLIED. If there is a sinus over the trochanter or tenderness there, it is often a matter of much convenience to split the upright THE TREATMENT OF HIP DISEASE 91 over cases, the the outer splint surface of the thigh, as shown. In other may be applied over the dressing. A cheap hip splint, made of gas-pipe, has been described by the writer,* where traction i s t o be made by means of leather straps a t- tached to the foot piece instead of by a windlass. The splint should cost only one or two dol- lars, and is fairly efficient. Judson's splint, or ischiatic crutch, dif- fers somewhat from the others. It is in- tended to exert only T-i- T 1 4. i i.- J Fig. 24. — DIAGRAM OF CHEAP Fig. 23.- SPLINT WITH slig-ht traction, and ^ OPEN SPACE OVER THE ,=' ,. . ' , GAS-PIPE HIP SPLINT. TROCHANTER. thc spliut IS madc heavier above than below, so that the centre of gravity is higher and makes walking with it easier. The pelvic band is covered with hard rubber, which is a cleanly but expensive method. The splint, in a modified form, can be made very cheaply, however, and is much used in New York clinics. It is open to the same objection as are all traction splints not supplied with some better ap- pliance than straps for obtaining traction. It does not pull evenly or strongly enough. Such a splint as one of these should be worn through the acute stage of the disease, until muscular spasm on manipu- lation has been absent for some months, as well as pain. R. W. Lovett, Boston Med. and Surg. Journal, March 12, 1S91. 92 DISEASES OF THE HIP JOINT It is safer to begin with the use of crutches, and building up the well foot by so high a patten that the splint swings clear of the ground in walking. Later the bottom of the splint may be shod with leather, and the patient allowed to walk directly on it. In children under careful control, and in the mildest cases, this may be done at first, but it adds to the risk. The splint serves as a protection splint as well as a traction appliance, inasmuch as it re- moves the body weight from the leg, even where the patient walks upon the splint. Its attributes as a fixation appliance will be dis- cussed in a subsequent section. The material of which the splint is made is a matter of detail, and the same may be said of the pattern used. The essential mat- ter is to have an appliance which holds the pelvis as a basis for counter-extension, and which projects below the foot enough to pull the leg down. When this is once understood, the construction of an appliance is compara- tively an easy matter. These splints should be worn night and day, and the limb disturbed as little as possible when they have to be removed. When the splint is not in place and exerting traction, 25.— juD- the leg should be gently pulled down by the hand until the traction straps are fastened in place. In all probability the splint will have to be worn from two to five years. Most cases under control recover from their acute symptoms in two or three years ; but a longer course of disease is common, and is not inconsistent with a favor- able issue. SON S PERINEAL CRUTCH THE TREATMENT OF HIP DISEASE 93 Faulty Appliances. Traction splints which are jointed at the junction of the upright and pelvic band, although, perhaps, in accord with the ideas of the originator of the splint, are not regarded to-day as desirable. The problem is not to facilitate, but to re- strict, motion at the hip lip. Sayre's short splint is almost worthless. It is too short to obtain any pull upon the hip worth mentioning, and it does not grasp the pelvis. It is but little used, although sold by the instrument-makers. Elastic perineal straps are faulty, and cause constant relaxation of trac- tion and jarring to the hip. They are almost never seen outside of the instrument-makers' shops. The Practical Objections to Traction. Theoretically, traction as a treat- ment of hip disease rests upon a scientific basis. Practically, it has some disadvantages. The skin is frequently made sore by the constant irritation from the plaster, and frequent changes of plaster are necessary. If the plas- ter is applied below the knee, and does not have a hold upon the thigh, the knee ligaments will be weakened and the knee hyper-ex- tended. In some rare instances, traction causes pain, as in two cases recently reported by Ridlon ; but such cases are so rare that they may be left out of account. Fig. 26.- ■SAYRE S SHORT SPLINT. 94 DISEASES OF THE HIP JOINT A serious objection to the long traction splint, and one which, in the writer's mind, makes the routine use of crutches almost advisable, is that, when the patient steps upon the splint, the traction is lessened ; and often the traction straps can be seen to hang loosely as the body sags down in the perineal bands. This leads to a series of jerks to the diseased joint. Attempts have been made to remedy this by the insertion of a spring in the shaft of the splint ; but such an arrangement is expensive and complicated. The use of elastic traction straps is not to be advocated* because elastic appliances are always uncertain quantities, and generally exert too much or too little traction at any given time. The problem is very easily solved by the use of crutches. The Theoretical Objections to Traction. In addition to the practical objections to the treatment of hip disease by traction, there are, in the writer's opinion, certain theoretical objections also, which demand considera- tion and discussion. The most important question in this regard is the consideration of the fixative power of traction. Does traction immobilize a diseased joint, or, if not, does it furnish practical fixation enough to protect it from traumat- ism .-• This question is one which is not only theoretical, but practical, and affects very strongly the whole question of the ambulatory treatment of hip disease. The American traction splint was not introduced with the idea that it was a fixative appliance. Dr. Henry G. Davis believed that it allowed " motion without friction " ; and Dr. C. F. Taylor, in speaking of the appliance, spoke of it as an apparatus which, first, should relieve pressure from the joint due to the muscular contraction by temporarily destroying the mus- cular irritability and contractibility, and, secondly, should pro- tect the joint from weight and concussion. He made no mention of the splint as a fixative appliance, and evidently did not consider it as such. THE TREATMENT OF HIP DISEASE 95 Later, however, traction seems to have come to be re- garded as a means of fixation, notably by Dr. A. B. Judson, v^rho has v^ritten an article dealing with the question of the fixative power of traction (Medical Record, July 7, 1883, May 13, 1883). Dr. Judson quotes Bauer, Yale, Wyeth, and Shaffer as the authorities believing that fixation fur- nishes traction. Dr. Judson believes "that, when the hip splint is applied to a patient, traction is made in such a manner that fixation is rendered more complete by the part of the apparatus which acts as a brake. As applied to the patient, the hip splint, when traction is exerted, makes friction on the tuber- osities of the ischia and rami of the ischia and pubes, these parts representing the periphery of a wheel revolving at the upper end of the femur, through a considerable arc in the plane of flexion and extension. In practice it is found that, when traction is made in the case of a patient to whom the hip splint is applied, motion in flexion and extension is prevented, although it may not as yet have been arrested by the disease." These theoretical considerations, however, have not stood the test of actual experiments, as made by the writer, who reported to the American Orthopedic Association in 1888 some experiments which seem to show that in practice the traction splint does not furnish any considerable degree of fixation to the hip joint (N.Y. Medical Journal, Feb. 8,, 1889). A long traction splint was fitted with a registering appliance to record motion at the hip joint. The shaft of the splint was simply carried up until it was opposite the skin over the crest of the ilium. This upper extremity of the shaft was provided with a pencil perpendicular to the skin, which recorded on the skin motion occurring at the hip joint, if any such took place. The splint was applied to a boy with anchylosis at the hip joint; and, after walking with the splint, no motion was recorded on the skin over the ilium. 96 DISEASES OF THE HIP JOINT The splint was next applied to a boy with normal hip joints; and a moderate degree of traction was applied, some three and one-half pounds as registered by a spring balance inserted in the extension straps. In walking and in sitting, the bov's hip described an arc of 35 degrees of joint motion, as recorded by the register of the apparatus. When traction was increased so much that it was almost unendur- able, the hip described an arc of 15 degrees of motion; and in a second experiment, made with a boy with healthy hip joints, the hip described an arc of 40 degrees of joint motion with moderate traction. If these experiments show anything, it is that " one may conclude from this that a long traction splint with one perineal band furnishes ver}- incomplete fixation to a healthy hip joint with any comfortable degree of traction, and conse- quently to a diseased hip joint it must furnish equally poor fixation." There is no doubt that, within the limits set by nature, motion in hip disease is not harmful. But it must be evident that from a mechanical standpoint it is very diffi- cult to restrain motion by an apparatus which allows 35 or 40 degrees of motion in flexion. If the joint is one which does allow so large an arc of motion, the long traction splint is a perfectly efficient apparatus under these circumstances. If, however, the joint motion is limited by nature to an arc of 15 or 20 degrees, it must be obvious that with rough usage the long traction splint must become an inefficient appliance, and must allow motion beyond the proper limits. This, then, seems to the writer a theoretical objection to traction : that traction is not fixatioji, and does not of itself produce fixation, and that in practice the traction splints in common use are not fixation appliances, and are liable to allow motion beyond the proper limits. In view of this the question arises. Is the matter one of any importance practically .' and is not the fixation furnished bv the traction splint sufficient for all practical purposes ? The answer to this is found in the fact which must appeal THE TREATMENT OF HIP DISEASE 97 to any surgeon, who sees much of this class of cases, that a certain proportion of children do not progress well under treatment by the long traction splint. In ihe writer's expe- rience it has seemed to him to be because these children have been allowed too much joint motion. The cause of most of the complications is to be found in the ceaseless activity of such children, which causes constant traumatism to the joint. They are allowed by their parents in most cases as much activity as healthy children. They climb fences, and jump rope continually. They run about all day, and indulge in all sorts of violent exercise. It stands to reason that in a joint which is at all sensitive, this cannot be indulged in without the risk of exciting joint irritability and increasing the muscular spasm, and such is practically the outcome. In hospital practice it is a very common experience to find that the patient is doing badly, that the joint is becom- ing sensitive and less movable, and that pain is becoming marked. In these cases, it is generally possible to find the explanation of the symptoms in the patient's constant activ- ity. In certain cases, the severity of the disease is enough to account for it, without further exciting causes ; but in the majority of cases the explanation of it is to be found in a constantly repeated traumatism of the joint. It does seem, then, that the lack of fixation afforded by the traction splint is an important element to be considered in the treatment of the disease ; and the question arises. In what way can this matter be remedied, and in what way can greater quiet be secured to the diseased joint ? In the first place, the use of crutches accomplishes a certain amount in this direction. If the children wear so high a sole on the well foot that the splint swings clear of the ground in walking, and are thus obliged to use the crutches continually, much is gained. Again, a traction splint with two perineal bands, and a steel pelvic band fitting accurately to the pelvis, is much to be preferred to a long traction splint, 98 DISEASES OF THE HIP JOINT which is provided with only one perineal band, inasmuch as it obtains a better hold of the pelvis, and affords better fixa- tion to the hip. Yet even this in children who are under poor control is unsatisfactory, and likely to yield poor re- sults. In such cases, the splint described by the writer may be of use. Fig. 27.— COMBINED FIXATION AND TKACTION SPLINT. It is practically a combination of the Thomas and Taylor splints. Embracing the thorax by a steel band, the splint follows the line of the Thomas splint as far as the calf of the leg, with the exception that it is provided at the pelvis with THE TREATMENT OF HIP DISEASE 99 an arm to encircle the pelvis and support the perineal band. Below the calf of the leg it terminates in a traction appliance similar to that of the traction splint described above. The advantages of the splint were stated as follows : * " It is not presented as a splint for the routine treatment of hip disease, but as a means of furnishing fixation and trac- tion in bad cases, while the patient goes about on crutches. It has these advantages : it necessitates the use of crutches, it makes it impossible for the patient to climb fences and knock about in the way so many children do with such dis- astrous results, and it makes it possible for the child to go comfortably about, even with the joint exquisitely sensitive to every jar." Although this is in general true, it is not possible to find any appliance which it is safe to use in these extremely sen- sitive cases without decided risk. Cases where sensitiveness is a marked feature demand, from the first, fixation in bed until the sensitiveness has improved. In concluding, it may be said that in most cases, and in all cases which are under good control, the long traction splint affords a perfectly efficient means of treatment, but that in unruly children, and in exceptional cases, certain more strin- gent measures are necessary ; and these will be more fully discussed. The Treatment of Convalescence. When muscular rigidity and pain have subsided and have been absent some months, the question arises as to abandon- ing traction, and making the first step toward regaining the use of the leg in applying a simple protection splint. This is a step which should be taken with much care and deliber- ation. Any precipitancy is likely to be regretted, and it is often very hard to wait what seems so unreasonably long a time before changing the splint. But the many relapses * Trans. American Orthopedic Ass'n, vol. i. lOO DISEASES OF THE HIP JOINT which occur, even when every care has been taken in mak- ing the change, should serve as a warning. It must be remembered that the process is a slow one, and that cure most often takes place by the caseation of the tubercular foci. These remain latent, but ready to be awakened by any irritation in their neighborhood. It is for this reason that it seems wise to keep on for the longest time possible the most efficient splint. The case shown in the figure is one of a series which have made the writer very cautious about recommending a change to the convalescent splint. The boy, twelve years old, had been under treatment with the long traction splint for three years, and had done well. As he had been for some months without pain or muscular spasm and was in ex- cellent condition, the traction splint was removed and a simple protection splint applied. His good general condition at that time is shown by the photograph. In about three months an old ab- scess cicatrix broke down, pain be- gan to be complained of, and in the last year the progress of the case has been downward until now, when it seems likely that excision will be necessary. It seemed as if a quiescent focus had been roused to activity by the change in splints. Reduced to its simplest terms, the protection splint is merely the traction splint cut off and attached to the sole of the boot instead of projecting below it. The illustrations Fig. 28. — CONVALESCENT SPLINT APPLIED. THE TREATMENT OF HIP DISEASE lOI will show more plainly than any description can do how simply this is accomplished. The foot piece is cut off and the end of the upright slotted to fit into the arm from a steel sole plate screwed to the sole of the shoe, as shown in the photographs. This supplies a perineal crutch, which trans- fers the weight from the hip joint to the perineum when the leg is used in walking. Fig. 29. — CONVALESCENT SPLINT FOR THE LEFT LEG UNAl'l'LIliD AND APPLIED. In this splint the patient is suspended by the perineal strap, so that the heel does not touch the ground on the affected side ; and, if the heel touches, the splint is of course inefficient, and the patient might as well be without any apparatus at all. I02 DISEASES OF THE HIP JOINT In adults and in older children, where expense is not an object, the splint may be jointed at the knee, which in no way impairs its efficiency, but which adds to its weight, although the ability to bend the knee makes the splint much less cumbersome. The theory of the splint has been very carefully worked out by Dr. Brackett,* who has demonstrated very clearly the reason for its usefulness in protecting the hip from traumat- ism. In normal walking the heel is the first part of the foot to strike the ground and receives the greater part of the shock, and the toe only bears its share of the pressure for one-sixth of the whole time. In the first part of the step the heel sustains all the weight of the body at the time when the leof is extended. Fig. 30. — NORMAL PROGRESSION (bRACKETt) By substituting the protection splint for the unaided leg, the first impact of the foot in touching the ground is borne by the splint and transmitted to the perineum without com- ing at all upon the hip joint. By means of this the foot (and consequently the hip) are protected from pressure except at * Bost. Med. and Surg. Journal, Oct. 6, 1887. THE TREATMENT OF HIP DISEASE 103 the last part of the step, when the foot is in the act of leav- ing the ground and the least protection is required. The difference in the mechanism of locomotion will be appreci- ated by comparison of this diagram (made from photographs by Dr. Brackett) with the one preceding. Fig. 31. — PROGRESSION WITH THE PROTECTION SPLINT (brACKETT). The Termination of Treatment. It is impossible to state in general terms how long the convalescent hip should be protected. Certainly for some years after the cessation of active treatment; perhaps to the time of puberty. The question of removal is a matter which must be decided for each case, and there is always the risk of removing the splint too soon. The active period of the disease is, in general, from two or three to five or six years; and, after that is over, it must be remembered that latent foci of tuberculosis may still be present, and that all risk of so serious a matter as a relapse should be avoided. The pathology teaches no lesson more clearly than that the process is in the milder cases a very slow one. I04 DISEASES OF THE HIP JOINT It is not, of course, possible to carry out such a careful routine in hospital practice nor always among the more intel- ligent classes ; but, if risk is to be run by an early discontin- uance of treatment, it would seem as if the responsibility should be taken by the parents who desire it rather than by the surgeon who believes it to be unwise. Relapses. The frequency of relapses is shown very well by the results of the investigation made by Shaffer and Lovett into the ultimate results of the mechanical treat- ment of hip disease.* Of 51 cases found which had been discharged "cured" after a careful examination, at least four years pre- vious to the search, 6 had suffered from re- lapses. These patients had been under treatment two and one-half, four, four, four, five, and seven years respectively. " In one case, the apparatus had been removed with- out the knowledge of the surgeon ; but in the five others treatment was discontinued only after the joint symptoms had ceased for some months, and the patient could hop, run, and perform other active movements with the affected leg." The Treatment of Double Hip Disease. Fortunately, double hip disease is an un- common affection ; for the Treatment in any event is confining and distressing, and the results apt to be unsatisfactory. The dis- ease may be treated in one of three ways. {a) Patients may be treated by rest in bed on a bed-frame with double traction. The Fig. 32. — THE CON- VALESCENT SPLINT WITH CURVED PELVIC BAND APPLIED (rID- lon). * N.Y. ^led. Journal, May 21, 1887. THE TREATMENT OF HIP DISEASE 105 only objection to this method is the prolonged confinement, but in the early stages of the disease it is to be advised as being more efficient than any portative appliance could be in the treatment of two acutely inflamed hip joints. It is however often necessitated by the presence of malposition of one or both legs. {b) The double Thomas splint may be used, and affords an admirable means of treatment. It fixes the trunk and limbs ; and, unless sensitiveness be present, de- manding the application of traction, the method will be found perfectly satisfac- tory. {c) The patient may be treated by two long traction splints, one on each side, buckling together at the waist. In the writer's opinion, this is a little the best of the three ways where practicable, as it seems likely to secure a better ultimate result than simple fixation. In any event, it will be possible for the child to get about very little indeed, as it is almost impossible to walk com- fortably or easily with either of the por- tative appliances described ; but they al- low riding and out-of-door air, and in that they have the advantage over simple recumbency. 33. — THE DOUBLE HIP SPLINT (rIDLON). The Treatment of the Complications of Hip Disease. The common complications are : - {g) Night cries. {h) Acute sensitiveness. (?) Malpositions of the limb. (j) Abscesses. I06 DISEASES OF THE HIP JOINT (g) AHgJit Cries. Ordinarily, night cries subside when traction is applied. If they persist, it will be found, as a rule, that the splint is improperly worn or that the child is going about too much. These causes are easily remedied. At other times, in spite of every care in patients under control, night cries will persist, generally in connection with much sensitiveness of the joint. In these cases salicylate of soda in full doses is of much use.* Antipyrine and phe- nacetine are sometimes temporarily of benefit. If these drugs fail to relieve the cries, and if the leg is fixed in the position of deformity and the mechanical treatment seems to be properly carried out in every way, it may be useful to elevate the leg slightly. In a case recently reported by Goldthwait, night cries were controlled in this way.f When mechanical measures fail after faithful trial, nothing but operative measures remain. The head of the femur may be trephined through the trochanter or the joint capsule may be incised anteriorly or posteriorly. The latter measure rarely fails to give relief for a while ; but cases zvhicJi are characterized by excessive sensitiveness in the beginmng be- long, as a rnle, to the ivorst type of the disease, and often resist all measures of treatment. {h) Acute Sensitiveness of the Joint. This condition, again, is commonly the result of a fall or of too much activity, although often occurring without assign- able cause. Rest in bed is essential, and heavy traction should temporarily be applied ; and all traction should be made in the line of the leg's position. Salicylate of soda is often of use ; and, if cases persist in * Boston Med. and Surg. Journal, April, 1889. t J. E. Goldihwait, Boston Med. and Surg. Journal, 1S90, vol. ii. THE TREATMENT OF HIP DISEASE lO/ spite of thorough mechanical treatment, the joint should be opened , Acute attacks of sensitiveness, especially if spontaneous, are in most cases the precursors of abscess formation. Cer- tain cases, however, continue acutely sensitive in spite of every care and in spite of thorough mechanical treatment. (/) Malpositions of the Limb. At the beginning of treatment, in the majority of hospital cases at least, abduction or adduction or flexion of the dis- eased limb is present to some degree. Later in the disease these malpositions come on spontaneously, or as a result of inefficiency of treatment, or from too much traumatism to the joint. At other times they come on as sequelae to the exanthemata occurring during the course of treatment. As a rule, malpositions of the limb are associated with an acutely sensitive condition of the joint, and point, generally, to some imperfection in the mechanical treatment. As soon as malposition reaches a degree which makes the splint fit awkwardly, or before that if the joint is acutely sensitive, rest in bed should be insisted upon, with traction made in the line of deformity, either by the ordinary traction splint or by a weight and pulley. The latter is generally preferable, and the pelvis should be made square, and trac- tion made upon the leg in whatever line it takes. It is obvious that an inclined plane will be necessary for this if flexion is present. The child should be secured to a bed- frame in every case, as a measure necessary to secure proper fixation. The figure (34) shows the application of this method in a case of flexion with abduction. Traction was applied to the well leg merely to steady the patient, and is not ordinarily necessary. It will be found in the pursuance of this method that at very short intervals it will be possible to bring the leg nearer io8 DISEASE OF THE HIP JOINT to a correct position, until the normal line is reached. The reduction of a moderate degree of deformity is generally only a matter of two or three weeks. There is a more forcible and a quicker method of reduction by etherization and forcible reposition. This is, firstly, a rough shock to an acutely sen- sitive joint, and often causes much pain afterward ; and, secondly, it is occasionally followed by abscess formation, which, it will be seen in the next section, is in many cases avoided by the milder method of deformity correction. If Fig. 34. — BED TRACTION IN A CASE OF FLEXION AND ABDUCTION. the leg is forcibly straightened, a plaster spica should be applied, while the patient is unconscious, to hold what has been gained in the position of the diseased leg. The method of Dr. Taylor for the correction of adduction is exemplified in the cut. It consists in a hip splint applied in a reversed position, so that the perineal band presses in the groin of the healthy side. In this way forcible lev- erage is obtained, which tends to straighten the leg. The splint is applied during recumbency only. In many cases the choice of a method will have to be dictated by the circumstances of the patient ; and forcible reposition is a perfectly legitimate proceeding where it is THE TREATMENT OF HIP DISEASE 109 desirable to save time or where good home or hospital care is not obtainable. If anchylosis occur in a deformed position, operative meas- ures must be resorted to. When an anchylosis of the hip has occurred in a position of much deform- ity, several operative measures are to be con- sidered which have been of use in the rectification of the deformity. If the anchylosis is bony, any- thing short of a cutting operation is not likely to be of use ; but the for- mation of a true bony anchylosis is a matter of some years probably, and many anchyloses appar- ently firm and osseous are in reality only fi- brous. It is a question whether it is better to operate upon a recent anchylosis or to wait until the local condition has quieted down, and then to do one of the cutting operations to be described. If it is decided to operate upon a recent anchylosis, the most common method is that of brisement force. The patient is etherized, and the hip is forcibly extended over the edge of the table, or by laying the patient on the face and crowding the pelvis downward, so as to obliterate the Fig- 3S- — Taylor's splint for the correction OF ADDUCTION. no DISEASES OF THE HIP JOINT angle between the trunk and the femur. It is hardly neces- sary to call attention to the fact that a proceeding of this sort is likely to start up any latent focus of tuberculosis which may exist in the joint, and that, in a certain proportion of pjg_ 2,5. — SEVERE FLEXION OF THE UISEASEL) LEG IN H[P DISEASE (AN UNTREATED CASe), NECESSITATING RECUMBENCY IN BED. cases, it is followed by an active outbreak of the disease. In acute stages of hip disease this proceeding, or forcible exten- sion of the hip, is not one of any great risk, although inferior to the method by recumbency ; but, after the acute stage of the disease is over, it seems to the writer an unjustifiable THE TREATMENT OF HIP DISEASE III risk to run for the surgeon to adopt any proceeding which is at all likely to again start up the acute disease. Con- sequently, in the writer's opinion, it is wiser and safer, in cases where anchylosis has occurred in a deformed position, to wait until the local condition is quiet, probably a matter of months or years, before proceeding to any operation, and then to do a thorough, cutting operation about to be de- scribed. One or two other proceedings should be mentioned before speaking of • the common operation for the correction of anchylosis in deformity. In certain cases even when oste- otomy has been performed, and in other cases where the an- chylosis is only fibrous, there is so much contraction of the skin and fasciae at the anterior part of the thigh that it is impossible to extend the leg without dividing the structures. Consequently, tenotomy and myotomy are occasional proced- ures, either alone or in connection with osteotomy. Osteoclasis is occasionally, although very rarely in these days, used as a means of correction for hip deformity. The operation lacks precision, and its interest is chiefly historical. Very rarely it is done by manual force, and most often by one of the osteoclasts for the purpose. Subtrochanteric Osteotomy. — The most common and the most useful operation for hip deformity is subtrochanteric osteotomy as performed by the method of Mr. Gant. The only other operation is that of Adams, which is a supra- trochanteric osteotomy of the neck of the femur. The advantage of the operation below the trochanter minor is that relapse is less likely, on account of the division of the bone below the insertion of the psoas muscle. If, as in Mr, Adams's operation, it is done above the trochanter minor, the continued pull of the muscles inserted into it is a factor which is likely to reproduce the flexion. The reason for the preference of subtrochanteric osteotomy is given by Mr. Gant (British Medical Journal, Oct. i8, 1879) : — "When, in consequence of continued disease of the hip 112 DISEASE OF THE HIP JOINT joint, the head of the femur has disappeared, leaving only a stunted nodule of bone representing the neck above the tro- chanter, in such a case the operation of section in the fem- oral neck cannot be performed, there being no neck to divide. Even when supratrochanteric section is practicable the state of the neck may render this operation abortive. The seat of the operation will be in an almost carious por- tion of bone, which is unfit to yield a fibrous union." It is for these reasons, and on account of its simplicity, that Mr. Gant's operation is, in the writer's opinion, prefer- able to any other for the correction of hip deformity. The risk of the operation is very slight. Poore analyzed 167 cases of osteotomy about the upper end of the femur. Of these, 138 were cured, 17 died, and 12 were failures. Of the 17 fatal cases, 12 occurred before the advent of antiseptic surgery. These figures are not in any way representative, and exaggerate very much the danger of the operation. So far as the writer's personal experience has gone, the operation has been always simple, and unat- tended by unpleasant symptoms ; and he has never person- ally heard of any trouble occurring in the operation, as per- formed in the last few years. The operation is done very simply, and every possible antiseptic precaution should be observed. The patient is etherized and turned upon the side, and the incision may be made exposing the trochanter if it is desired, although it seems entirely unnecessary, and the operation is less bloody if the chisel is driven directly into the bone through the sound skin. The place selected for section should be an inch or an inch and a half below the great trochanter, and the section should be made across the long axis of the bone. When it is evident that the bone is very nearly divided, and that only a shell is left, the femur should be fractured by gentle force, preferably bending the bone inward. The bone breaks with a loud snap, and in most cases the leg can be immediately placed in a correct position. THE TREATMENT OF HIP DISEASE 113 In some cases of long standing, division of the soft parts over the anterior surface of the thigh may be necessary, as has been said. An antiseptic dressing should be applied, and the patient is most easily cared for on a bed-frame, with traction applied to the leg which has been operated upon. A plaster spica is dirty and uncomfortable, and the leg cannot be inspected without a good deal of disturbance of the patient. It should be re- membered that the operation produces a compound fracture of the femur, and that con- finement to bed is necessary for about six weeks, beginning with a gradual use of the leg. A too early use of the leg is likely to be attended by a re- lapse and by fle.xion of the leg. If abduction or adduc- tion exist, they are easily rec- tified at the time of opera- tion ; and, in one or two in- stances coming under the writer's observation, the op- eration has been done chiefly to correct a lateral curvature which was beginning, and which seemed to be due to the obliquity of the pelvis caused by adduction of the diseased leg. The question of the advisa- bility of the operation is one which must be, of course, settled in each case. As a rule, when the deformity is severe enough to cause a very con- spicuous limp, or is enough to disable the patient by causing lateral curvature, or on account of its marked characteristics, Fig- 37- — A ISAU RESULT KKOM HIP DIS- EASE DUE TO ANCHYLOSIS IN THE POSITION OF DEFORMITY. 114 DISEASES OF THE HIP JOINT it is proper to recommend the operation. It is performed equally well upon children and adults, and is to-day done almost to the exclusion of all other similar operations. (_/') Abscesses. The occurrence of abscesses is in many cases due to the severity and destructive character of the disease in the indi- vidual case, but in most instances it is the result of inefh- Fig. 38. — A HIP ABSCESS. cient or-incomplete treatment. The joint being imperfectly protected or fixed, irritation of the articular surfaces is in- duced by constant traumatism, which is expressed first by increased muscular spasm and malposition of the limb, and then by the formation of pus in large quantities, which bursts THE TREATMENT OF HIP DISEASE II5 through the weakened capsule and seeks the surface, — some- times on the anterior surface of the thigh, at other times in the buttock, or still more uncommonly under the adductor tendons. Although no definite conclusions as to the seat and character of the disease can be drawn from the location of the abscess, those appearing at the inside of the leg under the adductor tendons are more likely to be associated with pelvic disease and to be more troublesome. The appearance of an ordinary hip abscess is well indicated in the figure. Widely differing views are held in regard to the treatment of hip abscesses by American orthopedic surgeons. In Europe it is the universal practice to incise such collections of pus, and for that matter such is the practice of most American orthopedists. But the fact that Dr. N. M. Shaffer and Dr. Judson, of New York, stand as the representatives of a few men who advise against operation, makes a careful consideration of the question necessary. Dr. Judson has formulated the objections to operation : " Incision is a tardy and fruitless procedure. The painful stage in the history of the abscess is long past. It was present when the pus was collecting under the periosteum and in the cells of the bone. . . . But, when the pus is in the cellular structures or the cavity of the joint, I do not see that the progress of the case can be materially affected by interference." " If we operate, we substitute artificial for natural closure; and, with the best antisepsis, we gain nothing by operating unless we reach and scrape out the purulent deposit or the interior of the joint. . . . And, if we operate in the manner described, we do not avoid the necessity of bringing to bear the best mechanical treatment and hygienic control, which, if they are supplied, will bring about a recovery, whether we operate or not, by the slow but sure process of natural re- pair, with the better result the less we interfere with the soft parts, as a general rule." * * New York Med. Journal, March 2, 1889. Il6 DISEASES OF THE HIP JOINT Dr. Judson had expressed similar views in 1885, with regard to which Dr. L. A. Sayre said in the discussion that "it was a disgrace to the orthopedic surgery of America to allow such statements to go abroad uncontradicted." * These views of Dr. Judson represent the best that can be said, presumably, of non-operative treatment ; and the fact that he and Dr. Shaffer advocate such treatment should not be estimated too lightly. In favor of the non-operative treatment it may be said, further, that absorption of ab- scesses occasionally occurs at even an advanced stage, when fluctuation is plainly to be felt ; that any operation is at- tended by the risk of accidents resulting in death ; and that, although there should be no risk of septicaemia from operation, there is, as after excision of the joint, a slight risk of the generalization of tuberculosis, undoubtedly by infec- tion at the site of the incision. The conservative treatment of abscess in hip disease should be limited to cases under good control, where an abscess is not painful and shows no tendency to increase ; where its spread can be limited by bandaging or the press- ure of the anterior pad-plate of the splmt, and its growth will be toward the surface instead of laterally between the layers of fascia. In such cases there is no impropriety in waiting almost indefinitel}' in the hope that the abscess ma\' be absorbed. In cases where perfect antisepsis is not obtainable, it is better to allow the abscess to burst, as also in the case of unusually delicate and nervous children, where the abscesses are not painful. In short, the non-operative treatment of painless hip abscess is sanctioned bv the best authority, but, in the minds of most surgeons, is inferior to the treatment about to be considered, and, so far as the writer's experience goes, should be limited to the class of cases just described. * New Vork Med. Journal. Jan. 31, 18S5, p. 116. THE TREATMENT OF HIP DISEASE II 7 The Prevention of Hip Abscess. — It may, however, first be permissible to speak of the prevention of hip abscesses as a most important part of the discussion of their treatment. The percentage of cases in which they occur varies very widely. In the cases reported by the London Clinical Society, in 1880, of 401 cases, 69 per cent, developed ab- scesses. Mr. Howard Marsh, in an analysis of cases since 1880 from the Alexandra Hospital, found abscesses in only 50 per cent, which diminution he attributed to improved methods of treatment. Gibney reported, in 1878, 80 cases of cured hip disease, 60 per cent, of which had developed abscesses. Mr. Marsh said, in speaking of his cases, " My own estimate, from what I have seen in the hospital and elsewhere, is that the formation of an abscess may be averted in at least 80 per cent, of the total number of cases." In contrast to these percentages, the series of cases re- ported by Lovett and Goldthwait * is of much interest. In 320 cases under treatment at the Children's Hospital in Bos- ton, only some 75 developed abscess, making a percentage of only 23, which is very strikingly less than any other series of cases, and seems to fulfil Marsh's prediction. More re- cently the writer has had the opportunity of investigating a still larger number of cases, including those just mentioned. From 1884 to 1890, inclusive, there presented themselves at the Out-patient Department of the Children's Hospital 574 new cases of hip disease. In pursuance of the operative treatment of these abscesses which has been followed out for some years, practically all cases of abscesses were ad- mitted to the hospital wards as soon as they appeared. In those years when 574 new cases appeared at the Out-patient Department, 107 abscesses were opened in the hospital, which means that 107 cases either had an abscess at the time of coming or developed it in the course of the disease. This gives a percentage of 18.7 per cent., which is very * Trans. Am. Orth. Ass'n, vol. ii. p. 82. Il8 DISEASES OF THE HIP JOINT much lower than in any other series of cases reported. There may be a sHght error, amounting to i or 2 per cent., caused by exceptional cases of abscesses which were not operated upon ; but these were so few that they would make very little difference in the percentage. The reason for this small percentage is believed by the writer to be due to the fact that cases under ambulatory treatment are at once admitted to the hospital whenever sensitiveness or deformity of the joint occurs, and are treated by recumbency. In 1 888,- 42 cases of hip disease were admitted to the ward; in 1889, 59 cases; in 1890, 81 cases. In these years the percentage of cases admitted for deformity and sensi- tiveness has steadily increased, and the percentage of cases admitted for abscess has steadily diminished. Of the 182 patients admitted in these three years (which are all that it has been possible to analyze), 107 were admitted for deform- ity or sensitiveness, and stayed only a short time in the hospital, returning to the Out-patient Department for ambu- latory treatment, while only 54 cases were admitted for abscess and 23 for application of apparatus. It seems reasonable, therefore, to conclude that the con- finement of the patient to bed during the occurrence of deformity or sensitiveness of the joint is a measure which renders the occurrence of abscess less likely, and is to be regarded as preventive treatment. When the abscesses occur, three courses are open, — the abscess may be let alone, it may be aspirated, or it may be incised. In general, as has been said, it may be let alone so long as it does not increase, or when the circumstances of the patient demand it. Personally, the writer is in favor of early and thorough operative-treatment, at least in hospital cases; but it should be stated clearly that it is a personal preference, and that expectancy is admissible and to be considered good treat- ment. Treatment by Aspiration. — Methods of treatment by aspi- THE TREATMENT OF HIP DISEASE II9 ration are, as a rule, unsatisfactory. These abscess cavities are lined by a pyogenic membrane, which will secrete more pus when the contents are drawn off ; and attempts to check its activity by the injection of solutions of iodoform or car- bolic acid are, to say the least, attended with danger. There is on record* the death of a child where 1-40 car- bolic acid was used in this way. Very rarely aspiration is effective. The writer recalls a case of extensive abscess at the inner side of the leg where the parents and child were so excessively nervous that operation was not possible, and where the distention was so great that much delbrmity was caused. The abscess was aspirated over a year ago as a palliative measure, and refilled temporarily to a slight ex- tent, after which it entirely disappeared. Such an experi- ence as this seemed so rare that it deserved notice. Yet within the last few months, one year after aspiration, this abscess has refilled and has broken externally. This has been the invariable experience of the writer in the aspira- tion of abscesses. Treatment by Incision. — In general, if operative measures are to be undertaken, free incision will be found the most satisfactory and thorough. The abscess should be opened throughout its whole extent and thoroughly irrigated. The pyogenic membrane should then be thoroughly scraped off of the abscess walls with a sharp spoon, and the cavity dried with sponges. The general plan is to insert a drainage tube and apply an antiseptic dressing, but this is practically sure to leave a sinus. The same may be said of packing the wound with gauze. The writer f has reported several cases of hip abscess where, after incision and drying of the wound, the line of incision was tightly sewed up without any drain- age whatever. In these cases, union by first intention occurred, and much discomfort and inconvenience were avoided by having done away with a sinus. * Bradford and Lovett, Orthopedic Surgery, iSgo, p. 326. t Bost. Med. and Surg. Journal, Sept. 18, 1890. I20 DISEASES OF THE HIP JOINT The writer has operated more recently upon several cases by this method, and has obtained a large proportion of suc- cesses. Sometimes the wound at once breaks down and a sinus forms, or the cicatrix may give way when the stitches are removed; but in most cases firm union is obtained by first intention, and in cases operated upon two years ago the cicatrix is still firm and normal. The experience with regard to drainage tubes at the Boston Children's Hospital is of interest : " Of 43 cases of abscess of the hip operated on at the Children's Hospital between 1884 and 1888, only one is Fig. 39. — HIP ABSCESS INXISED AND SEWED UP. THERE IS NOW A FIRM, HARD CICATRIX. recorded as having healed within six months, and about half of the sinuses healed within periods varying from one to two years, the rest remaining open almost indefinitely. These cases were all thoroughly cleaned out after a free incision, and were either packed with gauze or, more commonly, drainage tubes were inserted and an antiseptic dressing applied. .'. . The site of the drainage tube was almost always the site of a sinus which persisted for a varying period of time." There is a similar advocacy of treating abscess with- out drainage in the Practitioner for February, 1890. THE TREATMENT OF HIP DISEASE 121 If this method is to be pursued, the strictest antisepsis and asepsis are essential ; and, if there is reason to suspect the thoroughness of either of these, it is better not to oper- ate, or at all events to leave the abscess cavity open. It is better to leave the incision open in cases where there is much inflammatory exudation into the tissues around the abscess, in cases which are particularly acute, and in very extensive abscess cavities. In many, in fact in most, of the writer's cases which healed bv first intention, communication Fig. 40. — HIP ABSCESS OF GREAT EXTENT, INCISED AND SEWED UP THREE WEEKS PREVIOUS TO PHOTOGRAPH. CICATRIX IS FIRM, AND TISSUES ARE NOT INDURATED OR FLUCTUATING. of the abscess with the joint cavity was demonstrated at the operation, so that this cannot be accepted as a contra-indica- tion to suture. A change in the mortality at the Alexandra Hospital in late years is attributed by Mr. Marsh to the fact that of late years the abscesses have been opened and drained, whereas in former years this was not the case. There are two series of cases from which this inference is drawn, — those prior to 1880 reported by the Clinical Society, where the mortality was 30.4 9ic in the suppurating cases and 7% in the others, 122 DISEASE OF THE HIP JOINT while in a series of 614 cases since that time reported by Mr. Marsh the mortality was 6% only. If suture is to be attempted, the abscess should be incised from top to bottom, no matter how long a cut is made. The pyogenic membrane should be scraped out with a curette, reaching to every corner of the wound. The cavity should then be scrubbed with dry sponges, and packed with them until bleeding is stopped. Then, after the wound is dusted with iodoform, it should be tightly sewed up, and a heavy antiseptic dressing applied, which should not be dis- turbed for ten days, unless there is discomfort or elevation of temperature. The reasons that lead the writer to advocate the early operative treatment of abscess are these : If a careful and rigorous treatment is carried out, abscesses will only appear in a small proportion of cases, and these will be cases of exceptional severity. Under these circumstances, joint drainage will be of benefit, and waiting for the absorption of the abscess will in general prove futile. In such cases, abscess formation is generally associated with pain in the joint and a condition of acute sensitiveness. This is generally at once relieved by incision of the abscess, just as in similar cases, without abscess formation, joint incision is sometimes necessary. And, finally, the general surgical principles which demand the evacuation of pus influence the writer here, as in other parts of the body, to evacuate it, when present in more than a small amount ; and not the least consideration should be the possibility in a certain proportion of cases of securing evacuation of the contents of the abscess with an almost immediate closure of the wound, avoiding the formation of sinuses.' After the incision of abscesses, rest in bed is temporarily indicated until the effects of the operation are recovered from. Generally, in two or three weeks the incision will have firmly healed up (if sewed up tightly) or a well-defined THE TREATMENT OF HIP DISEASE I23 sinus will have been formed where the drainage tube was inserted. No treatment seems to be of much use in causing the closure of such sinuses. At times it has seemed to the writer that some benefit was derived from the insertion every two or three days of a urethral iodoform bougie, about iV of an inch in diameter, containing from three to five grains of iodoform in cocoa butter. In general, however, these sinuses run for some months, and their spontaneous closure is a most favorable prognostic sign. Resume of the Treatment of Hip Disease. It is very hard to summarize so extensive a subject as the treatment of hip disease ; yet, after so extended a considera- tion of the subject, the writer is anxious once more to de- clare his belief that the best treatment for hip disease is to be found in the traction treatment, combined with measures which are calculated to secure a large degree of rest to the affected joint. This plan would consist in the application of a long trac tion splint, and necessitates the use of crutches and a high shoe. This splint should be worn night and day until some months after the cessation of all muscular spasm. Sensi- tiveness of the joint and the occurrence of malposition are indications for rest in bed. The activity of children treated in this way should be restricted by recumbency for two hours or more a day and by most careful watching. In short, the writer would be glad to advocate in every way the necessity of greater joint rest in connection with the ambulatory traction treatment. II. The Operative Treatment of Hip Disease. Excision of the Hip. The operative treatment of hip disease is generally in- terpreted to mean treatment by excision of the joint. Cer- 124 DISEASES OF THE HIP JOINT tain minor operative procedures will be considered later. These are ignipuncture, incision of the joint, trephining the neck of the femur, etc. Considering, then, the operative treatment of the disease as contrasted with the mechanical treatment, two questions arise. First, Does operation diminish the death-rate of the disease } Second, Are the results better after operation than after mechanical treatment .-' It may be stated here that the advocates of excision as a treatment for hip disease are to be found among German and English writers ; while American orthopedic surgeons unite in advocating excision only as a last resort, to be used when mechanical treatment has failed. Excision of the hip joint is a serious operation, and should only be undertaken with (a) the hope of lowering the mor- tality of the disease, (d) in order to prevent systemic infec- tion (a generalization of the local tuberculosis), and (c) to obtain better functional results than by mechanical means. (a) TJie Mortality after Excision. — Mr. Wright, of Man- chester,* has collected 2,461 cases of hip excision, new and old, done with and without antisepsis, and finds 1,566 re- coveries and 841 deaths, which amounts to 34 per cent, of mortality. The older groups of cases give a higher death- rate, Leisrink's t being 63.6 per cent, and Culbertson's 41.6 in 418 cases. Caumont % divided his cases into two groups ; and he found that without antisepsis the mortality was 66 per. cent., while with antiseptic precautions it fell to 41 per cent. The time at which the resection is done, of course, is an important factor in determining its gravity. Grosch § an- alyzed 166 cases, and he divided them into classes according to the -stage of the disease at which they were done. In the first stage in children (where the suppuration has not reached the surface) the per cent, of mortality was zero, in * G. A. Wright, Hip Disease in Childhood. t Archiv f. Klin. Chir., xii. 177. i Caumont, Deutsch. z. f. Chir., xx., 1SS4, p. 344. § Cent. f. Chir., 1SS2, xiv. 229. THE TREATMENT OF HIP DISEASE 125 the second class (those with extensive suppuration) it was 24.1 per cent., and in the third and last class of advanced disease it was 67.5 per cent. As representative of the results obtained under modern conditions, Bradford and Lovett give the following table: — Cases. Mortality per Cent. Volkmann, 48 25.30 Korff, 33 48.5 Grosch, 166 36.7 Alexander, . 36 30.5 It is not to be supposed that these writers, nearly all of whom are advocates of excision of the hip, have reported any cases as deaths besides those which are legitimately to be attributed to the operation. The later cases of death, in most instances, are not counted as due to the operation. So that the outcome of the matter is that excision, as ordinarily performed, carries with it a mortality per cent, of 30 or more ; and this seems a serious risk to assume, unless it becomes evident that decided benefit is to ensue over any other method. That matter will come up for discussion later. {b) Excision has been advocated as a preventive of gen- eralization of tuberculosis from the focus in the hip. That such a danger exists is well known. In a series of cases at the Alexandra Hospital since 1880, analyzed recently by Mr. Marsh,* there were 35 deaths, and 17 of these were caused by meningitis or phthisis. From 1867 to 1879 3.t the same hospital there were 384 cases of hip disease, and only 23 deaths from tubercular meningitis. All these cases were treated conservatively. In coming to the consideration of operative treatment, Konig t reports that, of 21 hip excisions, 47.6 per cent, died of tuberculosis inside of four years. Wartmann analyzed 837 resections, and found that 10 per cent, of all deaths were * Br. Medical Journal, Aug. 3, 1889. t Arcliiv f. Klin. Chir., xxvi. 822. 126 DISEASE OF THE HIP JOINT the result of rapidly appearing miliary tuberculosis. Mr. Barker, in a lecture before the Royal College of Surgeons in 1888, stated that in 10 per cent, of all deaths follow- ing excision " rapid miliary tuberculosis came on in such a way as to suggest strongly, if not to prove, that the surgi- cal interference was the cause of the generalization of the disease." Caumont treated 26 cases of hip disease by conservative measures, and found that one-fifth died of tubercular disease ; while, of 22 cases resected, one-third died of generalization of the tuberculosis. These figures seem enough to establish the fact that resection of the hip does not prevent general tubercular infection. ic) Functional Results. — It will be readily understood from the casual consideration of the matter that the results after excision are not likely to be so good from a mechanical standpoint as when a cure has been secured by other means. It is not as if it were possible to do a complete subperiosteal operation and shell out the bone, leaving its case. This, in most instances, is not practicable. On the contrary, very important muscular insertions are severed, the joint capsule is destroyed, the head of the femur is removed, and with it, perhaps, part or all of the neck, and possibly the trochanter major, and even part of the shaft. This leaves a headless femur in loose or uncertain contact with the acetabulum. As a matter of fact, the results are not so bad as one would expect ; often they are almost perfect. There is, of course, alwas'S shortening; but a new joint may form of very good character, and be movable and serviceable. The dissection of such a case is figured in Sayre's Orthopedic Surgery as the frontispiece ; and other cases have been reported by Kuster, Israel, and many others. In the case of Sayre there had been the formation of a new fibrous capsule and of new cartilage, and of course in every operation an attempt should be made to save the THE TREATMENT OF HIP DISEASE 12/ periosteum as much as possible ; but in the later cases the periosteum is either so hopelessly diseased or so nearly- wanting that it has not, in the writer's experience, been possible to save it to any extent. Fig. 41. — RESULT OF HIP EXCISION FOUR YEARS AFTER OPERATION. SINUSES DISCHARGING. LIMB PARTLY USELESS AND POSITION FAIR. CHILD CAN WALK WITH CRUTCH. TO BE CLASSED AS A FAIR RESULT. Anchylosis may result after excision, which is a good and desirable result, and, perhaps, safer than a movable joint 128 DISEASES OF THE HIP JOINT would be ; but firm anchylosis is not common after hip excision. The results of late excision are not so good as the results of early operation ; but, on the whole, they are satisfactory, as a rule. Very often the most wonderful improvement will Fig. 42. — RESULT OF HIP EXCISION DONE AS A LIFE-SAVING MEASURE ONE YEAR PREVIOUS TO THE TIME OF THE PHOTOGRAPH. follow almost immediately upon operation. The case photo- graphed will serve as an example. This boy was seen in a most deplorable condition. Me- chanical treatment had been abandoned by the parents ; and THE TREATMENT OF HIP DISEASE 129 he was emaciated and so feeble that he was helpless, while the hip was apparently rapidly disintegrating, and the whole thigh very much swollen and discharging profusely. Exci- sion was at once undertaken by the writer, but had to be abandoned before throwing the head of the bone out of the socket on account of the boy's alarming condition. Three weeks later the operation was completed, and the boy's present condition at the end of nine months can be seen. The head of the femur was eroded and diseased as far as the shaft, the acetabulum necrosed, and all the parts about infil- trated ; yet such a result as this has been in the writer's experience not at all exceptional. Fig. 43. — A BAH RESIILT AFTER EX'CISION OF THE HIP. But there are many bad results after excision. Some cases do well for a while, and then relapse. Such may be counted as good results. Bradford and Lovett report a case which was one of these. This case was reported six months after excision, in Culbertson's Tables,* as " No. 464. Re- covered in six and two-thirds months. One-half inch shortening. Almost perfect motion." Seen five years later,! the report was that he could only touch the floor *Trans. Am. Med. Assoc, 1S76, p. 142. ■ N.V. Med. Journal, April, 1.S79. 130 DISEASES OF THE HIP JOINT with the toes of the affected Hmb, on which he could bear little or no weight ; and he was unable to walk without a crutch or cane. This case may serve as an example of the later histories of many cases of excision reported as suc- cesses. The case in the figure may serve as an example of a bad result and an almost useless leg following excision. The disease was originally extensive ; but some years after opera- tion the leg was as shown in the illustration, with the sinuses still discharging. With regard to the results to be obtained by excision, the lOO cases of Mr. Wright are instructive. When these cases were last seen by Wright, the results were as follows : — Soundly healed, 17 Unhealed, - . n Dead or dying, 18 In bad condition, 3 Amputated, 4 Recent case, doing well, i 100 In short, about 20 per cent, might be classed as satisfac- tory at that time. Now, 30 of these cases had been in progress only nine months or less when excision was done, being the most favorable class of cases possible to judge of the value of the early operation ; yet one is surprised to find that 4 died and 2 were amputated, 6 healed soundly, 7 were unhealed at the end of one year, 6 at the end of two years, while 5 were too recent for classification. The Clinical Society Committee investigated 12 cured cases after excision, and found that 2 could stand and hop on the excised limb, 4 could stand firmly, 4 others could stand, but not firmly, and 2 could not stand at all ; and the committee reported, as a result of their whole investigation, " that movement is more frequently present, and is also more extensive, in the former class (excision), but that patients often walk insecurely and THE TREATMENT OF HIP DISEASE I3I with considerable limp, while the limb after treatment by rest and extension, though frequently more or less fixed, is more firm and useful for purposes of progression." * Elben f traced 6i cases of hip excision, and found that 41 ■could walk without apparatus, 15 required some apparatus, while 5 were unable to walk at all. J Grosch § states, as the result of an extensive analysis of cases, that the functional results are no better than they were before the day of antisepsis. Holmes || speaks of the end results of excision as follows : ■"The limb is hardly ever so firm or powerful in walking as we constantly see that it is after the natural cure by anchy- losis, nor is the patient so active or enduring." These are not partisan views, but, so far as the writer knows, the most representative expressions of opinion on both sides. Shortening of the leg must necessarily be a marked feat- ure of cases treated by excision of the joint, not only on account of the amount of bone actually removed, but also because of the retarded growth due to the removal of part of the epiphysis. Mr. Croft believed that it was but little greater than after conservative treatment. The average shortening, however, in thirteen of his cases, reported by him, was 2f inches. In Wright's cases, the amount of short- ening is only given in thirty cases, where it was li inches. The case for excision is not a strong one, as must be evi- dent from the consideration of the figures given, although no one is more aware than the writer of the unreliability of statistics in general. But the mortality is evidently high. The operation does not prevent systemic infection. The pro- portion of unhealed and unsatisfactory cases is apparently larger than is supposed ; and, finally, the end results are not satisfactory altogether, considering them by themselves and * Trans. Clin. Society, xiv. p. 234. t Cent. f. Chir. , 1882, 2, 77. t Cent. f. Chir., 1879, No. 2. § Cent. f. Chir., 1882, xiv. II Med. Times and Gaz., Nov. 3, 1877. 132 DISEASE OF THE HIP JOINT not comparing them as yet with the results of conservative treatment. The End Results of Mechanical Treatment. There is scarcely more value to be attributed to the figures relating to the results of the mechanical treatment of hip disease than to those which deal with excision. They are comparatively few in number, they are brought forward by partisan writers, and they deal with different methods of treatment. Yet they offer enough information to make them worth careful consideration. With regard to the worst class of suppurative cases, Cazin had charge of the hospital at Berck where cases were sent from the hospitals in Paris when they seemed hopeless ; and these cases were treated by mechanical means in an atmosphere, of course, very favorable to improvement of the general condition. In 80 cases of such hip disease (all suppurative) treated in five years there, i2\ per cent, died, 55 per cent, were cured, 72 per cent, were improved, 25 per cent, were not cured or improved. C. Fayette Taylor, of New York, reported 94 cases of hip disease treated by the long traction splint under favorable conditions, with 91 recoveries and 3 deaths. 24 of these cases were suppurating ones. Of 288 cases which Gibney collected, which were treated at an institution where the treatment was purely expectant, the mortality rate was only 12^ per cent.; and these figures are of interest in contrasting what is practically untreated hip disease with the results of excision. But any mortality per cent, obtained from the analysis of recent cases must evidently be of little value, as the whole mortality of the disease must include man}^ late cases, where death occurs after a lapse of years. It must on this ground be evident that most analyses are not of great value, inas- much as they have to do with cases which remain under observation only a short time. THE TREATMENT OF HIP DISEASE 1 33 Motion. — With regard to the functional results to be obtained, the information is more definite. Shaffer and Lovett* analyzed 51 cases of cured hip disease discharged from the New York Orthopedic Dispensary from four to ten years previously. 4 of these had died, 6 had relapsed ; but 41 were well, and were apparently permanently cured. These latter were all active working people or school chil- dren. They all walked without cane or crutch (with one ex- ception, where Pott's disease was also present), and all were free from any serious inconvenience from their hip disease. These 51 cases were the only ones which could be found in some 75 cases selected for investigation. Those selected cases were merely all those living in or near New York, who had been discharged as cured (after being at least two years under treatment) between two dates. Few parents are willing to persist in treatment until the children can be considered by the surgeon as cured, and take them from under treatment as soon as the patient is convalescent ; and these cases, if investigated, would proba- bly show nearly as good results as those investigated by Shaffer and Lovett. Of these 51 cases, however, there were 26 suppurative cases carefully examined ; and they showed as good an average of joint motion as cases without abscess. There were 2 recoveries among these with perfect mo- tion in every direction, 3 with 90 degrees of motion, 5 with 10 to 45 degrees of motion, 4 with slight motion, and 12 with anchylosis. These cases were all treated by ambulatory traction throughout the disease. Howard Marsh analyzed a similar class of hip cases one year after discharge ; and of 37 suppurative cases he found perfect joint movement in i case, free joint move- ment in 10 cases, slight joint movement in 7 cases, anchy- losis in 18 cases. Among the 39 non-suppurative cases he found still better * N.Y. Med. Journal, May 21, 1887. 134 DISEASES OF THE HIP JOINT results : 9 were classed as perfect recoveries, 9 were classed as excellent recoveries, 12 were classed as good recoveries, 9 were classed as moderate recoveries. These cases were treated by traction in bed and fixation in the quiescent stages of the disease. Shortening is less important than motion ; but the results of mechanical treatment are excellent in this respect. In the cases of Shaffer and Lovett the shortening was from half an inch to two and a half inches, with 2 exceptions. 2 cases, on the other hand, had no shortening. Suppurative cases had a little more shortening than the others, but the table shows how slight is the difference : — - Shortening. Supp. cases. Non-supp. cases. None 2 ^ inch I I 1 inch 5 5 i^ inches 4 3 2 « 8 I 2i " 5 3" " I 6 " I Of Marsh's 2)7 suppurating cases, 3 had no shortening, 17 had less than one inch, 12 had from one to two inches, 3 had two inches or more, while the average of non-suppu- rating cases was two-thirds of an inch. The Results of Expectancy. Even expectancy or no treatment at all is not attended by such bad results as one would expect. Gibney* inves- tigated 80 cases of hip disease from the Hospital for the Ruptured and Crippled, and found that 61 could walk well, while 12 had an arc of motion of 15 degrees or more. This is not intended to excuse such lack of treatment, but to show that the disease cannot certainly be considered so ma- lignant as some English surgeons would have us believe. *N.Y. Med. Record, March 2, 1878. THE TREATMENT OF HIP DISEASE 1 35 Excision v. Mechanical Treatment. The outcome of all this is the question as to which of these methods offers the best prospect in hip disease, a conclusion which the writer has endeavored to present only- after a careful and separate consideration of the results to be expected from each method of treatment. Two questions proposed at the beginning of the section on excision can now be fairly answered on the evidence presented. One was, Does operation diminish the mortality of hip disease .? The answer is plainly, No. The other question was, Are the results better after operative than after mechan- ical treatment } And, again, the answer, as established by the evidence presented, would be. No. Those surgeons who believe that early excision is the best treatment for hip disease (of whom the most prominent rep- resentatives are Mr. Barker, of London, and Mr. Wright, of Manchester) are inclined to advocate very radical views in this direction. It is difficult for American surgeons to appreciate the grounds on which Mr. Barker * advocates excision of the hip joint as " soon as it is suspected that caseation is advancing in it," until it is understood that Mr. Barker regards " tubercle in the light of a malignant growth," and would deal with it accordingly. Of course, if this view is accepted, the position of these extremists is not to be criticised. " It is impossible, however, to shut one's eyes to the fact that this is an estimate of tuberculosis which the great majority of surgeons would not for a min- ute entertain. The estimate formed by Brodie, indorsed by Paget and Hilton, and accepted by a very large proportion of those who have studied the subject from a clinical point of view, is that, though often intractable and destructive in its later stages, tuberculosis, on a general survey, wears the aspect of merely an obstinate inflammatory process, the * Brit. Med. Journal, June 9, 1888. 136 DISEASES OF THE HIP JOINT whole course and progress of which are widely divergent from those of malignant disease." This quotation from Mr. Howard Marsh * is a fair state- ment of the position in the matter as it appears to most surgeons. The justification of early excision of the hip cannot be found on these grounds, evidently. It must rest on diminished mortality or improved results, and these as- pects of the question have just been considered. Yet, from his experience with excision of the hip, Wright has reached no more temperate conclusion than that " treat- ment short of excision, where once suppuration occurs, is useful only as a palliative or means of temporizing." Now, these statements of Mr. Wright and Mr. Barker are much more radical than those of the Clinical Society's Com- mittee, who reported in 1880, among their conclusions, that " with respect to the general question of operative interfer- ence [in hip disease] the committee are of opinion that the effect of complete rest and weight, or other modes of ex- tension, with the withdrawal of matter, should always be patiently tried in the first instance, and that operative in- terference should be resorted to only .when these means have failed to secure the favorable progress of the case." Certainly, Mr. Wright's figures in no wise justify the position which he takes, as must have been especially seen when the consideration of the end results of mechanical treatment was taken up. It seems unnecessary to dwell longer on the fact that exci- sion of the hip cannot be accepted as the proper treatment of hip disease. The writer can only state his views, which he believes to be representative of those of most American orthopedic surgeons. Excision of the hip is to be considered a proper and necessary measure under two circumstances, — where mechanical treatment is not obtainable, and where mechan- ical treatment, after careful and intelligent trial, has failed. * Brit. Med. Jounial, July 20, iSSg, p. 121. THE TREATMENT OF HIP DISEASE 1 3/ The children of the lower classes, in cities where hospital facilities are poor and where the parents are so circumstanced that they could not carry out simple bed traction, are to be considered fit subjects for excision, if it seems clear that the better treatment cannot be put within their reach. Where proper mechanical facilities are to be obtained, it would be the writer's feeling that excision should not be undertaken. Fortunately, this class of cases, where conservative treat- ment is not obtainable, is steadily growing smaller with the increase of hospital advantages. With regard to the time when mechanical treatment should be abandoned in favor of operation the question is a more difficult one to decide ; nor is it possible to lay down any definite rule which can be followed. The question in every case is one which should be settled by a delicate bal- ancing of the different features of the case. In suppurating cases, where there is a porky induration of the thigh and a profuse discharge from numerous sinuses, any pronounced failure of the general condition should lead the surgeon to consider the advisability of excision. Other cases show plainly that a rapid disintegration of bone and soft parts is taking place, and this goes on steadily in its de- structive course in spite of mechanical measures until it becomes evident that a limit must be set to the process. This is not common in cases under control, but in excep- tionally tuberculous children it occurs. Again, excision may be necessary, in exceptional cases, where excruciating pain is suffered, which cannot be relieved by mechanical treatment. In many cases, simple incision of the joint will relieve it; while, again, excision may be necessary as a further measure. Such rules as were laid down for excision by the Com- mittee of the Clinical Society are not of use to-day, because the methods of treatment have been changed and improved ; and the presence of necrosis or pelvic disease is in no way to be considered an indication for excision. Any extended discussion of the technique of the operation 138 DISEASES OF THE HIP fOIXT of excision of the hip does not, in the writer's opinion, come within the scope of this essay. The posterior incision is the one ordinarily used. The head of the bone should be thrown from the socket before being sawed off, and is thrown out most easily posteriorly. It is not generally possible to remove all diseased tissue from the acetabulum. The photographs of the various stages of the operation may serve better than a description to make the matter plain. Fig. 44. — POSITION OF THE PATIENT FOR EXCISION OF THE HIP JOINT. After excision the hip should be protected for a long time, preferably by some splint combining fixation and traction. Excision cannot be considered as a means of cutting short the disease, because a hip joint after excision demands very THE TREATMENT OF HIP DISEASE 139 Fig. 45. — THE INCISION EXPOSING THE TROCHANTER AND NECK OF THE FEMUR. Fig. 46. — THE HEAD OF THE FEMUR THROWN OUT OF THE SOCKET PREPARATORY TO CUT- I40 DISEASES OF THE HIP lOlXT Fig. 47. — THE HEAD OF THE FE.MIR REMOVED AND THE I.Ei; AI.AIN IN ILACE. Fig. 4.S. — THE DRESSING AriLIED. THE SPLINT IN THIS CASE IS THE CACOT POSTERIOR WIRE FRAME. THE TREATMENT OF HIP DISEASE I4I careful protection, at least from weight-bearing, for many months. In short, excision should be kept as a last resort, to be undertaken only when mechanical treatment is not to be had, or having been tried faithfully and skilfully has failed. Incision of the Hip Joint. This measure is of use in persistently painful cases, where salicylate of soda and traction fail to relieve the pain, and in cases of persistent abduction, where there is slight fulness beneath the adductor tendons, this condition being gener- ally associated with distention of the joint. Two cases were reported by Dr. Bradford, where much relief was afforded.* The incision may be made either anteriorly, in the line of the anterior superior spine, as described by Mr, Barker, or posteriorly, as for an excision of the joint. The incision is likely to persist as a sinus ; but, as it is made for drainage purposes, this cannot be considered an objection. Trephining of the Head of the Femur. This operation was advocated by Fitzpatrick twenty-five years ago ; and recently Stoker f has written in favor of it, and has advocated it as routine treatment, which seems un- reasonable. At times it may be a useful measure, as afford- ing bone drainage ; but, in general, it has little place in the treatment of hip disease. One or two cases only have been reported in America. It might be tried in cases where incision failed to relieve an acutely painful condition, and where it was not desired to excise the joint. The trochanter major is exposed, and a trephine, or gouge, is driven through the neck well into the head of the femur. The plan of *Bost. Med. and Surg. Journal, Aug. 16, 1888. t Dublin Journal, 1B86, S. 3, p. 81. 142 DISEASES OF THE HIP JOINT Fitzpatrick was to insert caustic potash into the hole ; but a curette will remove all the tissue necessary, and the trephine hole should be kept open as a drain. IgnipiDicture, as a mode of treatment, deserves mention onlv to make the account complete. Kolominn * is the ad- vocate of the measure, and claims wonderful results in hip disease from both deep and superficial cauterizations with the Pacquelin point. The writer has had no experience with it, and has seen no reports of cases. Amputation at the Hip Joint. The question of amputation only arises in the case of adults and in patients who are beyond the reach of excision, or who continue to do badly even after the joint has been excised. It is not a measure to be lightly advocated; but, on the other hand, it is capable of producing a marvellous change in the general condition, in certain cases, where there is extensive pelvic disease, and excision has been done, leaving a diseased femur. The combined irritation of the two is enough to cause serious local disturbance ; and the removal of the femur and the free drainage to the pelvic disease, only attainable by amputation, may be sufficient to cause a cessation of the local disturbance, to the great im- provement of the general condition. The mortality of this amputation, as done for hip disease, is not so high as one would expect it to be. The death-rate of hip amputation for injury, according to Ashhurst's tables,! is 70.9 per cent., and for disease in general 42.6 per cent. But for hip disease alone 60 cases gave a mortality of only 32 per cent. Of 22 cases in a col- lection not given by Ashhurst there were only 3 deaths, making ^2 cases with 22 deaths (27 per cent.). And in the 22 cases collected since 1880 there were only 3 deaths (14 • Bost. Med. and Surg. Journal, Apri' 26, 1SS5, Orth. Report, 392. + Int. Encyc. of Surg., vol. iv, p. 501. THE TREATMENT OF HIP DISEASE I43 per cent.), all of which shows that amputation of the hip, as done for hip disease, is an operation much less formidable, as done by modern methods, and especially as done for the relief of hip disease. It should, however, be borne in mind that such statistics as these are undoubtedly too favorable, because the tendency is to report successes, and not to report failures. So that, in, almost any operation where the cases are reported only in small groups, as here, the ten- dency is to present too favorable an aspect, unless one bears this fact in mind. Unless the femur is very extensively diseased, or unless the amount of pelvic disease is exceptionally large, it is proper to excise the joint rather than amputate the leg in the case of children. But here, again, it is not possible to lay down rules, and each case must be decided by its individ- ual features. When excision has been performed and has failed to pro- duce much effect, and the vital powers are notably failing, it seems, to the writer, proper to present to the parents the question of amputation as a life-saving measure. And his personal experience with the operation would lead him to advise it, but by no means to urge it. In many cases, it is possible to fit an artificial limb to the stump ; and, in a case reported by Dr. Bradford,* re-for- mation of bone occurred in the stump. This is, of course, unusual in the extreme. In adults the operation is more often indicated than in children. Wright would not excise in patients over fif- teen, Jacobson would set the limit at eighteen for excision, and nearly all surgeons are in accord that, in view of the severity of tuberculous ostitis of the hip in the adult, the more radical measure is to be adopted, if any operative pro- cedure is undertaken. And the indication for the operation would again be the failure of mechanical treatment after a faithful trial. * Bost. Med. and Surg. Journal, Sept. 13, 1885. 144 DISEASES OF THE HIP JOINT There is no need of entering upon the technique of amputation of the hip. A great gain has been made by the adoption of Furneaux Jordan's method, which consists briefly in amputation of the thigh at the upper third, with removal of the head and shaft of the femur by a lateral in- cision. The periosteum should be carefully preserved, in order to favor the formation of new bone, as in Bradford's case. This method saves blood, diminishes shock, and gives a better stump than any flap method possibly can. The method is dwelt upon at length in all modern surgical text- books. The operation must be done rapidly, and with every precaution against hemorrhage and shock. GUMMATOUS OSTITIS OF THE HIP I45 Chapter VII. GUMMATOUS OSTITIS OF THE HIP. Pathology. Gummatous formations about the hip joint are most often to be found in the synovial membrane or in the ligaments and periarticular structures. These conditions have been discussed in speaking of chronic synovitis. Especially, however, are they to be found in the perios- teum, where they are attended by much thickening and succulency of the covering of the bone, while at times they appear simultaneously in the bone, the joint, and the periar- ticular structures. When synovitis exists in connection with the formation of gummata, most often it is the primary affection, although the synovial inflammation may be sec- ondary to the osseous trouble. Gummata of the spongy tissue rarely occur in the epi- physes of the long bones ; but some recent researches of Chiari * would seem to show that they are not so very uncommon as had been supposed. When they are present, they are to be identified as yellow- ish or grayish nodules, in appearance somewhat like foci of tuberculosis except that they are not surrounded by a zone of hypersemia. Sometimes they are purulent in appearance, and sometimes cheesy. Within the nodule the bone is necrotic and disintegrated, and in part broken down into pus, and in part replaced by a typical gummatous formation. Such gummata, rare as they are, almost always exist along with a neighboring periostitis and overgrowth of bone in the neighborhood, * Vierteljahrsch. f. Derm, und Syph., 1882. 146 DISEASES OF THE HIP JOINT Probably the commonest condition is an osteochondritis, which is accompanied by a periostitis and perichondritis of a gummatous type, all occurring in the neighborhood of the epiphysis of the head of the femur.* There is much en- largement of the bone in that region ; and the periosteum is thickened and of an elastic consistency, and on microscopic examination it is seen to be rich in fluid and poor in cellular elements. This condition may result in a purulent degener- ation, or in caseation, or in the formation of fibrous tissue leading to a scar formation. Under the place where the gummata are found, the bone is absorbed, and the amount of absorption is great in proportion to the size and cellular activity of the gummata. With this is associated a tendency to the formation of hyperostoses in the neighborhood. If this osteochondritis becomes purulent and destructive, the epiphysis of the femur may be loosened, or more com- monly a purulent synovitis is started up.f Etiology. As elsewhere in the body, the occurrence of gummata in the hip joint is to be attributed to the presence of late syphilis, either acquired or hereditary. Syphilitic osteochondritis occurs most often in young children who have inherited syphilis. The other manifes- tations, rare clinically, are to be met in either the inherited or the acquired form. Treatment. The treatment of gummatous inflammation of the hip is, of course, first, the administration of iodide of potash and the inunction locally of mercurial ointment, together with * Deutsch. Arch. f. Chir., xxviii. 2 ; Archiv f. Kinderheilkunde, 1SS4, 5 (Cassell). t Syphilis of Joints : Lanceraux, Traite Hist, et Prat, de la Syphilis, 1874 ; Baumler, Ziemssen's Handbuch, iii., iS86; Deutsch. Arch. f. Klin. Med., ix., 1S70 ; Duffin, Trans. Clin. Soc, London, ii., 1869; Oedmanson, Nordisk. Med. Arck., i., 1S69; Gies, D. Zeitsch. f. Chir., xv. ; Finger, Wien. Med. Wchsft., 1884; Saug, Vorles. iiber Path. u. Thar. d. Syph., Wiesbaden, 1885. GUMMATOUS OSTITIS OF THE HIP I47 the exhibition of tonics and the adoption of hygienic meas- ures. Secondly, local measures are to be adopted to fix the joint and prevent irritation from traumatism, which can easily be accomplished by the fixation splints already de- scribed. If the diagnosis between tuberculosis and syphilis of the hip joint is not clear (and this must often happen in the present state of knowledge), the existence of the more de- structive disease must be assumed, and the child subjected to the mechanical measures described for hip disease, as well as to the constitutional treatment just mentioned. 148 DISEASES OF THE HIP JOINT Chapter VIII. ARTHRITIS DEFORMANS OF THE HIP JOINT. Arthritis deformans of the hip joint, or malum coxce senile, is considered by itself instead of in connection with the sections on synovitis or ostitis, because it is an affection whose origin is variously attributed to the three different tissues composing the joint, by the different authorities. It seems also a justifiable division, because the affection is so well marked as to appear as a pathological entity. The origin of ostitis deformans has been ascribed to the synovial membrane by Volkmann, Brodie, Adams, and others ; to the cartilage by Cornil and Ranvier, Howard Marsh, Orth, Garrod, and Billroth ; and to the bone by Barwell, and some less reliable authorities. With such a wide difference of opinion among the authorities, it seems wisest to consider the origin of the affection unsettled. The affection is also spoken of as rheumatic or rheumatoid arthritis (Adams and Garrod) ; rheumatic gout ; osteoarthritis (Royal College of Physicians) ; nodular rheumatism, rJieiima- tisme noueiix (Trousseau) ; nodosity of the joints (Haygarth) ; chronic rheumatism of the joints (Todd i') ; goutte asthe- niqne primitive (Landre Beauvais) ; senile arthritis ; arthri- tis urica ; malum senile ; rheumatisme chr. primitif (Char- cot) ; arthritis chronica ulcerosa sicca. Although it may be questionable whether all these names should be admitted to be synonymous with arthritis de- formans (Virchow), the pathological distinctions between them are so slight that it seems simplest, and therefore best, to consider them all practically as modification of one process. ARTHRITIS DEFORMANS OF THE HIP JOINT I49 Pathology. The characteristics of the affection are chiefly to be found in the disintegration and erosion of the articular cartilages, along with a tendency to increased bony formation about the margin of the head of the femur. It has been a matter of discussion whether the changes to be described were inflammatory or not ; and the modern conclusion is expressed by Senator, who says, "The changes in the joints are partly inflammatory, partly degenerative." * The changes are perhaps earlier noted in the cartilage than they are elsewhere ; and, since cartilage has but one way of reacting to inflammation and but one form of degen- eration, it is found in arthritis deformans to follow that type. The cells multiply, and the hyaline substance undergoes fibrillary degeneration. This renders the cartilage more friable than it should be ; and it looks yellowish and shreddy, and shows a tendency to wear away where the two articular surfaces are in contact. To the naked eye it presents the appearance of velvet. In other places it perhaps is split off in pieces of considerable size. In connection with this dis- integration, there is an hypertrophy of the cartilage around the periphery. Marginal ecchondroses develop, which may reach such a size that they perforate the synovial membrane, and appear in the joint as pedunculated or even as loose bodies. The ecchondroses are most marked at the margins, prob- ably because the cartilage is in that situation covered by a layer of synovial membrane, which prevents the escape of the proliferating and multiplying cartilage cells. Where ossification of these ecchondroses begins, it is in the layers nearest the bone ; and, even when ossification is well advanced, they are still covered by a layer of cartilage on their joint surface. *Ziemssen's Hdbch., 1875, art. Arth. Deformans. 150 DISEASES OF THE HIP JOINT Bony Changes. The disintegration of the cartilage brings together two bony surfaces unprotected by articular cartilage. But nature has already provided for this contingency by certain changes which have taken place in the bone before the cartilage was entirely destroyed. The condensation in the ends of the bones where they are in contact is the striking feature. The bony surface, as exposed by the loss of the cartilage, is dense and white, and capable of withstanding pressure. It resembles nothing so much as ivory ; and, if motion exists in the affected hip, it is capable of acquiring a remark- able polish, equal to that of the finest ivory. But, with the rubbing together of two such surfaces, wearing away of the bone must ensue ; and exposure of the ends of Haversian canals, and perhaps of cystic cavities results, which causes a worm-eaten appearance, which the head of the femur often presents. The formation of this eburnated bone is variously ac- counted for. Ziegler believes that it is the result of a softening process which has occurred in the deeper layers of the cartilage. This has resulted in cavities, which have been filled by a vascular marrow which has grown into them from the changed and degenerated bone marrow, which loses much of its fat and becomes in a measure a "lymphoid marrow," or it may become fluid and sometimes be included as cysts, which may afterward be exposed as the bone is worn down. This growth of the bone marrow into the car- tilage favors its early ossification. Other writers attribute the formation of the eburnated bone to a local ostitis, and others attribute it to purely me- chanical influences. However it comes about, a thin layer of very dense bone is formed at the articular end of the femur. Apart from this formation of eburnated bone and the ARTHRITIS DEFORMANS OF THE HIP JOINT 151 ossification of the hypertrophies which have occurred around the periphery of the articular cartilage, the process may be chiefly one of bone atrophy or absorption, or one of bone overgrowth. In the one case, the cancellous tissue of the epiphysis is thinned and eroded, and the cancellous interstices occupied with fat; or, in the other, it is abnormally thickened and dense, not only in the epiphysis, but, in some cases, in the shaft as well. From the fact that the cartilage and bone are worn away by pressure where the articular surfaces are in contact, and that the activity of cartilage hypertrophy and bone forma- tion is chiefly around the periphery of the head of the femur, it follows that the head of the femur becomes less globular and decidedly flattened. In bad cases, the head of the femur may almost entirely disappear, leaving an irregular, stunted, and useless mass of bone where the globular head formerly was. This change is spoken of as "absorption " of the head of the femur. A word more should be said about absorption, so called, of the head or neck of the femur, where the neck is short- ened and at a right angle to the shaft. The head wears away, and the marginal exostoses carry the rounded joint surface apparently toward the trochanter. As the head is worn away more and more, the marginal overgrowth pro- gresses toward the trochanter ; and, in addition to this, the neck hypertrophies, and becomes more at a right angle than it normally should be. This results in elevation of the tro- chanter above Nelaton's line and consequent shortening of the leg. The acetabulum, on the other hand, is deepened by the ossification of the cotyloid ligament and by the wearing away of the floor of the acetabulum, which is, however, gen- erally only a slight matter. 152 DISEASES OF THE HIP JOINT Synovial Changes. The synovial membrane in the early stages of the affection is strongly injected, and on examination appears to be ab- normally red. Synovial effusion may be considerable, and in the early stage of the disease, in some cases, may be the only objective sign of the impending trouble. Some writers state that synovial effusion is rarely or never present in rheumatoid arthritis (Senator, Homolle, etc.) ; but practical experience must negative that assertion, and a very consider- able weight of authority is to be quoted in favor of the fre- quent existence of effusion (Brodie, Adams, Fuller, Garrod). After the stage of acute injection the synovial membrane becomes thickened, and the synovial fringes are greatly hypertrophied, and may become the seat of fatty, fibrous, or cartilaginous changes to a marked degree. The branching, tufted appearance of these fringes may be so marked that it is spoken of as lipoma arborescens. And the whole appear- ance of the membrane is to be spoken of as " shaggy." The change to fibrous or cartilaginous tissue in the fringes is probably due to the fact that embryonic cells have re- placed the fat in the synovial fringes. These cartilaginous bodies often become so large and their attachment by the synovial fringe is so small that they become pedunculated bodies, ready to be cast loose into the joint at any time. In certain cases, the cartilaginous bodies in the synovial fringes may become the seat for the deposit of lime salts. Changes in Ligaments and Tendons. The ligaments become inflamed and thickened, and degen- erate to a substance like fibro-cartilage ; and the capsule at the same time suffers a similar degeneration, and is often the seat of cartilaginous deposits. The ligamentum teres de- generates to a frayed out fibrous cord, and gradually disap- ARTHRITIS DEFORMANS OF THE HIP JOINT 1 53 pears; and the muscles controlling the joint become pale and wasted. All these changes of course do much to impair the joint's mobility. Finally, in the severest cases, an ensheathing bony mass begins to form at the attached bor- der of the capsule and in the ligaments, which progresses until the joint is splinted, as it were, in a dense, compact, irregular mass of bone, which prevents mobility, and leads to complete obliteration of the hip. Cysts near the joint may form, as described by Mr. Morrant Baker. It is very rare in connection with disease of the hip joint ; but it does occur, as evidenced by one recorded case.* Such cysts are formed by the hernial protrusion of a dis- tended synovial sac into the periarticular region. Etiology. The antiquity of arthritis deformans f is attested by evi- dences of its existence in an Egyptian skeleton of the Ptol- emaic period, and in a Roman skeleton found in a sarcoph- agus at Smithfield, England. $ Chiaje found evidences of the disease in bones unearthed at Pompeii, and the Norse Viking whose remains were entombed in his war-ship in the Christiania fjord was a sufferer from the same affection. Etiological Theories. The essential character of the affection has been much disputed, and the long list of names by which the disease has been called is a commentary upon the various views which have been held. (i) It has been maintained that it is a form of rheuma- tism, or a combination of rheumatism and gout. (2) It has been considered by Arbuthnot Lane that it is *W. M. Baker, St. Barth. Rep., 1885, xxi. p. 177. t Eve. British Med. Journal, 1890, i. 423 ; Lebert, Hdbch. d. Pract. Med., 1859, ii. p. 874. J Norman Moore, Path. See. Trans., 1883, p. 226; Virchow's Archiv, 1869, xlvii. 298. 154 DISEASES OF THE HIP JOINT not a disease at all, but that the articular lesions merely result from pressure. (3) It has been attributed to a defective nutrition of the joints, due to a disturbance of the nervous system. (i) The Rheumatic Theory. — Many cases of chronic artic- ular rheumatism which lack the distinctive features of ar- thritis deformans (the destruction of cartilage and the forma- tion of exostoses) are continually described under the name of arthritis deformans ; and the distinction is, in fact, a hard one to make clinically, so that for this reason rheumatism and arthritis deformans necessarily become confused. In a certain proportion of cases, arthritis deformans is clearly dependent upon rheumatism, occurring in rheumatic individ- uals and in rheumatic families. This proportion is a vary- ing one, and each writer estimates it differently. But, in general, it would seem that its connection with rheumatism had been overstated. In most cases, it begins as arthritis deformans, and is not preceded by an attack of acute rheumatism. It affects women oftener than men, which is just the reverse of the case with rheumatism, and the old rather than the young. Exposure is a causative factor in both cases, and the clinical expression is much like rheuma- tisrn. But it seems unwarrantable to assume that rheumatism exists as the cause of arthritis deformans in more than a certain proportion of all cases, and the pathological evidence would seem to establish an independent character for ar- thritis deformans in another proportion of cases. In the same way with gout, it can be said that arthritis deformans in many instances is associated with and proba- bly caused by gout ; but it is an atypical manifestation of the disease, and, although in very many instances associated with that vague condition described as lithsemia, the disease cannot be described as a gouty one in more than a small pro- portion of cases. In typical cases of arthritis deformans, it must be said ARTHRITIS DEFORMANS OF THE HIP JOINT I55 that sodium urate in excess is not found in the blood in ar- thritis deformans, and that the symptoms of gout (other than the articular ones) are not present. It has been established by Sir Dyce Duckworth that in some countries, where gout is all but unknown, arthritis de- formans is a very common affection. In Scotland and Ire- land, where gout is very uncommon, arthritis deformans prevails to a marked degree. It is for these reasons that the writer rejected the com- monest name of the affection, rheumatoid arthritis, and adopted one advancing no etiological theory. (2) The Mechanical Theory. — Mr. Arbuthnot Lane is in- clined to attribute much importance to the effects of press- ure in modifying bone structure ; and much of his work has been highly instructive and original, as in his discussion of lateral curvature of the spine and bow-legs. But, in at- tributing the changes in arthritis deformans to pressure effects and purely mechanical influences, he of course goes too far.* The affection of the finger joints in women who have led a life of luxury, and nearly all the phenomena of the disease, tend to negative his ideas. One fact, however, calls attention to the possible value of this theory. The fact that senile coxitis often follows, and seems to have been caused by a fall upon the hip, would lead one to suppose that a purely mechanical influence was in many cases at work, and was in this instance the cause of the affection. (3) The DystropJiic Theory would find the cause of the disease in some disturbance of the nervous system, either primary or reflex, to local causes, which caused trophic dis- turbances of the joints. This theory was first advanced by Remak,f and at present is advocated by such authorities as Duckworth, Senator, and Ord. Of late much weight has been given to this view by the fact that the pathological changes in the arthropathies of *W. A. Lane, Path Soc. Trans., 1884, xxxv., and 1886, xxxvi. p. 387. t Galvano-therapie, 1858; also Deutsch. Klinik, 1863, p. 107. 156 DISEASES OF THE HIP JOINT tabes and similar affections seem to be only an intensifica- tion of the ordinary changes in arthritis deformans. That is, where we know that a lesion of the nervous system exists we find articular changes of a character similar to those of arthritis deformans, only more acute. In Charcot's disease the destructive processes predominate over the formative activity, but the erosion of cartilage and the formation of osteophytes are present in both. The symmetrical distribution of arthritis deformans in so large a proportion of all cases is thought by some writers to show the existence of some central nervous disturbance; but Sir James Paget puts it on broader ground in saying that symmetrical lesions are due to diseases in which the origin of the morbid process is in the condition of the circulating fluid. Dr. Ord and others would infer that a nervous dis- turbance was the cause of the affection from the fact that uterine derangements so often stand in a causal relation, and he alludes to the great power of uterine irritation in produc- ing excitement of the spinal cord. Senator lays stress upon the fact that emotional and mental disturbance have an effect in producing and increasing arthritis deformans, as they have in the case of nervous disease proper. Again, writers who favor this dystrophic theory would find an argument for nervous influence in the existence of mus- cular atrophy ; but there is no evidence whatever to show that it is not an arthritic atrophy, such as is found in all joint disease of any such severity. In short, the dystrophic theory rests on a very slender basis of facts, and is strictly a theory, and nothing more. It seems to call attention to the fact that general disturbance of the system is most often present, and that cold, exposure, uterine derangements, and all conditions which depress the general health are active as factors in causing the disease. But (except for the similarity of the disease to tabetic arthro- pathy) the advocates of this theory signally fail to prove the existence of a nervous causation of the disease. ARTHRITIS DEFORMANS OF THE HIP JOINT 1 57 These three theories show certain important points in connection with the etiology of arthritis deformans : that it is often associated with rheumatism or gout, but in a large proportion of all cases exists as a separate disease ; and that it is favored by all causes which depress the general condition or lower the vitality, although it cannot be proved that such causes act through the nervous system rather than through the general circulation. Traumatism. — The place of traumatism as a cause of malum coxae senile is not generally allowed so much weight as it would seem to deserve. It is a frequent cause of the affection, and was first clearly recognized by Canton in 1855.* Much attention was attracted by the case of the elder Charles Matthews, who fell and injured his hip when he was forty years old, and who was treated unsuccessfully by the most eminent surgeons of his time. At the end of ten years of lameness and partial disability he died of some other disease; and in his hip were found the evidences of chronic arthritis deformans, a fact which at the time excited much notice. Since then it has been recognized that people after middle life who are so unfortunate as to fall and bruise the hip, not uncommonly suffer from pain, progressive disability, and shortening of the leg; and in such joints are found the characteristic changes of arthritis deformans. The rationale of the process is but little understood, and the fact must be accepted as it stands. It occurs much oftener as a cause of the disease in the hip than elsewhere ; and, in the majority of hips affected, the history of an acci- dent can be found. Injury may cause multiple as well as single joint disease, as in a case related by Garrod, where a patient was kicked in the hip by a horse, and sixteen years later had the affec- tion in the joints of the fingers, in the right shoulder and right hip, the onset of which he traced back to the injury. *Surg. and Path. Observations on " Shortening of the Leg from Bruise of the Hip." 158 DISEASES OF THE HIP JOINT The hip alone was affected for ten years, and then the other joints became involved. Localized rheumatoid arthritis, affecting the hip alone, occurs more often in men than women, which is the reverse of the state of affairs in the more general manifestations of the affection. Heredity. — Hereditary influence is less marked than in gout or rheumatism. Charcot obtained a history of arthritis deformans in the parents of 11 out of 41 patients questioned.* In 500 of Garrod's patients with arthritis deformans a fam- ily history of such an affection was present in 84, while 64 showed a family histor}- of gout and 48 of rheumatism. f Age. — The disease is essentially one of early old age ; and, although occasionally one sees instances of the polyarticu- lar form in children, t the writer has never seen an instance of it in the hip. Occurring in the hip joint alone in a child, it would almost surely escape detection during life, however; for the symptoms would differ but little from those of ordi- nary hip disease. The table of Garrod shows the distribu- tion of the disease by age : — Under 9 years 3 10-19 22 20-29 64 30-39 85 4c^49 121 50-59 no 60-69 72 70-79 5 80-90 I In women it seems closely connected with the cessation of the menses in very many cases. Of 411 female patients * Charcot, These de Paris, 1853. t Garrod, A Treatise on Rheumatism, p. 239. fDally, Jonm. de Therap., 1S7S, 14; DuraDd Farrell, Union Med., iSSi, xxrii.; Gazette des Hop., 1SS2, -So. 116; Henoch, Kinderk'h'ten , 1SS3, p. 72S: Mantisen, These de Paris, 1S84; Moncows, Rh. Chronique Noueuxdes Enf., iSSo; Wagner, Miinchener Med.Wchnsft.,iSSS, xxxv.; Weil, Nouvelle Iconographie de la Salpetiere, 1S90, i. p. 16. ARTHRITIS DEFORMANS OF THE HIP JOINT 1 59 the disease began in i8 in the two years preceding the men- opause, and in 41 in the two years following it. Sex. — In the polyarticular variety women are much more commonly the victims, no less than 411 of Garrod's 500 pa- tients being females. When the hip alone is affected, men are affected rather more commonly than women. Uterine derangemejit is a very frequent cause of arthritis deformans. Dr. Ord * reported 38 cases of the disease in women of all stations, and in 30 of them some uterine diffi- culty was present. It is questionable whether such de- rangements act directly in causing the disease or merely by lowering- the general condition. Mental and Emotional Causes. Mental shocks are thought to be occasional causes of the affection.! Leyden states that many of those who suffer from arthritis deformans in Strassburg attribute the com- mencement of it to frights received, chiefly by the exploding shells, during the bombardment of the city in 1876.$ Pro- longed worry, mental overwork, and protracted mental anx- iety have a marked influence in many instances in causing and a.ggravating the disease. Dampness and exposure are two of the more common causes in the disease as it appears in the lower classes. Joined with these two conditions, one finds generally bad hygiene and insufficient food. With regard to these, as to the preceding causes, it must be said that it is not clear whether they act directly or by depressing the general con- dition. Treatment. The treatment can best be discussed as general and local. In the case of the disease as it affects the hip, local meas- *Brit. Med. Journal, 1S84, ii. p. 26S. t Kolits, Kl. Wchsft., 1S73, p. 304. + Klinik der Riickenmarkskrankheiten, 1874, p. 270. l60 DISEASES OF THE HIP JOINT ures are of such importance that they deserve the first con- sideration, especially as they are very generally left out of account, and senile coxitis is merely treated on general principles. Local Treatment. Mechanical. Certain theoretical considerations should suggest the propriety of local treatment. These are the fact that in so many cases the disease is caused by traumatism, whence it would seem proper to avoid the further traumatism of walk- ing by protecting the joint. The fact that the joint is in a condition of inflamm.ation and that walking is painful would also seem to indicate the propriety of joint rest. The theoretical objection to joint rest would be found in the fear that it would favor anchylosis. Patients with senile coxitis suffer much from pain, muscu- lar spasm, and sensitiveness of the joint in walking. This symptom group is the expression of joint irritation, and is associated in arthritis deformans, as has been seen, with a low grade of synovitis. Rest in bed, with traction if necessary, will do much to quiet this discomfort. The stiffness is in the early stages the result of muscular contraction, and not of anchylosis, and is diminished rather than increased by any measure which quiets the irritability of the joint. Traction is indicated in all cases where passive manipula- tion of the hip is painful and restricted by muscular spasm, and in cases where pain is continuous and excessive. The patient should lie in bed with a weight and pulley arranged for traction, as described under ordinary hip disease. The weight should be five pounds or more or less according to circumstances, and should pull in the normal direction of the leg ordinarily; but, exceptionally, it will be found neces- sary to allow for malposition of the limb and to make traction in the line of the deformity. ARTHRITIS DEFORMANS OF THE HIP JOINT l6l The weight should be enough to ease the pain without tiring the leg too much ; and traction should be continued for some days, or perhaps two or three weeks, when in most instances much improvement of the joint will be noted, and motion will be more free and less painful. Nowhere is traction of greater benefit, and nowhere is the relief from its use more quickly noticed, than in senile coxitis-. After the pain and irritability are con- trolled, the patient should be allowed to go about; but the joint should be protected from jar and traumatism, and this is best done by the convalescent hip splint men- tioned above. In this way the patient gets out of doors, and the joint is exercised within narrow limits, while pressure and the con- stant jar are removed ; and such splints should be jointed at the knee. Such a splint should be worn during the day, and exercise encouraged. If sensitive- ness returns, the patient should be sub- jected for a few days to rest in bed and weight and pulley traction. The results of treatment by this method are surprisingly good ; and such patients are much more comfortable than if dependent on crutches, while it is a treatment which is capable of producing much permanent benefit. The only article dealing with this aspect of the subject with which the writer is familiar is the admirable one of Dr. H. L. Taylor.* Other Measures of Local Treatment. Fig. 49. — PROTEC- TION SPLINT FOR THE HIP. Other measures must be regarded as Counter-irritation. only accessory. Counter-irritation is of use in many in *N.Y. Med. Journal, Dec. 15, i? l62 DISEASES OF THE HIP JOINT Stances. Perhaps as efficient a form of relieving the pain as any, when traction fails or is not available, is by the use of the Pacquelin cautery, which should be lightly and very quickly drawn over the skin, leaving a very superficial and almost painless eschar. The sensation is as if a mustard plaster had been over the hip. Liniments and blisters may at times be of use, but the effect of all these is only tempo- rary and palliative. Hot applications are useful in painful hip joints alone, or especially in connection with treatment by rest and traction. Massage may be of much benefit in senile coxitis, espe- cially where the sensitiveness of the joint has been controlled and it is desired to develop as far as possible the wasted muscles. It should not be carried to the extent of develop- ing pain, and joint manipulation should not be carried to a painful point under any circumstances. The object of mas- sage is to stimulate the local circulation, to promote the absorption of the diseased products, and to provide exercise within safe limits to the diseased limb. It is not to be re- garded as a means of breaking down adhesions or of roughly extending the arc of motion of the joint. If such a process were considered desirable, it should be done under ether; but experience has shown that, although temporarily a greater degree of joint motion may be obtained by such forcible manipulation, a greater degree of stiffness follows after a short time. Massage should ordinarily be given every other day, and, as has been said, it is not so well adapted to the painful stage of the affection as to the quiescent period which suc- ceeds good mechanical treatment. In cases where the latter, is not obtainable, massage may be of use if gently given in connection with rest and hot application. Electricity is often of much use in senile coxitis, chiefly as it modifies the circulation and improves the local nutrition. It is for this reason that the galvanic is the more beneficial of the two forms. ARTHRITIS DEFORMANS OF THE HIP JOINT 163 General Treatment. It was formerly supposed that therapeutic measures had little power over arthritis deformans. Later years have shown that, although the disease is one which is not easily controlled, it is, nevertheless, in most cases susceptible of much improvement. Where senile coxitis exists alone, less is to be expected from general measures of treatment than where it coexists with the affection of the other joints. Drugs. — The long list of drugs is a sufficient commentary upon the ill success of a purely medicinal treatment. Iodide of potash, iodine,* arsenic,! lithia and its salts, cimicifuga, the salicylates, | alkaline diuretics, quinine, and similar tonics, Fraxinus excelsior (Fuller), Actoea racemosa (Ringer), ichthyol (Lorenz), and many less important drugs have been advocated as beneircial. The drug treatment advocated by each writer is, as a rule, a matter of personal opinion ; and widely differing results are obtained from the same treatment by different authors. The first essential is that the general condition should be kept as good as possible. If the appetite is poor, bitter tonics are indicated, the bowels should be kept in good order, and a general regime followed out which should aim at keep- ing the patient in the best possible condition in every partic- ular. It is unnecessary to say that there is no specific for arthritis deformans. The writer has obtained better results with the salicylate of soda and alkaline diuretics than with any other drugs. The patients have taken five or ten grains of salicylate of soda after meals for long periods, and with the meals some mild diuretic, such as Vichy water or the artificial effervescent salt. A simple and nutritious diet has been enforced, avoiding large quantities of meat and taking from one to two quarts of milk daily. Where milk has been * Lasegne, Arch. Gen. de Med., 1S56, viii. 300. t De Miissy, Bull. G^n. de Th^r., 1864, Ixvii. 241. + Lancet, 18S2, p. 141 ; See, Bull, de I'Acad. de M^d., 1S77, v. 689. 164 DISEASES OF THE HIP JOINT badly borne, a measured quantity of water has been pre- scribed. With regard to this treatment the writer can only speak of his own experience, which is that the majority of patients improve perceptibly under such a regime as this, while some are relieved of their symptoms to a large extent. This, however, is not so likely to happen in arthritis deformans of the hip as where it is more generally distributed. Such a treatment should, however, be pursued in connection with the local measures advocated. Climatic Treatment. — Persons affected with arthritis de- formans are, as a rule, more comfortable in warm weather and in warm climates than in cold. Certain localities seem to exercise a very favorable influence on the disease, espe- cially in connection with the various baths and springs to be found at such health resorts. In America the Hot Springs of Arkansas deserve the first mention, while Richfield Springs in Central New York are often of benefit. But either place is inferior to some of the more widely known and better organized resorts in Europe. Aix-les-Bains * is, perhaps, as well known as any place where massage and hot douches constitute the essential part of the treatment. In England the same measures are em- ployed at Bath. Harrowgate and Buxton are other English resorts. On the continent one finds Bourboule, Aix-la-Cha- pelle, and Mont Dore especially advocated for these affec- tions ; while resorts of a wider range of applicability are Homburg, Carlsbad, Vichy, Wildbad, Marienbad, Kissingen, and similar spas, and these are much resorted to by patients with arthritis deformans. With regard to the relative importance of general and local treatment, the writer would be glad once more to emphasize his belief in the great benefit to be derived from rational mechanical treatment, consisting in joint rest and protection, *Garrod, Lancet, 1S89, i. S69. ARTHRITIS DEFORMANS OF THE HIP JOINT 165 with traction where indicated. Massage, electricity, etc., he would regard merely as measures of secondary importance, which should facilitate and assist this main line of treatment. From the combination of these, very satisfactory results are, in many cases, to be obtained in arthritis deformans of the hip. In short, joint irritation due to arthritis deformans is to be met by the same measures as joint irritation due to other causes. Other References. Althaus, Brit. M. J., 1872, p. 211, ii. (electricity) ; Bardele- ben, Lehrb. d, Chir., ii., Berlin, 1880; Bardsley, Med. Rep., 1807 (arsenic); Brachet, Brit, M. J., 1884, ii. p. 411 ; Bene- dict, Wiener Med. Halle, 1864; Baker, W. M., St. Barth. Hosp. Rep., 1877, xiii. ; 1885, xxi. p. 177 ; Cheron, Gaz. des Hop., 1869, No. 150 (elect.); Drachmann, Virch. Jahresber., 1873; Duckworth, Br. M. J., 1884, ii, 263; Echer, Arch, f, Phys. Heilkunde, 1843 ; Giirlt, Beitr. z. Path. Anat. d. Gelenkkrankheiten, Berlin, 1853 ; Meyer, Berl. Kl. Wchsft., 1870, p. 265 ; Moore, N., Path. Soc. Trans., 1883, xxiv. ; Nuscheler, Zeitsch. f. Rar. Med., 1855 ; Popu, These de Paris, 1881 ; Rhoden, D. Med. Wchsft., 1876; Riess, Eulen- burg's Real Encycl. ; Remak, Galvano-therapie, 1858, 413; Schomann, D. Malum Coxae Senile, Jena, 185 1 ; Trastour, Bull. Gen de Ther., 1879, cxvii. 509; Volkmann, Hdbch, d. Chir. von V. Pitha und Billroth, ii., 1872; Virchow, V. Arch., Bd. 4 and 47 ; Weber, V. Arch., Bd. xiii. ; Wehrner, Beitrg. zur Kennt. d. K'h'ten d. Hiiftgelenkes, Giessen, 1847; Wymer, Lancet, 1889,1. 933; Ziegler, Pathol. Anat., 1887, 5th ed., p. 169. l66 DISEASES OF THE HIP JOINT Chapter IX. CHARCOT'S DISEASE OF THE HIP JOINT. A CURIOUS affection of the joints has been described by Charcot, which occurs in connection with certain affections of the nervous system. The affection is consequently most often called by his name, while other terms in common use are spinal arthropathy, tabetic arthropathy, and arthropathy. Pathology. The pathological changes, it has already been said, are similar to those of arthritis deformans,* although, as a rule, more rapid and destructive, and possessing an occasional tendency to suppuration, which is almost unknown in that disease. Moreover, the effusion is generally more extensive, and the role played by the synovial membrane is a more active one than in arthritis deformans. The synovial membrane goes through the stages of a chronic synovitis, and becomes thickened, succulent, and pale, finally passing on to a granular condition in cases which suppurate. The cartilage degenerates, and the ends of the bones are exposed, to rub together and wear each other away, and, if suppuration should be present, to melt down into pus. At times bony overgrowth prevails, when the ends of the bones are much enlarged and irregular, while at other times they are atrophied and fragile. Spontaneous fracture and dislocation may occur. The capsule becomes thickened in *Virchow, Cent. £. Chir., 18S7, No. 22, p. 417. Charcot's disease of the hip joint 167 some cases, and perhaps invaded by the osteophytes, while in other cases it degenerates and disappears, as does in most instances the ligamentum teres. There is generally much thickening of the trochanter, and periarticular infiltration occurs in most of the cases to a very marked degree. Microscopic examination shows in the atrophic form the changes of rarefying ostitis, a widening of the Haversian canals, and their coalescence with the general cavity of the medulla, thinning of the trabeculae, etc. Cases in which the early pathological condition can be investigated are not common. Where it has been possible to do so, the synovial membrane has been found smooth, and the fringes hypertrophied to form tufts. The synovial effu- sion is generally serous, and only seldom a purulent one. The capsule is thickened, and the bones are either atrophied or hypertrophied. If atrophied, the rim of the acetabulum is lowered, and the cavity, although more shallow than nor- mal, is broader. The hypertrophic form shows bony over- growth, much as in arthritis deformans. A. S. Roberts classifies the pathological changes, perhaps more systematically, as follows : (i) a chronic asthenic hyperasmia of the synovial membrane (hydrarthrosis) ; (2) an interstitial atrophy of the epiphyses ; (3) a fungous or rarefying hypertrophy of the epiphyses ; (4) the formation of bony stalactites. These conditions may exist separately, but some combination of them is more common than any one alone. Analysis of affected bones shows that the fat is increased, while" phosphorus and calcium are diminished, when com- pared with normal bone. This is practically the same state of affairs as in osteomalacia. Associated with the joint changes are apt to be such trophic disturbances as dystrophy of the nails, muscular atrophy, etc. l68 DISEASES OF THE HIP JOINT Etiology. This condition of the joints occurs most commonly in locomotor ataxia (tabes dorsalis), and is most known in its connection with that disease. But it is found at times also in acute myelitis and the paralysis of Pott's disease, in hemiplegia and disseminated sclerosis, in progressive mus- cular atrophy, in syringomyelia, in connection with some tumors occupying the gray matter of the cord, and in cer- tain traumatic lesions of the spinal cord. In short, a joint disease of this type is likely to occur in any lesion of the cells of the anterior cornua of the cord.* The disease affects the knee most often of all the large joints, and the hip comes next in the order of frequency. In Weizsacher's cases, of 169 joints analyzed the knee was affected 78 times, the hip 31 times, the shoulder 21, the tarsus 13, etc. Most often one joint is affected, but occa- sionally two or more are involved. The 169 diseased joints mentioned above occurred in 109 individuals. The right and the left side of the body are affected with equal frequency. The joint affection, as a rule, occurs at a comparatively early stage in the spinal cord disease. The frequency of the affection is but little known. In 56 cases of tabes, Erb observed joint trouble in only 2. Of 109 cases collected by Weizsacher, 72 were men and 37 were women. The identity of this affection has been a matter of much discussion. It has been asserted that it was only the result of constant traumatisms to a joint whose sensation was de- stroyed. Just as the section of the facial nerve destroys the sensitiveness of the eye and renders it unconscious of harm- ful substances which may be rubbing it, so, it has been asserted, do these joints become inflamed and injured from * Charcot, vol. i. p. 121 ; Michaud. Sur le Meningite et Myelite dansle Mai Vert, Paris, 1871 ; Gull, Guy's Hosp. Rep., 1S5S; Daun, Lancet, 1S31, ii. p. 235; Cent. f. Chir., 1887, Nos. 22, 25, and 42 ; Phila. Medical Times, April iS, 1868. Charcot's disease of the hip joint 169 the fact that the patient does not feel pain from slight trau- matisms, and guard his joint accordingly. But this theory- has fallen into discredit, because the joint affection is often found where the disturbances of co-ordination are slight and not enough to account for rough, inco-ordinated use and in- sensitiveness of the limb. This is the condition in most cases.* The present disposition is to regard the affection as a dis- tinct entity, and not as a form of either arthritis deformans or syphilitic disease of the joints, both of which it resembles pathologically. Virchow attributes the destruction to a faulty cellular change in the affected joint, which amounts merely to calling it a trophic change, which explains very little. It must be accepted as such, however, in the absence of more definite pathological knowledge. Treatment. The treatment, of course, should aim at controlling, so far as possible, the spinal cord disease, whatever may be its nature. For the joint disease but little can be done, from the nature of the case. If syphilis is present, mercury, and especially iodide of potash, are indicated, and in some cases have a very favorable effect upon the local condition. In many of the cases it may be desirable to keep the joint at rest, which will limit or retard the destructive process ; but such joints are not commonly painful, and motion is likely to be somewhat restricted by nature through the periartic- ular swelling and the degeneration of the capsule in the hypertrophic cases. If the swelling is excessive from joint distension, aspira- tion will give relief temporarily. Apparatus is of little use except to fix the limb in painful cases, and the motor disability of these patients would often contra-indicate the use of anything more than bed traction. * Weizsacher, Beitrage zur Klin. Chir., Bd. iii. Hft. i. 170 DISEASES OF THE HIP JOINT Excision of the joints has been done in some cases with fair success at the knee, but at the hip nothing seems likely to be accomplished, because in the severer cases the process of disease will lead to a result which is practically a sponta- neous excision ; and so extensive an operation in tissue with so little reparative power would seem to be hardly justified. Incision may be necessary for the evacuation and drainage of pus. MALIGNANT AND OTHER TUMORS OF THE HIP I7I Chapter X. MALIGNANT AND OTHER TUMORS OF THE HIP. . ^ Malignant Disease of the Hip Joint. Malignant disease of the hip occurs very rarely, yet often enough to make it worthy of careful consideration. In nearly all cases, the malignant growth is a sarcoma. But formerly such tumors were classified as cancers; and, for this reason, it seems worth while to discuss somewhat care- fully the structure and pathological characteristics of sar- coma of bone, as accepted by modern writers. Although excessively rare, carcinoma of bone is not unknown. Ziegler states that primary cancer of bone never occurs. On the other hand, Virchow, Volkmann, Forster, and Paget believe that primary cancer of bone is occasionally to be met. How- ever that may be, in nearly all cases one has to deal with sarcoma, and it is that which should claim the first con- sideration. Sarcoma of the Hip. The name of osteosarcoma should be restricted to the description of those cases where ossification is present in the tumor to some extent. The name has been loosely applied to all the sarcomas of bone by many writers ; but modern usage is restricting it to that especial significance, and using the simple term sarcoma in connection with the ordinary cases. For our knowledge of the pathology of malignant growths of the bones we are largely indebted to the classical papers of Dr. S. W. Gross,* who has analyzed 165 cases of sarcoma •Am. Journ. Med. Sci., July and October, 1879. 172 DISEASES OF THE HIP JOINT of the long bones. He is inclined to attribute much clinical importance to the variety of the sarcomatous growth, a matter in which German pathologists do not agree with him ; and in malignant tumors of the hip joint the matter possesses practically no significance. There are two large divisions of sarcomas which are of practical importance. They are either central or periosteal. In most instances, the central growths are of giant-celled variety, while the periosteal tumors are composed of spindle cells. Central tumors are generally spherical, when seated in the epiphyses, and on section are seen to be dark red and moist, with perhaps an admixture of bony spicules. Periosteal tumors, on the other hand, are more fusiform in shape and of greater density ; and the tissue composing them is grayish white and dense. Here, also, bony tissue is more likely to be present. Both forms are extremely malignant, although, so long as they are contained in their investing capsules, they merely push aside the healthy parts, but, so soon as they rupture their proper covering, they infect the neighboring tissues for a wide distance, not so much by the lymphatics as by the circulation ; and metastases are common, so much so that Gross found them recorded in 46 per cent, of the cases reported by him. The tendency of these tumors to suppuration is very slight, which is a most important matter in their diagnosis, and often aids in distinguishing them from tuberculosis of bone.* Spontaneous fracture may occur at the seat of the disease in some cases, but not so commonly where an epiphysis is affected as where the growth is situated in the shaft of the bone. In considering these growths as they affect the hip, one is surprised to see how small a percentage of reported cases have been situated in the hip. *Gillette, Bull, et Mem. de la Soc. de Chir., Paris, 1S76, ii. 115; Poinsot, Bull, et Mem. de la Soc. de Chir., Paris, 1S77, iii. 208. MALIGNANT AND OTHER TUMORS OF THE HIP 1 73 Of 70 cases of giant-celled sarcoma, 21 were in the femur, and only 2 of these were in the upper epiphysis, while 17 were in the lower ; 28 cases affected the upper epiphyses of the tibia and fibula, giving in the 70 cases 2 which affected the hip, while 45 were in or about the knee joint. Periosteal sarcomas do not invade the joints in so large a proportion of cases as do the central sarcomas, of which 20 per cent, were found to have affected the joint, while in the periosteal variety only 5 per cent, are so recorded. The 165 cases analyzed by Gross were classified by him as follows : 70 were giant-celled sarcomas, 45 were periosteal osteoid sarcomas, 16 were central spindle-celled sarcomas, 13 were periosteal round-celled sarcomas, 12 were central round-celled sarcomas, 9 were periosteal spindle-celled sarco- mas. Central Sarcomas. Giant-celled Sarcomas. Giant-celled sarcomas are also described as myeloid tumors (Paget *) and myelopaxic tumors (Nelaton f). For- merly such tumors were classed as spina ventosa, cancer of bone, spleen-like tumor, fungus hematodes, erectile tumor of bone, encephaloid tumor, hematoid tumor, etc. This was before their true nature was understood. The tumors are circumscribed and smooth, although at times they may be uneven in contour. On section the con- sistency is seen to be much like that of muscular tissue, but sometimes softer. The color is most often reddish buff and mottled, while at other times the cut surface may be of a uniform dark red. Fatty degeneration gives a marbled ap- pearance. Cysts are likely to form. They are due to the disintegration and liquefaction of the elements of the tumor, and are filled with either clear straw-colored fluid or extrav- * Surgical Pathology, 1853. t D'une Nouvelle Espfece de Turn. Benignes des Os, etc. Paris, i860. 174 DISEASES OF THE HIP JOINT asated and degenerated blood. The occurrence of calcifica- tion or ossification is not nearly so common as in periosteal growths. Microscropic examination shows a stroma of spindle cells and round cells, in which are imbedded the characteristic giant cells. Fatty elements and blood may be present in the degenerating cases. Other varieties of the central sarcoma are the spindle- celled and the round-celled. Central Spindle-celled Sarcoma. These have been described under the names of fibroplastic tumors (Follin), recurrent fibroids (Paget), fibronucleated tumors (Bennet), albuminous sarcoma (Gluge), and fasicu- lated carcinoma of bone (Miiller). There are no cases on record where they have affected the hip. Central Round-cell Sarcomas. These growths have been described as embryoplastic tumors (Lebert), medulla-celled tumors (Nelaton), granu- lation sarcomas (Billroth), encephaloid sarcomas (Cornil and Ranvier), juiceless cancer (Forster), medullary cancer (Paget, Holmes, etc.), hematoid cancer (Paget), hsematoma of bone, etc. The growth consists of spherical cells, scarcely to be dis- tinguished from white blood corpuscles in a fibrillated matrix. They are generally excessively vascular,* and the arrange- ment is usually alveolar.f Hence they resemble cancer structure very closely, which has been the cause of much con- fusion in their classification.^ *Mercier, Bull. Soc. Anat. de Paris, ii., 2d Ser., 241 ; Virch. Archiv, xxxv. 530; Bryant, Guy's Hosp. Rep., xx. 358 ; Poland, Guy's Hosp. Rep., xvi. 469 ; Weil, Prag. Viertjhrschft., 1877, iv. 14. t Billroth, Langenbeck's Archiv, xi. 224. J Virchow's Archiv, iv. 151. MALIGNANT AND OTHER TUMORS OF THE HIP 1/5 It should be borne in mind that from their very vascular structure they may pulsate, and simulate aneurism. They may also rupture internally or externally, and become the seat of extensive extravasations of blood. Of 12 cases collected by Gross, 3 were situated in the hip. They are the most rapidly growing of all malignant tumors affecting the hip. Periosteal Sarcomas. Periosteal Osteoid Sarcomas. The second commonest variety of bone sarcoma is espec- ially prone to attack the articular ends of the long bones, particularly of the femur. Of Gross's 45 cases of this vari- ety, the femur was affected in 24. This form of malignant tumor has been described under the names of ossifying fungus (Miiller); malignant osseous tumor (Stanley), and many of the growths formerly described as osteoid cancer * are to be included under this affection. f These tumors consist of a groundwork of ossified tissue, surrounded by a hard or soft homogeneous mass like the variety just described. The osseous tissue consists of plates or spicules of bone radiating out from the shaft of the bone from which the growth comes. The interspaces are filled out with the sarcomatous mass. In the great majority of instances, the microscope shows the growth to consist of spindle cells, while round-celled growths and mixtures of round and spindle cells are also found. Until a late stage of the disease, the growth does not attack the bone proper, although in nearly half the cases there exists along with the periosteal tumor a sarcomatous condition of the marrow, or the spongy tissue of the epi- *Schuh, Der Zottenkrebs und das Osteoid, Mainz, 1852; Paget, Surg. Path., 1853 ; Wedl, Grundziige d. Path. Hist., 1854; Rokitansky, Wchnblt. d. Ztschft. d. Wiener Aerzte, 1857, i. t Virchow, Deutsche Klinik, 1858, No. 49 : Volkmann, Bemerk. iiber einige von Krebs zu trennende Geschwiilste, Halle, 1858. 1/6 DISEASES OF THE HIP JOINT physis. It is important to state that in these growths there is no alveolar arrangement of the stroma and no included epithelioid cells. Other varieties of periosteal sarcomata are the round- celled and the spindle-celled, the characteristics of which are well enough defined by their names. There are no recorded instances where either of these varieties has been known to attack the hip. The Etiology of Sarcoma of Bone. Bone sarcomas occur, in most cases, before the age of thirty years (the average age being twenty-seven). In 147 of Gross's cases, where the age was noted, it was distributed as follows : — From 10 to 20 years, 45 cases From 20 to 30 From 30 to 40 From 40 to 50 From 50 to 60 From 60 to 70 55 26 II 7 3 Males are slightly more liable to the affection than fe- males, 87 out of 149 cases being men. Traurnatism is the only definite causative factor of which anything is known. In about half of the cases some clearly marked injury is to be remembered, which in most cases is clearly to be accounted the cause of the affection. The history of a personal case of the writer's is character- istic. A little girl of ten, who was in good health to all appear- ance, while running on a sidewalk caught her right foot in the root of a tree, and violently wrenched her right hip, being thrown to the ground. She walked home, and complained of soreness and stiffness there ; but on that day and the next day she was able to walk about the house with very little discomfort. On the third day the leg became very painful ; and she was under the care of various physicians for six MALIGNANT AND OTHER TUMORS OF THE HIP 1 77 weeks, in which time a purely expectant plan of treatment was pursued. Six weeks after the accident, when seen by the writer, she presented the appearances of acute hip dis- ease, except that the swelling was disproportionate to the other symptoms. Many months have elapsed since that time, and the thigh is now an enormous mass of fungus and degenerating tissue, which leaves no doubt as to its malig- nant character. Treatment of Sarcoma of the Hip. The practical question that arises in the treatment of these malignant tumors is whether or not it is worth while to amputate the diseased leg at the hip joint, and statistics are not enough to settle the question. In fact, practically all the operations have been done for tumor of the knee joint or arm; but in two cases of disease of the humerus, in- volving the shoulder joint, disarticulation was done, and the disease returned very quickly. The statistics of cases where the growth and all neighboring tissues can be removed by operation have no bearing upon the question of malignant disease of the hip joint, because the complete extirpation of the sarcomatous growth is not possible. On general grounds the operation would be practically hopeless as far as eradicating the disease, unless performed at so early a stage that the diagnosis could not be expected to have been made. At the same time a thorough operation at times is likely to afford relief in removing a lar-ge, bleeding, and fungous mass, and allowing free drainage to the part that remains attached to the pelvis. The enormous size of the leg be- comes a most distressing feature in these cases ; and its re- moval, although attended by a very serious risk of death as a result of the operation, is, in some of the most distressing cases, to be considered. Practically, however, very few patients will be found ready to submit to so serious and for- 178 DISEASES OF THE HIP JOINT midable an operation, which holds out practically no hope of cure. Ca7icer of bojie in the modern pathology is exceedingly rare. It may begin either in the periosteum or the marrow, and may contain bony tissue in its meshes. It is accompanied by much hypertrophy of the periosteum and absorption of the bone tissue by rarefying ostitis. To warrant the diagno- sis of cancer, the microscopic structure should be thoroughly characteristic. Hydatid cysts of the hip joint have been described, and they have presented most of the characteristics of cold ab- scess. Tapping and the injection of iodine have sufficed to cure them. The two cases in the foot-note* are such hydatid cysts of the hip joint. Lipomata of the hip have been described in the following instances : Dupuy, Bull. Soc. Anat. de Paris, 1876, 4 s., 323 ; also Prog. I\Ied., Paris, 1876, iv. 635 ; Ferguson, Lancet, London, 1S62, i. 120; Pean, Med. Prat., Paris, 1883, 13; Za- boklicki, Gaz. Lek., Warszwaza, 1878, xxv. 33 ; Wade, Dub- lin Med. Press, 1843, ix. 5. Cases of ^Malignant Tumors of the Hip. Holmes, Trans. Med. Ass'n South. N.Y., 1858-61 ; Mur- ra}', Br. AI. J., London, 1865, ii. 254; Niese, Deutsche Klinik, Berlin, 1855 ; O'Ferrall, Proc. Path. Soc, Dublin,. 1840-49, i. 331; Santesson, Hygeia, Stockholm, 1859, trans, in Dublin Med. Press, 1859, xliii. ; Sawyer, Am. J. Med. Sci., Phila., 1858, x. s. 35, 109; Awan, Forh. Svensk. Lak. Sallsk. Sammank., Stockholm, 1870, 104; Jeffreys, Lancet, 1836, ii. 429; Key, Lancet, 1828, ii. 508; McRuer, B. M. -& S. J., 1854-55, Ii- 498; Alalgaigne, Gaz. d'Hop., Paris, 1846, viii. 562; Mears, Med. News, 1884, xlv. 752; Smith, j\Ied. Exam., London, 1877, ii. 566; Taramelli, Ann. L^niv. di Med., Milano, 1827, xlii. 295 ; Tansini, Gaz. Med. Ital. Lomb., Milano, 1886, xlvi. ; Baralz, Berl. Klin. Wchsft., 1887, xxiv. 610. *Abeille, Gaz. Med. de Paris, 1S72, xx™. 420; Bourdy, Bull. Soc. de Med. de la Sarthe, 1875, 33- LOOSE BODIES OF THE HIP JOINT 1/9 Chapter XT. LOOSE BODIES OF THE HIP JOINT. The possibility of the occurrence of this affection makes its consideration necessary, but the affection is of such rarity that the section need be only a brief one. Loose bodies are nearly always found in the knee joint; but the hip, elbow, and other joints are not to be considered exempt.* Such loose bodies are also called loose cartilages, joint mice, rice bodies, floating bodies, corpora libera articulorum, etc. In structure they are either to be described as fibroma- tous, lipomatous, or chondromatous, according to the struct- ure found on section. They are formed in one of the following ways : — {a) As the fibrous residue of an exudation. {b) As residue from a blood clot. This was Hunter's idea of the cause of most loose bodies; but proof that they may exist as the outcome of a simple effusion of blood is still wanting, although the possibility of free bodies from this source is recognized in every modern classification. {c) Broken off osteophytes in arthritis deformans. {d) Hypertrophied or degenerated portions of the synovial fringes, as seen in chronic synovitis and arthritis deformans. (e) Marginal ecchondroses, as seen in arthritis deformans, which have grown into the joint and have been broken off. (/) Foreign bodies, such as bullets and needles, which have penetrated into the joint cavity and perhaps have become encapsulated. * Howard Marsh, in Treves' Surg., vol. ii. p. 250; Konig, Arch. f. Klin. Chir., 1888. l80 DISEASES OF THE HIP JOINT (£■) Bits of cartilage or bone chipped off by accident, or more often loosened by a degenerative process set up by the accident.* It has been clearly proved that such bodies can be formed in consequence of a wrench or fall.f They seem capable of independent growth | as well as of calcifi- cation. These bodies may exist free in the joint, or they may be pedunculated and attached to the mucous membrane. In size they vary from that of a pin-head to that of a horse- chestnut, so far as the knee is concerned, where they have been chiefly studied. It will be seen that they exist most often in connection with some synovial affection, generally arthritis deformans. Traumatism would be much less likely to be a cause of loose bodies in the hip than in the knee. The treatment of loose bodies of the hip can be settled very briefly. No measure short of their excision would offer any prospect of relief. Consequently, in the event of such a diagnosis having been made, the question which arises is the delicate one of undertaking so extensive an operation as incision of the hip for the removal of the loose body. Under exceptional circumstances, this might be justified; but, in general, the treatment would best consist of pallia- tive measures. Two cases are reported by Konig where an operation was successful in removing what was practi- cally a foreign body, being the entire cartilage of the femur cast off by an osteochondritis, and lying loose in the hip joint, where it gave rise to the classical symptoms of a for- eign body. *Brodhurst, St. Geo. Hosp. Rep., 1867, ii. 141; Deutsch. Klinik, Volkmann, 1867, No. 48; Virchow, Die Krankhaften Geschwiilste, Berlin, 1863. t Marsh, Brit. Med. Journal, April 14, 1888; Shattock, Path. Soc. Trans., xv. 206. + Recklinghausen, De Corp. Lib. Artie, 1864. LOOSE BODIES OF THE HIP JOINT l8l Foreign Bodies of the Hip Joint. Afanasjev, Ejened, Klin. Gaz., St. Petersburg, 1882, ii. {formation of a large number of loose bodies); Beraud, Compte Rend, de la Soc. de Biol, 1852, iii. 27; Erchmann, Journ. d. Chir. und Augenk'h'de, 1883, xix. 120; Wagstaffe, Trans. Path. Soc, London, 1872-73, xiv. 192. l82 DISEASES OF THE HIP JOINT Chapter XII. CONGENITAL DISLOCATION OF THE HIP JOINT. Etiology. Congenital dislocation of the hip is not an affection which is at all common ; nor, on the other hand, should it be spoken of as a very great rarity. In 3,100 cases of surgi- cal disease in children applying at the Boston Children's Hospital there were only 24 cases of congenital hip disloca- tion, * or a little less than one in a hundred cases of surgical disease. Chaussier f found only one case of congenital dis- location of the hip in 23,293 children born at the Paris Maternite ; but Parise,| who dissected the hip joints of 332 children dying at the Hopital des Enfants Trouves, found 3 congenital dislocations. But any attempt at picturing the frequency of the disease by statistics must needs be unsatis- factory. The frequency of cases in the streets of any city must show to the careful observer that the affection is more common than is generally believed. Sex.-"— For some unexplained reason it affects girls much more often than boys, as will be seen from the following table, which includes all large groups of reported cases : — * Bradford and Lovett, ioc. cit. t Chaussier, Deutsch. Chirurgie, 26, p. 83. % Parise, Bull, de la Soc. de Chir., 1866, vii. 331. lO 67 II 96 H 1(^ 2 23 O 24 3 JJ 40 301 CONGENITAL DISLOCATION OF THE HIP JOINT 1 83 Reporter. Number. Boys. Girls. Drachman,* 77 Pravaz, 107 Kronlein, 90 N.Y. Orth. Hosp.,t .... 25 Boston Ch. Hosp ,f .... 24 Prahl4 _i8 341 Location. — The affection is more often single than double, and affects the right and left hip in practically the same number of cases. Of 313 cases, 122 were double, and 191 single. Of these^ 95 affected the right hip, and 96 the left. Connection with Other Deformities. — Occasionally disloca- tion of the hip exists in connection with other deformities^ such as congenital valgus, anencephalia, hare-lip, and the like; but, for the most part, it occurs in well-formed and healthy children, and in this respect it differs from other congenital dislocations, as well as in its greater frequency. The theoretical discussion of the etiology is capable of prolongation to any extent. There are a few settled fa'cts which should be reviewed before going on to the intricate theories which strive to account for this remarkable con- dition. Girls are very much more often affected than boys. The affection is more often single than double. The affection is in some cases hereditary (Dupuytren,§ Bouvier, II Stadtfeldt, Verneuil,^ and Volkmann **). To pass now to the purely theoretical considerations which have been advanced, one finds a series reaching from the time of Hippocrates (who believed the dislocation to be due to injuries or uterine pressure) to the present day, when the *Drachmann, Schmidt's Jahrbuch, 1881, p. 170. t Bradford and Lovett from reports. % Cent. f. Chir., 1881, p. 57. § Lecons Orales de Clin. Chir., Paris, 1832, vol.iii. il Lefon Clin, sur les Mai. de I'Appareil Locomoteur. ITGaz. desHop., 1886, 68. ** Volkmann, K'h'ten der Bewegungsorgane. 184 DISEASES OF THE HIP JOINT theory of non-development has established itself, and is accepted as the probable explanation of the condition. It will hardly be worth while to do more than to pass in review the other theories, and this can be done most clearly and easily by following Kronlein's* most admirable classifi- cation, 1. The so-called dislocation is traumatic, and is caused : — {a) By external forces acting upon the foetus, or by its own muscular contractions. Chaussier quotes, in support of this theory, a case where a woman, nine months' pregnant, felt such violent foetal movements on three occasions that she became unconscious, and was delivered of a child with dislocation of the forearm. Chatelain, Kleeburg, and Ziele- wicz attributed three cases to a fall in the seventh month. {b) By injury during delivery. It is possible to see how in some cases traction in the groin, during breech deliveries, might cause dislocation, especially where the hip ligaments are weak. The propor- tion of breech deliveries in these cases is abnormally large, as is well known, Adams reporting 7 breech presentations in 45 cases. 2. The so-called dislocation is spontaneous, and is caused {a) by softening and laxity of the ligaments (Sedillot), (b) by foetal hydrarthrosis (Parise), fungous synovitis, and effu- sion (Verneuil and Broca), or destructive disease of the bone (Morel, Lavallee, Albers, Von Ammon, Guerin). 3. The so-called dislocation is due to the peculiar position of the lower limbs of the foetus in utero. {a) This may be strong flexion, causing pressure on the lower and posterior part of the capsule (Dupuytren). {b) Strong adduction may be induced by a compression by the uterine walls, due to deficiency of the amniotic fluid (Roser). 4. The so-called dislocation is due to primary muscular contraction (like the deformities of club foot, wry neck, and * Deutsche Chir., Lief. 26, p. 82. CONGENITAL DISLOCATION OF THE HIP JOINT l8$ scoliosis) ; and this is to be regarded as evidence of an affec- tion of the central nervous system. This theory has had many supporters, among whom may be mentioned Jules Guerin, Chaussier, Melicher, Mercer, Adam, and Carnochan. It may be said in regard to this theory that the analogous deformities from which the theory was derived are not now regarded as the results of primary muscular contraction by most modern orthopedists. Club foot, at least, is regarded rather as an expression of retarded foetal development. 5. The so-called dislocation is often the last stage of a paralysis and atrophy of the peritrochanteric muscles (Verneuil, Reclus,* and Dalby) ; and iliac dislocation is the most common form, because of the paralysis of the gluteal and pelvitrochanteric muscles and the integrity of the ad- ductor group. Such theories as these need little refutation. They were devised in the absence of any satisfactory theory, and rest, for the most part, on a purely fanciful basis. They explain nothing for the most part, and can only be accepted as explaining an occasional case. Cases which are caused by traumatism at birth undoubtedly occur ; but they are not, strictly speaking, congenital. The causation of dislocation by external violence to the "mother rests on a very slender basis. In the same way it may be said of the other theories that it is perfectly possible that they may account for an occasional case, but that good evidence is, for the most part, wanting. Destructive bone disease in the foetus is very rare ; but one cannot say that it is not the occasional cause of a congenital dislocation, especially since the acute arthri- tis of infants produces a condition at the hip almost indis- tinguishable from congenital dislocation. In general, however, it should be said that the interest of these theories is chiefly historical, and that most cases are to be considered as coming under the head of the theory *Rev. Mens, de M^d. et de Chir., 1878, p. 88. 1 86 DISEASES OF THE HIP JOINT of retarded development about to be considered, which has received the sanction of nearly all modern authority. 6. The so-called dislocation is in most cases due to an ar- rest or defect of development. A theory of this nature was first advanced by Paletta, and taken up by Breschet, Dupuy- tren, and Schreger. Von Ammon * elaborated it still more fully, and the theory often goes by his name. It was, how- ever, Grawitz f who put the theory on a sound scientific basis; and it seems more just that it should be known by his name, if it is desirable that any person's name should be given to the theory which is the outcome of the writings of so many. According to X'on Ammon, this affection cannot properly be called a dislocation. He would class these cases as "dysarthroses congenitae," and he says in defence of this position : " In many cases there is in part the greatest cer- tainty and in part the greatest probability that the affection depends upon an arrest of development of the constituent parts of the joint. ... If the term 'luxatio' is, in general, understood to mean the slipping of a movable bone out of its natural joint connections, it is applicable only with the greatest restrictions to the congenital dislocation in ques- tion." The fault seems to lie in the failure of the Y-cartilage at the bottom of the acetabulum to carry on the growth of the three segments of the acetabulum. Dollinger believed that this defect was due to a premature ossification ; while Grawitz, from the examination of 12 specimens in 7 new-born chil- dren, seems to have proved that it is rather an arrest of de- velopment. For instance, in one case the acetabulum was only as" large as that of a foetus of five months, and the carti- lage was abnormally broad even then because of delayed ossifi- cation. The formative zone in each epiphysis on microscopic examination was seen to be very imperfect, with cells widely * Von Ammon, Die Angeborene Chir. K'h'ten des Menschen, 1842, ix. t Virchow's Archiv, 1S78, vol. bociv. p. i. CONGENITAL DISLOCATION OF THE HIP JOINT 1 8/ separated and scanty ; while in two other cases the zone of calcification was wanting, and the cartilage cells contained no nuclei and only fat granules. In no case was there any evidence of premature ossification. The femur in these cases seemed to have reached a com- paratively normal size, and in this disproportion lies the secret of the deformity. The head of the femur is too large to enter the shallow and constricted acetabulum, and lies out- side of it, not dislocated, but never having been in the proper relation with it. Although, as has been already stated, this theory cannot be held accountable for all cases, the whole weight of modern authority regards it as the most acceptable and most scien- tific of all the theories which would explain the cause of the deformity. One merit of this theory is to be found in the fact that it makes congenital dislocation analogous with other deformities, inasmuch as it finds its causation in a retarded development, as is the case in hare-lip, cleft palate, and other deformities. The fact that congenital dislocation occurs, in a certain pro- portion of instances, in connection with these deformities, also lends weight to this view. Numerically, females are more liable to deformity of all sorts than are males ; and, con- sequently, this theory gives a certain sort of explanation of the great preponderance of females among those affected by congenital dislocation of the hip. At the same time it is far from a satisfactory explanation of this overwhelming propor- tion. - The conclusion of the whole matter cannot be stated better than has been done by Stimson, who says that, while "a limited number of cases of dislocations existing at birth, especially in joints other than the hip, may have been caused by traumatism, abnormal position of the limb, or paralysis, in the manner alleged by various writers, yet, in the great majority of congenital dislocations of the hip, the cause is to be found exclusively in an arrest of development of the ace- l88 DISEASES OF THE HIP JOINT tabulum by deficient action or vitality of the cells of the Y- cartilage." In conclusion, it may be permissible to call attention once more to the fact that dislocations occurring during birth are not to be classed as congenital, but as traumatic ; and, although they are undoubtedly in the minority, still they should be recognized as a special class of hip dislocations, to be in some cases distinguished practically from congenital dislocations. Pathology. In discussing pathological changes found in connection with congenital dislocation of the hip, it should be remem- bered, as has been pointed out by Gurlt, that there should be distinguished two kinds of changes, — those due to the affection itself, and those changes produced by weight bear- ing upon the affected limb, which latter changes are super- added to those of the disease itself. Autopsies on cases which have not walked are rare, and most of the pathology has been learned from the examina- tion of cases which have borne weight on the limbs. Early autopsies have been reported by Mercer, Adams,* Parise,t Dollinger ; J and the seven cases of Grawitz § are the most important of all, as well as the case of Verneuil. || In the vast majority of cases, the head of the bone is found upon the dorsum of the ilium, resting either upon the iliac bone itself or upon the gluteus minimus muscle. Cases, how- ever, have been reported where the head of the femur was dislocated on to the pubis and into the obturator foramen. They are, however, extremely rare. It should be borne in mind that the femur and the acetabulum are developed in the embryo from one continuous tissue, and that, although at first they are for this reason necessarily in contact with each other, when the development of the acetabulum becomes * Journal Edinb. Phys. Soc, 1853. t Quoted by M. Adams. t Virchow, Archiv. § Arch. f. P. Anat., Ixxiv. || Gaz. des Hop., 1852, 530. CONGENITAL DISLOCATION OF THE HIP 1 89 retarded and the growth of the femur goes on normally, it is impossible for the normal relation to be maintained indefi- nitely. Consequently, even before weight is borne upon the limb, the head of the femur is drawn upward and backward, resulting in a distortion of the capsule and the formation of a new articular surface, where the head of the femur finally rests. So that, added to the naturally imperfect growth of the acetabulum, comes a still further element of disturbance in the fact that the femur is not in contact with it, as it should be, during its period of active growth. To consider the changes as they have been found in the cases reported, one comes first to the acetabulum. In no reported case has this been entirely absent ; and, on the other hand, rarely has it been reported as normal. In general, it is found smaller and more shallow than normal, often being changed into the shape of a flattened oval, a change due to the altered position of the femur. Some- times the new acetabulum is continuous with the old one, while at other times the two form distinct cavities. In cases which have not walked, the new acetabulum is not an important feature. In the case of Paletta, three distinct de- pressions had been made by the head of the femur. In cases which have walked, and especially in cases where the de- formity is comparatively little disabling, one finds a rough elevated border of bone, consisting of osteophytes deposited upon the upper border of the elongated oval, which is merely nature's effort to strengthen this new socket, and to protect, so far as may be, the head of the femur from slipping up- ward. The cartilaginous rim of the acetabulum is often wanting. Sometimes exostoses develop in the acetabulum itself (Porto). The femur shows changes that are less marked, but at the same time distinctive. The head of the femur in the reported dissections may be normal, or the head and neck may be entirely wanting. Intermediate conditions are found in all degrees. As a rule, the neck is shorter than IQO DISEASES OF THE HIP JOINT normal, and is more at a right angle to the shaft than is commonly found. Perhaps some of the most important changes are to be found in the capsule of the joint, which is much hyperlro- phied, and thickened and stretched. It may be constricted at its centre into an hour-glass form. In cases which have walked, the hypertrophy is the result of its new function ; for, in most cases of bad congenital dislocation, the body is hung upon the femur by means of the capsule of the hip joints, in the same way, as Volkmann has pointed out, that an old- fashioned stage-coach was hung upon its leather springs. The head of the femur plays loosely against the dorsum of the ilium, and is retained by a bony socket. The onl)" thing that keeps the head of the femur from slipping up indefi- nitely is the capsule of the hip joint, which runs from the rim of the acetabulum to the head of the femur. Conse- quently, it forms, perhaps, the most important part of the congenitally dislocated joint. Although the capsule is usually entire originally, the wearing upon it of the head of the femur may cause wearing away over the new acetabulum. The synovial surface of the capsule- is usually smooth and moist, and of normal appearance ; but attachments to the rim of the acetabulum from which the capsule is stretched, as well as to the head and neck of the femur, are common. The synovia varies in amount, sometimes being normal and sometimes excessive. The capsule, which is especially thickened in that part corresponding to the Y-ligament, is sometimes attached to the fascia of the gluteal muscles ; and the hour-glass constriction, already alluded to, is an impor- tant factor in preventing apposition of the head of the femur and the acetabulum. In -cases of long standing, that part of the capsule which lies between the head of the femur and the new socket is liable to be worn out by the constant rubbing and to dis- appear. In this case, the capsule appears to be attached to the rim of the new acetabulum. This, however, may not be CONGENITAL DISLOCATION OF THE HIP 191 the case ; and the capsule, along with the pelvitrochanteric muscles, and even the psoas and iliacus at, times, serves only as a tough suspensory ligament. In the case first mentioned. Fig. 50.— UNILATERAL CONGENITAL DISLOCATION OF THE LEFT LEG, SHOWING THE NATURAL POSITION IN STANDING. the capsule is fused with the periosteum of the ilium, and is adherent all around the periphery of the new socket. Inasmuch as the pelvis is suspended by the capsular liga- ment, it is a matter of some practical importance whether 192 DISEASES OF THE HIP JOIXT the new acetabulum forms directl}^ over the old one or above and behind it. If it forms direct! v over the old one, the pel- vis remains in practically the normal plane. If, however, Fig. 51. — THE SAME CASE Ar^ IX FIG. fO. SHOWING THE CORRECTED POSITION. the new socket develops posteriorly, the angle of the pelvis is of course changed, and it is tilted forward on a transverse axis, occasioning some lordosis in the back. This patho- logical condition is probably the explanation of the varying amount of distortion which is noticed clinicallv. CONGENITAL DISLOCATION OF THE HIP JOINT 193 Suspended in this way, one would suspect that the devel- opment and growth of the pelvis would be abnormal ; and such is the case. The crests of the ilia come nearer each other : while the tuberosities of the ischia are separated, so that the upper part of the pelvis is constricted, while the lower part is elongated. In addition to this, the sacrum is more curved than it normally should be. The condition of the lig- amentum teres varies within wide limits. In the infant it may be fused with the capsule, but it is never entirely wanting (Kron- lein), although it may be represented only by a very small thread. In the case of persons who have walked it may be wanting (Bowlby, Coudray, etc.). Most commonly it is elon- gated and thickened, ap- parently aiding in the sus- pension of the pelvis from the femora. Again it is subjected to all sorts of irregularities, sometimes rising by two heads from the acetabulum, and vary- ing in many other ways from the normal condition. It is not an important fac- tor in the pathology. The muscles around the hip joint are modified chiefly in a mechanical way, as must evidently be the case from the distortion of the parts involved. The gluteal muscles Fig. 52. — DOUBLE CONGENITAL DISLOCATION OF A SEVERE GRADE, SHOWING THE LORDOSIS OF THE BACK AND THE PROMINENCE OF THE TRO- CHANTERS. 194 DISEASES OF THE HIP JOINT are contracted ; and the muscles inserted around the neck of the femur are of course, for the most part, stretched and atrophied, as is also the case in the other muscles which Fig. 53- — DOUBLE COXGEXITAL DISLOCATION OF A MILD GRADE, SHOWING LESS LORDOSIS AND BLT LITTLE DEFORMITY. are not brought into activity in the new position assumed by the femur. Fatty or fibrous degeneration of the disused muscles is not uncommon fKronlein, Bardeleben). CONGENITAL DISLOCATION OF THE HIP JOINT 195 Treatment. The treatment of congenital dislocation of the hip has never been regarded as a credit to surgery. For the most part, the deformity has been regarded as irremediable, and surgeons have been slow to advise either operative or me- chanical treatment. Before the advent of antiseptic surgery operation was, of course, not to be advised ; and the results of mechanical treatment have been such that there was little to be said in favor of that. Treatment by Extension and Apparatus. The latest method of this form of treatment is that by continuous exten- sion, made most often by a weight and pulley while the patient is confined in bed. Pravaz, senior,* claimed to have cured a case by this method, and a committee was appointed from the French Academy of Medicine, which should investigate the claims ad- vanced by the surgeon. This committee disagreed as to the cure, but consid- ered that the patient was much benefited. Pravaz, junior, claimed a similar re- sult some years later in a patient whom he exhibited. A committee from the So- ciety of Surgery f was * Bull, de I'Acad. de Med., Paris, vol. iii. p Fig. 54. — SIDi; \IE\V Ol- A MILD CA.sl:, SHOW- ING THE CHARACTERISTIC ATTITUDE. t Bull, de la Soc. de Chir., 1864, 218. 196 DISEASES OF THE HIP JOINT again appointed to examine the case, but was of the opin- ion that, although much benefit had resulted, a reduction of the dislocation had not occurred. This is not surprising in the light of the modern view, which would regard the so- called dislocation as a malformation rather than a true dis- location. With an imperfect acetabulum and the head of the femur too large to enter it, it is not surprising that so many surgeons have failed to cure the deform- ity by extension, however prolonged. A similar re- sult was reached in the case of Guerin, who also treated cases by continu- ous extension. The com- mittee reported that two centimetres had been gained in one case, but that in this case, also, it could not be claimed that the dislocation was re- duced. Mr. William Ad- ams * has recently re- ported satisfactory results in the treatment of hip dis- location by the method of extension. In four cases, two unilateral and two bi- lateral, he reports that the head of the femur seems to be retained in its proper place in each case. Inasmuch as only two years and seven months have elapsed since the beginning of treatment, it seems hardly fair to consider the cases of Mr. Adams as more than very doubtful results. Fig. 55 — FRONT VIE"\V OF A DOUBLE Dl-LL" A- TION- OF MODERATE SEVERITY, SHOWING THE CHARACTERISTIC ATTITUDE IN STANDING, AS WELL AS THE BROADENING OF THE PERINEUM. * British iMed. Journal, 1890. CONGENITAL DISLOCATION OF THE HIP JOINT 197 The classical case that gives hope that extension may often be regarded as a cure for this distressing deformity is the one reported by Dr. Buckminster Brown, of Boston, in 1885.* A girl four years old had double congenital dislocation of the hip. The joints were loose, the walk was very bad, and no trace of an acetabu- lum could be found on manipulation. The pa- tient was put to bed, and traction was made by weights which had for their object the stretch- ing of the contracted tissues and the bring^inp: of the femur into its proper position. After some weeks, passive movements were made by changing the posi- tion of the pulleys. For thirteen months the child was kept in bed recumbent, and then she was encouraged to make the movements of walk- ing without bearing- weight on the legs. This was accomplished by the wheel crutch. About two years and three months after the beginning of treatment the heads of the femora were found in place on Nekton's line, and the child was allowed to walk gradually ; and at the time of Dr. Brown's report the Fig. 56. — FRONT VIEW OF A VERY SEVERE CASE OF DOUBLE DISLOCATION WHERE FLEXION OF THE LEGS WAS PRESENT AND WALKING WAS ALMOST IMPOSSIBLE. THE LORDOSIS IN THIS CASE WAS EX- CESSIVE. * Boston Med. and Surg. Journal, 1885, No. 23. iqS diseases of the hip joint walk was normal, and she was able to play and run about like other children. This case stands alone in the literature of orthopedic surgery. Most of the results obtained by oper- ative measures are not worthy of comparison with it ; and no other case, so far as the writer knows, has ever been reported where so successful a result was obtained by mechanical means. In such treatment, of course, the first matter must be to draw the head of the femur into place by continuous traction made upon the leg. This is not so easy a matter as it would seem, and is often accomplished only by pro- longed and continuous traction. Then by passive move- ments, as in the case of Dr. Brown, it may be hoped that at the site of the old acetabulum a lodgment of the head of the femur may be effected ; and this can only be accomplished by continued movements of the femur after it has been re- duced to its proper place. It is very undesirable to begin on a treatment of this sort unless there is a prospect that it can be carried out to the end, because simply to stretch the connections between the femur and the pelvis, without being able to retain the femur in its new position, is simply to make the limb worse, and the patient's condition more unfortunate than it w^as before. An apparatus is described by Dr. Bradford which has as its aim the maintenance of continuous traction without such prolonged recumbency as in the case of Dr. Brown, which consists of a leather jacket to which rods are attached at right angles, from which traction is made upon the flexed joints, so that the child mav be kept on a frame or sitting up without loosing the traction force. The writer has had no personal experience with the method, but it seems to offer certain advantages over the treatment by continued recum- bency. ■ The use of corsets and pelvic bands, which have as their object the retention of the head of the femur in its proper place, has been, largely advocated, especially by German writers. Konig* and Landererf use corsets of felt, sili- ■^ Lelirbuch d. Spec. Chir., 1S87, i'i. p. 287. i^ Archiv f. Kl. Chir., 18S5, xxxii. p. 516. CONGENITAL DISLOCATION OF THE HIP JOINT 1 99 cate, or plaster, which, they think, retain the head of the femur in place and improve the walk. In one of Landerer's cases shortening was reduced from two inches to two-thirds of an inch. Motta suspends the patient by the head and axillse, and takes a plaster cast of the affected side, while the limb is pulled down as far as possible into place. From this he makes a poroplastic splint, which is worn by day ; and at night he uses a gaiter and extension. He advocates the method as "giving an immediate correction, or at least a decided lessening, of the limp"; but from Landerer's corset he could not get any good results.* Volkmann's pupil, Martin, published the results of his master's experience with hip dislocation in the course of twenty-five years ; and the best that could be said was that in unilateral dislocation the results were partly satisfactory.! The method brought forward by Paci, of Pisa,:]: has re- cently attracted attention as a means of reducing congenital dislocation of the hip. It has as its object a series of manip- ulations to cause the descent of the head of the femur to a place near where the acetabulum should be, and, if such an acetabulum exists, to cause a reduction of the disloca- tion. It is claimed for this by Redard § that a better posi- tion may be obtained by affording a solid bony support to the head of the femur upon the ilium, which may result in the formation of a new joint. The obstacle to reduction is found in the pelvitrochanteric muscles and those of the thigh and leg. The first attempt is to cause relaxation of these muscles by effecting leverage upon the dislocated bone. This method consists of four steps. With the patient held firmly and the pelvis fixed, flexion of the leg to the full extent should be accomplished. This causes the descent of the head of the femur as far as possible. Next a slight amount of abduction is made, which is designed to *Giorn. della R. Accad. di Torino, 1886, xxxiv. p. 675. t Deutsch. Med. Wchsft., 1889, No. xvi. + Quoted by Redard. § Archives for Ped. (abst.), March, 1891. 200 DISEASES OF THE HIP JOINT place the head anterior to the acetabulum, if the descent has been complete, or against its posterior border, if the descent has been incomplete. In the third step, while abduction is maintained, slow external rotation is effected, which brings the head of the femur still more forward. Finally, and lastly, the thigh is slowly extended, one hand pressed upon the knee, while the other holds the foot and leg, the whole limb being turned outward. After a moder- ate degree of force has been used, the contraction generally yields ; and the thigh can be completely extended in general. It is said that ansesthesia is not generally necessary for this manipulation. It is directed that the limb should be kept in an immovable apparatus for a month, and that extension should be kept up for three months. It seems impossible to believe that so serious a deformity can be corrected by so simple and rapid a treatment. Some years ago Dr. Post, of Boston, * treated a case of single congenital dislocation of the hip in a young child by etherizing it, and pulling the head of the femur into normal position (in this case there was an acetabulum), and retaining it there by a plaster of, Paris bandage worn for a year. In discussing the various methods advocated for the reduction of hip dislocations by mechanical meas- ures, it is difficult to judge their merits correctly. The case of Dr. Brown was perfectly successful. In the case of the method advocated by Redard and others, it is doubtful if the results were equally good. With the atten- tion paid to mechanical orthopedics in America, it would seem as if there were a future for the treatment by extension properly carried out. In a personal case of the writer's recently under treatment, a girl of thirteen with single .dislocation was very much benefited by six months' extension in bed, and after that wearing a protection splint. The limb was lengthened nearly an inch ; and the gain has been held, although it is too early to judge of the case, only * Quoted by Bradford and Lovett, p. 519. CONGENITAL DISLOCATION OF THE HIP JOINT 20I a year and a half having elapsed since the beginning of treat- ment. The success of mechanical treatment would often seem to justify the undertaking of a course of traction treat- ment in the case of careful and faithful parents. The child should be first subjected to continuous and prolonged exten- sion in both the extended position and with the thigh flexed at a right angle to the body, in order to loosen up the con- tracted muscles and ligaments, due to the abnormal position of the femur. This may be accomplished — although hardly so well — by the use of the long traction splint. After that it would seem advisable that the head of the bone should be manipulated in this new position, in the hope of establishing a new connection for it. Then walking might be attempted very gradually, with the joint protected ; and the discontinuance of apparatus should only be considered after the lapse of a great many months, as the mechanical conditions are obviously not favorable for the maintenance of the new condition. The writer has had no personal ex- perience with the method advocated by Redard, and is not competent to speak of its merits. Operative Treatment. The treatment of congenital dislocation of the hip by operation apparently dates from the time of Guerin,* who believed that the cause of all congenital deformities lay in a primary muscular contraction, and practised tenotomy of the peritrochanteric muscles for the relief of this dislocation. Later he realized that there was present, also, an abnormality of the acetabulum ; and he added to his tenotomy subcutane- ous cuts of the capsule, and, following it, progressive move- ments of the limb, hoping to obtain the formation of a new articular surface. And, to aid in this, he used also prolonged extension. This method was tried in three cases of uni- lateral dislocation, and in one where both hips were in- * Jules Guerin, Recherches sur les Luxations Congenitales. 1S41. 202 DISEASES OF THE HIP JOINT volved. Two years later a commission of the Academy of Medicine, examining these cases, reported that two cases of the dislocation were not cured, but that a lengthening of two centimetres had been obtained. The treatment of the third dislocation had been temporarily given up, and the double dislocation was not far enough advanced for the re- port. This method is of significance, inasmuch as it has been the basis of similar operations largely practised since. Bouvier * performed subcutaneous tenotomy of the ad- ductors and of the psoas on both sides. This was followed by an apparatus which held the limbs abducted. Some benefit followed the operation. Pravaz, junior,! performed a subcutaneous section of the fascia lata. Corridge i: em- ployed tenotoni}' and continuous extension in i860. Brod- hurst,§ in 1865, performed a subcutaneous tenotomy of the contracted muscles in the case of a child twelve years old, who had not been benefited by continuous extension em- ployed for some months. It is reported that at the end of a year the patient walked with scarcely a limp. A second case was operated upon by Brodhurst ; and it is said that six months after operation the patient walked without appa- ratus, and that the head of the femur was in place. Brod- hurst apparently performed a third operation, which he alluded to in a discussion with Bennett. || An entirely different line of operation was undertaken by Mayer,^ in 1845, which has never been repeated, for obvi- ous reasons, by any other surgeon. It deserves mention on account of its uniqueness. In a case of unilateral disloca- tion an osteotomy of the unaffected leg was done, in order to shorten it, and thus lessen the limp. Barwell ** claims to have obtained two good results by the old operation of Guerin. He performed in these cases a * Lecons Cliniques sur les Mai de I'App. Locoraoteur. Paris, 1855. t Union Medicale, 1869. J Quoted by Giraldes, Union Med., 1869. § Lect. on Orth. Surg. London, 1S76. || Lancet, 1S85, i. p. 271. UA. Mayer, Das Neue Heilverfahr. bei Fotalluxationen durch Osteotomie. Wiirzburg, 1S55. ** British Medical Journal, May 2S, 18S7. CONGENITAL DISLOCATION OF THE HIP JOINT 203 subcutaneous tenotomy, making section as close to the bone as possible. Continuous extension was then maintained for some weeks. The cases, however, were reported too soon after operation to be of any great value. Hueter * proposed an operation which, so far as the writer knows, has never been performed. It was to free and re- sect the head of the affected femur, and then, making perios- teal flaps from the neck of the femur, to sew them to perios- teal flaps made from the ilium, thinking thus to obtain an osseous union between the pelvis and the femur. The ex- treme difflculty of the technique would make the operation seem impracticable. Konigf performed a similar operation, however. He made an incision exposing the posterior part of the acetabu- lum and the neighboring part of the iliac bone. Then, incis- ing the periosteum in a curved line parallel to the border of the acetabulum, a flap of periosteum was detached from the ilium, running from this incision to the articulation, thus being attached to the bone only at the border of the cavity. It was twisted so that the articular head was completely covered by it, and a series of sutures attached it to the cap- sule. Unfortunately, the child died of scarlet fever, so that the results of the operation cannot be stated. De Paoli $ shaved down the head of the femur, and, having enlarged the acetabulum, he nailed the femur in place. The result was so bad that he abandoned the operation in favor of resection. Resection of the Head of the Femur. Resection of the head of the femur is a proceeding which is open to two objections. In the first place, a stiff joint is very likely to result; and in the second place a certain amount of shortening is necessitated by a removal of part of the epiphysis of the femur in a growing child, as well as by * Klinik der Gelenkkrankbeiten. 1S70. t Lehrbuch d. Spec. Chir., iSSg, iii. + Cent. f. Chir.j 1877, p. 336. 204 DISEASES OF THE HIP JOINT the amount of bone actually removed. Nevertheless, the operation has been largely performed, almost entirely, how- ever, by continental surgeons. It was apparently done first by Edmund Rose,* in 1874, for a unilateral dislocation ; and the result of the operation is not on record. Reyher f removed the head of the femur in two cases of congenital dislocation. He refreshed the surface of the ace- tabulum, and, replacing the neck of the femur, immobilized the articulation. In two cases operated upon, at the end of three months the patients were able to walk. Margary ^ at first attempted a proceeding similar to that of Hueter. In the hope of improving on the simple opera- tion of resection, he chiselled an acetabulum where it should have been found, and, replacing the head of the femur in it, he made a capsule of periosteum. The patient died of pyaemia after operation, which was attributable to septic cat- gut. Since that time Margary has become a warm advocate of excision of the head of the femur, which he would practise systematically as a routine treatment in dislocations of the hip. He has reported six cases, three of unilateral disloca- tion and three of double. In all the cases but one, the dif- ference in length of the limb was corrected. With regard to the ultimate results, one of the patients is said to have walked well, one walks well with two canes, one limps even with two canes, one walks badly using two canes, one is re- corded simply as limping, and the condition of one is not stated. Even before Margary presented his cases to the In- ternational Congress at Copenhagen, the operation had been performed in Germany by Heussner, Schuessler, and Luecke. In Heussner's case § a girl of twenty was operated upon, who had suffered very much in walking. The head and neck of the f-emur were excised, and the acetabulum was deepened. The result as shown by Heussner, in 1884, was that the girl * Quoted by Kronlein (Deutsche Chir.). t Cent. f. Chir., 1S84, No. 14. t Archivio di Ortopedia, Anno i., fasc. 5, 6. § Arch. f. Klin. Chir., xxx. 666, and Cent. f. Chir., 1884, No. 45. CONGENITAL DISLOCATION OF THE HIP JOINT 205 could walk for half an hour with the aid of a cane without fatigue. The dislocation was a double one, and ultimately the patient was resected upon the other side as well. Yet she was finally obliged to undergo ovariotomy, after which the pain subsided. In the case of Schuessler,* it was a unilateral disloca- tion in a girl sixteen years old. Six months after operation the femur was firmly in its new cavity, and could not be dis- placed upward. The leg could be flexed through an arc of 40 degrees, and abduction of 8 degrees could be made, while ro- tation was fairly free. The leg was 5 centimetres short, and the walk was decidedly limping. Two years and a half after operation the patient could walk without a cane, and the tro- chanter was 5 centimetres above Nelaton's line. It is only necessary to add the comment as to the success of the opera- tion that before excision the trochanter was only 6 centi- metres above Nelaton's line. In the case of Luecke, f the patient was a boy of fourteen, the subject of various malformations besides the unilateral dislocation of the hip. The ordinary operation was per- formed, and a year and a half after operation the patient could walk a couple of hours without fatigue, and a new artic- ulation was said to have been formed, which did not permit the displacement of the trochanter upward. Lampugnani, J a pupil of Margary, has reported two cases of resection of the hip. In one, an excision was performed by the Langenbeck incision, with removal of the head of the femur. The patient was four months in an extension appa- ratus, and finally had a corset applied. Seven months after operation the extremity of the femur could be displaced upward and backward. There was some limping present, and the trochanter was still 5 centimetres above Nelaton's line, originally having been only 8 centimetres. Move- * Berl. Klin. Wchsft., 1887, xxiv. 398. t Quoted by Teufel, Deutsche Zeitsch. f. Chir., xxix. 343. + Giornale della R. Accad. di Med. di Torino, fasc. 6, 7, 1S85. 206 DISEASES OF THE HIP JOINT ment at the joint is said to have been fair. In a second operation he modified the proceeding by removing the head of the femur obliquely, so that the upper half of the head would be the part to come in contact with the upper part of the acetabulum. The patient was a girl twenty years old, and the trochanter was lo centimetres above Nelaton's line. The head of the femur was removed obliquely from the point of insertion of the round ligament to the limit of the neck and the head, so that the upper half of the head re- mained in place. In an examination nine months after operation, the legs were found to be of equal length, the tro- chanter was only 5 centimetres above Nelaton's line, and the movements of the joint possible to a moderate extent, but were accompanied by creaking. Motta, * another pupil of Margary, has reported two cases of excision for congenital dislocation in children six and nine years old. After excision he treated the cases by extension in a position of abduction and outward rotation. This was maintained even after the patients were allowed to go about in an immovable plaster splint. One case was able to walk indefinitely without fatigue, and the shortening of the limb was compensated by the obliquity of the pelvis. Raffo t is reported to have resected a case with much im- provement in the walk. Battini f has resected one case of unilateral dislocation and two of double dislocation, with very bad results. De Paoli :|: has modified the simple excision by nailing the head of the femur to the pelvis by a nail driven through the trochanter into the acetabulum. A good result was obtained in a case where a shortening of three inches had existed, but an alarming amount of fever and reaction accompanied the operation. MoUiere § has reported two cases operated by the method * Archivio di Ortopedia, ii. Nos. 3, 4, and 5. t Quoted by Ho£Ea, Revue d'Orth., March, 1891, p. loi. + Cent. f. Chin, 1877, p. 336. § Quoted by Porto, Les Lux. Congen. de la Hanche, etc. Paris, 18S7. CONGENITAL DISLOCATION OF THE HIP JOINT 20/ of Margary. One, a girl twelve years old, with unilateral dis- location, was resected by the usual method, and was confined to bed only two months. After that time she began to walk, and the length of the legs was shown by measurement to be equal : the trochanter of the right side, however, was 4 cen- timetres higher than the well side. Three months later the patient was improving in her walk from day to day. In a second case, a girl fourteen years old had double congenital dislocation of the hip. Resection of the right side was done in the usual way, and in six weeks the patient is reported as walking without pain. Two months later the other hip was resected, and at the end of a month the patient walked with the aid of a cane. Some months after the last operation the patient was still progressing favorably. Postempski * reports a very good result due to resection. Ogston t has operated twice for dislocation of the hip by re- section. In one case, a young man was operated on on both sides, and the result is reported as an improvement one year after operation. The second patient was less satisfactory, and complained of weakness in the operated limb. In France, Vincent J resected a hip for congenital disloca- tion by the method of Oilier. The result at the end of two years was a fibrous anchylosis, which permitted walking with much less pain and fatigue. One finds, therefore, 27 cases of reported resection for congenital dislocation of the hip, 17 of which were unilateral and 7 bilateral, leaving 3 cases in which it was not stated. In the 7 cases of double dislocation the results were not alto- gether satisfactory. Of these 7, 3 walked badly after opera- tion in spite of the support of crutches, 4 walked passably, but required the use of a cane. Displacement of the femur during walking persisted in the 3 cases which were examined in regard to this. In unilateral dislocation the results are but little better. * Quoted by Hoffa, loc. cit. t Ogston, Ann. of Surgery, viii. p. i. + Brit. Med. Journal, 1885, 116. 208 DISEASES OF THE HIP fOINT In 1 6 cases of the 17 operated upon, one was able to walk all day without fatigue (^lotta), 2 could walk for a time not exceeding an hour and a half, 5 presented an improvement in the walk in general, 2 were obliged to use crutches, 6 limped, while i walked worse than before operation (Langen- beck, Battini). These might be classed 3 good results, 5 moderate results, and 8 bad ones. The defective walk, as Hoffa points out, is due largely to the shortening produced by resection ; and it is to be expected that in certain of these cases shortening will ultimately appear in the operated leg, as the result of the injury done to the epiphysis of the femur. It therefore seems safe to say with regard to resection of the femur as a curative measure in congenital dislocation of the hip that the results are far from satisfactory. In double dislocation the results are notably bad in many cases ; and in the best cases they are not worthy of comparison with such a case, for instance, as that reported by Dr. Brown. In unilateral dislocation the results are somewhat better ; but the details of the cases as presented by the reporters are not altogether satisfactory, and a large proportion, as has been seen, are failures, so that even in these cases the oper- ation is to be regarded as a measure of doubtful utility. Cases of Resection already alluded to. Rose, .... . I case. Raffo, . . . . I case. Reyher, .... . 2 cases. Battini, . . . . 3 cases Margary, . . . . 6 cases. De Paoli, . . . I case. Heussner, . . . I case. Postempski, . I case. Schuessler, . . . T case. Ogston, . . . 2 cases Luecke, .... I case. Vincent, . . . I case. Lampugnani, . 2 cases. MoUiere, . . . 2 cases Motta, .... . 2 cases. CONGENITAL DISLOCATION OF THE HIP JOINT 209 Hoffa s Operation. Hoffa,* who believes firmly that the obstacle to reduction consists more in contraction of the periarticular soft parts than in any bony condition, has modified the operation to combat what he believes to be the source of failure. He operates by a free incision of all the soft parts which oppose reduction, following the example of Lorenz. In cases oper- ated upon by this method he reports a practical success enough to justify his theory. The essential point is the sec- tion of the soft parts all around the great trochanter, which permits the replacement of the head in the acetabulum, which can easily be made of the proper size to receive the head of the femur. The operation is, in a word, to cut down on the joint, extirpate the capsule, enlarge the acetabulum by a heavy curette, and then reduce the dislocation by the ordinary manipulation. A tight plaster dressing is then applied to the thorax and leg. Dr. Hoffa has recently in- formed the writer that he has already operated upon several more cases successfully. He reports 7 cases operated upon by this method : Case one, double congenital dislocation in a girl two years and a half old. The operation was done by the Langenbeck incision, and at first without division of all the soft parts. It was impossible to make the head of the femur descend more than a centimetre and a half. However, when subperiosteal division was made of the muscular inser- tions into the great trochanter, it was easy to make the head of the femur descend as far as the acetabulum. The acetabu- lum was slightly enlarged and the head of the femur was re- placed, being kept there by strong extension in an abducted position; and, owing to the free division of the parts, it showed no disposition to leave its new place. A slight diffi- culty was experienced by tension of the anterior soft parts, which was corrected by a transverse incision of the fascia lata. The flap, which had been detached from the bottom of the * Revue d'Orthopedie, March, 1S91. 210 DISEASES OF THE HIP JOINT acetabulum, was turned back and attached to the head of the femur. The wound was sutured as usual and the plaster bandage applied, fixing the limb in a position of abduction. Sixteen days later the wound was healed, and the head was found in the acetabulum with free movement. The great trochanter, moreover, was on Nelaton's line, and the oper- ated leg was 3 centimetres longer than the one which had not been touched. The patient was discharged from treatment two months and a half after operation ; and, when seen five months after excision, she could walk all day without any appliance. The characteristic limp had disappeared on the operated side, and the great trochanter was still on Nelaton's line. Nine months after operation the movement in the limb was perfect, and one year after the original operation the left hip was operated upon with the same success. Three months after leaving the hospital, the child was seen walking without appliances, there Avas no lordosis, and the heads of the femora were not displaced. In short, the case may be considered, so far as it has been reported, as a com- plete success. The second case, a girl a year and a half old, with double dislocation, was operated upon as in the former case, and both hips were exposed and the heads of both femora re- placed. The two limbs were kept in a position of abduction for a month, when passive motion was begun ; and two months after operation the patient left the hospital to have massage and passive movements done at home. When seen three months after operation, the patient could stand without support and solidly, the lordosis had disappeared, and the trochanter was on Xelaton's line. A final examination, made nearly a year after operation, showed that the child could walk without a trace of limp, and she used no support. The third case was a boy, four years old, with double dis- location. The patient had been treated for a year by the method of Landerer, and the trochanter was 6 centimetres above Xelaton's line. The operation was done on the left CONGENITAL DISLOCATION OF THE HIP JOINT 211 side, and five days later on the right side. The patient died of the influenza, which was prevailing at that time, ten days after the second operation. The autopsy showed pneumonia, w hich was the cause of death. The heads of the femora were very firmly fixed in their new cavities, and a certain effort was necessary to dislocate them. The head itself had preserved the same a ppearance it presented at operation. Where the muscular insertions had been detached from the great trochanter, there were granulating surfaces. The new cavity was round, large, and deep, and admitted the first phalanx of the thumb entirely. It was covered with carti- lage, except in a place at the bottom where the round liga- ment was inserted. The muscular insertions, which had been detached from the trochanter, were attached to it en- tirely, but a little higher than their original insertion. In short, the condition at the end of ten days showed the heads of the bones in place, and progress being made toward a firm and probably useful joint. The fourth case v/as a girl, nineteen years old, with double congenital dislocation. The operation was done on the two sides at an interval of fifteen days, and four months after operation the patient could walk with two canes without a trace of limp. The heads of the bones were solidly in their places and only two months' recumbency had been necessary to obtain this result. The fifth case was a girl, two years old, with unilateral dislocation. The operation was successful, and the child left the hospital two years after operation, completely cured. She wore, however, a Taylor's splint, in order to prevent relapse. The sixth case was a girl, six years old, with unilateral dis- location. She left the hospital two months after operation, and is recorded a complete cure. The seventh case was a girl, two years and a half old, with double congenital dislocation. One side had been operated upon successfully, and the patient had been discharged at the end of a month. The other leg had not been touched. 212 DISEASES OF THE HIP JOINT It is obvious that this series of results is far superior to any set of cases which have been reported. The movements of many of them are recorded as perfect, the limp is said to have disappeared, and, so far as one can judge from the mere record, in operative cases the method should be accounted as a wholly successful one. Hoffa believes that there is no fear of a relapse if one enlarges the cavity enough, to which excavation he attaches extreme importance. Once having reduced the dislocation, he believes that there is little danger of the head of the femur leaving the acetabulum, and with the beginning of movements the head adapts itself still better to the cavity. He quotes the law of Julius Wolff, which is that, when one has re-established normal relations between the bones, after static laws, nature tends to re-estab- lish the architecture and the normal forms. The objection to the operation which Hoffa states himself is that in cer- tain cases no trace of an acetabulum can be found. This amounts to but very little, because it would be very easy to raise the flap of the periosteum at the corresponding place and to chisel an acetabulum, as Ogston has done in his case. Certainly, the operation is so simple and so well vouched for that one would be justified in trying it, especially in unilat- eral cases. The writer regrets to state that he has no personal ex- perience in the operative treatment of congenital disloca- tion, and is merely able to present the literature of the subject, with only such obvious comments as may be made from the study of the cases. It is a difficult matter to sum up the results of this discus- sion of the treatment of congenital dislocation of the hip. Mechanical measures are, as a rule, unsuccessful ; and only in exceptional cases where the patient is under perfect con- trol can they be advised, and only then when an almost un- limited time is at the disposal of the surgeon and patient, and where the patient can be under control to the end. These cases are, of course, very unusual. On the other CONGENITAL DISLOCATION OF THE HIP JOINT 213 hand, the operative treatment, as a rule, has given unsatis- factory results ; and but little can be said in favor of tenot- omy as practised by Guerin and Barwell. Resection of the hip is obviously a measure which is likely to cause a stiff joint, which must cause shortening of the limb, and which in a certain proportion of cases, as can be seen from the table given above, ends in absolute failure. With regard to the operation of Hoffa it must be said that it is still on trial. All the cases which have been reported are comparatively recent ; and in spite of the very favorable showing of these seven cases, until the conclusions of the originator have been verified by the profession at large, it can only be said that the operation should be considered as being on trial, and one of much promise. Paralytic Dislocation of the Hip. A word should be said of a class of hip dislocations which simulate congenital dislocation very closely. These are dis- locations due to an anterior poliomyelitis which has destroyed the muscular tissue and weakened the ligaments about the hip, so that a flail-like joint may result by this. These joints are readily amenable to orthopedic treatment ; but certain of these patients are not able to carry this out properly, and in these the question of operation comes forward. Karewski * has operated seven times in cases of paralytic hip dislocations with the best of results. An operation similar to that of Hoffa or even resection would seem to be indicated in these cases. Recent Literature with regard to Hip Dislocation. Krause, 2 cases of catarrhal inflammation of congenitally dislocated joints; Arch, f, Klin. Chir., 1889, xxxix. 477; * Quoted by Hoffa, loc. cit. 214 DISEASES OF THE HIP JOINT Motta, Arch, di Ortop., Milan, 1889, vi. 304 ; Adams, Br. 'M. J., London, 1890, i. 406; Clark, Glas. Med. J., 1890, xxxiii. 102; Verneuil, Rev. d'Orth., Paris, 1890, i. 23 ; Dubreuil, Rev. d'Orth., Paris, 1890, i. 185; Hoffa, Wien. Med. Wchsft, 1890, xl. 926; Poggi, Arch, di Ortop., 1890, vii. 105; Rosenfeld, Mtinch. Med. Wchsft, 1S90, 37, 415, etc.; Paci, Arch, di Ortop., 1890, vii. 151. The rest of the bibliography has practically been given as references in the course of the section. HYSTERICAL AFFECTIONS OF THE HIP JOINT 21$ Chapter XIII. HYSTERICAL AFFECTIONS OF THE HIP JOINT. Pathology. The appearances are entirely negative except for pallor and atrophy of the muscles of the diseased leg, occasioned by disuse. Etiology. The designation of the diseases of this class as hysterical is more or less unfortunate, and the word neuromisis, or functional affection, is perhaps to be preferred. The dis- order is not to be regarded as imaginary, but is due to a disordered nervous and circulatory condition, the charac- ter of which is obscure, and the evidences of which are not revealed by microscopic examination. The term func- tional merely means that there are no evidences of organic disease, and the affection is one of such practical impor- tance that its etiology and treatment deserve consideration. Brodie makes the assertion, which Esmarch indorses, " 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 disease of the joints, labor under hysteria, and nothing else." Skey added that this includes a large proportion of the lower classes, and further : " In reference to spinal affections in young persons, I unhesitatingly assert that the real disease is not found in a greater proportion than one case in twenty," In these statements Shaffer agrees, believing neuromimetic joints are exceedingly frequent both in the upper and lower classes, especially at that age when hysteria is most likely to 2l6 DISEASES OF THE HIP JOINT develop. The cause of the manifestations of these symp- toms is obscure. The symptoms, as it is known, simulate very closely those of the real disease, even in persons igno- rant of the symptoms of hip disease. The patients are for the most part young girls or women who are not robust, as a rule. Occasionally, it occurs in connection with overgrowth, and not uncommonly at the age of puberty. In older women it is likely to be associated with ovarian tenderness or uterine disorders. It is not always confined to persons of an excitable, emotional tem- perament, but it is sometimes seen in persons who might be considered otherwise phlegmatic. It is rarely, however, that it is found \vithout some other symptoms of the condition known as neurasthenia. Most often there is associated with it a nervous condition, with either backache, tingling of the hands and feet, tenderness over the abdomen, or some other sensory disturbance. It must not be overlooked that, although, for the most part, these affections are seen in young women at or shortly after puberty and in w^omen at the time of menopause, they occasionally occur in young children and in young men. Such cases are not common, but they occur frequently enough to deserve mention. Perhaps the most constant accompaniment of the condi- tion is a state of disability and ill health, perhaps marked, perhaps only slight. Hysterical disease is associated in a large proportion of instances with a fall or sprain. In these cases, it seems as if an acute synovitis had occurred, which had been the occa- sion of real pain, and that on account of some circulatory disturbance the sensation had persisted after the cause for it had disappeared. It is not always the case by any means that these cases are traumatic, but a large proportion of them show this clearly. In other cases, which constitute a still more difficult class, the hysterical symptoms are asso- ciated with a certain amount of real disease ; that is to say, a HYSTERICAL AFFECTIONS OF THE HIP JOINT 21 7 slight ostitis of the hip is exaggerated by the patient into a condition of excessive sensitiveness, so that it resembles the severest hip disease that one would see. In these cases, the affection is more functional than real, and ostitis is to be accounted as one of the causes of functional hip disease. The place of errors of refraction of the eye in the causa- tion of hysterical joint manifestations ought not to be over- looked. In a certain proportion of cases where functional affections of the spine or hip exist, a myopia or an astigma- tism may be found to exist, which, if corrected by proper glasses, will aid much in the treatment of the local trouble. In a certain proportion of cases, however, it seems impos- sible to assign any reasonable cause for the hysterical joint affection, and patients may be in what appears to be good health. There is no history of accident, and they may be no more emotional and excitable than the average woman ; but the hip disease may nevertheless have occurred, and these cases are set down in the unsatisfactory classification of idiopathic. In short, apart from traumatism, there is little to be said about the etiology of hysterical hip disease which is different from the etiology of the hysterical manifestations in general, as they affect the same class of people and are subject to most of the same conditions. Treatment. It is exceedingly difficult to lay down any routine treat- ment for an affection which manifests itself in so many ways as does hysterical hip disease. The general treatment forms an important part, perhaps the most important part in the whole. The general condition is almost always below what it should be, and the morale is almost invariably at fault. The remedy of these two conditions requires all the sur- geon's skill, and often for its conduct a knowledge of human nature. 21 8 DISEASES OF THE HIP JOINT In regard to the general condition, a good plan of treat- ment is, as a rule, that of Weir Mitchell. It consists in the free nourishment of these patients. Even where confine- ment to bed and isolation are not necessary, additional meals and overfeeding with easily digested substances are of the greatest possible benefit. These rank in their usefulness much higher than the use of any medicine ; and the use of drugs, as a rule, should be limited to tonics, and temporarily to the use of nervous sedatives, such as bromide of potash. With regard to the diseased morale of the patient, it must be remembered that the fault lies in a concentration of the attention and of the imagination upon the affected joint. In directing this part of the treatment, it is absolutely essential that the surgeon should be sure of his diagnosis. Tempo- rizing has no place in the treatment, and the treatment that would be proper for hip disease is wrong for hysterical dis- ease ; and no middle course of treatment can be adopted which will cover both conditions. Consequently, the treatment must be based absolutely on the diagnosis, of which the surgeon inust be sure. Having assured himself that there is no organic trouble in the hip, the problem is one of diverting the patient's attention from the sensations experienced in the hip. This may be done in one of two ways : by a sudden mental impression, such as is made by charlatans and faith-healers, it is often possible to divert the attention, for instance, by a sudden command to walk, that the patient finds herself accomplishing movements which she had for a long time supposed herself unable to make. It is in these cases the absorption of the sensation in a stronger emotion ; but such treatment is not, as a rule, applicable in legitimate medical practice, and an attempt to carry out this treatment and its failure would be obviously disastrous to the future conduct of the case. With regard to the second and more usual method of treatment : this may be said to consist in a gradual educa- tion of the patient into better methods of thinking, by di- HYSTERICAL AFFECTIONS OF THE HIP JOINT 2I9 verting the attention from tlie diseased structure, and by gradually conducting tlie patient to use the affected limb without regard to the pain experienced. It is obvious for this reason, as has been said, that the diagnosis must be one which can be relied upon. In these cases, it is generally ad- visable to put the patient to bed at first, with perhaps trac- tion made in the line of deformity. Then either with or without the use of apparatus, as would seem best, the patient is encouraged to walk, perhaps one step ; on the next day perhaps two steps may be accomplished, and by gradual careful increase of the exercise the patient is led into the use of the affected limb, without always perceiving the prog- ress which is being made at every step in the treatment. The surgeon's own personal attention is almost an essen- tial to the rapid and successful treatment of these cases. The problem is, as has been stated, simply to educate the patient unconsciously into the use of the affected limb; and, when this has been accomplished, the pain is less complained of, and with the normal use of the hip the circulatory condi- tions are improved and the local trouble is diminished, so that the patient ceases to complain of pain, and the normal function seems once more established. Pain must be disre- garded as a significant symptom. It is not possible to lay down the use of any one apparatus for these cases. In some cases, a traction splint or a protec- tion splint may be indicated. In other cases, nothing more than crutches may be necessary. In other cases, plasters and electricity may be applied, whichever will appeal more to the imagination of the patient. One grand aim of the treatment is to impress upon the patient's mind the fact that the therapeutic measures em- ployed are those which are best suited to her individual case, and, as a rule, to use those which will make the strong. est mental impression. In other cases, mechanical, passive and active exercises by Zander's system may be of use. 220 DISEASES OF THE HIP JOINT Gymnasium exercises of a simpler character for the af- fected limb are also useful when the function has been par- tially restored, on account of the muscular atrophy which has accompanied the disease of the limb, which gives rise to a feeling of weakness. Massage often is of much use. In short, the treatment must be modified to suit each case, following in general the lines laid down in the earlier part of this section. One word should be said as to the absolute necessity of the surgeon's having complete control of the patient. Home influences are often much to be blamed as the cause of the affection ; and often isolation of the patient is necessary as a therapeutic measure, to cut her off from the ill-judged sym- pathy of friends and relatives. ''ly^d^'-^^ ■^:fe; ^;v?"i5:^ ;'i^ The etioloQv, Pathoioay, and treatment o 2002279460 ^-^k^: