various kinds, my preference is largely in lavor of simple asjiiration. I
make this statement, notwithstanding the increasing testimony in favor
of injections of various agents, because at the hospital I have analyzed
from time to time a series of cases treated after the various methods,
and the best results, I am sure, are attained by simple aspiration. This
plan of treatment has become so popular with me that 1 make it a rule
to subject all abscesses to aspiration.
AVhen the sac is tilled with extensive sloughs of cellular tissue, which
sloughs plug up the needle at every insertion, I resort to incision, pro-
vided the location of the abscess is flivorable for incision. I am nf.t
quite sure Init that a small incision in a large mnnber of cases, with
pretty free irrigation of tiie sac and an antiseptic dressing, is better than
the free incision. It is certainly better than the free incision unless the
latter is attended with a thorough dissection of the walls of the sac.
Where one is prc]iared to carry out all the details of thorough dissection
of the sjic I would advocate this plan for the class of cases which may
be described as tbllows : an aliscess that has existed for a long time, say
.several months, that has made little or no increase in size, and that con-
tains pus either too thick for an ordinary needle or contains a cheesy
mass ; a very large abscess which has burrowed extensively and en-
croaches upon important structures, such as the blood-vessels, or that
interferes with the pni])er application of tiie si)lint ; an abscess which is
attended with a daily rise of temperature and tiiat is interfering with
the nutrition of the ciiild. Sucli abscesses as I have just described are
suitable, in my judgment, for the treatment proposed. It is very easy
to dissect an abscess, to sew up the wound, and to get primary union,
but if one fails to follow up the track and remove the bone, the chances
are that at least 50 per cent, will recur and that subsequent openings
will have to be made. ^\'hile I have no figures bearing on this subject,
my hospital experience enables me to make tliis statement thus approx-
imately. Did space permit, I am sure I could report a number of cases
which go to bear me out in this opinion.
The treatment of sinuses is a most perplexing one, and I am free to
say that, at present, I have no specific to commend. The various agents
for closing a sinus are all commendable, yet time and again I have
regretted closing a sinus, for the reason tliat tiie pus must find exit, and
there is no better wav for tiie pus to esca])e than through one or two of
these old sinuses. After the discharge become insignificant, then the
curetting of tlie sinus may be adopted, this curetting to be followed by
thorough flushing, and the injection of peroxide of hydrogen or creasote
or iodoform and oil.
The removal of foci of disease in the lione is certainly to be com-
mended in nianv eases. If one can be s;itisfied that the focus can be
342 ORTHOPAEDIC SURGERY.
reached witliout too free gouging of the joint itself, then one's duty
is clear. The trouble, however, is that there are many foci, and the
removal of one does not relieve the others. On the contrary, it is well
estahlisiied that an incomplete operation serves sometimes to disseminate
the l)aeilli and to rather aggravate the original disease. The plan of
drilling the neck through the trochanter major promised brilliant results
a few years ago, but experience has shown that the disease is not always
confined to the neck, or even the cpipiiysis, and for this reason the
operation has not been so extensively resorted to within the last few
years.
The operation of arthrotomy or partial arthei>tomy is more especially
applicable to the knee, and has never gained many adherents where the
hi]) is concerned. The simple removal of the synovial sac and the soft
structures, even the cartilage lining the acetabulum and covering the
head, does not reach tiie seat of disease, and when one goes thus far it is
regarded as the jiart of prudence to remove the head of the Iwne.
Excision of the hip is an operation that is called for in a certain
proportion of cases. A very thorough study of the subject has not
inclined me to early excision, but the cases for this are those which
have failed to improve under the protection splint, under good hygienic
surroundings, and which seem to go from bad to worse. Statistics
bearing upon the subject are of little value, for the reason that most
men make a selection of their cases and final results are ditticult to obtain.
The brilliant work of two London surgeons a few years ago led us to
believe that a thorough aseptic excision, with complete removal of all
diseased structures, could be done, and that primary union would result.
Subsec[uent teachings and subsequent observation of the eases operated
upon in this way lead us now to believe that the ideal method has not
been attained. If one excises early, he is bound to get a large number
of good results. If he excises late and as a dernier ressort, he is bound
to get a large number of failures ; but, after all, the failures can scarcely
be regarded as failures, because these cases were necessarily doomed and
the excision was a life-saving method. It is a fact well established that
hospital and dispens;iry eases demand excision much more frequently
than tiiose in private practice. The former class usually occur in chil-
dren of shiftless parents — parents who are poorly trained in the sense of
co-operation, and who have never learned to set any correct value upon
the sj)lint treatment ; while in private practice the surgeon, as a rule, has
intelligent co-operation. He has more time to instruct the families,
and in addition to this the parents themselves enjoy better hygienic
surroundings.
The question of what incision is the best for an excision is largely a
personal one, and must always depend upon the individual judgment of
the surgeon. Where the bulk of the suppuration is in the gluteal region
or posterior aspect of the thigh either the incision of Sayre or the straight
incision j)osteriorly is recommended. Adhere the bulk of the suppura-
tion is in front, however, the anterior incision is 1)V all means preferable.
I have lone; since abandoned the saw, and the chisel and souge are used
exclusively in excision of the hip. With curved scissors and forceps as
supplemental instruments all the diseased tissues can be easily removed.
For the reason that a focus is usually found in the trochanter, it is best
IIIXOR DISEASES OF THE HIP. 343
to remove this portion of the bone as well as the neck. Furthermore,
better drainage is afforded, and the ultimate function of the joint is not
impaired by removal of the troelianter. Where one is satisfied that all
the diseased bone has not been removed, the larger part of the wound
should be left open and further drainage established. Tlie limb may be put
up in a wire cuirass or on an ordinary Thomas hip-splint with traction by
weight and pulley. On account of the ease with which I can employ
plaster of Paris, I dress most of my cases with a firm plastei'-of-Paris
bandage, applied from the free ribs to the ball of the foot, making a snug
fit just above the condyles and above the malleoli. A fenestrum is cut
in the plaster, and through this the wound can be dressed as often as is
necessary.
It does not follow because a hip is excised that the treatment has been
exhausted. If, for instance, the treatment should seem to fail of good
result and the suppuration should ]iersist, it is the surgeon's duty to
follow tiie operation uji with further procedures, draining pockets where
found, freshening up old sinuses, removing any bits of bone that maybe
retained by the healing process. In other words, the case should be con-
ducted to a successful issue if this is possible. The results are very
gratifying in properly-selected cases. Even in cases that are operated
on as a dernier ressort brilliant results follow.
It is tile practice of many surgeons to omit apjiaratus as soon as tlie
sinuses are healed or even long before this jieriod, yet I am forced to
believe it unwise, for the reason that deformity is apt to recur many
months after the closure of all sinuses. Flail joints are sometimes
reported after the operation, but I am convinced that they are rare.
Such a result can only follow a very extensive removal of the shaft of
the bone. Removal of the shaft is sometimes required where thei'e is an
extensive osteomyelitis. The pro])riety of thorough cui'etting of the
medullary canal is questionable. A bone that is so thoroughly diseased
as to require this procedure would be better treated, in my judgment, by
a complete removal of the member, although from the reports of Dr.
Cliarles T. Poore of this city good results have followed curetting. In
my own ex])erience I have had no such results. Destruction of the
acetabulum, iliac abscesses, extensive disease of the ilium, are not con-
traindications to the operation, because all disease can be removed and
good drainage can be established.
Amputation of a hip is called for when the entire shaft of the femur
is diseased, where a thorough excision has not only failed, but is fol-
lowed by amyloid changes in the liver and kidney, and where all dis-
eased processes cannot be removed in any other way. The projiortion,
of course, of cases for amputation is small, but yet indications do arise
for this extreme measure, and the life of a child should not be abandoned
when there is a possibility of saving it by amputation.
Minor Diseases of the Hip, including Congenital Dislocation.
Under this heading may be included periarthritis, periostitis of the
shaft near the hip, synovitis, bursitis, neurosis.
A periarthritis is usually phlegmonous in character, proceeds rapidly
to deformity of the joint, produces eoustiiutioual disturbance which is
344 ORTHOPAEDIC SURGERY.
entirely tlifferent from that pHxliiced l>y dironic o.<titis of the hip, and
runs a comparatively short course. The diagnosis can be made with
comparative ease, generally by exclusion, and the treatment should be
rest in bed and hot fomentations ; these failing, there should be free
incision. The abscess is always an acute one and demands the ordinary
surgical pn icedures.
Periostitis is a little more difficult of recognition, is essentially clironic,
and a diagnosis may be reached by exclusion. Palpation is an important
method of examining. The existence of localized tenderness and swell-
ing about the bone itself, with the history of an injury, goes to make up
the essential features in the diagnosis. The treatment is jirotection to the
joint — for the reason tiiat the Jiead and neck may become involved by
contiguity — lilisters to the parts or some other form of counter-irritation.
Really the best method, however, is a free incision down to the bone,
with an opportunity of the parts to heal from the bottom.
Synovitis of the hip is very rare, but is occasionally met witli. It
occin-s in children from ten to fifteen years of age. It is acute, invasion
is sudden, and the entire course does not extend over a jieriod of ten
weeks. The joint-tenderness is very marked. The patient after the first
twenty-four hours is unable to walk. The flexion of the limb comes on
early, within the first few days ; the entire limb is held with a great
amoniit of care. The diagnosis is reached by exclusion. There is a cer-
tain degree of tension in the gluteal region. The distention of the joint
can lie made out by close manual examination. There is absence of the
ordinary signs tliat accompany a eiironic disease. The treatment is rest
in bed. The limb should be maintained in that jjosition which is the
most comfortable. Fomentations may be ajjplied, or fly blisters. Aspi-
ration or piuicture of the joint is not called for, for the reason that there
is nothing to gain specially by rapid removal of the fluid. It is absorbed
witliin two or three weeks, and the recovery is perfect.
Bursitis is met with occasionally in the bursa in the gluteal region,
about as frequently in the bursa on the outer side of the hip under the
vastus externus. Such eases occur usually either after twelve years of
age or in early adult life. They date from an old strain or injury of
some kind. There is very little atrophy of the limb. There are long
periods of remission without any signs worth considering, no very acute
symptoms even during exacerbations — simply a little lameness, disability,
dread on the part of the parent and family that serious mischief will
follow. A careful examination of the parts, with a clear insight into the
history, will enable one usually to recognize these inflamed bnrste, and
treatment Mill depend a good deal u])on the sc\-erity of the case. The
mechanical ap])liance which has proved servicealtle in my own hands is
a simple straight sjilint attached to a jielvic band, with or without motion
at the joint — without motion at first, later with motion, giving simply a
hinge-jointed movement. This splint must extend down to the shoe,
with a free joint at the knee and a free joint at the ankle. It can be
secured to the liml) by thigli- and calf-ljands and by a perineal strap to
the pelvic band. This splint ])revents rotation of the limb, and in this
way affords rest to the parts under the vastus externus. It is applicable,
therefore, for inflanmiation of this bursa. In a number of instances I
have aspirated the bursa and made compression, only to get temporary
3nX0R DISEASES OF THE HIP. 345
relief. In one instance I dissected out tlie hnrsa, M'itli suljsequent nse
of an apparatus, and finally pit a good result.
Xeuroses of the iiip are so intimately associated with the hysterical
element that hard-and-fast lines of treatment cannot be laid down.
They are interesting simply from a diagnostic point of view. The diag-
noses are usually easy, because of the age at which the deformity occurs
and of the general neurotic condition of the patient. The deformity is
usually that of flexion and adduction. Tiie lameness is very marked at
times. There is a good deal of hypenostliesia along the course of the
anterior crural or sciatic nerves. There is spinal tenderness, as a rule ;
absence of joint-tenderness, though sometimes tliis may be present ;
absence of atrophy of the limb. In hysterical subjects, therefore, the
treatment should be adapted to the hysterical condition, yet it is true
that counter-irritation of the spine ami in the course of the distribution
of nerves does Ijring about sometimes brilliant results. In the neuroses
which depend upon exposure to cold in children past the tenth or twelfth
year there is nothing quite so good as a fly blister to the lumbar spine.
This should be ap]ilied at night, should lie two inches in width by six
inches in length, siiould be left on all night. The blistered surfaces
should be dressed for three days every six hours with hot flaxseed poul-
tices. I am thus dogmatic on this question, because I have seen many
brilliant results follow this line of treatment. In fact, it is the excep-
tion that a good result has not followed.
Congenital Dislocation of the Hip.
This is a deformity for which very little has l)een done in the way of
mechanical appliances. It is true there are a few cases on record wherein
long persistence in the use of traction and reposition of the limb has
resulted in what seems to be a prominent reduction of the deformity.
The very nature of it would seem to be an insu})erable obstacle to a cure
by mechanical devices. We have not only an ill-shapen head of the
femur, l)ut usually the neck is distorted as well. A portion of the
acetabulum is wanting. Nature has failed to make a proper recejitacle
for the head. During the early years of life use of the limb favors
shortening of important muscles about the hip. The capsular ligament
is altered in shape and in structure, so that, however well we may suc-
ceed in pulling the limb down into |)osition, there is nothing that will
hold it in place so well as a good rim to tiie acctal)ulum.
It is uiniecessary to go into furtlier detail about the etiology and
pathology of congenital dislocations of the hip, because all the text-
books on surgery and all tlie treatises have dealt so fully with the sub-
ject. I have for a long time entertained the opinion that a long traction
splint, with a rigid jielvic liand, under the daily observation of a well-
trained nurse for a j)eriod of from two to tiiree or four years, Mill result
in a small proportion of cures. I have effected one such myself, but the
time that has elapsed since the removal of all apparatus is not yet suf-
ficiently long to enable me to predict the end-result.
We come, therefore, to the operation which has found such able ex-
ponents in Dr. Albert Hoffa of M'urzburg and Dr. Lorenz of Vienna.
Their operations differ really very little in essential features. Hoffa's
346 ORTHOPAEDIC SURGERY.
opei'ation is a posterior incision, straifilit one ; Loreiiz's is an anterior.
Both aim to g'et to the joint and expose the acetal)uhim with a minimum
amount of difficnhy. The structures to be divided are about tiie same.
Bradford of Boston lias made a sujiii'estion — and, indeed, lias acted upon
this suggestion — which is certainly a very important snp])lement to the
operation of Lorenz. He has foiunl that division of the Y-ligament
enables him to bring the head of the bone down into normal position
without such extensive division of the muscles attached to the shaft.
The cardinal point is to make a sufficiently deep acetabulum, and one
in which the head of the bone will lie easily without traction. Trac-
tion, of course, is to be employe<l in the subse([uent treatment. The
wounds shouhl heal ])rom])tly, and the cicatrix that results will assist in
maintaining the head of the bone in position. From a limited experi-
ence in the operation I am convinced that it requires a great deal of dex-
terity, and that a large number of o]ierations must be ]ierformed before
one can feel justified in making a good |)r(ignosis. It is a tedious ope-
ration, an enormous amount of violence is done to the tissues, and the
shock is necessarily great. The results, so fiir as I have been able to
observe them, are not brilliant and are rather discouraging. I make
this statement from my own experience. Both Lorenz and Hoffa speak
very enthusiastically of the operation, and record wliat seem to be
excellent I'esults. The procedure, therefore, is at ])resent sub judice,
and it is unwise to make any extravagant stat^'inents until more final
results can be obtained. Among some cases of my own, recently pub-
lished, I procured photographs of a case before and after operation.
The deformity in this case was overcome ; the limb was held in good
position up to the time of the patient's discharge, which was six or eight
months after all wounds had healed.
As a rule, young children, under the age of three years, are better
cases upon which to operate. After the ninth or tenth year has been
reached it is difficult to obtain a good result.
The deformity itself is not a hideous one where both hips are involved.
The gait is sometimes rather graceful. I am convinced that it can be
improved upon by a certain amount of attention and education. Where
one side is involved a high shoe can make up the diiference and a very
easy gait can be attained. It is true, we have the limp, yet the little
patient can ^\-alk long distances and can indulge in all the plays that
other children enjoy. It is the exception for any painful conditions to
follow in after years. Such an exception I have recently had under
observation, but relief was afforded by a snug abdominal l)andage, which
made very good pressure over the hip. Spinal braces accomjianied by
j^erineal straps really do very little, but these are recommended b}' some
authorities, and in obstinate cases, where the operation is not to be con-
sidei'ed, are advisable.
Tubercular Ostitis of the Knee.
The most frequent and most important disease which affects the knee-
joint is the one which heads this section. The synonyms are — White
swelling (tumor albus). Strumous arthritis. Scrofulous knee, Fungous
arthritis, Articular ostitis, and Tubercular ostitis. Iteallj', the best term
Tl'BERCVLAE OSTITIS OF THE KNEE. 347
for popular use is white swelling. Follnwinii' the plan already set forth,
the term tuljereular ostitis tixes the patholduv upon one's mind and
carries with it a pretty intimate knowledge of the nature of the disease.
The etiology and jtathology have already been discussed.
Clinical History. — The disease belongs essentially to childhood, and
the ages between which it is most common are two and ten. The first
.symptoms noted are pain on handling the limb and on using it in walk-
ing, and the signs are extra heat over the knee, with slight reflex spasm
when flexion approaches the limit. It is usually the frail member of the
family that is affected. The first inijiression is that an injury has been
sustained, and it is easy to get a history of a trauma as the clause ; yet, as
in the other joints discussed, trauma is found on cross-examination to
play a very unimportant part in tlic etiologv.
The chiUl favors the limb in walking a little — complains of a little
stiflness. A sprain or twinge of rheumatism or the beginning of a bad
habit is diagnosticated liy the family. The exacerbation, like that where
other joints are involved, may be very slight and may extend over a few
days or a week. Then a remission occurs, which is regarded by the
parents as complete. Surgical or medical services are not usually sought
in these milder cases until the second or third exacerbation appears. The
limb during this first remission appears to be normal, but if one were
called upon to make an examination it would be found that the function
was not quite as good on the afl'ecteil side as on the sound side. The
contour of the joint, it is true, would show very little change, but to a
critical eye the depression on either side of the tt'udon of the (juadriceps
would be less pronounced than in the normal condition. The ligamentum
patella would appear a little broadened. In the midst of the exacerba-
tion there often is a moderate distention of the synovial sac, and the case
looks at this period very much like one of acute synovitis, but the history
of the former exacerbation and of a remission would enable one to rule
out acute primary synovitis. Yet it is true that this diagnosis is more
frequently made than any other. If the ])atient be subjected to treat-
ment during this second or third exacerbation, while the signs are not
very pronounced, rest in bed will relieve to a certain extent, and a re-
mission less pronounced than the former ones may follow. The epiphyses
gradually become enlarged, the function of the joint is impaired, and the
first stage, which is the stage preceding deformity, merges gradually into
the second, that of deformity.
Deformity is characterized l)y slight flexion and marked change in con-
tour of the limb; that is, increase in size with oblitei'atidu of the normal
depressions. The lameness now persists, and is so uniform in character
that a knee-limp is easily recognized, the limp characterized by a short
step, a disposition to walk on the too and ball of the foot, to lean to that
side and favor the limb.
Atrophy is an early sign, and ])ersists thrdugliout the entire course of
the disease. Exacerbations are induced by tratuiia, and deformity, such
as subluxation or luxation, is the natural result of the use of the limb,
aggravated by the reflex spasm of the flexors. There are various grades,
dependent more or less upon the number of foci. A focus may exist in
the head of the tibia, and very little deformity will result. It may be
confined to the lower epiphysis of the femur, in which event deformity
348 ORTHOPEDIC SURGEItY.
is more apt to follow. It is possible for the disease to extend over a
period of years and still produee very little deformity ; yet the rule is
to have a peculiarly shaped limb, such as has been described, and which
is so well shown in most of the text-books and brochin-es on tliis
subject. The tliird stao-c is marked by luxation or suliluxation, by a
bulbous appearance of the lower end of the femur, eniarj;ed veins, and
abscess which may have opened spontaneously or been incised, leaving
sinuses. Where resolution takes place only the deformity will remain,
but where the disease progresses from bad to worse there will be exten-