PRACTICAL OBSERVATIONS 
ON THE 
NATURE AND TREATMENT 
OF 
TUBERCULOSIS OF THE HIP-JOINT. 
BY 
S. D. GROSS, M.D., 
PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. 
[Republished from the North American Medico-Chirurgical Review for July, 1858.] 
PHILADELPHIA; 
J. B. LIPPINCOTT AND CO. 
1858. PRACTICAL OBSERVATIONS 
ON THE 
NATURE AND TREATMENT 
OF 
TUBERCULOSIS OF THE HIP-JOINT. 
Erom the earliest ages of medicine, hip-joint disease has been an object 
of the deepest interest with the practitioner. Its literature, scattered 
through an immense number of monographs, cyclopaedias, and periodicals, 
is exceedingly rich, and fully attests the truth of this remark; and yet, 
notwithstanding this, it is lamentable to think how imperfectly it is still 
understood by the mass of the profession; how little is known about its 
nature and etiology; and how much remains to be done to place it upon 
a proper scientific basis. 
The term coxalgia, by which this disease is usually described, should be 
discarded from surgical nomenclature, as wholly inexpressive of its true 
character. Literally signifying pain, or neuralgia suffering, it is neither 
denotive of its pathology, nor, indeed, even always of its seat; for, as will 
hereafter be seen, the pain is nearly as often situated in other parts as in 
the hip-joint itself. The words hip-disease, hip-joint disease, and coxar- 
throcace are not less indefinite, and should therefore be equally proscribed. 
The only appropriate name is strumous, tubercular, or scrofulous, the im- 
port of which is well understood, and which could not possibly more clearly 
and satisfactorily express the true nature of the complaint. I make these 
remarks because the nomenclature of a disease is frequently of great im- 
portance in regard to the proper appreciation of its pathology. 
Strumous disease of the hip-joint occurs at different periods of life; but 
the age at which it usually shows itself is early childhood. As far as 
my experience goes, and I do not hesitate to say that it is very large, I 
am satisfied that it is by far most common from the third to the eleventh 4 
Tuberculosis oe the Hip-Joint. 
year. Cases of it are occasionally witnessed as early as the eighteenth 
month, and a good many just before the time of puberty. After the twen- 
tieth year the malady is uncommon; and, if an instance is sometimes met 
with in middle life, it is to be regarded as an exception to what must be 
considered as the great law which presides over the development of this 
form of strumous disease. Tuberculosis of the lungs is most common 
between the ages of twenty and forty; of the lymphatic ganglions, the 
spleen, eye, and arachnoid membrane, between the ages of three and ten. 
Every organ in which the malady occurs has, it may be presumed, its pecu- 
liar laws of evolution, growth, maturation, and disintegration of the deposit 
from which the affection derives its distinctive features. That this is true 
of the hip-joint, as it is of other parts of the body, all experience attests. 
I recollect only one case of tuberculosis of this articulation after the thir- 
tieth year. 
The malady is met with in both sexes, but in what proportion has not 
been determined, as no statistics, illustrative of the subject, have been pub- 
lished. My observation has furnished me with a much larger number of 
cases in the male than the female; but this may have been a mere coinci- 
dence, and the question, after all, is one of no practical value, whatever 
may be the fact with reference to it. 
Tuberculosis of the hip-joint is occasionally observed in several members 
of the same family. The instances of this, however, are rare, and I have 
not seen more than three in my own practice and in that of my medical 
friends. If it is ever congenital I have not witnessed an example of it; 
nor have I ever known it to be hereditary, although many of my cases 
have occurred in the offspring of strumous parents, or in families in which 
tuberculosis had manifested itself in some form or other. In this respect 
it bears, as will appear by and by, the same relation to the structures of 
the hip-joint that phthisis bears to those of the lungs. 
I.—Etiology. 
The exciting causes of this affection have been a prolific source of specu- 
lation, of dispute, and even of angry discussion; and, still, the most that 
can, with truth, be said of them is, that they are, in general, exceedingly 
obscure. In the great majority of cases, it arises spontaneously, defying 
all conjecture in respect to its origin. The surgeon, it is true, is often told 
that the little patient received a fall, blow, or kick upon the affected parts, 
or that the joint was sprained, bruised, or twisted, several months, perhaps, 
before the appearance of the characteristic symptoms; but my experience 
is that such information is usually little reliable, or that, if the occurrence 
did take place as stated, it excited but little if any influence in developing Tuberculosis of the Hip-Joint. 
5 
the malady. Unless very severe, such accidents would no more occasion 
tuberculosis of the hip-joint than a similar injury of the chest would pro- 
duce tuberculosis of the lungs, or of the head tuberculosis of the arachnoid 
membrane. The possibility of such an occurrence cannot, of couz’se, be 
denied, but it may be safely affirmed that it is infrequent, and therefore 
exceptional. 
Exposure to cold, intense or protracted, is usually enumerated as another 
exciting cause of the malady, and generally with a better show of reason. 
That it may, in such an event, conduce to this result, especially in a child 
of feeble constitution, ill-fed, and with an impoverished state of the blood, 
hardly admits of doubt. It is well known that cold is one of the most 
common and powerful causes of pulmonary consumption and of strumous 
disease of the neck. Living in damp, under-ground, and ill-ventilated 
apartments operates in the same manner. Simple suppression of the 
cutaneous perspiration, suddenly induced, as when a person is exposed 
to a heavy current of air, might, it may be presumed, easily occasion the 
affection in one predisposed to its occurrence. 
The use of unwholesome food, derangement of the digestive organs, 
imperfect assimilation, or inadequate nutrition, however induced, are also 
among the causes of this disease, as they are among the causes of tuber- 
culosis in general. Protracted courses of mercury, establishing a severe 
drain upon the system, followed by the abstraction of the plastic elements 
of the blood, may lead to similar results. The same is true, though the 
circumstance does not always readily admit of proof, of the exhaustion 
consequent upon copious and protracted hemorrhages, infantile cholera, 
chronic diarrhoea, scarlatina, measles, smallpox, and of typhoid, intermit- 
tent, and other fevers; in short, of everything that has a tendency to en- 
feeble the system and degrade the blood. 
It has been asserted by writers on coxalgia that rheumatism is a com- 
mon cause of this disease, but I have never seen an instance corroborative 
of the truth of the statement. The fact is, it is not at all probable that 
that affection ever exerts such an influence; for, in the first place, it is well 
known that tuberculosis is exceedingly rare in rheumatic subjects, and, in 
the second, that, when disease of the hip-joint shows itself in persons of 
this description, it is very different from the strumous disorder under con- 
sideration. 
Persons of fair complexion, light hair and eyes, a delicate skin, and a 
languid circulation, with a tendency to eruptions of the scalp and enlarge- 
ment of the lymphatic ganglions, are most prone to tuberculosis of the 
hip-joint. In many cases the strumous diathesis exists in a most marked 
degree, the tumid lip and belly, the long eyelashes, the cold extremities, 
the flattened shape of the fingers, and the disordered condition of the 6 
Tuberculosis oe the Hip-Joint. 
digestive apparatus, affording unmistakable evidence of its presence. The 
intellectual faculties vary in this as in other forms of strumous disease. 
Occasionally the little patient is dull and obtuse, with little disposition to 
exertion; but for the most part he is remarkably precocious and active, both 
in mind and body, inclined to exercise and amusement even long after the 
malady has been fully established. No one who has frequently met with 
this affection can have failed to notice the different temperaments of those 
who are most liable to suffer from it. These are the sanguine and the 
lymphatic, or a combination of these. In the former the characteristics 
are, a rosy state of the countenance, a well-developed muscular system, 
with a tendency frequently to a certain degree of embonpoint, an active 
circulation of the skin, warmth of the extremities, and an active state of 
the intellect. Opposed to this, in every particular, is the lymphatic tem- 
perament. The face is pale, often swollen and pasty, the muscles are soft 
and flabby, the feet are cold, the cutaneous circulation is feeble, the mind is 
sluggish, and the pupil is dilated. In both, particularly in the latter, the 
belly and upper lip are often remarkably tumid, and most expressive of 
the tubercular diathesis. These two varieties of temperament, with their 
various modifications, deserve careful consideration, as they form the basis 
of important therapeutic indications. 
It is rare that both hip-joints are involved in this affection, either simul- 
taneously or consecutively. Ido not now recollect an instance of the kind 
within the sphere of my observation. During its progress it becomes occa- 
sionally complicated with tuberculosis of the spine, as Pott’s disease and 
psoas abscess, ophthalmitis, mesenteric disease, strumous enlargement of 
the lymphatic ganglions of the neck, and pulmonary phthisis. It is not 
impossible that some of these affections may occasionally precede the 
malady of the joint; but, however this may be, they rarely fail, when pre- 
sent, to aggravate it, and to hasten the fatal issue. In proof of the truth 
of this fact several cases will hereafter be cited from my own practice. 
11.—Symptomatology. 
Tuberculosis of the hip-joint may be described as consisting of three 
stages, each characterized by distinctive symptoms and pathological 
changes, as well as requiring peculiar treatment. As this division is not 
imaginary but real, it is deserving of the greatest attention. 
The symptoms by which the disease is usually announced are of so ob- 
scure and stealthy a character as to render it very liable to be mistaken 
for other affections of the joint. The first circumstance which commonly 
attracts attention, especially if the patient be a child, is a feeling of fatigue 
after exercise, with slight pain in the knee, and a disposition to drag the Tuberculosis of the Hip-Joint. 
limb, thus giving the gait a stiff, awkward appearance. In this manner 
the case may progress for several weeks, or, indeed, even for several months, 
with, perhaps, hardly any perceptible aggravation. The child still goes 
about, taking his accustomed exercise, and manifesting the same interest 
as formerly in his out-door amusements. Gradually, however, the pain 
increases; there is now a distinct limping, and the sleep at night is apt to 
be disturbed by spasmodic twitches of the extremity. The pain is usually 
referred to the knee, particularly to its inner side, and is either sharp and 
lancinating, or dull, heavy, and aching. It is sometimes felt in the very 
depth of the joint, but more frequently it is superficial, as it were just be- 
neath the integuments. Exercise, or motion of any kind, always increases 
it, and it is generally worse at night than in the day; damp states of the 
atmosphere, suppression of the cutaneous perspiration, and disorder of the 
digestive organs also frequently aggravate it. The knee, on inspection, is 
found to be free from swelling and discoloration, and commonly quite 
tolerant of rough manipulation, as motion, pressure, and percussion. Occa- 
sionally the pain is of a neuralgic nature, and distinctly periodical in its 
occurrence, very similar, in this respect, to the paroxysms of an inter- 
mittent fever; the attack, perhaps, coming on early in the evening, and, 
after having continued for a few hours, returning about the same time the 
next day. This form of pain is most frequent, as far as my observation 
enables me to judge, in persons living in a malarial atmosphere. 
It is not often, however, that the pain, whatever be its character, is con- 
fined entirely, at this stage of the disease, to the knee; or, if it be so at 
first, that it remains there exclusively for any length of time. In general 
it extends also to the thigh and leg, sometimes along the front, now along 
the sides, especially the inner, and now along the posterior surface, in the 
direction, apparently, of some nervous trunk, as the crural, obturator, 
saphenous, or sacro-sciatic. I have known cases where the pain was felt 
most keenly at the tendo-achillis, just above the ankle-joint, and in one 
instance, under my charge not long ago, it was distressingly severe over 
the instep. Sometimes, again, the pain seems to shift from one of these 
points to another, being most severe, perhaps, at one time in the knee, 
and at another in the thigh, leg, or foot. It is proper also to add that 
the pain is generally not persistent, and that the patient has frequently 
long intervals of ease or of comparative comfort. 
Yarious explanations have been offered respecting the occurrence of 
pain at the knee, but I cannot say that any of them, so far as it is in my 
power to appreciate them, afford any satisfactory solution. It has been 
supposed, for example, that it is owing to an inflamed condition of some 
of the principal nerves of the limb, especially the obturator, which, as is 8 
Tuberculosis of the Hip-Joint. 
well known, occasionally sends a small filament to the hip-joint; but what 
connection has this nerve with the knee ? None whatever; and the same 
is true of the other nerves of the lower extremity. Nor, in my judgment, 
is the opinion that it is owing to disease of the long head of the femoral 
muscle any more plausible. This muscle lies over, and is attached to, the 
capsular ligament of the hip-joint; but even supposing, what is not very 
probable at this early stage of the malady, that it participates in the mor- 
bid action, how could it give rise to the pain in the knee, the leg, and foot ? 
Again, it has been imagined that the suffering in question is caused by 
inflammation of the cancellated structure of the head and neck of the 
thigh-bone; but if this be so, we have no positive proof of the fact. Our 
knowledge, then, in regard to this matter, is wholly conjectural, nothing 
more; a circumstance so much the less to be regretted, because it is really 
not of the least practical importance how the pain is produced, provided 
it is recollected that it usually manifests itself first at the knee. So far as 
this is concerned it is a symptom of great diagnostic value. 
After some time, varying from a few weeks to as many months, the pain 
shifts to the hip and its neighborhood; or, if it do not entirely forsake the 
knee, it is generally less constant and severe there than it was in the first 
instance, or soon after the commencement of the morbid action. Com- 
monly it is most intense and persistent directly over the articulation, deep- 
seated, and of a dull, gnawing character. At times it is perceived most 
keenly in the sacro-sciatic notch, between the great trochanter and the 
spine of the ilium, or in the upper and outer ’part of the groin. Occa- 
sionally, again, it exists simultaneously at all these points, although not 
in an equal degree; or, as it leaves one, it fastens itself upon another. In 
rare cases the pain appears in the hip before it shows itself in the knee, 
thigh, or leg. Pressure upon the gluteal region, motion of the affected 
joint, and percussion of the knee, the leg being flexed at a right angle, or 
of the sole of the foot, the limb being extended, always augments the pain, 
and leads to the detection of its seat. 
As yet, there is no sensible impairment of the general health; the appe- 
tite is good, and the various tissues retain their normal development. The 
muscles of the affected hip and limb are, perhaps, a little thinner and 
softer than natural, but these changes are usually slight, and hence they 
often elude detection. 
The symptoms now described may be regarded as, at least in some de- 
gree, characteristic of the first stage of hip-joint disease. Another train 
now succeeds, denotive of the steady advance of the morbid action, and 
equally significant of its presence. 
The most prominent local phenomena, at this period, are, an increase 
of the pain in the hip and knee, flattening of the buttock, effacement of Tuberculosis op the Hip-Joint. 
9 
the gluteo-femoral crease, and apparent elongation of the limb, with spas- 
modic twitching and wasting of its muscles. 
The pain, hitherto seated chiefly in the knee, now also affects the hip, 
or, if it existed there previously, as, indeed, is not unfrequently the case, 
it becomes sensibly aggravated. It is particularly violent at night, often 
for hours interrupting sleep, and attended with the most distressing spas- 
modic twitches of the muscles of the limb, which thus greatly augment the 
local and general suffering. The pain at one time is fixed, deep, aching, 
gnawing, or boring in its character; at another, erratic, sharp, or lanci- 
nating, darting about in different directions—now through the joint, then 
down the limb, and then through the groin, or back along the course of the 
sciatic nerve. Occasionally it is most severe in the lumbar region, in the 
lower part of the pelvis, in the situation of the acetabulum, or at the upper 
and inner part of the thigh. As before remarked, it is sometimes of a 
neuralgic character—coming, going, and recurring at particular periods. 
Derangement of the digestive apparatus, exposure to cold, and damp states 
of the atmosphere, have a tendency to aggravate and protract it. The 
pain in the knee, instead of disappearing, generally increases in violence, 
at the same time that it becomes more frequent and fixed. 
The sleep is habitually disturbed by unpleasant dreams, and the patient 
often wakes up in great alarm, crying and screaming, being perhaps much 
bewildered, and unable to determine where he is or what is the matter with 
him. Occasionally he is partially delirious, and some minutes elapse before 
he regains his entire consciousness. He sleeps by snatches, and hence he 
usually feels fatigued and unrefreshed in the morning. Spasmodic twitch- 
ing, jerking, or starting of the limb is a prominent symptom in this stage 
of the disease, and is rarely absent in any case Sometimes, indeed, it sets 
in at a very early period, and continues with more or less violence during 
the whole progress of the malady. It is particularly distressing in the 
muscles of the thigh, but often affects those also of the hip and leg. 
Along with these symptoms are frequently, but by no means constantly, 
impairment of the appetite, and disorder of the secretions, with a certain 
amount of fever at night. The bowels are usually inclined to be consti- 
pated, the urine is scanty and high-colored, the skin is rather arid, espe- 
cially in the forepart of the night, and the patient is disposed to drink 
more than common. As the case progresses the fever becomes more fre- 
quent and severe, and is often followed by pretty copious sweats. The 
patient loses flesh and strength, he is peevish and irritable, and his coun- 
tenance has a care-worn appearance. Although such is ordinarily the 
state of the system, in the second stage, especially after the disease has 
made some progress, yet there are cases in which there is hardly any con- 
stitutional disturbance whatever, except what results from the loss of sleep. 10 
Tuberculosis of the Hip-Joint. 
The local phenomena at this stage of the malady are unmistakable. 
The buttock of the affected side is found to be remarkably flattened, so as 
to be in striking contrast with the sound one. It is much broader, as well 
as considerably larger than in the natural state; the gluteal muscles are 
soft and flabby, and the skin is preternaturally loose, apparently from the 
absorption of the subcutaneous adipose substance. The gluteo-femoral 
crease, which forms so prominent a feature of this part of the body in the 
natural state, is completely effaced, giving the thigh and hip an appear- 
ance of continuity, or as if they were fused together. The muscles of the 
thigh and leg are also wasted, and this circumstance, together with the loss 
of fatty matter, imparts to the whole limb an aspect of attenuation, which, 
however, upon accurate admeasurement is usually found to be much less 
than was at first supposed. The cause of this condition of the muscles is 
evidently twofold; want of exercise and perverted nervous action, leading 
to atrophy of their substance, as well as to the absorption of the subcu- 
taneous and intermuscular fat. It certainly cannot be explained on the 
assumption of mere inactivity of the muscles, because an effect so con- 
spicuous as this is never known to follow the want of exercise in a sound 
condition of the muscular fibre. Unfounded, however, as this explanation 
is, it is the one usually adopted by surgical writers. 
Another remarkable circumstance noticeable in this stage of the disease 
is an elongated state of the limb, connected with the affected joint. So 
constant is this occurrence that it may, along with several of the other 
symptoms above described, be considered as pathognomonic. The extent 
of the elongation is indefinite, though, in general, it may be said to vary 
from half an inch to an inch and a half. In rare cases it may amount to 
two inches and even two inches and a half. It is observed both in the 
erect and in the recumbent posture, but is commonly more conspicuous in 
the former than in the latter. Various explanations have been offered of 
this phenomenon, all, at first sight, more or less plausible. In the first 
place, it has been argued that it is owing to‘the presence of an unusual 
quantity of synovial fluid, the product of inflammatory action, by which 
the head of the thigh-bone is partially pressed out of its socket and the 
corresponding limb projected beyond the level of the sound one. No one, 
however, has yet verified this opinion by dissection. That there is an in- 
ordinate secretion of synovial liquor in this stage of the malady is highly 
probable, but that its quantity is generally so great as to cause such a 
result is hardly a supposable case. We do know that there are frequently 
large accumulations of this kind in other joints, as the elbow and knee, 
without producing such an effect. In the second place, the phenomenon 
has been ascribed to the relaxed condition of the ligaments and muscles 
of the joint; but of this occurrence, if it really exist, we have no more Tuberculosis oe the Hip-Joint. 
11 
positive proof than of the influence which has been attributed to the syno- 
vial fluid. A third opinion, and, in my judgment, the only correct one, 
is that the elongation in question is occasioned by the difference in the 
level of the two hips, that of the affected side being always lower than 
that of the sound side. Now, a careful examination of the body will not 
fail to satisfy ns that this difference is real, and not imaginary, and, more- 
over, that it is always in direct proportion to the increase in the length of 
the limb. Whatever mode of examination be adopted the result will be 
the same, whether the patient be recumbent or erect. In the latter case, 
he is necessarily obliged to support himself upon the sound limb, which, 
for this purpose, he maintains in a state of rigid extension, at the same 
time throwing the corresponding hip somewhat outward, so as to bring 
the axis of the trunk on a line with the sound foot, and thus take off 
its weight from the affected extremity. This, it will be observed, hangs 
loosely from the pelvis, upon which the thigh is slightly flexed, while the 
leg is bent on the thigh, and the foot extended on the leg, the knee pro- 
jecting prominently forward, much beyond the level of the opposite one, 
and the whole member resting upon the ball of the foot and toes. If this 
explanation be correct, as my experience warrants me in assuming, then 
the elongation of the limb, so constantly witnessed in this stage of the dis- 
ease, is not real but imaginary, not positive but apparent. 
I have never witnessed any shortening of the limb in this stage of the 
complaint, and doubt very much whether it really ever takes place. The 
symptom has been described as an occasional occurrence, and ingenious 
hypotheses have been framed to account for it, but as I have seen no in- 
stances of it, I do not deem it necessary to detain the reader with any 
further remarks concerning it. 
Finally, there is generally, in this stage of hip-joint disease, a marked 
depression, or hollow, in the lumbar region, with a slight inclination of 
this portion of the spine toward the sound side, and an unusual promi- 
nence of the belly. The inferior portion of the spinal groove is also more 
distinct than natural. 
In the third stage the nature of the disease is no longer doubtful, what- 
ever it may have been previously. The symptoms are characteristic, being 
such as denote the extensive and frightful mischief that has been effected 
within the joint, in its several constituents. Matter now forms, and, by its 
pressure upon the inflamed structures, greatly aggravates the suffering. 
The existence of the suppurative process is indicated by an increase of 
pain; by a sense of throbbing and tension, deep and persistent; by severe 
swelling of the gluteal region, generally most prominent at the centre of 
the articulation; by oedema of the subcutaneous cellular tissue; and by a 
remarkably turgid and enlarged condition of the subcutaneous veins. The 12 
Tuberculosis oe the Hip-Joint. 
affected joint is intolerant of the slightest motion and manipulation, so 
much so, indeed, that the patient is unable to raise himself up or turn in 
bed without experiencing the greatest agony. Every attempt to move 
the limb is attended by similar results. The constitutional disturbance is 
always in proportion to the local suffering, and violent rigors, followed by 
high fever and copious sweats, are rarely absent. Sometimes, however, 
the abscess forms in a quiet and insidious manner, without any of the 
severe symptoms that usually accompany the suppurative process in this 
and other varieties of inflammation. As the matter increases in quantity 
it gradually works its way toward the nearest surface, its approach being 
denoted by the occurrence of a circumscribed, erysipelatous blush. Here 
there is generally distinct fluctuation, and the parts, feeling soft and boggy, 
soon yield at one or more points, followed by the escape of the contents 
of the sac. 
The site at which the matter, when left to itself, obtains a vent, varies in 
different cases. Most generally it escapes at the gluteal region, either 
immediately over the joint, or in its immediate vicinity. The other 
situations at which it is most liable to discharge itself are the upper and 
back part of the thigh, a short distance below the great trochanter, the 
superior and external part of the groin, the sacro-sciatic notch, and the 
upper and inner surface of the thigh. Occasionally it escapes at several 
points, either simultaneously or successively, leaving thus a number of 
orifices, leading to a corresponding number of sinuses. These passages 
are sometimes very long and tortuous, and in old cases they are always 
lined by a false membrane. Many years ago I saw an instance in which 
there were nine distinct openings, and very recently another in which there 
were as many as twelve; two at the upper part of the thigh, and one just 
below the crest of the ilium, the remainder being scattered over the gluteal 
region. 
Occasionally the matter escapes both externally and internally. In the 
case of a young gentleman, named Eaton, aged nineteen, whom I attended 
with the late Dr. Robert Morehead, the hip was pierced with several open- 
ings, while at the same time the matter had passed through the bottom of 
the acetabulum into the pelvis, round the rectum, through a small ulcer by 
which it had found its way out, for several months, by the anus. In the 
female it has sometimes escaped by the vagina, and in both sexes by the 
bladder. A few examples are on record in which it has passed, by a small 
opening, into the. colon. Sometimes, again, as I have myself seen, the fluid 
lodges in a kind of sac, formed by the iliac bone and the soft parts of the 
pelvis, just as pus occasionally lodges between the skull and dura mater. 
The matter in hip-joint disease is generally more fluid than ordinary 
pus, and also of a more greenish tinge. In fact, it very closely resembles Tuberculosis of the Hip-Joint. 
the contents of a cold abscess, or the pus of a pulmonary cavern. It is 
often intermixed with small whitish particles, not unlike grains of soft 
boiled rice, with flakes of lymph, or even small clots of blood, especially 
when the antecedent inflammation has been unusually severe, or the parts 
have been roughly handled. More rarely it contains the debris of articu- 
lar cartilage, ligamentous tissue, or osseous matter, in the form of little 
granules of a whitish gritty character. Occasionally, though rarely, large 
pieces of bone are discharged, and a few instances are related in which 
the greater portion of the head and neck of the thigh-bone escaped. The 
pus, when long confined, is often very fetid, and it is always so when, in 
consequence of a perforating ulcer of the bowel, it is intermingled with 
fecal matter; very frequently, on the other hand, it is entirely free from 
odor. Received into a vessel, and permitted to stand for a while, it gene- 
rally separates into two parts, one at the bottom, solid and granular, the 
other at the top, fluid, and of a pale whey-like, or oleaginous aspect. 
When an abscess of this kind has once fully emptied itself, the subsequent 
discharge is often of a gleety character, ichorous, or thin and bloody. 
The quantity of matter may be very small, or so abundant as gradually 
but surely to exhaust the system. I have repeatedly seen cases where, at 
the first evacuation, upwards of a pint flowed off, and where, subsequently, 
the discharge amounted daily, for a number of weeks, to several ounces. 
At times the suppurative action is almost entirely suspended, perhaps for 
months, when, either suddenly or gradually, it reappears, and becomes as 
profuse as before. Once established, it has no special limit as to its dura- 
tion. I have recently examined a case where the discharge has main- 
tained itself, with hardly any interruption, for two years. The hip and 
thigh are covered with numerous scars, bearing evidence to the repeated 
formation of abscesses. The patient is a lad, aged fourteen, much stunted 
in his growth. Whenever the discharge is unusually protracted it may be 
assumed, as a general rule, that there is serious and obstinate caries of the 
bony structures of the joint, attended with the occasional escape of gritty 
substance. 
The symptoms which accompany the discharge of matter are such, 
usually, as are denotive of hectic irritation. The patient, at least for a 
time, has regular vesperal exacerbations, the face is flushed, the pulse is 
excited, the sleep is impaired, and during the night the surface is drenched 
with copious sweats. Rapid emaciation ensues, the strength declines, 
and the bowels at length become harassed with colliquative diarrhoea. 
Thus life may be gradually worn out by exhaustion, or, the discharge 
diminishing, reaction may take place, followed, sometimes even in appa- 
rently desperate cases, by ultimate recovery. 
Suppuration, however, does not always take place in this stage of the 14 
Tuberculosis of the Hip-Joint. 
complaint, or, if it do, the matter is either very small in quantity, or it 
is so soon absorbed as not to produce its characteristic symptoms. This 
is true, in many cases, even where the greatest ravages have followed the 
disease, as the complete disappearance of the articular cartilages, the 
round and cotyloid ligaments, and even a large portion of the head and 
neck of the thigh-bone. 
It is seldom, according to my observation, that abscesses form ex- 
ternally to the joint in this disease without internal articular suppuration. 
Indeed, the occurrence is rare under any circumstances. During the pro- 
gress, however, of the articular malady, the structures over and around 
the joint, participating in the inflammation, become hard and condensed 
from interstitial deposits, and from the same cause greatly enlarge in 
every direction. 
The changes which the relative position of the affected limb under- 
go in this stage of the malady are striking and important, and deserving 
of special consideration. The extremity, now actually, and not merely ap- 
parently, shorter than natural, is much attenuated from the wasting of its 
fatty and muscular tissues, and remarkably disfigured in its appearance, 
the heel being considerably elevated, and the ball of the foot and toes 
alone touching the ground when the patient makes an effort to stand. 
The degree of shortening is variable, and not always by any means in 
proportion to the destruction of the head and neck of the thigh-bone, 
the acetabulum, and the connecting ligaments, which forms so prominent 
a feature of the disease at this period. While in some instances it does 
not exceed an inch, or, at most, an inch and a quarter, in others it 
amounts to twice and even thrice that extent. One-third, and sometimes 
even one-half of this, as I have satisfied myself by careful examination, is 
generally attributable to the elevation of the pelvis on the affected side. 
The position of the foot is variable. Sometimes it looks directly forward, 
but most commonly it inclines inward or outward, the latter direction 
being by far the more frequent. These differences are unquestionably 
due to the extent and nature of the ravages experienced by the hip- 
joint. When the acetabulum has suffered most severely, the foot usually 
inclines inward, as in dislocation of the thigh-bone upward upon the 
dorsal surface of the ilium; if, on the contrary, there has been much de- 
struction of the head and neck of the thigh-bone, and the cotyloid cavity is 
only slightly involved, then the foot is generally everted, as in fracture of 
the neck of that bone, the external rotatory muscles tending to draw the 
whole limb in that direction. 
The thigh, as a general rule, is flexed upon the pelvis, the angle of 
flexion varying from the slightest perceptible change to 45°. In most 
cases it inclines somewhat toward the sound limb, and occasionally, Tuberculosis op the Hip-Joint. 
15 
though rarely, it overlaps or crosses it. Sometimes, on the other 
hand, it stands off widely and most unseemly from its fellow, as in the 
ease of a woman, aged twenty-five, who was under my charge several 
years ago. In this case, the two knees are habitually upwards of fifteen 
inches apart; the affected limb sticks out in the most grotesque manner, 
and the foot, in the erect posture, is at least six inches from the floor. 
The extremity of the thigh-bone, the head and neck of which appear to 
have been absorbed, can be plainly felt in the ischiatic notch. Nearly 
two years have elapsed since the disease first showed itself; a large 
abscess formed at the inner and upper portion of the thigh, and for a 
time the suffering was most severe and depressing. At present, there 
is an absence of all morbid action, a spontaneous cure having apparently 
taken place. 
The thigh, moreover, is always in a painfully rigid state, owing, 
probably, to two circumstances, the contracted condition of the muscles 
of the hip and limb, and the formation of adhesions between the remnants 
of the head and neck of the thigh-bone and the surrounding parts. By 
taking hold of the knee a slight degree of flexion may, perhaps, be pro- 
duced, but to abduct the thigh, or to move it backward, is generally im- 
practicable ; besides, every effort of the kind is ordinarily attended with 
excruciating suffering. Owing to the contraction of the hamstring mus- 
cles, the leg is commonly flexed on the thigh, and, for the same reason, 
the extensor muscles usually draw the heel upward toward the leg. 
The great trochanter generally lies directly over the acetabulum, or in 
its immediate vicinity, forming a hard, firm, immovable, or nearly immov- 
able, prominence, the nature of which it is not possible to mistake. In 
regard to the head and neck of the thigh-bone, they are, as was previously 
stated, usually completely annihilated, or so much wasted as to exist only 
in a rudimentary form. Much has been said by writers respecting the 
dislocation of this bone in this advanced stage of the disease; but gene- 
rally in so vague a manner as to convey the impression that their state- 
ments are either entirely unfounded, or that they are based upon the asser- 
tions of others equally unentitled to credence. Few authors seem to 
have expressed an opinion upon the subject from personal observation. 
The valuable facts collected by Professor March, of Albany, in the ex- 
tensive museums of the United States and of Europe, as well as in 
private practice, prove, most conclusively, that dislocation of the thigh- 
bone in any direction is exceedingly rare, as a consequence of this affec- 
tion. A true luxation, such as occurs in the normal state of the parts, 
is, in fact, impossible, from the very nature of the morbid alterations ex- 
perienced by the superior extremity of the bone in question,—its head 
being generally completely destroyed, and its neck in great measure. 16 
Tuberculosis of the Hip-Joint. 
Now, during the progress of the disease, this remnant of the neck, which 
is usually of a rounded conical shape, and frequently not more than three- 
quarters of an inch in length, if, indeed, so long, ordinarily places itself 
over the acetabulum, to the margins of which, and to the adjacent parts, it 
becomes, in the event of recovery, ultimately united. That it is occasion- 
ally drawn up beyond this point, especially when there has been complete 
destruction of the upper border of the acetabulum, backward toward the sci- 
atic notch, forward upon the pubic bone, or downward and forward into the 
thyroid foramen, does not admit of doubt. Dislocation, however, in most of 
these directions can take place only in those cases where there has been ex- 
tensive suppuration with separation or destruction of the soft parts, allowing 
the superior extremity of the bone to move about and thus seek, as it were, 
a new position. The upward displacement is, undoubtedly, most frequent, 
but even this must be extremely rare. In one of the cases related in a 
subsequent page, the end of the thigh-bone projected above the acetabu- 
lum, where it had formed for itself a superficial socket in the iliac bone, 
admitting of very slight motion. The real cause, then, of shortening in 
the third stage of tuberculosis of the ileo-femoral articulation is not dis- 
location, as has been so often asserted, but the destruction, partial or com- 
plete, of the head and neck of the thigh-bone, along with a certain degree 
of elevation of the corresponding hip. 
Ill,—Diagnosis, 
Although the symptoms of this disease are usually well-marked, espe- 
cially after the lapse of some time, my observation satisfies me that it is 
extremely liable to be diagnosticated erroneously. The inexperienced 
practitioner, misled by the seat of the pain, too often contents himself 
with a most superficial examination, and, taking this as the basis of his 
therapeutic indications, is very apt to make a wrong application of his 
remedies, addressing them, perhaps, solely to the knee, which is only sympa- 
thetically involved, when they ought to be directed exclusively to the hip, 
the actual seat of the morbid action. Numerous cases, illustrative of the 
truth of this remark, have fallen under my observation, and there are, I 
am sure, few surgeons in extensive practice who have not, like myself, had 
occasion to lament the great mischief that has thus been entailed. In a 
malady so grave as this an error of diagnosis may be fraught with the 
worst consequences both to part and system, eventuating, as it necessarily 
must, in the loss of precious time; for it but too often happens that, 
when the true nature of the disease is discovered, all our efforts to arrest 
its progress are unavailing. 
The affections with which this disease is most liable to be confounded, 
or which may, at least for a time, obscure its diagnosis, are sprains and Tuberculosis op the Hip-Joint. 
17 
rheumatism of the ileo-femoral articulation, psoas abscess, purulent collec- 
tions in the vicinity of the hip and in the upper part of the thigh, and in- 
flammation of the periosteum of the great trochanter. 
A sprain, twist, or contusion of the hip-joint is not an unfrequent 
occurrence, and may, if followed by considerable inflammation, give rise 
to severe pain and stiffness, seriously weakening the part, if not com- 
pletely disqualifying it for the performance of its functions. The conse- 
quence is that the patient, in attempting to walk, raises the hip of the 
affected side and relaxes the corresponding limb, by bending the knee 
and retracting the heel, very much as in the earlier stages of tuberculosis. 
The muscles, also, by degrees become flabby and attenuated, and there is 
a sensible diminution of the temperature of the cutaneous surface. The 
gluteo-femoral crease is in time effaced, and even the general health may 
suffer. The signs of distinction are, the history of the case, the absence 
of pain in the knee, the greater latitude of motion, the absence, in gene- 
ral, of constitutional disturbance, and, lastly, the fact that the foot, 
although everted, is usually easily rotated on its axis, whereas, in stru- 
mous disease of the hip-joint, it is commonly pretty firmly fixed. 
Rheumatism of the hip-joint, chronic and subacute, is generally caused 
by cold, or by sudden suppression of the cutaneous perspiration. It is 
seated principally in the ligamentous and synovial structures, the carti- 
laginous and osseous being seldom involved, except in very severe and 
protracted cases. The pain, which runs down the front of the thigh, is 
dull, heavy, or aching; the gait is limping, the pelvis is higher on the 
affected side than on the sound, and the limb exhibits, in the main, the 
same attitude as in lameness from sprains and contusions, with this pecu- 
liarity, that the foot is always strongly everted, while in the former case 
it is generally inclined inward. The patient in the morning complains of 
stiffness in the hip, which usually diminishes very sensibly after exercise, but 
is sure to return in the evening if there has been much exertion or fatigue. 
The muscles of the thigh are attenuated, but more firm than in tuberculosis, 
while those of the leg often retain their normal bulk; the gluteo-femoral 
fold is effaced; the limb, owing to the obliquity of the pelvis, is shorter, 
often from one to two inches, than natural; the great trochanter is un- 
commonly prominent; and a creaking noise is generally heard if the head 
of the thigh-bone be moved forcibly upon the acetabulum. Now, although 
these phenomena bear a very close resemblance to those of strumous dis- 
ease of this articulation, yet the absence of severe suffering at night, and 
at all times at the knee, the marked relief afforded by gentle exercise, the 
trifling annoyance from pressure, percussion, and motion, even when 
carefully performed, and the rare occurrence of rheumatism in children, 
together with the frequent coexistence of this disease in other parts of 18 
Tuberculosis of the Hip-Joint, 
the body, will generally be found sufficient to prove that the affection is 
not tubercular. 
It is not often that psoas abscess can be mistaken for tubercular disease 
of the hip-joint; for, although the matter which is poured out in its latter 
stages, occasionally points to the outside of the groin, or at the upper and 
inner part of the thigh, there is always the most marked difference in the 
character of the two swellings, to say nothing of other symptoms. In 
psoas abscess the tumor is usually situated above Poupart’s ligament, 
while in hip-joint disease it is commonly below; in the former, it always 
sensibly diminishes and sometimes even entirely disappears under pressure, 
or when the patient lies down, but quickly reappears when the pressure 
is removed, or when the patient raises himself up; in the latter, on the 
contrary, it never changes its position, or if it do, it is in consequence 
solely of the force of ulceration, absorption, and gravitation; in psoas 
abscess the swelling receives a distinct impulse in coughing, laughing, and 
crying, which is not the case in tuberculosis of the hip-joint. 
Again, in psoas abscess, the principal pain is in the loins; it is fixed 
there, and is always greatly increased by the erect posture, as well as by 
every attempt to extend the corresponding limb. In hip-joint disease, the 
pain is most severe in the knee, or in the knee and hip. In psoas abscess 
there is, at no period, any change in the position of the great trochanter, 
nor any alteration in the length of the limb; in hip-joint disease, on the 
contrary, especially in its more advanced stages, these are prominent sym- 
toms. Finally, psoas abscess occurs nearly always after puberty, whereas 
the other affection is most common in early childhood. 
Sometimes large deposits of pus take place in the cellular tissue of the 
nates, or beneath the gluteal muscles, and, forming a prominent tumor 
in the direction of the ileo-femoral articulation, may thus simulate ab- 
scess of the hip-joint from tuberculosis. These accumulations are com- 
monly the result of external injury, or of a phlegmonous, rheumatic, or 
erysipelatous state of the system, and are, therefore, in general easily dis- 
tinguished by their history, by the rapidity of their progress, by the 
severity of the local distress, and by the comparatively prompt recovery 
of the parts after the evacuation of their contents. Cold abscesses of the 
nates, besides being exceedingly infrequent, exhibit none of the diagnostic 
signs of articular disease, especially such as pain in the knee, or pain in 
the hip-joint upon rotating the thigh, so characteristic of the latter 
malady. It is only when they depend upon caries of the innominate bone 
that the distinction would be likely to be attended with difficulty, and in 
this case a thorough exploration with the probe would probably furnish 
the requisite light. 
Finally, diagnostic embarrassment, to an annoying extent, occasionally Tuberculosis op the Hip-Joint. 
19 
arises from periostitis of the great trochanter, in persons of a rheumatic 
or gouty habit of body. The fibrous membrane of this portion of the 
femur becomes exquisitely painful and tender to the touch, under the 
slightest motion and percussion, and the disease, extending above the 
neck of the bone and capsular ligament of the joint, causes distress and 
difficulty in walking, with elevation of the corresponding side of the pel- 
vis, similar to what is seen in coxalgia. The soft parts around are swollen 
and puffy, giving the hip an increased breadth and thickness ; by and by, 
suppuration takes place, sinuses form, and small portions of the bone 
separate and come away. Unless the case be well managed the joint 
becomes stiff, and the patient does not regain his health for a long 
time. The signs of distinction are the persistence of the gluteo-femoral 
crease, the coexistence of rheumatism or gout in other structures or re- 
gions, and the fact that the disease usually occurs later in life than 
coxalgia. 
But it is chiefly in the very early stages of this affection that erroneous 
views of its diagnosis are liable to be formed ; when it is fully established 
the phenomena are generally too well marked to be mistaken. It has 
been seen that the very first symptom, in every case, is pain in the knee ; 
so uniform and constant, indeed, is this occurrence that it must be re- 
garded as pathognomonic, and yet, as was previously stated, it rarely hap- 
pens that it is referred to its true source. Instead of being considered as 
an expression of disease of the hip-joint, it is too often regarded merely 
as an effect of neuralgia, rheumatism, or injury of the knee, to which, ac- 
cordingly, the treatment is exclusively directed. Its great value, as a 
diagnostic, is totally overlooked, and thus the disease is allowed to pro- 
gress, at the only time almost when it admits of prompt and radical cure. 
In order to avoid this serious and too common mistake, a most thorough 
examination should be made in every case presenting the slightest sus- 
picion of the existence of tuberculosis of the hip-joint. The very fact 
that there is pain in the knee, severe in degree, and of frequent recur- 
rence, should of itself excite the alarm of the surgeon; but especially 
should he be on his guard if, added to this, there is a limping in the gait, 
an increase of suffering after slight exercise, and disturbed sleep at night. 
If the diagnosis is obscure, the examination must be repeated, again and 
again, until it is perfectly cleared up. To conduct the investigation pro- 
perly the patient must be completely stripped, and viewed both behind 
and in front, as he stands on the floor. If there be any flattening of the 
nates, unusual prominence of the trochanter, or change in the gluteo- 
femoral fold, it will be sure to be detected, and so, also, if there be any 
alteration in the attitude, size, or length of the corresponding limb. If 
the patient be now requested to walk, the amount of limping will be dis- 20 
Tuberculosis of the Hip-Joint. 
covered, as well as the manner in which he raises and moves the leg and 
foot. To complete the investigation, the patient is now stretched out on 
the floor, or on a hard lounge, with a view of ascertaining the amount of 
suffering produced by rotating the head of the thigh-bone upon the aceta- 
bulum, and also by bringing these parts forcibly into contact with each 
other by percussing the knee, the leg being flexed, or the sole of the foot 
opposite the ankle, the foot being bent on the leg. The patient being 
next turned upon his abdomen, the hip is thoroughly examined, first, with 
reference to the condition of its soft parts, and, secondly, with relation 
to the sensibility of the component structures of the joint; finally, if 
there be any obliquity of the pelvis it may be easily observed both in the 
erect and in the recumbent posture ; and any change in the length of the 
affected limb may be determined by extending a piece of tape, or other 
suitable band, from the antero-superior spine of the ilium to the inner 
side of the lower extremity of the patella. The difference in the length 
of the measure on the two sides will give the difference in the length of 
the thighs, or the distance between the hip and knee joints. The use of 
chloroform will often be of great service in conducting the movements of 
the limb while the patient is recumbent, especially when the parts are 
very painful and intolerant of manipulation. 
The morbid changes induced by this disease vary, as might be sup- 
posed, according to the different stages of its progress. As it never 
proves fatal in its incipiency, all that we know of these changes at this 
period has been learned accidentally, by examining the bodies of those 
who have died of other maladies. Enough, however, has been ascertained 
to show that they do not differ materially, if any, from those of ordinary 
inflammation. The synovial membrane, which is commonly first implicated 
in the morbid action, affords evidence of slight vascularity—a few delicate, 
straggling vessels, loaded with blood, being observable upon its surface, 
and, in most cases, it is somewhat opake and softened, not uniformly, but 
at certain points. An appearance of thickening is often imparted to it, 
from a deposition of lymph, which being poured out, even quite freely 
in the disease, soon assumes a pulpy consistence and a pale-yellowish 
color, though occasionally it verges upon greenish. Sometimes it is 
shreddy, tomentose, or filamentous. The articular cartilage, if seriously 
involved in the inflammation, is of a dull whitish, or slightly grayish 
aspect, and somewhat thickened, softened, and partially separated 
from its osseous connections. The cancellated structure of the bones 
is abnormally vascular, light, porous, and humid, being at the same 
time easily broken and cut. Hot unfrequently its cells are distended with 
IY.—Morbid Anatomy and Pathology. Tuberculosis of the Hip-Joint. 
21 
yellowish tubercular matter, of a semi-solid caseous consistence ; or, this 
substance presents itself in the form of distinct masses, free or encysted, 
and, perhaps, not larger than a millet-seed. However this may be, these 
changes are always more conspicuous in the head and neck of the thigh- 
bone than in the innominate bone, which is seldom seriously alfected at 
this stage of the disease. The round ligament usually suffers early, being 
abnormally red, tumefied, and softened. The synovial fluid is generally 
increased in quantity, but rarely to any considerable extent. 
As the malady advances, the alterations above described become more 
distinctly defined; the disorganizing process being now in full play, its 
devastating effects are plainly visible in every portion of the joint. The 
lymph gradually increases in quantity, and is often intermixed with a little 
sero-purulent matter, or thick greenish-looking pus. The synovial mem- 
brane is partially destroyed, and what remains is of an opake, muddy, and 
ragged appearance. The cartilage is ulcerated, pulpified, discolored, per- 
forated, and almost completely detached. The bony structure is very red, 
soft, carious, rough, and easily crumbled. The round ligament is in a great 
degree destroyed, and the capsular ligament, as well as the cotyloid, ex- 
hibits well-marked signs of inflammation, being loose and spongy at one 
point, attenuated at another, and perhaps thickened or hypertrophied at 
a third. 
The disease having reached its acme, the structures of the joint are 
completely subverted, with hardly any traces of their original appear- 
ances. Pus is now usually seen, often, indeed, in large quantity, with 
all the qualities of strumous matter. This, however, is not always the 
case ; for, at times, it is thick and pultaceous, caseous, ichorous, or sero- 
sanguinolent. In one instance, observed not long ago, I found it very 
thin, and almost black, from the effects evidently of the necrosed condi- 
tion of the hip-bone. The synovial membrane, the round ligament, the 
articular cartilages, and the head and neck of the thigh-bone, with the 
margins, and frequently, also, the bottom of the acetabulum, are partially 
destroyed, or even completely annihilated. In the more severe cases the 
cotyloid, the transverse, and even the capsular ligament are entirely ab- 
sorbed, the surrounding parts are extensively separated by the ulcerative 
and suppurative processes, numerous fistulous openings exist, and the 
gluteal muscles are transformed into dense, firm bodies, of a pale-reddish, 
yellowish, or whitish color. Cases are not wanting, especially when the 
disease is of long standing, in which these muscles undergo the fatty de- 
generation. Occasionally both trochanters are absorbed; or there is ex- 
tensive caries of the innominate bone ; or the head and neck of the thigh- 
bone are necrosed ; or the joint contains numerous fragments of bone and 
cartilage; or the bottom of the acetabulum being perforated, the matter 22 
Tuberculosis of the Hip-Joint. 
extends into the pelvis, and passes off by the rectum. In children, prior 
to the completion of the ossific process, the hip-bone has been found sepa- 
rated, at the acetabulum, into its three primitive pieces. 
The head and neck of the thigh-bone being generally absorbed, the 
remnant of the superior extremity of this bone usually lies across the 
acetabulum, or in its immediate vicinity. Occasionally it is drawn up a 
little beyond this cavity, against the surface of the ilium, resting in a 
slight depression, which, however, bears only a very faint resemblance to 
a new socket. A few instances, and but a few, have been observed, in 
which it was found, on dissection, forced backward into the sciatic notch, 
forward upon the pubic bone, or downward into the thyroid foramen. 
When the disease has expended itself mainly upon the acetabulum, the 
head of the thigh-bone may remain in its original position; or it may 
even pass, as, in fact, it has been known to do in several cases, into the 
pelvis. 
If death takes place after a process of recovery has been set up, the 
acetabulum will be found fdled by a white, fibrous, organized substance, 
the extremity of the thigh-bone being anchylosed, or firmly attached by 
new matter to the surrounding structures. It is very rare for a new 
socket to be formed; yet that this is not impossible is proved by dissec- 
tion, as well as by specimens in different museums. In time, the artificial 
joint may admit of considerable motion, as is seen in persons who have 
recovered from the disease, attended with great shortening of the limb; 
but, in general, the motion is extremely restricted. Sometimes an imper- 
fect ligament is formed round the bony knob above described, and the 
surface of this bony knob may even become slightly tipped with cartilage. 
Finally, osseous growths, short, irregular, and friable, occasionally make 
their appearance upon the thigh-bone, and also upon the innominate bone, 
in the vicinity of the former disease. 
The bodies of those who die of strumous disease of the hip-joint, or 
while laboring under this affection, usually exhibit serious pathological 
changes in some of the internal organs. These changes appear to be the 
direct result of the tubercular cachexy, which is generally so well marked 
in the latter stages of the local malady, and they exist in various forms 
and degrees in different structures. The most common are tubercular 
deposits and dropsical effusions, which are rarely entirely absent in any 
case, especially if of long standing. 
Tubercles of the lungs are very common; they often exist in great 
numbers, especially in the summits of these organs, and they always ex- 
hibit the same characters as in ordinary phthisis. Cavities sometimes 
form, but death usually occurs before they attain any considerable magni- 
tude. The bronchial ganglions commonly participate in the pulmonary Tuberculosis of the Hip-Joint. 
disease, being enlarged and tuberculized. Occasionally extensive adhe- 
sions are found between the lung and costal pleura, with or without serous 
and other effusions. The heart is seldom affected. 
The peritoneum is sometimes extensively tuberculized, and considerable 
quantities of water are often found in its cavity. In children, the lymphatic 
ganglions of the pelvis and mesentery are apt to suffer from strumous 
deposits, and similar changes are occasionally witnessed in the spleen. 
The liver is often cirrhosed and hypertrophied. How and then the glands 
of Peyer suffer. In one of the cases mentioned below, they were pretty 
extensively ulcerated. The pancreas, stomach, and genito-urinary organs 
are usually sound. The rectum, and even the colon, the vagina, and the 
bladder, are sometimes found perforated, the matter passing directly from 
the hip-joint through the abnormal aperture. The blood is generally 
very thin, and deficient in fibrin and coloring matter. The lower extremi- 
ties, and even the hands, face, and genital organs are, at times, anasarcous, 
especially when the system has been worn out by tubercular disease of 
different parts of the body. 
Tuberculosis of the hip-joint, as the name coxwectly implies, is essen- 
tially a scrofulous disease, bearing the same relation to the structures of 
that articulation that phthisis bears to the lungs; in other words, it is, to 
use a common but sufficiently expressive phrase, like scrofulous complaints 
in general, merely a local symptom of a constitutional disorder. Take 
away this constitutional vice, this strumous cachexy, and in either case no 
local disease can arise. That this is not a mere assumption, but an indis- 
putable fact, is abundantly established by the symptoms and progress of 
the local affection, and by the appearances revealed on dissection of those 
who die of it. 
Tubercular disease of an organ does not necessarily suppose in that 
organ the existence of tubercular deposits. In strumous corneitis, for 
example, we find nothing of the kind, and yet no one, at all familiar with 
the character of that malady, would deny it such a parentage. In certain 
diseases of the skin there is undoubtedly scrofulous action, without, so far 
as can be determined, any secretion of tubercular matter. When the dis- 
ease begins in the synovial membrane of the hip-joint, it probably deports 
itself in the same manner as when it invades the tunics of the eye; and 
the same thing, there is reason to conclude, occurs when it takes its rise 
in the cartilaginous tissues. When, on the contrary, it commences in the 
osseous structures, whether in the thigh-bone or in the innominate bone, 
there may, and no doubt often is, a genuine deposit of this kind, such as 
is so frequently met with in the short bones, as those of the spine and foot, 
and also in the articular extremities of some of the long bones. Such, 
then, it is believed, is the true pathology of this affection; but to enter 24 
Tuberculosis op the Hip-Joint. 
into any further discussion here would be to describe the pathology of 
strumous affections in general, for which this is not the proper occasion. 
Yl.—Cases of Hip-Joint Disease. 
The following cases and dissections are introduced here as further illus- 
trations of the progress, pathology, and complications of this affection. 
Case I.—Eliza Kennedy, aged nine years and a half, the oldest of four 
children, of fair complexion, with light hair and eyes, and of a natu- 
rally delicate, strumous constitution, became the subject of tubercular dis- 
ease of the left hip-joint in April, 1841, soon after a severe attack of 
measles. Eor the first few months she suffered severely from pain in the 
knee and inner part of the thigh; but about this period it left these 
points, and fixed itself at the seat of the morbid action, shifting its place, 
however, occasionally, especially after exercise, from which her physician 
did not restrain her. The gluteal region was much swollen, and the limb 
gradually became stiff and useless. Thirteen months had elapsed before 
I saw the case. Suppuration had already taken place, and several sinuses 
existed in the neighborhood of the ileo-femoral articulation, discharging a 
considerable quantity of thin gleety-looking matter. The limb was in- 
verted, much shortened, and in close contact with the sound one; the 
thigh being, at the same time, a good deal flexed upon the pelvis. The 
child was hectic, greatly emaciated, racked with pain, and harassed with 
diarrhoea and night-sweats. In a few months a hacking cough set in, 
which rapidly increased in severity, and, together with other symptoms, 
only too clearly indicated the existence of confirmed phthisis. Death oc- 
curred nearly two years after the first signs of hip-joint disease, preceded 
by slight ascites, anasarca of the lower extremities, and the formation of 
new sinuses in the gluteal region. 
Both lungs were crowded with tubercles, especially at their summits; 
most of them were in a crude state, but several were quite soft, and, on 
the right side, a cavity existed capable of containing a pigeon’s egg. 
Extensive adhesions were found between the costal and pulmonary pleurm. 
The bronchial ganglions were enlarged, but not tuberculized. The heart 
was normal. The peritoneal cavity contained nearly half a gallon of 
limpid serum. The spleen and mesenteric ganglions were crowded with 
tubercular matter, mostly in a crude state. The stomach, bowels, liver, 
pancreas, and genito-urinary organs were sound. 
The gluteal region was unnaturally hard and prominent, and the seat 
of four sinuses, three of which communicated with the diseased joint, while 
the other, situated just below the antero-superior spine of the ilium, led 
to the interior of the pelvis. By pressure, a small quantity of thin gleety 
fluid could be forced from these openings. The principal prominence of Tuberculosis of the Hip-Joint. 
25 
the hip was formed by the great trochanter, which lay immediately be- 
neath the skin, and much nearer to the sacro-sciatic notch and the tube- 
rosity of the ischium, than in the normal state. The head and entire 
neck of the thigh-bone, except a small tubercle, hardly half an inch long, 
and of a rounded shape, had disappeared by absorption. This remnant, 
which was quite rough and considerably softened, closely embraced the 
acetabulum, and was directed backward toward the sacro-sciatic notch, 
from which it was distant about three-quarters of an inch. The shaft of 
the thigh-bone was strongly flexed upon the pelvis, and inclined over 
toward the opposite side, thereby throwing the trochanter prominently 
outward and upward. The acetabulum had lost its cup-like appearance, 
its margins having been removed by absorption, leaving thus a shallow 
elongated depression, closely embraced, as just stated, by the remains of 
the neck of the thigh-bone. The capsular ligament was entirely destroyed, 
except a small portion at the outer and upper part of the joint, which was 
much thickened and otherwise altered. There was no dislocation, pro- 
perly so termed, though the two articulating surfaces had undergone great 
changes in their relative position. Complete anchylosis existed. The 
gluteal muscles were remarkably pale, and so much wasted as to render 
their fibres very indistinct. All the soft structures about the joint were 
excessively indurated, from the deposition of plastic matter. Running 
along the inner surface of the innominate bone, in a transverse direction, 
was a long sinus, which opened, as already seen, just below the anterior 
spine of the ilium. 
Case ll.—James Franklin, a negro, aged ten years and a half, the 
third of eight children, was attacked with symptoms of hip-joint disease 
early in December, 1853. His health, up to that time, had always been 
delicate, although he had never been confined to his bed. Hone of the 
members of the family had ever suffered from scrofula in any form. 
Among the earlier symptoms complained of were a sense of uneasiness 
in the corresponding knee, and some degree of stiffness in the hip, causing 
a slight halt in the gait. As the affection advanced the lameness in- 
creased, and the boy experienced severe pain in the knee, usually ag- 
gravated during the night and during changes of the weather. Super- 
added to these symptoms were frequent startings of the limb during 
sleep, causing the patient to wake, and even to scream out. On such 
occasions he was in the habit, for several months, of jumping up in bed in a 
species of fright or partial delirium, some time being generally required 
to rouse him sufficiently to make him comprehend his situation. By-and- 
by he was able to exercise only on crutches; his general health began to 
decline, and he became sensibly emaciated. When I first saw him, early 
in November, 1854, he was hardly able to walk or stand, on account of 26 
Tuberculosis or the Hip-Joint. 
the stiffness of the hip-joint; and it was evident that his general health 
had greatly suffered. On examining him I found there was great flatten- 
ing of the nates of the left side, with complete effacement of the groove 
between the thigh and hip, and elevation of the corresponding iliac crest; 
the knee was greatly flexed, and, on holding the boy up in the erect posi- 
tion, it projected several inches beyond the sound one, the heel being, at 
the same time, raised more than two inches from the floor, and the toes 
inverted. Some motion existed at the hip in the direction of flexion, but 
the thigh could neither be extended nor drawn away from its fellow. 
The abdomen was considerably enlarged, but there was an entire absence 
of disease of the glands of the neck. 
A week after I first saw the boy, I applied the actual cautery, with a 
view of establishing a large issue. The eschar separated about the usual 
time, and the resulting sore seemed to be productive of some benefit, as 
was evinced by the diminution of the pain, and the improvement in his 
appetite and sleep, the former of which became quite voracious. About 
the middle of December the tumidity of the abdomen began sensibly to 
increase; he now voided but little urine, and he suffered under great 
embarrassment of breathing, accompanied with frequent and severe 
paroxysms of coughing. It was evident that he was laboring under 
ascites and serious disease of the lungs. Growing gradually worse, he 
expired on the 11th of February, 1855, having for the last fortnight 
labored under excessive oedema of the legs and scrotum, and been unable 
to lie down for a single moment on account of his dyspnoea. 
The body was examined the day after death, with the assistance of Dr. 
William H. Lyle. 
The abdomen contained about three quarts of limpid serum; the peri- 
toneum, especially the pelvic division, was studded with an immense num- 
ber of incipient miliary tubercles; the glands of Peyer were ulcerated over 
a considerable surface, and immediately over each ulcer the serous cover- 
ing was studded with well-developed tubercles. The spleen was filled 
with similar bodies, but they were much larger, and evidently in a much 
more advanced state. The mesenteric ganglions formed a large indu- 
rated mass, each gland being filled with tubercular matter, which, in some 
of them, had advanced toward softening. The pelvic lymphatic ganglions 
were likewise enlarged and tuberculized. The stomach, liver, large bowel, 
and genito-urinary organs were healthy. Both lungs had contracted ex- 
tensive adhesions, evidently of long standing, to the walls of the chest; on 
the right side they were formed by a false membrane at least one-third 
of an inch in thickness, and presenting here and there tubercular de- 
posits. The right lung was much softened, hepatized, and extensively 
tuberculized. Upwards of eight ounces of serum was found on this side of Tuberculosis of the Hip-Joint. 
27 
the chest. The left lung was nearly sound, but contained some tubercles 
at its summit. The heart and large vessels were normal. The bronchial 
ganglions were enlarged and tuberculized. 
The gluteal muscles were pale, indurated, much wasted, and closely 
matted together. The round ligament, and the whole of the capsular, 
except the inner and inferior portion, were destroyed; what remained 
was thickened, indurated, and ragged. The upper extremity of the head 
of the thigh-bone was absorbed, leaving a rough, scabrous surface, par- 
tially incrusted with lymph. The remainder of the head wTas much 
softened and covered with cartilage, which, however, was entirely loose 
over a large space on a line with the great trochanter, as well as thickened 
and softened in its texture. The neck of the bone was hardly half an inch 
in length, and completely horizontal in its direction. The thigh-bone was 
strongly inclined inward, and flexed upon the pelvis. The hip w-as ren- 
dered extremely prominent by the projection of the great trochanter. 
The bottom of the acetabrdum was thickly incrusted with organized lymph, 
and perforated at its iliac side; its edges, which were still covered with 
fibro-cartilage, being softened and partially absorbed. Directly over the 
opening, on the pelvic aspect of the innominate bone, lay an enlarged 
lymphatic ganglion. The head of the thigh-bone still retained its place 
in its socket, though it was drawn up more than half an inch beyond its 
natural situation. The two articulating surfaces were closely united by 
organized and tolerably firm lymph. 
Case lll.—The subject of this case was Harriet, a negress, aged twelve 
years. She had always been healthy, and no member of her family had 
ever had scrofula. A short time before she was attacked with hip-joint 
disease she became affected with inflammation of the eyes, which the 
physician in attendance pronounced to be of a strumous nature. It soon 
yielded to treatment. 
About two years and a half ago, she began to complain of a severe 
pain in the left hip and knee, particularly the latter, which was supposed 
to be of a rheumatic character, and was treated accordingly. Ho amend- 
ment, however, followed; instead of this, the symptoms steadily pro- 
gressed, the local distress increasing in violence, and the limb becoming 
so much contracted at the knee as to cause considerable lameness. The 
pain, at length, after some months, entirely ceased, but the difficulty of 
walking became so great that she was unable to move about without the 
aid of crutches. The general health, meanwhile, was not materially im- 
paired ; she was rather thin, however, and her sleep was occasionally in- 
terrupted by spasmodic twitches of the limb. Such was her condition at 
my first visit, in December, 1854. Upon examination, I found the cha- 
racteristic flattening of the nates, the effacement of the gluteo-femoral 28 
Tuberculosis of the Hip-Joint. 
groove, and the elevation of the iliac crest, with very marked shortening 
of the limb, which was bent at the knee, and inverted at the toes. Every 
attempt to draw it away from the opposite one was attended with severe 
pain, and similar effects were produced by percussion of the knee and 
foot. Pressure over the hip-joint caused considerable uneasiness, but no 
pain, properly so-called. The child was much emaciated, sleeping badly 
at night, and having but little appetite. She was unable to stand, ex- 
cept when assisted, and she experienced frequent attacks of pain at night. 
The application of the actual cautery, a few days after my first visit, 
had the effect of relieving her pain, and of improving her general condi- 
tion. After a few weeks, however, she became worse, being seized with 
a troublesome diarrhoea, which continued to harass her until she died. 
About three weeks before this event, she became affected with a severe 
cough and some dyspnoea, and there was a return of pain in the hip with 
all its original intensity. She now lay constantly on her right side ; had 
fever most of the time, especially at night: the emaciation rapidly in- 
creased, and she died, completely exhausted, on the 18th of February, 
1855, less than two months and a half after I took charge of the case. 
The immediate cause of her death was evidently pneumonia and diarrhoea. 
About a pint of serum was contained in the peritoneal cavity. The 
mesenteric glands were considerably enlarged, and pervaded with tuber- 
cular matter. The alimentary canal, the liver, spleen, pancreas, kidneys, 
and bladder were healthy. Both lungs exhibited evidence of pneumonia, 
but the right in a greater degree than the left, and the former also con- 
tained, especially at its summit, a number of miliary tubercles, for the most 
part in a solid state. 
The gluteal muscles were much reduced in size, pale, indurated, and 
apparently in a fatty condition. The round ligament and all of the cap- 
sular, except the lower posterior portion of the latter, had disappeared. 
The acetabulum was unusually deep, from the absorption of its bony walls, 
which were very rough, and deprived of cartilage. At its centre it had 
the appearance of giving way; and at its supero-posterior part, opposite 
the sciatic notch, was an opening large enough to receive the end of the 
thumb, caused by the detachment of a piece of bone. The margins of 
the acetabulum retained their natural sharpness and covering. The pubic 
bone was ulcerated and softened at its cotyloid extremity. The neck of 
the thigh-bone was abnormally short and horizontal, and encircled by the 
remains of the capsular ligament. About one-half of the head was gone, 
the portion which was left having a rough, scabrous surface, the exterior 
of which was covered with cartilage in a state of inflammation and par- 
tial softening. 
Case IY.—Timothy Connelly, twenty-six years old, a day-laborer, of Tuberculosis oe the Hip-Joint. 
29 
intemperate habits, and a native of Ireland, was admitted into the Louis- 
ville Marine Hospital, on the 3d of September, 1854, on account of disease 
of the left hip-joint, first perceived six months previously. The earliest 
symptom in the case was a pain in the joint and its immediate vicinity, 
accompanied with slight swelling, which gradually increasing in severity, 
at length extended down the limb as low as the middle of the thigh. 
At the time of his entrance he was unable to use the limb in standing or 
walking, and he complained of severe pain in the hip, knee, and back. 
The thigh was somewhat flexed on the pelvis, the heel was raised upwards 
of two inches from the ground, and the foot was inverted. During the 
last two weeks the swelling of the thigh had much increased, and the parts 
were now quite tender on pressure, with a distinct sense of fluctuation. A 
free incision being made, a large quantity of dark-colored and offensive 
matter was discharged, evidently scrofulous in its character. A tent was 
introduced to promote the escape of pus, which continued for several 
weeks. The man was placed on tonics and alteratives, under which he 
seemed to improve somewhat. Sometime after, the opening in the ab- 
scess being permitted to close, matter again accumulated in the sac, re- 
quiring another puncture. This was made on the 28th of November, 
before the medical class at the Hospital, and gave vent to about sixteen 
ounces of ill-elaborated and fetid pus. A tent was again inserted, and the 
patient was put upon the use of tonics with a nutritious diet. But little 
improvement followed, debility being a prominent symptom, although there 
was seldom any pain in the hip or knee, except when he attempted to walk. 
On the 10th of January, 1855, the man was again brought before the class, 
when I laid open a long sinus, extending along the antero-external part 
of the thigh, toward the interval between the great trochanter and the 
anterior spinous process of the ilium, the incision being at least eight 
inches in length. The same treatment was continued, with the addition 
of a compress and bandage to the affected limb. 
On the Ist of March, when my tour expired, the wound was still un- 
closed, discharging daily a small quantity of unhealthy-looking pus, and 
manifesting but little disposition to heal The patient was gradually grow- 
ing weaker, and now complained of a great deal of pain in the hip-joint 
and lumbar region. Cough, and a sense of constriction above the chest, 
accompanied with a dull pain, were a source of frequent annoyance to him. 
The progressive emaciation and debility, with other corroborative symp- 
toms, led to the suspicion that the original affection was now complicated 
with pulmonary phthisis, and the suspicion was fully verified by a careful 
examination. He continued gradually to decline, and died, completely 
exhausted, on the 3d of May, 1855, 
The body being inspected two hours after death, the legs and feet were Tuberculosis or the Hip-Joint. 
found to be quite oedematous; the left foot and knee were much inverted; 
and the limb was an inch and three-quarters shorter than the sound one. 
The peritoneal cavity contained upwards of a quart of water, but all the 
abdominal viscera were sound. The kidneys, supra-renal capsules, bladder, 
and prostate gland were free from disease. The lungs contained crude 
disseminated tubercles at their summits,—a few verging on softening. 
Similar deposits were found in the bronchial lymphatic ganglions. The 
pleura and the heart wore normal. The brain was not examined. 
The acetabulum was completely denuded of cartilage, very rough, and 
of an unnaturally darkish color; its edges being beveled off, it presented 
an elongated, ovoidal shape, being three inches in height and two inches 
and a half in breadth. The capsular and round ligaments were entirely 
destroyed, but the transverse was apparently unaffected. Extending in- 
ward, along the ramus of the pubic bone, was a large sinus, filled with a 
black, offensive fluid, which also existed, in considerable quantity, in the 
joint itself. The head and the whole of the neck of the thigh-bone, ex- 
cept a short, thick, rough stump, had disappeared. The great trochanter 
rested against the upper edge of the cotyloid cavity, the upper extremity 
of the latter being received into a small depression of the former. From 
the flexed position of the shaft of the bone, the trochanter lay across the 
acetabulum in an oblique direction, and consequently much nearer both 
to the spine of the ilium and the sacro-sciatic notch than in the natural 
state. The articulating surfaces were firmly united by plastic matter, and, 
although their relative position was greatly altered, there was no disloca- 
tion. The gluteal muscles were much attenuated, very pale, indurated, 
and matted together. Some of their fibres had evidently undergone the 
fatty degeneration. 
Case Y.—Thomas Farrell, Irishman, aged twenty-three, laborer, with 
black hair and eyes, pale complexion, and delicate constitution, was ad- 
mitted into the Louisville Marine Hospital, February 17th, 1852, for what, 
at the time, was supposed to be typhoid fever. His principal symptoms 
were cough, muco-purulent expectoration, and hectic irritation, under 
which, becoming gradually exhausted, he expired on the 16th of March. 
He had had hip-joint disease some years previously, but had so far re- 
covered from it as to have been induced to believe that a spontaneous 
cure had taken place. 
The dissection was made several hours after death. The body was 
sallow, and much emaciated The right lower extremity was three inches 
shorter than the left, the toes were much inverted, and the sole of the foot 
rested against the instep of the sound one. The knee was also turned 
inward, and three inches above the opposite one, but not in advance of it. 
The great trochanter was extremely prominent, and distant three inches and a Tuberculosis of the Hip-Joint. 
31 
quarter from the antero-superior spinous process of the ilium. Four old scars 
existed in the groin and round the great trochanter. The gluteal muscles 
were much wasted, and transformed almost completely into a pale, whitish, 
fatty, and fibrous substance. The head and neck of the thigh-bone had 
been absorbed, being represented by a hard, ivory-like, rough, scabrous 
knob, mounted some distance above the acetabulum upon the iliac bone, 
where it had formed a superficial socket, extending into the original 
cavity, which was filled up by osseous matter. The new joint thus formed, 
however, hardly admitted of any motion, and some force was required to 
break up the adhesions between the contiguous surfaces. The capsular 
ligament immediately round the new joint was very dense, and nearly three 
lines in thickness. All the rotator muscles of the limb were pale and 
atrophied, while the psoas and iliac muscles were completely transformed 
into fibrous tissue. 
Both lungs were crowded with gray granulations, which were particu- 
larly abundant in the summits of these organs. In none of them had the 
softening process commenced. Both lungs were of a dark-purple color, 
heavy, and much engorged with blood. Ancient adhesions existed on both 
sides, but more extensively on the left than the right. The bronchial tubes 
and the lymphatic ganglions were sound; as also the heart. 
The spleen, liver, and kidneys, especially the first, contained an immense 
number of tubercles, discreet, small, rounded, and solid. Of those in the 
liver, which was of the normal bulk, many were tinged with bile. The 
spleen was considerably hypertrophied, and the kidneys, particularly the 
left, were of unnatural size. The ureters, bladder, and prostate gland were 
healthy. Many of the mesenteric ganglions were enlarged and tubercu- 
lized. The stomach, bowels, and pancreas were natural. 
Case Yl.—The following case is subjoined as exhibiting the state of 
the part and system in a somewhat advanced stage of the disease:— 
Mary Ziegler, German, aged six years, light hair, eyes, and complexion, 
was seized with symptoms of hip-joint disease, in October, 1854. In the 
month of June previously she had a severe attack of cholera, which left 
her, until late in the season, in a very feeble and emaciated condition. Up 
to this time she had always enjoyed good health. The affection of the 
hip-joint came on without any assignable cause. During the first few 
months the child suffered excruciatingly both day and night, the pain 
shifting about from the hip to the knee, and from these parts to the ab- 
domen and the lower dorsal vertebrae, which, as was very apparent from 
their posterior curvature, must also have been the seat of tuberculosis. 
The upper and inner portion of the thigh was likewise a frequent seat of 
severe pain. In consequence of the violence of her suffering the little 
girl was deprived of sleep and appetite, and became again rapidly and 32 
Tuberculosis op the Hip-Joint. 
greatly emaciated. Toward the spring of 1855 slie began to improve for 
a short time, and the parents flattered themselves that she would gradually 
recover. These hopes, however, proved delusive, for after a few months 
all her distress returned, and late in the season, that is, sometime in 
November, a large abscess formed in the upper and forepart of the thigh, 
just below the groin, and soon breaking, discharged upwards of a pint of 
pus. This afforded great relief, for previously to this event, for several 
months, she endured excessive pain. This opening still existed, together 
with another on the inside of the thigh, near the groin, and one on its 
posterior surface, about two inches below the great trochanter. The dis- 
charge from them was very slight. 
The present condition of the child, March 11th, 1856, is as follows: 
She is in great degree free from pain, rests well at night, sits up nearly 
constantly in the day, and has a pretty good appetite, with a reasonable 
share of flesh and strength. She has still some diarrhoea, under which she 
has labored, more or less, ever since the commencement of her illness. The 
right hip is much larger than the left, as well as more flat, and consider- 
ably elongated transversely. The crease between the thigh and buttock is 
effaced, and the swelling extends, in a tapering manner, as far down as the 
upper third of the thigh. The surface feels hard, and has a perfectly smooth 
appearance, except at the site of the trochanter, where it is a little rough. 
The trochanter itself is quite prominent and firmly fixed in its new posi- 
tion. The thigh is in close contact with its fellow, and considerably flexed 
on the pelvis; the knee is in advance of and above the other; the leg is 
flexed on the thigh, and the foot is extended on the leg. When the child 
stands up the foot looks directly forward, but by taking hold of the ankle 
and moving it, it can be slightly inverted or everted. When in this po- 
sition she supports herself on the ball of the toes, the heel being elevated 
upwards of two inches from the floor. The spine, at the lumbar region, 
inclines a little over toward the affected side, and the iliac crest on that 
side is somewhat higher than that of the left. The projecting dorsal ver- 
tebrae are quite prominent, but free from pain and tenderness. The proba- 
bility is that the morbid action is suspended, and that a spontaneous cure 
is taking place. 
VI.—Prognosis. 
Tuberculosis of the hip-joint is essentially a chronic disease, which, after 
having endured for an indefinite period, terminates either in recovery or 
in death. The recovery may be complete, both as it regards the part 
and system, or, the local action disappearing, the joint may be left weak 
and anchylosed, and the general health regain its original vigor; or, as 
not unfrequeutly happens, particularly after the process of disorganization Tuberculosis op the Hip-Joint. 
33 
has commenced, both the articulation and the constitution may remain in 
a degraded and crippled condition for a long time, or even during the rest 
of life. No mortuary statistics of this affection have yet been furnished, 
and it is, therefore, impossible to state, with any degree of precision, 
the mean duration of fatal cases, or the relative proportion of deaths to 
recoveries. My opinion, founded upon numerous observations, is, that the 
mortality from the disease is slight in almost any event, even where there 
has been palpable neglect in regard to treatment, medical, surgical, and 
hygienic. In this view, I believe, most writers fully concur. When death 
does take place, it rarely happens before the eighteenth month, and very 
often not until after the second year. 
Many circumstances, mostly of an individual nature, conspire to influence 
the prognosis in this disease. So much, in truth, is this the case, that it 
is utterly impossible to lay down any definite rules for the guidance of the 
practitioner. Much will, doubtless, depend, in every instance, upon the 
state of the constitution, the presence or absence of complications, and, 
above all, upon the duration of the malady. Age also exercises an im- 
portant influence. It is a well-established fact that, other things being 
equal, children will live longer, and also stand a much better chance for 
recovery, than young adults and middle-aged subjects, in whom, especially 
the latter, the disease often proceeds with extraordinary rapidity, some- 
times ending fatally in a few months. When the constitution is naturally 
feeble, or when it has been rendered so by the intensity of the local suffer- 
ing, the probability of an unfavorable termination will be much increased. 
Imperfect alimentation, however induced, is another source of mischief, 
both as it respects the part and system. Intercurrent maladies, such 
as typhoid, intermittent, and eruptive fevers, diarrhcea, dysentery, and 
erysipelas, often retard recovery, or hasten the fatal crisis. These and 
other diseases, by establishing a drain upon the system, already exhausted 
by the local suffering, are, I am satisfied, the principal causes of the mor- 
tality in strumous affections of the hip-joint. When the malady proves 
fatal without such intervention, it will generally be found that death is 
directly due to the depressing effects of tuberculosis of the lungs, lymphatic 
ganglions, spleen, or peritoneum, which is so liable to show itself under 
such circumstances. 
Much of the mortality of this disease, as well as most of the bad effects, 
both temporary and permanent, which it entails upon the affected articu- 
lation, results from neglect of appropriate management, prior to the com- 
mencement of the disorganizing process. Properly treated at its begin- 
ning, it is, at least in the majority of cases, as amenable to our remedial 
agents as any ordinary chronic inflammation, although not generally so 
promptly. The morbid action gradually receding, the effused materials 34 
Tuberculosis of the Hip-Joint. 
are by degrees absorbed, and the parts restored to their normal functions. 
Arrived at its second stage, hardly any course of medication, however 
judiciously applied, will completely avert permanent rigidity, although life 
may not be at all in jeopardy. The morbid impression has already ad- 
vanced too far to admit of easy recession; a certain amount of organic 
lesion is present, and the patient may congratulate himself if he ever com- 
pletely regains the use of his hip. In the third stage, when the osseous, 
cartilaginous, and other structures are disintegrated and broken down; 
when, perhaps, the interior of the joint is converted into a large chronic 
abscess; when the lower extremity is shortened and stiffened, and, finally, 
when the constitution is worn out by pain and hectic irritation; there will 
not only inevitably be loss of function, but also danger of loss of life. If, 
under such circumstances, the patient survive, his recovery will be effected 
at the expense of much suffering, too often eventuating in premature decay 
and dissolution. 
Yll.—Treatment. 
In the treatment of this affection, which, if our notions of its pathology 
be well founded, is, like scrofulous disease in general, merely a local mani- 
festation of a constitutional vice, topical remedies alone will not avail; 
to prove efficient and truly useful they must be combined with and aided 
by means addressed to the general system with a view to the improve- 
ment both of the solids and fluids. It would be idle, in the present state 
of the science, to insist upon a course so palpably proper in itself and so 
long sanctioned by experience. As well might the practitioner expect 
to be able to cure consumption, or to ameliorate the condition of a person 
thus affected by the exclusive employment of counter-irritation and other 
external measures, as to cure tuberculosis of the hip-joint without the 
aid of constitutional remedies. Again, in treating this disease it should 
not be forgotten that it consists of different stages, which, although they 
run into each other by imperceptible gradations, are nevertheless of vast 
importance in a practical point of view. 
Whatever may have been the duration of the malady when the treat- 
ment is commenced, the first and most essential element in the manage- 
ment of every case of the kind is repose, not merely of the limb alone, 
but also of the body,—repose absolute, unconditional, and persistent. 
Upon this subject there must be no compromise between the patient and 
his attendant. The contract entered into at their first interview must be 
observed with the most scrupulous fidelity,—it must be both binding and 
permanent. The slightest departure from this injunction would in any 
stage of the complaint be of great detriment to the patient’s limb, while 
in its more advanced stage, when the bones and cartilages are destroyed Tuberculosis op the Hip-Joint. 
35 
and matter exists in the joint, it might seriously jeopard his life. Re- 
cumbency must be observed for months upon months. Too mucb stress 
cannot be placed upon this point, when it is remembered how important 
it is to keep parts, comparatively insignificant, perfectly at rest when in a 
state of suffering. In inflammation of the fingers and toes repose and 
elevation of the affected structures are instinctively sought, and, if possi- 
ble, maintained until the morbid action has in a great degree subsided and 
function been restored. Now, if this be necessary in ordinary inflamma- 
tion and in textures which have no important uses and sympathies, how 
much more necessary is it when the malady is of a specific nature and 
the organ involved is so important as that of the hip-joint? These 
facts are well known to practitioners, but the common people are igno- 
rant of them, and hence they should always be thoroughly explained to 
the patient and his friends at the very threshold of the treatment. 
In order to render the patient as comfortable as possible, and enable 
him to endure his protracted confinement without detriment or incon- 
venience, he must be furnished with a suitable bed provided with slats 
and a firm but elastic mattress. A common trundle-bed, about four feet 
in width, will answer every purpose, and is in every respect preferable to 
the common bed, especially if the patient is a child, as he will thus be 
less liable, if he should roll out, to hurt himself. The sheet should be 
well secured at the sides that it may not become rumpled, and the pillow 
should be of medium size, so that, while it affords adecpiate support to 
the head and shoulders, no undue weight may be thrown upon the trunk 
and pelvis. The confinement, if rigidly insisted upon, will not prove 
irksome; with the aid of toys and other sources of amusement the little 
patient will soon,—often, indeed, in a few days,—become reconciled to his 
new mode of life. 
The local remedies must be regulated by the progress of the malady 
and the constitution of the patient. If the disease be in its first stage, 
if the pain be violent and frequent in its recurrence, and if the general 
health remain unimpaired, we can scarcely fail to derive special benefit 
from the application of leeches, or, in their absence, from the use of a 
large blister. The leeches should be scattered over the affected joint, 
and after they have dropped off, the flow of blood should be promoted 
for some time with cloths wrung out of warm water and frequently re- 
newed. Their number must depend upon circumstances, but in general 
from six to eight will be sufficient for a child from three to six years of 
age. Sometimes a blister may be applied advantageously within a few 
days after the leeching, and I much prefer this mode of counter-irritation 
to the employment of liniments, embrocations, croton oil, tartar emetic 
ointment, and iodinized lotions, which is always attended with friction, 36 
Tuberculosis op the Hip-Joint. 
and for that reason often prejudicial to the inflamed structures. By 
these means, aided by a plain, simple diet, consisting mainly of farinace- 
ous articles, with milk, weak tea, or milk and water, at breakfast and 
supper, and an occasional purgative of from two to three grains of blue 
mass with double that quantity of jalap, most of the cases that are 
brought under the notice of the practitioner may be radically cured in a 
few months. If fever be present, or if there be decided plethora, as 
denoted by the state of the pulse and face, the antimonial and saline mix- 
ture may be given in such doses and at such internals as the nature of the 
case may seem to require. When the pain is so severe as to interrupt 
sleep, opiates must be used with warm anodyne poultices or fomentations, 
or, what I have found to be of greater benefit, a lotion composed of three 
parts of soap liniment and one of acetated tincture of opium with from 
half a drachm to a drachm of carbonate of potassa to the ounce, applied 
by means of a fold of flannel, kept constantly wet, and covered with 
gutta-percha. Cold applications are generally inadmissible both in this 
and in the other stages of the disease. Where the skin is unusually dry, 
or the system more than commonly irritable, the warm bath, carefully 
administered for half an hour at a time, with a Dover’s powder at night, 
is sometimes highly beneficial, but great care must be used in its adminis- 
tration lest the affected joint sustain injury. 
Such is an outline of the treatment which, according to my experience, 
will usually be found most serviceable in the earlier stages of the com- 
plaint. There is, however, not a little diversity in regard to the nature 
of the internal remedies required in different cases. As already stated, 
there are two distinct classes of patients, the plethoric and the ananniac, 
those with an apparently rich blood and those with an impoverished 
blood, and hence two very opposite courses of treatment are frequently 
necessary, the former demanding perhaps a certain amount of depletion, 
while the latter will be most benefited by tonics. I have not met with 
any cases where I thought the use of the lancet was indicated, and yet I 
am not prepared to say whether, when the inflammation and pain are very 
great, in a strong, robust child, soon after the commencement of the 
malady, venesection, to a small extent, might not be highly beneficial, 
tending to retard the suppurative crisis, and to prevent the destruction 
of the osseous and cartilaginous tissues ; in general, however, the remedy 
would be too harsh, and I am satisfied that the morbid action may be 
sufficiently repressed by the antimonial and saline mixture, in union with 
a minute quantity of tincture of aconite, assisted perhaps by the applica- 
tion of a few leeches to the seat of the disease. In the antennae, a not 
uncommon class of cases, tonics and stimulants are often required at the 
very commencement of the disease, consisting either of quinine and iron. Tuberculosis of the Hip-Joint. 
37 
or, what is peculiarly valuable under such circumstances, cod-liver oil, 
in such doses as shall not prove offensive to the stomach. The diet 
should of course be of a corresponding character, and the patient should, 
if possible, be induced to use milk-punch, wine, ale, or porter, in order 
to rebuild the system, and thus enable the affected parts the more effec- 
tually to resist the encroachments of the morbid action. 
I am not an advocate, as a general rule, for confining the affected limb 
in splints, as is the custom of many practitioners, with a view of securing 
more perfect rest of the joint. The patient himself will usually instinct- 
ively take care of this. It is only or chiefly when the limb is much 
out of shape, or in a position in which, if permanently retained, its use- 
fulness would be seriously impaired, that I have found such a proceeding 
either necessary or desirable. The restraint occasioned by all such con- 
trivances is generally exceedingly irksome to the child, and is often, I am 
sure, productive of harm rather than of benefit. When the malposition 
of the extremity is considerable, the first thing to be done, provided 
there is as yet no great structural lesion, is to rectify this by extension 
and counter-extension, aided, if necessary, by rotation and abduction, 
the patient being under the influence of chloroform, and then to apply a 
suitable apparatus for maintaining the limb in its new relations. The 
best material is gutta-percha, undressed sole-leather, or trunk-maker’s 
board, soaked in hot water, and adapted to the hip, thigh, and leg, being 
kept in place by a common roller. When dry, these articles form an 
admirable case, which may afterwards be padded with cotton to ward off 
pressure, and which will thus effectually prevent motion not only of the 
hip but also of the knee and ankle. 
The attempts at rectifying the malposition of the limb are occasionally 
annoyingly counteracted by the contraction of the principal adductor 
muscles of the thigh, especially the pectineal and short adductor, which 
are sometimes so much shortened as to draw .the extremity nearly across 
the sound one. When this is the case, the most expeditious plan is to 
divide these muscles subcutaneously; and the effect of such an operation 
upon the future welfare of the part and system is often most striking, the 
pain and spasm being relieved as if by magic, and the limb becoming 
perfectly docile and manageable. 
In the second stage of the affection, the only reliable local remedy, ac- 
cording to my experience, is a large issue, for the purpose of securing a 
free and permanent discharge of matter. If the case have not been seen 
before it has reached this crisis, some of the means already mentioned, as 
leeching and blistering, may be tried; but, unless they are promptly bene- 
ficial, no time should be wasted in their employment. The disease is now 
thoroughly established, and must be met in the most decisive manner, if 38 
Tuberculosis of the Hip-Joint. 
we would wisli to avo:d its disorganizing and destructive consequences. 
The best place for making the issue is the most prominent part of the 
swelling, which is usually either directly over the joint or in its immediate 
vicinity. It is reasonable, a priori, to suppose, that the nearer the dis- 
charge is established to the diseased structures, the more likely will it be 
to be useful; and this is precisely what experience has shown to be the 
fact. The place of election, then, is a circumstance of great importance, 
and should not be overlooked. 
The most eligible form of issue is that made with the actual cautery. 
The patient being under the influence of an anaesthetic, the iron, heated 
to whiteness, is gently pressed upon the part until a suitable eschar has 
been formed; one about the size of a twenty-five cent piece, if the patient 
be very young, or twice that size, if he be twelve or fifteen years old. 
The slough, which should not extend beyond the subcutaneous cellular 
tissue, will generally drop off within the week; and, during this period, as 
well as afterwards, the parts should be kept constantly covered with a lin- 
seed poultice, renewed several times in the twenty-four hours. The dis- 
charge, if flagging, may be promoted by savine ointment, by simple cerate 
containing a few drops of nitric acid to the ounce, or, what I prefer, the 
occasional application, for a few hours, of a small blister. In this man- 
ner I have known an abundant pyogenic discharge maintained for the 
greater part of a year. The cautery may, if necessary, be reapplied at 
any time during the progress of the treatment. 
I give the hot iron a decided preference, for making an issue in this 
disease, to all other modes of cauterization, as affording not only a more 
copious and persistent flow of pus, but, what is of no little importance, 
making a much stronger, as well as a more permanent, impression upon 
the part and system. It is impossible always to determine how long the 
suppurative action should be kept up; but it will be found to be a good 
rule to let it continue until there is reason to believe that the morbid pro- 
cess, for the relief of which it was instituted, has completely subsided. I 
have never, in any instance, experienced any bad effects from its pro- 
tracted continuance; indeed, quite the contrary has been the case. If 
the discharge becomes offensive, as it often does in warm weather, or 
where proper attention to cleanliness is not observed, the chlorides will 
come in play, with a more frequent change of dressings. Occasionally 
the linseed poultice oppresses by its weight, or it causes painful and 
itchy eruptions around the sore ; when this happens it must be temporarily 
suspended, or be replaced by some more suitable application. 
Independently of the advantages here alluded to, as being afforded by 
the issue made with the hot iron, there is another of nearly equal, if not, 
indeed, greater value. I allude to the fact that it may be used most Tuberculosis of the Hip-Joint. 
efficiently for the local application of morphia, not so much for inducing 
sleep, as with a view of allaying the excessive pain of the parts, and the 
spasmodic jerkings of the muscles of the limb. Employed in this wise it 
acts, according to my observation, much more promptly and energetically 
than when administered by the mouth. The quantity necessary to pro- 
duce the desired effect will, of course, depend upon circumstances; but, in 
general, from half a grain to a grain will be required for a child three or 
four years old. Sometimes an injection of laudanum, or an opiate suppo- 
sitory, will allay the pain and quiet the system more effectually than any- 
thing else. 
In regard to the patient’s diet, in this stage of the disease, the same 
rules should govern us as in the preceding stage; but it should, if pos- 
sible, be somewhat more restricted, especially if there be much pain, with 
occasional fever. The bowels should also be maintained in an active con- 
dition, the best general purgative being a few grains of blue mass, with a 
suitable quantity of jalap, or the compound calomel pill. Salines and 
nauseants will rarely be required. If the patient labors under symptoms 
of debility, as denoted by the pallor of his countenance, the coldness of 
the extremities, and the disorder of the digestive organs, tonics, especially 
quinine and iron, should be employed, along with a more generous diet 
and nutritious drinks. 
In the third stage, characterized by serious structural lesion, and the 
formation of matter, the treatment will require to be essentially modified, 
to meet the local and constitutional contingencies. Prior to this period, 
it was, if not decidedly antiphlogistic, at all events rather of a depressing 
character, intended to subjugate inflammation and establish resolution; 
now that the morbid action has gained the ascendency, and exhausted 
both part and system, a widely different course is demanded. 
Two most important indications are presented, in almost every case, at 
this stage of the complaint. The first is to limit the suppurative process; 
the second, to promote the speedy absorption of the effused fluid. To 
fulfill either is generally no easy task; for experience has proved that there 
are few cases in which our efforts, however skilfully conducted, are crowned 
with success. When the suppurative process declares itself by well-marked 
symptoms, as rigors, alternating with flushes of heat, and followed by 
copious sweats, something may be done to moderate its violence by the 
steady and energetic use of antiphlogistics; but, in general, it will be 
found that the patient is either too feeble to justify their employment, or 
that the disease has been so insidious in its approaches as to defy recog- 
nition before the mischief has been completed. It has been seen, however, 
that matter does not always attend this stage, and that when it does, it 
often exists only in small quantity. Now it is in the latter class of cases, 40 
Tuberculosis of the Hip-Joint. 
more particularly, and in those where the suppurative process can be 
carefully watched from its very inception, that strenuous and persistent 
efforts should be made to prevent its accumulation, with its concomitant 
mischief. For this purpose the affected hip should be painted at least 
twice a day with some sorbefacient lotion, such as equal parts of tincture 
of iodine and alcohol, or a weak solution of iodine and iodide of potas- 
sium, care being taken that, while applying it efficiently, it is not put on 
so freely as to cause pain or irritation beyond a few minutes. The object 
should be merely to excite the absorbents, the capillaries being fully kept 
in abeyance; otherwise injury, not benefit, will be likely to result. Some- 
times a large blister answers a good purpose; retained just sufficiently 
long to produce slight vesication, and repeated every four or five days for 
several successive weeks. Thorough or protracted vesication is to be 
avoided, as likely to prove detrimental, from its irritating effects, both 
upon the part and system. If the disease has not yet advanced too 
far, if the abscess is still small, and, above all, if the suppurative process 
be attended with great pain and constitutional disturbance, I know of no 
remedy so well calculated to fulfill the present indication as the actual 
cautery, applied in such a manner as to produce a broad but superficial 
issue. My experience teaches me that, even in this stage of the malady, 
when everything is apparently most unpromising, more benefit will, in 
general, accrue from this mode of counter-irritation than from any other 
with which we are acquainted. It will not only, in many cases, promote 
the absorption of the pus that is already effused, but materially curtail the 
suppurative process, and at the same time greatly ameliorate the local 
distress. If the accumulation be very large, the remedy must, of course, 
be dispensed with, and artificial evacuation encouraged. 
Along with the local remedies just pointed out, should be used certain 
internal means, to aid and expedite their sorbefacient action. At the 
head of the list may be placed mercury, especially the iodide and bichlo- 
ride, administered in small quantities several times a day, and properly 
guarded by opium, to prevent them from griping and purging; the iodide 
of potassium and Lugol’s solution are also valuable remedies. Ptyalism 
is of course avoided, and the strength is sustained with tonics, a generous 
diet, and nutritious drinks. 
If these means fail, or if the abscess be already very large when we are 
called to the case, the matter should be evacuated artificially. I am aware 
that, upon this subject, there is generally a great deal of repugnance 
evinced by practitioners, on the supposition that any interference of this 
kind will only tend to aggravate the local disease, and cause hectic irrita- 
tion. To such a view, however, I cannot subscribe. On the contrary, I 
can see no just reason why the general rules of surgery should be departed Tuberculosis of the Hip-Joint. 
41 
from in this disease any more than in others. It is well known that mat- 
ter, wherever and whenever existing in large quantity, invariably does 
harm; for, not only is it apt to burrow extensively among the surrounding 
parts, but it must necessarily, by the pressure which it exerts upon the 
inflamed surfaces with which it is in contact, increase the pain, and effect- 
ually prevent the restorative process. That this is the case in regard to 
extensive purulent collections generally is a fact so well established as to 
require no argument in its support, and if there be any exceptions respect- 
ing such accumulations in the hip-joint I am not aware of them. My con- 
viction is, that practitioners, influenced by the dogmas of the schools 
rather than by their personal experience and the dictates of common 
sense, have seriously erred in their treatment of strumous abscess of the 
ileo-femoral articulation, and been thus directly instrumental in the pro- 
duction of much mischief. In their endeavor to avoid too early an outlet, 
they have too frequently allowed themselves to wander into the opposite 
extreme, and neglected to make any opening at all: in other words, in 
attempting to steer clear of Scylla they have unwittingly rushed into Cha- 
rybdis. The proper plan, undoubtedly, is, in all cases where the absorption 
of the matter is no longer a probable event, to promote its escape by the 
knife. It is the one which I have invariably pursued in all joint diseases 
for upwards of twenty years, and in no instance have I seen any reason to 
regret it. In this manner vast suffering is avoided, as well as much struc- 
tural lesion prevented, as is abundantly shown by the numerous and tortu- 
ous sinuses which so frequently form in the hip when the disease is left to 
pursue its own course. The artificial opening, however, is not to be made 
heedlessly, or without due attention to the permanent exclusion of the air, 
which, although in itself innocuous, often proves pernicious, from its ten- 
dency, when brought in contact with the pent-up fluids, to favor decom- 
position, and, consequently, the development of hectic irritation. These 
effects may generally be prevented by giving the opening a valvular 
form, as in evacuating chronic abscesses in other situations, by making a 
puncture rather than an incision, and by closing the orifice, immediately 
after the operation, with adhesive strips, supported by a light compress 
and bandage. If the quantity of matter be unusually large, a portion 
only should be drawn off at a time, the process being repeated in a few 
days until the whole is removed; but ordinarily the sac may be emptied 
advantageously at the first operation. 
As soon as the fluid has been evacuated, whether partially or com- 
pletely, a full opiate should be administered, in order to prevent undue 
reaction; and, if the joint becomes painful, warm anodyne fomentations 
should be used, until relief is afforded. Afterwards, with a view of mode- 
rating suppuration, the parts are painted regularly once a day with some 42 
Tuberculosis oe the Hip-Joint. 
sorbefacient lotion, a linseed poultice or the warm water dressing being 
used as the permanent application. 
If sinuses form, whether as a result of spontaneous or artificial 
evacuation, the best plan is not to interfere with them, as the pain and 
loss of blood consequent upon the employment of the knife would more 
than counterbalance any good effects from the operation. If loose frag- 
ments of bone, or pieces of cartilage, present themselves, they should, of 
course, be promptly extracted. 
The violence of the suppurative action having been subdued, the plastic 
deposits are best dealt with by sorbefacient plasters, applied so as to em- 
brace the whole of the affected surface, and steadily worn for many weeks. 
Of these plasters, the most useful, for this purpose, is the ammoniac and 
mercurial, under the influence of which the induration and swelling often 
disappear with astonishing rapidity. If much pain be present, a suitable 
quantity of morphia, opium, or cicuta may be incorporated with its ingre- 
dients. 
During the latter part of this stage tonics and stimulants are usually 
indicated, and often imperatively demanded, by the exhausted state of the 
system. The patient, emaciated and anasmiac, must be supported with 
quinine and iron, cod-liver oil, a generous diet, and nutritious drinks, as 
milk-punch, wine-whey, ale, or porter. If night-sweats be present, the 
most suitable remedy will be the aromatic sulphuric acid, cither alone or 
in union with Huxham’s tincture of bark. Diarrhoea and pain must be 
checked with opiates. The patient’s apartment should be frequently ven- 
tilated, and the surface of the body should be daily washed with tepid 
salt-water, followed by dry frictions. Exercise in the open air is now 
generally of much service, and may often be taken by the little patient 
himself, seated in a go-car, and propelled gently round the yard, or over 
a smooth road. Carrying him about in the arms is highly objectionable, 
on account of its tendency to hurt the joint, by pressing the affected limb. 
In a word, nothing should be omitted that may tend in the slightest degree 
to invigorate the system and improve the health. 
When the extremity of the thigh-bone is necrosed, or so completely 
carious as to forbid all hope of recovery by time and ordinary means, the 
soft parts being ''riddled with sinuses, and the discharge copious and ex- 
hausting, excision of the diseased parts will be demanded, and should, if 
life be not too far exhausted, be promptly executed, as most likely to 
rescue the patient from impending death. The object of the undertaking, 
of course, is to remove all the ulcerated structures, and hence the surgeon, 
after having exposed the joint, should not limit himself merely to the 
thigh-bone, but perform a similar operation, if necessary, upon the margin 
and bottom of the acetabulum. The disease being thus arrested, the part Tuberculosis or the Hip-Joint. 
43 
and system will be placed in a much better condition for gradual and per- 
manent recovery, provided the shock of the operation is not so severe as 
to destroy life, either immediately or consecutively. With proper care after 
the excision, it may even be possible to preserve a certain degree of mo- 
tion between the contiguous bones. In an interesting and instructive 
paper on “Excision of the Head of the Eemur, and Removal of the 
Upper Rim of the Acetabulum, for Morbus Coxarius,” by Dr. Lewis 
Sayre, of New York, an analysis of thirty cases, including one by himself, 
is given, of which twenty recovered, and ten died, four of them within one 
week after the operation. It would thus appear that excision of this joint 
is by no means devoid of danger, although the mortality is much less than 
after amputation of the hip-joint. The statistics of Dr. Sayre have re- 
cently been extended by Dr. R. A. Kinloch, of Charleston, South Caro- 
lina, with no material variation, however, as to the results. In the case 
operated upon by himself, death occurred in less than thirty hours from 
exhaustion. 
The operation may be conveniently performed by making a curved in- 
cision, from five to six inches in length, perpendicularly over the joint, in 
a line with the great trochanter, separating the parts, and cutting off the 
diseased structures with the saw or pliers. If more room be required, the 
incision may be crucial, or in the form of aTor Y. The flaps are after- 
wards approximated with stitches and plasters, and the immobility of the 
limb is secured by appropriate splints, pads, and bandages, as in fracture 
of the thigh-bone. 
When the patient has been exhausted by protracted suffering, and life 
is fast ebbing away, it has been proposed, as a dernier resort, to amputate 
at the hip-joint; and the records of surgery contain several examples in 
which the operation has been followed by the most gratifying results. 
Notwithstanding this, however, I should hesitate before undertaking so 
grave a procedure, the more especially as the same end may generally be 
more readily attained by the more simple and less dangerous operation of 
excision.