The Relation of Suppuration to Shortening of the Limbs in Tuberculous Diseases of the Hip Joint. A Study of One Hundred and Six Cases. BY RUSSELL A. HIBBS, M. I)., House Surgeon to the New York Orthopaedic Dispensary and Hospital; Late Assistant to the Chair of Orthopaedic Surgery in the University Medical College. Yorfe f&eTu'cal journal for November 5, 1898. REPRINTED FROM THE Reprinted from the New Tori', Medical Journal for November 5, 1898. THE RELATION OF SUPPURATION TO SHORTENING OF THE LIMBS IN TUBERCULOUS DISEASES OP THE HIP JOINT. A STUDY OF ONE HUNDRED AND SIX CASES. RUSSELL A. HIBBS, M. D., HOUSE SURGEON TO THE NEW YORK ORTHOPEDIC DISPENSARY AND HOSPITAL; LATE’ ASSISTANT TO THE CHAIR OF ORTHOPAEDIC SURGERY IN THE UNIVERSITY MEDICAL COLLEGE. Suppuration in connection with tuberculous disease of the hip joint and the relation it bears to the shorten- ing of the limb can only be determined by a study of cases of both varieties of the disease existing under simi- lar conditions and being treated by the same methods. The tabulated report of the following number of cases, one hundred and six in all—forty-seven of the non-suppurative variety. Table I, and fifty-nine of the suppurative variety. Table ll—is made with the object in view of determining this question. The writer realizes that conclusions based upon a clinical study of so small a number of cases can not be considered final, but hopes that such study, and the con- clusions drawn therefrom, may be of some value in the final determination of this question. Copyright, 1898, by D. Appleton and Company. 2 TUBERCULOUS DISEASES OE THE HIP JOINT. These cases were patients of the New York Ortho- paedic Dispensary and Hospital at the time the measure- ments and notes were taken; and all of the cases there in which the disease had existed two years and upward which the writer could see and measure during a period of several months are included in this report, with the exception of cases in which bone had been removed by some operative procedure, and two or three in which the deformity was so great that correct measurements could not be taken. The measurement of the limb was taken from the anterior-superior spine of the ilium to the in- ternal malleolus. The mechanical treatment as effective in the pro- duction of the conditions found to exist is represented in most instances by the length of time they were under the care of the above-named institution, and was" by the traction method, as applied by the long traction hip splint. In only twenty-six cases had there been any previous mechanical treatment; and in these, so far as it could be determined, it was of little consequence, ex- cept in one instance. Case XXXI, Table I, which was treated in St. Luke’s Hospital for two years previously, and, as the method used was the same as in the others, this is not considered as previous treatment. The greater number received only the care of dis- pensary patients, only a small percentage having had any hospital treatment. The abscesses in those cases of the suppurative class, when the abscess developed while under the care of the dispensary and hospital, were treated, in most instances, by the non-interference plan, being allowed to open spontaneously, when opening oc- curred, and to continue uninterfered with through their entire course. That abscess may develop at some fu- TUBERCULOUS DISEASES OF THE HIP JOINT. 3 ture thus in the course of the disease in those cases classed as non-suppurative is to be expected. Still, this does not lessen their value in the determination of the question in hand, as abscess could not have been a de- termining factor in the amount of shortening found to exist at the time the observations were made. The arrangement of the cases in Tables I and II is such as to afford the reader, in brief, a complete history of each case, while Tables 111 and IY,based respectively on Tables I and 11, deal with the cases only from the stand- point of the duration of the disease, the amount of shortening, and the duration of treatment. There was no shortening in three cases, or 6.38 per cent., of the non-suppurative class, and in six cases, or 10.16, of the suppurative. Two of the latter number had, respectively, five eighths and three fourths of an inch lengthening. Three, or 6.38 per cent., of the non- suppurative, and fourteen, or 33.73 per cent., of the sup- purative class had less than half an inch; fifteen, or 31.91 per cent., of the non-suppurative, and fourteen, or 33.78 per cent., of the suppurative, from half an inch to an inch. Eight, or 17.03 per cent., of the non-suppura- tive, and fourteen, or 33.73 per cent., of the suppurative, had from an inch to an inch and a half. Eight, or 17.03 per cent., of the non-suppurative, and five, or 8.47 per cent., of the suppurative had from an inch and a half to two inches; five, or 10.63 per cent., of the non-suppura- tive, and three, or 5.08 per cent., of the suppurative, from two to two inches and half; four, or 8.51 per cent., of the non-suppurative, and one, or 1.69 per cent., of the suppurative, from two inches and a half to three inches; and one, or 3.13 per cent., of the non-suppurative, and two, or 3.38 per cent., of the suppurative, from three to 4 TUBERCULOUS DISEASES OF THE HIP JOINT. four inches. Exclusive of the number that have no shortening, seventy-one per cent, of the suppurative class and only fifty-five per cent, of the non-suppurative class have less than an inch a half shortening. Thus it is seen that whatever effect the process of suppuration may have had upon other conditions found to exist in these patients, it has not been that of caus- ing shortening of the limb, as those cases which have never had suppuration in the course of the disease in the majority of instances have a greater amount of short- ening. The course of tuberculous disease of the hip joint is so much an individual matter that general statements in regard to any feature of such cases are liable to he more or less inaccurate. However, it seems reasonable to credit with considerable accuracy conclusions based upon a study of cases similar as regards the most im- portant conditions affecting them. This similarity will be found to exist in a general way as applied to the whole number of eases, while a study of individual cases comparatively, both as regards the duration of the dis- ease, treatment, and the efficiency of the treatment as carried out in detail, will emphasize this fact and sus- tain the conclusion that the amount of shortening is greater in the non-suppurative eases than in the suppu- rative. The effect that suppuration produced upon the short- ening of the limb in these patients, if any, would seem to represent very nearly its true effect, as the suppura- tion has been allowed to pursue its own course as the natural expression of a morbid process uninterfered with by operative procedure, affected only by the means applied for the relief of the disease, which was the same TUBERCULOUS DISEASES OF THE HIP JOINT. 5 in both the suppurative and the non-suppurative cases. The moment that operative measures are instituted for the relief of abscess in connection with such disease the suppuration ceases to be the simple non-septie process that it is, as a rule, when undisturbed by operation, and becomes complicated, so that it no longer truly repre- sents such suppuration, and it naturally follows that conclusions based upon a study of suppuration existing under such circumstances in regard to its causative re- lation to shortening of the limb must necessarily be in- correct. The development of abscess in the course of such disease, being evidence of the destruction of tissue, would seem to justify the opinion held by most writers that the greater amount of shortening is to be expected in such cases than in eases which have no suppuration; particularly when it is believed, as it is by many, that the principal cause of shortening is the destruction of tissue. To the extent that shortening is caused by destructive changes in the joint, to the same extent is it indicative of the destruction of bone, as the destruction of other tissues would only to a very slight degree, if at all, affect the length of the limb. In view of the condi- tions found to exist in these patients, suppuration does not seem to have been evidence of as great destruction of bone as occurred in cases which had no suppuration, and suggests that suppuration-is evidence that the dis- ease was chiefly confined to the soft structures in and around the joint, and, their nature being such as to afford less resistance to the morbid process, they were more rapidly destroyed—-thus the formation of abscess; while in the cases where suppuration did not exist (caries sicca), the disease was chiefly confined to the TUBERCULOUS DISEASES OF THE HIP JOINT. Table lll.—Non suppurative Cases. Duka- SHORTENING. TION OF Dis- ease. Cases. None. Less than i in. 1-1 1-11 U-8 ?4-3 3-1 tion of treat- ment. Years. 2-3 5 1 1 3 o 1 Lli years. 3-4 7 1 3 3 a 4-5 7 1 2 1 2 1 n H 5 a 5-6 8 4 3 i a 6-7 5 2 1 1 i u 7-8 3 9 1 8* 7 a 8-9 2 1 i a 9-10 4 2 1 1 V* 10 a 10-11 1 1 a 11-12 3 1 1 1 105 a 12-13 1 1 4 u 13 and upw’rd 1 Hi u bone, and more active in its destruction and in interfer- ing with its growth, as evidenced by the greater amount of shortening. That in most instances such disease begins as an osteitis Is not opposed to this suggestion, as the structure Dura- SHORTENING. Average dura- tion of treat- ment. TTON OF Dis- ease. Cases. None. Less than 4 in. 4-1 1-14 14-2 2-24 24-3 3-4 Years. 2-3 10 3 4 1 2 If year. 2| years. 3Jr “ 3 A- “ 3-4 11 1 5 5 4-5 9 1 2 2 2 2 5-6 7 1 1 1 3 1 6-7 2 1 1 44 “ si “ 7-8 5 1 2 2 8-9 3 3 3| “ 51 “ 9-10 4 2 1 1 11-12 3 2 1 10 “ 13 and upw’rd 5 2 1 1 111 “ Table IY.—Suppurative Cases. TUBERCULOUS DISEASES OF THE HIP JOINT. 7 in which it has its origin does necessarily determine the nature of the structures to which it may extend and be most destructive of in its progress. If the develop- ment of the abscess in the course of the disease is evi- dence chiefly of the destruction of soft structures, the fact that abscess appears in the majority of cases would indicate that, though beginning as an osteitis, other structures are soon involved. The surrounding struc- tures, having less power of resistance than bone, certain- ly furnish a more susceptible field for the spread of the disease; particularly so in cases where the effect of traumatism in lessening the power of resistance of hone and increasing the activity of the disease is minimized to the greatest degree by efficient mechanical protection. What explanation can be offered that more fully justi- fies the conditions found to exist in many of these pa- tients—those in which the suppuration was profuse and had existed for long periods of time, but that had little shortening, none at all, or even lengthening? Note Case XXXVI, Table ll—the suppuration was profuse at the time of this observation, and had continued for four years and a half, and there was only a fourth of an inch shortening; and Cases 111 and IX, which had, respec- tively, five eighths and three fourths of an inch length- ening; the abscesses had discharged for sixteen months in the former and ten in the latter, and were still open in both at the time the notes were made. Certainly in such cases suppuration could not be regarded as evidence of the destruction of bone or as profoundly interfering with its growth, else there would have been a greater amount of shortening. In a few cases, where suppura- tion had existed for a long period of time, there was considerable shortening, but such cases, as a rule, are 8 TUBERCULOUS DISEASES OF THE HIP JOINT. those in which the treatment was very inefficient, and in consequence of the poor protection of the joint the effect of traumatism was greater in increasing the activ- ity of the disease and the destruction of bone. There is not necessarily, even in these cases, any relation exist- ing between the suppuration and the shortening, and it is probable that if the protection of their joints had been good the shortening of the limb would have been less. The important consideration in any ease, as in these, is the effect of traumatism upon the bone, which not only diminishes its disease-resisting power, but to the point of its being less than that of the surrounding structures, thus increasing the amount of bone de- stroyed and measuring the amount of shortening de- pendent upon this cause. One can understand that in some cases suppuration may depend to some degree upon the destruction of bone, but that, as a rule, it can not be considered indicative of the extent of such de- struction is certainly true of these cases, and a striking illustration of this is seen in such disease of the spine— as in that region of the spine, the upper dorsal, where there is the greatest destruction of bone, as evidenced by the greatest amount of deformity, abscess is compara- tively infrequent; while in the lower dorsal and lumbar region abscess is frequent and suppuration often profuse, the destruction of bone is small and the deformity slight; the greater destruction of bone in the one case, the upper dorsal, depending upon the effect of constant traumatism, which can not be relieved, while in the other, lower dorsal and lumbar, the relief of traumatism is less difficult and more complete and the destruction of bone less. Table I.—Non-suppurative Cases. Case No, Sex. Age. Hip dis- eased. Duration rf disease. Short’nmg of limb. Duration of treatment. Length of time in hos- pital. 4tte: dance at dispensary. Previous treatment. Notes. Years. Years. Inches. Years. Years. 1 F. 28 Right. 4 H 1 Regular but infrequent. Different methods. 2 M. 9 Left. 6 ii 5 4 Regular and frequent No mechanical. 3 M. 9 Right. 44 •- 14 Regular. Different methods. 4 F. 20 Left. 5 34 Regular* No mechanical. First attack, three years ; sec- ond attack, two years. 5 M. 12 Left. 6 f 3 3 No mechanical. 6 F. 16 Left. Hi 14 Hi Regular. No mechanical. 7 M. 5 Left. 34 i 3i Regular. No mechanical. 8 F. 10 Right. H None. 2 2 No mechanical. 9 M. 14 Right. 11 24 10| Regular but infrequent. No mechanical. 10 M. 14 Left. 9 3 84 i Regular but infrequent. No mechanical. 11 F. 18 Left. 114 1 104 Regular. No mechanical. 12 F. 8 Left. 44 8 8 44 Regular and frequent. No mechanical. 13 M. 15 Left. 2 f 2 2 14 M. 11 Left. 6 if 54 3 Regular. No mechanical. 15 F. 12 Left. 7 li 7 Regular and frequent. 16 F. 13 Right. 74 1 4 Irregular attendance. Different methods. 17 F. 10 Right. 74 14 54 Irregular. No mechanical. 18 M. 11 Right. 6 24 6 Regular and frequent. 19 F. 5 Right. 3 % 2f Regular and frequent No mechanical. 20 M. 17 Left. 15 2f H4 Regular. Different methods. 21 M. 6 Left. 3 None. 3 Regular. No mechanical. 22 M. 14 Right. 12 If 4 3 Regular and frequent. No mechanical. 23 M. 3 Right. 24 i 1| Regular and frequent. No mechanical. 24 M. 10 Left. 9 2 9 24 Regular. 25 M. 14 Left. 10| 2f 10 f Irregular. No mechanical. 26 M. 15 Right. 5 If 2 2 Different methods 27 F. 9 Right. 5 f 3 3 No mechanical. 28 F. 10 Left. 5 4 2 2 No mechanical. 29 F. 23 Right. 3i 4 14 Regular but infrequent. No mechanical. 30 F. 7 Right. 54 f 34 2 Regular. No mechanical. 31 M. 5 Left. H 1 3 Regular. Weight and pulley. In St. Luke’s Hospital two years of this time. 32 F. 54 Left. 3f 4 3 Regular and frequent. No mechanical. 33 F. 15 Left. H 2f 9f Regular. 84 F. 12 Left. 8 2 8 Irregular. 85 F. 8 Left. 2f 4 2f Regular. 36 M. 6 Left. 34 1 3 Regular. No mechanical. 37 M. 5 Left. 4 i 3 Regular and frequent. Wire cuirass foi one year. 38 F. 16 Left. 94 2f 34 14 Irregular. No mechanical. 39 F. 9 Left. 4 None. 2 Regular. No mechanical. 40 F. 7 Left. 2 4 2 Regular. 41 M, 26 Right. 8 f 6 Irregular. Weight and pulley 42 M. 8 Right. 4 1 3 Irregular. Different methods 43 M. 16 Left. 5| U 4f 2| Irregular. No mechanical. 44 M. 10 Right. 6 1 5| Regular. Different methods 45 F. 8 Left. 5 2 5 Regular. 46 F. 8 Left. 4 U 4 Regular. 47 F. 12 Right. 54 if 1 54 Regular. Table ll.—Suppurative Cases. Case No. M thigh. chanical. 7 F. 13 Right. 8 Outer aspect of thigh. Large. 14 }ear. H 3 3 Different methods. 8 F. 9 Right. 3 Femoral region. 5Iedium. H year. i 2 2 No me- chanical. 9 M. 10 Right. Outer aspect of thigh. Yery large. 10 months None. H 44 No me- | inch lengthening. (continues). Regular. chanical. 10 F. 13 Right. 9 Outer aspect of Large. 1 year. f 6 No me- Cured. Has gone with- thigh. chanical. out brace three years. 11 F. 10 Right. n Outer aspect of thigh. Large. 5 months. f 7| Regular. 12 F. 15 Left. 13 Outer aspect of thigh. Few H 114 Irregular. No me- months. chanical. 13 F. 14 Right. 6 Gluteal and femo- ral regions. Large. 2 4 years. i 5 Regular and fre- No me- chanical. quent. 14 F. 17 Right. n Outer aspect of thigh. Unknown Unknown. n 10 Irregular and in fre- No me- chanical. quent. 15 M. 21 Left. 134 Outer aspect of thigh. Unknown. if 12| Irregular and infre- No me- Treatment interrupted for three years. chanical. quent. 16 F. 14 Left. n Anterior aspect of thigh. 5Iedium. 3 years. if 5f Irregular. Different methods. 17 F 9 Left. Antero-lateral as- pect of thigh. 5Iedium. i 3 Regular No me- Abscess has existed and fre- chanical. three months. In- quent. creasing. 18 F. 14 Right. 9^ Outer aspect of thigh. Large. 3 years. if 54 Irregular. Weight and pul- ley for a few mos. 19 18 Left. Hi 5Iedium. 9£ yrs. and 4 104 Irregular and infre- quent. No me- Treatment frequently interrupted. external aspect of thigh. continues. chanical. 20 F. 13 Left. iu Outer aspect of Large. 1 year. 94 Regular. No me- thigh. chanical. 21 M. 6 Right. 4-5 Outer aspect of thigh. Large. 2 years (continues). i 4 Regular and fre- quent. No me- b 1 chanical. 22 F. 6 Left. 24 Outer aspect of Large. 20 mos. 1 14 Regular. No me- thigh. 21 Regular chanical. 23 M. 5 Left. H Outer aspect of thigh. Small. 10 mos. i No me- and fre- chanical. quent. 24 F. 18 Left. 14 Outer aspect of thigh. Large. 9 months. 2 14 Regular but infre- quent. Treatment interrupted for three years. 25 M. 8 Left. 3} Outer aspect of thigh. H year (continues). i 34 Regular Treatment interrupted for fifteen months. but infre- quent. 26 F. 15 Right 4 Very large. 14 year. If H Regular and fre- quent. No me- pect of thigh. chanical. 27 F. 8 Right 7 Large. 6 years (continues). 1J i l Regular but infre- quent. Weight and pul- ley for 3 months. 28 M. 10 Left. 54 Femoral region. Large, 21 months. 15 4 3 Regular but infre- quent. No me- chanical. 29 F. 6 Left. 2 Inguinal region. Small. 6 months. \ ]_3 Regular No me- and fre- quent. chanical. 30 F. H Right. H Outer aspect of thigh. 7 months. f 2 Regr lar and fre- Weight and pul- quent. ley. 31 M. 6 Right. 3 Outer aspect of thigh. 2 years. i 3 Regular and fre- quent. 32 M. 21 Right. 15 Anterior aspect of thigh. Large. Unknown. H 11 Irregular and infre- No me- chanical. quent. 33 M. 13 Right. 7i Large. 6 years (continues). a 61 Very reg- ular and No me- pect of thigh. chanical. frequent. 34 M 5 Right 3 Outer aspect of thigh. Large. 1| year (continues). i 3 Regular and fre- quent. ■ j 35 F 5 Right. Si Outer aspect of thigh. Not known. | 14 Irregular. No me- chanical. 36 M. 11 7f Yery large. 44 years (continues). i H Regular. No me- Five open sinuses at this writing. pect of thigh. chanical. 37 F. 6 Left. 6 Gluteal region. Small. i 4 Regular. No me- Abscess quiescent. chanical. 38 M. 4 Right. 2 Outer aspect of thigh. Yery large. None. 1 Regular and fre- quent. Different Abscess increasing. methods. 39 M 12 Right. 8 1 year. 1 6 Irregular. Unknown pect of thigh. 40 F. 8 Left. 41 Anterior aspect of thigh. Large. 2 4 years. U H Regular and fre- No me- chanical. quent. 41 F. 12 Right. 21 Outer aspect of thigh. Large. i Regular. Different Abscess disappearing. methods. 42 M. 8 Left. 3| Outer aspect of thigh. 1 year. None. 3-/j Regular. large. 43 F. 8 Left. H Outer aspect of thigh. Very large. H year. 1 H Regular and fre- quent. 44 M. 9 Right. H Outer aspect of thigh. ] 9 months. f 2 Regular. Plaster- of-Paris spica. 45 M. 10 Left. H Outer aspect of thigh. Unknown. Unknown. f 34 1$ Regular Different and fre- methods. quent. 46 M. 7 Left. H Outer aspect of thigh. Small. 3 months. f 25 24 Weight & pulley. Regular. 47 M. 10 Left. 2f Outer aspect of thigh. Large. 6 months. H 24 No me- chanical. 48 M. 10 Right. 4 Outer aspect of thigh. Small. Few days. i 4 Regular but infre- quent. 49 F. 7 Left. 54 Large. 15 mos. 4 4 4 Regular pect of thigh. and fre- quent. chanical. 50 M. 24 19 Outer aspect of thigh. Small. 4 months. 2| 10 Irregular. Plaster- of Paris Irregular spica. 51 F. 9 Left. 51 Anterior aspect of thigh. Unknown, Unknown 2f 3f Different and infre- methods. quent. 52 M. 14 Right. 4 Outer aspect of thigh. 14 year. U 24 24 Different methods. 53 M. 10 4 Very large. 34 years (continues) f 3f Irregular. No me- pect of thigh. chanical. 54 F. 16 Left. 9 Outer aspect of thigh. Unknown. 8 years. 2 6 Irregular and infre- quent. No me- chanical. 55 F. 8 Left. 24 Anterior aspect of thigh. Large. 14 mos. None. If if Different methods. 56 51 7 Left. 3f Outer aspect of thigh. 9 i 3f Regular and fre- quent. months. 57 M. ii Left. 5 Outer aspect of thigh. 9 H 1 1 Different during four years. methods. 58 F. 9 4 Outer aspect of thigh. Large. 6 months. i 24 1 Regular but infre- No me- chanical. quent. 59 51 3 Left. 2i Outer aspect of thigh. Large. 6 mos. None. 2 Regular. No me- chanical. TUBERCULOUS DISEASES OF THE HIP JOINT. In addition to the amount of shortening caused by destructive changes in the joint, there is undoubtedly a trophic disturbance operating as an effective cause of shortening, not only by seriously retarding the growth of the bone, but by producing its atrophy. Evidence of this is seen in the early appearance of atrophy of the muscles before disuse has occurred and in the shorten- ing of the tibia. An analogous condition of the bones is seen in infantile paralysis. There does not seem to be any reason to believe that suppuration has any effect in increasing the amount of shortening produced by this cause, particularly if it is left uninterfered with as the simple expression of the disease, but that the amount of shortening due to trophic disturbances depends upon the extent of the involvement of hone, as does that pro- duced by destructive changes in the joint and, as sup- puration is no index to the amount of bone diseased and destroyed, it bears no relation to shortening of the limb. So there is no reason to expect greater shortening in cases which have suppuration than in those which have not. 126 East Fifty-ninth Street. APPLETONS’ POPULAR SCIENCE MONTHLY. The Best Magazine for Thinking People.