A Report of Sixty-two Cases of Hip Disease, BY 1/ JOHN KIDLON, M. D., ASSISTANT SURGEON AT THE VANDERBILT CLINIC, NEW YORK. REPRINTED FROM sT})e "Ncto Vorlt |sUlrtcal Jfournal for October f 1890. Reprinted from the New Yorh Medical Journal for October J, 1890. A REPORT OF SIXTY-TWO CASES OF HIP DISEASE Observed in the Practice of Hugh Owen Thomas, of Liverpool.* JOHN RIDLON, M. D., ASSISTANT SUEGEON AT THE YANDEEBILT CLINIC, NEW TOEK. With a desire to present for your consideration farther facts regarding the use of the Thomas hip splint, I spent twelve days during the month of June of this year in Liver- pool, and examined all the cases of hip disease coming under the observation of Mr. Thomas during that time. It had been my desire to make a report upon cured cases, but I found that no records of cases had been kept, and that even the names and addresses of patients were wanting. I therefore contented myself with taking all cases as they came, not with the idea of showing ultimate results, but rather the presenting of a picture of Mr. Thomas’s daily work. New cases will be presented ; cases where the treat- ment has just been commenced ; cases that have been under treatment one and two years; cases that have been under treatment five and six years; cured cases; cases among the * Read before the American Orthopaedic Association, September 18, 1890. SIXTY-TWO CASES OF HIP DISEASE. poor and among the well-to-do; and cases that have done badly and cases that have done well. I realize, as must every one else, that a much more brilliant showing would have been made had only cured cases been considered; but it is not to make a brilliant showing that I present this re- port ; my only desire is to present to you the facts as I found them. Every opportunity was given me by Mr. Thomas to question and examine the patients; and the facts which I shall present to you were obtained from the patients them- selves, or their parents, and the measurements were all made by me. Statements as to the degree of deformity present when treatment was commenced, and as to the length of time spent in bed, I found to be so uncertain that they have been omitted; and I have contented myself with recording only the time from the beginning of the limp or pain, or both, to the commencement of treatment; the time which the long splint was worn; the time which the short splint was worn ; the time since treatment was discontinued, in cured cases; the presence or absence of abscesses, and, if present, when they appeared and how many, and the sinuses remaining; and the presence or absence of pain. The ex- amination consisted of inspecting the patient as to his gen- eral condition; noting the presence of abscesses, sinuses, and cicatrices of sinuses; flexing the sound leg on the chest while the affected leg was held in full extension; measur- ing the length of the legs and the degree of flexion and of abduction or adduction; and testing the motion in those cases where the splint was for any cause removed. The standard position taken for measuring flexion was that which is known as “ Thomas’s flexion-test position ”—that is to say, the sound leg is flexed on the chest to such a de- gree that the elbow can be hooked through the flexure of SIXTY-TWO CASES OF HIP DISEASE. 3 the knee, the anterior surface of the elbow being in contact with the popliteal space, and the forearm at right angles across the body. This position effectually overcomes all lordosis, and in some cases gives a lumbar kyphosis, so that if the affected leg can be carried down to the table, the pa- tient, of course, being supine, it shows that the joint is free from all flexion, and that extension to a certain degree is possible. With the patient then in the flexion-test position, the angle of flexion was measured after the plan of Dr. Kingsley, of Boston.* In those cases where motion was not tested, because the patient was not removed from the splint, if the sound leg could be flexed on the chest to the flexion-test position while the affected leg was confined in the splint, the popliteal space resting on the table, it was considered as being free from flexion, and so noted. It will be found that in all cases where flexion is present, or where any special joint tenderness remains, it will either be impos- sible to flex the sound leg to the flexion-test position, or very painful; and that involuntary muscular spasm can be as readily detected as on manipulating the affected leg. I have on that account noted whether there was present or absent tenderness on flexing the sound leg into the flexion- test position. The terras “ real ” and “ apparent ” shorten- ing or lengthening are used in the same sense as suggested by Dr. Lovett,f of Boston, and the abduction or adduction is calculated by Dr. Lovett’s table. Sixty-two cases of unilateral hip disease were seen and examined. Four of them (I, 11, 111, IY) were new cases and are recorded simply to show the condition of cases when they present for treatment. They are omitted from all the calculations excepting that of the average duration of the limp before commencement of treatment. * G. L. Kingsley, Boston Med. and Surg. Jour., July 5, 1888. f R. W, Lovett, Boston Med. arid Surg. Jour., March 8, 1888. 4 SIXTY-TWO CASES OF HIP DISEASE. The three cases, to wit, XXXIII, LX, LXT, were in chil- dren in well-to-do families, and had received the care that we are accustomed to expect in private cases. It is not surprising, then, to find that in these cases the results are better than the average in the other cases. All the remain- ing cases were from among the poorer classes, who, from ignorance and poverty, had received no better care than the dispensary class receive with us. Indeed, many of them were charity cases, and the sum total which these patients pay to Mr. Thomas for splint and treatment is, I have no doubt, no greater than dispensary patients with us are ac- customed to pay for the traction hip-splint, and in many cases not as much. It should, therefore, be evident that any as- sumption that Mr. Thomas ought to get better results than have elsewhere been imported, because his patients are pri- vate patients, is unfair. The average duration of limp before treatment was com- menced in these sixty-two cases was a little over ten months. The average duration of treatment was not computed, as only a few were cured cases, and as many had been under treatment but a short time. The “ long splint ” referred to is that which is ordinarily known as the Thomas splint, and extends from the lower angle of the scapula to the lower third of the leg. The “ short splint” is the long splint cut off, and not extending below the knee. Contrary to what we have been taught, it was found that the long splint had not always been put on at the beginning of treatment, but that the short splint, which “does not lock the knee,” had been put on instead. In some cases the short splint had been replaced later by the long splint, but in other cases its use had been continued throughout the entire course of treatment. Contrary, also, to what we have been taught, nearly all of these children were found walking around without high patten and SIXTY-TWO CASES OF HIP DISEASE. 5 crutches. In the same way patients were allowed to walk before the deformity had been overcome, and while muscu- lar spasm and deformity, and sometimes pain, still persisted. Of the 58 patients that had been under treatment for a longer or shorter time, 24 had shortening, 24 had adduc- tion, 5 had abduction, 3 had inward rotation, and 2 had outward rotation. In the cases where abduction coexisted with shortening the abduction was an advantage, as it com- pensated in a measure for the shortening. Of the 24 patients who had real shortening, 2 had inch, 9 had inch, 4 had f inch, 3 had 1 inch, 4 had 1-J inch, 1 had 2 inches, and 1 had inches. In 2 cases the affected leg was actually longer than the other leg. One patient had in-knee, apparently resulting from the action of the adductor muscles of the thigh, while the ankle was held by the splint and the knee was not. It should be noted that this patient was walking around without patten and crutches, while there still remained a very tense invol- untary spasm of the adductor muscles. Of the 58 cases, 23 had, at some time during their course, some before, but many after treatment had been commenced, presented one or more abscesses. Of these, one had disappeared without opening and another was fast disappearing. In 31 cases the motion was not tested, for the reasons above stated. In 27 it was tested; 12 patients had no mo- tion, 10 had some motion, 2 had motion to ninety degrees, and 3 had normal motion. It should be borne in mind that these 27 cases in which motion was tested were either cured cases, or so well advanced in convalescence that it was not thought in any way a risk to test the motion very thor- oughly ; while of those not tested it would seem probable that very many would have shown considerable motion, in- asmuch as they showed free flexion of the well leg to the 6 SIXTY-TWO CASES OF HIP DISEASE. flexion-test position ; or, in other words, they showed nor- mal extension of the affected limb. All these patients, unless otherwise so stated, were in good general health. Case I.—Female, fifteen years old ; has limped at times and complained of some pain for three years. There is involuntary muscular spasm and flinching on manipulating the leg, but there is no deformity, and the patient can be put in the “Thomas flexion-test position ” without pain or any special effort. Mr. Thomas refused to commence treatment without further ob- serving the case. The record of the cases is as follows Case ll.—Female, twelve years old; limped for six months ; no complaint of pain; no night cries; no abscess; general con- dition fairly good ; one inch real, but only a quarter of an inch apparent shortening; abduction, six degrees; flexion, twenty degrees; some motion in flexion ; well-marked involuntary mus- cular spasm. Hip splint now applied. Case lll.—Female, eight years old; limped for three months before treatment was commenced; long splint applied at the Liverpool Infirmary two months ago; now seen by Mr. Thomas for the first time; an abscess has been noticed for the past week; no pain; no tenderness on flexing the sound leg to the flexion-test position; no abduction; no adduction; some mo- tion in all directions, limited by muscular spasm. Case IY.—Female, eleven years old; began to limp nine months ago; a splint was put on six months ago by a Manches- ter surgeon, but it is too flexible to be of any use; patient now seen by Mr. Thomas for the first time; abscess noticed two weeks ago; has some screaming in sleep, but no pain other- wise; some tenderness on palpation and manipulation; muscu- lar spasm well marked ; no real shortening; half an inch ap- parent shortening ; adduction, four degrees; flexion, thirty-nine degrees; very little motion in any direction. A new splint was applied. Case Y.—Female, nine years old ; has limped at times for four years; has not complained of pain; no abscess; muscular SIXTY-TWO CASES OF HIP DISEASE. spasm well marked; very little tenderness on gentle manipula- tion ; leg one quarter of an inch longer than the leg of the op- posite side; flexion, thirty degrees; no abduction; no adduc- tion; very little motion in any direction; splint now applied for the first time. I saw the patient again at the end of a week. The flexion had been completely reduced and there had been no pain. Case Yl.—Male, nine years old; limp and some pain for four months before treatment was commenced ; has worn long splint one week; has swelling in the groin, but fluctuation is doubtful; has night cries; tenderness on flexing the sound leg to the flexion-test position; marked muscular spasm; has not yet been allowed to walk; no shortening; no flexion; no ab- duction ; no adduction ; motion not tested. Case YII.—Male, six years old; limp and pain for six months before treatment was commenced; has worn long splint for ten weeks; still has some night pain, but is allowed to walk without crutches; no abscess; some tenderness on flexing the sound leg to flexion-test position; no real, but half an inch ap- parent shortening; adduction, four degrees; no flexion; motion not tested. Case Ylll.—Male, three years and a quarter old ; has never walked; when three months old had a fall, and splint was put on at once at the Liverpool Infirmary and was worn for a year; then came under care of Mr. Thomas, and has continued to wear the splint for two years more ; no abscess ; no pain for a long time past; no tenderness on flexing the sound leg to the flexion-test position ; no real shortening ; two inches apparent shortening; adduction, twenty-one degrees; no flexion; motion not tested. Case IX.—Female, twelve years old; limped for six months before treatment was commenced; has worn long splint for nine months; no abscess; no tenderness on flexing the sound leg to flexion-test position; no real shortening; an inch and three quarters apparent shortening; adduction, fourteen degrees ; no flexion ; considerable inward rotation ; motion not tested. Case X.—Male, four years old; limp and pain for nine months before treatment was commenced ; has worn long splint 8 SIXTY-TWO CASES OF HIP DISEASE. twelve months; an abscess appeared soon after splint was ap- plied, and is now near breaking; no pain now; no tenderness on flexing the sound leg to flexion-test position; no real short- ening ; an inch apparent shortening; adduction, nine degrees; no flexion ; motion not tested. Case Xl.—Male, four years old ; limped for three weeks be- fore treatment was commenced ; has worn the long splint for six- teen months; some thickening in the groin, but no fluctuation can be made out; no pain ; no tenderness on flexing the sound leg to flexion-test position; a quarter of an inch real and an inch and a quarter apparent shortening ; adduction, nine de- grees; no flexion; motion not tested. Case XII.—Female, fourteen years old; limped for nine months before treatment was commenced; wore splint for six months before coming to Mr. Thomas, and has continued to wear the long splint for eight months since; abscess was pres- ent when she first came under the care of Mr. Thomas; it has never opened, and has now for some time been growing smaller; suffered great pain and could not walk for a long time ; no pain now ; no tenderness on flexing the sound leg to flexion-test position; half an inch real and an inch and a half apparent shortening; addiction, seven degrees; no flexion; motion not tested. Case Xlll.—Male, six years old; limped for two weeks be- fore treatment was commenced; has worn long splint eight months; no abscess; no pain; no tenderness on flexing the sound leg to flexion-test position; no real shortening; three quarters of an inch apparent shortening ; adduction, seven de- grees; no flexion ; motion not tested. Case XlY.—Female, six years old ; limp and pain for six months before treatment was commenced ; has worn long splint two weeks; was unable to walk for the last week before the splint was applied ; no abscess; no pain now ; some tenderness on flexing the sound leg to flexion-test position; half an inch real and an inch apparent shortening; adduction, four degrees ; no flexion ; motion not tested. Case XY.—Male, thirty years old; limped for five years be- fore treatment was commenced; has worn short splint three SIXTY-TWO CASES OF HIP DISEASE. 9 years; has had eight abscesses; one sinus remains; no pain now; no tenderness on flexing the sound leg to flexion-test po- sition; two inches real but only an inch apparent shortening; abduction, six degrees; no flexion; no motion. Case XVl.—Female, four years old ; limped for three months before treatment was commenced ; has worn long splint for six months; abscess, noticed four months ago, broke two days ago ; has no pain ; no tenderness on flexing the sound leg to flexion-test position; no real shortening; half an inch ap- parent shortening; adduction, four degrees; no flexion; some motion. Case XVll.—Male, eleven years old ; limp and pain for six months before treatment was commenced; wore short splint for two months; since then has worn long splint for twenty months; abscess appeared four months after treatment was commenced, but disappeared without aspiration or opening; no pain ; no tenderness on flexing the sound leg to flexion-test position; an inch and a half real shortening, but only three quarters of an inch apparent shortening; abduction, five de- grees; no flexion; motion not tested. Case XVlll.—Female, fifteen years old ; limped for fixe months before treatment was commenced; has worn the long splint fifteen months; no abscess; no pain on flexing the sound leg to flexion-test position; half an inch real shortening; half an inch apparent lengthening; abduction, seven degrees; no flexion ; motion not tested. Case XlX.—Male, twenty-one years old; limped for two years before treatment was commenced; wore long splint three years ; after going without splint for twelve months an abscess formed, opened spontaneously, and discharged for six months; during this time a short splint was applied, and has now been worn eighteen months; no pain; no tenderness on flexing the sound leg to flexion-test position; an inch and a half real, but only half an inch apparent shoi’tening; abduction, six degrees; no flexion ; some motion. Case XX.—Male, four years and a half old ; is a remarkably large child for his age; limped for twelve hours before treat- ment was commenced ; has worn long splint for two months; 10 SIXTY-TWO CASES OE HIP DISEASE. no abscess; no pain ; no tenderness on flexing the sound leg to flexion-test position; no real shortening or lengthening; half an inch apparent lengthening; abduction, four degrees; no flexion; motion not tested. Case XXl.—Male, seven years old ; was hurt by a cricket- ball five weeks before treatment was commenced; has worn long splint fourteen months; no abscess; no pain; no tender- ness on flexing the sound leg to flexion-test position; no real shortening or lengthening ; half an inch apparent lengthening ; abduction four degrees; no flexion ; motion not tested. Case XXll.—Male, five years old; limp and pain at times for two months and a half before treatment was commenced; has worn long splint for two months; no abscess; no pain; slight tenderness on flexing the sound leg to flexion-test posi- tion ; no real shortening; half an inch apparent shortening; adduction, four degrees; no flexion; some inward rotation ; motion not tested. Case XXlll.—Female, four years old; having been cured without deformity or stiffness, relapsed two years after treat- ment had been discontinued, and has now been wearing short splint two months; one cicatrix; no pain; no tenderness on flexing the sound leg to flexion-test position ; no shortening; adduction, four degrees; no flexion ; no rotation; slight motion. Case XXIV.—Male, ten years old; limp and pain for six weeks before treatment was commenced ; has worn long splint for six years; has had three abscesses, from which two sinuses remain, and another abscess broke into the intestine; had albu- minuria for many months, and was in a very precarious condi- tion; no albuminuria now; is fat and in good color ; no pain for a very long time ; half an inch real and two inches appar- ent shortening; adduction, sixteen degrees ; no flexion; no mo- tion. Has walked about for a long time without patten and crutches. Case XXV.—Male, six years old ; limped for three months before treatment was commenced; has worn long splint eight- een months; no abscess; no pain ;no tenderness on flexing the sound leg to flexion-test position ; no shortening; no abduc- tion ; no adduction ; no flexion; slight motion in all directions. SIXTY-TWO CASES OF HIP DISEASE. 11 Case XXYl.—Female, eleven years old; limp and pain for two years before treatment was commenced; wore long splint for two years; bas worn short splint for one year; no abscess; no pain for a long time; no real shortening; one inch apparent shortening; adduction, eight degrees; flexion, twenty-five de- grees; no motion. Case XXVII.—MaIe, two years old ; has had trouble since birth; long splint was put on when four months old; it has been very difficult to keep patient properly in the splint, and he runs about constantly; no abscess ; no pain; no tenderness on flexing the sound leg to flexion-test position ; half an inch shortening; no abduction ; no adduction; no flexion; some motion in all directions. Case XXVIII.—MaIe, nine years old; limp and pain for seven months before treatment was commenced; wore long splint for three years; has worn short splint two years; ab- scess four years ago, and another three years ago; no sinuses ; no pain; no tenderness on flexing the sound leg to flexion-test position; three quarters of an inch real and two inches apparent shortening; adduction, ten degrees; flexion, twenty-two de- grees; no motion. Lives far away and has been seen but once in three months. He has walked about without patten and crutches. Case XXIX.—Male, fifteen years old; limp and pain for seven years before treatment was commenced; father is con- sumptive ; wore long splint two years; has worn short splint one year; had one abscess before treatment was commenced ; no pain; no tenderness on flexing the sound leg to flexion-test position; patient has grown very rapidly and is a very tall boy for his age; an inch and a half real shortening, two inches ap- parent shortening; adduction, four degrees; no flexion; some motion in all directions. Case XXX.—Male, seven years old ; limped for four months before treatment was commenced; wore long splint fifteen months; has worn short splint twelve months; no abscess; no pain; no tenderness on flexing the sound leg to flexion-test position; half an inch real and an inch and a half apparent shortening; adduction, four degrees ; flexion, twenty degrees ; no motion. 12 SIXTY-TWO CASES OF HIP DISEASE. Case XXXl.—Female, nine years old; strained joint skip- ping rope; limped and had pain at times for three years and a quarter before treatment was commenced; was kept in bed one month before the splint was applied ; wore long splint eighteen months; has worn short splint for eighteen months; no ab- scess ; no pain for a long time; no tenderness on flexing the sound leg to flexion-test position; quarter of an inch real and three quarters of an inch apparent shortening; adduction, four degrees; no flexion ; some motion. Case XXXll.—Female, ten years old; limped for four months before treatment was commenced; has worn long splint for ten months; has in-knee of eight weeks’ duration, resulting from the use of the splint; no abscess ; no pain; no tenderness on flexing the sound leg to flexion-test position; shortening and the consequent adduction not measured because of the in-knee; no flexion ; motion not tested. Case XXXlll.—Female, eight years old; limp and some pain for three weeks before treatment was commenced; has worn short splint for three months; never has worn long splint, hut has not been allowed to walk; no abscess; no pain since treatment was commenced; no shortening; no flexion; no ad- duction; no abduction; normal motion in all directions; now to he allowed to walk with crutches. Case XXXIV.—MaIe, forty-two years old; limp and pain for twelve months before treatment was commenced ; no trau- matic cause; has never worn the long splint; has worn short splint for three months; no abscess; no tenderness on flexing the sound leg to flexion-test position; no pain ; no shortening; no flexion; no adduction; no abduction ; no rotation ; motion not tested. Case XXXV.—Male, sixteen years old; limped for five weeks before treatment was commenced ; has worn long splint for nine months; deep fluctuation in groin; still has some pain; some tenderness on flexing the sound leg to flexion-test position; three quarters of an inch real shortening; no abduc- tion ; no adduction; no flexion; motion not tested. Case XXXVI.—Female, nine years old; limped for twelve months before treatment was commenced ; has worn long splint SIXTY-TWO CASES OF HIP DISEASE. 13 twelve months; small area of deep fluctuation in front of the joint; no pain; no tenderness on flexing the sound leg to flexion- test position; no real shortening; half an inch apparent short- ening; adduction, four degrees; no flexion; motion not tested. Case XXXYII.—MaIe, fourteen years old; limp and pain for three months before treatment was commenced ; has worn long splint for two years; two sinuses in the groin for the past eighteen months; no pain now; no tenderness on flexing the sound leg to flexion-test position ; no shortening; no abduction; no adduction; no flexion; no motion. Case XXXVIII.—MaIe, eight years old; limped for fourteen months before treatment was commenced ; has worn long splint for ten months; no abscess; no pain; no tenderness on flexing the sound leg to flexion-test position; no shortening; no ab- duction; no adduction ; no flexion ; some motion. Case XXXlX.—Female, eight years old; limp and pain for twelve months before treatment was commenced; has worn long splint three years; first abscess ten months after treatment was commenced, and second soon after first; two sinuses re- main ; no pain; no tenderness on flexing the sound leg to flexion- test position; no shortening; no abduction; no adduction; no flexion; motion not tested. Case XL.—Male, twenty months old; pain and stiffness for six weeks before treatment was commenced ; has worn long splint ten months; one abscess opened spontaneously three months ago; sinus remains; another abscess now present point- ing in two places; no pain; no tenderness on flexing the sound leg to flexion-test position; no shortening; no abduction; no adduction; no flexion; motion not tested. Case XLl.—Male, thirteen years old; limp and pain for one year before treatment was commenced ; has worn long splint a year and a half; first abscess opened twenty months ago, and a second three months ago; one sinus remains; no pain now; no tenderness on flexing the sound leg to flexion-test position; no shortening; no abduction; no adduction; no flexion ; motion not tested. Case XLTl.—Female, fourteen years old ; limped for three months before treatment was commenced ; never wore long 14 SIXTY-TWO CASES OF HIP DISEASE. splint; has worn short splint four months; had one abscess; no sinus; has had disease, with abscess at right elbow, for eight months; no pain now ; some tenderness on flexing the sound leg to flexion-test position ; general condition fairly good ; no real shortening; three quarters of an inch apparent shortening; adduction, three degrees ; no flexion ; motion not tested. Case XLlll.—Male, thirteen years old; limped for three weeks before treatment was commenced ; wore long splint for six years ; has worn short splint for two years and a half; was in Liverpool Infirmary nine months at commencement of treat- ment, not under Mr. Thomas ; has had three abscesses; the last closed three years ago; all appeared while under the care of Mr. Thomas; an inch and a half real shortening; no abduc- tion ; no adduction ; no flexion ; some outward rotation ; mo- tion not tested. Case XLlY.—Female, eleven years old ; limp and pain for two years before treatment was commenced ; wore long splint for two years; has worn short splint for one year ; an abscess opened spontaneously at about the time treatment was com- menced ; it closed after discharging for about a year; no pain since that time ; no tenderness on manipulation; one inch real shortening; no abduction; no adduction ; no flexion ; no motion. Case XLY.—Female, nine years old; limped for four months before treatment was commenced; wore long splint for ten months ; has worn short splint two months; when three years old wore a Thomas splint, but not under Thomas’s care, for ten months; no abscess; no pain; no tenderness on flexing the sound leg to flexion-test position; no shortening; no abduc- tion ; no adduction ; no flexion ; some motion in all directions. Case XLYI.—Male, twenty years old ; suddenly attacked with pain and limping one month before treatment was com- menced ; no traumatism ; has worn long splint ten months; no abscess ; no pain now ; no tenderness on flexing the sound leg to flexion-test position; one inch shortening; no abduction; no adduction; no flexion ; no motion. Case XLYII.—MaIe, twenty-one years old; limped for twelve months before treatment was commenced; wore long splint for eighteen months; has worn short splint for four SIXTY-TWO CASES OF HIP DISEASE. 15 years; abscess opened spontaneously before treatment was com- menced and still discharges; no pain ; no tenderness on flexing the sound leg to flexion-test position ; one inch shortening; no abduction ; no adduction ; no flexion ; motion not tested. Case XLYIII.—Male, six years old; limped for two days before treatment was commenced; wore long splint for two years; has worn short splint three months; no abscess; no pain; no tenderness on flexing the sound leg to flexion-test position ; three quarters of an inch real and one inch and three quarters apparent shortening; adduction, nine degrees; no flexion ; motion not tested. Case XLIX.—Male, six years old ; limped for three months before treatment was commenced; has worn long splint for two years ; no abscess; no pain ; no tenderness on flexing the sound leg to flexion-test position; leg one quarter of an inch longer than well leg; no abduction ; no adduction; no flexion ; motion not tested. Case L.—Female, eight years old ; limped for four months before treatment was commenced; has worn long splint twelve months; no abscess; no pain; no tenderness on flexing the sound leg to flexion-test position; no shortening; no abduc- tion ; no adduction ; no flexion ; no motion. Case Ll.—Male, three years old ; limped for five weeks be- fore treatment was commenced; has worn long splint fourteen months; no abscess; no pain; no tenderness on flexing tlie sound leg to flexion-test position; no shortening; no abduc- tion ; no adduction ; no flexion ; motion not tested. Case Lll.—Female, five years old ; limp and crying in sleep for two weeks before treatment was commenced; has worn long splint two months; no abscess; still has crying in sleep, but does not complain of other pain ; some tenderness on flexing the sound leg to flexion-test position; no shortening; no ab- duction; no adduction; no flexion ; motion not tested. Case LIII.—Male, six years old; limped for six weeks be- fore treatment was commenced; has worn long splint for one week; no abscess; no pain; no tenderness on flexing the sound leg to flexion-test position; no shortening; no abduction; no adduction; no flexion ; motion not tested. 16 SIXTY-TWO CASES OF HIP DISEASE. Case LTV.—Male, four years old ; limp and some pain for three years before treatment was commenced; has worn long splint for three months ; no abscess; no pain of late ;no tender- ness on flexing the sound leg to flexion-test position; no short- ening; no abduction; no adduction; no flexion; motion not tested. Case LY.—Female, eleven years old; limp and pain for six months before treatment was commenced; wore long splint four years; has now been without treatment for two weeks; no abscess; no pain; no tenderness on manipulating leg; no shortening; adduction, two degrees; no flexion; slight inward rotation; no motion. Case LYL —Male, seventeen years old ; twisted hip in kick- ing a foot-ball, and was seen next day; was kept in bed three months without any mechanical treatment; then had the long splint for one year, and the short splint for two years; has had no treatment for the past six months ; no abscess; no pain for a long time; pain was very great for a long time at the com- mencement of the trouble; no tenderness on manipulating the leg; no shortening; no abduction; no adduction; no flexion; normal motion in all directions. Case LYll.—Male, twenty-two years old ; limp and pain for six months before treatment was commenced; wore long splint for three years and a half; no pain for a long time; cicatrices of six sinuses present; has been without treatment for four months; no tenderness on manipulating leg; three fourths of an inch real shortening ; one inch and a quarter apparent short- ening ; adduction, eight degrees ; flexion, thirty-one degrees; no motion. Case LYIII.—MaIe, three years old; limped for two weeks before treatment was commenced; wore long splint thirteen months; no treatment for past three months; no abscess; no pain; no tenderness on manipulation; no shortening; no ab- duction ; no adduction ; no flexion; considerable outward rota- tion; all motions, except inward rotation, smooth and free to ninety degrees. Case LlX,—Male, twenty-two years old; limped for five years before treatment was commenced ; wore long splint two SIXTY-TWO CASES OF HIP DISEASE. 17 weeks; wore short splint four years and four months; no treat- ment for past four montlis; no abscess; no pain now; no ten- derness on flexing the sound leg to flexion-test position; two inches and a half shortening ; great trochanter two inches and a half above Platon’s line; no abduction; no adduction; no flexion; no motion. Case LX.—Female, twelve years old ; limped for three months before treatment was commenced; wore long splint two years; had five abscesses; no treatment for past three years; half an inch shortening; no abduction; no adduc- tion; no flexion; some motion in all directions; walks with scarcely any limp, and can go up and down stairs without difficulty. Case LXl.—Male, eight years old; limped for four months before treatment was commenced; wore long splint two years and a half; has had no treatment for past year; no abscess; no muscular spasm; no shortening; no abduction; no adduction; no flexion; free motion in all directions to ninety degrees; runs and walks without limp or inconvenience. Case LXll.—Female, twenty years old; limp commenced one year before treatment; became unable to walk and suffered great pain; had haemorrhages from the lungs ; wore long splint three years; no treatment for past twelve months; general condition excellent; no pain now ; no tenderness on manipula- tion ; half an inch shortening; no abduction; no adduction; no flexion; normal motion in all directions. From a study of these cases conclusions can not prop- erly be drawn ; but, as I have probably given them a more careful consideration than any one else ever will, I will ven- ture the following suggestions : Very many of these patients that have had the short splint applied before muscular spasm and pain had subsided and before deformity had been reduced, that have been al- lowed to walk around without high patten and crutches— that is to say, those whose joints have only been partially immobilized, without being protected from the pressure of 18 SIXTY-TWO CASES OF HIP DISEASE. superincumbent weight and the concussion of walking— present a moderate degree of adduction, absence of motion, and, in a few cases, slight flexion, and in one instance in- knee. On the other hand, those patients that have worn the long splint until cured, that have remained in the horizontal position until all pain and muscular spasm had subsided, and had then used the high patten and crutches and had had the benefit of intelligent care and nursing, have been cured without flexion or other deformity than the shorten- ing due to actual bone erosion and arrested growth, and they have shown motion in a very large proportion of cases and in not a few has there been normal motion. The absence of any traction force, either in the line of the shaft or of the neck of the femur, does not seem to have increased the number of patients having abscesses or the number of abscesses in each case, nor to have increased the frequency of shortening or the amount of shortening in each case. No case has given any signs of perforation of the acetabulum by the head of the femur, and in only one has there been any indication of perforation by suppuration. And involuntary muscular spasm and pain arising therefrom are noticeable for their absence. In a word, those patients who have had no traction are found to be remarkably free from all those conditions which we have been taught can only be relieved by persistent and long-continued traction. In conclusion, nothing appears to indicate that the prin- ciples upon which Mr. Thomas has based his teaching are in any way at fault, though in practice there is still some- what to be desired. 337 West Fifty-seventh Street, REASONS WHY Physicians Should Subscribe The New York Medical Journal, Edited by FRANK P. FOSTER, M. D.,1 Published by D. APPLETON & CO., 1, 3, & 5 Bond Si I, BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE; It is the exponent of the most advanced scientific medical thought. 3. BECAUSE; Its contributors are among the most learned medical men of this country. 4. 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