Excision of the Hip-joint in Tubercular Disease.1 
BY B. MERRILL RICKETTS, M.D., 
CINCINNATI, O. 
The practice of excision of the hip- 
joint does not date back one hundred 
years, although Schlicting, in 1742, 
removed pieces of diseased bone from 
the human hip-joint. Experiments 
on the lower animals were begun by 
Charles White, of Manchester, Eng- 
land, in 1770, followed sixteen years 
later by Vermandois and Chaussier, 
in 1795. Schmalz, of Pirna, conceived 
the idea of making a double exsection 
of the head of the femur upon one of 
his patients in 1817, but after making 
his incisions he found that the head 
of the femur had already been re- 
moved by the disease, and conse- 
quently he could not claim to be the 
first to make the operation. Anthony 
White, of London, seems to have 
been the first to have made an ex- 
cision of the femur upon a living 
human being, a child. Huston made 
one in 1823, Oppenheim one in 1829, 
and Lentin one in 1832. Textor 
made one in each of the years 1834, 
1835, 1839 and 1845 ; the one in 1845 
lived. It was this year, 1845, that 
Ferguson began his renowned series, 
and up to 1855 he had made four 
operations with three successes. The 
operation now, 1855, became general, 
there having been performed forty- 
one operations up to i860 in spite of 
the opposition of Syme. Roux, 1847, 
was the first to operate in France, 
and the patient died, and the opera- 
tion does not seem to have again 
been made in that country until 1863, 
when Beckel operated with success. 
Ollier, of Lyons, made his first and 
successful operation in 1868. This 
was the year that Bonnet’s successful 
career began. Orthopaedics was little 
practised until the introduction of 
antiseptics, when the operations rap- 
idly multiplied under the Ray Barton 
method and the Adam’s section of 
the neck subtrochanteric. Volkman 
began on irreducible luxations in 
1878, while Margery, in 1885, en- 
deavored to remedy congenital luxa- 
tion by resection of the head of the 
femur. 
Charles T. Poor1 reports sixty-five 
cases of excision of the hip-joint out 
of sixty-seven, from 3 to 15 years of 
age, occurring in hospital practice 
from 1873 to 1893. Whether this is 
in St. Mary’s Free Hospital alone or 
not he does not say. There were 
five erasions; eight trephines of the 
trochanter major; eleven, the central 
cavity of the femur was cleaned 
(abscess in all) ; fifty-one, the joint 
was entered or behind the tro- 
chanter major; in fifteen cases the 
1 A paper read before the Cincinnati Academy of 
Medicine, November 20, 1893. 
1 New York Medical Journal, April 23, 1892. 2 
B. MERRILL RICKETTS. 
anterior incision on outer side of 
crural nerve below one-half an inch 
internally to anterior superior spine 
of ilium. In sixty-four cases only one 
joint was involved, and in three both 
were involved; thirty-six, the head 
and neck were removed ; twenty-four, 
made below trochanter major ; seven, 
head alone was removed ; thirty six 
cases, extensive bone lesion; thirty- 
one, confined to head alone ; in ten 
cases the end of the bone was after- 
ward removed ; thirty-five cases, old 
sinuses curetted owing to tubercular 
granulations ; five erasions performed 
afterward. Thirty-two were cured, 
twenty-five died, three returned, two 
not improved, and five not accounted 
for. 
Ollier gives three principal reasons 
for the joint being entered: First, 
acute suppuration, bony or synovial, 
origin due to any cause. Second,' 
acute tubercular suppuration. Third, 
arthritis, non-suppurative, but occa- 
sioning great pain or deformities by 
other means. In number one and 
two resection is the vital indication. 
Number three not so important; let 
alone except to walk orthopaedically. 
Do not remove the head for simple 
synovial fluid or marginal ostitis, or 
osteo-myelitis of head of bone, but in 
cocco-femoral articulations, involved 
by suppuration, the head should al- 
ways be removed. 
The views which I hold concerning 
hip-joint excisions might be considered 
radical, and, although I may be classed 
among the younger surgeons, I feel 
convinced through my own experience 
and that of others that even explora- 
tory incisions into the hip-joint are as 
justifiable as the exploratory incisions 
into the abdomen of any other cavity. 
I am also convinced that the indica- 
tions, as suggested by Ollier, for the 
operations are the most rational that 
I have seen. These conditions alone 
are sufficient to induce the most 
timid operator to discharge his duty 
both to himself and patient. It is 
not a question as to which one of the 
three stages of hip disease exists. 
Operative procedures in either of 
them may be demanded, especially so 
in the second and third stages; and I 
might say it is demanded in 90 per 
cent, of cases in the first stage. If 
we have evidence that the hip-joint or 
any other joint is diseased, it is our 
duty to determine as far as possible 
to what extent the disease exists. 
Unfortunately, in hip-joint diseases, 
as in most other diseases, the primary 
stage is overlooked. This is the most 
important time, for in the first stage 
operative procedure of any kind is 
most likely to result in good. I do 
not believe that there is 3 per cent, 
of tubercular hip-joints that do not 
result in more or less ankylosis. I 
am quite sure that no more than 6 per 
cent, of exploratory incisions in the 
primary stage would result in anky- 
losis ; I mean, of course, when per- 
formed aseptically. If the disease 
should, after exploratory incision, 
prove not to be tuberculous, primary 
union is to be expected. If it should 
be tuberculous, primary union could 
not under any circumstances be ex- 
pected. It is a great question as to 
the amount of destruction that is to 
take place when the head of the femur 
has become diseased even to the 
slightest degree. The earlier tuber- 
cular foci can be removed from the 
head, neck or shaft of the femur, the 
shorter will be the duration of the 
disease and the less the deformity and 
amount of ankylosis. Even at the 
present time the majority of operators 
in this and foreign countries delay any EXCISION OF THE HIP-JOINT. 
3 
direct surgical operation until the 
formation of fistulae. This, to my 
mind, is a dreadful state of affairs, and 
I would most surely condemn such 
procrastination. Operations under 
these circumstances can offer but 
little good as compared to operations 
in the earlier stages. By this time 
the patient has become subjected 
to the various tubercular sequelae, 
such as pulmonary infection, amyloid 
degeneration, etc. The patient has 
become practically worn out from the 
pain, loss of sleep, loss of appetite and 
general infection, besides having, 
from necessity, been compelled to do 
without sunshine, out-door exercise 
and fresh air. Do anything within 
reason before the second stages of 
hip-joint disease that will enable a 
patient to have these advantages. If 
these cases are allowed' to reach the 
third stage, years are required for a 
complete recovery if they should live. 
If the diseased tissue is removed 
early, the patient can be allowed to 
run about ad libitum from almost the 
beginning. 
I presented to this Society last 
spring the head, neck and greater 
trochanter removed from a boy 5*4 
years old. That specimen fully dem- 
onstrated what exists in what might 
be called the first stage of tubercular 
hip disease. I do not believe that 
there has been any good results fol- 
lowing the injection of iodoform into 
a hip-joint where tuberculosis exists, 
as in this case. As the majority of 
cases die sooner or later, perhaps 
before the age of 25, I do not believe 
it is wise to subject them to the con- 
finement that must necessarily be in 
placing the patients in plaster-of-Paris 
and the various kinds of braces that 
flail-joint may be avoided, because 
flail-joint may be the result even when 
fixation by any means has been re- 
sorted to. I do not believe the num- 
ber of flail-joints is increased by not; 
subjecting the patient to this plan of 
treatment. It is deplorable that the 
upper epiphysis of the femur should 
be removed during a surgical opera- 
tion ; it is surely equally deplorable, 
for life to be destroyed by disease. 
No man is supposed to remove more 
than the diseased portion of a bone ; 
that would be criminal, and the oper- 
ator would subject himself to suit for 
malpractice. It is supposed that the 
operator knows abnormal tissue from 
normal tissue, and unless he does he 
has no right to do this or any other 
kind of surgery. Therefore, I main- 
tain that the shortening is no greater 
in cases that have been operated upon 
than in cases that have not been 
operated upon, cases that have been 
allowed to run their course. Some 
maintain that the ankylosis as the re- 
sult of hip-joint disease is different 
and more substantial than the anky- 
losis following operative cases. How- 
ever, be this as it may, I feel that the 
end justifies the means. I am quite 
sure that the results in the cases that 
have come under my observation bear 
me out in this statement. While the 
operation of trephining the trochanter 
and neck has been done, I am scep- 
tical as to the indications for such a 
procedure. It is absolutely impossible 
for any man to determine the locality 
of tubercular foci, especially when 
they exist within the substance of the 
bone. I would add that there are 
three conditions which would permit 
me to operate: First, to get rid of the 
disease; second, to avoid infection ; 
third, to relieve pain when other 
measures have failed.