ORTHOPEDIC SURGERY 
A S 
A SPECIALTY. 
Reprinted'from NOR THWES TERN LA NCE1'. 
DISEASES OF THE HIP JOINT. 
Reprinted from MEDICAL N^WS. 
ARTHUR J. GILLETTE, M. I). 
ST. PA UI., MINN. ORTHOPEDIC SURGERY AS A SPECIALTY* 
A. J. Gillette, M. D. 
Orthopedic Surgeon to St. Luke's Hospital. Visiting Orthopedic Surgeon to 
University Dispensary. Member of the American Orthopedic Association. 
St. Paul. 
When the term orthopedic is used it seems to suggest to the 
general practitioner keys, steels, straps, buckles and a fair mechan- 
ical head. 
The orthopedist is regarded as a man who requires very little 
knowledge of medicine, surgery, physiology, anatomy or pathology. 
The only va riation in his treatment is the difference in the size 
and age of his patients requiring a little different measurement for 
the special brace which he is supposed to employ for each deformity. 
Yet the general practitioner is not to blame for regarding us in 
this light. Looking over the literature of orthopedic surgery, one is 
led to believe that it consists only of mechanico-therapy, and 
there are so many braces, cuts of which will be found in all the 
instrument makers' catalogues, with proper names for a handle, for 
instance, "Shaffer's Knee Brace," "Sayer's Hip Splint," "The 
Thomas Hip Splint," etc., etc., leading one to believe that the in- 
ventors of these appliances never employ anything else in the treat- 
ment of these diseases. 
I am free to confess that this was my impression until I knew 
these men personally and found that they used common sense as 
well. 
The general practitioner has a usual course of treatment in pneu- 
monia or typhoid fever, the surgeon in fractures and dislocations, 
the ophthalmologist in his work, but each varies his treatment ac- 
cording to the complications, environment and constitution of his 
patient. 
We are often asked ''what brace do you use for knee joint dis- 
ease, whose splint for hip disease, what is your cure for torti- 
collis," as though we could treat these cases by rule as you would 
do a sum in arithmetic, never stopping to consider the etiology, 
or pathology, the age, habits, occupation, mental temperament or 
constitutional condition of the patient. 
In some of the diseases which the orthopedist is called upon to 
treat, a brace plays about as important a part as Sim's speculum 
does in the treatment of uterine diseases. 
A young lady consulted me some time ago suffering with tubercu- 
lous synovitis of the knee joint. She was very much emaciated, 
had no appetite, had not had a good night's rest for months, her 
bowels did not move oftener than twice a week and she had not 
menstruated for three months. How little I should have accom- 
plished had my treatment consisted solely in the application of 
Shaffer's knee splint. Had I not built her up constitutionally she 
would be but little better off today than when she first visited me. 
A little boy under my care, at present in St. Luke's,Hospital 
*R,ead before the Minnesota Valley Medical Society, December^taTTJj- ORTHOPEDIC SURGERY 
suffering from tuberculous disease of both knees, tuberculous dis- 
ease of the right tarsus and of the hand, temperature ranging every 
evening from ioi to 102degrees, is suffering more constitutionally 
than from his local disease. 
In either of these cases all that was necessary as regards the lo- 
cal treatment was rest, and you may employ whatever you choose 
to accomplish this. 
In some cases where the reflex spasm is very slight, an ordi- 
nary ham splint, tightly bandaged to the limb, will secure rest; in 
other cases, especially in children, a plaster cast applied from the 
toe to the groin will relieve pain as well as secure perfect rest of 
the joint; in adults it is usually well to apply extension weight 
and pulley from the leg. Above all, avoid forcibly straightening 
the knee when flexed where it is due to reflex spasm; a few repeated 
dressings, and it can be straightened, and then if you wish to allow 
the patient the benefit of out door exercise do so with the use of 
crutches and a high shoe on the well foot. 
Most important of all, build up your patient, for you cannot ex- 
pect a local improvement from local treatment alone where a con- 
stitutional disease is indicated. 
In some cases braces do harm, more especially in lateral curva- 
ture of the spine where there is lack of development of one side 
of the muscles, or an over development, for it immobilizes the 
muscles and by not allowing the normal use of them really as- 
sists in increasing the deformity, thus causing more or less atro- 
phy from disuse. 
Many of these cases when they come to me are unable to go 
about when I first remove the brace, from lack of development 
on one side due to the weakened condition of the back from 
disuse. 
I have a little girl under my care at present, who when she came 
to me was wearing a brace (Fig- 1) the theory of which was a hip 
band with uprights or crutches attached which fit under the arm 
to keep the shoulders and back in the correct position and check 
the increase of the deformity. Now if the shoulders were like the 
pelvis, a fixed point, this theory would be a good one, but if we 
look at the anatomy of the shoulder joint and realize that it is freely 
movable in every direction, and that you can raise them until 
they almost touch the ears without affecting the spine one bit, it 
will be seen at once that this brace in regard to that is useless. 
Then, too, the argument in favor of this brace is sometimes used, 
that in lateral curvature you have one shoulder higher than the 
other and the crutch will overcome this. This is true, but you are 
not treating lateral curvature when you do this, you are only treat- 
ing one of its symptoms. The wide band which extends from the 
spinal upright about the chest and in front back to the pelvic 
band on the opposite side and buckled there, at first glance would 
seem to be of some benefit, but a closer examination will show the 
theory not practical but rather impractical and evil in its effects. 
In the first place, the upright to which it is attached behind is 
not stationary, for the pelvic band to which the upright is at- AS A SPECIALTY. 
3 
tached below is not the shape of the pelvis, and therefore fails to 
fix the only portion of the support where fixation is possible. 
The shoulder straps do not make the upper end of this upright 
fixed; then, too, if this upright was stationary it would still fail to 
fulfil the office designed for it, as the wide strap is brought around 
the chest across the abdomen back to the pelvic band, therefore 
FIG. I. 
making all its pressure on the abdomen and anterior portion of 
the chest. Thus you see its only effect is to retard thoracic res- 
piration, whereas it should be the object of the surgeon to encour- 
age development of the thoracic cavity, and the muscles of its 
walls. For in post mortem examination of subjects affected with 
lateral curvature.the muscles of the thorax have been much degen- 
erated and the diaphragm excessively developed, showing that res- 
piration in these cases is chiefly diaphragmatic, and therefore one 
important object of treatment should be to encourag£ the expan- 
sion of the thorax. When I removed this brace from the little 
girl, it was with an effort that she stood alone, but in a1 few days ORTHOPEDIC SURGERY 
4 
without one bit of treatment she stood straighter, so much so that 
the neighbors remarked how the child was improving, yet the only 
thing I had done was to remove the brace. The cause of this 
change by so simple a procedure was simply this: the muscles of 
the back were very much atrophied when the brace was first ap- 
plied, and the reason she did not hold her spine straight was be- 
cause of the lack of tonicity; the brace was then applied and she 
placed every confidence in it, relaxed all of the muscles of her 
back and sank into the brace without an effort to hold herself 
erect. When I removed the brace she did exactly the opposite, 
for she was obliged to use the muscles in the attempt to stand erect, 
and hence was removing the cause of her lateral curvature. You 
see the cause of her disease suggests the treatment, exercise, mas- 
sage, electricity, any thing to develop the muscles in the right 
direction. 
How absurd it would be to treatbeginning lateral curvature due to 
rickets with a brace, when the use of proper exercise, proper food, 
lime, soda, phosphorus and hygiene are all that are indicated. 
Find the cause and then remove it. If due to an improper desk 
in the school-room, too high or too low; in girls, if due to horse- 
back riding, I have seen one case where I am positive this was 
the cause; another case of a boy eleven years old who practised 
at the piano five hours each day, sitting on a stool without 
any support to his back and so high that his feet could not touch 
the floor-all of these causes can be and should be removed. 
Another very common cause of lateral curvature is the inequal- 
ity of the length of the lower limbs. 
This was brought very forcibly to my mind about three 
months ago, when I was treating a case of lateral curvature with 
little or no improvment. The mother asked me one day if I did 
not think one limb was longer than the other. I found by measuring 
a difference of of an inch, and that placing a book under the 
foot of the shorter limb I decreased the curve of the spine. It 
was very humiliating, for of course before this I was aware that 
this is one of the causes of lateral curvature, but I had not been 
systematic enough in my examination as to the etiology of the case. 
In the treatment of hip joint disease there is a good natured 
quarrel at present among orthopedists, between those who believe 
in traction and those who advocate fixation. One claims he can 
not cure a case without Sayer's long splint, another that this splint 
does harm by permitting motion of the joint, and that the Thomas' 
splint is the only brace from which you can expect any result in hip 
joint disease. 
I have found cases in which traction was the only thing that 
would relieve pain, that the simple Thomas splint would not; I 
have also had cases where the Thomas splint was all that was nec- 
essary and where extension caused pain; other cases which re- 
quired extension and abduction to relieve pain. 
I have at Resent two most promising cases in dispensary prac- 
tice where I am using simply a long board, well padded, extend- 
ing from the lower angle of the scapula to within a few inches of AS A SPECIALTY. 
5 
the heel, and the limb and trunk securely bandaged to with this, 
a high shoe on the well foot and the patient using crutches; another 
I am treating in about the same way with a plaster of Paris spica 
to immobilize the hip. 
I enumerate these different forms of treatment to prove my 
assertion that it is not necessary to rely upon any particular 
brace, but to meet the indications with no matter what, weight 
and pulley, long splint, plaster of Paris or sole leather splint. 
Many practitioners who live out of the city and are not able to 
have a special brace made in the town in which they reside, often 
send to some instrument maker with the measurements of their 
case to have some form of hip splint made which is figured in the 
instrument maker's catalogue, allowing their patient to go without 
treatment of any kind until the brace is made and shipped to 
them, thus allowing the most favorable time in which to begin 
treatment to slip by, the inflammation in the joint increasing day by 
day and the patient's constitution on the downward grade,instead of 
applying some simple appliance to relieve the patient as much as 
possible. 
To illustrate my point, the other day an instrument maker came 
to me and wished some information in regard to a brace which he 
was making for a doctor. It was then three weeks from the time 
the doctor took the measurements up to the time when the instru- 
ment maker visited my office, the child had not had any treatment, 
and it would be at least a week longer before the brace would be 
finished, permitting one month to elapse, you see, from the time 
the doctor diagnosed the disease until it was treated, and that 
too, provided the brace is a fit after he does receive it. If he 
did not have ingenuity enough to manufacture some form of ap- 
pliance to immobilize the joint while the brace which he was desir- 
ous of using was being made, he certainly could have kept the 
child in bed and thus relieve the trauma every time the child 
took a step. 
Then, too, I believe many of these cases, if not all, are not tuber- 
culous in the beginning, but are due to injury. Certainly we 
have many cases where it cannot be questioned from the history, 
that it was due to trauma subsequently becoming tuberculous by 
inoculation, and if early diagnosed and treated these cases can be 
cured in a few weeks, and do not become chronic or tuberculous al- 
though the symptoms are those of tuberculous hip joint disease. 
I have had two cases of undoubted hereditary syphilitic hip 
joints which resembled as far as pain and reflex spasm are con- 
cerned, ordinary so-called hip joint disease. About six weeks of 
anti-syphilitic treatment cured the cases. 
About two months ago an old lady was sent me from a neighboring 
city, suffering from inflammatory flat-foot. The arch of the foot 
was completely broken down and every step caused great pain,until 
finally she was scarcely able to walk, suffering the most intense pain 
night and day 
I applied the customary steel sole to support the arch but with 
no signs of improvement. Most of the night was spent in walking 6 
ORTHOPEDIC SURGERY 
the floor, wringing her hands and crying; she refused to eat and 
would talk of nothing but her feet. She had passed through six phy- 
sicians' hands before corning to me, and had given up every hope 
of being cured or even relieved. She was continually declaring 
that she would never recover and insisted on making preparations 
to die. 1 shortly saw that if ever I expected to do anything with 
this case without the employment of something besides the steel 
soles to raise the arch of the foot, I should only meet with disap- 
pointment. 
I therefore insisted that she be taken to St. Joseph's Hospital 
where I could be sure that my in structions were complied with. 
I then placed a pledget of cotton beneath the arch of each foot, 
and while Dr. Brimhall forcibly pressed upward upon the sole of the 
foot attempting to obtain as near as possible the normal arch of 
the foot, I applied a plaster cast extending from the toes to the calf. 
In this way I secured perfect rest of the inflamed parts as well as over- 
coming the deformity. Then with the use of sulfonal, tonics and elec- 
tricity to the feet, applyingone pole to the calf and passing the other 
over the exposed toes, I was enabled in six weeks to discharge her 
cured, which result I could never have accomplished had I continu- 
ed the usual orthopedic treatment of steel supports. 
As most general practitioners use the plaster cast in the treat- 
ment of Potts' disease, I cannot criticise their delay in sending 
to New York or Chicago, thus neglecting treatment until the brace 
is received. But there are many objections to the jacket; it 
becomes loose and fits badly after being worn for some time, 
every change in the size of the abdomen affects its bearing upon 
the back, and the size of the abdomen changes before, during and 
after each meal. It is hot and dirty unless it is so made as to be 
removable, but this requires considerable pains and experience. 
Very often bread crumbs and various foreign substances find their 
way under the jacket and cause deep sores and ulcers. It is very 
liable to chafe. 
Yet there are some things in its favor: it is cheap, and for 
careless and ignorant patients, a jacket which is not removable is 
far preferable to any apparatus which they can misuse. I cannot 
see that a plaster jacket has any advantage whatever over a sole 
leather jacket, which any physician, with the assistance of a har- 
ness maker can make. It is much cheaper, as a good one will 
last an indefinite period and cost only from $4.00 to $6.00; then, 
too, it is much cooler, as it can be perforated without weakening the 
jacket. 
For the proper treatment of caries of the spinal column only one 
thing is to be kept in view, and that is rest, thorough and com- 
plete rest, fixation. To do this there must be little or no forward 
or backward motion; the brace should work on the principle of a 
lever, the fulcrum being the diseased point of the spinal column. 
The simplest, most efficient and the cheapest is a modification of 
the Dr. C. Fayette Taylor's brace (Fig. 2). Any machinist can 
make it and any doctor can take the measures and properly apply 
it, and so can any mother after the doctor has instructed her. AS A SPECIALTY. 
7 
It consists of two uprights, A-A, of steel, or % an 
inch in width, the thickness according to the size and the age 
of patient, that is, thick enough to be rigid; the lower ends of 
the uprights are attached together below to a hip band, B, 
which grasps the pelvis just a little above the hip joint; these 
uprights are joined together near the top by two small cross bars, 
C C, extending laterally a little beyond the uprights, the lower one 
FIG. 2. 
corresponding to about the inferior angle of the scapula and the 
other about one inch above it; the uprights to be far enough apart 
to rest upon the transverse processes of the vertebrae, not so close 
together that they squeeze or in any way press upon the spinous 
processes, And to be carried as far up as will be permitted without 
interfering with the movements of the neck; at the top of the up- 
rights are attached two pieces of steel, D-D, one on either upright, 
which extend out and bend so as to fit over the shoulders. 
This steel skeleton is to be covered with padding which any 
harness maker can do. 8 
ORTHOPEDIC SURGERY 
All that is left to be made is the apron, E, which is nothing more 
nor less than a strong piece of muslin,the length of which is from 
the top cross bar to the hip band, and of a width equal to its length; 
to this are attached four pairs of wide straps; one pair at the bot- 
tom to pass through buckles attached to the hip band; the two 
middle pairs to be brought around the body and strapped over 
the brace; the fourth or upper pair of straps, which are attached 
to the top of the apron, are brought behind and fastened to the 
buckles which are attached to the upper crossbar. There is also 
a padded strap, extending from the steel which passes over the 
shoulder, under the arm to the lower cross bar. 
This brace can be changed from time to time by simply forci- 
bly bending the uprights, with only one rule to be kept in mind, 
"always make the brace to fit the deformity." 
In the treatment of upper dorsal and cervical Potts', I use the 
leather support referred to with the jury-mast attached, which is 
simple in its construction and application, or else put the patient 
to bed with an extension from the chin over the head of the bed. 
I believe that there is an erroneous idea that patients are greatly 
injured by being kept in bed; certainly my experience has been just 
the reverse, as I have had a number of cases of Potts' disease, 
cervical and dorsal, in which this with constitutional treatment re- 
lieved the suffering, and the patients increased in weight. 
According to Dr. Bauer, "a month's immobility of the spine by 
recumbency is more beneficial to the patient than three months of 
the plaster of Paris jacket ambulant." (57. Louis Clinic, July, 
1890). 
I am aware that my article has been of rather a rambling nature, 
but I have only attempted to prove that there is no panacea in or- 
thopedic surgery, but like general medicine and surgery each case 
must be treated on its own merits. DISEASES OF THE HIP-JOINT.* 
By Arthur J. Gillette, M. D. 
The title of this paper, "Diseases of the Hip joint," is used in- 
stead of "Hip-joint Disease" because the latter term is applied more 
generally to a tuberculous inflammation, although, with authori- 
ties, I am inclined to believe that tuberculous hip-joint disease al- 
ways begins as a simple inflammation following trauma, and by in- 
oculation subsequently becomes tuberculous. There are diseases 
of the hip joint the origins of which, I am sure, are not due either 
to injury or to tubercle bacilli, but which are constitutional dis- 
eases with local manifestations. 
I am prompted to choose this subject for two reasons: 
First. At the onset, these cases always have the same clinical 
appearance as those of the more chronic, or of a true tuberculous 
nature, and in several instances my prognosis did not prove cor- 
rect, although I am sure that my diagnosis was undoubtedly accu- 
rate as regards an inflammation of the hip joint. 
Second. On several occasions, when I gave a prognosis in cases 
of chronic hip-joint disease, the family physician informed me that, 
by rest in bed, and extension by weight and pulley, he had cured 
cases of hip-joint disease in a few weeks. Thus was strengthened 
my belief in an inflammation non-tuberculous in the beginning, 
but with subsequent inoculation-usually occurring before it is 
placed in the hands of the specialist, and hence running a chronic 
course, with effusions and rupture of the joint capsule. Dissection 
of the soft parts may follow by the effusion becoming purulent, be- 
cause of the breaking down of the soft parts, or of infection follow- 
ing the opening. This emphasizes the most important feature in 
the treatment of hip-joint disease, viz., an early diagnosis-since I 
believe it is sometimes possible to check the progress of these cases 
before they become chronic or tuberculous. 
The occurrence of periostitis in the long bones, following scarlet 
fever, measles or typhoid fever, is not at all uncommon. Dr. 
Keen1, of Philadelphia, has given a full account of all the bone-le- 
sions following th^ continued fevers. He found 69 cases, of which 
22 affected the head, 7 the trunk, 6 the upper and 42 the lower ex- 
tremities. There were 37 cases following typhoid fever. As to 
the date of occurrence in 47 cases, 10 were within two wreeks, 27 
from three to six weeks, and 10 some months after the fever. 
Keen's explanation was that the earlier cases probably came from 
clot, and the later from enfeebled nutrition.'^ He found that the 
periostitis arose spontaneously or as a result of slight injury. 
V. P. Gibney2 read an original article before the American Or- 
thopaedic /Association, entitled"Typhoid Spine," in which the clini- 
cal aspect resembled very closely that of beginning Pott's disease. 
In this paper he reports cases of disease of the hip which bear a 
*Read before the Inter-County Medical Society of Wisconsin, March io, 1891. 
iTrans. of Amer. Orthopaedic Assoc, vol. ii. "Typhoid Spine," by V. P. Gib- 
ney. 
2 Ibid., vol. ii. 10 
DISEASES OF THE HIP JOINT. 
close resemblance to tuberculous hip-joint disease. One was that 
of a young lady, eighteen years old, convalescing from tj pho-ma- 
larial fever and suffering with acute pain in the hip. Any move- 
ment of the limb would excite cries of pain. She was not of an 
hysterical, but rather of a lymphatic temperament. Weight and 
pulley and a traction hip-splint afforded relief in less than a month. 
A few months afterward there was no lameness, pain, or reflex spasm, 
although as compared with the other limb, there was some limit to 
the free range of motion. Dr. Gibney's conception of the pathol- 
ogy was a circum-articular lesion confined to the periosteum or 
ligaments. Another case was that of a boy aged thirteen. For 
four or five months after having had typhoid fever, while confined 
to his bed, he kept both limbs flexed on the abdomen, and during 
convalescence was unable to straighten them. He was poorly 
nourished, and quite unable to walk. The thighs were sharply 
flexed on the pelvis, the legs on the thighs, the heels touching the 
buttocks. Any attempt at motion of the right thigh caused reflex 
spasm. 
At themeeting referred to all the members seemed to acquiesce 
in the views of the author, and many reported cases of joint troubles 
occurring in their own practice, following acute severe fever, the 
exanthemata, etc. 
There is still another constitutonal affection that I believe ac- 
counts for many diseases of childhood, and which often manifests 
itself in the form of joint-diseases. I refer to hereditary syphilis; 
and I would ask the general practitioners present: How many 
cases of acquired syphilis continue the treatment so long as yon 
advise? Do they remain under your care after the initial sore is 
well? I have carefully questioned a number of fathers whole chil- 
dren I was treating for joint troubles, and have been somewhat 
surprised at the number who acknowledged that at some time pre- 
viously to their marriage they had had suspicious sores. I am also 
aware that syphilis usually manifests itself by pemphigus of the hands 
and feet, various eruptions, a copper-colored discoloration of the skin 
characteristic snuffles or coryza, stomatits, laryngitis, etc., and 
that all these symptoms usually occur before the end of the first 
year; but there are well-authenticated cases of hereditary syphilis 
in which the disease did not make its appearance until the twentieth 
and twenty-fifth years. 
Some time ago a patient, a child not quite two years old, was 
sent me from a neighboring town, exhibiting all the symptoms of 
double hip-joint disease, and with no history of an injury. The 
disease had existed in the left leg for some months longer than in 
the right. The parents gave me the following history: The child 
had always been remarkably healthy, well-developed and intelli- 
gent, never having had any eruptions, although the parents thought 
it had been troubled with "snuffles." The teeth appeared punctu- 
ally, and the fontanelles closed early. About three months prior 
to my seeing the child the first symptoms exhibited were loss of 
sleep and night cries. At times, if the left limb was handled a lit- 
tle roughly, the child would cry, but at other times this did not DISEASES OF THE HIP JOINT. 
11 
produce the slightest uneasiness. From day to day it was observed 
that the child held the limb flexed and adducted; following this the 
right limb became tender, was soon flexed and adducted in the 
same manner, so that when I saw the child both limbs were ad- 
ducted, both thighs were almost completely flexed upon the abdo- 
men, and the legs flexed upon the thighs. In this position the 
child had been for a number of weeks, and in all my experience 1 
have never, in any disease, witnessed a patient suffer such agony 
and excruciating pain. The slightest jar of the floor or bed would 
cause pain. When I saw the child, movement being so intolera- 
ble, the napkins had not been changed for a number of days. It 
was impossible to make an examination without etherization. Up- 
on extension of the limbs there was the characteristic lordosis of 
the spine. After etherization this entirely disappeared. The left 
leg, in which the disease first manifested itself, was one-quarter of 
an inch shorter than its fellow, although it appeared longer. This, 
of course, was due to the tilting of -the pelvis. I applied a plaster- 
cast to keep the joints quiet. A general practitioner, administering 
ether, called my attention to the gums and teeth, which had the ex- 
act appearance described by Hutchinson. The gums were of a 
highly congested, swollen and peculiar spongy appearance. The 
child had also a severe laryngitis. The immobility of the hips did 
not relieve the pain. After a few days I applied a weight.and pul- 
ley, and the child was asleep before I left the hospital. The flexion 
was not overcome so rapidly as usual under this treatment, although 
the pain was almost completely relieved. I then began the admin- 
istration of mercury, both internally and by inunction. From the 
very time that this was administered the child began to improve. 
In ten days of two weeks, every bit of pain about the hips had dis- 
appeared, the inflammatory condition of the mouth was completely 
relieved, and at the end of six weeks the little patient was appa- 
rently well. Six months have now passed, and the child has not 
had any local treatment for three months; the hips are freely mov- 
able in every direction, and the child, to all appearances, is in per- 
fect health. This history, together with the fact that the father ac- 
knowledged he had suffered from a sore on his penis, proves con- 
clusively that it was a syphilitic hip joint, pure and simple. 
Another case, I am sure you will agree with me, was undoubtedly 
spyhilitic; it was referred to me by Dr. Sweeney, of St. Paul. The 
disease was of the right hip, in a boy aged seven years. There 
was apparent lengthening, but actual shortening; there was atrophy 
of the calf and thigh, but only slight tenderness; the leg was ab- 
ducted and slightly flexed. The mother gave a history of the boy 
having had a similar attack four years previously. At that time 
the joint was very painful, and was put in a plaster cast; following 
this a peculiar eruption appeared, which puzzled the attending phy- 
sician. A consultation was called and medicine given that caused the 
disappearance of the eruption, the symptoms about the joint immedi- 
ately clearing up,and the child up to the present time seeming per- 
fectly healthy. I applied the long traction-splint, and the mother, 
without consultingthe family physician or myself, left for the country. 12 
DISEASES OF THE HIP JOINT. 
I did not see the child again for three months, when I was called, 
and found the child, of course, in a very much worse condition 
than when I first saw it. The thigh was flexed, the joint exceedingly 
tender, and there was swelling all about the hip. I had, in fact, a 
typical picture of a tuberculous joint. I reapplied adhesive plaster 
and a splint, and advised rest in bed. I continued this treatment 
for about ten days, with but little or no improvement. The mother 
called my attention to a peculiar eruption, which, she said, had 
appeared some time before, mostly on the upper part of the child's 
body. It was of a dull brownish-red color, with an ulcerated top, 
and varying in size from a pea to a nickel. At my request Dr. 
Sweeney was called, and he immediately placed the child under an- 
ti-syphilitic treatment. The child's general condition immediately 
inproved, the aggravated symptoms about the joint disappearing as 
if by magic. I have since learned that from the habits of the 
mother she would be a very fortunate woman indeed if she had not 
at some time been infected with syphilis.* The father was also im- 
moral. The child is stilll wearing the brace, and I fear has now a 
tuberculous hip, although I believe the origin of the disease was 
due to syphilis. Without doubt, syphilis is a distinct causative 
factor of rickets, and it is clearly demonstrated that among chil- 
dren affected with hereditary syphilis tuberculosis is rife1. 
I Annual of Universal Medical Sciences, vol. i., 1890, No. 29. 
* Since the above was written I have met a physician who had treated the mother 
for syphilis.