CONGENITAL DISLOCATION of the hip may be mistaken for hip-joint disease, but the history is different: there is no history of, traumatism, and there is usu ally no history of pain. The disturbance of gait has been noticed from the first efforts at walking, which generally have been made long after the time at which children ordinarily commence to walk, and there is usually marked prominence of the buttock on the side of the dislo cation, and while the child is recumbent the head of the bone can be caused to glide upon the dorsum of the ilium, while the great trochanter is felt to ap proach and recede from the crest of the ilium. The only point in common with hip-joint disease is the limp, which, how ever, is different in its characteristics from the limp of hip disease, and the fact that the great trochanter is above Nela ton's line. In hip disease the trochanter would only be above Nelaton's line in an advanced case, whose history would be absolutely different from that of con genital dislocation of the hip.
Dr. Lorenz's recent visit has brought out many new and important points in fixation and after-treatment. The steps of the operation are as follows:— L With the patient lying on the back, the leg and thigh of the affected limb are flexed each to ninety degrees, and the thigh is worked up and down in a line perpendicular to the table. This breaks up adhesions around the head of the femur in its unnatural position. During this and the subsequent steps the pelvis is held firmly by the assistant.
2. With leg and thigh extended, the whole limb is abducted in a plane par allel to the table and worked back and forth to tear the inferior adhesions of the joint capsule and to some degree to stretch the adductor muscles.
3. With leg flexed and thigh about forty degrees from the table, the thigh is repeatedly abducted with great force, each excursion bringing the thigh out ward nearer the table, stretching and tearing the adductor group, while at the same time vigorous blows and kneading of the adductor muscles near their origins on the isehium and symphysis serve further to tear their fibres.
4. With leg extended, the whole limb is forcibly and repeatedly flexed on the trunk, and the foot approximates the face—this to break up and stretch ad hesions and fibres in the posterior pelvi femoral group.
5. With the patient lying on the un affected side, the thigh is forcibly hyper extended to stretch anterior adhesions and muscles.
0. With the patient again on the back, the leg and thigh are flexed and the thigh is strongly rotated again and again.
7. With a wedge-shaped block under the great trochanter as a fulcrum, the flexed thigh is abducted with great force, this serving to break the last adductive fibres and thoroughly to release the head of the bone.
8. Acute flexion and outward rotation of the thigh should cause reduction of the dislocation with a distinct sound as the bone slips into place.
9. With the bone held in place, strong abduction now shows the adductor group to be again shortened, and they must be stretched still farther till they no longer have resiliency enough to tend to throw the head of the femur out of the acetabulum.
10. With the bone still in place, any contractures of the hamstrings which may now have appeared should be stretched.
11. Wadding and bandage are applied in such a manner that the head of the femur is held tight against the acetabu lum by turns around the knee and oppo site side of the pelvis, and the thigh in extreme abduction (ninety degrees) and to extreme hyperextension. Over this a thigh plaster-of-Paris bandage is applied. As Dr. Lorenz puts it, a child with both hips thus put up "looks like a jumping ja ek after you pull the string." The plaster is kept on six or seven mouths. The child is encouraged, after a few- days, to walk and jump about on both legs, a high shoe making up for lack of relative length on the affected side. The constant impact of femur against acetabulum obtained by the jar of walking is an important factor toward final success.