Dr. Lorenz feels that a good func tional, as well as anatomical, result is only likely in cases between three and seven years. The oldest ease he has treated is twenty-three years. Where he fails to reduce the hip, the muscle stretching followed by long fixation of the thigh in the manner already de scribed gives a fair functional result. In one case in Boston, that of a. boy 9'/2 years of age, he was tillable to get the head into the acetitbulum. Editorial (Boston Med. and Sttrg. Jour., Jan. 1, 1903).
Confusion may arise at times in regard to FRACTURES OF THE NECK OF THE FEMUR in small children where there is a history of traumatism, pain, and limping, but the diagnosis can usually be made by the fact that the disability and the pain immediately followed the tism, and the great trochanter was diately found to be above Nelaton's line; the only confusion possible being in cases which do not come under observation for months after the occurrence of the toms and where no history can be tained. Such cases often present a picture of flexion and adduction which greatly resembles that of old hip-joint disease with absorption of the head of the femur.
In COSA VARA, caused by the bending of the neck of the femur, the diagnosis is more obscure. In these cases, also, the great trochanter may be above Nelaton's line. The motion of the joint may be limited, but careful investigation of the relation existing between the trochanter :and the head of the femur, in combina tion with the direction of the neck of the femur to the shaft, and differentia tion between the limitation of motion produced by spasm of the muscles and that caused by abnormal relations of the neck of the femur, which cause the latter to strike the ilium, will clear up the diagnosis.
At times periostitis of the great tro chanter may simulate quite closely hip disease, pressure over the trochanter giv ing rise to acute pain. If the head of the femur, however, be pressed into the ace tabulum by one hand on the middle of the thigh while the knee is abducted with the other, no pain is produced and the sensitive spot is thus located in the trochanter and not in the head of the femur.
The occurrence of tumors of the femur and ilium should not be overlooked. These are almost always sarcomata; and can usually be differentiated from tuber culosis or syphilis by the rapid enlarge ment of bone usually following quite soon after a traumatism associated with pain, which is usually caused by pressure on nerve-trunks and does not resemble in its characteristics the night-crises of ordinary hip-joint disease. Muscular
spasm is also usually wanting. The im portance of a correct diagnosis' being reached very early in such cases cannot be overestimated, as it is only by prompt amputation that life can be saved.
A point to be borne in mind in mak ing a diagnosis of abscess in connection with a fluctuating swelling on the but tock is the possibility of confounding one with an aneurism, as there is on record a case of gluteal aneurism that was opened with fatal result under the impression that it was an abscess. It is always best to confirm the diagnosis by an aspiratory needle.
Etiology. — The ordinarily accepted type of "hip disease" or "morbus coxa rius" is a tuberculosis, which in the vast majority of instances begins in the bone, though it may, in exceptional instances, commence with synovial membrane.
How the tubercle bacilli gain access to the bone is a matter which is still under discussion. It is probable that the bacilli are present in the circulation and that under the influence of a traumatism, not necessarily severe, a lowering of the resistance is produced in the neighbor hood of the joint sufficient to favor the local development of bacilli which have been present in the general system for a long time, but which had not increased on account of lack of suitable conditions.
Tubercular material was injected by into the femoral artery of ani mals with negative results. When in jected into the crural artery from which the nutrient artery of the femur arises or into the nutrient artery itself, typical bone tuberculosis was set up.
Tubercular matter from phthisical lungs injected into animals' joints sets up tuberculous joint-disease, while in jection of inorganic matter not contain ing tuberculous matter either into the joints or general condition does not cause tuberculosis.
Schiiller rendered guinea-pigs and dogs tuberculous by inhaling solutions of tubercular material from diseased lungs and injected the same into the animals' lungs. The joints of these animals were then wrenched or bruised, which pro duced a typical chronic tubercular syno vitis in a great proportion of the cases, while healthy animals whose joints were similarly treated suffered from only a temporary sprain.