Another objection to the Thomas splint is the method by which it straight ens the deformity, which is effected by bending the splint backward by wrenches from time to time. If there is contrac tion of the flexor muscles, this proceed ing must result in crowding the head of the bone violently against the acetabu Tuna, thus running the risk of re-exciting inflammation.
In the majority of cases there is too much deformity when they first come under observation to permit the applica tion of a splint. Such cases should be put to bed, a long padded side-splint, with a cross-bar at the bottom, should be firmly bandaged against the sound leg and the trunk as far as the axilla, and the body and leg thus secured may, if necessary, be fastened to the sides of the bed for the purpose of retaining them in position.
It is sometimes found better to band age the patient with Bradford's frame, a rectangle of iron gas-pipe somewhat longer and broader than the child, which has canvass stretched tightly across it except at the part where the hips lie, which is left open for a bed-pan. A long board should be placed under the mat tress, as the ordinary spring-mattress is too yielding to allow proper control of an inflamed joint. Adhesive-plaster straps, furnished with buckles at one end, are next applied to the diseased limb, the buckles being just above the malleoli, and the plaster extending as high on the thigh as possible. Heavy extension diachylon plaster, spread on mole-skin, is best for this purpose, as the ordinary rubber plaster is irritating to many skins when worn for a long time, and is spread upon such thin cloth as to be incapable of enduring the strain nec essary in many cases to afford relief. In applying the plaster it should be warmed but very little, and in many cases need not be warmed at all, but should be snugly bandaged to the skin, and well rubbed with the hand to secure coapta tion of the plaster. This tight bandage may then be removed and replaced by one not so closely bound. Some prefer, in addition to the two side-straps of plaster, a spiral of plaster passing around the leg in both directions, which serves to hold the plaster more snugly in position. Properly-applied extension plasters should remain for several months without the necessity of change. To the buckles are now attached small leather straps, which are fastened to a cross-bar below the sole of the foot, from which cross-bar a stout cord extends over a pulley-wheel at the foot of the bed and supports a weight. The amount of weight will vary in different cases, and should be that which experience shows gives the greatest amount of relief in the particular case, and may vary from two to fifteen pounds. The direction in
which the traction is made should be de termined by the deformity which is pres ent in each particular case.
In hip-joint disease two lines of ex tension are absolutely necessary for'the relief of intra-articular pressure. One of these must correspond with the axis of the neck of the femur, because the glutei group and adductor muscles, which are affected by spasm, act upon a line with this axis. The other must correspond with the axis of the shaft, because the iliacus internus and psoas muscles, which are also in a state of spa sm, act on a line with the latter axis. All patients with deformity should be put to bed, with extension in the line of deformity and at right angles to that line. In fact, the treatment of any case of joint disease should be begun by overcoming the deformity, as a straight brace cannot be successfully applied to the deformed limb. There is hardly any deformity in joint disease which cannot be best overcome by extension in bed and by forcible means under anaesthesia. After the deformity has been overcome, a lateral traction or fixation brace, de vised by the writer, is used, which is perfectly straight and which, when properly applied, will prevent future de formity. The theory that longitudinal traction relieves intra-articular pressure is erroneous. The glutei and adductor groups of muscles are pulled upon, and, by the direction of their origin, any ex ertion must necessarily force the head of the bone into the socket. Cases treated with this splint seldom recover with ankylosis. It is very important to recognize the fact that no case of hip joint disease recovers inside of two years. and 73 per cent. of the cases brought to the author have abscess as the result of premature removal of the brace. After the patient has worn the brace for eighteen months or two years and the muscular spasm and the disease have subsided, a walking brace should be applied, which protects the child from injuring the limb if he falls. Joints are frequently seen with all the symptoms of inflammation, which re cover within a few months: Nit. this is pimply a traniitory condition due to normal inflannnatio», and if protected such joints will recover. if infection take place, however, disease occurs and the abscess results,—tuberculous, puru lent, gonorrhoeal, or pneninococcal,— and frequently surgical intervention is, necessary. A. M. Phelps (Medical News, May 31, 1902).