Deport of thirty-two cases to support the opinion that osteotomy of the femur in cases of coxitis and similar deformities of the hip is a very successful operation, and is capable of affording the best pos sible results in the shortest time. Hoffa ("Festschrift der Phys. Med. Gesellschaft Wurzburg," '99; Brit. Med. May 5, 1900).
Between these two extremes we find third class, in which the surgeon at times is in doubt whether the continued use of a splint for a longer period of years is better, or whether a free removal of the head of the bone, scraping of the acetabulum, and removal of all tuber cular tissue may not, in the end, give a better result. Such cases must be de cided by each man on his own experience.
In case operation is decided upon, if the patient has a large abscess and is very much exhausted, it is usually better to open the abscess freely and wash it out at one sitting, and in a few days, when the patient has rallied from the removal of retained pus, to complete the clearing away of dead bone, except in cases presenting many old sinuses, where it sometimes is best to unite these by an incision. The best method of reaching the joint is by an inci sion starting midway between the an terior superior spine of the ilium and the greater trochanter, and, passing over the great trochanter, down the thigh along its outer aspect. This incision should pass completely through the peri osteum and extend to a point below the lesser trochanter. By means of a curved bistoury the periosteum should now be ' divided at right angles to the original eut and, by means of a periosteal ele vator, peeled up from the femur. At the digital fossa it will be necessary to resort to the knife to divide the muscles in serted there. At all other points the periosteum can be peeled off by the peri osteal elevator. The femur should be sawed just above the lesser trochanter, and the head removed from the socket by means of a pair of lion forceps, or may be dislocated from the acetabulum prior to sawing, at the pleasure of the operator. If there are evidences of disease farther down the shaft of the femur the peri osteum must be split lower and the femur sawed in two lower down. The acetab
ulum should then be explored, and, if any foci of disease exist, they should be carefully removed with a sharp spoon. If the acetabulum is perforated, the opening must be enlarged so that no shoulder of bone shall cause pus to ac cumulate in the pelvis. Sometimes it is necessary to drain such intrapelvic abscesses through the sciatic notch in stead of the acetabulum. If any sinuses exist, they should be carefully cleaned and all tubercular tissue removed as far as possible. The wound should then be thoroughly packed from the bottom with iodoform gauze and the patient placed in a wire cuirass. The wire cuirass con sists of a wire frame-work extending from the head to the heels, with a pair of movable foot-pieces, which allow the legs to be lengthened or shortened. The sound leg and the trunk are firmly band aged in position by a roller bandage. Turns of the bandage also pass over cotton pads in the groin and around the handles of the cuirass and serve to give counter-traction. The diseased limb is then fastened to the foot-board of the cuirass by means of adhesive pieces ex tending to the thigh, as for the applica tion of a hip-splint, and the foot-board is then drawn down until both legs are of the same length, the bandages just mentioned as passing between the legs keeping the trunk from slipping down. The patient can be dressed in his cuirass, which is cut away under the buttock for this purpose, with much less pain than in any other manner, and can have the benefit of out-door life from the time of operation, being transported in a wheeled carriage.
Simple method presented by which re cumbency, with any advantage, can be obtained without the counterbalancing evils which attend it when used in the general way by confining a patient to bed. A light carriage with wicker-work sides, rubber tires, and well-tempered springs is made of a length suitable for the patient, allowing for at least three years' growth ; and it is surprising how a child will grow on such a carriage in the fresh air and sunlight. Cut illus trates carriage as used by the author. W. W. Bremner (Med. Record, Aug. 3, '95).