HIP-JOINT DISEASE.
The great majority of the eases coming under the care of the surgeon are of tuberculous origin, and the most important point in their treat ment is the promptitude with which rest can be secured for the articular surfaces. A great change has been witnessed in the treatment of hip joint disease during the last 20 years, operative procedures as incision and amputation being now very rarely resorted to. Most surgeons have entirely abandoned excision, and 1;owlby has recently published very remarkable success in 900 cases at the Alexandra Hospital treated by rest and extension with general hygienic measures, the mortality being less than 4 per cent., though 4o of the series were examples of bilateral disease.
As soon as the earliest signs of rigidity, tenderness and pain present themselves the child should be placed upon his back in bed, lying upon a firm hair mattress, a weight and pulley being employed to secure extension, the weight being attached to a stirrup. The degree of traction can never be such as will secure separation of the opposed articular surfaces, the object being to secure fixation and absolute rest from muscular spasms and startings, hence with young children the weight need seldom exceed r or 2 lbs. in order to avoid stretching of the liga ments. The traction in all cases where deformity is present should he applied in the direction of the axis of the contracted limb, and Edmund Owen points out the importance of making the traction in the line which the thigh takes when the pelvis is squared and the loins are flat. Where much adduction is present counter-extension by means of a perinea] band is necessary, and abduction may be corrected by attaching a weight to each limb or by applying a double long splint with a hinged cross-bar.
Restless children may be treated upon the same principle by the use of a double Bryant's splint and elevation of the foot of the bed; a Thomas's splint, on an abduction frame, may be applied at once, though the patient should be kept in bed till the deformity has disappeared and the pain has passed away.
The weight and pulley or other form of extension should not be dis carded till all symptoms and signs have been removed, but absolute rest of the joint must be afterwards maintained for a very considerable period, varying from at least r year and upwards, during which time the affected limb must never be permitted to bear any portion of the weight of the body.
As the tuberculous nature of the joint affection clearly indicates open air treatment, it becomes a matter of vital importance to secure im mobility of the articular surfaces by some method which will enable the patient to move about or be carried out of the sick-room, and this is especially desirable in the summer months. For all practical purposes, the skilful adjustment of a Thomas's splint suffices when pain, tenderness and muscular rigidity have been combated by extension. After the application of the splint a patten should be attached to the sole of the hoot on the sound side in order to prevent the foot of the affected limb touching the ground, then by the help of crutches the patient should be permitted to walk about for a period of twelve months. During this time gentle friction or mild massage of the muscles may be practised, but movement of any kind at the hip-joint is not permissible.
Very young children may have both limbs encased by a double Thomas's spinal caries splint, so that they can be carried about in the open air. Phelps' box answers the same purpose. The objection to the routine use of Plaster of Paris splints is the danger of an abscess being overlooked till the skin has become involved.
In neglected cases where extension fails to reduce the contracted state of the limb muscles these should be stretched under Chloroform, and occasionally it may be even necessary to perform tenotomy, after which extension must be again employed. Should an abscess occur it never should be permitted to discharge spontaneously, as septic infection of the cavity or sinus is certain to occur. It may be aspirated and the sac injected with Iodoform emulsion, and some surgeons recommend similar treatment of the joint itself when signs of effusion are present.