The principles and practice of modern surgery

by Roswell Park

The deformities and possibilities which may result from the advanced stage of hip disease are striking. Persistent muscle spasm leads to more and more flexure of the thigh, with abduction or adduction, as the case may be, while later the leg is drawn up so that the knee may almost touch the abdomen. As the bony portions of the joint change their shape there occur actual shortening and final dislocation, while all the adjoining parts show the effect of muscle atrophy and perverted nutrition. In addition to this the region of the hip may be riddled with abscesses or with sinuses, and the condition in every respect made extremely distressing.

While the disease is generally confined to one side, it may occur in both hip-joints, in which it, however, very rarely begins simultaneously. Existence of double joint disease of this character makes the case more than usually troublesome and complicates it seriously in every respect. The writer has been compelled to make double simultaneous resection of both hips.

Diagnosis.

—This has usually to be made from congenital dislocation, hysterical joint, infantile paralysis, non-tuberculous disease—such as synovitis, bursitis, etc.—acute osteomyelitis of the upper end of the femur, Pott’s disease in the lumbar region, and sacro-iliac disease, as well as from perinephritic abscess and appendicitis.

Prognosis.

—Hip-joint disease usually tends toward recovery, but generally with more or less deformity. When the circumstances are not favorable, ankylosis, with or without deformity, is inevitable, while abscesses, with persistent fistulæ, are not uncommon, and one may in extreme cases witness death from general tuberculous dissemination or from the consequences of hectic, with amyloid degeneration, or from acute septic infection.

One may naturally ask what may be considered as constituting recovery. In cases of this kind an absolute cessation of all symptoms and indications of the disease, with a minimum of deformity and of limitation of motion, are the nearest approach to ideal recovery that can be expected to secure. In favorable cases, seen early and properly treated for a sufficient time, there may be achieved almost a restitution ad integram, but such an ideal is seldom attained; otherwise there is nearly always more or less limitation of motion, with very frequent pseudo-ankylosis or actual ankylosis. Even this is favorable and most anything may be considered so which falls short of actual suppuration.

Treatment.

—The essential in the early treatment of hip disease is traction, so applied and regulated as to be effective. It should not be thought that by such traction as can be tolerated joint surfaces are actually pulled apart. What it really accomplishes is to tire out muscles which are in a condition of clonic spasm, overcoming thereby the deformity which they produce and thus permitting a reduction of their activity and of the harm which they have done. To do even this requires a considerable degree of traction, especially when muscle spasm is very prominent. Therefore it is best in pronounced cases of deformity to place patients in bed, and to apply traction by weight and pulley to a degree which actually overcomes the defects which we are combating. This will often require more weight than many men are in the habit of using. It should now be a question, not of amount of weight, but of effect, and of the easiest and best way of bringing this about. Physicians are very likely to use too small an amount of weight, and to neglect the use of counterextension and the benefit of more or less lateral traction, as well as that in direct line of the limb. Moreover, they often use inadequate means of applying traction, resorting to it only in such manner that traction is made at the knee and not at the hip. Even in young children it is often necessary to use twenty pounds, with a suitable traction apparatus, and four or five pounds for effective lateral traction.

Traction should be maintained until deformity has been overcome or the effort shown to be impracticable. After its complete benefit has been obtained it should be followed by fixation, the ideal method being that which accomplishes both fixation and traction at the same time; as, for instance, by the so-called Thomas splint, which permits the patient to be up and about with the use of crutches and a high shoe beneath the well limb, in order that the diseased limb may not be permitted to touch the floor, but rather to hang, and by its own weight afford a certain degree of traction. The Thomas splint is the simplest and cheapest for hospital work, while modifications in more elegant and expensive form are illustrated in works on orthopedic surgery. In cases which seem to demand it fixation can be effected by a plaster-of-Paris spica put on while the patient is standing upon the well limb and upon an elevation. The character of this work affords space neither for more elaborate description nor illustration than the hints embraced in the foregoing paragraphs.