CLINICAL LECTURE DELIVERED AT THE LONG ISLAND COLLEGE HOSPITAL, OF BROOKLYN.

By LOUIS BAUER, M. D., M. R. C. S., (Eng.,)

LICENTIATE OF N. Y. STATE MED. SOC.; CORRESP. FELLOW OF THE LONDON MED. SOC.; MEMBER OF THE N. Y. PATHOLOGICAL SOC.; PROFESSOR AND SURGEON TO THE LONG ISLAND COLLEGE HOSPITAL, ETC.

GENTLEMEN-Numerous cases of hip disease presented at our hospital and polyclinic, have given ample opportunities of inquiring into its pathology, and of testing the efficiency of our treatment. You have seen the disease in all phases and complications, from its local commencement to its constitutional termination; you have, therefore, collected sufficient clinical facts to review some important points intimately connected with the subject. Most cases being still in your recollection, we may dispense with the reiteration of their respective histories; nor need we enter upon details, you being fully conversant with the substance. Deviations in our present opinions from those propagated some years.

ago, you will readily recognize as the result of continuous investigation and augmented clinical experience. Looking upon stubborn facts as the only reliable and commanding authority within the compass of inductive science, and claiming no personal infallibility, we shall lose no time in needless vindication.

Passing over the first stage of hip-joint disease, as not arresting our attention in particular, we may at once proceed to investigate the characteristic phenomena of the succeeding period. As such we have to mention :

1. Immobility of the affected joint.

2. Malposition of the affected extremity. 3. Attenuation of the affected extremity. 4. The peculiar pain.

1. Immobility of the affected joint.-The second stage is, so to speak, initiated by this symptom. In the beginning, the immobility may not be perfect and in a certain measure attributable to volition, yet it very soon becomes obvious that all use of the joint has ceased, and that it has passed beyond the control of the patient. This becomes evident in the act of locomotion, in which the patients substitute the healthy articulation conjointly with the flexibility of the spinal column, more especially that of the lumbar portion, and they gradually acquire by constant practice such a facility as to delude not only their parents, but even their medical attendants. The true condition, however, will be easily ascertained, when the patient is undressed and moving; that is, he moves his pelvis in toto and not his limb separately.

In order to test the part volition may have in the performance, we need but to place our patient under the influence of chloroform, when it will become evident that both abduction and adduction are impossible, and that but a moderate flexion and commensurate extension are practicable.

2. Malposition of the affected extremity. In the same proportion as the joint loses its mobility, limb and pelvis assume a very characteristic malposition; the former becoming flexed in both hip and knee-joint, and, at the same time, everted and abducted; the latter oblique, projected, and turned around its transverse diameter, diminishing its angle

of inclination with the horizon.

That these relations are no fictions, but realities, we have repeatedly shown to you with mathematical precision. In placing your patient in the erect posture and dropping a plummet line from the seventh cervical spinous process, and in drawing a line from the ant. sup. spinous process of the ilium to that of the other side, we recognize the declivity of the pelvis in the following facts:

a. Ant. sup. spinous process of ilium stands lower on the affected side. The two lines form an obtuse angle instead of a right.

b. The plummet line should fall parallel and in the rima inter nates, but the latter is oblique and its continuation crosses the former in an acute angle.

c. The inferior circumference of the nates on the affected side is lower than the other.

d. There is a simple curvature of the spine with elevation of one shoulder, (affected side.)

The flattening of the nates (affected side) has been mentioned as a great pathognomonic sign, yet you will easily understand that it is merely subordinate, depending chiefly on abduction, but in part on the general attenuation of the limb. The same may be said as to the apparent elongation of the extremity-which is, of course, the inevitable effect of the obliquity of the pelvis and the abduction of the affected member, and in connection with which the patient assumes a very peculiar walk. He places first his affected extremity forward and outward on the ground, and draws his adducted healthy limb quickly after, shoulder and pelvis (affected side) projecting, so that his walk is actually diagonal.

The question as to the pathological condition of the joint giving rise to the articular immobility and the stated malpositions, is of no ordinary interest both in a scientific and practical point of view.

Many hypotheses have been advanced to explain the proximate cause of these symptoms, and by men justly esteemed both as practical surgeons and scholars. Yet the confusion and uncertainty seemed to increase with the number of theories until Rust precipitated the vexatious question in his usual dogmatic manner, by cutting the Gordian knot. To review all the hypotheses which have been started from Sabatier up to our time would be of little practical value; they have passed away, and it is but charitable that oblivion should cover the errors of our ancestors. For our age it has been reserved to relieve hip-joint disease from the incubus of individual authority, and to study it anew on the basis of pathological anatomy and stubborn clinical facts.

To Sir Benjamin Brodie is due the merit of having opened the first breach. He not only aided in clearing the road of progress from the rubbish of speculation and fiction: he also taught us to return from the green-room to the dissecting-tables, and to resume the patient and watchful observation at the bedside. The inquiry once started has been kept alive ever since, and the united efforts of zealous students have opened fair prospects of exact knowledge on this hitherto so obscure subject.

The chief cause of error has evidently been the supposition of a true elongation where but an apparent one existed; an idea of which but few authors could free themselves. Since Goedichen, however, has clearly proved this fact, we shall soon come to a general understanding of those mechanical principles that influence the malposition.

In repeating the interesting experiments of Prof. G. Weber, upon the hip-joint, some few years ago, the analogy of position produced by artificial injection, with that presented by the femur in the second stage, was so striking as to justify the conjecture of a like cause. The conjecture was diligently followed up in our clinical observations, and we are gratified in stating that their correctness was subsequently affirmed by facts of indisputable evidence. At first we concentrated our attention upon discerning the presence of fluctuation; indeed, no easy task, the hip-joint being surrounded and covered with muscles, tendons, and strong fasciæ. But the attenuation of these parts facilitated our object more than we originally expected. We preferred, moreover, those cases in which the malposition and the supposed effusion was greatest. In fine, we placed our patients under chloroform for such examinations in order to render them both painless and more simple. Thus we succeeded in discriminating the presence of liquid along the posterior circumference of the acetabulum, which you have had opportunities of confirming repeatedly. We then went a step farther, in carefully entering the fluctuating joint with a trocar by a valvular opening, and withdrew more or less liquid, as the case might be. This proceeding, no doubt, will be denounced by some surgeons as reckless and hazardous, but that their fear is totally unfounded, (provided it is done to the exclusion of atmospheric air,) you can bear testimony. Boyer, Goyrand, and other surgeons, had performed the operation upon the knee-joint with good success, before we ventured upon puncturing the hip-joint. Suffice it to say, that immediately after the withdrawal of the liquid from the affected joint, the limb could be moved in any direction, provided that no muscular contractions were present, and its previous flexed position altered at pleasure. We have thus conclusively proven that the effusion-serous, plastic, or purulent-is the proximate and only cause both of the malposition of the affected extremity and the immobility of the joint.

As to the declivity of the pelvis, it can be easily shown that it is but a mechanical sequel of the malposition of the extremity. For if the patient sits down he will always manage to keep the affected side from the chair and place his extremity in a position of abduction. Having done so, the pelvis rests with both tubera ischii on the seat, the spinous

processes of the ilium occupy the same height, and the curve of the spinal column disappears.

3. Attenuation of the extremity.-Attenuation of the extremity is an ordinary sign of hip-joint disease, but not the less characteristic. We see it at the very beginning of the malady and through all its phases. A few weeks will suffice to reduce the circumference of the affected extremity more than twenty per cent. To account for it by supposing want of exercise, or by suppuration, is a vain attempt, since not every patient abstains from his usual walks or ramblings, and not every hipjoint disease is suppurative. Nor would one or the other limit its morbid effects exclusively to the affected extremity. We have, therefore, to look for another interpretation more feasible and rational than the former.

The sudden waste of a single muscle, muscular group, or an extremity, to the exclusion of other parts of the body, finds no other analogy in pathology than in morbid reflex action. Wry-neck, club-foot or hand, talipes equinus, and other deformities, verify the correctness of our views. And in further exemplification, we beg to adduce the following case, that will show the rapidity with which the attenuation may be accomplished.

An Irish laborer received a stab in his back with a dirk near the spine. From the fact that his friends had some difficulty in extracting the blade, which was firmly fixed, we are justified to infer that it had entered the bony structure. The wound subsequently healed up without any untoward symptom. After the lapse of six weeks, the patient experienced some painful and drawing sensations in one of his calves, which grew in intensity, drawing up the gastrocnemius and soleus muscles, ultimately producing a complete talipes equinus. When the patient soon after came under our care for operation, the circumference of his leg had considerably diminished, so as to bear no comparison with its fellow.

Reflex action occurs in hip disease in both spheres of the diastaltie system, and manifests itself in retraction of muscles and pain. The former is not as prominent in the second stage as the latter, and we shall, therefore, consider it more particularly with the third stage of the malady. We proceed to

4. The peculiar pain.-A careful clinical observation will readily discriminate two kinds of pain in the second stage of the disease. One that appertains to the joint itself, which is directly connected with the inflammatory and disintegrating condition of the various tissues constituting the articular apparatus. This pain is fixed and unalterable; it