sudden change in the distortion, from flexion, abduction, and eversion, with elongation, to shortening, inversion, and adduction, has caused this belief in the occurrence of positive luxation, but in the sixty-three cases in which I have exsected the hip-joint, I have never seen luxation upon the dorsum of the ilium except in one single instance, and in that the dislocation was produced a few days before the operation by bending the limb in the effort to remove the patient from the bed, and was therefore due to the carelessness of the nurse, and not to spontaneous muscular contraction. The absorption of the head and neck of the femur, produced by constant pressure, diminishes its size, while the ilium being also pressed upon, becomes eroded and absorbed, thereby immensely increasing the size of the acetabulum. (Fig. 7.) But while this inter

stitial absorption has been going on within the acetabulum, there has been at the same time periostitis upon its upper and outer borders, causing the formation of new osteophytes; and the capsular ligament, attached to these new deposits, has thus been gradually pushed upward and backward on the dorsum of the ilium, immensely increasing the size of the joint, but still retaining within its embrace what is left of the head and neck of the femur. It might therefore with propriety be called a displacement of the acetabulum, but not a luxation of the head of the thighbone.

This may appear a small point to cavil about, but accuracy in observation is essential for obtaining correct knowledge of the pathology of any disease, and unless our pathology is correct, our treatment will be necessarily empirical.

The pus or other fluid having now escaped from the capsule, the patient is greatly relieved from the pain, but the disease still progresses. Constant muscular contraction produces interstitial absorption of the head and neck of the femur, and of the acetabulum, and the pus, which has escaped into the cellular tissue, burrows in different directions, according to the position which the patient maintains, forming extensive abscesses which finally make their way to the surface. These sometimes open behind the trochanter, sometimes at a long distance from it, opening either upon the outer or inner side of the thigh, or on both; and even,

as I have seen in cases in which the acetabulum has been perforated, making their way between the internal periosteum and the ilium, and forming openings above the pubis; so that the third stage of hip-disease may be accompanied with external fistulous openings in various directions, and with very great exhaustion from extensive suppuration.

We are now prepared to study the treatment of morbus coxarius, which of course varies according to the stage in which we find the disease; and the reason that I have dwelt so particularly upon the diagnosis of the affection in its earlier stages, is because, as I have before stated, proper treatment at this time, in the great majority of cases, will be followed by perfectly satisfactory results.

In the first stage of the disease, if the symptoms of inflammation be very acute, and pain and tenderness very great, absolute and perfect rest of the joint is most essentially requisite. In the hearty and robust patient, in vigorous health, leeches or cups, or some other form of local depletion, may be necessary; ice bags, surrounding the joint, often afford the greatest possible relief, while in other instances hot fomentations, the exact opposite, will give the greatest ease. There is no rule with which I am acquainted, that will guide you in the application of heat and cold, except the feeling of the patient, and this can only be determined by a practical test. The remedy which gives the greatest relief, and is the most agreeable to the patient, is the one to employ. In addition to these local measures, extension (very slight, but continuous) in the line of the deformity, should be made by means of a weight and pulley, secured to the limb by strips of adhesive plaster, and a roller. The adhesive strips should always extend above the knee, to avoid traction upon this articulation. The pulley should be attached in some manner to the bed, the foot of which should be elevated ten or twelve inches, so as to make the body act as a counter-extending force. (See Fig. 8.)

Fig. 8.

When the extension is first applied, the traction should be made in the line of the deformity, and the direction should be changed by slow degrees, day by day, until the limb is gradually brought into its natural position. It is sometimes necessary to apply a second extending power, at right angles to the limb, to remove the pressure of the head of the femur against the inner surface of the acetabulum. This is readily done by passing a handkerchief around the upper and inner part of the thigh, securing in its outer loop a cord to which is attached a weight playing over a pulley at the side of the bed.

If the bowels are constipated, cathartics as a matter of course are indi

cated; and all the secretions and functions of the body must be carefully looked to and kept as nearly in a normal condition as possible.

This plan is to be pursued until the more acute symptoms have subsided; but as the disease is chronic in its nature, time, as well as rest, is a very important element in its treatment. And as long confinement in bed is injurious to the general health, we must contrive some mechanical appliance which will give the necessary amount of extension and counterextension to relieve the joint from pressure, while at the same time it allows it to have free motion, and permits the patient to take exercise in the open air.

In some cases, when the disease is very acute, and the child very small, this is best effected by placing him in a wire cuirass (Fig. 9), which is a modi

fication of Bonnet's "grand appareil," and which will be found very useful. When this instrument, or any other fixed apparatus, is employed, it is necessary that the patient should be taken from it very frequently; and all the joints should be carefully moved, lest too long-continued rest may terminate in anchylosis, not only of the joint diseased, but of all the other articulations thus permanently deprived of motion. I am aware that Dr. Thomas, of Liverpool, has denied this doctrine; but having seen the result in a number of cases, I must be pardoned if I insist upon placing more confidence in my own personal observations than in the theories of

any one. Perfect rest, too long continued, even of the diseased joint, is decidedly injurious, as there is danger of its resulting in anchylosis; hence the objection to plaster of Paris, or any other fixed apparatus, in the treatment of this affection. The disease is essentially within the joint, the capsular ligament not being involved; hence, all that is required is extension and counter-extension, just sufficient to prevent the diseased surfaces from coming in contact; while at the same time motion is permitted, to keep the capsular ligament and other parts not involved in a healthy condition, by allowing the free use of this their natural stimulus. If the child is large enough to run about, and the thigh sufficiently long to give attachment to the adhesive plasters, then the short splint (Fig. 10) is altogether preferable. I have used this splint for many

years, and having tried all others, I find it altogether the best wherever it can be applied, as it allows free flexion at the knee, and is, therefore, more comfortable in the sitting posture. If the patient is ten or twelve years of age, and too heavy to bear the weight of the body upon the instrument without breaking it, or if too much tension is produced upon the skin by the adhesive plasters, then crutches will be necessary when the short instrument is used. If the child's thigh is too short, and he is too small, to receive a sufficient amount of extension by the use of the short splint, then the long splint, which I here show you (Fig. 11), is much to be preferred, and with it, if properly applied, the patient will be able to walk without the use of a crutch.

The short splint and its various modifications, together with the long splint with its abducting joint and rotating screw, and their mode of application, have already been so fully described (in my work on Diseases of the Joints), that I shall barely refer to them here.

The short splint (Fig. 12) consists of a curved cross-bar, surmounting the crest of the ilium or entire pelvis, well padded on its inner surface, and to its two extremities are fastened a perineal band or bands, for counterextension, and on its outer surface a ball-and-socket joint, from which

runs an iron rod or bar down the outer side of the thigh to within about two inches of the lower end of the femur. This outer bar is divided into two sections, one running within the other, and gauged or controlled by a ratchet and key, which can make it longer or shorter. At the lower

extremity of this outer bar is a projecting branch going around to the inner surface of the thigh to receive the attachments of the plaster, hereafter to be described. Both of the lower extremities terminate in cylindrical rollers, over which the tags of the plasters are attached to the two buckles placed at the lower ends of the instrument.

In applying the instrument, it is first necessary to have the adhesive straps to which it is to be fastened properly secured, and this is done as follows. When using the short splint, which is only worn during the day, night-extension is necessary, which is effected by means of weight and pulley: for this purpose a strip of adhesive plaster, to the lower end of which a stout piece of webbing is sewed, is placed on either side of the leg, extending from the malleoli to above the knee, in order to avoid traction on the lateral ligaments of the knee-joint; this is secured by a well-adjusted roller, leaving the pieces of webbing projecting for the attachment of the extending force. (Fig. 13.) Next, for the application of the instrument, triangular pieces of plaster, in which are cut several slits converging toward the apices of the pieces, are placed on both the outer and inner side of the thigh, first measuring with the instrument so that the tags which have been sewed to the apices of the plasters will exactly conform to the places of attachment upon its lower extremities. Having secured these with a roller, using care at the upper part of the thigh to reverse each alternate strip of the plasters in carrying round the