Symptoms. The condition is usually first recognized when the child begins to walk. If only one hip is dislocated, there is a peculiar limp; at each step the body is thrown toward the affected side, a sort of lunge forward and sideways. The affected leg is shorter than the other and becomes

shorter (the femoral head sliding upward) at each step. The trochanter is above Nélaton's line. As to the subjective symptoms, the child tires easily and as it grows older has pain on exertion. There is disinclination to walk. The parents may notice a lump on the buttock, which is the displaced head of the femur. In bilateral dislocation the patients walk with a peculiar ducklike waddle, the body lunging from one side to the other at each step. The disability in these cases is more marked. There is also a marked prominence of the buttocks and there is lumbar lordosis.

The diagnosis is easily made. A physical examination reveals the head of the femur in an abnormal place. There is no pain or spasm on motion, which is free in all directions, and the condition cannot possibly be mistaken for tuberculous disease of the hip joint. Coxa vara, although in this condition the trochanter is above Nélaton's line, is excluded by finding the head of the bone in its proper place and by the limitation of motion in the direction of abduction.

Treatment. The work of Lorenz and Hoffa has resulted in a marked change of opinion on this subject, and we are able to give a good prognosis for cure when formerly nothing could be done for these cases. Bloodless reduction, or the Lorenz method, consists in reducing the dislocation under ether and holding the limb in position by means of a plaster of Paris cast until the stretched capsule and soft parts have contracted and the head has secured a firm hold in its normal position.

The details are as follows: Under ether the resistance of the soft parts (the adductor and extensor muscles) is first diminished; this is done by forcibly abducting the leg in an intermittent manner, and with the ulnar border of hand forcibly massaging the adductor muscles at their insertion into the pelvis. The leg is now pulled upon to bring the head of the femur to the level of the acetabulum, an assistant applying countertraction at

CONGENITAL DISLOCATION OF THE HIP

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the perinæum by means of the hand or a sheet passed under the perinæum and having the two ends tied to the head end of the table. Traction is now intermittently applied until the soft parts are relaxed. The reduction manœuvre proper is now carried out. The leg is grasped with one hand above the knee, and flexed, rotated outward, and abducted. Motions like. those of a pump handle, but in the horizontal direction, are now carried out, and while the leg is held in the aforesaid position of flexion, rotation outward, and abduction, the knee is gradually brought behind the plane of the body (superextension). The other hand is placed in the groin, the thumb upon the trochanter, the fingers next to the genitals, and pressure inward is exerted upon the trochanter. In older children the surgeon's fist or a padded wedge may be used as a fulcrum upon which the trochanter rests; the head of the bone is then forced over the edge of the acetabulum. These manoeuvres having been properly and consistently carried out, the head will pop into the acetabulum with an audible snap.

The next important part of the treatment consists in retaining the head in its desired position, Lorenz's theory regarding the success of the treatment being that the constant impaction of the femoral head in the acetabulum while walking will cause a deepening of the usually shallow structure and give a firm hold to the joint. It will be noticed that while the limb is abducted the head remains in place, and when the leg is adducted the dislocation recurs; consequently we apply a plaster of Paris dressing in the position strong enough to assure a firm hold in the acetabulum; this Lorenz calls the indifferent middle position. The

original dressing is retained for from three to six months, depending largely upon the cleanliness. It is then removed, and the leg is very cautiously adducted a little in order to make locomotion easier and to insure the stability of the joint in the straightest position, and another dressing is applied. This is worn for two or three months. A cork sole is applied to the shoe of the side that has been operated on, in order to even out the difference in the length of the legs. A third spica

may be applied with the leg in a straight position and retained for two or three months.

The operation is not absolutely free from risk, for by too forcible manipulation there may occur a fracture of the neck of the femur or of the ramus of the pubes, paralysis of the sciatic and crural nerves, and other injuries of the soft parts. In bilateral cases both sides may be operated upon at one sitting.

The most favorable age at which to perform the operation is under six years, although in unilateral cases patients have been operated upon successfully as late as ten years of age,

while eight is about the limit in bilateral

cases.

The bloody method consists in deepening the acetabulum and then replacing the head. The operation may be performed after the bloodless one has been tried without success. Lack of success is often due to distortions of the head and neck of the femur, and it is often necessary to do a subsequent osteotomy at the upper end of the femur, causing the bone to heal in as good a position as possible.

Showing elevation of trochanters.

COXA VARA

This consists in bending of the neck of the femur, usually in a downward and backward direction. It is a deformity analogous to knock knee or bow leg. It occurs in late childhood and adolescence. It is more often unilateral than bilateral.

Etiology. "It is one of a group of static deformities caused by a disproportion between the strength of the supporting structure and the burden that is put upon it" (Whitman).

Fracture of the neck of the femur in childhood is often followed in later

years by coxa vara. Males are affected three times as frequently as females. Rhachitis is an ætiological factor.

Symptoms. Pain or discomfort in the hip joint and thigh, especially after overexertion, with a limp. There is shortening of the affected limb amounting to an inch or more; this is due to the change in the angle of the neck to the femur, the trochanter being an inch or more above Nélaton's line. Limitation of motion in the direction of abduction, inward rotation, and flexion.

In bilateral coxa vara the symptoms are more pronounced, the abduction of both thighs obliging the patient to sway the body from side to side

at each step, as in knock knee, to permit the legs to pass-the so called scissors walk. In extreme deformity the limbs are actually crossed.

The symptoms last a varying period, from one to three or more years, and usually end when the bones are completely ossified.

Diagnosis. From hip disease, by the absence of severe pain and muscular spasm; by motion not being limited in all directions; by shortening and elevation of the trochanter above Nélaton's line, which is present very early in this affection, coming later, with the destruction of bone, in hip disease. From congenital dislocation, by our not being able to feel the femoral head out of its normal position and by limitation of motion, which is free in dislocation of the hip. Coxa vara is not present at birth.

Treatment. Constitutional treatment is important in the early stages, with attention to diet, gymnastic exercises, massage, and avoidance of overstrain. A brace should be worn to take the weight off the disabled limb; a form of brace similar to the convalescent hip splint, which may have a joint at the knee, is very useful. This should be worn for a year or more. An operation is indicated when great deformity exists. A linear osteotomy just below the trochanter minor is performed and the limb rotated inward and abducted. A plaster of Paris spica is now applied, or a cuneiform osteotomy at the upper end of the shaft, with a view to restoring the proper angle to the neck of the shaft, is indicated in young patients.

KNEE DISEASE (WHITE SWELLING)

Tuberculous inflammation of the structures of the knee joint. It is an osteitis of the epiphysis beginning in either femoral or tibial epiphysis, less frequently in the synovial membranes. Another variety begins as a simple synovitis, the early symptoms of which are subacute, the condition becoming chronic, with thickening and infiltration of the sac.

The symptoms are those common to other tuberculous joints, namely, joint tenderness, muscular spasm, deformity, and in addition distention of the joint, heat, and swelling. Atrophy of the muscles comes on later in the course of the disease. There are pain and local sensitiveness. Shortening is not present at first; on the contrary, there is usually lengthening of the leg, due to hyperæmia and increased growth at the epiphysis. This increased growth, however, gives place to atrophy after the disease is cured, and almost all the patients recover with a shortened limb.

Frequently the inner condyle enlarges to a greater extent than the outer, thus causing knock knee. The pain is rarely severe, and night cries are not a common feature of the disease. If the condition is progressing rapidly or if there is an acute exacerbation or if the patient receives a fresh injury, the joint will be painful. Muscular fixation is a prominent symptom, the joint being fixed in slight flexion. Malpositions of the limb are flexion, rotation outward of the tibia on the femur, and subluxation of the tibia backward.

The synovial variety of the disease is found usually in adults, and it begins as a simple subacute synovitis. The condition goes on for years without marked symptoms, but there will be a thickening of the synovial

capsule, very slight limitation of motion, a gradual thickening of the bones, and occasional attacks of pain.

Differential Diagnosis. In rheumatism, usually more than one joint is affected, and the onset is sudden and accompanied by constitutional symptoms. A sprain has a sudden onset, with a history of injury and rapid recovery. In Charcot's disease there is the presence of tabes dorsalis, with sudden effusion into the knee and rapid destruction of the joint. The hysterical joint occurs in a neurotic patient, and there is absence of physical signs.

In sarcoma the disease extends rapidly and is not influenced by treatment. The x rays are of great value in the distinction.

Treatment. In childhood the treatment is conservative, because the prognosis is favorable as to cure of the disease and as to functional use. Moreover, an operation which would destroy the epiphysis would prevent further growth of the leg and cause great deformity by shortening in later years. In adults, where it is desirable to bring about a cure as quickly as possible and where, on account of full development, excessive shortening of the limb is not to be feared, excision of the joint with ankylosis is most advisable.

The

If any deformity exists, this must first be corrected, so that when healing takes place the leg will be in good position, namely, that of extension. flexion deformity may be corrected by rest in bed and traction applied to the leg. Or one may apply a plaster of Paris bandage, with an assistant making strong traction on the leg during the application of the bandage. It may be necessary to give an anesthetic. The leg being straight, a well fitting brace is now applied to take the weight of the body from the diseased knee. The Thomas brace fulfils all the demands for utility and simplicity. It consists of an iron ring irregularly ovoid in shape, in order to fit the thigh snugly at the perinæum, to which ring are fastened two upright bars which go down each side of the leg and extend two or three inches below the foot, where they are joined. The circular leather bands support the leg at the thigh and calf and the knee is still further fixed by being bandaged snugly to the brace. A high shoe, cork sole, or patten is worn on the sound foot. It is customary to increase the usefulness of the Thomas brace by com