The foundation material is a wire rod from three sixteenths to one fourth of an inch D in diameter, which can be readily bent with wrenches or in a vise to the form shown in Fig. 1. The free ends are then lashed together with copper wire at a. The measurements required are: DE. From the axilla to a point one or two inches below the heel; or if desired the splint may be finished to reach only to just below

F

FIG. 1.

a

the middle of the calf.

A D. The width of the trunk.
A B. From the axilla to a

point midway between the crest of
the ilium and the top of the tro-
chanter.

FE. Two to two and a half inches, according to the size of the leg.

A D and B C are then to be bent to conform to the curve of

the back; it being particularly important that B C shall be sufficiently curved to jump across the sacrum without exerting injurious pressure upon it. Lastly, the rods running longitudinally are to be bent so as to adapt themselves accurately to the curves of the back, hip, and knee.

This frame, especially in those parts which cross the body, is to be thickly wound with strips of cotton batting, and the whole covered with Canton flannel tightly stretched across it. Lastly a swathe is to be stitched onto the body part of the splint (A B C D).

After the frame is accurately fitted to the curves of the body the patient is to be laid upon it, so that point B takes its bearing on the gluteus muscle of the well side, and C rests a little outside the sacro-iliac synchondrosis on the affected side. The pressure of the splint is thus borne by parts well padded with muscles, and if B C is sufficiently curved the sacrum and surrounding bony prominences are not pressed upon. It is, however, a good precaution to put a large sheet of cotton batting upon the splint to still further protect against the danger of a bed sore.

The frame being accurately adjusted the swathe is to be pinned firmly round the body, and the leg is bandaged to the leg part of the splint.

When applied as I have described, the splint fits the patient comfortably but firmly, and as it leaves a considerable interval between the anus and any part of itself, it can be kept clean, and consequently can be worn for a long time without changing.

Besides its use in hip disease, this splint is of value in the treatment of fractured thigh in children. With

FIG. 2.

coaptation splints to the sides and front of the thigh, and with a foot piece, Fig. 2, added to the splint to prevent the rolling of the foot to one side or the other, we have perfect immobility of the fractured bone, and are able to move and handle the child with entire obvious application is to cases of excision of the hip. freedom, and without causing the least pain. Another Here again we need a foot piece to prevent rotation of the leg, and the wires where they pass behind the hip are divested of padding and can then be thoroughly cleansed and included in an antiseptic dressing. The splint has been so used in several cases of excision with satisfaction. The patients were free from pain and were easily moved. One child, indeed, was carried from Boston to Nova Scotia while the wound was far from well without discomfort or apparent detriment to the joint. If it is desired to combine extension with fixation, it can be done by fastening to the outer rod side just below the crest of the ilium. DE an arm coming forward and curving round the By a buckle attached to the top of this arm, and another behind the splint, a band can be carried through the perinæum. At the end of the leg of the splint are then to be attached two buckles through which the extension straps can be drawn and held down, or if desired an arrangement with a ratchet and pinion fastened to the foot of the splint will provide for more steadiness of exten

sion.

Lastly, this frame, if fitted to reach only to the middle of the lower leg, can be used like a Thomas' hip splint in the ambulatory treatment of hip disease, the and crutches. patient walking about with a high shoe on the well foot

It would seem at first sight that the splint would interfere with the patient's sitting down, but practically, if the body part is not made too wide, the splint is not more uncomfortable than a Thomas' splint in this respect, and it has the decided advantage that it is less likely to be displaced.

Heports of Societies.

SUFFOLK DISTRICT MEDICAL SOCIETY. SURGICAL SECTION.

S. J. MIXTER, M. D., SECRETARY.

NOVEMBER 7, 1883. DR. G. W. GAY reported

A FATAL CASE OF INTERNAL URETHROTOMY.1 DR. GANNETT exhibited the specimen, consisting of the whole urinary tract of Dr. Gay's patient.

DR. A. T. CABOT asked Dr. Gay whether he did not think that a catheter left in the bladder immedi

ately after the operation would, by providing for a free escape of the urine, have diminished the danger of Dr. Cabot also death from suppression in this case. asked if the result in this case would cause the reader to adopt some other method of operating in similar cases in future.

DR. GAY said that in such an unfavorable case for

operation he should be inclined to do external urethrotomy, though it is an operation to be avoided if possible, as it often leaves the patient with urinary fistulæ, and necessitates a much longer after-treatment than the

1 See page 2 of this number of the JOURNAL.

internal treatment. It is, perhaps, well to risk some thing in doubtful cases. The reader had since per formed internal urethrotomy in a case of stricture two inches from the meatus, the operation being followed by quite severe symptoms for forty-eight hours. The reader and all the other surgeons at the City Hospital had for some years abandoned the practice of leaving a catheter in the bladder after divulsion or internal urethrotomy, as they considered that it rather diminished than increased the chance of a favorable result.

In reply to a question by Dr. Watson, the reader said that the danger to life was decidedly greater in the internal than in the external operation. After the latter there is almost no fear of abscess, pyæmia, or other septic processes.

In reply to a question by Dr. Garland, Dr. Gay said there was almost no conceivable condition of the urinary tract where the surgeon should refrain from operating by some method to relieve symptoms of retention and stricture as severe as were present in this case. It is of primary importance to relieve the stricture, as that is the cause of the whole trouble, and must be removed before a change for the better in the bladder and kidneys can be hoped for. When, however, the symptoms were not severe, and the stricture could be kept well open by means of gradual dilatation, he was of the opinion that any operation should be avoided.

DR. GANNETT said that the changes seen in the bladder in this case were ante-mortem, and due to the long-standing cystitis caused by the stricture, while the pyelo-nephritis and diphtheritic inflammation of urethra and bladder followed the operation, the process spreading from the lower to the upper part of the urinary tract, probably by means of micro-organisms which passed up the ureter, and which may have been present in the bladder for some time. In cases where the kidneys are infected in this way the inflammatory process often skips from the bladder to the pelvis without manifesting its presence in the ureters.

DR. CHEEVER called especial attention to the much greater safety of the external operation of urethrotomy, which almost always gives a good result as regards the life of the patient, although it is usually adopted only in the most severe cases. After this operation the bladder is allowed to empty itself in the easiest possible manner, and perfect drainage is permitted. The subject for discussion was

EXCISION IN HIP DISEASE; ARE ITS PROGNOSIS AND ITS RESULTS BETTER THAN THOSE OF A SPONTANEOUS CURE.

DR. E. H. BRADFORD, in opening the discussion, said that it was impossible at present to deduce from the facts as yet presented exact surgical laws regulating excision, and cases will have to be judged chiefly according to their individual merits. Certain facts, however, have been collected justifying some generalizations of value, which may be grouped as follows:

It may be said as a preface that this consideration of the subject is limited to cases of hip disease, and chiefly of children under puberty.

I. There can be little doubt that among the grave surgical procedures excision of the hip cannot be considered an extremely dangerous one. The rate of mortality directly due to the operation, according to the report of the London Clinical Society's Committee, is fifteen per cent. According to Culbertson the mortality from partial excision is nineteen per cent., and from complete excision thirteen per cent.2

II. Forty-six per cent. of the cases of complete excision collected by Culbertson, and forty-three per cent. of partial excision, died within six months of the operation. According to the London Clinical Society the mortality was, in 320 cases, forty per cent.* Antiseptic surgery would appear to have lessened the rate of mortality, for Grosch, in 126 cases of the operation done under the strictest antiseptic precautions, reports a mortality of 36.7 per cent., and that in the last half of the decade during which the list of operations was collected the mortality was nine per cent. less than in the first half of that period, during which an apprenticeship to strict antiseptic principles was being served. The mortality also varies according to the stage of the disease at which the operation is performed, being 0 at the first stage, twenty-four per cent. at the second, and sixty-seven at the third."

6

III. It would appear from the clinical facts presented by Mr. Holmes that the limb after the most successful excision is not as useful as after a "natural" cure, This is emphatically the opinion of the London Clinical Society, and this view is apparently substantiated by a comparison between the anatomical appearances in the few reported cases of autopsy after successful excision with those found in a natural cure. The process of absorption and repair in the natural cure is a gradual one, and the bone becomes firmly welded in place by the slow deposits of the ossifying ostitis which follows the destructive ostitis of the original disease; only such portion of the bone is removed as cannot be saved, and the fragment of the neck and head becomes well surrounded and securely held in an acetabulum gradually altered in the successive processes of disease and repair. After excision, on the contrary, a large fragment of bone is removed, and the subsequent union with the ilium in the most successful cases is by ligamentous and fibrous bands, forming in some cases a false capsule, and if ossification ultimately takes place it can hardly be thought that the parts will be as accurately fitted as is the case after the more gradual process. A flail joint at the hip, or one approaching it, is certainly not so useful as a stiff joint. Cases which appear to be cured sometimes are ultimately not as satisfactory in the result as was at first considered probable. Case 464, Culbert1 British Medical Jourual, May, 1881.

2 Trans. of American Medical Association, 1876.

3 Culbertson does not consider many of these deaths (that is, twen

tion.

(2.) As to the chance of ultimate recovery after the operation.

(3.) As to the usefulness of the limb after such recovery, and the time required before such a result is gained.

(4.) As to the probability of and requisite length of time for a "natural" cure, and the subsequent usefulness of the limb.

as due to "other causes." A list of the diseases, however, makes it clear that this is hardly just; bed sores, amyloid disease, Bright's disease, meningitis, are all to be considered in estimating the chances of ultimate cure. According to the London Clinical Society about four per cent. of the deaths were due to causes other than the disease and not influenced by the operation.

4 British Medical Journal, May, 1881.

5 Centralblatt f. Chir., No. 14, 1882, p. 229.

6 Medical Times and Gazette, November 3, 1877.

7 Loc. cit.

8 New York Medical Journal, April, 1879. Archiv f. klin. Chir. Band xix., Heft 2, pp. 400-411.

son's Table, was reported as perfectly cured, and three years later was found in a permanently crippled condition, with a useless limb. Furthermore it has not been found that antiseptic dressings have any influence upon making the limb ultimately more useful, or upon the length of time necessary for a permanent cure. This, according to the London Clinical Society, is one and three quarter years; according to Culbertson 190 days. It is manifest, however, that it is difficult to obtain figures of great value bearing upon this point.

IV. In comparison with these figures Dr. Gibney reports the results of "natural" cure to be as follows: Eighty cases of recovery were recorded; no particular treatment being followed beyond constitutional (fortyeight of these had abscesses); cure was established in seventy-one of these before the fifteenth year, the disease lasting, in thirty-three, three years; in twentyeight from three to six years; and in one case fifteen years. In only eight of these cases did such a deformity exist as to interfere with walking. Out of the eighty cases, in twelve there was a recovery in motion of from fifteen to ninety degrees.2 Better results are of course obtained, as far as the usefulness of the limb is concerned, where careful and continued treatment can be carried out for a long time than where the limb is practically left to itself. The results reported by Dr. Judson clearly demonstrate this, as well as that remarkable results can be obtained even in desperate cases by the conservative treatment. Cazin found in five years that in eighty cases of suppurative hip disease treated by the expectant plan

Forty-four were cured (fifty-five per cent.).
Twenty not cured (thirty-three per cent.).
Ten died (twelve per cent.).

Of these fifteen were complicated by albuminuria, and five died, six were not improved, two were improved, two were cured.1

The mortality, according to the London Clinical Society, in suppurative cases treated conservatively was thirty-three per cent.; forty-two per cent, were known to be cured, and the duration of treatment of those who recovered was two and a half years, the duration of the disease being four years. In non-suppurative cases sixty-nine per cent. were cured (the duration of the disease being three years), ten per cent. died, and twenty per cent. remained incomplete.

Taking the facts, imperfectly recorded as they are as yet, it may be roughly stated that in one hundred average cases of excision about forty die, and of those who recover about twenty-five will have limbs that they can walk on without a cane, twenty-five will need a cane or crutch, and five will have limbs that are useless. The limbs will probably not be as useful as if the patients had survived the disease with the average result of a "natural" cure, the chances for which in an average suppurative case may be placed roughly at fifty in one hundred. The time required for a cure after the operation will be probably somewhat less than if no operation is performed.

Recurring again to statistics and quoting from Culbertson nearly a half of those who recovered from the operation had "perfect" limbs (that is, they could walk without support); about the same number had

1 New York Medical Journal, April, 1879

2 New York Medical Record, March 2, 1878.

3 History of Three Cases of Hip Disease in the Third Stage. 4 Bull. de la Soc. de Chir., No. 5, 1876.

"useful" limbs, and could walk with and without apparatus; five to seven per cent. had worthless limbs. Out of some eighteen cases Mr. Holmes was able to examine three from eleven to thirteen years after the operation, and but one was able to bear the whole weight upon the affected limb. It may be said, therefore, that excision of the hip is a measure to be resorted to only as a last resort and as a life-saving remedy, and is indicated in cases of profuse suppuration and continued loss of strength in spite of thorough treatment for some time, as well as in cases where the course of the temperature indicates a demand for complete drainage. Mr. Holmes has expressed the matter well as follows: "The operation has a claim for adoption from its success in saving life where natural cure seems improbable. These cases are rare, if care for years can be provided."

DR. A. T. CABOT said that he regarded excision of the joint in hip disease as a life-saving operation, to be resorted to only when recovery by the natural powers is manifestly impossible. Cure by anchylosis is the most favorable result which can follow an extensive caries of the head of the femur, and the pelvis adapts itself so readily to the changed condition of things that a patient with the hip anchylosed in a good position has a very serviceable limb upon which he can walk with often but a slight limp. As Dr. Bradford has just shown, the fibrous articulation frequently resulting from an excision is, in the majority of cases, far less useful than an anchylosed joint, so that the best result of excision is no better than that which follows spontaneous cure, and the limb is necessarily shortened by the length of bone removed.

In a severe case of hip disease, then, the first thing is to fix the joint with an appropriate apparatus and to use every effort to promote bony union. If abscesses form they should be freely opened, the tubercular lining membrane should be thorougly scraped out, sinuses should be followed up and curetted, and any rough bone which is reached should be removed. Counteropenings should be made, if possible, behind the hipjoint so that they may be dependent, and secure thorough drainage. Abscesses treated in this way heal much more readily than after a simple opening.

If in spite of all care the patient steadily loses ground, and suffers continuously from hectic, particularly if pain in the hip is a prominent and distressing symptom, then the removal of the diseased head of the femur and of the tubercular material about the joint is demanded.

As cure by anchylosis is the result to be sought it is of the greatest importance to apply an apparatus after excision which shall provide for perfect fixation, and which shall allow the dressings to be changed without movement of the joint.

Dr. Cabot showed a splint which he had used upon four cases of excision with entire satisfaction, and which is fully described in another part of this journal.

DR. GANNETT showed a section from a tuberculous joint in which the tubercles were plainly visible with a lens of low power, and spoke of the tendency of the process to become general throughout the body unless it yielded to proper treatment.

DR. CABOT said that, as Dr. Gannett had shown, the disease was to a great extent a morbid growth, which tended to recur if not fully removed unless the natural powers of the patient were great enough to resist its further progress. In case, therefore, that the

sinuses continued to discharge freely for a long time it would be a wise course to follow them up by a second operation, and again, with a sharp spoon, scrape out all granulation tissue which could be found either in the soft parts or in the bones.

DR. ROYAL WHITMAN showed a patient of Dr. C. D. Homans whose right hip had been excised nineteen months before.

The patient entered the City Hospital October 4, 1878, at the age of four, with a history of a fall six months previously, which was followed by gradually increasing pain and lameness.

The examination showed an obliteration of the right gluteo-femoral fold, moderate flexion of the thigh upon the abdomen, and considerable limitation of motion on the affected side.

He was treated by rest in bed with extension, and left the hospital six months later, wearing a Sayre's short splint.

In October, 1880, he entered the hospital, the symptoms being about the same as on his last admission. He remained there for two months, and the acute symptoms having subsided, he was discharged. On October 11, 1881, he again entered the hospital, with a history of a fall followed by pain and increasing disability.

The examination showed the leg to be flexed almost at right angles to the body. Dr. Bradford, under ether, forcibly extended the leg, and the child was placed in bed with eight pounds' extension. He remained in the hospital for three months, and was then discharged, on crutches, wearing a high shoe. At that time the leg was straight, and there was considerable motion in the joint. On January 31, 1882, he entered the hospital for the fourth time, with the usual his

tory.

Examination showed pain on motion, obliteration of the gluteo-femoral fold, moderate flexion and fixation of the joint, with a hard, elastic semi-fluctuating swelling in the groin. He was placed in bed, and a T splint and extension were applied.

At the end of three months, as there had been no improvement in the symptoms, Dr. C. D. Homans decided to excise the hip, which was accordingly done on April 10th, 1882, the head of the bone being removed at a point two inches below the trochanter, and the acetabulum, which was found to be roughened, was thoroughly scraped. Very little shock followed the operation, and there was an immediate improvement in the condition of the patient.

After the operation the patient was placed upon a frame, moderate extension applied, and the leg kept in a fixed position. The wound was dressed with iodoform and salicylic cotton. The patient was discharged February 5, 1883, the wound having completely closed. Since this time his health has been perfect.

At the present time examination shows the following result: The leg is somewhat smaller than the other, and there are two and one half inches shortening. The head of the bone appears to be in close apposition to the acetabulum. The wound has completely closed, and there is no pain or tenderness about the seat of the operation. A certain amount of limited motion still remains at the joint. The patient walks easily, with a considerable limp from the shortening. If the body is steadied he can support his weight upon the limb with

out discomfort.

DR. CHEEVER regretted the absence of many of the

older surgeons who had had such a large experience in the treatment of these cases, and spoke especially of the good work done by Dr. Buckminster Brown in this field. Fifteen years ago, when almost all authorities favored excision, Dr. Brown predicted that the opinion in regard to the operation would be greatly modified in time, and that it would be reserved for carefully selected cases. At that time the traumatic or constitutional origin of the disease was in dispute, but now almost all cases are regarded as the results of a tuberculous process.

It seems to be true that if a patient with hip disease does not recover before puberty the result is generally fatal. Dr. Cheever spoke of a patient who died at the age of twenty-two of hip disease that began in early childhood. Before death there were extensive sinuses about the joint and thigh, and the process had extended across the pelvis and in every direction until both sides of the pelvis, both nates, the sides of the abdomen, and even the thoracic wall, as well as the rectum, were the seat of extensive suppurative processes.

On the other hand patients may recover the use of the limb and fairly good health, though there may be occasional relapses. One patient, an active business man, wears a splint, and is quite well, though occasionally, if he remains in this cold climate in winter, abscesses form about the seat of the old disease. Another similar case is that of a young lady, who is quite well except for an occasional small abscess. These cases were treated without operation. Another case in which excision was performed was seen thirteen years after the operation with extensive sinuses, and in all respects as badly. off as though he had never been treated.

Constitutional treatment is all important. Fresh air and nourishing food are absolutely necessary, and often these alone seem to effect a cure. At Rainsford Island Hospital many cases of hip disease were formerly received; many in a very reduced and wretched state. These received little treatment beside plenty of plain, wholesome food and plenty of fresh sea air, and the number of recoveries was remarkable. It is often difficult to decide whether there is a loose sequestrum in the joint, though bare bone can be easily recognized. Bony crepitus is not always obtained after etherizing, as the joint is filled with granulations. No one doubts that excision is the proper treatment in desperate cases; but it should be borne in mind that the disease is apt to recur in the shaft of the femur after the head has been excised; that the limb after a spontaneous cure is almost always stronger; and that there is less shortening and greater power of eversion than after excision. If openings are made they should be large, and free drainage should be encouraged.

DR. BRADFORD spoke of the peculiar liability of children with hip disease to carbolic poisoning, aud mentioned a case where the drip was employed after excision, the death of the patient being undoubtedly due to carbolic absorption. No bad effects have been noticed in a large series of reported cases where a solution of corrosive sublimate had been used, except slight diarrhoea in two cases, supposed to be due to absorption.

DR. CABOT spoke of the beneficial effect of iodoform in the treatment of local tuberculosis, it having almost a specific action upon the tuberculous granulations. He had used it in comparatively small quantities, dusting it on and injecting it in oily solutions.