Transient or Ephemeral Form of Hip-Disease, WITH A REPORT OK CASKS. BY Robert W. Lovett, M. D., .Surgeon to Out-Patients, Boston City Hospital and Children’s Hospital, John L. Morse, M.D., AND Formerly House Physician at the Boston City Hospital. Reprinted from the Boston Medical and Surgical Journal of August 18, iBg2. BOSTON:, DAMRELL & UPHAM, PUBLISHERS No. 283 Washington Street. 1892. S. J. PARKHILL & CO., PRINTERS BOSTON A TRANSIENT OR EPHEMERAL FORM OF HIP-DISEASE, WITH A REPORT OF CASES. BY ROBERT W. LOYETT, M.D., Surgeon to Out-Patients, Boston City Hospital and Children’s Hospital, AND JOHN L. MORSE, M.D., Formerly House Physician at the Boston City Hospital. The following investigation was undertaken to ascertain if there is, as there appears to be at times, a short-lived and ephemeral form of hip-disease which presents at first the characteristics of common hip-dis- ease, but the symptoms of which disappear in a few months instead of continuing for years. These symp- toms are in many cases, of course, due to the existence of a simple, acute synovitis; but in others, as will be seen, they present characteristics of true bone disease. Attention was called to these cases chiefly by the fact that a certain number of patients came to the Children’s Hospital for advice in cases of early hip- disease but never returned. As there is no other hos- pital in the city where these cases are treated to any extent, it seemed probable that a proportion of them recovered and needed no further treatment. This state of affairs is so thoroughly different from what one expects in ordinary hip-disease, that as many as possi- ble of these cases were investigated at their homes last February, some years after their visit at the hos- pital, and the investigation not only showed some interesting points in connection with acute synovitis of the hip in children, but also seemed to establish the existence of a short-lived and transient form of hip- disease which occurs at times. This point is of such 2 importance practically that it seems worth while to consider these uncommon cases somewhat in detail. In general, the cases which proved afterward to be synovitis, came to the hospital with a limp and pain following injury; often night-cries were present, and there was a certain amount of resistance to passive motion of the hip induced by the pain of such manip- ulation. Here, then, was a symptom group identical with early hip-disease. The chief points of difference being that in synovitis the pain was out of proportion to the muscular rigidity in most cases, and was a vol- untary restriction rather than a true reflex spasm. But these are very slight matters and quite insufficient to establish a differential diagnosis. The fact that the symptoms follow closely upon injury can be allowed very little weight, because it is found among hospital patients that a certain proportion of children with hip- disease come with exactly this history, the fall being the occurrence which calls the attention of the parents to the child’s disability, which may have been of many weeks’ standing. The years 1888 and 1889 were selected for investi- gation ; and of 156 new cases of hip-disease coming to the hospital for advice in that time, it was found that 38 either did not return or only came once or twice, not receiving continuous treatment. It was among these cases that we were to look for cases of transient hip-disease, if it occurred. It was possible to find or hear from 24 of these 38 cases in February, 1892; 11 of them had developed undoubted hip-disease of the ordinary type and had gone from bad to worse, but for some reason had not returned to the clinic. The remaining 13 cases had made a rapid recovery, and had remained well, although from two to four years had elapsed sincei their visit to the hospital. 3 Of these 13 cases eight seem to have been a simple acute synovitis of the hip. A typical case of simple acute synovitis is the following: ACUTE SYNOVITIS. Case T. Flossy S., five years old, fell while playing, in May, 1888. Motion at hip was painful and the child limped, the pain becoming less while the limp remained. Night-cries were frequent. Two weeks later she was brought to the hospital, where the following condition was found; No shortening, atrophy or trochanteric thickening. Motion was limited in all directions by muscular spasm, flexion being possible to only 90°. The diagnosis of hip- disease was made, and the child directed to return in a week for a Thomas splint. She became so much better during this time that she did not come back, and was en- tirely well in three weeks. She has had no recurrence of symptoms. Now, three years and eight months later, she has perfectly free motion in all directions, with no atrophy or shortening. This seems to have been a typical case of simple traumatic synovitis ; but the beginning was so much like that of true hip-disease that the diagnosis of synovitis could not have been made with any certainty at the time. In fact, the diagnosis of acute synovitis of the hip in childhood is one which should be made only with the greatest caution, and the symptoms in general accredited to probable hip-disease. There was another type of synovitis, not induced by injury, where the symptoms seemed to be of rheu- matic character. Such was the following: Case 11. Frank 8., nineteen months old, was brought to the hospital in February, 1888. He had then been ill for six weeks, the last three in bed. The hip was very sensitive, and the slightest motion extremely jDainful. Night-cries were continual, and he had lost flesh rapidly. He had been treated for rheumatism for some time, but the 4 diagnosis of hip-disease was finally made by the family physician. Examination showed much tenderness about the hip, the thigh was held flexed at 45°, there was no mo- tion, and much trochanteric thickening. The diagnosis of hip-disease was confirmed, and the child measured for a Cabot frame. He improved so rapidly, however, that he did not return, and was well in ten days. He had no ab- scesses, and has not been lame since. Is now, four years later, perfectly well and strong. OSTITIS OF THE HIP. But, as already noted, certain of these cases which recover so quickly, show characteristics which cannot be accounted for by a simple synovitis and one must assume that an affection of bone has been present. Such is the following : Case 111. Frank F., eight years old, came to the hos- pital in September, 1889, six weeks after a slight fall. His symptoms were lameness, pain and night-cries. Examina- tion showed trochanteric thickening. Rotation was not free when the thigh was flexed at a right angle and flexion and hyperextension were limited. He walked with *a slight limp. A probable diagnosis of hip-disease was made. The boy was much better in two weeks, and in three months, motions were normal. Now, two years and six months later, there is no limitation in motion, but some trochanteric thickening; a shortening of one inch, but no atrophy. The fact that, two years and a half after the cessa- tion of symptoms, there remained a shortening of one inch in the affected leg along with trochanteric thick- ening, would point clearly to an affection of bone. A similar case was: Case IV. William H., six years old, came to the hospi- tal in April, 1889. He had been troubled by pain and lameness for some weeks, and the diagnosis of hip-disease had been made by the family physician. There was no history of injury, and at the time of examination at the hospital he presented the following symptoms: The right leg was half an inch shorter than the left. Flexion was resisted by marked spasm at a right angle, and rotation and hyperextension were much limited. The diagnosis of hip-disease was naturally made, and a traction-splint was advised. For some good reason the parents could not re- turn, and the boy never had any treatment. lie limped for about six weeks, then recovered, and has never had any further trouble. Three years later the motion in the right hip was not so good as in the left, and there was half an inch shortening of the right leg. It hardly seems worth while to report in detail the other three cases, which differ but little from these. One recovered in five months from the beginning of O her symptoms; one in eight months ; and one in a few months, the exact time of which cannot be stated. Enough, however, has probably been said to demon- strate the existence of this short-lived form of hip-dis- ease. With regard to its pathology, all must be con- jectural. It is probable that in these cases the focus of tuberculous disease is situated in a part of the epiphysis remote from the joint, and that in its growth it causes enough disturbance in its neighborhood to give rise to symptoms of joint irritation. The fact that joint irritation may be caused by a focus of dis- ease which has not ruptured into the synovial cavity, was clearly demonstrated by the autopsies of Lan- nelongue.1 Having caused these symptoms of joint irritation, it seems probable that the focus of disease either becomes quiescent or grows away from the joint if it continues active, and after a brief time the symptoms subside. It will be seen that these cases do not present any symptoms different from those of early hip-disease of the common type, so that their recognition seems im- 1 Coxotuberculose, Paris, 1883. 6 possible; moreover, hip-disease is characterized by such marked remissions of symptoms that this type of disease is easily simulated in that way. But the fact remains that, even if one leaves out of consideration cases of acute synovitis, certain cases presenting all the symptoms of true hip-disease run their course to a favorable termination within a few weeks or months, and the matter is one of such practical importance that it deserves recognition. THE BOSTON Medicaland Surgical Journal. A FIRST-CLASS WEEKLY MEDICAL NEWSPAPER. PUBLISHED EVERY THURSDAY. Two Volumes yearly, beginning with the first Nos. in January and July. But Subscriptions may begin at any time. This Journal has been published for more than sixty years as a weekly journal under its present title. Still it is incumbent upon this Journal, no less than upon others to assure its patrons from time to time, as the occasion arises, of its desire, ability, and determination to meet all the requirements or the most active medical journalism of the day, without sacrificing any of that enviable reputation which is an inheri- tance from the past. 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