The Management of the Ab- 
scesses of Hip Disease. 
BT , 
A. B. JUDSON, M. D., 
■ORTHOPEDIC SURGEON TO THE OUT-PATIENT DEPART. 
MENT OF THE NKW YORK HOSPITAL. 
REPRINTED FROM 
2Thf "Nffto Iforft f-ttclucal .Journal 
for •January 81, 1885. Reprinted from the New York Medical Journal 
for January 31, 1885. 
THE MANAGEMENT OF THE ABSCESSES 
OF HIP DISEASE * 
By A. B. JUDSOtf, M. D., 
ORTHOPAEDIC SURGEON TO THE OUT-PATIENT DEPARTMENT OF THE NEW 
YORK HOSPITAL. 
The present paper is founded on the study of a number 
of cases of hip disease in which the discharge of pus was a 
prominent feature. I hope to draw from a consideration of 
these cases, which occurred in my own practice, certain con- 
clusions of practical value. 
I have excluded those cases in which there was reason 
to believe that the pus was the product of inflammation of 
the soft tissues alone. Cases of peri-articular inflammation 
may perhaps properly enough be called instances of hip 
disease. They sometimes present serious and alarming 
symptoms, but the comparative brevity of the affection and 
the subsequent integrity of the functions of the joint are 
sufficient evidence that the disease is not that insidious and 
destructive hip disease which begins in the bony tissue 
and pursues a slow and baleful course through the struc- 
tures of the joint until the usefulness of the part and the 
symmetry of the body are compromised. The cases which 
have been reviewed in the preparation of this paper belong 
to the latter class. 
* Read before the New York Orthopaedic Society, January 29, 1885. 2 
THE MANAGEMENT OF THE 
These cases stand over against a class of cases of osteitis 
of the hip in which abscesses did not occur, or, if they oc- 
curred, took the form of fluctuating tumors, which were 
absorbed. From the nature of the case, it is not possible 
to demonstrate that the occurrence of abscesses in this 
disease can be prevented by treatment, as it may be said of 
a given patient who escaped abscesses, that he may have 
been the subject of a dry inflammation, and would have 
escaped them in the absence of treatment. It has been ob- 
served that this complication happens in some cases early 
and in others late in the course of the disease. This fact 
suggests the thought that the character of the inflammation, 
whether dry or purulent, depends on the diathesis or the 
general condition (liable to change) of the patient rather 
than on any change that may be effected in the tissues of 
the diseased hip. 
If it is possible for abscesses to be prevented by treat- 
ment, it would seem that the measures adopted in the cases 
under consideration might reasonably be expected to pre- 
vent suppuration in those cases in which it had not already 
set in. The treatment pursued has been based on patho- 
logical conceptions which may be expressed as follows : A 
center of inflammation appears within the bone and slowly 
spreads, accompanied by hypenemia and softening, until 
the shell of compact bone is perforated, and all the tissues 
of the joint are involved in the inflammatory softening and 
disintegrating process. We will leave out of account the 
questions of the strumous element and the pernicious 
effects of reflex muscular action. That the pressure from 
reflex muscular action is not an important element, I have 
tried to show in former papers.* However these questions 
* “St. Louis Courier of Medicine,” May, 1881, pp. 367—3^72; “New 
York Medical Journal,” July, 1882, pp. 1-17 ; “Medical Record,” May 
12, 1883, pp. 509-512, July 7, 1883, pp. 1-4. ABSCESSES OF HIP DISEASE. 
3 
may be viewed ultimately, there is no question that the dis- 
ease, in a great majority of instances, comes to a natural, 
not fatal termination, as is evidenced by the common ex- 
pressions, “ Nature’s cure ” and “ the natural cure ” of hip 
disease. 
Given these pathological elements, treatment presents it- 
self as a matter of course as follows: 1. The increased vas- 
cularity attending inflammation in the tissues of the joint 
requires arrest of motion in the joint, or fixation. 2. The 
softening of the bony tissue and its increased fragility re- 
quire that the joint be relieved from the weight of the body 
in standing, and the direct concussion transmitted up the 
long bones of the limb from the heel in walking and run- 
ning. 3. As the cure is to come by natural processes, it is 
important that the general condition be kept at the highest 
possible point of excellence. The patient should, therefore, 
be active out of doors, and enabled to follow the ordinary 
pursuits of his time of life. 
These difficult requirements are so well met by the use 
of the liip-splint, properly constructed, rightly adjusted, and 
worn day and night, that the pain attending the disease 
is mitigated, the duration of the affection is shortened, and 
the extent of its ravages limited, and it is surmised, with a 
fair degree of probability, that, in certain cases, abscesses 
have been prevented. It should not be lost sight of, in 
passing, that deformity, so liable to follow this disease, is 
largely prevented by the persistent use of the liip-splint, 
which also secures whatever mobility may have been left in 
the joint after the storm of inflammation has swept through 
it. 
I At the first glance it would seem that the prevention of 
abscesses in this disease is extremely desirable. In practice, 
however, it has been found that a comparison between those 
cases of osteitis of the hip which are free from purulent dis- 4 
THE MANAGEMENT OF THE 
charges and those in which such discharges occur brings 
to light several circumstances which take away the dread 
of abscesses, and make their occurrence, if not a desira- 
ble event, at least an evil attended with compensating ad- 
vantages. Their occurrence appears to shorten the dura- 
tion of the affection. The degree of deformity following 
treatment depends in no way on the presence or absence of 
purulent discharges, and the clear picture of pathological 
anatomy which may be inferred from the presence of sinus- 
es discharging pus, and leading to diseased bone, is not 
only interesting, but of practical value, as it leads to a cheer- 
ful endurance of prolonged mechanical treatment (always 
more irksome, by the way, to the friends of the patient than 
to the patient himself), and enables the physician to say 
with confidence, when the sinuses are permanently closed, 
that the bone is also firmly and permanently cicatrized. 
It follows, then, that the abscesses of hip disease are not 
to be considered dreadful precursors of a fatal result. In 
patients treated in accordance with the principles suggested 
above, a purulent discharge is more or less an inconveni- 
ence, but its occurrence, whether from one aperture or 
many, is not a cause of anxiety. It is exceptionally attend- 
ed with hectic or emaciation. When these appear, they 
indicate a condition of the patient serious indeed, hut by 
no means necessarily a result of the abscess. There is no 
evidence that the discharge, as such, exhausts the strength 
of the patient. This tradition, like many another, is dis- 
proved by experience. The general condition of the patient 
remains good, and not infrequently it is robust. He con- 
tinues active in locomotion without the assistance of crutches, 
excepting the ischiatic crutch of the hip-splint, and follows 
with success the ordinary pursuits of life. The diseased 
tissues are defended from motion, and the violence insepa- 
rable from standing and walking in the usual way. The ABSCESSES OF HIP DISEASE. 
5 
morbid process is replaced in time by the reparative pro- 
cess, and cicatrization is established and perfected in bone, 
connective tissue, and integument. The amount of ultimate 
deformity does not seem to be influenced by the presence 
or absence of sinuses, and the cases, few in number, which 
terminate fatally, give no convincing evidence that the pres- 
ence of a purulent discharge increases the liability to death. 
It may be recalled, at this point, that attempts have been 
made to establish early communication with the seat of the 
initial lesion in hip disease by operative interference, thus 
anticipating the formation of an abscess and its resulting 
sinus. Such an attempt was made in 1867 by Mr. Kirk- 
patrick, of Dublin,* who tunneled the great trochanter 
with caustic and the knife in a case of incipient hip disease ; 
and more recently Mr. Macnamara states that he is in the 
habit of boring through the trochanter into the head and 
neck of the bone. In this manner he thinks that we may 
excite in the part a different action, and often a more 
healthy one, than that which exists.f If the views which I 
have expressed above are correct, to the effect that repair 
depends on some favorable change that takes place in the 
general condition of the patient rather than on any change 
which may be brought about in the tissues of the diseased 
joint, it is difficult to see how the procedure of Mr. Mac- 
namara can hasten, any more than aspiration or an incision, 
the initiation of the process of repair. It is to be hoped, 
however, that in a future publication he will give us a re- 
port of the result in the cases thus treated. 
I am unable to throw light on the interesting but ob- 
scure question of the starting-point of the abscesses of hip 
disease. In very advanced cases the sac of the abscess com- 
* “British Medical Journal,” August 31, 1867, pp. 177-179. 
f “Diseases of Bones and Joints,” C. Macnamara, London, 1881, 
pp. 441, 442. 6 
THE MANAGEMENT OF THE 
municates with the cavity of the joint, and it is surmised 
that, in cases not so far advanced, the abscess is but a depot 
for the pus which occupies the cavity of the joint, where 
it exists as a product of secondary inflammation in the lining 
of the joint, or as the result of the breaking into the joint 
cavity of a caseous focus in the bone. But there are reasons 
for believing that many of the abscesses of hip disease are 
not connected with the cavity of the joint at all,* being the 
result, perhaps, of the perforation of the compact shell of the 
bone below the line of attachment of the capsular ligament, 
or the result of other less understood processes, as sug- 
gested by the fact that fluctuating tumors occurring in the 
progress of hip disease have been observed to give exit, by 
aspiration or incision, to fluids at first clear and later puru- 
lent. 
Although the starting-point of the abscess is uncertain, 
the location of the discharging aperture is, of course, easily 
recognized. A classification of the cases under review 
shows that about 30 per cent, of the sinuses appear on the 
anterior surface of the thigh, 27 per cent, on the outer sur- 
face, including the region of the great trochanter, 20 per 
cent, on the posterior surface of the thigh, including the 
gluteal region, and 13 per cent, on the inner side of the 
thigh. Of the remaining 10 per cent., half appear in 
the groin and the other half over the pelvic bones poste- 
riorly. I have observed that the sinuses which are found 
in the last-named regions are preceded by sinuses opening 
in the thigh. It may be inferred from this that collections 
of matter in and around the joint seek by gravitation an 
outlet at a lower level than that of the joint, and that 
sinuses appearing at a higher level indicate that the pelvic 
bones are invaded by the disease, an inference which 
* See some interesting observations on this point published in the 
“ Transactions of the American Medical Association,” 1863, pp. 169,160. ABSCESSES OF IIIP DISEASE. 
7 
is supported by the fact that a large proportion of the 
sinuses found at the higher level leave scars which are 
directly attached to the subjacent bone. I have found but 
little evidence that the pus in hip disease follows the lead 
of muscular sheaths. It appears rather to take the shortest 
course toward the surface, influenced to a certain degree by 
gravitation. Scars resulting from sinuses have been ob- 
served directly attached to the femoral shaft, the great tro- 
chanter, the horizontal ramus of the pubes, the crest or the 
spines of the ilium, and the posterior surface of the sacrum. 
Scars thus attached to underlying bone impart a curiously 
dimpled appearance to the part of the body in which they 
are found, especially in subjects inclined to be fat. Wher- 
ever they appear, the sinuses do not interfere with the 
proper application and comfortable wearing of the hip- 
splint, which makes pressure only where the perineal straps 
support the ischiatic and pubic bones. The pressure made 
by the straps forbids an eruption at these points. I have 
seen no case in which the pus has found an exit by the 
vagina or rectum. Dr. Gibney has reported an interesting 
case of the former kind,* and Dr. J. Randolph \ and Dr. 
Edmund Andrews cases of the latter. Dr. Andrews remarks 
in regard to his patient (whose hip joint he had exsected): 
“This is the only instance which I ever heard of where a 
fistula in ano opened on the outer side of the thigh.” J 
In regard to the treatment of the abscesses of hip dis- 
ease, the histories of the cases under review indicate that the 
precept that pus should be released by an early and free 
incision is a rule which is not to be always followed in the 
management of the abscesses of hip disease. This opinion 
was ably maintained by Dr. John F. Ridlon in a discussion 
* “The Hip and its Diseases,”Y.P. Gibney,New York, 1884, p. 181. 
f “American Jour, of the Med. Sciences,” February, 1831, p. 301. 
* “Chicago Med. Examiner,” June, 1861, p. 293, 8 
THE MANAGEMENT OF THE 
which took place in the New York Pathological Society in 
April, 1883.* 
It can hardly with reason be supposed that the pro- 
cesses, either destructive or reparative, which take place in 
the bone in the progress of this disease, can be affected 
by incisions, local medications, dressings, the introduction 
of drainage-tubes, the injection of antiseptic fluids, the 
distension of the sac of the abscess, or the use of the 
faradic current f as a means of hastening suppuration, 
when we consider that purulent collections, sinuses, and 
discharging fluids are but phenomena of the soft parts, 
secondary in every sense to the changes taking plaoe in the 
bony tissue. If the collection of pus were the starting- 
point or the main feature of the disease, an early and free 
incision, as for a furuncle, would be admissible. But in hip 
disease the trouble is primarily and chiefly a disease of the 
bony tissue composing a joint, which is best treated gener- 
ally by the administration of tonics and the regulation of 
the hygiene, and locally by fixation and protection from 
violence. If abscesses occur, it is shown by experience that 
the retention of pus, even in large quantities, or the pres- 
ence of a purulent discharge, does not prevent the process of 
repair. 
In the cases under review, 30 per cent, of the sinuses 
* “ Med. Record,” May 25, 1883, p. 584. On this point Mr. Ford 
wrote as follows: “ There is no rational system known which can point 
out the advantage to be derived from an artificial opening, made in any 
way whatsoever, during this stage of the disease; neither is there one 
case on record where an active employment of the art of operative sur- 
gery has been found materially useful in this period of the complaint.” 
“ Disease of the Hip Joint,” by Edward Ford, second edition, London, 
1810, p. 117. 
f Dr. A. D. Rockwell has reported cases of phlegmonous and cold 
abscesses in which good results were obtained by this agent. “ Medical 
Record,” September 21, 1878, pp. 226, 227. ABSCESSES OF HIP DISEASE. 
9 
followed incisions, while the remainder were the results of 
spontaneous openings. The proportion of the latter would 
have been still larger if I had not in the earlier cases impli- 
citly followed the old rule. 
In some cases the sac of the abscess attains a great size, 
inviting reduction by the aspirator or bistoury. The ap- 
pearance is that of a fluctuating tumor of enormous propor- 
tions, attended with scarcely any oedema, no pain, and no 
etfect on the general health, and interfering but little, if at 
all, with locomotion on the hip-splint. After this condition 
has persisted for many weeks or months, a small area is 
found in which the integument, reduced to the thinness of 
paper, is the only barrier to the escape of the fluid. This 
insensible membrane is at length perforated ; there is a tor- 
rent of thin purulent fluid containing caseous flakes or 
masses; the tumor collapses; there is no general disturb- 
ance, and cicatrization follows in a few weeks; and it is 
found that the diseased bone has undergone a reparative 
process, and the patient is cured, with more or less of the 
asymmetry and functional impairment which, as a rule, 
attend recovery from this disease. An unimportant scar, 
attached to the deeper tissues of the limb, is the only 
remaining trace of the abscess. Such a case follows the 
type of the cold abscess of caries, seen more often in cases of 
Pott’s disease of the spine. 
The abscess of hip disease does not by any means always 
present this character. Not infrequently the approach of 
matter toward the surface is attended by pain, heat, and red- 
ness, in addition to the swelling. There may also be present 
the transient general reaction commonly associated with a 
phlegmon.* When an abscess presents these characteristics, 
it is not uncommonly the first of a series, the individual 
members of which appear at varying intervals, and not in- 
* See Ford, op. cit., pp. 116, 117. THE MANAGEMENT OF THE 
10 
frequently at points remote from the seat of the initial 
eruption. When a case presents these features, it is likely 
to be long in duration, occupying many weary months be- 
fore the bone is healed and the sinuses are closed. Each 
new eruption may or may not be preceded by pain and 
general disturbance. 
It is in these cases that the hip-splint is especially use- 
ful. Sometimes the extreme sensitiveness of the joint, which 
resents the slightest jar or disturbance, is added to the pain 
caused by the abscess. In such a case the patient insists 
that the splint be tightly keyed, knowing by experience that 
on this depends fixation of the exquisitely tender joint. 
He also demands that the splint be so adjusted that his heel 
shall be held from touching the foot-piece of the splint, 
knowing that on this depends the protection of the joint 
from violence in standing and walking. In the treatment 
of the cases under review, considerations of an aesthetic 
nature have not prevented the use of a splint strong enough 
to render these important services. Many patients have 
been tantalized by the application of apparatus too weak to 
be effective. 
It sometimes happens that a tumor points, and is appa- 
rently about to open spontaneously, when a sudden copious 
discharge sets in from a sinus already established, on an- 
other side of the limb, perhaps, and the tumor collapses, 
leaving, when recovery takes place, a permanent depression, 
or dimple, where the pointing had been. The intercurrence 
of any of the exanthemata is marked by great local activity, 
the sinuses becoming cavernous, the discharge of thick pus 
being very profuse, and the integument distended and red. 
A sinus sometimes discharges freely, and at other times 
scantily, and for weeks together it may be closed to open 
again. In some cases the patient suffers malaise and head- 
ache while the discharge is scanty or suppressed, which ABSCESSES OF HIP DISEASE. 
11 
disappear when the flow resumes activity. When at length 
recovery is approaching, the sinus slowly contracts, and the 
surrounding tissues form a depression. The matured cicatrix 
occupies the bottom of the depression, and is perhaps at- 
tached to the underlying bone. When there are many 
sinuses, the order in which they close is not necessarily that 
in which they made their appearance. It is reasonable to 
surmise that the last to close is that one which is most 
directly connected with that surface or point of bone which 
is the last to cicatrize. 
In the progress of one of these cases of prolonged sup- 
puration the question of an incision for the release of pus 
will often arise. While I have seen no case in which such 
an incision has done harm, I have also seen no case in which 
it had a positive controlling influence for good generally or 
locally. If the physician has the opportunity, he may re- 
lieve tension and allay pain by an incision. But, as the 
cases under consideration have invariably been in “ office ” or 
“ dispensary ” patients, freed by the hip-splint from the sick- 
room and hospital ward, it has often happened that the 
patient, through dread of the knife, has remained away, the 
abscess pursuing its painful course until a spontaneous open- 
ing has occurred. I have seen, however, no case in which 
the welfare of the patient was seriously compromised by the 
expectant treatment thus forced on the physician. It may 
almost be said that in practice it is well to make light of 
this feature of a case of hip disease, especially as undue 
attention is almost certain to be accorded to it in the do- 
mestic circle. The borders of the aperture of a purulent 
sinus are not particularly sensitive to external impressions ; 
but the friends of the little patient will concentrate their 
attention on this feature, as entailing unusual distress and 
danger. Unless the stream is too copious, it is best to leave 
the opening uncovered, relying entirely on evaporation and 12 
THE MANAGEMENT OF THE 
frequent change of under-clothing, which is to be boiled 
the instant of removal. Sometimes a deodorizing applica- 
tion is desirable. In any event, poultices and kindred ap- 
plications are to be avoided after the discharge has begun. 
If the physician chooses to regard himself as a military 
commander, intent on subduing the enemy entrenched in 
the bony tissue, let him beware of having his attention dis- 
tracted by sorties in the soft parts. Let him control the 
bone disease by fixation, protection, and hygiene, and the 
abscesses and sinuses will not require the bistoury and 
drainage-tube. 
The following are illustrative cases: 
Case I.—A girl, aged seven. Right hip. Duration of dis- 
ease one year. Nine months after treatment was begun a 
fluctuating tumor appeared on the anterior surface of the upper 
part of the thigh. Two months later the abscess, having reached 
a great size, opened without pain when the child was sweeping 
the sidewalk with a toy broom. There was a torrent of fluid. 
Collapse of the tumor was followed by a purulent discharge, 
containing caseous flakes and masses, which continued for seven 
months, when it ceased and left a firm cicatrix. The sinus re- 
mained closed for seven months. At the end of that time moist- 
ure was found in place of a dry scar, and for the past year the 
place of the sinus has been moist and frequently covered by a 
small scab. The child is an active and healthy school-girl, still 
wearing the hip-splint on account of the delay of permanent 
cicatrization, and to make sure of recovery with the present 
good position of the limb. There is ankylosis. 
Case II.—A boy, aged five. Right hip. Duration of dis- 
ease three years. A fluctuating tumor occupied the anterior 
surface of the thigh, extending from the level of the great tro- 
chanter to one inch above the patella. Four weeks after treat- 
ment was begun the abscess opened when the patient was asleep. 
On awaking in the morning, he thought he had wet the bed. 
There was speedy collapse of the tumor. The boy’s general 
condition has remained good, excepting on two occasions, when ABSCESSES OF HIP DISEASE. 
13 
there was an arrest of the discharge, with accumulation of pus, 
and some general reaction. A profuse discharge, which occurred 
spontaneously by the original sinus, promptly relieved the local 
and general symptoms. All of the usual symptoms and signs 
of osteitis of the hip joint have been observed in this case. Fif- 
teen months after the abscess broke the sinus was firmly cica- 
trized. At the present time, three months later, the patient is 
an active and robust school-boy, with good prospect of making 
an excellent recovery with useful motion in the joint. 
Case III.—A girl, aged seven. Left hip. Duration of dis- 
ease two months. A fluctuating tumor was detected six months 
after treatment was begun. Ten months later the tumor had 
reached an enormous size, and pointed on the inner side of the 
thigh, presenting a small area of insensible integument, appar- 
ently the only barrier to-the escape of the fluid. I am informed 
that the child opened the abscess while at play, using a pin for 
the purpose. There was a copious flood and a speedy collapse 
of the tumor, followed by a purulent discharge for five months. 
There were no symptoms attributable to the abscess before or 
after its opening. Throughout the treatment the patient wore 
the hip-splint day and night, as did all the patients whose cases 
are here reported. The child made a good recovery, with anky- 
losis. It is now three years and three months since the sinus 
closed, and two years and nine months since treatment was sus- 
pended. The scar is small, deeply depressed, and attached to 
the bone, and the girl is in perfect health. 
Case IV.—A boy, aged four and a half. Right hip. Duration 
of the disease one year. Fifteen months after treatment was 
begun a fluctuating tumor was found over the great trochanter. 
It slowly increased until it extended on the outer and posterior 
surface from above the trochanter to the junction of the middle 
and lower thirds of the thigh. It then slowly decreased, and 
twenty-one months after it was first noticed it had disappeared. 
The tissues on the posterior surface of the thigh, however, re- 
mained condensed, and, three months after the disappearance 
of the tumor was recorded, two sinuses appeared on the outer 
and posterior surface of the thigh, and two months later a third 
appeared on the outer surface. They discharged freely, and, 14 
THE MANAGEMENT OF THE 
six months after the first appeared, they had permanently closed. 
In this case the repair of the diseased bone was in progress while 
the fluid collection attained a large size and disappeared, and 
while a subsequent copious purulent discharge was taking place. 
At the present time, sixteen months after the closing of the 
sinuses, and three months after treatment was suspended, the 
boy is free from symptoms, and the scars are depressed and at- 
tached to the deep fascia. There is free motion through 45° of 
flexion and 20° of abduction, with considerable motion in ad- 
duction. That the case was one of osteitis of the hip joint, 
however, is evident from the duration of the affection and the 
following well-marked features: recurring pain in the knee for 
a year, nocturnal crying, marked deformity and reflex arrest of 
motion when first examined, the thigh being flexed 67° and ab- 
ducted 40°, muscular atrophy, real shortening of one inch, and 
pain on the slightest disturbance of the joint, relieved by the 
application of traction or fixation. 
Case Y.—A boy, aged nine. Left hip. Duration of the disease 
sixteen months. Two sinuses—one the result of an incision and 
the other a spontaneous opening—had been discharging copiously 
in the region of the great trochanter. Three months after treat- 
ment was begun a third appeared in the upper part of the inner 
surface of the thigh, and in the following sixteen months six 
others appeared on the anterior and posterior surfaces of the 
thigh, in the groin, and over the sacrum. The discharge was 
for a number of months very copious, but it slowly diminished, 
and four years and five months after the last sinus appeared 
they had all permanently closed. While this prolonged dis- 
charge was taking place, the boy suffered, but without contract- 
ing permanent damage, from measles, scarlet fever, and mumps. 
At the present time, five months after the permanent closure 
of the sinuses, the lad is in perfect general health, and about to 
make a good recovery, with ankylosis. He is very active, still 
wearing the hip-splint in order to retain the present good po- 
sition of the limb. 
Case VI.—A girl, aged seven. Left hip. Duration of disease 
nearly three years. An abscess had opened spontaneously on 
the anterior surface of the upper part of the thigh, and had ABSCESSES OF HIP DISEASE. 
15 
been discharging for five months. Six months after treatment 
was begun the sinus permanently closed. At the present time, 
sixteen months after the sinus closed, the child is in per- 
fect health. The scar is deeply depressed, and attached to 
tissues near the femoral shaft. There is wide motion, 40° 
antero-posteriorly and 35° laterally, measured with the assist- 
ance of a goniometer devised by Dr. Gibney. That the case 
was one of hip disease, however, is evident from the following 
features, which were well marked: muscular atrophy, real 
shortening, frequently recurring pain in the knee for two years, 
contraction of the adductors, which was observed for two years, 
and for which section of the muscles was repeatedly advised,* 
deformity—the thigh being flexed 90° and adducted 35°—and 
pain on the slightest disturbance of the joint relieved by trac- 
tion or fixation. 
Case VII.—A boy, aged five. Left hip. Duration of disease 
two years. A sinus following an incision in the outer surface 
of the upper part of the thigh had been discharging for seven 
months. Six months after treatment was begun the sinus per- 
manently closed, and the boy made a good recovery, with anky- 
losis. One year after treatment was suspended the child was 
in excellent health, and the scar was deeply depressed and at- 
tached to the bone. 
Case VIII.—A boy, aged four. Left hip. Duration of dis- 
ease one year and six months. Four months after treatment 
was begun, pus was released by an incision in front of the great 
trochanter, and five months later another incision was made in 
the same region. Pus was discharged in varying quantities for 
six months, when the sinuses permanently closed. The patient 
remained under observation for twenty-two months longer, and, 
when last seen, was in good general condition, and in a fair way 
to make a good recovery, with ankylosis. 
Case IX.—A girl, aged nine. Right hip. Duration of dis- 
ease one year. Nine months after treatment was begun pus 
was released by an incision behind the great trochanter. A 
purulent discharge continued for two years and nine months, 
* Quando tandem chirurgi nostri praeclari discent contractiohem re- 
flexam musculorum esse unam ex indicationibus coxalgiae ? 16 
THE MANAGEMENT OF THE 
with brief intermissions, during which the patient suffered from 
lassitude and headache. One month after the sinus perma- 
nently closed, treatment was discontinued against advice. Three 
years and eight months later the child was found in perfect 
health. She had recovered, with ankylosis, and a strong and 
fairly useful limb. 
Case X.—A boy, aged six. Right hip. Duration of the 
disease two years. One year and three months after treatment 
was begun a tumor appeared on the outer side of the thigh 
An incision made, six months later led to a very copious dis- 
charge for three months, followed by a scanty discharge for 
seven months, when the sinus closed. The boy ultimately made 
a fair recovery, with ankylosis. I am informed that two years 
and six months after the sinus closed it reopened spontaneously, 
and discharged for about six months. At the present time, four 
years and nine months after the second closing of the sinus, the 
cicatrix is evidently final, and the lad is in excellent health. 
Case XT.—A girl, aged three. Right hip. Duration of dis- 
ease one year. Five months after treatment was begun fluctua- 
tion was detected, and an incision made on the outer surface of 
the upper part of the thigh. The sinus thus established was 
followed by five others, which appeared without incision on 
the posterior and inner surfaces of the thigh and in the groin. 
There was a constant discharge for eighteen months, when the 
sinuses permanently cicatrized, and the child made an excellent 
recovery, with ankylosis. It is six years and two months since 
the sinuses permanently closed, and five years and six months 
since treatment was suspended. The scars are deeply depressed, 
some of them are attached to the underlying bone, and the girl 
is in robust health. 
Case XII.—A boy, aged seven. Right hip. Duration of 
the disease four years. Four months after treatment was begun 
fluctuation was detected, and an incision was made on the inner 
side of the thigh. A copious purulent discharge continued for 
two years from this and three other sinuses on the outer sur- 
face of the thigh and in the groin. During this time the patient 
wore the hip-splint constantly, and was almost daily out of 
doors. This statement is true as applied to all the cases here ABSCESSES OF HIP DISEASE. 
17 
reported. The sinuses finally closed, and an excellent recovery- 
followed, with ankylosis. At the present time, eight years 
after the sinuses permanently closed, and six years and two 
months after treatment was suspended, the boy is in robust 
health. The scars are deeply depressed, and some of them are 
attached to the underlying bone. 
In these histories regard has been had only to the 
deportment of the abscesses. Other clinical features of 
interest have been omitted, excepting that in each in- 
stance enough of the history has been given to establish 
that the case was one of chronic osteitis of the joint. It is 
well to state, however, that the results and prospects as 
regards symmetry and mobility in the cases reported, as 
well as in the whole number under consideration, are such 
as to commend the treatment pursued. 
The cases above reported are cited as corroborating the 
views set forth in the preceding pages. They do not by any 
means include those of all the patients whose histories have 
been reviewed in the preparation of this paper. A number 
are still under treatment, a few have died from causes more 
or less directly connected with the joint disease (consump- 
tion, visceral degeneration, and tubercular meningitis), and a 
number, as happens in all affections of a chronic character 
in which perfect restoration can not be promised, have 
strayed away and are lost to observation. In the whole 
number, however, no case has shown clinical features at 
variance with the views which have been presented above, 
to the effect that abscesses are phenomena of secondary 
import in the progress and management of a case of hip 
disease, and that their treatment may in many cases be 
purely, or almost purely, expectant. This precept, however, 
is to be construed with a keen appreciation of the necessity 
of thoroughly treating, in accordance with the principles 
suggested above, the disease of which they are an incident. THE MANAGEMENT OF THE 
18 
[Reprinted from “ The New York Medical Journal for January 24,” 
1885.] 
I have devised the following improvements in the con- 
struction of the hip splint for the purpose of diminishing 
Fig. 2.—Side view. 
Fig. 1.—Front view. 
the weight of the splint, while retaining its strength and 
inflexibility by disposing the metal so that it shall resist to ABSCESSES OF HIP DISEASE. 
19 
the best advantage the strain to which it is subjected. 
When a hip splint is made strong enough in the pelvic band 
and upright to perform the function of an efficient ischiatic 
crutch, preventing the patient’s heel from reaching the foot- 
piece of the splint in walking or running, it is found neces- 
sary to give considerable weight to the apparatus when con- 
structed, as it often is, with a round upright, or with the 
flat side of the upright toward the patient’s limb. If the 
upright is made flat and attached to the pelvic band in such 
a way that its edge is toward the patient, it is practically 
inflexible, and the amount of steel used in its construction 
may be greatly reduced. The metal may be thinner even 
than is shown in Fig. 2. 
Having the rack at the upper part of the splint, as 
shown in the cuts, further reduces the weight of the appa- 
ratus by allowing the upright to taper rapidly toward its 
lower end, and also puts the heavier portion of the upright 
near the center of gravity of the body, where it is carried 
more easily than when massed near the patient’s foot. 
I have applied fifteen splints constructed on this plan. 
Some of them have been in use more than a year and a half, 
and have demonstrated that the changes indicated above are 
improvements. 
The cuts also show a U-shaped attachment, previously 
described, for more completely arresting motion in the joint. 
It has been in use nearly five years, and has proved its 
value. It is adjustable vertically on the barrel of the up- 
right, and takes the place of the flexible device known as 
the knee-cap. The lew York Medical Journal, 
A WEEKLY REVIEW OF MEDICINE. 
Published by 
0. Appleton &. Co. 
Edited by 
Frank P. Foster, 
M. D. 
The New York Medical Journal, now in the twenty-first year of its 
publication, is published every Saturday, each number containing twenty- 
eight largo, double-columned* pages of reading-matter. By reason of the 
condensed form in which the matter is arranged, it contains more reading- 
matter than any other journal of its class in the United States. It is also 
more freely illustrated, and its illustrations are generally better executed, 
than is the case with other weekly journals. 
It has a large circulation in all parts of the country, and it is largely on 
this account that it is enabled to obtain a high class of contributed articles, 
for authors know that through its columns they address the better part of 
the profession; a consideration which has not escaped the notice of adver- 
tisers, as shown by its increasing advertising patronage. 
The special departments of the Journal are as follows: 
LECTURES.—The frequent publication of material of this sort is a prominent fea- 
ture, and pains are taken to choose such as will prove valuable to the reader. 
ORIGINAL COMMUNICATIONS.—In accepting articles of that class, regard is 
had more particularly to the wants of the general practitioner, and all the 
special branches of medicine are duly represented. 
BOOK NOTICES.—Current publications are noticed in a spirit of fairness, and with 
the soie view of giving information to the reader. 
CLINICAL REPORTS are also a regular feature of the Journal, embracing clinical 
records from the various hospitals and clinics, not only of New York, but of 
various other cities, together with clinical contributions from private practice. 
EDITORIAL ARTICLES are numerous and carefully written, and we are able to 
give timely consideration to passing events. 
MINOR PARAGRAPHS.—Under this heading are given short comments and 
notes on passing events. 
NEWS ITEMS contain the latest news of interest to the profession. 
OBITUARY NOTES announce the deaths which occur in the ranks of the profes- 
sion, with a brief history of each individual when practicable. 
SOCIETY PROCEEDINGS are given promptly, and those of a great number of 
societies figure. At the same time we select for publication only such as we 
think profitable to our readers. 
REPORTS ON THE PROGRESS OF MEDICINE constitute a feature of the 
Journal which we have reason to think is highly valued by our readers. 
MISCELLANY' includes matter of general interest, and space is also given for 
NEW INVENTIONS and LETTERS TO THE EDITOR. 
As a whole, we are warranted in saying that the New York Medical 
Journal is regarded with the highest favor by its readers and by its con- 
temporaries. 
Subscription price, $5.00 per annum.