Reprinted from Archives of Pediatrics, August, 1892. 
EARLY SYMPTOMS OF HIP DISEASE AND 
zETIOLOGY OFHIPDISEASE.—TREATMENT 
OF ABSCESS IN HIP DISEASE* 
BY H. AUGUSTUS WILSON,HuD., 
Clinical Professor of Orthopedic Surgery in the Jefferson Medical College; Professor ot 
General and Orthopedic Surgery in the Philadelphia Polyclinic. 
Gentlemen:—Among the earliest symptoms of the in- 
vasion of the hip-joint is a rigidity of the muscles of the 
thigh which is produced by the child’s efforts to achieve 
an immobilization of the joint. The child realizes that 
every motion of the hip produces pain, and hence instinct- 
ively produces this involuntary action of the muscles. 
The methods of recognizing fixation of the joint are by 
watching the motion of the pelvis in the first place. By 
observing the crest of the ilium you may see the character- 
istic motion, while a still more delicate manipulation will 
show this fixation more clearly. If we move the healthy 
limb, the genitalia remain in the normal position, but 
if the affected side is moved, the genitalia are moved also 
in a direction corresponding to the movement of the leg 
on account of the rigidity of all of the muscles on that side 
of the body. Still another sign is the disappearance of 
the ileo-femoral fold or crease. The cause of the obliter- 
ation of this crease is muscular action together with a 
change in the position of the limb. The leg is drawn 
forward, and in this position the line is effaced. We can 
learn more of this disease by not touching the limb, but 
by noticing the motions of the child. If we ask the child 
to turn over you will observe that it will be done by the 
sound limb entirely, while the motions of the affected leg 
are guarded with supreme care. The “ shoe and stock- 
ing ” position is a capital way of making our diagnosis in 
the incipient stage. This is the position in which the 
* Delivered at the Jefferson Medical College Hospital 2 
WILSON : Early Symptoms of Hip Disease, etc. 
ankle of one side is thrown across the knee of the oppo- 
site side. In doing this there is necessarily rotation of the 
leg. The child, if diseased, will be unable to throw the 
limb of the affected side in this position. If you ask her 
how she puts on her shoe she will say she does it by stoop- 
ing down and putting it on at her side in such a position 
that rotation or any movement of the hip-joint will be 
avoided. There may or may not at this time be a swell- 
ing of the joint, usually not, because there is not apt to be 
any effusion or accumulation of pus at this stage. Another 
symptom, though not an infallible one, is pain in the knee- 
joint. Those who have studied their anatomy well, will 
remember that a branch of the obturator nerve runs to the 
hip-joint, and other branches extend to the knee-joint. 
Inflammation or irritation in one portion of this nerve will 
cause pain in other portions of the same nerve. Thus, as 
hip disease will give rise to pain in the region of the knee, 
so will pressure on the ulnar nerve produce tingling in the 
fingers more than any sensation at the point of pressure 
beside the olecranon process. Still it must be borne in 
mind that disease of a joint will give rise to pain in that 
joint itself. Over and over again has actual disease of the 
knee-joint been ignored because the physician believed 
that pain in the knee must mean hip-joint disease, and 
again has the knee been treated as the site of the disease 
when the pain present at that point only indicated a lesion 
elsewhere. 
In hip cases, the mother will also call your attention to 
the fact that the child has night pains, and cries out in her 
sleep. During the night and more especially the early 
hours of sleep when the voluntary control of the muscles 
is overcome, they become relaxed, and the diseased bone 
is impinged upon by some motion of the child. As a result 
a muscular spasm occurs to recover immobility and this 
gives rise to severe pain, the child waking with a scream. 
One point more I wish to impress upon you right here. In 
making your diagnosis do not hammer upon the knee or 
foot in order to elicit pain in the hip-joint. The reason for 
this injunction is plain. There exists an ostitis or syno- WILSON : Early Symptoms of Hip Disease, etc. 
3 
vitis here, and any traumatism will increase the intensity 
of the inflammatory action. I would emphasize this point 
most strongly, because I am convinced that it is a promi- 
nent factor in increasing the gravity of the disease. If 
one of you had a boil upon the nose I do not think you 
would ask some friend to pinch it in order that you might 
find out whether it hurt or not, and that you might be sure 
that pain could be produced. On the same principle do 
not hammer on a child’s foot or knee to see whether it 
would give pain in a diseased hip-joint, but rather make 
all of the necessary movements in manipulation with the 
utmost gentleness and caution. 
Causes of Hip'Disease.—Before considering the treat- 
ment of this disease, it is necessary to speak of the sub- 
ject of the causation. We may at the outset lay it down 
as a positive fact that in the great majority of instances 
that it is a tubercular disease, just as much so as consump- 
tion. It is analogous in many respects to phthisis, in 
that it is an inherited disease which has been lighted 
up by some traumatism. Among the many causes which 
have been assigned are falls, sprains, inadequate clothing, 
exposure to cold and dampness. These of themselves, 
however, would not produce such a terrible disease unless 
some predisposing cause existed in the form of a system 
full of tubercular deposits ready to be lighted up into in- 
flammatory action. It is.a well-known truth, that having 
a fact in hand we invariably ascertain to the best of our 
ability a known cause. If a child presents this condition, 
the mother will always ascribe it to some cause, which in 
itself is usually a trivial one. How many children suffer 
falls and blows with no such disastrous result following! 
The fact that, as a rule, there is a tuberculous disease of 
the bone, must not exclude from our mind that there are 
a number of cases where the disease occurs without any 
tubercular disease. It is a great comfort to the family to 
know that the trouble may result without the presence of 
this hereditary factor. We must allow a small margin to 
cover the comforting cases. From the fact that this is 
a tuberculous disease, it must be viewed in an entirely 4 
Wilson : Early Symptoms of Hip Disease, etc. 
different light from an acute synovitis or ostitis occurring 
elsewhere. We must view a manifested tubercular deposit 
as a malignant disease, I mean that the tendency is 
to destruction. A malignant tumor is one which menaces 
the patient’s life; a tubercular deposit is malignant because 
it has a tendency to a destruction of the surrounding tis- 
sues, not only the bone, but the soft tissues as well. It is 
not malignant in the view that it tends to the destruction 
of the patient’s life, and in this it differs from malignant 
tumors. 
As to the sites of the disease. Having settled in our 
minds that it exists in the head of the bone, I must not 
overlook the fact that it does not confine Itself to this point. 
Existing originally in the head, it is apt to pass on to the 
acetabulum. That there is a conjoined acetabular origin 
I am not quite prepared to say, but that acetabular 
disease does become associated we all know. The head 
being removed it frequently leaves in the acetabulum a 
tuberculous deposit which relights the inflammation 
and continues the old condition. Now the question will 
be asked, such being the case, why not resort at once to 
excision of the tuberculous deposit ? The reason is that 
in a certain number of cases nature has resorted to her own 
expedients to eradicate the disease by absorption. In 
some cases the cure has gone on until the patient has a 
very good leg. 
Acting upon this determination of nature to absorb the 
affecting deposit, there has ensued a plan of treatment 
known as the conservative plan, which aims at immo- 
bilization for a period covering the time of the pres- 
ence of inflammatory action. The results accomplished 
by a persistent attention to this plan of procedure prove 
far more satisfactory than those obtained by recourse to 
surgical procedure. The shortening is less and the gen- 
eral usefulness is better in every way, provided the case 
is given the full benefit of this plan sufficiently early to be 
of service, and it be persisted in with proper judgment for 
an adequate length of time. Wilson : Early Symptoms of Hip Disease, etc. 
5 
Conservative Plan of Treatment.—To illustrate the 
method of carrying out the conservative plan of treatment, 
I will bring before you the boy upon whom I two weeks 
ago performed infra-trochanteric osteotomy for the relief 
of deformity following hip disease. The method of immo- 
bilization used in this case is applicable to the treatment 
of the disease itself in its incipiency. Incidentally, I may 
say that his temperature on the day following the operation 
was ioo° and since that time has ranged from 98° to ggff 
indicating an entire absence of any inflammatory disturb- 
ance. I left the dressing intact for a period of ten days, 
and when I removed it it was perfectly clean and healthy. 
The great convenience of using the wire breeches is, that 
we can have the patient thoroughly immobile and yet have 
perfect access to every part. The wound is perfectly asep- 
tic. You will observe that the shortening will amount to 
not more than one inch. By means of the elevation of 
the breeches upon stools or benches placed across an 
ordinary bed we can pass the bed-pan, and keep the 
patient in a good sanitary condition without moving the 
hip. Extension is obtained here by means of a rubber 
band applied on the side and attached to the foot-piece. 
By means of scales we can test exactly the amount 
of weight applied. In this case very favorable and satis- 
factory results have been obtained. 
Treatment of Abscess in Hip Disease.—You will recall 
the little girl with the leg so flexed that it was with con- 
siderable difficulty that we brought her limb down in a 
horizontal position. You will remember, also, that I called 
attention to a swelling in the hip-joint. Her limb has 
been kept in a rigid position since. Her temperature rose 
on the evening of the 25th to ioi4/6°, and our attention 
was called to the fact that something was wrong. Imme- 
diately we examined her carefully and found nota single, 
but multiple abscesses; one in the groin of the affected 
side, one on the side high up, and one posterior on the 
spinal column. These abscesses when opened gave exit 
to the characteristic tubercular pus, and the peculiar 
granulations pathognomonic of these tubercular cases 6 
Wilson : Early Symptoms of Hip Disease, etc. 
followed. Her temperature fell to gglf° and with but 
occasional slight elevations has since remained normal. 
This abscess on the back is not connected with caries of 
the vertebrae but is purely a tubercular deposit in the soft 
tissues which is breaking down. If there had been necro- 
sis of the hip we would have removed the diseased bone 
at once. We have treated these abscesses as follows : 
First, they were washed out thoroughly with peroxide of 
hydrogen by means of which combustion of diseased tissue 
takes place. Following this is the use of the bichloride of 
mercury solution, i to 2000, which puts the parts in a chemi- 
cally antiseptic condition. Then, more important than all 
the rest, is the use of iodoform, which is preeminently of all 
the germicides the one which acts -advantageously in the 
treatment of diseases due to the bacillus tuberculosis. If 
this is dusted over, very little will reach the crevices where 
the germs lie. If we use the ethereal solution we are apt to 
have iodoform narcosis, and as well necrosis of tissues with 
which it comes in contact. Dr. Nicholas Senn advises the 
use of a ten per cent.' emulsion of iodoform in olive oil, 
the advantage of which lies in the fact that a suspension of 
iodoform takes place so that we can have a definite quan- 
tity present; it fills all the crevices and the excess runs off, 
the iodoform thus coming in contact with the germs. 
Iodoform has a very disagreeable odor and attempts have 
been made to substitute iodol for it, but I am not satisfied 
with it, and I therefore forget the odor in the decidedly 
great advantage it possesses as a germicide for bacilli 
tuberculoso. 
Favorable Result of Coiiservatism in Hip Disease.—The 
little child which is now before you has been carefully 
treated since the incipient stage by my chief clinical 
assistant, Dr. J. P. Mann. She was kept in bed for the first 
six months, during which time extension, fixation, and 
immobilization was maintained. When the symptoms 
warranted it, the child was allowed to get up and around, 
but was not allowed to use the diseased joint. She has 
been wearing a high shoe upon the sound limb, and used 
crutches in order to thoroughly protect the diseased joint. WILSON : Early Symptoms of Hip Disease, etc. 
7 
The position assumed by the child must be noticed. Let 
us carefully examine the present condition by taking the 
sound limb first in order that we may have something to 
compare it with. I have no trouble in producing rotation 
on the sound side and showing you the entire absence of 
rotation upon the affected side. I will move the sound 
limb out or abduct it, asking .you to notice the anterior 
superior spine of the ilium and the labia majora, and you 
will observe that they remain in a fixed position without 
the slightest indication of a change in their position show- 
ing that free motion of the head of the femur in acetabulum 
takes place. On the other side, I find there is an absence 
of motion of the joint as I rotate and abduct the limb. As 
I move the limb outwards you see that the mons veneris 
and the spine of the ilium move also. As the child turns 
over you can see how she guards her affected limb. Now 
looking at this patient you can see that the ileo-femoral 
crease is increased on the affected side and diminished on 
the well side. Hence, we cannot rely on this sign alone. 
Now let us observe the difference in length of the legs, 
and I will have you observe that there is an enormous 
amount of fallacy existing in the manner making measure- 
ments of the asymmetry of a limb. The points selected are 
usually the fixed bony points, but the difficulty in finding 
these points is so great that much error is apt to result. I 
usually determine the point of the anterior superior 
spinous process of the ilium and the external malleolus, 
and marking them, take my measurements from them, but 
in doing this I must avoid the danger of slipping my finger 
upward owing to the extreme mobility of the skin over 
these bony prominences. The position of the legs and as 
well the body must be straight. The better way is to 
corroborate by measuring from the umbilicus as a fixed 
point and swinging the other end of the tape-measure from 
one malleolus to the other. In this way the measurements 
will be more accurate and the avoidance of error facilitated. 
The very best and most accurate method is that in which 
the patient is made to stand, and while standing, thin 
boards of accurate and known thickness are slipped under 8 
Wilson : Early Symptoms of Hip Disease, etc. 
the foot of the short side until the pelvis is on a level with 
the floor. We can thus form an accurate idea as to the 
size of the sole required for the shoe. 
I find in this case one of the most satisfactory results 
we could desire. There is a slight amount of rotation as I 
can feel by means of the great trochanter and the ischium, 
and there is also a slight amount of adduction and 
abduction. The limb is in a perfectly straight position, 
and that is what we wished to secure. I wish to show you 
now how a worse condition can be produced in such cases 
if care be not taken. If the limb is not maintained at right 
angles to the line of the pelvis when recovery takes place 
it may become ankylosed either bent outwards, or over- 
lapping the other limb, the latter being one of the most 
serious deformities following hip-joint disease. Another 
mistake is to allow the child to lie in a bed which allows 
the limb to be flexed and thus thrown anterior to the body. 
As this child stands on the sound leg her affected limb 
hangs in the position of extension at right angles to the 
axis of the pelvis. In this position she does not use her 
limb, but a little later, when we are positive beyond a 
doubt that the disease is entirely arrested, we shall put the 
high shoe upon the affected leg and allow her to go with- 
out crutches. The result obtained in this patient is one of 
which anyone may be satisfied, for although seen in the in- 
cipiency the progress had been considerable, but was 
arrested without abscess, with a leg that will be a useful 
leg for locomotion.