REPORT 
ON 
MORBUS COXARIUS, OR HIP DISEASE. 
BY 
LEWIS A. SAYRE, M. D., 
RESIDENT PHYSICIAN OF THE CITY OF NEW YORK, SURGEON TO BELLEVUE HOSPITAL, 
ETC. ETC. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1860. On p. 22, 17 th line from top, under head of Posterior Superior Dislocation, 
third Stage of Morbus Coxarius,/or " Limb shortened and everted," read "Limb 
shortened and inverted." 
ERRATUM. MORBUS COXARIUS, OR HIP DISEASE. 
Before entering upon the consideration of the symptoms and 
morbid changes of structure in this disease, it will be necessary for 
me to give a brief description of the most important anatomical 
structures entering into the composition of the hip-joint, in order 
that there may be a proper appreciation of the pathological views 
entertained in this report, and that the reader may fully comprehend 
the principles which I shall endeavor to establish, as the proper 
basis for correct treatment. 
The osseous structure of the hip-joint is made up of the os inno- 
minatum and head of the os femoris, the latter being received into 
a deep cavity of the former, the acetabulum, by a kind of articu- 
lation called enarthrosis, or ball and socket joint. 
The head of the femur, and the acetabulum, are cancellous in 
structure; quite vascular, and subject to inflammation. 
The acetabulum is lined with cartilage at all parts, except at a 
circular pit (fundus acetabuli) which occupies the lower part of the 
cavity near the notch, and is cushioned with fat. The head of the 
femur, which fits to, and articulates with the acetabulum, is nearly 
two-thirds of the segment of a sphere, and is entirely covered with 
cartilage, except at the deep pit, which is for the insertion of the 
ligamentum-teres at its upper and inner face looking towards the 
cavity of the pelvis. 
The proper ligaments of the hip-joint are the capsular, the ilio- 
femoral, the ligamentum teres, the cotyloid, and the transverse. 
The Capsular Ligament (A, Fig. 1) is the largest and strongest 
capsule in the body. It is attached above to the outer border of 
the acetabulum and outer face of the cotyloid ligament; and below, 
to the anterior inter-trochanteric line, and neck of the femur, which 
latter it completely surrounds. It is thicker and longer in front 
than behind, and is more extensively attached at its upper part, 6 
REPORT ON 
where strength and security are required. The strength of the 
capsular ligament is further greatly increased by the ilio-femoral 
ligament (B, Fig. 1) which is accessory to it, and extends from the 
anterior inferior spinous process of the ilium to the anterior inter- 
trochanteric line. 
Fig. 1. 
Fig. 2. 
The Cotyloid Ligament ((7, Fig. 2) is a thick prismatic ring of 
fibro-cartilage, mounting and attached to the brim of the acetabulum 
by which the cavity is deepened. 
The Ligamentum Teres (A B, Fig. 2) is attached by a round apex 
to a pit just below the middle of the head of the femur; it divides 
into two fasciculi, which are inserted into the corners of the notch 
of the acetabulum A B and the cotyloid ligament, and is covered 
by synovial membrane. 
The Transverse Ligament is continuous with thecotyloid, extending 
from one point of the notch to the other, and completing the circle 
of the cotyloid ligament, thus converting the notch of the acetabu- 
lum into a foramen, through which the bloodvessels enter to supply 
the interior of the joint. 
The synovial membrane is quite extensive, lining the capsular 
ligament, the free surface of the cotyloid, the ligamentum teres, and 
the cartilage of the head of the bone. 
All the authors to whom I have referred, describe two forms of 
morbus coxarius or hip disease, one in which the inflammation 
commences in the cartilage; and the other where the cancellous MORBUS COXARIUS. 
7 
structure of the bone is the primary seat of the affection, this latter 
variety being generally considered to be a genuine tubercular de- 
generation. 
Every one seems to have overlooked the fact that this joint has 
an extensive synovial surface, which is as liable to inflammation as 
that of any other joint. Now I am satisfied that many of the cases 
commence as a pure synovitis, and should be treated on the same 
general principles as a synovitis of any other joint. 
CAUSES. 
These are as various as those of inflammation of any other joint; 
such as falls, blows, injuries, jumping from a height, over-exer- 
cise in running, jumping, skating, &c.; sitting down on a cold 
stone or damp place while overheated j1 or any other extraneous 
accident which may induce an inflammation of the hip-joint. If 
this inflammation should occur in a strumous constitution, it will 
go on, unless arrested, until the cartilage and bone are involved, 
only to terminate in death, or in deformity, anchylosis and short- 
ening, which are peculiar to coxalgia. 
Almost all surgical authorities agree that morbus coxarius is 
inevitably the result of a contaminated constitution, and especially 
of a vitiated nutrition. In other words, that it is essentially stru- 
mous in its origin and character. This view has descended from 
teacher to the taught, has been so often repeated and inculcated, 
that nobody considered it worth his while to question its truth, or 
to investigate the fact, taking for granted that an assertion so posi- 
tively made and universally accepted must be based upon mature 
investigation, and rest upon a solid foundation. 
This has been the universal opinion for the last seventy-five 
years, and still prevails among the majority of surgical practition- 
ers. Every day brings us clinical reports and clinical lectures of 
eminent surgeons in which the same doctrine is inculcated. 
The strumous origin of morbus coxarius is the drift of all we 
hear and read about its etiology. Pre-occupied with this instruc- 
1 Key says: " The hip-joint is less frequently the subject of acute inflamma- 
tion, probably from being well protected from the influence of atmospheric changes, 
to which the knee and almost all other joints are exposed. In the adult, acute 
disease of this joint is occasionally seen, in which the whole structure of the joint, 
cartilage as well as ligament, undergoes complete disorganization in the space of 
a few weeks."-(p. 230.) 8 
REPORT ON 
tion, the young practitioner, in approaching the bed of his patient, 
can never fail to construe the emaciated and anaemic condition of 
the little sufferer into that of strumous disease. Thus age and 
authority have rendered this doctrine a sort of surgical gospel, 
rebellion against which is considered but the heresy of blasphemy 
and ignorance. 
It seems to be ignored that medical science is essentially an in- 
ductive science, devoted to the investigation of natural truth, and 
facts appertaining to the healthy and morbid life of the human 
race; that therefore neither the age of a dogma, or the individual 
eminence of men, can be admitted as affording that indisputable 
authority in point of proof which is due only to "stubborn facts," 
that can be demonstrated to our own senses and perceptions. 
Whilst, therefore, I revere the scientific labors of our ancestors 
for the advancement of scientific truth, I must be permitted to 
question what is questionable, and to doubt what is doubtful. I 
must own in truth that I had accepted the same opinion, that they 
guided my first professional attempts in the treatment of this dis- 
ease ; but I also must here state that they never satisfied my mind 
as to their correctness. 
Most practitioners will admit with me that they never succeeded 
in curing hip disease by an antiscrofulous mode of treatment. To 
be sure the term scrofulous has essentially changed in its appli- 
cation within the past few years, and so has the treatment. For- 
merly, antimonials, the mercurials, and the iodine preparations, and 
bark were in vogue-to day, air, exercise, and generous diet are 
the chief remedies against this disease-but neither has cured mor- 
bus coxarius. Then derivatives were introduced extensively in 
order to eradicate the dyscrasic poison. The results have been 
equally unsatisfactory. In fact whatever remedies were 
to, morbus coxarius was never relieved thereby. It took its course 
to a spontaneous cure, or else to a fatal termination. 
Not until more attention had been paid to the local treatment of 
the disease have we had any satisfactory results. This fact alone 
should indicate the errors as to the nature of the disease formerly 
entertained. For it could hardly be asserted that a constitutional 
disease could be effectually relieved by merely local treatment. 
Since this fact became clearly established in my mind, I have been 
investigating my cases of this disease more closely with reference 
to its immediate causes. With comparatively a very few exceptions, 
I have been enabled to trace the disordered action to direct trau- MORBUS COXARIUS. 
9 
matic influences. Most of my patients were healthy, some of them 
even of a robust constitution previous to the commencement of 
their attacks, and their constitution gave way only when their 
sufferings became so intense as to deprive them of their nightly 
rest and appetite, and to render them incapable of enjoying their 
accustomed out-door exercise. 
Those surgeons who have had opportunity of clinically observing 
and studying hip-disease in numerous cases, will bear me witness 
that the sufferings accompanying this disease are truly fearful; so 
intense and prolonged as to reduce the strongest and healthiest 
frame to a mere skeleton in a very few months. 
And, again, experience teaches, that no disease is capable of in- 
flicting greater constitutional disturbance than affections of the 
bones or joints. Often have I seen phthisis of the lungs super- 
added to such cases in previously healthy subjects, &c. 
It seems, therefore, that the inevitable effects of the disease have 
been mistaken for its causes, that the attenuation of the patient, his 
anaemia, his vitiated nutrition in all respects, have been construed 
into previously existing scrofulous cachexia, originating and char- 
acterizing the disease; whereas, they were consecutively developed 
by it, and were therefore results and not causes of the disease. 
My own clinical observations of these facts stand by no means 
isolated. The same have been made by other surgeons, both in 
Europe and in this country. Among others Dr. Bauer, of Brooklyn, 
whose careful investigations are known to the profession in refer- 
ence to this subject, has carefully recorded the causes and origin of 
143 cases of hip disease, the result of which he has communicated 
to me as follows: "131 cases were clearly traced to traumatic in- 
juries, mostly applied directly to the hip-joint itself. A large 
majority of these cases were previously of robust and healthy con- 
stitutions. In 9 cases the causes remained doubtful, and in 3 only 
the disease seemed to have originated by strictly constitutional 
causes." 
It requires generally a very close examination to find out these 
causes, since the disease does not usually immediately follow the 
injury; but often commences or manifests itself weeks and even 
months after the accident, so that the patient and his friends natu- 
rally forget the accident and its connection with the disease, until 
specially reminded of it in the investigation. This same rule 
applies to the disease of other joints, more especially to the chronic 
diseases of the knee-joint. 
o 10 
REPORT OX 
All these circumstances are decidedly of sufficient importance to 
attract the attention of the profession, and I should be highly grati- 
fied if I have contributed my share to the better understanding and 
discrimination between causes and effects in this disease. 
SYMPTOMS. 
The symptoms of this disease vary according to the different 
stages in which we find it, and the character of the inflammation, 
whether it be acute, or chronic, rheumatic, strumous, or purely 
traumatic. In order to render the subject more dear, I shall 
divide them into three different stages: first stage-or inflammatory; 
second stage-effusion, with eversion, abduction, and apparent elon- 
gation ; third stage-rupture of the capsular ligament, escape of 
the effused fluid, inversion, adduction, and apparent shortening. 
First Stage.-The symptoms in the earlier part of this disease 
are sometimes obscure, particularly if the inflammation be of a low 
grade, or of the chronic character, as we generally find it in those 
of a strumous diathesis; they are referred to the knee instead of 
the hip, and this frequently misleads the careless observer, so that 
I have many times seen the knee blistered, and treated for months, 
when there was no disease whatever at that joint, it being merely 
affected by sympathy with the disease, which was in the hip. 
There will be a slight halting in the gait, or limp. When the 
child stands he will rest the weight of the body on the sound limb, 
the diseased one being thrown forward; there is very imperfect 
flexion; the knee on the well side can be brought up to the chin, 
but on the diseased side it cannot be, and this difference in flexi- 
bility is almost diagnostic. Pressure over the trochanter, or 
behind, or in front of the same, or with the femur, so as to bring 
the head of the bone against the acetabulum, produces pain. Pull- 
ing the limb slightly but constantly for a few minutes, so as to 
remove this pressure from the acetabulum, relieves the pain. And 
if a careful examination be made by pressure and extension there 
will be no difficulty in making a diagnosis. If the ligaments are 
involved, as they sometimes are, by a wrench or strain, or rheumatic 
inflammation, then extension increases the pain, and pressure relieves 
it; but if the synovial membrane, cartilage, or bones, be involved 
in the disease, then pressure aggravates the pain intensely, and exten- MORBUS COXARIUS. 
11 
sion, gradual and slight, but constant, for a little while, relieves it 
almost entirely. 
It is a remarkable fact, that the synovial membrane when in a 
healthy state, in common with all serous membranes, possesses no sen- 
sibility whatever, and will bear pressure of the severest kind, with- 
out the least sensation of pain, as is proved by jumping from great 
heights and striking upon the heels, producing no pain whatever. 
Yet when this membrane is inflamed, the slightest amount of pres- 
sure produces the most intense suffering, as we also find in pleu- 
ritis, peritonitis, &c.; and hence the necessity of removing all pressure 
from this delicate and sensitive membrane when in a state of in- 
flammation. 
Second Stage.-This inflammation, unless arrested, will readily 
produce effusion, and if this be of much amount, it will produce a 
peculiar deformity, viz., an apparent elongation of the limb; eversion 
and abduction; flattening of the natis; the rima natis on the dis- 
eased side being lower than on the sound side; flexion of the thigh 
on the pelvis, and the leg slightly flexed upon the thigh. If the 
effusion be excessive, or the inflammation acute, you will have an 
apparent anchylosis, caused by muscular contraction, which is an 
involuntary act, produced by reflex action, of the inflamed or irri- 
tated nerves, and is done for the purpose of keeping the joint perfectly 
still. It affords the natural indication for the surgeon by imitating 
this action, to accomplish the same result, of perfect rest to the in- 
flamed synovial membrane. This we may do in a much more effec- 
tual manner, for at the same time we succeed in relieving the other 
parts from a pressure which, if long continued, must cause, in the 
absorption of the cartilage and bone, the destruction of the joint. 
Motion, when not accompanied by extension, is much more painful 
than' rest, even if accompanied by the pressure caused by the mus- 
cular contraction. Hence the patient, naturally choosing the least 
of two evils, obtains rest of the part by muscular rigidity, even 
at the expense of the absorption arising from the pressure, as well 
as of the hectic and exhaustion caused by this constant muscular effort. 
The flexor muscles of the thigh, the tensor-vaginaa femoris, the 
pectineus, and rectus-femoris, are so firmly contracted that the whole 
pelvis moves on the opposite acetabulum; in short, the ilium of 
the opposite side may be distinctly seen to move upon any attempt 
to rotate, adduct, or abduct, the diseased limb. Even under chloro- 12 
REPORT ON 
form this motion takes place unless firm extension is made before the 
trial is begun, as I have seen in several instances. 
This rigidity does not depend upon true or bony anchylosis; for 
by division of the flexor and adductor muscles, or by puncture of 
the joint, you will have free motion of the limb, showing that there 
has been no borjy anchylosis. 
That the mere presence of liquid in the perfectly closed joint is 
capable of producing, and therefore accounting for the said immo- 
bility, is clearly demonstrated: 
1st. By the experiments of Prof. E. W. Weber, who injected the 
hip joint from an opening in the pubic bone, and by which proce- 
dure he invariably produced eversion and abduction of the thigh, 
besides immobility of joint. The latter was so complete, and so 
unalterable, that an attempt to overcome it drove either the stopper 
out of the artificial opening, or burst the capsular ligament. 
2d. By the juncture of joints morbidly distended, in which case 
the mobility and proper position of the thigh become at once es- 
tablished. 
It should, however, be borne in mind that the symptoms of ever- 
sion, abduction, and immobility, may sometimes be continued even 
after the capsule has become ruptured, and are then dependent upon 
the altered condition of the capsule and surrounding parts, these 
having become thickened and attached, and being thus unyielding, 
necessarily retain the parts in their malposition. 
Third Stage.-If the disease is not arrested, the acetabulum 
becomes perforated, or ulceration and rupture of the capsule take 
place, and the fluid, whether synovia, pus, or plastic lymph, becomes 
effused in the surrounding tissues, and in the majority of instances 
burrows in various directions, and finally produces an opening in 
different portions of the thigh ; sometimes only one, but frequently 
more, and in many instances, some distance from the affected joint. 
The peculiar change that takes place, in many instances, upon 
the rupture of the capsule, in all the symptoms, and the suddenness 
of the occurrence have led to the false idea that a luxation had taken 
place. But we need only refer to the able, masterly, and in fact 
unanswerable paper of Dr. Alden March, of Albany, presented to 
the Am. Med. Association, and published in their Transactions in 
1853, to prove the error of this opinion, and which, previous to the 
appearance of his paper, was the one universally adopted. In fact 
the profession in this country are indebted to Dr. March for the MORBUS COXARIUS. 
13 
first clear, comprehensive, and correct statement of the true patho- 
logy of this disease; and the basis was laid down by him for the 
proper plan of treatment, from which all the improvements since 
have been developed. 
When the capsule is thus ruptured, if no attachments have 
already occurred, the limb becomes apparently shorter, adducted, 
inverted, flexed in hip only, pelvis raised and projected backward; 
in fact, the position is almost the reverse of what it was in the 
second stage, and in order that they may be better comprehended, 
I will take the trouble, even at the expense of being considered 
tautological, of arranging them side by side for more easy reference, 
with a drawing taken from life, illustrating the peculiar deformity 
that occurs in each. 
This change from the second into the third stage is sudden when 
the opening in the joint is large, and allows of the total escape of 
its contents, into the surrounding tissues, or gradual, if the opening 
be small or fissure like. I have seen the former take place in a 
night, and the latter require weeks, until the change was accom- 
plished. It is possible also that the bottom of the acetabulum may 
give way to such an extent that the head of the bone may sink so 
deep into it, as to retain the limb in its former position. 
Second Stage. 
Third Stage. 
Limb (apparently) longer, 
" abducted. 
" everted. 
" flexed in both joints. 
Foot touches the ground with sole. 
Toes everted as in fracture of neck. 
Pelvis lowered on diseased side. 
" projected forward. 
" angle of inclination acute. 
Natis low and flat. 
Linea inter-nates inclined towards af- 
fected side. 
Pain most intense. 
Limb (apparently) shorter. 
" adducted. 
" inverted. 
" flexed in hip-joint only. 
Foot touches with ball only. 
Toes inverted as in post. sup. luxation. 
Pelvis raised. 
" projected backwards. 
" angle of inclination almost right. 
Natis high and round. 
Linea inter-nates deviates from affected 
side. 
Pain greatly diminished. 
Figs. 3 and 4, taken from life, are good examples illustrating the 
difference in the peculiar deformity that occurs in the second and 
third stages of the disease. 
As an evidence that the mass of our best authorities have always 
considered the peculiar deformity which occurs, in what I have 
described as the third stage of the disease, dependent on a true 
luxation of the head of the femur upon the dorsum of the ilium, 
and not upon muscular contraction and twisting of the pelvis, we 14 
REPORT ON 
need only refer to the following text books of surgery, which are 
found in every physician's library. 
Fig. 3. 
Second stage of hip-disease. 
R. Druitt, in his Principles and Practice of Modern Surgery, says, 
in his chapter on hip-disease: "But if the disease proceed, it is suc- 
ceeded by another kind of shortening, caused either by the destruc- 
tion of the neck of the femur by caries, or (as is more commonly the 
case) by the destruction of the acetabulum and capsular ligament, 
and dislocation of the bone upwards by the muscles." MORBUS COXARIUS. 
15 
James Miller, in his Practice of Surgery, under the head of mor- 
bus coxarius, says: "As disorganization advances within, the joint 
becomes more and more loose, and dislocation may occur by mus- 
cular action alone, without the intervention of a fall or other injury. 
The dislocation is usually upwards on the dorsum of the ilium." 
Sir Charles Bell, in his Institutes of Surgery, remarks: "Another 
peculiarity in the position of the patient with diseased hip, is that 
of throwing the thigh of the affected side over the other, that the 
head of the thigh-bone becomes as a lever loaded at the lower end, 
by which the upper end is raised and the pressure taken off the in- 
flamed glenoid cavity. It is a position of great relief; but the conse- 
quence is actual dislocation in extreme cases." 
Fig. 4. 
A 
B 
Third stage of hip-disease.-(A) anterior view. (B) posterior view. 
Dr. March states: "It has been my privilege to examine the 
specimens of this disease in the London University Hospital Mu- 
seum, where Mr. Bell's morbid specimens are deposited, and yet I 
could discover no preparation of'hip-disease' where it appeared in 16 
REPORT ON 
the least degree as though the head of the femur was luxated during 
the life of the patient." 
Baron Dupuytren, on the Injuries and Diseases of the Bones, sub- 
ject Congenital Dislocation, says: "Whatever importance may be 
attached to this dislocation in the abstract, it is deserving of still 
more attention on account of its presenting all the signs of ZuoxzZzon 
consequent on disease of the hip joint, with which it has always been con- 
founded! And in another place he remarks: " It (congenital dis- 
location) does not include that painful and cruel disease of the 
hip-joint which usually results in spontaneous dislocation of the 
femur! 
None of the above authors, although so positively stating that 
luxation occurs in this disease, have sustained their assertions by 
the evidence of a single post-mortem examination. 
Chelius, Pirrie, Liston, Sami. Cooper, and Gibson all agree with the 
authors above quoted in regard to the spontaneous luxation of the 
hip in the latter stages of the disease. And even Sir Astley Cooper, 
in his treatise on Dislocations and Fractures of the Joints, says: " Dis- 
locations may arise from ulceration, as we frequently find this 
state of the parts in the hip-joint; the ligaments ulcerated, the edge 
of the acetabulum absorbed, the head of the thigh-bone changed 
both in its magnitude and figure, escaping from the acetabulum upon 
the ilium, and there forming for itself a new socket." 
These references could be increased until they embraced all the 
authors that I have had the privilege of referring to; but as I have 
quoted from a sufficient number to establish the fact, that the idea 
of luxation in hip-disease has been one of almost universal adop- 
tion, I will not add to the length of my paper by making further 
references; and yet it must be borne in mind that, notwithstanding 
the high position of the authorities I have quoted, not one of them 
has proved his assertion by a single post-mortem. But, on the con- 
trary, whenever any one of them has made a post-mortem exami- 
nation, or has cut into the joint for exsection, he has invariably 
found that no luxation had taken place; but that the "head of the 
femur was still within the capsular ligament," much absorbed, pro- 
bably, and frequently separated from the shaft of the femur entirely, 
thus permitting the trochanter major to slip upon the dorsum of the 
ilium; and this no doubt has been mistaken for true luxation. I 
have seen this condition of the parts more than once, and seen the 
mistake made by most excellent surgeons. At other times the 
acetabulum has been found "much enlarged by absorption, and ex- MORBUS COXARIUS. 
17 
tending upwards and backwards, as if nature had made an attempt 
to form a new joint in this direction? As the upper portion of the 
acetabulum is absorbed by the constant pressure, the periosteal inflam- 
mation, which is occurring at the same time outside of the joint, is 
constantly throwing out new material, and we even find firm osteo- 
phytes of considerable magnitude; and thus, as the progressive 
absorption goes on within the joint, there is a constant deposition 
outside of the joint, by which means the acetabulum, with the cap- 
sular ligament and contents, is, as it were, slipped up on the dorsum 
of the ilium ; so that instead of a luxation of the hip, we have in 
fact a luxation, or rather a displacement of the acetabulum itself; and, 
if the disease is of long standing, this is frequently perforated, 
the synovial membrane and cartilages more or less destroyed by 
ulceration, the bones carious or necrosed, the ligamentum teres 
invariably destroyed, and the joint filled with pus; or else you will 
find the capsular ligament perforated by ulceration at one or more 
places through which the pus has escaped, and this generally occurs 
at the inner and lower border of the acetabulum. This, according 
to my observation, has been the real pathological condition of all 
the cases that I have examined; and it very satisfactorily accounts 
for the shortening and other appearances of luxation. 
If you diminish the head of the femur by absorption three-fourths 
of an inch, as is often the case, and extend the acetabulum upward 
and backward to the same amount, the gluteal and other muscles 
keeping the bones in close contact, will thus give you an inch and 
a half of shortening of the limb; and the twisting of the pelvis 
and its rotation on the body will increase this shortening, and pro- 
duce the other symptoms which have been mistaken for luxation. 
To illustrate my position, I will quote a post-mortem examination 
from Sir Benj. Brodie's work on Diseased Joints, published in 1834: 
" A middle-aged man was admitted into St. George's Hospital in 
the autumn of 1805, on account of a disease of his left hip. He 
labored also under other complaints, and died in the February fol- 
lowing. On inspecting the body, the soft parts in the neighbor- 
hood of the joint were found slightly inflamed, and coagulated 
lymph had been effused into the cellular membrane round the cap- 
sular ligament. There were no remains of the round ligament. 
The cartilages had been destroyed by ulceration, except in a few 
spots. The bones, on their exposed surfaces, were carious; but 
they retained their natural form and size; The acetabulum was 18 
REPORT ON 
almost completely filled with pus and coagulated lymph; the latter 
adhering to the carious bone, and having become highly vascular. 
The head of the femur was lodged on the dorsum of the ilium. 
The capsular ligament and synovial membrane were much dilated, 
and at the superior part their attachment to the lone was thrust up- 
wards, so that, although the head of the femur was no longer in the 
acetabulum, it was still within the cavity of the joint." 
Here we have the testimony of Sir Benjamin Brodie, that " the 
head of the femur was lodged on the dorsum of the ilium," and in 
almost the next sentence, he says, " it was still within the cavity of 
the joint." Comment, it seems to me, is unnecessary, for this can- 
not be called luxation, according to the ordinary definition of that 
term. 
In Braithwaite's Retrospect, No. 22, Jan. 7, 1851, page 196, is a 
case of exsection of the head of the femur, for "hip-disease," by 
Mr. Skey. After giving the age, sex, and previous condition of the 
patient, he describes her condition on admission to the hospital, 
and says: " The left femur was dislocated on the dorsum ilii, the limb 
shortened, and the leg and thigh flexed." After consultation, " it was 
considered that removing the head of the bone would give the pa- 
tient the best chance of recovery." He then describes the operation 
and the morbid appearances he observed about the joint. He states 
that " the acetabulum was found to have been enlarged by absorption, 
and was extended in a direction upwards and backwards, as if an at- 
tempt had been made by nature to form a new joint in this direc- 
tion. The head of the femur had been entirely absorbed; a portion 
of the neck remained, which, with the great trochanter, was the 
part removed." I would simply ask, how it was possible that there 
could have been a " dislocation on the dorsum ilii," if " the head of 
the femur was entirely absorbed?" Can a bone be luxated when it 
has no existence? The answer it seems to me is perfectly plain. 
The luxation never took place. 
In the tables of exsection which I have collected, it will be ob- 
served that in many of the cases the authors, in describing the 
condition, have stated that the "head of the bone" was "luxated 
spontaneously," and yet by a careful study of all the fully described 
cases that I have been able to read, I am fully satisfied that no 
luxation had taken place; but that either the head of the bone had 
been absorbed, or was separated from the neck, thus letting the 
trochanter slide high up on the dorsum ilii. 
I do not deny that luxation can take place in morbus coxarius, MORBUS COXARIUS. 
19 
as well as in a healthy joint; but, on the contrary, a much less 
force ought to be able to produce it; but if the nurse in lifting the 
patient out of bed, or by twisting the leg across the other, thus 
ruptures the capsule and produces a luxation (as I have seen done), 
it is as much a traumatic luxation as if it had been produced by a 
fall from a house or any other accident. And if a careful inquiry is 
made in all the cases of so-called "spontaneous luxation" we will 
find that they have occurred after the application of violence more 
or less severe, and not as the result of unaided " muscular contrac- 
tion," according to Miller and other authors whom I have quoted. 
The following specimen, Fig. 5, for which I am indebted to my 
friend Dr. Carnochan, shows the pathological condition of the femur 
and acetabulum, in the majority of fatal cases of morbus coxarius, 
except that in this specimen there are more exostoses or osteophytes 
around the enlarged border of the acetabulum than we generally 
find. It will be seen in this specimen how the acetabulum is en- 
larged upward and backward, in fact in all of its diameters. At 
A, a large perforation connecting with a pelvic abscess, and at B, 
Fig. 5. 
A 
C 
an extensive ulceration quite deep in the bone. The head of the 
femur, it will be observed, is very much diminished in size and 
carious. The capsular ligament was not ruptured, but was attached 
to the femur in its normal condition and to the enlarged acetabulum 
at its border, where the roughened exostosis is distinctly seen. 20 
REPORT ON 
This was a case of hip-disease of nearly three years' standing, 
the result of an injury in a previously good constitution, and the 
disease progressing so insidiously that the patient did not apply 
for treatment to any surgeon until it had arrived at its third stage, 
when it was mistaken for dislocation and so diagnosticated by all 
who saw it; and yet the post-mortem revealed the fact that the cap- 
sular ligament had never been ruptured, but still contained the 
head of the femur which had never been out of it. 
This case was not brought to the city until he was almost in a 
moribund condition, and then the gentleman who saw him, and who 
is one of the best surgeons in this country, mistook it for a luxa- 
tion upon the dorsum ilii, and presumed, from the careless manner 
in which the history of the case was detailed, that it had occurred 
at the time of the accident more than two years before, and as it 
was a hopeless case nothing was proposed for it. I never saw the 
case until after death, when, upon making careful inquiries among 
his friends, I found that the limb had been in its present shortened 
position only a few months, but previous to that it was as they 
" thought much longer and more crooked in the knee, and a great 
deal more painful, and since his leg had become shorter he was 
much easier of his pain, but his constitution run down so fast they 
feared he would die," and therefore brought him to the city for 
relief. This simple statement clearly explains the case, according 
to my description of the changes that take place in the second and 
third stages of the disease. And the perforation of the acetabulum, 
thus permitting the escape into the pelvic cavity of the contents 
of the joint, satisfactorily accounts for the change that occurred in 
the position of the limb, and for the relief from pain which the pa- 
tient experienced at the time the perforation occurred. 
DIAGNOSIS. 
Morbus coxarius may be confounded with sacro-iliac disease. In 
the first and second stages of coxalgia we may have elongation of 
the limb; this always occurs in sacro-iliac disease; but in coxalgia, 
the elongation is discovered by measurement from the anterior 
superior spinous process of the ilium to the internal malleolus, the 
elongation being caused by effusion into the hip-joint. If the dis- 
ease is between the sacrum and ilium, this measurement between 
the malleoli and superior spines of either side will be equal, and MORBUS COXARIUS. 
21 
the elongation will be found to be dependent on the displacement 
of the diseased ilium itself, which is tilted forward and rotated or 
slipped downwards, owing to the swelling and destruction in the 
affected articulation. The anterior spine is not only lower down, 
than its fellow of the opposite side; but is pushed forward and is 
much more prominent, and this is not produced by any obliquity 
of the pelvis consequent on a twist of the spine, as in hip-disease; 
but by the tilting forward and rotation downwards of the whole of 
the diseased side of the pelvis. 
The seat of pain is also different in the two diseases. In hip- 
disease it is most acute, when pressure is applied firmly behind and 
above the trochanter major, or when compression is exercised 
against the anterior part of the hip-joint through the pectineus 
muscle. In sacro-iliac disease little or no pain is experienced when 
pressure is made in these situations ; but tenderness is elicited by 
pressure upon the sacrum and along the line of junction between 
the sacrum and ilium behind, and altogether away from the joint. 
The movements also which occasion pain in the two diseases are 
entirely different. In hip disease, abduction and rotation outwards, 
or pressure of the head of the femur into the acetabulum, aggravate 
to a greater or less degree, often to an unbearable extent, the suf- 
ferings of the patient. In sacro-iliac disease the thigh may be 
moved in all directions, abducted or adducted, rotated, flexed, or 
extended, when the patient is lying on his back without any 
increase of pain, provided the side of the pelvis he immovably fixed at 
the time by an assistant. Should this precaution of holding the pel- 
vis immovable not be observed, the movements of the thigh will be 
communicated to the diseased articulation of the ilium and sacrum, 
and necessarily occasion suffering. 
For a differential diagnosis of most of the other diseases with 
which morbus coxarius may be confounded, the following table of 
differential diagnosis, with some alterations, taken from the notes 
of a lecture of Dr. Louis Bauer, in the Long Island College Hos- 
pital of Brooklyn, may be consulted with advantage. 
Feactuee and Distasis of Head. 
Second stage of Moebus Coxaeius. 
Produced suddenly. 
Eversion of limb. 
Shortening of limb. 
Straight limb. 
Loose articulation. 
Straight pelvis. 
Crepitus. 
Growing comparatively slowly. 
Eversion and abduction of limb. 
Apparent elongation of limb. 
Flexed in hip and knee. 
Fixed hip-joint. 
Oblique pelvis. 
No crepitus. 22 
REPORT ON 
Spine vertical. 
Shoulders square. 
Nelaton's test (apex of large trochanter 
above the line) .* 
Spine curved. 
One shoulder higher. 
Nelaton's test (trochanter below the line; 
The impacted fractures are of course excluded in this collection 
of differential symptoms. 
Dislocation of Femur. 
Anteriorly and superiorly. 
Second stage of Morbus Coxarius. 
Suddenly produced. 
Extremity much everted. 
Immobility. 
Moderate shortening. 
Abduction. 
Head can be felt in the groin. 
Comes on gradually. 
Less everted. 
Immobility. 
Apparent elongation 
Abduction. 
Head cannot be felt at all or very indis- 
tinctly, and then at the acetabulum. 
Posterior Superior Dislocation. 
Produced suddenly. 
Limb shortened and Averted. 
Adducted. 
Immobility of articulation. 
Flexion of the hip. 
Moderate shortening. 
Head usually felt under glutreus maximus. 
Apex of trochanter above Nelaton's line. 
No stationary contractions of muscles. 
Third stage of Morbus Coxarius. 
Growing gradually. 
The same. 
I C CC 
Cl cc 
cc cc 
Apparent shortening considerable. 
Head not felt at all. 
Below or even with Nelaton's line. 
Permanent contraction of flexors and ad- 
ductors. 
Pelvis raised and oblique. 
Healthy leg straight. 
Only with the ball of the foot. 
Spine flexed laterally and anteriorly. 
Angle of inclination of pelvis increased. 
Pelvis square. 
Walks with healthy leg bent. 
Touches ground with almost entire sole. 
Spine straight. 
Angle of inclination of pelvis unchanged. 
Pott's Disease and Psoas Abscess. 
Preceding pain in the spine. 
Posterior and anterior deformity (not al- 
ways) . 
Simple flexion and shortening of limb. 
Limb may be extended under chloroform. 
Pelvis square. 
Nates even. 
Cann ot walk except by supporting the spine 
by resting hands on the knees. 
Abscess under Poupart's ligament. 
Hip articulation free. 
Preceding pain in hip-joint. 
Lateral and anterior deformity. 
Third stage of Morbus Coxarius. 
Flexion, adduction, and inversion. 
Cannot. 
Pelvis oblique. 
One higher. 
Can walk on well leg and without these 
precautions. 
May have the same. 
Almost fixed. 
1 Nelaton's test is made by drawing a cord from the tuber-ischii to the superior 
spinous process of the ilium, which will generally pass at the very apex of the tro- 
chanter major; now in fracture of the neck or in true luxation, the apex of tro- 
chanter will be found above this line. MORBUS COXARIUS. 
23 
Slight retraction of flexors. 
Fixed contractions of both flexors and 
adductors. 
Has none. Order of development very dif- 
ferent. If there is perforation of the acetab- 
ulum, it may be ascertained by an examina- 
tion through the rectum. 
May have signs of paraplegia. 
Periostitis of Femur, 
Third degree of Morbus Coxarius. 
Mostly commences suddenly. 
Femur more or less enlarged. 
Femur painful on pressure. 
Joint free. 
Grows gradually out of preceding stages. 
Not at all enlarged. 
Femur not painful in the least. 
Almost fixed, and when moved often have 
crepitus. 
The same. 
Joint painful on pressure. 
The same. 
The same. 
Extension and abduction impeded. 
Joint painless. 
Pelvis oblique and spine curved. 
Contraction of flexors and adductors. 
TREATMENT. 
First Stage.-In the treatment of this disease in its first stage, 
local depletion by leeches or cups is often necessary, with a relaxed 
condition of the bowels. But the most important of all, and in 
which all prospect of success will depend, is rest of the joint, and 
perfect freedom from pressure of the inflamed synovial membrane, 
together with such constitutional remedies and general support of 
the system as may be requisite in each particular case. The use of 
issues at this stage of the disease is worse than useless, and only 
does harm instead of good. And the only good they have ever done, 
was from the fact that they made the parts so painful that the 
patient was compelled to keep more quiet than he otherwise would 
have done. The occasional application of iodine may be of some 
service; but in the majority of cases, I have found the application 
of leeches and ice to be much the most beneficial. If left to itself, 
the rest which is so essential to the joint is procured by the firm 
muscular contraction which prevents the motion in the joint, and 
is so perfect as in many instances to assume the appearance of 
genuine bony anchylosis. 
But this constant muscular contraction exhausts the nervous sys- 
tem, and induces hectic fever, gives the child nocturnal spasms of 
intense agony, caused by pressure of the head of the femur against 
the acetabulum, and produces absorption of both bones, and pre- 
vents nutrition of the limb which results in atrophy. I, therefore, 
resort to artificial means to produce this rest and remove this pres- 
sure, and formerly divided the firmly contracted muscles, to prevent 24 
REPORT ON 
the head of the bone from being pressed against the acetabulum, and 
kept them at rest in the horizontal position in the " wire breeches" 
invented by Dr. Bonnet, of Lyons : but now accomplished the same 
result by gradual but permanent extension by the means of the 
instrument I have devised, with very much more satisfactory re- 
sults and without any danger of anchylosis, or by a weight and 
pulley as suggested by Sir Benjamin Brodie.1 If we keep them in 
the straight splint, as recommended by Dr. Harris, or Dr. March of 
Albany, or in the wire breeches of Dr. Bauer, and keep up extension, 
we will relieve our patients from all suffering it is true, and generally 
arrest the disease. But unless the greatest care is observed, and in 
the later stages of the treatment the patient frequently removed, 
and passive motion employed, it will almost invariably result in 
anchylosis more or less complete, and so far as progression is con- 
cerned, the patient is in a much worse condition than when left to 
nature, according to the plan of Dr. Carnochan, for then the mus- 
cular contraction flexes the thigh upon the pelvis, and being an- 
chylosed in this position they can sit down, which they cannot do 
when in the straight position, and have much greater facilities in 
walking than when anchylosed in the straight position. If we 
attempt the passive motion in order to prevent anchylosis, it is of 
the greatest importance that extension should he made at the same 
time, or we will re-excite the disease, and have again to repeat the 
same tedious horizontal posture, and this long confinement is likely 
to endanger the general health from want of exercise. It was in 
consequence of this accident occurring in several instances, that I 
was led to contrive some plan by which extension could be main- 
tained which would remove pressure from the synovial membrane 
of the acetabulum and head of the femur, and at the same time 
permit motion of the joint, thereby retaining the capsular ligament 
in a healthy condition, for motion is just as essential to a joint as light 
is to the eye; it is in fact its physiological function, and as the eye 
1 Extract from Chelius' Surgery, edited by South, American reprint, page 296. 
Brodie says as follows: " At a later period when, in consequence of the extensive 
destruction of the articulation, the muscles begin to cause a shortening or retrac- 
tion of the limb, I have found great advantage to arise from the constant applica- 
tion of a moderate extending force, operating in such a manner as to counteract 
the action of the muscles. For this purpose an upright piece of wood may be 
fixed to the foot of the bedstead, opposite the diseased limb, having a pulley at 
the upper part." 
At page 300 is the following observation: " Ducros' case, already mentioned, 
appears to have been cured by continued extension for 50 days." MORBUS COXARIUS. 
25 
would eventually lose its power of vision if wholly excluded from 
the light, so the ligaments around a joint will become fibro-carti- 
laginous, or even osseous if entirely deprived of motion, particularly 
if a chronic inflammation is going on within the joint with which 
they are connected.1 
For a full description of my instrument, mode of application, 
and principles which govern its use, see remarks in connection with 
the case of J. C., page 499. 
Second Stage.-The treatment in this stage of the disease must 
necessarily differ according to the condition of the joint, and the 
character and quantity of its contents. If the disease is of a mere 
subacute character, and the joint not yet disintegrated, the effusion 
small in quantity (which is recognized by the small degree of mal- 
position and limited motion), repeated moderate depletion by leeches 
or cups, mild mercurial treatment both internally and externally, 
pressure by adhesive straps around the joint which will promote 
absorption directly by the pressure, and indirectly by stimulating 
the action of the skin; with slight but permanent extension, for 
the purpose of counteracting the morbid contraction of the mus- 
cles, and to relieve the pressure from the ligamentum teres, and 
persisted in until the more prominent inflammatory symptoms have 
subsided, is the only course to be adopted. This can be accom- 
plished by a weight of from four to eight or ten pounds, according 
to necessity, over a pulley at the foot of the bed, and secured to 
the limb by means of adhesive plaster, the same as in fracture; 
the body of the patient being the counter-extending force. If the 
patient has a tendency to slide down in the bed, this can readily 
be obviated by putting blocks under the lower parts, thus making 
an inclined plane. 
This treatment will be applicable to the majority of cases; but 
there may be some instances when the inflammation is so violent, 
and the pain on the slightest motion so intense, that absolute rest is 
requisite for a time; for these cases the " wire breeches" of Dr. 
Bauer are indispensable. 
The next indication in the treatment is to bring about the ab- 
sorption of the effused material. I am not of the opinion that the 
1 " M. Tessier, of Lyons, has shown that prolonged rest alone, even when little 
or no disease previously existed-a rest for five or six months-is sufficient to 
cause absorption or ulceration of the cartilages of joints. This prolonged rest also 
aggravates existing disease."-Braithwaite's Retrospect, part xxx. p. 93. 
3 26 
report ox 
reduction of the constitution will aid in doing this, but, on the con- 
trary, will inevitably injure the case and prejudice the prospects of 
ultimate absorption. And hence, I most emphatically proscribe 
the whole class of derivants from the mustard poultice up to the 
actual cautery. 
This I state not only on scientific principles, but from my own 
practical experience. For analogy teaches us that an inflamed 
serous sac is entirely disqualified to perform absorption of plastic 
material until the organizable elements have become deposited on 
their walls and organized, and all evidence of inflammation has 
ceased to exist, after which the process of absorption commences 
of the remaining serous portion. This is necessarily a process of 
time, during which the patient needs no confinement; but on the 
contrary, the invigoration of his constitution by out door exercise, 
is imperatively necessary to accomplish the result in view. 
Important as is the absolute rest in the active period of the disease, 
it is as decidedly prejudicial to the preservation of motion, not only 
in the affected joint, but even in the perfectly healthy joint if too 
long continued. I am in possession of a number of facts to prove 
this point, and have seen fibrous anchylosis take place in both 
knees, and the hip of the opposite side not previously affected, 
while the patient was being treated for hip-disease by too long con- 
finement. This point is furthermore exemplified by the observa- 
tion of the stiffened knee, which occurs in the treatment of fracture 
of the lower extremity. In fact a joint requires motion as its 
natural stimulus, as much as the eye requires light. 
In order, therefore, to facilitate the out door exercise of the pa- 
tient, and at the same time relieve the pressure of the joint, and 
thus protect the patient from a recurrence of the inflammation, I 
resort to the instrument previously referred to. 
If the inflammation of the hip-joint is of an intense and highly 
acute character, as manifested by the most aggravated symptoms 
of local pain, and general constitutional disturbance, the patient of 
a vigorous constitution, the cause of a clearly traumatic nature, and 
suppuration has not as yet commenced, I deem an energetic anti- 
phlogistic treatment necessary, as the safest method to bring the 
inflammation to an abortive termination. In such instances, how- 
ever, if the effusion and its consequences, malposition, &c., are con- 
siderable, acting as a new excitant for the perpetuation of the in- 
flammation; it not only distends beyond measure and endurance, MORBUS COXARIUS. 
27 
tlie capsular apparatus, and irritates its respective structure; but 
it also reflects most detrimentally upon the general constitution. 
In this condition the prompt removal of the morbid contents from 
the joint becomes absolutely necessary, and never fails to give 
immediate relief of all the most prominent symptoms, and to re- 
store rest and comfort to the patient. In fact it is the only ano- 
dyne which will perfectly relieve the pain. 
In removing this intolerable hydrostatic pressure I simply imi- 
tate nature, which accomplishes the same result by a spontaneous 
rupture of the capsule. 
There are two ways of performing this operation, viz., puncture, 
as suggested, if I am not mistaken, by Boyer, or subcutaneous inci- 
sion of the capsule, as recommended by Goyrand, both in hydro- 
throsis. 
In the treatment of inflammatory diseases of the joints for the 
purpose of removing the morbid effusions, and as a direct antiphlo- 
gistic remedy, Dr. Bauer was the first who employed this method 
with most happy results. I did the same years ago,1 and other sur- 
1 H. Y. Werckmuller, aged. 35, of vigorous and robust frame, and had always 
enjoyed perfect health; while crossing the corner of Broadway and Chambers 
Street, about the 1st of November, 1855, during the erection of the Shoe and 
Leather Bank, was struck on the right thigh and hip, by the accidental fall of a 
large piece of timber, which produced such intense pain at the time, that he was 
compelled to sit down on the stone steps in the street for more than two hours, 
before he was enabled to move; and, according to his own description, "looking 
like a drunken man leaning against a post." He walked home, a distance of one 
block, with great difficulty, and was confined to his bed for three days, suffering 
great pain, principally in the knee. He had no medical advice at the time, but 
applied fomentations and stimulating liniments to his limb. After the third day 
he got out of his room, and with some difficulty could walk a little; but the pain 
in the knee continued for ten or twelve days very severe, and then gradually sub- 
sided. About the 20th of December he began to feel pain in the hip-joint, and 
loss of appetite ; this increased very much until the 24th of December; he again 
took his bed, and was confined until the 4th of January, 1856, when he again got 
out, and walked for two days, feeling, however, some pain all the time. This exer- 
cise so aggravated his disease, that his limb began to elongate and turn outward, 
and stiffen in the joint, and with this change of position, his pain became so 
intense, that he was compelled to call in medical aid. Dr. Riggs saw him, and 
looking upon it as a case of rheumatism, treated him accordingly for about six 
weeks. 
His symptoms grew constantly worse, and his pain was intense and constant, 
requiring very free use of opiates. The spasmodic cramps at night were very fre- 
quent and severe. Entire loss of appetite, and very rapid emaciation. As there 
was no other joint involved, and the disease seemed rapidly progressing, and 
yielding to no treatment applied, the doctor began to doubt its rheumatic cha- 28 
REPORT ON 
geons under pressing circumstances have, without doubt, resorted 
to the same as an expedient for immediate relief, and with a view 
only of withdrawing purulent matter; but Dr. Bauer has clearly 
demonstrated the therapeutical efficacy in inflammation of the joints, 
even before it has proceeded to suppuration, and is I believe the 
first person who ever punctured the hip joint for this purpose, viz., 
the removal of non-purulent inflammatory effusion. These two 
operations, although essentially the same, differ, however, in this 
point: that in the puncture the fluid is removed entirely from the 
body, while in the other it is permitted to diffuse itself in the cel- 
lular tissue around the joint; and this difference qualifies their re- 
spective therapeutic value. If we have plastic material only in 
the joint, either operation is admissible ; but if the fluid is sero- 
purulent, the puncture by trocar is preferable, inasmuch as it pre- 
cludes the danger of consecutive abscess which almost inevitably 
racter, and called me in consultation, on the 18th of February, 1856. I found 
him semi-recumbent, with his right leg bent at the knee, over a pillow, everted 
and abducted; adduction or rotation was impossible, and the attempt produced 
the most intense agony. An indistinct fluctuation was discovered over the hip- 
joint. And looking upon it as a case of synovitis, with effusion, I applied iodine 
over the joint, and then long adhesive strips with firm compression, and a tight 
roller from the toes up over the hip, in order to promote absorption. Iodide of 
potassium was given internally. 
This treatment was continued until the 24th, six days, when I again saw him, 
with Dr. Riggs. He was more emaciated, and had had frequent chills and sweats. 
The limb was in the same position, and the pain on attempt at motion more in- 
tense. On removing the plaster, I found the fluctuation more distinct, and as the 
limb was more everted than before, and absolutely immovable at the hip-joint, I 
determined to puncture the joint, in order to prevent a rupture of the capsule. 
I punctured the joint with a small tenotomy knife, behind the trochanter major, 
and pus escaping, I extended the puncture to a free incision of about five inches, 
and then opened the capsule freely. Nearly a teacupful of pus escaped, and the 
limb almost immediately assumed its natural position. There was no crepitus 
detected; and, with the finger in the capsule, I could feel no roughness on the 
parts of the head with which I could come in contact. The joint was thoroughly 
syringed with warm water, and the wound filled with lint and covered with oiled 
silk. 
No constitutional symptoms followed, not even a chill. He slept well all night 
without any anodyne-the first time for some weeks. His appetite returned, his 
night-sweats subsided, and all his symptoms improved so rapidly, that I ceased 
my attendance in a few days, and left him in charge of Dr. Riggs. There was a 
free but healthy suppuration of the wound at the time I left him, and my prog- 
nosis was, that he would recover with an anchylosed hip. 
I have just seen Mr. Werckmuller, and it is now more than four years since the 
operation. He is in perfect health, and has perfect use of the joint in all direc- 
tions, and says that he has had for nearly three years. MORBUS COXARIUS. 
29 
follows the entrance of pus into the cellular tissue. As a mere 
explorative measure in order to ascertain the pathological condition 
of the joint the trocar should always have the preference. 
Method of puncturing the hip-joint.-The patient should be placed 
on a high table and on his healthy side, and chloroform invariably 
administered in order to obviate the pain incidental to the motions 
of the affected limb, which are necessary to expel the fluid. A flat 
and small trocar should be used similar in shape to that recom- 
mended by Andre, for the puncture of hydrocele. The best place 
is immediately behind the middle line of the femur, and above the 
large trochanter close to the superior margin of the tendon of the 
gluteus-maximus muscle, passing thus into the joint just above and 
in front of the digital fossa, in which are inserted the rotators from 
the pelvis. 
The everted and abducted extremity should then be gently re- 
versed in order to render the capsule more tense. After sliding 
the skin, the trocar should be inserted perpendicularly to the body, 
which will bring it at an acute angle to the neck of the femur. 
Care should be taken that the crown of the head is not struck, if 
so the handle of the trocar should be slightly turned off to let the 
point of the instrument glide by its side into the joint. The point 
should never enter the joint deeper than about a quarter of an inch, 
so as to leave the canula about one-eighth of an inch in the joint. 
The immense distension which is the only condition which will 
justify this operation, renders its performance much more simple 
and easy than if we attempt the same on the dead body, unless 
previously prepared by injection. 
The moment the capsule has been punctured the stiletto should 
be withdrawn, and at the same time the affected limb steadily in- 
verted, adducted, and rotated over and across the opposite limb by 
a reliable assistant, by which movement the entire fluid will be 
discharged from the joint. This fact can be fully illustrated by 
experiments upon the cadaver. 
This position should be retained until the canula is withdrawn, 
the wound carefully closed by adhesive strap and the joint care- 
fully surrounded by compress and long adhesive strips, thus exercising 
pressure and preventing the air from entering the vacuum, which 
will be created on the return of the limb to the straight position. 
The patient should then be secured from any possibility of motion 
for at least a fortnight, either in Gibson's apparatus, or, what I like 
better for this purpose, "Bonnet's wire breeches." Besides the 30 
EEPORT ON 
rest, low diet, and moderate antiphlogistic treatment should be 
adopted. 
By this plan reaccumulation very rarely takes place, but, if it 
should, the operation may be safely repeated if necessary, as has 
been done in two or three instances. 
Goyrand's method as applied to the hip-joint, differs but slightly 
from the one just described. A two-edged small knife is used like 
the trocar, inserted in the same place and manner into the joint, 
and an opening of the capsule made for about half an inch, and 
finally its contents driven into the cellular tissue in the same man- 
ner as above described, by changing the position of the limb and 
the same after-treatment observed. 
If the puncture of the joint reveals the fact that the fluid is 
already purulent in its character (which might have been clinically 
ascertained before by a careful analysis of the constitutional symp- 
toms), the question rises whether this pus is simply the product of 
synovitis, or, whether it is connected with the ulceration of the 
cartilage and caries of the bone. The former has been disputed, but 
erroneously so, for synovial membranes, like other serous mem- 
branes, are susceptible of suppuration without ulceration, the 
epithelial cells being simply converted into parental pus cells, as 
proven by " Haidenhein." With very few exceptions, when there 
is ulceration of cartilage and bone, we find more or less crepitus, 
and this can be clearly ascertained by rotation of the affected limb 
after the fluid has been withdrawn. 
In the absence of crepitus, and especially if the disease is of but 
short duration, we are justified in premising that the case is simply 
suppuration of the synovial membrane, and hence allow the patient 
the chance to recover without any further operative procedure. 
Analogy teaches us that synovial membrane in a state of simple 
suppuration may, like serous membranes, recover its integrity 
by the evacuation of its morbid products, in proof of which we 
need only to refer to Dr. Bowditch on Empyema. I therefore treat 
this punctured wound as already stated, when it was simply organ- 
izable lymph, and rather repeat the operation in case of reaccumula- 
tion, than to leave it open by a free incision. 
If we, however, satisfy ourselves of the fact that the articular 
surfaces have become ulcerated, the cartilages disintegrated and 
partly detached, the bones corroded, which can be ascertained with- 
out difficulty by the crepitus which is peculiar to itself, and alto- 
gether different from the crepitus of healthy bone, we consider the 31 
MORBUS COXARIUS. 
exsectwn of the joint not only justifiable, but in most instances ab- 
solutely essentia]. 
Under similar condition of other joints, more especially where 
the disintegration is of but limited extent, I have freely opened 
them, inserted setons through them, injected them with iodine, and 
attained thereby satisfactory results. In some instances I have 
even had perfect recovery, with free motion of the joint. 
But the same principle of free incision seems not to be applica- 
ble to the hip-joint; since the conformation of the joint, its deeply 
seated situation and investment with soft parts, opposes the free 
exit of the discharge. In fact, the hip-joint can hardly be said to 
be freely opened without removing the head of the femur, which 
fills it completely. 
Third Stage.-We have invariably in this stage of the disease a 
rupture of the articular apparatus either of the capsule, or a per- 
foration of the acetabulum, but the character of the disease differs 
widely, whether inflammation and plastic lymph caused the rup- 
ture, or whether ulceration of cartilage and bone and consequently 
purulent effusion brought about that change. In the former the 
lymph escapes into the cellular tissue, spontaneously relieving the 
hydraulic pressure of the joint, and the most prominent symptoms, 
and in fine organizing itself into new tissue, leaving, however, ad- 
hesion of the joint, and the extremity in a state of malposition, 
thus effecting a spontaneous cure. This variety of the disease is 
by no means rare, and has led many a surgeon to rely on the sim- 
ple efforts of nature more than on surgical art. 
Nor do I propose for such cases any active interference, but only 
the contrary. I only suggest to assist nature in effecting this spon- 
taneous cure by mechanical appliances in relieving the joint from 
pressure, in permanently distending the morbidly contracted muscles, 
and in fine in securing the perfect mobility, usefulness, and normal 
position of the extremity. 
If the cure has been thus effected by the unaided efforts of na- 
ture, it is invariably done by a fibrous anchylosis of the joint and 
the characteristic malposition of the extremity previously described. 
Even this result of the disease formerly considered as an incurable 
spontaneous luxation, though the most fortunate termination that 
was to be expected in this disease has now been brought within 
the scope of surgical art, and is susceptible of perfect relief. 
The division of the contracted muscles implicated in the defor- 32 
REPORT ON 
mity, the forcible breaking up of the adhesions under chloroform, 
and the proper orthopaedic treatment afterwards have, in numerous 
instances, re-established the proper form, motion, and usefulness of 
the afflicted extremity. 
Very different, however, is the surgical proceeding in cases 
of caries. Spontaneous cures are extremely rare, and if we deduct 
from them the cases of periostites, which have been mistaken for 
and confounded with caries of the hip-joint, we will find the number 
reduced to a very small percentage. Indeed, a careful examina- 
tion of many cases in my own practice, and an opportunity to study 
many cases of this disease in the practice of others, lead me almost 
to doubt whether it ever occurs at all. We can hardly be surprised 
at this state of things when we consider the many anatomical ob- 
stacles in the way of a free discharge of the detritus, which almost 
inevitably creates new disease of the bone in its way, and thus 
perpetuates the disease from the inability of throwing off the parts 
already destroyed. 
Nature herself has but one efficient method of curing caries; she 
removes gradually and in extremely small fragments the disinte- 
grated bone, sets up healthy granulation in the sound portion, and 
substitutes for the defect fibrous, and oftentimes ossifying structure. 
This process is extremely protracted and may require even years 
for the removal of a comparatively small fragment of bone. And 
from nature and her means of repair, we have to deduce the prin- 
ciples and measures which should govern us in the healing act. 
These principles have long been known and practically adopted 
by the profession ; exsections of bones and of joints for caries and 
necrosis are operations of every-day occurrence; but, strange to 
say, the caries of the hip-joint has inconsistently been precluded, 
or but rarely permitted to receive the benefit of this advancement 
in surgery. As for instance, Prof. Syme, who has performed nu- 
merous exsections of joints for caries with more than ordinary 
success, yet he most emphatically condemns the exsection of the 
hip-joint when afflicted with the same disease. It would seem to 
an unbiased mind, that the same therapeutical indications were 
equally applicable to the hip as well as any other joint. In fact, 
it is my firm conviction, that caries of the hip-joint on account 
of the impending danger of perforation of the cotyloid cavity, 
and a pelvic abscess whereby its important viscera may become 
involved, requires self-evidently a more prompt and decided sur- 
gical interference than when in any other joint. On a general MORBUS COXARIUS. 
33 
surgical principle, therefore, the operation of removing all carious 
bone, or, as it is commonly termed, exsection of the hip-joint, is not 
only justifiable, but imperatively demanded, and the more so as 
according to no less an authority than that of Prof. Syme, who 
says, " If the joint be carious the patient must die."' 
We can, therefore, lose nothing by the operation, but, on the con- 
trary, will invariably procure at least the comfort of the patient, 
and in the majority of cases, as shown by my statistical record, 
save their lives. But this is not all, we not only save the life of 
the patient, but with it we also restore form and motion. 
In the face of these arguments and facts, I do not hesitate to re- 
commend most emphatically the exsection of the hip-joint when 
affected with caries. 
Of course every exsection will not prove successful. Sometimes 
the disease is so connected with constitutional vitiation as not to 
be eradicated by a mere local operation. At other times, the dis- 
ease is so extensive as to preclude the possibility of its entire re- 
moval. In either of these cases, the disease will proceed to a fatal 
termination. But when the disease is chiefly of a local character, 
the constitution not yet undermined, and its extent so limited as 
to admit of its entire removal by the knife and gouge, and in fine 
where we have the advantage of good air and proper diet, I ven- 
ture to say that this operation, if performed at a proper time, offers 
the best possible chance of success. It follows, therefore, conclu- 
sively :- 
1st. That the operation should be resorted to as soon as the diag- 
nosis of caries has been positively ascertained. For delay can but 
diminish the chances of success by extending the disease. 
2d. That the operation should include the entire removal of all 
the diseased bone and cartilage. 
3d. That the wound should be kept open for the free discharge 
of pus and other disintegrating structural fragments, and especial 
care should be observed that no burrowing of matter takes place 
beneath the fascia. 
4th. Absolute rest and a moderate extension should be kept up, 
so as not to disturb the granulation or permit the sound bones to 
come in contact. 
The "wire breeches," repeatedly referred to, are the best appa- 
ratus known to me to insure this result. This apparatus having 
been fully described and illustrated by Dr. Hamilton, in his excel- 
lent work on fractures, and also published in the Transactions of the 34 
REPORT ON 
American Medical Association for 1857, I have deemed a further 
description unnecessary. 
Fig- 6. 
When placed in this apparatus, the patient is firmly secured in a 
comfortable position, protected against the possibility of motion, 
while he is fully enabled to urinate and defecate without the possi- 
bility of the parts being in the least disturbed. It admits even of 
the patient being carried about and driven out in the open air. 
For the special application of this instrument after an exsection, 
it is necessary to cut in it a window opposite the wound, in order 
to allow of its easy dressing without removing the patient from the 
instrument. 
In the after-treatment, the most scrupulous cleanliness should be 
observed; for the pus is mostly, and at least for a short time 
after the operation, highly offensive on account of the disintegrat- 
ing bone ; it carries a great deal of sulphuretted hydrogen, and acts, 
therefore, almost like a caustic. If permitted to soak the cotton, it 
will almost inevitably lead to bed sores; it will attract insects, ge- 
nerate maggots, and certainly vitiate the atmosphere of the patient. 
To prevent all these difficulties, the ordinary cleanliness will not 
always suffice, and, therefore, lukewarm baths should from time 
to time be resorted to. This has the great advantage also of cleans- 
ing the wound of all decomposing material. 
It must be left to the practitioner, whether he deems it necessary 
to add disinfectants, alterants, or tonics, as each special case may 
require. 
While the patient is being placed in the bath, while therein, and 
during the removal from the same, an assistant should support and 
fix the pelvis, and extend the extremity, in order to pre ven., both 
the pain and irritation of the wound, and also its closure, which 
will inevitably take place unless the extension be continued. 
The wound itself rarely requires any local application, unless the 
granulation is inefficient or too profuse; in the former instance, 35 
MORBUS COXARIUS. 
tinct. iodine, either pure or diluted with glycerine or creasote; and 
in the latter instance the acidulated nitrate of mercury in prefer- 
ence to lunar caustic, have been found the most satisfactory agents. 
When the wound has been reduced in size, and the discharge 
has become healthy, the granulations showing tendency to cica- 
trization, then it is time to apply during the day my splint, still re- 
taining the patient in the " wire breeches " at night. This is done 
with a view of affording the patient the advantage of active out- 
door exercise, and to prevent the ossification of the intermediate sub- 
stance, which otherwise might terminate in bony anchylosis, a result 
by no means desirable. 
According to my personal observation, the intermediate sub- 
stance is formed of very firm fibrous structure, which in a com- 
paratively short time acquires the firmness of whalebone, or at any 
rate a sufficient mechanical strength for the support of the patient. 
The lower extremity of this intermediate substance is invariably 
and intimately connected with the femur, and the more closely so 
if the periosteum has been saved at the time of the operation; it is 
also connected with the surrounding soft parts, whereby it acquires 
additional strength; but is not directly attached to the ilium, but 
seems to form an artificial articulation. 
Having had no opportunity of a post-mortem examination of an 
articulation of this kind in the hip, I am unable to give a detailed 
description of its anatomical construction. But I believe never- 
theless, that my clinical inferences are correct, for almost all these 
articulations permit in a more or less limited way all the motions 
of a normal hip-joint, that is to say, flexion, extension, abduction, 
adduction, and rotation. I am fully satisfied that these motions 
as a general thing are not performed by the bending or twisting in 
the continuity of this intermediate substance; but on its superior 
extremity and against the acetabulum. As far as I can ascertain, 
I have found but one exception to this arrangement, viz: one case 
of Dr. Bauer (No. 57 of table). 
With reference to this case, that gentleman who has but lately 
seen it, reports to me that the intermediate substance is still soft 
and yielding, so much so that it almost doubles up when the weight 
of the body rests upon the extremity. The shortening produced 
by this flexion of the intermediate substance amounts to two inches 
and a half. But when the patient is placed in the recumbent pos- 
ture, the extremity can be extended to within half an inch of its 
normal length. The growth and development of the leg have not 36 
REPORT ON 
in any other respect been impeded. This is the same condition in 
which the Dr. found the limb nine months after the operation, and 
as yet it has shown no tendency to any firmer consolidation. The 
rotation of the limb appears to be performed by a twisting of this 
intermediate substance. 
The cause of this unusual softness and flexibility of the new tis- 
sue he ascribes to the excessive obesity of the patient, in which 
most probably this structure also participates. 
For the purpose of making the views and principles inculcated 
in this paper more fully comprehended, I have copied from my 
note book several cases, each of which is a type of the different 
phases of the disease in its different stages, and in different consti- 
tutions. I would beg to call the particular attention of the reader 
to these cases, and the remarks accompanying each, as in them will 
probably be found a more clear and comprehensive view of my 
suggestions, and the reasons which guided me in their adoption, 
than I have been able to state in the more particularly didactic 
part of this report. 
Morbus Coxarius far advanced-treated by division of contracted mus- 
cles, perfect rest in wire splint and then passive motion-recovered 
with anchylosis in straight position. Broken up and splint applied, 
permitting motion and exercise while keeping up extension-recovery 
perfect, illustrated by photographic drawings taken from life. 
The following case of hip-disease illustrates in a remarkable man- 
ner the objections which I have made to the treatment, by entire rest 
in an immovable splint, viz., the injury to the general health and the 
danger of anchylosis; and at the same time the superiority of the 
plan I have suggested. I may here remark that the history of the 
case was furnished in a letter by his mother, a most intelligent and 
cultivated lady, and I have copied it without alteration, as it gives 
a perfect view of his previous condition and treatment. 
"J. C., aged eight years, was a perfectly healthy child when born, 
and continued so until he was seven months old, when he had a 
severe attack of inflammation of the lungs; it passed to his bowels, 
and for a few months he was much prostrated. 
" Through the winter he recovered his health and strength en- 
tirely, but had another attack of the same character the following 
spring, continuing through that summer, and again reducing him 
to a very low point. At the suggestion of his physician he was MORBUS COXARIUS. 
37 
taken in the early spring to the south, where his health was entirely 
restored, and he became in every respect a strong, large, robust 
boy, well developed, with limbs and figure perfectly formed. 
" lie was three years and a half old, when he was taking a very 
long walk, during which he complained much of fatigue and weari- 
ness, and, seeming unable to walk farther, sat down on a damp pave- 
ment where he remained for some time. The long walk, too much 
for his heavy frame, and the contact with the damp pavement in 
the middle of winter, produced an inflammation of the hip, w'hich 
was discovered the very next day by lameness, and his inability to 
walk without a very decided limp. 
" Drs. J. P. and W., of Philadelphia, were at once called in, and 
after consultation pronounced it a case of hip-disease. He was in 
the course of a few days placed in a splint, confining one limb, and 
permitting freedom to the other.1 
''This he wore for eighteen months. At the end of this period 
his limb began to stiffen in the joints, and his health to decline so rapidly 
that, although opposed to the advice of his physician, his friends 
removed the splint and took him to the country. 
" The splint was left off for six months; his health improved so 
much with country air and slight exercise, that it was thought best, 
as the disease in the hip continued, to return to the splint. After 
again wearing it for six months, his health gave way and it was 
removed. During the two years following he was confined in the 
splint at intervals, as his health and strength permitted, but con- 
stantly growing worse, with more pain, and occasional swelling of 
the hip. During all this time he was attended by experienced and 
skilful physicians, and everything which skill and science could 
suggest was done. 
• "After four years of suffering he was taken to New York, mis- 
erably attenuated and terribly deformed, unable to walk even with 
crutches. 
"The diseased limb powerless, very much drawn up at the knee, 
and his only means of supporting it was by laying it on the other 
leg. There was an entire loss of appetite, his nights were restless, 
requiring the constant use of opiates, and often waking with sud- 
den shrieks of pain. He was unable to bear without suffering the 
lightest touch upon his limb, and the least motion of it gave him 
intense agony. 
1 She does not state whether extension was made or not. 38 
REPORT ON 
"Dr. P., of New York, was first consulted, who thought he could 
not be relieved, and said that recovery with a child whose consti- 
Fig. 7. 
J. C.-Morbus Coxarius of Four Years' Duration.-Drawing taken March 9, 1859. 
tution was so weak and shattered, would be a miracle; but that 
even if he rallied his deformity was hopeless. That for it no medical MORBUS COXARIUS. 
39 
skill could avail, and that it was doubtful whether he could sur- 
vive. Other eminent gentlemen of the city concurred in this 
opinion." 
On examination, he presented a white waxy tinge of the skin, 
Fig. 8. 
J. C.-Same Case as Fig. 7.-Taken March 1,1860. 
pale cachectic expression of countenance indicative of great suffer- 
ing. The general attitude was partially recumbent on the right side 
and back, and semi-flexed. Pelvis twisted on the body towards 
the left side; thigh flexed on the pelvis, and turned outwards; heel 
resting on the lower part of the tibia of the opposite leg, which was 40 
REPORT ON 
drawn very much to the left of the median line in order to get under 
the diseased limb and act as a support. The diseased limb appeared 
firmly fixed in its position, and the pelvis was twisted in order that 
the well limb could accommodate itself to it. The muscles of the 
thigh and pelvis of the left side were so rigidly contracted as to 
retain this unnatural position permanently; any attempt tq change 
it pained him most intensely. In the erect posture he had to be 
supported under the axilla, being unable to support any weight on 
the sound limb, owing to the obliquity of the pelvis, which twisted 
towards the left side and destroyed the natural line of gravity. 
But as no description can give so correct an idea of his condition 
and position as a picture, I therefore had him photographed in the 
usual position he had occupied for some months. 
March 9, 1859. The child being placed fully under the influ- 
ence of chloroform by Dr. Jones, I divided the tensor-vaginae- 
femoris, pectineus, and rectus-femoris muscles subcutaneously, and 
readily brought the limb in a straight position. Previous to the 
division of the muscles it was impossible to straighten the limb, 
pelvis, or spine, even when under the influence of chloroform; any 
movement of the left leg would move his whole pelvis and body 
in the same twisted and crooked position in which he is represented 
in the picture. 
In a few minutes after the division of the muscles, by slight ex- 
tension upon the foot, the spine and pelvis were brought into their 
natural position, and the leg the same as the other. He was then 
placed in the " wire breeches" of Dr. Bauer, and extension made 
by adhesive plaster. 
March 10. Slept well all night without opium, the first time 
in many months. No fever; pulse 80; ate a tolerable breakfast, 
and is entirely free from pain. He was kept in the wire splint for 
ten days, when he was removed, and the wounds made by the teno- 
tome were entirely healed, but the least motion of the joint gave 
him great pain ; but his general health was much improved. After 
thorough washing and friction he was replaced in the wire splint, 
and extension applied as at first. Prom this time on he was put 
on a stimulating and highly nutritious diet, and given iron and cod- 
liver oil, which were the only medicines he ever used while under 
my treatment. In a few days he could be carried out to ride in 
the apparatus without the least inconvenience, and thus get the 
benefit of fresh air, and improved most rapidly. It is hardly neces- 
sary to give the tedious details of daily visits, but suffice it to say MORBUS COXARIUS. 
41 
in general terms, that this course was continued until the 10th of 
June, when he went to the country under the care of his family 
physician, who continued the same treatment through the summer, 
taking him from the instrument every eight or ten days and using 
passive motion, which he thought occurred at the hip-joint, but 
which, in fact, was obtained by a movement of the whole pelvis. 
The child's general health improved, and he was carried out daily 
riding, ate and sl$pt well, and had no pain, and the parents and 
friends thought him rapidly recovering, and so stated to me in 
their letters. 
In August they wrote me that they feared his joint was stiff; 
I visited him at Williamsport, Pa., and found his hip-joint quite 
firmly anchylosed; considerable motion could be made by elevat- 
ing and depressing the limb, when the pelvis was left free, but as 
soon as it was firmly secured no motion whatever could be made at 
the joint, and rotation was impossible. There was no pain what- 
ever about the joint, and he could bear his entire weight upon the 
leg which seemed to be a trifle longer than the other, owing pro- 
bably to some organized effusion in the joint, and which rendered 
locomotion almost impossible, and very awkward. He could not 
flex the hip so as to sit at all. 
I therefore put him fully under the influence of chloroform, and 
with the assistance of Dr. Pollock, of Williamsport, who firmly 
held the pelvis, I succeeded in breaking up the bony anchylosis of 
the hip, which required a good deal of force, and was accompanied 
with a number of distinct snaps of the breaking bony attachments. 
Quite free motion was obtained, and he was then placed in the 
wire splints and cold water applied to the hip, and a large anodyne 
administered. The cold water with the occasional use of ice, en- 
tire rest, low diet, and a relaxed condition of the bowels was con- 
tinued for about ten days, when all symptoms of inflammation 
having passed off, the same treatment as before was adopted, viz., 
removal from the splint and passive motion every few days, being 
careful to confine the pelvis in order to secure the motion at the hip. 
He returned to the city under my care in November 1859, much 
improved, but with imperfect motion, and I observed that he al- 
ways had more or less pain for one or two days after the motion 
had been applied, which I thought was owing to the fact that I 
could not keep up sufficient extension ivhile I was applying the motion. 
This was a desideratum I had tried long to accomplish, but 
never succeeded to my satisfaction until Dr. H. Gr. Davis, of this 
4 42 
REPORT ON 
city, applied to him one of his instruments, which answered the 
purpose admirably, and in its construction embraced the very 
principles I had so long sought to obtain. 
As Dr. Davis is, I believe, the first person who has constructed 
an instrument embracing these important advantages-extension 
with motion-I have taken the liberty of presenting a plate of the 
same, and his own remarks in regard to its method of application. 
I have made, as I think, some very important improvements and 
modifications of this instrument, which I will describe more fully 
hereafter. 
Description of Splint.-" The several parts employed in the treatment are four 
strips of adhesive plaster (see Plate, Fig. 1) ; a roller to confine them to the limb, 
firm webbing to be attached to the lower end of the adhesive plasters when upon 
the limb (Fig. 2) ; a cord, pulley, and weight, for extension when upon a bed or 
couch; a corrugated steel splint (Fig. 3), with a perineal hand, composed of two 
parts-an inelastic (Fig. 4), and an elastic (Fig. 5)-arranged in a peculiar man- 
ner, so as to keep up extension while the patient may take exercise within the 
house or in the open air. 
" When called to treat a case of morbus coxarius, I bring the tibia in a line with 
the femur, but attempt no change in the direction of the latter if it is not parallel 
with the body. If the femur is flexed upon the pelvis, the body should be raised 
until the limb will lie extended upon the mattress or couch. Adhesive straps are 
placed upon each side of the limb, in the following manner: First, double over 
one inch of each adhesive strap designed for the sides of the limb, bringing the 
adhesive surfaces in contact for the purpose of increasing the strength of the part, 
to which a firm inelastic webbing is to be attached. The strip for the outside of 
the limb commences with the folded end mentioned, at a point one inch above the 
external malleolus, and extends to the region of the great trochanter ; that upon 
the inside, from one inch above the internal malleolus to within one inch of the 
pubis. Upon the lower end of the adhesive strap, on the outside of the limb, I 
commence with a narrower and longer one, and run it spirally around the limb 
until it reaches the upper end of the longitudinal straps ; another starts from the 
same point upon the outside of the limb, but winds in the opposite direction. 
These spiral strips accomplish a twofold purpose: they connect the outside lon- 
gitudinal adhesive plaster with that upon the inside of the limb, so that any ex- 
tension made upon the outside plaster is shared by that upon the inside. This 
arrangement also secures the bottom of the outside longitudinal plaster from being 
displaced laterally when the splint is applied, always retaining it in a line with the 
limb. The width of these plasters varies from an inch and a quarter to two 
inches and a half, according to the size of the patient. 
" When the extension is made by the splint, it is always upon the outside of the 
limb ; at other times it can be made from both sides ; the latter mode of extension 
supports the sides of the foot equally, and is therefore preferable when the patient 
is upon the bed or couch. 
" Before proceeding further, I would say a word upon the character of the ad- 
hesive plaster to be used for such purposes, as that ordinarily used for dressing  -Lich. of & Stum 22 WUzam ) 'C N. Y 
H.M DAVIS' SPLINT FOR HIP DISEASE, 
as Manufactured bv Olio & Reyiulers.aS Chatham St.NrwYork.smre 185.). MORBUS COXARIUS. 
43 
wounds will only disappoint the surgeon. It should be spread upon twilled goods 
as they are more elastic ; and when the extension is made the parts first affected 
will yield until the whole surface of the plaster bears a portion of the draught; 
whereas plaster upon plain cloth draws only in a straight line, therefore is only 
applicable to an even surface. 
" The material of the plaster should not only be good, but it should have been 
spread upon the cloth for at least one year, and it is still better if two years old ; 
age oxidizes the oil, rendering it resinous, so that the oily secretions from the skin 
do not readily soften it. Plaster of this description I have had remain upon an 
adult for seven months, sustaining a weight of twelve pounds every night, and not 
unfrequently during the day a considerable portion of the entire weight of the 
body. 
" After the application of the adhesive straps in the manner described, the limb 
should be covered with a bandage from the foot to the pelvis, to secure firm ad- 
hesion of the plasters, also to prevent their edges from being raised by coming in 
contact with the clothing, or by the hands of the patient during sleep; this band- 
age should be affixed to the limb for some hours, with the patient warm in bed, 
before any draught is made upon the adhesive straps, that they may become 
firmly adherent to the limb; after this time has elapsed, a weight, varying from 
two to six pounds, according to strength of muscle and the sensibility of the joint, 
may be attached to the adhesive straps upon each side of the limb by a cord that 
runs over a small pulley secured to the foot of the bed or couch ; the top of the 
pulley being a little above a line with the centre of the limb. This weight should 
be increased from day to day, until a general sensation of fatigue is felt in the en- 
tire limb to an unpleasant extent, and then diminished until it just falls short of 
this point. The extension is first made at that angle with the body that I find 
the limb, as the tenderness of the joint subsides the body should gradually be 
lowered until it is brought in a line with the limb ; when this is effected the splint 
is applied, and the patient put upon crutches and permitted to exercise."1 
This instrument of Dr. Davis was applied in this case with the 
happiest results for a few days, but it soon began to excoriate the 
groin, and the method of extension was not satisfactory, and could 
not be controlled at will; but would be either too feeble or too 
severe, and I therefore constructed an instrument embracing all 
the principles in this, but much more effectual in its application, 
more comfortable to the patient, and entirely under the control of 
the surgeon. 
It consists of a narrow steel splint, extending from just above 
the crest of the ilium to within two or three inches of the external 
malleolus, and is divided into two parts at the knee, so that one 
runs into or by the side of the other, and is capable of being ex- 
tended at will by a ratchet and cog-wheel near the knee, which is 
worked by a key, or the same extension may be made by means 
of a screw, which will run more smoothly than the ratchet and cog- 
1 From Am. Med. Monthly, for April, 1860. 44 
REPORT ON 
wheel, and be less expensive; but is not quite so easy of application 
and removal. 
Fig. 10. 
I 
A/ 
a 
a 
5 
I 
e 
ai 
6 
Cl 
6 
N-Y. Me ' 
The upper portion of the instrument is corrugated to increase 
its strength, and in the groove at its upper extremity is a ball and 
socket or universal joint, to which is attached a pully or wheel, for 
the counter extending catgut cord to play through. This catgut 
is attached at either end of the perineal or counter-extending belt, 
which is made of thick India rubber tubing, and being firmly se- 
cured at either end, makes an elastic and comfortable air cushion 
for the perineum, and will not excoriate or chafe the parts. 
At the lower end of the instrument is a small roller, extending 
nearly its entire width, and just above it a buckle for the purpose MORBUS COXARIUS. 
45 
of securing the firm webbing or strap, which plays over the roller 
at the lower end of the instrument and is sewed fast to the strong 
adhesive plaster for the purpose of making extension. The adhe- 
sive plaster is spread on very firm canton flannel or twilled cloth, 
and the older it is the better, as it is less likely to irritate the skin. 
The plaster is cut two or three inches wide according to the size of 
the limb, and commences from about two or three inches above the 
external malleolus, and extends to within a few inches of the tro- 
chanter major. Two other and longer strips go around the limb 
in a spiral manner in opposite. directions, commencing from the 
lower end of the first or longitudinal strip and extending upwards. 
The plaster is very smoothly adjusted, and then well secured by a 
carefully applied roller from the toes upward embracing the entire 
limb, and taking three or four turns around the body in the form 
of figure of 8. 
After the plaster has been applied a few hours, and becomes well 
set to the skin so that it will not slide, the instrument is applied, 
and extension made by the key at the cog-wheel. This is made 
slight at first, and as the muscles become fatigued and relaxed, it is 
gradually increased, and continued until the patient can bear quite 
firm pressure against the heel without producing pain at the hip. 
The perineum becomes accustomed to the pressure in a few days 
if it is not too severely applied at first, and the patients begin to 
run around with ease and comfort, after which it is impossible to 
persuade them to abandon it, even for some time after they are 
entirely cured. At least this has been my experience. 
If the patients are young and of light weight, I let them go about 
without crutches; but if they are heavy and I fear the plaster will 
not bear their weight, I make them use them as a protection. 
This instrument was applied to this case about the middle of 
December, 1859, and he wore it constantly until the 1st of March, 
when he walked to Mr. Guerney's gallery and had his photograph 
taken, which is engraved in Fig. 8, and which gives a better idea 
of his present condition than I can do by description; I have 
placed it beside the one taken a year before for comparison. 
It will be observed that there is an unnatural fulness about the 
upper part of the thigh. This is doubtless owing to the division 
of the tensor vaginae femoris, rectus and pectineus muscles, which 
I had performed in the first operation. 
He left for his home in Pennsylvania early in March, and I have 
not seen him since; but I have just received a letter from his 46 
REPORT ON 
father, dated Williamsport, June 4th, 1860, in which he says: "He 
has grown wonderfully, his general health is perfect, his appetite 
good, sleeps soundly all night, and his flesh is as sound and hard 
on his lame leg as on the other, and he never complains of any 
pain. The only thing that I observe is an appearance of stiffness 
of the lame leg, particularly when the instrument is on, but which 
is not apparent when the instrument is off.1 His figure is quite 
good, but his hip bulges outward, and always looks as if it was 
swelled; but there is no pain in it whatever." This apparent ful- 
ness of the hip and upper part of the thigh I have already ex- 
plained to be dependent, as I think, upon the division of the muscles. 
There may be also some deposition in the joint which presses the 
femur more outward than natural, as it will be remembered it had 
once been anchylosed and had to be broken up. This case is now 
well, and I have no doubt the instrument may be left off with per- 
fect safety; I have written to them to that effect. I do not know 
of any other treatment that would have given him so good a result. 
I certainly have never seen any that would at all compare with 
it, and as, in the course of the treatment, many of the principles 
which I have been anxious to inculcate were compelled to be put 
in practice, I have, therefore, written out the case in full, as it will 
illustrate my views better than any other way I could do it. 
Morbus Coxarius, 2d stage-treated by division of muscles; perfect rest 
in wire splint of Dr. Bauer, and afterwards passive motion ; recovery. 
Disease returned, same treatment, partial anchylosis-broken up and 
recovery with tolerable motion. 
Henry W. Hunt, aged ten years, of good constitution, though 
not rubust, was observed to walk lame on the right side for the 
first time in September, 1856. No reason could be assigned for 
the lameness. 
When he came under my observation in the latter part of Sept. 
1856, the symptoms of hip-joint were recognized. The foot was 
everted, knee flexed, natis flattened. An issue had been made and 
a sole-leather splint applied, and the patient was ordered to use 
crutches, and means were instituted to invigorate the constitution. 
His general health improved, but the local disease continued in the 
1 This apparent stiffness is due to the immobility of the knee which is caused 
by the instrument. MORBUS COXARIUS. 
47 
same condition. My engagements not permitting me to bestow 
the attention the case demanded, I advised the parents to place 
the patient under the charge of Dr. Louis Bauer, in his private 
orthopaedic institution in Brooklyn. It was accordingly done about 
Christmas, 1856. 
The treatment adopted was that usually followed by Dr. Bauer, 
viz., complete rest with extension, obtained by means of the " wire- 
splint," and appropriate regimen and nutritious diet. 
Under this treatment his symptoms rapidly improved, and in 
December, 1857, he returned home in perfect health, walking and 
running with ease, without pain, but the motions of the joint were 
always limited, and seemed to be checked suddenly as if there was 
some bony effusion about the joint. He continued well during that 
and the following year, going to school and playing with other 
children without any perceptible limp; but on the 22d of Feb., 
1859, while sliding on the ice, his legs becoming more widely 
stretched apart than ordinary, he must have broken up some of 
the attachments that had formed around the hip-joint; for a few 
minutes he felt severe pain in the hip, but soon resumed his sports, 
and continued on the ice for some hours. In the middle of the 
night, however, he complained of pain in the right knee, which 
came on very suddenly, and, as he thought, without any apparent 
exciting cause. The pain increasing, I was summoned to see him 
on the 24th of Feb., when the following condition of things was 
noted. 
He was suffering acute pain in knee and thigh. Pain in knee 
constant, more severe at times, and greatly increased by the slight- 
est movement of the joint. He had had fever; pulse over 90. No 
sleep for two nights. 
Anteriorly.-On assuming the erect posture, the affected limb was 
thrown forward,everted and abducted; knee slightly flexed; pelvis 
inclined downward on that side, so that the anterior superior spi- 
nous process of the right side was an inch lower than the opposite 
side. The pectineus, gracilis, tensor vaginae femoris, sartorius and 
rectus muscles were rigidly contracted, so that any attempt to move 
the thigh on the pelvis caused motion of the whole pelvis, as if 
complete anchylosis existed. 
Posteriorly.-Same obliquity of pelvis prominent, and marked 
flatness on right side; distance from median line to trochanter 
greater than the opposite side; rima natis half an inch lower. 
Leeches to the inflamed joint were ordered, anodynes and entire 48 
REPORT ON 
rest. He was by these means partially relieved. On Sunday, the 
27th of Feb., assisted by Dr. L. Bauer and Dr. E. Lee Jones, chloro- 
form having been administered, the patient was placed in the "wire 
splint," and the sound leg being firmly bandaged to the splint, the 
pectineus, gracilis, tensor vaginae femoris, and rectus muscles were 
divided, with the immediate effect of restoring the limb to its natu- 
ral length, and the pelvis to its proper relations. It is worthy of 
note that, though under the full influence of chloroform, the semi- 
anchylosed condition of the pelvis was not in the smallest degree 
relaxed before the division of the muscles. 
He passed a comfortable night, feeling but little pain and some 
inconvenience from the constrained position. He was ordered 
nourishing diet. He continued to improve in evey respect until 
the 31st of March, when he was taken with a fever, loss of appetite, 
and headache, which was probably induced by indulging his appe- 
tite too freely. This unfavorable state subsided in ten days. From 
this time nothing untoward happened; his condition rapidly im- 
proved generally and locally; he increased in flesh. His limb was 
dressed every fourth or fifth day, passive motion being used at 
each dressing. Once or twice a week he was taken out to ride. On 
the 27th of June the splint was removed, and he was permitted to 
go about on his crutches; but by over-exercise the pain and lame- 
ness returned, and he was placed in the " wire breeches" again on the 
23d of July. He was removed from the same every six to eight 
days, washed, rubbed, and passive motion applied. This plan was 
continued until the 2d of September, when, although the pain had 
entirely ceased, the motions of the joint were very limited, and re- 
stricted so suddenly in certain movements as to indicate pretty firm 
adhesions. He was put fully under the influence of chloroform, and 
these adhesions broken up with a very decided snap that could be 
heard all over the room, and required considerable force to accom- 
plish. He was then replaced in the " wire breeches," and pretty 
firm extension applied, and entire rest, with cold water over the 
joint for some days, when all symptoms of local inflammation had 
subsided ; the treatment was then continued the same as before, only 
being more careful when applying the passive motion, to have an 
assistant hold the pelvis immovable, and at the same time the motion was 
made, firm extension was hept up by the person having hold of the 
foot. This is a most important point in practice, and frequently 
overlooked even by good surgeons and very careful observers. I 
am satisfied that I myself have not been as careful in many of my MORBUS COXARIUS. 
49 
former cases to observe this principle, as I should have been. And 
if we trust the dressing to the family or careless assistants, they 
will certainly be deceived when they are applying motion, and ob- 
tain it from the pelvis when they think they are moving the hip. 
This is one of the objections to the plan of treatment suggested 
by Dr. March and Dr. Bauer, by fixed splints in the recumbent 
posture, for, although you relieve the pain by constant extension, 
yet unless you are careful in frequently applying passive motion, 
and that done.in a proper manner, you will cure your case by anchy- 
losis. And this, when done in the straight position, is infinitely 
worse than when the case has been left to the unaided efforts of 
nature, as formerly suggested by Dr. Carnochan, for then the limb is 
flexed at such an angle as to render it much more useful than when 
entirely straight, as it will permit the patient to sit, and at the same 
time give him much more freedom of motion. 
This treatment was continued until about the middle of January, 
when I found that he could bear pressure without pain, had quite free 
motion of the limb, but not perfect, and as his general health was 
good, and no tenderness whatever about the joint, he was permitted 
to go about on crutches. These he used for about six weeks, since 
when he runs and uses his limb quite freely, and has had no further 
trouble. June 27th, 1860,1 saw young Hunt to-day, and found him 
in perfect health, walking freely without crutches, and no symptoms 
of any return of the disease. He cannot flex, or rotate the limb as 
freely as the other; but walks and runs without any limp. 
Morbus Coxarius, 2d stage-treated without division of muscles with 
my splint, permitting exercise and motion, while it keeps up extension. 
Recovery perfect. 
S. M., aged 14 (whose father has had anchylosis of his left knee 
for many years as the result of a strumous synovitis, and has also 
had exfoliation of a portion of his clavicle from necrosis), came 
under treatment in November, 1859, with morbus coxarius of the 
left hip in the 2d stage. The limb was apparently longer, ab- 
ducted, everted, flexed in the knee and hip; pelvis lowered on the 
left side, and projecting forward; natis lower than the opposite 
side, and flat; muscles around the affected joint rigidly contracted, 
permitting no motion of the joint, and giving it the appearance of 
anchylosis; when the pelvis was firmly held, flexion and rotation of 
the limb caused great pain, and the least pressure on the limb, so 50 
REPORT ON 
as to bring the head of the femur against the acetabulum, produced 
the most intense agony. The limb was much smaller than the 
other, and his general health was much broken down; no appetite, 
and but little sleep without opiates. 
Fig- li- 
S. K. M. Morbus Coxarius, second stage. Nov., 1859. 
Previous History.-In examining for the cause of this disease, I 
was informed there was none, that it came on without any cause 
eight or nine months since, and was now growing rapidly worse. 
This is the usual history of almost all cases; but being satisfied that 
there is in a great majority of cases, if not in all, a certain fixed 
point of departure from the healthy state, to which the disease can MORBUS COXARIUS. 
51 
be traced, if we are only careful enough to hunt up the evidence, 
I, therefore, interrogated him more thoroughly, and discovered that 
he had been struck with a stone over the joint more than two years 
before, which caused him great pain at the time, causing him to 
stop his play for some hours, and made him quite lame for a few 
days; but by limiting the amount of exercise, it all passed off in a 
few days, and he had quite forgotten the occurrence. He now, 
however, remembered distinctly that ever since that time he had 
always suffered in his hip whenever he had taken any very severe 
exercise, and mentioned several instances when he had been 
skating, playing football, jumping, and once after running a race. 
After all these, several times he had been compelled to keep quiet 
for some days, and was for a long time quite stiff in his hip every 
morning, and could not stand on it as well as the other. All of 
these circumstances he had nearly forgotten, and did not think they 
had anything to do with his present condition; but had been at- 
tributable to the fact of his rapid growth, and had, therefore, been 
called by his family " growing pains," and. no attention was there- 
fore paid to them. 
I have been thus particular in writing out this case, because it 
is, according to my experience, almost a type of the generality of 
cases of this disease, when it occurs in a tolerably good constitution. 
It is generally, as I have before stated, a synovitis more or less 
severe, and attributable to some distinct exciting cause; and if it 
occur in a perfectly healthy child, will pass off in a few days by the 
rest which he voluntarily gives it, without being noticed. If it 
occur in a constitution similar to this young lad, it will generally 
give a similar history, and if it happens in a strongly tainted stru- 
mous child, it will be much more rapidly developed and disastrous 
in its consequences. But in either instance, whether recent or of 
long standing, I have always been able to trace it to an exciting 
cause. 
Treatment.-I applied six leeches around the joint, and then kept 
it enveloped in cloths constantly wet with very cold water for a 
few days, until the more violent inflammatory symptoms had sub- 
sided, during which time he was kept perfectly quiet in bed, and 
his limb slightly but constantly extended by means of a weight and 
pully over the foot of the bed and attached to the leg by means of 
adhesive plaster. During this time, I think the leeches were re- 
applied once or twice. 
On the third of December, 1859,1 put on my splint, and applied 52 
REPORT ON 
as much extension as he could bear without pain in the groin, and 
gradually increased it a notch or two at a time every few hours, 
until the limb and body were brought in a perfectly straight line, 
and the twist in the pelvis entirely disappeared. This occupied 
about two days. The last day, the instrument was extended but 
little, the object having been nearly accomplished within a few 
hours after the extension was first applied. From the very hour 
of its application his pain was relieved, he slept well all night with- 
out any pain, and without the use of opiates, which he had not 
done before for months, and in a few days his appetite was perfectly 
restored, and was gratified and encouraged by the most nutritious 
and palatable diet I could suggest, and aided by the use of ale and 
other stimulants. 
The instrument was removed at night, and extension was kept 
up by a weight and pulley for a short time; but he soon discovered 
that he was more comfortable in the instrument, and, therefore, 
wore it all the time, night and day. This has been the testimony 
of every case in which I have used it, and I have now abandoned 
the weight and pulley altogether, as I find by the use of the India 
rubber tubular air cushion, there is no danger of excoriating the 
groin. 
lie was walking about in three days after the application of the 
splint, and has continued to do so all the time. 
The bandage has been renewed once a week, and the knee well 
moved at each dressing. In February a chronic or cold abscess 
was discovered between the scapulae, which gave him much annoy- 
ance and destroyed his appetite; it was opened, but lasted some 
weeks, and eventually healed by the use of iodine and pressure. 
Whether this was metastatic or not I am unable to say; but coin- 
cident with its appearance, all the distension and fulness about 
the hip-joint disappeared. No internal remedies were used but cod- 
liver oil and iron. Whenever the instrument was on and extension 
applied, he was comfortable, free from pain, could walk with ease, 
and had free motion of the joint. When the extension was re- 
moved, he could not bear any weight upon the limb, and motion 
gave him pain.1 
1 July 10,1860, walked to my office and had a photograph taken by Mead, from 
which the annexed plate was engraved, which gives a better idea of the result of 
the treatment than I can do by description. (See Fig. 12.) Can walk several 
miles without crutches, go up and down stairs with perfect ease, has no pain what- 
ever in the joint on pressure or motion, has perfect motion of the same, and is in MORBUS COXARIUS. 
53 
Morbus Coxarius, 2d stage-treated by division of contracted muscles- 
and extension in wire splint of Dr. Bauer; recovery. Return of 
disease and treated in my splint, permitting motion and exercise. 
George Brough, native of England, five years old, as far as can 
be ascertained, had enjoyed good health until May, 1858, when he 
all respects healthy. The leg is still much smaller than the other, and I have 
directed him to use the splint for some months still as a precaution, as he is going 
Fig. 12. 
Fig. 13. 
S. K. M., with instrument applied. 
Photographic view, with instrument removed. 54 
REPORT ON 
arrived in New York, to reside with his adopted parents. At that 
time they observed that the right leg was longer, and the knee 
swollen and bound with a piece of red flannel, which the little pa- 
tient stated had been put on by his grandmother previous to leaving 
England, and he had also been blistered on the knee. At times 
the pain in the knee was so severe as to prevent his foot touching 
the ground. It was noticed that in standing or walking he would 
always favor the right limb. 
This condition of things continued with but slight variation in 
the symptoms until Sunday, Feb. 13, 1859, when, for the first time, 
without any apparent cause, he experienced pain in the right hip, 
of a character so severe as to confine him to bed the greater por- 
tion of the time. 
On Wednesday, Feb. Ifoth, he first came under my observation, 
when, on examination, the following state of things was found :- 
Present Condition.-Standing (see Fig. 3, page 478), would bear 
entire weight on left leg, the right (affected) limb thrown forward, 
everted, abducted, and knee slightly flexed, anterior superior spi- 
nous process of right side one-half to one inch lower than left. Pos- 
terior aspect, pelvis presented same obliquity, right natis flattened, 
the distance from mesial line to the trochanter major of right side 
greater than left side, the rima natis lower on right side. Pressure 
over trochanter major, on the knee or bottom of the foot, produced 
pain in the hip-joint. Adduction almost impossible, and the attempt 
produced pain. The muscles connecting the hip and thigh rigid 
and firmly contracted, producing the effect almost of bony anchy- 
losis. Flexion and rotation of opposite limb perfect. 
to the country for a month or two to hunt and fish. I have no doubt that the mus- 
cles of the thigh and leg will become developed again as soon as the roller is re- 
moved, and they are permitted free use again. 
I have given this case in full, because it was the first case I treated on this plan 
of motion with the extension, and the result has been infinitely more satisfactory 
than when I treated them by perfect rest, with extension in the straight splint, 
as I formerly did. I have many more cases now which are almost exact duplicates 
of this, with the exception of the cold abscess, and it is, therefore, unnecessary to 
detail them, as one is just as good to illustrate the principles as a thousand. 
The plate (Fig. 11) shows his condition at the time of the application of the 
instrument in Nov. 1859, and Fig. 12 is a photograph by Mead, of the same case 
July 10th, 1860, with the instrument still on him. Fig. 13 is a photographic 
front view of the same case, with the instrument removed. It will be observed 
that the thigh is still much smaller than the other; but the form is perfectly 
restored, and he bears his entire weight without pain, and has perfect motion. MORBUS COXARIUS. 
55 
lie was pale and emaciated in consequence of want of sleep and 
suffering. 
Operation.-On 16th of Feb., in presence of Dr. E. Lee Jones and 
Dr. Phelps, of Bellevue Hospital, while under the influence of 
chloroform, I divided the tensor vaginae femoris, sartorius, gracilis, 
and pectineus muscles, when the pelvis assumed its natural position, 
and the movements of the joint were perfectly free. No crepitus 
detected. He was then placed in the wire splint of Dr. Bauer, 
and both limbs and pelvis firmly confined by bandages. The knee 
of the affected side was slightly flexed ; the foot everted, due to the 
action of the rectus muscle, which had not been divided; this was 
obviated by a compress and firm bandaging. On the night of the 
operation he was compelled to have a small quantity of morphine 
to relieve pain. He continued to suffer considerably, crying out 
with pain in the knee, until Sunday, the 27th, when, by bending the 
body forward, thus relaxing the rectus muscle, he was entirely re- 
lieved. Discovering this fact, I divided the rectus muscle, and he 
has remained in a comfortable state up to present time, March 7. 
Appetite good; spirits cheerful. 
March 15. Removed splint; passive motion; reapplied appara- 
tus ; everything continues progressing favorably. 
May 10. Continues to improve; when out of the splint he can 
elevate the leg to a right angle, turn the foot outwards and inwards 
with ease. Pressure of the head of the femur against the acetabu- 
lum occasions no pain. He has since improved in his general 
health ; his appetite good, bowels regular, weight increased. Every 
second or third night the limb is taken out of the splint, which is 
not applied until the next morning. No inconvenience is experi- 
enced. 
29/A. Removed apparatus, and the little patient went to church. 
June 4. He was allowed to go to the country to visit his friends. 
Getting out of the cars he twisted his leg, which the next day gave 
evidence of pain when walking. Ten days after he returned to the 
city, suffering a good deal from tenderness of the joint. The pain 
was relieved by a small blister. A few days after the splint was 
again applied. 
21s£. Everything is now progressing favorably. 
August 9. Removed the instrument, and applied passive motion. 
No pain; appetite good, and sleeps well; bears pressure of the femur 
against the acetabulum without pain ; legs of the same length, and 
pelvis straight. 56 
REPORT OFT 
Feb. 11, 1860. This little patient was again sent to me from the 
country, where he had removed in August last, with all his symp- 
toms as bad as when I first saw him. The mother stated that he 
had been well all the summer and fall, and, fearing that his leg 
would get stiff, she left off the use of the instrument early in Novem- 
ber, and after a few days he could run as well as any of the children; 
Fig. 14. 
but in the course of a few weeks, as the cold weather came on, she 
observed he would be slightly lame after any severe exercise. MORBUS COXARIUS. 
57 
One day he hurt his hip while sliding on the ice, and from that time 
grew rapidly worse, lost his appetite and sleep, suffered«great pain 
at night, requiring opiates, and was becoming so much emaciated 
that she removed with him into the city. I found him with all the 
symptoms of hip-disease in the second stage; but instead of again 
dividing the muscles, I put upon him my splint for permanent 
extension, which also admits of motion, and his deformity was 
almost immediately removed, and he could walk with perfect ease, 
without the use of crutches. (See Fig. 14, which was taken by 
Gurney in less than half an hour after Fig. 3, page 478, with which 
the reader is requested to compare it. A longer time should have 
elapsed after the application of the instrument, before the picture 
was taken, when the deformity would have been more materially 
relieved, as in Fig. 12.) 
March 27. Mrs. Brough again brought her boy to me to-day, to 
have the bandages removed, as they had become very much soiled. 
When I censured her for neglecting to bring me the case more fre- 
quently, she replied, that he got so much better and slept so perfectly 
comfortable, the first night after the instrument was applied, that 
she did not think it necessary, and that he improved so much in a 
few days, that she concluded to return with him to the country; 
and that he had been running around and enjoying himself all the 
time; ate and slept well, and that she only now came down because 
he needed a clean bandage. The instrument had not been removed 
since its first application, early in February. She had twice turned 
the key and extended the limb a trifle, and had by that means 
relieved all his pain. To my surprise, on removing the instrument, 
there was no chafing or excoriation in the groin, or other abrasion 
of the skin in any place. The bandages were renewed, and he 
returned to the country with instructions to return once a week. 
May 25. I have seen little Brough weekly since last report, and 
find him constantly improving; has grown quite stout, and his 
general health is perfectly good. The limbs are nearly the same 
length, and he can bear his weight upon the diseased limb without 
pain, when the instrument is on; but gives a slight halt when he 
attempts to walk without it. This case I feel satisfied will progress 
to a favorable recovery, but as the disease has a great tendency to 
return, I shall let him wear the instrument for some months even 
after he has entirely recovered, as a matter of precaution. And 
this is the great advantage of this plan of treatment over that I for- 
merly adopted, that it permits free exercise, and the child can enjoy 
5 58 
REPORT ON 
all his out-door sports, running simply with his knee stiffened by 
the splint, which he soon learns how to accommodate himself to. 
Case of Hip-disease, 2d stage-puncturing of the joint for excessive sero- 
purulent effusion-gradual and perfect recovery.1 
Mary Corbitt, aged five years and nine months, well developed, 
and rather of robust frame, though pale and sickly looking when 
taken in charge on the 4th of June, 1857. Parents healthy, and 
no trace of tuberculosis in the divers lineage of their ancestors. 
The patient had sustained a severe fall from the lower steps of 
a staircase directly upon the left hip-joint • pain immediately ensued, 
but gradually subsided again so as to leave the patient comfortable 
and ease in locomotion. Months after that accident had elapsed, 
before the little girl manifested any symptoms of uneasiness and 
febrile disturbance, she showed very little disposition to walk, was 
easily tired, and would lean upon objects for support, on account of 
her weakness. In fact, the accident had been entirely forgotton. A 
physician being called in, pronounced the difficulty of a gastric 
character, advising gentle purgatives and restricted diet. But this 
course of treatment brought no relief; on the contrary, the child 
grew worse, became more pallid, lost flesh, passed very uneasy 
nights, refused food, and drank much water. In this way the dis- 
ease continued for weeks and months, the patient pining away, 
when on dressing her, it was noticed that her frame had become 
seriously distorted, the left extremity rather elongated, its toes 
everted, and that the left hip-joint had assumed a peculiar shape. 
Moreover,- and for the first time, pain was discovered in that joint. 
At this juncture, another physician was consulted, who pro- 
nounced the disease "coxalgia," established issues in the neighbor- 
hood of the affected joint, prescribed cod-liver oil, generous diet, 
and to be carried or driven about in the open air, with the exclu- 
sion of active exercise. 
For a few days the treatment seemed to be beneficial; the little 
patient looked more cheerful and contented; appetite improved 
slightly, and enjoyed better sleep. But this improvement proved 
itself of no duration. Again signs of fever and general discomfort 
rose, and with them more pain in and about the affected joint set 
in. The child was tortured with excruciating nocturnal pains, 
1 For the notes of this case, I am indebted to my friend Dr. Bauer. MORBUS COXARIUS. 
59 
which threw her into profuse perspiration; although to all appear- 
ance sound asleep, she would cry out every few minutes, raising 
herself into the sitting posture and sink quietly back again in 
order to be painfully aroused in the same way: this would occur 
repeatedly every night. 
When the disease had advanced to this stage, the patient was 
placed under my charge. In addition to all the symptoms already 
described, the patient presented, on more close examination, the 
following morbid appearances. 
"Left extremity apparently elongated, abducted, and besides 
everted: slightly bent in hip and knee-joint; pelvis projecting and 
inclining downward on that side; natis flat, left buttock below the 
right;" linea internates oblique towards left; spine thrown out of 
its perpendicular, single curvature with its convexity to the left. 
Pain on moving the left extremity, which is slightly attenuated; 
immobility of the left hip joint, all motions being produced by the 
pelvis on the opposite hip articulation. But when quickly moved 
allows a slight degree of flexion and extension, but no particle of 
adduction. The joint highly tender on concussion of the thigh, but 
relieved on extension. By pressing upon the circumference of the 
affected joint, besides great tenderness, there is a sort of round 
puffy fold which evidently fluctuates. Otherwise there is no dif- 
fuse fluctuation anywhere, but some cedematous swelling around 
the joint. 
On examining the pelvic cavity per rectum, there is no perfora- 
tion or thickening of the tissues about the acetabulum. The sub- 
sequent examination of the joint and its environs under chloroform, 
gave no other results than those mentioned. 
As to the nature and advancement of the disease there could be 
no doubt, and it was therefore set down as "traumatic morbus cox- 
arius," with considerable effusion of most probably a sero-purulent 
character. State of the articular surfaces dubious, and its diagnosis 
deferred. 
After three days' preparatory treatment, the patient was brought 
under the influence of chloroform and the left hip-joint punctured by 
means of a fine trocar, when about six drachms of sero-purulent 
liquid was discharged through the canula, whereupon the joint 
was surrounded with adhesive strips and the patient subsequently 
placed into the well lined " wire breeches." 
During the ensuing fourteen days the patient was completely 
relieved, the local as well as the general symptoms positively 60 
REPORT ON 
silenced. It was indeed wonderful to notice the rapidly returning 
signs of health under the ease and comfort of the condition thus 
secured. 
But this improvement was not of long duration, for in about two 
weeks after the operation the joint had gradually filled again, the 
limb had reassumed the previously described malposition, and the 
local and general symptoms had again become aggravated. Under 
these circumstances it was decided upon to withdraw once more 
the articular contents, which I did by a subcutaneous incision into 
the joint, according to the method of Goyrand. But from a few 
drops of the articular effusion escaping from the wound incident- 
ally, its purulent serous composition was noticed. 
This second operation was performed with the same immediate 
beneficial effects, the pain was relieved instanter, the limb could 
be brought into any position, and no crepitus was noticed on this 
occasion, hence it was inferred that we had to deal with purulent 
synovitis only. 
From this time to the ultimate discharge of the patient in Novem- 
ber following, the patient progressed favorably, the treatment 
having been the same as I have described in the other cases. 
Two years after I saw her again, and I exhibited her to quite a 
number of physicians. The limb had then acquired almost perfect 
position, and the joint a moderate freedom of motion. 
Evidently some fibrous adhesion had formed restricting perfect 
motion, but I did not deem it prudent to break them up at that 
period, apprehending recurrence of the disease. This, however, will 
be done at a future occasion if opportunity is offered. 
Her general health was perfect. 
Case.-Morbus Coxarius, six mouths'1 duration; used splint three months; 
recovery without deformity, and motion perfect. 
W. P., aged seven, fell down a flight of stairs in fall of 1859. 
Had some pain in hip and back for a few days, but was not con- 
fined to his bed, and after a short time ceased to complain of any 
pain, until Dec., when he began to complain of his left knee, and 
was slightly lame every morning. These difficulties increased, 
until he was confined to his bed in Jan. 1860, and suffered much 
from spasms every night. His limb became much contracted at 
the knee and hip, and was intensely painful, upon any attempt at 
motion. These symptoms grew more and more severe, until I was MORBUS COXARIUS. 
61 
called to see him the 1st of March, 1860. I found him on his back, 
with his leg on a pillow, and slightly everted and abducted. Any 
attempt at flexion or adduction gave him great pain, as also did 
pressure on the trochanter, or against the heel. There was an 
eruption on the knee and lower portion of the thigh, like eczema; 
but whether it was from the treatment he had received or not, I 
was unable to say. It was a well-marked case of hip-disease, far 
advanced towards the second stage, complicated with eczema of 
that limb. I applied lapis caliminaris to the limb, and extension 
by means of a weight and pulley, and put him on the use of cod- 
liver oil and iron, internally. In about ten days Dr. Parker saw 
him in consultation with me, and I applied my splint, and put on 
moderate extension, when he \vas relieved of his pain immediately. 
In about two weeks he was running around the streets, with the 
instrument on, without the use of any crutches, and his general 
health improved most rapidly. The bandages had to be removed 
about twice a week, for the first month, on account of the eczema, 
but after that only once in eight or ten days. The plaster was 
never reapplied but once during the treatment. 
He wore the instrument constantly until the 1st of June, when 
he was completely cured, and had every motion of the joint per- 
fect. The limb was somewhat smaller than the other; but there 
was no pain whatever on pressure around the joint.1 
Exsection of the head of the femur and removal of the upper run of the 
acetabulum for morbus coxarius. 
On the 20th of March, 1854, I was called, in consultation with 
Dr. Throckmorton, to see Ellen G., 297 Fifth Street, aged 9 years, 
who had been suffering for 18 months with morbus coxarius of the 
left hip, which was supposed to have resulted from a fall. She had 
been treated with issues, blisters, etc., together with the general 
tonics, and anti-scrofulous remedies adapted to such cases ; but the 
disease continued to progress, until an abscess was discovered, in- 
volving the whole upper front and inner portion of the thigh, 
accompanied with repeated chills, profuse sweats, and great pros- 
tration. 
When I first saw her, this abscess had pointed in two places, 
1 Nov. 1860. This little patient remains in perfect health, and his limb has 
grown nearly as large as the other. This case is a fair type of many that I have 
treated in the same way since. 62 
REPORT ON 
and apparently just ready to open; the point nearest the surface 
and most fluctuating was just by the anterior superior spinous pro- 
cess of the ilium, immediately in contact with the attachment of the 
tensor vaginae femoris muscle, and Poupart's ligament. The other 
place of pointing was about five inches below the ligament, just 
over the femoral artery; pressure on any part of the upper portion 
of the limb distended both of these pointing abscesses, showing 
communication between them. 
The leg was shortened 2| inches, and turned inward, but not per- 
manently fixed in its position (as is usual), but allowing of consider- 
able motion, which gave a distinct bony crepitus between the femur 
and ilium. The pelvis was twisted and drawn upwards. Her 
general health had become much affected, having lost her appetite, 
and she was suffering from hectic, with constant chills and profuse 
sweats, and was only rendered comfortable by the constant use of 
anodynes. 
I advised a free opening of the abscess, and, if necessary, to re- 
move the head of the femur. At first this was objected to; but, as 
the child's health rapidly failed and death seemed inevitable, the 
father, in a few days, consented to the operation. Accordingly, on 
the 29th of March, 1854, assisted by Drs. Throckmorton, Drake, 
Thebaud, Bauer, and Bertholf, I proceeded to perform it. 
I first laid open the abscess by a free incision of about six inches, 
over the trochanter major, on the outer aspect of the thigh, and in 
a line with the femur, and then cut into the floor of the abscess 
(which principally occupied the inner and front portion of the thigh), 
and discharged about a pint of thin serous and flaky pus. The 
finger was then readily passed around the neck of the femur, and 
detected an opening in the capsular ligament on the inner surface 
of the neck. The upper border of the acetabulum had been ab- 
sorbed, and the head of the femur was upon the dorsum of the 
ilium, near the anterior superior spinous process, surrounded by its 
capsule (which seemed to have been slipped up), and a large deposit 
of bone, apparently being an attempt of Nature to make a new 
acetabulum. But this cavity thus formed had no lining membrane, 
as the femur grated roughly upon it. I then opened the capsular 
ligament on a line with the external incision, and disarticulated by 
bringing the leg strongly across the opposite thigh, and then, with 
a large pair of Luer's forceps, readily cut off' the head of the femur 
at the lower extremity of the neck. The bone at this point ap- 
peared perfectly healthy. I was very cautious not to injure the MORBUS COXARIUS. 
63 
insertion of the psoas-magnus, or iliacus-internus, or any of the 
rotator muscles, which are inserted just behind the trochanter 
major. 
The upper rim of the acetabulum had been absorbed (according 
to the theory of Dr. March, of Albany), and the new deposit of bone, 
which was intended to supply its place, was denuded and carious. 
I gouged it off with a sharp, firm chisel made for that purpose, and, 
in this way, took off a number of flakes of bone, until I came to a 
healthy, bleeding surface. 
The anterior superior spinous process on its outer surface, and 
the external lip of the crest of the ilium, was black and carious 
for some distance, and with the forceps I easily clipped it off* until 
I came to healthy bone. Very little blood was lost in the opera- 
tion, and after cleaning away all the debris, I brought the leg in the 
straight position, filled the wound with lint, and dressed with a 
roller and cold water compress. She was then put to bed, and a 
cup of strong coffee administered, after which she soon fell asleep. 
The child was under the influence of chloroform during the 
operation, which occupied nearly 20 minutes, and was perfectly 
insensible the whole time. 
The following extracts from my note-book, taken at each daily 
visit, exhibit the progress of the case :- 
11 P. M. Has slept occasionally and is quite comfortable; pulse 
128 ; skin good; vomited freely about 4 P. M. 
March 30, 10 A. M. Passed a good night, without any narcotic, 
and slept about four hours; has had no chill; taken breakfast 
with a relish, and is surprisingly comfortable, considering the 
magnitude of the operation; pulse 120; no hemorrhage; passed 
urine twice. 
31s<. Took half a grain of opium last night; slept well; pulse 
120; skin good; removed external layer of lint; found small 
amount of pus. 
April 1. Slight fever; heat of skin and thirst; pulse 130. Ad- 
ministered 5 gr. Dover's powder, with addition of half a grain ipecac., 
every four hours. 
2c?. Has passed a good night, slept six hours, ate a good break- 
fast, and feels every way better, but is much more feeble; dressed 
the wound; on removing the lint found healthy pus in abundance. 
The abscess, which pointed at the anterior superior spinous pro- 
cess, being again full and fluctuating, I opened it, and gave exit to 
about a tablespoonful of tolerably healthy pus; pulse 140, and more 64 
REPORT ON 
feeble; directed to administer brandy and beef-tea liberally. I do 
not think the family give sufficient stimulant or nourishment, as 
they are very strongly opposed to brandy, and are afraid of meat 
on account of fever. 
3<f. Slept well all night without opiate; pulse 120; bowels moved 
twice naturally; appetite good ; finding great improvement follow 
a more nutritious diet, I advised its continuance. 
4th. Same as yesterday; healthy suppuration rather abundant. 
5th. Child very comfortable, amusing herself by cutting paper 
dolls ; applied the straight splint for counter-extension to the well 
side, and made extension by means of the foot board, bringing the 
limb down to the same length of the opposite one. 
6th. Slept well; bowels moved naturally; but pulse more quick 
and feeble, 160; has not eaten so well; ordered brandy and soup 
to be given.more liberally. 
7 th. Slept well, but much weaker, having had three loose dis- 
charges in the night, and some hemorrhage from the nose, which 
was arrested by astringents and compress. Ordered brandy and 
laudanum, with liberal use of iron. 
Sth. Diarrhoea not yet checked; the brandy and opium were not 
given, and yet the child is somewhat stronger than yesterday; pus 
more consistent. 
9z/z. Diarrhoea checked; slept well; eats freely; discharge less 
copious and more consistent; pulse 120. 
IOzZz. Very comfortable; looks as if it will require a counter- 
opening on the front of the thigh, at the old place of pointing. 
137/z. Doing well, and the wound filling with healthy granula- 
tions. 
\4th. I applied a compress and adhesive straps on the inside of 
the thigh. 
July 1. Dr. Throckmorton has seen the child daily since my last 
visit, and reapplied the bandage and compress, which has had a 
most salutary effect, and the abscess has the appearance of healing 
rapidly. 
10Z/i. I was again called to meet Dr. T. to-day, and found the 
child much prostrated from a severe attack of dysentery, which had 
lasted four or five days; she is very much reduced, and I fear will 
not rally. The granulations are flabby, and pus thin and copious. 
August 1. The dysentery has been checked for some days; but 
the wound, which was nearly closed, has opened, and a small piece 
of ragged bone came away, which was probably some portion of MORBUS COXARIUS. 
65 
the shavings or chips removed from the ilium at the time of the 
operation, and which I had not been sufficiently careful to remove.1 
20zA. The child very much improved, but the fistulous opening, 
from which the piece of bone had escaped, remaining, and having 
rather a white and flabby appearance, I injected it with tincture of 
iodine. 
The injection has been followed by a smart attack of ery- 
sipelas, which lias extended down some distance below the knee, 
and there is considerable constitutional disturbance. 
Sept. 1. The erysipelas gradually subsided, but seems to have 
been of great service, as it has caused union of the walls of the 
abscess all around the thigh, and the small opening in the cicatrix 
is nearly closed, discharging a very few drops of healthy pus. 
The limb is still in the extending splint; but on removing it there 
seemed no tendency to retraction of the limb. The splint was re- 
applied ; but the body was left free from the bandage, so as to 
allow of flexion in order to prevent anchylosis. 
I might here mention, that for some weeks past, since about the 
1st of August, at each dressing her body has been brought at a 
right angle with the thighs, having this object in view; and I have 
now permitted her to do it as often as she likes. 
Abv. 1. I had not seen the case for two months until to-day, 
when, to my astonishment, I found her walking on her crutches, 
which she has been able to do for some two weeks. Her limb 
appears the same length as the other, and she can flex and rotate 
it freely. I directed her to bear no weight upon it yet. 
To-day I placed her in the horizontal position, and mea- 
sured her carefully, and find there is about one-eighth or nearly one- 
fourth of an inch shortening. By taking hold of the foot, the whole 
body can be drawn down in bed without pain in the joint, and a 
pressure may be made sufficiently strong to move the pelvis and 
body upward without producing any shortening of the limb. When 
she lies upon the back, with the leg extended upon the thigh, she 
can elevate the heel sixteen inches from the bed, and flex the knee 
1 Since making this note, my impressions have been more confirmed, as two 
similar pieces of bone have been removed from different parts of the cicatrix, and 
have thus materially retarded the progress of the case ; I should therefore advise 
great care, after the performance of this operation, that all debris and foreign 
bodies be carefully washed from the wound ; and in so large and ragged an abscess 
as this one was, it will require more care than any one would imagine, unless they 
had seen it. 66 
REPORT ON 
so as to bring the thigh at a right angle with the pelvis; she can 
rotate it internally so as to touch the other foot, and externally so 
as to touch the bed. Her general health is perfect, and the case 
has terminated perfectly successfully. I feel in duty bound to ex- 
press, in this place, my warmest thanks to Dr. Throckmorton, for 
his constant care and attention of this interesting case, and to which 
I am confident I am greatly indebted for so successful a result, as 
the distance from my house rendered it impossible for me to give 
it the care required. 
The bone was carefully examined, microscopically, but no trace- 
of tubercle was found. 
It is now nearly seven years since this operation was performed, 
and the patient is as large, active, and robust as most of young 
ladies of her age; can dance, waltz, and run as actively as any of 
her playmates, and about two months since was presented at a 
meeting of the Surgical Section of the N. Y. Academy of Medicine, 
held at Dr. Jas. B's. Woods, and was there examined critically, 
when all of the motions of the limb were found perfect, even to 
flexion, which was so complete that she could bring her knee 
almost to her chin, and she could run up and down stairs with as 
much ease and rapidity as any other person. 
Case of Morbus Coxarius of more than three years' standing-perforation 
of acetabulum-external abscesses-operation resorted to merely as a 
palliative measure to relieve pain-perfect relief afforded-death on 
the 8th day. 
Oct. 12, 1859. Raymond, 152 Hicks Street, Brooklyn, aged 11; 
has hip-disease of four years' standing; emaciated to the greatest 
possible degree; pulse 140 to 160, and has been so some weeks. A 
large open abscess over the right trochanter major of the right side, 
two on the inside of the thigh about four inches below Poupart's 
ligament, and one on the outside, about five inches below the great 
trochanter. An inflamed slough over both tuber-ischii, and 
another at the end of the coccyx. The thigh was flexed strongly on 
the pelvis, and the pelvis much twisted, so that the limb appeared 
nearly three inches shorter than the other. The general appearance 
of the boy's position was very similar to J. C., only more abducted. 
(See Fig. 7, p. 502.) The diagnosis was hip-disease in the third 
stage, and far advanced ; and I feared the acetabulum had become 
perforated, but, upon examination per rectum, I could not feel the MORBUS COXARIUS. 
67 
head of the bone rotate, as we can do usually when the base of the 
acetabulum is broken away. Neither could I feel the smooth flat 
surface of the plane of the ilium, which is opposite the acetabulum ; 
but there was a large, round, firm tumor projecting inwards to- 
wards the opposite side, and nearly half filling the pelvis, making 
quite a bulging projection into the side of the rectum, and which 
eventually proved to be an immense abscess connecting with the 
perforated acetabulum; the pus was retained between the bones 
of the ilium, ischium, and pubis, and the periosteum of these bones, 
which had been peeled off from them and carried inward, and in 
this manner formed the bulging mass I felt, and which prevented 
me from feeling either the flat surface of the ilium or the head of 
the femur through its perforation. I ought, however, to have made 
out the case as abscess behind the internal periosteum, and then I 
would not have operated; but I did not, and I have thus minutely 
detailed the case, in order that others may not commit the same 
error. Had I made an accurate diagnosis of this abscess, it is pro- 
bable that the better treatment would have been to have punctured 
it through the rectum, as I would thereby have secured the same 
relief that I obtained by a much more formidable operation. 
Drs. Parker, Hossack, and Cockroft saw the child with me, and 
we all considered it a hopeless case for operation at the time; 
but consented to perform it if he could be rallied a little, and 
recommended nutritious and sfa'muZaZwiy diet. (It is but proper 
here to state that he had never had a physician to see him before, 
and that the disease had never been diagnosticated, or even sus- 
pected until that time. He had been under the constant care of a 
celebrated homoeopath, who treated him for neuralgia of the hip, 
but no physician had seen him until our visit. And I make this 
statement injustice to the profession.) 
The following day the father called on me and begged me to 
perform the operation at once, as he had now a correct idea of the 
condition of his child, and feared that he would not improve until 
the cause of the difficulty was removed. But as he had eaten no 
meat or any other substantial diet for nearly four years, I positively 
refused, as I did not think he could live through the operation. 
He continued to importune me daily in this way, and, as the 
child's sufferings were so intense and agonizing, I finally consented 
to perform the operation of exsection, not with any prospect of 
successful recovery, but merely as a means of relief to his suffering, 
and that he might have some comfort during the few remaining 68 
REPORT ON 
days of his life. And on the 20th October, 1859, assisted by Drs. 
Cockroft, Miner, and E. Lee Jones of New York, and Dr. Bauer, of 
Brooklyn, I proceeded to exsect the hip-joint. The boy was placed 
fully under the influence of chloroform (Squib's) by Dr. Jones, and 
then removed from his bed to the operating table in another room ; 
and by a straight incision over the trochanter, and up on the dorsum 
of the ilium, in a line with the shaft of the femur when straight, I 
came at once down to the bone through the periosteum, and, find- 
ing the capsular ligament ruptured, disarticulated the head of the 
femur, and sawed it off just below the trochanter major. On re- 
moving the head of the femur from the acetabulum, a large amount 
of very offensive pus gushed out, and we discovered that the 
acetabulum was perforated by a large irregularly oval opening an 
inch in diameter, and into which the irregular shaped head of the 
femur fitted like a bung in a barrel, and from which pus flowed 
freely, and was much increased at every inspiration and when 
coughing. The finger passed in at this opening glided down on 
the plane of the ischium to the tuberosity, back on the inner cavity 
of the ilium for nearly an inch, and forward on the body of the 
pubis to nearly the symphysis; this whole extent of bone was 
denuded of its periosteum, which was not destroyed, but had been 
separated from the bones and pushed inwards, and formed the inner 
wall of the abscess, which was contained between the periosteum 
and the bone; and on which account I had not been able to feel 
the head of the femur, in my examination at the time I suspected 
the perforation as above stated. The father now told us that he 
fell out of bed about six months previous, and struck upon the 
trochanter, and since that time his leg had been in exactly the 
same position as we first found it, and more abducted and fixed 
than it was previous to the fall. It is therefore probable that the 
head of the femur was thus forcibly pushed through the acetabulum, 
and the periosteum not ruptured but separated from the bone, thus 
making a pocket for the retention of matter. And in order that 
it might have a free escape, I therefore with strong forceps divided 
the ilium and ischium at the outer border of the acetabulum, and 
ischium and pubis at the inner, and cut out the entire plane of the 
ischium almost to the tuberosity; it was entirely denuded of peri- 
osteum on both sides, and only had attachment at the insertion of 
the ligaments. I also removed the upper and outer border of the 
acetabulum, and almost the entire body of the pelvis. MORBUS COXARIUS. 
69 
The internal layer of periosteum was not wounded at all, so that 
no communication was made with the peritoneal cavity whatever; 
but the periosteum which had been peeled off from the inner wall 
of the pelvis, and was bagged inwards by the pus retained between 
it and the bones, now fell down to its natural level, and was the 
only partition between the intestines and the external world. 
The operation was necessarily tedious, occupying nearly twenty 
minutes; but he suffered no pain whatever, being under the con- 
stant use of chloroform, and he did not lose more than an ounce 
of blood. No vessels required ligature, the wound was filled with 
dry lint, and the patient removed to his bed. In a short time he 
waked up, and anxiously inquired if I would not oblige him by 
performing the operation before I left, and was quite delighted and 
astonished to find it already accomplished. A cup of strong beef 
broth with brandy and eight drops of morphine was administered, 
with instructions to repeat every four hours if he was awake, and 
if he slept to omit the morphine, but not the others. 
21s£. Pulse 120; skin soft; no pain; a good night's sleep, better 
than he has had for eight months; eats well, and very comfortable; 
countenance much improved. 
2 2 <7. Pulse 112 ; otherwise same as yesterday, but very weak, 
although the suppuration is not so great as before the operation. 
He continued in this condition of comparative comfort; but 
gradually growing weaker, died on the eighth day after the ope- 
ration from exhaustion. 
Post-mortem examination revealed caries of almost the entire 
ilium of that side, which was denuded of its periosteum on both 
its external and internal surface. The periosteum was peeled from 
its inner wall entirely, but was not perforated, so that no pus was 
found within the peritoneum, and although he had this extensive 
pelvic abscess, yet it did not connect with any of the pelvic viscera, 
lie had tubercles in the lungs and also in the kidneys, the latter 
organs having partially undergone the fatty degeneration. Even 
in this case, although tubercle was found abundantly in the lungs 
and kidney, yet no tubercle was found in the diseased bone by the 
most careful examination. The emaciation in this case was so ex- 
cessive, that we measured the height and weight of the body; 
height four feet nine inches, and weighed only forty pounds. 70 
REPORT ON 
REMARKS. 
The history of exsection of the head of the femur in hip-joint 
disease lies within the present century. The first surgeon who 
suggested the possibility of exsection of this bone was Mr. Charles 
White, in 1769; but the first to attempt its performance in morbus 
coxarius seems to have been Schmalz, in 1817. In this case the 
head of the bone was found loose, and simply required removal; 
the cases of Sclitching,1 Hoffman, Batchelder, and Klinger, are 
similar to that of Schmalz. 
In 1818, Anthony White performed his celebrated operation, 
which has generally been referred to as the first successful attempt 
to exsect the head of the femur in morbus coxarius. It seems to 
have been repeated but by two surgeons, until the year 1845, viz., 
Hewson, of Dublin, in 1828, and Textor, Sr., who operated four 
times, once in 1834, once in 1838, and again in 1839, all terminat- 
ing unsuccessfully. Textor operated again in 1845, which was 
perfectly successful, the man obtaining his living afterwards as a 
peddler. Mr. Fergusson has operated five times, and with uniform 
success; one patient died two years after the operation "of enlarge- 
ment of the liver, after having experienced great relief from the 
proceeding." Mr. Fergusson states (Med.-Chir. Trans., vol. xxviii.) 
that he has learned that Mr. Brodie performed this operation, and 
"the patient died within a few days after, the direct effect of that 
proceeding;" but Mr. Henry Smith, writing in 1848 {Land. Lancet'), 
remarks that he has not been able to "obtain any accurate infor- 
mation respecting the correctness of this assertion." There is no 
doubt, however, that this surgeon did exsect the femur at St. 
George's Hospital about the year 1836, but under what circum- 
stances and with what result, I have been unable to ascertain. 
Carmichael, of Dublin, has been supposed to have performed this 
operation in 1820; but it is more than probable that the case has 
been confounded with an exarticulation for medullary sarcoma 
which he made at that time. 
In this country this operation seems to have attracted but little 
attention until I published my first case in the New York Journ. Med. 
for Jan. 1855, and which is condensed in this report (No. 38). This 
was the first successful case operated upon in this country, and I 
1 Sclitching's case was one of exfoliation, and not of exsection, and is the first 
case of this description ever reported, as far as I can discover. It occurred in 
1720. (See Philosophical Transactions for 1742.) MORBUS COXARIUS. 
71 
thought at the time, the first time the operation had been performed 
here; but I afterwards learned that Dr. Bigelow, of Boston, had 
performed it a year before, but had not published the case. Dr. 
Bigelow's case terminated fatally on the twelfth day; mine is there- 
fore the first successful case recorded in this country. Since that 
time the subject has attracted a great deal of attention, and the ope- 
ration has been performed seventeen times: by Dr. Bauer 9, Markoe 
2, Church 2, Carnqchan 1, A. B.Mott 1, Hewson 1, Kinlock 1, and 
I have performed it twice since. It may have been performed by 
other surgeons, but I have been unable to obtain any evidence of it.1 
A case is reported in the A". K Med. Surg. Rep., Jan. 10, 1846, 
in which Dr. S. P. Batchelder, of this city, removed the head of the 
femur in 1845, under the following circumstances: A young man 
was kicked by a horse upon his hip four or five years before, which 
gave rise to severe symptoms; fistulous openings formed and dis- 
charged pus freely; the probe finally detected dead bone ; the fis- 
tula was dilated with sponge tents, and the dead bone picked out with 
forceps, which proved to be the head of the femur; the patient now 
rapidly improved and eventually recovered. This could not be 
called a case of exsection, and I have therefore not included it in 
my tables. 
I have heard that Dr. Parkman, of Boston, exsected this bone in 
1853, but have been unable to obtain any particulars of the case. 
By a careful examination of the accompanying table, I think the 
propriety of the operation will be admitted. We might maintain 
its importance also, from the fact that it is but following the indi- 
cations of nature. 
The cases of Kluge, Batchelder, Vogle, Sclitching, and Harris, in 
which the head of the femur was found separated from the shaft, 
are examples of natural efforts to remove the foreign body. Two 
striking instances of this kind were reported to the Zhz&Zm Patholo- 
gical Society, in 1839, by Dr. Carlile, who exhibited two specimens 
of the epiphysis of the femur, which had been spontaneously dis- 
charged in two cases of hip-disease. One patient was twenty years 
of age, the other five; both rapidly and completely recovered. 
In preparing the following table, regard was had to exsection in 
morbus coxarius only, as it is in reference to this particular class 
1 Nov. 24th, 1860. Since this report was written, I have exsected the head of 
the femur for morbus coxarius in two cases, both of which were successful; one of 
the patients, after the wound had completely healed, died of dysentery ; the other 
is now going around with a useful limb, and almost perfect motion in the joint. 72 
REPORT ON 
of cases that we wished to estimate the value of the operation. I 
have, however, collected all the cases of exsection that I could find 
for gunshot wounds, and arranged them in another table, amount- 
ing in all to twelve cases, of which eleven died, and only one 
recovered; thus showing a much greater fatality in operations 
for recent injuries than where it is done for chronic disease. In 
the one case, the operation more nearly resembles a wound of a 
healthy joint, and consequently is attended with the same dangerous 
consequences; whereas in the other instance, the parts have lost all 
the characteristics of a joint, and are in fact nothing more than a 
bone abscess, and an incision or exsection is attended by no con- 
stitutional disturbance; but on the contrary has invariably given 
great relief to the constitutional symptoms, even if the case did not 
eventually terminate successfully. I wish to acknowledge my ob- 
ligations to my friend Dr. Voss, for valuable assistance in prepar- 
ing the following tables, in giving me the translations from the 
German literature on the subject. 
It will also be observed by a reference to the tables, that the 
cases which have been operated upon for an acute disease, and of 
but short duration, have been more fatal than when the disease has 
been of long standing, and a lower grade of inflammation. (/See 
Cases 98, 107, 108, and 63. 
To arrive at the most satisfactory conclusion in regard to the 
propriety of this operation for Morbus Coxarius, each case ought 
to be separately examined, and all the complications duly con- 
sidered. And even in cases where the disease has so far progressed 
that we have no prospect of a successful result, the question arises 
whether we ought not to perform it merely as a palliative pro- 
cedure, in order to prolong their life, and render their lingering 
days more comfortable by giving a relief to pain, as in the cases 
(63 and 94) where there was no hope of recovery, the acetabulum 
being perforated, and the ilium much diseased; and yet the ease 
and comfort given to the patients by the operation in each case 
fully justified its performance even as a palliative measure. 
By a careful examination of all the fatal cases, and the cause of 
death as far as given, I have been unable to trace a single instance 
in which the operation could be ascribed as a cause of death. 
Hewson's Case.-Died three months after the operation ; profuse 
suppuration; extensive disease of the cotyloid cavity, with per- 
foration of the acetabulum, and abscesses in the pelvic cavity. 
Textor's First Case.-Died on the twenty-third day, from exces- 
sive suppuration. MORBUS COXARIUS. 
73 
Textor's Second Case.-Gangrene of the wound took place, and 
the patient died on the fourth day. 
Textor's Third Case.-Died on the fifty-third day after the opera- 
tion from extensive sloughing of bed-sores on the sacrum: on 
examination, the wound was found nearly cicatrized; there was 
the commencement of a false joint, consisting in bony deposits on 
the femur, and a depression of the ilium. 
Smith's Case.-Died in four and half months, with Bright's dis- 
ease of the kidqey, and caries of the vertebrae, but his pain was 
greatly relieved, and his symptoms improved after the operation. 
Fergusson's Case.-Died after two years of enlargement of the liver; 
wound never entirely healed owing to a piece of necrosed hone from 
the edge of the acetabulum, which the trochanter major prevented from 
escaping. The operator remarks: " I left the trochanter, being 
under the impression that by taking away the diseased head of the 
femur only, I lessened the danger; but it was found in the after- 
treatment that the trochanter major so projected outward in the 
line of incision as greatly to retard the closing of the wound, and 
I had no doubt, on inspection after death, that it had acted as a 
kind of cap to the acetabulum, and prevented the necrosed portion 
of the bone, above referred to, from getting out."1 
Roux's Case.-Died on the seventh day from secondary hemor- 
rhage, the rough section of the femur producing slough of the 
femoral artery. Post-mortem revealed a large collection of pus 
between the glutei muscles; extensive disease of the cotyloid cavity, 
and of the femur below its section; pus in the medullary cavity, 
and disease of the pelvic bones; thus proving the necessity of an 
earlier operation, and also showing the importance of carefully 
applied splints and extension after the operation, by which means 
the perforation of the artery might have been obviated. 
Sayle's Case.-Wound healed; but abscess formed subsequently,, 
and did not progress favorably; particulars not given, but it is pro- 
bable there was diseased bone left. 
Watson's Case.-Particulars not given. 
Hawkins's Case.-Died on the third day ; although his patient 
was very much exhausted, she suffered but very little from the ope- 
ration, and was much relieved and improved for two days. 
On post-mortem examination the acetabulum was found perforated 
1 We do not learn that he used any extension-if so, this should not have 
occurred. 
6 74 
REPORT ON 
so as readily to admit the passage of the finger, and pus was in the 
pelvic cavity. 
Erichsen's Case.-We have not full particulars; all the author 
says is " rapid improvement; suppuration became profuse; died 
some months after." 
Bigelow's Case.-Died on the twelfth day; acetabulum perforated 
one-quarter to one-half an inch in extent, and extensive caries re- 
maining. 
Bauer's First Case.-Died eighteen months after the operation of 
convulsions. The wound nearly healed, and had been much im- 
proved by the operation. 
Bauer's Second Fatal Case.-Died after twelve months of croup; 
the wound having done well. 
Bauer's Third Case.-Died of uraemia and convulsions twelve 
months after the operation. 
Bauer's Fourth Case.-Died in four months from inanition and ex- 
haustion, the caries still progressing. In both of these last cases 
the operation was not performed with any prospect of a successful 
termination, but simply to afford relief from suffering, and make 
the patients more comfortable; and the result in both instances 
was so perfectly satisfactory in this respect as to fully justify the 
operation in each instance. I saw these cases before and after the 
operation, and therefore feel authorized to make this remark. 
Kinloch's Case.-Died in thirty hours; no particulars given. This 
is the shortest time of any. 
Holston's Case.-Died in seven days; but we must recollect this 
was the most extensive removal of bone, taking away a large por- 
tion of the ilium, ischium, and pubis; and the suppuration was 
very profuse previous to the operation, and the patient much pros- 
trated. 
Marhoe's Case.-Died in thirteen days; perforation of the aceta- 
bulum ; purulent infiltration of the whole upper part of the thigh, 
and pus in the femoral vein. Had this case been operated upon at 
the proper time, I have no doubt it would have been as successful 
as his first case. 
Keuchler's Case.-Died of acute tubercular meningitis six months 
after, the wound having healed entirely, and the patient was able 
to elevate the limb. 
My Second Case.-Died on the eighth day, having been infinitely 
more comfortable during those seven days than he had been for 
months. Had not a single paroxysm of nocturnal pain, which MORBUS COXARIUS. 
75 
formerly and for months had given him such torture; but slept 
well all night, and ate more food in one day than he had done 
before in several. 
In this case I performed the operation merely as a palliative, 
with not the slightest hope of success ; and the satisfaction of 
seeing the little fellow's smiling face during the few days he lived, 
when compared with his agonized expression previous to the 
operation, more than compensated me for its performance. 
Church's Case.-Which was another hopeless one, having existed 
eleven years, was followed by immediate relief of all his painful 
symptoms; appetite improved, and he slept comfortably without 
anodynes. In fact, he improved so much that I began to think 
there was a slight chance that he might possibly recover, when 
erysipelas and fever began to appear at the hospital, and he gradu- 
ally sunk and died at the end of three months. On post-mortem 
examination, the ilium was found extensively carious; acetabulum 
perforated, and broken in three pieces. Femur rounded off by efforts 
of nature, and attached to a small healthy portion of the acetabulum by 
fibrous tissue. An abscess in the pelvis connected with the fissure 
in the acetabulum, and extended to the sacro-iliac junction, which 
was carious. 
Simon's Case.-Was one of advanced phthisis. 
Stanley's Case.-Had severe cough and expectoration, and died 
in a few months of phthisis. 
Esmarch's Case.-Died on ninth day, of pyemia. 
Langenbeck's Case.-On the eighth day, of phlebitis and metas- 
tatic abscess. 
Fock's First Case.-On thirteenth day, of pyemia. 
Fock's Second Case.-In eleven weeks, of Bright's disease. 
Fock's Third Case.-Died on fourteenth day, of phlebitis and 
metastatic abscess. 
Hancock's Case.-Did well for eight days, when erysipelas super- 
vened, of which she died. 
Kuhn's Case.-Died on the sixth day; but the caries involved 
also the sacrum and ischium. 
It will be seen that, as far as the particulars of these fatal cases 
are given, death was attributable in most instances to some grave 
complication. The operation almost invariably produced the most 
favorable change in the general symptoms of the patient, and, in 
several of the fatal cases, the parts involved in the operation have 76 
REPORT ON 
healed in the most satisfactory manner, when at length the patient 
has succumbed to some new and acute disease. 
By a careful examination of the tabulated cases, the propriety of 
the operation must be admitted, and also the great importance of 
not neglecting it too long, lest the constitution become so exhausted 
as not to rally from the shock, or sink from excessive suppuration. 
By too long delay also, the acetabulum may become so much in- 
volved as to render the operation useless, although in two of the 
successful cases the acetabulum was found to be perforated. I 
cannot but think, after a careful study of all the fatal cases that I 
have reported, that, had the plan proposed been earlier adopted, 
we might have anticipated a more favorable result, at least in 
some of them. 
In Braithwaite's Retrospect (Part XIX., page 119), Mr. Syme, in 
concluding some remarks on hip-disease, says: " The result depends 
chiefly upon the state of the bones composing the joint. If they are 
carious, he must die; if they are not, he may recover." The Italics 
are his own. And then goes on to censure any operative interfer- 
ence in the following language. 
"Some operations have lately been performed in London, with 
the view of remedying caries of the hip joint, by cutting out the 
head of the thigh-bone; but this proceeding must have originated 
and been conducted in forgetfulness of the well-established patho- 
logical fact, that when caries attacks the surface of a joint, it is 
never limited to one of the bones which compose the articulation. 
If the articulating surface of the head of the thigh be carious, it 
follows as a matter of absolute certainty that the acetabulum must 
be in a similar condition. But as the acetabulum does not admit 
of a removal in the living body with any prospect of safety or 
advantage, no benefit can be derived from taking away a part of 
the articulation, and, therefore, excision of the head of the thigh-bone 
for caries of the joint should be regarded as no less erroneous in 
theory than objectionable in practice." 
Having once himself successfully removed the head of the hu- 
merus for disease of the shoulder joint, and fearing that his own 
case might be quoted in opposition to the principle he was then 
anxious to establish, he refers to it in the following language. "In 
an old volume of The Lancet, it is stated that Mr. Syme cut out 
the head of the humerus for disease of the shoulder-joint, leaving 
the glenoid cavity to 'shift for itself,' the fact really being that the 
patient labored under necrosis of the upper end of the bone, so that MORBUS COXARIUS. 
77 
the head was expanded into a thin shell containing an exfoliation, 
which was removed with the effect of preventing amputation at the 
shoulder-joint previously deemed requisite, and enabling the sub- 
ject of the case, then a boy, to grow up into a strong and healthy 
man. This statement, like many others, having no foundation ex- 
cept in the depraved imagination of their authors, was treated with 
the silence that it deserved, and would not be noticed now unless 
there seemed 4 risk of its being stumbled on by some one in search 
of authorities for bad practice;" and even as late as 1855 (see Braith- 
waite, Part XXXI., p. 117), in speaking of "Sinuses of the Hip de- 
pending upon exfoliation from the Pelvis f he says: " Sinuses about the 
pelvis are unhappily met with very frequently as the attendants or 
consequences of disease in the hip joint, when the disease being of 
an incurable kind, and the part concerned not admitting of removal, 
any sort of treatment can produce no better effect than a very im- 
perfect degree of palliation, and it has hence been usual to regard 
such cases as of a very hopeless character." 
In order, therefore, to justify myself against so high an authority 
as Mr. Syme, and to sustain the principles which I have endeavored 
to establish in this report, I have taken the trouble to collect all 
the cases of exsection of this joint which I could find, and arrange 
them in a tabulated form, and in chronological order, for easy re- 
ference. I feel quite confident that, by a careful study of these 
cases from the various authors to whom I have referred, even Mr. 
Syme will modify, if not entirely change, his previously expressed 
opinion. 78 
REPORT ON 
Tables of Exsection of 
No. 
Sex. 
Age. 
Cause and 
Duration. 
Condition at Time of 
Operation. 
Operation. 
1 
M. 
6 
One year. 
Caries; head separated 
from shaft. 
2 
• 
M. 
14 
Fall three years 
before. 
Head dislocated on dor- 
sum ; great exhaustion ; 
several fistulae. 
Straight incision ; straight saw ; 4 
inches removed. 
3 
M. 
Caries. 
Removed above lesser trochanter. 
4 
M. 
7i 
Fract. of femur 
and pelvis. 
Caries. 
5 
M. 
22 
Caries; head dislocated. 
6 
M. 
54 
Disease of neck of bone 
and trochanter; head 
healthy. 
Removed head, neck, and tro- 
chanter major. 
7 
M. 
7 
Caries. 
Caries. 
Removed all above lesser trochan- 
ter. 
8 
M. 
15 
Some months. 
Head dislocated on dor- 
sum ilii; large sinuses 
extending to it. 
Straight incision; chain saw broke; 
used the straight; 4 inches re- 
moved. 
9 
M. 
8 
Some months' 
standing. 
Head dislocated; abscess 
over the ilium ; sinuses; 
hectic and emaciation. 
Crucial incision; edges of aceta- 
bulum removed; left the tro- 
chanters. 
10 
M. 
15 
Long standing. 
Dislocation; emaciation ; 
cough ; hectic ; no ab- 
scess or fistulas. 
Straight incision; removed head 
and part of neck. 
11 
M. 
18 
Long standing. 
Anchylosis. 
12 
M. 
20 
Limb had been anchy- 
losed, but had given 
way; acetabulum filled 
with pus and fragments 
of bone. 
Resected in 1848. 
1 This case of Mr. White's died some five years after, some authors have erroneously stated twelve 
years after the operation; but Mr. South, in giving an account of this case (Chelius' Surgery, vol. ii. 
p. 980) gives the true date of his death as five years subsequent to the operation. The ilium and the 
remains of the femur were found thin and light. The thigh-bone rested with its upper extremity 
against the hinder part of the acetabulum, and was united to it and to the neighboring pqrtion of the MORBUS COXARIUS. 
79 
Hip-Joint for Caries. 
No. 
Progress of Case and Result. 
Date. 
Operator. 
Authority. 
1 
Recovered. 
1817 
Schmalz 
Hedenus, Comment. 
Chir., Leipsic, 1823. 
2 
Bandages and splints used as in compound 
fractures; fever slight; discharges soon 
ceased; health rapidly improved ; well in 
a year; perfect use of limb, except in ro- 
tating knee ih. 
1818 
A. White.1 
Cooper's Surgical Dic- 
tionary. 
3 
Perforation of acetabulum, and formation 
of abscess in the pelvis; died in 3 mo's. 
1828 
Hewson (in 
Dublin). 
4 
Died on 23d day, of excessive suppuration. 
1834 
Textor, Sen. 
Inaug. Dissert. Wurtz- 
burg, 1834. 
5 
Gangrene of wound took place, and death 
followed on the 4th day. 
1838 
Textor, Sen. 
Oppenheimer's Inaug. 
Dissert, on Resection 
of Hip-Joint, Wurtz- 
burg, 1840. 
6 
Sloughs formed on the sacrum ; death on 
53d day ; wound nearly healed ; from the 
small trochanter, new bone was formed 
over the upper third of femur, the cut 
surface of which had become rounded off; 
the acetabulum, which was covered by 
granulations, was healthy; at separate 
points in it were found deposits of new 
bone ; the upper end of femur rested on 
ischium ; at posterior edge of acetabulum, 
a depression had been formed in this bone 
1 j inch long, j inch broad, 2 lines deep. 
1839 
Textor, Sen. 
Ibid. 
7 
Recovered, with good limb ; obtains his 
living as a peddler. 
1845 
Textor, Sen. 
Dircks de resectione 
' capitis femoris, 
Wurtzburg 1845. 
8 
Dressed as in compound fracture; shock 
slight; wound healed well; health rapidly 
improved ; limb very useful, 2 j inches 
shorter than the other. 
1845 
Fergusson. 
Med.-Chirurg. Trans., 
vol. xxviii. 
9 
Treated as in former case; health im- 
proved ; wound never entirely healed ; 
died 2 years after of disease of the liver. 
1847 
Fergusson. 
Fergusson, Pract. Sur- 
gery, Lond. ed., 1852. 
p. 473. 
10 
Secondary hemorrhage ; collection of pus 
between the glutei muscles ; death on 7th 
day; extensive disease of cotyloid cavity. 
1847 
Roux. 
Gazette des Hopitaux, 
No. 28, 1847. 
11 
Recovered, with partial usefulness. 
1847 
Maisonneuve 
12 
Sixteen months after amputation was per- 
formed ; died 2| years after the first ope- 
ration. 
1848 
Heyfelder. 
Heyfelder on Resec- 
tions and Amputa- 
1 tions, Bonn, 1855. 
os ilii by a firm ligamentous tissue, which appeared to belong partly to the remains of the articular 
capsule, which had been left between the bones. A muscle was inserted into this tissue, and into 
the upper portion of the femur. (See Catalogue of the Pathological Specimens contained in the 
Museum of the Royal College of Surgeons of England, London, 1817, vol. iii. page 230.) 80 
REPORT ON 
Tables of Exsection of 
No. 
Sex. 
Age. 
Cause and 
Duration. 
Condition at Time of 
Operation. 
Operation. 
13 
M. 
33 
Disease ; eigh- 
teen months. 
Hip swollen; sinus dis- 
charging ; caries. 
Straight incision; removed three 
inches of rim of acetabulum; no 
ligatures. 
114 
c'ild 
Two years. 
Head dislocated on dor- 
sum ilii; sinuses and 
abscesses. 
Removed head and portions of ace- 
tabulum. 
1 15 
F. 
10 
Disease; some 
time. 
Head carious, and dislo- 
cated on dorsum. 
Head and trochanter removed; 
acetabulum healthy. 
16 
F. 
not 
g'vn 
Caries. 
Removed head. 
1 17 
M. 
16 
Two years' 
standing. 
Caries ; severe pain ; 
sinuses with discharge. 
Straight incision; removed four 
inches, and the carious part of 
cavity. 
18 
M. 
Caries. 
119 
M. 
| 20 
M. 
8 
Caries. 
Removed head. 
1 21 
F. 
12 
Large open sore on hip ; 
caries; sinuses ; ema- 
ciation, etc. 
Straight incision; common saw ; 
removed four and a half inches. 
22 
F. 
Three years. 
Caries; head dislocated. 
Crucial incision; removed head 
and trochanter major. 
1 23 
18 
Caries. 
24 
M. 
41 
Two years. 
Great suffering; grating 
in joint; large discharge 
of matter. 
Made a T incision ; capsule entire, 
except at inner edge; removed 
below great trochanter ; head ca- 
rious, edge of cavity also. 
25 
Caries; head and neck 
partially destroyed. 
Removed head. 
26 
F. 
32 
Removed head. 
27 
M. 
17 
Caries. 
28 
F. 
10 
Several years. 
Feeble and emaciated ; 
fistulas discharging free- 
ly- 
Circular incision ; large collection 
of pus under glutei. 
29 
F. 
10 
Four years. 
Head carious; emacia- 
tion and hectic. 
Straight incision; removed one 
inch below trochanter, also edge 
of acetabulum. 
30 
M. 
10 
Caries. 
Removed head. MORBUS COXARIUS. 
81 
Hip-Joint for Caries-Continued. 
No. 
Progress of Case and Result. 
Date 
Operator. 
Authority. 
13 
Water dressings; fever slight; symptoms 
improved for 4 months, when leg became 
oedematous, and he died 4| months after 
the operation; Bright's disease of kid- 
neys, and caries of vertebrae found. 
1848 
Smith. 
London Lancet, Nov. 
25, 1848. 
14 
Died 4 days after the operation. 
1848 
Simon. 
London Lancet, April, 
1848. 
15 
Recovered. 
1848 
French. 
London Lancet, 1848. 
16 
Recovered ; good limb. 
1848 
French. 
Fergusson's 3d Lond. 
edition, p. 435. 
17 
Dressed as in fracture ; pain ceased ; health 
rapidly improved ; wound closed well. 
1848 
Walton. 
London Lancet, 1848. 
18 
Recovered perfectly. 
1848 
Fergusson. 
Ibid. 
19 
Unsuccessful. 
1848 
Walton. 
20 
Died 23 days after the operation. 
1 
1848 
Textor, Jr. 
Textor on Resection 
of Head of Femur, 
Wurtzburg, 1858. 
21 
Placed in straight position ; slight fever ; 
symptoms soon improved ; ulcers healed ; 
died after some months. 
1849 
Cotton. 
London Med. Gazette, 
1849. 
22 
Recovered perfectly. 
1849 
Fergusson. 
Fergusson, pp. 473, 
475. 
23 
Recovered, with perfect motion of thigh, 
and could walk a short distance. 
1849 
Morris. 
Prov. Med. and Surg. 
Journ., Feb. 6, 1850. 
24 
Wound cicatrized rapidly; severe symp- 
toms all subsided ; died 3 months after of 
dysentery, the wound being nearly heal- 
ed ; parts found in a healthy condition, 
and in an advanced stage of repair ; ace- 
tabulum studded with new bone, and filled 
with healthy granulations. 
1850 
Buchanan. 
Glasgow Med. Journ., 
April, 1853, p. 10. 
25 
Wound healed, but abscess formed ; did 
not progress very favorably. 
1851 
Sayle. 
26 
Recovered perfectly. 
1852 
Jones. 
Med. Times, Nov. 6, 
1852. 
27 
Recovered perfectly. 
1852 
J. Heusser. 
Schweig. M. Zeitschr., 
2, 1854. 
28 
Symptoms rapidly improved ; made exten- 
sions by weight attached to foot; wound 
healed. 
1852 Stanley. 
London Lancet, Feb. 
14, 1852. 
29 
Progressed favorably two days ; died on 
third day after operation ; found large 
perforation of acetabulum. 
1852 
Hawkins. 
London Lancet, Feb. 
.28, 1852. 
30 
Successful; could walk in one year ; limb 
shortened 2j inches. 
1852 
Reid. 
Schillbach, Resection, 
Jena, 1858, p. 12. 82 
REPORT ON 
No. 
Sex. 
Age. 
Cause and 
Duration. 
Condition at Time op 
Operation. 
Operation. 
31 
M. 
8 
Caries. 
32 
M. 
10 
About twelve 
months. 
Caries and complete dis- 
location ; very loose ab- 
scess ; extensive disease 
of socket as well as of 
the thigh-bone. 
Bone separated while sawing ; cru- 
cial incision. 
33 
Caries. 
34 
F. 
26 
Caries. 
35 
M. 
1 I 
Greatly reduced; bone 
dislocated. 
Neck and great trochanter re- 
moved. 
36 
F. 
12 
Long standing. 
Caries and necrosis. 
Removed head and both trochan- 
ters. 
37 
M. 
8 
Long standing. 
Great emaciation; hec- 
tic ; caries. 
Removed head and edges of ace- 
tabulum. 
38 
M. 
23 
Caries. 
39 
F. 
9 
Eighteen mo's. 
Great emaciation; hec- 
tic ; extensive caries. 
Removed head and edges of ace- 
tabulum. 
40 
M. 
26 
Caries. 
Resected. 
41 
M. 
11 
Caries; involving, also, 
sacrum and ischium. 
Resected. 
42 
M. 
Fall months be- 
fore on hip. 
Caries. 
Removed head. neck, and part of 
large trochanter, and gouged ace- 
tabulum thoroughly. 
43 
M. 
10 
Fall on hip 3 
mo's before. 
Caries. 
44 
M. 
4 
Extensive caries. 
Removed head, neck, large tro- 
chanter, and part of small, and 
part of acetabulum. 
45 
F. 
14 
Caries. 
46 
M. 
10 
Caries. 
47 
M. 
20 
Caries. 
48 
M. 
14 
Caries. 
49 
M. 
17 
... 
Caries ; luxation sponta- 
; neous. (?) 
50 
M. 
6 
1 . 
(Canes. 
Tables of Exsection of MORBUS COXARIUS. 
83 
Hip-Joint for Caries-Continued. 
No. 
Progress of Case and Result. 
Date. 
Operator. 
Authority. 
31 
Successful; walked with crutches in 18 
months ; patient strong and healthy. 
1852 
Stanley. 
London Lancet, 1854, 
vol. i. p. 61. 
32 
Cold water dressings ; pulse unaltered three 
days ; death on twelfth day ; one-third of 
neck of femur remained; perforation of 
acetabulum one-quarter to one-half inch 
in extent; below this, bone eaten in ap- 
pearance. 
1853, 
Feb. 
21 
Bigelow. 
Surg. Records of Mas- 
sachusetts General 
Hospital, vol. li. p. 
18. 
33 
Perfect recovery. 
1853 
Parkman. 
Ibid. 
34 
Perfect recovery. 
1853 
Jones. 
35 
Rapid improvement; suppuration profuse ; 
died some months after. 
1853 
Erichsen. 
36 
Recovered. 
1854 
Fergusson. 
London Lancet, 1854. 
37 
Recovered. 
1854 
Erichsen. 
38 
Died. 
1854 
Textor, Sen. 
Textor on Resection of 
Head of Femur, 1858. 
39 
Recovered perfectly, with half inch short- 
ening ; has now, seven years after the 
operation, perfect use of the limb, can 
dance, and run up or downstairs, with as 
much ease and freedom as any child of 
her age. 
1854, 
Mar. 
29 
Sayre. 
New York Journal of 
Medicine, Jan. 1855. 
40 
Recovered, and died three years after of 
phthisis. 
1854 
Esmarch. 
Stromeyer, Maxims of 
Military Surgery, p. 
714. 
41 
Died on sixth day. 
1854 
Kuhn. 
Gunther's Tables, No. 
23. 
42 
Recovered, with two inches shortening, 
and articulation. 
1854 
Bauer. 
Operator. 
43 
Recovered; walked without crutches. 
1855 
Roser. 
Verbal communication 
to Textor. 
44 
Died eighteen months after of convulsions. 
1855 
Bauer. 
Operator. 
45 
Recovered, with useful limb. 
1856 
Shaw. 
46 
Died one month after. 
1856 
Textor, Jr. 
47 
Died thirty hours after. 
1856 
Kinlock. 
Charleston Journal, 
May, 1857. 
48 
Recovered ; useful limb. 
1856 
Hancock. 
49 
Recovered, with perfect usefulness of limb. 
1856 
Morgan. 
50 
Recovered perfectly, with useful limb. 
1856 Erichsen. 84 
REPORT ON 
Tables of Exsection of 
No. 
Sex. 
Age 
Cause and 
Duration. 
Condition at Time of 
Operation. 
Operation. 
51 
M. 
13 
Caries. 
52 
M. 
5 
Caries. 
53 
M. 
3 
Cause not trace- 
able ; caries of 
2 y'rs stand'g. 
Caries ; emaciation ; five 
fistulous openings. 
Removed part of head and neck, 
and part of acetabulum. 
51 
F. 
7 
Periostitis, ter- 
minating in 
caries of neck, 
and external 
perforation of 
capsule. 
Caries of neck of femur ; 
perforation of acetabu- 
lum. 
Removed head and neck. 
55 
F. 
8 
Caries, with hectic fever 
and suppuration. 
Crescent incision ; removed head 
of femur below trochanter ; neck 
fractured in attempt to disarticu- 
late ; acetabulum gouged. 
.56 
M. 
10 
Caries, and profuse sup- 
puration. 
Removed upper third of femur 
and gouged acetabulum, which 
was perforated so that two fingers 
could be introduced. 
57 
M. 
17 
Rheumatic in- 
ilammation of 
right hip, with 
suppuration. 
Resected, Feb. 1856. 
58 
F. 
9 
Diastasis, and 
subsequent ca- 
ries. 
Caries. 
Removed a portion of neck ; the 
head had been discharged through 
an opening in the anterior part of 
the capsule, and was found in the 
muscles on anterior of the thigh. 
59 
M. 
10 
Caries. 
60 
M. 
8 
Caries. 
61 
M. 
11 
Caries. 
62 
M. 
16 
Two years. 
Luxation in ischiatic 
crotch. 
Resected, Dec. 21, 1857. 
63 
M. 
6 
Fall some mo's 
previous. 
Extensive caries and per- 
foration of acetabulum. 
As a palliative operation, removed 
head and neck, gouged acetabu- 
lum and surrounding bone. 
64 
M. 
Three years. 
Caries, luxation, ab- 
scess, and hectic. 
Resection by T incision ; sawed 
through trochanters, and gouged 
acetabulum. 
65 
M. 
8 
Three years. 
Caries, abscess, and fis- 
tulas ; spontaneous lux- 
ation. (?) 
Resected through neck, and ace- 
tabulum gouged. 
66 
M. 
12 
Three years. 
Caries ; spontaneous lux- 
ation ; fistula. 
Resected below trochanter major ; 
gouged acetabulum, June 2, '57. 
67 
M. 
6 
Two years. 
Caries, abscess, and fis- 
tula. 
Resected through neck; acetabu 
lum gouged. MORBUS COXARIUS. 
85 
Hip-Joint for Caries-Continued. 
No. 
Progress of Case and Result. 
Date. 
Operator. 
Authority. 
51 
Recovered perfectly ; useful limb. 
1856 
Stanley. 
52 
Recovered ; useful limb. 
1856 
Ure. 
53 
Died about twelve months after, from diph- 
theritic croup. 
1856 
Bauer. 
Operator. 
54 
> 
Died twelve months after, from uraemic 
convulsions coexisting with general ex- 
haustion. 
1856 
Bauer. 
Operator. 
55 
Successful; in three years, could walk 
well and rapidly with high heel, without 
cane or crutches. 
1856 
Nussbaum. 
Fock's Table. 
56 
Recovered, with 3| inches shortening; re- 
quired mechanical support to walk. 
1856 
Nussbaum. 
Ibid. 
57 
Successful; walked with crutches in May; 
in October, could walk three miles with 
stick ; good motion of joint. 
1856 
Shaw. 
London Lancet, vol. 
ii. p. 430. 
58 
Recovered ; half inch shortening ; inter- 
mediate substance yet soft, but promises 
a useful limb. 
1857 
Bauer. 
Operator. 
59 
Recovered; useful limb. 
1857 
Hancock. 
Lancet, 1857, vol. ii. 
p. 390. 
60 
Recovered; useful limb. 
1857 
Price. 
61 
Recovered; useful limb. 
1857 
Bowman. 
62 
Recovered in one month. 
1857 
Holmes Coote 
Lancet, 1857, vol. ii. 
p. 417. 
63 
Symptoms immediately relieved, but died 
four months after from inanition ; caries 
progressive. 
1857 
Bauer. 
Operator. 
64 
Applied extension ; result successful; could 
walk in six months; cough and hectic 
cured. 
1857 
Erichsen. 
Lancet, 1857, vol. i. p. 
310, and vol. ii. p. 
363. 
65 
Result good ; half inch shortening ; walked 
without cane ; had motion of joint. 
1857 
Ure. 
Lancet, 1857, vol. i. p. 
530, and vol. ii. p. 
418. 
66 
On 5th of July, result was favorable, and 
patient was free from pain. 
1857 
R. Cooker & 
N. Davies. 
Lancet, 1857, vol. ii. 
p 55. 
67 
Two months after, nearly healed ; walked 
with high-heel shoe ; motion good. 
1857 
Holt. 
Lancet, 1857, vol. ii. 
pp. 84 and 363. 86 
REPORT ON 
Tables of Exsection of 
No. 
Sex. 
Age. 
Cause and 
Duration. 
Condition at Time of 
Operation. 
Operation. 
68 
F. 
11 
Caries far advanced. 
Resected below trochanter. 
69 
M. 
Caries, abscess, fistula, 
and advanced phthisis. 
Resected in 1857. 
70 
F. 
6 
Two years. 
Anchylosis of femur at 
right angle; head de- 
stroyed by caries. 
Removed head below trochanter 
chiselled off edge of acetabulum 
and pubis. 
71 
M. 
13 
Luxation of head ; femur 
on os pubis ; hectic fe- 
ver, with cough. 
Resected in 1857. 
72 
M. 
21 
Two years 
Fistulous openings on 
thigh, with extensive 
femoral abscess; spon- 
taneous luxation. (?) 
Resected near trochanter ; gougec 
out carious cavity in trochanter. 
73 
F. 
6 
Uncertain. 
Caries ; abscess ; fistulse; 
thigh much flexed. 
Resected one inch below trochan- 
ter ; acetabulum chiselled out. 
74 
F. 
10 
Four years. 
Suppuration, hectic, lux- 
ation, (?) and head an- 
chylosed by callus. 
Resected through neck near tro- 
chanter ; removed two sequestra 
from acetabulum. 
75 
F. 
13 
Two years. 
Abscess, fistulas, hectic, 
and spontaneous luxa- 
tion. (?) 
T incision sawed three and a hal 
inches below trochanter, on Dec 
16, 1857. 
76 
M. 
45 
Caries. 
77 
M. 
41 
Traumatic in- 
jury, contu- 
sion of hip. 
Caries of head ; no ex- 
ternal opening. 
Removed head, and gouged upper 
edge of acetabulum. 
78 
M. 
27 
Caries and spontaneous 
luxation. (?) 
79 
M. 
8 
Nine months. 
Caries ofhead, neck, and 
acetabulum. 
September 27, 1858, head removec 
through upper edge of both tro 
chanters; acetabulum gouged 
thoroughly. 
80 
M. 
18 
Ten months. 
Fistulas, hectic, etc. ; 
head carious; acetabu- 
lum nearly perforated. 
Dec. 6, 1858, removed through 
trochanter ; head carious ; aceta- 
bulum, appearing healthy, was 
not gouged. 
81 
M. 
7 
Eighteen mo's. 
Extensive caries. 
Carious head and neck removed 
two points in acetabulum gougec 
out. 
82 
F. 
26 
Twenty years. 
Anchylosis, fistula, pel- 
vic abscess, and caries. 
Resected below trochanter ; mosl 
of acetabulum, of the spine, anc 
large portion of tuber ischii re- 
sected. MORBUS COXARIUS. 
87 
Hip-Joint for Caries-Continued. 
No. 
Progress of Case and Result. 
Date. 
Operator. 
Authority. 
68 1 
Walked with crutches in nine weeks. 
1857 
Fergusson. 
Lancet, 1857, vol. ii. 
p. 362. 
69 
Died of phthisis a few days after. 
1857 
Simon. 
Lancet, 1857, vol. ii. 
p. 390. 
70 
Result good, but has disease of heart. 
1857 
Bowman. 
Fock's Table, No. 64. 
71 
Died of phthisis a few months after. 
1857 
Stanley. 
Lancet, 1857, vol. ii. 
p. 391. 
72 
Gradual extension ; result successful; in 
two months, walked with crutches. 
1857 
Dumreicher. 
Fock's Table, No. 68. 
73 
Cured and dismissed in three months. 
1857 
B. Langen- 
beck. 
Fock's Table, No. 69. 
74 
Died of exhaustion on tenth day. 
1857 
B. Langen- 
beck. 
Fock's Table, No. 70 
75 
Was doing well ten days after, when the 
case was reported. 
1857 
Hewson. 
North American Med.- 
Chir. Review, March, 
1858, p. 325. 
76 
Recovered, with usefel limb. 
1858 
Bowman. 
Nos. 60, 61, and 76, 
notices reach only to 
the first month after 
the operation. Bos- 
ton Med. Jour., Jan. 
1858. 
77 
Recovered ; half inch shortening; useful 
limb. 
1858 
Bauer. 
Operator. 
78 
Died seven days after. 
1858 
C.F. Holston. 
79 
Recovered, with useful limb; walked in 
Feb. 1859, with good motion of joint. 
1858 
Markoe. 
Operator. 
80 
Died thirteen days after, when the aceta- 
1 bulum was found perforated, purulent in- 
filtration of upper part of thigh, and ab- 
scess in femoral vein. 
1858, 
Dec. 
6 
Markoe. 
Operator. 
81 
Wound healed ; could elevate the limb, but 
| died six months after with tubercular me- 
1 ningitis. 
1858. 
May 
21 
Kiihler. 
Deutsche Klinik, 1859, 
No. 40. 
82 
Doing well for eight days, when erysipelas 
supervened and patient died. 
1858 
Hancock. 
Lancet, 1858, vol. ii. 
p. 118. 88 
REPORT ON 
Tables of Exsection of 
No. 
Sex. 
Age. 
Cause and 
Duration. 
Condition at Time of 
Operation. 
Operation. 
83 
F. 
13 
Sixteen mo's. 
Abscesses, fistula, pro- 
fuse suppuration, and 
hectic. 
Resected below trochanter; head 
absorbed ; removed large mass of 
carious bone from acetabulum, 
and also tuber isehii. 
84 
F. 
10 
Eighteen w'ks. 
Large abscess ; another 
descended to the fibula. 
Resected March 3, 1858, near tro- 
chanter major; trochanter re- 
moved by forceps, also small piece 
of ilium. 
85 
M. 
54 
Two years. 
Bed-sores; luxation. 
T incision ; resected below tro- 
chanter minor. 
86 
M. 
16 
Several years' 
standing. 
Suppuration, hectic, and 
caries. 
Crescent incision; head luxated 
against symphysis pubis ; sawed 
below trochanter; acetabulum 
perforated ; removed margin and 
gouged cavity. 
87 
M. 
21 
Fall one year 
and a half be- 
fore. 
Suppuration ; spontane- 
ous luxation; numerous 
fistulas ; great emacia- 
tion. 
Removed below trochanter, Nov. 
25, 1858. 
88 
F. 
12 
89 
Caries. 
Head and part of acetabulum re- 
moved. 
90 
Below the trochanter and half the 
acetabulum. 
91 
92 
M. 
7 
One year. 
Abscess. 
Head removed. 
93 
F. 
19 
One year. 
Caries; abscess opened 
spontaneously in six 
months. 
Straight incision; removed head 
and neck ; ligamentum teres de- 
stroyed. 
94 
M. 
8 
Four years. 
Caries ; abscess ; emacia- 
tion extreme. 
Operation performed as a pallia- 
tive measure only ; straight inci- 
sion'; removed head, large por- 
tion of ilium, ischium, and pubis ; 
acetabulum perforated. 
95 
F. 
9 
Three years. 
Abscess from crest of 
ilium to middle of thigh; 
crepitation perceptible 
under chloroform. 
Resected, May 13, 1859, by cres- 
cent-shaped incision ; sawed be- 
low trochanter major with chain 
saw; acetabulum gouged. 
96 
M. 
14 
Fall; one year. 
Abscess; crepitus. 
Resected, June 10, 1859, in neck 
of femur by chain saw ; posterior 
margin and bottom of acetabu- 
lum carious and gouged out. 
97 
M. 
49 
Chronic rheu- 
matism. 
Crepitation under chlo- 
roform ; no suppura- 
tion. 
Resected, Oct. 11, 1859, below tro- 
chanter ; acetabulum enlarged; 
head and neck covered with os- 
teophytes around margin.1 
1 This case is one of chronic rheumatic arthritis, and hardly belongs to this table of exsection for 
caries. MORBUS COXARIUS. 
89 
Hip-Joint for Caries-Continued. 
No. 
Progress of Case and Result. 
Date. 
Operator. 
Authority. 
83 
Left the bed in three and a half months ; 
some fistulous openings, but health gain- 
ing and limb straight. 
1858 
Erichsen. 
Lancet, 1858, vol. ii. 
p. 88. 
84 
Cured in ten weeks. 
> 
1858 
Erichsen. 
Lancet, 1858, vol. ii. 
p. 89. 
85 
Died from exhaustion eleven days after. 
1858 
Hilton. 
Lancet, 1858, vol. ii. 
p. 116. 
86 
Nearly well four months after; patient 
walks with crutches. 
1858 
Nussbaum. 
Fock's Table, No. 80. 
87 
In fall of 1859, walked with stick and high- 
heeled shoe ; has fistula still, but probe 
does not touch bone. 
1858 
Esmarch. 
Fock's Table, No. 81. 
88 
Recovered perfectly. 
1858 
Beaney (Aus- 
tralia) . 
Original contributions 
to the Practice of 
Conservative Surg., 
1859. 
89 
Recovered; good limb. 
1859 
Price. 
London Lancet, Nov. 
26, 1859. 
90 
Recovered. 
1859 
Price. 
Ibid. 
91 
Recovered perfectly. 
1859 
Jones. 
Ibid. 
92 
Recovered perfectly. 
1859, 
Oct. 
16 
Church. 
Operator. 
93 
Recovered ; walked without crutches. 
1859 
F. Van Du- 
minski (Vi- 
enna). 
94 
Died on the eighth day; for full report of 
post mortem, see case J. R., embodied in 
report. 
1859, 
Dec. 
Sayre. 
Operator. 
95 
Three months after, only one fistula; used 
Bonnet's wire breeches ; in eight weeks, 
walked with crutches ; now, 1860, walks 
well all day ; one inch shortening. 
1859 
Fock. 
Archive for Clinical 
Surgery, by Langen- 
beck, 1860, vol. i. p. 
172. 
96 
Beginning favorable ; died in eleven weeks 
of Bright's disease. 
1859 
Fock. 
Ibid. 
97 
Walked with crutches ten weeks after ope- 
ration ; heel inch and a half higher than 
the other. 
1859 
Fock. 
Ibid. 
7 90 
REPORT ON 
Tables of Exsection of 
No. 
Sex. 
Age. 
Cause and 
Duration. 
Condition at Time of 
Operation. 
Operation. 
98 
M. 
22 
Acute coxitis; 
four months. 
Luxation. 
Resected, Sept. 27, 1859; straight 
incision ; head on posterior mar- 
gin of acetabulum; neck carious ; 
removed at trochanter major. 
99 
M. 
6 
Traumatic in- 
jury nine mo's 
previous. 
Caries of head and ace- 
tabulum ; perforation of 
capsule; external ab- 
scess forming. 
Removed head and neck ; gouged 
acetabulum superficially in May, 
1860. 
100 
1 
M. 
7 
Direct injury of 
hip three y'rs 
previous. 
Caries of head and ace- 
tabulum. 
Removed head and neck ; gouged 
acetabulum very thoroughly on 
the 4th of April, 1860. 
101 
F. 
<■ 
Falls two years 
previous. 
Three fistulous openings ; 
great emaciation. 
Resected through the trochanter 
major, and removed some loose 
pieces from acetabulum, May 1, 
1860. 
102 
M. 
16 
Fall on trochan- 
ter when a 
child ; but 3 
years ago fell 
in a cistern, 
and injured 
the hip serious- 
ly, and dates 
the disease to 
the last injury. 
External abscess, pro- 
fuse suppuration, and 
great emaciation ; limb 
shortened nearly three 
inches; trochanter ma- 
jor high up, and back 
on ilium ; like luxation 
in ischiatic notch. 
Operation in March, 1860 ; neck 
entirely absorbed, and trochan- 
ter over ischiatic notch, having 
remains of head of femur still 
loose in the acetabulum; removed 
the same and trochanter, with 
portions of acetabulum, which 
was perforated. 
103 
M. 
13 
A fall. 
Caries, with external ab- 
scess and fistula). 
Semilunar incision ; arch over tro- 
chanter major, and straight inci- 
sion over trochanter; removed 
four inches of femur. 
104 
M. 
4 
Fall when two 
years old, pro- 
ducing inflam- 
mation of left 
hip-joint. 
Capsule ruptured; exten- 
sive femoral abscess; no 
external opening. 
Free incision into abscess ; after 
its evacuation, crepitus was de- 
tected, and exsection was imme- 
diately performed ; head, almost 
absorbed, was removed, and ace- 
tabulum, carious, was thoroughly 
gouged. 
105 
M. 
11 
Coxitis; two 
years. 
Anchylosis ; thigh much 
flexed; abscess behind 
trochanter; fistulas and 
hectic. 
Resected, March 23, 1860, near 
trochanter ; difficulty in removing 
from joint on account of anchy- 
losis. 
106 
F. 
13 
Coxitis; three 
years. 
No suppuration; hectic 
fever; crepitation un- 
der chloroform. 
Resected, Jan. 9, 1860 ; ligament- 
urn teres destroyed ; joint full of 
pus ; head partly destroyed ; neck 
and trochanter major carious ; 
removed below trochanter, with 
chain saw ; acetabulum gouged. 
107 
F. 
13 
Acute coxitis; 
two months. 
Abscess; crepitation. 
Resected, March 16, 1860; head 
and neck carious; ligamentum 
teres destroyed ; sawed through 
trochanter major; cauterized pos- 
terior margin of acetabulum with 
hot iron. 
1 Case 100 had been treated for hip-disease in the second stage two years previous, by puncture and 
rest, with extension in the wire breeches ; recovered perfectly without internal treatment, and dis- 
charged. Remained well one year, and was in the country at school. Violent exertion and fall re- MORBUS COXARIUS. 
91 
Hip-Joint for Caries-Continued. 
No. 
Progress of Case and Result. 
Date. 
Operator. 
Authority. 
98 
Doing well until 10th of October; died of 
pyaemia. 
1859 
Fock. 
Archive for Clinical 
Surgery, by Langen- 
beck, 1860, vol. i. p. 
172. 
99 
Recovered ; three-quarter inch shortening; 
mobility July 20., 1860. 
1860 
Bauer. 
Operator. 
100 
Recovered ; one and a quarter inch short- 
ening, with motion ; commenced walking 
July, 1860. 
1860 
Bauer. 
Operator. 
101 
Recovered perfectly, without any untoward 
symptoms, with free motion, yet not suffi- 
ciently firm to bear any weight upon it, 
August 1st. 
1860 
A. B. Mott. 
Operator. 
102 
Improved very much after the operation, 
but died of erysipelas at the end of three 
months, hospital gangrene having occur- 
red in the ward of the hospital in which 
he was confined. 
1860 
IV.R.Church. 
Operator 
103 
Perfect recovery, with motion ; two and a 
half inches shortening. 
1860 
J. M. Carno- 
chan. 
Operator 
104 
Wound healed perfectly in six weeks, with 
motion; half inch shortening. 
1860, 
July 
8 
Sayre. 
I 
105 
Two months after, femur straight; could 
move limb in every direction ; promises 
good result. 
1860 
Rausche. 
Fock's Table, No. 93. 
106 
April, three months after, promising well. 
1860 
Fock. 
Archive for Clinical 
Surgery, by Langen- 
beck, 1860, vol. i. p. 
172. 
107 
Died of phlebitis and metastatic abscess in 
ankle on 14th day. 
1860 
Fock. 
Ibid. 
produced the disease, which remained some months without treatment; and, when seen, presented 
the condition as above described, when I assisted at the operation by request, and have seen the 
patient in his improved condition. 92 
REPORT ON 
Tables of Exsection of 
No. 
Sex. 
Age. 
Cause and 
Duration. 
Condition at Time of 
Operation. 
Operation. 
108 
M. 
5 
Coxitis after 
measles; nine 
months. 
Suppurativeluxation; (?) 
hectic fever. 
Resected, Feb. 13, 1860, below 
trochanter major. 
109 
M. 
27 
Contusion one 
year before. 
Abscess. 
Removed head and neck, Jan. 24, 
1860. 
110 
F. 
5 
Fall eighteen 
months before. 
Great emaciation; three 
fistulous openings lead- 
ing to dead bone; de- 
formity very great. 
Straight incision; removed head 
and neck, and part of trochanter 
major; gouged acetabulum. MORBUS COXARIUS. 
93 
Hip-Joint for Caries-Concluded. 
No. 
Progress of Case and Result. 
Date. 
Operator. 
Authority. 
108 
Died of phlebitis and metastatic abscess 
on 21st of February, eight days. 
1860 
Langenbeck. 
Fock's Table, No. 88. 
109 
31st Jan., bed-sore; 5th Feb., rigor, and 
death on 9th of pyaemia. 
1860 
Esmarch. 
Fock's Table, No. 89. 
110 
Placed in wire breeches, with extension ; 
recovered perfectly in seven weeks ; half 
inch shortening ; good motion, and walked 
with stick in three months (Nov. 27th). 
1860, 
Aug. 
4 
Sayre. 
RECAPITULATION. 
Total number of resections of head of femur for caries . . .110 
Died 36 
Reported as unfavorable 2 
Recovered, with more or less useful joint . . . .72 
110 94 
REPORT ON MORBUS COXARIUS 
Table of Exsection of Head of Femur from Gunshot Wounds. 
NO. 
SEX. 
AGE. 
OPERATOR. 
YEAR. 
RESULT. 
AUTHORITY. 
1 
M. 
Oppenheim. 
1829 
Died in 17 days from epidemic 
plague. 
Hamburg Zeitschr., 
vol. i. page 737. 
2 
M. 
Seutin. 
1832 
Died in 9 days after. 
Gazette de Med. de 
Paris, 1833. 
3 
M. 
30 
Textor, Sen. 
1847 
Died 9 days after from gan- 
grene. 
4 
M. 
Schwartz. 
1849, 
May 13 
Died 7 days after of gan- 
grene. 
Esmarch on Resec- 
tion. 
5 
M. 
Ross. 
1850 
Removed loose head of femur 
from gunshot wound 2 years 
before. 
6 
M. 
30 
Baum. 
1854 
Died in 24 hours. 
7 
M. 
Blenkins. 
1855 
Diedin 3 weeks from pyaemia. 
8 
M. 
Macleod. 
1855 
Died. 
9 
M. 
Crerar. 
1855 
Died. 
10 
M. 
Hyde. 
1855 
Died. 
11 
M. 
Comhe. 
1855 
Died. 
12 
M. 
O'Leary. 
1855 
Recovered after 12 weeks, 
could walk on crutches; mo- 
tion. 
R£sum£.-Total number of exsections of head of femur for gunshot wounds 12; 
of which 11 died and 1 recovered. 
An apology is almost due to the profession for the apparently 
careless manner in which this paper has been prepared, and the 
want of method and connected arrangement of many of its parts. 
But I have written it in broken fragments of time, absolutely stolen 
from the hours of rest I so much needed to restore a constitution 
severely shattered by a recent illness of a most dangerous character, 
caused by a dissecting wound, and this I offer as my only excuse. 
I was appointed to make a report, and was therefore compelled 
to comply as well as my limited time would allow. If I have 
thrown any new light upon the subject, or shall have been the 
means of exciting to its investigation other more competent minds 
in the profession, who will develop any new method for the more 
perfect relief of these heretofore almost hopeless cases, I shall be 
more than compensated for the time and labor I have had in pre- 
paring it.