relaxing the extensors, and allowing him, with a little force, to place the thigh in extension, i.e., flat upon the bed.

In most cases, however, indeed in all those which have continued some time in this stage before coming under treatment, this method would be not only too painful, but would be absolutely injurious. M. Bonnet* employed and recommended machines and manipulations of vast power for this purpose, which to me appear not only unnecessary, but dangerous, and conceived upon false principles. Moving a diseased hip backwards and forwards, producing such forcible flexion that the front of the thigh touches the abdomen, simply in order to relax contracted parts sufficiently to allow its being straightened, can hardly be wise. During the whole of this second stage, the deformity is due only to muscular contraction from nervous irritation, and a very slight force, if continuous, will overcome this power. The essential is to obtain a continuous force. All the various forms of screws, pinions, and racks are not continuous when applied to a living organism; the former are fixed, the other is moving: so that at one time the power will be intense and rigid, at another will not be exerted at all. A spring is the only force which, while it yields sufficiently to the movements and struggles against confinement, which a living part is sure to make, yet exercises a constant, never-failing traction, sure in the end to overcome muscular force, without painful rending and violent stretching of parts. Any deformity from muscular contraction † at the hip may be restored to the proper posture by means of the extending splint, with the pelvic wire-belt. I will not detain the reader by describing the mechanism of pulleys, straps, &c., as it has been already done (p. 266), but the method of using the splint for this particular purpose must be explained. Let us suppose the patient lying on his back, with the affected limb bent both at hip and knee. The surgeon begins by applying a broad piece of strapping on either side of the leg, from the knee to the foot, allowing an inch or an inch and a half of the material to project below the sole; he then bandages firmly to the knee. The plaister ought

* Traité de Thérapeutique des Maladier Articulaires,' p. 416 et seq.; and Métnodes Nouvelles de Traitement,' &c., p. 69.

The reader must be reminded that the word contraction in this sense only

refers to an active condition; when muscles have been for some considerable time morbidly contracted, there supervenes a form of atrophy, accompanied by passive shortening and rigidity-contracture.

to be spread upon strong cloth; it is for the purpose of making extension upon the limb after the American fashion, and is much more comfortable than any other mode.

It is better to leave the patient some hours before any force is exerted on the strapping, that it may establish strong adherence. When it is supposed to stick sufficiently firmly, the splint is to be placed in position; the upper portion will pass round the pelvis, the lower lie along the bed, quite out of reach of the distorted limb. The surgeon now bandages from the foot to the top of the thigh, independent of the splint; arrived at the latter place, he causes the bandage to pass round pelvis and thigh, including all the upper portion of the splint, thus fixing it with sufficient firmness. Catgut is now to be fastened to the ends of the plaister projecting below the foot; the perinæal band, properly padded, is to be adapted, and both to be fastened to the accumulator with the proper degree of tension.*

SPLINT FOR HIP-DISEASE.

For the first ten minutes, or quarter of an hour, the strain should be slight; the muscles soon after its application set up a startled sort of resistance, which, however, soon subsides, and then the India-rubber is to be pulled tighter. In a very few hours the foot or knee will have descended so much that a nurse, or other person in attendance, must tighten the spring, and in from eighteen to thirty hours the limb will have come down, and may be bandaged to the thigh part of the splint. This will have

*It is not always desirable to continue | extension upon the perineal band when the patient is apt to chafe (until the deformity is overcome, the force must be thus applied); the upper end of the accumulator may then be fastened to the top of the splint. A glance at the mechanism will show that the force acts both upwards and downwards; but the lower pulley being in the situation of a movable one, causes the upward to be.

just double as much as the downward pressure on the splint. Hence, to prevent the apparatus riding up it is necessary to use a perinæal band, fastened to the splint, but the tension upwards will be equal to only one-third of the power of the accumulator.-Mr. Bigg, of Leicester Square, has undertaken to make these splints according to my pattern.

been effected without pain or violence; indeed, the starting pains previously complained of will even abate under the downward traction.

If, however, the mal posture be more fixed-that is, if the disease be further advanced into the second stage, the thigh cannot be thus drawn down without producing considerable pain; and in such case it will be better to give chloroform, and while the patient is under its influence, to draw down the limb into the proper position—namely, straight, and to bandage it upon the splint.

The better to consider the treatment now to be adopted, let us glance at the condition of parts. The patient has had an inflammation in the hip-joint, and there is sufficient remaining (be it much or little) to keep up a destructive process; and at the same time he has morbid contraction of certain muscles, which under ordinary circumstances produce a deformity. We have overcome the deformity, and by bandaging can keep the limb in its place. This is the whole that M. Bonnet's, Dr. Bauer's, and all the other instruments at present used, profess to do; but, in my opinion, this is not enough. Binding the thigh to an immovable iron does not annul the contraction of muscles, but simply prevents the flexion or abduction of the thigh; the muscles still contract, and they drag the upper part of the head of the thigh bone violently against the superior lip of the acetabulum. I have already (p. 312) pointed out that this pressure is the cause that hip-joint disease continues so long. It follows that, to enable the disease to get well, we should prevent this abnormal pressure.

Upon this principle, our plan of treatment is simple. We have only to prevent the muscular spasm from pressing these two portions of bone together, and the disease will decrease; for in the majority of cases the pristine inflammation would be subdued by the time the second stage comes on; but that it continues in consequence of the pressure. The muscular contraction which pulls the thigh up must be met by another force which will pull it down. We cannot, nor do we wish, to separate the bones, but we can so arrange that the muscular force shall expend itself upon an external object, and leave between the head of the thigh and the acetabulum no more, perhaps rather less, than

their normal amount of pressure. This can be done by the extending splint, examples of the use of which shall be given; these means will not cure hip-disease, but they will place it in the best possible circumstances for getting well. The rest of the treatment must be adapted to the peculiarities of the case; thus, there may be tension of the capsule, evidenced by heat, considerable tenderness, and swelling behind the trochanter and at the groin, accompanied by deep-seated and confined fluctuation. A few rare cases occur whose rapid course of events would justify our including them under the head of acute synovitis of the hip, in which so much strong inflammatory fever is present that we may conclude the fluid to be synovia. By far the larger proportion of diseases in this joint belong to the subacute or chronic form; the slow succession of symptoms, and the irritable hectic-like fever, rather warrant us in assuming that the fluid in the cavity is pus.

In the former instance, I would strongly recommend the application of the actual cautery, at the back of the trochanter, in two lines, so disposed as not to interfere with the application of the splint. A short line of cauterization at the groin, inside the femoral vein, has, in my experience, great effect in easing the pain, and also, I believe, in producing absorption of the effusion If, on the other hand, the fluid in the joint-cavity be, judging from the symptoms, probably pus, we cannot hope to procure its absorption by such means, and any counter irritation will be not only useless, but positively injurious, by adding to the pain and irritable condition of the patient.

We may, however, consider whether it will not be advisable to let out the fluid. It has been shown that at a certain period of the disease the capsule gives way, and the contents are poured into the surrounding parts; that a period of ease then supervenes, which is generally followed by abscess. We have, therefore, this warranty in nature for such a procedure, viz., that if we do not empty the abscess, it will evacuate itself; and by drawing out the pus by means of a canula, we prevent its diffusion among the muscles, and may even check, or very much retard, the formation of external abscess. Surgery is, I believe, indebted to Dr. Bauer for this operation, and it will, as far as my experience

*The possibility of curing a chronic inflammatory disease has been already doubted. See p. 264.

goes, be found very valuable. In my hands it has certainly relieved pain to a remarkable degree, and the formation of abscess has seemed, to say the least, postponed. But the more extended experience of Dr. Bauer himself will afford a more reliable account of its benefits than my smaller number of cases can furnish.

"But what shall we do with the effusion in the joint? If it is of plastic character and small amount, we may leave it to resorption, and if it should organise and cause fibrous adhesions between the corresponding articular surfaces, it would matter but little, since we have it in our power to break them up again and re-establish mobility; occasional motion of the joint in the process of their formation may even prevent them effectually; this should be done, however, with great discretion, and not before the inflammation has abated in some degree. A considerable quantity of effused material is not only a great impediment to the restoration of the position of the extremity, but it is in some respects the means of continuing inflammation by keeping up the distension of inflamed tissues. With the quantity of exudation the degree of malposition and the violence of symptoms correspond.* In order to relieve both we have to withdraw it. We may do this in two ways, with knife or trocar. A straight and pointed tenotome is flatly inserted behind the joint, then so turned as to penetrate the capsular ligament. The wound of the latter should at least be a quarter of an inch long, so as to facilitate the escape of the fluid. Whilst this is being done the extremity should be inverted so as to diminish the size of the articular cavity so as to drive all the liquid out. The punctured wound, in fine, should be carefully closed with adhesive straps and the limb fastened on the wire apparatus. We should proceed in a similar manner with the trocar, with this difference however, that the canula remains in the joint until the limb has been inverted. The limb should be kept in this position until the canula has been removed, the wound closed, and itself fastened down in the wire breeches, otherwise the formation of a vacuum would invite the air to rush in and cause mischief. The exact place to enter is to be determined by the fluctuation, mostly an inch posterior and superior to the great trochanter, where the

This statement (the italics are Dr. | whole extension, to many joint-diseases Bauer's) is hardly to be applied, in its with violent symptoms.