Hip Disease in Childhood: With Special Reference to Its Treatment by Excision

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Chapter I. General Considerations - - i

II. Points in the Anatomy of the Joint 6

III. Etiology and Pathology - - 9

IV. Symptoms - - - - - 36 V. Diagnosis - - - - - 67

VI. Prognosis and Relapses - - 79

VII. Treatment - - - - 84

VIII. Causes of Death - - - 127

IX. Other Diseases of the Hip - - 129

Appendix I. Cases of Excision - - - 161

II. Cases Illustrating various Affections OF the Hip alluded to in

the Text _ . - - 223

Note on Diastasis - - - - - 239

List of Authors referred to in the Text - 240

Preface

The greater part of the present work has been already published in America, in the Archives of Pediatrics; and most of the cases in Appendix I., with some of those in Appendix II., have appeared in the annual numbers of Abstracts, edited by the staff of the General Hospital for Sick Children, Manchester. The text has, however, been much revised and expanded from the American issue, into which many mistakes crept from my having no opportunity of correcting proof sheets. The list of excisions has been enlarged, and later records of the condition of many of the cases obtained. That this record is not more complete is due to the practical impossibility of tracing many patients after their discharge from hospital. Most of the cases, however, have been followed up for considerable periods.

I have thought it worth while to publish the work in its present form since hip disease is one of the subjects on which the most directly conflicting views are still held, especially as to the question of excision, and the results of an experience of several hundred cases cannot be without interest. The present uncertainty in the matter is, in my opinion, to no small extent due to the habit of assuming that all joints of the body are affected by disease in the same way, while, in fact, the effects of disease are as different as is the construction of the several joints, and the hip stands much by itself in its pathology. The i viii PREFACE.

subject has been treated mainly with reference to the question of operation.

I have to acknowledge many obligations in collecting my material for the work. My colleagues at the Royal Infirmary and the Children's Hospital have kindly sent me, or allowed me, to use many cases. To several generations of Resident Medical Officers at the Children's Hospital I am indebted for help and note-taking, and to our present senior Resident Officer, Dr. Kershaw, for the photographs from which Figs. 43 and 46 were engraved.

To my friend and colleague, Mr. Southam, I am specially indebted for much help and advice in correcting proof sheets.

Of the fifty-three illustrations forty-eight are original, and those representing the pathology of the disease have been selected from my own collection, as showing fairly the different conditions met with. The whole collection is now being placed in the Museum of the Owens College.

The engraver, Mr. Langton, has spent much trouble in getting accurate representations from photographs taken of the preparations and from study, with me, of the specimens themselves.

The series of 100 excisions are, with one exception, consecutive, and are therefore entirely unselected.

Appendix I. consists of short abstracts of the cases in the Table. Appendix H. contains similar reports illustrating various affections of the joint.

G. A. W.

8a, St. John Street,

Manchester.

ON HIP DISEASE IN CHILDHOOD.

GENERAL CONSIDERATIONS.

Hip disease, coxalgia or morbus cox^e, in the commonly accepted use of the term, forms a considerable feature in the list of diseases of general hospitals, and is in children's hospitals often the largest contributor to the surgical wards ; for, at the Hospital for Sick Children, Manchester, nearly 300 cases were admitted in the thirteen years (1S72-84); and in the five years (1881-5), 254 cases were taken in — the number of surgical beds during that time averaging about 30* In addition to these, many more attended the Out-patient Department, so that I have had probably between 500 and 600 distinct cases in the last six years.

Mr. Bryantt thinks that thirty per cent of the total number of joint diseases are cases of morbus coxk.

Age. — As to predisposing causes of the disease, the influence of age is the first and most striking point in hipdisease statistics. For instance, in the Manchester Royal Infirmary, where the admission of children under six years is discouraged, of 423 cases of morbus cox^, 345 were under twenty years, 279 under fifteen years, and 150 under ten years. No evidence is, however, necessary to demonstrate the well-accepted fact that the disease is especially one of

'Numbers of this kind ate, however, always uncertain, inasmuch as readmissions couot as new coses. + PrxKticc 0/ Surgtry.

ON HIP DISEASE IN CHILDHOOD.

childhood further than such as may be gathered from the following tables of cases, collected by Mr. Bryant, Professor Sayre* and myself, respectively.

My own table, collected specially for this purpose, includes 619 cases — ^418 at one hospital, and 201 at another.

Under 6 years From 6 to lo years „ 10 to IS „

„ 251030 it tf tt

it it

40 cases, no „ 129

• • • •••

••• •••

3 I

2 years and under ...

From 2 to 5 years 5 to 10 „ 10 to 14 „ tt tt

Mr. Bryant gives 360 cases.

Under 4 years

From 5 to 10 years II to 20 „ 21 to 30 „

••* ...

97 „ 86

••• •••

13 II

Prof Sayre gives 365 cases, of which 221 were under fifteen years, and 121 under five years.

Thus, of 1,344 cases, nearly 1,000 occurred under fifteen years, and even this is much within the truth. Mr. Barwellt says he knows of no case of hip disease beginning after twenty-five, and only one after eighteen years, though of many relapses even between thirty and forty. This is, however, an unusual experience, I think; I have met with several cases later than the ages he mentions.

* Orthopcedic Surgery and Diseases of Joints, t Treatise on Diseases of Joints,

^^^^^^H GENERAL CONSIDERATIONS. $

^^P The alleged causes of the great frequency of the disease

^^M in childhood are :

^^M I. That in the active period of growth more change is

^^H going on, and therefore more instability exists, and conae-

^^M quently a greater liability to disease (Barwell). ^H 2. That children are more liable to falls and injuries,

^^V which are such a fertile source of joint and bone lesions. ^^M 3. That it is not till after puberty that the process of

^^1 natural selection has eliminated the weaklings from the

^^m stock.

^^H 4. That children are less easily than adults made

^^H amenable to the prolonged quiescence required to prevent

^^H a slight injury from developing into a formidable disease. ^^H 5, Tuberculosis is common in childhood. ^^B Sex. — There is, I think, little doubt that hip disease

^^H is more common among males than females — though

^^H Mr. Bryant thinks the proportion equal.* Of 619 cases

^^m I collected, 371 were males. The probable reason of

^^H the difference is that boys are more liable to injury and

^^M accident than girls; and this is especially so in our large

^^B manufacturing towns, where the mothers go out to work,

^^M and the girls soon learn to be too staid to run about or

^^M play. Possibly, too, the cau.se suggested by Mr. Barwell

^^M as having some influence in the production of hip disease

^^M has something to do with it, I speak of phimosis— a con-

^^M dition which, he thinks, by irritation of the lumbar portion

^^M of the spinal cord, gives rise to reflected trophic changes

^^M in the joint ; he, however, describes a corresponding con-

^^H dition in girls — vaginitis, etc. It is difficult to see why

^^M the hip should be affected to the exclusion of other joints ;

^^M yet there is, no doubt, a certain coincidence, if nothing

^^f more, between the two. Mr. Barwell collected 100 cases of hip disease, and found eighty-three had phimosis, more or less complete, I examined sixty-three boys, taken at I

random, suffering from various diseases ; among them I

I" Dr. Clippingdale, MiJ. Press and Circ., 1S82-83, found the disease M

affecled males aod remiles in ihe proportion of abopt 3 to 2. ^^ were twelve cases of hip disease ; twenty-eight of the sixty-three had no phimosis, though some of them had slight adhesions ; seventeen had complete phimosis, and fifteen had the condition less marked ; of the twelve hip patients, four had completely, and four partially, developed phimosis, and four were normal. Thus, twenty per cent of the patients had hip disease; of these, about sixty-seven per cent had phimosis, while of the cases in which there was no hip disease, fifty per cent had long prepuces, and the proportion of complete phimosis cases was greater among the hip patients than the others ; there is, therefore, a decided balance in favour of Mr. Barwell's view.

Keen, writing in the Philadelphia Medical Times, 1 88 1, has recorded a case of spasm of the hip muscles cured by circumcision, an interesting illustration of the question.

The disease is said (Bryant) to be somewhat commoner on the left side than the right. Out of 72 cases, I found disease of the left hip in 42 instances, and of the right in 27 cases, while in three children both hips were affected.

Social Status. — Hip disease is enormously more common among the poorer classes, for obvious rea.sons : worse hygienic conditions, less care if injured, greater liability to injury, and, in many cases, a worse inherited constitution, are sufficient to account for the excess; for similar reasons, country-bred children arecomparatively rarely the subjects of this complaint.

Mortality. — It is very difficult to get any idea of the mortality resulting directly or indirectly from morbus coxre, mainly because of the duration of the disease. Very few cases die in hospitals, many die of some intercurrent disease, many change their abode and will be returned, perhaps differently, two or three times over, in any statistical statement, and it is exceedingly difficult or impossible to trace a large number of the cases to their termination. The best test is that we so rarely see cases of hip disease cured or still going on in adults ; those that have the

GENERAL CONSIDERATIONS. 5

disease in childhood seldom seem to live to adult age with the disease continuing, and perhaps still fewer recover completely. The causes of death will be considered later. The Report of the London Clinical Society's Committee on Excision of tite Hip in Childhood* showed from an analysis of 429 cases — of which 45 were excised, 260 suppurated, but were not excised, and 124 did not suppurate — that 108, or just over one in four, died, and this is probably under the mark, for, if the history of the non-suppurating cases was traced out, I believe a very large proportion would have been found to relapse, and many to die of the disease.

* Transactions of the Clinical Society , 1881.

Chapter II. POINTS IN THE ANATOMY OF THE JOINT

I PROPOSE here only to mention certain peculiarities in the anatomy of the hip which have a direct bearing upon the disease. These points are largely taken from Mr. Morris' able work on the Anatomy of the Joints. The peculiarities I would lay stress upon are :

1. The complete inclusion of the head of the bone in the acetabulum.

2. The fact that the whole upper epiphysis of the femur is within the joint.

3. The direction of the axis of the neck of the bone, by which a force applied to the trochanter will tend to straighten out the angle formed by the neck and shaft, and consequently will be largely expended upon the inner aspect of the neck. This is a fact of great importance, though I have not noticed comments upon it in its relation to disease. This spot is, as will be seen from the figure {Fig, i), the weakest part of the bone, and a very common site for extensive disease is the " calcar femoris," where the neck forms part of the articular surface.

4. The thinness of the fundus of the acetabulum.

5. The junction of the three pelvic bones in the acetabulum, and the existence of a tri-radiate centre of ossification at their point of meeting; this centre, however, is not developed till puberty.

6. The fact that the main vessels of supply to the bone enter it on the upper surface of the neck.

7. The extensive area enclosed within the capsule, the attachments of which reach beneath the gluteus minimus, and up to the anterior inferior iliac spine.

8. The thinness of the capsule between the ilio-femoral and pectineo-femoral bands in front and behind between

POINTS IN THE ANATOMY OF THE JOINT. ^

the ischio- fern oral band and the intertrochanteric line. Another weak spot lies in front, where the branch of the external circumflex artery passes into the joint.

g. The parts of the capsule on which strain is thrown in the different movements of the joint

a. The thin inner and posterior part of the capsule is made taut in extreme flexion with abduction; hence the pain in that movement; the pec tineo- fern oral band is tightened at the same time.

b. The frequent communication of the psoas bursa with the joint through the thin triangular space between the ilio- and pectinco-femoral bands.

lo. The ligamentum teres is loosest in flexion and abduction combined.

ir. The cartilage capping the head of the femur is by no means all articular in the sense that it forms part of the bearing surface. A considerable zone of cartilage extends around the rest, and is covered more or less perfectly with synovial membrane. Through this zone, which may be called the "marginal cartilage," numerous vessels pass, and in disease these are often targe, though in health the supply is less obvious.* The vessels are apparently derived from the synovial membrane, and in some cases, no doubt, inflammation spreads along their channels and reaches the synovial tissue. So far as I know, these facts are not sufficiently, if at all, recognised. The articular cartilage is especially thick round the insertion of the ligamentum teres, to which it is so closely attached that it may be torn away with the ligament in case of dislocation. The ligamentum teres forms as it were a channel through the articular cartilage to the bone, a fact of great importance, since, as will be seen subsequently, disease beginning in the bone may take this course towards the joint cavity.

12. The vascular supply to the joint need not be specified, except to note that it is perhaps doubtful how far the vessels running along the ligamentum teres supply the epiphysis of the femur *

13. The nerve supply is derived from the anterior crural, obturator, sacral plexus, and accessory obturator sometimes.

14. There are numerous bursae in the neighbourhood of the joint, disease of which may either cause or simulate mischief in the hip. Eleven of these are described, the most important being those beneath the psoas and gluteus maximus.

15. The normal range of movement of the joint is through 145° — 150''. Flexion is checked by contact of the thigh with the abdomen when the knee is flexed. In one instance, I met with congenital inability to adduct the thigh sufficiently to cross one leg over the other, in two individuals of one family; in another less-marked case, the patient could not tell me whether the condition was congenital or not.

16. Clippingdale {loc, cit,) thinks that the obturator internus muscle plays an important part in determining the course of suppuration within the pelvis {vide infra)

* Cf, HyrU ; Morris, however, describes them as doing so.

ETIOLOGY AND PATHOLOGY.

As to the etiology of hip disease two principal views are taken — the one that the affection is of traumatic origin, and the other that it is due to a "strumous" or " tubercular " tendency in the subject of it. A certain number of cases appear also to be due to cold and wet ; in many other instances the disease follows one of the specific fevers. Enquiry, however, does not show such clear evidence of the exanthems as a frequent exciting cause, as is often stated. In 102 cases of hip disease of my own, there were five cases in which measles and six in which scarlet fever could be traced as a cause. It wiil, however, often be found that if the exanthems occur in a child the subject already of hip disease, the result is disastrous to the joint. In those cases where other joints are affected with synovial disease, or where much thickening exists, the specific fevers, including erysipelas, sometimes appear to cause disintegration of the chronic inflammatory material, and improvement follows. In twelve cases of acute scarlatinal synovitis recorded by my colleague, Dr. Ashby, the hip was affected twice ; in one case pus was withdrawn from the Joint ; both recovered perfectly. These are, of course, a different type of disease altogether, and probably pyasraic; while in the other chronic cases the disease is usually tubercular, sometimes pyEeraic.

It is urged in favour of the first view that there is, in the majority of cases, a history of injury, and this is undoubtedly true ; but there can be very few children who do not at some time hurt their hips, and yet only a certain proportion get disease of that joint ; it is also said that it

ON HIP DISEASE IN CHILDHOOD.

is not the unhealthy, but the active, robust children that are always about and getting into danger that meet with these accidents, and this is also true, but is it not a wellrecognised fact that one of the so-called "strumous types" is characterised by excessive energy and activity ? Do we not see these delicate children just as active as their fellows ?

Numerous authorities could be quoted in support of either view ; for instance, Prof. Gross describes the disease as tuberculosis of the hip joint, and Dr. Gibney, of New York, from an analysis of 860 cases, concludes that joint diseases in children are nearly always connected with a "strumous tendency," While on the other hand Mr. Warrington Haward, in 1871, collected 130 cases of joint disease, of which he says that only nine were tubercular and seventeen scrofulous ; Mr, Bryant and Prof, Sayre both look upon the disease as traumatic.

Albrecht, in 1883,* examined 325 cases of disease of various joints. In one-third "scrofula" existed, in onesixth there was a history of injury, and in one-half no definite cause could be assigned.

The results of my own observations on this point will be given presently, as my conclusions depend upon the exact pathology of the disease ; but I may say here that out of 102 cases of hip disease, I obtained a history of injury in 40 and a family or personal history of tubercle in 3 1 instances. ( V^ide also the Table of Excisions.)

Seai of the Disease. — The question of the primary lesion in hip disease has been and still is quite as warmly discussed as the etiology. The synovial membrane, cartilages, ligaments, bones, subsynovial tissue, etc, have all had an initial share in the disease assigned to them. Erichsen divides the disease into femoral, acetabular, and arthritic forms, by the latter meaning lesions beginning in any of the ways that occur in other joints. He considers the femoral form to be most common in children, and usually

ETIOLOGY AND PATHOLOGY.

tubercular. Bryant believes the disease to be local, and in children usually an "articular ostitis."

Erichsen, in his work on Surgery, p. 451, vol. n., edit, viii., describes the post mortem appearances of the hip in a child of eight, who died of pneumonia six weeks after the onset of hip disease. The joint contained pus; the ligamentum teres was softened and coated with lymph; the synovial membrane inflamed ; a yellow, dense, hard patch of bone occupying parts of both the epiphysis and diaphysis was found on section of the femur; hard tubercular spots lay in the cancelH; the deep surface of the cartilage was eroded, and the synovial membrane destroyed where it came into contact with the diseased bone. This I take to be a typical example of the common form of hip disease, except that perhaps the tubercles were more than ordinarily abundant and well marked. In another case there was one tubercular focus in the acetabulum, another at the epiphysial line of the femur.

Ford.in 18 io,*described it as a "white swelling," beginning in the bone or cartilage and not differing from other joints.

Bonnet.f whose treatise is as interesting and in many ways valuable as it is elaborate, does not discuss very fully this point, but seems to decide from the analogy of other joints that the mischief begins in the synovial membrane.

Brodiet describes a synovitis, now sometimes called by his name, or more often perhaps "pulpy" or "gelatinous degeneration," corresponding to the " tumeur fongeuse" of Bonnet. He (Brodie) also cites cases of acute synovitis, and believes that there may be a primary ulceration or absorption of cartilage by means of its own vessels, the process beginning on the free surface, as well as by extension from both bone and synovial membrane. He also describes a fibrous change in cartilage frequently preceding ulceration, and giving rise to absorption of the cartilage, the rest of the joint structures remaining normal, except that some-

ON HIP DISEASE IN CHILDHOOD.

times there is caries of bone but no suppuration. The change may occur in many joints.*

Ford quotes De Hacn, "de Morbo Coxario," assaying that the causation is unknown, but the disease exists "in the integuments, in the cellular membrane, the membranous fascia, the muscles, the involucrum of the ischiadic nerve, the periosteum of the bone, the capsular ligament, the cartilages, the bone itself, the glandula innominata, the ligamentum teres, or finally in all the parts together." Ford remarks, not unnaturally, that " there are objections to our adopting De Haen's opinion as perfectly just and satisfactory,"

Brodie says when the bone is primarily attacked it may be either inflammation of the articular lamella or a " scrofulous" change in the cancellous tissue that is the primary lesion. He lays stress upon the fact that often ulceration of cartilage and even caries of bone may go on to a considerable extent without suppuration.

In regard to the pulpy disease of synovial membrane he suggests its analogy to new growths, "tubercle, scirrhus, sarcoma, etc.," and notes with his usual exactness the fact that it is most commonly found in its typical form in the knee. He further describes a case of abscess in the hip joint, with " acute ulceration of the synovial membrane," after an injury.

Brodie also records, out of others in his experience, two cases of circumscribed ulceration of the synovial membrane, one in the hip. A child of nine years old fell and wrenched her hip. In the evening she went to a dance, but while there had a rigor. Fever and delirium followed, and she died in a week. At the post mortem examination, the organs were healthy. An ulcer as large as a shilling was found on that part of the synovial membrane which is reflected over the neck of the femur, with about J oz. of dark coloured pus in the joint.

Brodie also, among several others, records the following

* This appears to be chronic osteoarthritis.

ETIOLOGY AND PATHOLOGY.

I I case of "ulceration of cartilage":— A girl of seven, with hip disease and a sinus. The acetabular cartilage was entirely gone, and most of that on the head of the femur. Pus and granulations were found in the joint, and there was partial dislocation. The other (left) hip joint also contained pus and had ulceration of cartilage. The bones of the right hip were darker than normal and superficially carious, those of the left healthy. The girl died of erysipelas. [Was not the affection of the left hip pysemic, and was not the right a case of primary osteomyelitis, with secondary destruction of cartilage ?]

Finally, he sums up his views by saying that a large proportion of " diseased hips " are cases of ulcerated cartilage, and "it is the disease which forms the great majority of those cases of caries of the hip joint which occur in adult persons, whereas in children the hip joint is principally affected by the scrofulous disease affecting the cancellous structure of the bones."

Key,* as is well known, originated the classical belief that the disease begins in the ligamentum teres; this Brodie did not think correct, while Key further considered that ulceration of cartilage was always the result of overgrowth of synovial fringes.

Bryant considers that hip disease is pathologically identical with other joint diseases; that it is not specially strumous; that it is local; that it is rare to find strumous or tubercular matter in the hip joint, and that as in other joints the disease may be primarily synovial or an articular ostitis.

He thinks nine-tenths of the cases in early life are ostitis, those in adults commonly synovial.

He points out that a hyperemia of the articular extremity is followed by condensation of bone, and then by suppuration or necrosis, i.e., articular ostitis, and he also lays stress on the fact that the disease may begin in the epiphysial cartilage.

■ 2ilid. Chir, Trans. , vol. )

Billroth* considers that synovitis is the commonest beginning of hip disease, but that in tubercular people ostitis may occur affecting the joint secondarily. The synovitis may be of the ordinary form or a "serosynovitis or catarrh."

He describes " ostitis malacissans " as common in the head of the femur, the joint long remaining intact. As regards the process of destruction of cartilage, he attributes it first to an implication of it by extension from the synovial membrane, and later the cartilage cells themselves assist in the destruction of the matrix in some cases and in others take no part. He describes how while the cartilage is attacked superficially by the synovial membrane a simultaneous process of erosion by the granulations of subchondral caries may be going on beneath, and these two may meet and completely separate the cartilage. In very acute conditions the cartilage may become necrotic.

Barwell, like the majority of other writers on joint diseases, singles out hip disease. He describes it as either a synovitis or osteitis, the latter the less common. Writing in 1879, however, he believes that nearly all cases begin in bone, especially about the epiphysial or pelvic junctions.

Rust, of Vienna, believes that the disease always begins in bone.

Sayre attributes the condition to either synovitis or to rupture of the ligamentum teres and consequent failure of nutrition of the head of the bone, or to rupture of small vessels beneath the cartilage or " blood blister." He describes cases of synovitis with moderate effusion and others with great effusion and rapid destruction of the

joint.

Holmes, in his Diseases of Children^ believes the disease begins often in the ligaments. He quotes three cases where the ligamentum teres was ulcerated or injected, two of his own and one of Martin and Collineau's,t and criticises

* Surgery, ^ De la Coxalgie,

ETIOLOGY AND PATHOLOGY.

Barwell's older belief that it begins in the subsynovial tissue as over exact. In a case of Holmes', figured in his book, the synovial fringes are much enlarged. He says sometimes, but less often, the disease begins in the bones. He describes the synovial membrane as converted into a thick pulpy mass. He argues that as suppuration sometimes occurs outside the joint, in those cases the ligaments were the parts first attacked. In his address to the British Medical Association, 1880, he believes disease of bone is secondary to that of soft parts, and that disease of the epiphysial cartilage is rare.

Gross* describes the disease under the heading of tuberculosis of the hip joint, and says that it usually begins in the bone.

Macnamarat says aconsiderable number of cases begin as a synovitis, and that in adult cases the majority are synovial. In acute cases in childhood the disease is probably an epiphysitis, excluding septic cases. He considers a considerable number scrofulous; chronic osteomyelitis spreading to the joint is a common condition.

Adams alluding to Aston Key's celebrated case, where disease is said to have spread from the round ligament to the synovial membrane, the cartilage, and thence to the bone, describes another similar case of his own, and attributes it to rupture or strain of the Hgamentum teres, Coulson describes three other similar cases. Adams believes other cases begin in the bone, either femur or acetabulum.

Gay {Lancet, 1872) believes the disease begins in the head of the femur and extends to the acetabulum.

Howard Marsh describes the disease as sometimes scrofulous, is., a chronic inflammation, with tendency to relapses, occurring in families with a tubercular history; sometimes he thinks the lesion is purely local. He believes that it usually begins in the bone, either femoral or pelvic. (Heath's Diet, of Practical Surgery, 1886.)