we are liable to have an acute suppurative process in the hip joint simulating that of tubercular trouble which runs a rapid

course.

The symptoms of this disease are characterized by their sudden onset. In this disease death may result from septicemia in a very short time. This, no doubt, is caused by an acute and rapid osteomyelitis. Whenever a child is brought to you and complains of a limp, you should not treat it with slight consideration as this is one of the first symptoms of hip-joint trouble. I mean of the character which is known as the hip limp. It is very peculiar and should be readily recognized. The tenderness and muscular spasm is what produce this condition. The free motion is reduced, and instead of bending the hip freely the spine is bent, and with a pelvic swing the leg is brought forward. The limitation of motion and muscular spasm are the most important symptoms and make their appearance very early.

Oft

Next, we find the deformity which is due to muscular contraction. Fixion is one of the constant symptoms, more freely met with in adduction and inward rotation than otherwise. times the first symptom to be complained of is pain in the knee which, of course, is reflex. Then we have a pain most severe at night. The child will cry out in its sleep. Still we may have advanced hip-joint disease and the child suffer very little pain. In this respect tubercular trouble differs from that of the osteomyelitis and rheumatic affections. The rheumatic affection is quite as liable to have amelioration upon rest in bed and getting the parts warm, but in osteomyelitis the pain continues throughout the twenty-four hours. It matters not whether the patient is in a recumbent posture or up and around.

In tubercular troubles when, from the first, we see the child lying in bed, the affected limb is apparently longer. This is due, however, to a tilting of the pelvis. The actual shortening begins in the second stage when the deformity increases. Then we also get the usual atrophy. At this point the folds of the buttocks have usually entirely disappeared and fixation of the joint is complete. This is usually the time the surgeon is consulted,

when it is past the time of simple treatment and has arrived at the stage of compound.

There is one more trouble we must not forget in making a diagnosis of hip-joint disease and that is hysteria of the hip. This, however, differs materially from other hip-joint troubles as the pain comes on more rapidly and is of longer duration without deformity and also ceases abruptly; does not continue as the regular hip-joint pain. The pain in the hip-joint disease is due to stimulating the articular twigs of the obturator nerve. Of course, all cases of hip-joint trouble must be watched for some time before making absolute diagnosis, as sometimes these troubles simulate the true tubercle hip to such an extent that upon the first examination it is next to impossible to make a diagnosis; therefore, it is better to take a little time, watch the case closely, than it is to take back what you have said.

The treatment of this malady is divided into two cases, medical and surgical, but there is no time where either one should be used alone. At the earliest possible moment after a diagnosis has been made, the medical and surgical should be combined. Fortunately we, as Homeopaths, are far superior in the treatment of hip joint disease, because we have remedies which materially aid us and have curative effects, whereas our friends, the Allopaths, seem to rely very little upon remedial agents. The most prominent of these in my experience are Rhus tox at the head of the list, then comes Sulphur, Iodoform, Arnica, Tuberculinum, Bryonia, Pulsatilla, Hepar Sulph. and Phosphorus. The remedy must be chosen as in all other cases, by a thorough study of the symptonis.

When we are satisfied that we have a case of hip-joint disease, the first thing to do is to place the patient in a recumbent posture, and put on extension and counter-extension. Of course, in putting on counter-extension we are liable to put on a perineal band or more likely one under the arm. The perineal band is not a good method to use, as it becomes more tiresome to the patient, and we are more likely to get excoriation. Another good way when we have a patient who is old enough to understand they must keep quiet and remain on their back, is to

elevate the foot of the bed from eight to twelve inches, and then put on your pulley, and they are not liable to slide down in the bed. You can get the proper extension in this way. This is much more comfortable and will not fatigue the patient so readily.

In placing a weight for extension, the way in which the adhesive straps are applied is very important. The longer you have the adhesive straps the better. For instance, take a piece of adhesive strap that is sufficiently long to extend to the knee, or two or three inches above. Then take about three strips which are long enough to go around the leg, placing one just above the ankle, then at the middle third, and the other just below the knee. The circular strips will prevent the adhesive from tearing loose from the sides of the leg. The weight which should be applied is as follows: two pounds for a child of two years, and for each additional year add one-half pound up to the age of twenty. Rest and extension are two of the most inportant measures we have in the surgical treatment of early hip-joint disease. There are some patients whom it would be exceedingly unwise to confine to the bed, and we are obliged to resort to other means than the continued recumbent posture to produce immobility of the joint. Then we must choose one of the many splints which are advised at the present time. The one I believe to be the most serviceable is that devised by Phelps. Of course, there are several other good splints. The plaster jacket is about as satisfactory as any appliance which can be put on, because in this we can get absolute immobility with less discomfort to the patient than with the splints made by an instrument maker. This jacket is applied in the following manner: beginning at the knee and extending to about two or three inches above the pelvic brim. This should not be made too heavy, and one should be careful not to get undue pressure on any one part. Of course, it requires more skill to adjust the plaster jacket than it does the ordinary splints. The idea with all treatments is to keep the joint immoveable and to avoid pressure and spasm of the muscles. When this has all been done, we must give the well selected remedy together with nutritious diet and plenty of

fresh air. Many times we are able to relieve the patient by hot fomentations with the addition of belladonna tincture.

Now we arrive at the operative treatment. This comes into use after there is a necrosed condition and the beginning of an abscess. This stage is exceedingly hard to positively diagnose as it requires great skill to detect an abscess in its early stages, as fluctuation is very hard to ascertain. When pain begins to increase and increasing the weight will not relieve it, it is reasonable to expect we have a pressure within the joint caused by an abscess. Now we have two methods to pursue. One is the injection of iodoform and glycerine, which treatment is so highly recommended by Dr. Senn. This must be used when the abscess is very small, as when there is a large quantity of pus it will be of no use. Iodoform is a remedy which I have found very efficacious in all tubercular troubles, may it be of joint or otherwise. This when given internally should be administered in one-tenth grain doses; but it has one great disadvantage, in many cases it will cause nausea and loss of appetite, and this, of course, is one of the things we must avoid. The injection of iodoform is used as follows: with a heavy syringe and a very long needle, which is thrust down to the joint, or the affected part, and a ten per cent solution of iodoform and glycerine, one drachm is injected. This is to be repeated not oftener than eight or ten days. This treatment at times, if the trouble has not gone too far, will bring about brilliant results. When a large abscess is bound to occur, we may look for its pointing in the Scarpa's triangle or inner side of the thigh below the anterior superior spine, between the tensor fascia femoris and the sartorius, just above the insertion of the psoas muscle, or beneath the gluteal behind. In some cases they may pass into the pelvis and open above Poupart's ligament, or they may open into the bladder or rectum. A case was referred to me some time ago where the abscess had broken into the bladder, and the patient was treated for stone in the bladder, the sound coming in contact with necrosed bone which suggested diagnosis of stone. This is brought about when the pelvic bones are extensively involved. When an abscess of this nature is opened, it should be done by free in

cision, all the sequestra removed and drainage inserted. Put in as large drainage tubes as it is possible and pack gauze tightly around the same. In making the operation, be careful to preserve all the periosteum that is possible. Never allow an abscess of this nature to open spontaneously as it is very bad treatment. If you are obliged to make extensive resection, put on sufficient weight to overcome retraction, so that when new bone formation takes place, you will have as little shortening as possible.

After your case has recovered, and you have eradicated the tubercular trouble, and you wish to break up the ankylosis, you must use extreme caution so as not to produce a fracture instead of breaking up the ankylosed condition.

Great benefit will be derived by change of air in all these cases. Some seem to thrive in the mountains, others at the sea shore, but my experience has been that about as much relief will be obtained in the Adirondacks as any place in this country. When sending patients, do not have them go to the fashionable resorts where all the consumptives are assembled, but send them to the thickest part of the woods, but where they are able to get good acommodations.

EVERY DISEASE HAS ITS ODOR.-Dr. McCassy declares that every doctor should be able to diagnose measles, diphtheria, typhoid fever, consumption, and even epilepsy, by the smell, as every one has an especial odor when disease is present. Thus in case of favus, the patient exhales the odor of mice; in rheumatism there is an odor of acid that is very easily recognized. In cases of pyemia the breath is nauseating in its smell; in scurvy, too, there is a putrid odor. In peritonitis the odor is like musk; in case of scrofula, like sour beer. In ordinary fever there is an ammoniacal odor. In intermittent fever the odor is like that of fresh baked bread. Among hysterical women there are many delightful odors, violet, and pineapple being most manifest.-Doctor's Magazine.