2. That motion is not necessary to preserve the normal histological character of a joint.

3. That when a healthy joint becomes ankylosed, or its normal histological character changed, it is not from prolonged rest, but from pathological

causes.

4. That immobilizing a joint in such a manner as to produce and continue intra-articular pressure will result in destruction of the head of the bone and of the socket against which it presses, as is evidenced by the specimen secured in one of the

cases.

5. That atrophy of the muscles of the limb will follow prolonged immobilization of the joint.

If these experiments prove that prolonged fixation will not produce ankylosis of a normal joint, that motion is not necessary for the preservation of its normal function, then the causes of ankylosis must depend upon the pathological conditions, and not. upon prolonged fixation.

In the treatment of inflamed joints it is claimed that motion prevents ankylosis. This must be a mistake, because the statistics of joints so treated show that ankylosis and deformity to a greater or less extent are by far the most frequent results.

The statistics published by Shaffer and Lovett in the New York Medical Journal show that, in 39 cases finally reported upon in the series, there was

The three with free motion were treated during the first stage of the disease. Two were under three years old. There were only two cases without shortening.

The splint used was the long traction-splint, which admits of free motion at the hip-joint. To test this question still further, I sent a patient with kneejoint disease, whom I had nearly cured, to a distinguished masseur for treatment by massage. I had perfectly fixed her joint for one year. The apparatus was removed, and she had motion to about 35 degrees; there was no pain, and she could walk with ease. She was attended daily by the masseur. Her leg was flexed and systematically moved and rubbed. After six months I found almost complete ankylosis. A recent examination showed fibrous ankylosis and only a slight degree of motion.

The so-called "ossified man paid a masseur to move his inflamed joints during two years of his early joint-trouble. The result was perfect bony ankylosis of all the joints that were inflamed.

The fakirs of India, after twenty years of penance, holding their limbs in one position, quickly regain the normal use of their joints after their religious frenzy has passed. (Thomas.)

I have several cases of children suffering from joint-disease that have been immobilized in a portable bed ten, twelve, and eighteen months, the joints of the lower extremities being kept perfectly quiet during the time. Recent examinations demonstrated that ankylosis had not taken place in the normal joints, while the inflamed joints are freely movable.

tissues, rest is one of the most important surgical laws. The surgeon protects the wound from friction by means of proper dressings, and the ophthalmologist puts the inflamed iris at rest by the use of atropine. Since rest is a surgical law in the treatment of inflamed tissues in other parts of the body, and motion is not necessary for the normal preservation of a joint (nor can it in any way prevent ankylsi s of an inflamed joint) I believe that we should not make an inflamed joint an exception to a well-established surgical law.

from three weeks to three or four months, until the deformity is entirely overcome, and the more active stage of the disease somewhat ameliorated.

Fig. 2, from a photograph, shows a patient with the bed-dressings adjusted. A long splint is put on the well limb, and the leg and body to the axilla are enveloped in a plaster-of-Paris bandage. Adhesive plasters are applied to the limb; extension and traction are made in the line of the deformity and at right angles to that line-from six to ten pounds of longitudinal traction, from one to three

The question of ankylosis is determined by the Severity, the character, and the duration of the inflammation, the presence of intra-articular pressure, the subsequent cicatricial contraction of soft parts around the joints, the tissues involved, and the amount of destruction of bone and cartilage. Motion of an inflamed joint only interferes with repair, and more certainly hastens the case on to ankylosis and deformity. To prevent this calamity, when possible, absolute rest and the relief of intra-articular pressure should constitute the plan of treatment. Inflamed joints treated upon this plan furnish by far the fewest cases of ankylosis, limited motion, and deformity. Let us now consider mechanical treatment. During the period of deformity and the acute and primary stage of the disease, nearly all cases of hip-joint disease are better treated in bed than elsewhere-for the reason that in bed the joints can be more perfectly immobilized. Here we can apply extension uninterruptedly, and at the same time fix the joint by holding the limb and body in a fixed position. No one would for a moment think of adjusting a walking splint to the fractured limb of a child, or even allow the child to go about on crutches with a splint. Still this practice is almost universally resorted to in hip-disease-a disease much more menacing to life and limb than a simple fracture of the femur.

At the Post-Graduate School and Hospital we usually put our patients to bed for a time varying

pounds of lateral traction being employed, for the purpose of overcoming the spasm of the adductor and abductor muscles.

Children under three and a half years of age are treated with a plaster-of-Paris portable bed. Others are put upon crutches, with a high shoe and a lateraltraction fixation splint adjusted.

The bed-treatment, as described, relieves pain, overcomes deformity, and the symptoms subside. This suggests the perfection of mechanics. If the principle could be continued, and the patient allowed to exercise, the perfection of mechanical treatment would be attained. To accomplish this I devised the fixation lateral-traction splints.

To make the portable bed, place the child on a piece of paper; mark around him, with the limbs. somewhat spread. Put this piece of paper on a board one-half inch in thickness, and cut the board to fit the pattern. Upholster the board with cotton batting, and cover with cotton cloth. A piece of rubber cloth is placed across the portable bed.

The child is laid on the board and enveloped with the plaster-of-Paris bandage from the foot to the axilla, to the thickness of one-half inch. When the plaster becomes set the front is cut away. The child is now removed; the bed is trimmed for the inside either by pasting flannel or rubber adhesive plaster over the plaster-of-Paris.

The child is placed on this and bandaged in. Extension is made to the foot-piece of the bed, and

mobilizes the hip-joint, prevents the possibility of angular deformity, and applies traction so as to overcome spasm of the muscles that operate upon the thigh. The patient is never allowed to step upon this splint. Splints to immobilize the joint must extend above and below the joint. The long traction-splint stopping at the joint does not immobilize it, and the patient injures the joint by stepping upon it, as is evidenced by the almost constant increase in the deformity, observed in a considerable percentage of all cases.

It has been stated that patients wearing the splint extending up on to the thorax cannot sit down. This is certainly incorrect, as all of these patients can sit very comfortably on the side of a chair, with the diseased limb hanging over the side.

The crutches are an inconvenience; the long splint passing up on the body is an inconvenience, but the patient had better submit for a year or two to this slight inconvenience than to go through life with a deformed limb.

The Thomas splint, like the long traction-splint, only tells half the story. Thomas originally believed that the best result to be attained in hip-joint disease was ankylosis. Believing that prolonged rest would result in ankylosis, and that fixation of the hip-joint could only be accomplished by grasping the body above and below the joint (which is a fact), he devised the splint bearing his name. This splint extends from the axilla to the calf posteriorly. His patients recovered without angular deformity, but nearly all had shortening, many to a great extent, and abscesses occurred with astonishing frequency. A large number of cases presented to the British Medical Association by Mr. Sidney Jones showed that motion was present in nearly every case. Thomas's splint, not controlling muscular spasm, allows of great intra-articular pressure, resulting in destruction of the joint and the formation of ab

scesses.

Another serious objection to the Thomas splint is that the patient will step upon the foot. The splint, ending as it does at the calf, protects the limb only so far as the normal movements are concerned. If the splint extended below the foot, and the patient then attempted to step upon it, and if there were a perineal strap, he could not do so much damage to the joint.

My Results.

Cases received before the development of abscesses rarely develop them.

Small abscesses and effusions into the joint are frequently absorbed or heal by primary union after operation.

Discharging sinuses rapidly cease discharging unless there is extensive bone-disease.

Many cases recover with perfect motion.

All cases recover with but slight or no angular deformity.

Shortening of the limb does not increase, and cases of ankylosis I seldom see.

To conclude, my observations lead me to believe that one of the most serious elements of destruction in hip-joint disease is the trauma and pressure produced by muscular spasm; that fixation of the joint without extension is an impossibility; that the successful treatment of the joint must depend upon its absolute immobilization, which can only be produced by proper extension and fixation; that the constitutional treatment of hip-joint disease amounts to but little, independently of mechanical. treatment; that mechanics is everything; that exten