the brain which did not cause a marked increase of the intracranial pressure due to the resulting cerebral hemorrhage and edema, so that not only is the operation of decompression and drainage advisable to lessen this pressure, but also as a means of lessening the danger and even preventing a meningo-encephalitis so frequent in the patients who survive the initial period of shock and active hemorrhage. Naturally, if the missile has passed through the basal ganglia, ventricles, the subtentorial tissues and large intracerebral vessels, then the shock with or without a large hemorrhage is so rapid that these patients rarely survive a period of time sufficient to warrant any operative procedures. Besides, if in severe shock, naturally no operation should be attempted, just as in brain injuries following head trauma. If the patient with a pulse-rate over 120 cannot react sufficiently to overcome this condition of shock, surely no operation will assist him. If the patient does survive the shock, then a decompression should be performed; and, if necessary, a bilateral decompression, and both the skull openings of entrance and exit should be enlarged with rongeurs, "cleaned" as well as possible, and rubber tissue drains inserted. By no means should the brain be probed or "ex

Figure 2.

Showing "bursting" type of fracture of both sides of the vault extending down to the middle fossa of the base, in a girl eleven years of age, following a fall from a one-story window. Oozing of much blood

plored" for bone or bullet fragments, as more damage, such as an increase of the cerebral hemorrhage and edema, as well as a direct destruction of the delicate nerve tissues, usually results from such procedures. There is little danger from subcortical foreign bodies other than that of infection, and the mere removal of the foreign body would not lessen that danger as it would have occurred at the time of the injury. Such meddlesome procedures, especially when the patient is in the initial shock, merely hasten the death of the patient. Just as in brain injuries following head trauma, if the patient is in severe shock, treat him for shock, and "let him alone," not even careful neurological examinations to ascertain the exact cerebral status; such examinations of a patient in severe shock merely do not benefit the patient but undoubtedly they lessen his chances of surviving the shock; if however, the patient. can overcome this condition of shock, then he should be most carefully examined and the proper treatment of the local injury instituted as soon as possible.

The symptoms and signs of brain injuries in babies and children are very different from those following similar injuries in adults. In babies, owing to the open fontanelles and to the greater elasticity of the dura, the symptoms and signs of brain injuries are often so mild that they are frequently overlooked. Unless most careful and thorough neurological examinations are made and certain special aids to diagnosis are utilized, such as the ophthalmoscope and the examination of the pressure of the cerebrospinal fluid by the spinal mercurial manometer, then these intracranial lesions may escape serious attention for a period of months in newborn babies, and even years in many children. The remote effects, such as spasticity, mental impairment in many cases, and frequently epilepsy, are merely reminders of the former intracranial damage, so often a supracortical hemorrhage, and we should be most careful in our examinations and treatment to anticipate these frightful sequelae.* The older the child following a cerebral birth trauma, and the

intracranial pressure did not become markedly increased, the patient in this manner probably "decompressed" herself so that no operation was necessary. Excellent recovery.

the older children, the less hopeful is the prognosis. These late cases are derelicts, as it were,

*International Clinics, Vol. III, Series 27, 1917.

and can merely be improved, whereas if the condition of cerebral hemorrhage and edema is recognized as early as possible after the intracranial lesion has occurred, and if there is a marked increase of the intracranial pressure, and the proper operative treatment of cranial decompression and drainage instituted, then in these cases so treated not only will the ultimate improvement be greater and even a cure obtained, but the immediate recovery of life will be greatly aided. These lesions in babies and children have been so overlooked and even neglected, that it has seemed advisable to report a large number of these cases in detail.* Naturally, the older the child, the more do the symptoms and signs of an intracranial lesion approximate those occurring in an adult, and yet the brain in children under the age of puberty is so adaptable to changed conditions, and to a certain extent less delicate, that even a high degree of intracranial pressure due to cerebral hemorrhage and edema may present clinically few signs of its presence, and in many cases it can be withstood and undoubtedly is successfully overcome by natural absorption alone. This fact should always be remembered in the treatment of brain injuries in children, so that no operation should be advised, unless the intracranial pressure in these cases is very high and when it is doubtful if the child can "take care of" this increased pressure alone; thus does the treatment of brain injuries in children differ from that in adults. Naturally, just as in adults, all traumatic depressions of the vault with or without a definite fracture of the bone itself should be elevated or removed; in babies, the use of forceps in difficult labors frequently produces a definite depression of the vault without a fracture of the bone itself owing to its greater resiliency, and unless this depressed area of bone is elevated or removed, the danger of future cerebral impairment is great indeed. It is frequently not necessary to open the dura in these cases of local depression of the vault in babies, as subdural supracortical hemorrhage is apparently of rare occurrence. Naturally, in cases of doubtful subdural hemorrhage and cerebral edema, the dura should always be opened through a subtemporal decompression, just as in adults hav

*New York State Journal of Medicine, Oct., 1916.

ing an increased intracranial pressure associated with a depressed fracture of the vault the local bony depression is elevated or removed.

The end results of patients having brain injuries with or without a fracture of the skull have been an interesting study. It has become quite a common belief that once a man has had a fracture of the skull and then recovers, he is never the same person again. In 1912, I examined the records of three of the large hospitals of New York City during the decade of 1900-1910; the mortality of fractures of the skull was 46 to 68 per cent; the mortality of the patients operated upon was 87 per cent; this high percentage due undoubtedly to the operation being postponed until the extreme stages of medullary compression and edema, and also to the fact that the operation performed was the "turning down" of a bone flap (a much more formidable procedure than a decompression) and then the bone replaced so that even the benefits of a decompression were thus prevented; besides, in many cases the dura was not opened, and as the dura is inelastic in

Huge multiple fractures of the vault, allowing the vertex of the skull to become elevated as the result of the "bursting" type of indirect fracture, in a boy sixteen years of age, following a severe fall upon an asphalt pavement. A very extensive haematoma appeared within an hour beneath the entire scalp of the vault; in this manner, the signs of an increased intracranial pressure did not occur owing to this escape of blood from the intracranial cavity out under the scalp, and therefore the cranial operation of decompression and drainage was avoided. Excellent recovery.

adults, no adequate relief of the pressure could possibly be obtained. Of the patients, however, who were finally discharged as "well" or "cured," I was able to trace only 34 per cent, but of these 34 per cent of the total patients found, 67 per cent of them were still suffering from the effects of the injury-that is, twothirds of them were not as well as before the injury; the chief complaints were persistent headache, a change of personality of the depressed or of the excitable type and thus emotionally unstable, early fatigue making any prolonged mental or physical effort impossible and thus the inability to work, lapses of memory, spells of dizziness and faintness, and even epileptiform seizures in a small percentage of them. In examining the hospital records of the patients having these post-traumatic conditions, it was most interesting to ascertain that these were the patients (and there were but few exceptions who regained consciousness gradually after several days and remained in the hospital for a period of four weeks and longer), whose charts made frequent mention of the severe headache and a low pulse-rate of 60, and in some cases below 60-that is, the usual clinical signs of an increased intracranial pressure; an ophthalmoscopic examination had rarely been made. Many of these patients

still showed the results of the increased intracranial pressure in their fundi and at lumbar puncture, and these were the ones upon whom a cranial decompression even at this late date of several years caused a marked improvement; the operative findings were always associated with a "wet," swollen edematous brain. Many of the so-called post-traumatic neuroses are, in my opinion, frequently superimposed upon this definite organic basis as the result of the brain injury. The treatment, therefore, of brain injuries should not be limited merely to the recovery of the patient as far as life is concerned, but it should also be directed toward obtaining a normal individual -approximating as closely as possible the condition of the patient before the injury.

DIAGNOSIS AND TREATMENT OF TUBERCULOUS ARTHRITIS OF THE HIPJOINT.*

H. W. MEYERDING, M. D., F. A. C. S., Mayo Clinic, Rochester, Minn.

Shortening and ankylosis in deformity, after prolonged suffering and disability, are the results of nature's cure of tuberculous disease of the hip. Abscess formation with annoying multiple sinuses frequently complicates the condition and adds to the misery of the patient. To avoid these end-results, early diagnosis and careful, prolonged treatment must be carried out under competent supervision.

While tuberculous disease of the hip is usually found in the first decade, Whitman's' report of 88.1 per cent of patients under 10, and 45.6 per cent between 3 and 5 years of age, and a review of cases observed at the Mayo Clinic leads us to conclude that our practice consists principally of long-standing severe or neglected cases. In one hundred consecutive cases there were 23 patients in the first decade, 23 in the second, 24 in the third, 22 in the fourth, 4 in the fifth, and 4 in the sixth. The average duration of the disease before our examination was 20 months, the shortest 2 weeks, and the most prolonged, 46 years. The histories clearly show that early diagnosis and proper treatment was instituted, only to be discarded at the termination of acute symptoms, to be followed by recurrence, the formation of abscess, ankylosis, etc. Fifty-six per cent of these patients were males and 44 per cent females. The right hip was affected in 60 per cent.

A diagnosis should not be made by roentgenograph alone nor should it depend entirely on laboratory findings but rather on a carefully written history, a clinical examination substantiated by the roentgenograph, and the laboratory findings. The fact that Perthe's osteochondritis deformans juvenilis has been but recently differentiated from tuberculous arthritis makes this summarization of findings in diagnosis obvious. The history is of great impor

*Presented before the Southern Minnesota Medical Association, Mankato, Nov. 26-27, 1917.

'Whitman, R.: A treatise on orthopedic surgery. Phila., Lea., 1901, 650 pp.

Forty-four per cent of our patients gave a history of trauma directly preceding the primary complaint and referred to it voluntarily as the cause of the arthritis. Trauma was the most frequent cause of recurrence of symptoms, those second in importance being. illness or pregnancy. Exposure to tuberculosis in the home was noted in 17 per cent.

Among the earliest symptoms are musclespasm, limping, pain and atrophy, the patient frequently resting the well foot on the affected one, pushing down in the effort of traction and fixation. Pain is often referred to the kneejoint. Night starts and cries may or may not be present and are not in themselves diagnostic, but associated with other symptoms, aid in the conclusions. Later deformity, shortening, periarticular thickening, and cold abscess formation may become evident.

Roentgenographic findings are dependent on the stage of the disease, varying from synovitis, and thickened or distended capsule, to areas of rarefaction and general haziness or destruction of the entire joint and acetabulum, with upward displacement of the greater trochanter. Even perforation of the acetabulum and sequestrum in the urinary bladder may occur. In our series there were two cases of perforation of the bladder. One patient was operated on, the sequestrum proving to be the femoral head.

Von Pirquet's test is of the greatest value as an aid to early diagnosis in children under 5 years of age. Its value decreases with increasing age. Aspiration and guinea pig inoculation. proving the presence of tuberculous bacilli is final evidence. Our observations would lead us to believe that there is, independent of Perthe's disease, a mild and fulminating type of tuberculous arthritis. The blood count is of value as showing increase in lymphocytes and secondary anemia. In forty-eight patients the hemoglobin averaged 67 per cent. The temperature, night sweats, other tuberculous lesions, etc., give further evidence of the disease.

Differential Diagnosis.

1. Traumatic arthritis or periarticular injury is differentiated by local tenderness, ecchymosis, the history, and a negative roentgenograph, while impaction fractures, later

up of the impaction, give positive roentgenographs.

2. Chronic hypertrophic arthritis has frequently been confused with the tuberculous type. The condition appears in older persons, and shows characteristic lipping arthritis without rarefaction, etc. The limitation of motion. is usually in abduction and rotation due to mechanical obstruction and there is little or no muscle-spasm, shortening, etc.

3. Infectious arthritis is usually multiple, acute and accompanied by high fever, and leukocytosis. A search for focal infection and its removal lead to rapid recovery. Aspiration and bacteriologic examination aid in differentiation. The observation of the patient may be necessary for some time.

4. Perthe's disease, osteochondritis deformans juvenilis, may resemble tuberculosis clinically but may be differentiated by the characteristic epiphysial changes.

5. Infantile paralysis is easily differentiated in the paralytic stage. In the acute stage. there may be local pain and tenderness for a short time which soon leaves a typical paralysis.

6. Arthritis of the knee allows motion of the hip without pain when the knee is held immobilized, and the entire limb carefully manipu lated. An examination of the hip should always be made when pain in the knee is complained of without local objective findings.

7. Pott's disease of the lumbar spine has as its earliest symptom muscle-rigidity. Careful manipulation of the hip with negative roentgenographs will make clear that the hip itself is not involved.

8. Congenital dislocation lacks muscle spasm, rigidity, atrophy, etc., and is positively diag nosed by the gait, palpation, and the roentgenograph.

Treatment.

The general hygienic antituberculous care of the patient is of the utmost importance. Rollier's methods are productive of excellent results. Sunshine, fresh air and simple substantial food are the most useful general aids and preferable to dosing the patient with medicine,

Rollier: The practice of sun-cure for surgical cases of tuberculosis and its clinical results. Tr. Internat. Cong. Med., 1913, Lond., 1914, Sub.-sect. vii, (a). Orthoped., pt. 2. 251-269.

1. Child on Jones' abduction frame showing extension and perineal strap.

although tonies and constructives have a value. The use of a sun porch is urged, and patients are instructed to live thereon. They should sleep with windows open, and be properly protected against wind and cold.

The local treatment is dependent on the stage of the disease and the circumstances. We prefer the Jones abduction frame and have used it with much satisfaction during the acute stage (Fig. 1). It allows the fixation and extension; it relieves pain and spasm, while at the same time correcting the deformity. The bed-pan may be used without moving the patient. When necessary, by grasping the bar between the legs and the head piece, the patient and the frame may be transported without discomfort. Pressure sores seldom develop, and then only from neglect. The body may be inspected and

Fig. II

2. Child sitting up first time after treatment on Jones' abduction frame.

if dressings are required, easy access is permitted. The length of time the patients remain on this frame is of little consequence, just so they remain long enough. It is far better to keep them there until all acute symptoms have subsided, the general condition has improved, the deformity has been corrected, and roentgenographic examination shows redeposit of salts. Many of our patients remain on this frame a year or more when the severity of the disease, sinus or abscess formation make it necessary (Fig. 2).

In adults the acute stage may be treated by Buck's extension in bed, the limb being supported by sandbags.

During the subacute stage, if no drainage. exists, a cast of the Lorenz type may be used, together with crutches and the elevation of the sound limb by means of a patten (Fig. 3).

The length of time required during this stage of treatment must be determined in each individual case. When weight-bearing is attempted under supervision and no pain ensues, the patient is warned as to the danger of trauma, provided with a Thomas hip splint and advised to continue crutches, gradually applying more