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to bear in mind that the destructiveness and inveteracy of this disease are largely the result of mechanical envi- ronment. Its full counterpart in the upper extremity is not found, evidently because in the upper extremity the focus ignited in the cancellous tissue is, as a rule, resolved at an early stage by reason of the exemption of the upper extremities from the labors and hardships attending loco- motion. We cannot do better, therefore, than to nullify pernicious mechanical environment. By so doing we directly banish trauma from the part affected, and indi- rectly fortify the general health, and in both ways invite the advent of a " natural cure." The three cases which are to be cited illustrate the good effect of mechanical treatment, in the most unprom- ising cases. Case I, — .\ boy, six years of age, presented an enor- mous abscess, and all the usual symptoms of the last stage of the disease, which had continued in the right hip for nineteen months. Exsection of the joint had been urged by a surgical attendant. The abscess opened spontaneously on the first day the patient was seen, and before treatment could be begun. The child's general condition was bad. The limb was greatly adducted and fle.\ed, and the slightest disturbance of the joint caused severe pain. Mechanical treatment was begun the sixth day after the patient was first examined. Pain was relieved at once. He was enabled to be out of bed with- out delay, and out of the house nearly every day, through- out the entire course of treatment, which lasted two and a half years. The affected joint received the benefit of fix- ation, or a reasonable degree of immobilization, and was thoroughly protected from the traumatic incidents of lo- comotion. The adduction of the limb gradually and painlessly disappeared as the boy made use of the limb, protected by the splint, in walking, and flexion was reduced till the limb was in a position favorable for locomotion. Wearing the splint Generic Imigran the patient pursued the ordinary oc- cupations of a boy of his age, while the reparative pro- cess supplanted the ravages of disease. The abscess already referred to was followed at irregular intervals by other purulent collections which were incised or allowed to open spontaneously. .\t one time there were nine sinuses about the joint, all derived from diseased bone. Five of these extended in a line down the outer side of the thigh from the trochanter to near the middle of the ' Presented at Purchase Imigran the Pan-American Medical Congress, held at Wash- ington, September, 1893. shaft of the femur, as seen in Fig. i. The position of these sinuses, from one of which a sequestrum was extruded, and the attachment of the resulting cicatrices to the bone showed that the shaft of the femur was, to a great extent, in- volved in the destructive process. The patient's Buy Cheap Imigran condition six months after the cessation of treatment is shown in Figs. I and 2. The limb is in good position, neither abducted nor adducted, and flexed at a slight angle, enough to allow him to sit comfortably, and yet not enough to in- terfere with graceful locomotion. He walks with firm- ness, runs fast, and never uses a cane. There is practi- cally no " apparent " shortening, that is, the shortening due to adduction and flexion. The " real " shortening is one inch, due partly to changes in the femoral head and neck, but more to the fact that the skeleton of the affected limb is smaller than that of the well limb. This difference is seen in the difference between the outlines of the feet, as shown in Fig. 3, Buy Imigran Online and is also due partly to the fact that the growth of the affected limb has been re- tarded by disease, while the de- velopment of the well limb has been forced by over-exertion for p,j. so long a period. The position of the sinuses is shown in the figures. The scars are depressed and attached to the deep fasciae and bone. They are numbered in the order in which the sinuses ap- peared. Figs, I, 2. 4, 5, 7, and 8 are copied from photographs. Case II. — A girl, three years of age, had a family his- tory in which the mother, the maternal grandmother, and 546 MEDICAL RECORD. [October 28, 1893 three paternal uncles and aunts had died of pulmonar\- tuberculosis. (The family histories in Cases I. and III. were remarkably Imigran Online free from similar incidents.) The dis- ease had l)een present in the right hip a year and more. Treatment had been by the immovable plaster- of- Paris dressing, the wheel crutch, and by portative apparatus in which there was provision for motion at the knee, but not for traction. When first seen, the child presented the marked adduction and flexion characteristic of an ad- vanced stage. She had suffered for several weeks the severe pain which forebodes an abscess, and is due proba- bly to the retention of pus in the cancellous tissue of the '■^^ ^ i» /, elaborate appliances, the chief defect of which had been Imigran Cost in the slight construction of the frame of the portative splints which had failed to make sufficient traction or to relieve the affected joint from the weight of the body in standing and walking. The usual signs of an advanced stage were present, and an abscess was pointing when bone. Soon after the application of mechanical treat- ment the position of the limb improved, adduction giving place to abduction, and flexion being materially reduced. The pain ceased, as the result, perhaps, of the escape of pus from the hard shell enclosing the cancellous tis- sue. Five months after treatment began the pus was re- leased from the soft parts by incision, and in the follow- ing eighteen months five other sinuses Buy Imigran were established spontaneously or by incision. Their location and order are indicated in Figs 4 and 5, which show the child's condition eight months after the cessation of treatment. The scars are attached to periosteum and deep fasci;B. Her health is perfect and she walks and nms without assistance of any kind. The position of the femur is fa- vorable both for walking and sitting, there being no abduc- tion or adduction, and but a moderate degree of flexion. The realshortening is only one- fourth KiG. 6 of an inch. The outlines of her feet are shown in Fig. 6. AVhen she walks with Purchase Imigran Online care it is difficult to perceive any de- fect, although the motion in the joint Order Imigran Online itself is so slight as to beof very little use in locomotion, advantage being uncon- sciously taken of the flexibility of the lumbar region of the spine and of the unimpaired mobility of the sound hip- joint. Fast walking and running develop a limj), but not enough to exclude her from the ordinary pastimes of youth. Case III. — A boy, seven years of age, had suffered from disease of the right hip for four years. His father was a dealer in surgical instruments and the boy had worn Fig. 7. Fig. 8. treatment commenced. Improvement in the position Order Imigran ot the limb was soon seen. In course of time four sinuses were established, either spontaneously or by incision, as seemed to be necessary. The case progressed favorably and the duration of treatment was four and a half years — longer than was necessary through excess of caution and anxiety on the part of the father. Figs. 7 and 8 show the boy's condition eighteen months after all treatment was discontinued. Scars 2 and 4 are attached to the un- derlying bone. He Imigran Tablets takes long walks without fatigue, is a good skater, and walks and runs with great speed, although motion in the joint Imigran Price is practically wanting. He never uses a cane. When walking carefully there is no defect in his gait. There is one-half inch of real short- ening. The outlines of his feet are shown in Fig. 9. The position of the limb is good, there being a moderate Fig. 9. degree of fle.xion, enough to facilitate sitting, but not enough to interfere with graceful locomotion. There is neither abduction nor adduction. Since these cases were reported the patients have re- tained their health and activity, but two of them have lost some of the symmetry above noted. The femur be- came flexed and adducted, not enough to compromise ability in locomotion, but yet enough to give a defect to the gait. This is evidently the result of a failure to re- October Imigran Mg 28, 1893J MEDICAL RECORD. 547 tain the prescribed natural rhythm of walking. The third patient, becoming a medical student, understood and appreciated the importance of rhythmical locomo- tion, and retains the symmetry recorded. These cases are not presented to illustrate the achieve- ments of mechanical treatment in early and promising cases, but to show what should be the result in cases of the worst kind taken in advanced stages, provided the assistance of intelligent and thrifty parents is assured. In favorable circumstances and with treatment begun at the earliest sign of a focus, the result should be, and sometimes is, such as to make it difficult by careful ex- amination and measurement to discover any asymmetry or trace of disability. The same general rules or principles of treatment hold good in the earliest stage and in tlie most desperate and advanced stages. Treatment should make sure of four things: i. Preservation of the general health throughout the treatment ; 2, the arrest of motion in the joint in the acute stage ; 3, the removal of the weight of the body from the joint in all stages ; and 4, provision for final symmetry and locomotor ability. The first consideration is the general health of the pa- tient. On this we rely, in the absence of specific medica- tion and established operative procedures, for the natural return of the affected part from progressive destruction to progressive repair. Can a patient thus beset be better

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