Arthur Thornton Legg (1874-1939), while Junior Assistant Surgeon at Children's Hospital in Boston, presented a description of osteochondrosis of the femoral head before the American Orthopaedic Association meeting in June of 1909. The presentation appeared in print as this Classic. The lesion was later described by Perthes in the German literature (Perthes, G. C.: Über Arthritis deformans juvenilis, Deutsch Z. Chir. 107-111, 1910) and by Calvé in the French (Calvé, J.: Sur une forme particulière de pseudo-coxalgie greffe sur des déformations caractéristique del'extrémité supérieure du femur, Rev. Chir. (Paris) 42:54, 1910). All three papers appeared in 1910.
Rang, in his Anthology, has recently noted that Perthes in a later report courteously acknowledged Legg's priority and Legg acknowledged the fact that Perthes had made the lesion more widely known. It is at present known as Legg-Calvé-Perthes disease.
E. M. B.
We are at times painfully aware of the fact that there are many symptoms which we readily recognize in our clinical observations to which we can assign no cause, and it is also an undoubted fact that there are many conditions even which exist today of which we are ignorant, simply from our neglect to observe, or from faulty observation, or, again, from faulty deduction even from good observation.
The cases which I bring to your attention today seem to me illustrative of the fact that we, in the past, have not observed certain conditions which truly exist, and that now, having observed, we naturally must ask ourselves, Are our observations faulty or are they correct? and, assuming them to be correct, what is the cause of the condition?
I invite your attention to the report of five cases, four of which I have followed at the Children's Hospital and one which is a patient of Dr. Joel E. Goldthwait, for the privilege of reporting which I am indebted to him.
The first case, a well-developed girl of eight, was brought to the Children's Hospital in October, 1907, with a history of a fall nine months before, immediately followed by a limp on the right which had persisted. There had been no pain or constitutional symptoms.
Examination showed normal flexion of the right hip with all other motions much limited. There was very slight spasm, slight atrophy of the thigh and calf, but no shortening. There was a slight amount of thickening anterior to the neck. The motions of the left hip were normal.
A traction hip splint was applied, which she has worn since. She has had no acute symptoms, nor pain, and has remained in excellent general condition. The very slight spasm present at the first examination disappeared in about a month.
Examination of the right hip at the present time shows motion in flexion to 100°, abduction to 50°, adduction normal. Internal and external rotation is possible to about 45°. The thickening about the joint has remained the same, and the right leg now measures one quarter of an inch longer than the left.
There has been no pain or limp on the left, and the motions of this hip are normal. A slight amount of thickening, however, is felt about this hip.
The Von Pirquet test was negative. Roentgenological examination shows the head of the right femur to be flattened and apparently spread out. The neck appears thickened and shorter than normal. An area of increased radi- ability appears in the upper part of the head and neck. The left or apparently normal side shows the same condition with the exception of the area of increased radiability.
The second case was an active boy of eight who first came to the Children's Hospital in January, 1908. In May, 1907, he had fallen, fracturing his right humerus. Two months later a limp on the right was noticed which had persisted. No pain or constitutional symptoms had been noticed.
On physical examination the right hip showed 20° permanent flexion and 10° permanent adduction. There was considerable limitation of motion in flexion and outward rotation, while other motions were normal. There was atrophy of the thigh and calf, but no shortening. There was slight spasm.
A flannel spica was applied, allowing him to use the leg as he wished. At the end of six months the permanent adduction was 15°, the great trochanter was more prominent than the left, and the thickening about the trochanter was greater. There was still no pain or constitutional symptoms.
A plaster spica was at this time applied, which treatment has been followed since. He now shows no permanent deformity, with motion in flexion to 90°, abduction and adduction 45°, and rotation one half of normal. The legs are of equal length. The Von Pirquet test was negative. The roentgenogram of this case shows a flattening of the head of the femur, with an irregular area of increased radiability near the epiphyseal line. The neck seems shorter and thicker than the other side and there is no atrophy of size of the shaft. The left hip is apparently normal.
The third case was a well-developed Italian boy of five, who came to the Children's Hospital in August, 1908, with a history of a fall ten months previous and a limp on the left for nine months.
Extremes of motion in flexion and abduction were the only motions limited. There was slight atrophy of the thigh and calf and no shortening or spasm.
He was put under traction treatment, which has been followed since.
He now shows on physical examination motion in flexion to 100°, in abduction 45°, and in adduction 30°. Rotation is normal and there is no spasm. The left trochanter is more prominent than the right and there is slight thickening anterior to the joint. The left leg measures one quarter of an inch longer than the right.
There has never been any pain or constitutional symptoms, and the Von Pirquet test was negative.
The Roentgen examination of this case shows a flattening of the head and a spreading out, as seen in the first case. The neck is shorter and thicker than on the right.
The fourth case, a boy of six, came to the Children's Hospital in January, 1909, with a history of limp on the right for a year and a half, immediately following a fall from a ladder.
Examination showed only slight limitation of motion in abduction and internal rotation, with no spasm. There was very slight atrophy of the thigh and calf, but no shortening. The examination of the left hip was negative.
This case has been under protective treatment by a flannel spica since his first visit and has shown no change on physical examination, nor has there been any pain, spasm or constitutional symptoms. No thickening about the hips was palpable in this case.
The Roentgenogram of this case shows a small, flat head with a short thick neck on the right. On the left, where there are no symptoms, a similar condition is seen, but to a more marked degree. On this side is seen a small area in the neck near the epiphyseal line similar to a necrotic area.
The fifth case (Dr. Goldthwait's) was a boy of six, who came to him in December, 1908. One year previous he had a fall in which the legs were spread apart. He was lame for a week, and apparently recovered. Seven months later a limp on the left was noticed. He was restless at night and had indefinite pain referred chiefly to the left groin. A short time before this he had an abscess of the ear.
In the extremes of motion there was slight limitation. There was slight atrophy of the thigh, but none of the calf, and no shortening was present. There was distinct thickening over the neck of the femur.
The Roentgenogram showed a flattened head and a distinct necrotic area just outside the epiphyseal line in the neck, with apparently some thickening of the neck. The focus was curetted out, it being approached through the great trochanter. A culture from the necrotic material obtained showed a staphylococcus growth. The case is now under protective treatment.
In reviewing these cases, the following facts in a general way are observed:
- Age, five to eight years.
- History of injury.
- Thickening about the neck of the femur.
- Absence of pain.
- Absence of constitutional symptoms.
- Little or no spasm.
- Absence of shortening.
I have to record one exception to the above. You will observe in Case V that indefinite pain was a symptom. This is the case in which there existed a low grade of infection in the neck of the femur.
It is worthy of note that all these cases sought advice solely on account of the limp. It is also of interest that in two of the cases (the first and the fourth) the condition of flattening of the head of the femur exists on both sides; and it is of the greatest interest that in both cases there was entire absence of symptoms in one of the hips.
We have considered a group of cases all presenting practically the same conditions, both positive and negative, and which are to my mind atypical of any condition heretofore described, and granting that our observations are correct, we naturally seek a cause for this most interesting clinical picture. In so doing we must consider some of the possibilities.
Is this condition the result of congenital deformity or faulty development?
Is it the result of a constitutional disease?
Is it the result of direct injury?
Is it indirectly due to the injury?
We see in many cases of congenital dislocation of the hip a deformed and poorly developed head of the femur. None of these shows a condition similar to the one described, and the history would seem to rule out this possibility.
In rickets and in syphilis the nutritional impairment affecting the bones never to my knowledge produces a condition of this kind, and the general condition of these cases is apparently excellent.
Direct injury, if severe enough, might cause a flattening of the head of the femur, and in children of this age the head is certainly impressionable. Should this be the cause in these cases, the thickening and shortening of the neck without evidence of fracture remains unexplained. We all know that the history of injury, especially in children, should be given much latitude, but in this group of cases, with a history of distinct injury in all of them, it seems to me that it must be considered, and at this time it seems to me that a possible explanation of the conditions is that the injury may indirectly cause this condition by causing injury or displacement at the epiphyseal line, whereby the nutrition of the head, coming mostly through the neck, is impaired, and by the poorly nourished epiphysis bearing on the acetabulum, it becomes flattened. From such an injury a hyperemia of the neck of the femur would occur, and by this to stimulate bone growth the thickening of the neck may be explained.
Of the occurrence of a similar condition appearing in the apparently normal hip, I shall not, at this time, attempt to offer any explanation. Contre-coup and sympathetic inflammation may be considered, but these are, to my mind, very remote possibilities.
If a hyperemic condition is present in the neck of the femur as a result of a deranged circulation, it may be the explanation of infection taking place at this point, as is seen in the fifth case. It does not seem probable to me that the change in the head in this case is secondary to the infection in the neck, for we see many cases of infection in the neck, and in none of these have I seen the condition described present in the head.
It is unnecessary for me to say in closing that in reporting these cases I make no claim to any definite conclusion, both on account of the small number of cases observed and from the length of time they have been under observation; still, I am glad to have brought them to your attention in the hope that in so doing more cases of this type may come under observation and that by further study their true etiology may be determined.