ABNORMAL CONDITIONS OF THE HIP-JOINT. 



789 



the right side, extending from the hip to the 

 knee, and resembling the pains of rheumatism. 

 He attributed these pains to his having caught 

 cold about a month before his admission. He 

 laboured also under a complaint of his bowels, 

 of which he died on the 4th of December. On 

 dissection, no preternatural appearances were 

 discovered, except in the right hip. The cap- 

 sular ligament and synovial membrane were in 

 a natural state, the cartilages covering the head 

 of the femur and lining the bottom of the ace- 

 tabulum were destroyed by ulceration in about 

 one-half of their extent, and wherever the carti- 

 lage was destroyed an ulcerated surface of bone 

 was exposed ; the round ligament was readily 

 torn in consequence of ulceration having ex- 

 tended to it at the part where it was inserted 

 into the acetabulum. The bones possessed 

 their natural texture and hardness ; there was 

 no pus in the joint. It was observed that the 

 ulcerated surface of the acetabulum correspond- 

 ed to that of the femur, these surfaces being 

 exactly in contact in the position in which the 

 patient had remained since his admission into 

 the hospital. 



Mr. Aston Key, from the cases he had an 

 opportunity of examining of ulceration of the 

 cartilage of the hip-joint in the early stage of 

 the disease, is of opinion that the ulceration of 

 the cartilage is preceded by inflammation of 

 the ligamentum teres. He adduces the follow- 

 ing interesting case. 



A young female, who, for six months prior 

 to her death, had laboured under the usual 

 symptoms of chronic inflammation of the hip- 

 joint, and when the symptoms had nearly 

 yielded to the treatment employed, was attacked 

 with another disease, of which she died. 



The ligamentum teres was found much 

 thicker and more pulpy than usual from inter- 

 stitial effusion ; the vessels on its investing sy no- 

 vial membrane were distended and large, with- 

 out being filled with injection. At the root of 

 the ligament where it is attached to the head of 

 the femur, a spot of ulceration in the cartilage 

 was seen commencing, as it does in other joints, 

 by an extension of the vessels in the form of a 

 membrane from the root of the vascular liga- 

 ment. The same process had also begun on 

 the acetabulum, where the ligamentum teres 

 was attached.* 



Bone. The scrofulous affection of the hip- 

 joint or morbus coxae of Ford is, according to 

 modern writers, a specimen of strumous osteitis. 

 The disease, as far as the hip-joint itself is con- 

 cerned, commences deep in the cancellous 

 structure of the bones, and in general is re- 

 markably slow in its progress. 



\Vhile the disease goes on in the cancellous 

 structure of the bones, before it has extended 

 further, and while there is no swelling, the 

 patient experiences some degree of pain, which, 

 however, is never so severe as to occasion seri- 

 ous distress ; it is often so slight, and increases 

 so gradually as scarcely to be noticed ; after a 

 time the external parts sympathize with those 

 within, and serum and coagulated lymph being 



* SeeMedico-Chirurgical Transactions, vol. xviii. 



effused into 1 the cellular membrane, the joint 

 appears swollen : should the patient be a child, 

 it not unfrequently happens that this swelling 

 first attracts the attention of the nurse or pa- 

 rents. The swelling is puffy and elastic, with 

 blue veins meandring over its surface, but 

 though usually more in degree than in those 

 cases in which ulceration of the cartilage occurs 

 as a primary disease, it is not greater in ap- 

 pearance, because the muscles of the limb are 

 not equally wasted from want of exercise ; the 

 pain increases, but is not severe until matter 

 has formed, and the parts over the abscess have 

 become distended and inflamed, but then it is 

 immediately relieved upon the abscess burst- 

 ing. The skin, under these circumstances, 

 assumes a dark red or purple colour, the ab- 

 scess is slow in its progress, and when it bursts 

 or is opened it discharges a thin pus, with por- 

 tions of a curdy substance floating in it; after- 

 wards the discharge lessens in quantity, be- 

 comes thicker in consistence, and at last nearly 

 resembles the cheesy matter which is found in 

 scrofulous absorbent glands. In most instances 

 several abscesses take place in succession, but 

 at various intervals, some of which heal, while 

 others remain open, assuming the form of fistu- 

 lous sinuses, at the bottom of which carious 

 bone may be distinguished by means of a 

 probe. The principal difference which is to be 

 observed between the symptoms of this affec- 

 tion and that in which the cartilage is primarily 

 the seat of inflammation, is in the degree or 

 angount of pain which the patient endures, and 

 which is much greater in the latter than in 

 those cases where the disease exists in the can- 

 cellous structure of the bones. A girl laboured 

 under an affection of the hip-joint, in which 

 the nates were flattened, and an abscess had 

 broken on the outside of the thigh, but it was 

 observed she had suffered comparatively little 

 pain. Under these circumstances she died, 

 and when, says Sir B. Brodie, I was about to 

 examine the body, I observed to those who 

 were present, that there was little doubt but 

 that the origin of the disease would be found 

 to have been, not in the cartilages, nor in the 

 bony surfaces to which they are connected, but 

 in the cancellous structure of the bone. The 

 appearances verified this remark : the cartilages 

 were ulcerated and the bones destroyed to 

 some extent ; the latter were soft, so that they 

 might be cut with a scalpel, and on dividing 

 the articulating extremity of the femur longitu- 

 dinally, a considerable collection of thick pus- 

 was found in the neck of that bone below the 

 head, which either had not escaped at all, or 

 had escaped in very small quantity by oozing 

 through the cancellf which were interposed be- 

 tween it and the cavity of the joint. The hip- 

 joint wears externally the peculiar aspect of a 

 white swelling, and internally the anatomical 

 structure will be found similar. In this disease 

 of the joints the cancellous structure of the 

 bones is the part primarily affected, in conse- 

 quence of which ulceration takes place in the 

 cartilages covering their articulating surfaces. 

 The cartilages being ulcerated, the subsequent 

 progress of the disease is in many respects .the 



