790 



ABNORMAL CONDITIONS OF THE HIP-JOINT. 



same as where the ulceration takes place in 

 them in the first instance, flust is of opinion 

 that, under the influence of the disease in ques- 

 tion, the head of the bone becomes more volu- 

 minous than in the normal state, and that from 

 its gradual increase the cavity destined to re- 

 ceive it can no longer contain it ; that the cen- 

 tre of the eminence becomes very vascular and 

 softened, and presents evident traces of inflam- 

 mation, which Rust thinks always begins in 

 the membranous medullary tissue which occu- 

 pies the interior of the cancelli of the head of 

 the bone. Roche and Sanson, from whom we 

 have taken this account of Rust's opinion, add 

 that sometimes the articular head of the bone 

 is not changed in volume, but that the cavity 

 for receiving the head is filled by a swelling of 

 the cartilage which clothes it, and by that of 

 the cellular flocculi or Haversian glands. 



Having stated the opinions of those who 

 would wish to arrange and distinguish from 

 each other the different morbid affections of the 

 hip-joint according to the different structures 

 they originate in, we regret to feel obliged here 

 to express our dissent from this arrangement, 

 as we find the greatest difficulty in adhering to 

 it practically. 



VVe have no doubt but that the disease of 

 the hip, whether acute or chronic in its attack, 

 may begin by an inflammation of the synovial 

 membrane of the joint, and that occasionally, 

 particularly in scrofulous subjects, the cancel- 

 lary structures of the bones may be the first 

 seat of the local disease ; we might even yield 

 an assent to the opinion of some, that the car- 

 tilages may in rare cases be the structures first 

 engaged ; but if we seek for facts to convince 

 the mind of the truth of all such speculations, 

 we shall find but little that is satisfactory to 

 guide us. Post-mortem examinations seldom 

 reveal to us the state of the joint, until the dis- 

 ease has made great ravages, and until several 

 structures have been implicated ; the external 

 signs of synovitis, chondritis, and osteitis, can- 

 not, in our judgment, be distinctly recognized 

 in all cases in an articulation so covered by 

 muscles and so remote from the surface as the 

 hip-joint is. We feel convinced, therefore, 

 that in the present state of our knowledge 

 the effects of disease on the articulation of 

 the hip may be best considered under the fol- 

 lowing heads: 1. acute arthritis coxae; 2. 

 chronic strumous arthritis coxae ; 3. chronic 

 rheumatic arthritis coxae. 



1. Acute Arthritis coxa. The following case 

 presents an example of an ordinary case of acute 

 arthritis coxae . Daniel Reddy , aet. 1 8, a labourer, 

 was admitted into the Richmond Hospital on 

 the 1 1 th of October, 1 838. He now had all the 

 symptoms of a very severe attack of acute inflam- 

 mation of the hip-joint. He stated that he had 

 always been remarkably healthy until about 

 four weeks ago, when in consequence of having 

 lain for some hours on damp grass, he had a 

 shivering, which was succeeded by fever ; on 

 the following morning he had severe pain deep 

 behind the great trochanter ; he became so very 

 lame and unable to walk from the pain in his 

 left hip-joint, that he was compelled to keep 



his bed; he also complained of pain in the 

 groin and starlings in the limb. When the 

 patient was supported as far as it was possible 

 in the erect position, we observed posteriorly 

 that there was a remarkable flatness and breadth 

 of the nates of the affected hip, and that its 

 lower fold had disappeared ; there was a gra- 

 dual pyriform tapering down of the hip into 

 the thigh, which was already much wasted ; the 

 pelvis itself was rotated on the spine, the left 

 side being directed backwards, and the spinal 

 column much curved forwards, rendering the 

 abdomen very prominent in this direction. 

 There was at first an apparent elongation of the 

 limb, which soon became flexed on the pelvis, 

 and so strongly adducted as to cross the median 

 line, if the term adduction can be so applied. 

 There was great heat all around the hip-joint ; 

 when pressure was made either on the great 

 trochanter or in the groin, it caused great pain 

 to the patient, and if the least movement was 

 communicated it seemed almost insupportable. 

 In bed he lay on the right or sound side, with 

 the left side of the pelvis directed backwards, 

 the left thigh and leg both much flexed and 

 directed inwards, as already remarked, across 

 the middle line ; he kept the limb by holding 

 it grasped with both hands near the knee. 

 There was some fulness, fluctuation, and ten- 

 derness on pressure over the left iliac fossa, and 

 shooting pain passed down to the knee. There 

 was constitutional fever and much general heat 

 of surface. To rest and active treatment by 

 leeching, blistering, and calomel with opium, 

 his symptoms yielded for a time, then he re- 

 lapsed, and such alternations occurred thrice, 

 and then all the urgent symptoms subsided. 

 In March his fever and constitutional distur- 

 bance had disappeared, and from the recovery 

 of his flesh and expression of countenance, we 

 judged that this attack had passed over, but 

 had left him liable to fresh and dangerous re- 

 turns of inflammation from the most trivial 

 causes, either local, such as injuries, or consti- 

 tutional. In April there was a shortening of 

 one inch and a half, the foot of the affected 

 limb rested on the instep of the other in stand- 

 ing, and in lying the knee was supported 

 by a cushion placed above the other knee ; ad- 

 duction extreme ; and although the thigh, leg, 

 and foot were habitually somewhat inverted, 

 eversion was admissible ; behind there was a 

 great widening of the buttock and retraction 

 of the trochanter major; no fluctuation of 

 matter could be felt about the joint, nor had 

 he any pain in the knee or hip. 



Such, we imagine, is the more ordinary 

 course of acute arthritis coxae. In this case 

 acute synovitis followed the lying on the damp 

 grass; there was noticed an apparent elonga- 

 tion of the limb, which was of very short dura- 

 tion, and was succeeded by a shortening at first 

 very trifling, scarcely appreciable, but after a 

 month half an inch, and at last fully an inch 

 and a half. In consequence of the very decided 

 elevation on the dorsum ilii of the great tro- 

 chanter, with the habitual inversion, flexion, 

 and adduction of the whole limb, we might be 

 led to infer that in this case the articular liga- 



