792 



ABNORMAL CONDITIONS OF THE HIP-JOINT. 



place in this part of the cavity, as thickened 

 periosteum supported the bone, while the ulce- 

 rative absorption was so active in the interior 

 of this cavity, removing the bone, osseous 

 spiculae or stalactiform growths, such as we are 

 familiar with as being produced around scro- 

 fulous joints, had been deposited around the 

 entire circumference of the acetabulum ; some 

 of these had much narrowed the usual extent 

 of the obturator foramen, at that point where 

 matter had passed from the joint into the inte- 

 rior of the pelvis. The bones have been mace- 

 rated and preserved in the Richmond School 

 Museum, and verify many of the statements 

 made relative to this very singular case. 



What influence the communication between 

 the cavity of the abscess and the interior of the 

 vena cava had in producing the fatal result in 

 this case, we do not feel ourselves called upon 

 to determine, nor is this the place to dwell on 

 this obscure subject. The usual phenomena of 

 apparent elongation at first and real shortening 

 of the limb afterwards, either did not exist or 

 were so trifling as not to be appreciated in this 

 case, and the disease ran its course rapidly to a 

 fatal termination, the head of the bone remain- 

 ing in its normal position in the acetabulum. 

 It was probably from having witnessed such 

 cases as the foregoing that that experienced 

 surgeon, Boyer, was induced to make the fol- 

 lowing remark : " On a observe un variete de 

 la carie qui n'attaque que le fond de la cavite 

 cotylo'ide ; de sorte que ce fond settlement est 

 detruit, tandis que ces bords restent intacts ; 

 alors la maticre purulente de mauvaise qualite, 

 qui la remplit, se porte j usque dans le bassin, 

 ou elle forme un foyer plus ou moins conside- 

 rable ; dans ce cas, la maladie fait perir le 

 sujet, sans deplacement du femur." 



We will adduce but one example more of 

 the acute arthritis coxae, with the post-mortem 

 examination. 



Alexander Clarke, set. 17, on admission into 

 the Richmond Hospital, it was observed that 

 there was much swelling about the hip-joint; 

 the integuments over it were tense and shining, 

 the glands in the groin were swollen and very 

 tender; he suffered from pain, shooting to the 

 knee and spasmodic starlings, which awoke 

 him at night; he could not permit the slightest 

 motion of the limb, which was shortened one 

 inch and a quarter ; it was habitually inverted 

 and flexed on the trunk ; the constitutional dis- 

 turbance was considerable. From the treat- 

 ment adopted he derived benefit, and a partial 

 recovery resulted. He left the hospital, but 

 soon returned, in consequence of an aggravation 

 of all the former symptoms, caused by a fall on 

 the diseased hip. A deep abscess formed in 

 the groin and extended under Poupart's liga- 

 ment; hectic symptoms showed themselves. 

 There were alternate diarrhoea and attacks of 

 vomiting. The abscess in the iliac fossa in- 

 creased, the tumefaction around the joint dimi- 

 nished, the shortening and inversion of the limb 

 became greater, and oedema of the foot and leg 

 occurred ; he now became suddenly insensible; 

 his left arm was totally paralyzed, while the 

 right was convulsed and constantly in motion ; 



his face too was distorted by twitchings, and he 

 passed his discharges involuntarily ; he lay thus 

 for several days and died, being in all eighty 

 days ill. 



Post-mortem examination. Upon cutting 

 down to the hip-joint the capsular ligament was 

 found to have been extensively removed ante- 

 riorly; posteriorly and laterally it was not ulce- 

 rated, but seemed to have been greatly length- 

 ened and widened ; the synovial membrane 

 was lined with a yellowish-green membrane, 

 just like what we see investing the interior of 

 the sac of an old chronic abscess ; the ligamen- 

 turn teres and cartilage, which invested the 

 head of the bone, had been removed, the bones 

 were rough, unusually red and vascular, and 

 were coated with yellowish-green lymph ; the 

 acetabulum was much enlarged, and the head 

 of the bone was drawn to the upper and outer 

 part. The left iliac fossa was entirely filled by 

 an immense abscess, lying between the muscle 

 and bone, passing down under Poupart's liga- 

 ment as far as the lesser trochanter. The iliac 

 vessels and the anterior crural nerve were 

 pushed forwards ; half an inch below Poupart's 

 ligament a process of the abscess had passed 

 outwards and backwards, which communicated 

 with the hip-joint, and having the muscles pos- 

 terior tp the joint, which were thinned and 

 matted together, to form its wall in that direc- 

 tion. In the brain purulent matter was found 

 on the arachnoid surface as well as between the 

 several convolutions of the right hemisphere. 

 The neighbouring portion of the brain was 

 softened and vascular; there was no effusion 

 into the arachnoid sac or into the ventricles.* 



Sometimes the acute arthritis coxse is an 

 essential disease, and the only one present at 

 the time in the constitution, being simple and 

 confined to the one articulation, as in the case 

 of Reddy before quoted. Sometimes, however, 

 the acute inflammation of the hip-joint is a 

 symptom of another disease. In acute rheu- 

 matic fever the hip-joint is, in its turn, some- 

 times severely visited. Finally, the cases yet 

 published of acute periostitis and synovitis 

 combined, and of acute puerperal rheumatism, 

 in which the hip-joint became implicated, need 

 not be discussed here. We are of opinion that 

 such cases should be looked upon as true spe- 

 cimens of that almost intractable disease called 

 diffuse inflammation. 



Anatomical characters. -From the post-mor- 

 tem examinations of cases of acute arthritis 

 coxae which have been hitherto made, we can 

 collect that all the structures around the joint 

 are in a state of active vascular congestion. 

 The synovial membrane and subsynovial struc- 

 ture present the ordinary characters of active 

 congestion and the results of acute inflamma- 

 tion. Sometimes there is an increased secretion 

 of synovial fluid, and sometimes, in its stead, 

 purulent matter distends the articulation. The 

 synovial membrane, where it is reflected over 

 the neck of the femur, has been found de- 



* See Dublin Journal, vol. iii. and iv,, also pre- 

 paration in the Richmond Hospital Museum, which 

 the writer has recently inspected. 



