ABNORMAL CONDITIONS OF THE HIP-JOINT. 



793 



stroyed by ulceration. Sometimes the purulent 

 matter has been known to have escaped from 

 the articulation by ulcerated openings in the 

 capsule of the joint, and to have passed into 

 the pelvis, and penetrated between the muscles. 

 The fatty mass at the bottom of the acetabulum 

 has been found swollen, inflamed, and covered 

 with a membranous layer of lymph, at the 

 same time in some of these cases the neigh- 

 bouring periosteum has been found detached 

 from the bone, which was redder than usual. 

 These are appearances which have been noticed 

 in those who have died of acute arthritic in- 

 flammation, whether it may have arisen from 

 diffuse inflammation or simple acute disease 

 confined to the one articulation. In acute 

 cases, actual dislocation of the bones, we be- 

 lieve, has not been noticed, as the disease seldom 

 arrives at its second or third stage under such 

 circumstances, but the cartilage and synovial 

 membranes have been altogether destroyed, and 

 the porous structure of the bones has been ex- 

 posed, digital depressions have been seen pro- 

 duced by acute caries in the acetabulum and 

 head of the femur. The bones have then pre- 

 sented a rough vascular surface, and in many 

 cases lymph has been found to cover the con- 

 vexity of the head of the thigh-bone and to line 

 the acetabulum. The head of the femur some- 

 times is but little altered, either as to form or 

 position, but when the acetabulura is largely 

 excavated by disease, the head of the thigh-bone 

 will be found to be drawn by the muscles to 

 its upper and back part. Even in acute arthri- 

 tis coxae in the young subject, the epiphysis of 

 the head of the femur has been found de- 

 tached.* The ligamentum teres is generally 

 absorbed early, and the capsular ligament is 

 usually ulcerated in some one part, so that, on 

 the post-mortem examination, the bones are 

 found to be very moveable on each other. They 

 are usually observed to be highly vascular, and 

 some imagine the head of the femur is en- 

 larged. Hyperosteotic depositions or stalacti- 

 form productions, which are very friable, exist 

 around the diseased joint. 



2. Chronic strumous arthritis coxa. The 

 scrofulous disease of the hip-joint is very gene- 

 rally slow in its progress, and is seldom seen, 

 except in persons who bear other evidences of 

 the strumous diathesis ; there are examples of 

 it occurring in individuals who have passed the 

 age of thirty years, though generally seen in 

 those of more tender years. This affection of 

 the joint, although slow and insidious in its 

 attack, yet is attended with the usual pheno- 

 mena of an inflammatory or sub-inflammatory 

 action. Many of the writers who have de- 

 scribed the " disease of the hip-joint," have 

 assigned to it three periods or stages, as Ford 

 has done, while succeeding authors have added 

 to the description of the three stages of Ford, a 

 period which they call the period of the inva- 

 sion of the disease. In this their first stage, 

 there is pain in the thigh, extending to the 



* See a preparation in the museum of the Col- 

 lege of Surgeons, Dublin, presented by the late 

 Professor Todd. 



knee, which appears and disappears alternately; 

 a marked weakness in the thigh, and a sense of 

 feebleness in the whole limb; the gait is limp- 

 ing, and some tension is felt in the groin. This 

 period lasts sometimes but a few days, at other 

 times many months. In the second period the 

 limb is wasted, and apparently, though not really, 

 elongated; the trochanter is placed lower down, 

 and is more outward than that of the opposite 

 side ; the buttock is flattened, and its fold is 

 lower than natural ; the patient's lameness is 

 characteristic ; he moves the affected limb 

 round with a shuffling motion, the foot scraping 

 the ground, and he sometimes assists the eleva- 

 tion of the thigh with his hand. At this time 

 the knee is painful, and not unfrequently a 

 puffy swelling appears in it, both which cir- 

 cumstances often too much attract the attention 

 of patient and surgeon, and divert it from the 

 true seat of the disease. The third period 

 is characterized by a real shortening of the 

 limb ; this is sometimes sudden, and the im- 

 mediate consequence of caries of the brim of 

 the acetabulum and luxation of the head of the 

 femur upward and backward on the dorsum of 

 the ilium. The shortening of the limb, however, 

 is more commonly gradual, and the consequence 

 of the slow ulceration and widening of the ace- 

 tabulum. 



It has of late been truly observed, that the 

 luxation is not so common as generally ima- 

 gined, but when it does occur, it usually takes 

 place in the direction upwards and outwards ; 

 when the fibrous capsule and other ligaments 

 are destroyed by ulceration, the head of the 

 femur escapes by the superior and posterior 

 part of the acetabulum, and obeying the action 

 of the glutaei muscles, it glides from before 

 backwards and without inwards upon the con- 

 vex surface of the ilium ; the thigh is flexed, 

 adducted, and turned with a strong rotation in- 

 wards ; the great trochanter approaches the 

 crest of the ilium, the muscles are raised up by 

 the head of the femur, and the buttock is 

 rounded, and becomes very protuberant poste- 

 riorly. Although this is the direction in which 

 the luxation usually takes place, still it has 

 been noticed to have occurred in a direction 

 horizontally backwards towards the ischiatic 

 notch (Earle). It has also been seen in the 

 direction downwards and inwards towards the 

 foramen ovale, in which case the limb is elon- 

 gated and directed outwards. Still more rarely 

 has it been thrown upwards and inwards on the 

 horizontal ramus of the pubis. In one in- 

 stance, says Brodie, I have seen the dislocation 

 in the direction forwards, the head of the femur 

 resting on the pubis, the knee and toes being 

 turned outwards. 



It would be wrong, however, to suppose that 

 a true dislocation of the head of the femur 

 from the ulcerated acetabulum is a very com- 

 mon occurrence; although all these cases, 

 above alluded to, have been witnessed, we be- 

 lieve very frequently the shortening of the limb 

 in the third and fourth stage of the disease 

 arises from ulceration and widening of the ace- 

 tabulum and destruction of the head of the 

 femur. The head of the femur sometimes sepa- 



