ABNORMAL CONDITIONS OF THE HIP-JOINT. 



797 



of early affections of the hip-disease, in which 

 little or no displacement of the head of the 

 femur occurred. 



The acetabulum, we know, is generally 

 widened in this disease, and the head of the 

 femur is drawn upwards and outwards; if at 

 this period the inflammation be arrested, true 

 bony anchylosis may occur ; and if a happy 

 direction can be given to the shaft of the femur, 

 a very useful limb may remain, even though 

 the hip-joint itself has lost all motion ; the 

 sacro-lumbar joint and the neighbouring inter- 

 vertebral structures admit of much freedom of 

 motion. 



In examining anatomically the hip-joints of 

 those who, having had the chronic scrofulous 

 disease of this articulation in their youth, and 

 have recovered and lived for years, though 

 lame, in these, instead of anchylosis, we find 

 a false joint is formed. Of this imperfect cure 

 of hip disease we have seen some examples, 

 and we possess one remarkable specimen of it. 

 In this the acetabulum was altogether removed, 

 and a triangular space, encircled by a rounded 

 brim covered with a compact stratum of bone, 

 existed. The removal of the neck of the femur 

 was so complete that a plane or rather concave 

 surface corresponded to the inner side of the 

 trochanter major, from which the neck of the 

 bone naturally arises. 



It has been stated that luxation on the dor- 

 sum of the ilium sometimes happens as a con- 

 sequence of chronic disease of the joint; some- 

 times the disease which carried away, in this 

 instance, the borders of the acetabulum, seems, 

 as it were, to have been transferred to the new 

 surface of the os innominatum with -which the 

 head of the femur came in contact, and we find 

 the process of ulceration has even continued its 

 course; again it sometimes happens that an- 

 chylosis or a false joint has been formed. 



Albers and Rust have described the change 

 which the bones of the pelvis undergo in their 

 form and situation. The pelvis, in those who 

 have for a long time gone lame, is pushed up- 

 wards, and the sacrum is flat and straight. In 

 a few cases, however, it is more curved than in 

 the natural state ; the coccyx is bent strongly 

 forwards, and the connexion of the last lumbar 

 vertebra with the sacrum forms a right angle ; 

 the ilium of the affected side stands higher, and 

 has in general a perpendicular direction, and 

 more of a triangular form ; the external surface 

 is smooth, whilst the iliac fossa appears more 

 hollowed than usual ; this hollowing probably 

 depends on the action of the iliacus internus, 

 which is greater than that of the gluttei. The 

 horizontal ramus of the pubes often seems 

 lengthened and lower than in the natural state, 

 and the ischium is usually drawn outwards 

 and forwards ; the perpendicular direction of 

 the foramen ovale is changed more to a hori- 

 zontal one, and the opening assumes more of a 

 triangular form, its base being turned towards 

 the acetabulum. In consequence of the 

 changed situation of the bones of the pelvis, its 

 different diameters undergo an essential devia- 

 tion from the natural state, the superior aper- 

 tures of the pelvis are commonly somewhat 



oblique, and the pelvis is broader on the affected 

 side from before backwards.* 



The muscles in advanced cases are in a state 

 of atrophy, of a greenish hue, and often matted 

 together; sometimes they form the walls of 

 scrofulous symptomatic abscesses, containing a 

 thin serous pus mixed with flakes ; sometimes 

 the pus is inodorous, of ordinary character. 

 Usually the contents of the abscess make their 

 way to the skin, more rarely to the mucous 

 surfaces. In more advanced cases these ab- 

 scesses are found to contain fetid air and puru- 

 lent matter of a very bad quality ; in these 

 latter circumstances we discover either an ex- 

 ternal or internal fistulous opening ; the walls 

 of the abscesses have collapsed, and have been 

 converted into fistulous canals lined by false 

 membranes ; these have become, as it were, the 

 excretory canals, through which the matter has 

 been discharged from the interior of the dis- 

 eased joint, and through which sabulous mat- 

 ter, small hard pieces of bone, or pieces as large 

 as the epiphysis of the head of the femur, as 

 elsewhere noticed, have made their way. The 

 abscesses are found, on dissection of those who 

 have died of morbus coxae stramosae, pointing 

 or to have opened in various directions. 



We have already stated that the capsular 

 ligament has been found perforated by fistulous 

 openings, and that in the advanced stage of the 

 disease little or no vestige of the capsule is left. 

 The abscesses, therefore, we meet with on dis- 

 section may be considered as reservoirs for the 

 matter which proceeds from the carious bones ; 

 occasionally, no doubt, we shall find around 

 the joint abscesses which have no communica- 

 tion whatever with the diseased articulation : not 

 only in the soft parts around the joint have we 

 met with such isolated collections of matter, 

 but also in the body of the os ilii, and in the 

 centre of the trochanter major of the femur. 



We have given an account of an acute case 

 of morbus coxa?, in which a psoas abscess was 

 found to have originated in a carious hip-joint. 

 The communication of the carious bones with 

 the interior of the sheath of the psoas took 

 place through a small perforation in the hori- 

 zontal ramus of the os innominatum. In this 

 case also an abscess existed in the true pelvis, 

 and death was the consequence of it, having 

 burst into the vena cava. In Mr. Listen's 

 collection there is a specimen shewing ex- 

 tensive destruction of the acetabulum, head 

 and neck of the femur, with several sinuses 

 leading from the joint, and one in particular 

 of large size, leading towards the rectum 

 through the foramen ovale ; there is also the 

 rectum corresponding to this preparation, with 

 a rounded opening sufficient to admit the point 

 of the little finger, about an inch and a half 

 above the anus. In this case the abscess lay 

 across the pelvis ; by one of its extremities it 

 communicated with the diseased hip-joint 

 through the foramen ovale and ulcerated cap- 

 sular ligament, and by its posterior extremity 

 with the rectum. The case of pelvic abscess 

 I have so often adverted to was very similarly 



* Coulson, p. 42. 



