ABNORMAL CONDITIONS OF THE HIP-JOINT. 



801 



while the right leg hangs in front and slightly 

 across the left, and seems to be at least three 

 inches shorter; he leans slightly back and 

 supports himself on two sticks : as he walks 

 the right foot is considerably everted, and when 

 he moves without sticks (which he accomplishes 

 with the greatest difficulty) he places the whole 

 sole of the foot flat upon the ground. He 

 never, however, ventures of his own accord to 

 move without the help of two sticks, by the assist- 

 ance of which he is enabled to walk quicker; 

 while moving along thus, the heel of the 

 affected limb does not quite reach the ground, 

 and the lumbar vertebrae undergo great motion. 

 He cannot under any circumstances flex the 

 thigh on the abdomen, so that when he assumes 

 the sitting posture, he is obliged to place him- 

 self forwards on the very edge of the seat, the 

 right thigh remaining in the same line as the 

 axis of the trunk, the leg usually flexed and 

 placed under the chair, or across behind the 

 other, and he finds the utmost difficulty in 

 putting on his stockings and shoes. He has 

 scarcely any motion in the hip-joint. When 

 we view the hip in front, and examine it, we 

 see and can feel a considerable bony fulness, 

 corresponding to the horizontal branch of the 

 pubis : the trochanter major seems placed very 

 high up, and is extraordinarily large as if sur- 

 rounded with ossific deposits. The thigh is 

 somewhat atrophied, being an inch and a half 

 less in circumference than the other, but the 

 calf of the leg is not reduced, and the muscles 

 seem firm ; the apparent shortening of the limb, 

 when he rests on the sound one, arises from the 

 lumbar vertebra being much curved to the oppo- 

 site side, and the pelvis being elevated on the 

 affected side, while the real shortening ascer- 

 tained by accurate measurement amounts only 

 to half an inch. 



If we place the patient horizontally and 

 attempt to communicate to the hip-joint any 

 movement, as of rotation, flexion, abduction, a 

 well-marked crepitus is elicited, and the range 

 of motion is found to be very limited indeed ; 

 a little abduction is admitted ; rotation and 

 flexion seem just to a sufficient degree to 

 shew that no anchylosis exists. The move- 

 ments give some pain to the patient, but we 

 can press the trochanter firmly so as to direct 

 the head of the bone deep against the fundus 

 of the acelabulum, and we can even strike the 

 heel and sole of the foot with violence without 

 giving the patient the slightest sensation of pain. 

 The anatomical characters of this disease 

 are very well marked. The muscles are usually 

 of a paler colour than natural, and are found 

 not to be so well developed as those of the 

 opposite or sound hip. The fibrous capsule 

 of the joint is greatly thickened, the cotyloid 

 ligament is either ossified or absorbed, and 

 the ligament which completes the notch, and 

 in the natural state gives origin to the liga- 

 mentum teres, is usually converted into bone, 

 leaving generally beneath its arch whether 

 bony or not a space for the transmission of 

 bloodvessels to the interior of the joint ;* when 



* Cravcilhier, livraison iv. p. 1. La presence 

 VOL. ii. 



the disease is fully established the ligamentum 

 teres is altogether removed, the synovial fluid 

 is deficient in quantity, and the cartilage is 

 removed from the bottom of the acetabulum, 

 and upper surface of the head of the femur. If 

 here and there some vestige of the synovial 

 membrane or sub-synovial tissue remain, it is 

 in a highly vascular condition, presenting an 

 intensely red colour. In a case of dissection 

 which Messrs. Smith, Brabazon, and the writer 

 witnessed lately of this disease, we observed 

 that the shortened neck of the femur was 

 entirely surrounded with a number of red 

 villous - looking productions of the synovial 

 membrane. These were of a rounded and 

 conical form, half an inch long and two or 

 three lines broad at their bases. They resem- 

 bled much in form the long conical papillae to 

 be seen on the tongue and about the fauces 

 of herbivorous quadrupeds ; however, instead 

 of being white and firm they were soft and 

 villous, and of an intensely red colour. The 

 line of the corona of the head was absorbed and 

 excavated in points, and the different foveae or 

 depressions were completely occupied by these 

 vascular fimbriae. Still more recently the wri- 

 ter met with a similar specimen which he pre- 

 sented for inspection to the Pathological So- 

 ciety, in which these vascular fimbrise were 

 equally conspicuous.* 



The acetabulum is generally much larger 

 and deeper than natural, and forms a circular 

 cup often two inches deep with a complete level 

 brim, which is sometimes so much narrowed as 

 to render the extraction of the head of the 

 femurdifficult. This is the most frequent abnor- 

 mal appearance the acetabulum presents ; but 

 occasionally it is increased in size, and is at the 

 same time very shallow and of an oval form. 



When we examine the bottom of the acetabu- 

 lum we find it widened and not any trace of 

 Haversian gland is left ; the interior presents a 

 worn and porous appearance, the cartilage and 

 compact stratum of bone which the cartilage 

 normally covers, having been removed, and in 

 some places where the friction and pressure 

 from the head of the femur have been greatest, 

 instead of a rough and worn porous appearance, 

 resulting from the exposure of the cells of the 

 bone, a dense enamel has been as it were 

 ground into these pores, and here the surface 

 presents the polish, smoothness, and hardness 

 of ivory. This mechanical removal of the carti- 

 lage and exposure of the interior of the cells of 

 the bone, and substitution for the cartilage of 

 a dense inanimate enamel, we imagine, are pro- 

 cesses which are not confined to the acetabu- 

 lum ; but their results are seen also on those 

 parts of the head of the femur which are sub- 

 jected to pressure and friction; hence we find 

 the effects of friction, above alluded to, most 



cTun nerf et d'un vaisseau, ces parties fondament ales 

 de 1'organisation, semblent en quelque sorte re- 

 spectees par les lesions organiques, qu'elles soient 

 ces lesions circulent tout autour, mais ne les en- 

 vahissent presqtie jamais, on du moins les envahis- 

 sent apres tous les autres tissues lorsquelles so n't 

 parvenus a leur derniere periode. 



* Dublin Journal for March 1839, No. xliii, 

 3 G 



