LOUVRIER thinks it necessary to make upon the thigh, at the knee, direct pressure from before backwards, and to push it in that direction, whilst the leg is extended. This is effected by means of two uprights fixed on each side of the knee, by their lower ends upon the splints, the four upper ends of which are connected by a rectangular parallelogram, in which they are enclosed and retained by copper nuts. A thick pad is placed on the knee, and, between the metallic rectangle and this compress, a cushion formed of a plate of metal, and padded towards the thigh. The limb thus fixed is placed in a rectangular wooden gutter, at the end of which is a winch; within these planes is a chase, on which the foot, supported laterally by the bar attached to the sole, travels. A set of cords attached to these parts connects them with the winch, and with a few turns of its handle, the leg is straightened always in less than a minute, and most commonly, when the anchylosis is angular, with one or two distinct and successive cracks." (p. 396.) VELPEAU evidently is no favourer of this apparatus; and he enumerates among the objections to its employment, the severe pain, but as this is very short it may be borne with; and the violent purulent inflammation of the joint which may ensue, the danger of this, however, is exaggerated. But the more serious accidents are laceration of the integuments of the great arterial or venous trunks; of the nerves and ligaments; and the more or less severe bruising of the soft parts, in consequence of which sloughing occurs. "If, however," says he, "we observe the cases (about twenty) on which LOUVRIER has operated, there are but few in which symptoms, more or less serious, occur immediately. I know, however, that these facts are still too few; at present we may presume that this plan of treatment is not so dangerous as one might be led to suppose." (p. 208-15.) To the question "What benefit is the patient to derive from this treatment?" VELPEAU replies, as regards the re-establishment of the motions of the joint, that neither theory nor LOUVRIER's facts are favourable. To prevent the reunion of the bone frequent motion must be resorted to, which is dangerous; but if not employed the bones become resoldered, and the leg either becomes straight, with the sole of the foot flat on the ground, (which is the most favourable result,) or the limb continues more or less bent, and the foot cannot be put flat, so that the patient needs crutches. Another result is, that the head of the shin-bone is thrown behind the condyles, and dislocation is produced, as, if the knee-cap be soldered to the fore and lower part of the condyles, which is often the case, it prevents the head of the shin-bone resuming its natural place, and, serving as a wedge, pitches the latter into the ham, so that a dislocation being produced the patient is not benefited by the operation. (p. 215-17.)

HYSTERICAL AFFECTIONS OF THE JOINTS.

Hysterical females are often subject to affections of the joints, especially of the hip and knee, which, without any actual disease in the part, produce excessive suffering, and are liable to be mistaken for dangerous ailments. BRODIE, in reference to this point, says: At first there is a pain referred to the hip, knee, or some other joint, without any evident tumefaction; the pain soon becomes very severe, and by degrees a puffy swelling takes place, in consequence of some degree of serous effusion into the cells of the cellular texture. The swelling is diffused, and in most instances trifling; but it varies in degree; and I have known, where the pain has been referred to the hip, the whole of the limb to be visibly enlarged from the erista of the ilium to the knee. There is always exceeding tenderness, connected with which, however, we may observe this remarkable circumstance, that gently touching the integuments in such a way as that the pressure cannot affect the deep-seated parts, will often be productive of much more pain than the handling of the limb in a more rude and careless manner. In one instance where there was this nervous affection of the knee, immediately below the joint there was an actual loss of the natural sensibility; the numbness occupying the space of two or three inches in the middle of the leg. Persons who labour under this disease are generally liable to other complaints, and in all cases the symptoms appear to be aggravated, and kept up by being made the subject of constant anxiety and attention." (pp. 339, 40.) In an affection of this kind in the knee, TYRRELL (a) observes:-" The point which convinced me that the affection was not one of actual inflammation of the ligaments of the knee, but a sympathetic disease depending on the peculiar condition of the constitution, is this, that if she had inflammation merely of the internal lateral ligament and the posterior ligament, the pain would be confined to those parts, particularly when the limb was at rest, and she would complain of pain particularly on pressure on those parts; but when you examined the surface of the joint, it mattered little where you pressed, it was all the same, she complained of pain." (p. 316.) BELL (b) (a) St. Thomas's Hospital Reports.

(b) Medical Gazette, vol. xiv. 1933, 34

mentions a very remarkable case of hysterical affection, "in which there was great difficulty of discovering whether there was actual disease or not, in which the pelvis was pitched obliquely, as if there were disease in the hip. But there arose a class of symptoms which pointed to the right source, a singular contraction and retraction of the leg, so that the knee was bent almost to the bursting of the ligaments, and the foot turned in so extraordinary a manner, that the great toe lay close to the anus. The retraction was so powerful that we naturally apprehended that the ligaments of the joint must be destroyed. It proved to be a case of hysteria, and, what was extraordinary, was the resemblance it had in every feature to the disease of the hip-joint." (p. 297.) COULSON also mentions a case which he saw in St. Bartholomew's Hospital, in which "the patient was twenty-eight years of age, and had suffered from hysterical affections for ten years. The right heel was doubled under the thigh, the heel rested against the tuberosity of the ischium, and the great toe, as in the case just related, was close to the anus." (p. 117.)

COULSON observes that, in this affection," the affected limb is liable to remarkable alternations of heat and cold; at one part of the day the limb feels cold, and assumes a purple aspect; at another, hot flushes, followed by perspiration, break out over the extremity; again, the limb does not merely feel hot to the patient, but is actually so to the touch of another, and the whole capillaries of the affected part become turgid with excess of blood." (p. 117.)

GOODLAD (a) objects to the term hysterical being applied to these affections, and says : "If after a careful examination of the hip, or of any other joint, and of the muscles connected with it, no adequate cause of pain can be discovered there, it surely becomes an imperative duty, and it is the only one remaining to ascertain whether any and what cause exists in the course of the nerves, and if there be no such cause discoverable, the practitioner may safely rely upon finding it where it very frequently, nay, by much the most frequently exists, viz., at the point of connexion which those nerves possess with larger masses of the nervous system; it matters not whether in the brain or in the spinal marrow, the same effects follow. The tenderness of the skin both here and on the spine may alike be disregarded; it is sometimes permanent, at others fugitive; but in either case it is an indication only where disorder may be found by tracing the nerves distributed on these parts to their origin." (p. 93.)

In these cases menstruation is generally either irregular or defective, and the bowels are torpid; the most important point, therefore, towards the cure consists in putting these matters to rights by constitutional remedies. Local applications, I do not think, are of much service; but BRODIE Says:-"The parts may be bathed with a cold evaporating lotion, or they may be enveloped in a plaster composed of equal parts of the extract of belladonna and soap plaster, an application which will be found of singular utility, not only in these, but in a great number of other painful nervous affections." (p. 340.) GOODLAD thinks that, in addition to whatever may be deemed necessary for the general state of the system, local measures must be had recourse to, not applied to the part where the pain is experienced, but to the origin of the nerves distributed to it; and the greatest caution seems necessary that nothing applied there can give local activity to vessels already too active.-J. F. S.]

225. As we shall now consider these diseased conditions of the various joints, under the several names already mentioned, (par. 198,) we shall be able to show, by the difference of their course and the result of pathological anatomy, in what structure the disease has primarily developed itself. Thus, the various opinions which have been advanced with great partiality, as to the nature of these diseases, will be known to be well founded in particular instances, although their universal correctness is denied.

I.-IN THE HIP-JOINT.

(Coralgia, Morbus Coxarum, Luxatio spontanea Femoris, Coxarthrocace.) 226. The symptoms of this disease exhibit three very well-defined stages, according as the inflammation has an acute or chronic character.

(a) A letter to Sir B. BRODIE, containing a Critical Inquiry into his Lectures illustrative of certain local Nervous Affections. London. 8vo.

227. In the Acute Inflammation of the Hip-Joint, after any occasional cause, there arises sharp pain in the hip-joint, which extends on the inside of the thigh to the knee-joint, not increased by touching the knee if the thigh be undisturbed at the hip-joint, but increased by any pressure and motion of the hip-joint itself. The region of the hip, especially the buttock, is more or less swollen, consequently its wrinkles are mostly somewhat deeper; the thigh is drawn up towards the belly, because outstretching it is very painful; the foot is turned somewhat outwards, and cannot be moved inwards without pain. If the length of both extremities be compared, they are either alike or the diseased extremity is seemingly shortened or seemingly lengthened; both, however, only in a slight degree. Fever exists in proportion to the severity of the symptoms. Standing and walking are very difficult, or even quite impossible; the patient, therefore, throws the whole weight of the body upon the sound limb, draws up considerably the hip of the ailing side, bends the knee, and merely touches the ground with the tip of his foot.

[KEY (a) says:-"The hip-joint is less frequently the subject of acute than of chronic inflammation, probably from being well protected from the influence of atmospheric changes, to which the knee and most other joints are exposed. In the adult, acute disease of this joint is occasionally seen, in which the whole structure of the joint, cartilage as well as ligament, undergoes complete disorganization in the space of a few weeks." (p. 230.)]

228. If the inflammation do not subside, it passes into suppuration, with an increase of all the general and local symptoms; collections of pus are formed within the joint as well as on its exterior; the fever assumes a hectic character, the powers sink, the patient wastes considerably, the muscles of the hip and thigh become flabby, and a careful measurement of both extremities shows that the diseased one is really lengthened. The abscesses become superficial around the joint, either in its immediate neighbourhood or at a distance from it; and, during this time or subsequently, when the abscesses have burst, the head of the thigh-bone escapes from the hipsocket, and is dislocated commonly upon the back of the hip-bone (b), so that the diseased extremity becomes considerably shortened, is rolled inwards, and appears somewhat bent at the knee-joint. The patient now either sinks under long continued hectic consumption, or, what is more rarely the case, the suppuration diminishes, portions of bone come away, and the apertures of the abscesses close.

229. In the Chronic Progress of Inflammation of the hip-joint, the three stages are, on account of the gradual development of the symptoms, more distinctly and determinately marked (1). In the beginning, the patient complains of slight pain in the hip-joint, of some weariness in the thigh and stiffness of the joint, especially in the morning, which subsides during the day, but is always increased by much exertion. The pain is not continuous; it often increases towards evening, with slight febrile excitement, and specially resembles rheumatic pain moving slowly about the thigh (2). At the hip-joint itself no disease is discoverable, except an increase of pain on pressure behind the great trochanter, or on the front of the joint where the femoral vessels pass beneath POUPART'S ligament. These symptoms

(a) Med.-Chir.

(b) I have presumed to use the ordinary English terms, hip-bone, haunch-bone, share-bone, and hip-socket, in preference to the Latin names, ilium, ischium, pubes, and acetabulum, and I purpose always employing English names wherever parts of the

Trans., vol. xviii.

body possess them. I know no reason why we should be more ashamed of using our mother tongue than the Germans or the French, and I see no particular advantage in using the figurative Latin of the Schools.-J. F. S.

may continue, better or worse, for months or years, under a lingering course of this disease. The gait is merely trailing, and the foot commonly somewhat turned outwards.

[(1) BRODIE says:-"I believe in the greater number of those cases to which the name of Diseased Hip has been usually applied, the ulceration of the cartilages is the primary affection, and the other parts in and near the joint become affected only in a secondary manner." (p. 137.) KEY (a), however, holds a different opinion, and observes:-" The Hip Disease, emphatically so called, is a chronic affection, uniformly attended with ulceration of the cartilage;" and, from the cases which he has examined, he is induced to believe "that the ulceration is preceded by inflammation of the ligamentum teres.” (p. 230.)

(2) It is somewhat remarkable that CHELIUS does not enumerate, among the symptoms of the first stage of hip-disease, the pain more particularly about the inside of the knee, which almost invariably exists, and being often the only pain noticed by the patient, has frequently led to mistake of the actual seat of the disease, and to the treatment of the knee as if that were the part affected. It indeed presents an example of JOHN HUNTER's (b) “ remote sympathy," in which “ there appears no visible connexion of parts that can account for such effects. In these cases there is commonly a sensation in the sympathizer which appears to be delusive, and produces a wrong reference of the mind to the seat of the disease." (p. 7.) This sympathetic pain in the knee is by some held to depend on irritation of the anterior crural plexus of nerves as it passes over the hip joint; but Sir CHARLES BELL thinks the obturator nerve is the communicant. "The obturator nerve," he says (c)," passes through the thyroid foramen, down to the hipjoint, and, after supplying the muscles, is distributed upon the inner part of the knee. The nerve in its course is thus involved in the inflammation which affects the hip-joint, and the pain is referred to its extreme cutaneous branches, at a part distant from the seat of the disease." (p. 77.) COULSON does not agree with this explanation, as "very commonly we find the pain extending along the middle, and even outer part of the thigh, whilst the obturator nerve is distributed to the muscles of the inner side of the limb." He therefore suggests, that "from the intimate connexion of the long head of the m. rectus femoris with the outer edge of the acetabulum and with the capsular ligaments, the fascia of this muscle may take on the inflammatory action, and the pain in this way be conveyed down the limb to the thigh." (p. 3.) I prefer BELL's explanation, however; as certainly in the majority of the cases of diseased hip which I have seen, the pain is usually on the inside of the knee.-J. F. S.]

230. The second stage is characterized by a lengthening of the diseased extremity; the buttock of the affected side is flatter, its fold becomes deeper, the whole thigh is wasted and flabby, the great trochanter stands more upwards and outwards; every movement by which the surfaces of the joint are brought into contact is in the highest degree painful; the gait of the patient is very limping; the weight of the body rests entirely on the outstretched sound leg; the lengthened limb is bent at the knee, approached to the sound one, and the foot most commonly much everted. A peculiar sharp pain now comes on in the knee, which, however, usually retains its natural condition, only now and then being changed in its form, according to the observations of ALBERS and RUST. Although the pain in the knee is nearly always more severe than that in the hip-joint, yet the latter only is increased by direct pressure.

[ASTLEY COOPER observes :-"The motions of the joint are impeded; extension is performed with difficulty; the child's knee is bent; and the heel, on the diseased side, scarcely touches the ground. Besides this incapacity for extension, great difficulty is experienced in the flexion of the joint. Thus if you attempt to bend the knee towards the abdomen, the child shrinks from the touch and complains of pain. If you throw something on the floor, and desire the child to pick it up, you will observe, that, in attempting to get possession of it, it bends only the sound knee. If you say, 'Let me see you put your foot on the chair,' the child does this readily enough with the sound leg, but is incapable of doing it with the other, in consequence of the confined state of the flexions of the joint. The rotation of the joint is also impeded, more especially the rotation inwards, which cannot be attempted without great pain and uneasiness. If the (a) Med. Chir. Trans., vol. xviii. (b) On the Blood, &c. (c) London Medical Gazette, vol. i.

patient be laid down on his face, to examine whether the nates are lower on one side than the other; there is generally a difference of an inch or more on the diseased side.” (pp. 454, 55.)

As to the mode of determining the special part of the joint which is diseased, KEY (a) observes "the motions of the joint, that give the patient most pain, are strongly indicative of the seat of the affection. In the earliest stage, before the soft parts could well be affected, if the disease commenced in the cartilage, eversion of the thigh and abduction of the limb from the other produce the greatest degree of suffering to the patient, while he can bear the joint to be flexed, and to be slightly inverted, without complaining. A similar indication of the ligamentum teres being inflamed, is the pain sometimes expressed on pressing the head of the femur against the acetabulum; in its healthy state the ligament being lodged in the hollow of the acetabulum, receives but little pressure, but when it is swelled by inflammation, the cavity of the joint affords it less protection; and, when pressure is made by forcing the head of the femur upwards, the ligament is compressed, and usually produces some degree of pain. The circumstance, too, of the ligamentum teres being destroyed by ulceration, when the head of the bone and acetabulum are only partially ulcerated, may be considered as presumptive proof of it being very early engaged in the disease. There are few cases of post-mortem inspection of the hip-joint in an advanced stage of disease in which the ligamentum teres is not found destroyed." (pp. 232, 33)]

231. The disease gradually runs on to its third stage; the diseased extremity becomes shortened, either as a consequence of displacement of the head of the thigh-bone, or, if that and the hip-socket have been destroyed by caries, by the diminished head of the bone being drawn into the much expanded socket. Oftentimes the disease here terminates, the pain diminishes, and on the spot where the displaced head of the thigh-bone lies a hollow is formed, or the head of the bone being retracted into the socket is anchylosed to it, and the patient consequently recovers with an incurable lameness. Most frequently, however, in this stage a painful fluctuating swelling occurs about the whole hip-joint, which ultimately breaks, and a quantity of pus is discharged; the suppuration becomes bad; the probe introduced into the abscess openings indicates carious destruction, and the powers of the patient are worn out by hectic fever. But rarely do these apertures close; the suppuration then diminishes, pieces of bone are thrown off, &c. &c.

In order to measure accurately the length of the extremity during the progress of this disease, we examine it most satisfactorily, according to FRICKE'S method (b), in the following manner :-The patient being laid on a table covered with a woollen rug, an assistant fixes the pelvis, and places his thumb beneath the anterior superior iliac spine, for the purpose of steadying the skin. A painted tape, or a wooden measure furnished with two moveable pointed transverse pieces, and a Paris measuring-scale, is now to be applied above the thumb of the assistant upon the spine, and being there fixed the other part of the measuring instrument is to be carried down to, and immediately beneath, the outer ankle. The same measurement is repeated on the sound side. In the same manner then is the thigh measured, the measure being stretched to the upper end of the splintbone; and then the leg alone, which is especially necessary if the patient be unable to straighten the leg.

[Abscesses of the hip-joint do not always burst externally. "Sometimes the abscess," says ASTLEY COOPER (c), "breaks into the pelvis, at other times into the rectum, and a large quantity of pus is voided with the stools, which was the case with a young gentleman I attended; in another case it opened into the vagina; the lady was lame, but ultimately recovered." We have also a preparation at St. Thomas's museum, of which, however, I do not know the history, excepting that ASTLEY COOPER used to mention it as a case in which abscess of the hip-joint, in making its escape, had ulcerated a small hole in the femoral artery, as that vessel passed over the front of the joint. Besides these, COULSON mentions a case in which matter had made its escape from the affected joint into the pelvis, so as to press on the neck of the bladder, and had caused (a) Med.-Chir. Trans., vol. xviii. (b) Ueber Coxalgie und Coxarthrocace; in Anna(c) MSS. Lectures on Surgery.

len der chirurg. Abtheilung des allgemeinen Kran kenhauses zu Hamburgh, vol. ii. p. 21.