paralysis of that organ. (I presume he means retention of urine.-J. F. S.) On exam ination after death, I discovered," says he, "that the matter had escaped through the acetabulum to the posterior part of the bladder, and had made a lodgment close to its neck." (p. 23.) SAMUEL COOPER quotes a case under Dr. MACKENZIE, of Glasgow, of a lad of sixteen, who died of enormously enlarged liver; but, on dissection, a communication was found through the bottom of the acetabulum, between the cavity of the hipjoint and the colon, smooth, as if of long standing. (p. 869) SCOTT also mentions a case of this disease affecting both hips, and the abscesses communicated with the cavity of the pelvis on each side, through the acetabulum. (p. 106.)

So great is the importance of Diseases of the Hip-Joint, that I think it advantageous to give at length BRODIE'S account

Of the difference between the Hip-disease arising from Ulceration of the Cartilage, and that from Scrofulous deposit in the cancellous structures of the Bones.

As already stated, BRODIE considers that ulceration of the cartilages is the primary affection in the disease to which the term Diseased Hip is usually applied, and that the scrofulous affection of the cancellous structure is less common in the hip and shoulder than in many other joints, and that these two diseases have many circumstances in common, but have certain points of difference which, in their early stages, admit of their being distinguished from each other by careful and minute observation, it will be advisable to give his account of the symptoms presented by each.

The occurrence of ulceration of the cartilages at any period of life, though most frequently between the age of puberty and thirty-five years, has been already noticed, (p. 236,) as has that of scrofulous affection occurring frequently in children, though rarely after thirty years of age. (p. 238.)

"When the cartilages of the hip are ulcerated, the only symptoms met with for some time are pain, and a slight degree of lameness in the lower limb. The pain at first is trifling and only occasional; afterwards becoming severe and constant. It resembles a good deal the pain of rheumatism, since it often has no certain seat, but is referred to different parts of the limb in different individuals, and even in the same individual, at different periods. As the disease advances the pain becomes exceedingly severe, particularly at night, when the patient is continually roused from his sleep by painful startings of the limb. Sometimes he experiences some degree of relief from pain in a particular position of the joint, and in no other. A patient in St. George's Hospital never obtained any rest except when he had placed himself on the edge of the bedstead, with his feet on the ground and resting on a pillow. As the pain increases in intensity, it is more confined in its situation. In the greater number of instances it is referred to the hip and knee also, and the pain in the knee is generally the most severe of the two. At other times there is pain in the knee and none in the hip. Sometimes there is pain referred to the inside of the thigh, sometimes even to the foot. Wherever the pain is situated it is aggravated by the motion of the joint; but it is aggravated in a still greater degree by whatever occasions pressure of the ulcerated cartilaginous surfaces against each other. Hence the patient is unable to support the weight of the body on the affected limb; and if he be placed on an even surface, in a horizontal position, and the hand of the surgeon applied to the heel, so as as to press the head of the femur against the concavity of the acetabulum, violent pain is the consequence, although this be done in so careful a manner that not the smallest degree of motion is given to the hip-joint. This circumstance is well deserving of attention; and no one should attempt to give an opinion as to the nature of a disease connected with the hip, without having made an examination in the manner which has been just described. Soon after the commencement of the complaint the hipjoint is found to be tender, whenever pressure is made on it either before or behind. The absorbent glands in the groin become enlarged, and sometimes suppurate. Occasionally there is a slight degree of general tumefaction in the groin. In this there is nothing remarkable, since we must suppose that a disease going on within the articulation must ultimately occasion inflammation in the neighbouring parts. But it is a curious circumstance, that in some cases there is tenderness of those parts, to which, though not diseased themselves, the pain is referred from sympathy with the disease in the hip. I have observed this in the knee several times, and I have also seen a slight degree of puffy swelling of this joint, where pain was referred to it in consequence of disease in the hip. ***When the disease has existed for some time the nates undergo a remarkable alteration in their form. They become wasted and less prominent, so that, instead of their usual convexity, they present the appearance of a flattened surface; they are flaccid to the touch, and hang more loosely towards the lower edge, and they have the appearance of being wider than those of the other side. In a very few cases, in the

advanced stage of the disease, the nates are really wider, in consequence of the acetabulum being filled with coagulable lymph and matter, and the head of the femur being pushed out of its natural situation. But in general the increased breadth of the nates is only apparent, and on an accurate measurement no difference will be found between the nates on one side and those of the other. The alteration in the figure of the parts, in those cases may arise partly from the position in which the patient usually places himself when he stands erect; but the principal cause to which it is to be attributed, is the wasting of the large fleshy bellies of the glutei muscles, from want of use; and this has been ascertained by repeated and accurate examinations of the living, and numerous dissections of the dead body." (p. 153-57.)

"While the disease is going on in the cancellous structure of the bone, before it has extended to the other textures, and while there is still no evident swelling, the patient experiences some degree of pain, which, however, is never so severe as to occasion serious distress, and often is so slight, and takes place so gradually, that it is scarcely noticed. After a time (which may vary from a few weeks to several months) the parts external to the joint begin to sympathise with those within it, and, serum and coagulable lymph being effused into the cellular membrane, the joint appears swollen. The swelling is puffy and elastic, and though usually more in degree than it is, at the same period, in those cases in which the ulceration of the cartilages occurs as a primary disease, it is not greater in appearance, because the muscles of the limb are not equally wasted from want of exercise. I have observed that in children the swelling is, in the first instance, usually less diffused and somewhat firmer to the touch than in the adult. If a suspicion of some disease of the joint has not existed previously, it is always awakened as soon as the swelling has taken place. Should the patient be a child, it not uncommonly happens that the swelling is the first thing which the nurse or the parents discover. This leads to a more accurate inquiry, and the child is observed to limp in walking, if the disease be in the lower limb, and to complain of pain on certain occasions. * * * The swelling increases, but not uniformly, and it is greater after the limb has been much exercised than when it has been allowed to remain for some time in a state of quietude. As the cartilages continue to ulcerate the pain becomes somewhat, but not materially, aggravated. It is not severe until abscess has formed, and the parts over the abscess have become distended and inflamed. The skin, under these circumstances, assumes a dark-red or purple colour. The abscess is slow in its progress; when it bursts, or is opened, it discharges a thin pus, with portions of curdly substance floating in it. Afterwards the discharge becomes smaller in quantity, and thicker in consistence; and, at last, it nearly resembles the cheesy matter which is found in scrofulous absorbent glands. In most instances several abscesses take place in succession, but at various intervals; some of which heal, while others remain open, in the form of fistulous sinuses, at the bottom of which carious bone may be distinguished by means of a probe. (p. 250-53.)

The progress of the malady in both these forms of hip-disease are very nearly alike; in both is there the same reference of the pain to the knee rather than to the joint affected, the same alteration in the appearance of the nates, the same shortening of the limb from destruction of the head of the thigh-bone, or its dislocation, and the same production of abscesses. But the principal distinction is in the less degree of pain which accompanies the scrofulous disease, "except in a very few instances, and in the most advanced stage of the disease, when a portion of the ulcerated bone has died, and having exfoliated, so as to be loose in the cavity of the joint, irritates the parts with which it is in contact, and thus becomes a source of constant torment." (p. 256.)]

232. Among the phenomena which appear in the course of the coxalgia, the shortening and lengthening of the diseased limb have specially attracted the attention of physicians, and have given rise to various explanations, which must be particularly considered.

["In most cases of lameness or wasting of the lower extremities, the affected limb," says JOHN HUNTER (a), “appears longer than the other, in consequence of the patient pressing most on the sound limb, and putting the diseased one further out from the pelvis so as to raise the ilium. This is particularly the case in diseases of the hip, although the leg is not found to be longer than the other, if the patient is laid on the back. It arises from the centre of motion in the pelvis being rather altered by habit, which is removed if the patient is laid on the back. But sometimes, when the muscles are much wasted, the limb is shorter, which I cannot account for, nor why the limb is

(a) Lectures, PALMER'S Edition.

sometimes drawn up more, and sometimes put out further than the other. Mr. CLINE says the limb is actually longer and shorter in different stages of the disease, and accounts for it thus:-In the first instance, inflammation takes place in the ligaments of the joints, occasioning the parts to swell, and a larger quantity of synovia to be accumulated in the joint, which displaces and pushes out the head of the femur, thus occasioning a lengthening of the limb; but as the disease advances absorption takes place, not only of the accumulated synovia, but also of the bone itself, with the surrounding ligaments; and the head of the bone being drawn into the new-enlarged cavity by the action of the gluteal and other muscles, occasions a shortening of the limb; and this lengthening and shortening of the limb is peculiarly evident on laying the patient on the belly." (p. 595.)

66

"In order to form a correct judgment" upon the actual state of the limb, LawRENCE (a) says, you must strip the patient, and make the examination on a straight horizontal surface. You will then immediately observe the position of the pelvis and discover the cause of the apparent elongation or shortening of the affected limb. At all events, you may remove every doubt as to the apparent or manifest shortening or elongation, by measuring on each side from the anterior superior spine of the ilium to the patella; this will enable you to ascertain whether there is a real, or only a seeming alteration in the length. The change, however, in the subsequent period of the affection is quite a different matter. The disease, as it proceeds, is attended with destruction of the ligamentum teres, with ulcerative destruction of the orbicular ligament of the hip-joint, with destruction and ulceration of the head of the thigh-bone, and of parts of the acetabulum. Thus all the causes which would prevent the muscles from retracting the limb are removed; the muscles, therefore, draw the extremity upwards and outwards, and a real shortening to the extent of some inches, is the consequence." (p. 485.)]

233. The shortening of the extremity which, commonly, occurs in the first period of acute inflammation of the hip-joint, is always a seeming shortening dependent on a shifting upwards of the pelvis on the diseased side. All other explanations given of this shortening are incorrect, and incompatible with the true situation of the hip-joint; such as RUST's, and specially FRICKE's, explanation, that, by violent muscular contraction, which occurs in this acute inflammation of the joint, the head is pressed deeper into the socket, and thereby the shortening of the limb is produced.

FRICKE (b) seeks to ground his opinion on the circumstance, that the leg in its healthy condition may be shortened by voluntary effort of the muscles of the thigh, -as every one may prove on himself. But this assumption is quite incorrect, and whoever makes the experiment on himself or on some other person, will, if, at the same moment when the thigh is retracted, the hands are placed on both hip-bones, easily and decidedly be convinced that the retraction of the extremity depends only on the elevation of the hip-bone. It is perfectly inadmissible to explain the shortening by the com pressibility of the cartilaginous overspreading of the head of the thigh-bone and its socket. In the severe painfulness of the acute inflammation of the hip-joint, the thig is always more or less bent and drawn up towards the belly; the muscles are no doubt contracted, but at the same time the patient draws up the pelvis, especially if, as usual, he lies bent towards the sound side, and the extent of this drawing up of the pelvis is in close dependence upon the degree of painfulness and upon the position which the patient constantly assumes. We therefore observe the same in bruises of the parts about the hip-joint, and in every painful affection of the thigh and hip. An unprejudiced observation and attentive measuring, will convince every one of the truth of the statement here advanced. I have observed two cases of traumatic inflammation of the hip-joint, in which this seeming shortening of the extremity had led the medical attendants into the belief of a luxation, and to the employment of very improper means for its reduction.

234. The lengthening of the extremity which occurs in chronic, and in the latter course of the acute coxalgia, when morbid changes have been set up in the joint, may be either seeming or real. The seeming lengthening is here again dependent on the shifting of the pelvis, because the patient in the tedious course of this disease still limps about, and in doing so throws the weight of the whole body upon the sound extremity, and, by this means (a) Lectures in Lancet. (b) Above cited.

and by the position he keeps in bed, the pelvis is so twisted that the hipbone on the sound side is raised, and that on the diseased side depressed. In the subsequent course of the coxalgy, when the morbid changes in the joint have proceeded still further, there is real lengthening of the diseased extremity, which does not depend on mechanical disproportion between the head of the thigh-bone and its socket, and the expulsion of the head of the bone on account of its increased bulk, but upon the extension of the capsular ligament, on the collection of fluid, on the relaxation of the capsular ligament, and on flaccidity of the muscles.

The most different reasons have been assigned for the lengthening of the extremity consequent on the supposed expulsion of the head of the thigh-bone from its socket; for instance, accumulation of synovia (PETIT, CAMPER, and others;) swelling and degeneration of the mass of fat, improperly called the synovial gland, in the hip-socket, (VALSALVA, MONRO, VAN DER HAAR, DE HAEN, VERMANDOIS, SCHWENCKE, CALLISEN, PLENCK, PORTAL, FICKER, &c.;) inflammation and swelling of the joint-capsule (DUVERNEY, CLOSSIUS;) Swelling of the cartilage, round ligament, and mass of fat (BOYER;) Swelling of the cartilage and periosteum of the head of the thigh-bone and its socket (FALCONER;) swelling of the head of the bone from caries centralis (RUST;) destruction of the lower edge of the hip-socket (LANGENBECK ;-in destruction of the upper edge shortening is said to occur;) relaxation and unnatural extension of the ligaments and muscles (RICHTER, SCHREGER, LARREY, CHELIUS ;) relaxation of the muscles (FRICKE.) BRODIE first accurately explained the seeming lengthening of the limb as dependent on the twisting of the pelvis, produced by the position of the patient, and connected with a lateral twisting of the vertebral column. This opinion, however, was not particularly regarded, and considered to have been only incidentally noticed in single cases (FALCONER, Crowther, Rust;) while, on the other hand, the explanation given by RUST of the enlargement of the head of the bone by caries centralis was most commonly received, which opinion, however, is groundless, and was formerly disproved by me by the results of morbid anatomy, and more recently by FRICKE'S (a) experiments on the dead body.

WEBER's interesting experiments show that the head of the thigh-bone is chiefly retained in its socket by atmospheric pressure; since, if all the muscles and ligaments surrounding the hip-joint and even the capsular ligament itself be cut through, the head of the bone is not withdrawn from its socket by the weight of the depending extremity; whilst, with perfect integrity of the ligaments and muscles, the head of the bone drops from three to four lines out of the socket so soon as, by boring through the latter from the pelvis, the atmospheric pressure is permitted to operate on the surface of the head of the bone (b). These experiments are of great importance in reference to diseases of the hip-joint, as GEDECHENS has shown in a very perspicuous manner (c). Hence it is most completely proved that, as we have already observed, a shortening of the extremity from violent pressing of the head of the bone into its socket is perfectly inadmissible; and, on the other hand, that by mere relaxation of the muscles (as FRICKE supposes) no lengthening of the extremity can be produced: since neither, as already mentioned, does there exist any space between the socket and the head of the thigh-bone which can be changed by any muscular action, or can be increased by their relaxation, as the most perfect and intimate contact exists. It further follows that, when an actual lengthening of the extremity takes place, the stated relations between the head of the thigh-bone and its socket must have been first destroyed by diseased changes, and the ground of the actual lengthening we can only seek in the simultaneous relaxation and distension of the capsular ligament by increase of its fluid contents, and in the relaxation of the muscles.

FRICKE'S observation, that in the seeming lengthening of the extremity, (by dropping of the pelvis,) measurement shows the shortening of the thigh to be, as GEDECHENS correctly observes, and as every one can prove to himself by voluntary dropping of one or other side of the pelvis, and placing one finger on the crest of the hip-bone and another on the great trochanter, dependent on the whole hip-bone of the sunken side being approached nearer to the great trochanter, whilst on the opposite side the hip-bone is proportionally separated from the trochanter; in consequence of which, in the one instance a shortening, and in the other a lengthening, of the space between the great trochanter and the iliac spine, and consequently of the whole bone, must be produced.

[As regards the lengthening of the limb ASTLEY COOPER says:-"It is possible that an effusion into the joint may push the limb a little, but I doubt whether this has any influence in producing an elongated appearance of the limb. The length of the limb is not really increased, but an appearance of elongation is produced by the parietes being depressed on the diseased side." (p. 454.)

LAWRENCE gives a very good description of the lengthening of the limb. He says:"In the earlier period of the disease we sometimes find the limb longer than that on the sound side, and sometimes shorter. This is only apparent. It depends on the position of the pelvis; hence, when the lower extremity of the affected side appears to be longer than that of the other, we shall find that the anterior superior spine of the ilium on that side is so much lower than its fellow; if the extremity of the sound side appear to be the longest, we shall find that the anterior superior spine of the ilium of that side is lower down than that of the affected side. When a patient has this disease of the hip-joint, the weight of the body is not supported on both hips, but by that of the sound side; so that when the patient stands erect, the sound thigh sustains the weight of the trunk, and the diseased lower extremity is placed in front of the sound leg, the knee being a little bent, and the anterior part only of the foot brought to the ground. Under these circumstances, the pelvis, generally speaking, sinks a little towards the diseased limb, and this is compensated by the limb being bent a little towards the opposite side; a degree of curvature of the spine is thus not unusual in affections of the hipjoint. In other instances, however, the patient bends the knee slightly on the affected side, and rests the foot on the ground; this will be attended with an apparent shortening of the extremity. In order, then, to form a correct judgment, you must strip the patient, and make the examination on a straight horizontal surface. You will then immediately observe the position of the pelvis, and discover the cause of the apparent elongation or shortening of the affected limb." (pp. 484, 85.)]

235. Dislocation of the head of the thigh-bone is not a necessary phenomenon in the third stage of coxalgy, it is rather accidental, and depends on the position of the diseased extremity, on the motions of the patient, and other influences during the relaxation of the muscles, and on the relaxation and destruction of the ligaments, specially of the round ligament. Hence the dislocation may occur in various directions; most commonly, indeed, backwards and upwards; but also downwards and inwards, (NESTER, Van DER HAAR, BERDOT, SCHREGER, TEXTOR,) in which case the direction and length of the extremity are differently circumstanced. In rare cases the head of the bone superficially destroyed by caries may remain, and become anchylosed with the socket, which has also been deprived of its cartilaginous overspreading by similar caries; of this termination of coxalgy I have two specimens. Spontaneous separation, and throwing off of the head of the bone through the enlarged apertures of the abscess, may also ensue (a).

[COULSON quotes from HOFFMAN two cases in which the detached head of the femur made its way through the abscess and was removed by the assistance of the surgeon. (p. 23.)

If the patient's constitution be sufficiently strong to carry him through the stages of this disease which have been mentioned, the hip-joint will be found on examination after death, in one of three or four different conditions; two of these I have already noticed, viz., the overspreading of the head of the thigh-bone and its socket with an ivorylike deposit, and anchylosis of the ball and socket, almost invariably by bone. But sometimes the capsular ligament having given way the head of the thigh-bone slips through and is dislocated, and the most common direction it takes is upwards on the back of the hip-bone (dorsum ilii.) But it may be displaced, though more rarely, into either of the other localities of dislocation; thus the younger EARLE (b) mentions a dislocation into the ischiatic notch; in the Museum of the Royal College of Surgeons of England there is a dislocation into the foramen ovale; BOYER also mentions a case of

(a) Cases of this kind, in which the cure was always followed by the use of the joint, are to be found in SCHLICHTING; in Philos. Trans. 1742: A. F VOGEL, Obs. quæd. chirurg. Kiliæ, 1771,

No. 2: HOFMANN, vom Scharbrocke, Münster, 17-2, § 283: HEDENUS de Exstirpatione Femoris, p. 65: KLINGE; in JÆGER'S Handwörterb. der Chir. u. Augenheilk, vol. i. p. 585.