this kind, BRODIE another, and COULSON another in a boy nine years old, in which "the limb was much elongated, the knee and foot turned outwards, and the head of the femur near or in the foramen ovale," (p. 19); DUCROS the younger (a) speaks of a dislocation forwards on the horizontal branch of the share-bone (os pubis) in a female twenty-seven years old, who had inflammation of the hip-joint.

66

When dislocation has taken place the new socket is formed on that part of the pelvis on which the head of the thigh-bone rests, and according as the head is nearer or farther from the hip-socket, does the latter participate in the formation of the new joint, the unoccupied part of the socket being filled up with a structure which in one case SAMUEL COOPER (b) describes as consisting ❝ partly of a fungoid (granulating, I presume, J. F. 8.) mass, and partly of firm coagulating lymph. The brim of the acetabulum was rough and gritty, and the os ilium above the acetabulum destitute of periosteum." (p. 255.) The same writer also mentions a most remarkable instance which is in University College (London) museum, in which "the articular cavity is formed in the upper portion of the femur and a new ball on the ilium. The old acetabulum is nearly obliterated, and near it within the pelvis the remains of the cyst of an abscess." (p. 868.)

At other times, however, no dislocation takes place, but the hip-socket expands, perhaps in part from the pressure of the pus contained in the capsular ligament or within the walls of the abscess which form about it, and in part from the continual pressure of the head of the thigh-bone against the edge of the socket, softened by its spongy tissue, which has lost its cartilaginous and bony articular covering, soaking constantly in pus, in consequence of which the socket loses its deep cuplike shape, and often resembles a shallow saucer with a much-everted lip. Upon this the wasted head of the bone moves, and were it not for the adhesive deposit which has taken place in the surrounding soft parts and rendered them unyielding, so that they really act as a mould to keep the parts of the joint together, the thigh would dangle, and never permit the weight of the body to be borne on it, which is contrary to what frequently happens.— J. F.S.]

236. Characteristic, however, as are the phenomena of coxalgy, yet may they be confounded with other diseases; for instance, with the congenital luxation of the thigh, with a shortening of the extremity from a recession and twisting of the hip-bone, nervous sciatica, and malum coxæ senile.

In Congenital Lameness, the cause of which lies in dislocation of the hip-joint, the thigh is shortened from the very beginning: if, whilst the child lies in the horizontal position, the pelvis be fixed with the hand by slight drawing down, the thigh can be, without pain, somewhat lengthened, but again shortens when the extension is withheld. The buttock is either natural or flatter, the motion of the thigh is free, and the sole of the foot can be placed completely on the ground. If the congenital dislocation exist, as it usually does, on both sides at once, the diagnosis is thereby assisted; but, if it exist only on one side, a mistake in the diagnosis can only arise from superficial examination. I have, however, seen two cases of congenital dislocation of the thigh on one side, which were really treated as coxalgy.

In Twisting of the Hip-bone, which depends on weakness and looseness of the ligaments, the patient suffers least pain in the morning but most in the evening, the one hip is higher than the other, the extremity is from the first shortened, and can be lengthened by a slight pull.

In Sciatica the pain follows the course of the ischiatic or crural nerves; there is a sense of lameness in the whole thigh; no change is observed in the position of the great trochanters or in the length of the two extremities (1).

In the malum coxa senile, which depends on interstitial absorption and wasting of the head and neck of the thigh-bone, pain and stiffness first appear in the hip-joint; the former does not continue with equal severity, and the latter is diminished or lost in walking, but generally (a) Gazette des Hôpitaux, June 30, 1835. (b) Surgical Dictionary,-article, Diseases of Joints.

towards evening becomes worse, which is also invariably noticed in cold moist weather, and in oppressive heat. The extremity gradually begins to shorten; the patient begins to limp, but can set the sole of the foot flat upon the ground; the toes are turned outwards; the lumbar vertebræ acquire a great degree of mobility; the buttock on the affected side is less prominent; a careful measuring of the limb in the mode directed shows actual shortening. The patient frequently complains of pain in the region of the knee, which has its seat, however, rather in the knee-cap, and which he describes as if it were dependent on the contraction of the flexing muscles. I have never observed increase of pain in pressing on the hip-joint (2).

Coxalgy cannot be well confounded with white leg, (phlegmasia alba dolens,) with psoas abscess (3), nor with primitive dislocation of the thigh; but it may be confounded with fracture of the neck of the thigh-bone, if the shortening be slight, the patient still walking, the upper fractured portion thrust into the shaft of the lower, and if inflammatory symptoms have taken place (JÆGER).

[(1) In regard to the pain in hip disease, Sir CHARLES BELL (a) observes," that pain arising from disease of the great sciatic nerve, as it passes near the hip-joint, may be mistaken for inflammation of the hip involving the same nerve; so that when you find a patient with pain in the hip, the very first thing you have to inquire is, whether this be not symptomatic of internal disease? and I would remind you that it is not the more formidable disease of the viscera which produces this affection of the nerve, but rather disordered function. The next thing you have to consider is the lesser degree of pain in the hip, which still proceeds from disorder in the lower part of the canal; for example, accumulation in the colon will produce pain in the hip, which may be mistaken for disease in the hip-joint." (p. 297.) I remember a very good example of the pain produced as just mentioned by BELL, though the accumulation was very slight, but recurred continually a few hours after eating even a small quantity of hard biscuit, which, as soon as it reached the synovial flexure of the colon, produced a dull heavy pain in the iliac pit, and thence extending down the inner and fore part of the thigh to the knee increased on walking. This would continue, although the bowels acted freely and as usual, for two, three, or four days, till either castor oil were taken, or an injection thrown up for its special relief; soon after which all the pain ceased.-J.F.S.] (2) This disease, my own personal observations of which entirely agree with those of SMITH (b) and of WERNHERR (c) cannot, if attention is paid to the symptoms above mentioned, be readily mistaken for coxalgy. I have, however, seen such mistake twice. The disease occurs generally in elderly persons, rarely before fifty years of age. I have most frequently seen it after concussion and contusion of the hip-joint, specially in women, but occurring, also, without any previous cause. In some cases the gout seemed to me connected with it. This disease never runs into suppuration, and, above all, excites no symptoms dangerous to life. On examination of such a joint, the capsular ligament is found thickened, the cotyloid ligament bony or absorbed, the round ligament destroyed, the mass of fat in the hip-socket wasted, the cartilage of the socket absorbed, and in its stead a hard enamel, and the hip-socket materially changed in form and extent. The cartilage on the head of the bone is absorbed, and the surface of the head is porous. I have, however, found, in advanced disease, the cartilage on the head of the bone unchanged. In cases of long continuance, a hard glossy enamel is generally deposited on the surface of the bone; the round shape of the head is changed, at first it is flattened from above downwards, but, subsequently, it assumes the shape of the socket.

The neck of the thigh-bone is subject to a partial or complete absorption, and the head sinks together with the shaft at a right angle, and appears to stand out directly from it. If the head and neck of the bone be sawn vertically, it has completely the appearance of a fracture of the neck of the thigh-bone, externally to the capsule, which has united; the bony mass is remarkably light, and the shaft of the thigh-bone consists merely of a thin bony shell, and the medullary canal is much widened. ASTLEY COOPER and CHARLES BELL have made remarks on these changes of the head and neck of the thigh-bone; and SMITH has also observed them in the shoulder-joint.

(a) Medical Gazette, 1838-39. (b) Dublin Journal of Medical Science, vol. vi. Sept. 1834.

(c) SCHMIDT's Jahrbucher.

[(3) COULSON says:-"The disease of the hip in this (third) stage may be mistaken for psoas abscess; attention, however, to the following points will materially assist us in our diagnosis. First, in psoas abscess, the patient complains of violent or dull pain in the region of the loins, which is very much increased in the upright posture of the body, and by every motion of the limb, particularly on extending it; in the diseased hip there is no fixed pain in the loins; it is felt more in the neighbourhood of the hip, and especially in the knee. Secondly, in psoas abscess, during the whole course of the complaint, there is no deviation to be perceived in the natural situation of the trochanter, and no difference in the length of both limbs; in diseased hip, on the contrary, this is always the case. Thirdly, in affection of the psoas muscle, the patient cannot turn the foot of the affected side outwards, without increasing the pain; in diseased hip, on the contrary, the foot is generally turned outwards. Fourthly, on taking a deep inspiration, on coughing or crying, and in the erect posture of the body, the fluctuating swelling, either on the nates, or in front of the thigh, increases, and the exit of matter, if the abscess burst or be opened, will be facilitated; in abscess of the hip-joint from disease, neither is the case. In this stage, also, the disease of the hip may be confounded with deep-seated formation of matter in the region of the groin, either connected or unconnected with a carious state of the bones of the pelvis. In these cases there is very acute pain in the anterior region of the hip, with shiverings, and inability to rest the limb on the ground, but the great diagnostic mark is the absence of pain on rotating the head of the femur. There is no pain over the posterior part of the joint, or at the knee." (pp. 34, 5.)]

237. Examination of the joint after death presents different results, according to the degree of the disease and its original seat. In the earlier stage, the cartilaginous covering of the head of the thigh-bone is mostly inflamed, ulcerated, often the spongy substance itself is inflamed and more rarely the synovial membrane, the capsular ligament is swollen, the round ligament still maintaining the connexion between the bone and its socket; at a later period of the disease the cartilaginous covering of both the head and socket is destroyed; the former is carious, often entirely separated from its neck; the carious destruction penetrates even into the cavity of the pelvis; the synovial membrane and capsular ligament are entirely changed, swelled up, and destroyed; pus is collected in the joint and between the muscles. If the head of the bone be displaced, the socket also is entirely filled with a steatomatous mass, or with brown pus.

[It has been already stated, that BRODIE holds ulceration of the cartilages to be a primary form of disease of joints; his reasons for which opinion are quoted previously (p. 229); and his statement of the symptoms which peculiarly characterize it in the hipjoint are also subsequently mentioned. (p. 254.) KEY, however, does not entirely, at least, agree with BRODIE on this point, and the following are his views:-" The opportunities," says he," which present themselves to any individual of observing this disease in its early stage by dissection, must necessarily be few. The cases which it has fallen to my lot to examine, have induced me to believe that the ulceration of the cartilage is preceded by inflammation of the ligamentum teres." He found in "a young female who, for six months prior to her death, had laboured under the usual symptoms of chronic inflammation of the hip-joint," and in whom "the symptoms had partially yielded to the treatment employed, when she was attacked by another disease, of which she died, the ligamentum teres much thicker and more pulpy than usual, from interstitial effusion, the vessels upon its investing synovial membrane distinct and large, without being filled with injection. At the root of the ligament, where it is attached to the head of the femur, a spot of ulceration in the cartilage was seen commencing, as in other joints, by an extension of the vessels, in form of a membrane, from the root of the vascular ligament. The same process was also taking place on the acetabulum, where the ligamentum teres is attached. I cannot undertake to say, that the hip-disease shall, in every instance, present these morbid appearances, or that cases do not occur in which ulceration exists as a primary disease, without any affection of the ligament or synovial membrane. Mr. BRODIE's assertion, that it does exist as a primary disease, coming from so excellent a pathologist, is sufficient to substantiate the fact. But observation of this disease in its different stages, and of the mode in which the disease is brought into action, together with the post-mortem appearances, afford strong proof that, at least in many instances, the action is propagated from the ligament to the cartilage, and that ulceration of the latter is consequent upon inflammation of the former.” (pp. 230, 31.)

In confirmation of KEY's opinion, I mention the following account of the examination of a hip-joint by my friend WILLIAM ADAMS, in a case with which I was most deeply and painfully interested. The child, ten years of age, had been lame in the right hip for five or six months, but had no other symptom of hip-disease, no pain on motion nor on pressure, nor any restriction to the motion of the limb, till within a fortnight of his death, (which was caused by tubercles and effusion into the ventricles of the brain,) when he complained of violent pain, if the thigh were only slightly moved in lifting him from or to the bed. A small abscess, of the size of a nut, was found close to the origin of the upper head of the m. rectus femoris. On laying open the capsular ligament, a small quantity of dirty brown-coloured fluid escaped. The synovial capsule had become thickened, tender, in the sense of being readily torn, granular on the surface, and yellowish in colour. The round ligament and contiguous synovial membrane in the portion of the acetabulum uncovered by cartilage had been the seat of inflammation, the vessels were injected, the membrane was thickened, and a small quantity of lymph adhered to its surface. The state of the synovial membrane of the round ligament, just described, appears to me precisely the same as that described in KEY's case, but less advanced.J. F. S.]

238. The general observations already made apply to the etiology. Inflammation appears to arise in the hip-joint, more frequently in the cartilage and bone than in the soft parts.

FRICKE (a) makes a distinction between coxalgy and coxarthrocacy. In the former, at the onset, there is not, he says, any inflammatory affection in the hip-joint, but only relaxation of the muscles, whereby in time an inflammatory affection of the hip-joint is secondarily produced. The latter is always from the beginning connected with distinct inflammatory symptoms of the hip-joint. We cannot, however, agree to the admission of a coxalgy in this sense, after what has been said of the lengthening of the extremities, and after the results of our experience.

239. The prognosis is always unfavourable, least so, however, if disease have arisen in the ligaments, or in the synovial membrane. In the first period of the disease only is the cure of the disease possible; subsequently, even if healing should follow, there still remains a more or less halting gait. In actual dislocation, or in anchylosis, the lameness is very decided. It is generally less dangerous in children than in grown persons. In robust people, and where external violence has caused the disease, the prognosis is more favourable than in generally dyscratic subjects. If it have already proceeded to carious destruction, to the formation of abscess in the hip-joint, there is but rarely any cure possible.

240. The treatment of coxalgy is guided by the rules already laid down, and must vary according to the activity of the inflammation, the stage of the disease, and the general causes connected with it.

241. In the first stage of acute coxalgy, the treatment corresponding to it must be strictly antiphlogistic, and the diseased extremity kept in the most perfect quiet. In traumatic inflammation, if very severe and in robust persons, blood-letting, repeated application of a great number of leeches, and continued cold applications, with corresponding attention to food, and cooling medicine given internally are required. If the inflammation be less active, especially when it springs from rheumatic causes, or in scrofulous persons, repeated application of leeches or cupping will always be found sufficient. If the pain and inflammation diminish, which is shown by the natural direction and length of the limb being restored, rubbing in mercurial ointment and repeated blisters must be by turns employed around the whole joint. Care must be taken in warm bathing, which is recommended by many, as the motion connected with it, and the cold so easily taken after it, frequently operate prejudicially. If the inflammation continue for a

(a) Above cited.

long time in a less degree, especially in strumous subjects, a continued and powerful derivation must be kept up by a pea-issue behind the great trochanter. If all pain cease, and the motions of the hip-joint become free, only gradual and careful use of the limb may be permitted, so that no cause may be given for a relapse, or a passage of the disease into the chronic form, which so easily happens in negligent and too early motion.

* *

*

[With regard to salt-water bathing COULSON observes:-" In no class of patients, and in no stage of this particular disease, are sea air and warm salt-water bathing so beneficial as here. Warm or tepid bathing agrees with nearly every patient. * * The sea-side, however, is not beneficial in cold weather. The best time is from the beginning of May to the end of October; but, if the autumn sets in cold earlier than usual, the patient should return before this. The period at which patients affected with diseases of the hip-joint derive most benefit from going to the sea-side is, either at the commencement of the disease, before much inflammatory action has begun, or towards the end of the third stage, when the abscesses are discharging, and the health is impaired by the long continuance of the complaint. On the contrary, during the formation of matter, and before the abscess begins to discharge, the patient will not derive much benefit from the change. The plan adopted at the Margate Infirmary is as follows:For the first two or three days after the patient's admission, warm bathing only is employed, in order that the constitution may recover the effect of the journey, and adapt itself to the atmospheric change. The patient commences with the warm salt-water bath about three times a-week, at a temperature of 96 degrees, and is directed to remain in it from fifteen to twenty minutes each time. Afterwards the tepid bath is used; and then, dependent on the state of the weather, and the health of the patient, the cold bath is employed; one dip only in the sea being allowed each time. The time selected for bathing is in the morning. The cold or warm douche bath is often used in this stage with very good effect." (p. 79-82.)]

242. If the coxalgy have from the beginning assumed a chronic course, the most perfect rest, which can be produced by securing the diseased limb in a suitable apparatus, is essential, and is often alone sufficient in slight form of the disease, to produce a cure, in a space of time varying from eight to ten weeks. According to the degree of pain in the hip-joint and the inflammatory symptoms, leeching or cupping, rubbing in mercurial ointment with caustic ammonia, repeated blisters, or an issue behind the great trochanter, are here especially indicated.

NICOLAI (a), KLEIN (b) and others have recommended, (and employed with advantage,) for keeping up the continued rest of the diseased limb, the apparatus for fractured neck of the thigh-bone. PHYSICK (c) has proposed a treatment of coxalgy, of which the fixing of the limb in apparatus is the principal part. If the joint be swollen and inflamed, he applies leeches; then gives his patient for some weeks a laxative of cream of tartar, and jalap every other day, so as to produce copious stools. During the employment of the purgatives, the patient must be kept lying horizontally in bed upon a horse-hair mattress, and not leave that posture till he is perfectly cured. When the patient, during the use of the purgatives, has become accustomed to lying, a padded splint, reaching from the middle of the chest to the outer ankle, fitting closely, and surrounding nearly half of the parts, is to be applied. If the leg be bent, the splint must be accommodated to the curve of the limb. When the patient has worn the angular splint for some time the limb may be brought to a straight position, and a straight splint applied. In most cases only two splints are necessary. The splint should be attached by one bandage around the breast, and by a second from the ankle to the hip. The shortest time for the cure is six months, the longest two years, and the middle and usual time a year. During this time the splint should be continually on the limb, and never removed till the symptoms of the disease are manifestly diminished; in which case the limb may be moved very gradually. This treatment is, however, admissible only when the head of the thigh-bone is neither destroyed by caries, nor has become displaced; when no abscess has yet formed, and the patient has not apparently a scrofulous constitution.

The following is the plan of treatment recommended by the SCOTTS (d), which is often very efficient, and may be employed on any joint.

(a) Journal voN GRAEFE und WALTHER, vol. iii. part ii.

(b) Ib., vol. iv. p. 25.

(c) American Journal of Medical Science, Feb., 1831.

(d) Cited above.