CHAPTER XIV.

HIP-JOINT DISEASE.

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SEMEIOLOGY.

IT not be in accordance with strict logical arrangement, that one particular joint should be singled out for a special chapter; but it will, I believe, tend to make this book more valuable, if the diagnostic signs of hip-disease be separately discussed. By means of this articulation, the strongest limb in the body is fastened to the trunk itself, and it lies so deep, that at no part can we put our fingers immediately upon or over the synovial membrane, as in every other important joint; and we cannot, therefore, detect fluctuation, changes of shape, or of size, with anything like the readiness, with which we can find the like alterations in other and more superficial joints. For example, a strumous synovitis of the knee is often detectable from the swelling, before any pain shall have called the patient's attention to the part; the changes of shape, size, &c., are perfectly distinguishable, and the failure of mobility is easily detected. But the round massive form of the parts about the hips, the difficulty, or rather impossibility, of fixing the pelvis with the hand, the projection of the trochanter, and the bend of the neck of the femur, rendering the true radius of motion very short, the mode in which the whole head of the bone is impacted in the socket, and many other circumstances, throw great obstacles in the way of a diagnosis, concerning merely the presence or absence of hip-joint disease, and a minute distinction between the inflammation of one structure and that of another is extremely difficult, in very many cases impossible. The obscurity of the subject is still further increased by the confusion of opinion and description, which authors have expended on the question, many of them taking no pains with direct experiment, and very little in pathological research, but giving à priori reasonings all the weight and importance of direct facts.

Thus the disease has been made to commence in the ligamentum teres, and in the cartilage as well as in the bone and synovial membrane. The symptoms, viz., lengthening, shortening, pain in the knee, &c., have been attributed to almost as many causes as there have been authorities to assign them, and thus the subject is involved in a labyrinth of falsity and conjecture, from which nothing but a simple following out the lead of truth can ever rescue it.

First, as to the structure in which disease of the hip-joint may commence there can be no doubt that it may begin in the synovial membrane, and in the bone, like other joint diseases; there is no reason to suppose, nor is there the slightest proof, that it may commence in structures, in which diseases of other joints do not begin, for instance, the ligaments. We have seen that when the subsynovial tissues, in which ligaments are placed, inflame, the ligaments themselves suffer, soften, and become thickened or absorbed as the case may tend; we have seen that internal ligaments, as the crucial of the knee, which are surrounded by folds of synovial membrane, and which are in the position of a subsynovial tissue, are more apt to follow quickly in this course, than external ligaments; but the disease is not the less a synovitis, because there happen to be internal ligaments which participate early in the inflammation and become quickly changed or absorbed. How very frequently does it occur in the knee joint, that the crucial ligaments have entirely disappeared, even in cases of subacute synovitis, where the cartilage is hardly altered, and where the general change in the synovial tissues is but slight! I have also seen the crucial ligaments all but converted into gelatinous structure, their presence being only marked by a few white ligamentous lines, running parallel to each other through the pink mass. In the same way, the ligamentum teres of the hip joint has been found to be much softened and inflamed, while the synovial membrane around it is red and hyperemic; but there is no possible reason for assuming that the disease begins in an inflammation of that structure more than in any other part of the synovial and subsynovial tissue.* Other authors have located the diseased action in the

* Mr. Aston Key unfortunately adds | lacy; he gives an account of a hip-joint in the weight of his authority to this fal- which he finds the whole synovial and

fat which lies in the bottom of the cotyloid cavity; but this opinion is too antiquated, and too far behind the science of the present day to need serious refutation. Again, the cartilages of the hip are not differently situated to those of other joints in regard to their nutrition and diseases; they are as often, or indeed may be more often than in other joints, the seat of degeneration (p. 290); and in old subjects, in whom during life no symptom of joint disease existed, such degenerative ulcers will very frequently be found; but, except this condition, which does not produce a detectable joint disease, there is no malady of the hip commencing in the cartilage, any more than there is a malady of other joints beginning in that structure.

Thus we come again to the two tissues, viz., synovial membrane and bone, whose inflammation is, as we have seen, the cause of disease in other joints; and I am sure of truth in asserting, that every hip disease commences in one or other of these parts. It is, however, a matter extremely difficult-often, I believe, in practice impossible-to decide whether a disease already somewhat advanced may have been originally synovial, or osseous; as may be supposed from the fact, that some men of great experience and care, have asserted that all hip joint diseases begin in the bone (Rust, of Vienna, held this opinion), while others have as positively affirmed, that all such maladies commence in the synovial membrane. In the earliest stages of the disease, we are able to conclude with tolerable certainty concerning the structure in which it is situated during the patient's life, and on examination, pathologically can always ascertain the fact; but if the disease have advanced to the second period, the attempt at diagnosis on the living patient will be vain, and the anatomical examination even will very frequently lead to no positive conclusion. In order to point out distinctly the difficulties in such minute diagnosis, and to place the whole truth before the reader, it will be well to enter minutely into the symptomatology of the disease, and to trace where possible the cause of each

subsynovial tissue inflamed, and among it that portion which envelopes and in part constitutes the ligamentum teres. He says, "the cases which it has fallen under my lot to examine have induced me to believe that ulceration of the cartilage is preceded by inflammation of

the ligamentum teres." Med. Chi. Trans., vol. xviii., p. 230. We need not here enter into the general relationship between ulceration of cartilage and inflammation of synovial membrane: the same words of course apply to this as to other joints.

separate symptom: in doing so, I will endeavour, to the best of my ability, to make a clear and broad distinction between what is absolute fact, and what is mere conjecture. The pathology of the synovitis or osteitis, will not be again broached; we have now only to do with the symptoms and their corresponding morbid anatomy.

First Stage.*-The beginning of hip-joint disease is marked in children, who do not and cannot express all their sensations, by slight limping, during which the knee is somewhat bent, and the foot turned either inwards, or more commonly outwards. In adults, the disease commences by a sense of fatigue, or of actual pain, the more readily remarked, that it is only situated in one hip. At this period, and for a short time afterwards, there appear certain symptoms in some cases, which are absent in others, and which may enable the surgeon to define the synovial or osteal locality of the disease. Pain, tenderness, swelling, heat, more or less immobility, are, at this stage, all we can fix upon as indications of the disease, and it is to the variations of these symptoms that we must look for our means of distinguishing the one form of malady from the other.

Synovitis. Pain includes all the different dolorous symptoms produced by the disease, whether they occur in the hip itself, or in other parts of the body. The pain of chronic synovitis may, in the hip as in other joints, be absent during the first days of the disease; but when it comes on, it is continuous, and more severe after exercise. Limping in children, which is produced by the pain,

* Brodie, in his admirable work 'On | Diseases of the Joints,' has not given a special division to morbus coxæ, but describes it with other joint-diseases according to the anatomical seats of the malady. Ford, whose 'Observations on Disease of the Hip-Joint,' 1794, has been a sort of unacknowledged loan-office for many subsequent writers on the subject, is the first surgeon who makes three periods in morbus coxarius. He does not say in so many words that he divides the malady into three stages, but he gives a description of three successive periods. This division is of the greatest importance. His first stage extends from the commencement of the disease to the first appearance of lengthening of the limb; the second stage

reaches from this occurrence to the supervention of marked shortening, either from dislocation or other cause; the third, beginning with this shortening, goes on to the end of the case. Boyer and Maisonneuve take two stages, the first extending from the commencement of the disease to dislocation of the head of the femur. Rust makes four: first, the commencement; second, lengthening; third, shortening; fourth, suppuration. Chelius (South's Translation) divides the malady into the first three of Rust's sections. We will adhere, more or less closely, to Ford's divisions; but he has hardly made them sufficiently definite, and it is a defect which shall, as far as possible, be supplied.

may be observed to have the following periods of greatest intensity. In the morning, on first rising, there is some lameness, which goes off entirely in the earliest beginning of, and only partially a little later in the disease. Towards evening, or after any continuous exercise, limping returns, and is more marked than in the morning, and becomes more and more so as the day goes on, or fatigue increases. In older persons, who can define their sensations, stiffness is complained of in the morning, while in the evening, or after long exercise, pain more or less acute, with a sense of fulness and distension, is felt.

With this, there is tenderness on pressing at the back of the trochanter, and tenderness at the groin; but pressing the trochanter inwards, so as to bring the head of the femur and the acetabulum into close contact, does not cause pain. There is not in this early stage of synovitis any pain in the knee. There are none of those startings that wake up the patient at night with a great dread.

As these symptoms come on, they are accompanied and followed by a certain amount of swelling in the groin, and behind the trochanter. The former of these tends to obliterate the fossa in that situation, or at least to render it narrower by an apparent increase in breadth of the posterior part of the trochanter. This, in its early condition, will only be seen when the patient, placed with the back to a window, permits equally oblique light to fall on both hips. The swelling in the groin is both more visible, and more easily felt; it lies of course below Poupart's ligament, is deep seated, has an even surface, and must not be mistaken for enlarged glands. Be it remarked, that when this swelling in the groin becomes easily perceptible, sympathetic pain in the knee usually supervenes. Increased heat at the part, chiefly noticeable at the back of the trochanter and at the groin, comes on with the swelling.

Osteitis.-Pain, in and about the hip joint, is of a heavy, dull aching character; it is not increased by exercise, but is generally most severe in bed at night; there is no stiffness in the morning. The pain is often irregularly remittent, being continuous for three or four days and nights, and then disappearing for a time. In children, a pale, worn, weary look will be observed, before any limping actually comes on, and the child will