sleep badly at night, cry perhaps if laid on the diseased, but as yet unsuspected, side. The signs of pain, as well as the worn look in children, come on before any limping; in older persons, pain is complained of before such a positive symptom is perceived; the limping, when it once does come on, is equable throughout the whole day. There is no tenderness while pressing behind the trochanter; nor, unless inflamed by other causes, over the groin. We shall see directly that certain circumstances change this condition. There is early pain in the knee, startings at night may come on in this, the first stage of the disease, and tenderness on pressing the joint surfaces together is not uncommon.

With these symptoms, there is no swelling either behind the trochanter, or deep in the groin; the glands of the groin however are frequently enlarged; this is a point which should have great weight in forming the surgeon's opinion, and is the cause alluded to in the last paragraph, as influencing tenderness of the groin on pressure. There is no increased heat about the part. Add to these local signs, that a child in a very cachectic condition from struma is more liable to be attacked with osteitic than with synovitic hip disease, and the fact of the general health failing in a manner still more marked, before any lameness is perceptible.

A long series of careful observations have convinced me that this account may be relied on wherever the semeiology is sufficiently marked. To render this more distinct, I will tabulate the symptoms of the first stage.

Synovitis-Symptoms.

The pain is a sense of fulness, distension increased in evening, and after exercise, but constant.

Stiffness in morning.

Limping comes on with the pain. It is at first slight in morning, then disappears, and is more marked in evening.

Pain in knee does not come on till after the deep swelling in the groin is perceptible.

Starting of the limb a late symptom. Tenderness behind trochanter, and at groin: none on pressing articular surface together.

The swelling in the groin is deep, and below Poupart's ligament; the glands there do not swell.

Osteitis-Symptoms.

Pain, dull aching; most at night in bed; remittent.

No stiffness in the morning.

Limping does not come on till after the pain has existed some time, then is equable throughout the day.

Pain in the knee an early symptom.

Starting of the limb an early symptom. No tenderness on pressing behind trochanter and groin, but sometimes on pressing joint surfaces together.

The glands in the groin swell before any deeper swelling is perceptible, if ever such come on in the first stage.

Nothing can tend more effectually to throw undeserved doubt upon facts than straining them beyond their legitimate application; and I would deprecate as strongly as possible any attempt to press the above diagnostic difference into cases, that have advanced beyond the first stage, or even towards the latter end of that period. As the disease proceeds, the clearness of the symptoms becomes obliterated; the limping in either case is continuous; there is tenderness both behind the groin, and on pressing the joint surfaces together; and starting at night, if previously absent, will come on. The whole train of symptoms may have continued an indefinite time, for morbus coxarius, like all diseases, has an acute and a chronic form: the acute malady may gallop through all the variations of the first stage in a few days, or even hours; the chronic may continue for months as so slight a disease in appearance, that it is scarcely regarded; until the more serious symptoms which immediately precede and lead to the second stage supervene.

The Second Stage consists of lengthening of the limb; flattening of the nates, with a lateral twist of the spine; constant and strongly marked lameness; a more or less continuous pain in the hip and knee; spasmodic pains at night in the limb, beginning about the hip and upper part of the thigh ending at the knee; contraction of certain muscles and wasting of the limb. In this period of the affection we have no longer anything to do with detecting in which structure the disease commenced, but have simply to observe the symptoms of the malady. Those which had been increasing towards the latter end of the first stage, viz., pain, both at hip and knee, tenderness, swelling, and limping continue, and there is added another symptom, viz., posture. The thigh is constantly flexed upon the abdomen, more or less in different cases; the knee is generally rotated outwards, and the foot everted. If the patient be made to stand up, he bears all the weight of the body upon the sound limb; the knee of the diseased one will be in a plane in front of that of the other, in consequence of the hip being flexed, and also in consequence of a malposture of the pelvis, shortly to be described, it (the knee) will be also separated from its fellow, i.e., abducted; the foot will rest with the sole upon the ground, a good deal in front, with the toe usually turned out, though it will sometimes

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be turned in.* At the same time, the knee of the affected side becomes lower than the other; that is, the thigh appears lengthened. The buttock of that

side is flatter, the folds of the nates longer and less marked than normal, the depression at the back of the trochanter nearly obliterated. (See Figure.) The appearance of lengthening in the limb is the symptom, par excellence, which marks this stage of the malady. Much thought, and more writing, has been expended in endeavouring to account for this apparent increase in the length of the limb. Most English, and some Continental, authors refer it entirely to position; others believe that a real lengthening may take place, that is to say, they believe that the head of the thigh bone may, without dislocation, be projected sufficiently far from the pelvis to cause the whole distance between knee and acetabulum to be increased. I am, from the results of experiments, able to affirm, that real increase in this distance is without dislocation downwards utterly impossible.† The position whereby apparent lengthening in hip-joint disease is obtained is a twist downward and forward of the affected side of the pelvis ; the thigh is flexed upon the body, abducted, and rotated outwards.+

I have seen this position twice, both times in young children.

†These experiments and the opinions of certain authors are, in order to leave the course of our narrative uninterrupted, placed together in an appendix to the present chapter.

M. Bonnet has given at great length an analysis into all the varieties of position which the thigh may assume in hip-joint disease; but not perceiving the

practical value of such minute distinctions, I shall not quote all his definitions and arguments here. He shows by drawings from the skeleton and other means, that whenever the thigh appears lengthened, from depression of that side of the pelvis, the femur must be abducted; whenever it is shortened by elevation of that side of the pelvis it must be adducted. In this sense the two words only relate to the pelvis itself, not to the axis of the

The whole side of the pelvis is also thrown forwards. This aids in increasing the apparent lengthening of the thigh, and it diminishes the projection backward of the tuberosity of the ischium, thus procuring a flattening of the nates, even though there be no wasting of the gluteus. These twists of the pelvis cause the rima natium to incline from below upwards and towards the diseased side. The spine itself will be thrown into corresponding curvatures all the way up, and thus a look of general distortion be produced. These signs are all merely the result of posture, and may be imitated by any one who has an accurate knowledge of the appearance to be assumed. The only unproducible point is the obliteration of the fossa behind the great trochanter; this in disease is much filled up by swelling. But in examining a diseased hip it does not suffice merely to place a patient upright before us; the examination must also be made under different conditions.

In the first part of the second stage the position is not so determined, nor is the limb so fixed that it cannot be moved slightly and examined in the recumbent posture. Let the patient first be on the back, upon a hard surface, such as the paillasse of a bed, or a table. The pelvis must, if possible, be placed at right angles with the spine, and the thighs at right angles with the transverse pelvic axis. In all probability these attempts at adjustment will be unsuccessful, but at all events there may remain so little twist that it would require a very accurate and practised eye to detect it. The inner condyle of the femur of the diseased side will seem lower than that of the sound one, so will the tuberosity of the tibia, internal malleolus, or other anatomical points. Now, if we measure the limbs we shall find little if any difference in their lengths. What difference we do find is, surprising as it may seem, contrary to ocular appearances. Thus, the limb which appears longer will (particularly if the measurements be taken rather on the outer

body. I will explain this in my own language more tersely. Let us suppose the transverse axis of the pelvis an imaginary line drawn between the two acetabula, the thigh is neither abducted nor adducted as long as its axis is at right angles with this line. Suppose the pelvis tilts so that the axes of the thighs remain the same, but that of the pelvis become oblique, this latter will be at an

obtuse angle with the axis of one, at an acute angle with that of the other, limb; the former is ab- the latter ad-ducted. If the axes of the thighs be of the same length, it will be at once seen that while the pelvis thus tilts, one will be drawn up, shortened; the other depressed, lengthened. Shortening corresponds then with adduction; lengthening with abduction.

side) measure shorter than the other.* Various instruments and methods, of different degrees of complication, have been invented, in order to get accurate measurements of the thigh in hip-disease. They are all futile, as they have been invented to find out differences which are only apparent.

Another point in this position should be attended to. It has been said that in the second stage of morbus coxarius the thigh was flexed on the abdomen, yet the patient may lie with shoulders, buttocks, and heels upon a plane surface. If under such conditions, however, the position of the pelvis be examined, it will be found to be abnormally perpendicular; in consequence of which the lumbar and the lower dorsal spines are arched very considerably, and the hand placed below the loins will find a large gap between them and the mattress or table. This, it need scarcely be said, is not the method in which a healthy person lies. In fact, instead of the thigh being flexed upon the pelvis the pelvis is flexed upon the thigh, and the relative position is the same.

Next, let the patient turn upon the stomach, and let the state of the nates, the inclination of the spine, and the relative apparent length of the thighs be examined, and it will be observed that distortion is not so great in this as in the erect posture, but it still exists. In this position the surgeon will most comfortably and readily examine the depression at the back of the trochanter, find any swelling or fluctuation, and the exact seat of tenderness.

Such is the condition of the patient, as far as mere deformity goes, in the early part of this stage. The pains of which he complains are several. One, a bursting, aching, gnawing, or burning pain, situated behind the trochanter, and in the groin, generally both, and this is combined with some deep-seated, perhaps fluctuating swelling. There is another pain, of a less defined nature, the well-known "pain at the knee," which is usually referred to the inner condyle of the femur; but if the patient be told to put the finger on the exact spot, he will be rather uncertain as to the locality. It is sometimes remittent,

*This curious fact was first explained by Gädechens ('Hamburger Zeitschrift,' 1836), who showed that when the ilium inclines to one side, its crista must approach the trochanter of the femur:

thus, though the whole thigh may sink and appear longer, the measurement between any point of the crista ilii and of the thigh must be shorter than the other limb.

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