it projects backwards almost to a point. The diseased side of the pelvis is raised, and the rima natium slopes from below upward and away from that side. The lumbar spine is curved laterally, its concavity looking towards the disease; the dorsal region is bent in a contrary sense, its convexity being towards the affected side, and the shoulder of that side slopes more down, is more depressed than the other. The foot of the diseased limb may be either inverted or everted; the former is the more common, but cases occur in which the contrary posture obtains.

At the same time the tenderness behind the trochanter and in the groin diminishes. The deep fluctuating swelling is exchanged for a more diffuse non-fluctuating tumefaction, which is superficial, and accompanied by a certain puffiness of subcutaneous tissues. Soon afterwards abscesses form and burst in places, which vary in different cases according to certain circumstances to be hereafter considered.

The whole series of symptoms indicate the following pathological changes. During the latter end of the second stage the capsule of the joint has been distended by fluid, generally by pus, and the alleviation of the pain forming an interregnum between the two periods corresponds to the rupture of the sac and cessation of distension, after which a more diffuse action is set up in the parts around.

It is not possible to say why, during distension, contraction of the abductors should predominate; why, therefore, as long as such condition lasts, the limb should be lengthened; nor why a change in these circumstances should afterwards supervene. At p. 309 was described a position which, at the end of the second stage, the patient assumes, in order, as is evident, to yield more. and more to the contraction of the adductor mass, whose power at that time begins to prevail. A glance at the position of shortening will show that the axis of the affected thigh is at an acute angle with the transverse axis of the pelvis,* the thigh therefore adducted. This adduction is the primary malposture in "shortening;" for such condition, unless balanced by a compensating position, would cause one thigh to cross the other, a posture which cannot be maintained while standing, and only to a limited degree while reclining. In order therefore to preserve a paral

* For explanation of ab- and adduction as measured by the angles of the axes, see note at p. 303.

lelism between the two limbs, the patient must abduct the sound one to the same extent as the other is adducted. This can only be done by producing an obliquity of the pelvis; by raising the diseased and depressing the sound side, thus causing the affected thigh to look shortened, while measurement carefully carried out shows no real shortening whatever.*

These nervo-muscular phenomena in hip-disease are so prominent and remarkable, that their evident results as seen in the posture and apparent length of the limb have chiefly attracted the attention of surgeons, and yet, the peculiar influence which they have upon the continuance of the malady has escaped notice. Be it observed that the constant and violent contraction does not merely produce ab- or adduction, according as one or the other set of actions may prevail; but, as from the direction of the muscles is evident, it must also draw the thigh upward and cause the head of the femur to press abnormally against the acetabulum. Thus the pristine inflammation having produced a contraction, the head of the thigh bone begins to press with abnormal force and constancy in the upward direction. We might subdue the inflammation but that the very pressure keeps up the contraction whereby it was primarily caused.† To prove this position we have only to look at pathological museums: we shall find a few specimens in which the action is distributed over the whole joint-surface; a very few indeed in which the inflammation has chiefly attacked the lower posterior or anterior part of the acetabulum and femur; but in a proportion of cases so large as to render the above examples mere exceptions, the upper lip of the cotyloid cavity and the corresponding part of the caput femoris are ulcerating, while all the rest of the bone may be untouched. Such constancy of action can only be accounted for by the fact that abnormal muscular contraction produces pressure, and thereby ulcerative absorption of these parts. The annexed figure, from Mr. Howship's collection in the CharingCross Hospital Museum, is not taken from a specimen particu

That posture produces shortening in the majority of cases was also the opinion of Bonnet.

This sort of reactive tendency is the constant law of muscular irritation: if a sharp-cornered atom be thrown into the eye the lids close upon it, and, if the part be irritable, the more it cuts the conjunctiva (that is the more it is

pressed upon), the more violently does the muscle contract. A man's thigh is broken by some violence that causes the fragments to pierce, or otherwise injure, some of the muscles; contraction instantly commences; the more the organs be damaged the more spasmodically do they act, and the more they contract the more will they be hurt.

larly chosen to prove these circumstances; in fact, it presents an unusual amount of action at the lower part of the acetabulum, evidently produced by the gravitation of pus. Let it be observed how the cavity of the acetabulum has been prolonged about an inch upwards; how the head of the femur has been altered in form; how, also in the position which in life they last assumed, the two fit accurately together, and how the track left behind became narrower as the caput femoris wasted. It is plain from

this mere physical evidence that the head of the femur was used almost like a copper-plater's graver, to furrow the cotyloid cavity

upwards on the ilium, and has been almost worn out in the process. It has been held tightly to the floor of the cavity by the pyriform, obturator and other capsular muscles, while it was forced upwards by those previously specified as abnormally contracted. Thus the acetabulum is made to travel upwards and also inwards, whereby an opening through the floor of the cavity into the pelvis is not unfrequently produced, as shown by the figure. I say, that such evident yielding to the pressure upwards is not an exceptional case, but is the rule: that when we find a hip-joint ulcerating in any other way and position, it is that some rare circumstance has caused a primary osteitis in that particular spot. It must also be remarked that as the head of the femur travels upward, producing, in that part against which it presses so abnormally, ulcerative absorption, it causes beyond that point an additional growth of bone, forming a new lip to the new cavity,* (according to the law of increased growth and induration beyond the focus of a suppurative inflammation.) It follows, naturally, that the change in place of the joint cavity as in the head and neck of the femur produces a certain amount of real shortening, but this is slight-probably does not exceed an inch-yet adds to the difficulty in appreciating the occasional, later and more violent effects of the disease.

During this osteitis and the mutual compression of the articular surfaces, we find the symptoms of that condition developed in a remarkable degree. We have already seen, that when the bone in the neighbourhood of any joint becomes inflamed, starting pains supervene. This symptom is very strongly developed at the hip, producing great dread, suffering, restlessness and wasting. The shocks attack the patient just as he is sinking to sleep, and are in proportion to the tonic spasm. It seems that as long as the person is awake the controlling influence of the brain is sufficient to prevent any irregular nervous phenomena; but that when this is withdrawn the excito-motary system exerts all its power. So constant are these symptoms to the particular morbid change, that when a patient presents himself, whose limb is shortened, and who suffers much from these starting pains, it may be confidently asserted that the head of the thigh

*The production of new bone is most marked in rheumatic osteitis (in which malady, also, the acetabulum

travels upwards); in the most cachectic cases of strumous hip-disease very little or no new rim is produced.

bone is slowly ploughing a groove from the acetabulum upwards. Moreover, these pains are so violent, so much dreaded, that they deprive the patient of sleep and appetite, plunge him into perspirations, render his whole nervous system extremely irritable, and add greatly to the rapidity and destructiveness of the disease. The muscles which are affected with contraction gradually shorten organically and permanently; they become passively contractured; that is to say, their decrease in length is not merely a passing state, which, when the stimulus ceases, will disappear. They become fixed in this shortened condition, either by the glueing together of their elements, or some like cause, and they cannot of themselves resume a relaxed and lengthened position.* Thus, the deformity becomes more and more permanent and organic, while the active condition still going on increases not only the deformity but the morbid pressure.

It was observed (p. 311), that at the end of the second stage the capsule of the joint is distended by fluid, generally by pus; that there follows rupture of the sac, after which a more diffuse action is set up, which is followed by the formation of abscesses. These present themselves in various localities, according to certain circumstances, and chiefly according to the spot at which rupture of the capsule may have taken place, and the position in which the patient has been kept. It is most usual that the first appearance should be somewhere in the neighbourhood of the great trochanter, most frequently behind it. This pus comes from an opening at the back and upper part of the joint; an abscess at the outside of the thigh from the posterior and inferior aspect, the pus travelling beneath the fascia lata. Abscess at the lower part of the groin, or inside of the thigh, shows that the capsule is torn in front.† The appearance of an abscess high

It appears to me from the very slight opportunity for examination of such condition which has presented itself, that this change is located in the sheathe of the fibres rather than in the fibres themselves. Every fibre of a muscle is composed of a sarcos and of an investing wall; the active contraction of a muscle is produced by shortening of the flesh; passive contracture appears to supervene after the interior has been for some long time in this shortened condition, when the investing part adapts itself. permanently to that

shape, and each wall of every musclecell is fixed in its abbreviated form. Moreover each portion of areolar tissue investing the fibrous bundles, assumes permanently the new form impressed upon it by the enclosed and contracted cereos. Such change does not forbid continuation of active contraction, for the state (contracture) depends upon change in the passive parts of the organ, to which ordinary muscular contraction may be added.

The length of these burrowing abscesses-in fact, the choice of a down