in the groin, i.e., immediately below Poupart's ligament, is of great importance in diagnosis, for in such case we may conclude that the acetabulum has opened into the pelvis, or that the floor of that cavity is perforated. There are two modes in which an abscess, in this situation, may communicate with the hip-joint, either directly running backwards through the capsular ligament (a rare condition), or by entering the pelvis and passing through the floor of the acetabulum; indeed, a pelvic abscess, connected with hip-joint disease, may occur before the bone has been actually perforated, when the whole thickness of the floor of the acetabulum is involved. Some remarks on this subject by Mr. Hancock are so pertinent that I cannot forbear quoting them.

"We must assure ourselves that the pelvic abscess has been preceded by hip-disease; is connected with it, and not with disease of the spine, with psoas, or iliac abscess. One point, therefore, in this diagnosis is the preexistence of hip-disease. Another is the locality at which the spontaneous openings usually occur. When the matter is poured into the pelvis through the perforation of the acetabulum, it falls, as we have seen, between the obturator fascia and the bone, and in consequence of the firm attachment of the former to the falciform margin of the great sacro-sciatic ligament, the matter cannot reach the skin in that direction; but by gravitating posteriorly by the rectum it presents itself by the side of the anus, simulating fistula. It occasionally bursts into the rectum itself, or the vagina; and it has been known, by its pressure upon the neck of the bladder, to interfere greatly with the process of micturition; but the more frequent position, as far as my experience serves me, is at the outer part of the groin, near the anterior-inferior spinous process of the ilium, probably induced by the position maintained by the patient at this stage of the disease. This is a point to which I am induced to attach some importance, as affording a means of diagnosis between pelvic and psoas abscess, as the latter usually presents more internally nearer the middle of the groin. The existence of openings externally in the neighbourhood of the joint will also assist; as pelvic abscess connected with hip-disease very rarely, if ever, takes place without having been preceded by suppuration about the joint itself.

"When the opening occurs in the groin, the existence or non-existence of perforation of the acetabulum may be ascertained by a probe, slightly curved; by introducing it into the opening, and directing its point downwards and outwards it may be passed through the perforation into the

ward direction for burrowing at all- | depends upon gravitation; hence those who have been kept on the legs while hip-disease goes on will have abscesses

down the thigh almost to the knee; those who have been kept in a recum bent position have them opening about the hip, buttock, or groin.

joint; and I have also observed, that whereas in psoas abscess the probe can be more readily passed backwards and upwards, in these cases it takes the opposite direction-backwards and downwards. In some cases of hipdisease an abscess forms in the pelvis before actual perforation of the acetabulum occurs.'

Dislocation of the head of the bone from disease, or spontaneous dislocation, as it is called, is an occurrence so unusual that one is astonished at the general credence in its frequency. It is only about ten or fifteen years ago that every hip-joint disease was supposed to end in this way; but if a search be made in the College of Surgeons, St. Thomas's, St. Bartholomew's, or other of our great pathological museums, there will be found but very few specimens exhibiting simultaneously the signs of morbus coxarius and of dislocation. On the other hand, it is by no means uncommon to find the head and neck of the femur shrivelled to little. more than a button-like projection, the acetabulum quite altered in form and place, and yet the bone retained in its cavity.†

Sir B. Brodie evidently attributes all shortening of the limb to dislocation; he calls it real, in contradistinction to lengthening, which he very rightly considers apparent. Unfortunately, this distinguished surgeon quite overlooked the influence of position as a cause of shortening, and has thereby added his great weight to that fallacy, which produces a mode and habit of looking upon hip-disease which is not likely to aid in establishing a rational and successful treatment.

Liston, however, in his Lectures (Lancet, 677, p. 40), says that shortening does not often take place from dislocation. Dr. Bauer (Op. cit. p. 12) also insists upon its rarity. For myself, I am persuaded that spontaneous dislocation of the hip joint is uncommon in comparison to the frequency of its absence. It occurs only in cases of so cachectic a character, that new bone is not produced beyond the focus of suppuration, as was pointed out at p. 304 to be usually the case.§

* Mr. Hancock, 'On Excision of the Head of the Femur,' Lancet, April 25th, 1857, p. 421.

The condition figured and described at p. 313 is not a dislocation, for the head of the bone still remains in the acetabulum, though both may be altered in shape and even in position. Luxation is only to be affirmed when the

cavity, however altered, no longer contains the caput femoris.

Op. cit., 5th ed., p. 117, 118; the passage is too long to quote.

§ The remarks upon spontaneous dislocation refer only to displacement upon the dorsum ilii. There are one or two instances on record in which the thigh has been luxated on the pubes into

The diagnosis in an old case of hip-disease, between a dislocated and a non-dislocated bone, is not so difficult as it is supposed to be, if the surgeon will bear in mind this singular and important fact. When the head of the bone becomes spontaneously dislocated upon the ilium the malposture of the pelvis gradually decreases, so that the thigh is in such a case not shorter than the limb affected with ordinary hip-disease, but still with its head in the cavity. It must be remembered, that in a full-grown person, the thigh may be apparently shortened through mere position by three inches-that is to say, the knee is that distance above the other; if, in such a case, a dislocation upon the dorsum ilii were to shorten the limb two more, the knee of the affected side would be very little beyond half way down the thigh of the sound one. As before stated, however, in those rare cases in which dislocation takes place, the side of the pelvis slowly comes down, since mutual pressure of the joint surfaces ceases, and even the passive contracture of the muscles yields to a considerable extent. Such has been the condition in the two instances of old spontaneous dislocation, which I have seen during a pretty extensive search of more than ten years. Hence, if a surgeon find the pelvis in the ordinary oblique posture of hipdisease, and only an ordinary amount of shortening, he may conclude with considerable confidence, that he has not to do with a case, in which dislocation had occurred. In the example from which the annexed plate was taken, there was no dislocation, and it is given in order to show the amount of distortion which may prevail without such concomitant. Anatomical examination and manipulation of the limb, must be used to aid the diagnosis; but to discriminate the actual position of distorted parts, among a mass of swollen and diseased textures, is extremely difficult. Nelaton's test is ingenious and simple: a piece of string is carried from the anterior-superior spinous process of the ilium to the tuberosity of the ischium; if the bone be normally placed, this line falls on the upper part of the trochanter major; but if the head of the femur be upon the ilium, that process will lie far above the string. It is to be remembered, in using this test, and in manipula

the foramen ovale and into the sciatic notch, but these are so rare that it is hardly necessary to notice them. In those cases of spontaneous dislocation upon the ilium which I have seen, the

posture of the patient and the form was so different to that of ordinary shortening, that if it were once pointed out upon the living subject it could not be again mistaken.

OLD HIP-DISEASE-SHORTENING WITHOUT DISLOCATION.

ting these parts, that the position of the trochanter is often greatly changed, in the absence of luxation. The head, as also the neck, of the thigh bone (a part which in all its injuries and diseases suffers from defective nutrition), yields rapidly to carious disease, so that not unfrequently all that is left of these parts is a little button projecting into the acetabulum, from between the trochanters. Again, as we have seen, the cotyloid cavity itself becomes altered, its projecting rims more or less eaten away, and the place where the button-like remains of the head are in contact with the pelvis, very much changed.

True Anchylosis is a rare sequela of disease in the hip-joint: it

is chiefly mentioned here, in order to point out the extreme difficulty of diagnosing the presence or absence of this condition, if the patient be a child under twelve or fourteen, and the disease have lasted a considerable time. A certain amount of movement in the thigh can be produced, but a closer inspection will show that in all cases of advanced hip-disease the axis of motion is not the joint itself, but the sacro-iliac synchondrosis, which becomes excessively flexible. A patient was in the Charing-Cross Hospital, at the end of the last and beginning of the present year, in whom this mobility was remarkably developed. It was impossible to come to any conclusive judgment, until chloroform was administered.

TREATMENT.

First Stage. The first sign of limping, the first complaint of pain in the hip, should, in young and strumous persons, attract instant attention; and unless it be the merest passing evil, the sufferer should be subject to skilled examination, so that any disease which may be found to exist may be at once subjected to treatment.* In the commencement of hip-disease, we have simply to do with an inflammation not combined with any muscular spasm or other complication, and our efforts therefore are to be directed simply to combating this morbid action. The first indication is to render the joint motionless, and to do this it is necessary that the pelvis, thigh, and lower leg be fixed. A large number of apparatus has been devised for this purpose. The double inclined plane, Earle's bed, Heine's complicated couch, have all the disadvantage of confining the diseased hip too little, and the rest of the body too much. Bonnet's grand appareil, and Dr. Bauer's imitation of it, which he calls "wirebreeches," † have this great fault, that in rendering the diseased hip immoveable, they at the same time absolutely fix the other limb and in a considerable degree the vertebral column. The irksomeness of such treatment, is something inconceivable; indeed, Bonnet acknowledges that it is impossible to keep a patient

Constitutional treatment is not considered in the present chapter, as it was fully handled in Chapter V. On Strumous Synovitis.

These machines consist of iron bars

connected by wire gauze, which enclose the pelvis, both thighs, legs, and feet; fixing immoveably the whole lower half of the body.