March
1, 1880.]
LECTURE ON DISEASES OF THE HIP-JOINT.?BY C. MACNAMARA.
ORIGINAL COMMUNICATIONS.
\
the affected liinb by on the sound
firmly LECTURE ON DISEASES OF THE HIPJOINT. By C.
Surgeon
Macnamara,
to the Westminster
London
Hospital
and the
Royal
Ophthalmic Hospital.
Morbus-Coxarius.
Excluding cases originating in disease external to the joint, morbus-coxarius may commence either in the synovial membrane, medulla of the bone, or, before puberty, in the soft structures between the epiphyses and the diaphyses, as well as in the acetabulum ; it is, however, almost impossible for abnormal action to be confined for any length of time either to the bone or any other structure entering into the formation of the joint, because prolonged irregular action in any one part of the articulation is almost certain to implicate contigu-
This being the case, it will save reiteration this lecture with an account of the symptoms characteristic of morbus-coxarius, irrespective of its origin. My remarks apply to the diagnosis of liip-
ous
tissues.
if I
commence
disease in its earlier, rather than its more advanced stages, when there can seldom be much difficulty in determining its nature. I may here observe that hip-disease is an affection of
joint
child-life?about two-thirds of the cases being under ten years of age, four-fifths of the whole number not having reached the adult period of life. A patient affected with morbus-coxarius (whatever may have been its origin) suffers from a certain amount of stiffness in the affected joint. This stiffness of the joint may depend upon one of two causes, or perhaps more often upon a combination of these causes. First) from irritation going on in some part of the joint reflex action is propagated through the spinal cord to the muscles surrounding the joint, and from the spasm thus produced the head of the femur becomes firmly locked in the acetabulum. Secondly, if the synovial membrane of the joint becomes inflamed and distended with fluid, the ilio femoral and pectineo-femoral ligaments, together with the tendons of the psoas, iliacus, and other muscles the articulation, press upon the inflamed membrane when the patient extends his femur on the pelvis. To relax these ligaments and muscles the patient involuntarily keeps his thigh fixed and flexed on the pelvis. The same position is assumed if the acetabulum or the head of the femur is rendered painful on pressure in consequence of the existence of inflammation within the cancellated structure of the bone. In order that we may determine if slight stiffness of the hip-joint exists, the patient should be very carefully examined. His clothes having been romoved, observe in the first place if he has lateral or angular curvature of the spine ; notice if there is any tenderness on pressure over the vertebras or stiffness when he bends his back as in picking up a small object from the floor. As the patient stands naked, notice if he endeavours to save
surrounding
57
slightly flexing it and resting more one. During these observations do
your best to gain the child's confidence. The patient must then be laid flat on his back upon a hard smooth surface, such as a floor or table : place the first finger of one hand 011 the anterior superior spinous process of his ilium on the affected side, and gently flex and extend
corresponding thigh ; while doing so watch if the his femur, which will bo patient's pelvis moves with the case if the head of his thigh bone is locked in tho acetabulum. Compare the movements of the diseased
the
with the sound limb?you can flex and extend the latter freely without moving the pelvis. When manipulating the diseased limb it not unfrequently happens that no movement of the spinous process of the ilium with tho femur is noticed until the thigh is either fully flexed or extended. It is quite possible, however, that the move-
thigh on the pelvis may be limited in tho I have described in consequence of a psoas or iliac abcess ; in all doubtful cases not only ascertain if the movements of the joint are perfect in complete flexion and extension, but also if the head of the femur rotates freely in the acetabulum when the thigh is semiflexed on the body, in which position neither psoas nor iliac abcess would influence the action of the muscles. The diseased limb being semi flexed, grasp the patient's thigh with one hand and rotate the head of the femur in the acetabulum. If its motion is perfectly free under ments of the manner
these circumstances it is hardly possible that disease of the hip-joint exists. In almost all cases of morbus-coxarius?for reasons above referred to?the diseased limb is more or less flexed 011 the body, the head of the bone in this position being fixed against the pelvis. In order to ascertain if this state of things exists as the patient lies on the table, observe if the spines of his lumbar vertebra) rest iu contact with the flat surface on which he reclines. If there is disease of the hip joint, the corresponding thigh will be more or less flexed on the body, (unless in very
exceptional cases)
; should the
patient's
lumbar spine be
arched forwards, flex the diseased limb still
more
until the
of his vertebras rest in contact with the table, leave the diseased thigh flexed to this extent, and fully extend the sound limb ; the lumbar spines will not move forward during this manipulation, so long as tho diseased limb remains flexed on the body ; now place the fingers of one hand between the patient's lumbar spine and tho table he reclines, and extend the diseased limb on which and slowly; if the femur is locked in the acetabugently lum by muscular rigidity or from any other caiise, as the diseased limb is being extended the brim of the pelvis will be titled forward, and with it the movable lumbar
spines
This movement may be repeated, each time the limb is fully flexed on the body the patient's spine will rest upon your hand placed between it and tho surface upon which tho child reclines ; as tho limb is again extended thG patient's vertebra) are felt to movo slowly forward into an arched position.
vertebra)
In the the
cases
of morbus-coxarius, therefore, not only will its movements but also in by far the femur will be flexed 011 the
hip-joint be stiff in majority of cases
58
THE INDIAN MEDICAL GAZETTE.
pelvis, and in this position locked in the acetabulum, under which circumstances, if the diseased limb is extended, the pelvis is titled forwards, and the lumbar spine becomes arched. But in the earlier stages of the disease, patient is placed completely under the influence of anaesthetics, the head of the femur will move with perfect freedom in the acetabulum. Subsequently false anchylosis may occur as a result of the disease, and then the movements of the joint are impaired, although the if the
influence of chloroform. may be fully under the Patients suffering from morbus-coxarius, when lying flat on their back, frequently appear to have marked lengthening of the affected limb. This condition is due to contortion of the pelvis, and not to the diseased limb being really longer than the sound one. In a case of this kind if you draw a line through the two anterior superior spinous processesof the ilium you will find that the pelvis on the diseased side is lower than on the sound side. The explanation of this state of things is as follows :?
patient
Supposing a patient suffering from morbus-coxarius has his thigh flexed and abducted, in walking he cannot bring his foot to the ground ; in order therefore to get the limb parallel with the other leg he raises the pelvis on the sound side so as to tilt it over towards the diseased side, the loss of movement in the affected hip being transferred to the flexible lumbar spine, which in a case of this kind becomes curved towards the diseased side. As the patient therefore lies on his back, the abnormal condition of the brim of his pelvis produces an apparent lengthening of the diseased limb. Shortening of the limb in morbus-coxarius may in the advanced stages of the disease be due to absorption of the head of the bone, in rare cases to dislocation of the head on the dorsum of the ilium, or to separation of head?the result of like the lengthening but shortening ephysitis ; apparent of the limb may be caused by muscular action. If from rigidity of the muscles, the thigh, instead of being abducted, is fixed in the acetabulum and adducted, the
the neck
patient
of the femur
in
diseased
endeavouring
from
the
to walk is unable to
bring the
limb into the middle line ; and to overcome this he raises the pelvis on the affected side, pro-
difficulty ducing curvature
of the lumbar vertebra) towards the sound side. The brim of the pelvis, being tilted downwards towards the sound side, produces an apparent shortening of the diseased limb. As I have already remarked, some of the earliest indications of hip-disease are connected with muscular spasm causing stiffness of the joint and mal-position of the limb which disappear under the influence of anaesthetics, and may in like manner pass away under appropriate
treatment, leaving the movements of the joint perfectly free. In the earlier stages of morbus-coxarius when the patient is laid flat on his back, and his thigh is extended, the adductors, particularly the longus femoris, form a well marked rigid band extending from the pelvis to the femur ; these muscles, as well as the synovial membrane of the joint and the head of the bone,
receive branches from the obturator nerve. The abnormal neive action in these cases is not confined to the
[March
I 1880-
excitation of spasm, but the affected muscles also waste away in hip joint disease ; nevertheless, tiie obliquity of the fold of the buttock noticed on the diseased side is
by no means constantly due to wasting of the muscles in region, but rather to the position in which the patient stands. If you examine the buttock of a healthy person when in the erect posture, the transverse character of the gluteal fold will be noticed. If you now ask him to bear the weight of his body on one limb and slightly flex the other limb, the transverse character of the fold of the buttock will at once disappear, and it will become oblique as in the early stages of hip-disease.
this
The pain especially at the commencement of morbuscoxarius is often described by the patient as being most severely felt in or above the knee, and along the inner part of the thigh?so much so that if you attempt to press on these parts, or to move the knee joint, the
pain, but perhaps he will allow you superficial examination of the hip without complaining. This condition of things is due to the distribution of the obturator nerve to the skin covering the inner and lower portion of the thigh. But, as the hipjoint receives nerves from the obturator, and also from patient
cries out with
to make a
the anterior crural and offsets from the sacral
plexus,
the
region in which pain is complained of in morbus-coxarius, often very ill-defined : as a rule it is most severe at for as the patient falls asleep the reflex irritation of the muscles?which he could partially control when
is
night,
awake?gains the ascendancy and the limb starts involuntarily and gives excessive pain. Pressure over the joint or the femur, so as to jam the head of the bone against the acetabulum, almost invariably produces great pain in the hip-joint. I have before remarked that lameness in the earlier stages of morbus-coxarius may amount to simply weakness or giving way of the leg as the patient walks. As the disease advances the lameness becomes a more marked feature of the complaint, but. it is almost unnecessary to observe that this symptom, unless combined with stiffness in the joint, can in no case be relied upon as characteristic of hip disease. The truth is, during the earlier stages of morbus-coxarius there is sometimes considerable difficulty in forming
opinion regarding the complaint ; you may meet with instances in which a patient is lame with paiit about the hip joint, the limb being slightly flexed anil the muscles surrounding the hip somewhat rigid. There
an
evidence of disease of the spine, presthe vertebrfe causes the patient no pain, and yet the case may be one of disease of the spine and not of the liip-joint In doubtful cases of this descrip-
is
no
sure
marked
over
tion it is only by carefully watching a child when the floor that you he is trying to pick up something from notice his inability to accomplish such a movement with ease in consequence of a certain amount of stiffness of the vertebral column. In such a case any doubt as to the existence of hip-disease is set at rest if, when the child's thigh is in a semi-flexed position and he is lying flat on his back, the head of the femur rotates naturally in the acetabulum.
It is however quite possible that morbus-coxarius and disease of the spine may co-exist ;
March 1, 1880
LECTURE OS DISEASES OF THE HIP-JOINT.?BY C. MACNAMARA.
]
infantile paralysis lias been mistaken for hip-disease. The former affection however generally comes on suddenly, commencing with fever. After a few days, if the child attempts to rise or even move in bed, marked loss of power in the affected limb, especially in the extensors of the leg, is noticed, the position of the foot is gene-
rally that of equino-varus; in some cases the little patient in the commencement of the attack suffers excessive pain, and cries out the moment the foot, leg or thigh is touched ; in the absence of pain the paralysed limb can be moved in any direction on the pelvis without indications of stiffness of the hip joint. Synovitis
of the
Hip-joint.
Synovitis of the hip-joint is nt un frequently an acute affection, and, if it continues for some time, generally leads to disease of the cartilages and bones entering into the formation of this articulation as well as to abnor-
mal
changes
in the soft structures
surrounding
the
joint.
Among the most common causes of synovitis in the hipjoint I may mention injuries, exposure to cold, and ; I think there can be no doubt' that considerable number of cases of hip-disease among the syyoung people originate in inflammation of novial membrane. The circumstances of synovitis in the early stages
septic poisoning a
of
liip-disease are illustrated by the following case, the details of which have been kept for me by my dresser,
Mr
Glassington.
T E., set. 11, was admitted into the hospital on the 12th of February ; his family history is free from The evidence of constitutional disease. patient's general health h >s been good up to the present time; he has never suffered from rheumatic fever: his mother says, before injured his right
and
accident,
the
boy
was
coming into hospital her hip ; within a few days
son
fell
of the
unable to walk without consider-
able pain in the joint. into hospital, T. E could not put right foot to the ground, the limb being flexed and extremely painful. During the early hours of the night the patient was kept awake by the involuntary starting On admission
his
of his leg. which caused him excessive pain. When supported and standing on his left leg the right thigh is flexed, the toes touching the ground ; any pressure applied to the trochanter or over the region of the hip-joint causes the boy to cry out with pain ; when laid perfectly his back, if an attempt is made to extend the right thigh, the lumbar spine is immediately arched forward. The natural furrow in the spine below the crural arch is obliterated, there being evidently considerable distension of the synovial membrane of the right flat
on
hip-joint. The thermometer
applied
persistent
to the skin over the rise of
inflamed
temperature from 1 to 1? degrees as compared with the corresponding spot on the other side of the body. The limb was fixed to a splint and the Extract of Belladonna smeared over the groin. After a few days, when the patient could bear pressure, it was employed and india-rubber bandage over the by means of a pad joint indicated
a
5j)
joint ; Iodine paint being freely applied over the skin night and morning. The pain gradually subsided and the patient left the hospital in a month's time perfectly cured. This is
a typical example of serous synovitis of the hipmarked by a sudden invasion of the disease, after joint ; an accident, the local temperature and the evident distension of the synovial membrane with fluid, the pain increased by the slightest pressure made over the
joint or in moving the limb, the flexed position of the thigh, and stiffness of the hip-joint, together with the swelling in the region of the articulation commencing so soon after an injury, were all symptoms pointing to inflammation of the hip. Acute serous s}Tnovitis, excluding cases of rheumatism, as I have before remarked, most commonly results from an accident; it is characterized by severe pain in the hipjoint increased by any movement of the limb or the slightest pressure applied over the articulation, the natural fold beneath the crural arch is
obliterated in consequence
of
the distension of the
synovial membrane ; there is stiffness in the movements of the joint, the femur being locked in the acetabulum, and the thigh more or less flexed on the body. This position is not only due to the involuntary effort which the patient makes to relax structures pressing upon the inflamed synovial membrane, but whenever this membrane is distended with fluid the limb invariably becomes flexed on the trunk. The temperature of the skin over the inflamed hip-joint in serous
synovitis, is seldom more than a degree or two higher than that of the corresponding healthy limb. I believe that disease of the hip commencing after the adult period of life is, in the majority of cases, due to synovitis, or else to granular degeneration of the synovial membrane. Cases of arthritis-deformans are 110 exception to this rule among children ; also, synovitis in acute rheumatism is occasionally followed by suppurative changes in one or more of the joints affected ; I have seen several cases in which after an attack of rheumatic fever the hip-joint has remained di-tended with fluid, the patient's general and the local temperature continuing high the symptoms pointing to purulent synovitis of joint. Under these circumstances I have 011 three
the
in adult patients, passed an aspirator into the and drawn off several ounces of purulent matter, at the same time washing out the cavity of the abscess or joint with a solution of chloride of zinc, four grains to the ounce. In one of these cases the operation had not to be repeated, no further collection of pus occurring ;
occasions,
joint
in another case the aspirator had to be used a second in one instance three times, but in all three
time, and
the patients recovered with stillness but 110 anchylosis of the hip-joint. This stiffness was due to the formation of adhesions in and around the joint, and under anassthetics I was subsequently able to break through thes->. adhesions, after which the patient regained full use of the hip-joint. Among children synovitis is no uncommon cause of morbus-coxarius, and the majority of these cases if properly treated from an early stage of the disease, may be cured; doubtless they form a large per-centage of cases
60
THE INDIAN MEDTCAL GAZETTE.
instances of
hip-joint disease which do recover. The reported for me by Mr. Gubbins, is an illustration of synovitis advancing to active changes in the hip, which, unless successfully treated, would very probably have terminated in osteomyelitis a d
following
case,
necrosis of the head of the femur. F. II., aged 13 : this as
girl's family history is
far
a
good
one
her health is concerned ; she has never had rheumatism or any other illness prior to the affection of the hip from which she now suffers. The disease commenced last August, after a fall from a cart, when she injured her right leg ; from the time of the accident she had more or less pain in the right hip-joint, but was able to move about and attend to her work until the month of September, when symptoms of hip-disease became so strongly marked that she was sent into the as
hospital by Mr. F. Nicholls of Croydon. On admission, the patient's right thigh was flexed, so that she could only touch the ground with her toes ; the
slightest movement of the limb caused her intense pain in the hip-joint; she was kept awake at night by the involuntary starting of the limb. The head of the right femur was fixed in the acetabulum, and the synovial membrane was evidently much distended The temperature
of the skin over the joint varied from 1-5? to 2? over that of the corresponding point on the other side of the body The patient was at ease so long as the right leg was kept extended and abducted. The fluid contained in the joint was on two occasions drawn off by means of
the aspirator. Extension was maintained for two months, and a succession of blisters and subsequently the actual cautery were applied with no abatement of the symptoms ; the patient's health began to give way and her temperature to rise during the evening to 100 degrees, the local temperature over the diseased joint was now
degrees above that of the sound of February F. H. bein>,' under the was influence of ether, her right thigh brought the other and the with tensor leg sartorius, parallel vagina) femoris and the adductor longus muscles which had been extremely rigid before anassalways
side.
2 and 3 On the 2nd
thetics were given, were divided subcutaneously. A valvular opening through the skin was made over trochanter major and a small-sized hand-drill the passed through the trochanter and neck of the bone into the synovial cavity of the hip-joint. A long outside splint was then applied to the limb and the patient put to bed. From the time of the operation F. H. was free from pain, and in ten days was up and moving about the wards with a stiff joint (for anchylosis had taken She soon after left the hospital, and has since
place).
no pain or any other symptom of hip-joint disease. In this case it would appear that synovitis, leading to
had
alterations in the structures in and around the joint, given rise to bands of adhesion about the articula tion, at the same time some acute inflammation of the synovial membrane existed when the patient first came under our treatment. In cases of this description relief is frequently afforded by breaking down the bands of
had
fibrous tissue which have grown round, and confine the action of the joint. It may however, as in the in
[March 1,
1880.
stance I have referred to, be necessary not only to overcome the symptoms producer! by the existence of bands
of adhesion about the articulation, but also to resort to measuns calculated to relieve the inflammatory action going on in the synovial sac.
Synovitis resulting
from
cold
sometimes
leads to
results very similar to those I have described as from an injury for instance. J.
ret.
H.,
winter
was
14
:
this boy
exposed
to
throughout
great privation.
arising
the whole of last He had never
suffered from acute rheumatism.
During the month of December after sleeping one cold night in a barn, he awoke in the morning complaining of great pain in the right hip-joint. He was admitted into a workhouse infirmary, and subsequently sent into our wards by Mr. Ivelsey of Red Hill. On admission, three weeks aftc the commencement of the disease, we found the right femur fixed in the acetabulum, the thigh being adducted and flexed,
intensely
the limb
was
two inches shorter tunn
the left one, the
pelvis being tilted upwards on the right side. The lumbar spine was arched forwards ; there was considerable swelling beneath Poupart's ligament from distension of the synovial membrane of the hip joint with fluid. The patient suffered from very great pain in the right knee and hip-joint, aggravated by the slightest He was relieved when the limb was fully movement.
and adducted ; but as treatment of this kind with counter-irritation had jeen employed before
extended
together
admission into hospital without benefit, and again for a month while in our wards without apparent relief to the symptoms, the patient wms placed under the influence of ether, and the fluid in the joint having been drawn off by the aspirator, the sartorius and two of tlie adductor muscles were divided subcutaneously ; and the integument over the trochanter having been incised, a hand-drill was
the trochanter and neck of the femur into outside splint was applied to the limb for Fi'om the time of the operation the pain in the and the knee almost entirely disappeared ; no
passed through joint. An
the a
week
hip-joint
subsequent treatment was employed, the boy was able to get up and without stiff a
and in a month's time move
about the ward
pain. He subsequently left the hospital hip-joint but otherwise apparently free
disease. There
with from
no question that spasm of the muscles this kind may be oveicome by extension effected through a weight and pulley ; perfect rest of the part is a means to the same end, but after treatment can
be
in cases of
of this description has had a fair trial, in conjunction with counter-irritation first by Linimentuin Iodi and it may be subsquently with actual cautery, and failed to relieve the symptoms, it seems desirable to divide the affected muscles in order to overcome their abnormal rigidity and its consequences. The histories of the above given illustrate the fact that treatment of this kind whatever its ultimate value may prove to be. is attended with less risk than some practitioners might should of suppose to be the case. Such an operation been made has never be effort undertaken until an course to overcome the symptoms by rest, counter-irritation and
patients
Ma-rch 1,
1880.]
Dr. McLEOD ON FRACTURE OF ULNA AND DISLOCATION OF RADIUS. 61
pressure exercised over the
joint. The distended synovial membrane may also be tapped more than once by an aspirator. I would only remark, however, that treatment of this kind should not be persisted in, if after a reasonable
period
it fails to relieve the symptoms. It is then passage
better to open the synovial membrane through a made into the bone such as I have described,
dividing
muscles, rather than allow the to rest on until he patient passes into an almost incurable form of disease, the cartilages, ligaments and the head and neck of the femur ultimately being destroyed by the abnormal action commencing in serous inflamI am convinced mation of the synovial membrane. or serous in cases of muco-purulent synovitis of that, the hip joint, it is advantageous to draw off the fluid
also
some
of the
distending
the
rigid
synovial
membrane
by
means
of the
-aspirator. The operation may have to lie repeated three or four times, but it often happens that each time the fluid is evacuated it becomes less in quantity, and In chronic or long-standing cases I do not hesitate after drawing off the synovial fluid to inject the capsule with a solution of first, one part of Tincture of iodine to three of water,- and then with the undiluted Tincture, allowing it to remain in the joint. Pressure subsequently applied by means of cotton wool and an India-rubber bandage, with rest ensured
by
a
long splint
are
most
important adjuncts
in
our
treatment.
be
And, lastly, counter-iritation in systematically and persistently
one or
used.
any form must
1, 1880.]
LECTURE ON DISEASES OF THE HIP-JOINT.?BY C. MACNAMARA.
ORIGINAL COMMUNICATIONS.
\
the affected liinb by on the sound
firmly LECTURE ON DISEASES OF THE HIPJOINT. By C.
Surgeon
Macnamara,
to the Westminster
London
Hospital
and the
Royal
Ophthalmic Hospital.
Morbus-Coxarius.
Excluding cases originating in disease external to the joint, morbus-coxarius may commence either in the synovial membrane, medulla of the bone, or, before puberty, in the soft structures between the epiphyses and the diaphyses, as well as in the acetabulum ; it is, however, almost impossible for abnormal action to be confined for any length of time either to the bone or any other structure entering into the formation of the joint, because prolonged irregular action in any one part of the articulation is almost certain to implicate contigu-
This being the case, it will save reiteration this lecture with an account of the symptoms characteristic of morbus-coxarius, irrespective of its origin. My remarks apply to the diagnosis of liip-
ous
tissues.
if I
commence
disease in its earlier, rather than its more advanced stages, when there can seldom be much difficulty in determining its nature. I may here observe that hip-disease is an affection of
joint
child-life?about two-thirds of the cases being under ten years of age, four-fifths of the whole number not having reached the adult period of life. A patient affected with morbus-coxarius (whatever may have been its origin) suffers from a certain amount of stiffness in the affected joint. This stiffness of the joint may depend upon one of two causes, or perhaps more often upon a combination of these causes. First) from irritation going on in some part of the joint reflex action is propagated through the spinal cord to the muscles surrounding the joint, and from the spasm thus produced the head of the femur becomes firmly locked in the acetabulum. Secondly, if the synovial membrane of the joint becomes inflamed and distended with fluid, the ilio femoral and pectineo-femoral ligaments, together with the tendons of the psoas, iliacus, and other muscles the articulation, press upon the inflamed membrane when the patient extends his femur on the pelvis. To relax these ligaments and muscles the patient involuntarily keeps his thigh fixed and flexed on the pelvis. The same position is assumed if the acetabulum or the head of the femur is rendered painful on pressure in consequence of the existence of inflammation within the cancellated structure of the bone. In order that we may determine if slight stiffness of the hip-joint exists, the patient should be very carefully examined. His clothes having been romoved, observe in the first place if he has lateral or angular curvature of the spine ; notice if there is any tenderness on pressure over the vertebras or stiffness when he bends his back as in picking up a small object from the floor. As the patient stands naked, notice if he endeavours to save
surrounding
57
slightly flexing it and resting more one. During these observations do
your best to gain the child's confidence. The patient must then be laid flat on his back upon a hard smooth surface, such as a floor or table : place the first finger of one hand 011 the anterior superior spinous process of his ilium on the affected side, and gently flex and extend
corresponding thigh ; while doing so watch if the his femur, which will bo patient's pelvis moves with the case if the head of his thigh bone is locked in tho acetabulum. Compare the movements of the diseased
the
with the sound limb?you can flex and extend the latter freely without moving the pelvis. When manipulating the diseased limb it not unfrequently happens that no movement of the spinous process of the ilium with tho femur is noticed until the thigh is either fully flexed or extended. It is quite possible, however, that the move-
thigh on the pelvis may be limited in tho I have described in consequence of a psoas or iliac abcess ; in all doubtful cases not only ascertain if the movements of the joint are perfect in complete flexion and extension, but also if the head of the femur rotates freely in the acetabulum when the thigh is semiflexed on the body, in which position neither psoas nor iliac abcess would influence the action of the muscles. The diseased limb being semi flexed, grasp the patient's thigh with one hand and rotate the head of the femur in the acetabulum. If its motion is perfectly free under ments of the manner
these circumstances it is hardly possible that disease of the hip-joint exists. In almost all cases of morbus-coxarius?for reasons above referred to?the diseased limb is more or less flexed 011 the body, the head of the bone in this position being fixed against the pelvis. In order to ascertain if this state of things exists as the patient lies on the table, observe if the spines of his lumbar vertebra) rest iu contact with the flat surface on which he reclines. If there is disease of the hip joint, the corresponding thigh will be more or less flexed on the body, (unless in very
exceptional cases)
; should the
patient's
lumbar spine be
arched forwards, flex the diseased limb still
more
until the
of his vertebras rest in contact with the table, leave the diseased thigh flexed to this extent, and fully extend the sound limb ; the lumbar spines will not move forward during this manipulation, so long as tho diseased limb remains flexed on the body ; now place the fingers of one hand between the patient's lumbar spine and tho table he reclines, and extend the diseased limb on which and slowly; if the femur is locked in the acetabugently lum by muscular rigidity or from any other caiise, as the diseased limb is being extended the brim of the pelvis will be titled forward, and with it the movable lumbar
spines
This movement may be repeated, each time the limb is fully flexed on the body the patient's spine will rest upon your hand placed between it and tho surface upon which tho child reclines ; as tho limb is again extended thG patient's vertebra) are felt to movo slowly forward into an arched position.
vertebra)
In the the
cases
of morbus-coxarius, therefore, not only will its movements but also in by far the femur will be flexed 011 the
hip-joint be stiff in majority of cases
58
THE INDIAN MEDICAL GAZETTE.
pelvis, and in this position locked in the acetabulum, under which circumstances, if the diseased limb is extended, the pelvis is titled forwards, and the lumbar spine becomes arched. But in the earlier stages of the disease, patient is placed completely under the influence of anaesthetics, the head of the femur will move with perfect freedom in the acetabulum. Subsequently false anchylosis may occur as a result of the disease, and then the movements of the joint are impaired, although the if the
influence of chloroform. may be fully under the Patients suffering from morbus-coxarius, when lying flat on their back, frequently appear to have marked lengthening of the affected limb. This condition is due to contortion of the pelvis, and not to the diseased limb being really longer than the sound one. In a case of this kind if you draw a line through the two anterior superior spinous processesof the ilium you will find that the pelvis on the diseased side is lower than on the sound side. The explanation of this state of things is as follows :?
patient
Supposing a patient suffering from morbus-coxarius has his thigh flexed and abducted, in walking he cannot bring his foot to the ground ; in order therefore to get the limb parallel with the other leg he raises the pelvis on the sound side so as to tilt it over towards the diseased side, the loss of movement in the affected hip being transferred to the flexible lumbar spine, which in a case of this kind becomes curved towards the diseased side. As the patient therefore lies on his back, the abnormal condition of the brim of his pelvis produces an apparent lengthening of the diseased limb. Shortening of the limb in morbus-coxarius may in the advanced stages of the disease be due to absorption of the head of the bone, in rare cases to dislocation of the head on the dorsum of the ilium, or to separation of head?the result of like the lengthening but shortening ephysitis ; apparent of the limb may be caused by muscular action. If from rigidity of the muscles, the thigh, instead of being abducted, is fixed in the acetabulum and adducted, the
the neck
patient
of the femur
in
diseased
endeavouring
from
the
to walk is unable to
bring the
limb into the middle line ; and to overcome this he raises the pelvis on the affected side, pro-
difficulty ducing curvature
of the lumbar vertebra) towards the sound side. The brim of the pelvis, being tilted downwards towards the sound side, produces an apparent shortening of the diseased limb. As I have already remarked, some of the earliest indications of hip-disease are connected with muscular spasm causing stiffness of the joint and mal-position of the limb which disappear under the influence of anaesthetics, and may in like manner pass away under appropriate
treatment, leaving the movements of the joint perfectly free. In the earlier stages of morbus-coxarius when the patient is laid flat on his back, and his thigh is extended, the adductors, particularly the longus femoris, form a well marked rigid band extending from the pelvis to the femur ; these muscles, as well as the synovial membrane of the joint and the head of the bone,
receive branches from the obturator nerve. The abnormal neive action in these cases is not confined to the
[March
I 1880-
excitation of spasm, but the affected muscles also waste away in hip joint disease ; nevertheless, tiie obliquity of the fold of the buttock noticed on the diseased side is
by no means constantly due to wasting of the muscles in region, but rather to the position in which the patient stands. If you examine the buttock of a healthy person when in the erect posture, the transverse character of the gluteal fold will be noticed. If you now ask him to bear the weight of his body on one limb and slightly flex the other limb, the transverse character of the fold of the buttock will at once disappear, and it will become oblique as in the early stages of hip-disease.
this
The pain especially at the commencement of morbuscoxarius is often described by the patient as being most severely felt in or above the knee, and along the inner part of the thigh?so much so that if you attempt to press on these parts, or to move the knee joint, the
pain, but perhaps he will allow you superficial examination of the hip without complaining. This condition of things is due to the distribution of the obturator nerve to the skin covering the inner and lower portion of the thigh. But, as the hipjoint receives nerves from the obturator, and also from patient
cries out with
to make a
the anterior crural and offsets from the sacral
plexus,
the
region in which pain is complained of in morbus-coxarius, often very ill-defined : as a rule it is most severe at for as the patient falls asleep the reflex irritation of the muscles?which he could partially control when
is
night,
awake?gains the ascendancy and the limb starts involuntarily and gives excessive pain. Pressure over the joint or the femur, so as to jam the head of the bone against the acetabulum, almost invariably produces great pain in the hip-joint. I have before remarked that lameness in the earlier stages of morbus-coxarius may amount to simply weakness or giving way of the leg as the patient walks. As the disease advances the lameness becomes a more marked feature of the complaint, but. it is almost unnecessary to observe that this symptom, unless combined with stiffness in the joint, can in no case be relied upon as characteristic of hip disease. The truth is, during the earlier stages of morbus-coxarius there is sometimes considerable difficulty in forming
opinion regarding the complaint ; you may meet with instances in which a patient is lame with paiit about the hip joint, the limb being slightly flexed anil the muscles surrounding the hip somewhat rigid. There
an
evidence of disease of the spine, presthe vertebrfe causes the patient no pain, and yet the case may be one of disease of the spine and not of the liip-joint In doubtful cases of this descrip-
is
no
sure
marked
over
tion it is only by carefully watching a child when the floor that you he is trying to pick up something from notice his inability to accomplish such a movement with ease in consequence of a certain amount of stiffness of the vertebral column. In such a case any doubt as to the existence of hip-disease is set at rest if, when the child's thigh is in a semi-flexed position and he is lying flat on his back, the head of the femur rotates naturally in the acetabulum.
It is however quite possible that morbus-coxarius and disease of the spine may co-exist ;
March 1, 1880
LECTURE OS DISEASES OF THE HIP-JOINT.?BY C. MACNAMARA.
]
infantile paralysis lias been mistaken for hip-disease. The former affection however generally comes on suddenly, commencing with fever. After a few days, if the child attempts to rise or even move in bed, marked loss of power in the affected limb, especially in the extensors of the leg, is noticed, the position of the foot is gene-
rally that of equino-varus; in some cases the little patient in the commencement of the attack suffers excessive pain, and cries out the moment the foot, leg or thigh is touched ; in the absence of pain the paralysed limb can be moved in any direction on the pelvis without indications of stiffness of the hip joint. Synovitis
of the
Hip-joint.
Synovitis of the hip-joint is nt un frequently an acute affection, and, if it continues for some time, generally leads to disease of the cartilages and bones entering into the formation of this articulation as well as to abnor-
mal
changes
in the soft structures
surrounding
the
joint.
Among the most common causes of synovitis in the hipjoint I may mention injuries, exposure to cold, and ; I think there can be no doubt' that considerable number of cases of hip-disease among the syyoung people originate in inflammation of novial membrane. The circumstances of synovitis in the early stages
septic poisoning a
of
liip-disease are illustrated by the following case, the details of which have been kept for me by my dresser,
Mr
Glassington.
T E., set. 11, was admitted into the hospital on the 12th of February ; his family history is free from The evidence of constitutional disease. patient's general health h >s been good up to the present time; he has never suffered from rheumatic fever: his mother says, before injured his right
and
accident,
the
boy
was
coming into hospital her hip ; within a few days
son
fell
of the
unable to walk without consider-
able pain in the joint. into hospital, T. E could not put right foot to the ground, the limb being flexed and extremely painful. During the early hours of the night the patient was kept awake by the involuntary starting On admission
his
of his leg. which caused him excessive pain. When supported and standing on his left leg the right thigh is flexed, the toes touching the ground ; any pressure applied to the trochanter or over the region of the hip-joint causes the boy to cry out with pain ; when laid perfectly his back, if an attempt is made to extend the right thigh, the lumbar spine is immediately arched forward. The natural furrow in the spine below the crural arch is obliterated, there being evidently considerable distension of the synovial membrane of the right flat
on
hip-joint. The thermometer
applied
persistent
to the skin over the rise of
inflamed
temperature from 1 to 1? degrees as compared with the corresponding spot on the other side of the body. The limb was fixed to a splint and the Extract of Belladonna smeared over the groin. After a few days, when the patient could bear pressure, it was employed and india-rubber bandage over the by means of a pad joint indicated
a
5j)
joint ; Iodine paint being freely applied over the skin night and morning. The pain gradually subsided and the patient left the hospital in a month's time perfectly cured. This is
a typical example of serous synovitis of the hipmarked by a sudden invasion of the disease, after joint ; an accident, the local temperature and the evident distension of the synovial membrane with fluid, the pain increased by the slightest pressure made over the
joint or in moving the limb, the flexed position of the thigh, and stiffness of the hip-joint, together with the swelling in the region of the articulation commencing so soon after an injury, were all symptoms pointing to inflammation of the hip. Acute serous s}Tnovitis, excluding cases of rheumatism, as I have before remarked, most commonly results from an accident; it is characterized by severe pain in the hipjoint increased by any movement of the limb or the slightest pressure applied over the articulation, the natural fold beneath the crural arch is
obliterated in consequence
of
the distension of the
synovial membrane ; there is stiffness in the movements of the joint, the femur being locked in the acetabulum, and the thigh more or less flexed on the body. This position is not only due to the involuntary effort which the patient makes to relax structures pressing upon the inflamed synovial membrane, but whenever this membrane is distended with fluid the limb invariably becomes flexed on the trunk. The temperature of the skin over the inflamed hip-joint in serous
synovitis, is seldom more than a degree or two higher than that of the corresponding healthy limb. I believe that disease of the hip commencing after the adult period of life is, in the majority of cases, due to synovitis, or else to granular degeneration of the synovial membrane. Cases of arthritis-deformans are 110 exception to this rule among children ; also, synovitis in acute rheumatism is occasionally followed by suppurative changes in one or more of the joints affected ; I have seen several cases in which after an attack of rheumatic fever the hip-joint has remained di-tended with fluid, the patient's general and the local temperature continuing high the symptoms pointing to purulent synovitis of joint. Under these circumstances I have 011 three
the
in adult patients, passed an aspirator into the and drawn off several ounces of purulent matter, at the same time washing out the cavity of the abscess or joint with a solution of chloride of zinc, four grains to the ounce. In one of these cases the operation had not to be repeated, no further collection of pus occurring ;
occasions,
joint
in another case the aspirator had to be used a second in one instance three times, but in all three
time, and
the patients recovered with stillness but 110 anchylosis of the hip-joint. This stiffness was due to the formation of adhesions in and around the joint, and under anassthetics I was subsequently able to break through thes->. adhesions, after which the patient regained full use of the hip-joint. Among children synovitis is no uncommon cause of morbus-coxarius, and the majority of these cases if properly treated from an early stage of the disease, may be cured; doubtless they form a large per-centage of cases
60
THE INDIAN MEDTCAL GAZETTE.
instances of
hip-joint disease which do recover. The reported for me by Mr. Gubbins, is an illustration of synovitis advancing to active changes in the hip, which, unless successfully treated, would very probably have terminated in osteomyelitis a d
following
case,
necrosis of the head of the femur. F. II., aged 13 : this as
girl's family history is
far
a
good
one
her health is concerned ; she has never had rheumatism or any other illness prior to the affection of the hip from which she now suffers. The disease commenced last August, after a fall from a cart, when she injured her right leg ; from the time of the accident she had more or less pain in the right hip-joint, but was able to move about and attend to her work until the month of September, when symptoms of hip-disease became so strongly marked that she was sent into the as
hospital by Mr. F. Nicholls of Croydon. On admission, the patient's right thigh was flexed, so that she could only touch the ground with her toes ; the
slightest movement of the limb caused her intense pain in the hip-joint; she was kept awake at night by the involuntary starting of the limb. The head of the right femur was fixed in the acetabulum, and the synovial membrane was evidently much distended The temperature
of the skin over the joint varied from 1-5? to 2? over that of the corresponding point on the other side of the body The patient was at ease so long as the right leg was kept extended and abducted. The fluid contained in the joint was on two occasions drawn off by means of
the aspirator. Extension was maintained for two months, and a succession of blisters and subsequently the actual cautery were applied with no abatement of the symptoms ; the patient's health began to give way and her temperature to rise during the evening to 100 degrees, the local temperature over the diseased joint was now
degrees above that of the sound of February F. H. bein>,' under the was influence of ether, her right thigh brought the other and the with tensor leg sartorius, parallel vagina) femoris and the adductor longus muscles which had been extremely rigid before anassalways
side.
2 and 3 On the 2nd
thetics were given, were divided subcutaneously. A valvular opening through the skin was made over trochanter major and a small-sized hand-drill the passed through the trochanter and neck of the bone into the synovial cavity of the hip-joint. A long outside splint was then applied to the limb and the patient put to bed. From the time of the operation F. H. was free from pain, and in ten days was up and moving about the wards with a stiff joint (for anchylosis had taken She soon after left the hospital, and has since
place).
no pain or any other symptom of hip-joint disease. In this case it would appear that synovitis, leading to
had
alterations in the structures in and around the joint, given rise to bands of adhesion about the articula tion, at the same time some acute inflammation of the synovial membrane existed when the patient first came under our treatment. In cases of this description relief is frequently afforded by breaking down the bands of
had
fibrous tissue which have grown round, and confine the action of the joint. It may however, as in the in
[March 1,
1880.
stance I have referred to, be necessary not only to overcome the symptoms producer! by the existence of bands
of adhesion about the articulation, but also to resort to measuns calculated to relieve the inflammatory action going on in the synovial sac.
Synovitis resulting
from
cold
sometimes
leads to
results very similar to those I have described as from an injury for instance. J.
ret.
H.,
winter
was
14
:
this boy
exposed
to
throughout
great privation.
arising
the whole of last He had never
suffered from acute rheumatism.
During the month of December after sleeping one cold night in a barn, he awoke in the morning complaining of great pain in the right hip-joint. He was admitted into a workhouse infirmary, and subsequently sent into our wards by Mr. Ivelsey of Red Hill. On admission, three weeks aftc the commencement of the disease, we found the right femur fixed in the acetabulum, the thigh being adducted and flexed,
intensely
the limb
was
two inches shorter tunn
the left one, the
pelvis being tilted upwards on the right side. The lumbar spine was arched forwards ; there was considerable swelling beneath Poupart's ligament from distension of the synovial membrane of the hip joint with fluid. The patient suffered from very great pain in the right knee and hip-joint, aggravated by the slightest He was relieved when the limb was fully movement.
and adducted ; but as treatment of this kind with counter-irritation had jeen employed before
extended
together
admission into hospital without benefit, and again for a month while in our wards without apparent relief to the symptoms, the patient wms placed under the influence of ether, and the fluid in the joint having been drawn off by the aspirator, the sartorius and two of tlie adductor muscles were divided subcutaneously ; and the integument over the trochanter having been incised, a hand-drill was
the trochanter and neck of the femur into outside splint was applied to the limb for Fi'om the time of the operation the pain in the and the knee almost entirely disappeared ; no
passed through joint. An
the a
week
hip-joint
subsequent treatment was employed, the boy was able to get up and without stiff a
and in a month's time move
about the ward
pain. He subsequently left the hospital hip-joint but otherwise apparently free
disease. There
with from
no question that spasm of the muscles this kind may be oveicome by extension effected through a weight and pulley ; perfect rest of the part is a means to the same end, but after treatment can
be
in cases of
of this description has had a fair trial, in conjunction with counter-irritation first by Linimentuin Iodi and it may be subsquently with actual cautery, and failed to relieve the symptoms, it seems desirable to divide the affected muscles in order to overcome their abnormal rigidity and its consequences. The histories of the above given illustrate the fact that treatment of this kind whatever its ultimate value may prove to be. is attended with less risk than some practitioners might should of suppose to be the case. Such an operation been made has never be effort undertaken until an course to overcome the symptoms by rest, counter-irritation and
patients
Ma-rch 1,
1880.]
Dr. McLEOD ON FRACTURE OF ULNA AND DISLOCATION OF RADIUS. 61
pressure exercised over the
joint. The distended synovial membrane may also be tapped more than once by an aspirator. I would only remark, however, that treatment of this kind should not be persisted in, if after a reasonable
period
it fails to relieve the symptoms. It is then passage
better to open the synovial membrane through a made into the bone such as I have described,
dividing
muscles, rather than allow the to rest on until he patient passes into an almost incurable form of disease, the cartilages, ligaments and the head and neck of the femur ultimately being destroyed by the abnormal action commencing in serous inflamI am convinced mation of the synovial membrane. or serous in cases of muco-purulent synovitis of that, the hip joint, it is advantageous to draw off the fluid
also
some
of the
distending
the
rigid
synovial
membrane
by
means
of the
-aspirator. The operation may have to lie repeated three or four times, but it often happens that each time the fluid is evacuated it becomes less in quantity, and In chronic or long-standing cases I do not hesitate after drawing off the synovial fluid to inject the capsule with a solution of first, one part of Tincture of iodine to three of water,- and then with the undiluted Tincture, allowing it to remain in the joint. Pressure subsequently applied by means of cotton wool and an India-rubber bandage, with rest ensured
by
a
long splint
are
most
important adjuncts
in
our
treatment.
be
And, lastly, counter-iritation in systematically and persistently
one or
used.
any form must
