sort of new joint is formed; the limb, after some time, may thus again become so far useful to the patient.
In many cases, the appearance which the various parts of the diseased joint present, are similar to those which have been already described when treating of affections of the joints generally. Frequently, however, the osseous tissue in this situation is much more extensively affected. Often the whole cartilage on the head of the femur is
completely removed, exposing the bone in an ulcerated condition; and when the system has long borne up under the disease, the greater portion of the head, neck, and even of the trochanter, is destroyed, the extremity of the bone being completely altered in form, and composed of a loose and spongy structure. A similar disorganisation occurs in the acetabulum; the mucous gland is destroyed, the cartilage is often wholly removed, and the margins of the acetabulum absorbed, a large and flat ulcerated depression merely being left for the reception of the diseased femur; in other instances the margins remain unaffected, whilst the ulceration proceeds in the centre, and the cavity is thereby much deepened. Not unfrequently the ulceration proceeds farther, and an aperture is formed in the acetabulum, so that matter accumulates within the pelvis. The opening is sometimes so large that the femur is protruded through it. When matter has formed in the soft parts round the joint, portions of the bones of the pelvis, in contact with the pus, are ulcerated to a greater or less extent, and sometimes these ulcers are surrounded by deposits of new bony matter.
From such changes in the osseous parts of the articulation the limb is shortened, sometimes to a great degree, though no dislocation has occurred. Indeed, dislocation is by no means so frequent a cause of the shortening as is generally believed.
If the head of the femur has been dislocated, and if the disease in the joint has afterwards subsided, the acetabulum is found to be much contracted, with its margins smooth and little elevated, and, if the patient survive for a number of years, it will be almost wholly obliterated. But a portion of the dorsum of the ilium, upward and backward, which is the most frequent dislocation in this disease, is gradually absorbed, so as to form a sort of glenoid cavity for the
reception of the femur, the extremity of which becomes more solid in texture, and more smooth on its articular surface. The remaining neck of the bone is in the sketch here given turned forwards, and must have given rise to great eversion of the toes. I have seen one other specimen of this form of luxation. The limb is generally, however, inverted; and what remains of the head of the bone consequently points backwards. The consecutive luxation occasionally, also, though rarely, takes place upon the pubis. Whilst a depression is thus formed, new bone is sometimes deposited round its margins, whereby the cavity is increased in depth, so as to resemble somewhat the original acetabulum, the new deposit having become smooth and of a regular form.
ON CERTAIN ALTERATIONS OF FORM IN THE HEAD AND NECK OF THE THIGH BONE.
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When treating of atrophy of the articular cartilages, it was observed that, in the latter stages of the disease, the subjacent bone was liable to become denuded, and its articular extremity more or less deformed. Now one of the most interesting of these changes occurs in the head of the thigh bone, which becomes polished on its surface, flattened and expanded, with a corresponding alteration in the acetabulum. In other cases the head of the thigh bone is somewhat elongated, and the acetabulum becomes deepened in proportion, by a deposition of new bone around its margin, as shown in the preceding
page, frequently to such an extent as to render the removal of the head of the bone, even after the removal of all the soft parts by maceration, almost impossible without fracture of the edge of the socket. The head of the bone may also become still further misshapen, and anchylosis result; while in some instances the new bony matter presents in the form of nodosities, sometimes projecting towards the cavity of the articulation. This cut represents a section of the upper end of the femur of a labouring man, aged 49, who had fallen on the trochanter ten years before death, and became gradually lame in consequence, with shortening of the limb and anchylosis of the joint, although he had never been confined more than a day or two on account of the injury.
But there is another affection in which the femur may be shortened in a comparatively brief space of time from absorption of the intra-capsular portion of its neck, generally succeeding to a fall on the trochanter, and sometimes occurring in young and middle-aged subjects. In treating of fractures of the cervix femoris, it will be observed that retraction of the limb is occasionally delayed for a while: hence the importance of an accurate knowledge of those cases in which shortening of the neck of the thigh bone may succeed to an injury short of fracture. The deficiency of accurate anatomical details concerning such cases led to a doubt as to their existence; but this question has been completely put at rest since the history and dissection of two unequivocal examples by Mr. Gulliver; and the annexed cut represents the changes of form in the head of the bone, the shortening of the neck and comparative length of the femora, in a young man from whom these bones were obtained, and who walked about as many others have done, during the progress of the disease.
In the above, and in many other cases, the shortening of the neck of the bone is unaccompanied by any absorption of the articular cartilage of its head. A section of another well marked specimen may be here added. This bone also exhibits approximation of the head to the shaft, from absorption of the neck. The head is somewhat flattened and expanded, but the articular cartilage is entire, and of its natural thickness. The acetabalum was diminished in depth, but enlarged laterally, so as to correspond with the alteration of shape in the head of the thigh-bone. The preparation was obtained from a man at 32, who died at the General Hospital at Chatham of pulmonary consumption, after a confinement of two years in hospital. Previously to his admission, he had regularly performed his duty as a light infantry soldier, from which it is plain that his limbs were then of equal length, although, when the body was examined, the affected femur was upwards of one inch and a half shorter than the other. From a careful inquiry after his death, it appeared that he had, five years previously, fallen on the trochanter, in consequence of which he often complained of pain in the hip, but continued to do his duty long after, never having been confined on account of the accident. It therefore results, that morbid change had taken place during his long confinement in hospital, a circumstance not very favourable to the recommendation by some surgeons of the horizontal posture, as a remedy in such cases, and equally adverse to the opinion of certain continental pathologists, who inform us, that shortening of the neck of the femur is to be attributed to the gradual operation of the superincumbent weight of the body.
In old subjects, particularly in fat women, the neck of the femur is often shortened, and becomes more transverse and brittle than natural, from a true interstitial absorption or atrophy of the osseous tissue. This has sometimes been described as a natural effect of age, but it is undoubtedly disease, for in the greater number of old people the neck of the thigh-bone presents its usual length and obliquity. The affection is obviously a very serious one, as predisposing to fracture of the part, under circumstances which render its reunion almost hopeless.
Treatment of Affections of the Joints.—After the infliction of a wound, accidental or not, in order to prevent inflammation of a joint from becoming violent, it is of the utmost importance to bring the edges of the wound into close apposition. Sometimes neither local action, nor disturbance of the constitution, supervene on an opening, even of considerable size, being made into a joint, while the slightest puncture often gives rise to the most dreadful symptoms, both local and general. An incised wound, of no great extent, will be sufficiently closed by the careful application of adhesive plaster, and attention to the position of the limb; but if it is extensive stitches
