1863 The Lancet  
31 brought under the influence of chloroform. A flat and slightly curved trocar and canula is the best instrument for the pur. pose. It is to be inserted about three-quarters of an inch behind the upper end of the trochanter, and passed onwards and a little forwards. The hand holding the instrument will detect immediately when it has entered the cavity. It may then be pressed a little more home, and the trocar withdrawn. The thigh is next to be inverted and rotated inwards. Pressure with the
more » ... d may be made both on the groin and behind the trochanter, which m!mo3uvres will as far as possible procure the emptying of the capsule. While withdrawing the canula, the finger must be placed over its outer opening; the wound must be closed at once, and the limb placed in the splint. By this simple procedure we spare the patient a great deal of very severe and wearing pain, evading that period of intense suffering which precedes the shortening. We lessen the widely destructive effects of the inflammation, and we render the subsequent course of the disease more manageable. Moreover, if the fluid in the capsule be pus, we certainly do to a very considerable extent diminish the probability of subsequent abscesses, which are so generally produced in the neighbourhood of hip-joint disease. Indeed this method, combined with other and more essential treatment, will prevent such occurrence altogether. Very soon after distension of the capsule is relieved, whether by natural or artificial means, the thigh becomes shortened (unless mechanically prevented). The peculiarities of this posture to be observed in the living patient are these: Erect, he supports the weight of the body on the sound limb ; the diseased one rests on the ground only by the ball of the foot, which is generally inverted; the heel is raised; the knee is higher than the other ; the thigh is bent on the pelvis more or less according to the severity and age of the case; the pelvis is raised on the diseased side, and the haunch projecting (Fig. 7) ; the fold of the nates is higher on that side than on the other; the buttock drawn up and pointed backward ; the rima natiugn, traced from below upward, slopes away from the diseased side; the more or less defined and fluctuating swelling which continued through the second stage has now yielded to a more diffuse tumefaction ; and in cases left to themselves, after the establishment of , shortening, abscesses form in positions determined by the locality of rupture in the synovial mem-. brane, and the disposition of fasciain the neighbourhood. , I have already shown how adduction produces lengthening; it will be unnecessary to adduce opposite and similar reasons why i adduction should cause shorteni ing. Let me refer back to the above diagrams of the pelvis, but change in your mind's eye the position of the disease from the right to the left side, and observe that shortening corresponds with an acute angle between the femur and pelvis. It will also be as well for me to point out that when adduction is established the diseased thigh would cross the other, but for the changes in its posture and in that of the pelvis ; thus, while in abduction or lengthening, support for the weight of the limb is the chief cause of the pelvic distortions, the malposture is principally produced in adduction or shortening by the necesi sity of parallelism between the two thighs. But observe that I in both these conditions, the chief symptoms and appearance of the second and third stages of the disease, are produced by abnormal muscular contraction. Recollect the position of all the affected muscles-that their attachment to the femur is below in nearly all cases, as well as outside their origin from the pelvis, so that their power, besides producing adduction, must have the effect of pressing the head of the femur with considerable violence against the acetabulum. Gentlemen, this fact, one of the most important, though previous to my investigations unnoticed, in hip disease, is so essential to its successful comprehension and treatment, that I do not know how I can lay sufficient stress upon it, or impress it too deeply on your minds. It certainly cannot be done at the end of a lecture. In our next it will be proved to you that nearly all the ultimate I mischief and nearly all the pain is produced by this spasmodic contraction and hy this pressure, and it will be shown how such disastrous effects may be counteracted.
doi:10.1016/s0140-6736(02)62721-7 fatcat:e4zhg7thfveq7jf3of7cxto4ea