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This disease has been supposed to commence in the cartilages; it appears, however, to originate indiscriminately in the cartilage and the bone, as well as in the membrane lining the capsule and investing the cartilage and the ligaments; but whether it begins in one or other of these tissues, it soon, if neglected, involves them all. It affects patients of all ages, though children under twelve are most generally its victims; and in these it often makes considerable progress without its existence being suspected. The patient is observed to be a little lame, and to be awkward in the use of the affected limb, but he experiences little or no pain in the first instance; and if he does, it is of a dull kind, and generally referred to other parts. Thus, pain in the knee is generally the prominent symptom of this affection, and occasionally pain is also referred to the ankle, or to the sole of the foot: careful study and considerable experience are here required, to guard the young practitioner from error in diagnosis. Parts remote from the seat of morbid action have often been made the subject of treatment in this and other affections; the knee, in morbus coxarius, has been leeched, poulticed, blistered, and burnt, and that, too, when this joint was not at all altered in appearance, and showed no symptom of disease.

Again, and particularly in adults, the limb is easy only in certain positions, and cannot be moved without great suffering; pain is also complained of in the groin, and often immediately behind the trochanter major. If an examination is made when the patient is thus halting, and even though he complains of no pain, the limb is found shrunk, wasted, and lengthened. The elongation of the limb occurs mainly in consequence of the inclination of the pelvis towards that side. When the disease has made progress, it has been supposed that swelling of the apparatus of the joint, and effusion into its cavity, might separate the head of the bone from the acetabulum, when pressure from the trunk was not applied. The lengthening is often great, and its extent and cause are ascertained by accurate comparison of the two limbs, laid in contact when the patient is in the recumbent posture.

The degree of lengthening is here carefully represented from a recent case. But occasionally, even in the first stage, before destructive ulceration has set in, in consequence of the pain and spasms, the limb becomes remarkably shortened and retracted. This also will be found, on careful examination, to depend upon the relative positions of the two ossa innominata.

When the patient stands, the affected limb is considerably advanced before the other, on which the weight of the trunk is chiefly, or entirely, supported; the knee is generally bent, and the toes only rest on the ground. In the advanced stages of the disease, and when there is reason to suppose that ulceration of the cartilages has set in, the patient, during progression, moves the affected limb with the hands grasped round the thigh, and in bed it is moved by the aid of the sound one. The spine is frequently affected, becoming bent in different directions, to preserve the equilibrium of the body; and a deformity of the trunk to a certain degree occurs, which, however, may be in general easily remedied. The nates are much altered; they become flattened, and those parts which are naturally most prominent are reduced to the level of the others; the usual niche between the buttock and thigh, in the erect position, is effaced, and the upper part of the thigh is often considerably swollen. The alteration is at once manifest on contrasting the healthy with the diseased side. Even from the first, locomotion is difficult: in the morning, the movements of the joint are constrained and stiff; afterwards, however, the patient walks with more ease, though still by very slight exertion the limb is speedily tired, and he is unwilling to use it. Pain is produced by pressing on the groin, or by tapping on the trochanter, and by pushing the head of the femur forcibly against the acetabulum. The inguinal glands occasionally become enlarged. As the disease advances, the lameness is more apparent; pain is produced and increased by motion, and by any attempt to stretch, and more especially to abduct the limb whilst in the recumbent posture. The emaciation of the member becomes more and more visible. The muscles, as it were, are paralysed from inaction and pain, abscesses form, and the constitution then sympathises remarkably; hectic fever supervenes, with its usual train of symptoms.

The circumstances attending the first stage of the disease in childhood, in which the limb is lengthened, and there is no decrease, but rather an enlargement of the parts composing the joint, have been already described and illustrated. When, however, absorption occurs, and the articulation begins to be destroyed, the second stage of the disease commences, and the limb becomes then sensibly shortened; the toes are turned inwards or outwards; in many cases there is every appearance of dislocation of the thigh upward and backward; and in others the limb is much bent, the toes only reaching the ground. The ultimate position of the limb and degree of shortening will depend much upon the extent to which the head and neck of the femur is destroyed, upon the inclination of the pelvis, and also upon the portion of the acetabulum which is most diseased. The joint becomes tender, the slightest motion causing much pain, and the parts around appear swollen. The patient retains the limb in the most comfortable position, and it is generally bent upon the pelvis and inverted. This may arise from relief being afforded when the psoas is relaxed, and the pressure thus removed from the fore part of the joint. In many cases matter forms behind, or rather below, the trochanter major, and the collection often attains a large size. When the presence of matter has been ascertained in this situation, it has been recommended that an early opening should be made, on the supposition that the disease arises from an acrimonious discharge into and round the joint, and that, by the matter being allowed to escape, the cause of the disease may be removed. The synovia has been compared by one old author to bland oil, the vitiated secretion to oil of vitriol. Though the principle is incorrect, still the rule of practice is important; for in consequence of the long-continued presence of matter, accumulating in a cavity which is not dilatable in proportion to the increase of purulent secretion, the original affection will be much aggravated, and disease induced in the neighbouring parts. But the existence of matter in the joint could only be ascertained to exist in a very emaciated person.

The formation of matter is preceded by great pain, and frequent startings of the limb during sleep, accompanied with fever, and other symptoms of severe constitutional disturbance. On the escape of matter by the natural process from the capsule the painful feelings usually subside. The abscess may appear, as already stated, near the trochanter major, or in the back part of the thigh. Matter sometimes makes its way into the pelvis, through a perforation in the acetabulum, thence it may fall through the sacro-ischiatic notch into the thigh, and find its way under the fascia, nearly to the knee; or again, it may present to the side of the rectum, or even, as I have seen, burst into the bowel and continue to be discharged thus for a long period. If the treatment is neglected, abscess succeeds abscess; and in consequence of the profuse discharge, which may be evacuated from one or many openings round the joint, the patient is at length exhausted, and sinks. In some instances the spontaneous cure by anchylosis occurs, as in the instances from which these sketches are taken. In the one, the head and neck of the bone had been almost entirely destroyed by ulceration, before anchylosis had begun; in the other, the change is very slight, but the head of the femur and os innominatum are inseparably united by bone, and their cancellated texture runs into each other. Or when the femur has been dislocated, which is a very rare occurrence, the disease sometimes gradually abates, and a 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.