Case 8.-Dislocation of the hip-joint consequent on rheumatism.-Mary Elsely, aged 32, admitted into St. Bartholomew's Hospital, December, 1837, on account of general febrile disorder, combined with pain in the left shoulder joint, in the right hip joint and down the front of the thigh. She was in the fifth month of pregnancy; her occupation was that of a hawker of brushes, which exposed her to the vicissitudes of the weather. She stated that she had been in good health until within a fortnight of her admission, when she was attacked first with pain in the right elbow and left shoulder-joints, and afterwards in the back of the right thigh. The pain varying in severity, was occasionally acute; on some days it was confined to the thigh, and on others was excruciating through the whole limb from the hip to the toes. Throughout there had not been more constitutional disturbance than might be referred to the amount of pain she endured. Her disorder was treated as rheumatism. Her complaints slowly subsided, and more than ten weeks had elapsed before she was able to quit her bed. On doing so, she discovered a shortening and distortion of the right lower limb. There was a dislocation of the head of the femur on the dorsum of the ilium.

Case 4.-Dislocation of the hip joint consequent on pain in the thigh, treated as sciatica.-A woman, aged 30, was admitted into St. Bartholomew's Hospital in March, 1838. She had been servant in a gentleman's family at Hampstead, where her illness had commenced with a painful swelling of one of the joints of the right thumb. which, after a day or two, subsided, and was immediately succeeded by pain and stiffness in the right hip-joint, so far impeding its motions, that she was occasionally confined to her bed. She was seen at this period by several medical men, who considered the case to be sciatica, and treated it as such for between two and three months before her admission into the hospital. She now complained of pain in the right hip, but extending upwards to the loins, and down the thigh, with stiffness of the whole limb. The skin was tender on pressure through the course of the ischiatic nerve. Succussion of the whole limb by the application of force to the sole af the foot, and with the knee-joint extended, produced no pain in the hip-joint; and although the movements of the hip were impeded by the pain in the thigh and the general stiffness of the limb, yet she could bear the weight of her body upon it without much inconvenience. In the view still taken of the disease, as being sciatica, no other treatment was adopted than the administration of opium, with the application of mustard poultices to the limb. This treatment having been continued for some time without benet, she was removed to a surgical ward, when there was discovered to be a complete dislocation of the affected hip. This must have occurred in the hospital. There was no inflammation, but nervous excitement which gradually subsided. An attempt, of dubious utility, was made to extend the limb gradually by a pulley and weight.

Case 5.-Dislocation of the hip-joint consequent on rheumatism.-"I was consulted in June, 1836, respecting the propriety of attempting to reduce a dislocation of the hip-joint which had occurred under the following circumstances A youth, aged fourteen, suffered, at Gibraltar, an attack of inflammation in both

hip-joints, with severe constitutional derangement, which was reported to be of the nature of rheumatic fever. He was confined to his bed above twelve months. Then, on beginning to move about, it was discovered that the right hip-joint had become dislocated, but he was wholly unaware when the dislocation had occurred. At the time of my seeing this patient, four years had elapsed since the commencement of his illness. His general health is now perfectly good. There is not the slightest pain in the hip or elsewhere, but the limb is everted and shortened, as ascertained by exact measurement, to the extent of three inches and a half. The trochanter major is greatly more prominent than in the opposite limb, and the head of the femur is readily distinguished through the glutei muscles, having its proper relation to the trochanter consistent with the integrity of the neck of the bone, and with the everted position of the limb. Flexion and extension of the thigh are perfectly free. Rotation of the thigh inwards can be executed, but not outwards. The soft parts of the hip, and in its neighbourhood, are sound." 133.

Mr. Stanley did not attempt reduction.

CASE 6.-Dislocation of the hip-joint, which occurred in the sixth week from a fall.-A female, aged 14, in passing through a passage, the stones of which were slippery, fell upon the outer side of the right thigh. There immediately ensued a powerless condition of the limb, which was soon followed by severe pain and swelling in the front and outer part of the thigh, with spasms of the muscles. The surgeons summoned to the case could detect no deviation from the proper length and position of the limb, and accordingly expressed their opinion that the injury was confined to the muscles. At the expiration of a month there was no recovery of the power of using the limb, and the patient was in consequence removed to the sea side. Gentle efforts to walk were here made with the help of a stick, and at the same time the limb was every day placed in a vapour bath. At this period the patient occasionally remarked that she thought her hip was growing out; on one occasion, whilst using the vapour bath, she observed to her attendants that the projection of the hip had suddenly increased, and on examining the limb immediately afterwards, there was found to be a well-marked dislocation of the head of the femur. How this dislocation had occurred no opinion could be given; but the surgeon who had been in daily attendance was certain no dislocation had existed before the present time, which was in the sixth week from the occurrence of the fall. There was no tendency to inversion or eversion of the limb, and it could be moved freely in any direction, when the head of the bone might be felt rolling beneath the fingers placed upon the hip. The neck of the femur could be distinguished, and of its integrity there could be no doubt, from the movement of the head of the bone simultaneously with the trochanter, and from the preservation of the natural distance between the two prominences. Nothing but quietude was recommended. When about six months had elapsed from the occurrence of the accident, the patient, on rising from her bed, exclaimed that the projection of the hip had disappeared, and that her limbs were of the same length. A careful examination of the injured limb confirmed the statement of the return of the head of the bone to its socket, but it subsequently became again displaced; for at a later period, the head of the femur could be plainly felt on the dorsum of the ilium, and the limb was now shortened to the extent of three

inches, but still neither inverted nor everted. The power of using the limb was however progressively increasing.

CASE 7.-Injury to the hip-joint, attended with shortening of the limb, from a fall upon the knee.-A youth, aged 18, in walking, was thrown down by his foot striking against a pole which lay unperceived in his way. His face and left knee were the only parts bruised. But on being raised from the ground, he was unable to bear weight upon the left leg, and felt pain in the upper part of the thigh. He remained in bed until the pain in the thigh ceased, and then, on moving about, the limb was, as he stated, very feeble. Three months after the accident, the limb was in this state By comparison with the sound limb, there was found to be a diminution of the space between the anterior superior spine of the ilium and the top of the patella to the extent of two inches. There was no inversion or eversion of the foot. The head of the femur could not be anywhere distinctly recognized. The trochanter major was considerably more prominent than on the opposite side. All the movements of the thigh could be freely executed, and without pain. By moderate extension with the hands, the limb could be brought down to its natural position, when the unnatural prominence of the trochanter disappeared; but on remitting the extension, this prominence reappeared, and the limb became again shortened. No thickening or other morbid change could be discovered in the soft parts around the hip-joint. Mr. Stanley remarks on the preceding cases :

"In the first and second cases which have been related, the displacement of the head of the femur from the acetabulum occurred as a consequence of impaired nervous power, combined with spasms in the muscles of the limbs, in one case ascertained to be from disease of the spinal cord; and in the other, presumed, from the collateral symptoms, to be from the same cause. It may be affirmed that in the first, and very remarkable case, where both hip-joints were dislocated, there had been, at no period, inflammation in the joints or contiguous parts; and under such circumstances we must, I think, conclude that the pathological changes in these joints had been the elongation of their capsules and ligaments. In the second case, dissection showed such to be the condition of the joint, the capsule and ligamentum teres being lengthened to the extent of allowing the head of the femur to pass considerably beyond the acetabulum. We know that lengthening of the arm may be the consequence of paralysis of the deltoid and other muscles combining in their natural actions, to maintain the articular surfaces in contact It may be said that the looseness and thinness of the capsule of the shoulder-joint permit no comparison of it with the dense, thick, and closely-embracing capsule of the hip-joint. However this may be, we have before us the fact of the lengthening of this capsule, and with it of the ligamentum teres, of which no other account can be rendered than that it was a consequence of impaired nervous power in the muscles surrounding the articulation.

In the third, and in the fifth case, the dislocation of the hip must be viewed as the consequence of rheumatic inflammation in the fibrous and synovial tissues of the joint; and in the fourth case, the dislocation may be ascribed to the same cause, although the disease had been treated under the name of sciatica. It can scarcely be a question, that in each of these three cases, the pathological changes were elongation of the capsule, with either the elongation or actual destruction of the ligamentum teres. The sixth and seventh cases are examples of injuries to the hip-joint from external violence in young persons, followed by a gradual shortening of the limb, which, from the attendant circumstances, can be

explained only by the yielding and consequent lengthening of the ligamentous tissues of the joint. In the sixth case, the head of the femur was gradually, and at a distant period from the injury, displaced from the acetabulum. In the seventh case, a similar change in the relations of the articular surfaces was indicated by the shortening of the limb, although the head of the femur could no where be distinctly recognized. Other cases have been reported to me of dislocations of the hip-joint, occurring gradually, and without inflammation, after injuries from external violence. Whatever difficulty there may be in explaining such a form of dislocation, the knowledge of the simple fact of the possibility of its occurrence is of much importance to the establishment of a correct diagnosis of the various injuries occurring to the hip-joint." 140.

Mr. Stanley goes on to remark, that it is well ascertained that inflammation of a mild character, whether rheumatic or otherwise, may, without evident change in the organization of ligamentous tissue, so far affect its property of resistance, that it will yield considerably to an extending force; thus, in the knee-joint, the crucial and lateral ligaments may become lengthened to the extent of permitting such a displacement of the articular surfaces, that, from the view of the outside of the joint, it might be inferred actual destruction of the ligaments had taken place; and it is to be observed, that these changes in the ligaments of a joint, very slow in progress, may be unaccompanied by pain or other symptoms of inflam

mation.

In the hip-joint, again, from inflammation of a mild character, and probably commencing in its fibrous tissues, there may be effusion of fluid into the capsule with the yielding of it, and of the ligamentum teres producing, first, an increased length of the limb, and an increase of its circumference in the district of the joint; and subsequently, on the head of the bone reaching the brim of the acetabulum, a shortening of the limb, as the capsule gradually yields to the action of the powerful muscles constantly tending to draw the limb upwards and backwards.

Mr. Stanley mentions a remarkable instance of voluntary dislocations of the hip, in a person whose capsules were preternaturally elongated by exercise. A boy, aged 18, was sent to St. Bartholomew's Hospital, in whom the following particulars were observed. His muscular system was remarkably well developed. When standing erect, he could, by the action of the muscles, throw the head of either femur out of its socket to the back of the pelvis, where it was felt projecting as in the ordinary dislocation from external violence, and as readily, still standing erect, he could, by renewed muscular effort, throw the head of each bone back again into its socket. It was remarkable that with such a degree of motion in the hip-joints, neither the firmness of his erect position, nor his power of progression, was in any degree impaired. They learned that he had been. exhibiting feats at a country fair.

Mr. Stanley adverts to the supposition that in a proportion of the cases described, the primary injury was rupture of the ligamentum teres. This is rendered improbable by occasional absence as well as rupture of that ligament without injurious consequences.

Mr. Stanley adds, with a lengthening of the capsule of the hip-joint, it is unlikely that the head of the femur would be displaced in any other direction than upwards and backwards, with a corresponding shortening of the limb, the action of the more numerous and powerful muscles tending

to this result; and it may be presumed, that the precise situation of the head of the bone will then be between the gluteus minimus muscle and the dorsum of the ilium. An exception to this would occur in the yielding of the capsule consequent on a paralytic condition of the muscles, when an increased length of the limb may be its permanent character, as in the second case which has been related. With the lengthening of the capsule and the passage of the head of the femur upwards and backwards to the dorsum of the ilium, there may be inversion or eversion of the limb, or no inclination of it to one or other position. Whether these differences depend on the condition of the ligamentum teres, as this may be elongated or removed, future observation must determine. It will be remarked, that in the majority of the cases which have been related, the displacement of the head of the femur occurred so gradually, and with such a freedom from uneasiness in the part, that the patient was wholly unaware that changes so important were in progress; in fact, there was no suspicion of them before the discovery that the dislocation had actually taken place. The remarkable mobility of the limb in most of these cases is also to be noticed as another distinctive character of these displacements when contrasted with the ordinary dislocations of the hip-joint consequent on external violence, or on disease.

The preceding, like all Mr. Stanley's Papers, is indicative of his sound observation and sense.

X.-OBSERVATIONS ON THE ANATOMY OF THE LUNGS. By Thomas Addison, M. D.

Dr. Addison, than whom no man better merits attention, tells us that he hopes he has succeeded in demonstrating, almost beyond dispute-1st that the aerial cellular tissue of the lungs is made up of well-defined, rounded or oval lobules, united to each other by interlobular cellular membrane, each lobule constituting a sort of distinct lung in miniature, having its own separate artery and vein; 2ndly, that these lobules do not communicate directly with each other; 3rdly, that they do not, as Reissessen and others have supposed, consist of the globular extremities of as many bronchial tubes, but, on the contrary, as my friend Dr. Hodgkin has suggested, are made up of a collection of cells, in which, by a common opening, a minute filiform bronchial tube abruptly terminates; 4thly, that the pulmonary artery accompanies the bronchi branch, for branch, to the minutest divisions of the latter; 5thly, that pneumonia consists essentially in inflammation of the aeriel cells; 6thly, that pneumonia and inflammatory tubercle are identical; 7thly, that acute pneumonia in moderately good constitutions scarcely ever leads to the formation of an abscess, unless deposit previously existed; but that when it occurs in cachectic or broken-down constitutions, or supervenes in the process of chronic or organic diseases, it occasionally causes one or more distinct and separate lobules to soften down into an ill-conditioned abscess; Sthly, that ordinary tubercles present the same varieties in the lungs, as they do in serous membranes; 9thly, that emphysema of the lungs consists chiefly of mere dilatation of the cells, but in part also sometimes of more or less extensive