Report Ashhurst J. Tuberculosis of the hip joint (1898). The author discusses the function of the LCF as a supporting element of the body, its role in the development of deformity of the hip joint, reducing pressure and stress in the femoral head. The most notable quotes:
«Of course, the whole weight of the body is
not sustained by this ligament, but mostly by the head of the femur in more or
less close contact with the cotyloid cavity; but this ligament, I believe,
serves to diminish the pressure of the pelvis upon the head of the bone, and to
lessen strain. The position of the ligamentum teres is like that of the
old-fasioned leather springs which used to be found in stage- coaches, the body
of the coach being balanced upon two broad strong bands of leather. The pelvis
is to a certain extent similarly balanced upon these ligaments on either side,
which are attached to the heads of the thigh- bones, and then pass down to the
lower edges of the cotyloid cavities. I believe that their function is to ease
up, as it were, and prevent sudden concussions, which would otherwise be
experienced at every step that we take.»
«As a result of the
stress put on the ligament in the various movements of the part it becomes
weakened, and thus a place of less resistance; a deposit of tubercle follows ;
and the ligament, softened and partially disintegrated, ceases to protect the joint,
the other constituents of which then suffer from the effects of concussion and
other slight traumatisms, and in turn become tuberculous, this primary lesion
of the ligamentum teres thus furnishing a prolific cause of hip-disease.»
«Although it is a
commonly accepted idea that the ligamentum teres is an unimportant ligament of
the hip- joint, it seems more rational to believe that it is of considerable
importance, especially when we consider its topographic anatomy.»
«In this way, instead
of being an unimportant ligament, the ligamentum teres plays an active part in
the mechanism of the hip-joint, helping, as it were, to suspend the pelvis and
the organs contained within and above that bony arch on a framework of which
the shafts of the femurs act as the principal support. Examining into the
function of the ligamentum teres from this point of view, it would at once
appear that it assists in preventing concussion at the joint, and helps to
prevent the head of the bone being driven up into the acetabulum.»
Tuberculosis of the
hip joint
A Verbal Communication by JOHN ASHHURST, JR. , M.D., LL.D. , with Description of Specimens by JOSEPH P. TUNIS, M.D.
When your President
asked me to make a few remarks this evening on some subject in surgical
pathology, after consultation with Dr. Tunis, who kindly consented to assist
me, we thought it might be of interest to bring forward the subject of
tuberculosis of the hip-joint, although the society had had, not very long ago,
a meeting principally devoted to the general subject of tuberculosis of the
bones and articulations. In the remarks which I had the honor of making at that
meeting I dwelt more upon the general subject of osseous tuberculosis, and this
evening I propose to confine myself to the disease as affecting the hip-joint,
which has not always received the attention it deserves. In the first place, I
think we may classify cases of hip- disease into three varieties, the
rheumatic, the simple traumatic, and the tuberculous. The two first named are
sometimes spoken of as cases of arthritic coxalgia, which is not really a good
name to apply in this connection , because all forms of coxalgia which involve
the joint tissues as distinct from the bone may properly be called arthritic.
There is a not infrequent form of coxalgia, or hip- disease, which is really a
rheumatic synovitis. We have in these cases a history of the child being
exposed to cold or wet, sitting down on a cold stone or on the wet grass, for
example, and oftentimes symptoms of hip-disease will thereafter develop. These
patients improve under careful treatment, and the child is ultimately as well
as before. These might properly be called cases of rheumatic synovitis of the
hip-joint, and the patient may be expected to recover as he would from a
similar condition of any other part. Then there are cases in which,
occasionally, a mild form of synovitis of the hip-joint seems to follow
traumatism. These are not very common, because the hip- joint is so deeply
placed as to escape in most instances; but we see cases in which children have
met with doubtful injuries previous to the development of coxalgic symptoms.
For instance, the parent thinks that the child may have fallen from its coach,
or from a stool, to the ground, and while the history is very obscure, and
while there are no external marks of injury, the child shortly develops symptoms
pointing to hip-disease, which last for a variable period, eventually passing
off and the child getting well. It is possible that there may have been in such
cases a simple synovitis, the result of contusion of the hip-joint, just as we
may have a synovitis, the result of contusion of the knee. The large majority
of cases of hip- disease, however, have as their essential lesion the existence
of tuberculosis in some of the tissues about the joint, and superadded in many
cases to the previous existence of the tubercle-bacillus in some part of the
body is a slight traumatism, which seems to determine the locality in which the
disease shall be developed. Often the child may have had a number of slight falls,
perhaps falls on the ice, or even in the house, and a child that is naturally
awkward is, of course, more predisposed to fall than others. Again, boys, from
the rougher plays in which they engage, fall more than girls, and we find that
hip-disease is nearly twice as frequent in the male as in the female.
Hip-disease follows these falls, but the child previously has had tuberculosis
in some part of its body. Modern pathologists believe that the tubercle bacilli
are very widely distributed, and may be stored up, as it were, in some part of
the body, probably in the bronchial glands. As the result of traumatism, what
the Germans call a place of less resistance is developed, and then the
tuberculous action begins. Thus we have in the case of a tuberculous child the history
of a fall or a succession of slight falls, which establish a place of less
resistance in some of the tissues connected with the hip-joint. The tubercle
establishes itself at that point and goes on to the production of hip-disease.
The traumatisms concerned in the production of hip-disease are usually slight.
A person who has received a severe injury of the hip may have a fracture or a
dislocation, but is not apt to become the subject of hip- disease.
FIG. 1. Complete loss of the head of the bone down to the anatomic neck. There is apparently no disease of the neck of the bone itself, and therefore no alteration in the normal angle between the neck and the shaft of the bone.
It is from a succession of slight bruises rather than from any great violence that the condition is established which leads to this affection. The lesions of tuberculous hip disease may begin in any one of the constituent parts of the joint. I do not believe that any portion of the joint is exempt in this respect. Tuberculosis may exist first in the head of the bone, constituting a form of hip-disease of which we have specimens here. (Figs. 1 and 2).
FIG. 2. Complete loss of the head and extensive disease of the neck of the bone, associated with an alteration of the angle, reducing the latter to 110°. The dotted lines indicate the loss of substance, which has extended down below the surgical neck.
We have other cases
in which the disease shows itself first in the neck of the bone (Fig. 3), the
head being unaffected even at a very late period.
FIG. 3. Results of rarefying osteitis, probably tuberculous, affecting principally the neck of the bone. The head of the femur is shown to be for the most part free from disease, and only that portion in the neighborhood of the anatomic neck has been affected. Marked shortening has occurred in this case, and great loss of bone- tissue as the result of the continued suppuration. The head of the bone was found firmly fixed in the acetabulum, and was removed separately.
FIG. 4. Extensive disease of the neck of the bone from the anatomic neck to the surgical neck of the femur. The dotted lines represent diagrammatically the amount of tissue lost.
The destruction of the neck sometimes leads to separation of the head (Fig. 4), which remains as a sequestrum in the articular cavity. Then there are other cases, though not very common, in which the disease begins in the acetabulum. A frequent classification of cases of hip-disease is into the arthritic (those affecting only the soft tissues), the femoral, and the acetabular, and attempts have been made to differentiate between the latter by the position of the sinuses which form in the progress of the disease. In cases of femoral coxalgia the sinuses are on the outer portion of the limb, whereas in acetabular coxalgia they are on the inner side, while in cases in which the acetabulum has been perforated, they may open in the groin above Poupart's ligament. These diagnostic marks, however, are not very satisfactory, because in advanced cases we usually have both parts involved. While I would not deny that the acetabulum may be primarily the seat of disease, it is certainly much less often so than the head or neck of the femur, as is shown by the fact that in most cases the acetabulum is only slightly implicated even when the femoral disease is far advanced. We may also have hip- disease arising in the soft tissues of the joint, not merely in the mild forms of synovitis which get well under simple treatment, but we may have tubercle making its appearance first in some of the soft tissues, and especially, I believe, in the ligamentum teres. The points to which I wish particularly to invite the attention of the society to-night are the function of the ligamentum teres as explaining the circumstance under which it becomes involved in hip- disease-and it is my belief that hip-disease begins here oftener than is usually supposed -and the very marked changes observed in the head and neck of the femur, and the explanations which may reasonably be given as to their occurrence.
Taking up the bone-
changes first, we have in one case the head remaining and the neck partially
absorbed, or perhaps disappearing completely, while in other cases we have the
neck of the femur remaining, though the head of the bone may be reduced to a
mere osseous button. The changes in the head of the bone may be due to several causes.
Oftentimes tubercle is deposited in the first instance in the caput femoris,
and it is easy to understand that with the extension of the disease the bone
will become softened, and that portions may be thrown off into the joint as the
result of the carious process, the head thus becoming gradually disintegrated.
Then there is another cause to which attention has been called by Dr. Lovett,
of Boston, who believes that the reason that the head of the bone disappears in
some cases is its attrition against the acetabulum, gradually causing its
disintegration. Dr. Lovett advocates the treatment of hip- disease by powerful traction,
or what he calls distraction, and he gives one illustration showing the upper
end of the femur in a patient who had been thus treated, and a second representing
the specimen from a case of about equal severity, in which the patient had been
treated without traction. In the first instance the head of the bone was but
slightly worn away, while in the other case it had almost disappeared. I have
no doubt that Dr. Lovett is correct in his views upon this subject. Then there are
cases in which the articular cartilage being separated, the bone is exposed to
prolonged maceration in the purulent contents of the joint, and becomes
roughened and finally disappears, to a certain extent, as a consequence of this
maceration. We see the same thing in cases of empyema, where, the pus having
been discharged through an incision, the rib sometimes becomes carious or
necrosed by maceration, and partial disintegration follows. The same thing is
seen in the secondary disease of the vertebrae which sometimes follows upon
such an affection as perinephric abscess. The coexistence of vertebral caries
and a lumbar abscess does not necessarily prove that the abscess is of spinal origin.
We may have a perinephric abscess causing superficial caries of the vertebrae
by prolonged contact of the bone with the pus of the abscess cavity, and
similarly may have maceration of the head of the femur by pus in the hip-joint.
The disappearance of the caput femoris in hip-disease may therefore be due to a
combination of three causes: 1 , the presence of tubercle ; 2, the attrition of
the head of the bone against the acetabulum ; and, 3, the maceration of the
bone in the purulent contents of the joint.
As regards the
changes in the neck of the bone, we have a very interesting alteration in the
shape of the neck and in the angle which it makes with the femur. This is very
well shown in some of these specimens. The head of the bone in the normal
position (Fig. 5) occupies a position considerably above the level of the
trochanter, and the neck joins the shaft at an angle of about 140 degrees. This
varies in the individual at different periods of life, but in the normal bone
the neck always makes an obtuse angle with the shaft. Here is a specimen (Fig.
6) in which the disease appears to have affected principally the soft tissues,
and yet there is a change in the bone, the neck being shortened and the angle
of its attachment being reduced to about 130 degrees. In another specimen there
has been extensive disease of the bone itself, and the head has separated from
the neck, which occupies a position at right angles to the shaft. Here is
another specimen (Fig. 2, supra), showing a case in which, the head and neck of
the bone have almost entirely disappeared, but what is left of, the neck
occupies a position at right angles to the shaft. This change in the neck of
the bone is very striking, and is due to a form of osteitis which is often spoken
of as rarefying osteitis, but which is not necessarily a tuberculous lesion. It
is met with very often as the result of ordinary traumatism. It is a change,
too, that we are familiar with in old persons, and is usually spoken of as a
senile change. It has been believed that old age of itself leads to this change
in the angle of the bone, and its occurrence is given as one of the reasons why
old persons are more subject than younger ones to fracture of this part. But
Sir George Humphry, of Cambridge, England, whom I regard as one of the very
highest authorities on bone-pathology, has contravened this view, and has
established the fact that this change of angle is not properly a senile change,
but that it is a pressure-change.
FIG. 5. A perfectly healthy femur- head, removed post mortem from a child in whose case the opposite caput femoris had been removed by excision six years previously, with marked improvement resulting. The angle of the neck with the shaft is shown to be about 140°. The ligamentum teres is represented in its normal position.
FIG. 6. Marked shortening of the neck of the femur and decrease of the angle between the neck and the shaft. The angle is reduced in this specimen to 130°. The position of the ligamentum teres is well shown. The deformity has been the result of a rarefying osteitis of the neck of the femur. The head of the bone is not diseased.
He maintains that the change is gradually brought about in the course of a long life by the weight of the body being sustained upon the necks of the femurs, thus gradually pressing down the heads of the bones. It is therefore the result of pressure from walking through a long period of years, and is not the result of age. Sir George Humphry has demonstrated this by comparative observations in persons who had been subjected in early life to amputation of one of the lower limbs. In cases, for example, in which there had been an amputation of the right leg, so that it was necessarily relieved from the pressure caused by walking during the rest of the patient's life, the weight of the body being borne upon the left leg, he found that in the limb which had thus been relieved from pressure, although the person may have lived to extreme old age, the neck of the femur retained its normal angle, whereas in the limb which had been exposed to pressure, not having been amputated, and therefore continuing to sustain the weight of the body, the so- called senile change was thoroughly established, and, in some instances, even more marked than usual. He has thus made it very clear that this change, which is ordinarily observed in advancing years, is not really dependent upon old age, but is simply a result of pressure. We may have a rarefying osteitis which, by softening the bone, hastens this change, and cases are on record in which this condition, ordinarily met with only in advancing years, has been produced in the course of a few months as the result of traumatism. There have been suits for malpractice under such circumstances, the accusation being made that the surgeon had not recognized a fracture of the neck of the bone, because when the patient was discharged from treatment the limb was found to be shortened. I believe it, however, to be a well- established fact that as the result of traumatism this condition of rarefying osteitis may occur, and the so- called senile change be brought about in a short time as the result of pressure upon the softened bone. The same thing takes place in these cases of hip-disease. The bone becomes softened from the presence of tubercle, and then the angle of the neck changes as the result of pressure through the child walking upon the limb. The change, therefore, results from pressure on the softened bone, and not necessarily from the presence of tubercle or of osteitis, which would not produce the effect if pressure could be avoided. Clinically, we find many cases in which this change has occurred. The neck of the bone, instead of occupying its normal position at an obtuse angle with the shaft, makes with the latter a right angle, or even an acute angle. This is the chief cause of the shortening in the advanced stages of hip-disease. It has been supposed that in these cases the head of the bone was dislocated, and in some cases dislocation actually occurs. I have found, in the operation of excision, the head of the bone resting on the ilium above the acetabulum. But in most cases where dislocation is supposed to have occurred there is really no displacement of the head, but the angle of the neck of the bone is changed so that the trochanter slips as it were beyond the head, which still remains in its socket. This may occur in connection with caries, or with that condition which Sir James Paget calls interstitial absorption, where suppuration may be entirely absent. This interstitial absorption is frequently met with in the vertebra, where it causes great deformity, and more rarely in the long bones. We have the same interstitial absorption occurring in hip-disease, and we see its effects in many cured cases, the patient getting well under careful treatment without any abscess forming, but with marked shortening due to the head and neck of the bone being partially absorbed, and to its angle being changed. In other cases, of course, abscesses form in connection with ordinary caries, which is very often tuberculous, though not necessarily. The head of the bone may then be separated, and may be found completely loose in the joint. Disease of the acetabulum is comparatively rare, and I do not know that I have ever in excising the hip-joint found the acetabulum extensively involved while the femur had escaped. It is, on the other hand, very common to find the femur extensively and the acetabulum only slightly diseased. It is usually involved to a slight extent, but only in advanced cases of hip-disease is it much affected. It is seldom involved to anything like the same degree that the femur is, and in the acetabulum, necrosis often takes the place of caries.
Disease of the hip may also begin in the soft tissues of the joint, particularly, as I have already said, in the ligamentum teres. Most surgeons are, I think, under the impression that this ligament has no function, and this view is encouraged by the opinion of many anatomists, who maintain that it is almost constantly in a state of relaxation. I cannot but believe, however, that the ligamentum teres really has an important function, and that it is in connection with this function that its liability to injury-and in consequence to become the seat of tubercle -occurs, just as we find, in other regions of the body, that parts which are functionally active are especially exposed to traumatism. The lower jaw, for example, is much more liable to fracture than the upper jaw, and the clavicle is much oftener injured than the scapula. Another common impression is that the ligamentum teres runs from about the center of the acetabulum directly across the joint to the head of the femur, but this is not correct. The drawings which Dr. Tunis has had placed on the blackboard, taken from Testut 1 (Figs. 9 and 10) , illustrate what is really the normal position of the ligamentum teres.
1 E. Testut, Traité d'Anatomie, tome i. , pp. 435, 436. Deuxième edition . Paris. 1893.
You will observe that it is a wide band attached to the lower edge of the acetabulum, divided below into two branches, and passing up in contact with the femur to which it is joined at a depression in the head of the bone. You will notice that when the patient is erect it is almost a vertical ligament. Now, I believe, and I think that this view is sustained by the evidence derived from a study of hip- disease, that, as long since pointed out by Turner and Savory 2, the ligamentum teres really has an important function, and may be properly described as a suspensory ligament of the trunk.
2 Journal of Anatomy and Physiology, vol. viii.
Of course, the whole weight of the body is not sustained by this ligament, but mostly by the head of the femur in more or less close contact with the cotyloid cavity; but this ligament, I believe, serves to diminish the pressure of the pelvis upon the head of the bone, and to lessen strain. The position of the ligamentum teres is like that of the old-fashioned leather springs which used to be found in stage- coaches, the body of the coach being balanced upon two broad strong bands of leather. The pelvis is to a certain extent similarly balanced upon these ligaments on either side, which are attached to the heads of the thigh- bones, and then pass down to the lower edges of the cotyloid cavities. I believe that their function is to ease up, as it were, and prevent sudden concussions, which would otherwise be experienced at every step that we take. If these ligaments were absent, the cases in which we have disease as the result of concussion or slight contusion of the hip-joint would be much more common than they are now. That the anatomic relations of the ligamentum teres are what I have described, is shown by these specimens, in which a portion of the ligament is still attached. (Figs. 5 and 6).
FIG. 7. Anterior aspect of the head of a femur in which the articular cartilage was principally involved. The neck of the bone has been shortened, and the angle of the neck with the shaft reduced to 128°. The peeling off of the articular cartilage of the head of the femur and the erosion of the cancellous bone are well shown.
FIG. 8. Posterior aspect of the same bone. Change of angle to 128°, shortening of the neck, and necrosis ofthe articular cartilage are well shown. There is also a pocket of diseased bone at the anatomic neck of the femur.
Here is one where the
neck of the bone is almost entirely gone, while the head is hardly involved at
all. The ligamentum teres is seen passing downward, hugging, as it were, the
head of the bone, until it reaches its point of attachment at the lower part of
the acetabulum. As a result of the stress put on the ligament in the various
movements of the part it becomes weakened, and thus a place of less resistance;
a deposit of tubercle follows; and the ligament, softened and partially
disintegrated, ceases to protect the joint, the other constituents of which
then suffer from the effects of concussion and other slight traumatisms, and in
turn become tuberculous, this primary lesion of the ligamentum teres thus
furnishing a prolific cause of hip-disease. The older writers maintained the
importance of the ligamentum teres in the development of hip-disease, and I
think with reason. I believe, then, that we may have tuberculosis affecting the
head and neck of the femur primarily and the acetabulum secondarily; or, more
rarely, the acetabulum primarily and the other parts secondarily. In other cases,
the disease affects first the soft tissues, and particularly the ligamentum
teres. In some cases, the neck of the bone is shortened and its angle changed,
or it may be so much disintegrated that the head becomes separated while itself
but little affected.
 |
| FIG. 9. Origin and termination of ligamentum teres. (POIRIER) |
In other cases, the head of the bone may have almost disappeared, and what is left of it may yet be attached to a nearly unchanged neck. In still other cases the disease, beginning in the ligamentum teres, the soft tissues of the joint may be extensively diseased and the caput femoris deprived of its articular cartilage, while in other respects the bone is but little affected. (Figs. 7 and 8.) Dr. Tunis has had drawings made from these specimens, illustrating the different points to which I have asked your attention, and these he will now present for your examination.
 |
| FIG. 10. Position of ligamentum teres in erect posture. |
Description of the Specimens.
Before taking up in detail the interesting series of specimens which have been selected from a large number of femoral heads removed by excision at different times at the Children's Hospital, it may be well to review, briefly, some of the more important points of the anatomy of the hip-joint. (See Figs. 9 and 10).
In addition to the muscles which surround and give support to the head of the femur at the point where it is received into the os innominatum, there are a number of ligaments peculiar to this joint--namely, the iliofemoral, the ligamentum teres, the cotyloid, and the transverse. The cotyloid ligament occupies the brim of the acetabulum and helps to deepen that cavity. A reference to the accompanying illustration (Fig. 10) will show the relative position of the component parts of this joint. We wish especially to call attention to the ligamentum teres.
In Morris's Anatomy 1 its origin and insertion are most carefully gone into, and six different plates used to illustrate the manner by which it may be put upon the stretch. " It is an intra- articular flat band which extends from the acetabular notch to the head of the femur, and is usually about an inch and a half long. It has two bony attachments, one on either side of the cotyloid notch immediately below the articular cartilage, while intermediate fibers spring from the under surface of the transverse ligament. The ischial portion is the stronger, and has several of its fibers arising outside of the cavity, below, and in connection with the transverse ligament, where it is also continuous with the capsule and periosteum of the ischium. At the femur it is fixed to the front part of the depression on the head, and also to the cartilage round the margins of the depression. "
1 Morris's Anatomy, p. 266, ed. 1893, P. Blakiston, Son & Co., Phila.
" The ligamentum teres 2 is of but very little use in resisting violence or giving strength to the joint. It assists in checking rotation outward and abduction during flexion. A ligament can only be of use when it is tight, and it was found by trephining the bottom of the acetabulum, removing the fat, and threading a piece of whip- cord round the ligament, that the ligament was slack in simple flexion, and very slack in complete extension, but that its most slack condition was in abduction. It is tightest in flexion combined with abduction and rotation outward, and almost as tight in flexion with outward rotation alone, and in flexion with abduction alone. "
2 Morris's Anatomy, p. 266, ed. 1893, P. Blakiston, Son & Co. , Phila. P. 270.
It is also of interest as bearing practically on the subject, that the angle which is made by a line drawn through the axis of the neck meeting a line drawn through the axis of the shaft of a bone ranges between 110° and 140° . It is a smaller angle in women and children, according to Quain's Anatomy.3
3 Quain's Anatomy, Part I., vol. ii. , 1890, p. 123. See also Humphry's Journal of Anatomy vol . xxiii., p. 273; and W. Braune's monograph in German.
Although it is a commonly accepted idea that the ligamentum teres is an unimportant ligament of the hip- joint, it seems more rational to believe that it is of considerable importance, especially when we consider its topographic anatomy. While it is usually believed that the ligamentum teres stretches from the cotyloid notch directly over to the head of the femur, such is not really the case ; but the ligament, on the contrary, passes from the depression in the head of the femur to the lower border of the cotyloid notch, as is well shown in Fig. 10. In this way, instead of being an unimportant ligament, the ligamentum teres plays an active part in the mechanism of the hip-joint, helping, as it were, to suspend the pelvis and the organs contained within and above that bony arch on a framework of which the shafts of the femurs act as the principal support. Examining into the function of the ligamentum teres from this point of view, it would at once appear that it assists in preventing concussion at the joint, and helps to prevent the head of the bone being driven up into the acetabulum.
In an exhaustive article in G. Schwalbe's Morphologische Arbeiten, Jena, 1893, Dr. E. Moser reviews the literature of the ligamentum teres briefly and thoroughly. In the bibliography fifty-eight references are given, and the article is illustrated with twenty-seven drawings, principally embryologic.
In the specimens about to be described, the position of the ligamentum teres is well shown in Figs. 5 and 6. These specimens illustrate especially the favorite seats of tuberculous disease, and, taken as they are from a large number of specimens, they may be regarded as fairly representative.
Gray 1 says: " The hip-joint is rarely the seat of acute synovitis from injury, on account of its deep position and its thick covering of soft parts. Acute inflammation may and does frequently occur as the result of constitutional conditions, such as rheumatism, pyemia, etc. … Disease of the hip-joint is much more frequently of a chronic character, and is usually of a tuberculous origin. It begins either in the bones or in the synovial membrane, more frequently in the former, and probably in most cases at the growing, highly vascular tissue in the neighborhood of the epiphyseal cartilage. In this respect it differs very materially from tuberculous arthritis of the knee, where the disease usually commences in the synovial membrane.
1 Gray's Anatomy, p. 369, ed. 1893, Lea Brothers & Co. , Philadelphia.
An examination of Figs. 1 , 2, 7, and 8 will show one of the most common seats of tuberculous disease of the hip- joint-namely, the head of the femur. This may or may not be associated with disease of the neck, as is shown in Fig. 1. Or, again, the disease may commence in the neck itself and not affect the head of the bone and the acetabulum, although the two conditions usually go hand in hand. This disease of the neck of the bone alone may go on to such an extent that a complete separation of the head from the shaft results. This is well shown in Figs. 3 and 4.
In excision of the head of the femur for this disease, an operation which is frequently practiced at the Children's Hospital, it sometimes happens that the head of the bone with its articular cartilage remains in the acetabulum, and requires the division of the ligamentum teres and some additional dissection before it can be removed.
Fig. 2 shows a case in which complete absorption and disappearance not only of the head but of the neck as well has resulted.
Shortening of the neck of the femur is a frequent result of tuberculous disease. This is well shown in Figs. 3, 6, and 7, as the result of osteitis and necrosis of the bone. It is an almost invariable accompaniment of hip-joint disease, and gives rise at certain stages to the condition of inequality in the length of the two limbs, associated, as it is, with tilting of the pelvis and outward rotation of the head of the bone.
A change of the angle which the shaft makes with the neck of the femur frequently results. This is well shown in Figs. 6 and 7, and is a result of the extension of the tuberculous process either up or down the shaft. Specimens 7 and 8 show how the normal angle of 140°, which the neck makes with the shaft in a healthy femur (see Fig. 5), may be changed to an angle of 128°, or even 110° (Fig. 2). This tuberculous. process is one of a rarefying osteitis, and is associated with the formation of pus and the discharge of bone-salts.
In this connection it
is interesting to record a typical case of cured coxalgia, which has been under
observation for the last nine months. The history of the case is as follows:
Edna K., aged nine years, with a negative family history, except that a maternal aunt died of consumption, had always enjoyed good health until the age of six years, when she had scarlatina and diphtheria at the same time. This was followed by whooping- cough, and the child was so desperately ill that her life was despaired of. In February, 1895 , her mother first noticed that she complained of pain in her left knee. It was variously accounted for by different physicians, to whom the child was taken, as growing- pains, rheumatism, and neuralgia. These pains continued, and in April she began to grow lame. She was then restless at night, and frequently cried out with pain in her sleep.
 |
| FIG. 11. A case of cured coxalgia with the diseased limb in a position of flexion nine months after treatment was begun. |
She was seen at the Children's Hospital Dispensary on April 8, 1895, and a diagnosis of incipient coxalgia made. She was advised complete rest in bed, with extension to the diseased leg, and she was accordingly admitted to the Methodist Episcopal Hospital on April 26th. There she remained in bed for four months, with sand- bags on either side of the left leg, and an extension of four pounds in weight. On her admission to the hospital, she was in very poor physical condition and extremely pallid. During the four months she remained in bed her color was much improved, and her strength considerably increased. At the end of four months a plaster- of- Paris dressing was applied in place of the extension and rest in bed, and she was allowed to get about with a high shoe on the sound leg and crutches.
CONDITION OF THE HIP. In April, 1895, it was impossible to make the slightest motion of the left hip without causing pain. Four months later there was slight pain on free motion, especially when the knee was flexed on the abdomen. In November, or eight months after treatment was begun, there was very slight fixation on extreme flexion, and no pain whatsoever. This is well shown in Fig. 11, in which the child may be seen standing on her right foot, with the left one elevated in such a way as to bring the knee on the affected side almost up to the abdominal wall. A fixation-splint is to be made for this child, and she will be allowed to go about on crutches until all inflammatory symptoms have disappeared, for six months, when the cautious use of her limb will be allowed. She is now in excellent general condition. She is apparently on the road to perfect recovery, and her case seems to be one of those encouraging ones in which a cure of coxalgia is possible. It is probable that in her case the disease was arrested promptly by the treatment instituted, and, as there was no grave constitutional taint, the routine treatment has been successful. Time alone will decide whether the disease has been successfully arrested. If so, it is probable that the disease was limited to the articular cartilage of the head of the bone, and the inflammatory process arrested before the development of any rarefying osteitis.
We are indebted to Mr. Clifford B. Parker, a second-year student in the Medical Department of the University of Pennsylvania, for the excellent drawings from which figures 1 to 10, inclusive, were taken.
CONCLUSIONS.
1. Tuberculous
disease of the hip- joint attacks either the head of the femur, the neck of
that bone, or the soft tissues in the neighborhood of the articular cartilage,
being especially liable to effect the ligamentum teres primarily. It rarely
appears first in the acetabulum.
2. Rarefying osteitis
of the neck of the femur soon leads to shortening of that portion of the bone.
3. Rarefying osteitis
of the neck of the femur allows a change of angle, from pressure, of from 10°
to 30° , or even more.
4. The head of the femur may escape disease, and become detached from the shaft if the disease at the neck fail to be arrested.
DISCUSSION
DR. G. G. DAVIS: The subject of tuberculosis of the joints is a very interesting one. I believe that the history will generally show that some injury has preceded the development of the disease. A postmortem injury cannot cause tuberculosis.
Tuberculosis is caused by tuberculosis. An injury may give rise to a simple inflammation, and this injury in an unhealthy person-a person with a tuberculous deposit-may give rise to tuberculosis. In that way I believe tuberculosis oftentimes begins in the joints. There is no doubt that in the knee-joint tuberculosis frequently affects the synovial membrane. The primary cause is in the membrane, and you may find the membrane enlarged and the bones practically intact. In the hip-joint there seems to be less opportunity for membranous disease, but the osseous disease is more marked, though why tuberculosis should begin in the bones primarily is extremely hard to see. One can see why the ligamentum teres, the capsular ligament, and all the soft structures entering into and surrounding the joint should be damaged by an injury to the joint, and why that injury should take on a tuberculous inflammation, yet very often, if not in the majority of cases, tuberculous disease begins in the bone and not in the membranes. It is not at all uncommon to find a tuberculous process oftener in the bone itself than in the superficial part of the joint, where an exfoliation goes on, and this, studded with tubercles, is deposited in the injured part on account of its acting as a locus minoris resistentiæ, but why it should be so I cannot see.
From the facts, and the relative importance of the soft parts in diseases of the hip and diseases of the knee, I should be inclined to consider the soft parts more liable in disease of the knee and the bone more in disease of the hip. The bone is more often the primary seat of lesion than the ligament. Dr. Ashhurst's remarks upon the function of the ligamentum teres are very interesting, but I certainly think it is an open question as regards the function of that ligament. It is considered by some to be a retrograde part, and to be like, the vermiform appendix, apparently in process of extinction, and it is perfectly possible that, as in the vermiform appendix, its function may be unknown at present. The resemblance to a coach-spring is certainly a very good one, and, from a mechanical point of view, it does seem to act in that way. When we find children with hip-disease flexing the thigh on the abdomen and abducting it, because abduction and flexion are the two deformities most common in hip- disease; when we find the victims of hip-disease assuming such an attitude, and that an attitude which tends to put the ligamentum teres on the stretch, it leads me to doubt as to whether it plays the important part which is sometimes attributed to it. It seems to me that, in such cases, the tendency of the child would be rather to relax the ligament and not to put it on the stretch.
DR. ASHHURST closed by saying: There is one point that I omitted to mention which was recalled to me by Dr. Tunis' reading the extract from Morris's Anatomy. Morris maintains his view of the ligament from the fact that he has found it relaxed in almost all cases by trephining the acetabulum. I do not think that we can always assert from our observations on the dead body that a similar condition is present in life. We know that for about 2000 years anatomists maintained that the arteries contained air. I do not wish here to go into a history of this fact. It was not until nearly 2000 years after the arteries had been described that the discovery was made that they contained blood. In those 2000 years the anatomists had only described the arteries from the dead subject. From the time of Harvey, the arteries have been described as containing blood instead of air.
In regard to Dr. Davis's opinion, while it is true that tuberculosis manifests itself primarily in the joints, still, at the same time, I believe it is not true that the tuberculosis, or the tubercle- bacillus, really extends to those joints first. I cannot imagine how the bacillus of tuberculosis can make its way into a healthy knee- joint or hip-joint from the external surface, and the only way in which I can account for the occurrence is from the fact, which I think is generally accepted by pathologists, that a very large number of persons-some say almost everyone have tubercle bacilli somewhere in their body, probably in their tissues, or gone to sleep, as it were, in the glands or in other parts, whence they are roused up. Traumatism usually occurs at the places of least resistance. Although the primary manifestations of tuberculosis are oftentimes in the joints, I do not believe that the bacillus makes its appearance in the joints in the first instance. It must enter through the lungs, or the alimentary canal, or an accidental wound, possibly. It must enter in some way before it can possibly get into the bone or joint. With regard to the effect of traumatism in causing the place of least resistance, and the fact that tuberculous deposits may occur in places not in contact with the soft tissues, I have under my observation at the present time a very interesting case of a man who is the picture of robust health (a surgeon) , and who has, at the same time, a very severe and serious tuberculous ulcer of the abdominal wall. While driving around seeing his patients an accident occurred by which he was thrown forward, striking his abdominal wall. A swelling appeared, which gradually yielded to treatment, and he got well. He had a second accident, and again received a bruise of the same part. After this a lump formed, which slowly softened and finally opened, and it became the seat of a large, tuberculous ulcer. He has had the ulcer scraped and cauterized, and after long and careful treatment his tuberculous ulcer is healing. I believe all tuberculous matter has been removed from it. I have no doubt at all that in this case there was a tuberculous deposit somewhere in his body, though it is barely possible that he may have gotten some on the abdominal wall at the time of the injury. The bacillus might have gotten in there, but it is just as likely he had it before. As the result of this bruise an inflammation followed, and there the bacilli took the opportunity to implant themselves.
In regard to what Dr.
Davis said as to the analogy of the appendix, I must confess to be so heterodox
as to believe that the vermiform appendix has a function. The late Dr. Harvey
taught that it had a function which seems reasonably likely to be the case. Dr.
Harvey believed that the function was to secrete a certain amount of mucus, which
mucus dropped upon the fecal mass and served the purpose of lubricating it very
much as an oil- can would lubricate any machinery to which it was applied. This
is a reasonable view, it seems to me. I always like to find a function for
organs if I can. In the case of the appendix, we cannot say absolutely that it
is entirely without function, and certainly the ligamentum teres I believe has
a function, which is explained in the way that I have described. Dr. Davis said
very truly that a child with hip-disease may flex the limb upon the abdomen
without causing great pain. These cases are those in which the ligamentum teres
is not involved. We have pointed out and shown by specimens that in some cases
there may be advanced hip-disease without involvement of the ligamentum teres.
A child with advanced hip-disease not involving the ligamentum teres no doubt
can flex the limb without suffering. That probably is the case in those
instances to which Dr. Davis refers. I still believe that the view which I have
advanced as to the function of the ligamentum teres is the best one, and is not
disproved by the clinical fact which Dr. Davis has told us.
November 14, 1895.
External
links
Ashhurst J. Jr. Tuberculosis of the hip joint. Transactions of the Pathological Society of Philadelphia. Philadelphia, 1898;18:2-21. [books.google]
Authors
& Affiliations
John Ashhurst, Jr. (1839-1900) a prominent Philadelphia surgeon who worked at the Hospital of the Protestant Episcopal Church, as well as the University of Pennsylvania Hospital. [findingaids.library.upenn.edu ; photo: ancestors.familysearch.org]
Keywords
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, role, function, pathogenesis, coxarthrosis, tuberculosis, pathology
NB! Fair practice / use: copied for the purposes of criticism, review, comment, research and private study in accordance with Copyright Laws of the US: 17 U.S.C. §107; Copyright Law of the EU: Dir. 2001/29/EC, art.5/3a,d; Copyright Law of the RU: ГК РФ ст.1274/1.1-2,7
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