ABNORMAL CONDITIONS OF TIIF. IlII'-JOINT. 



819 



foot upon a round stone, which rolled from 

 under liim, and lie came down with consider- 

 able violence on his left knee and side ; when 

 raised, he was incapable of walking, and was 

 immediately carried to hospital. The follow- 

 1 "'nint!, on examination, we made the fol- 

 lowing observations : while standing, the body 

 was bent forwards, inclining towards the left or 

 affected side ; the left knee and foot were 

 turned inwards ; the knee somewhat more ad- 

 \.iiiri-il and higher than the other, half Hexed, 

 and tlie toes were resting on the ball of the 

 great toe of the opposite foot ; posteriorly, the 

 iiiitis was prominent, and its lower fold was 

 obliterated ; the distance between the anterior 

 superior spinous process of the ilium and tro- 

 chanter major was less by one inch than be- 

 tween the same points on the unaffected side ; 

 the head of the bone could not be distinctly 

 felt ; the limb could be drawn inwards across 

 the opposite thigh, but any attempt to move it 

 in the contrary direction was productive of 

 considerable pain ; he complained of much 

 uneasiness in the groin (which was attributed 

 to the tense state of the muscles inserted into 

 the trochanter minor) ; the patient complained 

 greatly of numbness extending along the poste- 

 rior and outer part of the thigh and leg to the 

 foot. The bone was, in this case, easily re- 

 duced, not, however, without the assistance of 

 the pulleys. 



Tins dislocation is improperly denominated 

 by some, luxation downwards and backwards. 

 Some surgeons, on the other hand, describe 

 cases of this accident, and yet name them dis- 

 location upwards and backwards on the dor- 

 sum ilii. Of this class, is an interesting ex- 

 ample published by the late Dr. Scott, of the 

 Armagh Infirmary, in the third volume of the 

 Dublin Hospital Reports. The man, the sub- 

 ject of the accident, died thirty-six hours after 

 the injury. 



Dr. Scott says : " When the patient was 

 lifted out of bed and placed erect, the limb 

 retained the posture before described ; it was 

 nearly two inches shorter than the other ; the 

 knee rested above its fellow ; the toes were 

 turned inwards, and lay above the opposite 

 instep. On viewing the hip, the trochanter 

 was manifestly higher on the maimed side than 

 the other. The hollow naturally formed behind 

 that process had disappeared the buttock was 

 shorter and rounder, but flaccid ; the head of 

 the bone could not be felt through the glutrei 

 muscles. No effort of the patient could extend 

 the limb, but he had the power of bending it a 

 little towards the abdomen, by making the op- 

 posite leg a fulcrum for the inverted toes to 

 creep upwards upon. The dislocation was re- 

 duced, and he died in thirty-six hours after- 

 wards, in consequence of the injury some of 

 the organs in the abdomen received, at the same 

 time that the hip-joint was dislocated." It is 

 stated, that " on dissecting down to the hip-joint, 

 an extensive extravasation of blood presented 

 itself in the cutaneous cellular membrane, co- 

 vering the trochanter major, and also beneath 

 flip fascia lata of the thigh, extending several 



inches above and below the trochanter. The 

 ulut;i-iis magnus being raised from its origin, a 

 considerable extravasation was found in the 

 loose cellular tissue under the glutseus medius. 

 A cavity capable of containing a pullet's egg 

 H brought into view. This cavity was 

 situated directly where the great sciatic nerve 

 passes under the pyriform muscle ; it contained 

 fluid blood ; its boundaries were the pyriformis 

 above, the sciatic nerve before (supposing the 

 body u pright), the trochanter major, and insertion 

 of the glutxus medius external and posterior ; 

 the glutteus maximus directly posterior. Here 

 the displaced head of the femur had been 

 lodged. The fleshy substance of the gemelli 

 and quadratus muscles was found torn across. 

 The pyriformis and obturator internus were 

 perfect; the extravasated blood followed the 

 course of the sciatic nerve deep into the thigh ; 

 there was also extravasation between the 

 glutaeus medius and minimus muscles. The 

 internal and upper part of the capsular liga- 

 ment of the joint was ruptured ; the external 

 portion remained unbroken. On turning the 

 head of the bone out of its socket, the liga- 

 mentum teres was found to have been torn from 

 its insertion into the dimple of the head of the 

 thigh-bone ; the brim of the acetabulum, at its 

 upper part, was fractured to the extent of about 

 one inch ; the fractured portion lay loose and 

 nearly unconnected ; a fracture traversed the 

 acetabulum." In this case it is manifest, from 

 the dissection, that the head of the bone lay 

 beneath even the level of the lower edge of the 

 pyriform muscle, as Dr. Scott states that the 

 boundaries of the cavity (capable of containing 

 a pullet's egg, and filled with coagulated 

 blood,) which no doubt was the new situation 

 that the head of the dislocated femur for a time 

 rested in, that the boundaries of this cavity 

 were "the pyriformis above," &c. The dis- 

 section we consider a valuable one, adding 

 something to our knowledge of the anatomical 

 characters of the luxation into the ischiatic 

 notch ; differing, however, in some few particu- 

 lars, from that of Sir A. Cooper, Dr. Scott's, it 

 is to be recollected, was the dissection of a case 

 in which the bone had been only a few hours 

 misplaced. When we analyse the previous 

 symptoms of Dr. Scott's case, we do not, it 

 must be confessed, read the characteristic fea- 

 tures detailed of the dislocation backwards ; 

 still the pain the patient suffered along the 

 course of the sciatic nerve rather pointed the 

 attention to a dislocation on the sciatic notch, 

 than to the ordinary one of dislocation upwards 

 on the dorsum ilii, in which the nerve is 

 not, at least directly, interfered with; and the 

 observation added, that " the head of the bone 

 could not be felt through the glutaei muscles," 

 also would lead us to infer that among many 

 of the symptoms this patient laboured under, 

 some were such as would lead us to suspect 

 that the luxation was that backwards towards 

 the sciatic notch, a suspicion that, in the wri- 

 ter's mind, the dissection given by Dr. Scott 

 would fully justify. 



We suspect, also, that one of the cases 

 3 u 2 



