784 



ABNORMAL CONDITIONS OF THE HIP-JOINT. 



and would of course consider all the pheno- 

 mena of the malformation we have dwelt on, 

 as the mere consequences of the paralytic con- 

 dition of the muscles. With such a doctrine 

 we are not at all disposed to agree; in no other 

 instances do we find paralysis produce similar 

 results; besides, the muscles of the hip-joints 

 in many of these cases seem in the exercise of 

 running and leaping endowed with very ener- 

 getic powers of action. It is perfectly clear 

 that to refer all in these cases to a paralysis of 

 the muscles is quite unsatisfactory, because the 

 abnormal conditions of the several structures 

 around the affected joints are in these cases so 

 varied and numerous that we feel that they 

 never can be rationally referred to this single 

 source. In some instances we find a very well 

 marked oval eminence on the side of the pelvis 

 for articulation with the malformed head of the 

 femur, while no trace of cotyloid cavity exists; 

 in some the defect is slight, in others the de- 

 formity is great; thus the ligamentum teres 

 may be a long and slender thread without vas- 

 cularity or strength in some cases, in others we 

 have seen it four inches long, and at the same 

 time of considerable breadth; while in others 

 again no trace of ligamentum teres or head of 

 the femur existed, the imperfect representation 

 of a head being retained by a lengthened cap- 

 sular ligament, supported by the smaller mus- 

 cles around the malformed articulation. 



These observations satisfy us that we cannot 

 refer to " paralysis of the muscles of the lower 

 extremity as a consequence of irritation from 

 teething arising during infancy," the pheno- 

 mena that this affection termed congenital mal- 

 formation of the hip-joint presents. 



We have no doubt seen some instances in 

 which a certain paralytic tendency and other 

 congenital defects seemed combined with the 

 malformation of the hip-joint ; but again we 

 have seen many others in which there was no 

 paralytic tendency, and in which no other de- 

 fect than a double congenital luxation of the 

 hip-joint existed ; and in Dupuytren's twenty- 

 six cases no mention is made of paralysis, nor 

 of atrophy of the cerebral convolutions. 



We confess we are glad to feel ourselves able 

 successfully to oppose the hopeless idea of pa- 

 ralysis of the muscles being in fault, because 

 we have reason to believe that mechanical treat- 

 ment of the malformed hip-joint has succeeded, 

 when early applied, in lessening the infirmity. 

 The idea of paralysis of the muscles being the 

 root of the evil, precludes all hope of mecha- 

 nical treatment being at all serviceable to these 

 unfortunate individuals. 



History of a case of congenital malformation 

 of the left hip-joint, with the anatomical exa- 

 mination of the articulation. A man named 

 John North, set. 31, of weak intellect, was 

 admitted under the care of Dr. Hutton, July 

 1835, into the Richmond Hospital; he was 

 afflicted with a most severe form of inflamma- 

 tion of the larynx, trachea, and lungs. I was 

 asked to visit him, and report my opinion as to 

 whether the operation of tracheotomy should 

 be performed, or whether such a measure would 

 be calculated to relieve the urgent symptoms of 



dyspnoea which seemed in this case to threaten 

 suffocation. While I was examining the pa- 

 tient he wished to get out of his bed, and then 

 I noticed that besides having an atrophied and 

 contracted state of the left forearm and wrist, 

 his left lower extremity was deformed, and 

 seemed much shorter than the opposite limb. 

 Upon even a very superficial view of this left 

 hip-joint and the position of the limb, all the 

 more obvious features of a dislocation up- 

 wards and backwards on the dorsum ilii, were 

 recognized. Upon inquiry it was ascertained, 

 as far as could be from such a patient and from 

 his ordinary attendants, that the hip-joint had 

 never suffered any accident, and that, although 

 he had issues inserted, he never had had any 

 acute disease or suffering in the deformed hip, 

 which deformity, with the contraction of the 

 upper extremity, was coeval with their earliest 

 recollections of him. 



I agreed with those in consultation on the 

 case that the state of the lungs would speedily 

 bring about the death of the patient, and that 

 no operation, such as tracheotomy or laryngo- 

 tomy, should be resorted to. I also expressed 

 my conviction that the left hip-joint presented 

 a very fine illustration of the abnormal state of 

 this articulation, which Dupuytren and others 

 had described as a congenital or original luxa- 

 tion of the hip. The next day the patient died 

 of the inflammatory affection of the chest, and 

 a post-mortem examination was made by Dr. 

 Hutton, at which Mr. Smith and the writer 

 were present. There were observed the same 

 appearances of luxation on the dorsum ilii 

 as before noticed ; the body being held up and 

 maintained in the erect posture, the pelvis was 

 seen to be very oblique and elevated towards 

 the malformed side, the left lower extremity 

 seemed three inches shorter than the right or 

 perfectly formed limb, but on measurement it 

 was plain that the deformed limb was not 

 really shortened, but had merely ascended on 

 the dorsum ilii. The trochanter major (natu- 

 rally on a level with the horizontal ramus of 

 the pubis) was elevated two inches above this 

 bone. In the prominence and elevation of the 

 great trochanter, in the semiflexion and adduc- 

 tion of the limb, in the circumstance of the 

 motions of rotation and abduction being li- 

 mited, in all these the case nearly resembled 

 the ordinary luxation on the dorsum ilii, whe- 

 ther produced by accident or the result of an 

 old caries; but the history of the case was op- 

 posed to either of these conjectures, and the 

 marks of issues placed there through ignorance 

 were not to mislead us, or induce us to alter 

 our opinion already expressed, as we were well 

 aware that in almost all the cases seen by Du- 

 puytren similar evidences of surgical ignorance 

 of the true nature of the affection had existed. 

 Besides the unusual prominence and elevation 

 of the trochanter major already mentioned, the 

 head of the femur could itself be plainly enough 

 felt, when a movement of rotation outwards was 

 given to the shaft of the bone; but when the 

 limb was forcibly elevated or extended, even 

 now in the dead subject, its range of move- 

 ment of ascent and descent was not more than 



