ABNORMAL CONDITIONS OF THE HIP-JOINT. 



791 



ment and fibrous capsule had yielded from 

 ulceration, and the muscles had dislocated the 

 head of the femur from the acetabulum on 

 the dorsum ilii ; but the shortening was not 

 sudden, as we have known it to have been in 

 such cases, but gradual, nor by a careful ex- 

 amination of the dorsum of the ilium, and 

 searching deeply behind the situation of the 

 great trochanter, could we feel the head of the 

 femur where it should be, were it really dis- 

 located from the cavity of the acetabulum, nor 

 by a forced rotation inwards of the whole limb 

 could the head of the bone be rendered mani- 

 fest. Our strongest reason, however, for con- 

 cluding that the head of the bone is not really 

 luxated on the dorsum ilii is, that although 

 the foot may habitually be directed a little in- 

 wards, still the foot is susceptible of rotation 

 outwards to a greater extent than is compatible 

 with any idea of the head and neck of the 

 femur being thrown, as in the ordinary luxation, 

 on the dorsum ilii. 



The following case of acute arthritis coxae 

 presents a remarkable example of this affection, 

 in which the course of the disease was rapid, its 

 symptoms obscure, and death occurred sud- 

 denly and unexpectedly. 



On the llth of January, 1829, I was 

 requested by my friend Mr. Speedy, then 

 one of my pupils at the Richmond School of 

 Medicine, to assist him at the post-mortem ex- 

 amination of a grenadier, who died with a 

 psoas abscess rather suddenly and unexpect- 

 edly. The man, aged 32, had been only one 

 month complaining of pains about his loins 

 and hip-joint, and was only a few days confined 

 to bed. The body was thin, though not ema- 

 ciated^ in the inguinal region a large fluctua- 

 ting swelling was perceived, which evidently 

 extended into the abdominal cavity, and had 

 assumed the situation and form of a psoas 

 abscess. \Vhile cutting into the cavity of the 

 abdomen, pus was noticed to issue from some 

 of the veins which were divided, and particu- 

 larly from the epigastric. When the abdomen 

 was opened, we observed that the sheath of the 

 psoas muscle was distended as high up as the 

 diaphragm, and on puncturing it a quantity of 

 purulent matter escaped. A second abscess 

 was discovered in the true pelvis, which ex- 

 tended from the back part of the thyroid fora- 

 men to the sacrum, lying outside the bladder 

 and rectum. We next laid fully open the 

 sheath of the psoas muscle, which we observed 

 had not been organized into the usual form of 

 a cyst, and search was made for some point of 

 diseased bone along the spinal column, but 

 none was found here; we then directed our 

 attention to the hip-joint ; we found the cap- 

 sular ligament perfect, except where it arises 

 from the transverse ligament of the notch 

 near the thyroid foramen. Here a large per- 

 foration existed in the capsular ligament, 

 through which the finger could be passed on 

 through the thyroid foramen into the interior of 

 the abscess in the true pelvis ; the sac of this 

 last abscess we traced as high as the bifurcation 

 of the aorta and junction of the common iliac 

 veins with the vena cava; here this latter vessel 



was found firmly adherent to the sac, and on 

 carefully removing both in connection, and 

 slitting up the vena cava posteriorly, we had a 

 view of a perforation in its anterior wall, close 

 to its junction with the iliacs; this perforation 

 was large enough to admit a goose-quill, and 

 established a free communication between the 

 vein and the cavity of the abscess, by which 

 blood and purulent matter had an easy passage 

 from one to the other. How long this commu- 

 nication had existed we could not ascertain ; 

 but thus was satisfactorily explained the extra- 

 ordinary phenomenon which had attracted our 

 attention in an earlier stage of the dissection, 

 viz. the issue of pus from some of the veins of 

 the abdominal parietes which were cut across. 

 On prosecuting the examination still further, 

 we found that close to the anterior inferior spine 

 of the ilium and iliopubal eminence, where the 

 united tendons of the psoas and iliacus mus- 

 cles pass over this part of the horizontal ramus 

 of the os innominatum, a vertical perforation of 

 the brim of the acetabulum existed, half an 

 inch deep, of a funnel shape, with its largest 

 part towards the acetabulum, and capable of 

 allowing at its smallest part a large sized bougie 



Fig. 310. 



to pass ; through this the matter had passed up 

 and elevated the psoas muscle or distended its 

 sheath, which thus presented the ordinary cha- 

 racters of a psoas abscess, but which we learned 

 had appeared suddenly and without having 

 been preceded by the usual premonitory signs. 

 There was no trace of cartilage, Haversian 

 gland, or synovial membrane on the acetabu- 

 lum; the round ligament was gone, and the 

 cartilaginous covering of the head of the femur 

 had been removed, as well as the synovial 

 membrane of the neck of this bone. The ex- 

 posed surfaces of the bones were carious, but 

 the acetabulum had suffered more particularly ; 

 it was deeper, but not wider than usual ; its 

 fundus, where formed by the ischium, was thin 

 as paper, but yet no perforation had taken 



