ABNORMAL CONDITIONS OF THE HIP-JOINT. 



803 



fracture of the femur, which had occurred some 

 years previously. Besides this severe injury of 

 the hip, it was also manifest, from some 

 dyspnoea, cough, and bloody expectoration, that 

 his chest was also injured, but venesection and 

 other suitable treatment having been resorted 

 to, the affection of the chest seemed to subside. 

 His cough and dyspnoea for a time had disap- 

 peared, and his pulse fell to 80. On the twenty- 

 third day from the accident, he said he felt that 

 he had caught a most severeand violent cold, from 

 a window having been kept open over his head. 

 On this (23rd) morning, I found him suffering 

 from great difficulty of breathing and violent 

 fits of coughing, accompanied by scanty frothy 

 expectoration. His pulse was 110, and hard, 

 his tongue was brown and dry, his skin was hot, 

 and I learned that these symptoms had suc- 

 ceeded to a rigor. They were attributed by me 

 to pneumonia with acute pleuritis and consi- 

 derable effusion, of which there were found, on 

 examination of the chest by auscultation and 

 percussion, very evident signs. These were 

 actively combated by the ordinary treatment, 

 but without success. His pulse was generally 

 120. He had cough, with muco-purulent ex- 

 pectoration, and dyspnoea. He slill obstinately 

 refused to permit any accurate examination of 

 the limb to be made. He said his right thigh 

 was now as powerless as at first, but the injury 

 did not prevent him sitting up in bed, when, 

 from the urgency of the dyspnoea, he felt the 

 desire for this position ; on one occasion he 

 had himself taken up, and placed for a time 

 sitting up in a chair. On the thirty-third day 

 after his admission, I found that his right leg and 

 thigh had swollen, that he had raved much 

 during the night; and that he had alternate 

 flushings and paleness of countenance, which 

 betrayed much distress. He now complained 

 of pain in the right shoulder. His pulse was 

 130, small and compressible. He had reten- 

 tion of urine. His temper was irritable; his 

 tongue was red, and morbidly clean and dry. 

 He had much thirst. His lips were pale and 

 bloodless. He died on the 12th January, the 

 fortieth day from the accident. 



Post-mortem examination. There was effu- 

 sion of pus into the cavity of the right pleura, 

 and the usual results of acute pleuritis ; pus 

 also in the cavity of the pericardium, and a thin 

 reticulated layer of lymph on the surface of the 

 heart. An incision made through the soft parts 

 to expose the bones of the hip-joint gave exit 

 to a large quantity of dark brown serum, mixed 

 with pus. This collection of matter extended 

 from the superior part of the thigh, under the 

 peritoneum up to the kidney. The soft parts 

 having been removed, and the bones exposed, 

 it was found that the shaft, head, and neck of 

 the femur were uninjured, but the head of ihe 

 bone was driven through the fundus of the 

 acetabulum, which was fractured in a stellated 

 manner, having been divided into three por- 

 tions. The spiculated edges of the cavity pro- 

 truded into the pelvis to the extent of one inch. 

 They were sharp and hard. Nature had not 

 made the slightest attempt at reparation. The 

 finger could be passed along the neck of the 



thigh-bone into the cavity of the pelvis, 

 through the perforation in the bottom of the 

 acetabulum. The pelvis had been broken in 

 several places. There was a comminuted 

 fracture of the horizontal ramus of the pubis 

 near its crest. There was another fracture of 

 this ramus at its junction with the ilium, and 

 a fracture through the body of the os innomi- 

 natum extended from the anterior inferior spi- 

 nous process to the great sciatic notch. 



B. Fracture of the brim of the acetabulum. 

 The superior and back part of the cotyloid 

 cavity, which overhangs the head of the femur, 

 which is called by Soemmering the supercilium, 

 is sometimes broken off, and it follows almost 

 as a necessary consequence, that a dislocation 

 upwards and backwards of the head of the 

 femur shall occur. It is an accident most liable 

 to be mistaken, and most difficult to manage. 

 We believe, indeed, in all the cases which have 

 occurred, that permanent lameness has been the 

 result. In such cases, the luxation of the hip 

 is reduced without much difficulty, but dis- 

 placement again shortly recurs. In symptoms 

 and effects the case has a strong resemblance 

 to the congenital luxation of the femur. I was 

 once invited by my friend, Mr. Hilles, (now of 

 London,) to see a case of supposed dislocation 

 upwards and backwards on the dorsum of the 

 ilium. I met the late Dr. M'Dowel in con- 

 sultation on the case. It was as follows : 



Thomas Venables, aet. 25, on the 4th of Oc- 

 tober, 1834, received a severe injury of the 

 right hip-joint in leaping across a ditch, having 

 alighted with force upon the right leg. He fell 

 immediately, and was unable to rise from the 

 ground, or to walk or stand when raised. 

 When the patient was supported in the erect 

 posture, he had the ordinary symptoms of dis- 

 location of the thigh-bone upwards and back- 

 wards on the dorsum of the ilium. No cre- 

 pitus was discovered. On the following 

 morning an extending force having been ap- 

 plied by the pulleys, the head of the bone 

 resumed its natural situation, and the deformity 

 of the limb disappeared. When the patient 

 was visited on the following morning, (the 6th,) 

 it was found that during the night the head of 

 the bone had started from the acetabulum, and 

 that all the former signs of the injury had re- 

 appeared. On the 7th, the displacement was 

 again reduced. While the bone was yielding 

 to the force of the pulleys, the writer had the 

 palm of his hand pressing on the great tro- 

 chanter, as this last advanced slowly towards 

 the acetabulum. He was sensible of a rough 

 grating sensation, which was communicated to 

 his hand, and gave him the idea as if the head 

 of the bone were dragged along a scabrous rough 

 surface. The case proceeded favourably until 

 the night of the 10th, when, owing to the dis- 

 turbance occasioned by the action of a purga- 

 tive medicine, the dislocation recurred a third 

 time. It was observed that, although when the 

 patient was supported out of bed the foot was 

 inverted, still the toes could be somewhat 

 everted. An accurate examination being now 

 instituted to ascertain whether a fracture ex- 

 isted, a distinct crepitus was discovered at the 

 3o 2 



