824 



ABNORMAL CONDITIONS OF THE HIP-JOINT. 



cartilage still remained, the ligamentum teres 

 was entirely broken, and the capsular ligament 

 partially torn through. The pectinalis muscle 

 and adductor brevis had been lacerated, but 

 were united by tendon. The psoas muscle and 

 iliacus internus, the glutsei and pyriformis, were 

 all upon the stretch. 



e. Cases of unusual dislocations. In (Guy's 

 Hospital Reports we find the account of two 

 cases of dislocation of the head of the femur 

 upwards and outwards towards the anterior 

 superior spinous process of the ilium. 



In the first of these cases, detailed by Mr. 

 Morgan, the affected leg (the left) was short- 

 ened to the extent of at least two inches, the 

 foot was excessively everted, so much so as 

 almost to give the toes a direction backwards. 

 The injured limb had a tendency to cross that 

 of the opposite side, so that the heel was thrown 

 over the instep of the opposite foot; neverthe- 

 less when the feet were placed side by side, 

 they remained in that position. The limb was 

 susceptible of all the natural motions to some 

 extent, with the exception of rotation, but the 

 man complained of great pain when under ex- 

 amination. The projection of the trochanter 

 major was entirely lost, whilst the luxated head 

 of the bone might be felt under Poupart's liga- 

 ment, just below and to the inner side of the 

 anterior superior spinous process of the ilium, 

 and it apparently lay between the anterior and 

 inferior spinous process of the ilium, and the 

 junction of this last bone with the pubes ; it 

 thus rested upon the brim of the pelvis, and 

 projected upwards towards the abdomen ; the 

 femoral artery was not displaced in this dislo- 

 cation, but could be traced taking its usual 

 course, and consequently situated to the inner 

 side of the displaced bone. 



In this case a speedy reduction of the dislo- 

 cated bone was effected, but in the second case 

 I have alluded to, the bone was left unreduced 

 for years. We are indebted for the publication 

 of the whole case, accompanied with the dis- 

 section, to Mr. Bransby Cooper, who tells us 

 that the preparation which illustrates the acci- 

 dent the patient suffered from, was presented to 

 Sir Astley Cooper, by his friend Mr. Old- 

 know of Nottingham, and the bones are pre- 

 served in the museum of Guy's Hospital. The 

 subject of the accident was a lunatic, aged 28, 

 and as far as we can learn from the detail of 

 the case given, his symptoms were very much 

 those which Mr. Morgan's patient presented 

 before the dislocation was reduced.* 



Upon dissection it was found that the old 

 acetabulum was deprived of articular cartilage, 

 and was in part filled up by bony deposit, so 

 as to be rendered wholly unfit for the reception 

 of the head of the femur. The new acetabulum 

 was nearly directly above the original cavity, 

 and was bounded on the outside by the two 

 anterior spinous processes, and on the inside by 

 the line of junction of the ilium and the hori- 

 zontal branch of the pubes, that is to say, by 

 the ileo-pubal eminence. The form of the new 



* Guy's Hospital Reports, January, 1836, p. 99. 



cavity for the reception of the head of the femur 

 was very like the natural acetabulum, but not 

 quite of equal dimensions ; it is protected above 

 by a growth of bone which overlapped the head 

 of the femur, and must have formed the princi- 

 pal point of support of that bone. The inferior 

 part of the new acetabulum was the most defi- 

 cient. The trochanter major sunk partly into 

 the old acetabulum, and polished points on both 

 the old and new acetabulum indicated where 

 the head of the femur and trochanter major 

 played in the various motions this imperfect 

 joint enjoyed. 



We are not informed how the muscles were 

 altered from their normal state, but may infer 

 that most of them were more or less atrophied ; 

 it is probable, however, that both the obturator 

 externus and internus were put much iipon the 

 stretch, and retained the bone more or less 

 downwards. It would have been interesting to 

 have learned the precise situation of the rectus 

 femoris, tensor vaginae, and sartorius, psoas, 

 and iliacus, but we can easily imagine that 

 the latter were much shortened, and that they 

 were raised up from the pubes by the dislocated 

 bone, the tendon of the rectus must have been 

 thrown outwards over the rest of the femur and 

 trochanter major. The head of the femur was 

 altered from its original figure, so as to be 

 adapted to the new acetabulum, portions of it 

 being diminished where it did not come in con- 

 tact with the new cavity, so that its spheroidal 

 figure was lost. The periosteum of the femur, 

 as well as of the new acetabulum, assisted in 

 forming the new capsular ligament. The arti- 

 cular cartilage of the head of the femur has 

 been absorbed, and the same porcelain-like 

 concretion, as is seen in the acetabulum, is 

 provided at corresponding points. From the 

 form of the articulating surfaces, and the fixed 

 position of the femur, both at the head and the 

 trochanter major, it will be observed that no 

 other motion than flexion could be permitted, 

 and even that motion, from the closeness of the 

 attachment at the trochanter, but to a limited 

 extent. 



Luxation of the head of the femur down- 

 wards and backwards. This luxation may 

 be considered as a very rare accident. When 

 the last edition of Sir A. Cooper's work on 

 Fractures and Luxations was published, the 

 baronet had not seen such an accident, as he 

 remarked, " it is to be remembered that there 

 is no such accident as a dislocation of the hip 

 downwards and backwards." 



Dupuytren says, " I have only twice or thrice 

 seen this luxation downwards and backwards. 

 The limb was then twisted inwards, a little 

 elongated, and it was impossible to adjust it to 

 its ordinary place and position, without reducing 

 the luxation, which once accomplished, the dis- 

 placement did not a second time recur/' 



My friend Mr. Wormald, assistant-surgeon 

 to St. Bartholomew's Hospital, has published an 

 account of an accident of this kind in the Medical 

 Gazette, June 28, 1837, and the preparation, 

 which shews the relative .position of the head 

 of the dislocated bone, See. and the acetabulum, 



