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 intljeCttpirflfomgnrk 
 
 College of ijSfjpsiictang anb burgeons 
 
 Hibrarp 
 
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ON 
 
 CONGENITAL DISLOCATIONS 
 
 HEAD OF THE FEMUR. 
 
TREATISE 
 
 ETIOLOGY, PATHOLOGY, AND TREATMENT 
 
 CONGENITAL DISLOCATIONS 
 
 HEAD OF THE FEMUR. 
 
 ILLUSTRATED WITH PLATES. 
 
 BY 
 
 JOHN MURRAY CARNOCHAN, M.D.. 
 
 LECTURER ON OPERATIVE SURGERY WITH SURGICAL AND PATHOLOGICAL ANATOMY, 
 
 &C , &C. 
 
 . . . . "mon but n'a point ete lie grossil le catalogue dcja trop nuinbreux des niiseres 
 humaines, mais d'eviter am practiciens de graves erreurs de jugement. ei atu malades, des 
 traitemena aussi iautiles qu'ils sont dangereux."— Ddpuytrkn— CWjujim Chirurgicalc. 
 
 NEW YORK: 
 
 S. S. & W. WOOD, 261 PEARL STREET 
 
 MDCCCL, 
 
?2> 
 
 
 Entered, according to Act of Congress, in the year 1850, by 
 
 JOHN MURRAY CARNOCHAN. 
 
 in the Clerk's Offioe of the District Couit of the Southern District of New York. 
 
CONTENTS 
 
 PARE 
 
 Preface via 
 
 Chap. I. — General Observations 11 
 
 II. — Anatomical Remarks 35 
 
 III. — Etiology ........... 46 
 
 IV. — Symptomatology ......... 91 
 
 V. — Diagnosis . . . . . . . . . .131 
 
 VI.— Prognosis 139 
 
 VII.— Pathology 147 
 
 VIII. — Treatment '-215 
 
PREFACE. 
 
 Science is progressive, and it is necessary to keep pace with 
 its rapid advancement. 
 
 The department of Surgery occupies an extensive domain ; 
 its beneficial influence upon mankind is universally' acknow- 
 ledged, and its professors now hold a prominent rank in the 
 great intellectual arena of the world. 
 
 The more correct and definite knowledge derived, in more 
 modern times, from a better directed and closer study of Ana- 
 tomy, Physiology, and Pathology, has led to vast improvements, 
 and given, among others, a new impetus to what may be 
 termed curative and conservative surgery. 
 
 The progress of this department of science, in its intimate 
 connection with the great interests of the human race, demands 
 of the surgeon of the present day, not only the ability of per- 
 forming dexterously a complicated operation, but chiefly a 
 profound knowledge of the various pathological conditions to 
 which the human organism is liable. Without this knowledge, 
 a correct discrimination among the various morbid afTections 
 of the body cannot be attained; the diagnosis must be uncer- 
 tain for want of reliable data for its basis, nor can remedial 
 measures be adopted intelligently or judiciously. 
 
 From the increased light now shed upon Surgical Pathology, 
 
Vlll PREFACE. 
 
 it is to be hoped that the time has gone by for the recurrence 
 of many grave errors in practice, heretofore committed, and 
 that we shall not again hear, for instance, of opening an aneu- 
 rism, under the supposition of merely giving exit to a collection 
 of purulent matter, or of the application of the ligature upon a 
 large arterial trunk, for the cure of aneurism, where no aneu- 
 rism existed ; — the lamentable results of erroneous diagnosis. 
 
 Some few years since, while in Europe, and availing myself 
 of the advantages at hand in the Hospitals and Surgical Schools 
 of the great foreign capitals, I drew up the outline of a sketch, 
 to be filled up on my return to the United States, which should 
 embrace a general parallel between the state of British and 
 French Surgery, and the actual condition of the science in our 
 own country. Other matters, however, claimed my attention, 
 and have prevented the immediate fulfilment of my design. 
 
 There is one point of Surgical Pathology, however, previ- 
 ously altogether unnoticed in this country, upon which, among 
 other investigations, I bestowed considerable attention while 
 abroad, and in relation to which I contributed at times brief 
 articles to some of the Medical Journals : — I allude to the Con- 
 genital Dislocations of the Head of the Femur at the Ilio- 
 femoral articulation. 
 
 Contributions of that kind being, however, necessarily con- 
 fined within narrow limits, and nothing having since appeared 
 on the subject from other sources, in the English language, 
 1 have endeavored in the following pages, in some measure, 
 to fill up the void existing in relation to this important point 
 of surgery. 
 
 The arrangement I have adopted is a simple one ; beginning 
 with the Etiology, and then passing on, successively, to the 
 
PREFACE. IX 
 
 Symptoms, the Diagnosis, the Pathology, and concluding with 
 the Remedial Treatment. 
 
 The cause of this Displacement has given rise to much 
 discussion, and the variety of opinions offered shows sufficiently 
 the obscurity of the origin of this connate affection. I have 
 ventured to propose my own opinions on this head, which, 
 I trust, are justly founded upon Anatomy and Physiology. 
 
 The Symptoms and Pathology are illustrated by correct 
 delineations, taken from cases, which came under my own obser- 
 vation, and from dissections, made by myself. 
 
 With regard to the Treatment, I have recorded that course 
 which has been attended with success, and have also mentioned 
 additional suggestions which have been advanced by eminent 
 authority. 
 
 The subject of the present monograph being a novel one. 
 and, indeed, quite new upon the American continent, I may 
 claim some indulgence for any imperfections which may be 
 met with in its pages, on the ground of its being the first 
 attempt to introduce to the Surgeons of this country a systematic 
 account of this important affection of the human organism. 
 
 498 BROADWAY, 
 
 Dec, 1849. 
 
I 
 
 
( i 
 
 
 
 
 
 N°U • 
 
 
EXPLANATION OF PLATE No. I. 
 
 Antcro-latcr.il view, as presented during life, in a case of Double Congenital Dis- 
 location of the Head of the Femur upon the Dorsum of tho Ilium. 
 
 a Anterior Inferior Spinous Process of the Ilium. 
 
 6 Trochanter Major. 
 
 d Superior Margin of the Patella. 
 
 k Inguinal Fold. 
 
 g Region of the Pubes tilted downwards and backwards. 
 
 / The foot resting on the sole, the toes being directed forwards. 
 
 EXPLANATION OF PLATE No. II. 
 
 Lateral view of the samo case as the preceding, of Double Congenital Dislocation 
 of the Head of tho Femur upon the Dorsum of the Ilium. 
 
 a Anterior Inferior Spinous Process of the Ilium. 
 
 b Trochanter Major. 
 
 e Tho excurvation in the lumbar region. 
 
 / The foot resting on the ground, and directed forwards, without inversion or aver- 
 sion of the toes. 
 
 See Report of this Case, Chapter IV. 
 
ON 
 
 CONGENITAL DISLOCATIONS 
 
 HEAD OF THE FEMUR. 
 
 CHAPTER I. 
 
 GENERAL OBSERVATIONS ON CONGENITAL DISLOCATIONS OF 
 THE HEAD OF THE FEMUR. 
 
 The diseases and accidents occurring at, or in prox- 
 imity to, the coxo-femoral articulation, are numerous and 
 complex. An intimate knowledge of the pathology of 
 each of them is requisite, in order that, when circum- 
 stances render an opinion necessary, a correct differential 
 diagnosis may be formed in relation to affections of this 
 portion of the organism. The morbid conditions of the 
 hip-joint are attended by peculiar and characteristic symp- 
 toms, frequently accompanied with displacement of the 
 articulating surfaces, either gradual, from causes more or 
 less prolonged, or immediate and simultaneous with 
 external violence; and thus, the discrimination of one 
 
J 2 GENERAL OBSERVATIONS ON CONGENITAL 
 
 pathologic state from another might be supposed to be free 
 from difficulty or embarrassment. Yet errors in diagnosis 
 do often occur in regard to the real nature of affections of 
 this region, and, as an unavoidable sequent to error of 
 judgment, an improper course of treatment is adopted, 
 useless in itself, and dangerous in its results. 
 
 It is somewhat remarkable that those dislocations 
 of the hip-joint which have been denominated original 
 or congenital, and which are of equal importance in a 
 scientific point of view with the traumatic displacements 
 of the head of the femur, should have been so entirely 
 overlooked by the surgical writers of England and of this 
 country. The great authority on the subject of disloca- 
 tions, Sir Astley Cooper, in his enumeration of the differ- 
 ent varieties of articular displacement, has not referred to 
 any other luxations of the head of the femur than those 
 happening during the different epochs of extra-uterine 
 existence, and resulting from external violence, from 
 relaxation of the ligaments, from paralysis of the muscles, 
 from excess of the synovial secretion, or from strumous 
 ulceration at the joint ,* and even Brodie, whose researches 
 into the pathology of the joints have been so extensive 
 and erudite, has not made a cursory allusion to the re- 
 
 * In the last London edition of Sir Astley Cooper's " Treatise on Dislocations," 
 muscular spasm is mentioned as sometimes causing in certain individuals dislocation, 
 for example, of the lower jaw ; and an instance is alluded to where dislocation of the 
 second phalanx of the little finger resulted from the shock of an electric machine, 
 but in these eases he evidently has no reference to intra-uterine dislocations. 
 
DISLOCATIONS OF THE HEAD OF THE FEMUR. 13 
 
 markable dislocation of the femur of which we are about 
 
 to treat, and which has frequently been mistaken for oilier 
 diseases of this part, and especially for morbus coxarius. 
 
 In examining the extensive collections in the museums 
 attached to St. Thomas' and Guy's, and to the other 
 hospitals of London and Great Britain, I was unable to 
 find any specimens illustrative of congenital dislocation 
 of the head of the femur; and I may make the same 
 remark in regard to the pathological collections of this 
 country. 
 
 From this fact, and from the silence of American sur- 
 gical writers on the subject, I have thought that the fol- 
 lowing description of the causes, symptoms, and morbid 
 appearances of this dislocation at the hip-joint, with the 
 accompanying cases, and with drawings taken from dis- 
 sections which I have had the opportunity of making, 
 might be deemed worthy of perusal ; or, at all events, 
 that they might direct attention to a pathologic condi- 
 tion of this joint, not generally understood, and which, 
 in the details of surgical practice, is not unlikely to be met 
 with. 
 
 Luxations differing in their nature from those occurring 
 as the result of traumatic lesion, are alluded to by Hippo- 
 crates, but in so vague a manner that no definite conclu- 
 sion can be drawn from his remarks. In his Book ' De 
 Articulis"* he says that children in the womb may have 
 
 * Liber d<- Articulis. sect. 3. sent. B8 61 94 ; sect. 4, Bent 1 61 5. 
 
14 GENERAL OBSERVATIONS ON CONGENITAL 
 
 their arms and legs dislocated by falls or blows, or by 
 having been pressed upon, as is remarked in those who 
 are born with club-foot. 
 
 This matter had fallen into oblivion when Ambroise 
 Pare, and, at a later period, Verduc, again pointed out the 
 existence of displacements occurring at the joints befoie 
 birth, but still in language of much obscurity as regards 
 their real nature. 
 
 Pare, in his Chapter on the Causes of Dislocations, 
 thus expresses himself : — "Les causes des luxations sont 
 trois en general, a. scauoir internes, et externes, et la 
 troisieme est Mreditaire. 
 
 " Internes, comme quand il y a certaines hutneurs et ven- 
 tosites qui tombent aux iointures en si grande abondance, 
 qu'elles lubrifient et relaschent les ligaments qui lient les 
 os ensemble et les jettent hors de lew boette : ou bien 
 remplissent lesdits ligamens, de telle sorte qu'iceux engros- 
 sis, et par consequent accourcis, venans a se retirer ensem- 
 ble, retirent ou les apophyses des os, dont ils ont leur 
 origine, ou bien les os mesmes hors lews sinus et cauite. . . 
 La cause hereditaire est celle qui vient de pere et mere 
 aux enfans, comme quand les bossus engendrent des enfans 
 bossus et contrefaits, et les boiteux engendrent des boiteux : 
 dont F experience fait foy, non pas tousiours, mais le plus 
 souuent."* 
 
 * Le Qvatorzieme Livre Traitant des Luxations. Chapitre III (Edition by Mal- 
 gaigne). 
 
DISLOCATIONS OF THE HEAD OF I'lli: I I. MM; 10 
 
 And again in bis chapter " Da la luxation de la hanche,"* 
 he says, " xM;iis es luxations faites de cause interne^ elle 
 peal estre incouiplette, parce que les muscles ei ligamens 
 sont relasches, et n'ont hi force i!<' ramener ledil os en sa 
 iointe, ou cauite." 
 
 In these passages, and particularly where I have used 
 italics, allusion to congenital luxations at the hip and else- 
 where may be intended, hut if Pare were conversant with 
 the real nature of the displacement in question, he does 
 not express himself in explicit language in relation to it ; 
 although it is probable that the hints thrown out In the 
 great French surgeon of the sixteenth century have been 
 made available by some modern writers. In fact, one 
 recent writer, rejecting other opinions, has assumed the 
 hypothesis that the cause of congenital luxation at the hip 
 is nothing more than a superabundant secretion of fluid 
 into the ilio-femoral articular cavity. 
 
 A distinct and definite statement of the existence of an 
 intra-uterine dislocation, takiug place before birth, at the 
 ilio-femoral articulation, appears to have been made in 
 1812 by Chaussier, who is reported to have entered in the 
 note-book of the Hopital de la Maternity of Paris an 
 account of the skeleton of a foetus, in which man) frac- 
 tures were found, besides two congenital luxations, one 
 situated at the humero-scapular articulation, the other at 
 the hip joint; which luxations he designated l>\ the name 
 of spontaneous (Luxations Spontam 
 
 ■ Le Civaturzieinc Livrc. Cbapitre XL. De la Luxation dela Hanohe. 
 
10 GENERAL OBSERVATIONS ON CONGENITAL 
 
 Palleta, an Italian surgeon, practising in Milan, at the 
 commencement of the present century, is, as far as I can 
 learn, entitled to the credit of having first given, in 1820, 
 an intelligent description of the congenital dislocation of 
 the head of the femur from the cotyloid cavity ;* but 
 many years previously he had indicated with considerable 
 precision this obscure morbid condition of the hip-joint in 
 his work published in 1 788, entitled " Adversaria Chirur- 
 gica." In the essay " De Claudications Congenita" he 
 describes certain malformations at the hip-joint, which 
 can only be referred to the class of dislocations at this 
 articulation, which, under the name of congenital, have 
 attracted the attention of some modern French surgeons. 
 It is probable, however, that, at this early period of his 
 labors, this author was not well acquainted with all the 
 characteristics of the displacement. But from observa- 
 tions on the living, and dissections made of persons who 
 had succumbed to various maladies, he had acquired more 
 knowledge in regard to this morbid condition of the hip- 
 joint than any of the surgical writers who had preceded 
 him. The descriptions which he has left of the symp- 
 toms manifesting themselves during different stages of life, 
 and of the results of the post-mortem examinations which 
 he was enabled to make, conclusively siiow that the 
 Italian surgeon was acquainted with the general patholo- 
 gical facts appertaining to this affection. In his first case, 
 
 * Exercitationes Patholoaicse. 
 
DISLOCATIONS OF THE HEAD OF THE FEW I;. 17 
 
 although unable to verify it farther by autopsic examina- 
 tion, he thus proceeds: "Puerum octenticm claudicantem 
 consilii causa ad me adduxerunt 28 aprilis ann. L78U. . . 
 E rat cms sinistrum sesqui pollice hrevius dextero ; genu 
 introrsum non nihil conversum, trochanter major ah heva 
 parte emincntior. Resupinato puero dam manu altera 
 trochanterem deprimeham, altera cms et genu extendere 
 eonabar, membrom affectum par sano reddebatur: sublata 
 extensione idem membrum ad pristinam brevitatcm re- 
 ducebatur. Motus articuli in omuem partem erat facilis. 
 Causa cui quidem ea contractio tribui poterat, nulla prse- 
 
 cesserat manifesta Quid eidem evenerit, ignoro, 
 
 nunquam enim postea rediit."* 
 
 Although there are symptoms in the above case that 
 are common to other affections at, or about, the hip-joint, 
 as well as to congenital luxation of the head of the 
 femur, yet the age of the patient, the lameness — not being 
 referred to external injury, — the easy extension of the 
 limb, already shortened by half an inch, to the length of 
 the sound member, the immediate return to its pristine 
 shortness as soon as extension was removed, and the free 
 motion of the joint, give, when taken collectively, a gene- 
 ral character. to the malady described, which precludes the 
 supposition of its having been the result of strumous ac- 
 tion, or of accidental lesion. 
 
 * Adversaria Chirorgicai 
 
18 GENERAL OBSERVATIONS ON CONGENITAL 
 
 Passing over another case similar to that just related, 
 and of which also Palleta was prevented from making a 
 post-mortem examination, we shall make an abstract of a 
 case in which he had an opportunity of dissecting the 
 various structures about the joint. u Adolescens tenui ha- 
 bitus vigesimo aetatis anno moritur ex capitis vulnere, 8 
 maii 1783. Gluum mensae anatomicae alium in fin em im- 
 poneretur, eras dextri lateris contractum observavimus. Cal- 
 caneum tribus transversis digitis supra sinistrum erat, genu 
 duos ; trochanter tuberosior et eminentior ; natis item ro- 
 tundior et globosior, sulcus autem ejus vix mutatus erat ex- 
 cepto apice, qui paulo incurvus versus trochanterem ten- 
 debat. Caeterum nee triceps coxae musculus distentius, 
 nee pes in latos conversus observabalur ; nee item alii 
 musculi coxam ambientes quidquam a naturali diversum 
 
 habebant. praeter matatam directionem Capsa 
 
 dein articulari incisa, cotyle sanum erat, 
 
 profundum, cardla^ine sua obductum. figura duutaxat 
 matatam. Caput femoris in vertice valde depressum, 
 atque inferius productum velut in obtusum rostrum 
 terininabat. Tota ejus superficies cartilagine, colore. 
 et crassitie naturali tegebatur, excepto exiguo tractu circa 
 ligamenti teretis foveam, ubi sic attenuata cernebatur. at 
 diaphana redderetur. Ligamentum teres infra capitis cen- 
 trum trochanteri minori propius inserebatur. Robustum 
 tamen illud erat, crassum, et lata triangulari basi, ex coty- 
 
DISLOCATIONS OF THE HEAD OF THE FEMUR. 19 
 
 lis sulco prodibat. Femoris colluin eral perbreve, si eo 
 nomine distinguenda est ossea portio a capitis rostro in 
 transversura ducta, atque in trochanteric basiui inserta. 
 Hncc porro una cum capite compressa ab lateribus, et cir- 
 cum eminentiis parvis obsita erat, circulari articuli liga- 
 mento inclusis."* 
 
 The author then proceeds by giving a detailed account 
 of the dimensions and measurements of the articulating 
 surfaces of the cotyloid cavity and head of the femur, & 
 which it is unnecessary to repeat here. The extract just 
 made is sufficient to point out some of the pathological condi- 
 tions peculiar *o the congenital dislocation of the hip-joint. 
 
 The next case, reported by the Italian surgeon, which 
 presented an opportunity of inspecting the body after 
 death, is also characteristic of this affection. It is detailed 
 as follows . — " Femoris colluin eo, quod descripsimus, 
 modo vitiari posse altera me docuit sectio in puella bimula. 
 Hujus femur sinistrum transverso digito con- 
 tractus erat; pes in neutram partem inclinabal ; trochan- 
 ter sublimior, et extrorsutn crassior erat: sulcus qui imtis 
 terminum designat, pauJulum versus trochanterem inflecte- 
 
 batnr Ablaiis muscnlis femur, de quo antea dubita- 
 
 bamus, cum cavitate cotyloide dearticulatum esse comperi- 
 mus. Capsam articularem a parte posteriori liberam, in 
 solet ; a priore vero in vicinia foraminis ovalis cum interno 
 ligamen o accretam deprehendimus ; cujus phaenomeni ra- 
 
 * A'hvrsariii Cliirnririea. 
 
20 GENERAL OBSERVATIONS ON CONGENITAL 
 
 tio a singulari ipsiusmet ligamenti structura pendebat. Hoc 
 enim neque in funiculum colligatum, neque in prismatis 
 modum conformatum erat, sed expansum dijectumque in 
 form am membranae, atque sic totam acetabuli superficiem 
 occupabat ; dumque circulari et lato exoriebatur principio, 
 mediam relinquebat cavitatem fere ad formam infundibuli, 
 et deinde paulatim fibras contrahebat, quo capiti propius 
 accessisset. Utrumque cotylis labrum cartilagineum nempe 
 et osseum valde depressum erat ; orijiciwn ipsum cotylis 
 fere ovale, latius nempe a superiori parte, et ab ima magis 
 coarctatum. Ab acetabuli centro usque ad marginem seg- 
 menti inferioris surgebat tuber, aut colliculus osseus, lawi 
 contectus cartilagine, atque convexus, qui ubi diligentius 
 observabatur, ab ilii ossis, qui in acetabulum concurrit, pro- 
 cessu prseter modum crassescente videbatur productus, 
 Frmur, pene dixerim, acephalum fuit ; nam complanatam 
 habebat faciem, qua sese aptabat tuberi ex cavitate articu- 
 lari prominentir* 
 
 Here again, as in the following case, we have a descrip 
 tion of pathological appearances found to exist at the ilio- 
 femoral articulation, which have but little affinity with an) 
 other of the affections of this part, than those occurring as. 
 the result of the congenital form of displacement of the liead 
 of the femur. The same author thus proceeds with another 
 observation of a case which afforded an opportunity for the 
 autopsy ; — " Eadem, ut siguificavi, die inter multa alia, ca- 
 
 * Adversaria Chirurgica. 
 
DISLOCATIONS OF THE HEAD OF THE FEMUR. -'1 
 
 daver hominis robusti qui ex morbo inflammatorio deces- 
 serat se obtulit, cujus dexterum crus decurtatum erat. 
 Artu diligenter examinato, collatoque cum sinistro duobus 
 transversa digitis deficere animadocrti ; natis sulcus pan In 
 ti/fior, et magis incurvntus erat ; nee praterea alterius 
 morbi signum ullum extrinsecus notabatur. Dum capsula 
 
 articularis incideretur, qua? justo densior apparuit ; 
 
 caput ovatum, a summo latins, dein convergendo in obtu- 
 
 sum rostrum abibat ; ligamentum teres 
 
 validissimum fait ex duobus fasciculis compositum, primum 
 quidem invicem decussatis, dein expansis in trianguli for- 
 mam, cujus una radix anterior, posterior altera, tertia de- 
 mum inferior ad pedis anserini similitudinem alte in sinum 
 acetabuli defigebantur.* Cotyle ossis depurati ad conoi- 
 
 deam pariter figuram accedebat ; fundi autem 
 
 cotyloid is media pars superior cartilaginem suam habebat; 
 altera cartilagineorbataperamplam pro triangulari ligamento 
 aivam ostendebat. Femoris collum erat breve, novem li- 
 nearum, transverse positum, cujus caput magis repandom 
 pro ratione amplitudinis acetabuli, margines suos a parte 
 inferiori, posteriorique multum ultra collum exporrectos 
 habebat, atque ab ima parte in rostrum aduncum produce- 
 batur, interjecto profundo sinu inter femur, et rostri curva- 
 turam ; retrorsum vero idem excrescens margo sic dilata- 
 
 * It is probable that this account of tho ligamentum teres is drawn from the liga- 
 mentous agglomeration which sometimes occurs between the capsular ligament and 
 the ligamentum teres, which become converted into a strong fibrous cord, as will be 
 s . en in a case described hereafter (vide plates viii. and ix.). 
 
22 GENERAL OBSERVATIONS ON CONGENITAL 
 
 batur, ut tribus duntaxat lineis a minori trochantere dis- 
 taret. Et quamquam anterius ob colli brevitatem margo 
 capitis naturalis et femori, et trochantere proximior esset, 
 posterius tamen spatium illud, quod est inter caput, et 
 utrumque trochauterem, pollicem unum, et tres lineas la- 
 tum reperiebatur ; atque id ex eo contigit, quod caput 
 oblique positum in priorem partem, et simul in inferiorem 
 declinaret; proptereaque trochanter, qui extrinsecus emi- 
 nebat plurimum, totum etiam pollicem ipso capite eminen- 
 
 tior erat Capitis centrum occupabat area scabra, 
 
 .... ad cujus terminum longe infra capitis medium 
 ligamenti teretis sinus erat conspiciendus."* 
 
 The details of these cases, taken from Palleta, although 
 not as complete or minute as those resulting from more 
 modern investigations, are yet sufficiently distinct in their 
 character to preclude the supposition of any of them be- 
 ing referable to a traumatic dislocation or fracture, or to 
 any morbid or accidental lesion likely to occur at the hip- 
 joint, other than the peculiar articular displacement which 
 takes place at the ilio-femoral articulation during intra- 
 uterine existence. They are interesting, as being the 
 earliest attempts to illustrate anatomically this curious point 
 of surgical pathology, and in giving an account of those 
 cases which have come under my own observation, I shall 
 have occasion to allude to them again. 
 
 Dupuvtren, without taking any notice of the several 
 
 * Adversaria Chirurgica. 
 
DISLOCATIONS OF THE READ OP THE FEMI R. 23 
 
 observations of the learned Palleta, published in 1826 his 
 Essay, entitled "Memoire sur le deplacement originel ou 
 congenital de la tite du femur"* Tliis production, clear 
 in its descriptions, and practical in its tendency, attracted, 
 when first issued, considerable attention among the scien- 
 tific men of the French capital. 
 
 On the continent of Europe, where pathology is studied 
 with so many advantages and with such assiduity, this 
 point of surgical inquiry into the congenital dislocations 
 of the hip-joint has been elucidated, in more modern times, 
 by contributions from Breschet, Sedillot, Pravas, &c, and 
 particularly from Jules Guerin, who has entered more phi- 
 losophically than other writers into the etiology and treat- 
 ment of this particular class of dislocations. 
 
 The obscurity of the nature of this diseased condition 
 of the coxo-femoral articulation, and the circumstance of 
 its being a lesion which occurs before birth, has deterred 
 surgeons, until recently, from attempting any therapeutic 
 means to bring about, and render permanent, the natural re- 
 lation of the displaced articulation; and many enlightened 
 practitioners have supposed permanent reduction to be be- 
 yond the reach of art. Of late years, cases have, how- 
 ever, been reported of successful attempts having been 
 made to reduce fixedly the head of the femur to its natu- 
 ral position ; and, to bring about this result, one French 
 surgeon, referring this dislocation to the theory of active 
 
 • Read before tho Academy of Sciences l-'Jii. 
 
24 GENERAL OBSERVATIONS ON CONGENITAL 
 
 muscular retraction {retraction musculaire active) as its 
 cause, lias advised, and, in accordance with notions founded 
 on this supposition, put into operation, the sub-cutaneous 
 section of the muscles supposed to be implicated, as well 
 as of the new fibrous structure that may have been adven- 
 titiously thrown out as a consequence of the abnormal po- 
 sition of the articulating surfaces. 
 
 The varieties of the congenital dislocations of the fe- 
 mur, in regard to the position which the head of the bone 
 may occupy relatively to the circumference of the aceta- 
 bulum, have been enumerated as being four in number ; 
 the luxation, however, upwards and outwards upon the 
 dorsum of the ilium being by far the most common. The 
 other forms, occurring only in monstrosities, are not met 
 with under circumstances where surgical relief is required, 
 and therefore merit but a cursory allusion. They have 
 been described as occurring, firstly, directly upwards; se- 
 condly, forwards and upwards ; thirdly, a sub-luxation 
 backwards and upwards. * 
 
 Lastly, the term pseudo-luxation has beeu applied to 
 certain permanent deviations in the direction of the femur, 
 resulting from a morbid muscular retraction simulating dis- 
 location at the joint, but without the exit of the head of 
 the femur from the cotyloid cavity. 
 
 The causes of these pathological phenomena are not 
 so free from obscurity as to be beyond controversy. Nearly 
 every writer who has given attention to this subject, has 
 
DISLOCATIONS OF THE FEMUR. 
 
 assumed a hypothesis to account for the origin of the 
 displacement, and has found ingenious arguments to sup- 
 port his conjectures. Some authors construct their theon 
 on ideas connected with the evolution of ih<' embryo, and 
 refer the incipiency of the morbid condition of the joint 
 to an arrit fife develappement, to an aberration of the nutri- 
 tive forces (fo7'ce formatrice), or to a primitive alteration 
 of the genu. Others, unable to comprehend that the head 
 of th«' femur can be transported from its natural recepta- 
 cle without the aid of a cause analogous in some way to 
 that )f traumatic luxations, attribute the displacement of 
 the femur to improper traction exercised, by the accoucheur, 
 upon the extremities of the infant, during its passage 
 through the pelvis of the mother. Again, external vio- 
 lence acting upon the foetus, while it is in utero, has been 
 assigned as a cause. Also, the contractions of the uterus 
 and of the abdominal muscles upon the extremities of the 
 Levers presented bj the long bones of the inferior members 
 of the child, the unnatural position occupied, perchance, 
 by the foetus in the cavity of the womb, the absence of 
 the liquor amnii, permitting the walls of the uterus to act 
 directl) upon the foetus during the contractions of this or- 
 gan, have been regarded as mechanical antecedents, which. 
 acting separately, or in combination, might displace the 
 head of the femur from its natural situation. .More re- 
 cently, it has been attempted to trace an analog) between 
 the congenital form, and that species of luxation which 
 
 3 
 
26 GENERAL OBSERVATIONS ON 
 
 occurs at different periods of life, as the result of relaxa- 
 tion of the muscular and ligamentous structures surround- 
 ing the joint. One recent author has gone so far as to 
 take up again the theory of the ancients regarding certain 
 articular displacements, and has attributed the abnormal 
 position of the articular apparatus of the hip-joint, which 
 takes place in the foetus before birth, to the relaxation and 
 elongation resulting from an effusion into the cavity ol the 
 articulation whilst the child is still in utero. On the other 
 hand, it has lately been maintained that the articular ap- 
 paratus, in the cases under consideration, is always prima- 
 rily in a state of integrity, and that the derangement which 
 takes place in utero at the articulations, destroying the 
 normal relations of the component parts of the joints, 
 without leaving any evidences or traces of inflammatory 
 action, is dependent upon a morbid retraction of a portion of 
 the muscular tissue, resulting from a defect in, or absence 
 of, some portion of the nervous centres. My own 
 opinion is, that the displacements of the hip-joint in ques- 
 tion are the result of spasmodic muscular retraction, not 
 dependent, however, upon mere absence of the central ner- 
 vous substance, hut upon an irritation conveyed to, or ori- 
 ginally existing in, the ganglionic centre of the medulla 
 spinalis. This irritation or altered action, which occa- 
 sionally may result in structural lesion, is thence transmit- 
 ted by the reflex-motor power of the excito-motor appa- 
 ratus of the spinal system upon the muscles, which conse- 
 
DISLOCATIONS OP THE FKMi l;. 27 
 
 quently become affected^ mid In/ their continued retraction 
 disarticulate the head oj the femur. This last theory is 
 based iij)i)ii physiology, and, if assumed as a law, may be 
 made available to explain the existence not only of the 
 dislocations of the hip-joint occurring before birth, but 
 also of many other congenital articular displacements found 
 in die trunk, and extremities. 
 
 Notwithstanding tbese conflicting hypotheses as regards 
 the cause of this peculiar species of displacement at the 
 ilio-femoral articulation, it is generally admitted tbat here- 
 ditary predisposition has a certain agency in die occur- 
 rence of the congenital dislocation of die hip-joint, as it 
 has been acknowledged to have in the various kinds of 
 club-foot or talipes. 
 
 Dupuytren relates a curious history, which was commu- 
 nicated to him of a family living at Nantes, in France, in 
 which, as many individuals belonging to it were found 
 affected with this displacement of the femur occurring be- 
 fore birth, this peculiar predisposition may be supposed to 
 have been developed in an extraordinary degree; and as 
 there is no instance recorded more illustrative of this 
 point, I shall transcribe the description given hj him in 
 one of his "Legons Orales de Clinique Chirurgicale" de- 
 livered at the Hotel Dieu of Paris. He proceeds as fol- 
 lows: — " We shall now relate a very curious one (lac 
 which appears to indicate that this vice of conformation 
 
28 GENERAL OBSERVATIONS ON 
 
 can be transmitted to mauy generations of individuals of 
 the same descent. 
 
 " There exists, in the town of Nantes, a family, many 
 members of which have been, and are, affected with origi- 
 nal luxation {luxation originelle) of the femurs. The 
 oldest member of this family is a woman eighty years of 
 age, named Marguerite Gardas, fruiterer, and here follow 
 the particulars of her case, taken from her own lips, and 
 corroborated by other persons of the same age. 
 
 " Two of her aunts, on the maternal side, who died 
 at seventy years of age, had been affected with a lame- 
 ness from their earliest attempts at walking. These females, 
 moreover, were in the habit of stating that they had 
 always been lame. Their hips were elevated, protuberant, 
 and abruptly salient. They walked with their elbows 
 projecting backward, and hobbled like ducks. Mar- 
 guerite's father had had a sister lame upon the right side 
 from birth, who died at eighty years of age. Another 
 sister, who was well formed, gave birth to a female child, 
 which presented a shortening of the right inferior 
 extremity. 
 
 •• .Marguerite Gardas, who is the subject of this observa- 
 tion, is a large and robust woman, and appears to have 
 possessed a remarkable degree of activity in her youth. 
 With her the disease was not prominently marked until 
 she was thirty years of age, and its symptoms are those of 
 
DISLOCATIONS OF THE FEMUR. 29 
 
 ;i spontaneous luxation* (luxation spontanee) of the Femur. 
 Tin* affected member is one fourth less in diameter than 
 the other, which is, besides, three or four lines longer. 
 This woman has had, by her marriage with a health} 
 man, who had come from distant parts, a daughter named 
 Simone, who has a congenital shortening of the right 
 inferior member of about three inches. This girl is also 
 married to a man of healthy conformation, but whose 
 father had a congenital luxation of both femurs; she has 
 had four children, two of whom present the hereditary 
 infirmity. The one is a young woman aged twenty-three 
 years; she has a luxation of the two femurs, the heads of 
 which are situated in the external iliac fossa; the other is 
 a young man twenty-one years of age, who has a con- 
 genital luxation of the left thigh. The member affected 
 is shorter by five inches than the other; the head of the 
 lemur has ascended upwards and backwards; the trochan- 
 ter major projects forwards and outwards, and the toes are 
 turned inwards; the two extremities are equally well 
 developed." 
 
 After the recital of this instance, it would be difficult to 
 doubt that hereditary predisposition exerts some influence 
 over the recurrence of this disease in children wh 
 parents or ancestors had previously been affected l>\ it. 
 
 Another opinion is entertained, and generally agreed 
 
 •The word apontanee, in the French text, is here used as .-yn.>nymon.- wuli 
 origineUe. 
 
30 GENERAL OBSERVATIONS ON 
 
 upon to be correct, in relation to the more frequent occur- 
 rence of the congenital form of dislocation at the hip in 
 the female than in the male sex; and, although I cannot 
 coincide entirely with Dupuytren when he says that 
 " presque tons les individus affect es de cette luxation sont du 
 sexe feminin," I am satisfied from my own observation 
 that the majority of persons in whom this disease is found 
 to exist are females, and that the proportion of males 
 affected should not be put down at more than one third. 
 The cause of this greater proneness may possibly proceed 
 from the susceptibility of the female organization to be 
 more easily impressed by the existence of any morbid 
 irritation of the nervous centres, which might be incited 
 during the period of evolution of the embryo or foetus ; 
 and not improbably in connexion with this, or by itself 
 alone, the anatomical configuration, such as the more for- 
 ward position of the acetabulum in the female pelvis, 
 might facilitate the action of the pelvi-trochanteric mus- 
 cles when once thrown into a state of active morbid 
 retraction, in producing the displacement of the head of 
 the femur from its natural cavity. 
 
 The pathological appearances met with in cases of con- 
 genital dislocation vary with the period of life at which 
 they are subjected to examination. The alterations obser- 
 vable in the articulations and the ligamentous structures 
 concerned in the malady are greatly diversified. " In 
 fact the primitive characters of this disease become more 
 
DISLOCATIONS OF THE FEMUR. 3] 
 
 extensively modified in proportion as they are more remote 
 from its commencement. There arrives, indeed, a period 
 when the alterations which are met with would not. even 
 indicate a primitive lesion, were it not that in some cases 
 these very lesions had been previously found to exist. In 
 relation to the congenital luxations, we are not permitted 
 to see them produced. When we are able to examine 
 them they have generally existed for some time ; conse- 
 quently the primitive lesions are modified by so much as 
 the age of the patient is advanced. It is, then, in young 
 subjects that the essential character of congenital displace- 
 ments must be sought ; for it is at this early age that the 
 changes are least." 
 
 The extensive alterations met with in adult life are not 
 to be seen in the congenital dislocations of the hip-joint in 
 the new-born infant. In the latter, the signs of displace- 
 ment are less marked than in the former. The soft tissues 
 surrounding the articulation depart but little from the nor- 
 mal structure ; the capsular ligament has as yet undergone 
 but trivial change in its form or dimensions, and is found 
 only lengthened and put upon the stretch by the partial 
 ascent of the head of the femur ; and the articulating sur- 
 faces of the acetabulum and of the head of the femur are 
 found to be still in nearly a natural condition. But in the 
 progress of advancing age, changes occur which com- 
 pletely modify the relations of the whole of the articular 
 apparatus of the joint. The head of the femur become 
 
32 DISLOCATIONS OF THE FEMUR. 
 
 softened, atrophied, or completely removed ; the acetabu- 
 lum becomes more or less contracted and altered in shape, 
 and is sometimes filled up with a new semi-osseous mate- 
 rial; and the fibrous capsule assumes an entirely novel ap- 
 pearance, presenting sometimes a cavity retaining the head 
 of the femur, sometimes a perforation which allows of its 
 transit, sometimes an agglomerated fibrous cord running 
 between the remains of the ancient acetabulum and the 
 atrophied remains of what was originally the head of the 
 femur. Likewise, the head of the femur, escaping from 
 its natural capsule, contracts new relations ; a new fibrous 
 capsule is formed for it, and either a depression is shaped 
 out for the reception of the displaced head, or an acetabu- 
 lum of new formation, less profound, but similar to the 
 osseous effusion, which frequently takes place in cases of 
 unreduced traumatic luxation at this part, springs up from 
 the surface of the dorsum of the ilium, as an effort of na- 
 ture to give support to the unfixed bone. The muscles, 
 and other soft tissues, undergo corresponding perversion 
 from their normal condition ; and the bones appertaining 
 to the dislocated limb participate in the general derange- 
 ment, by showing a deterioration in their development and 
 structure as regards their natural length, volume, and con- 
 sistence. 
 
Z tdi. c/ Sarony tMeuc 
 
EXPLANATION OF PLATE No. III. 
 
 Posterior view of the Foetal Pelvis — about the end of the ninth month. 
 
 The drawing represents a dissection of the parts concerned in Congenital Dislo- 
 cation of the Femur, and is intended to explain the manner in which the head "i 
 the lemur may escape from the cotyloid cavity during foetal life ; and also the 
 mechanism by which the consecutive malformations are brought about, chiefly by 
 means of muscular traction. 
 
 X The right Femur, slightly flexed. 
 
 a The Dorsum of the Ilium. 
 
 6 Head of the Femur. 
 
 c Trochanter Major. 
 
 d Ligamentous Margin of the Acetabulum. The dotted line shows the portion of 
 
 the acetabulum which is cartilaginous in this direction, at this period — the ilio- 
 
 iscbiatic depression is thus formed. 
 e Ligamentum Teres. 
 / Gluteus Medius. 
 g Gluteus .Minimus. 
 h Pyramidalis. 
 » Superior Gemellus. 
 k Obturator Interims. 
 m Inferior Gemellus. 
 a ( tbturator Bxternus. 
 o Quadratic Femoris. 
 
35 
 
 CHAPTER II. 
 
 ANATOMICAL OBSERVATIONS. 
 
 In the adult, traumatic dislocations of the femur from 
 the acetabulum are not of frequent occurrence. I am in- 
 clined to believe, from what I have seen, that the conge- 
 nital form of luxation of the femur, more especially that 
 variety where the femur ascends upon the dorsum of the 
 ilium, is of as frequent occurrence, if not more so, as the 
 corresponding dislocation caused by external violence dur-* 
 ing extra-uterine life. 
 
 During adult life, various causes are opposed to the dis- 
 placement of the head of the femur from its proper recep- 
 tacle. The depth of the acetabulum, the strength of the 
 capsular ligament, aided by the auxiliary resistance of the 
 ligamentum teres, the resisting influence of the pelvi-fe- 
 moral muscles which surround the ilio-femoral articulation, 
 the limited motion of the joint in certain directions, are 
 obstacles which oppose the dislocation of the femur from 
 its natural socket. 
 
 On the other hand, during foetal life, the anatomical 
 disposition of the parts, and the flexed position main- 
 
36 ANATOMICAL OBSERVATIONS. 
 
 taiiied, generally, by the thighs upon the abdominal wall 
 during this epoch, predispose the head of the femur to 
 pass from its shallow acetabulum, and mount upwards 
 and backwards, in the direction of the dorsum of the 
 ilium. 
 
 It is probable that intra-uterine dislocations of the hip- 
 joint may occur in the fcetus from spasmodic muscular re- 
 traction as early as the third or fourth month of gesta- 
 tion. 
 
 If the doctrine be correct, as I suppose it to be, that a 
 morbid condition of the medulla spinalis — as one of the 
 important parts of the spinal excito-motor circuit — must 
 be present, in the production of intra-uterine dislocations, 
 the previous junction with the medulla spinalis of the 
 nervous trunks, which are ultimately ramified in the 
 muscles implicated, must also be essential. Now, accord- 
 ing to M. Serres, the nerves have a separate evolution 
 from the cerebro-spinal axis, and pass eentripetally from 
 the organs to the encephalon, and to the medulla spinalis. 
 This junction takes place between the optic nerves and 
 the tubercula quadrigemina, as remarked by this writer, at 
 about the end of the second month ; and during the fourth 
 month they become joined with the thalami and the cor- 
 pora geniculata. 
 
 The Rachidean nerves, following the same law, join 
 the medulla spinalis in a similar manner, and probably 
 about the same time. The spinal excito-motor system 
 
ANATOMICAL 0BSER1 \tio\s. 
 
 may reasonably be supposed to COtne into pla\ then, and 
 not previous to the nervous junction.* 
 
 It would be superfluous to trace the modifications ob- 
 servable at the hip-join! during the different phases of 
 embryotic and foetal life; I shall only therefore take a cur- 
 sory glance at the anatomical relations of the ilio-feuioral 
 articulation, as it is seen about the middle period of intra- 
 uterine existence. 
 
 In the adult, two bones enter into the formation of the 
 osseous part of the ilio-femoral articulation — the os inno- 
 minatum and the os femoris. In the foetus, however, a 
 different arrangement results from the fact, that ossifica- 
 tion is not yet completed cither at the acetabulum or 
 at the head of the femur. The articular part, corres- 
 ponding to the osseous acetabulum in the adult, is here 
 partlv cartilaginous. The three portions, now called 
 ilium, ischium, and pubes, and which ultimately join to 
 form one bone, the os innominatum, are seen progressing 
 towards development, by the deposition of osseous material 
 in the cartilaginous matrix, or framework, by which, ;it 
 this early period, the acetabulum is chiefly made up. 
 
 * Several anatomists have recorded examples which go to prove the separate 
 lotion of the nerves and >■! the nervous centres, — Lallemand ,-/-• Montpellier). 
 Thiee inaugurate. — Lonsdale. — Serrea, Anatomie <lr Syst. rwrv. — 1 bave myself 
 Been an amyllencephalous embryo of aboul the fourth month, in which the spinal 
 nerves seemed to terminate in tin' vertebral canal, opposite the intervertebral foramina, 
 like ;l range <■! minute dots. 
 
38 ANATOMICAL OBSERVATIONS. 
 
 These three osseous portions, in their centripetal progress 
 towards final development, leave between them three 
 spaces, occupied in the recent subject by cartilage ; by 
 means of which, and with the assistance of the ligamen- 
 tous border, formed by the cotyloid ligament, the circular 
 arrangement of the cotyloid cavity is completed in the 
 foetus. This cotyloid cavity, at the fifth month, is 
 found to measure about nine lines in circumference, 
 and about two lines in depth. If the parts are now ex- 
 posed to the air for a short time, the cartilaginous compo- 
 nents of the acetabulum become dried and shrunken, and 
 the extent to which the osseous portions contribute to 
 form this cavity is exhibited ; the three depressions 
 already alluded to, and which were scarcely appreciable 
 while the cartilage of the acetabulum was in its natural 
 state, being now strongly marked around its perimeter. 
 These marginal depressions of the acetabulum can be 
 seen in the skeleton of the adult pelvis, but they are 
 much more distinct in that of the foetus. One of these 
 depressions is situated between the os ischium and the os 
 pubis, and conducts, as it were, from the acetabulum 
 to the foramen ovale ; the other is between the os ilium 
 and the os pubis, and is on a level with the horizontal 
 branch of this bone ; while the third occupies the poste- 
 rior half of the margin of the acetabulum, corresponds to 
 the space between the ilium and the ischium, and leads 
 towards the ischiatic notch, or upwards to the dorsum of 
 
ANATOMICAL OBSEIM \Tlu\s. tt) 
 
 the ilium. This last, <>i' ilio-ischiatic depression, which in 
 the skeleton of the foetus is seen to be extensive, and 
 which originally was filled nj) with yielding cartilaginous 
 material, may permit, during foetal life, the head of the 
 femur to slip readily over the margin of the acetabulum, 
 which, at this period, and in this direction, is so shallow 
 — as observed in the dried state of the parts — that the 
 margin, at its most depressed point, is almost on a level 
 with the bottom of the cotyloid cavity. By this anato- 
 mical configuration, and the pressure of the head of the 
 femur towards the lower and posterior part of the acetabu- 
 lum during the flexed state of the thighs, the exarticulation 
 of the head of the femur, upwards and backwards, to- 
 w aids the dorsum of the ilium, could, evidently, be easily 
 accomplished by spasmodic muscular retraction prolonged 
 and acting in the direction of the force which would be 
 exerted by the two smaller glutei, and by some of the 
 other pelvi-femoral muscles, if thus morbidly affected. 
 Vide Plate hi. 
 
 Above the acetabulum, the dorsum of the ilium is seen 
 presenting upon its surface a slight elevation or ridge, 
 which extends from the anterior third of the crest to the 
 upper pari of the acetabulum. This ridge, only slightly 
 marked, divides the dorsum into two unequal parts. The 
 more posterior presents a concave surface, which becomes 
 continuous with the margin of the acetabulum, by an in- 
 clined plane, upon which the head of the lemur, when 
 
40 ANATOMICAL OBSERVATIONS. 
 
 dislocated, will glide upwards towards the external iliac 
 fossa upon the dorsum. Below the cotyloid cavity, and 
 between its inferior margin and the tuberosity of the 
 ischium, is the groove in which passes the tendon of the 
 obturator extern us ; while, posteriorly, are seen the 
 spine of the ischium, still cartilaginous, the groove for the 
 passage of the obturator internus, and the several points 
 which give origin to the small pelvi-trochanteric muscles. 
 J n front and below, is the obturator foramen filled by the 
 membrane of the same name, which supports on its two 
 surfaces the origin of the obturator muscles. Extending 
 forward from the anterior portion of the acetabulum, is 
 the horizontal branch of the pubes, terminating in its 
 body. The horizontal ramus gives attachment to the pec- 
 tineus, while the anterior surface of the body of the 
 pubes and its descending ramus, and the ascending branch 
 of the ischium, — the two last named portions being still 
 cartilaginous, — give points of origin to the other adduc- 
 tors of the thigh. These anatomical details have a bear- 
 ing upon the mechanism by which malformations, conse- 
 quent upon (he congenital dislocations at the hip-joint, are 
 produced. Vide Plate hi. 
 
 The Acetabulum. — The acetabulum, composed as it 
 is of the three osseous facettes which the ilium, ischium, 
 and pubes present upon the inner aspect of its cavity, and 
 the unossified, cartilaginous matrix which exists between 
 
\ \ \ rOHIG \l. OB8ER1 \tio\s I 1 
 
 these osseous parts is. in its receni state, about the fifth 
 month of gestation, a shallow cavit} of about two lines 
 in depth, and i » i n « * or ten lim's in circumference, it is lined 
 with synovial membrane for aboul lour fifths of its extent 
 
 superiorly, and presents a smooth surface — the portion 
 uncovered by membrane being between the notch and the 
 centre. One part of the inferior fifth is appropriated for 
 the attachment of die round ligament; the other, In a 
 fatt) cellular mass, which tends, in its position, to dimi- 
 nish the depth of the cavity. The cotyloid ligament sur- 
 mounts the margin of the semi-osseous and semi-cartila- 
 ginous acetabulum, and with the exception ot this notch, 
 through which the articular vess Is and nerves pass, masks 
 almost entirely the marginal depressions, already alluded to 
 as existing so plainly upon the skeleton. 
 
 The Head of the Femur. — The head of the femur, 
 which, with the acetabulum, composes the ilio-femoral ar- 
 ticulation, is entirely cartilaginous during foetal life. It 
 is nearly globular, forming, as it dot's, a considerable seg- 
 ment of a sphere, which, in the recent state, is about three 
 lines in diameter. The articular cartilaginous surface is 
 covered b\ synovial membrane, and presents, at its inner 
 and inferior part, a depression for the insertion of the li- 
 gamentum teres. It is supported l>\ the neck, the pedicle 
 of which is but little developed. The trochanter major 
 is also cartilaginous; it gives attachment to the two 
 
42 ANATOMICAL OBSERVATIONS: 
 
 glutei muscles, which take their origin from the dorsum 
 of the ilium, aud is apparently continuous with the shaft 
 of the femur; its summit being placed on a plane some- 
 what below the highest point of the head of the femur. 
 
 Capsular Ligament and Ligamentum Teres — The 
 articulating surfaces of the semi-cartilaginous hip-joint 
 are maintained in their natural relations by means of se- 
 veral ligaments. The capsular ligament, which in the 
 adult is strong, is delicate in the articulation of the foetus. 
 It is attached on one side to the margin of the acetabu- 
 lum and the contiguous surface around its circumference ; 
 on the other, to the neck of the femur. The accessory- 
 fibrous band, which has received the name of ligamentum 
 sujjerius, and which, in the adult, strengthens the capsule 
 anteriorly, is scarcely perceptible in the foetus. The cap- 
 sule is lined upon its inner surface by a layer of synovial 
 membrane, which passes also over the ligamentum teres 
 and the other parts of the articulation. This capsule, 
 when deprived of the tendinous expansions and muscu- 
 lar tissue, by which it is surrounded, permits the head of 
 the femur to be separated considerably from the cotyloid 
 cavitv. 
 
 The other ligament, called the round ligament, slight 
 and fragile in the foetus, extends from the apex of the 
 head of the femur, and becomes inserted at the marginal 
 notch as well as at the depression found at the ante- 
 
LNATOMICAL OBSERVATIONS. 43 
 
 rior ;iikI inferior part of the bottom of the aceta- 
 bulum. 
 
 Tin 1 intra-articular vessels, which chiefly subserve 
 the nutrition of the head of tin* bone, pass through 
 this marginal notch, which becomes converted by the 
 transverse ligament into a distinct foramen ; and finally 
 there is the cotyloid ligament, tipping the margin of 
 the cavity with a delicate ligamentous border. Vide 
 Plate hi. 
 
 In adult life many muscles are grouped around the iKo- 
 femoral articulation, and protect the joint from external 
 injury ; but, in foetal life, if struck with the abnormal state 
 of spasmodic retraction to which the muscular system is 
 liable, they become, most probably, the active cause of 
 the displacement of the head of the femur from its natu- 
 ral cavity. Some of these pelvi-femoral muscles, owing 
 to the direction of their fibres, do not participate in pro- 
 ducing this dislocation. After birth, however, ami at a 
 more advanced stage of the case, and in combination 
 with other causes, such as the superincumbent weight of 
 the trunk, and the ordinary physiological contraction 
 which the\ then more vigorously exert, they tend to pro- 
 duce by their abnormal traction those consecutive malfor- 
 mations of the pelvis, and of the contiguous osseous tis- 
 sue, thai constitute one of the chief complications accom- 
 panying the congenital dislocation of the femur upon ih< v 
 ilium. Vide Plate hi. 
 
44 ANATOMICAL OBSERVATIONS. 
 
 The individual action of the muscles concerned in 
 these results will be more fully stated, when the subject of 
 the pathology comes to be considered. 
 
 A consideration of the anatomical disposition thus pre- 
 sented, of the component parts of the foetal ilio-feinoral 
 articulation, and of the influence which the strong mus- 
 cles, inserted into the upper part of the femur, may be 
 supposed to exert when once thrown into a state of mor- 
 bid retraction, will aid materially in removing the difficul- 
 ties in accounting for the displacement of the femur dur- 
 ing intra- uterine life. 
 
 The os feinoris of the foetus is generally flexed upon 
 the anterior abdominal wall, and consequently the head 
 of the bone is pressed against the posterior and inferior 
 portion of the shallow acetabulum, and of the correspond- 
 ing part of the capsular ligament. By this disposition of the 
 parts, the head of the femur is supported in its place, as it 
 were, in a sling, composed on one side of the pelvi -tro- 
 chanteric muscles and of the two lesser glutei. While 
 the femur is in this position, it may easily be supposed 
 that an abnormal and continued spasmodic retraction of 
 these muscles, especially of the glutei, will induce the 
 head of the femur to slip from its cavity over the poste- 
 rior part of the margin of the acetabulum, upon which is 
 observed the depression, resulting from the unossified 
 space, still existing betweeu the rudimentary ilium and 
 ischium. Having once passed the border of the cotyloid 
 
ANATOMICAL OBSERVATIONS. I •'. 
 
 cavity, i he extension of the limb, after birth, will throw 
 the head of the femur still more upon the ilium, and the 
 retracted muscles, continuing to act, in combination with 
 
 other causes which subsequently come into play, will in 
 the progress of time induce the head of the femur to 
 glide still further in the direction of the fossa, observed 
 upon the dorsum of the ilium, and thus the displacement 
 is effected to its ultimate limit. 
 
46 
 
 CHAPTER III. 
 
 ETIOLOGY OF CONGENITAL DISLOCATIONS OF THE HEAD 
 OF THE FEMUR. 
 
 Like the ordinary traumatic dislocations of the hip- 
 joint, the dislocation we now treat of, implies a removal 
 of the articulating portion of the head of the femur from 
 its natural receptacle, the acetabulum. Occurring during 
 intra-uterine life, it differs materially from the form of dis- 
 location caused by external violence, in its origin, progress, 
 and symptoms ; and therefore writers, who have paid at- 
 tention to this point of surgery, have designated it by a 
 distinctive name. Some have applied the term spontane- 
 ous ; others the term original; and others again the 
 term, congenital, to this form of dislocation. The term 
 spontaneous, however, has also been used, in speaking of 
 the displacement which occurs at the hip-joint as a result 
 of morbus coxarius, and it is therefore objectionable. 
 The word congenital, as indicating the existence of the 
 disease when the child comes into the world, seems most 
 applicable, and I shall therefore adopt it. 
 
 The congenital dislocations of the head of the femur 
 occurring at the ilio-feinoral articulation, are either com- 
 
BTIOLOG1 . I J 
 
 plete ox incomplete; and 1 1 1 « • \ ma} exisi upon one side 
 <>nl\, or, as inosl frequently happens, the displacement 
 m;i\ <-\ i->i simultaneously on both .sides, forming ;i double 
 luxation. 
 
 The head of the femur ma} be complete!} dislocated 
 before birth in three different directions: — 
 
 Firstly, upwards and outwards; this form of disloca- 
 tion corresponds to that variety which is described l>\ au- 
 thors as being situated upon the dorsum of the ilium. It 
 is the variety which is most common, and to it prac- 
 tical authors have chiefly directed their attention. The 
 head of the femur is here situated, in the new-born child, 
 above the margin of the acetabulum; and. in the progress 
 of time, mounts upon the dorsum of the ilium, and i 
 in the externa/ iliac fossa* Of this variety 1 have seen 
 many examples, and the accompanying plates, taken from 
 an adult during life,f and also from some dissections 1 
 have made, will illustrate the appearance and nature of 
 the luxation in this direction. This form is general!} a 
 double luxation, but it is also met with upon one side 
 only. 
 
 Secondly, the luxation direct!} upwards. This kind ot 
 dislocation has been seen only in those foetal monstrosi 
 which have been called agenosome, in which, with 
 other anomalies, the abdominal walls are not complete!} 
 developed The head ol the femur is here placed iuime- 
 
 • Vide F vii. t Vide Plates L, ii., an i •■ 
 
48 ETIOLOGY. 
 
 diately external to the anterior and inferior spinous pro- 
 cess of the ilium. 
 
 Thirdly the luxation forwards and upwards. Like 
 the preceding, this displacement has been only met with 
 in the foetal monstrosity. The head of the bone rests 
 upon the eminentia ilio-pectinea, and forms a well marked 
 tumor in the groin. 
 
 M. Guerin mentions, in addition to the forms already 
 noticed, a sub-luxation upwards and backwards, which in 
 reality appears to be but a modification or incomplete de- 
 velopment of the dislocation upwards and outwards.* He 
 describes it as being characterized by the partial escape of 
 the head of the femur, which does not pass beyond the 
 margin of the acetabulum. This variety is met with in 
 new-born children, and sometimes in cases where luxation 
 from muscular retraction has occurred spontaneously soon 
 after birth. 
 
 Tbe same author has also indicated two varieties of 
 what he terms pseudo-luxations of the hip ; one, simulat- 
 ing a luxation back wards and outwards ; the other, resem- 
 bling a luxation downwards and forwards. " There exists," 
 he says, " an order of congenital dislocations of the hip, to 
 which I have given the name of pseudo-luxations, because 
 they present the fallacious appearance of luxations, al- 
 though the head of the femur has not escaped from the 
 
 * Strictly speaking, the head of the femur,' in the dislocation upon the dorsum of 
 the 1 : m, passes upwards and backwards. I have retained, however, the designation 
 adopted by Dupuytreu, " en haut et en dehors." 
 
ETIOLOGY. 49 
 
 cotyloid cavitj ; the varieties of these pseudo-luxations 
 are themselves the result of the muscular retraction, 
 duTerentlj distributed among the pelvi-femoral muscles." 
 
 This pathologic condition of the pelvi-femoral muscles 
 had alreadj beeB noticed !>\ Delpech,* and the novelty 
 presented by M. Guerin consists in the adoption of a de- 
 signating term, which serves a useful purpose in individu- 
 alizing a class of affections. 
 
 From this enumeration of the varieties of the congeni- 
 tal dislocations occurring at the hip-joint, it will be seen 
 that several of them are only to he met with in the im- 
 perfectly developed foetus, and consequently cannot come 
 within the range of surgical practice : others, however, 
 are met with in the living individual, and become the ob- 
 ject of remedial attention The former are interesting in 
 a scientific point of view only ; the latter belong to the 
 practical details of the profession. 
 
 To no other class of maladies is the phrase, "felix qui 
 yotuit rerum cognoscere causas" more applicable than to 
 the congenital dislocations observed at the ilio-femoral ar- 
 ticulation. 
 
 The researches into the origin and nature of the class 
 of displacements which occur at the articulations of the 
 lotus, while still in the womb of the mother, haw perhaps 
 suggested more ingenious hypotheses than any other of 
 the obscure parts of surgical pathology. Laying aside 
 the predisposition engendered by hereditary transmission, 
 
 ' l >•■ l'( Irthomorphie par rapport a t\ sp&ce bumaine. 
 
50 ETIOLOGY. 
 
 and by sex, as being generally concurred in, the other 
 causes mentioned by writers, as tending to bring about 
 the dislocation in question, may be referred to different 
 heads. First, external violence, acting upon the foetus 
 while in utero (J. L. Petit) ; second, a primitive altera- 
 tion in the germ, or an aberration of the formative power 
 (force formatrice) (Dupuytren) ; third, an arrest in the 
 development of the osseous portions forming the cotyloid 
 cavity (Breschet ) ; fourth, certain articular maladies, oc- 
 curring in the foetus during intra-uterine life (revived by 
 M. P arise and others) ; fifth, a primitive alteration in the 
 nervous centres (Chaussier), revived by Delpech and Gue- 
 rin ; and lastly, to be more definite, I would add to the 
 causes mentioned above, a pathological spasmodic reti ac- 
 tion of the muscular tissue, resulting from a perverted or 
 disturbed condition of the excito-motor apparatus of the 
 medulla spinalis ; especially of that portion which is in direct 
 relation with the nervous branches distributed among the 
 pelvi-femoral muscles. 
 
 J. External Violence. — Hippocrates,* as before 
 stated, says, that children yet contained in the organ of 
 gestation, may have the arms or the inferior limbs dislo- 
 cated by falls, blows, or by pressure exerted upon the ab- 
 dominal walls of the mother. 
 
 The powerful contractions of the uterus acting upon 
 the extremities of the levers presented by the femurs, 
 
 * Liber de Articulis. 
 
ETIOLOGY. 5] 
 
 while the thighs are flexed upon the abdomen, and the 
 effecl ofviolenl tractions exercised by the accoucheur upon 
 the inferior extremities daring a difficult parturition, as 
 suggested by Pare, have also been regarded as sufficient 
 to account for the displacement* 
 
 It is certain that dislocations at the hip-joint, from trau- 
 matic causes, are exceedingly rare in early life, and anj 
 force originating externally — and of a mechanical kind — 
 of sufficient energy to act upon the foetus in utero, might 
 he supposed to produce fracture rather than dislocation. 
 The tendency to hereditary transmission, and the frequent 
 occurrence of congenital dislocation in the double form. 
 and closely similar on both sides, would go to disprove 
 the agency of any purely mechanical cause in the pro- 
 duction of intra-uterine dislocation of the hip-joint. 
 
 The position of the inferior memhers of the foetus, 
 while it is contained in the uterus, has been brought for- 
 ward to give probability to the effect said to be produced 
 h\ causes of external origin. Before birth, as a general 
 rule, the thighs of the child are flexed upon the abdomen ; 
 and the heads of the femurs consequently must make a 
 continual pressure upon the posterior and inferior portion 
 of the capsule of the joint. This circumstance is no 
 doubl favorable to the displacement of the head of the 
 
 * " Ce que aduient auasi souuentesfoi aua enfantemena difficile quand lea 
 femmes tirana lea brae dea enfans, dealoquenl lea iointurea de I'eepaule ou de i;i 
 ■ ■." — Pari, Chapitre L4me, Livre L4ffw. Edition by Malgaigne—{Old 
 French). 
 
52 ETIOLOGY. 
 
 femur from its natural receptacle, but it is more in co-re- 
 lation with the agency of morbid muscular retraction, to 
 which further allusion will be presently made. Taking 
 into consideration what has just been stated, and the proba- 
 ble action of more potent causes, originating primarily in the 
 foetus itself, it does not appear that external injury, or mere 
 mechanical agency, could have much influence in the 
 production of intra-uterine dislocations of the head of the 
 femur. 
 
 II. An Original Defect in the Organization of 
 the Germ, or Aberration of the Formative 
 Power. — This hypothesis of Dupuytren is sufficiently 
 vague and inexplicit. It refers the origin of the displace- 
 ment to the first organization of the embryo, or, in other 
 words, to an original vice of conformation, which depends 
 upon a defect in the constitution of the germ. Adopting 
 this theory, he says : " We may very well conceive the 
 simultaneous displacement of both femurs, as is observed 
 in most individuals affected, the perfect health which 
 they enjoy at birth, and the complete absence of morbid 
 action, or of symptoms of a previous or present malady, 
 either around the head of the femur or in the cotyloid 
 cavity." 
 
 This hypothesis of Dupuytren is unsatisfactory, and has 
 no support from physiological facts, or the acknowledged 
 doctrines regarding Embryogeny. 
 
ETIOLOGY. 
 
 III. Arrest <>f Development at the Cotyloid 
 Cavity. — ( Am f <l< developpement de la Ccwite ( btylo'ide.) 
 — .M. Breschet refers the congenital luxations of the head 
 of the lemur to the laws, which, from Ins researches, he 
 supposes, govern the evolution of tin- osseous system of 
 the foetus or of the embryo, and he considers these dis- 
 placements as the result of an arrest of the development 
 of the cotyloid cavity. He asserts that the osseous cen- 
 tres, from which development is last completed, are those 
 from which the cavities and processes result, as is exem- 
 plified at the acetabulum, where several osseous pieces ul- 
 timately form a junction. It is known that the cotyloid 
 cavitj is composed originally of three pieces, and that the 
 complete formation of this cavity takes place only at the 
 late periods of osteogeny. The iliac hones are there- 
 fore liable, according to this author, to meet with obstacles 
 in their development al the acetabulum, in which case 
 the head of the femur — not having a proper receptacle — 
 will he carried upwards, beyond the undeveloped cavity. 
 Now, it so happens, that the cotyloid cavitj and the head 
 of the femur have both been found progressing to their 
 normal development,* or to have completed it, in cases of 
 this dislocation which have come under observation ; and 
 although the cotyloid cavity in its osseous state is made 
 up by the junction of the three original hones of the OS 
 innominatum, yet, according to .M. ( 'ruveilhier.f the carti- 
 * Vide Craveilhier, Anatomie Patholog. + Cruveilhior, Anatomie Doeoript. 
 
54 ETIOLOGY. 
 
 laginous matrix of the future hone is present, continu- 
 ously at all its points, at the same time, and not at iso- 
 lated points, as is the case with the osseous centres from 
 which the bones are ultimately formed. 
 
 For myself, I am not aware of any case having been 
 met with in the foetus, of a defect or perforation occurring 
 at the union of the three bones which constitute the aceta- 
 bulum, and which, according to the laws of centripetal 
 development, — if the doctrine of arret de developpement be 
 true — would be the point where a deficiency should be 
 found, if any existed. Even supposing that in some in- 
 stances the head of the bone were deprived of its usual re- 
 ceptacle, by reason of its arrested development, those cases 
 of dislocation, in which there were found to exist a corre- 
 lative and normal development of the cotyloid cavity, as 
 well as of the head of the femur, could not be explained 
 by this theory. Besides, there frequently come under 
 observation at the other articulations, instances of con- 
 genital dislocation, to explain or account for which, M. 
 Breschet's theory would be wholly insufficient. 
 
 IV. Certain Articular Maladies occurring in 
 the Fcetus during Intra-Uterine Life. — Pathologi- 
 cal investigations have taught us that the fcetus is liable 
 to many affections while in utero, which may cause 
 death, or terminate in resolution or health, before birth.* 
 
 * Vide Cruvedhier's Anatomic Pathol. 
 
ETIOLOGY . 
 
 Prom iliis Tact it was apparent^ ;i rational inference to 
 suppose, that the same morbid cause which, in the adult, 
 sometimes produces the spontaneous luxation at the hip. 
 might also in the foetus determine the congenital luxation 
 ;n this joint. This hypothesis is of old date, and has 
 been revived by some recent writers with the parade of 
 originality.* We find that Pare, alluding to the fact 
 "that a child while still in the womb, ma\ have apo- 
 stemes, which may open and cicatrize," proceeds to say, 
 " it may happen also that the ligaments which retain 
 the hones at their articulation are not firm, but slender and 
 small in their conformation, or are humid in themselves, 
 and very much Inhriiied, or moistened by a fluxion of pitui- 
 tary and mucous humors, which relax, and render soft the 
 ligaments that ought to bind the articulation ; and hence 
 the bones art- easily displaced at their joints.'' Also, 
 again alluding to this subject, he says elsewhere, that 
 • 4 the causes are internal, when there are certain humors 
 and swellings, which fall upon the joints in such abun- 
 dance that they lubrify and relax the ligaments which 
 bind the bones together, and throw them from their 
 socket." f 
 
 M Parise, who is the most strenuous advocate of this 
 theory, stales, as his view, that the cause of the ligamen- 
 
 • ( lri.lv ; Sedillol ; Malgaigne ; I 
 
 t Pari, Le quatorzieme livre. Edition by Malgaigne. 
 
56 ETIOLOGY. 
 
 tons relaxation is an effusion of fluid into the ilio-femoral 
 articulation, u hence results the expulsion of the head of 
 the femur from its natural cavity. This author asks : 
 " Wherefore should it not be admitted that a few deci- 
 grammes of fluid can be secreted in the articulation of 
 the hip-joint, when it is known that among the mala- 
 dies to which the foetus is liable, articular dropsies are 
 of the most frequent occurrence ? . . . . Hereditary pre- 
 disposition in either case can be as well conceived to exist 
 in regard to a h) drarthus, as to a vicious development ; 
 observations prove that different members of the same 
 family have been attacked with dropsies, spontaneous lux- 
 ations {luxations spontanees), &c. In this hypothesis it 
 is necessary to admit that the luxation once produced, 
 the dropsy disappears, and the dilated capsule returns to 
 its proper dimensions ; sometimes, in young subjects, it 
 has been found more dilated, aud containing more synovia 
 than in the na ural state ; but that it should have re- 
 turned to its nearly natural state at birth, ought not to 
 astonish those who are acquainted with the energy of the 
 assimilating force, and the rapidity of the nutritive revo- 
 lutions appertaining to foetal existence What 
 
 renders so grave the coxalgir affections in the adult, is the 
 extension of the inflammation to the neighboring osseous 
 tissue, whence result caries, suppuration, fistula?. Now, 
 it is not so with the foetus, the cotyloid cavity of which, 
 as well as the head and neck of the femur, are cartilagi- 
 
ETIOLOGY. 57 
 
 nous ;it birth. We <l<> n<>i even know ani fact of coxal- 
 gia terminating by abscess in children under one or two 
 years of age, although at this period ossification is al- 
 ready advanced.'' M. Parise, in the above remarks, seems 
 to make no definite distinction between articular dropsj 
 and coxalgia, and to overlook the different results which 
 must follow from a simple effusion into the joint from a 
 common inflammatory action, and that, consequent upon 
 a scrofulous engorgement of the tissues of the articulation. 
 In his hypothesis, on account of the absence, at the time 
 of birth, of any marks of inflammatory disease in cases of 
 luxation, he concedes, that as soon as the displacement is 
 produced, the effusion must disappear, and the dilated cap- 
 sule return to its natural dimensions. By those who are 
 acquainted with the difficulty of procuring immediate or 
 prompt resolution in strumous affections, this admission — 
 if the effusion accompanying morbus coxarius be meant 
 — could not be assented to; and we are inclined to virw 
 the objections urged by Dupuytren against the theon of 
 effusion of fluid, being the cause of congenital luxations 
 at the hip, as repuguant to the explanation given by 
 i\I. Parise. ''Many circumstances," says Dupuytren, 
 •• oppose the supposition that the origin of these congeni- 
 tal dislocations can be the same as that of coxalgia, and 
 first, all the individuals in whom the displacement has 
 been observed, hail been in good health when thej came 
 into the world — a circumstance which would scarcely ad- 
 
 5 
 
58 ETIOLOGY. 
 
 mir of the supposition that they had suffered from a ma- 
 lady so grave as that which induces the spontaneous luxa- 
 tion of the femur." Moreover, luxation of the ilio-femoral 
 articulation has been met with in the foetus without the 
 presence of any superabundant secretion in the joint. 
 
 V. A Primitive Alteration in the Nervous Cen- 
 tres. — The theory, which refers congenital luxations to 
 this cause, will be best considered in connexion with the 
 
 following : 
 
 VI. A Perverted Condition of the Excito-Motor 
 Apparatus of the Medulla Spinalis. — The different 
 parrs of the body are not all developed at the same time. 
 The nervous system begins its evolution primarily, and 
 seems to take precedence and control over the other sys- 
 tems. The circulating organs soon appear, and succes- 
 sively" are evolved the muscular, osseous, and other struc- 
 tures. 
 
 i he muscular tissue is liable to be sensibly impressed 
 l>v almost every incident which can take place during ex- 
 tra-uterine life, and its dynamic condition is constantly 
 varying even in a state of health. " Comme on le sait, 
 ri< n nest plus variable que l'etat dynamique des organes 
 de ce systeme ; dans toute la duree de la vie le moindre 
 evenement y exerce une influence plus ou moins marquee. 
 Une maladie aigue, une lesion organique, une fievre pas- 
 sagere, une perturbation temporaire dans les fonctions di- 
 
BTIOLOQY. 59 
 
 gestives, la gestation, des travaus corporels, une conten- 
 tion d' esprit, le repos prolonge, le seul defaut des exercises 
 habitueis, ['abstinence, les exces, la simple fraveur, suf- 
 fisent pour diminuer notablement, et quelquefois d'une ma- 
 niere grave, la contractilite musculaire."* 
 
 It is reasonable to suppose that a set of organs, which 
 have so extensive a sympathy in the animal economy, 
 must, to a great extent, either in health or disease, be 
 under the immediate influence of the nervous system. 
 
 The pathologic states manifested in the muscular sys- 
 tem by means of which deformities, subluxations, and luxa- 
 tions at the joints are induced, are, a paralytic state of this 
 tissue ; and a morbid, tonic, spasmodic retraction. There 
 is another cause, sometimes producing deformities at the 
 joints through the muscles, which proceeds from direct 
 irritation and the continuance of a vitiated position, such 
 as is seen to result from the influence of rheumatic in- 
 flammation ; but of this cause, being foreign to our pre- 
 sent subject, it is unnecessary to speak farther. 
 
 The two causes first mentioned, viz. a paralytic state 
 of the muscles, and a morbid muscular ret rati ion, although 
 conditions directly opposite to each other, sometimes pro- 
 duce a set of deformities, having, in many respects, a 
 similar appearance. The modes, however, in which the 
 various deformities are thus produced differ entirely. 
 
 Ill the one instance the disturbed relation of the parts 
 
 • Delpeoh, De l'Orthomorpliie. 
 
60 ETIOLOGY. 
 
 is the effect of the action of antagonistic muscles, 
 although enfeebled themselves, overcoming the more de- 
 fective action of the other set of paralysed muscles. 
 This is well exemplified in those cases of club-foot, 
 which occur from a paralytic state of one set of conge- 
 ner muscles, while their antagonists retain more or less of 
 their activity. 
 
 When the paralysis is entire, this preponderance of 
 greater apparent power in one set of muscles — almost al- 
 ways of the flexors — over another set, must be attributed 
 to the inherent contractile tonicity, which is peculiar to the 
 muscular system, and not to any influence derived from 
 the nervous system. 
 
 In the other instance the deformity, which may be ac- 
 companied, or not, with luxation or subluxation, is brought 
 about by a purely abnormal retraction of the muscular 
 tissue, evinced by an immovable rigidity which pervades 
 it, and which results from an unnatural tonic spasmodic 
 condition of the muscles. Examples of deformity, pro- 
 ceeding from this latter cause, are also to be met with in 
 cases of club-foot, where the disposition to morbid mus- 
 cular retraction is localized in one set of muscles, while 
 the other set act only within the range of their healthy 
 contractile power. Some cases of lateral curvature of 
 the spine, of torticollis, &c, may also be referred to this 
 cause.* 
 
 * Delpech mentions a curious instance, where a complete talipes varus was formed 
 
ETIOLOGY. o*l 
 
 This abnormal muscular retraction, as has hccn alread) 
 said. I believe to be the result of a morbid condition of 
 the excito-mdtor apparatus of the medulla spinalis, either 
 conveyed to its ganglionic portion, or primarily originat- 
 ing in it, and thence transmitted or reflected upon thai 
 portion of the muscular tissue in which the irritation be- 
 comes localized and manifested. 
 
 The muscular tissue is endowed with the health \ phy- 
 siological property of alternate contraction and relaxation, 
 which, whether it show itself as the result of volition, of 
 involuntary motion,* or as the sequent of the action of 
 the excito-motor system, is subordinate to the influence of 
 the nervous centres. Besides this healthy action, it is 
 liable to pathological conditions, which are manifested by 
 
 in an adult, consecutively to the paralysis resulting from the division of the ischiatic 
 nerve, by a bullet which traversed the thigh. 
 
 The same author mentions also a case whore club-foot followed the i tinned use 
 
 of an irritating injection in treating an abscess situated at the inferior and inner part 
 of the thigh, and which was accompanied by necrosis. He thus describes tin- result : 
 '• Pendant cette longue maladic laquelle dura trois ans entiers, les muscles de la lace 
 posterieur de la jambe Bouffranl aympathiquement, <>u plutot, par lea effets de la par- 
 ticipation du nerl crural aux inflammations freipientes et profondea de la i< 
 interne de la cuisee, tomberent dans un etat de contraction tel, que le pied en tut en- 
 traine en bas, el en dedans, el deforme\ comme dans I'etel du pied-bol le plus com- 
 plel el le plua avance* qu'il soit possible d'imaginer." Here the irritation mual have 
 been transmitted to the muscles producing the varus, <>r rather it may have been 
 
 carried to the medulla spinalis, and thence reflected. 
 
 * The functions of the Great Sympathetic Nerve are more or le a under the 
 influence oi the Cerebro-Spinal System. •• Tout ganglion Bympathiqne commu- 
 nique ou bien aveo lee deux ordres de raoinee des nerfc spinaux, ou bien i la fois avec 
 
 des uerl's n aiiini- uioteurs et scnsilifs." — Lonact, SiislSmr .Xrirriir. 
 
62 I ETIOLOGY. 
 
 disturbance of its normal functions, limited and localized 
 to a particular set. of muscular fibres, or diffused more 
 or less throughout this entire system. Farther, the in- 
 vestigations of science have also ascertained, that the mor- 
 bid state of the muscular system, observed during certain 
 of its diseased conditions, such as paralysis, tetanus, epi- 
 lepsy, and some other affections accompanied by spasmo- 
 dic muscular contraction, is likewise subordinate to a pa- 
 thologic influence, located primarily in the cephalo-rachi- 
 dian centres, or conveyed indirectly to them. It is therefore 
 a fair deduction, that, as the healthy physiological contrac- 
 tion of the muscles is the result of healthy enervation, 
 so the peculiar condition of the muscles which is mani- 
 fested by the abnormal tonic retraction and spasmodic 
 shortening of their fibres, is a sequent to the existence 
 of an irritation, or of an altered condition of some kind in 
 the central nervous system. 
 
 There is also another function exerted by the muscles, 
 which is peculiar to them, and independent of any influ- 
 ence derived from the nervous system. This inherent 
 property is manifested in certain cases where the influence 
 of the nervous system has ceased to have any agency ; 
 the muscles themselves retaining the power of tonic con- 
 tractility, as is exemplified in the rigid and contracted 
 state of the ventricles of the heart, which occurs within 
 an hour or two after death.* 
 
 * This inherent tonic muscular contractility is strikingly illustrated by a case 
 
KTIOI.OOY. 63 
 
 \i the present dav it is do longer a matter of doubt 
 that the foetus, inclosed in its uterine envelopes, is liable 
 to many of the diseases witnessed in extra-uterine exist- 
 ence. 41 
 
 Many years ago the French anatomist, Chaussier, from 
 facts which came under his observation, and probably 
 from suggestions derived from the learned Pallet a, was 
 induced to assert that convulsions might occur to tin 
 foetus while still in the uterus, and he was consequent!) 
 led to refer the occurrence of certain congenital luxations, 
 which came under his inspection, to a morbid alteration 
 of the nervous centres. 
 
 The celebrated German physiologist, Rudo/phi. enter- 
 tained similar views; and Delpech has advanced opinions 
 in corroboration of the dependence of congenital malfor- 
 mations and luiations oi the articulations, such as the 
 various forms of Talipes present, upon some morbid 
 affection of the nervous apparatus 
 
 In speaking of the analogy to he observed between 
 club-loot and certain congenital deformities at the ilio- 
 
 published originally by Professor Herrmann of Bern, and recorded by Dr. Dew 
 which the contractile pi e uterus three days after death was 
 
 to expel twins: " On the third day after the death of a young woman, who •■■■ u 
 herpixth month of pregnancy, the nurse heard a loud noise proceeding from the i 
 A physician was immediately Bent for, who on his arrival found thai the dec< 
 bad brought forth twins, which were inclosed in a membrane quite entire, and i 
 ill.' [east putrid. The placenta only appeared t>> have Buffered from the effects o( pu- 
 trefaction." — Dewrex' System of Midwifery. 
 * Vide Cruveilhier's Anatomic l'mlml. 
 
64 ETIOLOGY. 
 
 femoral articulation, owing to muscular retraction, the latter 
 savs : " II nous semble difficile de separer l'idee de ces de- 
 formites, surtout quand elles sont parallele, repetees dans 
 deux articulations, accompagnees, comme il n'est pas rare 
 de l'observer, de quelques anomalies de plus, dans les arti- 
 culations des genoux,dans la disposition des muscles de la 
 fesse, de la cuisse, &c. ; il nous semble, disons-nous, diffi- 
 cile de separer l'idee d'une semblable aberration de l'acte 
 nutritive, de celle d'un etat anormale anterieure de l'un des 
 grands foyers vitaux; la moelle epiniere, par example." 
 
 M. Guerin has reproduced this theory, and has ex- 
 tended it so far as to refer to an alteration, or rather to an 
 absence of the whole, or of a part, of the nervous centres, 
 the source of that morbid muscular retraction, which pro- 
 duces the class of deformities to which the foetus is sub- 
 ject, and which consequently have been called conge- 
 nital. He has carried this theory, however, to the 
 length of attempting to prove that there is always to be 
 observed, a rigorous relation between the absence of the 
 nervous centres, or a portion of them, and the extent, 
 number, and locality of the dislocations which may be 
 present. The labors of Guerin may have tended to give 
 some additional light on this theory, but in his endeavors 
 to simplify a point of science he has generalized too far, 
 and in attempting to make facts square with his views, 
 he has made assertions which have not been substan- 
 tiated by correct observation. 
 
ETIOLOGY. 65 
 
 Although not agreeing with M* Gueria in regard to 
 the invariable antecedence of partial or total destruction, 
 or absence, of the nervous centres, as the cause of morbid 
 
 muscular retraction, it must be admitted that his remarks 
 are ingenious. As the point in question is one of scien- 
 tific interest, I have made the subjoined extract from a 
 memoir read by him before the Academy of Sciences of 
 Paris, which may serve as a summary of this writer's 
 ideas upon the etiology of congenital displacements of 
 tin 1 joints, and among them, of congenital luxation, at the 
 head of the femur. 
 
 " The observation of certain monstrosities presents to 
 us in a striking manner the combination of these four 
 orders of facts, namely, that in them may be observed, at 
 the same time, a material lesion of the nervous centres, 
 the retraction of the totality or of the greater portion of 
 the muscular system, and of concomitant luxations; a 
 rigorous relation between the seat, the extent, and the 
 degree of the nervous lesion, and the seat, extent, and 
 degree of the retraction ; and finally, a relation of direction, 
 of extent, and of degree, between this retraction and the 
 dislocations which it produces. 
 
 "I have already frequent!} shown you, in certain mon- 
 strosities, the coincidence of a partial or total destruction of 
 the central nervous system, with a retraction, more or less 
 general, of the muscular system, and the deformation of 
 nearly all the parts of the skeleton, and particularly of 
 
66 ETIOLOGY. 
 
 the articulations. Here is a series of anatomical speci- 
 mens, and of drawings taken from specimens, which I 
 have not been able to preserve, where this double fact ap- 
 pears in the most varied manifestations, from its most fee- 
 ble and circumscribed expression, to its most energetic 
 and extended. Thus you can see in these facts, cases 
 where the alteration of the nervous centres has been su- 
 perficial and transient ; others, where they have been par- 
 tially destroyed ; and in each of these cases, the retraction 
 of a greater or less number of muscles, and of luxations 
 of the members, are met with simultaneously. And 
 farther, you see represented monsters in which there 
 is at the same time a complete disappearance of the 
 nervous centres, and a retraction of the totality of the 
 muscular system. I present to you in particular a foetus 
 anencqjhale-symele, in which you observe, with this same 
 retraction of the muscles, not only a turning of the head 
 behind, and large curvatures of the vertebral column, but 
 also dislocations, which are more or less complete, of the 
 principal articulations, such as the hip-joint, the knees, the 
 feel, the shoulders, the elbows, and the wrists. 
 
 " It is evident then that the congenital luxations form 
 a part of a large group of deformities, springing from a 
 common origin, and that they are only special manifesta- 
 tions of the same cause, which can be viewed in an isolated 
 manner, only abstractly, and in relation to the different 
 determinate portions of the skeleton which they occupy. 
 
ETIOLOGY. 67 
 
 "The anatomical circumstances which accompanj the 
 
 two facts, the existence of which ice have just established, 
 viz. the absence, more or less complete, of the nervous 
 centres on one part, and the shortening (raccourdssement ) 
 of the muscles on the other, fully demonstrate that tin 
 fust is the result of a pathologic process, and not of an 
 arrest in the development, as most modern authors have 
 thought ; and that the second is not the result of a retrac- 
 tion, cither passive or consecutive. 
 
 "In the fust place one may be assured, by the compa- 
 rative study of those monstrosities, where a greater or 
 less portion of the brain or of the spinal marrow has dis- 
 appeared, that the absent portion of the nervous pulp has 
 real!} existed, but that it has been removed by means of 
 gradual destruction. Without doubt, if we confine our- 
 selves to determine this fact from a foetus completely 
 anencephalous, it would be difficult perhaps to demonstrate 
 rigorous!} (he anterior existence of this morbid process, 
 of which the principal traces may have more or less dis- 
 appeared for a long time. But if you consider that the 
 specimens and the plates, now under view, show all the 
 degrees of destruction of the nervous centres following in 
 a decreasing series, which commences at the complete dis- 
 appearance of the encephalOn and the spinal marrow, and 
 closes with a simple lesion of the membranes, vou will 
 easily understand bj what chain of facts and of indue- 
 
68 ETIOLOGY. 
 
 tions I have been enabled to establish rigorously, the 
 reality of this destruction in those cases, where we no 
 longer find the union of all the characters which apper- 
 tain to it. In the second place, the retraction of the 
 muscles maintaining the articulation displaced, has specific 
 characters which enable it to be distinguished from the 
 consecutive retraction. Thus the muscles are not, as in 
 this last case, shortened merely within the limits of the 
 physiological contraction, and simply between their two 
 points of insertion. But on one part their shortening 
 surpasses by far the range of this contraction ; we see, for 
 example, in the same foetus the muscles of the spine and 
 the gastrocnemii, reduced to a third or a fourth of their 
 natural length ; on the other hand, they are in an extreme 
 state of tension, and the osseous parts upon which they 
 are inserted, or which they course along, are often the 
 seat of alterations, of avulsions, and even of fractures, in- 
 dicating that they have been subjected to considerable 
 violence. Independent of this tension, these muscles pre- 
 sent still, by reason of the more or less complete fibrous 
 transformation which they have undergone, an extreme 
 hardness, entirely in opposition to the soft consistence 
 which their fatty transformation gives to muscles short- 
 ened consecutively. Finally, the generality of the re- 
 traction in a great number of cases, and this remarkable 
 fact, that it takes place simultaneously and symmetri- 
 
ETIOLOGY. 69 
 
 call \ in the same articulations <>l both sides, lulK show 
 that ii is not consecutive, and cannoi be in anj manner 
 referred to external and local influences. 
 
 " Here then arc already established two orders of facts ; 
 the existence of the lesion of the nervous system, and 
 that of muscular retraction, considered in an isolated 
 manner. Now, the relation which directly unites these two 
 facts springs from the constant harmony which they pre- 
 sent in their different degrees of manifestation, and in 
 regard to the different portions of the nervous and of the 
 muscular system which they occupy. . . . When 
 besides there is harmony, harmony of seat, and har- 
 mony of degree, between the alterations of the cephalo- 
 rae Indian centre and the alteration of the muscles, it is 
 impossible not to admit an immediate relation between 
 them. This is constantly seen in cerebral pathology. 
 Now. then, this harmony exists in the case which we are 
 now considering. Examine the specimens which are be- 
 fore yon, and you will see in some of them, that tht luxa- 
 tions confined to the inferior extremities coincide with the 
 absence of the inferior portion of the Spinal morrow ; tlie 
 luxation* of th<" superior extremities with absena of the 
 superior portion ; and the luxation oj the members upon 
 oio side only, coinciding with the absence oj one half oj 
 the brain. And here 1 can onl\ give \ on rapid indications ; 
 but I have established a decreasing series of cases of luxa- 
 tions, subluxations, and pseudo-luxations, produced !>\ 
 
70 ETIOLOGY. 
 
 muscular retraction in its different modes of combination — 
 a series in which one may discover a very manifest relation 
 between the seat and the degree of the destruction of the 
 brain and of the spinal marrow, and the seat and the de- 
 gree of the deformities of which we are treating. The 
 specimens placed before you belong to this series, and 
 suffice already to establish the existence of this rela- 
 tion."* 
 
 M. Guerin has here crowded together a number of ge- 
 neralities which it would be difficult for him to support 
 by autopsic observations or physiological facts. In the 
 first place he has in no manner, except by assertion, 
 proved the anterior existence, and consequent disappear- 
 ance, of the cerebral structure, or controverted the doctrine, 
 now acknowledged, which admits the occurrence of arret 
 de develojjpement, or, in other words, of a hindrance in 
 the progress of the complete evolution of the ovum, 
 which evolution at the present day, as regards the nervous 
 system, is admitted to extend in the progress of develop- 
 ment from the periphery, as well as from the centre. 
 
 In the second place, the rigorous relation which he 
 has attempted to determine, as existing between destruc- 
 tion, partial or total, of the encephalon and the medulla 
 spinalis, and certain correlative deformities, is proved by 
 numerous observations to be fallacious.f It is a paradox 
 
 * Guerin, Memoir read before the Academy of Sciences, 
 f Vide Cruveilhier, Anatomie Pathol. 
 
ETIOLOGY. 7 I 
 
 to s,-i\ thai morbid muscular retraction depends upon an 
 altered condition of the nervous centres, and at the same 
 time to assert thai the oervous centres, upon the verj ex- 
 istence of which the morbid muscular retraction depends, 
 have ceased to be present J have seen instances of the 
 existence of general deformities at the joints similar to 
 those mentioned by M. Guerin, and where the encepha- 
 lon and the spinal marrow were not present; but I can- 
 not understand how these deformities can be reasonably 
 referred to an altered action of the nervous centres, 
 which were found wanting, and which, to all appearance, 
 had not previously existed. In those instances that I 
 have seen, there was no reason to suppose that the ner- 
 vous centres had existed and afterwards been destroyed. 
 But supposing they had disappeared by means of a pa- 
 thological process of destruction, their influence would 
 cease with their disappearance, and the condition of things 
 would then be the same as if no brain or spinal marrow 
 had ever existed. 
 
 1 see no way of accounting for those deformations 
 which are met with at the articulations of the foetus, 
 where no evidences or traces of the cerebro-spinal cen- 
 tres are present, but by referring them to the effect of the 
 inherent contractile tonicity of the muscular system itself. 
 There would certainly be an analogy between deforma- 
 tions thus caused during foetal life, and those instances of 
 deformity arising from paralysis, having for their origin 
 
72 ETIOLOGY. 
 
 extensive destruction of the medulla spinalis. In this 
 latter case, the muscular tissue, deprived of the nervous in- 
 fluence derived from the medulla spinalis, acts indepen- 
 dently of the nervous centres ; and its inherent contrac- 
 tile tonicity predominating, as is the case in health, in 
 the flexor muscles generally, determines the consecutive 
 deformity, in the direction of the action of this set of 
 muscles. It is so also with those monstrosities I have 
 just mentioned, for the deformities present in them, were 
 generally manifested in the direction of the action of 
 the flexor muscles. 
 
 In regard to the other statement, that the absence of 
 the inferior and superior portions of the medulla spinalis, 
 and of specific portions of the brain, is followed by defor- 
 mities, or by dislocations at specific articulations, I have 
 merely to remark, that pathological observations do not 
 corroborate the assertion. Besides the instances which 
 have come under my own examination, the cases reported 
 by Cruveilhier and others go directly to prove, that no 
 such relation, as that upon which M. Guerin founds his 
 theory, exists. 
 
 If the total or partial absence alone of the nervous 
 centres were the invariable cause of congenital deformi- 
 ties, then they must occur as an invariable sequent, when 
 this absence of the nervous centres takes place, and in 
 proportion also to the greater or less disappearance of the 
 nervous substance. In other words, there could be no 
 
ETIOLOGY. 73 
 
 congenital displacements without absence of some portion 
 of the central nervous system, nor could there be any 
 foetal anencephalous monstrosities, without the existence 
 of numerous luxations <>r subluxations. 
 
 As soon as the correlation of circumstances, reported 
 by M. Guerin, is found to be at variance with facts, the 
 generalization he has adopted, must be pronounced falla- 
 cious. Now, anencephalous foetal monsters are to be 
 met with, in which no dislocations of the articulations are 
 present, and it is no uncommon event to see congenital 
 dislocations attributable to muscular retraction — not only 
 of the hip-joints, — but also of many of the other articula- 
 tions, without any palpable absence of the nervous 
 centres. 
 
 Thus, in those cases I have to relate hereafter, and 
 from which I have had the drawings taken, there was no 
 absence of the nervous centres apparent, nor in the cases 
 related by Palleta and Dupuvtren, is the absence of any 
 portion of the spinal marrow or of the encephalon al- 
 luded to. 
 
 The physiology of the nervous system, and its influ- 
 ence over muscular contraction, will nevertheless induce 
 the inquirer to look to the centres of this system as the 
 source, whence is radiated the pathologic influence, which 
 manifests itself in the muscles, in the form of morbid 
 muscular retraction, and upon which probably depend 
 many congenital dislocations, and among them the dislo- 
 
 6 
 
74 ETIOLOGY. 
 
 cation of the head of the femur from the cotyloid cavity. 
 This doctrine is the most philosophical among the vari- 
 ous theories which have been brought forward to account 
 for the displacement, and seems to be corroborated by 
 physiological induction. 
 
 The nervous centres of the cerebro-spinal axis are 
 composed essentially of a grey or cineritious matter, 
 which forms the ganglionic part, and the white fibrous or 
 tubular structure, which is more or less intimately con- 
 nected with the former. The physiology of the present 
 day teaches us, that the grey material or ganglionic 
 structure, is the source from which enervation emanates, 
 and that the fibrous or white matter is the conducting 
 medium, by means of which the various functions of 
 sensation and motion, whether voluntary, involuntary, or 
 consensual, are carried on. The cephalo-rachidian mass 
 is formed by an aggregation of the fibres of the white 
 tubular nervous substance, into a large nervous cord, 
 composed of several columns or strands, which ascend, 
 under the name of the medulla spinalis, through the osseous 
 canal formed by the several vertebrae. Most of the 
 fibres of these strands, emerging from the medulla oblon- 
 gata, traverse successively, from behind forwards, 
 the pons varolii, the tubercula quadrigemina, the optic 
 thaiami, and the corpora striata, and are then radiated 
 in the cerebral lobes ; while some pass to the cere- 
 bellum. Interspersed in different directions, and bear- 
 
ETIOLOGY. 75 
 
 ing certain anatomical relations to the white fibrous 
 structure, the vesicular grej matter is found, forming the 
 several ganglionic centres, which, in conjunction with 
 this white fibrous structure, are subservient to the per- 
 formance of the several functions peculiar to the cerebro- 
 spinal system. These various fundamental parts, besides 
 the decussations which take place in certain directions, are 
 more intiinatelj connected by another set of while fibres, 
 which are called commissures, and which run in such a 
 direction as to form various communications between 
 the different parts of the brain, hut chiefly between the 
 analogous organs of one side with those of the other. 
 
 Commencing above, we find the cerebral hemispheres 
 covered h\ the hemispherical ganglia,* holding a close re- 
 lation with intelligence,* and other psychological pheno- 
 mena. These lie above the grey matter of the corpora 
 striata and of the optic thalami, as well as above the ganglia 
 which arc in immediate connexion with the organs of 
 special sense; the medulla oblongata furnishes ganglionic 
 centres for the movements of respiration, mastication, and 
 deglutition ; from the upper portion of the medulla oblon- 
 gata the cerebellum shoots oflf, supplied with its cineri- 
 tious mailer; and lastly, a continuous track of grey OF 
 cineritious matter, analogous to the chain of the locomo- 
 tive ganglia in the articulata, is found extending the whole 
 
 ■ Hemispherical ganglion i> the term applied by Mr. Solly i" the oineritioua mai- 
 tor capping the een bra! hemispheres. 
 
76 ETIOLOGY. 
 
 length of the medulla spinalis, invested by the white fibres 
 of the tubular structure. 
 
 Besides contributing to the performance of certain other 
 functions, most of these various cineritious deposits or 
 ganglia are the centres of a class of exceedingly important 
 phenomena in the animal economy, which in lat- 
 ter times have been denominated the excito-motory 
 or reflex functions of the nervous system* Certain 
 reflex movements are admitted by some modern physiolo- 
 gists to emanate from the ganglia contained in the cra- 
 nium ; but the medulla spinalis is undoubtedly the centre 
 of the excito-motor functions manifested in the organs 
 of locomotion. 
 
 The peculiarity of the healthy nervous action, termed 
 reflex, consists in the occurrence of muscular movements or 
 contractions, as the sequent to impressions, not involving 
 sensation or consciousness, and taking place through the 
 medium of a set of incident-excitor nervous fibres, and 
 another set of reflex-motor nervous fibres, both of which 
 are in connexion with the cineritious ganglionic mass, 
 acting as the centre of the excito-motor circuit. 
 
 Examples of muscular movement, entirely independent 
 of volition or of sensation, are presented in the experi- 
 ment upon a frog which has been decapitated ; the spinal 
 marrow being left uninjured. In such a case, if the pat 
 
 * This class of motor functions, independent of sensation, was known to Pro- 
 chaska. The writings of Dr. Marshall Hall and of Miiller have, however, greatly 
 elucidated this subject in more recent times. 
 
ETIOLOGY. 77 
 
 of the frog be touched with citric acid, or any other suf- 
 ficientrj powerful irritant, the animal will evince muscular 
 contraction of the limb, as if from volition. 
 
 The medulla spinalis, viewed as the centre of the spinal 
 excito-motor system, offers other points for consideration 
 in regard to its extensive connexions. 
 
 The thick cord which composes this portion of the 
 cerebro-spina] axis, is distinctly a double tract, although 
 united by numerous commissural bands, and is divided 
 into two equal parts by an anterior median and a poste- 
 rior median fissure. Each half is again subdivided into 
 two columns — a posterior and an antero-lateral column — 
 forming the strands for sensation, and for motion. 
 
 On each half of the spinal column three furrows are 
 observed , one, called the posterior intermediate furrow, 
 which commences on the outside of the small protube- 
 rance adjoining the nib of the calamus scriptorius, and 
 terminates towards the middle of the dorsal portion of 
 the medulla spinalis ; another, situated a little outside of 
 the preceding, called the postero-lateral furrow, extend- 
 ing the entire length of the spinal cord ; and the third, 
 extending the same length, called the antero-lateral furrow, 
 situated a little external to the anterior median fissure. 
 From these last two lateral furrows, on each side, spring 
 the several spinal nerves, which are distributed to the 
 organs of locomotion. All the spinal nerves* emanate 
 
 * The lir.-t spinal or sub-occipital nerves sometimes arino by a single B8t <>t FOOtay 
 from the motor columns. 
 
78 • ETIOLOGY. 
 
 from the cord by two roots ; an anterior, subservient to 
 motion, which is seen to emerge from the antero-lateral 
 furrow, and a posterior, subservient to sensation, which is 
 implanted in the postero-lateral furrow. Upon the poste- 
 rior root, at the intervertebral foramina, a ganglion is 
 formed, immediately external to which, the two roots in- 
 terlace, and unite into one cord, whence result the several 
 branches which pass onwards to their ultimate distribution. 
 In tracing the roots of the spinal nerves into the sub- 
 stance of the medulla spinalis, we find that each root 
 becomes connected by some of its fibres with the peaks 
 which the cineritious matter of the cord forms, in approxi- 
 mating the antero-lateral and postero-lateral furrows on 
 each side. The course and direction which the other 
 nervous fibres take, after their junction with the cord, has 
 not been clearly demonstrated in man, although from 
 physiological analogy they no doubt become continuous 
 with the white fibres of the spinal strands, and ascend- 
 ing with them, communicate with the encephalon.* 
 
 * Vide Grainger, Observations on the Structure and Functions of the Spinal 
 Cord. 
 
 The anatomical connexion between the spinal cord and the roots of the rachidian 
 nerves is a point of much interest, both in a medical and chirurgical 
 point of view. From dissections made by Mr. Newport of some of the 
 Articulata, it would appear " that of the fibres, constituting the roots, by which 
 the nerves are implanted in the ganglia of the ventral cord, some pass into the vesi- 
 cular matter of each ganglion, and aftei coming into relation with its vesicular sub- 
 stance, pass out again on the same side ; while a second set, after traversing the vesi- 
 cular matter, passes out by the trunks proceeding from the opposite side of the same 
 
Etiology, 79 
 
 From this cursory statemeni it will be seen thai the 
 spinal column, besides the component parts aecessarj for 
 the transmission of sensation and of voluntan motion, 
 has in its composition the structural elements necessary 
 for the performance of the excito-motor functions. Thus, 
 there arc the longitudinal whiir fibres ascending towards 
 the encephalon; next, invested by these, is found the 
 crescentic-shaped grey ganglionic mass; and in direct 
 connexion with this cineritious nervous pulp, arc the 
 fibres appertaining to the double roots of the .spinal 
 nerves, some of which fibres join the ascending strands, 
 and subserve volition ; while others terminate more 
 abruptly, and are subservient to the incident -excitor and 
 reflex-motor action of the medulla spinalis. 
 
 It is a well ascertained fact that the posterior root of 
 the spinal nerves is the structure, by means of which 
 impressions are conveyed centripetally to the nervons 
 centres, and also that the anterior root is subservient to 
 the excentric or motor functions which take place in the 
 
 ganglion ; and a third Bel runs along a portion of the cord which connects the gan- 
 glia nt' different segments, and enters the nervous trunks thai issue from them, at a 
 distance of one or more ganglia above or below. Thus it appears, thai an impression 
 conveyed by an afferenl fibre to any ganglion, ma] ex< ite a motion in the muse! 
 the Bame Bide of its own segment ; or in those of the opposite si>lo ; or in those oi 
 ments at a greater or [ess distance, according to the poinl at which the efferent ; 
 
 leave tin- cord." This arrangement has not hitherto been discovered m man, 
 
 but physiological facta would induce the belief of a similar arrangement, which 
 
 would account anatomically for man] of the complex phenomena of reflex a< i. — 
 
 Vide Carpenter'* Physiology, and Newport, in Philosophical Trah9oction$,fm 16 19 
 
80 ETIOLOGY. 
 
 muscles, as the result of impressions. These facts are 
 determined by what follows upon the section of the two 
 roots of the spinal nerves. Thus, after the section of 
 the posterior root, if an irritant be applied to the remote 
 divided end, there is no manifestation of sensation ; while, 
 if it be applied to the divided end near to the cord, the 
 animal will show evident symptoms of pain. The con- 
 trary effect is observed when the anterior root is divided ; 
 in that case muscular contractions follow the application 
 of the irritant to the remote divided extremity of the 
 nerve, while no manifestation is made when the stimulus 
 is applied to the divided end next to the cord. 
 
 Here we have an afferent set of fibres which convey 
 impressions to the central nervous system, and another 
 set of efferent fibres, conveying thence the motor impulse 
 to the muscles. There is no doubt that many of the 
 sensations and manifestations of voluntary motion ascend 
 to, and descend from, the encephalon, along the spinal 
 strands ; but there is another set of muscular motions 
 which are not attended by consciousness, and are wholly 
 independent of the will. With the exception of those 
 involuntary movements depending upon the influence of 
 some of the inter-cranial cineritious masses,* the class of 
 
 * The reflex functions of the medulla oblongata, which is viewed merely as a pro- 
 longation of the medulla spinalis, are comprised in the spinal excito-motory system, 
 a; recogm-ed by Dr. Marshall Hall. But Miiller has gone further, and applied the prin- 
 ciple of reflexion which takes place from the sensorial nerves upon the motor nerves, 
 through the medium of the encephalic ganglionic masses, to the theory of all automa- 
 tic movements consequent upon sensations. — Vide Miiller, Physiolog. Nerv. Syst. 
 
ETIOLOGY. 81 
 
 involuntary movements are dependent for their exercise 
 upon the medulla spinalis. The grej cineritious mass of 
 the spinal cord is the centre or source of enervation of 
 these movements which are unconnected with volition; 
 and those fibres of the various nerves that are in direct 
 connexion with it, are the Lncident-excitor and re Ilex- 
 motor conductors, which, by their junction with the grey 
 ganglionic mass of the medulla spinalis, form the true 
 spinal excito-motory system. 
 
 The experiment of the decapitated frog, already alluded 
 to, will serve to illustrate this principle. The head heing 
 removed, the iufluence of volition is at an end. But 
 v\ hen the pat is irritated by the application of an ignited 
 match, or any other efficient irritant, muscular contraction 
 immediately takes place, and an apparently voluntary 
 effort is made to escape from the effects of the irritant. 
 If, however, the integrity of the spinal marrow he de- 
 stroyed l>\ passing a wire down the vertebral canal of 
 the animal, no irritant, however powerful, applied to 
 its foot or its cloaca, will excite any muscular movement 
 
 Again, as is observed in the human subject, in cases of 
 accidental fracture of the vertebra-, with serious lesion of 
 tin' spinal marrow of the dorsal region, both voluntary 
 motion and sensation are entirely destroyed in all the 
 parts below the point of the solution of continuity. 
 Notwithstanding the isolation of the interior portions of 
 the boil\ from the encephalon, reflex movements can be 
 
82 ETIOLOGY. 
 
 excited in the limbs by irritants applied to the feet, the 
 anus, or any other part of the surface below the injured 
 point. Here we have the manifestation of the normal 
 reflex action of the spinal cord. The excito-motor circle 
 is brought into play by the afferent conducting fibres, 
 which convey the impression to the ganglionic centre. 
 Thence, by means of the efferent set of fibres, the impres- 
 sion is again transmitted to the locomotor muscles, which 
 consequently are thrown into a state of contraction. 
 
 The examples of the influence of the healthy excito- 
 motory functions of the spinal cord over certain actions of 
 the muscular system are numerous, but it is unnecessary 
 at present to draw upon them for further illustration. 
 Enough has been said to exhibit the principle upon 
 which a large class of normal muscular phenomena 
 depends. 
 
 Notwithstanding the assertion, already commented upon, 
 of M. Guerin, that absence of the brain and spinal mar- 
 row are the essential antecedents to the production of 
 congenital dislocations, I am inclined to believe that their 
 origin must be accounted for in a different manner; 
 and that derangement of the functions of the spinal 
 excito-motor system must be regarded as the true cause 
 of those congenital dislocations, which are the result of 
 morbid muscular spasmodic contraction ; and it is to that 
 source I would attribute the dislocation of the hip-joint 
 occurring to the child while still in utero. 
 
ETIOLOGT. 
 
 The peculiar functions of the excito-motor apparatus, 
 like the functions of the other portions of the nervous 
 system, may become perverted or disturbed by pathologi- 
 cal influences, ft is probable that all spasmodic convul- 
 sive muscular movements, taking place in the different 
 parts of the body, originate from the same principle, 
 whether from reflex action of the spinal marrow, of the 
 medulla oblongata, or of the nervous apparatus in con- 
 nexion with the encephalic ganglia. 
 
 Examples of this perverted function of reflex action 
 are met with in the symptomatic phenomena which are 
 to he observed in tetanus, hydrophobia, epilepsy, &c. 
 
 It is to a morbid condition, then, of th^ reflex function 
 of the spinal cord that the peculiar tonic spasmodic 
 niraction of the muscles should he referred, which, either 
 during intra-uterine or extra-uterine life, is sometimes seen 
 to pervade the entire muscular system,* or at others to show 
 itself, by attacking in an isolated manner, a single set of 
 muscles only, or within still narrower limits, by being con- 
 fined to a few muscular fasciculi. 
 
 When the antagonistic muscles are equally affected, so 
 
 * A case was shown me, while in London, by Mr. Tamplin, the eminent surgeon 
 of the Orthopaedic Institution, which exhibited in a remarkable decree this morbid 
 tonic spasmodic muscular retraction. All the muscles "f locomotion were aflected, 
 bo thai the trunk and limbs of the patient, a lad a^k-A about fourteen, wew in ■ 
 <>f absolute rigidity. The differenl Bets of muscles, however, in this instance • 
 equally aflected, bo thai the flexors and the extensors antagonized each other, and 
 [uently there was no deformity of the articulations. 
 
84 ETIOLOGY. 
 
 that an equilibrium is still maintained, the relations of the 
 articulating surfaces of the joints to each other are not 
 disturbed ; but in those instances where the retractive 
 spasmodic influence appears to be particularly concen- 
 trated upon one set of congener muscles, luxations or sub- 
 luxations are likely to occur. 
 
 Muscular spasmodic retraction, resulting from a per- 
 verted state of the excito-motor apparatus, may take place 
 from irritation, whether localized at the periphery, or at 
 some point along the course of the afferent or incident- 
 excitor nervous fibres ; or it may show itself, when the 
 irritation is localized in the central ganglionic mass itself 
 of the spinal co^l ; or it may result from this nervous centre 
 being in a state abnormally susceptible to impressions. 
 In this latter -condition, a morbid train of reflex muscular 
 movements is put into operation upon the occurrence of 
 some trivial irritation of the afferent nervous fibres, which 
 are proceeding towards the ganglionic centre of the cord. 
 From the ganglionic centre, the morbid impression is ulti- 
 mately transmitted to the muscles, through the agency of 
 the reflex-motor nervous fibres. 
 
 Whether the irritation is primarily located in the central 
 grey substance of the medulla spinalis, or is conveyed 
 there by ni£ans of the incident-excitor fibres — whose 
 function it is to convey impressions to it — I believe it is 
 absolutely necessary that this ganglionic focus of enerva- 
 tion should be morbidly impressed, before the muscles 
 
ETIOLOGY. 85 
 
 supplied l>\ the reflex-motor nervous fibres can be thrown 
 into convulsn e spasm. 
 
 I should say, then, that the congenital displacements, 
 
 occurring at the ilio-femoral articulation, result from active 
 morbid muscular retraction ; that morbid muscular retrac- 
 tion itself is to be traced to a morbid condition of the 
 central ganglionic mass of the cord ; and that this patho- 
 logical condition is either located in the ganglionic mass, 
 or convened thither by the incident-excitor nervous influ- 
 ence of the excito-motor apparatus of the medulla spinalis. 
 
 When the shallow condition of th" acetabulum, and 
 the flexed position of the thighs of the foetus in utero — 
 causing the head of the femur to press continually against 
 the depressed lip of the acetabulum — are considered, it 
 will not be difficult to comprehend the facility with 
 which the head of the femur may escape from the coty- 
 loid cavity, if the glutei muscles and the other pelvi- 
 leinoral muscles are thrown into a state of spasmodic mus- 
 cular retraction.* 
 
 It is probable, in congenital dislocation of the hip-joint, 
 that the cineritious substance of that portion of the me- 
 dulla spinalis, in direct relation with the reflex-motor 
 nervous fibres which are distributed to the glutei and the 
 other pelvi-femoral muscles, is the implicated point, from 
 which the morbid impressions radiate, that ultimately 
 affect the muscular tissue. 
 
 • vat tlate hi. 
 
86 ETIOLOGY. 
 
 The numerous incident-excitor nervous fibres which 
 are connected with the cord, the extensive communications 
 existing between the various portions of the nervous 
 system by means of the longitudinal fibres of the spinal 
 strands and of tbe commissures, and the decussa- 
 tions which take place in certain directions, will serve to 
 explain the facility with which impressions, arising from 
 irritation located at a distance, may be conveyed towards 
 certain points of the ganglionic portion of the nervous 
 centres. 
 
 What this particular source of irritation or pathologic ac- 
 tion — the necessary antecedent of morbid muscular retrac- 
 tion — may be, it is not easy to determine strictly. W hether 
 it amounts to inflammation; or to ramollissement ; or to 
 vascular congestion of the cineritious matter, or of the 
 white structure in contiguity with it; or simply to what 
 is called nervous irritation, caused by pressure or 
 otherwise ; or whether it depends upon an abnormal 
 accumulation of nervous fluid, • which by some has 
 been supposed to be as nocuous in regard to the 
 nervous substance, as the accumulation of biood in an 
 inflamed tissue is to the several structures of the body ; 
 or whether from some poisonous condition of the biood — 
 the nervous tissue bathed by this fluid as it circulates 
 becoming morbidly impressed ; — or whether an imperfect 
 development of a portion of the medulla spinalis, or an 
 atrophy of it, be essential, in producing tliis disturbance of 
 
ETIOI.OOV. 87 
 
 the exsito-motor apparatus, are points which can onlj 
 with grea! difficulty be decided in a rigorous manner. 
 
 A.cute spasmodic, muscular affections ma\ have various 
 remote or ultimate causes for their, production,* and ii is 
 not improbable thai the sources of irritation above enu- 
 merated may at times act singly or conjointly, in arousing 
 the more chronic form of spasmodic contraction, which 
 shows itself in a tonic rigidity and retraction of the mus- 
 cular tissue. 
 
 Pathological facts, then, will not sustain the theory, 
 which supposes mere ahsence of the nervous centres to 
 be the invariable cause of the spasmodic muscular retrac- 
 tion, upon which congenital displacements depend, 
 Neither will facts derived from physiology induce this 
 belief. Thus, if M. Guerin's assertion were true, that all 
 anencephalous foetal monsters present numerous luxations 
 throughout the body, and that these are in proportion to 
 the quantity, and in relation to the part of the brain, which 
 is wanting, we should be led to believe that convulsions 
 and spasmodic muscular movements would be produced 
 by removal of the brain from an animal in the experi- 
 ment of vivisection. 
 
 That this is not the case any one may determine bj 
 removing, for example, the cerebral lobes of a pigeon, leav- 
 
 mplee of this kind are the spasmodic muscular contractions which follow 
 tin- exhibition of Strychnine, — occur in Traumatic Tetanus, — in Idiopathic Tetanus, 
 — result from the rinu of Hydrophobia, &c. 
 
88 ETIOLOGY. 
 
 ing, however, the nervous apparatus of respiration, and of the 
 other animal functions, intact. The animal thus treated, 
 not only manifests no symptoms of convulsive muscular 
 movements, but the muscles of respiration act normally 
 for several days, and even the functions of walking and 
 flying can be induced by pushing the animal onward, or 
 by throwing it upward in the air ; no evidences of spasm 
 or of irregular muscular action being apparent. 
 
 After the examination of these various theories, I shall 
 conclude these etiologic remarks by saying, that it appears 
 most in accordance with science to refer the muscular spas- 
 modic retraction, upon which congenital dislocation of the 
 head of the femur from the cotyloid cavity depends, to a per- 
 verted condition of the excito-motor apparatus of the me- 
 dulla spinalis, and more especially of that portion of it 
 which is in direct relation with the reflex-motor nervous 
 fibres, distributed to the pelvi-femoral muscles surround- 
 ing, and in connexion with, the ilio-femoral articula- 
 tion. 
 

EXPLANATION OF PLATE No. [V. 
 
 ioi view of Double Congenital Di location of th< Head of both I 
 upon the dorsum of the Ilium. 
 
 6. Trochanter Major. 
 
 ,-. ( )- Coccygis tilted upwards and backwards. 
 
 d. The Lumbar Region curved forwards by the traction of the Psoas Mus< 
 
 j. The fold between the buttock and thigh. 
 
 /". The Feel — directed forwards. 
 
 The case from which plates Nos. i., ii., and iv., wore taken, came under mj 
 i while I was temporarily in London. 
 Irawing was taken by Mr. Kearnej [lent draughtsman, attached tu 
 
 St. Thomas' Hospital as Curator of thi museum. 
 
 ons of that hospital expressing ad the case, as they were 
 
 not acquainted with this form of dislocati f the hip-joint, I sent the lad i''>r their 
 
 examination. Mr. South, our of the eminent surgeons attached to St. Thon 
 urred s\itii me in my d i te to permit a full lenj 
 
 I iorti I this ca e in th I 
 1844, an abstract of which will be found in the following chapter. 
 
91 
 
 CHAPTER IV. 
 
 SYMPTOMATOLOGY OF CONGENITAL DISLOCATION OF THE 
 HEAD OF THE FEMUR UPON THE ILIUM. 
 
 The symptoms accompanying congenital dislocations 
 of the hip-joint necessarily vary in intensity, according to 
 the age of the individuals that may he thus affected, or 
 the progress which the malady may have made towards 
 its extreme development. In the infant it may readily he 
 supposed that the pathognomonic signs are not so dis- 
 tinctly marked as in after life, when a combination of 
 causes, such as the superincumbent weight of the body 
 acting during progression, the physiological contraction of 
 the muscles, and their imperfect development consequent 
 upon their altered action and relations, have been exerting 
 their influence for many years. The evidences of the 
 existence of this displacement are, however, sufficiently 
 characteristic, at all ages, to enable the practitioner ac- 
 quainted with this subject to avoid making an erroneous 
 diagnosis. 
 
 In describing the displacement at the hip-joint, now 
 
92 SYMPTOMATOLOGY. 
 
 under consideration, which, if not arrested or remedied in ' 
 the early stages of life, is generally progressive in its 
 course, I have preferred to delineate the symptoms as they 
 are presented towards the period of puherty or adoles- 
 cence, presuming that the general characters when once 
 known, as they appear in a marked degree of develop- 
 ment, could not easily be mistaken when met with in a 
 form less distinctly defined. 
 
 As has previously been remarked, the head of the 
 femur may be dislocated from the acetabulum in several 
 directions. We shall pass over, however, those variations 
 which occur in monstrosities only, and direct our atten- 
 tion to that form of displacement which is met with in 
 practice, and in which the head of the femur is found 
 upon the ilium, immediately above and behind the coty- 
 loid cavity, or completely upon the dorsum of the ilium, 
 according to the stage at which the examination of the 
 luxation may be made. 
 
 The congenital dislocation upwards, and outwards 
 upon the ilium, is found at times to be present simulta- 
 neously in the same individual, on both sides. In other 
 instances the luxation exists on one side only. 
 
 The changes which have taken place in cases of this 
 dislocation can be best studied by observing the malfor- 
 mations which are seen upon inspecting the patient 
 when entirely stripped of clothing ; by tracing the altered 
 relations of the component parts of the ilio-femoral arti- 
 
81 MPTOM ITOLOG1 ■ 93 
 
 dilation, discoverable by manual examination; and by 
 regarding die functional disturbance occurring at the 
 joint itselfj in reference to its various movements. 
 
 Double Congenital Dislocation of the Femur 
 
 i pon the i:.M m. — When the dislocation is on both sides, 
 as is mosl frequently the case, the deformity is often 
 symmetrical. Both of the inferior extremities m;i\ have 
 the same development and length, but the body being 
 generally well formed, a marked disproportion is seen to 
 exist between the relative height and size of the trunk, 
 and the apparent shortness of the lower limbs. 
 
 Upon viewing- an. adult person while in the erect pos- 
 ture, affected with this kind of double luxation of the 
 femur upon the ilium, the curvature forwards of the lum- 
 bar region, and the convexity which the anterior wall of 
 the abdomen presents, are apt to be among the first 
 characteristic features of the disease, which attract the 
 attention of the surgeon. The pubic region appears to 
 
 he tilted forwards and downwards, while the lower part 
 of the trunk appears to have sunk down between the 
 upper portion of the thighs; and this last circumstance, 
 which actually takes place on account of the ascent of 
 the ossa femorum, gives to the aims the semblance of 
 being relatively too long, the extremities of the fingers 
 ranging sometimes nearly on a level with the upper mar- 
 gin of the patellae. \'i<l> Plates i. and n. 
 
94 SYMPTOMATOLOGY. 
 
 Both of the great trochanters project abnormally, and 
 are seen to have mounted considerably higher, so as to be 
 situated nearer than is natural to the crests of the ilia, 
 forming with the retracted muscles which surround them, 
 an unusual eminence, somewhat rounded on each side, at 
 the superior and lateral part of the hip, while the 
 lower and posterior portion of the nates is generally flat- 
 ter than in the healthy condition of this region. The 
 tuberosities of the ischia, carried outwards and more apart 
 from each other, are denuded of muscular tissue, and 
 covered only by the integuments. 
 
 The fold in the groins is deeper, its direction less trans- 
 verse and more vertical, and the usual niche between the 
 buttocks and the thighs is placed higher, and more curved 
 outwardly than it ordinarily is. 
 
 The whole of the inferior extremities, probably owing 
 to want of exercise, as well as to the imperfect develop- 
 ment, which takes place from defective nutrition, and 
 which manifests itself in the muscular and osseous tissues 
 in this affection, appear more slender than is observed in a 
 healthy individual. 
 
 The thighs sometimes retain their normal direction ; at 
 other times they take an oblique direction from above 
 downwards and inwards, forming with the leg, at the 
 femoro-tibial junction, an angle obtuse outwardly, while the 
 knee presents internally an unusually acute angular aspect. 
 
 Persons affected with this dislocation, when standing 
 
81 MPTOMATOLOGY. 95 
 
 erect in a passive state, can always, I believe, rest upon 
 t lie entire sole of the foot. In this posture the muscles 
 
 around the hip arc more relaxed than when put into eon- 
 traction, during the various exercises of progression or 
 locomotion, and the femurs are thus allowed to ascend to 
 their ultimate limit upon the iliac hones. 
 
 As a consequence of this ascent, the psoas magnus and 
 iliacus interims muscles of either side are put upon the 
 stretch, and draw forwards the lumbar and lower dorsal ver- 
 tebrae, and thus in the most marked degree can be seen the 
 unnatural excurvation of the loins with the correspond- 
 ing exaggerated convexity of the anterior region of the 
 abdominal parietes. Dupuytren says, " Us ne touchent le 
 sol que par la pointe des pieds." Observation, however, 
 goes to contradict this assertion of the celebrated French 
 surgeon. It would seem, in fact, that in the passive erect 
 attitude, the patient can rest fully upon the soles of both 
 feet; but, while the heel is descending to the ground, the 
 lumbar region becomes still more incurvated, owing to the 
 increased traction then exercised on both sides by the 
 tendons of the psoas magnus and the iliacus interuus. 
 
 The position of the patient remaining the same, the 
 toes are frequently directed straight forward, as exhibited 
 in the drawings,* a reference to which will aid materially 
 in following the verbal description given. Sometimes, 
 however, the posture of the individual varying, the feet 
 
 * Vide Plates i., ii., and iv. 
 
96 SYMPTOMATOLOGY. 
 
 may be turned outwards ; or inwards, as is the case in 
 the corresponding dislocation of traumatic origin. 
 
 One of the most characteristic differential signs of con- 
 genital dislocation of the head of the femur upon the dor- 
 sum iiii, is the disappearance, as soon as the patient is 
 placed horizontally on the back, of most of the symptoms 
 observable to the eye, when he is standing in the erect pos- 
 ture. The superincumbent weight of the trunk is then 
 removed, and the muscles around the articulation now per- 
 mit the great trochanters to descend to a nearly natural 
 position ; and as the small trochanters also approach their 
 normal situation, the psoas and internal iliac muscles 
 become relaxed, and thus the curvature of the loins, and 
 the corresponding convexity of the abdomen anteriorly, 
 become diminished or effaced. 
 
 By the aid of manual examination, signs are disco- 
 vered not less worthy of note than those which are 
 observed by mere inspection. If traction upon the limb 
 be exercised, so as to act from above downwards, the 
 limb becomes elongated, the head of the femur descends, 
 the great trochanter becomes more separated from the 
 crest of the ilium, and the projection they previously 
 formed, is found to have diminished ; while on the con- 
 trary, if force in an opposite direction is applied, that is, 
 from below upwards, the head of the femur does not meet 
 with resistance at the natural locality of the acetabulum, but 
 mounts with facility to its abnormal position upon the dor- 
 
81 MPT0MAT0L0G1 . 97 
 
 sum ilii. The evidences of this symptom have been denied, 
 and thej have been attributed to a want, of proper pre- 
 cau(ii)ii in fixing the pelvis, while the traction w;is made 
 upon one side; but iii those cases yhere the dislocation 
 exists on both sides, both limbs can be made to descend 
 at the same time, and often to the same extent, when 
 they are both simultaneously pulled upon. The only 
 exception to this symptom occurring, is when the head of 
 the lemur has escaped from the natural capsule in which 
 it was originally enclosed, and a new socket has been 
 formed upon the dorsum of the ilium ; after the man- 
 ner of those new formations, which occur as the 
 result of traumatic dislocations in this region. Under 
 these circumstances, it will naturally follow that the head 
 of the bone will be more or less confined in its new situa- 
 tion, and will be less influenced by motion imparted to it, 
 than when it simply reposes on the surface of the ilium, 
 unfettered by any adventitious osseous effusion in the 
 shape of a new receptacle or acetabulum.. ' 
 
 When the head of the femur exists, il* a motion of 
 flexion be given to the thigh upon the pelvis, the head of 
 this bone, instead ot turning upon its axis, will describe 
 an are of a circle, the centre of which w ill seem to be 
 at the union of the neck with the trochanter major 
 This sign, under some circumstances, may be of service, 
 but as the head and neck of the lemur are often stunted 
 and small, and sometimes even altogether removed during 
 
98 SYMPTOMATOLOGY. 
 
 the progress of the displacement, it must frequently be 
 inapplicable and deceptive. 
 
 When the head of the femur is in its natural position, 
 it can be felt by exploring the fold of the groin during 
 rotation of the limb outwards. In seeking after this sign, 
 the hand is made to grasp the upper and outer part of the 
 thigh, so that the thumb may be placed transversely in 
 the fold of the groin, a little external to the point where 
 the pulsation of the femoral artery can be felt. If a 
 movement of rotation be then given to the abdominal 
 extremity, the head of the femur, if it be in its natural 
 place, will be felt rolling under the thumb. The absence 
 of this sensation of a rounded body moving under the fin- 
 ger, as M. Pravaz remarks, is a certain sign of displacement. 
 
 In obscure cases, as may occur particularly in young 
 subjects, the diagnosis may be rendered more certain by 
 tracing a line — having first flexed the thigh upon the 
 pelvis, and given it a slight adduction — from the anterior 
 superior spinous process of the ilium, to the most salient 
 point of the tuberosity of the ischium. This line will, in 
 the normal position of the head of the femur, nearly cor- 
 respond with the summit of the trochanter major ; while 
 if the head be dislocated upwards and outwards, it will pass 
 over the central part, or more towards the base of this pro- 
 cess, according to the extent of the displacement. Vide 
 Plate v. 
 
 The functional derangements of the joint are made 
 
31 HPTOMATOLOQ1 . ■ l - ) 
 
 manifesl l»\ the peculiarities observable duriDg the differ- 
 ent acts of locomotion, and l>\ the confined or exagg 
 rated movements which the joint can be made to perform. 
 An adult person laboring under the effects of disloca- 
 tion of the heads of both femurs, presents peculiarities in 
 his gait during the diversified efforts of using the inferior 
 extremities, which are not to be met with in any variety of 
 lameness resulting from the other maladies occurring at 
 the hip-joint. In walking, owing to the want of fixed- 
 ness of the heads of the femurs, and the displacement 
 which they must undergo of alternate depression and ele- 
 vation, according as the weight of the body is transferred 
 from one inferior member to the other, and also owing to 
 the strain which is put upon the psoas and the internal 
 iliac muscles upon the side where, for the moment, the 
 weight of the trunk is thrown, a kind of double lameness 
 is produced, somewhat resembling the hobbling motion of 
 the duck. " The subjects so affected, when about to 
 commence walking, are seen to elevate themselves upon 
 the point of the feet, to incline the superior part of the 
 trunk towards the member which is about to support the 
 weight of the body, and to lift the other with an effort, 
 in order to brine it forward in advance. At this moment 
 one of the great trochanters — that which corresponds to 
 the column of sustentation — appears to become approxi- 
 mated to the crest of the ilium in a greater degree than 
 while standing upon both feet. From this mobility in 
 
100 SYMPTOMATOLOGY. 
 
 the vertical direction, oscillations of the trunk take place, 
 which render the walk as inconvenient as ungraceful. 
 These oscillations are often accompanied by a Crepitat- 
 ing sound loud enough to be heard at a distance of seve- 
 ral paces." 
 
 Contrary to what might have been anticipated, the 
 effects, resulting from the abnormal condition of the heads 
 of the femurs, after they have lost their natural support at 
 the cotyloid cavity, and have mounted on the dorsa of the 
 ilia, are less observable during the acts of running, leap- 
 ing, dancing, &c, than during simple or slow progression. 
 This can be accounted for, by the energetic contraction of 
 the muscles surrounding the hip-joints retaining the heads of 
 the femurs in a more fixed position during these quick 
 movements, and by the rapid transfer of the weight of the 
 trunk from one extremity to the other, which does not 
 allow time enough for the heads of the femurs — thus 
 somewhat solidly held by the muscles — to pass through 
 their accustomed range along the external surface of the 
 iliac bones. Protracted locomotion, however, of anv 
 kind is not borne well by individuals thus affected. The 
 strain upon the muscles, consequent upon their change of 
 direction and perverted action, the friction of the dis- 
 placed heads of the femurs upon the ilia, the coustant 
 efforts kept up in balancing the body during the acts of 
 progression, do not fail, if long continued, to produce the 
 sensation of fatigue and pain. 
 
 As regards the isolated movements, which cau be pro- 
 
SI MP rOM ITOLOOY. ]<il 
 
 ed .11 the ilio-femoral articulation ilms affected, bj im- 
 parting motion to it through the inferior extremity, 
 find that rotation can be performed without much impedi- 
 ment Extension and adduction are executed with faci- 
 lity; l>iit the limb can undergo abduction only to a slight 
 extent. Flexion can be produced with great ease, and 
 some instances arc related where the limb could be made 
 to touch the anterior part of the shoulder. 
 
 It should be recollected, in reference to the diagnosis of 
 i his displacement of the hip-joint, that these various move- 
 ments are not accompanied by pain, when moderation and 
 not more than the requisite force is used in the examina- 
 tion of the functions of the joint. 
 
 The extent of these movements may be somewhat 
 modi lied by the effusion of osseous matter upon the sur- 
 face of the ilium, around or in contiguity with the head 
 of the femur, as happens in those cases where nature has 
 attempted to form a new acetabulum. 
 
 Congenital Dislocation of the Femub dpok the 
 Ilium, on onl: side only. — When the dislocation <>1 the 
 head of the femur upon the ilium exists but on one Bide, 
 the general characteristics in reference to the affected arti- 
 culation, are the same as when the luxation is double. 
 
 During progression there is some deformity oi the ver- 
 tebral column*, which, on account of the shortness ol the 
 displaced extremity, and in order to bring the centre ol 
 
102 SYMPTOMATOLOGY. 
 
 gravity within the base of sustentation, is often inclined 
 laterally. The side of the pelvis, corresponding to the 
 affected articulation, is depressed. 
 
 The buttock inferiorly is more flat, while at the upper 
 and external part of the hip there is seen a rounded pro- 
 tuberance corresponding to the unnatural portion occupied 
 by the trochanter major. 
 
 The fold between the nates and the thigh of the abnormal 
 side is situated higher, and is directed more outwardly than 
 on the opposite side. 
 
 The inguinal fold is deeper and less transverse, and in 
 the female, the border of the vulva corresponding to the 
 luxated femur is slightly deflected, being carried upwards 
 and outwards. 
 
 The trochanter major, now much more prominent than 
 naturally, is seen to have mounted along the dorsum ilii, 
 and to have approximated the crest of this bone. The 
 limb is consequently shortened in proportion to the extent 
 of the ascent of the femur, and this may vary from a few 
 lines, to two or three inches, according to the age of the 
 patient and the duration of the displacement. 
 
 The affected limb has the appearance of having suf- 
 fered from defective nutrition, not being as large as the 
 other ; the flesh is also softer than that of the limb upon 
 the sound side. 
 
 In cases not complicated with other deformity, the 
 bones of the thigh and leg, measured together, offer but 
 
SYMPTOMATOLOGY. 103 
 
 little difference in length, in either extremity ; but in ap- 
 proaching the two members, the two anterior and supe- 
 rior spinous processes of the ilia being placed upon a 
 level, the malleolus interims of the affected side is found 
 to be situated higher than upon the sound side, and the 
 extent of the shortening of the limb will be greater or 
 less, according to the ascent of the head of the femur 
 upon the ilium. 
 
 The thigh is more oblique from above, taking a direc- 
 tion downwards and inwards, with a tendency to cross 
 the limb of the sound side, while the leg inclines in an 
 opposite direction, from above downwards and outwards, 
 presenting an angle more or less obtuse on the outer 
 aspect of the knee-joint. 
 
 The foot, in a state of extension to counterbalance the 
 defect resulting from the unnatural brevity of the limb, 
 generally rests upon the toes, but when the body is 
 inclined forwards, the sole of the foot may rest entirely 
 upon the ground, the toes being neither remarkably 
 inverted nor everted. When the sole of the foot rests 
 upon the ground, and the weight of the trunk is thrown 
 upon this side, the lumbar region of the vertebral column 
 is inclined laterally and forwards. 
 
 Manual examination discovers the same characteristics 
 appertaining to the dislocation on one side, as have already 
 been noticed as accompanying the double luxation. If 
 the hand is applied behind the trochanter major, and 
 
104 SYMPTOMATOLOGY. 
 
 movements of flexion and extension be imparted to the 
 thigh, at the time of flexion, the head of the femur will 
 be felt impressing itself upon the hand. In these move- 
 ments, the head of the femur is felt describing the arc of 
 a circle from above downwards, instead of pivoting upon 
 itself as it does when situated in the acetabulum. 
 
 In searching by pressure, along the inguinal fold and to 
 the outer side of the femoral artery, for the head of the 
 femur while the thigh is rotated, instead of a rounded 
 body rolling under the fingers, a vacuity is felt which indi- 
 cates the absence of the head of the thigh from its natu- 
 ral situation. 
 
 If the patient be laid on the back, the lateral inflexion 
 of the spine becomes less marked, or disappears, and the 
 limb can be pushed upwards, so that the upper part of the 
 femur can be felt within a short distance of the iliac crest, 
 or it can be pulled downwards, so as to be about the same 
 length as the sound limb. 
 
 After flexing the thigh upon the pelvis, and slightly 
 adducting it, as has already been observed when speaking 
 of the double dislocation, if a line be drawn from the 
 anterior superior spinous process of the ilium to the most 
 prominent part of the tuberosity of the ischium, and the 
 summit of the trochanter major is found to surpass supe- 
 riorly this line, the dislocation of the head of the femur, 
 upwards, may be supposed with great certainty to have 
 taken place. This sign is useful in detecting the presence 
 
SYMPTOMATOLOGY. ' L05 
 
 of the single congenital dislocation, the diagnosis of which is 
 generally more difficult than in the double form of tliis 
 displacement 
 
 While in the erect posture, the patient, suffering from 
 single congenital luxation of the femur, is apt to rest the 
 toes of the affected limb upon the ground, in order to 
 compensate for its defective length. When, however, the 
 sole is entirely placed upon the ground, the sound limb, 
 being then the longer, becomes flexed at the knee, and 
 the psoas and the iliacus muscles in this position of the 
 foot, pulling forwards the lumbar vertebra? towards the 
 affected side, twist the trunk, which is also thrown back- 
 wards, and cause the region of the loins to be excur- 
 vated, and the abdomen anteriorly to become correspond- 
 ingly convex in appearance. 
 
 As a consequence of the un fixedness of the head of 
 the femur, and the tractions exercised by the psoas mag- 
 nus and iliacus internus muscles of the affected side, the 
 trunk of the patient, in the act of walking, is inclined 
 at first towards the side where the luxation exists, the 
 flank of the same side becomes curved forwards, and a 
 movement of alternate depression and elevation of the 
 hip takes place, producing a peculiar postcro-lateral lame- 
 ness. 
 
 When the patient, resting upon the displaced mem- 
 ber alone, attempts to leap, he finds it almost impossi- 
 ble to do so owing to the absence of a point (Tappui for 
 
 8 
 
106 ' SYMPTOMATOLOGY. 
 
 the head of the femur, and on account of the mutations 
 which, during the effort, take place in the relative position 
 of the component parts of the ilio-femoral articula- 
 tion. 
 
 The different movements which take place at the 
 abnormal articulation, in regard to their extent, direction, 
 and freedom, are analogous to those which have been 
 noticed while considering the symptoms of the double 
 congenital dislocation of the hip-joint, and need not be 
 again repeated. 
 
 In connexion with this account of the symptoms of 
 congenital dislocation of the head of the femur upon the 
 ilium, I have made an abstract of a case I published ori- 
 ginally in the London Lancet in 1844, in which the 
 characteristics of this affection, as presented in the double 
 form, were exceedingly well marked, and which being free 
 from the complications that often accompany this displace- 
 ment, I insert here, as being well adapted to illustrate 
 the symptomatology of this dislocation in the adult. 
 
 " The affection of which I propose at present to speak, 
 I consider to consist in a transposition of the head of the 
 femur from the cotyloid cavity upon the external iliac 
 fossa of the os innominatum, occurring during intra- 
 uterine existence, generally not so fully manifested in 
 the early period of childhood as it becomes in adult 
 age, when some of the symptoms attendant upon it are 
 peculiar, and the displacement greater and more marked 
 
SI MPTOMATOLOGY. J07 
 
 than in the usual luxation of this character resulting from 
 external injury. 
 
 " Some weeks ago, a ease came under niv observation 
 of a lad, who, from the curious and hobbling motion of 
 his gait, and other symptoms, I judged to be laboring 
 under that peculiar affection, which has been termed con- 
 genital dislocation of the head of the femur upon the 
 dorsum of the ilium. With a view of ascertaining the 
 nature of the affection, and of determining the diagnosis, 
 I requested my friend Mr. Clark, of the British Navy, to 
 see this case with me, and as upon examination, every 
 appearance and account given, went to show that the 
 displacement was owing to an unusual luxation of the 
 heads of both femurs upon the iliac bones, I have deemed 
 the case worthy of attention, and have drawn up the fol- 
 lowing statement of it, to which, as illustrative of the 
 position of the parts presented externally, the annexed 
 drawings are added. Vide Plates i., il, and iv. 
 
 " Benjamin Gott, the subject of this article, is now 
 nineteen years of age, a shoemaker by trade, of good 
 temperament, and has always been in the enjoyment of 
 perfect health, with the exception of slight indisposition 
 at times. From his earliest recollection, as well as that 
 of the persons who brought him up, he has labored under 
 an impediment in his walking, but has never met with 
 an\ accident which confined him to his bed, or to which 
 his present condition could be attributed. There is no 
 
108 SYMPTOMATOLOGY. 
 
 abscess nor fistula around either hip-joint, nor is there any 
 mark or cicatrix to be seen in the ilio-femoral region to 
 induce the belief that those conditions which frequently 
 attend or accompany the spontaneous luxation from mor- 
 bus coxarius have ever existed. 
 
 " When looked at while he is standing in the erect 
 position, a striking want of proportion and harmony 
 between the upper and lower portions of the body is at 
 once observed, the lower appearing relatively shorter than 
 the upper, and the hands, — owing to the ascent of the 
 heads of both femurs upon the iliac bones considerably 
 above the usual situation of the cotyloid cavities, and the 
 consequent falling down or sinking of the pelvis, — are seen 
 to descend about five inches below their usual point, the 
 ends of the fingers reaching beyond the superior margin 
 of the patellae, when the arms rest along the sides of the 
 body.* The head, neck, trunk, and superior extremities 
 are well developed, but the trunk appears to be somewhat 
 thrown forwards, and the lower or abdominal portion pre- 
 sents a remarkable and salient projection, while in the 
 lumbar region there is a corresponding hollow or depres- 
 sion. The inferior extremities, which do not deviate 
 much from the normal position, as regards the direction 
 of the knees or toes, appear shorter, and are more attenu- 
 ated than natural, and towards the junction of the pelvic 
 extremities with the trunk, the thigh bones seem to be 
 
 * Vide Plates I. and n. 
 
SYMPTOMATOLOGY. ] 09 
 
 separated from each other farther than natural, so that, 
 superiorly, a space between them is left, giving to the 
 perineal region a resemblance in breadth to that of the 
 female. With respect to the position of the knees and 
 toes, this part of my description differs from that given by 
 I)iipu\ i n ■ 1 1 . who states that the toes were inverted in 
 some of his patients, and that there was also a disposi- 
 tion of the knees to approximate. It is probable that 
 this lias been more or less the condition of things in the 
 present instance, as the lad states that his foot had for- 
 merly an inward tendency, and that his limbs, within the 
 last few years, have assumed a more natural direction. 
 As regards the position of the sole of the foot, there is also a 
 difference to be observed in this case, for in the erect posi- 
 tion the sole rests entirely upon the ground, as will be seen 
 by a reference to the drawings, nor is there any elevation of 
 the heel, which forms a symptom of this kind of disloca- 
 tion w hen it is the result of external injury. In tracing 
 the femur of one side (both being similarly situated) 
 downwards from its present resting-place, the upper mar- 
 gin of the great trochanter is felt to be nearly on a level 
 with the crest of the ilium, and the shaft to incline slightly 
 downwards and forwards to the femoro-tibial articulation, 
 -w hich, in every respect, is natural. The pelvis, instead 
 of having the usual oblique position, approaches more to 
 the vertical direction ; the sacro-vertebral angle, and upper 
 portion of the sacrum inclining downwards and forwards, 
 
110 SYMPTOMATOLOGY. 
 
 while the coccyx and lower pieces of the sacrum are 
 forced upwards and backwards. By tracing the superior 
 margins of the ossa ilia from the posterior superior spinous 
 processes forwards, to the anterior superior spinous pro- 
 cesses of these bones, the ossa innominata are found to 
 be tilted much more forwards, than is observed in the nor- 
 mal inclination of the pelvis, and the anterior superior 
 spinous processes are depressed downwards and forwards 
 so far, that the convexity of the iliac crests presents almost 
 an anterior aspect. The symphysis and arch of the 
 pubes are thus thrown downwards, whilst the tuberosities 
 of the ischia are made to ascend slightly upwards and 
 backwards, so that these eminences are nearly on a level 
 with the arch of the pubes, and the rami of the ischia 
 and of the ossa pubis consequently almost horizontal. 
 Although the position of the pelvis is thus out of its usual 
 inclination, there is not apparent any relative alteration of 
 the individual parts which compose this important part of 
 the skeleton. Thus, the alee of the iliac bones are not 
 misshapen, and the tuberosities of the ischia are distant from 
 each other about four inches, while at the anterior superior 
 spines of the ilia there is a space of nine inches and a 
 quarter. Between the anterior superior iliac spine and 
 the tuberosity of the pubes the measurement is five inches 
 md three-quarters, which is slightly more than in the 
 generality of young adult males, and the pelvis so far gene- 
 rally well formed, as regards its relative dimensions, is 
 
31 tfPTOM LTOLOGY. 1 1 1 
 
 also apparently free from an\ of the results of rachitis, or 
 any of the oilier forms of disease to which the osseous 
 tissue is liable* 
 
 "The mosl prominenl deviatioD from the nor;. 
 of pans, which the deformity in question presents, is 
 caused by the unnatural position and remarkable proj 
 don of the great trochanters. The heads of the fem 
 having escaped from the acetabala, have mounted upon 
 the dorsa of the ilia so high as to earn the upper porti 
 of the trochanters nearly on a level with the iliae cri 
 The heads of the femurs being thus so far removed from 
 the proper situation of the cotyloid cavities, the nearly 
 equilateral triangle which the anterior superior spine of 
 the ilium, the tuberosity of the pubes, and the trochanter 
 major, will form, when the coxo-femoral articulation is 
 undisturbed, is entii ken up, and a prominenc 
 
 produced by the projecting trochanters on either side 
 
 * ] liiirkcJ that this subject was young, and that the cha 
 
 dissection | place in the osseous tissues at a m f the 
 
 lisease, had, as yet, in aim bee >me but slightly apparent outwardly. 
 
 Although in the case abo\ d, as far as could be ascertained bj i 
 
 t, the diameters of the pelvis remained nearly nat 
 am perfi ctly ^:> ' i~ti.-c I t'r< m dissections I I f several cases "t' this 1 i 
 
 tli.- diameters of the pelvis, both at ti> inferior stra 
 
 illy altered. 
 
 Tl from the asc trtaiiu ■ ! 
 
 affectii d occurring more frequently in females than in male- ; and 
 accoucheur tin- necessity "t being fully prepared t" encounter much difficulty during 
 parturition, where tin- luxati i tin- female, whether il ho single "r dou 
 
112 SYMPTOMATOLOGY. 
 
 marked, that even a casual observer could riot fail to notice 
 it. In the present case of congenital luxation, the heads 
 of the femurs rest also higher up, and more posteriorly, 
 than in the common dislocation from external injury, and 
 the normal relative position of the head and trochanter, 
 with the surface of the iliac bone, is maintained, that is, 
 the head of the femur is not thrown backwards and the 
 trochanter forwards, as generally takes place in this form 
 of the traumatic luxation. The head and neck of the 
 bone standing out, as it were, nearly at a right angle from 
 the resting-place on the dorsum of the ilium, gives the 
 trochanters the prominent appearance which they present, 
 and this also will enable us to account for the non-inversion 
 of the toes, and the almost natural direction of the 
 limbs. 
 
 " Besides the other symptoms, such as shortening of 
 the limbs, the slipping up of the head of the bone on the 
 external iliac fossa, and the unnatural relation of the great 
 trochanter, which this luxation presents in common with 
 the other dislocations in which the head of the femur is 
 carried upwards and outwards, in a similar direction, the 
 muscles in connexion with the joint offer some peculiari- 
 ties worthy of remark. The spinal muscles, which form 
 the sacro-spinal mass, taking their origin from the sacrum, 
 umbar vertebrae, and posterior part of the ossa ilia, and 
 running along the vertebral grooves on each side of the 
 spinous processes of the vertebrae, are found to be hard, 
 
SYMPTOMATOLOGY. 113 
 
 Cense, and prominent, particularly in the lumbar region ; the 
 psoas, and the internal iliac muscles, — coming from tin- low er 
 dorsal and lumbar vertebrae and the internal iliac fossae, to 
 
 be inserted into the small trochanters, — being pulled upon 
 l>\ the ascent of the femur and stretched over the brim of the 
 pelvis now acting like a pulley, are also found tense and 
 cord-like, while nearly all the muscles of the superior 
 part of the iliac region, the gluteus maximus, medius, and 
 minimus, &c, are retracted towards the crest of the iliac 
 bones, — 'oil ils forment, autour de la tete du femur une 
 espece de cone, dont la base est a l'os iliaque et le som- 
 met au grand trochanter.' — (Dupuytren.) 
 
 " The particulars, so far stated, refer to the subject in 
 the standing attitude ; but in the recumbent position, some 
 of the causes of displacement, such as the physiological 
 action of the muscles and the weight of the superior 
 parts of the body ceasing to exist, the signs of this affec- 
 tion become evidently less marked, and in some respects 
 almost effaced, which never is the case in the usual trau- 
 matic dislocation. The muscles, now, not being called 
 into action, the hollow in the lumbar region disappears, 
 the abdomen does not present the anomalous projection 
 formerly alluded to, the pelvis seems to acquire a more 
 natural inclination, the head and trochanter descend seve- 
 ral inches more towards the usual situation of the coty- 
 loid cavity, and present an elevation neither so prominent, 
 nor so much removed from the normal position thej 
 
114 SYMPTOMATOLOGY. 
 
 ought to occupy. The measurement from the tubero- 
 sity of the pubes to the summit of the great trochanter is 
 seven inches and a quarter, when in the recumbent pos- 
 ture ; while it is nine inches and a half when he is stand- 
 ing. 
 
 " In walking, the heads of both femurs ascending and 
 descending alternately, upon the dorsa of the iliac bones, 
 and playing, as it were, through a space of nearly three 
 inches, produce the hobbling motion which has been 
 mentioned. Thus, while the body is supported upon the 
 right limb in the act of stepping, the right femur ascends ; 
 while the left, being freed from the superincumbent 
 weight of the trunk and superior extremities, descends, to 
 ascend again as soon as the left foot rests upon the 
 ground, and the weight of the body is transferred to it. 
 Contrary to what, at first, might be anticipated, this 
 unsteady gait is less observable in the act of running 
 than in walking, the increased energy of the muscular 
 contraction, and the more rapid movements of the limbs 
 not permitting, nor allowing time for, the head of the bone 
 to pass through its accustomed range of motion, during 
 the slower mode of progression. Although, as has just 
 now been said, the alternating movements of the body are 
 not so marked in the quicker motion of running as in 
 walking, yet owing to the friction, more or less, of the dis- 
 placed head of the femur upon the external iliac fossae, the 
 altered and unfavorable position in which the muscles 
 
SYMPTOMATOLOGY. 1 I 5 
 
 have now to act, and the irregular and fatiguing swinging 
 of the body from one side to the other, this individual is 
 unable to take exercise in the ereci posture, without. s< on 
 evincing signs of discomfort, and complaining of consi- 
 derable pain, more particularly in the groins and lumbar 
 regions. 
 
 " By grasping the thigh, and moving the limb after the 
 pelvis is fixed, a sensation of crepitus, resembling that 
 given by joints which have suffered from rheumatic inflam- 
 mation, or effusion into their cavities, is distinctly per- 
 ceived. From the present abnormal position of the [tarts 
 around, and in connexion with the ilio-femoral articula- 
 tion, as a natural consequence, the various motions of the 
 inferior extremities are considerably interfered with, and 
 limited, but by no means are they so restricted as in the 
 traumatic form of this dislocation. Adduction of the 
 extremity is not much interfered with, and one thigh can 
 be carried over the other with facility, but abduction is 
 performed with difficulty, the thigh having but a few 
 inches of latitude in this direction ; and in the endeavor to 
 sit, as in the attitude of riding on horseback, across a high 
 chair of the common breadth in the seal, it is found that 
 this position cannot be effected, owing to the limited 
 extent of separation allowed to the ossa lemorum. While 
 
 thf knee-joint is not bent, the movements anteriorly are con- 
 
 siderabl) impeded, but when the thigh is Hexed upon the 
 
116 SYMPTOMATOLOGY. 
 
 pelvis, as takes place in the act of stepping upon a foot- 
 stool, or going up a stair-case, little effort is required. 
 The motion of the thigh directly backwards is somewhat 
 confined, but rotation inwards, and particularly outwards, 
 is nearly natural. 
 
 " In the sitting posture, while the trunk is kept nearly 
 erect, the lumbar vertebrae are not then dragged so much 
 forward, and this appears to be the position least irksome 
 while it can be maintained ; but in the stooping attitude, 
 as that of the cobbler at work, which in his trade this 
 youth has to adopt, the lumbar and lower dorsal vertebrae 
 assume a convexity backwards, and the psoae being thus 
 put upon the stretch, great uneasiness is experienced in 
 the loins if this posture be prolonged for any considerable 
 length of time. 
 
 " These, then, are some of the most marked pathogno- 
 monic characters observed in this congenital affection, 
 which, I am inclined to believe, is of much more common 
 occurrence than the slight notice, or rather entire silence 
 observed regarding it by authors in Great Britain, or my own 
 country, would induce me to suppose. Thus we are told 
 by Dupuytren that he met with twenty-five cases of the 
 " luxation originelle de la tete du femur." Jules Guerin 
 records that he has seen over thirty cases, and within the 
 last two years, since my attention has been attracted to 
 the subject, although I have been prevented by circum- 
 stances from making as many observations on this subject 
 
st MPTOH kTOLOGY. 1 17 
 
 as I might otherwise have done, I have met with four 
 well-marked cases.* 
 
 • From a consideration of the serious evils which a 
 continuation of this displacement will entail upon the 
 sufferers, as regards the enjoyments of life, and the 
 performance of its duties, it behoves the surgeon to 
 he prepared to form a correct diagnosis in relation 
 to this affection, to prevent erroneous and painful prac- 
 tice being resorted to, and in order that the proper 
 therapeutic means, as far as jet known, or superior judg- 
 ment might suggest, may be adopted to remedy the 
 deformity before the approach of adult age would pro- 
 scribe the utility of such an attempt. The subject of the 
 case I have detailed has been sent down to Margate by 
 his medical attendants, for six months at a time, for the 
 benefit of his hip-joints, under the supposition of the 
 affection being of a scrofulous nature; and we find Du- 
 puvtren writing as follows in regard to this point: ' Plu- 
 sieurs individus, affectes de luxation originelle, ont ete 
 contraint, par suite de cette erreur de diagnostique, a gar- 
 der le lit pendant plusieurs annces. J'en ai vu d'autres, 
 qu'on avait forces a. supporter des applications, sans noni- 
 
 * Since this paper was written, I have seen, at Paris, London, and New York, 
 at least twenty more cases of this dislocation, which have .'■till farther confirmed the 
 opinions I have advanced in relation t<> its greater frequency than is generally sup- 
 posed. From these additional observations which I have had an opportunity of mat- 
 ing, I am also inclined to corroborate the opinion of Dupuytren regarding its more 
 common occurrence in the female 
 
118 SYMPTOMATOLOGY. 
 
 bre, de sangsues, de vesicatoires, de cauteres, et, surtout, 
 de moxas. Je me rappelle, entre autres, line jeune fille 
 qui souffrit l'application de vingt-et-un moxas autour des 
 hanches, sans que ce traitement, inutile ou barbare, cut 
 apporte aucun changement a la situation de cette infor- 
 tunee.' 
 
 " The affections most likely to be confounded with or 
 mistaken for, the congenital luxation of the head of the 
 femur upwards and outwards upon the dorsum of the 
 ilium, are the dislocation which takes place in the same 
 direction at the ilio-femoral articulation, as the result of 
 external injury ; or that inflammation of the hip-joint whe- 
 ther accompanied, or not, by the spontaneous luxation, as it 
 is called, of the femur upon the external iliac fossa, which 
 results sometimes, as a consequence of the absorption and 
 destruction of the head and neck of the bone, during the 
 progress of that strumous disease of the hip-joint, known 
 generally by the name of morbus coxarius. Upon exami- 
 nation, however, each of these affections will be found to 
 possess characteristics sufficiently remarkable to enable us 
 to arrive, with reasonable certainty, at the differential diag- 
 nosis. In the recent dislocation from external injury 
 upon the dorsum ilii, the shortening of the limb, the 
 inversion of the toes, the lessened mobility of the joint, 
 and more flattened appearance of the affected hip, are not 
 difficult of detection. The strumous diathesis of the 
 patient, and the relation of his case by himself or friends, 
 
s 1 * MPTOM OTOLOGY. I i 9 
 
 the previous inflammatory condition of the hip-joint, with 
 the accompanying symptoms of fever, pain, &c, the 
 formation of abscess, the existence of fistula?, and in the 
 latter stage the ulceration and disappearance of the head 
 and neck of the bone, the trochanter alone being left re ti 
 in the acetabulum, or upon the dorsum of the ilium, the fiv- 
 quent resulting anchylosis and flat aspect of the hip, are 
 symptoms sufficiently pathognomonic to characterize the 
 condition of things usually attendant upon the various phases 
 of hip-disease While, in regard to the congenital trans- 
 position of the head of the femur upon the external iliac 
 fossa, the whole history of the patient, from the earliest 
 period of infancy up to the time that relief or advice is 
 applied for, the lameness shown upon the first attempts 
 to walk, the general good health he has enjoyed, the total 
 absence of primary inflammatory symptoms, the immunity 
 from antecedent injury, the extraordinary hobbling (clo- 
 chant) gait during the act of slow progression, the prominent 
 aspect of the abdomen, and the corresponding hollow 
 appearance of the lumbar region, the existence general!} of a 
 double ami similar luxation on both sides, the partial or total 
 disappearance of many of the above symptoms in the recum- 
 bent position, the unusual projection of the great tro- 
 chanter, owing to the presence and direction of the head 
 and neck of the femur, which are placed nea.lv at a right 
 angle and not in a line with the surface of tin iliac 
 bone, as happens in the traumatic luxation; ami ab 
 
120 SYMPTOMATOLOGY. 
 
 all, the ascent and descent of the head of the femur upon 
 the external iliac fossa, through a space of nearly three 
 inches, the upper margin of the trochanter major becom- 
 ing nearly horizontal with the crest of the ilium, or 
 appearing several inches below the same point, and 
 according as the limb is pushed upwards or pulled down- 
 wards ; — these data, taken collectively, and in connexion 
 with the entire freedom from all pain during the attempts 
 to move the parts about the seat of the displacement, will 
 form an assemblage of peculiarities so evidently and pal- 
 pably different from the circumstances accompanying 
 either of the two forms of lesion already referred to, that 
 we are obliged to look upon the morbid condition asso- 
 ciated with the group of symptoms last enumerated as 
 belonging to another species of disease, and to classify it 
 as more properly belonging to that genus of affections 
 which, in more modern times, have received the name of 
 congenital luxations. 
 
 " It would appear that the congenital luxation of the 
 head of the femur is more or less of a hereditary charac- 
 ter, and that females are more subject to it than males. 
 I have not had the means of confirming the former obser- 
 vation, but should be inclined to give credence to it, as 
 experience has corroborated the existence of this family 
 predisposition in Talipes, which affection most proba- 
 bly belongs to the same class of maladies as the 
 congenital dislocation of which we have been speak- 
 
SYMI'TOMATOUM^ . I J I 
 
 ing. In relation to its more frequent occurrence among 
 females, Dupuytren states; that out of the twenty-five 
 cases which he had seen, three onlj wen- males; of the 
 cases which have come under mj own observation, the 
 greater proportion w ere females. 
 
 " The peculiarities and symptoms accompanying con- 
 genital luxation of the head of the femur upon the dor- 
 sum ilii, being found, upon comparison, to be so different 
 from either of the other forms of the disease above alluded 
 to, and with which, from a cursory examination, it might 
 be confounded, we are naturally led from seeing a result 
 or effect so different, to seek also for a difference of ante- 
 cedence or cause. The celebrated surgeon, to whom we 
 have last alluded, asks, in relation to the cause of displace- 
 ment, ' Can it be the product of a disease occurring to 
 the foetus in the womb of the mother, and cured before 
 birth ! Can it be the result of an effort, or of violence, 
 which might have caused the head of the femur to escape 
 from the cotyloid cavitj ; and the cavity itself, might it 
 not become obliterated without disease, and oiil\ because 
 from want of action, it would become useless 1 Can 
 nature have forgotten to mould a cavity for the head 
 of the lemurs, — or rather, can this cavity, which iv the 
 result of the concurrence and union oi the three pieces 
 of which the os inuominaium is composed, have remained 
 imperfect on account of some obstacle to the evolution of 
 the bone, as M. Breschet has been induced to suppose V 
 
 9 
 
122 SYMPTOMATOLOGY. 
 
 Each of the causes named in the foregoing; interro- 
 gatories might, we can conceive, be supported by argu- 
 ments more or less favorable, none of them, however, 
 bearing a character so entirely conclusive as to carry impli- 
 cit conviction, or sufficiently satisfactory to render far- 
 ther investigation into the origin of these affections 
 unnecessary. If disposed to attribute this transpo- 
 sition of the head of the bone to some violence exerted 
 during the act of parturition, it would be difficult to ima- 
 gine, even when we consider the different positions which 
 the foetus may assume in the uterus, by what means the 
 mechanical force could be applied so as to displace the head 
 of the bone in an upward direction, or by what species of 
 manipulation, either instrumental or manual, the accou- 
 cheur could so proceed, as to produce the transfer of the 
 head of the femur upwards and outwards upon the dor- 
 sum ilii, in other words, in a direction exactly contrary 
 to that of the force which may be supposed to be brought 
 into play. Nor would it be more easy to follow the head 
 of the bone, after it had been once dislocated downwards 
 into the foramen ovale by traction, — as some have sup- 
 posed, during a difficult labor with a breech or lootling 
 presentation, — taking again an upward course over the 
 natural position it ought to occupy at the acetabulum, 
 and refusing to remain quiescent until it had arrived at 
 the external iliac fossa. Something may be said in sap- 
 port of the theory of the arret de developpement, as con- 
 
B1 MP TOM kTOLOGl . I 23 
 
 tributiog to the primary displacement of the articulating 
 surfaces, bat, in the present case, if we can judge from 
 the projecting trochanters, there is but little alteration as 
 regards the head and neck of the fetuur, and autopsic 
 examinations which have been made, go to prove the fill- 
 ing np and contraction of the acetabulum from its inutility 
 and consequent inactivity, rather than any imperfection 
 in the ossification of the cotyloid cavity at the junction 
 of tlic three pieces which unite to form it, and which 
 should I)'- the place where the occurrence of auy defect, 
 if any existed in the evolution of the osseous tissue, 
 would be observable, according to M. Breschet's theory. 
 The hypothesis of M. Dupuytren, that a primary imperfec- 
 tion of the germ ('des vices de conformation originels, et qui 
 tiennent a un defaut dans {'organization des germes') must 
 have some relation with the cause of the displacement — and 
 which idea led him to gn e the name of original luxations to 
 this class ol affections — carries but little probability with 
 it; nor does the position of the thighs, Hexed as they are 
 upon the abdomen of the child in utero, and the conse- 
 quent pressure of the head of the femur against the lower 
 and interior portion of the iho-femoral capsule, satisfac- 
 torily explain the reason of the ascent of the head o\ the 
 boue upon the ilium. We can imagine that this position 
 ol the head ol the femur, and the ualuralU shallow state of 
 
 the acetabulum during foetal life, niaj predispose to the 
 displacement; but we do not believe that mere position 
 
124 SYMPTOMATOLOGY. 
 
 without the action of some morbid auxiliary cause, could 
 alone have the effect of bringing about the pathological con- 
 dition of which we are treating. Although it is well known 
 that the child, while jet in the womb, is liable to many dis- 
 eases, yet children who have been born with this altered re- 
 lation of parts at the ilio-coxal articulation have not shown 
 any particular bad condition of health at birth, sufficient to 
 attract the attention even of medical attendants, and this 
 consideration and the absence of anything like inflamma- 
 tory engorgement, abscess, fistula, or cicatrix, at the 
 period of birth, must leave little doubt that the displace- 
 ment cannot have for its origin that strumous affection 
 which, in extra-uterine life, we sometimes remark to 
 be the cause of spontaneous luxation of the head of 
 the femur upon the dorsum of the ilium. 
 
 " The remote cause then, of the class of congenital 
 deformities, and among them, that of congenital luxa- 
 tion of the head of the femur, we should be inclined to 
 refer to a morbid condition of the nervous system or cen- 
 tres ; and the proximate cause, or that which most obviously 
 produces the displacement of the parts, to a pathological 
 muscular contraction, which, acting as the unavoidable 
 result of the primary disease, with more or less activity 
 and diversified combination, ultimately effects the entire 
 
 dislocation of the articulating surfaces 
 
 The existence of a state of disease which may have an 
 influence so extensive over the whole muscular sys- 
 
s\ mi-Tom itoloqi 1 25 
 
 tern, or be limited t<> ;i particular portion onh of it, 
 ni;i\ enable the pathologisl to attribute to one common 
 source, the origin <>l numerous maladies which formerly 
 were referred to as mam differenl causes, and from data 
 now known we can thus. I>\ generalization, simplih and 
 reduce to a unity of origin the whole class of those defor- 
 mities of the human shape which, as a resuli <>i morbid 
 muscular action, take place at the articulations in the 
 shape of club-toot, distortions of the spine, torticollis, 
 congenital luxations, &c. 
 
 " But congenital luxation of the head of the lemur 
 upon the ilium, although caused primarily, as we believe, 
 by this dynamic or morbid retraction of a portion of the 
 muscular apparatus, occurring during intra-uterine life, is 
 also subjected to causes which begin to act only after 
 birth, and which materially modify the appearance and 
 extent of the displacement of the articulating surfaces in 
 relation to the age of the individual affected. Thus, in this 
 luxation, the head of the bone is generally, at first, placed 
 near the confines of the acetabulum, resting upon its mar- 
 gin or a little above it, but as soon as progression begins 
 to be performed, the superincumbent weight of the trunk 
 carries the pelvis downwards, and the heads ol the lemurs 
 being entirely freed from their natural cavities, and having 
 now no point of resistance superiorly, ascend gradually 
 upon ih<' external iliac fossae, until at last, as adult age 
 approaches, as in the example before us, the pelvis i^ 
 
126 SYMPTOMATOLOGY. 
 
 wedged down between the upper portions of the ossa 
 femoram, and the superior margins of the great trochan- 
 ters are found almost on a level with the iliac crests. One 
 of the primary effects of the pathological contraction of 
 the muscles (as exemplified by the attenuated state of 
 the muscles in the ordinary forms of talipes), is a dimi- 
 nished nutrition, which gives rise to a kind of ' arret de 
 developpem.ent' in the parts affected. The osseous struc- 
 ture of the pelvis increases as extra-uterine life advances, 
 while those muscles original!} affected, and which produced 
 the displacement, suffering still from this impediment to their 
 natural development, do not elongate in proportion to the 
 increase of the other parts, and thus also when the head of 
 the hone has once escaped beyond the limits of the cotyloid 
 cavity, is its tendency to ascend on the external iliac fossa, 
 
 w 
 
 promoted. It is not difficult to understand that the physio- 
 logical action also of the muscles acting in the direction of 
 the displacement, will have a tendency to induce a farther 
 removal of the head of the bone upwards ; and that 
 the muscles, towards the internal part of the thighs, 
 such as the long adductors, semi-membranosus, semi-ten- 
 diuosus, &c, having changed their angle of insertion, will, 
 during the progressive movements of the inferior extremi- 
 ties, aci upon the ossa femorum so as to throw the head of 
 each upwards and somewhat outwards. These auxiliary 
 causes, viz. the weight of the body, the impeded growth 
 of the muscles affected, and the physiological action of 
 
SYMPTOMATOLOGY. 127 
 
 the muscles, taking effect only after extra-uterine life lias 
 begun, readily account for the transposition, in chm-s <>t' 
 congenital luxation of the hip-joint as well as in the 
 other affections of this class, occurring in a gradual man- 
 ner, and becoming in the course of time more marked, 
 after these various causes of displacement have fully 
 exerted their combined influences. 
 
 " Having said thus much at present in relation to the 
 symptoms, diagnosis, and cause of the congenital luxation 
 of the head of the femur upon the dorsum ilii, I shall 
 recur at a future time to the pathological appearances 
 observed upon post-mortem examination, and the thera- 
 peutic means which have been adopted to remedy the 
 deformity or palliate its inconveniences." — London Lan- 
 cet, 1844, No. 27, vol. I. 
 
\ 3 
 
 
 .. y y~i- ■ 
 
EXPLANATION OF PLATE No. V . 
 
 This figure represents a range of salient points, indicating the normal position 
 of the head of the Femur. In cases of traumatic dislocation of the femur, or in 
 
 congenital displacement of the head of this bone, where there is obscurity, this diag- 
 nostic sign may be made available. 
 
 The plate gives a side view of the fetal pelvis, about the end of the ninth month, 
 with the femur flexed upon the pelvis, and slightly adducted. 
 
 a. Anterior Superior Spinous Process of the Ilium. 
 6. The prominent point of the tuberosity of the Ischium. 
 c. Tin- upper margin of the Trochanter Major. 
 X A lino along the range of these three poiuts. 
 
13 
 
 CHAPTER V. 
 
 DIAGNOSIS OF CONGENITAL DISLOCATIONS OF THE HEAD 
 OF THE FEMUR. 
 
 The congenital dislocation of the head of the femur 
 upwards and outwards upon the ilium, has probably been 
 mistaken more frequently for morbus coxarius than for 
 anv of the other diseases which are met with at the ilio- 
 femoral articulation. The hip-disease, as it is called. is 
 essentially an inflammatory affection, and from its com- 
 mencement to its termination, — whether in resolution, or in 
 ulceration of the synovial membrane, cartilage, ligaments, 
 and bones, and consequent dislocation, — symptoms of ante- 
 cedent or present phlogosis can, on can lul examination, 
 generally be detected While this inflammatory affection 
 is in its dormant or incipient state, as a general rule, 
 lameness does not occur, and it is not until lame- 
 ness has manifested itself, in what is termed the second 
 stage of the disease, that difficult} ma\ arise in forming 
 tin- correct diagnosis between the congenital dislocation 
 
132 DIAGNOSIS. 
 
 of the hip-joint and the affection known as morbus 
 cox a ri us. 
 
 The history of the disease, and the consideration of 
 the constitutional temperament of the individual, will 
 serve as useful information to the surgeon, when about to 
 analyse the real nature of a doubtful affection at the ilio- 
 femoral articulation. It is unnecessary to recapitulate 
 the several symptoms which have been enumerated in the 
 preceding chapter as pathognomonic of the congenital 
 dislocation of the femur upon the ilium ; but there are cer- 
 tain characters, standing out in forcible contrast to the 
 symptoms attendant upon the hip disease, which merit 
 consideration. A knowledge of them ought to preclude 
 the possibility of the congenital affection being mistaken 
 for the other disease in question. 
 
 In the lameness resulting from congenital dislocation of 
 the femur upwards and outwards, the shortening of the 
 limb, which from the first can generally be detected, has 
 not been preceded by pain or inflammatory symptoms of 
 any kind ; in the hip-disease, on the contrary, the lame- 
 ness, which becomes apparent towards the latter part of 
 the first stage of the complaint, is unaccompanied by any 
 perceptible shortening of the limb, and considerable pain 
 is felt when any motion is made which causes increased 
 pressure of the head of the bone against the acetabulum, 
 at the same time that great suffering is almost always experi- 
 enced, which is generally referred to the region of the knee of 
 
DIAGNOSIS. 133 
 
 the affected side. In congenital dislocation, flexion oj the 
 joint is performed with greal ease, while in the hip-dis- 
 ease, the same movement is attended with pain, and the 
 patient shrinks from the touch. 
 
 In congenital luxation, when the patient is laid in the 
 recumbent position, the deformit} which is so evident 
 in the erect attitude, disappears, and the head of the 
 femur on the affected side, can be pushed upwards or 
 draw n downwards, or rotated, without causing an} uueasi- 
 ness : whereas in bip-disease, auj attempt to elongate bv 
 forcible traction the limb of the diseased side is attended 
 with great pain. 
 
 [n hip-disease, during rotation of the thigh outwards, 
 the head of the lemur can generally he felt in the groin, 
 occupying its natural place; in congenital luxation, the 
 head and trochanter major can be felt above the acetabu- 
 lum, on the surface of the ilium, while a palpable vacuity 
 exists iu the groin, opposite the acetabulum. 
 
 In hip-disease, the nates becomes Hat, so that die usual 
 niche between the buttock and the thigh is effaced; 
 while in the congenital affection, this furrow is present, 
 although situated higher up. and more curved outwards 
 than natural. 
 
 Before the occurrence of spontaneous dislocation — 
 which, as a result of ulceration of the border of the 
 
 acetabulum, someti s takes place, although rarely, in 
 
 morbus coxarius — the thigh being flexed al righi angles 
 
J 34 DIAGNOSIS. 
 
 with he pelvis, and slightl) adducted, a line, drawn from 
 the anterior superior spinous process of the ilium to the 
 prominent point of the tuberosity of the ischium, will 
 range nearly on a level with the upper margin of the tro- 
 chanter major; while in congenital luxation, this line 
 would pass over a part of the trochanter, approaching 
 more or less to its base. Vide Plate v. 
 
 Although there is much lameness in congenital luxa- 
 tion, the health of the patient does not directly suffer ; 
 he can walk, skip, or run for a short time with consider- 
 able facility, and without experiencing pain ; whereas in hip- 
 disease, the general health is always impaired, and the acts 
 of locomotion are performed with much difficulty and pain. 
 
 In hip-disease, it is exceedingly rare for the malady to 
 occur symmetrically and simultaneously on both sides — a 
 circumstance which is of common occurrence in the con- 
 genital dislocation of the femur. 
 
 These differential signs, in connexion with the pecu- 
 liarity of the gait and attitude, and the other symptoms 
 mentioned in the previous chapter, as observable in indivi- 
 duals affected with congenital dislocation, exhibit the 
 pathognomonic characters of the two affections in such a 
 distinct manner, the one from the other, that if appre- 
 ciated, the error of mistaking a congenital luxation of the 
 coxo-femoral articulation for morbus coxarius will not be 
 likely to occur. 
 
 In cases of incipient congenital luxation, or as it has been 
 
DIAGNOSIS. I 15 
 
 termed, congenital subluxation of the femur, where the 
 bead of the bone rests on the margin <»i the acetabulum, ;i 
 correct diagnosis will necessarily be more difficult of at- 
 tainment, than when the lemur bas ascended higher on 
 
 the dorsum ilii. 
 
 There are other affections which niay be confounded 
 with congenital displacement of the femur. 
 
 M. Guerin has described a class of congenital deformi- 
 ties at the hip, which lie lias named pseudo- luxations, 
 because they offer the deceptive appearance of positive 
 luxations. In these, however, the head of the femur is 
 not transferred from the cotyloid cavity. Pseudo-luxa- 
 tions at the hip present two varieties, one simulating a 
 dislocation of the femur backwards and outwards ; the 
 other, a dislocation of the hone downwards and for- 
 wards. This kind of deformity consists in a permanent 
 abnormal direction of the members, referable, as its cause, 
 to morbid muscular retraction, which, however, is exerted 
 in a degree not sufficiently intense to produce the exarti- 
 culation of the head of the femur. Pseudo-luxations are 
 allied only to congenital luxations, in having a common 
 cause for their origin, and in presenting a kind of similarity 
 in the external appearance of the deformity. The first 
 variety of the pseudo-luxations mentioned ahove, ma\ 
 
 simulate somewhat the congenital luxation of the femur 
 upon the ilium.* 
 
 • These pseudo-luxations, with other deformities From muscular retraction :i!><.>ut 
 ili< nip-joint, are alluded to by Delpeoh, Vide I'Orthomorphie. 
 
136 DIAGNOSIS. 
 
 There are certain alterations in the head and neck of 
 the thigh bone, and of the acetabulum, which may also 
 give rise to some doubt in forming the diagnosis of 
 this congenital dislocation. We find that Palleta 
 speaks of several malformations, which may resemble this 
 affection; such as an unusual enlargement of the acetabu- 
 lum, permitting a vacillating motion of the head of the 
 femur; a malformation of the upper extremity of the 
 femur, where the head and neck are in part atrophied, 
 and, as it were, fused with the trochanter major which 
 rises above them ; an exostosis springing from the bot- 
 tom of the acetabulum, and changing the natural relations 
 of the femur ; and an atrophy, manifesting itself upon 
 one half of the pelvis and upon the inferior extremity of 
 the same side. 
 
 Mr. Liston mentions a curious case of malady of the 
 hip-joint,* of a young infantry soldier, who died of pul- 
 monary consumption after two years' confinement in the 
 General Hospital at Chatham. In this case, the head of 
 the bone was found approximated to the shaft, owing to 
 absorption of the neck, without any ulceration of the 
 articular cartilage. " Previously to his admission, he had 
 regularly performed his duty, from which it is plain that 
 his limbs were then of equal length, although wheu his 
 body was examined, the affected femur was upwards of 
 
 * Liston's Surgery — report of acase of Mr. Gulliver's. 
 
DIAGNOSIS. 137 
 
 o/n inch and a half shorter than the other. From a 
 careful inquiry, after his death, ii appeared that he had, 
 five years previously, fallen on the trochanter, in conse- 
 quence of which he often complained of pain in the hip, 
 but continued to do his duty long after, never having been 
 confined on account of the accident/' 4 ' The shortening 
 of the limb in this case is attributed to the accident, and to 
 the long confinement with the pulmonary malady, which 
 ultimately proved fatal. 
 
 Sir Benjamin Brodie has noticed that the lower 
 extremities are sometimes of unequal length, from origi- 
 nal conformation ; the femur, tibia and fibula of one side 
 being shorter than these bones of the other side. 
 
 In aged persons, the neck of the femur becomes some- 
 times altered by interstitial absorption, causing an unna- 
 tural shortening of the inferior extremities ; and this cir- 
 cumstance predisposes in a remarkable degree to fracture 
 of the neck of the femur, accompanied by still farther 
 shortening of the limb. 
 
 Delpechf has mentioned an osseous malformation 
 causing lameness, most probably depending on a rachitic 
 condition, where there is malposition of the acetabula 
 either more forwards or more backwards than natural. 
 The same surgeon also mentions an atrophied state of 
 the halves of the sacrum and of the ilium, as causing 
 
 • Liston's Surgery — report of a case of Mr. Culliv. rV 
 t Delpech, l'Orthomorphic. 
 
 10 
 
138 DIAGNOSIS. 
 
 lameness ; and M. Gerdy has described several anomalies 
 of the upper extremity of the femur, from which a limp- 
 ing gait is produced, where the neck of this bone is 
 inserted at a greater or less distance from the trochanter 
 major, and in a direction, sometimes inclining obliquely 
 forwards ; at others, obliquely backwards. 
 
 All these morbid affections may simulate, more or less, 
 the congenital luxation of the head of the femur. A 
 knowledge of, and familiarity with their existence, and 
 the application to them of the signs which have been 
 enumerated and described for determining the pathogno- 
 monic characteristics which accompany congenital dislo- 
 cation of the femur upon the ilium, will enable the sur- 
 geon to arrive with great certainty at a just differential 
 diagnosis. 
 
139 
 
 CHAPTER VI. 
 
 PROGNOSIS OF CONGENITAL DISLOCATIONS OF THE HEAD 
 OF THE FEMUK. 
 
 In congenital dislocations of the femur, much di- 
 versity of opinion has existed in regard to the pos- 
 sibility of effecting permanent reduction by the efforts 
 of art. Dupuytren supposed that it was useless to 
 attempt the permanent adjustment of the articulation, 
 and confined his treatment simply to ameliorating mea- 
 sures. 
 
 Of late years science has advanced a step farther in 
 this matter, and cases, successfully treated, of congenital 
 dislocation of the femur, are recorded, which place beyond 
 a doubt the possibility of reducing fixedly the head of 
 the femur at the cotyloid cavity. 
 
 The difficulties, however, attendant upon the treatment 
 of this affection arc great, and the altered condition oi 
 the component parts of the articulation, which i^ apt to 
 take place even in early life, as well as ol the other lis- 
 
140 PROGNOSIS. 
 
 sues surrounding the ilio-femoral articulation, render this 
 displacement one of the most formidable maladies to 
 which the articular apparatus of the body is liable ; the 
 surgeon then should be guarded in giving a prognosis 
 which might be too favorable as regards the facility of 
 reduction, or the certainty of a rapid and permanent 
 cure. 
 
 It is certain that after middle life, the relative confor- 
 mation of the acetabulum, and of the head of the femur, 
 as well as of the articular capsule, are so entirely changed, 
 that a reciprocal adjustment between these component 
 parts of the joint is beyond the reach of surgery. A 
 more favorable prognosis may be given, when the requi- 
 site treatment is adopted in early life. 
 
 The curability of congenital dislocations of the femur, 
 and the principles upon which their treatment has been 
 founded and attempted, will be spoken of in detail in a 
 following chapter. 
 
 It has been stated that the single luxation of the 
 head of the femur upon the ilium is more serious 
 in its nature, from the fact, that in this form, the dia- 
 meters of the pelvis are more deranged, than when the 
 luxation is double. I do not believe there is much differ- 
 ence in this respect, in either case, as regards the 
 impediment which will be presented during parturition, 
 to the passage of the child, from defective space in some 
 of the measurements of the pelvis. 
 
PROGNOSIS. 1 I I 
 
 lii cases where females, suffering from this displace- 
 ment, have become pregnant, I think thai pathological 
 investigation will justify the expression of an unfavorable 
 prognosis in regard to the probable facility or safety of 
 the process of parturition. From the dissections I have 
 made of persons who had been affected with congenital 
 dislocation of the hip, I cannot doubt that the diameters 
 and measurements of the pelvis, in cases either of the 
 double or single form of this affection, are so modified 
 and changed as to he most unfavorable for the passage of 
 the head of the child through its two straits, Dupuytren, 
 whose great authority always merits attention, has ex- 
 pressed himself in the following words, asserting that the 
 pelvis retains its natural dimensions and conformation : 
 " II est a remarquer que les phenomenes qui ont lieu a 
 l'exterieur du bassin n'in fluent en rien sur le developpe- 
 ment de cette cavite, et qu'avant l'epoque de la puberte, pen- 
 dant cette epoquc, et apres quelle est passee, le bassin 
 acquiert les dimensions les plus favorables a Pexercice des 
 fonctions des visceres qu'il renferme; et qu'il est aussi propre 
 a recevoir, a conscrver et a transmettre le produil de 
 la fecondation que chez les personnes les mieux con- 
 formees." 
 
 The facts occurring from autopsic examinations go 
 directly to refute the statement of Dupuytren. Ii\ 
 a reference to Plates Nos. vi., vii., viii., and i\.. 
 
142 PROGNOSIS. 
 
 and the description of the cases which they repre- 
 sent, it will be seen that in these specimens, the 
 pelvic diameters are entirely altered from their natural 
 standard. 
 
littu . ofS^'O'i- k M<ye>- 
 
EXPLANATION OF PLATE No. VI. 
 
 Front view of a dissection of a female pelvis, with Double Congenital Disloca- 
 tion of tho Femurs upon the Dorsa of the Ilia. 
 
 a. Anterior and Superior Spinous process of tho Ilium. 
 
 b. Trochanter Major. 
 
 c. Trochanter Minor. 
 
 d. Anterior part of tho Original Capsular Ligament. 
 
 e. The Original Capsule laid open. 
 
 f. Tho Annular Opening, by which the Head of the Femur escaped upon the 
 
 Dorsum Ilii. 
 
 g. Tho Original Acetabulum, become now triangular. 
 
 h. The cavity of tho Original Capsule laid open by removal of its Anterior 
 Wall. 
 
 i. Tho Neck of tho Femur grasped by the Annular Opening in tho Capsule 
 through which the Head passed. 
 
Z ith. of Ja.v«/ * Mnji 
 
EXPLANATION OF PLATE VI! 
 
 Posterior view of a dissection of the same pelvis, with Double Congenital Dislo- 
 cation of the Femurs upon the Dorsa of the Ilia. 
 
 a. Tho Crest of the Ilium. 
 
 b. The Dorsum Ilii. 
 
 c. Posterior surface of the new Capsule entire. 
 
 d. Trochanter Major. 
 
 e. Trochanter .Minor. 
 
 /. Head of the Femur lying in the now Capsule. 
 g. Now Capsule laid open, showing its interior. 
 
147 
 
 CHAPTER VII. 
 
 PATHOLOGY OF CONGENITAL DISLOCATIONS OF THE HEAD 
 OF THE FEMUR. 
 
 Except in cases of foetal monstrosities, instances of 
 congenital dislocation at the ilio-femoral articulation, are 
 not met with in any other form, than that in which the 
 head of the femur is exarticulated from its socket, and 
 passes upon the external surface of the ilium. 
 
 Another variety, under the name of a subluxation 
 upwards and backwards, has been mentioned, where the 
 head of the femur has not yet entirely cleared the mar- 
 gin of the acetabulum. This variety appears to be only 
 the initiatory stage of the dislocation upon the dorsum of 
 the ilium, and I shall only regard it as such. In fact, 
 the head of the femur, to ascend on the ilium, most slip 
 out of its socket, at the posterior portion of the acetabu- 
 lum, where, in the foetus, there is a space unoccupied by 
 bone. A depression thus exists on the pourtour of the 
 acetabulum, between the ilium and ischium, occupied in 
 
148 PATHOLOGY. 
 
 the recent subject by cartilage only ; the deepest part of 
 which, in the skeleton, is almost on a level with the bot- 
 tom of the acetabulum. It must be recollected also, that 
 the thighs are generally flexed upon the abdomen before 
 birth, and that after the head of the femur has once 
 passed the posterior margin of the cotyloid cavity, the 
 mere act of extension of the thigh after birth, will induce 
 the head of the femur to describe a segment of a circle 
 upwards in the direction of the dorsum ilii. 
 
 It has been supposed that in attempts to reduce the 
 congenital dislocation of the femur upon the ilium, the 
 head of the bone has been thrown into the ischiatic 
 notch. This seems, however, to be only the result of the 
 application of mechanical force, and the head of the 
 femur does not appear to have been found primarily in 
 this position. 
 
 The morbid appearances to be met with in this luxa- 
 tion, on autopsic examination, vary, according to the 
 age of the individual, and to the extent of the altera- 
 tions which may have occurred in the tissues at, or in 
 contiguity to the ilio-femoral articulation ; but there 
 are pathological characters which are common, amid 
 the numerous changes which take place in the liga- 
 mentous and osseous structures of the joint, as well as 
 in the soft parts by which it is surrounded. 
 
 If the examination of this displacement be made dur- 
 ing the foetal period, or when extra-uterine life has been 
 
P LTHOLOGY. L49 
 
 of short duration, the (Styloid cavitj is round to be but 
 little altered in its normal shape and dimensions, and to 
 retain the capacity of receiving the head of the femur. 
 The period of life ;u which the cotyloid c;i\ii\ begins to 
 assume an alteration of shape and of dimensions is nol 
 the same in all cases; it is probable, however, thai beyond 
 the twelfth or fourteentb year of age, the changes which 
 this cavitj has undergone, have so far destroyed the nor- 
 mal relations of the joint, that reciprocal adaptation would 
 be impossible. 
 
 The acetabulum, surmounted by its fibrous border, at 
 the earlier periods of this displacement, is generally found 
 to present a depression on the superior and posterior part 
 of its margin ; and a kind of adipose tissue, probably the 
 degenerated and hypertrophied soft structure belonging to 
 the cavity, is sometimes found to a greater or less extent, 
 occupying the acetabulum, in place of the head of the 
 lemur. 
 
 The head of the femur now rests upon the margin of 
 the acetabulum, or upon the ilium near its circumference, 
 and presents hut little deformity, retaining its hemi- 
 spherical appearance, except upon its inner aspect, where 
 it is sometimes flattened, from resting upon the ilium. 
 
 The capsular ligament is elongated, as also the liga- 
 mentum teres; the structural integrity of both, however, 
 is still maintained, and the capsule at this early period 
 has been said to resemble an hour-glass, large at its pelvic 
 
150 PATHOLOGY. 
 
 and femoral attachments, and small at its centre. The 
 capsule is put upon the stretch by the ascent of the head 
 of the femur, which is still kept from direct contact with 
 the external surface of the os ilium by an intervening layer 
 of the capsule. 
 
 The synovial secretion is found to exist sometimes in 
 its natural condition. 
 
 This may be said to be the usual appearance in the 
 early stage of this displacement ; still exceptions may 
 occur, as appears from a case already quoted from Palleta, 
 on pages 19 and 20, of a child two years of age, where 
 alteration had taken place at this early period of the 
 affection, in nearly all the parts of the articular apparatus 
 of the hip-joint ; but in this instance there is reason to 
 suppose that the head of the femur had become entirely 
 detached, which would render the real nature of that case 
 somewhat doubtful. 
 
 In proportion to the duration of the dislocation, and to 
 the more or less advanced period of life, the nutrition of 
 the parts, from various causes, being materially disturbed, 
 the structural changes in the various tissues become also 
 more marked. 
 
 The separation between the acetabulum and the head 
 of the femur becomes gradually greater, owing to the 
 progressive ascent of the latter upon the ilium. 
 
 The Cotyloid Cavity, in the progress of the affec- 
 
PATHOl OGY. L5J 
 
 tion, lends to become contracted, and to assume an oval or 
 even a triangular shape, approximating, ;i^ ii were, to the 
 primitive form of the acetabulum daring foetal life, before 
 its three component parts have arrived at the period of 
 osseous consolidation. The acetabulum remains sometimes, 
 however, nearly circular, and presents upon its upper semi- 
 circumference a depression of a somewhat cresccntic form, 
 which allows the head of the femur to pass to and fro 
 from the dorsum of the ilium into its original receptacle, 
 now deprived of its cartilaginous lining. This was the 
 condition in one of the cases of congenital luxation, of 
 which I had an opportunity of making a post-mortem 
 examination. This subject was a female, about fifty 
 years of age. The head of the femur had passed through 
 the upper part of the capsular ligament, and rested upon 
 the external surface of the ilium, about an inch from the 
 border of the acetabulum. A semicircle of new osseous 
 material springing from the ilium, towards forming a new 
 acetabulum, prevented the femur from ascending farther 
 in this direction. The cotyloid cavity, although uearly 
 circular, had become more shallow, but was sufficiently 
 large to allow the head of the femur, which was not 
 much under the natural si ze, to pass into it. Owing to 
 the disappearance of a lunated portion of the upper cir- 
 cumference of the acetabulum, the head of the femur 
 could readily pass from this cavity upon the ilium, and 
 reduction could thus easily be effected, but in this condi- 
 
I 5"2 PATHOLOGY. 
 
 tioii of the parts, it could never have been rendered per- 
 manent. 
 
 Sometimes the cotyloid cavity is filled up with cellulo- 
 osseous material, readily yielding to the pressure of a 
 pointed instrument. 
 
 In one of the cases I have described farther ou, it will 
 be seen that the acetabula had assumed a contracted tri- 
 angular shape, and were nearly filled up with softish 
 adipo-osseous tissue. Vide Plate vi. 
 
 In another case, the acetabula were found contracted to 
 a cavity still smaller than in the previous instance, and 
 were filled entirely with a semi-osseous tissue of a similar 
 character to that before mentioned. Vide Plate vii. 
 
 The Head of the Femur becomes altered to as great 
 an extent as the cotyloid cavity, and the neck also soon 
 participates in the progressive alterations. 
 
 The head loses its spherical appearance, and becomes 
 changed in its dimensions and texture. The articular 
 cartilage, with which it is invested, having lost its rela- 
 tions with the articulating surface of the acetabulum, and 
 not being naturally supplied with the synovial fluid, or 
 with its usual amount of vascular nutrition, gradually 
 undergoes mutations which lead to its ultimate disappear- 
 ance, particularly where the head comes in direct contact 
 with the osseous tissue of the ilium. The aspect of the 
 head, where the round ligament ought to be inserted, 
 
PATHOLOGY. I 53 
 
 often presents a flattened surface, denuded of its articular 
 cartilage, a thin brittle shell of bone only covering the 
 deteriorated cancellated interior structure of the head. 
 The neck of the femur is also small, short, and stunted, 
 and assumes a more horizontal direction to the axis of the 
 femur than is usual, the head being more on a level with 
 the trochanter major, and losing its normal obliquity in 
 relation to the shaft of the bone. Vide Plates vi. 
 and vii. 
 
 The consistence of the osseous tissue of the head is 
 very considerably changed, being brittle and softer than 
 natural, and presents the evidences of perverted or dimi- 
 nished nutrition. 
 
 In some instances, where the displacement has been of 
 long standing, the head and neck are found to have 
 entirely disappeared; the ligamentous connexions between 
 the pelvis and the femur being attached, on the femoral 
 side, to the trochanter major or to the upper portion of 
 the shaft of the bone. This disposition of the parts is 
 represented on Plates viii. and ix. 
 
 The head and neck of the femur may assume in this 
 affection various shapes and degrees of deformity, from 
 the simple changes which take place in earlj life, up to 
 their complete atrophy and disappearance which occur 
 sometimes in old age. 
 
 This will not seem extraordinary, when it is consi- 
 dered that the head of the femur is peculiarly situated in 
 
 11 
 
154 PATHOLOGY. 
 
 regard to its vessels of nutrition, which chiefly pass to 
 its structure by means of the round ligament, which 
 is attached upon its inner aspect. The head of the 
 femur is not ossified for some time after birth, and being 
 isolated from the shaft by intervening cartilaginous 
 tissue at the early periods of life, it receives no arterial 
 supply from the vessels distributed through the other por- 
 tions of the os femoris, and but little from those ramifying 
 in the contiguous investing periosteum. From the nature 
 of the displacement, the ligamentum teres must be unduly 
 stretched in the very commencement of the luxation, and 
 the arteries coursing along it, more or less compressed. 
 When this circumstance, and even the total destruction of 
 the round ligament, which frequently takes place, is taken 
 into consideration, it can easily be understood how — particu- 
 larly after the protracted existence of this affection during 
 the course of many years — the nutrition of the head may 
 become so perverted as to produce structural deteriora- 
 tions, terminating sometimes in its total disappearance. 
 In the case represented on Plates vii. and nil., it will 
 be observed that the round ligament had entirely dis- 
 appeared. 
 
 It is also possible, even in the early years of this dis- 
 placement, for the head of the femur, before it is ossified, 
 to become detached from the shaft, from the effects of 
 violence or of friction, and its early disappearance may 
 in this manner be accounted for. It is difficult to explain 
 
PATHOLOGY. 1 55 
 
 the condition of the upper part of the femur, in the case 
 described l>\ Palleta, and already referred to, of a child 
 two years of age, in which, he says, "femur, pene dixe- 
 rim, acepkalum Juit" except upon the supposition, that 
 
 the cartilaginous head of the femur had thus become de- 
 tached. 
 
 The Capsular Ligament and the Ligamentum Teres 
 are found also to present various phases and alterations. As 
 a natural consequence of the ascent of the head of the 
 femur upon the dorsum ilii, the capsule must become 
 e/ongated and stretched beyond its normal dimensions. 
 The extent of the pelvic and femoral attachments will 
 prevent the two extremities of the capsule from coal- 
 escing, but towards its middle portion, the walls approach, 
 producing a contracted appearance at this part, so that 
 the capsule in the primary stages of the malady, before 
 it has given way in its continuity, has been compared, as 
 already stated, to an hour-glass, large at each end and 
 contracted in the middle. The round ligament also 
 becomes stretched and more slender, and is embraced by 
 the central contracted portion of the capsule through 
 which it must extend while it remains unbroken. 
 
 The articular capsule mav retain tor many years its 
 integrity, the head of the femur playing upon the dorsum 
 ilii during progression, a layer of the capsule inter- 
 vening between the head and the external surface of the 
 
156 PATHOLOGY. 
 
 ilium. At length, from continued friction and pressure, 
 absorption takes place, and a portion of the wall of the 
 capsule gives way, so as to allow the head of the femur 
 to escape from its cavity, and to come in direct contact 
 with the osseous structure of the dorsum ilii. This state 
 of things may exist lor a longer or shorter period ; the 
 head of the femur passing to and fro between its original 
 capsule and the external surface of the ilium. The ace- 
 tabulum, however, having now lost its normal configura- 
 tion, permanent reduction is scarcely attainable. When 
 the capsule has been perforated, so as to allow the head to 
 escape from it, the ligamentum teres, becoming elongated 
 and slender, must give way, and soon disappears. This 
 ligament, in the early stage of the displacement, is gene- 
 rally found to retain its continuity. Vide Plates vi. and 
 
 VII. 
 
 The capsule and ligamentum teres, as would appear 
 from one of the dissections, hereafter more particularly 
 described, may coalesce in proportion to the disappear- 
 ance of the head, and form a strong ligamentous cord, 
 running between the pelvis and the upper portion of the 
 femur. Vide Plates viii. and ix. 
 
 New Capsule. — When the head of the femur has 
 escaped from its natural capsule, and become placed in 
 contact with the surface of the os ilium, a new set of 
 phenomena takes place. Reparatory efforts are made to 
 
PATHOLOGY. 107 
 
 restore the head of the bone to something like its former 
 
 condition, and nature attempts to form a new capsular 
 ligament, which on the one hand is attached to the dor- 
 sum and contiguous portion of the ilium, and on the 
 other, to the outer and posterior surface of the old cap- 
 sale, and to the margin of the perforation through which 
 the head of the femur had made its escape. (Vide 
 Plates vi. and vn.) Or, the head may never have 
 escaped upon the ilium, and in that case, in proportion as 
 the head becomes atrophied and disappears, the sides of 
 the old capsule become coalesced and glued together, as 
 previously remarked. To the posterior part of the cord 
 thus formed, a set of radiating fibres, springing from the 
 dorsum of the ilium, become attached, and fortify it. 
 These fibres probably represent, in another form, a 
 recent capsule, which, under other circumstances, as when 
 the head has pierced the old capsule and rests upon the 
 dorsum ilii, would assume a regular capsular form. Vtdt 
 Plates viii. and ix.. 
 
 New Acetabulum or Socket. — By the formation of 
 the new capsule, a false articulation is parti) accom- 
 plished, which, to be complete, requires a new arrange- 
 
 nt upon the dorsum of the ilium, to represent a new 
 
 acetabulum. This end is attained in two different ways. 
 In one, there is a simple glenoid depression scooped out, 
 as it were, upon the dorsum of the ilium. { \'i<L Plate 
 
158 PATHOLOGY. 
 
 vii.) In the other, nature increases her efforts, and, as 
 often happens after traumatic dislocations, new osseous 
 matter is thrown out upon the ilium, which, at times, 
 assumes to some extent the cup-like form of an acetabu- 
 lum. In the first case, the new capsule attaches itself to 
 the margin of the depression (vide Plate vii.) ; in the 
 second, to the osseous border of the new socket. 
 
 M. Guerin has stated that it was an invariable sequent, 
 for a new osseous socket to be thrown out upon the dor- 
 sum ilii, as soon as the head of the femur, in congenital 
 dislocations of this bone, has escaped from the articular 
 capsule, and becomes placed in circumstances somewhat 
 similar to those attendant upon the traumatic dislocation 
 of the femur, and he has founded a theory of treat- 
 ment upon this supposed fact. The formation of a new 
 socket by osseous effusion, is not an invariable result of 
 the perforation of the articular capsule and the escape of 
 the head of the femur. The drawings of a pelvis, now 
 in my possession, establish the presence of only a simple 
 depression upon the dorsum of the ilium, notwithstanding 
 that the head of the femur has on both sides passed 
 through a large aperture at the upper part of the capsule, 
 and has become placed in immediate contact with the 
 osseous structure of the ilium. Vide Plate vii. 
 
 The secondary depressions, or the sockets, intended to 
 hold a certain relation with the displaced head, after it 
 has passed from its original capsule, are generally lined 
 
PATHOLOGY. I. '/.» 
 
 by a thin layer of tissue, depending probably upon the 
 periosteum of the ilium ; and this may at times present a 
 smooth surface, somewhat analogous to the sj aovial mem- 
 brane. At other times, from age and continued friction, 
 an appearance of eburnation is present ; at others again, 
 a rough surface. The osseous tissues of the pelvis and 
 of the femur, when thus deprived of the intervention of 
 any soft tissue, come into immediate contact, and when 
 moved upon each other, produce a harsh grating 
 sound. 
 
 Another modification which the capsule is seen to 
 assume, is represented in Plates viii. and ix. The head 
 of the bone, in this case, has never escaped from the cap- 
 sule, but has become absorbed, and the walls of the cap- 
 sule coalescing, have finally become conglomerated into 
 a firm, dense, ligamentous cord, running between the 
 remains of the old acetabulum and the stunted upper 
 extremity of the femur. Here, there is neither depression, 
 nor new socket upon the ilium, and the numerous auxili- 
 ary ligamentous fibres, which seem to occupy the place of 
 a new capsule, take their origin from the plain surface upon 
 the ilium, and run forwards, converging, to become incor- 
 porated with the posterior aspect of the ligamentous 
 remains of the ancient capsule Vide Plate ix. 
 
 The Synovial Membrane and the Articular Car- 
 tilage of the primitive cotyloid cavity, like the same 
 
160 PATHOLOGY. 
 
 structures covering the head of the femur, gradually disap- 
 pear, leaving, in some instances, the osseous tissue entirely 
 denuded. 
 
 We see then, from this account of the articular apparatus 
 of the hip-joint, as it appears in the different forms of conge- 
 nital dislocation of the femur upon the ilium, pathological 
 conditions, essentially distinct, which must exert an impor- 
 tant bearing upon the prognosis, and probable efficacy of the 
 therapeutic means that may be adopted in this affection. In 
 one case, the capsule is found to retain its continuity of struc- 
 ture, and the head of the femur rests enclosed in it on the 
 ilium, towards the margin of the acetabulum, or entirely 
 upon the dorsum ilii. In another, the capsule is found con- 
 verted into a conglomerated fibrous cord, which at one of 
 its attachments grasps firmly the upper part of the femur, 
 and is sufficiently extended to allow the head of this bone 
 to play upon the dorsum ilii through a space of from one 
 to three inches. ( Vide Plates viii. and ix.) In this case the 
 head of the femur has disappeared, but in neither of these 
 two cases does nature attempt to produce a new osseous 
 socket upon the external surface of the ilium, although a 
 simple depression may sometimes be found. 
 
 In a third condition of the pelvis, the round ligament 
 has most frequently disappeared, and the head of the 
 femur is found in direct contact with the external surface 
 of the ilium, having passed through a perforation in the 
 upper portion of the articular capsule. (Vide Plates vi. 
 
PATHOLOGY. 16] 
 
 aud vii.) In cases of this kind, an effasion of new osseous 
 matter, more or less profuse, in the shape of a socket, is 
 often found upon the dorsum of the ilium. This effort 
 of nature is similar to the process which occurs in those 
 instances of traumatic dislocations that have been allowed 
 to remain unreduced. At times, however, notwithstand- 
 ing the assertion of M. Guerin to the contrary, a simple 
 depression only exists upon the dorsum ilii, although the 
 capsule has become perforated and the head of the femur 
 lies in direct contact with the dorsum of the ilium. 
 ( Vide Plate vii.) In the two first conditions of the 
 parts, no new articulation is ever formed, but in the third, 
 a new socket may be produced, as well as a new capsule, 
 and a kind of pseudo-articulation thus result. 
 
 The Muscles. — The pathological state of muscular 
 retraction, by the instrumentality of which the dislocation 
 of the head of the femur is primarily produced, has 
 already been considered, under the head of etiology. 
 The muscles surrounding the hip suffer a still farther 
 shortening, owing to the contraction resulting from the 
 unnatural position in which they are placed when the 
 dislocation has actually occurred The points of origin 
 and of insertion ot several of the muscles now become 
 approximated, and this circumstance is another cause 
 which tends still farther to produce a shortened state of 
 
162 PATHOLOGY. 
 
 the muscles originally implicated in the production of the 
 dislocation. The existence of the abnormal retraction of 
 the muscles is necessarily one of the chief obstacles to 
 the permanent success of the reduction of the head of the 
 femur to its natural position. 
 
 At the same time that the points of origin and of in- 
 sertion of the pelvi-femoral muscles are relatively changed, 
 the course of their fibres assumes a different direction 
 from that which is natural to them while the normal dis- 
 position of the component parts of the joint is main- 
 tained. 
 
 In progress of time, the muscular tissue itself becomes 
 changed. It may present a fibrous appearance, or it may 
 be pervaded by a fatty degeneration, and become atro- 
 phied ; or in some cases it may even become hypertro- 
 phied. These conditions of the muscular tissue result 
 from the perverted action of the pelvi-femoral muscles, 
 some of them being so placed as seldom to be brought 
 into a state of action, while additional exertion is required 
 of others. The increased exercise which certain muscles 
 have to undergo, induces a hypertrophic state, as often 
 happens in some portions of the gluteus maximus, gracilis, 
 &c, while, where the traction is still more energetic and 
 continued, fibrous degeneration takes place, as is seen in 
 the conjoined tendons of the psoas-magnus and iliacus 
 internus, and frequently of the gluteus minimus; while 
 
PATHOLOGY, ]G3 
 
 fatty degeneration and atrophy arc the conseqaence of 
 
 the relaxation and inertia which follow the approxima- 
 tion of the points of origin and insertion of some of 
 the muscles, examples of which are met with in most 
 of the pelvi-trochanteric muscles; such as the gluteus 
 medius, &c. 
 
 From what has been said in relation to the mor- 
 bid retraction of the muscles, and the fibrous transforma- 
 tion which pervades the tissue of some of them, it 
 would seem that these conditions in themselves must 
 sometimes form an insurmountable obstacle to the perma- 
 nent reduction of the head of the femur. Upon this con- 
 sideration, the principle of dividing the implicated muscles 
 by subcutaneous section, as in the treatment of Talipes, 
 and some other articular deformities, has been applied to 
 the retracted muscles of the hip-joint, in cases of conge- 
 nital dislocation of the head of the femur. This exten- 
 sion of myotomy was suggested by M. Guerin, and merits 
 attention, as one of the resources that may be made avail- 
 able in cases of this displacement. 
 
 Arteries and Veins. — The arteries in persons affected 
 with congenital dislocation of the femur do not take the 
 direct course which is observed in their normal distribu- 
 tion. They are hV\uoiis and serpentine, and exhibit a con- 
 tracted state of their calibre, while the reins are direct to 
 their course, and larger in diameter than in the natural 
 
164 PATHOLOGY. 
 
 condition of the parts. The arteries of the ligamentum 
 teres must, in the early period of the displacement, become 
 compressed, and finally, when this ligament becomes rup- 
 tured, or has given way from pressure, and disappeared, 
 the head of the femur must be deprived of the nutrition 
 supplied to it through the medium of this structure. 
 
 Nerves. — The nerves, which are generally found to be 
 smaller, are disposed in such a manner as to take a direct 
 course to arrive at their distribution in the muscular 
 tissue. Therefore they might, from the shortening 
 resulting from this arrangement, be the source of consi- 
 derable pain during the efforts made in attempting to 
 accomplish the reduction of the luxation. The arteries 
 in this respect are differently disposed; for being flexuous, 
 the extension, by which the extremity can be elongated, 
 would only efface their sinuosities without putting these 
 vessels on the stretch. 
 
 Cellular Tissue and Skin. — The cellular tissue is 
 generally abundant, is studded with pelotons of adipose 
 tissue, and pervades in considerable quantity the depres- 
 sions resulting from the new disposition of the parts, as 
 well as the inter-muscular spaces. The skin, in old sub- 
 jects, is apt to be flaccid, but presents nothing unnatural, 
 except the ordinary appearances which might be expected 
 to result from enfeebled nutrition. The facility with 
 
PATHOLOGY, 166 
 
 which the cutaneous and cellular structures will accom- 
 modate themselves by their elasticity to extension exerted 
 upon the limb, would prevenl their ever offering anj obsta- 
 cle in attempts to effect the reduction of the head of the 
 
 femur to its natural position. 
 
 Changes which take place in the Osseous Tissue. 
 — The alterations which occur in the parts of the skele- 
 ton in proximity to the morhid articulation, or even at a 
 considerable distance from it, merit consideration. From 
 the perverted and diminished nutrition to which the osse- 
 ous tissue is subjected in this malady, alterations occur in 
 the different portions of the pelvis, extending to the 
 femur, and to the other component parts of the bony 
 structure of the inferior members, producing ultimately 
 formidable complications during the progress of this affec- 
 tion. 
 
 As far as my own observations extend, the diameters 
 and the several measurements of the pelvis are invariably 
 changed, and the tissue of the bones, not only of the ossa 
 femora, but also of those more remote, undergo alterations 
 in their texture, density, and volume. The thigh bones 
 and the tibia and fibula, as is seen in the drawing of one 
 ot the cases I examined (vide Plates viii. and ix.), have 
 participated very materially in the degeneration of struc- 
 ture. 
 
 This softened and fragile condition of the I. ones is dil- 
 
166 PATHOLOGY. 
 
 ferent from that which has received the name of rachitis. 
 In the osseous deterioration of the pelvis and femurs, in 
 persons laboring under congenital dislocation of the hip- 
 joint, there is no reparatory attempt made towards the 
 restoration of the osseous structure while the displace- 
 ment exists. In rachitis, however, the soft and yielding 
 state of the bones is generally temporary, and in fact the 
 rachitic bone, once cured, often presents a denser and more 
 compact interior texture, than a bone which had never 
 suffered from this disease, as may be observed on the con- 
 cavity of the long bones which have suffered from rachitic 
 derangement. 
 
 The osseous structure depends indirectly upon the vas- 
 cular supply to the periosteum, and to the internal medul- 
 lary membrane, for its healthy nutrition. As has already 
 been observed, the arteries in the vicinity of the disloca- 
 tion are not in their normal condition, besides being 
 under their usual size. As a natural consequence of this, 
 the medullary membrane is not supplied sufficiently for 
 the interior nutrition of the bone, while from the same 
 inadequate supply to the periosteum, the more superficial 
 parts likewise suffer in this respect. When this is taken 
 into consideration, it may reasonably be expected that the 
 pelvis and femurs would become deteriorated in their tex- 
 ture. 
 
 In connexion with the increased muscular traction 
 which, in congenital luxation, must take place during 
 
PATHOLOGY. 1G7 
 
 locomotion, this deficiency of density and the fragile state of 
 the hones predispose to the production of osseous malfor- 
 mations, and thus the curvatures, and fractures even, of 
 the long bones, such as the femur, can be satisfactorily 
 
 accounted for. Vide Plates viii. and ix. 
 
 Changes Observed in the Configuration of the 
 Skeleton of the Pelvis, &c. — The pelvic diameters 
 and other measurements are materially changed in cases 
 of long standing, the alterations being modified, according 
 as the dislocation is present upon one side only, or simul- 
 taneously upon both. The assertion of Dupuytren, in 
 regard to the natural conformation of the pelvis being 
 maintained in cases of either single or double congenital 
 dislocation of the femur on the ilium, is proved now by 
 pathological investigations, to be incorrect. In the speci- 
 mens which I have had the opportunity of examining 
 and of dissecting, the diameters of the pelves were mate- 
 rially changed from the normal standard, and I have no 
 doubt that similar irregularities will be observed to exist, 
 as a general rule. 
 
 During life, and in the erect posture, where there is 
 dislocation upon one side only, the hip posteriorly, of the 
 side affected, is apparently more elevated, owing to the 
 projection of the trochanter major; but the ilium is found 
 to have descended lower than the corresponding part of 
 the opposite side. In the skeleton, however, the half 
 
168 PATHOLOGY. 
 
 of the pelvis, which corresponds to the dislocation, is 
 dragged or twisted from before backwards, and from below 
 upwards, so that the side of the pelvis upon which the 
 dislocation has existed, is situated, in relation to the os 
 innominatum of the sound side, upon a higher plane 
 and more posterior, than on the side where the head of 
 the femur has maintained its normal position. 
 
 At the superior strait, the antero-posterior diameter of 
 the affected half is diminished, and the symphysis pubis 
 is drawn beyond the mesial line, in the direction of the 
 affected side. The semi-inferior strait corresponding to 
 the affected side, on the contrary, appears more open 
 and enlarged laterally, and is drawn, as it were, 
 outwards and upwards. These malformations, occur- 
 ring in the diameters of the straits, although confined 
 chiefly to one side, necessarily interfere with the functions 
 of parturition, and render it difficult and dangerous ; and 
 after reduction, where this is practicable, they would still 
 be a source of lameness. 
 
 The individual parts of the pelvis on the affected side, 
 present also deviations from the natural configuration. 
 The ilium, besides being more thin and atrophied, 
 is more vertical and less excavated. The anterior 
 superior spinous process of the ilium is carried some- 
 what inwards ; the inferior anterior iliac spine is 
 more prominent than natural, and immediately below 
 it, and between it and the eminentia ilio-pectinea, 
 
PATHOLOGY. I G9 
 
 is observed a deep groove, in which the conjoined 
 tendon of the iliacus interims and psoas magnns has 
 played. (Vide Plate viii.) The transverse or horizon- 
 tal branch of the pubes is longer and more slender, and is 
 directed more obliquely upwards and backwards, than the 
 corresponding part of the sound side 
 
 The ischium is drawn outwards by the pelvi-trochan- 
 teric muscles, so that the tuberosity is seen situated more 
 externally than on the opposite side. As a consequence 
 of the change of direction outwards of the ischium and 
 of the descending ramus of the pubes, the long diameter 
 of the obturator foramen is found to be disposed nearly 
 transversely, instead of almost vertically. 
 
 When the head of the femur is dislocated upon the ilium 
 on both sides, both halves of the osseous pelvis participate 
 in the deformity, and frequently the alterations are so 
 nearly alike on either side, that the resulting malforma- 
 tions are symmetrical. 
 
 The wings of the ossa innominata in this case, are 
 found less dense, smaller, and more vertical ; the anterior 
 inferior spinous processes of the ilia are found prominent, 
 and the depressions existing below them are seen to be 
 deeply grooved by the continued traction of the tendons, 
 which played in them during life. (Vide Plates vi. and 
 viii.) The horizontal rami of the pubes are found also 
 more slender and longer, extending considerably farther 
 outwards, on each side from the symphysis, than in the 
 
 12 
 
170 PATHOLOGY. 
 
 natural state ; while the body of the pubes, on each side 
 of the symphysis, is less deep, and also more fragile in tex- 
 ture. The ischia are drawn outwards, and the long diame- 
 ters of the foramina obturatoria run somewhat in a transverse 
 direction, instead of being nearly vertical. The sacrum 
 is generally more stunted, and narrower than natural. Vide 
 Plates vi. and vn. 
 
 The superior strait of the pelvis is contracted in the 
 antero-posterior diameter, while laterally or transversely 
 the measurement is proportionally increased, although, as 
 the whole pelvis is generally on a smaller scale, this mea- 
 surement is, in reality, less than is met with in a well 
 formed pelvis. 
 
 The inferior strait presents a contraction in the mea- 
 surement from the apex of the coccyx to the arch of the 
 pubes, while the transverse diameter between the ischia, 
 is considerably more ample than in the natural pelvis. 
 Vide Plates vi. and vn. 
 
 From this statement, it is evident that so great a de- 
 parture from the normal relations of the different measure- 
 ments and straits of the pelvis, must of themselves add to the 
 lameness, as well as materially impede the progress of the 
 head of the full grown fcetus, in its passage through the 
 pelvis, during parturition, and that a difficulty may be 
 anticipated so formidably, as to render the intervention of 
 instrumental aid necessary to preserve the life of the 
 mother. From the extent of malformation which takes 
 
PATHOLOOT. 171 
 
 place in the pelvis, whether the dislocation be single 01 
 double, there seems little reason to suppose that in either 
 
 case the obstacles to parturition would be materially lessened. 
 
 Analysis of the Malformations op the Pelvis. — 
 The extent of the deformity which pervades the pelves 
 of individuals who are affected with congenital disloca- 
 tion upon the dorsum ilii, must in a great degree be sub- 
 ordinate to the extent of the displacement of the head of the 
 femur, and also to the length of time the luxation may have 
 existed. The characteristics, however, of these malfor- 
 mations are generally so similar and definitely marked, 
 that they can be chiefly referred to a set of anatomical 
 causes which must always exert their influence during 
 the existence and progress of this affection. 
 
 The escape of the head of the femur from the confines 
 of the acetabulum, and its ascent upon the dorsum ilii, 
 will necessarily change the direction and relative action 
 of all the muscles inserted into the upper portion of the 
 femur. The psoas magnus and iliacus interims, on each 
 side, when the luxation is double, will be put upon the 
 stretch in proportion as their points of insertion at the 
 trochanter minor are dragged upward* during the ascent of 
 the head of the femur. 
 
 The quadratus femoris, the gcmelli, the obturatorcs, the 
 pectineus, and probably tin 1 upper portion of (be adductor 
 magnus, attached on the one side to the pelvis, and on 
 
172 PATHOLOGY. 
 
 the other to the upper portion of the femur, are also put 
 upon the stretch by the removal of their points of inser- 
 tion at the femur to a greater distance from their points of 
 origin. Vide Plate hi. 
 
 In connexion with the deteriorated organization of the 
 bones of which the pelvis is constructed, the increased 
 traction exercised by the muscles, and the perverted 
 direction in which they must now act, during progression, 
 will, to a certain extent, account for many of the changes 
 which are observed in the form and dimensions of the 
 pelvis. The vertical direction which the wings of the 
 ilia acquire, may result from the suspended antagonism 
 between the iliacus internus on the one hand, and 
 the gluteus medius and gluteus minimus on the other. 
 The ascent of the femur puts these two glutei into a 
 state of relaxation and consequent inactivity, as regards 
 their effect upon the dorsum ilii ; while, on the contrary, 
 the iliacus internus is in a state of tension, which tends to 
 pull inwards the internal iliac fossa. The deep groove to 
 be seen below the anterior and inferior spinous process 
 of the ilium is evidently the result of the tractions exer- 
 cised upon the conjoined tendons of the psoas magnus 
 and iliacus internus muscles, which pass over this groove 
 like the cord of a pulley, and play in it during progression. 
 These tendons, by their continued traction on each side, 
 will tend, besides, to elongate outwardly the horizontal 
 ramus of the pubes. The ischia are pulled outwards by 
 
PATHOLOGY. 173 
 
 the continued traction of the quadratus femoris, the superior 
 .ukI interior gemelli, and the obturator internus, while the 
 
 obturator externus impresses the mark of its passage over 
 the anterior and external part of the body of the ischium ; 
 the tractions of the upper fibres of the adductor magnus 
 on each side may also aid in separating the descending rami 
 of the pubes, and thus contribute to enlarge the angle 
 below the symphysis pubis. Vide Plates hi., vi., and 
 
 VII. 
 
 These abnormal results, in the configuration of the 
 pelvis, brought about by the perverted action of the pclvi- 
 femoral muscles, are materially augmented by the influ- 
 ence which the weight of the body exerts upon the mus- 
 cles, during locomotion, after the heads of the ossa femorum 
 have escaped from the limits of the acetabula. It mav 
 easily be understood that, as soon as the heads of the 
 femurs have mounted on the ilia, and lost the fixed sup- 
 port which they naturally receive from the walls of the 
 cotyloid cavity, the trunk must sink down, as it were, 
 between the upper portions of the ossa femorum. An ad- 
 ditional superincumbent weight being now thrown in a 
 great degree upon the muscles surrounding the hip-joint, 
 the traction exercised by those muscles which are 
 attached to the framework of the pelvis, is necessarily 
 increased, and the fragile osseous tissue becomes distorted 
 in the direction of the action of theil fibres. 
 
 It is also by the agency of the several causes above 
 
174 PATHOLOGY. 
 
 mentioned, confined, however, to one side only, that the 
 lateral parts of the pelvis corresponding to the side 
 affected, become deformed and drawn upwards and back- 
 wards, in cases of single congenital luxation of the femur 
 upon the ilium. 
 
 The occurrence of fracture of the femurs, as well as of 
 the bending of these bones, and of the tibia and fibula, 
 which is sometimes observed, must also be attributed to 
 the deteriorated condition of the bones themselves, and to 
 the increased action imposed upon the muscles, both by 
 the superincumbent weight of the body, and by the ordi- 
 nary muscular contractions which come into play during 
 the different acts of locomotion. 
 
 These pathological remarks on the changes which take 
 place in congenital dislocations of the femur, at the ilio- 
 femoral articulation, in the osseous structure in proximity 
 to it, and in the soft tissues by which this joint is sur- 
 rounded, will be referred to, when the subject of treatment 
 comes to be considered, as they have a direct bearing upon 
 the curability of these affections. 
 
 I shall now proceed to the description of a case of 
 double congenital luxation of the heads of the femurs 
 upon the dorsa of the ilia, which I select from those I have 
 had an opportunity of examining after death, as a pure 
 and uncomplicated specimen of this affection, and as signally 
 elucidating its pathological characters.* 
 
 * I take pleasure iu acknowledging here the facilities afforded me hi the prosecu- 
 
PATHOLOGY. L75 
 
 It presented all the pathognomonic characters exter- 
 nally, appertaining to the case related al page L06 el seq., 
 and which is delineated in Plates Nos. i., il, and iv. 
 
 To aid the description of the parts, I refer to the 
 admirably executed drawings of the pelvis and the liga- 
 ments of the coxo-femoral articulation, as seen imme- 
 diately after the removal of the soft tissues, in Plates vl 
 and vn. 
 
 The subject from which the following description is 
 taken — a female, apparently between sixty and seventy 
 years of age — as observed while lying on the table, is seen to 
 be somewhat emaciated, but this condition is most evident 
 as regards the inferior extremities. The soft parts about 
 the basin are flabby ; a considerable disproportion between 
 the size of the trunk and the length of the inferior ex- 
 tremities is observable, owing to the ascent of the heads 
 of the femurs upon the dorsa of the iliac bones. The 
 head, thorax, and abdomen, present nothing abnormal 
 while the body is in a recumbent position, but being 
 placed in the erect attitude, the superior extremities 
 appear too long for the trunk; the trunk itself appearing 
 as it were, wedged and sunk between the upper portion 
 of the femurs. The thorax and abdomen an 1 thrown for- 
 ward with a salient anterior curve, while the region ol the 
 
 don of my inquiries on this suhj</ct,hy M. I> L<-m:ir<iuuy, at that time connected with 
 the Hdtel thui ami \\w Emir Pratique, of Pans. 
 
176 PATHOLOGY. 
 
 loins, and the lower part of the dorsal vertebrae, present a 
 curvature forwards with a corresponding concavity. In this 
 latter position, also, the anterior superior spinous processes 
 of the ilia are thrown forwards, while the lower part of the 
 sacrum and coccyx take a direction upwards and back- 
 wards ; the base of the sacrum being consequently tilted 
 forwards and downwards. The eristic of the iliac bones 
 are almost vertical, and the trochanters can be felt stand- 
 ing out at a right angle to the external surface of the dor- 
 sum, nearly on a level with the posterior portion of the 
 crests, and forming the apex of a conoid eminence, the 
 base of which is at the ilium itself. The heads of both 
 femurs enjoy free motion upon the dorsa of the iliac 
 bones, and, while the trochanters can be pushed upwards 
 and outwards, so as to be within half an inch of the crests 
 of the ilia, when traction in the opposite direction is 
 exerted, they are felt to descend through a space of nearly 
 two inches, and become nearly on a level with a direct 
 line drawn transversely from the depressed anterior and 
 superior spinous processes. The pelvis itself, with the 
 exception of the unusual inclination of its axes, and the 
 unnatural projection caused posteriorly by the abnormal 
 position of the trochanters, appears to be, in other respects, 
 tolerably well formed; the transverse diameter being, 
 however, somewhat increased at the expense of the 
 antero -posterior, but neither as regards the pelvis, nor the 
 other osseous parts of the extremities or trunk, are there 
 
PATHOLOGY. 177 
 
 to be seen ;m\ evidences of a rachitic disposition. Between 
 the anterior and superior spinous processes, there isa distance 
 of eight inches; between the anterior superior spinous pro- 
 cess and the tuberosity of tin* pubes, lour inches and a 
 half; while between the tuberosities of the ischia there is 
 a space of five inches and three quarters, showing a con- 
 siderably exaggerated diameter in this direction. The 
 nearly equilateral triangle observed in the natural position of 
 the parts, between the upper margin of the trochanter, the 
 tuberosity of the pubes, and the anterior superior spinous 
 process of the ilium, is altogether changed, the measure- 
 ments between these several points differing materially, 
 according as the head of the femur is pushed upwards, or 
 is drawn downwards upon the dorsum of the ilium. The 
 play of motion which the head of the femur must have 
 had in the act of progression during life, may be said to 
 have been about two inches, as that extent of change of 
 position of the head of the bone can be obtained. h\ an 
 alternating force applied to its shaft, of traction down- 
 wards, or propulsion upwards. In the attempt to rotate 
 or move in different directions, the inferior extremity, a 
 sensation of crepitus is felt, analogous to that produced 
 by effusion or thickening of the ligamentous structure 
 about an articulation ; and the various motions can be 
 effected with less facility than is generalh observed in a 
 healthy joint. Adduction and the action of flexing tin- 
 thigh upon the pelvis, is less impeded than the other 
 
178 PATHOLOGY. 
 
 motions, but abduction and extension are permitted to a 
 very limited extent. 
 
 As far as can be seen externally, the dislocation on 
 both sides is exactly similar in every particular, and the 
 two sides of the pelvis, in regard to the relations they 
 bear with the displaced head and trochanter of the femur, 
 offer no perceptible variety. It will be seen by reference 
 to the case already inserted, at page 106 et seq., that the 
 pathognomonic characters described, as belonging to the 
 patient there alluded to, are perfectly analogous to those 
 which claim our consideration in the present instance. 
 
 The external appearances then being, in both cases, the 
 one a facsimile of the other, it may reasonably be sup- 
 posed that the deeper tissues are also analogous. After 
 these preliminary remarks, as regards the external charac- 
 ters or signs presented by the double congenital luxation 
 of the head of the femur upon the dorsum ilii, we shall 
 now describe the appearances met with upon dissection ; 
 first of the soft parts, and then in connexion with the 
 articular surfaces appertaining to the skeleton. 
 
 The skin occupying the region of the haunch is soft 
 and flaccid, but in other respects presents nothing remark- 
 able. The subcutaneous adipo-cellular layer is dense 
 and interspersed with pelotons of adipose tissue, which 
 also are more condensed than usual. The aponeurosis 
 covering the glutei is natural, but in attempting to remove 
 this from the gluteus maximus, the fibres of this muscle 
 
PATHOLOGY. L79 
 
 are found to be so friable, that it is impossible to remoi e the 
 investing fascia, without carrying along with it some of the 
 degenerated muscular tissue. The first layer of muscles 
 
 O J 
 
 being exposed, consisting of the gluteus maxinius, the 
 anterior portion of the gluteus medius, and the upper por- 
 tion of the semi-membranosns, semi-tendinosus, and 
 biceps, the general character of the muscular tissue is 
 found to be much changed. These muscles are soft, 
 flabby, and pale, and have undergone, in many points, a 
 partial conversion from the muscular into a kind of yel- 
 lowish, fatty tissue. This is particularly to be observed 
 with regard to the gluteus maxinius and the anterior por- 
 tion of the gluteus medius, but the other muscles partici- 
 pate more or less in the degeneration. The muscular 
 fibres, in regard to their length, seem to have accommo- 
 dated themselves to their altered position, and are 
 found to be shorter than they ought to be, when the nor- 
 mal relation of the parts exists, and this can easily be 
 understood when it is considered that the points of origin 
 and insertion are considerably approximated by the ascent 
 of the head of the femur. The gluteus maximus being 
 divided transversely through its middle, and the two por- 
 tions reflected, an unusual quantity of adipo-cellular tissue 
 is met with enveloping the large nerves, arteries, and 
 veins situated beneath this muscle. Bj removing this 
 loose tissue, the deep-seated muscles are exposed, and are 
 found to have undergone the same fattj degeneration as 
 
180 PATHOLOGY. 
 
 the more superficial layer, and the change or alteration in 
 the direction of their fibres is particularly evident. Thus 
 the quadratus femoris, obturator externus, gemelli, and 
 obturator internus, instead of passing transversely outwards, 
 as they generally do, assume a direction almost directly 
 upwards, and but slightly outwards, to arrive at their 
 point of insertion, at the root of the great trochanter. 
 The pyriformis, which in the healthy subject is inclined 
 downwards from its origin, has taken an inverse direction, 
 and ascends upwards and outwards to reach its place of 
 insertion at the digital fossa. In regarding the parts from 
 above downwards, the gluteus medius, pyriformis, and 
 obturator internus, instead of resting upon the posterior 
 portion of the cotyloid cavity, lie upon the partially 
 destroyed head of the femur and the posterior surface of 
 the coxo-femoral capsule. The gluteus medius, the an- 
 terior fibres of which have become transverse, is pushed 
 upwards towards the iliac crest, while the gluteus mini- 
 mus is also shortened, and more fibrous than natural, par- 
 ticularly towards its insertion, where it becomes con- 
 founded with the capsular ligament. 
 
 Upon removing the tegumentary tissues from the ante- 
 rior and upper part of the thigh, the femoro-pelvic muscles 
 in that region are found to be shorter than natural, by the 
 amount of the distance that the head of the femur has 
 passed up beyond the cotyloid cavity. The same fatty 
 degeneration and paleness of muscular tissue before 
 
PATHOLOG1 . 1 v I 
 
 alluded to, is found to pervade, more or less, the rectos, 
 tensor vaginae femoris, and the belly of the Iliacus Inter- 
 ntis. The sartorius and adductors presenl a more normal 
 appearance of tissue, as docs also the gracilis, which last 
 is even somewhat hypertrophied. The psoas magnus, 
 taking its usual origin from the bodies and transverse 
 processes of the last dorsal and lumbar vertebra-, passes 
 downwards, and becomes tendinous about its middle. 
 Where it passes over the brim of the pelvis and becomes 
 mixed with the iliacus interims, a strong cord-like tendon 
 results from the junction of these two muscles, which, 
 instead of passing downwards and outwards to the usual 
 point of insertion, hooks, as it were, over the margin of 
 the pelvis, below the anterior inferior spinous process of 
 the ilium, where it forms a deep groove ; it then takes a 
 course upwards, outwards, and slightly backwards, to the 
 extent of nearly three inches, to gain the trochanter 
 minor. It is important to bear iti mind the reflected 
 course of the tendon of the psoas magnns, as it accounts 
 anatomically for the curvature forwards of the lumbar 
 region, and also operates in conjunction with the short- 
 ened state of the adductors in materially impeding the 
 adduction of the limb. From the continued friction to 
 which the parts must have been subjected during life in 
 the act of locomotion, a large bursa, extending in various 
 directions, exists beneath the conjoined tendons ol the 
 psoas and iliacus, and the finger, when inserted into it, 
 
182 PATHOLOGY. 
 
 meets with an extensive cavity, which in the natural state 
 would have been occupied by the margin of the aceta- 
 bulum and a portion of the head and neck of the 
 femur, covered with the anterior part of the capsular liga- 
 ment. 
 
 The arteries are much smaller than natural, and pre- 
 sent a remarkably tortuous disposition, not unlike the 
 flexuosities of the vessels of the impregnated uterus. 
 Thus the main arterial trunk of the pelvis and inferior 
 extremity, from the bifurcation of the aorta into the pri- 
 mitive iliacs to the place where the femoral artery per- 
 forates the tendinous sheath of the adductor magnus, 
 presents a series of sinuosities bending in various direc- 
 tions ; and this disposition is observed in the smaller 
 branches, as well as in those which spring from the 
 internal iliacs to supply the parts on the gluteal 
 region. 
 
 The veins corresponding to the arteries, if any dif- 
 ference exist, are larger than usual, and differ from the 
 arteries in following a direct course, without presenting 
 any irregular flexuosities. 
 
 The nervous centres in their structure present nothing 
 abnormal in their individual parts, but they are somewhat 
 under the average size. The remains of a small bloody 
 effusion (foyer sanguine) exists in the substance of the 
 corpus striatum of the left side, and also another in the 
 cerebellum near the corpus dentatum. The spinal mar- 
 
PATHOLOGT. 183 
 
 row, except the diminution in volume just alluded to, 
 appears generally natural, and the nerves forming the 
 Cauda equina, as also the sacral plexus, and the branches 
 which take their origin from them, viz. obturatrix, glu- 
 teals, less and greater sciatics, &c., are below the normal 
 size. 
 
 The ligamentous structure of the coxo-femoral articu- 
 lation presents peculiarities and changes even more remark- 
 able than the other tissues already spoken of, and merits 
 special attention as regards the possibility of effecting the 
 reduction of this dislocation after a certain age, and the 
 probability of maintaining the displaced articular surfaces 
 in contact, should the attempt to reduce the dislocation 
 be successful. The form and dimension of the capsular 
 ligament have undergone a complete change, and in fact 
 the disposition of the ancient capsule, and the parts it 
 originally contained, have assumed altogether a new 
 character, and abnormal relations with each other. The 
 former ligamentous tissue itself has in some parts been 
 replaced by a fatty structure, and has become thickened, 
 or more attenuated in others. 
 
 It is not easy to describe by words the complex 
 changes which the articular apparatus of the joint has 
 undergone, but by a reference to the drawings on Plates 
 vi. and vii., the description of the parts, as disclosed 1>\ 
 dissection, will he better understood. Upon each side, 
 the coxo-femoral articulation has become, as it were, fur- 
 
184 PATHOLOGY. 
 
 nished with two capsular ligaments ; one, which is the 
 remains of the ancient capsule, and the other, which is of 
 more recent formation, and in which the head of the 
 femur has been lodged since its escape from the original 
 capsule. The old capsule, retaining its attachments at 
 the margin of the acetabulum, has changed its usual 
 direction, and is stretched upwards and outwards, in pro- 
 portion as the head of the femur has mounted upon the 
 dorsum ilii. The head of the bone becoming indepen- 
 dent of the acetabulum, and placed during the erect pos- 
 ture of the subject at the upper portion of the interior 
 of the natural capsule, would naturally ascend and 
 descend, during the act of locomotion, and remain 
 within the original capsule until, in the progress of time, 
 farther changes occur. Owing to the weight of the body 
 being now thrown chiefly on the capsular ligament, and 
 the consequent pressure of the head of the femur against 
 its upper portion, particularly during progression, it is 
 reasonable to suppose that this part more especially of 
 the capsular ligament, would be subjected to material 
 changes. Tins apparently has been the case. The 
 head of the femur acting from below upon the superior 
 and inner portion of the old capsule, while the weight of 
 the body afforded the counter resistance from above, this 
 portion of the capsule, thus situated between the internal 
 part of the head of the os femoris and the dorsum of the 
 ilium, being continually subjected during the actions of 
 
PATHOLOGY. 185 
 
 locomotion to the influences of powerful traction and 
 pressure between two bard bodies, gives way, either bj 
 
 rapture, or more probablj has become, as ii were, worn 
 through (use) by a species of progressive absorption. 
 The perforation of the capsule being now accomplished, 
 
 and the weight of the body still continuing to be thrown 
 upon the inferior extremities, the bead of the os femoris, 
 pressing in one direction and the superincumbent weight 
 of the body in another, escapes at length through this 
 perforation, and now becomes situated upon the dorsum 
 of the ilium, in contact, superiorly and externally, with 
 the deep surface of the gluteus minimus, and inferiorly 
 with the upper surface of the old capsule, an annular 
 portion of which passes around and thus encircles the 
 cervix femoris. Vide Plates vi. and vn. 
 
 As happens in traumatic dislocations, the formation of 
 a new capsule has followed the escape of the head of the 
 femur from the confines of its original receptacle. This 
 new capsule, which entirely surrounds the head of the 
 femur in its new position, is of a hbro-ligaineiitous 
 character, mixed in some points with a considerable 
 quantity of yellowish, dense, adipose structure. (]'/</> 
 Plate vir.) It is inelastic, but from the length of its 
 fibres, free motion of the bone is allowed in even direction 
 after the muscles have been removed Internally, it is 
 attached to the margin of an oval depression situated on 
 the dorsum of the ilium in front of the iscbiatic notch ; 
 
 13 
 
186 PATHOLOGY. 
 
 externally, it has formed adhesions with the annular per- 
 foration in the ancient capsule, through which the head 
 of the bone has passed. The external surface of the 
 capsule is generally surrounded by a cellulo-adipose tissue, 
 but above, it is confounded with the fibrous structure of 
 the deep surface of the gluteus minimus, and below, with 
 the outer and superior part of the original capsule. The 
 internal surface of the new capsular ligament is smooth 
 and shining, studded in various points with numerous 
 pediculated granular bodies of a yellowish adipose ap- 
 pearance, and at the lower and external portion, may be 
 observed the perforation already mentioned, and which is 
 seen to allow a free communication between the ancient 
 capsule and the one of more recent formation. Within 
 the cavities of both capsules a considerable quantity of 
 synovial liquid is found, which most probably has been 
 secreted from the lining membrane of the original cap- 
 sule. 
 
 The ligamentum teres, most likely after being ruptured 
 or worn through, on account of the stretching it must have 
 undergone by the displacement of the parts, has entirely 
 disappeared, leaving no trace of its existence behind, 
 either at its attachment to the head of the femur, or at 
 the bottom of the cotyloid cavity. 
 
 The head of the femur has changed its character in 
 regard to its size, shape, and consistence. Its dimensions 
 are much smaller than natural, being at least one third 
 
PATHOLOGY. 187 
 
 below the natural standard. ( Vide Plate vii.) Th<- 
 aspect upon which the round ligament is generally 
 attached, is flattened, and seems either to have never 
 been developed in this direction, or to have been absorbed, 
 or, as it. were, worn down by the friction to which it 
 must have been subjected upon the dorsum of the ilium 
 during progression. This flattened aspect presents super- 
 ficially a thin lamina of bone, which is entirely denuded 
 of articular cartilage, and on the surface of which are 
 seen numerous irregular elevations and depressions per- 
 forated with small foramina, as if the subjacent cancel- 
 lated tissue had been encroached upon. The osseous 
 tissue of what remains of the head of the femur is en- 
 tirely altered. Instead of the spherical form and resisting 
 tissue of the adult normal bone, the head of the femur in 
 the subject before us presents an unshapely, stunted 
 appearance, covered externally by a thin, friable, osseous 
 shell, which lies upon a spongy, cellular tissue of bone, so 
 soft as to be easily crushed between the fingers, and inca- 
 pable of resisting the pressure of a common writing quill. 
 The articular cartilage exists, but to a very limited extent, 
 and is seen to end abruptly in a greyish undulating line, 
 leaving that portion of the head in contact with the dor- 
 sum of the ilium, as has already been mentioned, entirety 
 bare. The neck of the femur is shorter and more slen- 
 der than natural, and forms a right angle with the shaft 
 of the bone, which arrangement, however, may in part 
 
188 PATHOLOGY. 
 
 be accounted for by the advanced age of the patient. 
 The ancient acetabula present changes no less remark- 
 able than the corresponding heads of the femurs which 
 have escaped from them. Instead of the round cup-like 
 cavity, there is seen a triangular depression, not more 
 than half an inch in depth, and two and three-quarter 
 inches in perimeter. (Vide Plate vi.) The upper and 
 inferior borders of this triangle are nearly equal in length, 
 but the inner is shorter, and presents an excurvation, 
 which is probably the remains of the notch on the mar- 
 gin of the acetabulum, for the passage of the articular 
 vessels into the joint. This notch is crossed by a trans- 
 verse ligament, which completes the border of the cavity, 
 but the cotyloid ligament, whose use in the natural state 
 of the parts is to deepen the acetabulum, exists but in a 
 rudimentary manner. To the margin of the acetabulum 
 thus constituted, is attached the pelvic portion of the old 
 capsular ligament. The capsular ligament, in its passage 
 across the cotyloid cavity to be attached to the cervix 
 femoris, becomes immediately connected with the cellulo- 
 adipose tissue, which fills up that depression ; still, by 
 reason of its distinct fibrous structure, it can be distinctly 
 traced to its attachments at the margin of the acetabulum. 
 The bottom of the acetabulum is entirely ossified, show- 
 ing no signs of an arret de developpement. There is no 
 remains of the ligamentum teres, and what fills up the 
 cavity may be said to have a resemblance to the fatty 
 
PATHOLOGY. 189 
 
 mass usually situated at the bottom of the acetabulum, 
 and which lias received the name of the glands of 
 Havers. 
 
 There is no new cavity formed for the head of the 
 femur in its new position, as might he supposed, hut on 
 the dorsum of the ilium, in front of the upper part of the 
 sciatic notch, there exists an oval depression of about an 
 eighth of an inch in depth at its centre, and which is 
 excavated at the expense of the ilium. (Vide Plate 
 vn.) The head of the bone has played on this surface 
 during life, and has probably determined this species of 
 depression. The circumference of this depression receives 
 the attachment of the new capsular ligament, the fibres 
 of which extend in a radiating manner, and becom- 
 ing confounded with the periosteum, have the appearance 
 of lining its floor, except at the centre, where the friction 
 of the two bones against each other must have been 
 greatest; there the osseous tissue is entirely denuded, and 
 at this point the ilium appears to be almost perforated. 
 It will be seen that there has been no attempt at the 
 formation of a new socket by ossific effusion from the 
 surface of the ilia, as generally takes place in those 
 instances of traumatic dislocation which have not been 
 reduced. This is particularly worthy of remark, as M. 
 Jules Guerin, of Paris, has stated that the deposition of 
 new bony material, as an effort to form a uew acetabu- 
 
190 PATHOLOGY. 
 
 lum, was an invariable result in those cases of congenital 
 luxation where the original capsular ligament had been 
 ruptured or torn, so as to allow the head of the femur to 
 escape, and it is from this supposition, erroneous, as 
 proved by the case now under consideration, that he has 
 deduced certain principles of treatment for these congeni- 
 tal affections of the hip-joint. 
 
 These are the principal alterations which are found to 
 have taken place in the soft tissues, and at the ancient and 
 recent articulations ; but the changes of form and dimen- 
 sion which the bones of the pelvis, taken collectively, 
 have undergone, merit also consideration, especially in a 
 therapeutic point of view, and in relation to the passage 
 of the head of the child during parturition. After the 
 description which has been given of the muscles and of 
 their abnormal direction, it is not difficult to suppose that 
 the diseased retraction, as well as their physiological 
 action, and the superincumbent weight of the body, act- 
 ing conjointly, would modify, more or less, the natural 
 shape of the bones under these influences during the early 
 periods of infancy, while the osseous tissue was yet not 
 completely consolidated. In analyzing the changes 
 which the parts have undergone, most of the deviations 
 in inclination, form, and dimension, can in a great degree 
 be referred to the abnormal direction in which the mus- 
 cles have been obliged to act after the displacement of the 
 
PATHOLOGY. IP] 
 
 bead of the bone upon the dorsum of the ilium has taken 
 place. It will be seen that the pelvis generally i s more 
 slender, in its construction, the osseous texture at the same 
 time being less compact, owing probably to an original 
 and continued diminution of nervous and vascular supply. 
 Vide Plates vi. and vir. 
 
 In comparing the denuded pelvis with that of the 
 healthy female, the most prominent difference observed, in 
 a practical point of view, is that between the upper and 
 lower straits. In the present pathological specimen the 
 upper strait is found to be generally below the usual 
 measurements, both in the transverse and anteroposterior 
 diameters; the latter, however, is proportionally much 
 more contracted than the former. In a dried healthy 
 female pelvis before me, the transverse diameter is five and 
 a quarter inches, while in the morbid specimen it is four 
 and seven-eighths inches; the autero-posterior diameter 
 in the natural specimen is three and seven-eighths inches; 
 in the other instance, it is only two and three-quarter 
 inches. 
 
 The inferior strait in the morbid pelvis is still more 
 anomalous. Between the apex of the coccyx, and the 
 arch of the pubes, the measurement is one and seven- 
 eighths inches, against four inches in the healthy pelvis : 
 while the distance between tin 1 tuberosities of the iscbia, 
 making up, as it were, for the small antero-posteriof dia- 
 meter, is live and three-eighths inches ; the ln\ilili\ pelvis 
 
192 PATHOLOGY. 
 
 in this direction being only four and a quarter inches. 
 Vide Plate vii. 
 
 The wings of the ilia are smaller than natural, pre- 
 senting angular prominences along the borders of the 
 crests, and upon the dorsa are found the glenoid depres- 
 sions already alluded to, where the heads of the femurs 
 had played during life. Immediately below the anterior 
 and inferior spinous process of the ilium on each side, the 
 superficial groove in the healthy bone, over which the 
 conjoined tendons of the psoas magnus and iliacus inter- 
 ims passed, is converted into a semicircular deep depres- 
 sion or gutter, giving a more than usually projecting ap- 
 pearance to the anterior inferior spine of the ilium. 
 The descending rami of the pubes, and the ascending 
 rami of the ossa ischia seem spread laterally, and pass 
 almost transversely outwards, giving to the arch of the 
 pubes more of a semicircular appearance than of an ob- 
 tuse angle, which is observed in the natural condition of 
 this part of the osseous structure. (Vide Plates vi. and 
 vn.) The long diameter of the foramina obturatoria, 
 instead of running nearly parallel with the body, takes 
 almost a transverse direction. 
 
 The sacrum is somewhat stunted, showing a greater 
 curvature upon its anterior aspect than in the natural 
 bone, and at its junction with the vertebral column, the 
 sacro-vertebral angle is seen to be more prominent than 
 usual. The spinal column in the lower part of the dor- 
 
PATHOLOGY. L93 
 
 sal and lambai regions, presents anteriorly a remarkable 
 convexity, corresponding to the concavity seen in the loins 
 during life. 
 
 Although the superincumbent weight of the body, and 
 the original diseased retraction »>f the muscles have con- 
 tributed materially to the production of the changes, just 
 
 alluded to, in the direction of the hones, it is evident that 
 the pelvi-trochanteric muscles, whose course and manner 
 of action have become entirely altered from the relative 
 change of position of their points of origin and insertion, 
 after the heads of the femurs have been dislocated, and 
 ascended on the dorsa of the ilia, must, in the ordinary 
 performance of their functions, have aided somewhat in 
 bringing about those deviations in direction and inclina- 
 tion, which the component parts of the pelvis have now 
 assumed, so different from what is to be seen in one na- 
 turally constructed. The head of the femur having 
 
 J O 
 
 slipped upon the dorsum of the ilium, it is easj to nip- 
 pose that in progression, the lower dorsal and lumbar ver- 
 tebrae would be pulled forwards \x) the action of the 
 psoas magnus, while the deep gutter observed on the brim 
 of the pelvis below the anterior inferior spine of the ilium, 
 is no doubt caused l>\ the conjoined tendon S of the psoas 
 
 magnus and iliacus internus playing like a pulley in this 
 depression; these muscles being almost continual!] in a 
 state of tension, owing to the increased distance of the 
 
 small trochanter, since the ascent of the femur upon the 
 
194 PATHOLOGY. 
 
 ilium. The same muscles will also, in acting on both 
 sides, flatten or depress the brim of the pelvis, and thus 
 the antero-posterior diameter is reduced ; and in con- 
 nexion with the relaxed state of the gluteus minimus and 
 medius, the iliacus internus by its contractions will tend 
 to render the wing of the ilium more vertical. The 
 psoas magnus, through the medium of its connexion with 
 the lumbar vertebrae, tilting forward the base of the 
 sacrum, and the conjoined tendons, in their passage to 
 their insertion, pushing downwards and backwards the 
 brim of the pelvis, conduce to change the axes of the 
 pelvis, and to render nearly vertical, in the erect posture, 
 the crests of the ilia. The increased transverse diameter 
 of the inferior strait and the almost horizontal direction 
 of the rami of the pubes, and of the ischia, where they 
 form the arch, as well as the outward direction and in- 
 creased separation of the tuberosities of the ischia, can be 
 accounted for by the perverted action of the quadratus 
 femoris, the gemelli, the obturatores, and perhaps the upper 
 fibres of the adductor magnus.* Vide Plates vi. 
 and vii. 
 
 The case just related presents comparatively but little 
 complication beyond the dislocation itself; in another, 
 which I had an opportunity of examining, and which I 
 now introduce, complications of various kinds will be 
 
 * This case was originally furnished by me to the N. Y. Journal of Medicine, and 
 published in the XXXI. No., for July, 1848. 
 
/£ 
 
 liA >fS*--onyl:Mcjt 
 
EXPLANATION OF PLATE No. VIII 
 
 Antero-latcral view of a Male Pelvis, with Double Congenital Dislocation of the 
 Femurs upon the Dorsa of the Ilia, from a person aged about sixty. 
 
 A. The right Femur deformed, bent, and stunted. 
 
 B. The left Femur stunted and fractured towards its upper extremity. 
 a. Anterior Superior Spinous process of the Ilium. 
 
 I). Anterior Inferior Spinous process of the Ilium. 
 
 c. Deep Groove under the Anterior Inferior Spinous process of the Ilium, in which 
 
 has played the conjoined tendon of the Psoas Magnus and Iliaeus Internes. 
 
 d. The remains of the Head and Neck of the right Femur, now atrophied. The 
 
 old Capsular Ligament, now converted into a cord-like structure, is firmly 
 inserted into the upper extremity of the Femur. 
 
 r. The Ancient Capsular Ligament agglomerated into a dense fibrous Ligamentous 
 
 Cord. The Ligamentum Teres may have become incorporated with the fibrous 
 
 Cord. 
 /. The margin of a small oval-shaped cavity in the Original Capsule, which ia 
 
 laid open by removal of its Anterior Wall. 
 g. The remains of the Ancient Acetabulum, which is contracted, and tilled with a 
 
 softish adipo-osscous material, penetrable by a probe for nearly an ineh. 
 h. Ligamentum Patellae. 
 
 j. Inferior extremity of the Femur partially luxated. 
 k. Tibia and Fibula participating in the oseeoufl degeneration. 
 
J. lc/% of Sctrty * Maje 
 
EXPLANATION OF PLATE No. IX 
 
 Posterior view of the same pelvis, with Double Congenital Dislocation of the 
 Femurs upon the Dorsa of the Dia. 
 \ Eli rhl Femur degenerated in its tissue — Head and Neck atrophied. 
 
 ('• Left Femur — its tissues also degenerated — the Head and Neck have entirely die 
 
 appeared — the upper part of the Shaft has been fractured by muscular traction. 
 
 </. Dorsum Ilii. 
 
 b. Remains of the Head and Neck of the right Femur. 
 
 c. Trochanter Major. 
 
 '/. Tendinous insertion of the Pelvi-Trochanteric Muscles. 
 
 r. Abrupt termination of the Shaft of the left Femur at the point of Fractun-. 
 
 /, Pseudo-articulation, laid open, between the fractured portions of the Shaft of 
 the Femur. 
 
 ?. New Ligamentous Structure attached by radiating fibres to the Dorsum of the 
 Ilium, and becoming incorporated with the posterior surface of the Original 
 Capsule, B0 :i- to form in part the Ligamentous Cord upon which the supor- 
 incumbenl weight of the Trunk lias been chiefly thrown during r 
 
 A. Inferior extremity <>f the Femur partially Luxated from the Tibia. 
 
 ,-. Tuberosity <'t the Ischium. 
 
 it. Tibia ami Fibula, smaller and less dense in Structure than is natural. 
 
PATHOLOGY. J 09 
 
 met with, which have occurred ;is consequences of the 
 primarj exarticulation of the head of the femur. 
 
 The subject was a male, of about sixty years of 
 age, and, as may be inferred from tin' annexed drawing of 
 the pelvis, and the ossa femora appertaining to it, as pre- 
 sented in Plates viii. and i\.. exhibited during life a de- 
 formity of a remarkable kind. 
 
 The trunk was tolerably well developed, but from the 
 region of the pelvis downwards to the tibio-tarsal articu- 
 lation, on both sides, the aberration from the usual forma- 
 tion was carried to an extraordinary extent. The pecu- 
 liar appearance of the nates, the mobility, and other signs 
 observable at the ilio-femoral articulation, indicated the 
 existence of the congenital form of dislocation upwards 
 and outwards of the femurs, at this joint. Besides the 
 change in the relations of the component parts of the 
 articulations, the appearance of the thighs showed the 
 existence of complications which may sometimes occur in 
 the later periods of this displacement. 
 
 The inferior members on each side could be pulled 
 downwards or pushed upwards on the dorsum ilii, over a 
 space of about three inches, and on account of the atro- 
 phied state of the upper portions of the ossa femora, 
 the stunted superior portions only of these bones could be 
 discovered during the rotation or flexion of the limb. 
 The tuberosities of the ischia could be fell denuded of 
 their muscles, and separated from each other much far- 
 
200 PATHOLOGY. 
 
 ther than is seen in the normal pelvis. The thighs are 
 of unequal length, that of the left side being the shorter, 
 notwithstanding the curvature which exists on that of 
 the opposite side. The femoro-tibial articulation is par- 
 tially luxated, and the legs also present appearances of 
 malformation, which is increased by the disposition of 
 the parts at the tibio-tarsal articulation. 
 
 The skin, cellular tissue, muscles, arteries, veins, and 
 nerves presented the same characteristics which were 
 pointed out as existing in the dissection of the preceding 
 case ; it will therefore be unnecessary to reconsider these 
 structures in the present instance. I shall therefore only 
 describe the appearances and changes in the ligamentous 
 and osseous structures of the joint itself, and of the skele- 
 ton in contiguity to it. 
 
 Capsular Ligament. — Instead of the natural and capa- 
 cious capsule, a dense fibrous structure extends from the 
 natural locality of the acetabulum to the upper portion of 
 the femur, to which it is firmly attached, grasping, as it 
 were, the superior part of this bone, on either side. This 
 structure extends from the pelvis to the upper portion of 
 the femur, and from the position it occupies, must be 
 considered as the perverted remains of the original cap- 
 sule which has become converted into a strong fibro-liga- 
 mentous cord, entirely solid, with the exception of a small 
 oval cavity, situated opposite the old acetabulum. This 
 
PATHOLOGY. 201 
 
 cavity is little more th;in half an inch in diameter, is lin 'I 
 by a smooth synovial surface, and from its situation and 
 relations to the place where the remains of the anci< al 
 cotyloid cavity are seen, is evidently the representa- 
 tive of the large articular cavity which the capsular liga- 
 ment presents under ordinary conditions. Vide i'i \n 
 viii. 
 
 The weight of the trunk has been supported mainly 
 by this strong ligament during progression; and the 
 attachments it has formed to the ilium and to the femur 
 are exceedingly firm and extensive. In front, it takes its 
 origin from that portion of the ilium where the acetabu- 
 lum would naturally exist, and from the osseous suri 
 contiguous to the anterior inferior spinous process of the 
 ilium, and becoming ligamentous at the outer part of the 
 small cavity mentioned, it ascends upwards and outwards 
 for the distance of about three inches, to become strongly 
 attached to the upper extremity of the femur of both 
 sides. On the right side, it grasps the atrophied remains 
 of the head and neck of the femur, and on the left, the 
 abrupt termination of the upper portion of the shaft oi 
 the femur, which on this side lias been fractured bj mus- 
 cular traction. On the left side, where its attachments 
 to the femur are formed, it encloses a small portion ot 
 bone, the remains of the upper fragment <>f the fractured 
 shaft. This upper fragment rests horizontally among tli« 
 fibres of the ligamentous cord, and presents a plane sur- 
 
 14 
 
202 PATHOLOGY. 
 
 face, opposed to a corresponding smooth surface, which is 
 met with on the inner aspect of the superior end of the 
 lower fragment of the shaft. The fibres of this ligamen- 
 tous cord, as they become attached to the deb?-is of the 
 upper portion of the femur, extend in a diverging man- 
 ner over the place where the two fragments lie in contact. 
 {Vide Plate ix.) During progression these contiguous 
 osseous surfaces must have been subjected to continued 
 friction upon each other. There has been no attempt at 
 union between them, but a moveable pseudo-articulation 
 has resulted, invested by the fibres of the femoral attach- 
 ments of the cord-like ligament, and lined internally by a 
 smooth thin membrane. 
 
 Besides the attachments already spoken of as arising 
 from the site of the old acetabulum, the cord-like ilio- 
 femoral ligament receives a numerous accession of fibres, 
 which take their origin in a radiating form from the dor- 
 sum ilii, and from the osseous surface adjacent to the 
 anterior inferior spine of the ilium. These auxiliary 
 fibres converge, and become incorporated with the other 
 fibres of the ligament, whence results the strong fibrous 
 cord running from the ilium to the femur. The ligamen- 
 tum teres has most probably become agglomerated with 
 the coalesced capsule, or it may have disappeared by ab- 
 sorption. 
 
 The Acetabulum. — The alterations which have taken 
 
PATHOLOGY. 203 
 
 place at the acetabulum arc so considerable as to have 
 destroyed nearly every vestige of it In examining the 
 locality where the three primary hours unite to form the 
 cotyloid cavity, at first view nothing is mel with af all 
 analogous to the large articular surface of the healthj 
 acetabulum. Upon close inspection, however, a small 
 depression is seen. Upon farther examination, this de- 
 pression is found not to be the limit, but the entrance, as 
 it were, to a contracted cavity, which is filled up by a 
 soft semi-osseous deposit only. This semi-osseous mate- 
 rial can be easily perforated to the depth of an inch, by a 
 probe which, passing thus far, becomes impeded in its 
 progress by an osseous tissue of a dense character. This 
 kind of osseous canal, extending in the direction of the 
 primary acetabulum, is all that remains to represent the 
 ancient cotyloid cavity. The soft osseous materia] can 
 be broken down with facility, and then the real bonj 
 limits of the depression are seen to approach somewhai 
 to a triangular shape. 
 
 The disposition of the parts observed ai the right ace- 
 tabulum is the same at the left, with slight modifications. 
 The soft osseous tissue Idling up the cavitj cannot be 
 penetrated for more than half an inch, and the borders 
 or limits of the altered acetabulum are, consequently, 
 still more contracted than on the other side. 
 
 Tht Head of tin Femur. — The superior extremities 
 
204 PATHOLOGY. 
 
 of both femurs are entirely altered in shape and dimen- 
 sions. 
 
 On the right side the head and neck have disappeared. 
 The upper portion of the femur has become curved, so 
 that the trochanter major takes an inward direction 
 towards the ilium, and receives the attachments of the 
 ligament which now takes the place of the capsular liga- 
 meut. The corresponding portions of the left femur pre- 
 sent appearances which are extremely abnormal. The 
 upper portion of the remaining shaft terminates abruptly, 
 and not the slightest trace of the head or neck remains. 
 The upper portion of the shaft has been fractured from 
 the muscular tractions exercised upon .the bone, the struc- 
 ture of which had no doubt previously become softened 
 and atrophied. The upper fragment, deprived of nutri- 
 tion, has gradually disappeared, excepting a small portion 
 only. This is pulled horizontally inwards, at right 
 angles with the lower fragment, and it presents a smooth 
 surface, which lies in apposition with the inner aspect of 
 the superior end of the other portion. The ligamentous 
 cord, attached on one side to the pelvis, on the other, 
 grasps the upper extremity of the femur, in such a way as 
 to maintain the surfaces of the fragments in contact, and 
 thus a pseudo-articulation is formed between the upper 
 and lower fragments of the broken shaft. Vide Plate ix. 
 
 These extraordinary alterations, which the upper por- 
 tions of the ossa femorum have undergone, are. altogether 
 
PATHOLOGY. 
 
 unaccountable, except by taking into consideration the 
 pathological conditions which must supervene in the 
 
 osseous structure of these bones, from the diminished 
 nutrition with which they are supplied, soon after the 
 head of the femur is exarticulated from its natural recep- 
 tacle, and has ascended upon the ilium. If this circum- 
 stance be kept in mind, it will not appear strange thai tie- 
 heads of the femurs, deprived early, as they musl have 
 been, of nearly all vascular supply by the compression 
 or destruction of the ligamentum teres, should become 
 atrophied, and ultimately disappear. 
 
 The reduction of the calibre of the arterial tubes, 
 which has been mentioned as obtaining in cases of con- 
 genital dislocation at the hip-joint, and the consequent 
 impoverished supply of blood to the osseous tissue of the 
 other portions of the femur, will explain the existence of 
 that friable and atrophied condition of the osseous tissue. 
 from which, owing chiefly to muscular tractions, has 
 resulted the fracture of the shaft of the left femur. The 
 almost total disappearance of the upper fragment must 
 also be the result of its isolation from the sources of nutri- 
 tion, after it has become detached from the oilier part of 
 
 the lemur. The right femur, suffering fr tie' same 
 
 causes, has not been fractured, but is curved in the direc- 
 tion of the muscular action, which has been aided proba- 
 bly by the influence of the superincumbent weight of the 
 trunk. 
 
206 PATHOLOGY. 
 
 Dorsum Ilii. New Capsule. New Socket. — In the 
 description given of the post-mortem appearances of the 
 previous case, the dorsum ilii was represented as being 
 occupied by the attachments of the new capsule, by 
 which the head of the femur had become enveloped after 
 its escape from its original capsule. In the case which 
 now claims our attention, the head on either side had 
 never passed from the capsular ligament. The head of the 
 femur appears to have become absorbed, and the cavity of 
 the capsule contracting pari passu, as the head disap- 
 peared, has become agglutinated, and ultimately converted 
 into a strong inelastic fibrous cord, upon which devolved 
 the function of giving the chief support to the trunk dur- 
 ing progression. The attempt to form a new capsule 
 may have been simulated by the substitution of the addi- 
 tional ligamentous fibres, which are seen to spring from 
 the dorsum ilii, and to converge towards the posterior sur- 
 face of the old capsule — or rather, of the cord-like liga- 
 ment, which now represents the capsule — with the fibres 
 of which they become incorporated. (Vide Plate ix.) 
 The disposition of these converging fibres, which take 
 their origin from the ilium, is somewhat analogous to the 
 arrangement of the fibres which contribute to the forma- 
 tion of the new capsule in the previous case. Vide 
 Plate vii. 
 
 These ligamentous fibres, originating from the dorsum 
 ilii, are the only substitute nature has adopted to fortify 
 
P LTHOLOGY. 
 
 the soft parts, which alone, in this case, have to 9upport 
 the weight of the trunk, in the absence of the normal 
 arrangement at the ilio-femoral articulation. The} are 
 attached to the space of about an inch and a half in dia- 
 meter upon the dorsum ilii ; then- is no depression, how- 
 ever, on the surface of the ilium, under these attachments. 
 From the length of this ilio-femoral ligamentous cord, 
 thus made up, the upper portions of the ossa femorum must 
 have played, during progression, along the external sur- 
 face of the ilium, over a space of about three inches in 
 extent. There is no attempt whatever at the formation 
 of a new socket, and with the exception of a slight 
 groove, caused by the friction of the upper portion of the 
 right femur upon the corresponding dorsum ilii, there is 
 not even a depression present for the lodgement of the 
 femur. As in the former case described, it is evident that 
 in tin' present instance also, the upper parts of the ossa 
 femorum could have had no lived support upon the surface 
 of the ilium, and consequently, during the acts of pro- 
 gression, the femurs must have ascended and descended, 
 according as the weight of the trunk happened to be throw n 
 upon one or the other inferior member. 
 
 The alterations which have taken place in the skeleton 
 of the pelvis, as a consequence of the displacement of the 
 head of the femur upon the ilium, are similar in their 
 general characters to those observed in the case before 
 
208 PATHOLOGY. 
 
 described, and it will be unnecessary to consider them as 
 fully in the present instance. 
 
 The dislocation being double, and the causes of mal- 
 formation acting with nearly equal intensity on each side, 
 the two halves of the pelvis participate almost equally in 
 the amount of deformity. The general configuration of 
 the pelvis is below the average size, and the bones of the 
 ossa innominata are thinner, softer, and lighter in texture, 
 than the corresponding parts taken from a well formed 
 skeleton. 
 
 The wings of the ilia are more vertical, thinner, and 
 flatter ; the sacrum is somewhat narrower, but is nearly of 
 the natural size. The pelvis towards the pubic region is 
 somewhat salient ; and owing probably to the greater 
 amount of muscular traction exerted on the side where 
 the femur had suffered most, the corresponding horizontal 
 branch of the pubes between the symphysis and the infe- 
 rior spine of the ilium is longer by about three-eighths of 
 an inch than on the opposite side. 
 
 The foramina obturatoria have their long diameters 
 thrown into a direction almost transversal. The groove 
 between the anterior inferior spinous process of the ilium, 
 and the eminentia ilio pectinea, for the lodgement of the 
 tendon of the psoas magnus and iliacus internus, is seen 
 to be exceedingly deeply impressed. 
 
 The tuberosities of the ischia are retracted outwards, 
 
t kTHOLOOl . 
 
 and for ;i male pelvis present an unusuallj large measure- 
 ment betweeo them. Vidi Plate ix. 
 
 Diameters of the Pelvis. — Like the female pelvis, pre- 
 viously described, the diameters of the male pelvis in this 
 
 case are perverted by the malformation which occurs 
 consequent upon the dislocation of the femur upon th< 
 ilium. This circumstance in the male is of hut little 
 consequence, but it confirms the opinion, I have already 
 expressed, that malformation of the pelvis is an invari- 
 able accompaniment of this form of congenital dislocation 
 of the femur upon the ilium. 
 
 I 1 he statement simply of the measurements of the 
 pelvis, from which this description is taken, will be suffi- 
 cient at present, without again giving the comparative 
 measurements of the well formed pelvis. They are as 
 follows : From one anterior superior spinous process of 
 the ilium to the other, seven and five-eighths inches ; 
 from the anterior superior spinous process of the ilium ft 
 the symphysis pubis, on the right side, five inches ; on the 
 left side, four and five-eighths inches; transverse diameter 
 of the superior strait, four and a quarter inches : from the 
 promontory of the sacrum to the symphysis pubis, t! 
 and one-eighth inches. 
 
 At the inferior strait, the transverse diameter betv 
 the inner side of one tuberosity <>! the ischium to thai of 
 the other, lour and three-quarter inches; while the antero- 
 
210 PATHOLOGY. 
 
 posterior diameter, from the point of the coccyx to the 
 arch of the pubes, is two and three-quarter inches. 
 
 The depth of the pelvis anteriorly from the highest 
 part of the ramus of the pubes to the corresponding tube- 
 rosity of the ischium, is three inches, and from the pro- 
 montory of the sacrum to the point of the os coccygis, it 
 is four inches. 
 
 These measurements show that the pelvis, taken as a 
 whole, does not present the average dimensions, and that 
 the contractions observable are proportionally greater in 
 the antero-posterior, than in the transverse measurements. 
 
 The various influences, such as the shortening of the 
 morbidly affected muscles, the influence of the superin- 
 cumbent weight of the body during progression, and the 
 ordinary muscular contractions which have contributed, 
 either separately or conjointly, to increase the malforma- 
 tion of the pelvis and of the other adjacent bones, need 
 not be recapitulated ; nor need the analysis of the deformi- 
 ties of the individual parts of the pelvis, and of the action of 
 certain muscles in producing them, be repeated in this place, 
 since the subject has been fully considered in the descrip- 
 tion of the preceding case of this dislocation. 
 
 It must be recollected, however, particularly in regard 
 to cases like the present, where the malformation is so exten- 
 sive, that these various causes owe much of their effi- 
 ciency to the deteriorated condition of the osseous struc- 
 ture of the pelvis and of the other contiguous bones, 
 
PATHOLOGY. 2 I 1 
 
 which either accompanies or results from the displacement 
 
 of the head of the femur. 
 
 It is evident, as the result of these investigations, thai 
 there is a wide range in the morbid alterations which 
 take place in the progress of congenital dislocations of the 
 femur upon the ilium, from the simple changes in the 
 initiatory stage, to the extreme complications presented 
 in this last case, but the general pathological principles 
 upon which they depend, I trust have been fully set 
 forth. 
 
EXPLANATION OF PLATE A. 
 
 This plate represents the Apparatus of Sustentatioo, upon which the patient reposes 
 while the preparatory extension is being made to bring down the head of the 
 femur opposite the acetabulum. 
 
 a. Arch opening at the centre, by means of a hinge on each side, passing over 
 
 the patient, so as to give attachment to the strap of counter exti 
 
 b. The strap for making the counter extension attached interiorly t'> the plan 
 
 the bod, and passing from without inwards and upwards to n- superior attach- 
 ment at the centre of the arch. 
 
 c. Two crutch-like supports well padded, upon which the axillae rest 
 
 d. Encasement made of thick leather, padded, and furnished with straps and 
 
 buckles, in winch «he limb is placed and retained. 
 
 e. Hook fixed to the leather encasement, for the attachment of the cord of exten- 
 
 sion. 
 /. Cord of extension passing over a pulley at the foot of the 
 g. Pulley over which the cord passes. 
 
 A. Weight attached to the cord of extension, and by which the extension i- kept op. 
 ». Cords, attached to a fixed point above the bed, and passing along its -id. -. The 
 
 plane of the bed being movable, the patienl by polling these cords ma] 
 
 muscular exercise, without interfering with the extension. 
 

a is 
 
 CHAPTER VIII. 
 
 TREATMENT OF CONGENITAL DISLOCATIONS OF THE HEAD 
 OF THE FEMUR. 
 
 In the natural condition of the ilio-femoral articulation 
 a reciprocal harmony of configuration of a most perfect 
 character exists between the head of the femur and the 
 cotyloid cavity. Under ordinary circumstances these 
 component parts of the joint are maintained in their 
 normal relations by the pressure, from without, of the atmo- 
 sphere, by the ligamentous connexions, l>\ the action of 
 the muscles, and by the depth of the cotyloid cavitj . 
 
 From the pathological account heretofore given of the 
 parts implicated in congenital dislocation of the femur 
 upon the ilium, it is evident that the mutual adaptation of 
 the various structures of the joint is early disturbed, 
 and that ultimately the alterations become so extensive 
 that the natural relations cannot be restored. 
 
 Dupuytren, reasoning from antopsic examinations, 
 generally of individuals advanced in life, was of opinion 
 
216 TREATMENT. 
 
 that permanent reduction of the head of the femur in 
 cases of congenital dislocation was beyond the reach of 
 art. " On se consolerait aisement de ne pas connaitre la 
 cause de ces deplacements, si Ton connaissait les moyens 
 de les faire cesser, ou du moins de pallier leur mauvais 
 effets ; malheureusement il n'en est pas ainsi, et ces de- 
 placements ne comportent ni remede curatif ni meme de 
 palliatif bien efficace." Notwithstanding the opinion 
 of the celebrated surgeon of the Hotel-Dieu, attempts 
 have been made in more recent times to bring about per- 
 manent reduction of the head of the femur in these 
 cases, and in some instances this object has been 
 attained. 
 
 The first attempt to replace permanently the head of 
 the femur at the acetabulum, appears to have been made 
 by means of continued extension, by MM. Duval and 
 Lafond, upon a child nine years of age, affected with 
 double congenital luxation of the femur upon the ilium. 
 The results, however, of this case do not appear to have 
 been satisfactory, for although the limbs were observed to 
 resume their proper length and direction, after the employ- 
 ment of extension for several weeks, yet there is no men- 
 tion made of the permanency of the reduction. 
 
 In 1835, two other surgeons, MM. Humbert and 
 Jacquier, who, like the preceding, confined themselves 
 specially to the treatment of deformities, in a publication 
 issued by them upon the mode of reducing congenital 
 
TREATMENT. 217 
 
 dislocations, endeavored to prove thai the component parts 
 of the articulation, in these luxations ai the hip-joint, were 
 not always so entirely changed, as to preclude the possi- 
 bility of reduction, and supported their opinion by cases, 
 in which the treatment was said to bave been successful 
 and permanent It is very certain thai in some ol those 
 cases the head of" the femur was forced to change its 
 position, and that it assumed a new relation, winch 
 lessened or modified the lameness, and restored the limbs 
 to a more natural length. Doubts, however, have 
 been entertained regarding the positive success ol the 
 reduction, in the cases reported by these gentlemen, 
 and the change of position of the head of the femur has 
 been attributed to the conversion of the dislocation upon 
 the ilium, into one, where the bead of the lemur was 
 thrown into the ischiatic notch, Consequent upon the 
 extension and force made use of to effect reduction. 
 However this maj be, the report made of these cases 
 excited attention, and led to farther attempts to neat 
 congenital displacements of the femur, which in some 
 instances, as verified by scientific authority, were attended 
 with success. 
 
 Another surgeon of some eminence. M. Bouvier, pi 
 Paris, has also made attempts to reduce these dislocations, 
 hut failing to accomplish this object, he has denied the 
 Utility of therapeutic means in these affections. 
 
 The successful efforts, however, of M Pravaz, oi 
 
 15 
 
218 TREATMENT. 
 
 Lyons, in the treatment of congenital dislocations at the 
 ilio-femoral articulation, authenticated as they have been 
 by positive testimony, place beyond a doubt the practi- 
 cability of reducing, under favorable circumstances, the 
 head of the femur to its natural receptacle, and the possi- 
 bility of retaining it there permanently. 
 
 The utility of remedial means being doubted, and the 
 curability of this dislocation being still denied by some 
 men well instructed in the profession, the Royal Academy 
 of Medicine of Paris, in 1838. appointed a commission to 
 report upon a case presented by M. Pravaz, as establish- 
 ing the possibility of reducing permanently the congenital 
 dislocation of the head of the femur upon the ilium. 
 
 The subject of this critical examination was a male 
 child, seven years of age, affected with congenital luxa- 
 tion of the right femur upon the external surface of the 
 ilium. The diagnosis had been confirmed by an eminent 
 surgeon, M. Richard, of Nancy — the treatment was com- 
 menced in March, 1836 — and the commission of the 
 Royal Academy of Medicine, composed of MM. Blandin, 
 Gerdy, Sanson, and Naquart, reported on the case in 
 1838. They commenced their statement by admitting 
 that the child had been affected with congenital disloca- 
 tion on the ilium, and close their extended report — drawn 
 up by M. Gerdy — as follows : — " D'apres tout cela, 
 Messieurs, est-il possible de contester le succes obtenu par 
 M. Pravaz 1 Nous ne le pensons pas, au moins quant au 
 
THE I i MEN i . 2] 9 
 
 jeune garcon dont nous venons de vous entretenir; et 
 pour o'assurer que ce que qous avons \u par Qous-memes, 
 nous affirtnons que ce jeune malade n'esl point affecte* 
 aujourd'bui de luxation cong6nitale. w * 
 
 Without mentioning other cases to the 9ame effect, 
 brought forward in addition by M. Pravaz, and confirmed 
 by names eminent in science, I think the above case, 
 reported upon by the commission of the Royal V.cadetnj 
 of Medicine of Paris, and asserted subsequently as re- 
 maining cured, two years after the reduction, sufficient to 
 establish the principle of the curability, under favorable 
 circumstances, of congenital luxation of the femur upon 
 the ilium. 
 
 Still more recently, additional resources have been used 
 by M. Guerin, in the treatment of these displacements. 
 Tn those instances where the head of the femur has been 
 reduced, and where, from the continued muscular retrac- 
 tion, and the defective formation of the acetabulum, i ; has 
 
 been found impossible to retain the bead of tie- lemur in 
 its normal position, M. Guerin has advised the division of 
 die retracted muscles, and has also practised subcutaneous 
 scarifications in the \i<init\ of the cotyloid cavity, in 
 order to provoke an effusion of organizing material, bj 
 which the defect in the acetabulum ma\ lie remedied, and 
 the head of the femur thus be retained in its cavity, and 
 supplied with a sufficient 'point >Fu/>>>'//. 
 
 • Traiii- '1.- Luxations Congenitales du 1't'mur. pai le Docteui Prevail 1841 
 
220 TREATMENT. 
 
 In 1843, the Council General of the Civil Hospitals 
 of Paris nominated a commission to inspect the treatment 
 advocated and practised by M. Guerin, at the Hopital 
 des Enfans, in relation to congenital dislocations of the 
 femur, and to other deformities. The commission was 
 composed of MM. Rayer, Serres, Louis, Jobert, Blandin, 
 and Orfila. In their report upon three cases of congeni- 
 tal dislocation of the femur upon the ilium, which they 
 had observed, they thus conclude their report on the 
 peculiar treatment adopted by M. Guerin : — " Quant a 
 l'efficacite des methodes de traitement, nul doute que les 
 resultats obtenus, rapproches surtout de ceux qui existaient 
 deja dans la science, ne temoignent de la maniere la plus 
 positive en faveur de ces methodes. II est a remarquer d'ail- 
 leurs que les ameliorations d'un genre tout particulier, et con- 
 sistant dans un ordre de faits entierement nouveaux, obtenus 
 dans les deux premiers cas, ouvrent a l'art des ressources 
 sur lesquelles il n'avait pas compte jusqu'ici."* Thus 
 we see that congenital dislocations of the head of the 
 femur, long considered beyond the reach of surgical aid — 
 like other maladies of a kindred character, regarded at 
 one time in the same light, such as Talipes, Strabismus, 
 &c, though not equally complicated — have yielded to 
 therapeutic resources, derived from the increased know- 
 ledge which pathology and physiology have afforded. 
 
 Let it not be supposed, however, that in admitting the 
 
 * " Rapport de la Commission," &.c, 1846. 
 
TEE \tmi:nt. 
 
 curability of these connate displacements of the hip-joint, 
 I overlook, the serious nature of this affection, and the 
 difficulties to be encountered in effecting a permanent ad- 
 justment of the articulation. 
 
 As the treatment is not immediately effective, as in the 
 traumatic dislocations of this joint, bul aecessarilj pro- 
 longed and tedious, it may he a question, whether the 
 advantages derived from a successful result would com- 
 pensate for the delay and difficulty, by which onlj it could 
 be obtained. 
 
 When the gravity of this affection and the evils it 
 entails upon existence, and which go on increasing as 
 long as the displacement remains, are considered, the 
 importance of the re-adjustment of the articulation can- 
 not admit of a doubt. The lameness alone, with its 
 inconveniences, might be submitted to, but as a result <»t 
 the displacement, nearly one half of the organism becomes 
 perverted in its structure and functions, on account ol the 
 deterioration of the several tissues, extending even to the 
 osseous. The pelvic diameters also, in the female, become 
 so changed as to render parturition dangerous or impos- 
 sible. 
 
 The treatment of congenital dislocations of the femoi 
 ought to commence as soon after the discover} ol the dis- 
 placement as the tractabilitj of the patient may render 
 practicable. Imong the cases of success mentioned, the 
 ages have been, from as earl) as three, to six, eight, and 
 
222 TREATMENT. 
 
 twelve years ; although an instance of successful reduction 
 at the age of fifteen is recorded. The capsule at these 
 early periods, although contracted at its centre, may yet 
 be entire in its structure ; the round ligament with its 
 vessels, may be only elongated and stretched, but not yet 
 ruptured or worn through ; and the head of the femur 
 and acetabulum, although somewhat modified in shape, 
 from the disturbance of their normal relations, are still 
 susceptible of being again brought into a state of recipro- 
 cal adjustment with comparative facility. 
 
 In connexion with these data afforded by the patholo- 
 gical conditions at the early period of this displacement — 
 even where the acetabulum has become considerably 
 changed in shape — the physiological principles, from which 
 therapeutic means have been adopted, are expressed in the 
 proposition, "that we may, by continued and progressive 
 mechanical action, sometimes restore the head of the 
 femur to the rudimentary cotyloid cavity, whence it had 
 been dislodged before birth, and maintain it in this place 
 of election, where, by the plastic effort of the organism,* 
 assisted by suitable movements, in imitation of those of 
 ambulation, the head will, at last, form for itself a kind of 
 artificial articulation. "f 
 
 * This term, denoting the reparatory process, is synonymous with the nisnt 
 formatitus of Blumenbach, and the organic force of Miiller ; for ?ome interesting 
 rem ;.k- on which see Paget's Lectures, in the London Medical Gazette. 
 
 t Pravaz. 
 
 
 
TRB I I mi.m . 
 
 If oihcr favorable conditions, such as the general good 
 health, besides the youth of the patient ; the absence <<i a 
 false articulation upon the dorsum ilii ; the continuant 
 and free movement, of the bead <>f the femur within the 
 capsular ligament, accompany the case; the application «>t 
 remedial measures ma) be commenced with a prospect 
 of ultimate success. 
 
 The curative treatment of congenital dislocation of the 
 head of the femur upon the ilium comprises three periods, 
 viz., first, the preparatory extension; secondly, tin- redac- 
 tion ; thirdly, the normal consolidation of the articular 
 structures, so that the head of the femur may be perma- 
 nently retained in the acetabulum. 
 
 The different kinds of apparatus, which have been con- 
 trived to fulfil these indications, are complicated in struc- 
 ture, and cannot readily he understood from mere verbal 
 description; I have therefore introduced drawings of 
 them, from the designs in M. Pravaz' work, that the 
 principles of treatment may he better comprehended.* 
 
 The method of effecting the preparatory extension, 
 and the apparatus used for the purpose, is represented on 
 Plate A, and the component parts of it are explained in 
 the accompanying references. It will be seen, 03 turning 
 
 » I have in tlii- chapter only attempted t>> lay down tl 
 treatment; for details of oases, ill" n '-<1 to the I 
 
 already named. 
 
224 TREATMENT. 
 
 to the plate, that the patient is placed in the recumbent 
 posture on a gently inclined plane. The limb is placed 
 wirhin a padded, thick leather encasement, in which it is 
 secured by means of straps and buckles; and elastic 
 extension is kept up by a weight, attached to the end of 
 a cord, which passes over a pulley at the lower part of 
 the apparatus, and the other end of which is attached to 
 a hook, fastened upon the lower margin of the leg-case. 
 The framework of the apparatus is movable, and the 
 cords which the patient is seen to grasp, can impart 
 various motions to it, by being pulled upon ; and thus 
 muscular exercise may be taken during the treatment, 
 without interrupting the process of extension. The 
 counter-extension is maintained by the thigh-strap, aided 
 somewhat by the resistance which is afforded at the 
 axillae by the crutch-like supports. The patient is sub- 
 mitted to this kind of extension, which at first ought to 
 be gentle, not exceeding at the outset a force of a few 
 pounds, and should be progressively increased. The 
 duration of this extension may vary from two to six 
 months, in proportion to the resistance of the retracted 
 muscles and ligaments. 
 
 As a part of the medical treatment, during the confine- 
 ment necessarily accompanying the period of preparatory 
 extension, the use of the condensed air-bath, at a pressure 
 of from twelve to fifteen centimetres, has been recom- 
 mended, especially for very young patients, in order to 
 
TREATMENT. 
 
 equalize the circulation, and counteract the evil eflei I 
 the confinement 
 
 When the preparatory extension lias been maintained 
 a sufficient length of time i<> effeci the descent of the 
 head of the femur a lit r 1< * below the anterior and interior 
 spinous process of the ilium, and the projection of the tro- 
 chanter major has become less prominent, and the incurva- 
 tion of the lumbar region diminished, reduction ma\ then 
 be attempted. 
 
 To effect reduction, gentle extension must be kept up, 
 while at the same time the limb is abducted, and the head 
 of the femur is pushed from above downwards, and from 
 without inwards. One method of accomplishing this, 
 will be understood by referring to Plate B. The cord 
 of extension is here removed from the crotchet attached 
 to the inferior part of the leg-case, and, in its place, a set 
 of pulleys is affixed. The other part of the same tackle 
 is attached to the inferior extremity of an iron lever, 
 which again is engaged upon a vertical pivot, at its upper 
 extremity, so as to be movable in various directions. 
 This vertical pivot, nivinu the point (Toppui to the lever, 
 is attached to the side of the apparatus of snstentation, a 
 
 little below and to the outer side of the affected joint. 
 
 After ibis arrangement is completed, the assistant is 
 directed to exercise gentle traction upon the cord passing 
 from the pulleys, while the operator himself "pressing 
 
 with one hand on the trochanter, from above downward*. 
 
226 TREATMENT. 
 
 and from without inwards, directs, with the other, the 
 lateral movement of the lever, which, turning upon its pivot, 
 will carry outwards the member in powerful abduction." 
 
 According to the extent of the malformation which 
 may exist at the acetabulum, the reduction is effected, 
 either immediately, and is rendered evident by the 
 improved conformation at the joint, sometimes at- 
 tended by an audible sound, as happens in traumatic 
 dislocations ; or, the head of the femur can only be 
 brought into its anatomical position and retained there, 
 until the plastic power of the organism be aroused, and 
 the elemental parts of the joint be gradually and mutually 
 adapted to each other. 
 
 To prevent the re-escape of the head of the femur 
 from the rudimental cotyloid cavity, a circumstance which 
 is apt to occur, two large concave plates, padded and 
 movable upon hinges, are fixed upon the side of the 
 apparatus, as seen in Plate B, and which, by means of 
 screws, may be so adjusted as to embrace firmly the 
 haunches, and thus retain the head of the femur in its 
 new position. 
 
 When it is necessary to remove the patient from the 
 bed, a girdle, with perineal straps, and confining the hips, 
 is substituted, to prevent the femur from slipping from the 
 acetabulum. 
 
 A short time after the reduction has been effected, pains, 
 accompanied by heat and tumefaction, are manifested in 
 
THE ITMENT. 
 
 the inguinal region, attended l>\ febrile symptoms, and 
 sometimes bj dysurj and incontinence of urine, [f th 
 symptoms are excessive, 1 1 1 » • \ are to be calmed bj a 
 moderate extension of the affected limb, and b\ emollient 
 applications; but as these phlogistic evidences are indi- 
 cative of the occurrence of the organo-plastic effort, upon 
 which the remodelling, as it were, of the acetabulum, — as 
 well as the modifications of* the adjacent parts, necessan 
 for the maintenance of the head of the lemur in its 
 new position, — are dependant, they are to be regarded, 
 when not excessive, as favorable signs; and where 
 too feebly developed, they must be aroused by artificial 
 means. 
 
 When the acetabulum and the head of the femur are 
 considerably changed, the process of this plastic effort of 
 reparation generally requires from five to six months, 
 before the configuration of the head of the femur and 
 the capacity of the acetabulum become reciprocally fitted 
 for each other. 
 
 In cases where the head of the femur is at first placed 
 upon the orifice, as it were, of the cotyloid cavity, during 
 this process of reparaion CO-aptation, the head of tin 
 femur is felt to pass progressive!) deeper into the aceta- 
 bulum, until finally the more perfect adjustment is accom- 
 plished. 
 
 The muscles and other tissues, being now placed 
 in more normal relations, commence to assume 
 
2'28 TREATMENT. 
 
 natural disposition, and a more healthy structural appear- 
 ance. 
 
 When the articular apparatus of the joint has appa- 
 rently become adjusted, and the head of the femur is felt 
 to project but little below the horizontal branch of the 
 pubes, and does not leave the articulation during the 
 different movements of the limb, especially during that of 
 adduction, the third period of treatment may be commenced. 
 
 The articulation, being still fee yet, generally 
 
 unable to support the superincumb ^ t of the trunk, 
 
 without a recurrence of the exarticulation of the head of 
 the femur. 
 
 To give time for the proper consolidation of the new 
 relations of the different articular structures, at the same 
 time that motion and exercise shall be imparted to the 
 joint, while the weight of the body is removed ; a kind 
 of chair has been made use of, which is represented on 
 Plate C Upon this apparatus, the drawing of which 
 is sufficiently explanatory of its action, the patient can 
 lie in the recumbent posture, and by means of its me- 
 chanism and facility of movement upon wheels, he can, 
 by flexing and extending the limbs, simulate the process 
 of ambulation, and throw the structures of the joints and 
 surrounding parts into exercise. 
 
 This kind of exercise is persevered in daily, for four 
 or five months, at the end of which time the articulation 
 has generally acquired such solidity and freedom of 
 
TRKATMKVI 
 
 motion, that the bead does oot become exarticolated even 
 by strong adduction of the limb. When these conditions 
 an- present, the patient is then allowed to take exen 
 in the ••reel attitude, l>ut in order to lessen the effeci of 
 the superincumbent weight of the trunk upon the articu- 
 lation, the apparatus, represented al Plate D, is resorted 
 to; a reference to which will sufficiently indicate its 
 mechanism and purpose. 
 
 If, as son ippens, the exercise taken in the 
 
 erect posture reproduce the dislocation, recourse 
 
 must again fck- uati to the use of the apparatus represented 
 on Plate C; and it may even be necessary to provoke 
 and maintain, by artificial pressure, a sufficient degree of 
 irritation, to excite anew the plastic effusion in the region 
 of the joint. 
 
 If, however, the articulation appears to have acquired, 
 by these various means, sufficient strength, alter the 
 continuance, for a short time, of the kind of exercise repre- 
 sented on Plate D, simple crutches are then resorted 
 to, for a while, and finally the patient is allowed to walk 
 unaided by any support. 
 
 The results obtained by this method of treating these 
 dislocations have proved that the head of the femur can 
 be returned to its natural cavity, ami be permanently re- 
 tained there: and although a slight halt in the gait has 
 geuer;ill\ remained. \ci the lemurs have acquired a nor- 
 mal point ttappui at the articulation ; and the inconve- 
 
230 TREATMENT. 
 
 nicnces, as well as the unseemly deformity, resulting from 
 the displacement, have been thus evaded. 
 
 The softer tissues around the articulation recover 
 slowly, but the return to their natural condition may be 
 aided by muscular exercise, the use of the different mineral 
 baths, friction, electro-magnetism, and the adoption of a 
 measured gait in walking. 
 
 In cases where the dislocation exists upon both sides, 
 the difficulties of treatment are not materially increased, 
 and the extension may be resorted tt> upon both limbs 
 at the same time, and reduction attempted successively 
 upon each, as soon as the position of the head of the 
 femur and the elongation of the soft parts may warrant 
 the proceeding.* 
 
 In addition to the preparatory extension, and the other 
 means mentioned above, which have been employed to 
 effect, and render permanent, the reduction of the head of 
 the femur in cases of congenital dislocation of this bone, 
 M. Guerin has offered some novel suggestions in the 
 treatment of this affection One is, to practise the sub- 
 
 * I have not alluded to the palliative treatment, such as that recommended by 
 Dupuytren, of wearing a girdle around the haunches to embrace the pelvis, and 
 which, by grasping the trochanters, is intended to prevent the motions of the exarti- 
 culated heads of the femurs along the dorsa of the ilia : since their use appears to 
 be both inconvenient and inefficient. The choice of an occupati* n, however, for 
 persons thus affected, and who from their age are beyond remedy, should be such as 
 not to keep the deranged muscles, as the psoas magnus and iliacus internus, upon 
 the stretch continually, during the exercise of their vocation. 
 
THE \ i mi.nt. 
 
 cutaneous section ol the retracted muscles, thai product d 
 the dislocation, generally of the glutei This procedure 
 
 is resorted to alter the preparatorj extension has ! 
 kept up for a time, and has been found unavailing in 
 maintaining the head of the femur opposite the aceta- 
 bulum. 
 
 In those cases where it has been found difficuh 
 to retain the head of the femur in the acetabulum, 
 ow r ing to its imperfect formation in certain points, alter 
 reduction had been effected, subcutaneous scarifications 
 around the acetabulum have been recommended, in 
 order to induce the effusion of new osseous material, to 
 
 - 
 
 remedy the defective development existing upon its cir- 
 cumference, 
 
 The other suggestion is, to make a subcutaneous inci- 
 sion into the capsule, so as to permit the head of the 
 lemur to escape, and to become placed in direct contact 
 with the dorsum of the ilium, in those cases where reduc- 
 tion cannot he accomplished on account of the altered 
 state of the articulation, and where the head of the bone 
 continues to play along the surface of the external iliac 
 fossa. This proceeding is accompanied l>\ additional 
 scarifications at a place of election, in the vicinit\ ol the 
 acetabulum, in order to increase the irritation, and induce 
 there the effusion of plastic material towards the forma- 
 tion of a new socket. The principle upon which this 
 treatment is founded rests upon the supposition, thai the 
 
232 TREATMENT. 
 
 immediate contact of the two osseous surfaces of the 
 head of the femur and of the ilium, will induce the forma- 
 tion of a new acetabulum upon the dorsum of the ilium, 
 as takes place generally in cases of unreduced traumatic 
 dislocation of the hip-joint in this direction. It is antici- 
 pated here that a new socket will be formed for the head 
 of the femur, and that it will consequently become more 
 fixed, and will be prevented from playing upon the 
 external surface of the ilium, during progression. 
 
 The idea of tracing an analogy between the circum- 
 stances attendant upon an unreduced traumatic disloca- 
 tion of the femur upon the ilium, and the congenital 
 luxation of the femur in this direction, where the head 
 has escaped from its capsular ligament, and has become 
 placed upon the dorsum of the ilium, is plausible ; but the 
 supposition that the formation of a new socket always 
 follows the escape of the head of the femur from the 
 capsule, whether occurring spontaneously or artificially, is 
 not correct, as is seen from the description of the patho- 
 logical appearances in one of the cases of this displacement, 
 previously given, and exhibited at Plate vii. 
 
 The theory upon which this treatment is predicated is 
 ingenious, but facts do not corroborate the notions upon 
 which it is founded. Nevertheless, it is not improbable 
 that the direct apposition of the osseous tissues of the 
 femur aud of the ilium, after the escape of the head of 
 the femur from its capsule, may predispose to the forma- 
 
TREATMENT. 
 
 Hon of ;i vicarious socket. It is well known that the 
 effusion of osseous material is invited sometimes l>\ irri- 
 tation, as i^ observed in Physick's method of treating dis- 
 united fractures by the insertion of the setbn. 
 
 In practical surgery, every reasonable conjecture merits 
 consideration ; particularly in the treatment of an affec- 
 tion so formidable as congenital dislocation of the head of 
 the femur up( n. 
 
 The subcut ;tion of the retracted muscles v 
 
 at times be ad. .. , eta one of the resources of art, to faci- 
 litate reduction, as well as the peri-articular scarifications, 
 to aid in maintaining reduction after it has been effected. 
 The subcutaneous incisions of the capsular ligament, 
 with scarifications practised at the same time, at a place 
 of election, on the external surface of the ilium, ma\ 
 likewise be made available, in those cases where the 
 brad of the hour cannot otherwise be solidly fixed, nor 
 prevented from playing along the dorsum of the ilium 
 during progression. 
 
 Before closing these remarks, I shall offer a fevt obser- 
 vations on congenital sub-luxations and pseudo-luxations 
 of the head of the lemur. 
 
 Although, as heretofore stated, the partial removal of the 
 head of the femur from* the cotyloid cavity, termed Conge- 
 nital Si B Ll KATION OF THE lli:\l> OF I'HB FeMI R, ma\ 
 
 be regarded as the commencement of the absolute luxa- 
 tion of the femur upon the ilium, yet it ma\ be proper to 
 
 L6 
 
234 TREATMENT. 
 
 observe that the head of the femur may remain for many 
 years in this initiatory stage of displacement, thus in 
 reality constituting a variety of the deformities of the hip- 
 joint. 
 
 The head of the femur is here found resting upon the 
 posterior and upper part of the margin of the acetabu- 
 lum, and has only partially escaped from its cavity. This 
 variety is found to exist at birth, and it also may take 
 place soon after birth, from muscular retraction. 
 
 The diagnosis in instances of this kind must be care- 
 fully formed, by attentive examination, and from the facts 
 heretofore laid down in the chapters on the Symptoma- 
 tology and on the Diagnosis. The treatment must be 
 regulated upon the general principles, already recom- 
 mended, in relation to the complete congenital dislocations 
 of the head of the femur. 
 
 With regard to the Congenital Pseudo-Luxations of 
 the hip-joint, as they are called, from the similarity they 
 bear to perfect luxations of the head of the femur, two va- 
 rieties have already been spoken of, viz., one, simulating a 
 luxation of the head of the femur downwards and for- 
 wards ; the other, simulating the luxation backwards and 
 upwards. 
 
 The latter deformity only, can be mistaken for the con- 
 genital dislocation of the femur upon the ilium. 
 
 In these deceptive deformities, which are also caused by 
 muscular retraction, the head of the femur still remains in 
 
TREATMENT. 
 
 the acetabulum, and thej musi be distinguished from 
 those cases where the bead of the femur is exarticulated, 
 !)\ careful manual examination, and the application of the 
 diagnostic symptoms, already pointed our, when this divi- 
 sion of the subject was under consideration. 
 
 The head of the femur in these instances can generally 
 be felt in the fold of the groin, a little to the outer 
 side of the artery, during rotation of the 
 
 limb; and t ed movements, and the permanent 
 
 deviation of the members from their natural direction, can 
 generally be traced to a retracted condition of the tensor 
 vaginas femoris and some of the other pelvi-femoraJ mus- 
 cles in the vicinity of the joint. 
 
 The subcutaneous section of the retracted muscles, 
 aided by the mechanical means applied on the principles 
 usually observed in orthosomatic therapeutics, will often 
 remedy these deformities, and restore the functions of the 
 affected members to their natural condition. 
 
ERRATA 
 
 Page 24, line 18, close the paragraph at " upwards.'* Then read as a new para- 
 graph : " A sub-luxation backwards and upwards is also met 
 with ; and. lastly, the term pseudo-luxation." &c. 
 
 " 56, " 10, tor "hydrarthus" read " hydrarthrus." 
 
 " 79, " 2, for '-column'" read •■ cord." 
 
 " 95, " 11, for " excurvation " read "incurvation.'' 
 
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