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2fOTES ON THE DISSECTION OF A CASE OF CON- 
 GENITAL DISLOCATION OF THE HEAD OF THE 
 FEMUR By Fkancis J. Shepherd, M.D., CM., M.E.C.S., 
 
 Eng., DemonstrcUor of Anatomy, M'Gill University, Montreal. 
 
 A FEMALE subject about 50 years of age was brought to the dis- 
 secting-room of M'Gill University in the autumn of 1879 in 
 whom it was noticed that the right leg was smaller and shorter 
 than the left, and everted. The woman was very stout, and 
 the head of the femur could not be distinctly made out, but it 
 was noticed that the trochanter was higher than usual ; abduc- 
 tion was limited, but otherwise the joint was freely movable. 
 The tuberosity of right ischium was quite subcutaneous, the 
 muscles appearing as if carried up with the trochanter-major. 
 Amount of shortening, 2 inches. The exact nature of the 
 lesion was not made out from an external examination, and it 
 was only on dissection of the part that it was discovered to be a 
 congenital dislocation. 
 
 Dissection. — There are no scars to be seen on the skin of 
 gluteal or femoral region, indicating that old sinuses had existed, 
 the skin is perfectly smooth. On removing the skin and fascia 
 of the gluteal region, the fibres of the gluteus maximus, and 
 gluteus medius muscles are found to be shorter than normal, 
 thoir points of origin and insertion being approximated; the 
 muscular tissue is much altered, in some places being com- 
 pletely changed into fatty tissue. I may here remark that all the 
 muscles of the body have become fatty degenerated to a greater 
 or less extent, but this condition is much more marked in some 
 of the muscles about the affected hip. On removing the two 
 superficial gluteal muscles (between which a lot of fat is seen), 
 the quadratus femoris, obturator externus, genieili, and obturator 
 iuternus are brought into view. These muscles, instead of 
 passing transversely outwards to get to their insertion, pass 
 upwards ; the pyriformis is found to pass outwards and slightly 
 upwards, instead of downwards. The gluteus medius, obturator 
 internus, genieili, and pyriformis in passing to their insertions go 
 over the head of the femur. More of the obturator externus is 
 
congen:tal dislocation of the head of the femur. 369 
 
 (Exposed to view than usual ; this muscle passes upwards to the 
 great trochanter close to the old capsule, which is seen lying 
 between it and the gluteus minimus ; the obturator cxtemus is 
 much longer than normal, and is quite a strong muscle, the 
 tissue of which is healthy and without any trace of fatty degener- 
 ation. The gluteus minimus is shortened, and nearly all 
 composed of fibrous tissue, it is pushed upwards by the ascent 
 of the great trochanter, and has a smaller origin than usual, 
 owing to the space on the dorsum of the ilium bet\^een the 
 middle and inferior curved lines being partly occupied by the 
 new socket for the head of the femur. This muscle covers the 
 head of the femur, and is so closely united to the new capsule 
 that it can only in places be separated from it. 
 
 The adductors and gracilis muscles are shortened and tense, 
 and have participated but slightly in the general degeneration ; 
 the pectineus is smaller than usual, its outer portion being 
 fibrous; it is attached as usual to the shaft of the femur. The 
 iliacus intemus muscle has nearly all atrophied away, and now 
 consists of a very thin flat layer of muscular fibres, streaked 
 with fat, which become united to the tendon of the psoas 
 magnus, an inch above Poupart's ligament, so that none of its 
 muscular fibres are seen below this ligament ; above and below 
 this muscle in the iliac fossa is a large deposit of fat. The 
 psoas magnus has the usual origin, but consists almost entirely 
 of fatty tissue, streaked here and there with muscular fibres, it 
 ends in a flat tendon a little higher up than usual, and after 
 being joined by the wasted iliacus muscle passes as a narrow, 
 thin, ribbon-like tendon in the groove below the anterior inferior 
 spine of the ilium under Foupart's ligament, in a direction out- 
 wards and upwards, and becomes blended with the anterior part 
 of the old capsule. 
 
 Liganuntous Sttiictures. — Two capsular ligaments are seen, 
 the old and the new. The old capsule is still attached to the 
 margin of the acetabulum, and is much thickened ; the ilio- 
 femoral ligament is well marked, being strengthened by the 
 blending with it of the tendon of the psoas and iliacus muscles. 
 The capsule is stretched upwards and outwards, following, of 
 course, the ascent of the head of the femur ; in its upper and 
 posterior part is seen the head of the femur protruding through 
 
370 
 
 DR FRANCIS J. SHEPHERD. 
 
 a slit; this slit embraces the neck of the femur, and it appears 
 as if the head of the femur has worn away the capsule at this 
 point by pressing it against the dorsum ilii. The new capsule 
 is attached at its pelvic extremity around the socket which has 
 been formed on the dorsum ilii by the wearing away of the bone, 
 — at its femoral end it is attached internally to the slit in the 
 old capsule through which the head of the femur protrudes, and 
 externally is continuous with the inner surface of the gluteus 
 minimus. It is ligamentous in structure, its inner surface is 
 smooth, and a number of small villous processes are seen hang- 
 ing from it. No synovial fluid can be seen. The ligamentum 
 teres is entirely absent, no trace of it being seen either in the 
 old acetabulum or in the head of the femur ; it has probably 
 been worn through and the two ends absorbed. 
 
 Osseous Strudures. — Femur. The whole bone is perceptibly 
 smaller than that of the opposite side. The head is remarkably 
 altered in appearance, it is of less size than normal, and where 
 the ligamentum teres should be attached it is flat and devoid of 
 cartilage, as if it had been worn away or had lost its epiphysis ; 
 on the upper part of this flattened surface a shallow groove is 
 seen, crescentic in form. The remaining part of the head is 
 covered with cartilage. The compact bony tissue covering the 
 head is remarkably thin, and on breaking it through the cancel- 
 lated structure is found to be very soft. The neck of the bone 
 is much shortened, and forms a right angle with the shaft ; the 
 upper part of the shaft is arched outwards ; where the gluteus 
 maximus was attached a rather prominent crest is seen. The 
 lesser trochanter is absent, its place being occupied by a shallow 
 groove. 
 
 Pelvis. — The whole right half is smaller than the left. The 
 wing of the right ilium is much thinner, more upright, more 
 curled inwards, and altogether smaller than the left; the 
 anterior inferior spine is prominent, and in consequence the 
 groove below it in which lay the tendon of the psoas and iliacus 
 is deeper. The rami of the pubis and ischium on the right side 
 are flatter, thinner, and seem to spread out more than those of 
 the opposite side, that is if a perpendicular be dropped from the 
 symphysis pubis, the angle formed by it with the rami of the 
 right side is much more obtuse than that formed by it with the 
 
 
CONGENITAL DISLOCATION OF THE HEAD OF THE FEMUR. 371 
 
 ; appears 
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 rami of the left. The right obturator foramen has lost its trian- 
 gular shape, and is now broadest in its transverse diameter. 
 The acetabulum is much altered in appearance, being a mere 
 triangular depression in the bone ; the apex of the triangle is 
 upwards and to the right, and the base corresponds to the 
 cotyloid notch. The. edges of this triangular depression are 
 smooth and curled inwards, and but slightly covered with fibro- 
 cartilage ; the transverse ligament has almost disappeared. 
 Around the edges of the depression is attached the old capsular 
 ligament. The bottom of the cavity is completely ossified, and 
 shows no trace of any disease having existed, the depression for 
 the Haversian gland is well seen, it is small, being about the 
 size of a sixpence. The acetabulum measures two inches in 
 length, three-quarters of an inch in breadth, and half an inch in 
 depth, it was filled with fatty tissue. The Ttaw socket for the 
 head of the femur is an oval depression on the dorsum ilii 
 between the middle and inferior curved lines, and on a level 
 with the great sciatic notch, the inner edge of this new socket 
 corresponding to the bony edge of the notch. It has not been 
 deepened by ossific deposit, but appears to have been made by 
 the wearing action of the head of the femur. It is t\vo inches 
 in diameter and a quarter of an inch in depth. Around its edge 
 the new capsule is attached, and its floor is covered by a sort of 
 periosteum, which receives fibres from the capsule. The ilium 
 is not very thin at this point 
 
 The measurements of the pelvis are altered, the diameters of 
 the inlet being increased and outlet slightly diminished : — 
 
 Diameters. 
 
 Inlet. 
 
 OuUet 
 
 Conjugate, . 
 
 4| inches. 
 
 4 inches 
 
 Right oblique, . 
 
 . 6i „ 
 
 — 
 
 Left oblique, 
 
 6i „ 
 
 — 
 
 Transverse, 
 
 6 „ 
 
 4J „ 
 
 The distance between the anterior superior spines of the ilia 
 measured nine inches. 
 
 The sacrum is slightly turned to the affected side, but other- 
 wise is not much altered in appearance. There is no great 
 anterior convexity of the lower dorsal and lumbar vertebrae, but 
 the vertebrae incline laterally to the aifected side. 
 
 Remarks. — (1.) The absence of anterior convexity \\\ tlie lower 
 
372 CONGENITAL DISLOCATION OF THE HEAIT 0¥ THE FKMUK. 
 
 dorsal and lumbar regions was probably due to the atrophied 
 condition of the psoas and iliacus muscles and their abnormal 
 attachment to the old capsule. Probably during life, when the 
 woman assumed the erect position, this anterior convexity 
 existed, though not to the great degree that is usual 
 
 (2.) The absence of the lesser troeharUer was due no doubt to its 
 having been torn away from its attachment to the femur at the 
 time the dislocation occurred, and to its afterwards having been 
 absorbed. This would account for the insertion of the psoas 
 and iliacus tendon into the old capsule, the muscles thus having 
 a very limited action would atrophy. This condition would also 
 favour the opinion held by some that this form of dislocation 
 is due to violence (at birth). 
 
 (3.) There was no twisting forwards of the head and neck of 
 the femur, a condition which is described by some, and which, 
 had it existed, would have accounted for the eversion. The 
 eversion of the limb may have been only a post-mortem. 
 symptom due to the relaxed state of the muscle, the large 
 capsule, and small liead of femur. 
 
 Note. — ^The subject in which the above described dislocation 
 occurred, owing to the unfortunate state of affairs in Canada, 
 had been illegally obtained, so that no history could at the time 
 be procured. I have since heard that this woman had suffered 
 from ** lameness " all her life, that she walked with a waddling 
 motion, and also that she had borne a large family of children. 
 This information I have fair reasons for supposing is authentic. 
 
 
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