BIBLIOGRAPHICAL NOTICES.
Ji Treatise on the Etiology, Pathology and Treatment of Congenital
Dislocations of the Head of the Femur. Illustrated with plates.
By John Murray Carnachan, M. D., Lecturer on Operative
Surgery with Surgical and Pathological Anatomy, &c. &c. New
York : S. S. & W. Wood, 261 Pearl street.
The progression which has taken place in the science of medi-
cine within the last few years, cannot fail to prove a source of
abiding interest to all engaged in its pursuit. Nothing, perhaps,
demonstrates more clearly that its progress is advancing rapidly,
not toward perfection and certainty, but towards a higher position
than it has heretofore reached, than the fact that its different and
special departments are assiduously cultivated by accurate and
industrious observers, who are ready and willing to confer on their
fellow’-laborers the benefits of their experience and investigations.
The field of science, like that of agriculture, may be most advan-
tageously cultivated when judiciously divided, and especially when
to every division some capable and accomplished laborer is willing
to devote himself, and to contribute the fruits of his labors to the
common stock of others concerned in its culture.
Special departments of medicine have long since been laid out,
and the sub-division is now so extensive, that there is scarcely a
subject of importance on which monographs have not appeared,
which, while they reflect credit on the ability and research of their
authors, prove to the profession of inestimable value.
The work before us, giving an account of a special department
of surgery, cannot fail to prove of interest to the practical surgeon,
as it appears to be an elaborate and faithful delineation of a very
distressing and badly understood affection, which, until recently,
has been deemed incurable, and to which the attention of the pro-
fession has been directed only within the last few years.
In the preface, our author dwells upon the necessity of an accu-
rate knowledge of anatomy, physiology, and pathology, to the
surgeon, and throughout the book he demonstrates not only his
willingness, but also his ability, to follow up his precept by ex-
ample, in the full description of congenital dislocations of the head
of the femur upon the dorsum of the ilium, and by the details of
his individual investigations as to the different conditions of the
affection.
The work entitled “ A Treatise on the Etiology, Pathology, and
Treatment of Congenital Dislocations of the Head of the Femur,”
is divided into seven chapters, the whole occupying 235 pages,
and illustrated by thirteen well executed engravings.
The 1st chapter is occupied with “ General considerations on
congenital dislocations of the head of the femur,” and a history is
given of most that has been published on the subject since the days
of Hippocrates, who first noticed that children, while in utero,
may be affected with various deformities, and among them with
certain dislocations, without dwelling at all on the variety under
consideration. In latter times, the affection has been studied by
Ambrose Pare, Verdue, &c., who demonstrate the possibility of the
occurrence of this and other dislocations, while the child is still
in utero, which almost inevitably prove the source of deformity for
life. Dislocations occurring, no matter at what period, or how,
are of deep interest to the surgeon, as on his efforts alone can the
misfortunes which would otherwise follow them be averted. Un-
happily, from the difficulties of diagnosis attending those occurring
congenitally, and the insufficiency of the means for their reduction,
they are usually allowed to pass unnoticed, until certain changes
have taken place in the structures about the articulation, which
may forever preclude the possibility of a cure.
Our author quotes from Pare, Palleta, and Dupuytren, in proof
that these malformations do take place, and that they occur much
more frequently than is usually supposed, and also shows that these
writers were aware of the difficulties to be encountered in the diag-
nosis of them, and especially between these and others, which are
described as pseudo-luxations and sub-luxations. He gives a gene-
ral description of the malformation, and of the changes which
ultimately follow in the structures in the neighbourhood of the
articulation.
In Chapter 2d, the anatomical relations of the joint, the bones
composing it, with the ligaments, &c., are carefully described, and
the difference between the articulation as perfected in the adult, and
its imperfect or rudimentary state in the foetus or even in the child
for some time after birth, is given, and the facility with which the
head of the femur may escape from the acetabulum, is shown, not
only from the shallowness of the cavity, but also from the want of
perfection in the conformation of the head of the bone itself.
The position of the child in utero, with the thighs strongly
flexed upon the pelvis, is considered favorable to the escape of the
head of the femur, whenever there is any irregularity in the deve-
lopment of the parts about the pelvi-femoral articulation, or when-
ever the muscles, already on the stretch, are brought into active
contraction. The conditions of the articulation favorable to the
accident, are very well shown in plate No. 3.
In Chapter 3d, the etiology of the deformity is very elabo-
rately entered into, and although the author is decided in his views
as to its production, he is still candid in giving the opinions of
others, notwithstanding the weight of their authority.
A distinction is made between terms used indiscriminately,
though of different meaning, as expressive of the affection, such
as spontaneous, original, congenital, and the latter is adopted as
most appropriate under all circumstances. Congenital luxations
of the head of the femur, are divided (as when occurring after
birth) into complete and incomplete, and the directions in which they
may take place, are three, 1st, upwards and outwards ; 2d, directly
upwards, and 3d, forwards and upwards. The first is the variety
which is of the most frequent occurrence, and which is most likely
to take place from the natural relations of the parts; the two last
are stated to occur as forms of foetal monstrosities. A sub-luxa-
tion, described by M. Guerin, as occurring upwards and back-
wards, and two varieties of pseudo-luxation, of the same author,
are given, though not dwelt upon ; the first simulating a luxation
backwards and outwards ; the second, downwards and forwards ;
the head of the femur in neither instance having escaped from the
acetabular cavity. One author considers these varieties as belong-
ing to the imperfectly developed foetus or to monsters, and leaves
them with the intention of giving a more full account of those
which more especially “ belong to the practical details of the
profession.”
The causes given by different writers as producing the affection
under consideration are—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 occurring in the foetus during
intra-uterine life. {Revived by M. Parise, and others.} Fifth.
A primitive alteration in the nervous centres. {Chaussier} revived
by Delpech and Guerin ; and lastly, to be more definite ; I would
add to the causes mentioned above, a pathological spasmodic re-
traction of the muscular tissue, resulting from a perverted or dis-
turbed condition of the excito-motor apparatus of the medulla spinosis ;
especially of that portion which is in direct relation with the nervous
branches distributed among the pelvi femoral muscles.'”
Discussing fully the first four causes as stated, our author dis-
cards them, believing the last, which, to a certain extent, embraces
the fifth, enough to account for the production of the affection.
He gives at length the causes which induce muscular contraction,
and the aberrations from the normal conditions. Indeed, his re-
marks constitute a resumb of the doctrine of excito-motor func-
tion, and he bases on its derangement the production of congenital
dislocations of the head of the femur, as well as of other defor-
mities which doubtless have the same etiology. He combats freely
the doctrine advanced by Chaussier and Palleta, and subsequently
adopted by Rudolphi, Delpeclc, and Gu&rin, of the absence of or
alteration in any parts of the nervous centres, and argues to prove
that the aberration may be and is entirely functional, which is
certainly nothing more than reasonable, when we know that chil-
dren are born with every variety of malformation, and yet both
brain and spinal column are found to be in a perfectly healthy
condition. The anatomical relations of the nervous system as
bearing on the argument, are clearly pointed out, and many func-
tional derangements given in support of what our author believes
the true causes of these congenital dislocations, niz.,morbid, mus-
cular, spasmodic contractions, and to which he attributes the dis-
location under consideration.
In Chapter 4th, the symptomatology of the affection is described,
and the difference between the appearances presented at the dif-
ferent periods of life is considered.
Our author thinks that the affection may be entirely overlooked
in the infant or young subject, but believes that when the atten-
tion is once directed to the articulation, the nature of the case
becomes evident, as the appearances are very much the same as
those presented in traumatic luxation of the femur, while the
muscles in the neighborhood of the joint are usually so atrophied
as to render a comprehension of the relation of the parts suffi-
ciently easy.
The deformity, which may be slight at first, is increased so soon
as the child supports itself, when the weight of the body is thrown
upon the coxi-femoral articulation, inasmuch as the head of the
femur, which at first rests just without the socket, is then forced
higher up, until it ultimately assumes a position on the dorsum
ilii. Strange to say, the dislocation of both bones is more com-
mon than that of one alone. When such is the case, the diagnosis
is rendered more difficult, inasmuch as there is then no inequality
in the length of the limbs. When such is the case, the dispropor-
tion between the length of the body and inferior extremities is
striking ; there is a curvature forwards of the lumbar region, the
pubic region is tilted forwards and downwards, and the lower por-
tion of the trunk appears to be sunken between the upper portion
of the thighs. From this circumstance, the arms, when hanging
by the sides, appear too long. The trochanters project abnormally,
and the contour of the hips is altered; the fold in the groin is
deeper than usual, and the extremities, from want of use, are not
fullv developed. The direction of the limbs varies, and the loco-
motion of the patient is difficult, and “ a kind of double lameness
is produced, somewhat resembling the hobbling motion of the
duck.” When the patient is placed in the recumbent posture, the
limbs may be elongated, and many of the symptoms observable to
the eye disappear. Among the appearances presented to the eye,
as well as the signs manifested by manual manipulation, the
absence of the head of the femur from its natural position when
the limb is rotated, while the fingers are placed in the fold of the
groin, is looked upon both by our author and M. Prevaz as “ a
certain sign of displacement.”
The different measurements and the motions which may be
given to the limbs, are well described, and the appearances pre-
sented are illustrated by a reference to the plates. The symptoms,
when the head of one femur only is dislocated, are also well
pointed out, and an abstract is given of a well written paper on
congenital dislocations of the femur, published by our author in
the London Lancet, in 1844, which seems to cover the whole
ground.
Chapter 5th.—Diagnosis. The diseases with which this defor-
mity may be comfounded are: morbus coxarius, sub-luxation of
the femur, the pseudo-luxations of M. Guerin, malformations about
the joint, osseous deposits, and shortening of the limbs. Our
author thinks that the appearances given are sufficiently distinctive
when carefully studied, and that the present symptoms and history
of morbus coxarius will prevent any mistake so far as it is con-
cerned.
Chapter 6th.—Prognosis. Notwithstanding the opinion of M.
Dupuytren, as to the incurability of the affection, our author
assumes its curability, and subsequently shows that cases have
been successfully treated, when the patients have been young.
He, however, cautions the surgeon against a too favorable prog-
nosis. He demonstrates also by drawings from specimens, that
the capacity of the pelvis may be altered or interfered with, by the
existence of the affection, by which he controverts the assertion of
Dupuytren, that the pelvis is not affected by the occurrence of
congenital dislocations of the femur. He does not agree with
others that such cases are most likely to occur when one side only
is affected. He admits, however, that after middle life, the con-
formation of the head of the femur and that of the acetabulum and
articular capsule become so altered as to render the case hopeless,
and only limits a favorable prognosis to such cases as fall into the
hands of the surgeon in early life, or as he states in the next
chapter, the patient must not have passed beyond the twelfth or
fourteenth year of age.
Chapter 7th. The pathology is shown to vary very much, accord-
ing to the extent and duration of the displacement; yet there are
certain post-mortem appearances which belong to the affection
under all circumstances. In early life, the head of the femur, the
acetabulum, its cartilages, and its ligaments, may have undergone
very little actual change, but “ 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 dis-
turbed, the structural changes in the various tissues become also
more marked.”
In the sequel, our author points out these changes very clearly.
Those occurring in the cotyloid cavity being not only a speedy
alteration in its size and shape, but also a deposition occasionally
on its surface, with an alteration of its investing cartilage. The
head of the femur soon alters in its shape, dimensions, and tex-
ture, too much so, we fear, to justify even so much hope as our
author entertains of the success of any plan of treatment which
may be attempted, especially in those cases in which “ the nutri-
tion of the head may become so perverted as to produce structural
deterioration, terminating sometimes in its total disappearance.”
The capsule and ligamentum teres may remain for a consider-
able time unaltered, except in being much elongated, but ulti-
mately the former will become much attenuated, and in consequence
of the constant pressure of the head of the femur, and the friction
on the dorsum of the ilium, will become perforated so as to allow
the bone to escape from its investment, while the distended liga-
mentum teres will rupture, and afford to the joint no further sup-
port ; or they may coalesce, forming a strong ligamentous cord,
uniting the upper portion of the femur to the pelvis. These con-
ditions, together with the formation of a new capsule which some-
times takes place, are well shown in plates 6, 7, 8, and 9.
Our author believes that a new socket or acetabulum may be
formed on the dorsum of the ilium, after the head of the femur has
reached that location, in two different ways: 1st. At the expense
of the ilium, out of which a shallow cavity is scooped by its con-
tinued pressure ; and 2d. By a deposition of new’ osseous matter.
M. Guerin believes that the latter mode of formation of a new
socket always occurs, from which opinion our author disagrees,
and in plate No. 7 shows that the simple depression on the dorsum
of the ilium for the lodgment of the head of the bone does some-
times take place.
The altered appearance of the muscles about the articulation,
the atrophied state of some of them, and the contracted condition
of others, while others are changed in their texture, are well de-
scribed.
The changes also in the vessels, nerves, cellular tissue and skin
about the parts, as well as the alterations in the osseous tissues,
are sufficiently dwelt upon. Our author also shows by actual
measurement of morbid specimens, that the pelvis becomes altered
in its configuration and capacity, and points out the difficulties
which may result during parturition, from the existence of the
affection under consideration.
A clear analysis of malformations of the pelvis, &c., and of the
causes and methods of operation in their production, is given, and
much influence is very properly ascribed to the faulty direction of
muscular contraction, aided by the pressure of the trunk on the
pelvis, the bony structure of wffiich is perhaps frequently diseased.
In confirmation of his views of the pathology of congenital
luxation of the head of the femur on the dorsum of the ilium, our
author details minutely the post mortem appearances presented on
dissection of two subjects, one female and the other male, which
embrace almost every thing which he previously states to exist,
including the many and extensive alterations in the different soft
and hard structures about the thighs and hips. In the case of the
male, the extent of the deformity and shortening of the femurs
themselves, must have been such as to have rendered locomotion
extremely imperfect.
Chapt. 8th. Treatment.—Our author fully appreciates the diffi-
culties to be encountered in the treatment of the deformity, and it
could scarcely be otherwise, when the extensive alterations which
he has shown to occur in most cases, are taken into consideration.
The practitioner undertakes with diffidence the reduction of a
common traumatic luxation (no matter of wffiat bone) when more
than a few weeks have elapsed since its occurrence, because he is
aware of the changes which invariably take place to a greater or
less extent, not only in the structures belonging to the joint itself,
but also in those in its neighborhood; how much more distrustful
then must he be of his efforts for the relief of an affection which
dates its existence from the birth, and the difficulties of which
have grown with the growth of its unfortunate victim, more
especially when a number of years have probably passed before
his assistance is demanded.
Dupuytren, with all his pathological knowledge, and full of sur-
gical skill as he was, deemed such cases hopeless, and rested
content with a palliative means of relief, in the form of strong
plates so adjusted and fixed as to retain to a certain extent the
heads of the bones in their unnatural positions, and to prevent
them from sliding up and down at every effort of locomotion. But
as one fact of right takes precedence of all hypotheses, no mattes1
how plausible, so it appears that cases of luxation of the head of
one or of both femurs have been successfully treated, and conse-
quently attempts at their reduction may hereafter be undertaken
with a prospect of a fortunate result. Unsuccessful attempts for
the relief of the affection were first made by MM. Duval and
Lafond, and subsequently by MM. Humbert and Jacquier, which,
however, directed the attention of the profession to its manage-
ment. By the report of a commission of the Royal Academy of
Medicine of Paris, made in 1838, it appears that M. Pravaz suc-
ceeded in the reduction of a congenital luxation of the head of the
femur upon the ilium. Other cases detailed by M. Pravaz, as well
as those given by other practitioners, demonstrate the occasional
curability of the deformity. “ In 1843 the council general of the
civil hospitals of Paris nominated a commission,” which reported
the successful termination of three cases of the deformity treated
by M. Guerin at the Hopital des Enfans, and M. Guerin has him-
self reported other successful results.
As the disease may be said to be chronic, so is the treatment
“ necessarily prolonged and tedious,” and can only be justified by
the prospect of ultimate relief to a deformity not less distressing
than the most horrible of its class.
The treatment should be commenced as soon as possible, and it
has proved successful from the age of three to that of fifteen years.
The younger the patient, the fewer and less permanent are the
changes in the structures about the parts.
After remarking on the condition of things which may justify
the operation, our author divides the curative treatment into three
periods, viz.: “First, the preparatory extension; secondly, the
reduction; thirdly, the normal consolidation of the articular struc-
tures, so that the head of the femur may be permanently retained
in the acetabulum.” The preparatory extension having for its
object the dislodgment of the head of the femur from its unnatural
position on the dorsum of the ilium, and the stretching of the con-
tracted muscles and fascia, must be gradual, and should be kept up
for a long time, varying from two to six months. For this purpose
the complicated apparatus devised by M. Pravaz is recommended,
and of it a plate is given.
When enough extension has been obtained, the reduction is to
be attempted by abducting the limb, and by pushing the head of
the femur from above downwards and from without inwards.
Sometimes the reduction is immediate and complete, at others “ the
head of the femur can only be brought into its anatomical position
and retained there,” when it should be fixed by some appropriate
contrivance until nature has effected such changes in the acetabu-
lum as to render it fit for its permanent lodgment.
After the articulation has been established, and when the
muscles, &c., have to a certain extent assumed their normal con-
dition, the third period of the treatment may be commenced, which
consists in the use of an apparatus in which the limbs can be ex-
ercised, while the weight of the body is not allowed to rest upon
them, until the parts have become fully consolidated. Subse-
quently crutches are recommended at the convenience of the
patient. Appropriate apparatus for fulfilling the above indications
are described, and well executed plates given in illustration.
The plans recommended and practised by M. Guerin to assist in
the reduction and retention of the head of the femur, do not seem
to find much favor in the eyes of our author, although he says
nothing against their employment. They consist of a subcutane-
ous division of the resisting muscles and fascia, the making in
the same way an opening in the closed capsule to allow the head
of the bone to return, and of scarifications about the acetabulum,
so as to excite sufficient inflammation to cause a deposition to be
thrown out which will retain the head of the femur in its new.
though natural position.
To Dr. Carnachan we take pleasure in returning our thanks for
presenting to the profession so interesting a treatise, which will
doubtless fall into the hands of surgeons generally, by whom it
will be duly appreciated; and to the publishers our thanks are due
for the handsome style in which the work appears.
We trust that at some future day the author will favor us with
his views on other important deformities of the bones and ioints.
W. B. P.