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pubis was found to project forward and upward at the symphysis, about a centimetre, although the patient had not changed his position, and the pelvis had been supported by a broad bandage. The patient recovered entirely, without deformity in three months.

DISLOCATIONS OF THE COCCYX.

The systematic descriptions of dislocations of the coccyx which are given by the earlier writers were called in question by those of the first half of the present century, some of whom, especially Boyer, went so far as to deny that the lesion had ever occurred. Malgaigne, however, collected six cases of dislocation forward, and described a backward form on the authority of Lauverjat. To these six may be added four that have been since reported, Roeser, Bonnefont,2 two cases, and Mouret,3 the first of which is an example of a variety, lateral dislocation, that has not heretofore been described. It must further be said that many cases have been encountered and reported in which a group of symptoms identical with those observed in cases reported as dislocations, and following similar accidents, falls, blows upon the anal region, has been presented, and the conclusion seems to be unavoidable, either that dislocations or fractures of the coccyx are much more frequent than the number of reported cases indicates, or that the prominent symptoms which accompany the recognized cases, the excessive pain, disability, and general nervous disturbance, are due to something else than the displacement of the bone. Against the latter alternative may be urged the immediate relief and prompt recovery which have followed the reduction of the displacement. Six cases in which the general symptoms were similar to those of dislocation, but in which no displacement was recognizable, are reported by Warren,* and Mouret's case may perhaps be classed with them.

Of eight of the above cases in which the sex is noted, six were women, and two men; all were adults; and the obscure injury just referred to, in which the symptoms are the same, except that no displacement is recognizable, is also much more frequent in women than in men.

Dislocations forward. The usual cause is violence received upon the region of the coccyx in a fall upon the buttocks or astride a bar, or by the breaking of a chamber upon which the patient was sitting. The two men, Ravaton, Mouret, were injured while on horseback, one of them suddenly in jumping a ditch, the other without special cause or incident, the pain coming on gradually, and increasing for twenty-four hours, and then suddenly becoming very severe after a slight change of position, with a sensation of something slipping in the rectum.

The pain at the moment of the accident is so severe as sometimes to cause the patient to faint; there is pain in defecation, and frequent calls to urinate. The pain radiates down the thighs, and sometimes over the trunk, head, and arms; the patient is unable to sit up, and the slightest

Roeser Froriep's Notizen, 1857, vol. 2, No. 10. Abstract in Brit. and For. Med. Chir. Rev., 1857, vol. 20, p. 414.

2 Bonnefont: Union Médicale, 1859, i. p. 136.

3 Mouret: Red. de Mém. de Med. Chir. et Pharm. militaires, 1859, i. p. 350. Warren: Surg. Observations, Boston, 1867, p. 593.

movement may greatly increase the suffering. Coughing and sneezing, and sometimes even every act of inspiration increase the local pain. If the condition remains unrelieved (Turner, a week; Ravaton, seventeen days; Bonnefont, a month) the general health suffers seriously, the patient becomes feverish, and the mind dulled.

External examination may show an ecchymosis and swelling over the situation of the coccyx and a displacement of this bone forward; the finger introduced into the rectum recognizes an angular displacement of the coccyx, in which its point is directed forward, and which is sometimes. so great that the bone stands almost at right angles to its normal position, and presses the posterior wall of the rectum sharply forward.

If now the finger is hooked over the projecting end of the coccyx it can be readily drawn back into place, and the reduction is followed by immediate, instantaneous relief of all the symptoms. A marked tendency to recurrence usually exists and may make it necessary to repeat the reduction several times. In one of Bonnefont's cases a gum catheter with a stylet was bent into the shape of a hook and so placed in the anus that by traction upon the projecting portion the bone could be kept in place. In Turner's case the cure was less complete; the coccyx preserved an abnormal mobility for many years, and the patient was obliged to facilitate defecation by introducing her finger into the anus.

Dislocation backward is lightly mentioned by some writers as a not infrequent accident during parturition. Malgaigne quoted Lowenjat as follows: "The considerable deviation backward of this bone sometimes causes its dislocation. I have seen one case. The patient suffered astonishingly, and could not sit; I reduced the coccyx and she was immediately

cured.'

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Lateral dislocation. Of this only one case, Roeser, has been reported. The patient, a large, corpulent woman, thirty-six years old, fell astride the back of a chair. She at once suffered severe pain in the coccygeal region, much aggravated by attempts to sit, but she was able to go about for some hours. At last the pain became so severe that she took to her bed, when she found she could neither move nor turn. When seen the next day there was so much immobility and stiffness of the body as to suggest tetanus. Besides the severe pain in the coccygeal region she complained of a painful, tense, dragging sensation, extending up toward the nape, and along the arms to the fingers which felt numb. She could not bear to make the slightest movement. The head was confused, and the intellect somewhat clouded.

No unnatural sensation in the lower limbs; urine and feces were passed naturally.

A small swelling was felt on the left side of the fissure of the buttocks, which proved to be the coccyx torn away from the sacrum, and carried toward the left ischium. The end of the scrotum from which it had been displaced could be plainly felt. The finger in the rectum showed the exact nature of the displacement still better, and when firm pressure was made downward and to the right against the displaced bone, it suddenly resumed its normal position. The patient declared she immediately felt quite another being, the confusion of the head and painful sensation along the spine and anus disappearing. At the end of the fifth day no inconvenience beyond a slight burning pain near the sacrum remained.

CHAPTER XXV.

DISLOCATIONS OF THE HIP.

ANATOMY. STATISTICS.

CLASSIFICATION.

BACKWARD DISLOCATIONS.

Anatomy. The bony constituents of the hip-joint are the acetabulum, or cotyloid cavity of the os innominatum, and the globular head of the femur. The former is an almost hemispherical cavity, situated at the junction of the ilium, ischium, and pubis, and formed by the projection from their outer surface of a strong bony rim, which is especially thick and prominent behind and above, and is lacking below for nearly an inch at the point where the cavity adjoins the foramen ovale, the cotyloid notch. The posterior, upper, and anterior portions of the cavity are lined by articular cartilage, but the centre of the cavity and the portion between it and the cotyloid notch are uncovered by cartilage, and are occupied by fat, and, at the lower part, by the ligamentum teres. The depth of the cavity is increased by a fibro-cartilaginous rim set upon its edge, the labrum cartilagineum, or cotyloid ligament, which crosses the cotyloid notch, and is there termed the transverse ligament. The centre of the cavity lies in a line drawn from the anterior superior spine of the ilium to the lowest or most anterior part of the tuberosity of the ischium. The wall of the cavity is thin at its centre and lower part, and is elsewhere very thick and strong. Its growth takes place at the junction of the three bones which combine to form it, this junction being marked during the period of growth by a thin layer of conjugal cartilage having the shape of an inverted Y.

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The head of the femur is rather more than half of a sphere, having a radius of about an inch, and is so placed upon the neck that rather more than half of its cartilage-covered surface is in front and above (in the upright position), and rather less than half is behind and below. point a little below that at which a prolongation of the long axis of the neck would touch its surface is a depression, within which the upper end of the ligamentum teres is attached.

The curves of the head and the cotyloid cavity are almost, if not entirely, identical; the small gaps that are sometimes found between them are probably due to irregularities in one or the other surface, although they are attributed by some anatomists to normal departures from the exactly spherical form, or to slight differences in the length of the radii of the two surfaces.

The neck is directed inward, upward, and slightly backward from its junction with the shaft, the angle which it makes with the long axis of the latter being about 130°. The great trochanter, continuous with the outer surface of the shaft, overlaps the neck above and behind, its highest part being situated posteriorly and curved inward; the portion which is

most external and most nearly subcutaneous is about an inch below the upper margin. To this trochanter and to the digital fossa which adjoins it on the inner side above and behind pass all the outer and posterior muscles, except the gluteus maximus and quadratus femoris, which come from the hip-bone. The small trochanter is a rounded prominence upon the inner and posterior aspect of the shaft close below its junction with the neck, and gives attachment to the psoas-iliacus muscle.

FIG. 118.

The capsule is attached above along the entire periphery of the cotyloid cavity, just outside the free margin of the labrum cartilagineum, and below to the femur at or near the junction of the neck and shaft, extending in front to the inter-trochanteric line, above nearly to the root of the great trochanter in the digital fossa, behind to the neck itself a little short of its outer limit, and below to the upper part of the lesser trochanter. It is composed of fibres arranged longitudinally and circularly, and varies greatly in strength and thickness at different points. Those portions which are especially thickened by multiplication of the longitudinal fibres are known as accessory ligaments; of these the strongest and most important is the one situated in the anterior part of the capsule, and known as the ilio-femoral ligament, or the ligament of Bertin, or Bigelow's Y-ligament (Fig. 118). This arises from the anterior inferior spine of the ilium, and from the surface of the bone immediately behind it and above the edge of the acetabulum, and its fibres passing downward diverge to form two strong bands, of which the inner passes almost vertically to the lower part of the anterior intertrochanteric line, and the outer to the upper part of the same line. The ligament is about one-fourth of an inch. thick at its thickest part, and is very strong, perhaps the strongest in the body, and will sustain without rupture a strain of from 250 to 750 pounds (Bigelow). Its inner portion is especially concerned in limiting extension of the limb; its outer portion in limiting eversion.

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The ilio-femoral, or Y-ligament. (BIGELOW.)

The other thickened portions of the capsule are those known as the pubo-femoral and ischio-femoral ligaments; the former arises from the anterior and inferior portion of the acetabular margin and the pubis as far inward as the pectineal eminence, and extends in the anterior and lower part of the capsule to its insertion above the small trochanter. The

ischio-femoral ligament is a strong band of fibres on the outer and posterior portion of the capsule, arising from the groove on the ischium below the acetabulum. The pubo-femoral ligament limits abduction; the ischiofemoral limits inversion. On each side of the pubo-femoral band the capsule is very thin, and through these thin portions the head of the femur passes in the pubic and obturator dislocations; outside and behind the Y-ligament, where some of the dorsal dislocations occur, the capsule is very strong, limiting adduction and inward rotation (Bigelow).

The ligamentum teres is a triangular band attached by its base to the transverse ligament and the adjoining central portion of the acetabulum, and by its apex to the depression on the inner surface of the head of the femur. It is not strong and probably is without important influence in limiting the movements of the femur; its chief function appears to be to convey blood vessels to the head of the femur.

The cavity of the joint usually communicates through an opening in its anterior portion with a bursa under the tendon of the ilio-psoas muscle.

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Relations of the head of the femur and the obturator internus. (BIGELOW.)

The joint is thickly covered in by muscles, of which it is desirable here to mention only one, the obturator internus, which plays an important part in the backward dislocations. This muscle, arising from the inner surface of the obturator foramen and the surface of bone between it and the great sacro-sciatic notch, passes outward through the small sacro-sciatic notch, turns sharply forward, and is inserted upon the front part of the inner surface of the great trochanter in conjunction with the two gemelli which arise respectively from the spine and tuberosity of the ischium. Bigelow found it to be the strongest of the external rotators,

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