1820PallettaGB

 

The author extensively describes the topography, structure, and blood supply of the ligamentum capitis femoris (LCF). Presumably, it is in this work that the opinion was first expressed that the LCF serves as a conductor and protector of blood vessels. However, Giovanni Battista Palletta does not exclude that the LCF to some extent restrains abnormal movements of the femoral head. Noteworthy is the abundance of synonyms used to denote LCF in Latin: interiori ligamento, interiori vinculo, ligamenti interioris, ligamenti teretis, ligamento interiore, ligamento terete, ligamentum interius, ligamentum suspensorium femoris, ligamentum teres, medii ligament, teres ligamentum, teretis ligament, teretis vinculi, vinculi teretis, vinculum teres. Several synonyms have added to our collection, which now comprises about eight dozen terms. Additionally, in a work written over 200 years ago, there are at least two important hints for modern surgeons. Their implementation could significantly change the methodologies of surgical treatment of hip joint pathology. If you noticed them, please write in the comments. In our opinion, G.B. Palletta was also the first to notice changes in the fibrous base of the LCF (stroma) that occur throughout life. Inattention to this pathomorphological process is reflected in the results of modern studies.

The translation was done in collaboration with ChatGPT 3.5.   

Palletta GB. Exercitationes pathologicae. Mediolani: Societas Typ. e Classicis Scriptoribus Italicis, MDCCCXX [1820]. [fragments]
Quote p. 52
Verum utique videbitur iis, qui claudicantes attente observaverint, et qui sectiones ischiade demortuorum administraverint. Observavi non semel, artum excruciatum elongari, antequam luxatio consequatur. Id ego tribuo inflammationi perichondrii, et cartilaginum articularium, et ligamenti teretis; quæ partes adauctæ et tumentes femoris caput e cavitate tantisper extrudunt. Expulso autem capite, devastato ligamento interiori et cartilaginibus, artus ad duorum, trium, imo quatuor transversorum digitorum brevitatem sedigitur.	Those who have closely observed the lame and made incisions on those who died from sciatica will undoubtedly see this as truth. I have observed on multiple occasions how the afflicted joint elongates before dislocation occurs. I attribute this to inflammation of the perichondrium, articular cartilage, and rounded ligaments; these enlarged and swollen parts temporarily push the femoral head out of the socket. However, after the displacement of the head, and the destruction of the internal ligaments and cartilage, the joint shrinks to the length of two, three, or sometimes four transverse fingers.
Quote p. 67-69
Alterum argumentum, quod adversus lúxationis facilitatem adducitur, ab capitis ligamentis desumptum est, cujus quidem futilitatem paucis demonstrabo: et ligamentum, quod orbiculare vocant, licet valentissimum sit; ita tamen subtensum non est, ut non laxetur, et obsecundet variis femoris motibus. Præterea ejusdem ligamenti origines sive insertiones multum ab articulatione remote sunt. Nam ex parte acetabuli circulatim ab osse innominato procedit sat ultra fines marginis cotyloidei; et ex parte femoris non nisi ad basim longæ ejusdem cervicis inseritur, quæ connexionum distantia facit, ut minuatur robur, et vis, qua alias luxationi obsisteret. Demum, si animadvertamus, ligamentum capsulare non obstare, quominus caput cotylis fundo accedat propius, nunc ab eo recedat, atque vel in interiorem, vel in exteriorem partem convertatur; facile est judicare illud ligamentum non adeo esse adstrictum tensumque, ut caput cum quadam vi et firmitate in sua cavitate valeat retinere; imo scire licet, inter manticulæ insertionem et labrum acetabuli tantum spatii intercipi, ut in eo tanquam in sinu proprio caput femoris excipi possit absque ullo præcedentis lacerationis vestigio. Et revera ab experimentis discimus, et ex animadversionibus Kirklandii (1), nunquam orbiculatum ligamentum lacerari a femoris capite, dum prolabitur; sed ligamentum discerpi duntaxat circa femoris collum; et, si quando id contingat, ideo discerpi, quia nimiam circa collum, cui inhæret, distensionem patitur. Solidissimum vero (putant) adversus luxationis facilitatem argumentum ab ligamento interiore petunt. Vulgata opinio est, quod non solum id ligamentum validissime sese luxationi opponat; sed etiam quod luxatio nunquam eveniat sine ejusdem laceratione aut evulsione; hinc illud vinculum inter præcipua esse subsidia, quibus femoris caput in naturali sede conservatur. (1) Epist. super fem. luxat.  Videamus modo, utrum hæc sententia anatomicis suffulta sit demonstrationibus. Primum, quod demonstrari oportet his, qui ligamentum teres contemplantur; est nimia ejusdem longitudo, quæ luxationi præcavendæ nequaquam idonea est. Præcisis enim musculis omnibus, ipsoque vinculo orbiculato circa articuli ambitum, femoris caput, superata interim labri cartilaginei resistentia, anatomici manu propellitur ex cavitate, lineis aliquot ultra acetabuli fines excurrit, quin teres ligamentum disrumpatur, aut recedenti capiti, cui inhæret, obsistat. Dum vero in suam cavitatem caput denuo compellitur, idem vinculum adhuc integrum plurimum laxatur, et quasdam veluti flexiones facit, ut cavitati cotyloideæ sese accommodet. Sed nimiæ longitudinis ratio, quæ tereti ligamento tribuitur, in iis solum luxationibus locum habere potest, quæ in inferiorem et interiorem partem accidunt, non item in iis quæ superiora versus contingunt. Porro concedamus, vinculum teres tunc solummodo longius, quam par esset, videri, et integrum manere, cum luxationes in inferiorem partem fiunt. Quod cum reapse et naturaliter longius sit, demonstratum esse puto, supradictum ligamentum non posse ob longitudinem suam hujusmodi luxationibus obsistere , quæ infra acetabulum fiunt. Sed neque iis resistit, quæ sursum fiunt; nam data causa femur luxatur etiam in partem superiorem, et tunc ligamentum discerpitur potius, quam ut femur contineat, et hæ luxationes prioribus sunt frequentiores. Illud porro hoc in casu animadversione dignum est, quod capite in pristinam cavitatem reducto, ex ea non amplius prolabatur, quamvis suspicari liceat ligamentum teres fuisse laceratum. Itaque non opus est hujus ligamenti subsidio, ut in ossis innominati sinu caput femoris contineatur; sive enim illæsum sit ligamentum, sive discindatur; femur perinde luxatur, et repositum in sinu absque ligamenti integritate conservatur. Quod nunc assero, id pluribus exemplis et nostris et alienis comprobare, nisi pauca sufficerent. Exceptus est in nosocomium die 22 aug. 1785 juvenis annorum 17, cui paucis ante horis femur sinistrum in superiorem et exteriorem partem prolapsum fuerat. Mox illud restitutum fuit, atque tertia hebdomada nondum præterlapsa, tam bene valebat, ut singulis motibus exequendis esset idoneus. Huc referas observationem a Zaccharia Plattnero (1) memoratam: Artifici ex contignatione prolapso femur in interiorem et inferiorem partem excidit, restitutumque fuit a chirurgo. Non multo post tempore ex gravi capitis vulnere obiit, cadaverisque sectionem perfecit ill. Walther, qui femur quidem restitutum invenit, teres autem ligamentum disruptum; ex quo credidit, in adultis hunc articulum vix unquam posse promoveri absque interioris ligamenti fractura. Non desunt etiam argumenta directa, quibus probatur, femoris cap in sede sua fixum et stabile esse sine medii ligamenti interpositione. H … desumpta sunt ex sectione eorum, qui nullam, dum in vivis erant, l… tionem passi sunt. Memini vidisse me aliquos inter secandum, ligamentum tereti omnino carentes quibus tamen femora non exciderant. Id observavit ill. Caldanus in viro, dum viveret, non claudicante, cu… teres ex utroque latere vinculum, et fovea in capitis femore ad id excipiendum deerat. Nam circumsecto articulari ligamento uterque femur in tabulam anatomicam decidit (2). Id ipsum adnotatum est a celeb. Sandifort (3), a Salzmanno (4), a cl. Andrea Bonn (5) et forte ante hos omnes a Bernardino Genga (6), qui teretis vinculi jacturæ in iis deprehensæ mentionem faciunt, in quibus luxatio nulla præcesserat (*). Quod ligamentum ubi desideratur, rubescens quædam macula in capitis summitate observatur, cui tenuis supertenditur membrana locum designans, in quem vinculum teres immitti debuisset. In acetabuli autem fovea, ex qua ligamenti radices educuntur, vix quidquam, nisi informis pinguedo reperitur. Etsi autem deficiente interiori vinculo femur prolabi non soleat; verendum tamen est, ne illius defectus in alterutro latere artum saltem ita afficiat, ut claudicare hominem cogat. Id certum est, quod ab alicujus corporis interpositione debent paullum a se invicem diduci femoris caput et acetabulum; hinc eo liberiores erunt motus capitis, quo minus arcte illud a sinu comprehenditur, et quo magis ei ligamentum sese opponit, ne in acetabuli parietes impingat. (1) Instit. chirurg., S 1194, not. A. (2) Ex literis 26 maji 1786. (3) Observ. anat. pathol., lib. III, cap. 10. (4) Haller, diss. anat., vol. VII. (5) Thes. oss. morb., n. 42, 43, 47. (6) Anat. chirurg. (*) In iis, quorum ossa arthritide, vel atroci et male tractata vel inveterata admodum et neglecta, læsa sunt, nec ligamentum suspensorium femoris, nec fovea pro ejus insertione prehenduntur. Ligamentum consumptum est, et fovea nova materie ossea aut ex parte, aut omnino obductæ, aut penitus obliterate sunt. Nec tamen femur excidit, nec excidere valet; acetabulum enim accedente ut plurimum nova materie ossea tantopere elongatur, ut non solum femoris caput, sed et ejusdem collum fere penitus, et firmiter quidem includat. Insignem hujus mali coxarum et femorum numerum in collectione pathologica cum fratre dilectissimo communi asservamus. Occurrunt quidem coxæ ex arthriti corum numero, quarum acetabula supra modum plana sunt, et in quibus nullum simul foveæ illius pro ligamenti suspensorii femoris insertione vestigium cernitur, ut exinde femoris luxatio inevitabilis præsumatur; sed etiam in hisce speciminibus, saltem in iis, quæ nos coram habemus, nihil omnino luxationis observare licet. Plura desuper protuli in dissertatione mea: De ossium arthriticorum indole. Maguntiæ, 1791, in 8. (Wenzel.) Sed hæc non nisi conjectando proposui; quæ tunc demum rata erunt habenda, cum demonstrata fuerint ex eorum anatome, qui a sola ligamenti interioris inopia claudicasse videbuntur. Itaque si acetabuli capacitas superat capitis magnitudinem; si ligamenta et musculi non ea vi luxationi resistunt, qua vulgo existimatur illas potentias obsistere posse; facultatem, qua caput in propria sede retinetur, his causis minime subesse credendum est. Aliam igitur potentiam articulo inhærere, quæ id præstat, neque ab omnibus animadversam, satis constat. Labrum scilicet cartilagineum acetabuli, quod crasso principio ab ora sinus innominati ossis exortum, summeque elasticum sensim in aciem extenuatur quin ideo imbecillius evadat, amplectiturque femoris collum sub capite, valideque circa illud coarctatur. Quapropter, si cuidam placuerit femur ex sinu suo expellere, postquam orbiculatum ligamentum subsecuerit; vis, quæ in osse promovendo adhibetur, excipitur tota a labro cartilagineo, enjus elasticitas cum devicta fuerit, caput prorumpit edens crepitum magis minusve vehementem, qui tum a cartilagineo margine superato, tum ab aëris impetu in acetabulum irruentis oboritur. Quare cum cartilaginei marginis vis et constrictio præcipuum ponat obstaculum capiti, ne ex sinu suo prolabatur, evidens est, interiori ligamento aliud officium a natura esse tributum, quam quod eidem hucusque imponebatur; cujus ideo ut usus melius appareat, exponenda sunt quæ per sedulam dissectionem deprehendi.	Another argument, which is put forward in favor of the ease of dislocation, is an argument taken from the ligaments of the head, whose uselessness I will demonstrate briefly: although the ligament, called the orbicular, may be very strong; however, it is not so robust that it does not stretch, and hinder various movements of the thigh. Moreover, the beginning or ending of this ligament is far from the joint. For on one side it passes in a circle from the part of the pelvic bone, well beyond the edge of the acetabulum; and on the other side, it attaches only to the base of the long neck of the same femur, which distance between the connections significantly reduces the strength and force that could otherwise resist dislocation. And finally, if we note that the joint capsule does not prevent the head from coming closer to the bottom of the acetabulum, sometimes receding from it, and even turning inward or outward; it is easy to conclude that this ligament is not so tight and tense as to hold the head with force and strength in its socket; more likely, there is such space between its attachment point and the edge of the acetabulum that the head of the femur can be placed there, as if in its own pocket, without any traces of previous rupture. And indeed, from experience, we learn, and from the observations of Kirkland, that the orbicular ligament is never torn from the femur head during its dislocation; but the ligament tears only in the area of the femur neck; and if it ever happens, it is torn because it undergoes excessive stretching around the neck to which it is attached. It is assumed that the most reliable argument against the ease of dislocation is the internal ligament. The common opinion is that this ligament not only strongly resists dislocation, but also that dislocation never occurs without its damage or rupture; therefore, this connection is considered one of the most important means by which the head of the femur is held in its natural position. (1) Letter on femoral dislocation.  Now let's see if this view is supported by anatomical evidence. Firstly, what should be demonstrated by those studying the round ligaments is their excessive length, which is not suitable for preventing dislocation. After dissecting all the muscles and even the circular bond around the joint, the femoral head, overcoming the resistance of the cartilaginous labrum, can be pushed out of the socket by the anatomist's hand, extending beyond the edge of the acetabulum by several lines, without tearing the round ligament or it opposing the withdrawing head. However, when the head returns to its socket, the same bond remains intact but significantly relaxes and takes on some bends to adapt to the acetabulum. However, the reason for the excessive length attributed to the rounded ligament can only occur in those dislocations that occur downward and inward, but not in those directed upward. Let's assume that the round bond does indeed appear too long and remains intact when dislocations occur downward. I believe this has been proven, and therefore, the mentioned ligament cannot withstand such dislocations due to its length, which occur below the acetabulum. However, it also does not resist dislocations directed upward; because in this case, the thigh is also dislocated upwards, and then the ligament tears instead of holding the thigh, and such dislocations are more common. Additionally, it should be noted that after the head is returned to its original position in its socket, it no longer shifts out of it, although it can be assumed that the round ligament was torn. Thus, to keep the femoral head in the acetabular socket, support from this ligament is not necessary; regardless of whether it is intact or torn, the thigh still dislocates and remains in place in the socket when the ligament is damaged. What I am now asserting, I can confirm with numerous examples, both personal and others', if brief explanations are insufficient. On August 22, 1785, a 17-year-old youth was admitted to the hospital with his left hip recently dislocated upwards and outwards. He was soon put back in place, and within three weeks, he felt so well that he was ready for any movements. Here can be added an observation mentioned by Zaccharia Plattnero (1): The hip of an artist was dislocated inwards and downwards after a fall on the floor, and it was reduced by a surgeon. Shortly after, the patient died from a severe head injury, and an autopsy was performed. Walther, upon examination, found that the hip was reduced, yet the round ligament was torn; from which he concluded that in adults, dislocating this joint is practically impossible without tearing the internal ligament. There are also direct arguments demonstrating that the hip head is fixed and remains stable in place without the involvement of the medial ligament. These arguments were derived from anatomical dissections of individuals who had not experienced any dislocations during their lifetime. I recall having seen some of them dissected, where the round ligaments were absent, yet their hips did not dislocate from the joint. This was observed by Dr. Caldanus in a live person without lameness, who lacked round ligaments on both sides, and the depressions on the hip head for their attachment. After dissecting the joint ligament, both hips fell onto the anatomical table (2). This same phenomenon was noted by the renowned Sandifort (3), Salzmann (4), cl. Andrea Bonn (5), and possibly even earlier by Bernardino Genga (6), who mentions the absence of rounded bond in those who had no dislocations (*). Where the ligament is absent, a reddish spot is visible on the top of the head, over which a thin membrane is stretched, indicating where the rounded bond should have been attached. However, in the depression of the acetabulum, from which the roots of the ligament emerge, almost nothing is found except undeveloped fat. Although without the internal bond, the hip usually does not dislocate from the joint, it should be feared that its absence will at least significantly affect the limb, causing the person to limp. It is quite obvious that when any body is positioned, the head of the femur and the acetabulum must be slightly separated from each other; therefore, the freer the movement of the head, the less tightly it is held in the acetabulum, and the more resistance to displacement the ligament provides, so that it does not rest against the walls of the acetabulum. (1) Instit. chirurg., S 1194, not. A. (2) Ex literis 26 maji 1786. (3) Observ. anat. pathol., lib. III, cap. 10. (4) Haller, diss. anat., vol. VII. (5) Thes. oss. morb., n. 42, 43, 47. (6) Anat. chirurg. (*) In cases where the bones are affected by arthritis, whether due to severe injury or poor treatment, neither the suspensory ligament of the femur nor the socket for its attachment are observed. The ligament wears out, and the depression is either completely or partially covered with new bone tissue, or it may be completely worn away. However, the hip does not dislocate and cannot dislocate because significant new bone tissue often develops around the acetabulum, which not only almost completely encases the femoral head but also its neck. We have preserved a significant number of such cases of hip joints and hips in the collection of pathological material along with my dear brother. Among them are cases where the acetabula are too flat, and there are no signs of a depression for the attachment of the thigh suspensory ligament, making hip dislocation inevitable. But even in these specimens, at least in those we have before us, there are no signs of dislocation. I have described this in more detail in my dissertation: De ossium arthriticorum indole. [On the Nature of Arthritic Bones]. Maguntiæ, 1791, in 8. (Wenzel). But these assumptions I have put forward are mere conjectures; they will only be considered convincing when they are proven based on the anatomy of those who seem to limp solely due to the absence of the internal ligament. Therefore, if the capacity of the acetabulum exceeds the size of the femoral head; if the ligaments and muscles do not resist dislocation as strongly as it is usually assumed they can resist these forces; then it should be considered that the ability to maintain the head in its natural position is hardly dependent on these reasons. Clearly, there is another force in the joint that prevents this, and it does not always attract attention. This is the cartilaginous rim of the acetabulum, which starts from the broad part of the edge of the acetabulum and gradually becomes thinner and more elastic, tightly encircling the femoral neck and narrowing significantly under the head. Therefore, if someone needs to extract the femur from the joint after the circular ligament is torn; the force applied to displace the bone is fully absorbed by the cartilaginous lip, whose elasticity, once overcome, causes the head to exit with more or less intense noise, arising either from overcoming the cartilaginous rim or from the rush of air entering the acetabulum. Therefore, considering that the force and compression of the cartilaginous lip are the main obstacles to the head exiting the joint, it is evident that nature assigns a different significance to the internal ligament than previously attributed to it; to better understand its role, it is necessary to describe what was found as a result of careful dissection.
Quote p. 69-71
ART. II. De ligamenti teretis structura. Porro examen ligamenti teretis institutum est in infantibus diversæ ætatis, tum etiam in adultorum corporibus; ex quo liquet, vinculum, quod vocatur teres, ex tribus portionibus seu funiculis ligamentosis constare. Eorum alter anterior est; alter videtur esse superior, idemque posterior; postremus vero inferiori loco situs est. Prior a transverso acetabuli ligamento exsurgit, quod interruptum ejusdem marginem jungit, et transversa directione versus caput femoris procedit; alter ab eodem transverso ligamento, sed magis retrorsum exoritur, tum ab ea ossis ischii parte, quæ in acetabulum confluit. Postremo funiculo radix expansa, et veluti duplicata contigit, quæ acetabuli foveæ a cartilagine liberæ inhæret. In juvenili ætate tres, quos indicavi, fasciculi satis inter se distincti sunt, atque ex ligamentosis fibris coagmentati, paullo diversa directione in capitis foveolam immittuntur. Dixi paullo diversa: etsi enim funiculus ex tribus portionibus conflatus manifeste triquetrus sit; anguli tamen non in rectum porriguntur, sed leviter intorquentur, maximeque superior, quæ contorsio in adultis manifestior est, quam in infantibus. Communi tenuique obteguntur membrana prædicti fasciculi, per quam vulneratam si demittatur exile specillum, cavitatis cujusdam vestigium in funiculo deprehenditur. Specillo tres patent via altera sursum versus femoris caput, et ad ejus foveolanı, quo absque conatu specillum pergit: altera deorsum versus cotyle ducit, quæ amplior, et a fasciculo superiori tecta in acetabuli foveam desinit. Quum autem radices fasciculi superioris, ut dictum est, latæ sint, et sub eo lateat glandula mucipara cum adipe, sive quod dicitur apparatus synovialis; ita contra eas partes difficilius urgetur specillum. Demum si specillum versus primum fasciculum, anteriorem dirigatur; canalem satis amplum offendit, et sine mora sub ligamento transverso, quod scissuram acetabuli conjungit, super externum obturatorem musculum excurrit prope minora illa vasa, quæ, uti exponetur, ab ipso interiori ligamento excipiuntur. Ita in pueris ligamentum hocce examinando evenit interdum, ut immissum a parte capitis tenue specillum totam vinculi longitudinem percurreret, et per acetabuli scissuram juxta memorata sanguinea vasa prodiret. Hæc vasa præcipue arteriosa in superiori parte foraminis ovalis ab obturatoriis educta, et ligamento transverso protecta per incisuram acetabuli in caveam vinculi teretis penetrant inter ligamentosas ejusdem portiones. Truncus deinde arteriosus versus caveæ medium in duos abit ramos, quorum alter per ipsam funiculi cavitatem usque ad capitis femoris foveolam fertur: alter oppositam viam tenens, in scabra acetabuli fovea disperditur (1). In fovea illa aspera, quæ cartilagine caret, et quæ ab altera ex radicibus vinculi teretis occupatur, non infrequenter observantur foraminula quædam, in juniorum præcipue acetabulis, per quæ vasa ad diploen perveniunt.  (1) Conf. Ruysch, Adv. anat. 2, tab. III, B. B.  Ligamentum, cujus partes mox descripsimus, figuræ est prismatice in fœtubus 7 vel 8 mensium; angulique ab ipsis fasciculis ligamentosis constituuntur, communi, ut dictum est, membrana colligatis, a perichondrio nempe continuata, quod acetabulum femorisque caput convestit. Cum portiones sæpius dicta ligamentosæ triplicem habeant originem; mediam, sed exiguam relinquunt cavitatem, quæ tenuem aciculam admittat. Hæc cavitas amplior est, qua acetabuli foveæ et ligamento transverso obvertitur; angustior vero, quo femoris capiti propior est; ut proinde figuræ sit fere conica, basi ad acetabulum, apice vero ad femoris caput spectante. Cavea, quam modo indicavi, manifestior erit, si nudato musculo obturatorio externo, ablataque cellulari, quæ circa foramen ovale est, specillum tenue demittatur per ligamentum, et juxta illa vasa, quæ superius fuerunt notata impellatur usque ad capitis femoris foveolam. Itaque teres ligamentum, qua parte foramen ovale spectat, veluti pervium et hians est ad speciem infundibuli, præsertim in toto illo tractu, quo se extendit acetabuli incisura; proptereaque non difficilis est vasculorum illorum scrutatio, quæ per ligamenti interioris caveam ascendunt. Ligamentum interius trianguli formam habere in fœtubus, angulosque ab ligamentosis portionibus esse constitutos jam monuimus. Porro varie tatem quamdam animadverti in figura angulorum, quæ alia est in fœtibus, alia in adultis. In illis anguli lineam rectam conservant; in his paullum se intorquent, et spiralem lineam affectant. Hoc phænomenon contemplanti videbatur mihi a vero non esse alienum, quod ob varios femoris motus quibus pueri adultique subjacent, angulorum directio ab recta in aliam mutaretur. Et sane fieri aliter nequit, dum femoris caput in gyrum movetur, quam ut ligamentum teres ejus motus, et rotationes sequatur, vel anterius in flexione, vel retrorsum in extensione, vel intus forisve in motibus femoris lateralibus. Itaque dum femoris caput intra cavitatem circumducitur, et veluti supra axim movetur, necesse est ut quædam fiat in ligamento tereti contorsio, per quam ejus figura infantili ætati propria mutatur. Hujusmodi contorsio præter figuram exteriorem mutat etiam interiorem ligamenti habitum, caveam in adultiori ætate obliterando; motuum enim et variarum pressionum ope, quas femoris caput exercet, fasciculi ligamentosi comprimuntur, et magis inter se junguntur, ita ut ex uno funiculo conflati videantur. Exposita sic ligamenti interioris structura una cum observationibus pathologicis ad id attinentibus, statuendum esse apparet, munus ligamenti aliud non esse, quam illud, vasa nempe sanguinea intra funiculi caveam dirigere eaque protegere, ut juncturæ nutritioni inserviant, tum etiam abnormes capitis motus aliquo modo coërcere.	Art. II. On the Structure of the Round Ligament. Next is presented the examination of the round ligament in infants of different ages, as well as in adult bodies; from this, it becomes clear that the bond, called round, consists of three parts or bundles of ligamentous fibers. One of them is located anteriorly; the other, it seems, is situated superiorly and also posteriorly; and the last one is found inferiorly. The first arises from the transverse ligament of the acetabulum, which connects its interrupted edge, and extends transversely towards the femoral head; the other begins from the same transverse ligament, but closer to its posterior aspect, as well as from the part of the pelvic bone that forms the acetabulum. Finally, the root of the bundle widens and, as if doubling, penetrates the cartilage-free acetabular fossa. In adolescence, the three mentioned bundles are quite clearly distinguishable and consist of ligamentous fibers connected together, and are inserted in a slightly different direction into the fossa of the head. I spoke of a slight deviation: although the ligament, consisting of three parts, is clearly triangular, the angles are not directed straight but are slightly twisted, especially the upper one, which is more noticeable in adults than in children. These bundles are covered by a common thin membrane, through which, if damaged, examination can be conducted with a thin probe, revealing a trace of the certain cavity within the bundle. The probing can proceed in three directions: one directed upward towards the femoral head and its fossa, where the probe easily penetrates without effort; another downward towards the acetabulum, which is wider and terminates in the acetabular fossa covered by the upper bundle. However, when the roots of the upper bundle, as mentioned, are wide, and beneath them lies a mucous gland with fat, or the so-called synovial apparatus, the probe penetrates with difficulty. Finally, if the probe is directed towards the first bundle, the anterior bundle, it encounters a sufficiently wide canal and immediately passes beneath the transverse ligament connecting the edges of the acetabular gap, passing through the external obturator muscle near those smaller vessels which, as will be explained, are embraced by the innermost ligament. Thus, during the examination of this ligament in children, it sometimes happens that the thin probe introduced from the side of the head passes the entire length of the ligament and exits through the slit of the acetabular fossa near the mentioned blood vessels. These vessels, mainly arterial, emerge from the upper part of the oval opening, protected by the obturator muscles and the transverse ligament. Through the notch of the acetabular fossa, they penetrate into the cavity of the rounded bond, between its ligamentous parts.  Then, the arterial trunk proceeds towards the center of the cavity, dividing into two branches. One branch passes through the cavity of the bundle itself to the pit of the femoral head, while the other, in the opposite direction, dissipates in the rough depression of the acetabular fossa. In this rough depression, devoid of cartilage and occupied by one of the roots of the rounded bond, some openings are often observed, especially in the acetabular fossae of children, through which vessels penetrate into the spongy substance (diploë).  (1) See Ruysch, Adv. anat. 2, tab. III, B. B.  The ligament, the parts of which we have just described, has a prismatic shape in fetuses of 7 or 8 months; the angles are formed by the ligamentous fiber bundles themselves, bound by a common membrane, as already mentioned, continued over the synovial membrane covering the acetabulum and femoral head. Since the parts of this ligament most often have a triple origin, they leave a small cavity in the middle that can admit a fine needle. This cavity is wider where it extends to the acetabular fossa and is covered by the transverse ligament; and narrower where it is closer to the femoral head; thus, it approximates a conical shape, with the base facing the acetabulum and the apex facing the femoral head. The cavity I mentioned will be more noticeable if the external obturator muscle is removed and the tissue surrounding the oval opening is cleared, allowing a fine needle to be inserted through the ligament and passed along the vessels previously noted to reach the pit of the femoral head. Thus, the round ligament, which overlooks part of the oval opening, as if being permeable and open to the form of a funnel, especially in the section where it extends through the notch of the acetabulum, therefore, the study of these vessels passing through the cavity of the internal ligament is not difficult. The internal ligament has a triangular shape in fetuses, and we have already noted that the angles are formed by ligamentous bundles. Furthermore, I observed some variation in the shape of the angles, which differs between fetuses and adults. In adults, the angles maintain a straight line; in fetuses, they twist slightly, forming a spiral line. It seems to me that this phenomenon is not alien to truth, as due to various movements of the hip performed by both children and adults, the direction of the angles changes from straight to another. And this is indeed inevitable, as the femoral head rotates, and the round ligament follows its movements and rotations, either forward during flexion, backward during extension, or inward or outward during lateral movements of the hip. Therefore, when the femoral head rotates within the socket, as if around an axis, some twisting of the rounded ligament inevitably occurs, causing its shape, characteristic of childhood, to change. This curvature not only alters the appearance of the ligament but also its internal cavity, disappearing in adulthood, as under the influence of movements and various pressures experienced by the femoral head, the ligamentous bundles compress and connect more tightly, so that they seem to merge into one cord. Therefore, after presenting the structure of the internal ligament along with pathological observations, it appears that the function of the ligaments is nothing other than in directing the blood vessels inside the cavity of the strand and protecting them, so that they serve to nourish the joint, and to some extent restrain abnormal movements of the head.
Quote p. 86
Dum hanc profero observationem ad asserendam subluxationem, præterire non debeo argumenta, quæ contra hanc ipsam opponi possunt; ut, si fieri possit, inde demonstretur, affectionem modo indicatam diversæ omnino a luxatis esse naturæ. Et profecto, cum in nosocomium delatus esset puer, de quo supra sermo fuit, adulto jam morbo, neque ex eo neque ex ejus parentibus sciscitando resciri potuit, quænam causæ præcessissent quibusve auxiliis occursum esset: si animum unice advertamus ad observationis expositionem, videretur esse statuendum, caput a cervice fuisse avulsum: cumque illud non inventum fuerit in sinu suo, ejusque vices faceret summa cervix; suspicari liceret, caput, utpote in ea ætate tenerum fuisse dissolutum et absorptum ; quam jacturam natura sic sublevasset, ut cervix superficiem latiorem haberet, eaque sinum parum cavum sibi pararet. Et vidi profecto nonnunquam femoris collum, ubi id fractum erat, cavitatem sibi parasse, quæ plus minusve a cotyli distabat, et in qua motus aliquos exercere poterat. Verum nunquam in simili casu femoris caput detritum; sed semper intra ipsum acetabulum hærere observavi. Hinc in eam potius descendo opinionem, ut credam vitium quod modo descripsimus, fuisse subluxationem: videlicet excussum ex acetabulo caput super oram ejus internam fuisse propulsum, ibique hæsisse. Quoniam autem caput spongiosum, et pro ea ætate mollius erat; et quoniam id per quod enutritur, maximam partem ab interiori ligamento suppeditatur; necesse fuit ut illa duo acciderent: alterum ut a capitis impulsione labrum cartilagineum extrorsum verteretur, atque longius a sua sede proveheretur, cujus area novum sic acetabulum constituit; alterum, ut jugis pressio femoris motusque ejusdem cum reticulata substantiæ mollitie capitis formam immutarent, et penitus everterent, præsertim ob nutritionis defectum, quia teretis ligamenti neque vestigium supererat.	When I bring forward this observation to confirm the dislocation, I must not overlook the arguments that could be raised against it; to, if possible, demonstrate that this condition, which has just been described, is entirely different from dislocation. And indeed, when the boy mentioned above was brought to the hospital with the disease already developed, neither he nor his parents could determine what causes preceded it and what assistance was provided; if we focus solely on the description of the observation, it would seem that we should consider that the head was detached from the neck: since it was not found in its socket, and only the upper part of the neck was present in its place; one could assume that the head, at such a young age, weakened and dissolved; nature alleviated this loss in such a way that the neck became wider, forming a small cavity for itself. And I have seen repeatedly how the neck of the femur, when broken, formed a cavity for itself, which was closer or farther from the acetabulum, and in which it could perform some movements. However, I have never observed the head of the femur worn out in such a case; it always remained within the acetabulum itself. Therefore, inclining to this opinion, I believe that the defect just described was a subluxation: namely, that the head expelled from the acetabulum was pushed upwards through its inner edge and stuck there. Since the head was porous and soft for this age; and since its nourishment, for the most part, is provided by the internal ligament; it is inevitable that two things will happen: first, that under the impact on the head, the cartilaginous lip will turn outward and be pushed further from its place, forming a new area of the acetabulum; second, that the constant pressure and movement of the hip, together with the elasticity of the head, completely changed it, especially due to the lack of nourishment, as there was no trace left of the rounded ligament.

 An interesting observation by the author: the acetabulum of a triangular form.

External links 

Palletta GB. Exercitationes pathologicae. Mediolani: Societas Typ. e Classicis Scriptoribus Italicis, MDCCCXX [1820]. [books.google] 

Authors & Affiliations 

Giovanni Battista Palletta (1748-1832), was a professor of anatomy and primary surgeon in Milan. [wikipedia.org]  

Giovanni Battista Palletta with anatomy textbook.
Engraving portrait; unknown author;
original in the wikimedia.org collection
(CC0 – Public Domain, no change, image adjustment)

Keywords

ligamentum capitis femoris, ligamentum teres, ligament of head of femur, anatomy, topography, structure, synonyms, absence, observation, conductor of blood vessels

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