thigh is flexed upon the trunk, carried toward the navel, and rotated inward.

But it has happened that after unsuccessful efforts a hip has been reduced when semi-flexed in the act of extension; which shows that in certain cases the ligament may be needlessly relaxed by extreme flexion, and may be advantageously drawn tighter by a little extension or outward rotation.1

I may here refer, in connection with the subsequent treatment of the patient, to the practical importance of preventing such a relaxation of the anterior ligament, whether by flexing the thigh or raising the body to a sitting posture, as may permit a recurrence of luxation. For this purpose, where the bone inclines to slip from the socket after reduction, certain cases may require not only that the limb should be kept straight, but also that the thigh should be confined for a time in the position which completed the reduction; namely, for the dorsal luxations, in abduction and eversion, or in vertical extension; for the pubic and thyroid, in a position of inward rotation and adduction, thus taking advantage of the tense ligament to bind the bone to the socket.2

1 Markoe, in an interesting paper upon this subject, states that he found it necessary to vary a little from the method by flexion, abduction, and rotation outwards, recommended by Reid in dorsal dislocation. He says: "It failed us so completely from the first that we were led to add the bringing down of the thigh to the straight position in a state of abduction, still keeping up the rocking motion; and it has been uniformly in the act of thus bringing down the limb that the reduction has been accomplished." (See "An Account of the Cases of Dislocation of the Femur at the Hip-Joint, treated by Manipulation alone, after the Plan proposed by W. W. Reid, M. D., of Rochester, which have occurred in the New York Hospital during the past Two Years. By Thomas M. Markoe, M. D., one of the Attending Surgeons." New York Journal of Medicine, etc., vol. xiv., January, 1855, p. 23.) See also note, p. 46 of this volume.

2 See case, p. 53 of this volume.

HOW THE LIMB IS TO BE HELD.

The thigh should be bent upon the body, and the leg at a right angle with the thigh. With one hand the surgeon grasps the ankle from above, while with the other, placed beneath the head of the tibia, he lifts and guides the limb. In this way, by using the flexed leg as a lever, keeping it always flexed at a right angle for that purpose, great power is brought to bear upon the head of the femur, especially in rotating the thigh. It is therefore important to keep accurate account, during such manipulation, of the position of the head of this bone, which should not be moved at random, or indiscriminately urged when locked, lest it be broken from the shaft; and it may be convenient to remember that in every position the head of the femur faces nearly in the direction of the inner aspect of its internal condyle.

CAPSULAR ORIFICE TO BE ENLARGED.

Much stress has been laid by certain writers upon the difficulty of replacing the head of the bone, when it has escaped by a small aperture in the capsule. That this condition may occasionally occur seems probable; and it is suggested by Gellé,1 in his elaborate paper upon the subject, that when the slit occurs close to the femoral insertion of the capsular ligament, it may be impossible to replace the head of the bone. This writer, with Malgaigne, Gunn, and others, urges the importance of placing the bone in the position it occupied when luxated, with a view to its re-entering the socket by exactly retracing its path. But while this path cannot always be known, any difficulty is easily obviated by carrying the head of the bone toward the opposite side of the socket, and thus enlarging the

1 Étude du Rôle de la Déchirure Capsulaire, etc. Par M. Gellé. Paris, 1861.

slit, a simple manoeuvre, easily accomplished by circumducting the flexed thigh across the abdomen in a direction opposite to that in which it is desired to lead the head of the bone, which should be made in this way to pass across below the socket, and never, it is needless to say, above it, across the Y ligament. This expedient, of which I have had occasion to avail myself, will, as I believe, be in future generally adopted when any such difficulty is encountered in reducing the hip. The subcutaneous injury is trifling in comparison with that resulting from a protracted and ill-planned manipulation, or from the brute force of pulleys. It depends for its success upon the strength of the Y ligament, which, in firmly attaching the base of the neck of the femur to the inferior spinous process of the ilium, forms a fulcrum or pivot round which the shaft and the neck of the femur can be made to revolve, like opposite spokes in a wheel, the Y ligament being strong enough to rupture, in this way, the whole of the rest of the capsule and the obturator muscle without itself yielding.1

When a slit has thus been made by circumducting the neck of the bone across the posterior aspect of the capsule, the head of the bone has traversed an interval reaching in some cases from the dorsum to the thyroid foramen, and slips readily from side to side. This laceration already exists in most cases of dorsal dislocation below the tendon, where the head of the bone has reached a secondary position after a previous luxation downward, and is also known to surgeons who have reduced dislocations by the old and awkward method of extension, where the bone sometimes slipped many times. backward and forward from the dorsum to the foramen ovale; and yet I can find recorded only one instance of this familiar

1 Reid, in the paper already quoted (New York Journal of Medicine, July, 1885, p. 69), proposes, in a similar case, "to make an incision down to the head of the bone, and open the capsular ligament sufficient to admit the return of the head into its place."

occurrence as being followed by any permanent injury, and even in that case there may have been a predisposition to the hip disease which ensued. It will hereafter be seen that when the head of the bone has thus been made to slip from side to side, rotation becomes a less efficient manœuvre for reduction, the bone tending at the critical moment to slip laterally away from the socket instead of into it, especially where the rim of the acetabulum is prominent, or the Y ligament is relaxed. It is here that vertical traction, sudden or continued, is especially to be relied on. This will be further explained.

FRACTURE OF THE NECK.

Except in a very old subject, no apprehension need be felt of fracture from tolerably skilful manipulation, or from circumduction with a view to tearing the capsule. The femur has, indeed, in rare instances been fractured by manipulation as well as by pulleys; and if the head of the bone be forced into a position where it is confined by the Y ligament, and from which it cannot escape, it will be acted upon with great power by the shaft serving as the long arm of a lever, if force be still indiscreetly applied.

FLEXION, EXTENSION, ADDUCTION, ABDUCTION, AND ROTATION.

Of these terms the last two alone require notice. If a thigh abducted at a right angle be rotated outward, with the knee bent, this position of the limb has been sometimes

1 Verneuil relates a case of fracture resulting from an attempt to reduce a dislocation on the pubes in a man eighty-one years of age, but only after the bone had resisted many attempts at reduction. (Medical Times and Gazette, December, 1865, p. 661.) Similar cases have been reported of fracture from the use both of manipulation and of pulleys. (See Cooper's "Treatise on Dislocations and Fractures of the Joints," Case XXXVII.)

erroneously described as one of flexion.

only as the knee is brought forward.

It becomes so

Rotation is here always intended to apply to the thigh, the inward or outward rotation of which, in a limb bent for reduction, carries the foot in an opposite direction, and may thus lead to doubt.1

CIRCUMDUCTION.

When the patient lies on the floor, circumduction carries the knee of the dislocated limb through arcs of a horizontal circle of which the Y ligament is the centre. In attempting reduction, the direction of this motion is of primary importance, as well as the point at which it begins. The following varieties of circumduction should be distinguished from one another:

Circumduction of the extended thigh, outward (continued by)

The patella here always faces to the front. If it inclines outward or inward, rotation has been added to circumduction.

REGULAR DISLOCATIONS.

DISLOCATION UPON THE DORSUM ILII.

THE dorsal dislocations having a mutual resemblance, resulting from the regular outline of the bone upon which they rest, may be more readily grouped than the others.

1 The thigh, abducted and a little flexed, was rotated inward; the leg and the foot, on the contrary, were in forced rotation outward. OLLIVIER: Archives de Médecine, 1823, tom. iii. p. 545.