and seems with the latter to cover the acetabulum. The manipulation in this case was conducted in the presence of a considerable number of medical gentlemen; and the manner in which the head was detached from the shaft left no doubt upon their minds that the neck, as the result either of an original fracture or of subsequent inflammatory action, had not its normal strength. On the other hand, the present condition of the patient is much better than it would have been had not the dislocation been treated. He walks freely and firmly, with but little lameness, runs up and down stairs, and can swing the limb in all directions.

DISLOCATION FROM HIP DISEASE.

In the dorsal luxation which follows aggravated hip disease, the anterior part of the capsular ligament usually supports and inverts the shortened limb. On the other hand, the head of the femur, which rests upon the dorsum of the ilium, produces, when disintegrated by disease, less inversion than if it were of normal size. Again, the displacement is generally a sub-luxation; but it may sometimes be complete. In a case of hip disease, occurring in a boy about ten years of age, which terminated fatally, I excised the head of a femur (the first instance of this operation in the United States) that was completely dislocated upon the dorsum.

The following is an instructive case of dislocation, perhaps connected with hip disease, and reduced by manipulation.

The patient was a feeble and slender boy thirteen years of age, who was said to have dislocated his hip upon the dorsum by a fall upon a barn floor about three months before, and whom I was requested to see in consultation. The head of the bone could be plainly felt upon the dorsum, the limb being as usual inverted, shortened, and a little flexed. I found that in abducting the limb after it was flexed, a very considerable force was required to raise the head over the socket, and still

more in outward rotation to make it enter, which it did only after the capsule and other attachments had been freely lacerated. After reduction, the head of the bone readily and repeatedly escaped, and could be kept in place only by the expedient, elsewhere alluded to, of confining the limb. The foot was secured to the inside of the sound knee, and the limb, thus flexed, was abducted down to the level of the bed, where it was bound to the side of the bedstead by a folded sheet under the knee. In this constrained position of flexion, abduction, and eversion, the patient remained for two and a half weeks, when I again saw him, and found the bone in place. But soon the hip-joint became stiff and painful, and sinuses slowly formed and opened in the groin, as if from hip disease. Upon inquiry, it was ascertained that the child had suffered from pain near the hip after a fall the preceding year, and had also lately recovered from protracted and grave disease of the bone near the ankle. The dislocation may or may not have been facilitated by this tendency to disease of the bone; but there can be little doubt that serious inflammatory action was awakened by the presence of the reduced femur in the socket.

DISLOCATION OF THE HIP, WITH FRACTURE OF THE SHAFT

OF THE FEMUR.

Cases have been reported of fracture, even of the upper third of the shaft, in which an accompanying dislocation was reduced by manipulation. There seems to be no good reason why, after the firm application of lateral splints to the thigh, the attempt should not be made with entire success,1-reliance being especially placed upon flexion and the local management of the head of the bone, which may be guided into its socket by the hands of the operator applied directly to it, or by a towel in the groin. Angular extension of the lower

1 See Hamilton's "Practical Treatise,” etc., p. 666.

fragment of the femur may draw upon its upper muscular insertions, and likewise make room for the upper fragment to follow it; but it is obvious that nothing can be effected by its rotation.

SPONTANEOUS DISLOCATION.

Cases have been cited of individuals who could partially luxate and reduce the head of the thigh-bone at will, by the action of the muscles of the hip. Hamilton has collected three such cases. I have had an opportunity of examining two, and Dr. Lyman, of Boston, has communicated to me the details of a third, all of which were dorsal luxations.

In the first of these cases, that of a soldier under the charge of Dr. Langmaid, to whom I am indebted for the opportunity of examining it, the hip was dislocated while the legs were crossed, a wagon in which the man was riding having pitched into a hole. In a few hours the hip was reduced by flexion. Eight days after the accident, in attempting to walk upon the limb, it was again partially luxated, — when the patient himself replaced it by pushing against it with one hand and pressing with the other against his knee. Since that time both luxation and reduction have been comparatively easy, and the patient now displaces the head of the bone backward upon the edge of the socket by muscular action, and reduces it by "throwing the leg out sideways." The luxation is sometimes attended with pain, and the prominence caused by the head of the luxated bone is sensitive to the touch. In this and the following case, the displacement is rather a sub-luxation; and the limb exhibits slight flexion, shortening, and inversion.

In the second case, that of a gentleman formerly of Boston, the phenomena are much like those just described; the bone being slipped out and in upon the dorsal edge of the socket by muscular action at will.

1 Practical Treatise, etc., p. 644.

A third case was under the care of Dr. E. M. Moore, of St. Mary's Hospital, Rochester, N. Y., who has published photographs of it, from which the annexed figures are taken. The following account of this case has been kindly furnished me by Dr. G. H. Lyman, of Boston, who obtained it from Dr. Moore:

"John B. Parker, private, Co. H, 148th New York Volunteers, while on the march from Bermuda Hundred to Drury's Bluff, May 13, 1864, was skirmishing up a hill, and sprang back suddenly to avoid the gun of a comrade in advance. His left foot became entangled, and his weight dislocated his hip. He felt the injury, and supposed it out of joint. Some comrades pulled it in. He immediately resumed his skirmishing, and marched seven miles, from 10 A. M. till 6 P. M. He lay down at night, and went on duty the next day, sharp-shooting, crawling all day. He con

1 Spontaneous luxation of the thigh. Dr. Moore's case.

tinued this kind of duty five days, and returned to camp, when he was immediately put on intrenchments, and worked two days and nights. Afterward he went on picket, and entered the hospital May 28. At present he can luxate the hip-joint at any time, and does it by pressing the foot on the floor to fix it firmly, contracting the adductors, and throwing out the pelvis. The head suddenly leaves the acetabulum, and goes on the dorsum ilii."

Although the lateral displacement and slight inversion show that this is only a sub-luxation, with the head upon the edge of the socket, yet the flexion of the limb, due to the elasticity and comparative integrity of the living tissues, makes it perhaps a better representation of a common dorsal luxation than Fig. 4, which was photographed from the dead subject, and where the limb was purposely extended as far as the Y ligament would allow.

FRACTURE OF THE PELVIS.

THE following remarks on fracture of the pelvis are introduced here, chiefly with the view of showing how far this injury may be mistaken for regular dislocation of the hip. With this view the subject has been divided into four heads, comprising, respectively: (1) Fracture of the rim of the acetabulum; (2) Fracture in which the head of the bone is driven through the acetabulum into the pelvis ; (3) Suspected fracture of the acetabulum; (4) Fracture of other parts of the pelvis. A few cases are given in illustration of each of these lesions. The more instructive of these are, of course, such as have been verified by autopsy. But there are some which are authenticated only by well-marked crepitus, and perhaps by mobility of the detached fragment; and it is then important that crepitus should not be confounded with the grating which results from the attrition of unbroken bone or cartilage.