DISLOCATION OF THE HIP.

THE original object of the following paper was to show that in dislocations of the hip the position of the limb depends chiefly upon a ligament which has been of late years imperfectly described, and that the reduction of these dislocations should be managed accordingly. In connection with this subject, I also attempted to show how the anatomical structure of the neck of the femur leads to a common variety of fracture of that bone.

These views have been, as I believe, so well established by repeated experiments upon the dead subject, and so corroborated by current pathological phenomena, and by the mass of reported cases and autopsies, that little doubt can exist of their correctness.

Since about the year 1854-55, the four dislocations of the hip, as usually described, together with the method of reducing them by manipulation alone, have been annually shown to the classes attending the lectures at the Medical School of Harvard University. These four luxations were made in each case upon a single dead subject, which, notwithstanding the great laceration to which the capsule of the hip had been subjected, in no instance failed to exhibit, and to demonstrate in a striking manner, the appropriate and well-known attitude of each dislocation. In fact, the firm and persistent position of a joint displaced under such circumstances is quite remarkable. In these experiments, the fixed attitude of the

limb was at first attributed to the muscles, which when fully extended are capable of considerable resistance in the dead subject as well as in the living one; but it was supposed that the action of their complicated mechanism would hardly repay the labor of its study.

In the spring of 1861, having been led to expose a joint, the luxation of which had been the subject of a lecture, I was agreeably surprised to observe the simple action of the ligament, a simplicity which subsequent experience has confirmed, and which strikingly explains the phenomena observed in the living subject.1

The dislocated joint alluded to presented on examination the following appearances:

1. Great laceration of the muscles about the joint.

2. The ligamentum teres broken.

3. Laceration of the inner, outer, and lower parts of the capsule.

4. The anterior and upper parts of the capsule uninjured, and presenting a strong fibrous band, fan-shaped, and slightly forked.

The remaining tendinous and muscular fibres about the joint being now completely divided, with the exception of the strong fibrous band above alluded to, it was found that the four commonly described dislocations of the hip could still be exhibited without difficulty, and that in each of them the anterior portion of the capsular ligament, which alone

1 Of the figures accompanying this paper, those of the Y ligament numbered 1, 6, 7, 8, 19, 24, 25, 27, 29, 31, and of the impacted fracture, 1, 2, 3, were reproduced, in the spring of 1861, from photographs made from this hip after dissection. In June, 1861, a paper upon the subject was read before the Boston Society for Medical Improvement; a second paper before the Massachusetts Medical Society, in May, 1864; another, in June, 1865, before the American Medical Association. In the present paper the rarer forms of dislocation have been added, with references to the more interesting reported cases.

remained, sufficed at once to direct the limb to its appropriate position and to fix it there.

Assuming that each of these dislocations does occur, and that, however much it may vary in degree, it uniformly exhibits its proper and familiar diagnostic signs; that the anterior portion of the ligament of the capsule far exceeds in strength any other part of it, and that on this account it not only is less likely to be torn, but generally remains intact; that when this alone remains, it is itself able to give position to the displaced limb; and that when it is divided, the other parts of the capsule, the muscles, and other tissues do this very imperfectly, as will be hereafter shown, then the a priori evidence is strong that a luxated femur assumes its attitude chiefly in obedience to the traction of the tense fibres of this part of the ligament.

The resistance of a dislocated limb is unyielding, and unlike that of muscular action elsewhere, in illustration of which a few cases may be cited, taken almost at random from Sir Astley Cooper.1

"CASE XXXVIII.— . He was bled thirty ounces in the recumbent posture, and small doses of tartarized antimony were administered, but without these means producing syncope. He was then placed upon a large table, and his pelvis fixed in the usual manner, by long jack-towels passed between the perinæum and the injured joint; the extending apparatus, composed also of a round towel, was then applied above the knee, and to it were attached weights to the amount of one hundred and twelve pounds, fastened to a rope, which was rove through a pulley. To the influence of this weight he was submitted for four hours, but without any effect being produced. He was therefore then sent to Guy's Hospital. At half-past seven P. M. he was taken into the operating theatre. The pelvis was fixed by the common padded bandage, while to the knee was attached the circular bandage and pul

1 A Treatise on Dislocations and Fractures of the Joints. London, 1842.

leys, and gradual extension was made across the lower third of the opposite thigh for the space of twenty minutes, during which period he was given three grains of tartarized antimony in solution."

"CASE L. John Cockburn, a strong, muscular man, aged thirty-three, was admitted into Guy's Hospital on the 31st of July, 1819. While carrying a bag of sand at Hastings on the 24th of July, he slipped, and dislocated the left hip-joint. The foot on the affected side was plunged suddenly into a hollow in the road, which turned his knee inward at the same time that his body fell with violence forward. On the day of the accident two attempts were made to reduce the dislocation by pulleys, but without success; and on the 27th of July a third, but equally unsuccessful, trial was made, although continued for nearly an hour.

"It was found, upon examination, that the thigh was dislocated backward into the ischiatic notch. The patient was carried into the operating theatre soon after his admission; and when two pounds of blood had been taken from him, and he had been nauseated by two grains of tartarized antimony, gradually administered, extension was made with the pulleys in a right line with the body, and the upper part of the thigh was raised, while the knee was depressed. The extension was continued at least for an hour and a half, during which time he took two grains more of tartarized antimony, by which he was thoroughly nauseated. The attempts at reduction, however, did not succeed." 1

To a surgeon accustomed to the comparative ease with which the powerful muscles of a recently fractured thigh may be extended by a moderate effort continuously applied, these cases of enormous resistance in the reduction of a dislocated hip suggest a force more powerful and unyielding

1 It is curious to remark that this case ultimately yielded, in the hands of Sir Astley, to the employment, unusual for him, of the flexion method, though combined with pulleys. In further illustration of the disadvan tage of horizontal extension, let this case be compared with a similar one (dorsal below the tendon) where the reduction occupied three seconds (p. 69).

than that of muscular action. Indeed, the facility with which muscular contraction is overcome by ether, while the deformity and resistance of dislocation continue, should long ago have led to the conviction that muscular contraction is not a chief agent in this deformity.

But modern writers, with few exceptions, have adopted the theory of active or passive muscular resistance. Sir Astley Cooper says:

"With respect to the fixed position of the head of the femur in the four dislocations which have been described, it is not to be considered as a mere matter of chance, but the natural result of the influence of the muscles, which draw the bone into these positions; and that therefore, under common circumstances, the condition is inevitable.1 . . . The capsular ligaments, in truth, possess but little strength either to prevent dislocation or to resist the means of reduction. . . . The difficulty of reducing dislocations arises neither from the bones nor from the ligaments, but from the resistance which the muscles present by their contraction." 2

Dr. Nathan R. Smith recognizes muscular contraction as the chief agent in effecting both dislocation of the hip and its reduction.3

That similar views are still entertained by distinguished surgical authorities is shown by the following reported remarks of M. Chassaignac at a meeting of the Société de Chirurgie in 1865: "The employment of chloroform in the reduction of dislocations had convinced him [M. Chassaignac] that obstacles to reduction said to be due to other causes than muscular contraction were chimerical," 4 an observation that seems to have passed unchallenged.

1 A Treatise on Dislocations and Fractures of the Joints (p. 100). London, 1842.

2 Ibid., pp. 20, 21.

Medical and Surgical Memoirs (pp. 166, 167). By Nathan Smith, M. D. Edited by Nathan R. Smith, M. D. Baltimore, 1831.

♦ London Medical Times and Gazette, December, 1865 (p. 661).