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TREATISE
ON
DISLOCATIONS,
AND ON
FRACTURES
OF THE
JOINTS.
LONDON.
PRINTED BY F. WARR,
RED LION PASSAGE, HOLBORN.
o
TREATISE
ON
DISLOCATIONS,
AND ON
FRACTURES
OF THE
JOINTS.
BY SIR ASTLEY COOPER, BART., F.R.S.
SURGEON TO THE KING,
&;€., S;c., ^c.
FOURTH EDITION.
g LONDON '.C^
PUBLISHED FOH THE AUTHOR,
BY MESSRS. LONGMAN, HURST, REES, ORME, BROWN, AND GREEN, PATERNOSTER ROW ;
S. HIGHLEY, 174, FLEET STREET; T. & G. UNDERWOOD, 32, FLEET STREET;
AND COX & SON, ST. THOMAS'S STREET, SOUTHWARK.
MDCCCXXIV.
X
TO THE STUDENTS OF SAINT THOMAS'S AND GUY'S
HOSPITALS.
My Dear Young Friends,
This Work having been composed for your use, my principal object will be attained if you derive advantage from it. I cannot, however, omit to embrace the oppor- tunity of expressing my gratitude for the affectionate and respectful manner in which you have always received me as your instructor. Your parents and relatives, many of whom were my pupils, are also entitled to my most grate- ful acknowledgments ; they fostered me in early life ; and by their friendship and recommendation have largely con- tributed to procure to me a degree of success which, I fear, is beyond my merits, and a course of uninterrupted happiness which few have been permitted to enjoy.
Believe me, always.
Your affectionate Friend,
ASTLEY COOPER.
B
PREFACE
TO THE FOURTH EDITION.
It is incumbent on me to observe, that although I believe the matter of this Work to be correct, and regard it as the result of a considerable share of experience, yet, I am aware that the reader may detect a too familiar mode of expression, and may censure me for want of attention to its style. The familiarity of the language arises from my desire to be per- spicuous. I prefer a significant expression to a finely turned sentence, just as I would a good plain suit to the finest embroidered dress, and am ready to own, that I think much more of the matter which I give, than of the manner in which it is conveyed.
I am much indebted to my friends for their communications;
the life of man is too short to allow him, even with the greatest
industry, zeal, and opportunity, to witness all the varieties of
accident or disease ; and I should feel that I was not properly
discharging my duty, if I omitted to take advantage of all
the evidence which might be adduced by those on whom I
could depend.
b2
VIU PREFACE.
Whilst, then, I sincerely thank niy friends for their kindness, I wish to state to them and to others, that they will always oblige me, by giving me any information which it is in their power to convey upon this or any other subject in surgery.
In looking over the following pages on dislocations, I feel that my professional brethren will be disposed to think that I have limited to too short a period the attempts at reduction. It has been stated, that dislocations have been reduced at four and even six months after the injury had been received, which I am not disposed to deny; indeed, I have myself had an opportunity of witnessing examples of the fact; but, excepting in very emaciated, relaxed, and aged persons, I have observed that the injury done in the extension, has been greater than the advantage received from the reduction ; and, therefore, in the case of a very strong muscular person, I am not disposed, after three months, to recommend the attempt, finding that the use of the limb is not, when reduced, greater than that which it would have acquired by having remained in its dislocated state. Let this be fairly represented to the patient; and then, at his request only, the reduction should be attempted; but " with all appliances and means to boot," the extension must be very gradually made, and without violence, to avoid injury to the muscles and nerves.
I have stated, that in fractures of the upper part of the thigh-bone, the foot is generally everted; to which there is
PREFACE. IX
sometimes an exception; for I have seen a case of Mr. Lang- staffs, surgeon in the City, in which the foot was inverted, and the bones, although they rubbed against each other, had not united.
Mr. Guthrie considers it probable, that the inversion of the foot in fractures of the upper part of the thigh-bone, which now and then happens, arises from a diagonal fracture through the trochanter major. The gluteus medius and minimus, with the tensor vaginae femoris, draw the thigh-bone forwards, and roll it inwards. He shewed me a preparation which confirmed this opinion.
I have received from Mr. Brindley, surgeon of Wink Hill, an account of a dislocation of the os femoris, which the patient is able to produce and reduce when he chooses ; the man is fifty years of age. Mr. Morley, of Uttoxeter, has transmitted to me a case of compound fracture of the head of the os humeri ; the end of the bone was sawn off, the bone reduced, and the patient did well ; the length of the limb differed but little from that of the other. And Mr. White, of the West- minster Hospital, has shewn me a case of dislocation of the OS femoris from ulceration, in which the head of the femur was sawn off, and the person recovered.
I have been accused of publishing doctrines, respecting frac- tures of the neck of the thigh-bone, which differ from those of my jnedical brethren, and this I am ready and proud to acknowledge;
PREFACE.
on the other hand, I have heard that I am abused for not having acknowledged that others had previously given similar opinions. To this animadversion I have only to reply, that I began to deliver lectures in the year 1792, and that I never failed in them to give publicity to the opinions which I have here advanced. I have procured early copies of my lectures, taken by some of my students, and I could obtain a great number of others, which shew that my opinions of non-union were those which this book contains. By a comparison of the dates of my lectures, with that of the publication alluded to,* it will be readily seen who had the priority in forming those opinions.
UNION OF THE FRACTURED CERVIX.
The earliest notes of my lectures, and I began to give lectures in 1792, ran thus:
Fractures of the Thigh-Bone at its Cervix.
"These fractures seldom, if ever, become afterwards united,
for which two reasons may be given ; first, that the uniting
matter is thrown into, and lost in the joint ; and, secondly , that
the fractured portions of the bone are not in apposition, the
* Principles of Surgery, by John Bell, published in 1801.
PREFACE. XI
thigh-bone being drawn from its head (which still remains in its socket) by the action of the glutei muscles."
Extract from Sir Astlev Cooper's Surgical Lectures, delivered in the year 1793, tahen from the notes of Mr. Fiske.
" When a bone which forms part of a joint is fractured
transversely, union seldom takes place between the fractured
ends, as in the patella and olecranon; where the same effusion
of blood takes place, but is lost in the cavity of the joint, from
which it receives vessels and becomes of a ligamentous substance.
When the cervix of the os femoris is fractured, it becomes united
to the capsular ligament by bands ; the reason for this kind of
union taking place is exactly the same as in a trepanned skull;
for the action of the muscles inserted into the upper part of
the bone draws it upwards, and those into the lower part draw
it downwards, and the space becomes too great for the vessels
of the bone to shoot into the coagulated blood and form it
into bone. This, I think, will hold good, though it is different
from the opinion of many men."
Charles Fiske.
Saffron Walden; Nov.Uth,'[^2L
Xll PREFACE.
From Mr. LvKVjr, of Fever sham. Dear Sir,
I am sorry to say that my notes on your surgical lectures, delivered in 1793, are very short: in the one on simple fractures you said, " There are some fractures that happen in joints that never unite, as in the neck of the thigh-hone ; the blood is extra- vasated into the joint, and only ligamentous matter deposited, the vessels shooting into the coagulum coming from the ligament. Another reason is, the parts cannot be kept in apposition."
I remain, dear Sir, Feversham, Your very obedient Servant,
Nov. 12th, 1824. Robert Lukyn.
From Dr. Pidcock, of Watford.
My dear Sir,
Ih a copy I made of the lecture on simple fractures there is this brief remark on the subject of your inquiry : " In fractures of the cervix femoris, the ends of the bone are never opposite to each other ; the callus is thrown into the acetabulum, and union never takes place."
Watford; I remain, very faithfully your's,
Nov. lith, 1824. John Pidcock.
Pupil in 1794-5.
PREFACE. Xlll
From Mr. Pullev, of Bedford,
Dear Sir,
I send you with much pleasure your observations on fractures of the neck of the thigh-bone. You will find my language in- correct in some parts, owing to the hurry of transcribing, arising from the multiplicity of matters then to be attended to ; but I can vouch for the accuracy of the statement, and had much rather send you an exact copy of the lecture now in ray possession, not knowing the reason of your present application.
" Fracture of the neck of the thigh-bone : — This fracture never unites ; tell the patient this, and that he must be lame for life. When the injury happens with persons not more than fifty-five years of age, the recovery may be so far that the patient may be able to walk with a stick ; but should it happen with very old people, they will never after be able to walk out without crutches. The fractured cervix does not unite, because the extravasated matter, or coagulable lymph thrown out for union, is lodged in the joint, so that it is not applied to the ends of the bone ; be- sides, union cannot be effected, as the ends of the bone are so far removed from each other. Attempts have frequently been made to effect an union, but they have never succeeded."
I remain, dear Sir,
Bedford; Your most obedient Servant,
J^ov. I2th, 1824. John Pulley.
Pupil in 1796.
XIV PREFACE.
From Mr. IVeekes, of Hurtspur Point, Sussex?. Dear Sir,
I am sorry I have been prevented answering your letter before ; but upon referring to your lectures I find the following observations, viz. :
" Of fracture of the cervix femoris : This is of frequent occur- rence, but seldom or ever happening but in people of advanced age. These fractures are often supposed to be cured, but in reality they never are. People, after these fractures, should always walk with a stick ; and if they are stout and fat, crutches are admissible.
" The reason why fractures of the cervix femoris do not get well so soon as fractures of the trochanter, is, that in the former the callus becomes extravasated in the joint, and renders union of the bone impracticable."
I remain, dear Sir,
Your very humble Servant, Hurtspur Point, H. Weekes.
Sussex:. Pupil in 1796.
From Mr. Overend, of Sheffield. Dear Sir,
In referring to my notes of your lecture on fracture of the cervix femoris, delivered in the year 1797, I find the following
PREFACE. XV
observations. After describing the appearances indicating the fracture of this part of the thigh-bone my notes state :
" A crepitus in fracture of the cervix femoris can never be observed, originating from the two extremities of the broken bone never being in contact, and, consequently, a bony union never takes place ; in the first instance, from the want of contact ; and, secondly, from extravasation surrounding the affected part, which progressively becomes vascular, and forms a ligamentous union, if union at all."
Your obedient humble Servant, Sheffield; Hall Overend.
Nov. Uth, 1824.
Dr. Jeffries, of Liverpool, took the following notes of my Lectures in the year 1797.
" In the cervix femoris, an union never takes place ; the leg is much the shortest, the foot and knee turned outwards, and great motion at the hip-joint : occurs only in old people. The fractured surfaces become smooth by callus, but no union ever follows, because the two pieces of bone are never applied, and the callus matter is lost within the cavity of the joint."
From Mr. Alexander, of JVewbury. " The cervix of the os femoris is a part that never unites. It
c 2
Xvi PREFACE.
is an accident which generally occurs in old people after the age of fifty-six; the limb becomes shortened, and the knee and foot turned outwards. Ligamentous matter only is poured out into the joint and around the head of the bone."
Richard H. Alexander. Attended in 1797-8-9; believe the notes were taken in 1798.
From Mr. Rose, of High JVycomhe. Dear Sir,
I am sorry to have been prevented by various engagements attending to your request earlier, in sending you the extract from the lecture delivered by you, on the subject of fracture of the cervix of the os femoris, in the year 1798.
"The reason why this fracture does not unite; first, one cause is, that the callus is effused into the cavity of the joint ; secondly, the head of the bone cannot be kept in apposition with the cervix, which explains why the patient is always lame."
You then related some cases published by Desault, wherein he stated his having succeeded, and union had taken place; but as they were in young subjects, you expressed your opinion, that they were fractures of the trochanter, and not of the cervix.
I am, dear Sir, Your faithful and obedient Servant, . High Wycombe; William Rose.
Aug, SOth, 1824.
PREFACE. XVll
JVotes on Fracture of the Neck of the Thigh-Bone, taken from Sir Astlev Cooper's Lectures in 1799, by W. Jacksoj^.
" This fracture never unites, therefore you must inform your patients they will always be lame."
The expression of never uniting is a little too strong, for it will be seen in my work that I have mentioned certain exceptions in which such union might be possible ; but still, lameness is a never- failing consequence ; it may be also stated that in addition to the two causes of want of union which I have mentioned, there is a third, which I have much dwelt upon in this work, viz., the supply of blood to the head of the bone being cut off (excepting through the medium of the ligamentum teres) by the laceration of the reflected ligament and periosteum.
The question of union or non-union of the fracture of the neck of the thigh-bone, as a general principle, involves very important consequences; as the lameness which invariably follows these accidents would expose every surgeon in the kingdom to an action for neglect or want of skill, if such fractures would unite so as to render the limb firm, and prevent the lameness which in every case I ever saw was the uniform result, although union in a large proportion of them was attempted.
If 1 were called upon to give my evidence in a court of justice in such a case, I should say, that the lameness which was the
:*Vm PREFACE.
result was not imputable to any want of skill, but to the nature and seat of the fracture, as I have never seen an instance in which it did not occur. But to those who hold a contrary opinion, all that could be said is, that you have exposed yourself to this action from want of proper attention to the issue of these accidents, " and out of thy own mouth shalt thou be condemned."
Since writing the above observations, I have received the following letter and case.
Dear Sir Astley,
I beg to forward you a note of a case of fracture within the capsular ligament, which fully illustrates your opinion of the nature and consequences of that injury. I have abstained from drawing any conclusions on the case, confining myself to its history and dissection. The bones, not yet subjected to any preparation, are in my possession, and if considered as worthy a place in the museum, I shall feel great pleasure in forwarding them to you.
I am, with great respect, Sheerness ; Your obedient Servant,
Dec. Isif, 1824. Arch. Robertson.
CASE. On the 25th of June, 1822, William Daruin, aged sixty-two, a tall athletic convict, of a sanguine temperament, fell with a very
PREFACE. XIX
inconsiderable violence across a piece of timber in the Dock-yard, his left hip coming in contact with the wood. On rising, he felt an acute pain in the region of the acetabulum, but no other incon- venience, for he walked on board to exhibit himself to the surgery man. From finding him ranked up with the sick of the hulk on my morning visit of the 26th, from his walking on board, and from his own account of the accident, I did not suspect any seri- ous injury of the joint, and treated the case as one of concussion. On the 29th, however, he complained of a very sudden, and very agonizing accession of pain, which induced me to subject him to a more critical examination. No evident alteration in the size of either hip could be discerned, but a shortening of the limb was conspicuous, which was rendered more evident by making him stand on the sound limb ; extension removed this difference, but on being freed from restraint, it again assumed its morbid shape ; the knee and foot were everted, and rotation greatly increased his pain.
I removed him to the hospital as a case of fracture within the capsule, but a continued attention for a period of six months to position (chiefly with the view of restraining the motion of the pelvis, and of securing the limb), made no other alteration in the symptoms than a gradual diminution of pain. A pair of crutches were given him, he was placed on the invalid list, and remained so till the 26th of December, when he died from general dropsy.
On dissection, the injury proved a transverse fracture of the
XX PREFACE.
head of the femur within the capsular ligament. No species of union had taken place. The upper portion of the fractured bone was retained in situ by the sound ligament ; tolerably smooth on its surface, but without any ossific deposit. The lower portion very irregular, with several detached pieces of bone adhering to the insertion of the capsular ligament. Between the acetabulum and the portion of bone retained in situ by the ligament, several small oval shaped loose cartilaginous substances, apparently fragments of bone. The capsular ligament partially lacerated, in a line above the trochanter major, and greatly thickened in its insertions.
Convict Hospital Ship, Arch. Robertson.
Sheerness, 1st Dec. 1824.
I may be permitted to add here, that I have just added to the collection at St. Thomas's Hospital, a fracture of the patella ; in which the portions of bone are in contact, and in which an ossific union appeared at first sight to have been produced, and in the living body it must have been concluded to be united ; yet the union is only ligamentous.
A. C. Dec. 1824.
CONTENTS.
Page,
On Dislocations in general - - - - - . 1
Particular Dislocations .--,.- 31
Dislocations of the Hip-joint - - - - - 31
Dislocation upwards, or on the Dorsum Ilii - - - 33
Dislocation downwards, or into the Foramen Ovale - - 56
Dislocation backwards, or into the Ischiatic Notch - - 68
Dislocation on the Pubes - - - - - - 82
Fractures of the Os Innominatum - - - - - 94
Fractures of the Upper Part of the Thigh-bone - - - 102 Fractures of the Neck of the Thigh-bone, within the Capsular Ligament 104
Additional Observations on Fractures of the Neck of the Thigh-bone 139 Fractures of the Cervix Femoris, external to the Capsular Ligament, and
into the Cancelli of the Trochanter Major ... 144
Fractures through the Trochanter Major . . - . 156
Fracture of the Epiphysis of the Trochanter Major - - 169
Fractures below the Trochanter - - - - - 171
Dislocations of the Knee .-.-.- 174
Dislocation of the Patella - - - - - . - 176
Dislocation of the Patella upwards - - - • ' ■> 179
Dislocation of the Tibia at the Knee-joint . - - . jgl
Partial Luxation of the Thigh-bone from the Semilunar Cartilages 186
Dislocation of the Knee-joint - . - - - ' . 190
Compound Dislocation of the Knee-joint - - ' - 191
Dislocation of the Knee from Ulceration ... - 194
Fractures of the Knee-joint - - - - - - 196
Fracture of the Patella ------ 196
Perpendicular Fracture of the Patella - - - - 205
Compound Fracture of the Patella - - , - 208
D
XXll CONTENTS.
Page.
Oblique Fractures of the Condyles of the os Fenioris into the Joint - 212
Compound Fracture of the Condyles of the Femur - . . 215
Oblique Fractures of the Os Femoris, just above its Condyles - 217
Compound Fracture, just above the Condyles of the Os Femoris <■ 219
Simple Fracture above the Condyles of the Os Femoris - - 221
Fracture of the Head of the Tibia .... . . £25
Dislocations of the Head of the Tibia - - - - 226
Dislocations of the Ancle-joint . - . . . 228
Simple Dislocation of the Tibia inwards - . . . 229
Simple Dislocation of the Tibia forwards . . - . 232
Partial Dislocation of the Tibia forwards - . . . 234
Simple Dislocation of the Tibia outwards - - - - 235
Compound Dislocation of the Ancle-joint - - - . . 237
Compound Dislocation of the Tibia inwards - - . 248
Compound Dislocation of the Tibia outwards - - . 249
On removing the Ends of the Bones - . » - 278
Additional Cases of Compound Dislocation of the Ancle-joint - 304
Cases which render Amputation necessary . . - - gjQ
Fractures of the Tibia and Fibula near the Ancle-joint - - 330
Fracture of the Tibia at the Ancle-joint - - - - 332
Dislocation of Tarsal Bones - - - - - - 334
Simple Dislocation of the Astragalus .... 334
Compound Dislocation of the Astragalus - - - - 338
Dislocation of the Os Calcis and Astragalus ... 343
Dislocation of the Os Cuneiforme Internum - . - . 354
Dislocation of the Toes from the Metatarsal-bones - - - 355
Dislocations of the Lower Jaw - - - - . 357
Complete Luxation of the Jaw . - . - . 359
Partial Dislocation of the Jaw . - - - - 362
Subluxation of the Jaw ...... 353
Dislocations of the Clavicle .-..-. 3^5
Junction of the Sternal Extremity of the Clavicle with the Sternum . 365
Dislocation of the Sternal Extremity of the Clavicle - - - 367
CONTENTS. xxiii
Page.
Junction of the Clavicle with the Scapula - - - . 372
Dislocation of the Scapular Extremity of the Clavicle - - 373
Dislocation of the Clavicle, with Fracture of the Acromion - - 376
Structure of the Shoultler-joint - - - . - 373
Dislocation of the Os Humeri - - . - . 332
Dislocation in the Axilla - - . . - - - 333
Dislocation forwards behind the Pectoral Muscle, and below the
middle of the Clavicle - - . . - - 393
Dislocation of the Os Humeri on the Dorsum Scapulae - - 403
Partial Dislocation of the Os Humeri ..... ^7 Fracture of the Neck of the Os Humeri, with the Dislocation forwards
under the Pectoral Muscle - - - . - 411
Compound Dislocation of the Os Humeri .... 422
Partial Dislocation of the Os Humeri forwards - - - 415
Dislocation of the Os Humeri backwards .... 415
Fractures near the Shoulder-joint, liable to be mistaken for Dislocations 418
Fractures of the Acromion ...... 423
Fracture of the Neck of the Scapulae - - - . . 420
Fracture of the Neck of the Os Humeri - . . - 422
Structure of the Elbow-joint ..... 425
Dislocations of the Elbow-joint - . - - . 430
Dislocation of both bones backwards - - - - - 430
Dissection of the Dislocation of the Elbow-joint - . . 431
Compound Dislocation of the Os Humeri at the Elbow-joint - 433
Lateral Dislocation of the Elbow .... - 435
Dislocation of the Ulna backwards ..... 437
Dislocation of the Radius forwards - . - - - 439
Dislocation of the Radius backwards - - - - 443
Lateral Dislocation of the Radius ..... 444
Fractures of the Elbow-joint ------ 445
Fractures above the Condyles of the Humeri - . - 445
Fracture of the Internal Condyle of the Os Humeri . - 443
Fracture of the External Condyle of the Os Humeri - - - 449
XXIV CONTENTS.
Page.
Fracture of the Coronoid Process of the Ulna - - - 451
Fracture of the Olecranon --.-.. 453
Compound Fracture of the Olecranon .... 459
Fracture of the Neck of the Radius - - - - . 459
Compound Fractures and Dislocations of the Elhow-joint - - 460
Structure of the Wrist-joint .---.- 464
Dislocations of the Wrist-joint ----- 466
Dislocation of the Radius at the Wrist - - - - 468
Dislocation of the Ulna -..--- 469
Simple Fracture of the Radius, and Dislocation of the Ulna - - 470 Fracture of the lower End of the Radius, without Dislocation of the Ulna 472
Compound Dislocation of the Ulna, with Fracture of the Radius - 473
Dislocation of the Carpal-bones . . - - . 477
Compound Dislocation of the Carpal-bones - - - . 479
Dislocation of the Metacarpal-bones ----- 482
Fracture of the Head of the Metacarpal-bones - - - 484
Dislocations of the Fingers and Toes ----- 485
Dislocation from Contraction of the Tendon - - - - 486
Dislocation of the Thumb - - - - - - 488
Dislocation of the Metacarpal-bones from the Os Trapezium - 489
Dislocation of the First Phalanx . . - - - 493
Dislocation of the Second Phalanx ----- 495
Dislocation of the Ribs ------ 497
Injuries of the Spine ------- 499
Concussion of the Spinal Marrow - - - - - 502
Extravasation in the Spinal Canal ----- 504
Fracture of the Spine ..---- 595
Fractures of the Bodies of the Vertebrae, with Displacement - 509
Inflammation and Ulceration of the Spinal Marrow - - - 517
Plates and Explanations.
TREATISE
ON
DISLOCATIONS.
DISLOCATIONS IN GENERAL.
A DISLOCATION is a displacement of the articulatory portion of a Definition. bone from the surface on which it was naturally received.
Of the various accidents which happen to the body there are Necessity of
prompt as- few which require more prompt assistance, or which more directly distance.
endanger the reputation of a surgeon, than cases of luxation. If much time shall have elapsed before the attempt at reduction is made, the difficulty of accomplishing it is proportionably increased, and it is not unfrequently totally impracticable : and if the nature of the injury be unknown, and the luxation consequently remain unreduced, the patient will become a living memorial of the sur- geon's ignorance or inattention. " What is the matter with me.^" j^fftakT **
B
j£ DISLOCATIONS IN GENERAL.
said a patient who came to my house, placing himself before me and directing" my attention to his shoulder: "Why, Sir, your arm
is dislocated." — " Do you say so ! Mr. told me it was not
out." — " How long has it been dislocated.^" — " Many weeks," he replied. — " Oh then you had better not have any attempt at reduc- tion made." — He said, " Well, I will take care that Mr. has
no more bones to set ; for I will expose his ignorance in that part of the country in which I live." — He was a man of malevolent disposition, and carried his threat into execution, to the great injury of the surgeon, who was also frequently reminded of his want of skill, by meeting his former patient in his rounds ; and what was worse, by hearing the following observation frequently
repeated : '^ Mr. is a good apothecary, but he knows
nothing of surgery."
In a dislocation of the os femoris, which still remains unreduced, a consultation was held upon the nature of the injury, and after a long consideration, a report was made by one of the surgeons to this effect : " Well, Sir, thank God, we are all agreed that there is no dislocation." Knowledge A Considerable share of anatomical knowledge is required to
of Anatomv /» i
necessary. ' dctcct the uaturc of thcse accidents, as well as to suggest the best means of reduction ; and it is much to be lamented, that students neglect to inform themselves sufficiently of the structure of the joints. They often dissect the muscles of a limb with great neatness and minuteness, and then throw it away, without any examination of the ligaments, cartilages, or ends of the bones ; a knowledge of which, in a surgical point of view, is of infinitely greater importance ; and from hence arise the errors into which
DISLOCATIONS IN GENERAL. 3
they fall when they embark in the practice of their profession; for the dislocations of the hip, the elbow, and the shoulder, are scarcely to be detected, but by those who possess accurate anato- mical information. Even our hospital surgeons, who have neg-lected their anatomy, mistake these accidents ; and I have known the pullies applied to an hospital patient, in a case of fracture of the neck of the thigh-bone, Avhich had been mistaken for a dislocation, and the patient exposed, through the surgeon's ignorance, to a violent and protracted extension. It is therefore proper, that the form of the extremities of the bones, their mode of articula- tion, the ligaments by which they are connected, and the direc- tion in which their most powerful muscles act, should be well understood.
Yet it would be an injustice not to acknowledo^e, that the Difficulty
*' *-' from tume-
tumefaction arising from extravasation of blood, and the tension f*"=''on' resulting from the inflammation, which frequently ensues, will, in the early days of the accident, render it difficult for the best sur- geon to be perfectly assured of the exact extent of the injury; and, therefore, conclusions drawn at a time when the muscles are wasted, and the swelling is dispersed, when the head of the bone can be distinctly felt, and the motions of the limb are found to be impeded in a particular direction, if they tend to the prejudice of the individual who may have given a different opinion under circumstances so much less favourable for forming a correct con- clusion, will be both illiberal and unjust.
The immediate effect of dislocation is to change the form of the symptoms. joint, and often to produce an alteration in the length of the limb ; to occasion the almost entire loss of motion in the part after the
b2
Length of limb altered.
DISLOCATIONS IN GENERAL.
muscles have had time to contract, and to alter the axis of the limb. This altered position of the limb has been attributed, by some surgeons, to the influence of the remaining- portion of ligament; but, in every accident, the direction of the bone is too much the same to induce the belief of its being chiefly the effect of muscular influence ; for the ligament is extensively torn, in most cases scarcely any portion of it remaining whole, particularly in dislocations of the thigh, yet the position of the limb under the different species of dislocation is found sub- ject to little variation. The form of the bone has, hoAvever, some influence on its future position : for in fracture of the neck of the thigh-bone, the knee is turned outwards ; whilst in disloca- tions, it is turned inwards, a diff*erence which arises from the greater capacity of the bone to roll upon its axis when the neck is broken.
In the first moments, however, of the dislocation, considerable motion remains, and the position is not so determinately fixed as it afterwards becomes ; for I have seen a man brought into Guy's Hospital, who, but a few minutes before, had the thigh-bone dislo- cated into the foramen ovale, and I was surprised to find in a case otherwise so well marked, that a great mobility of the bone still existed at the dislocated part ; but in less than three hours, it became firmly fixed in its new situation by the permanent, or, as it is called, tonic contraction of the muscles.
In some dislocations the limb is rendered shorter, and thus the muscles influenced by it are immediately thrown into a state of relaxation ; but if the limb be elongated, the tension of the principal muscles around the joint is extreme, and they are
DISLOCATIONS IN GENERAL. 5
sometimes stretched to laceration. Blood is often effused in EfFusion of
blood.
considerable quantity around the joint, which renders detection of the accident difficult ; the swelling- being sometimes so con- siderable as to conceal entirely the ends of the bones. This effusion is in proportion to the size and number of the vessels lacerated.
A severe but obtuse pain arises from the pressure of the head of the bone upon the muscles, and, in some cases, this pain is ren- dered more acute from its pressure upon a large nerve. From this cause also is produced a paralysis of the parts below, instances of which occur in dislocations of the shoulder. In other cases the bone presses upon important parts, so as to produce effects Effects of dangerous to life. I have for manv years mentioned, in my from the
° . ' . . dislocated
lectures, a case of a dislocated clavicle, pressing upon the '"'°^- oesophagus so as to endanger life ; which Mr. Davie, of Bungay, was so kind as to send me an account of. I shall give a more detailed history of this case hereafter.
In most dislocations, the head of the bone may be readily felt criterion of
•' •> the accident
in its new situation; and the rotation of the limb best discovers the ''^ '^°"'''<*"- nature of the accident, as the head of the bone can be felt to roll. The natural prominences of the dislocated bone, in some instances, either disappear, or become less conspicuous, as the trochanter in luxations of the hip-joint ; but the reverse of this happens in dis- locations of the elbow, for there the olecranon is more than usually prominent, and serves as the principal guide for discovering the nature of the injury.
The more remote effects of the accident are, that frequently a sensation of crepitus is produced by the effusion of adhesive matter crepitus.
6 DISLOCATIONS IN GENERAL.
(fibrin) into the joint and biirsae; the synovia becomes inspissated, and crackles under motion, a circumstance of which every practi- tioner should be aware, as he may be otherwise induced erro- neously to suspect the existence of fracture. luflamma- 'j'jjg dcfifree of inflammation which succeeds to these accidents
tionandsup- o
puration. -^ ggjjgj.Q^ijy gUght ; but iu soiue cases it becomes so considerable as to produce a tumefaction, which, added to that resulting- from extravasation of blood, frequently renders the detection of the injury exceedingly difficult. Sometimes, after the reduction of dislocations, suppuration ensues, and the patient falls a victim to excessive discharge and irritation. Mr. Howden, who was one of our most intelligent apprentices at Guy's Hospital, and was afterwards surgeon in the army, related the following case : — "A man had his thigh dislocated upwards and backwards on the ilium, which was soon after reduced ; the next day a consi- derable swelling was observed on the part, which continued to increase, accompanied with rigours, and in four days the patient died. On dissection, the capsular ligaments, and ligamentum teres, were found entirely torn away, and a considerable quan- tity of pus extravasated in the surrounding parts." See Minutes of the Physical Society, Guys Hospital, JVovember 12, 1791. — I attended the master of a ship, who had dislocated his thigh upwards; an extension was made, apparently, with success; but in a few days a large abscess formed on the thigh, which destroyed the patient : fortunately, however, such a result is by no means common.
fidiacera- Whcu, froiu length of time, or any other circumstance, the reduction of the limb is rendered impracticable, the bone forms for
tion of mus- cles
DISLOCATIONS IN GENENAL. 'J
itself a new bed, and some degree of motion is gradually reco- vered; although, in neglected dislocations of the lower extremity, the patient is ever after lame ; and in those of the upper, the motion and power of the limb are very much diminished.
On examination of the bodies of persons who die in conse- Appearances quence of dislocations arising from violence, the head of the bone is found completely removed from its socket. The capsular liga- ment is torn transversely to a great extent; the peculiar ligaments Ligaments. of joints, as the ligamentum teres of the hip, are torn through ; but the tendon of the biceps, in dislocations of the os humeri, remains uninjured, as far as I have been able to ascertain by dis- section ; although I should be sorry to be understood to say that this is universally the case.
The tendons which cover the ligaments are also torn; as the Tendons. tendon of the sub-scapularis muscle, in the dislocation in the axilla; and according to the extent of this laceration, is the facility with which the accident recurs after reduction ; a circumstance frequently very difficult to obviate.
The muscles also are influenced by the nature of the accident, Muscles. being in some cases put upon the stretch, even to laceration ; as the pectineus and abductor brevis, in dislocation of the thigh downward ; and large quantities of blood become extravasated into the cellular membrane.
The appearance of ioints which have Ions: been dislocated. Dissections
^^ •' ^ ^ of old dislo-
depends not only on the length of time that has elapsed from the «'"'0"s- accident, but also on the structure upon which the head of the dislocated bone is thrown ; for if it be found embedded in muscle, Sfne'^embed! its articular cartilage remains, and a new capsular ligament lorms cie.
8 DISLOCATIONS IN GENERAL.
Manner of its forma- tion.
Formation arouiicl it, which does not adhere to its cartilaginous surface.
of a new ^
iT-amlnt This ligament, in dislocations of the femur, contains within it the head of the bone, with the lacerated portion of the ligamentum teres united to it, (^See plate) In these instances the bones them- selves underg^o little change. The capsular ligament is formed from the surrounding cellular tissue; which, being pressed upon by the head of the bone, becomes inflamed, thickened, and condensed. By this means a substance is produced somewhat less dense than original ligament, but still possessing sufficient firmness to bear considerable pressure, and to furnish some degree of support.
Head of the But if thc head of the dislocated bone be placed on the surface
bone resting'
bonT*''" of another bone, or upon a thin muscle over it, that muscle becomes absorbed, and the bone undergoes a remarkable change ; thus it is found, if the dislocation be not reduced, that both the ball and the bone which receives it are changed in their form. The pres- sure of the head of the bone produces absorption of the periosteum, and of the articular cartilaginous surface of the head of the bone; a smooth hollow surface is formed, and the ball becomes altered in its shape to adapt it to its new surface ; and whilst this absorp- tion proceeds upon the part on which the head of the bone rests, an ossific deposit takes place around it from the periosteum, which is there irritated but not absorbed. By the deposition of this bony matter between the periosteum and the original bone, a deep
Foimationof cup is formcd to Tcceive the head of the bone ; and perhaps no
a new socket. •• ■••■•■
instances can be adduced which more strongly mark the powers of nature in changing the form of parts to accommodate them to new circumstances, than these effects of dislocation. (^See plates 2, 3 and 4.)
DISLOCATIONS IN GENERAL. 9
The new cup which is thus formed, sometimes so completely surrounds the neck of the bone, as to prevent its being removed from it without fracture (see plate); and the socket is smoothed upon its internal surface, so as to leave no projecting parts which can interrupt the motion of the bone in its new situation.
The muscles losing their action, become diminished in bulk, and reduced in their length, in proportion to the displacement of the bone towards their origin ; and if the dislocation has been long unreduced, they lose their flexibility, and tear rather than yield to extension.
Dislocations from
Although dislocations happening from violence are accompanied by laceration of the ligaments of the joint, yet they may occur relaxation. from relaxation of the ligaments only, of which the following case is an example.
CASE. A girl came to my house, Avho had the power of throwing her case. patellse from the surfaces of the condyles of the os femoris. Her knees were bent considerably inwards; and when the rectus muscle acted upon the patella, it was drawn from the thigh-bone into a line with the tubercle of the tibia, and laid nearly flat upon the side of the external condyle of the femur. She came from the south of Europe, and said she had been brought up as a dancing girl from her earliest years, thus, gaining her daily bread, as we see children dancing upon elevated platforms in the streets of London; and
10 DISLOCATIONS IN GENERAL.
she imputed to these continued and early exertions the weakness under which she laboured.
Dislocation from accu- mulation of synovia.
A similar relaxation of ligaments, is also produced by an accu- mulation of synovia in joints. Mr. Shillito, surgeon at Hertford, requested me to see the servant of a gentleman in my neighbour- hood, who had a great enlargement of the knee-joint from an inordinate secretion of synovia ; and when this became absorbed, the ligaments remained so much relaxed, that the efforts of the muscles in walking dislocated the patella outwards. 1 ordered her into the hospital, that the students might observe this case, of which the following is an account.
CASE.
Dislocation Auu Parisli was admitted into Guy's Hospital in tlie autumn of
trnm relaxa- * ■•-
1810, for a dislocation of the left patella from relaxation of the ligaments. She had for four years previously a large accumulation of synovia in that knee, causing some pain, and much inconveni- ence in walking. Blisters had been applied without much effect, and other means tried, for four months before her admission. When the knee had acquired considerable size, the swelling spon- taneously subsided, and she then first discovered that the patella became dislocated when she extended the limb. She suffered some pain whenever this happened, and she lost the power of the limb in walking, so that she fell when the patella slipped from its place, which it did whenever she attempted to walk without a bandage. The patella was placed upon the external condyle of the os femoris, when thrown from its natural situation, to which it did not return
from relaxa tion
DISLOCATIONS IN GENERAL. 11
without considerable pressure of the hand. In other respects her health was good. Straps of adhesive plaster were ordered to be applied, and a roller to be worn, which succeeded in preventing the dislocation so long as they were used, but the bone again slipped from its place whenever they were removed. A knee-cap, made to lace over the joint, was ordered for her.
Dislocation sometimes arise from a loss of muscular power ; Paralysis. for when the muscles are kept long and forciby extended, their tone becomes destroyed ; or if, from a paralytic affection, they lose their action, a bone may be dislocated easily, but is as readily replaced : of the first of these two causes, the following case is an illustration.
CASE.
Mr. , a gentleman, now residing in the City, whilst in the
East Indies, as a junior officer on board his ship, had been placed under the orders of one of the mates when the captain was on shore, and for some trifling oifence this young gentleman was punished in the following manner : — His foot was placed upon a small pro- jection on the deck, and his arm was lashed tightly towards the yard of the ship, and thus kept extended for an hour. When he returned to England, he had the power of readily throwing that arm from its socket, merely by raising it towards his head ; but a very slight extension reduced it ; the muscles were also wasted, as in a case of paralysis. A prosecution was commenced for this act of cruelty, and I was subpoenaed to give evidence ; but the petty
c2
12 DISLOCATIONS IN GENERilL.
tyrant chose to pay the forfeit of his misconduct prior to the commencement of the trial.
I have also seen in a dislocation of the thumb, the first phalanx capable of being thrown from the os metacarpi pollicis, merely by the action of the muscles, from a relaxed state of the ligament.
Of the influence of paralysis, the following- case is an example :
CASE.
I was desired to see a young gentleman, who had one of those paralytic affections in his right side which frequently arise during dentition. The muscles of the shoulder were wasted ; and he had the power of throwing his os humeri over the posterior edge of the glenoid cavity of the scapula, from whence it became easily reduced.
In these cases, particularly in the latter, no laceration of the ligaments could have occurred ; and they shew the influence of the muscles in preventing dislocation from violence, and in im- peding its reduction.
Dislocation from ulcera-. tion.
Dislocations arise from ulceration, by which the ligaments are detached, and the bones become altered in their form. We fre- quently find this state of parts in the hip-joint; the ligaments ulcerated, the edge of the acetabulum absorbed, the head of the thigh-bone changed both in its magnitude and figure, escaping from the acetabulum upon the ilium, and there forming for itself
DISLOCATIONS IN GENERAL. 13
a new socket. We have in the anatomical collection at St. Thomas's Hospital, a preparation of the knee dislocated by ulce- ration, anchylosed at right angles with the femur, and the tibia turned directly forwards. A boy, in Guy's Hospital, had his knee dislocated by ulceration, whose tibia was thrown on the inner side of the external condyle of the os femoris ; and a girl, in the same hospital, had the knee dislocated by ulceration, the head of the tibia being placed behind the condyles of the os femoris.
Dislocations are sometimes accompanied with fracture. At the Fracture and
'^ dislocation.
ancle joint it rarely happens that dislocation occurs without a fracture of the fibula, and at the hij)-joint the acetabulum is occasionally broken : — of this an example will be seen in the following
CASE. Thomas Steers was admitted into Guy's Hospital, on the 28th Dislocation of October, 1805, with a dislocation of the os femoris into the ksion!'^^*"'' ischiatic notch. The dislocation was reduced by a very slight extension, compared with that which is commonly required; this was imputed to the muscular relaxation caused by nausea, the patient having vomited at the time of his admission. But he soon complained of severe pain, extending over his abdomen, and he died on the day following his admission. Upon inspecting his body, the intestinum jejunum was found ruptured ; and upon examination of the hip-joint, a portion of the edge of the aceta- bulum was discovered to be broken off.
14
DISLOCATIONS IN GENERAL.
Dislocation and fracture,
Dislocations of the os humeri are also sometimes accompanied with fracture of the head of that bone, of which we have a specimen in the Museum at St. Thomas's Hospital. The coronoid process is sometimes broken in dislocations of the ulna, producing a species of luxation, which does not admit of the bone being afterwards preserved in its natural situation.
When a bone is both broken and dislocated, it is proper to endeavour to reduce the dislocation without loss of time, taking" care that the fractured part be strongly bandaged in splints, to prevent any injury to the muscles ; for if this be not done at first, it cannot be afterwards effected without danger of re-producing the fracture.
If a compound fracture of the leg, and a dislocation of the shoulder, happen in an individual at the same time, the reduction of the arm should be immediately undertaken, after the fractured
limb has been secured in splints. The Rev. Mr. H , owing to
his being thrown from his chaise, had a compound fracture of the leg, and a dislocation of the shoulder forwards. The dislocation was not at first observed, nor was its reduction attempted till a fortnight after the accident. The trial proved unsuccessful, as, from a dread of fever and of injury to the leg, sufficient extension could not be used.
The accidents which have been called dislocations of the spine, are generally fractures of the vertebrae, followed by displacement of the bones, but not of the intervertebral substance ; and even the articulatory processes are broken, as well as the bodies of the vertebrae, so that they are not true dislocations of the spine, excepting those of the upper cervical vertebrae, dislocations of
DISLOCATIONS IN GENERAL. 15
which are said to have occasionally occurred. The injuries of the spine, which produce paralysis of the lower extremities, are frac- tures of the bodies of the vertebrae, pressing upon, and sometimes lacerating', the medulla spinalis.
In compound dislocation, not only the articulatorv surfaces ^?'?p«>™''
-t •' .' Dislocations
of the bone are displaced, but the cavity of the joint is laid open by a division of the skin and the capsular ligament. The imme- diate effect of compound dislocation is, to occasion the extrava- sation of blood into the joint, and to allow the escape of the synovia.
Compound dislocations are attended with great danger, and for Danger. the following reason:
When a joint is opened, inflammation of the lacerated ligaments and synovial surface speedily succeeds ; in a few hours suppuration begins, and granulations arise from the surface of the secreting membrane; which, being of the mucous kind, is more disposed to the suppurative, than to the adhesive inflammation. But the same process does not immediately ensue upon the extremity of the bone^ because it is covered by the articular cartilage. This cartilage, before the cavity fills with granulations, becomes absorbed, by an ulcerative process instituted on the end of the bones, but sometimes beginning from the synovial surface. The bone inflames, the cartilage becomes ulcerated, numerous abscesses are formed in different parts of the joint, and at length granulations spring from the extremities of the bones deprived of their cartilages, and fill up the cavity; generally these granulations become ossified, and anchylosis succeeds ; but sometimes they remain of a softer texture, and some degree of motion in the joint is gradually regained.
16 DISLOCATIONS IN GENERAL.
This process of filling up joints requires great general, as well
as local efforts ; a high degree of irritation is produced ; and if
the constitution be weak, the patient, to preserve his life, is
sometimes obliged to submit to amputation.
, . In addition to the above circumstances, the violence necessarily
Injury to ^ J
biTOd-^ves- inflicted on the parts, in compound dislocations, the injury which the muscles and tendons sustain, and the laceration of blood- vessels, necessarily lead to more important and dangerous conse- quences than those which follow simple dislocations.
With respect to the treatment of compound dislocations, it is not my intention, in this part of the work to describe it, but to reserve what I have to say on that subject for the description of compound dislocations of the ancle, where such observations will be required, and where they will be better understood ; and thus a repetition, which would be both irksome and useless to the reader, will be avoided. I shall just remark, that some joints are more liable to compound dislocations than others. The hip-joint is scarcely ever so dislocated ; of the shoulder I have known two instances ; but the elbow, wrist, ancle, and fingers, are frequently the seats of this accident ; and I have seen an instance of it at the knee.
Some joints In cousequeuce of their different formation, we find that in some
more easily ., ,.,.. , ^ I'l tt\\
dislocated joints, dislocatiou IS much more frequent than in others. Ihose
than others. '' ^
which have naturally extensive motions are easily luxated, and hence the dislocation of the os humeri occurs much more fre- quently than that of any other bone ; and having once occurred, it happens again easily in the mere natural elevation of the arm. It is wisely ordained, that in those parts to which extensive motion is
DISLOCATIONS IN GENERAL. 17
assigned, and for which g-reat strength is required, there is a mul- tiplicity of joints. Thus, in the spine, in which great strength is necessary to protect the spinal marrow, numerous joints are formed, and the motion between any two bones is so small, that dislo- cations, except between the first and second vertebrae, rarely occur, although the bones are often displaced by fracture.
The carpus and the tarsus are constituted on a similar prin- ciple ; they allow of considerable motion, yet maintain great strength of union. For if the motion between two bones, as in the spine, be multiplied by twenty-four, and that at the carpus by eight, the result will shew that great latitude of motion is given, and the strength of the part preserved ; whilst, if the spine had been formed of a single joint, dislocations might have easily happened, and death from this cause might have been a frequent consequence.
Dislocations are not always complete, since bones are sometimes Partial dis-
•^ locations.
but partially thrown from the articulatory surface on which they rested : this species of dislocation now and then occurs at the ancle-joint. An ancle was dissected at Guy's, by JMr. Tyrrell, and instance. given to the collection of St. Thomas's, which was partially dislocated ; the end of the tibia still rested in part upon the astragalus, but a larger portion of its surface on the os navi- culare, and the tibia, altered by this change of place, had formed two new articulatory surfaces, with their faces turned in opposite directions towards the two tarsal bones. (^See plate.^ The dislo- cation had not been reduced. The knee-joint is, I believe, rarely dislocated laterally in any other way ; for its extensive articular surfaces almost preclude the possibility of complete displacement.
D
18 DISLOCATIONS IN GENERAL.
The OS humeri sometimes rests upon the edge of the glenoid cavity, and readily returns into its socket ; and the elbow-joint is dislocated partially, both in relation to the ulna and the radius.
The lower jaw is also sometimes partially dislocated, but in a different manner ; one of the joints being luxated, and the other remaining in its place. Cause. Dislocations are generally occasioned by violence, and the force
is usually applied whilst the bone is in an oblique direction to its socket ; but it is necessary that the muscles should be in a great degree unprepared for resistance, otherwise the greatest force will hardly produce the effect : when they are unprepared, it will often ensue from very slight accidents. A fall, in walking, will some- times dislocate the hip-joint, when the muscles have been prepared for a different exertion.
While dwelling on this subject in my lectures, I have usually adverted to the execution of Damien, as illustrative of this position. Resistance Damicu was cxccutcd for the attempt to murder Lewis XV. Four young horses were fixed to his legs and arms, and were forced to make repeated efforts to tear his limbs from his body, but could not effect this purpose; and after fifty minutes, the executioners were obliged to cut the muscles and ligaments to effect his dismemberment.
The following is the French account of this execution :
" II arriva a la place de Greve a trois heures et un quart, regardant d'un ceil sec et ferme le lieu, et les instrumens de son supplice. On lui brula d'abord la main droite ; ensuite on le tenailla, et on versa sur ses plaies, de I'huile, du plomb fondu, et
of the mus- cles
DISLOCATIONS IN GENERAL. 19
de la poix-resine. On proceda ensuite a recartellement. Les qiiatre chevaiix firent pendant cinquante minutes des efforts inutiles pour demembrer ce monstre. Au bout de ce terns la, Damien, etant encore plein de vie, les bourreaux lui couperent avec de bistouris, les chairs et les jointures nerveuses des cuisses, et des bras ; ce qu'on avoit ete oblige de faire en 1610 pour Ravaillac. II respiroit encore apres que les cuisses furent coupees, et il ne rendit I'ame que pendant qu'on lui coupoit les bras. Son supplice depuis I'instant qu'il fut mis sur I'echafaud, jusqu' au moment de sa mort, dura pres d'une heure et demie. II conserva toute sa connoissance, et releva sa tete sept ou huit fois, pour regarder les chevaux, et ses membres tenailles et brules. Au milieu des tourmens les plus affreux de la question il avoit laisse echapper des plaisanteries. — Dictionnaire Historique"
Old persons are much less liable to dislocations than those of Dislocations middle life, because the extremities of bones in advanced age are persons, often so soft as to break under the force applied, rather than quit their natural situations. Persons of lax fibre are prone to disloca- tion, because their ligaments easily tear, and their muscles possess little power of resistance. From these circumstances old people would be exposed to frequent dislocations, but for the softened state of the extremities of their bones.
Young persons are also very rarely the subjects of dislocations Dislocations
- . rare in the
from violence ; but now and then such accidents do occur ; or young^. which I have described an instance in a child at seven years of age. It generally happens that their bones break, or their epi- physes give way, rather than that the parts displace. I read of dislocations of the hip in children, but their history is that of
D 2
20 _ DISLOCATIONS IN GENERAL.
diseases of the hip-joint, in which the dislocation arises from ulceration. A child was brought to me from one of the coun- ties north of London, who had repeated extensions made by one of those people called bone-setters, — but who oug-ht rather to be called dislocators, — for a supposed dislocation of the hip-joint. Uj)on examination, I found the case to be that disease of the hip which is so common in children ; and for this only, was a child wantonly exposed to a most painful extension. That in this enlightened country, men, without education, should be suffered with impunity to degrade a most useful profession, and put to the torture those Avho have the folly to apply to them, is a dis- grace to our laws, that calls loudly for prevention. Elbow-joint Dislocations of the elbow-joint in children are said to be of
dislocations.
frequent occurrence. Surgeons have been heard to say, " I have a child under my care with luxation of its elbow, and I can easily return the bone into its place, but it directly dislocates again." Such a case is, in reality, an oblique fracture of the condyles of the OS humeri, which produces the appearance of dislocation, by allowing the radius and ulna, or the ulna alone, to be drawn back with the fractured condyle, so as to produce considerable projec- tion at the posterior part of the joint.
TREATMENT.
Reduction. '^^^^ rcductiou of dislocatious is often difficult ; and in some of the joints, the form of the bone may occasion impediments. Thus, when the socket is surrounded by a lip of bone, as in the hip- joint, the head of the bone, during the act of reduction, stops at
Difficulty in this projection, and requires to be lifted over it; another difficulty
DISLOCATIONS IN GENERAL. 21
occurs wben the head of the bone is much larger than its cervix, as for example, in the dislocation of the head of the radius ; but still these causes are slig-ht in comparison with others which we have to detail.
The capsular ligaments are supposed to resist reduction ; but xhecapsuiar those who entertain that opinion must forget their inelastic struc- '°'""^" ^* ture, and cannot have had opportunities of witnessing, by dissec- tion, the extensive laceration which they sustain in dislocations from violence. The capsular ligaments, in truth, possess but little strength either to prevent dislocation, or to resist the means of reduction ; and if the tendons with which they are covered, and the peculiar ligaments of the joints did not exist, dislocation must be of very frequent occurrence.
The joint of the shoulder, and those of the knee and elbow, are Tendons. strongly protected by tendons ; the shoulder by those of the spi- nati, sub-scapularis, and teres minor muscles ; the elbow by the triceps and brachialis ; the knee by the tendinous expansion of the vasti; but still some ligaments resist dislocations ; these, however, are the peculiar, not the capsular lisfaments. The wrist and the Peculiar
*■ 1 o ligaments.
elbow have their appropriate lateral ligaments to give additional strength to these joints. The shoulder, instead of a peculiar liga- ment, has the tendon of the biceps received into it, which lessens the tendency to dislocation forwards ; the ligamentum teres of the hip-joint prevents a ready dislocation downwards ; the knee has its lateral and crucial ligaments ; and the ancle, exposed as it is to the most severe injuries, is provided with its deltoid and fibular tarsal ligaments, of very extraordinary strength, to prevent dislo- cation. The bones of this joint often break rather than their
22 DISLOCATIONS IN GENERAL.
ligaments give way ; however, in many of the joints, as these liga- ments are torn, they afford no resistance to the reduction of dis- locations, as in the hip, elbow, and wrist; but if one of them remain, it produces difficulty in the reduction, as I have seen in the knee-joint.
The difficulty in reducing dislocations arises principally from
Muscles. ^\^Q resistance which the muscles present by their contraction, and which is proportioned to the length of time which has elapsed from the injury ; it is therefore desirable that the attempt at reduction should not be long delayed.
The common actions of the muscles are voluntary or invo- luntary, but they have a power of contraction independent of either state.
Fatigue of A musclc, whcu cxcitcd to action by volition, soon becomes fatigued, and requires rest. The arm can be extended only for a few minutes, at right angles with the body, before it feels a fatigue which requires suspension of action ; and, indeed, the same law governs involuntary action, as the heart has its contraction and relaxation.
Permanent But whcu a musclc is dividcd, its parts contract ; or when the antagonist muscle is cut, the undivided muscle draws the parts into which it is inserted, into a fixed situation. Thus, if the biceps muscle be divided, the triceps keeps the arm constantly extended; if the muscles on one side of the face are paralytic, the opposing muscles draw the face to their side. This contraction is not succeeded by fatigue or relaxation, but will continue an indefinite time, even until the structure of the muscle becomes changed ; and its contraction increases from the first occurrence
muscles.
contraction.
DISLOCATIONS IN GENERAL. 23
of the accident. Thus it is, that when a hone is dislocated, the muscles draw it as far from the joint as the surrounding parts will allow, and there by their contraction they fix it. It is this resistance from muscles, aided by their voluntary contraction, which the surgeon is required to counteract. If an extension be made almost immediately after a dislocation has happened, the resistance produced by the muscles is easily overcome : but if the operation be postponed for a few days only, the utmost difficulty occurs in effecting it.
Mr. Forster, son of the surgeon of Guy's Hospital, informed me, ^„sc£*'^''^ that in a fatal case of fracture of the thigh-bone, which he had an opportunity of dissecting before its union, the ends of the bones overlapped, and the muscles had acquired a contraction so rigid, that he could not, even in the dead body, bring the bones to their natural position, after employing all the force he was capable of exerting ; and it is this state of muscles in dislocations, which gives rise to the difficulty in their reduction ; and which, even in the dead body, is still capable of opposing a very considerable resistance.
That the muscles are the chief cause of resistance, is strongly evinced by those cases in which the dislocation is accompanied by injury to any vital organ, and when the power of muscular action is diminished; for it is then found, that a very slight force is suffi- cient to return the bone to its situation. Thus, in the case already mentioned, of the man who had an injury to his jejunum, and a dislocation of his hip, the bone was restored to its place with little difficulty.
•' • • r Other diffi-
When a dislocation has long existed, difficulties arise irom cuuies.
24 DISLOCATIONS IN GENERAL.
three other circumstances. The extremity of the bone contracts adhesion to the surrounding parts, so that even when in dissection the muscles are removed, the bone cannot be reduced. In this state I found the head of a radius, which had been long- dislocated upon the external condyle of the os humeri, and which is preserved in the collection at St. Thomas's Hospital (see plate); and in a similar state I have seen the os humeri when dislocated. The socket is also sometimes so filled with adhesive matter, that if the bone was reduced, it could not remain in its original situation, and the original cavity is in part filled with ossific matter, so as to render it incapable of receiving the head of the bone. Lastly : a new bony socket is sometimes formed, in which the head of the bone is so completely confined, that nothing but its fracture will allow it to escape from its new situation. {See plate.^ Means of Thc mcaus to be employed for the reduction of dislocations,
are both constitutional and mechanical ; it is generally wrong to employ force only, since it would be required in so great a degree as to occasion violence and injury ; and it will in the sequel be shewn, that the most powerful mechanical means fail when unaided by constitutional remedies. The power and direc- tion of the larger muscles are, in the first instance, to be duly appreciated, as these form the principal causes of resistance.
The constitutional means to be employed for the purpose of reduction are those which produce a tendency to syncope, and this necessary state may be best induced by one or other of the following means, viz. : bleeding, warm bath, and nausea. Of these remedies, I consider bleeding the most powerful ; and, that the effect may be produced as quickly as possible, the blood
Constitu- tional.
DISLOCATIONS IN GENERAL. 25
should be drawn from a large orifice, and the patient kept in the erect position, for by this mode of depletion, syncope is produced before too large a quantity of blood is lost. However, the activity of this practice must be regulated by the constitution of the patient ; if he be young, athletic, and muscular, the quantity removed should be considerable, and the method of taking it away should be that which I have described.
Secondly ; in those cases in which the Avarm bath may be thought preferable, or where it may be considered improper to continue the bleeding, the bath should be employed at the tempe- rature of 100° to 110°; and, as the object is the same as in bleeding, the person should be kept in the bath at the same heat till the fainting effect is produced, when he should be immediately placed in a chair, wrapped in a blanket, and the mechanical means employed which I shall hereafter particularly describe.
Of late years, I have practised a third mode of lowering the action of the muscles, by exhibiting nauseating doses of tartarized antimony ; but as its action is uncertain, frequently producing vomiting, which is unnecessary, I rather recommend its application merely to keep up the state of syncope already produced by the two preceding means ; which its nauseating effects will most readily do, and so powerfully overcome the tone of the muscles, that dislocations may be reduced with much less effort, and at a much more distant period from the accident, than can be effected in any other way.
The two cases related in the following pages, one from Mr. Norwood, surgeon, at Hertford, and the other from Mr. Thomas, apothecary to St. Luke's Hospital, will illustrate the efficacy of
26 DISLOCATIONS IN GENERAL.
the treatment recommended. By the comhination of bleeding, the warm bath, and nauseating doses of tartarized antimony, two dislocations were reduced at a more distant period from the accident than I have ever known in any other example. One of these cases occurred at Guy's, and the other at St. Thomas's Hospital, at the time when these gentlemen were officiating as dressers. (^See cases of dislocation on the ilium.)
Opium. The effect of opium I have never tried, but it would probably
be useful in a large dose, from its power of diminishing muscular and nervous influence.
Mechanical Tlic reductiou of the bone is to be attempted, after lessening the powers of the muscles, by fixing one bone, and drawing the other towards its socket. It is now generally agreed among the
Force gra- most eminent surgeons, that force should be only gradually applied ; for violence is as likely to tear sound parts, as to reduce those which are luxated ; and it is apt to excite all the powers of resistance to oppose the efforts of the surgeon. But it is his duty to produce, gradually, that state of fatigue and relaxation which is sure to follow continued extension, and not to attempt at once to overpower the action of the muscles.
One great cause of failure in the attempt to reduce dislocations, arises from insufficient attention to fixing that bone in which the socket is placed. As for example : in attempting to reduce a dis- location of the shoulder, if the scapula be not fixed, or one person pull at the scapula and two at the arm, the scapula will be neces- sarily drawn with the os humeri, and the extension will be very imperfectly made; the one bone, therefore, must be firmly fixed, or drawn in the opposite direction, whilst the other is extended.
means
dual
DISLOCATIONS IN GENERAL. 27
The force required, may be applied either by the exertion of compound assistants, or by a compound pulley ; but the object is to extend the muscles by gradual, regular, and continued efforts ; the pulley, in cases of difficulty, should ahvays be resorted to; its effect may be gentle, continued, and directed by the surgeon's mind; but when assistants are employed, their exertions are sudden, violent, and often ill-directed; and the force is more likely to produce laceration of parts, than to restore the bone to its situation. Their efforts are also frequently uncombined, and their muscles as necessarily fatigue, as those of the patient, whose resistance they are employed to overcome.
In dislocation of the hip-joint, pullies should always be em- ployed ; and in those dislocations of the shoulder which have long remained unreduced, they should also be resorted to. I do not mean to doubt the possibility of reducing dislocations of the hip by the aid of men only, but to point out the inferiority of this mode to the pullies. The employment of pullies in dislocations, is not a modern practice ; Ambrose Pare was in the habit of employing pullies, and good practical surgeons have used them since his time ; — and most writers on surgery have mentioned their use, but they have not duly appreciated them. Mr. Cline, whose professional judgment every one must acknowledge, always strongly recommended them.
During the attempt to reduce luxations, the surgeon should Relaxation endeavour to obtain a relaxation of the stronger opposing muscles, er muscles. The limb should therefore be kept in a position between flexion and extension, as far as it can be obtained. Who has not seen, in the attempt to reduce a compound fracture in the extended
E 2
extension should be applied to the disloca- ted bone.
28 DISLOCATIONS IN GENERAL.
position of a limb, the bone, which could not be brought into apposition under the most violent efforts, quickly replaced by an intelligent surgeon, who has directed the limb to be bent, and the muscles to be placed in a comparative state of relaxation?
Whether the ^ differcucc of opiniou prevails, whether it is best to apply the extension on the dislocated bone, or on the limb below. M. Boyer, who has long taken the lead in surgery in Paris, prefers the latter mode. As far as I have had an opportunity of observing, it is generally best to apply the extension to the bone which is dislocated. There are, however, exceptions to this rule in the dislocation of the shoulder, which I generally reduce by placing the heel in the axilla, and by drawing the arm at the wrist in a line with the side of the body.
Influence of In thc rcduction of dislocations, great advantage is derived from attending to the patient's mind ; the muscles opposing the efforts of the surgeon, by acting in obedience to the will, may have that action suspended, by directing the mind to other muscles. Several years since, a surgeon in Blackfriars' Road, asked me to see a patient of his with a dislocated shoulder, which had resisted the various attempts he had made at reduction. I found the patient in bed, with his right arm dislocated ; I sat down on the bed by his side, placed my heel in the axilla, and drew the arm at the wrist ; the dislocated bone remained unmoved. I said, " Rise from your bed. Sir;" he made an effort to do so, whilst I con- tinued my extension, and the bone snapped into its socket ; for a similar reason, a slight effort, when the muscles are unprepared, Avill succeed in the reduction of dislocation, after violent measures have failed.
the mind.
DISLOCATIONS IN GENERAL. 29
The reduction of the limb is known to have been effected by the restoration of its natural form, the recovery of its original motion, and by a snap, which is heard when the bone returns into its articulatory cavity.
When a bone has been redjiced by the pullies, it will not
remain in its situation without the aid of bandages to support
it till muscular action returns. In the hip, however, dislocation second dis- location.
rarely occurs a second time, but the shoulder and the lower jaw very frequently slip again from their sockets, owing to the little depth of the cavity into which the head of the bone is received ; and, therefore, they require bandages for a considerable period subsequent to reduction.
Rest is necessary for some time after the reduction of the limb, Rest of the in order to produce an union of the ruptured ligament, which would be prevented by exercise. The strength of the muscles and ligaments may also be greatly promoted by pouring cold water upon the limb, and by the subsequent employment of friction.
I believe that much mischief is produced by attempts to reduce q,j jisj,,^^. dislocations of long standing in very muscular persons. I have bered"ced/ seen great contusion of the integuments, laceration and bruises of muscles, tension of nerves, leading to an insensibility and paralysis of the hand, occasioned by an abortive attempt to reduce a dislocation of the shoulder ; so that the patient's condition has been rendered much worse than before. In such cases, even when the bone is replaced, it is often rather an evil than a good, from the violence of the extension.
In those instances, in which the bone remains in the axilla, in dislocations of the shoulder, a serviceable limb, and very
30 DISLOCATIONS IN GENERAL.
extensive motions of it may be regained, although reduction has
not been effected. Captain S — , who dislocated his shoulder
four years ago, called to shew me how much motion he had recovered, although the arm still remained unreduced. Time for at- I am of opiniou, that three months after the accident for the
tempting re- *
auction. shoulder, and eight weeks for the hip, may be fixed as the period at which it would be imprudent to make the attempt at reduction, except in persons of extremely relaxed fibre, or of advanced age. At the same time, I am fully aware, that the shoulder has been reduced at a more distant period than that which I have men- tioned, but, in most instances, with the results I have just been deprecating.
In cases of unreduced dislocation, the only course which the surgeon can adopt, after the inflammation which the injury pro- duces has subsided, is, to advise motion of the limb, and friction of the injured part : — The former, to produce a new cavity for the head of the bone, to assist in forming a new ligament, and in restoring action to muscles, which would otherwise lose it by repose ; — the latter, to promote absorption, and remove the swelling and adhesions which the accident has produced.
PARTICULAR DISLOCATIONS.
DISLOCATIONS OF THE HIP-JOINT.
The acetabulum of the hip-joint is deepened by a cartilaginous Anatomy of ridge, which surrounds its brim ; and although in the skeleton it is not a complete cup, yet it is rendered such in the living subject, by an additional portion of cartilage, which fills up a depression in the bone in the inferior and anterior part of the cavity.
The ligaments are two : the capsular arises from the edge of ^'g^™^"*^- the acetabulum, and passing over the head and neck of the bone, is inserted into the cervix of the os femoris at the root of the tro- chanter major. It is much more extensive upon the anterior than on the posterior portion of the neck of the bone. The inner side of this ligament is a secreting surface, producing the synovia ; and a reflected portion of it towards the head of the bone is also pro- vided with a similar secreting surface.
On the anterior surface of the neck of the thigh-bone, the cap- sular ligament is received into a line, which extends from the
32
PARTICULAR DISLOCATIOIVS.
trochanter major to the trochanter minor. The synovial secreting surface is reflected towards the head of the hone, and the ligament is reflected close on the neck of the bone, to form the periosteum ; whilst its fibres are blended in with the common periosteum, below the insertion of the lig-ament, into the bone.
On the posterior surface the capsular ligament is received upon the neck of the bone, nearly midway between the edge of the head of the bone and the trochanter major. The common peri- osteum on the neck of the bone blends in with the reflected liga- ment, to form the periosteum of the neck of the bone within the capsule.*
The ligamentum teres is contained within the capsular ligament, and proceeds from a depression in the lower and inner part of the acetabulum, to be fixed in a hollow upon the inner side of the thigh-bone : it has a tendency to prevent dislocations in all direc- tions, but particularly the dislocation downwards ; for when this dislocation occurs, the thighs are widely separated from each other, as in fencing ; and the head of the thigh-bone would be in danger of slipping from its socket, but that this ligament prevents it; — an example of its use, which shews the principal reason of its formation. Modeofdis- The thiffh-bone I have seen dislocated in four directions: —
location. *-'
First, upwards, or upon the dorsum of the ilium. Secondly, downwards, or into the foramen ovale. Thirdly, backwards.
* Query. — Can this ligamentous periosteum be one cause of a ligamentous union in fractures within the joints ? I believe that when an union of the neck of the thigh-bone is met with, it will be in a case in which this ligamentous sheath of the cervix is not torn. (See plate XIII Jig. 3. J
PARTICULAR DISLOCATIONS. 33
and upwards, or into the ischiatic notch ; and. Fourthly, forwards, and upwards, or upon the body of the pubes. A dislocation down- wards and backwards, has been described by some surgeons, who have had opportunities for observation; but I have to remark, that no dislocation of that description has occurred at St. Thomas's or Guy's Hospital, within the last thirty years, or in my private practice ; and although I would not deny the possibility of its occurrence, yet I am disposed to believe that some mistake has arisen upon this subject.
DISLOCATION UPWARDS, OR ON THE DORSUM ILII.
This dislocation is the most frequent of those which happen to ^dislocation
^ 1 l on the dor-
the hip-joint ; and the following are the signs of its existence : sumiin.
The dislocated limb, is from one inch and a half, to two inches symptoms. and a half shorter than the other, as is well seen by comparing the malleoli interni, when the foot is bent at right angles with the leg. The toe rests upon the tarsus of the other foot ; the knee and foot are turned inwards, and the knee is a little advanced upon the other. When the attempt is made to separate the leg from the other, it cannot be accomplished, for the limb is fimly fixed in its new situation, so far as regards its motion outwards ; but the thigh can be slightly bent across the other. If the bone be not concealed by extravasation of blood, the head of the thigh-bone can be perceived during rotation of the knee inwards, moving upon the dorsum ilii ; and the trochanter major advances towards its anterior and superior spinous process, so as
p
34 PARTICULAR DISLOCATIONS.
to be felt much nearer to it than usual. The trochanter is less prominent than on the opposite side, for the neck of the hone and the trochanter rest in the line of the surface of the dorsum ilii ; and upon a comparison of the two hips, the roundness of the dislocated side will be found to have disappeared. A surgeon, then, called to a severe and recent injury of the hip-joint, looks for a difference in length, change of position inwards, diminution of motion, and decreased projection of the trochanter. Distinction Thc accidciit with which the dislocation upwards is liable to be
from frac- ■% -i ' i c f i i f t i ' ^ i • ^ '
tuie of the confounded, is the fracture or the neck of the thiffh-bone within
neck of the "
femur. ^jjg capsular ligament. Yet the marks of distinction are, in gene- ral, sufficiently strong to prevent an error in a person commonly attentive. In a fracture of the neck of the thigh-bone, the knee and foot are generally turned outwards ; the trochanter is drawn upAvards and backwards, resting upon the dorsum ilii ; the thigh can be readily bent towards the abdomen, although with some pain ; but, above all, the limb, which is shortened according to the duration of the accident, from one to two inches, by the contraction of the muscles, can be made of the length of the other by a slight extension : and when the extension is abandoned, the leg is again shortened. If, when drawn down, the limb is rotated, a crepitus can often be felt, which ceases to be perceived, when rotation is performed under a shortened state of the limb. Frac- ture of the neck of the thigh-bone, within the capsular ligament, rarely occurs but in advanced age, and it is the effect of the most trifling accident, owing to the interstitial absorption which this part of the bone undergoes at advanced periods of life. Fractures externally to the capsular ligament, occur at any age, and they
PARTICULAR DISLOCATIONS. 35
are easily disting-iiished by the crepitus which attends them, if the limb be rotated and the trochanter compressed with the hand. The position is the same as in fractures within the lig-ament. Fractures of the neck of the thigh-bone are very frequent accidents when compared with dislocations. (See the plate of the positions of the limb in dislocations. J
Diseases of the hip-ioint can scarcely ever be confounded with Diseases of
^ " •' the hip-joint
dislocations from violence, but by those who are ignorant of anatomy, and who are very superficial observers. The gradual progress of the symptoms, the pain in the knee, with the apparent elongation at first, and real shortening afterwards ; the capacity for motion, yet the pain given under extremes of rotation, as well as of flexion and extension, are marks of difference which would strike the most careless observer. The consequences of a disease of this kind, when it has existed a great length of time, are, ulceration of the ligaments, acetabulum, and head of the bone, which allow of such a change of situation of parts, as sometimes to give to the limb the position of dislocation ; but the history of the case at once informs the medical attendant of the nature of the disease.
This dislocation may be caused by a fall when the knee and cause. foot of the patient are turned inwards, or by a blow whilst the limb is in that position ; and the head of the bone is thus dis- placed upwards, and turned backwards.
In the reduction of this dislocation, the following plan is to be adopted : — take from the patient from twelve to twenty ounces of blood, or even more, if he be a very strong man ; and then place him in a warm bath, at the heat of 100°, and gradually
F 2
36 PARTICULAR DISLOCATIONS.
increase it to 110', until he feels faint. During the time he is in the warm bath, give him a grain of tartarized antimony every ten minutes until he feels some nausea ; then remove him from the bath and put him in blankets : he is then to be placed between two strong posts about ten feet asunder, in which two staples are fixed; or rings may be screwed into the floor, and the patient be laid upon it. My usual method is, to place him on a table , covered with a thick blanket, upon his back ; then a strong girt is passed between his pudendum and thigh, and this is fixed to one of the staples. (See plate.) A wetted linen roller is tightly applied just above the knee, and upon this a leather strap is buckled, having two straps with rings at right angles with the circular part. The knee is to be slightly bent, but not quite at a right angle, and brought across the other thigh a little above the knee of that limb. The pullies are fixed in the other staple, and in the straps above the knee. The patient being thus adjusted, the surgeon slightly draws the string of the pulley, and when he sees that every part of the bandage is upon the stretch, and the patient begins to complain, he waits a little to give the muscles time to fatigue ; he then draws again, and when the patient suffers much, again rests, until the muscles yield. Thus he gradually proceeds until he finds the head of the bone approach the acetabulum. When it reaches the lip of that cavity, he gives the pulley to an assistant, and desires him to preserve the same state of extension, and the surgeon then rotates the knee and foot gently, but not with a violence to excite opposition in the muscles, and in this act the bone slips into its place. In general, it does not return with a snap into its socket
PARTICULAR DISLOCATIONS. 37
when the pullies are employed, because the muscles are so much relaxed, that they have not sufficient tone remaining' to permit them to act with violence, and the surgeon ascertaining- the reduction only by loosening the bandages, and comparing the length of the limbs.
It often happens that the bandages get loose before the exten- sion is completed, an accident which should be guarded against as much as possible, by having them well secured at first ; but if they require to be renewed, this should be expeditiously per- formed, to prevent the muscles having time to recover their tone.
It is sometimes necessary to lift the bone, by placing the arm under it, near the joint, when there is difficulty in bringing it over the lip of the acetabulum ; or a napkin may be passed under it as near the head of the bone as possible, and by its means an assistant may raise it. After the reduction, in consequence of the relaxed state of the muscles, great care is required in removing the patient to his bed.
I have seen a reduction of the bone effected, even where the extension was not made in the best possible direction ; for when the muscles have not had time to settle, they will allow the bone to be restored into its socket, even when extension is made in a direction not the most favourable for its reduction. I cannot by any means subscribe to the method adopted by the late Mr. Hey, although no person feels greater respect for his talents, more highly appreciates his acquirements, or is more disposed to pursue the study of the profession in the mode which he so successfully adopted. The direction which he gave to a limb, in the case which he has represented of this accident, was one little calculated
38 PARTICULAR DISLOCATIONS.
to succeed, where the means were not used immediately after the injury had been sustained. But I state this with great deference, because I am not sure, that in all respects, I understand the description of the method which he adopted ; nor do I think that I should be able, from that description, to be certain that I was pursuing" the means by which he succeeded.
I may here observe, and I trust without ostentation, that the plans which I have recommended, are the result of considerable experience ; that they have been successful in a great number of cases ; and that they have very rarely failed, under the most dis- advantageous circumstances : they may require a little variation, from some slight difference in the position, but this will only be an exception to a general rule, and will very rarely occur.
The following cases will serve as illustrations of the history and treatment of dislocations on the dorsum ilii : the first of them points out in a striking manner the evils that ensue when dis- location of the hip-joint remains unreduced, and the advantages arising from the use of pullies in eifecting its reduction. It shews also that such dislocation may happen in a strong healthy man, even after he has attained the age of sixty.
Cases of Dislocation on the Dorsum Ilii.
CASE I. James Ivory, aged sixty-two, of Pottensend, Herts, on the yth of Feb. 1810, was working in a clay-pit about twenty-five feet below the surface of the earth, when a large quantity of clay fell
PARTICULAR DISLOCATIONS. 39
in upon him, while he was in the act of stooping with his left knee bent rather behind the other ; and he was in this position buried under the earth. Being soon removed from his perilous situation, and carried home, a surgeon was sent for, who, discovering the accident to be a dislocation, directly employed some men to extend the limb, whilst he attempted to push the head of the bone into the acetabulum ; but all his efforts were unavailing, as, unfor- tunately for the patient, pullies were not employed. The appear- ances of the limb at present, when nine years have elapsed since the accident, are these : the limb is three inches and a half shorter than the other, and the patient is obliged to wear a shoe having an additional sole of three inches on that side, which lessens, though it does not prevent, his halt in walking. When he stands, the foot of the injured limb rests upon the other ; the toes are turned inwards, and the knee, which is advanced upon the other, is also inverted, and rests upon the side of the patella of the sound limb, and upon the vastus internus muscle ; it is also bent, and cannot be completely extended. The thigh, from the unemployed state of several of the muscles, is very much wasted ; but the semi-tendinosus, semi-membranosus, and biceps, owing to the shortened state of the limb, form a considerable rounded projec- tion on the back part of the thigh. The trochanter major is seven eighths of an inch nearer to the spine of the ilium of the injured side than of the other. On viewing him behind, the tro- chanter major is seen projecting on the injured side much farther than on the other ; the situation of the head of the bone on the dorsum ilii, is easily perceived ; and when the limb is rotated
40 PARTICULAR DISLOCATIONS.
inwards, it is still more obvious. The spinous processes of the ilia are of an equal height. In the sitting posture, the foot is turned very much inwards, and the knee is placed behind the other, whilst the toe only reaches the ground. If fatigued, he experi- ences pain in the opposite hip, and in the thigh of the injured limb. This unfortunate man has an arduous task to gain his bread by his labour, as he cannot stoop but with the greatest difficulty, and is therefore obliged to seek those employments which least require that position. When he attempts to take any thing from the ground, he bends the knee of the injured limb at right angles with the thigh, and throws it far back. He can now stand for a few seconds upon the dislocated limb, but it was twelve months before he could do so. When in bed, it is painful to him to lie on the injured side. His hip, without any apparent cause, is much weaker at some times than at others. When sitting down to evacuate his faeces, he is obliged to support himself by resting the injured knee against the tendo Achillis of the other leg, placing his right hand on the ground. He now walks with two sticks ; at first he employed crutches, and these he used for twelve months, after which, he was enabled to trust to one crutch and a stick, until his limb acquired greater strength. In getting over a stile, he raises the injured limb two steps, and then turns over the sound limb ; but this he cannot accomplish when the steps are far apart; and he is frequently obliged either to turn back, or to take a circuitous route. When lying with his face downwards, the dislocated hip projects very much. He sometimes falls in walking, and would very frequently do so, but that he
PARTICULAR DISLOCATIONS. 41
takes extreme care,' as the least check to his motion throws him down. The knee is bent, and the shortening of the limb partly depends upon that circumstance.
The following' cases illustrate the method of reduction detailed in the preceding pages, and shew in strong colours, the advantages to be derived from constitutional treatment, and the use of pullies.
CASE II. John Forster, aged twenty-two years, was admitted into the Chester Infirmary, July 10th, 1818, with a dislocation of the thigh on the dorsum ilii, occasioned by a cart passing over the pelvis. Upon examination, I found the leg shorter than the other, and the knee and foot turned inwards. The patient being firmly confined upon a table, I extended the limb by pullies, for fifty minutes without success, and he was returned to bed for three hours ; after which he was put in the warm bath for twenty minutes, and the extension Avas repeated for fifteen minutes unsuccessfully ; I therefore took twenty-four ounces of blood from him, and gave him forty drops of tinct. opii. Continuing the extension, but not succeeding in producing faintness, I gave small doses of a solution of tartrate of antimony, which, in a quarter of an hour, produced nausea ; in ten minutes afterwards, 1 succeeded in reducing the limb, and in less than a fortnight he left the Infirmary quite well. Unfortunately, he began to work hard immediately, and brought on an inflammation of the hip, of which he has not recovered.
Chester. S. R. Bennett.
42 PARTICULAR DISLOCATIONS.
CASE III.
Sir,
I beg leave to forward to you the particulars of the follow- ing case : —
John Lee, aged thirty-three, of a strong and robust constitu- tion, in passing over a foot-bridge, October 9th, 1819, fell from a height of about four feet on a large stone, and dislocated his left hip. I did not see him until the 4th of December, when I found the limb full three inches shorter than the other, the knee turned in, the foot directed over the opposite tarsus, and the trochanter major brought nearer the spinous process of the ilium. On laying the man on his face, the head of the femur and trochanter could be distinctly seen on the dorsum ilii, so as to leave not the slight- est doubt of the nature of the injury. With the assistance of a neighbouring practitioner, I immediately set about to reduce it ; a girt was applied between the legs, and a bandage over the knee, to fix the pullies, &c., in the usual manner. I then made the extension downwards and inwards, crossing the opposite thigh two thirds downwards ; and immediately when the extension was com- menced, I gave him a solution of two grains of tartar emetic, which was repeated five times every ten minutes, but it produced very slight nausea. I shortly after bled him to sixty ounces without syncope ; and after keeping up the extension gradually for about two hours, with all the force one man could employ with the pullies, we found the limb as long as the opposite; we then endea- voured to lift the head of the bone over the acetabulum, bv means of a towel under the thigh and over one of our heads, at the same
PARTICULAR DISLOCATIONS. 43
time rotating the limb outwards with all the force we were able to exert ; the foot at length became somewhat turned out, and the head of the bone to be less distinctly felt, and in about half an hour we heard a grating of the head of the bone, when the man instantly exclaimed it was replaced;* and, upon examination, find- ing the foot turned out, the limb of its natural length, and no appearance of the head of the bone on the dorsum ilii, we con- cluded it must be within the acetabulum, and desisted from any further violence, put the man to bed, and tied his legs together ; his foot iiiimediately became sensible, which it had not been before since the accident, and he altogether felt easier. A large blister was applied over the trochanter, and he slept well in the night, and complained of pain only in the perineum and just above the knee, where the bandages had been applied ; there was no subse- quent fever, nor any unpleasant symptom whatever.
In a few days the man could bear slight flexion and extension without pain, and in a week some degree of rotation ; the limb became gradually stronger, and the power of motion so increased, that on the twelfth day he could by himself bring the thigh at right angles with the body. He was now taken out of bed, and bandages were applied round the thigh and pelvis, and he could stand perfectly upright, so as to walk with his heel on the ground with the assistance of crutches: and, from exercise, he grew so rapidly stronger, that on the twenty-second day he left off one crutch, and on the twenty-fifth the other. In a month he was able
* 111 dislocations which have remained long unreduced, the bone does not usually snap into its socket at its reduction. — A. C.
G 2
44 PARTICULAR DISLOCATIONS.
to walk without a stick; and in five weeks, having particular business, he walked nearly twenty miles, perfectly upright, and without the least limping.
I am, my dear Sir, Collumpton, Devon. Your's very truly,
Jan. 27, 1820. S. Nott.
The following case forms a striking contrast to the preceding, and to some of those hereafter related.
CASE IV.
I was desired to visit a man aged twenty-eight years, who, by the overturning of a coach, had dislocated his left hip more than five weeks before ; and who had been declared not to have a dis- location, although the case was extremely well marked. His leg was full two inches shorter than the other ; his knee and foot were turned inwards ; and the inner side of the foot rested upon the metatarsal bones of the other leg. The thigh was slightly bent toAvards the abdomen, and the knee was advanced over the other thigh. The head of the thigh-bone could be distinctly felt upon the dorsum of the ilium ; and when the two hips were com- pared, the natural roundness of the dislocated side had disap- peared. I used only mechanical means in my attempts at reduction, and although I employed the puUies, and varied the direction of repeated extensions, I could not succeed in replacing the bone, and this person returned to the country with the dislo- cation unreduced.
PARTICULAR DISLOCATIONS. 45
The following' case was communicated by Mr. Norwood, surg-eon, Hertford.
CASE V.
William Newman, a strong muscular man, nearly thirty years of age, was admitted into Guy's Hospital, on Wednesday, Decem- ber 4th, 1812, under the care of Mr. Astley Cooper, for a dislo- cation of the hip-joint. In springing from the shafts of a waggon, on Thursday, November 7th, his foot slipped, and his hip was driven against the wheel with considerable force. He immediately fell, and being found unable to walk, was carried to Kingston Workhouse, which was near the place where the accident hap- pened. On the evening of that day, he was examined by a medical man, but the nature of the accident was not ascertained. He remained at Kingston until the SOth of November, knd was then removed to Guildford, his place of residence, and from thence, on the 4th of December, to Guy's Hospital. On examination, the head of the thigh-bone was found resting* on the dorsum ilii ; the trochanter was thrown forward towards the anterior superior spinous process of the ilium. The knee and foot were turned inwards, and the limb shortened one inch and a half; the great toe rested upon the metatarsal bone of the other foot, and there was but little motion in the limb.
On Saturday, the 7th of December, being thirty days after the accident, an extension was made to reduce the limb ; and previ- ously to the application of the bandage, he was bled to twenty-four ounces from his arm ; in about ten minutes after this he was put into a warm bath, where he remained until he became faint, which
46 PARTICULAR DISLOCATIONS.
happened in fifteen minutes ; he then had a grain of tartarized antimony given him, which was repeated in sixteen minutes, as the first dose did not produce nausea. The most distressing- nausea was now quickly produced, but he did not vomit ; and while under the influence of this debilitating cause, he was carried into the operating theatre in a state of great exhaustion. Being placed on a table on his left side, the bandage was applied in the usual manner to fix the pelvis, and the pullies were fastened to a strap around the knee ; the thigh was drawn obliquely across the other, not quite two thirds of its length downwards, and the extension was continued for ten minutes, when the bone slipped into its socket. The man was discharged from the hospital in three weeks from the period of his admission, making rapid pro- gress towards a recovery of the perfect use and strength of the limb.
For the history of the following case, I am obliged to Mr. Thomas, apothecary to St. Luke's Hospital, who attended this case while acting as dresser at St. Thomas's Hospital.
CASE VI. William Chapman, aged fifty years, was admitted into St. Thomas's Hospital, on Thursday, September 10th, 1812, with a dislocation of the left hip upon the dorsum ilii, which was occa- sioned by the mast of a ship falling upon the part and throwing him down, on the Wednesday sia? weeJcs prior to his admission into the hospital. It was reduced on Friday, the llth of September, in the following manner. The patient was bled by opening a
PARTICULAR DISLOCATIONS. 47
vein in each arm, and thirty-four ounces of blood were taken away. He was then put into a warm bath, and a grain of tarta- rized antimony given to him, which was repeated every ten minutes ; this, with the previous means, produced fainting and nausea.
The patient was then placed on a table on his right side, and a girt was carried between his thighs and over his pelvis, so as completely to confine it; a wetted roller was applied above the knee, and upon it a leathern belt, with rings for the puUies. The extension was then made in a direction causing the dislocated thigh to cross the other below its middle, and in half an hour the reduction was accomplished.
The three following cases shew that we are not to despair of success, even after a considerable time from the accident has elapsed.
CASE VII.
Mr. Mayo has mentioned the case of William Honey, who came into the hospital in August, 1812 : the dislocation had taken place seven weeks before, and was reduced the day after his admission ; he was discharged, cured, on the 18th of November. This was a dislocation on the dorsum ilii.
CASE VIII. Mr. Tripe, surgeon at Plymouth, has sent to the Medico-Chirur- gical Society, an account of a case of dislocation of the thigh-bone on the dorsum ilii, which had happened seven weeks and one day
48 PARTICULAR DISLOCATIONS.
prior to his making" an extension, in which he was so fortunate as to succeed in restoring' the bone to its natural situation.
The following instances prove, indeed, that the dislocation on the dorsum ilii may he reduced without pullies ; but they shew, at the same time, how desirable the pullies would have been, especially in the two first instances.
CASE IX.
William Piper, aged twenty-five years, sustained an injury from the wheel of a cart, laden with hay, which passed between his legs and over the upper part of his right thigh. IMr. Holt, sur- geon at Tottenham, was sent for nearly a month after the accident had happened ; he found him in great pain, attended with fever, and with much local inflammation and tension. He bled him largely, purged him freely, and applied leeches. The leg was shorter than the other, and the head of the bone was seated upon the dorsum ilii ; the knee and foot were turned inwards.
As I visited Tottenham frequently at that time, Mr. Holt asked me to accompany him to see the man, and we agreed to the propriety of making a trial at reduction. Mr. Holt and myself, assisted by five strong men, exerted our best endeavours for that purpose. Repeatedly fatigued, we were several times obliged to pause and then renew our attempts. At length, exhausted, we were about to abandon any further trial, but agreed to make one last effort; when, at fifty-two minutes after the commencement of the attempt, the bone slipped into its socket.
PARTICULAR DISLOCATIONS. 49
CASE X.
I also, in a case which I attended with Mr. Dyson, in Fore Street, succeeded in reducing the limb without the pullies ; but the violence used was so great, and the extension so unequal (our fatigue being nearly as severe as that of the patient), that I am confident no person who had used pullies in dislocation of the hip, would have recourse to any other mode, excepting in the disloca- tion into the foramen ovale.
CASE XL Mary Bailey, aged seven years, was admitted into Guy's Hospi- tal, June 16th, 1819, under the care of Mr. Astley Cooper, for a dislocation of the os femoris upwards on the dorsum ilii. This accident was occasioned by the child swinging on the shaft of a cart, which, being insecurely propped, suddenly gave way, and she fell to the ground upon her side. The nature of the accident was exceedingly evident ; the limb on the dislocated side was at least two inches shorter than the other ; the toe rested on the tarsus of the opposite foot, and was turned inwards ; the knee was also inverted and rested on the other. The child was admitted into the hospital at half-past five in the afternoon, the accident having happened a little more than half an hour before. Where so little resistance was expected the pullies appeared unnecessary, and towels were substituted, one being applied above the knee, and the other between the pudendum and thigh ; then, bending the knee, and bringing the thigh across the other just above the knee, gradual extension was made, and in about four minutes the head
H
50 . PARTICULAR DISLOCATIONS.
of the bone suddenly snapt into its socket. On the seventh day the child was walking in her ward, and suffered little inconvenience.
To Mr. Daniel, one of Mr. Lucas's dressers, I am obliged for the foregoing particulars ; he having reduced the limb in the presence of many of the students.
CASE XII.
In this case the extension was made at the ancle, and it is consequently worthy of attention;
My dear Sir,
William Sharpe, an athletic young man, in wrestling, received a fall ; his antagonist falling with and upon him, their legs were so entangled that he cannot say how he came to the ground. He complained of great pain in the hip, and was inca- pable of rising. About twenty minutes after the accident, I found him lying on his belly in the field where it had occurred, and the left limb in a trifling state of abduction, shortened, and the knee and foot turned inwards, the prominency of the trochanter gone, and the head of the bone obscurely felt on the dorsum ilii. He was conveyed home, and in order to reduce the dislocation, for such I considered it, I placed the man on his right side diagonally across a four-post bedstead. The centre of a large sheet, rolled up, was passed in front and behind the body, and fastened to the upper bed-post, as low as possible. The centre of a napkin, rolled in like manner, was then applied upon the dorsum ilii, between its crista and the dislocated bone ; and each extremity being brought
PARTICULAR DISLOCATIONS. 51
under the sheet, forwards and backwards, was reflected over it and tied in the centre, by which means I hoped to keep the pelvis secure ; the counter-extending* force was applied above the ancle (it appearing' to me to interfere less with the muscles upon the thigh), first, by rolling round a wetted towel, and then placing upon this the end of a long or jack-towel : three men were now directed to pull gradually and steadily ; and when I perceived that the head of the femur was brought down to the edge of the acetabulum, I raised it a little with my clasped hands, placed under the upper part of the thigh, and immediately the head of the bone entered the cotyloide cavity with a smart snapping noise. The man had considerable pain about the hip and knee for some time, but is now quite well.
I am, dear Sir, Nottingham, Your's truly,
August 8th, 1819. Henry Oldnow.
CASE XIII.
Dudley/, January 19^A, 1824. Dear Sir,
A youth, about sixteen or eighteen years of age, while at his work in a pit, was buried under a fall of coals ; and besides being severely injured in several other parts of his body, had one hip dislocated on to the dorsum of the ilium, and the same thigh broken about the middle of the bone. As the reduction of the hip was, of course, impracticable, the thigh was bound up in the usual manner, and treated without any reference to the dislocation of the joint, with a hope that when the thigh-bone was re-united,
H 2
52 PARTICULAR DISLOCATIONS.
tlie hip might possibly be reduced. At the end of five weeks, the bone appearing tolerably firm, I had a very careful but unremitting extension of the limb made by means of pulUes, and, in less than half an hour, had the satisfaction of feeling the head of the bone re-enter the socket. It is very probable that the reduction would have been accomplished in less time, had I dared to allow a more powerful extension of the limb, but I very much feared lest a separation of the newly united bone should be produced by it. The patient became so upright as to shew scarcely any signs of lameness afterwards.
I have met with several instances of these accidents conjoined with another injury, which at first sight presented a complication sufficiently embarrassing, but without being, in reality, productive of much additional difficulty. I allude to cases in which, with dislocation of one hip, there has been a fracture of the bone of the opposite thigh. In such circumstances I have fixed some splints temporarily, but very firmly, upon the broken limb, and then, turning the patient on that side, have proceeded to the reduction of the dislocated hip in the usual way. After this has been accomplished, I have taken the splints from the broken limb, and bound it up again in the customary manner; and every case which I have seen has done well, without any additional inconvenience.
I once witnessed a case, which I mention rather for its singu- larity than for any practical inference which it furnishes. — A man had received (I forget how) a severe hurt on one of his hips. When laid on a bed for examination, the thigh-bone was found not to be broken, and the limbs were exactly of the same length ;
PARTICULAR DISLOCAtlONS. 53
but the foot of the injured side turned somewhat inwards, and any attempt to move the hip-joint was extremely painful. On a more careful examination of the parts about the hip, it was plain that the thigh-bone was dislocated, and that its head was on the dorsum of the ilium, and yet the limb seemed not at all shortened. A brief enquiry, however, led to an explanation of this apparent anomaly. It appeared that the opposite thigh-bone had been formerly broken, and had united in such a way as to leave the limb several inches shorter than it had originally been ; and the dislocation of the other thigh upwards, had now brought that to a corresponding length. It is scarcely needful to add, that the reduction of the dislocation restored the patient to his former lameness, and to the deformity produced by limbs of unequal length.
With the greatest respect,
I remain, dear Sir,
Your most obedient Servant,
John Badley. To Sir Astley Cooper.
CASE XIV.
Dislocation of the Thigh upon the Dorsum Ilii, with Fracture of the Thigh-Bone.
Abraham Harman, aged thirteen years, a patient under Mr. Forster, in Guy's Hospital, gave the following account of his accident :
54 PARTICULAR DISLOCATIONS.
About four months since, he drove his master's horses to a chalk- pit ; he went down into the pit to pack the chalk, and to break it into small pieces, and whilst he was thus occupied, the side of the pit gave way, and a large piece of chalk striking him violently on the hip, knocked him down. Being immediately taken to a neighbouring public-house, a surgeon was sent for. The thigh was discovered to be fractured near its middle, but very consider- able contusions prevented the dislocation from being at first discovered. Fomentation and other means of reducing the swell- ing at the hip being employed, it was ascertained that the thigh was also dislocated, and some attempts were made to reduce it ; but the fracture would not then bear the extension, and the boy was sent to the hospital. No attempts have been made to reduce the bone.
This case presented unusual difficulties ; and the probability is, that dislocation thus complicated with fracture, will, generally, not admit of reduction ; as an extension cannot be made, until three or four months have elapsed from the accident, and then only with strong splints upon the thigh, to prevent the risk of disuniting the fracture.
CASE XV.
Marlborough, Feb, 12, 1823. Sir,
Permit me to send you the following case of dislocation of the thigh-bone on the dorsum of the ilium.
George Davies, aged thirty-five, on the first of the present
PARTICULAR DISLOCATIONS. 55
month, in descending a flight of steps at a mill in this neighbour- hood, with a sack of wheat on his back, missed a step or two, and in endeavouring to regain his footing, the whole weight of the load fell upon him, and the violence of the shock bore him down several steps lower, where he lay totally incapable of further motion till assistance was procured.
He was then conveyed to the adjoining village. On examina- tion, the limb was found considerably shorter than its fellow, the foot turned inwards, and resting upon the tarsus of the other leg. The head of the bone was distinctly felt, lodged among the glutei muscles. All the other symptoms were unequivocal. In about three hours after the occurrence of the accident, due preparation having been made, thirty ounces of blood were taken from the arm, the pullies were adjusted according to your directions, and gradual extension being made, the head of the bone was even- tually brought on a line with the acetabulum ; a towel was now passed under the thigh, by which means the bone was elevated, and suddenly, with an audible snap, it slipped into its proper cavity. The man is going on well, but as he is still suff'ering from the effect of the contusion, he has not been allowed to make much use of his limb.
I am, Sir,
Your's respectfully,
T. Maurice.
P. S. The reduction was accomplished in about ten minutes.
"v
56 PARTICULAR DISLOCATIONS.
DISLOCATION DOWNWARDS, OR INTO THE FORAMEN OVALE.
Anatomy.
accident.
The foramen ovale is formed by the junction of two bones, the ischium and the pubes ; it is situated below the acetabulum, and is somewhat nearer the axis of the body. It is filled by a lig-ament which proceeds from the edges of the foramen, and has an opening in its upper and anterior part, to permit the passage of the obtu- rator blood-vessels, and the obturator nerve. It is covered on its external and internal surface by the obturator externus, and obturator internus muscles. Mode of This dislocation happens when the thighs are widely separated
from each other. The ligamentum teres and the lower part of the capsular ligament are torn through, and the head of the bone becomes situated in the posterior and inner part of the thigh, upon the obturator externus muscle.
It has been erroneously supposed, that the ligamentum teres is not torn through in this dislocation ; because in the dead body, when the capsular ligament is divided, the head of the bone can be drawn over the lower edge of the acetabulum without tearing the ligamentum teres. But the dislocation in the foramen ovale happens whilst the thighs are widely separated, during which act the ligamentum teres is upon the stretch ; and when the head of the bone is thrown from the acetabulum, this ligament is torn through before it entirely quits the cavity.
The limb is in this case two inches longer than the other. The head of the bone can be felt by pressure of the hand, upon the
Symptoms.
PARTICULAR DISLOCATIONS. 57
inner and upper part of the thigh towards the perineum, but only in very thin persons. The trochanter major is less prominent than on the opposite side. The body is bent forwards, owing to the tension of the psoas and iliacus internus muscles. The knee is considerably advanced if the body be erect ; it is widely separated from the other, and cannot be brought, without great difficulty, near the axis of the body to touch the other knee, owing to the extension of the glutei and pyriformis muscles. The foot, though widely separated from the other, is, generally, neither turned outwards nor inwards, although I have seen it varying a little in this respect in diiferent instances ; but the position of the foot does not in this case mark the accident. The bent position of the body, the separated knees, and the increased length of the limb, are the diagnostic symptoms. ^ The position of the head of the bone is below, and a little anterior to, the axis of the ace- tabulum ; and a hollow is perceived below Poupart's ligament.
We have an excellent preparation of this accident in the col- Dissection. lection at St. Thomas's Hospital, which I dissected many years ago. The head of the thigh-bone was found resting in the foramen ovale, but the obturator externus muscle was completely absorbed, as well as the ligament naturally occupying the foramen, now entirely filled by bone. Around the foramen ovale, bony matter was deposited so as to form a deep cup, in which the head of the thigh-bone was inclosed, but in such a manner as to allow of considerable motion ; and the cup thus formed, surrounded the neck of the thigh-bone without touching it, and so inclosed its head, that it could not be removed from its new socket without breaking its edges. The inner side of this new cup was extremely
I
58 PARTICULAR DISLOCATIONS.
smooth, not having the least ossific projection at any part to impede the motion of the head of the bone ; which was only- restrained by the muscles from extensive movements. The original acetabulum was half filled by bone, so that it could not have received the ball of the thigh-bone if an attempt had been made to return it into its natural situation. The head of the thigh-bone was very little altered ; its articular cartilage still remained ; the ligamentum teres was entirely broken, and the capsular ligament partially torn through ; the pectinalis muscle and adductor brevis had been lacerated, but were united by tendon ; the psoas muscle and iliacus internus, the glutei and pyriformis, were all upon the stretch. Nothing can be more curious, or, to the surgeon and physiologist, more beautiful, than the changes produced by this neglected accident, which exemplify the resources of nature in producing restoration.
The reduction of this dislocation is in general very easily effected. If the accident has happened recently, it is requisite to place the patient upon his back, to separate the thighs as widely as possible, and to place a girt between the pudendum and the upper part of the luxated thigh, fixing it to a staple in the wall. The surgeon then puts his hand upon the ancle of the dislocated side, and draws it over the sound leg, or, if the thigh be very large, behind the sound limb, and the head of the bone slips into its socket. Thus I saw a dislocation reduced, which had happened very recently, and which was subjected to an extension in St Thomas's Hospital, almost immediately after the patient's admission. In a similar case, the thigh might be fixed by a bed-post received between the pudendum and the upper part of the limb, and the leg be carried
Reduction.
PARTICULAR DISLOCATIONS. 59
inwards across the other. But in general it is required to fix the pelvis by a girt passed around it, and crossed under that which passes around the thigh, to which pullies are to be attached, otherwise the pelvis will move in the same direction with the head of the bone. (See plate.)
In those cases in which the dislocation has existed for three or four weeks, it is best to place the patient upon his sound side ; to fix the pelvis by one bandage, and to carry under the dislocated thigh another bandage, to which the pullies are to be affixed perpendicularly; then to draw the thigh upwards, whilst the surgeon presses down the knee and foot, to prevent the lower part of the limb being drawn with the thigh-bone. Thus the limb is used as a lever of very considerable power. Great care must be taken not to advance the leg in any considerable degree, otherwise the head of the thigh-bone will be forced behind the acetabulum into the ischiatic notch, from whence it cannot be afterwards reduced.
Dislocation of the Right Thigh into the Foramen Ovale.
CASE I.
A gentleman was thrown from his horse on the 4th of January, 1818, by the animal suddenly starting to the right side; and whilst he endeavoured to keep his seat by the pressure of the right thigh against the saddle, he was thrown, and from the fall received a severe contusion upon his head, which produced alarming symp- toms. On the following day it was observed that the right thigh
I 2
60 PARTICULAR DISLOCATIONS.
was useless, and that the knee was raised and could not be brought into a straight line with the other, having- at the same time a direction outwards, which required it to be tied to the other knee : the symptoms of injury to the head precluded, at this time, the attempt at reduction. In fourteen days he w'as so far recovered that he was able to rise from his bed, and in a month he began to walk with crutches.
On November 1st, 1818, I first saw him ; and the appearances of the injured limb were then as follow: — the thigh was longer than the other by the length of the patella; the knee was ad- vanced; and when he was in the recumbent posture, the injured leg could not be drawn down to the same length with the other. The upper part of the thigh-bone was thrown backwards, so as to render the hollow of the groin on the injured side deeper than that on the other. The toes were rather everted, but when the body was erect, were capable of resting on the ground, though the heel was not. The head of the bone could not be felt, and the trochanter was much less prominent than usual. When the upper part of the thigh-bone was pressed against the new acetabulum, and moved, there was a sensation of friction between two cartila- ginous surfaces, which, although not easily described, is readily distinguished from the crepitus occasioned by a fractured bone. In a sitting posture the injured leg was two inches longer than the other ; and to that degree the knee was projected beyond the sound one. In progression the knee was bent; and the body being thrown forwards the patient rested chiefly upon his toe, and halted exceedingly in walking. The sartorious and gracilis muscles were very much put upon the stretch. At first he suflTered much
PARTICULAR DISLOCATIONS. 61
from pain in the dislocated hip and thigh, but is now free from pain, unless when he attempts to stand on that limb only. His toe, at first, was with difficulty brought to the ground, but he is now improved in walking ; for when he first made trial, with the ,
assistance of a crutch and stick, he could not exceed half a mile, but he is now capable to walk two miles. In flexion his thigh admits of considerable motion, but he cannot extend it further • than to bring the ham to the plane of the other patella. The knees cannot be brought together, but he advances one before the other in the attempt. He can sit without pain, but the jolting of a carriage hurts him exceedingly ; and the attempt to sit on horse- back produces excessive suffering. He cannot straighten his leg when his body is erect, nor can he stoop to tie his shoe on the injured side. Pain is produced by resting on that hip in bed. No attempt was made to reduce the limb ; the injury to the head might have rendered it dangerous in the commencement, and at the time Avhen I saw him there was no chance of success.
Sir,
Inclosed is the case of dislocation which you requested me to forward to you, and I am sorry it has not been in my power to put you in possession of it before, for reasons which I stated when I saw you last.
I am. Sir, LeadenJiall Street, Your obliged Servant,
February 18^^, 1820. J. S. Daniell.
62 ' PARTICULAR DISLOCATIONS.
Dislocation of the Right Femur Downwards, or into the
Foramen Ovale.
CASE II.
Mr. Thomas Clarke, a farmer, about fifty years of age, was driving home in his cart from market, when the horse took fright and ran away with him. The following is the account he gives of the manner in which the accident happened : — in his endeavour to stop the horse, he fell over the front of the cart on his face, and the knee struck against some part of it in the act of falling, by which means the thighs were separated ; the wheel, he also states, passed over his hip.*
My friend, Mr. Potter, of Ongar, in Essex, whose ability as a surgeon in that neighbourhood is justly appreciated, was con- sulted in this case, between two and three weeks after the accident had happened ; and, as I was visiting him at the time, I had the pleasure of accompanying him.
The nature of the accident was extremely evident ; the limb was fully three inches longer than the other, the body bent for- wards, the knees separated, and the foot rather inclined outwards ; these were the leading diagnostic marks. Mr. Potter, having clearly ascertained the position of the dislocated limb, I accom- panied him the following morning, in order to assist in the reduction ; and the following were the means employed.
Our first object was to produce relaxation ; and finding the
Query. — Was this, or the extended state of the limbs, the cause of the dislocation ?
PARTICULAR DISLOCATIONS. 63
patient was sufficiently strong to bear the plan usually recom- mended in cases of dislocation, where much resistance is ex- pected, we drew away some blood from the arm ; this, however, was not sufficient for our purpose, and a solution of tartar emetic, which we had brought with us, was administered. The patient was laid upon his side, close to the edge of the bed (that being the most convenient place), a girt was passed round the pelvis, and carried through the frame of the bedstead, which completely prevented the possibility of the body moving whilst extension was going on ; a second girt was applied between the thighs, fixed to the one above, to which the puUies were attached. Whilst extension was making, Mr. Potter took hold of the limb at the knee, and drew it rather upwards, and towards the sound thigh, occasionally rotating the limb. When the extension had been continued about ten minutes, the nausea produced by the tartar emetic was so excessive, that the patient begged of us to desist until the morrow, observing, he felt so bad that he was fearful of falling off the bed : this exclamation, it hardly need be said, was a stimulus to our proceeding ; and in five minutes after, the limb was suddenly heard to snap into its original cavity. The patient was put to bed, a roller being applied round the pelvis, and at the end of five days, he felt so well that he left his room ; and at the expiration of a short time, suffered no other inconvenience than stiffness in the joint.
J. S. Daniell. Mr. Daniell's knowledge of his profession, and his zeal in the pursuit of it, which I have had frequent opportunities of observing, will ensure his success whenever he embarks in practice.
A. C.
64 PARTICULAR DISLOCATIONS.
Mischief Although a dislocation into the foramen ovale may be occasion-
from im-
properex- ally rcduced by attempts made in a very inappropriate direction, yet an instance has occurred which shews the mischief that may arise from an error in this respect.
casg I once saw the following case : — a boy, sixteen years old, had
a dislocation of the thigh into the foramen ovale : he was placed upon his sound side, and an extension of the superior part of the thigh was made perpendicularly ; the surgeon then pressed down the knee, but the thigh being at that moment advanced, the head of the bone was thrown backwards, and passed into the ischiatic notch ; from which situation it could not be reduced.
I am indebted to Mr. Key, for the particulars of the annexed case, which was admitted into Guy's Hospital, under Mr. Forster.
Dislocation of the Thigh into the Foramen Ovale.
CASE in.
Stephen Holmes, aged forty-one, while working in a gravel pit, at Camberwell, was suddenly overwhelmed by a large mass of gravel, and remained buried under it, till dug out by his com- panions. When the gravel was removed, he was found in a sitting posture with his legs widely separated, and unable to approximate them. In this position he was brought to Guy's, about seven o'clock in the evening, an hour after the accident had happened, and was placed under the care of Mr. Carey, dresser to Mr. Forster.
PARTICULAR DISLOCATIONS. Q^
Being undressed and placed in bed in the recumbent posture, he was seen lying with his left thigh bent upon the pelvis, his knee consequently elevated, and the whole limb fixed at a con- siderable distance from the other. On carrying the eye to the upper part of the thigh near the hip-joint, a considerable change in form was manifest ; the projection of the trochanter was entirely lost, and in its place a deep hollow was perceptible ; and at the inner part of the thigh, near the pubes, a distinct projection appeared, having the form of the head of the bone covered bv the adductor muscles. From these general appearances, we regarded the accident as a dislocation of the femur into the foramen ovale of the pelvis, and proceeded to make a more minute examination of the limb, to ascertain the precise nature of the injurv.
The man was desired to rise from his bed and sit on the edge of it, which he did without inconvenience or pain ; in this position his left knee projected at least two inches and a half beyond the sound limb ; this apparent elongation of the leg, arose prin- cipally from the oblique bearing of the pelvis, the real elongation being afterwards ascertained to be not more than an inch and a quarter. In the erect posture, which he maintained with some difficulty, his body was bent forward in consequence of the pro- jection of the pelvis over the thigh ; the knee was bent, and the toe, which was slightly inverted, rested on the ground ; the whole limb was advanced before the sound one, and remained in a state of abduction. He was then laid upon a firm table on his back, and the capability of motion in the limb was carefully noted. His knee was first bent toward his breast without any difficulty, and to as full an extent as the opposite limb ; the power of
K
66 PARTICULAR DISLOCATIONS.
abduction was also complete, and the attempt was unattended with pain ; but extension and adduction of the thigh were the motions most impeded. When the limb was made to approximate to the sound one, which could not be done without producing- pain and numbness on the inner side of the thigh, the patellae remained eleven inches distant from each other; and as soon as the hand was withdrawn from the ancle, the leg flew outward with a spring, from the reaction of the two small glutcei. The limb could not be carried backward, but remained permanently bent at the hip- joint ; and when any attempt was made to fix it, the patient com- plained of great pain in the direction of the psoas and iliacus muscles. The depression observed at the site of the trochanter was such as to render it difficult to feel that process ; while on the inner side of the thigh, a distinct projection was formed by the head of the bone, which could be felt under the adductors. These latter muscles were rendered very tense by the projecting bone. The nates appeared to preserve their usual form.
Reduction. — Having never had an opportunity of witnessing this kind of dislocation since my attendance at the hospitals, during the last eight years, I wished to see how far the method of reduction which you have laid down was applicable in the pre- sent case. Your " Treatise on Dislocations and Fractures" being in the hands of one of the students, we referred to the plate, and proceeded to apply the pullies and bandage in the manner there delineated. The apparatus being once carefully and securely adjusted, required no alteration, as it neither slipped from its situ- ation, nor occasioned any inconvenience to the patient. Extension was then made by drawing the displaced limb across its fellow.
PARTICULAR DISLOCATIONS. Q^
while the piilHes drew the head of the bone outwards ; but in doing this, we ran some risque of throwing the head of the femur into the ischiatic notch ; for the thigh being large and fleshy at the back part, was, when drawn across the other, necessarily carried somewhat forward, and thus tilted the head of the bone backward : had any alteration taken place in the situation of the head of the femur during this extension, it would have been carried under the acetabulum into the ischiatic notch, it was therefore thought adviseable to carry the leg behind the sound one ; and as soon as this was done, the head returned, with an audible crash, into the acetabulum. The whole extension occupied fifteen minutes.
This species of dislocation of the femur, is by far the most easy of reduction of any that has come under my observation ; and it may be presumed, that had the leg at first been carried behind instead of before the other, the replacement of the limb might have been effected immediately. Where the limb is large it is impossible to carry it in a right line across its fellow; and, perhaps, in order to avoid the danger to which I have alluded, and which I have often heard you point out in your lectures, it would be as well to adopt the line of extension which in this instance answered so well.
October 15, 1822. — This patient could stand by the side of his bed without support in a week after the accident.
W. A. Key.
K 2
68
PARTICULAR DISLOCATIONS.
structure.
DISLOCATION BACKWARDS, OR INTO THE ISCHIATIC NOTCH.
Anatomical TliG spacc which is called the ischiatic notch is bounded above and anteriorly by the ilium, posteriorly by the sacrum, and inferi- orly by the sacro-sciatic ligament. It is formed for the purpose of giving passage to the pyriformis muscle and to the sciatic nerve, as well as to the three arteries, the glutseal, the ischiatic, and the internal pudendal. In the natural position of the pelvis, it is situated posteriorly to the acetabulum and a little above its level. When the head of the bone is thrown into this space, it is placed backwards and upwards, with respect to the acetabulum ; therefore, although I call this the dislocation backwards, it is to be remembered that it is a dislocation backwards and a little upwards.
In this dislocation the head of the thigh-bone is placed on the pyriformis muscle, between the edge of the bone which forms the upper part of the ischiatic notch, and the sacro-sciatic ligaments, behind the acetabulum, and a little above the level of the middle of that cavity.
This dislocation is the most difficult both to detect and to reduce : to detect, because the length of the limb differs but little, and its position, in regard to the knee and foot, is not so much changed as in the dislocations upwards : to reduce, because the head of the bone is placed deep behind the acetabulum, and it therefore requires to be lifted over the edge of that cavity, as well as to be drawn towards its socket.
Nature of the accident.
Detection difficult.
PARTICULAR DISLOCATIONS. 69
The signs of this dislocation are, that the limb is from half an signs, inch to one inch shorter than the other, but generally not more than half an inch ; that the trochanter major is behind its usual place, but is still remaining nearly at right angles with the ilium, with a slight inclination towards the acetabulum. The head of the bone is so buried in the ischiatic notch that it cannot be distinctly felt, except in thin persons, and then only by rolling the thigh-bone forwards as far as the comparatively fixed state of the limb will allow. The knee and foot are turned inwards, but less than in the dislocation upwards ; and the toe rests against the ball of the great toe of the other foot. When the patient is standing, the toe touches the ground, but the heel does not quite reach it. The knee is not so much advanced as in the dislocation upwards, but is still brought a little more forwards than the other, and is slightly bent. The limb is so fixed that flexion and rotation are in a great degree prevented.
We have a good specimen of this accident in the collection at Dissection. St. Thomas's Hospital, which I met with accidentally, in a subject brought for dissection. The original acetabulum is entirely filled with a ligamentous substance, so that the head of the bone could not have been returned into it. The capsular ligament is torn from its connection with the acetabulum, at its anterior and posterior junction, but not at its superior and inferior. The ligamentum teres is broken, and an inch of it still adheres to the head of the bone. The head of the bone rests behind the aceta- bulum on the pyriformis muscle, at the edge of the notch, above the sacro-sciatic ligaments. The muscle on Avhich it rests is diminished, but there has been no attempt made to form a new
70 PARTICULAR DISLOCATIONS.
bony socket for the head of the os femoris. Around the head of the thigh-bone a new capsular hgament is formed ; it does not adhere to the articulatory cartilage of the ball of the bone which it surrounds, but could, when opened, be turned back to the neck of the thigh-bone, so as to leave its head completely exposed. Within this new capsular ligament, which is formed of the surrounding cellular membrane, the broken ligamentum teres is found. (See plate.) The trochanter major is placed rather behind the acetabulum, but inclined towards it relatively to the head of the bone.
In this specimen, from the appearance of the parts, the dislocation must have existed many years ; the adhesions were too strong to have admitted of any reduction, and if reduced, the bone could not have remained in its original socket. Cause. This spccics of dislocation is produced by the application of
force, when the body is bent forward upon the thigh, or when the thigh is bent at right angles with the abdomen ; when, if the knee be pressed iuAvard, the head of the bone is thrown behind the acetabulum.
The reduction of the dislocation in the ischiatic notch, is, in general, extremely difficult, and is best effected in the following manner : the patient should be laid on a table upon his side, and a girt should be placed between the pudendum and the inner part of the thigh, to fix the pelvis. Then a wetted roller is to be applied around the knee, and the leathern strap over it. A napkin is to be carried under the upper part of the thigh. The thigh- bone is then to be brought across the middle of the other thigh, measuring from the pubes to the knee, and the extension is to be
PARTICULAR DISLOCATIONS. 71
made with the pullies. Whilst this is in progress, an assistant pulls the napkin at the upper part of the thigh with one hand, rests the other upon the brim of the pelvis, and thus lifts the bone, as it is drawn towards the acetabulum, over its lip. For the napkin I have seen a round towel very conveniently substituted, and this was carried under the upper part of the thigh, and over the shoulders of an assistant, who then rested both his hands on the pelvis, as he raised his body, and lifted the thigh. (See plate.) Although the preceding is the method in which this dislo- cation is most easily reduced, yet I have seen a different mode practised; and I shall mention it here, as it shews how the muscles opposing the pullies, will draw the head of the bone to its socket, when it is lifted from the cavity into which it has fallen.
CASE L A man, aged twenty-five, was admitted into Guy's Hospital, under the care of Mr. Lucas ; upon examination, the thigh was found dislocated backwards ; the limb scarcely differed in length from the other, not being more than half an inch shorter; the groin appeared depressed ; the trochanter was resting a little behind the acetabulum, but inclined upon it ; the knee and foot were turned inwards, and the head of the bone could, in this case, be felt behind the acetabulum. An extension was made by pullies in a right line with the body ; at the same time, the trochanter major was thrust forward with the hand, and the bone returned in about two minutes into its socket with a violent snap.
I have already mentioned, that I have seen no instance of a
72 PARTICULAR DISLOCATIONS.
dislocation dotvnwards and backwards ; and when I state, that I have been an attentive observer of the practice of our hospitals for thirty years, was also for many years in the habit of daily seeing the poor of London at my house early in the morning", and have had a considerable share of private practice, I may be allowed to observe, that if such a case does ever occur, it must be ex- tremely rare. I cannot help thinking, also, that some anatomical error must have given rise to this opinion, as, in the dislocation downwards and backwards, the head of the bone is described as being received still into the ischiatic notch ; but this notch is, in the natural position of the pelvis, above the level of the line drawn through the middle of the acetabulum ; and hence it is, that the leg becomes, not shorter, but longer, when the bone is dislocated into the ischiatic notch.
Dislocation of the Right Thigh into the Ischiatic Notch.
The following case I received from Mr. Rogers, a very intel- ligent surgeon, at Manningtree.
CASE ir.
Dear Sir,
William Dawson, aged thirty-four, on the 15th of August, 1818, while spending his harvest-home with several of his companions, became quarrelsome with one of them, who threw him down and trod upon him. Upon extricating himself, and endeavouring to rise, he found some serious injury to his right
PARTICULAR DISLOCATIONS. 73
thigh, rendering him incapable of standing ; in this state he was dragged by his associates for many hundred yards into a stable, where he lay till the next morning. I then saw him lying upon a mattress, with the hip and thigh, on the right side, prodigiously swollen and painful ; and I was particularly struck with the appearances of the knee and foot on the same side, which were very much turned inwards, but the limb was scarcely shortened. T ordered him to be carefully conveyed home upon a shutter, supported by six men, a distance of about half a mile. From the immense swelling and general enlargement of the whole of the thigh, and of the soft parts around the pelvis, it was impossible to ascertain exactly the state of the injury ; but it was fully impressed upon my mind, that there was some unusual dislocation of the head of the thigh-bone. He was accordingly ordered immediately to lose blood, both by general and topical means, and emollient poultices were applied to the whole of the swollen parts ; brisk purgatives were also administered, succeeded by saline medicines, and a quiet position was enjoined for eleven days, by which time the swelling began somewhat to subside. Still the precise nature of the injury was not satisfactorily evident ; but it was thought by Mr. Nunn, of Colchester, and Mr. Travis, of East Bergholt, who had kindly come over to witness it, that there was a luxation. The only difficulty we had in reconciling this notion to ourselves was, the belief in our minds that no author had adduced an instance of this accident, without an alteration in the length of the limb, except it might be Mr. Astley Cooper, in his new publication, which neither of us had yet seen. We accordingly had recourse to a minute examination of the skeleton ;
L
J4: PARTICULAR DISLOCATIONS.
when we immediately fancied we could account for the absence of the usual marked signs of displacement of the head of the bone, excepting the inversion of the knee and foot, in this kind of luxa- tion ; for we noticed, that if the head of the bone be luxated sideways into the ischiatic notch, it will produce scarcely any difference in the length of the limb. Trusting that a little further delay might not be attended with any material disadvantage, but give a chance for the entire subsidence of all the inflammation and swelling, we proposed meeting again as soon as we conveniently could, by which time we might consult Mr. Cooper's book. We accordingly met on Sunday, the 30th of August, which was fifteen days after the accident ; and from the complete removal of all swelling, the whole of the femoral bone was satisfactorily traced to its rounded head, which was lodged in the ischiatic notch. Upon referring to the "Essays," which we had now before us, we had the case delineated and described ; and as it was exhibited in a plate, we had only to imitate, in order to accomplish the reduction of the bone. In the presence of two or three other medical gentlemen, who had now joined us, we commenced the operation ; and as it would be unnecessary to state every par- ticular, considering the manner in which the position of the patient, and the fixing of the pullies and towels, are demonstrated by that publication, suffice it for me to remark, that, after ten or twelve minutes of gradual extension, the reduction of the bone was most readily and admirably accomplished.
Preparatory to commencing the operation, we took thirty ounces of blood from the arm ad deliquium, and afterwards, while fixing the pullies, &c., we gave four grains of tartarized
PARTICULAR DISLOCATIONS. 75
antimony, at intervals, to produce nausea. Immediately after the operation, we gave one grain of opium, applied sedative lotions to the parts, and proceeding carefully for about a fortnight, the patient was enabled to move upon crutches, and was shortly after sent home perfectly well.
I am your's, Manningtree, John Rogers.
August 15thf 1818.
The relation of the foregoing case, from the kind manner in which Mr. Rogers has expressed himself, may savour a little of vanity ; but I shall readily suffer this imputation ; as it will ever be ray greatest gratification to find that my humble endeavours may, in the slightest degree, have conduced to the advantage of my professional brethren, or to the benefit of those who may be placed under their care.
The dislocation in the ischiatic notch has been, as far as I incorrect know, in every author who has written on the subject, incorrectly by authors. described ; for it has been stated, that the limb was lengthened in this accident, and I need scarcely mention the mistakes in prac- tice to which so erroneous an opinion has given rise ; one instance, however, of such an error I must here give. A gentleman wrote to me from the country in these words : — " I have a case under my care of injury to the hip, and I should suppose it a dislocation into the ischiatic notch, but that the limb is shorter, instead of being longer, as authors state it to be." Into this error those authors must have fallen from having examined a pelvis separated
L 2
'^6 PARTICULAR DISLOCATIONS.
from the skeleton, and observed that the ischiatic notch was below the level of the acetabulunci when the pelvis was horizontal, although it is above the acetabulum in the natural oblique position of the pelvis, at least, as regards the horizontal axis of the two cavities. It is to be remembered, that there is no such accident as a dislocation of the hip downwards and backwards.
CASE III.
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 June, he slipped, and dislocated the left hip-joint ; and the following is the account he gives of the accident: — the foot on the affected side was plunged suddenly into a hollow in the road, which turned his knee inwards at the same time that his body fell with violence forwards. On the day on which the accident happened, two attempts were made to reduce the dislocation by puHies, but without success ; and, on the 27th of June, a third, but equally unsuccessful, trial was made, although continued for nearly an hour. He was directed to Guy's Hospital by IMr. Stewart, surgeon at Hastings.
It was found upon examination, after he had been admitted, that the thigh was dislocated backwards into the ischiatic notch, the limb was a little shortened, the knee and foot were turned inwards, and the toe rested on the ball of the great toe of the other foot ; the head of the bone could not be felt ; the trochanter major was opposite the acetabulum, the rim of which could be distinctly perceived. When the body was fixed, the thigh could
PARTICULAR DISLOCATIONS. 77
be bent so as nearly to touch the abdomen. 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, gradu- ally administered, extension was made with the pullies 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 nau- seated ; the attempts, however, at reduction, did not succeed.
On the 3rd of August, the tenth day from the accident, Mr. Astley Cooper succeeded in reducing it in the following manner: — he ordered so much blood to be taken from the arm as to produce a feeling of faintness. A table was placed in the centre, between two staples, upon which the patient was laid on his right side ; a girt was passed between the scrotum and the thigh, and carried over the pelvis to the staple behind him ; and thus the pelvis was, as far as possible, fixed; a wetted roller was carried around the lower part of the thigh, just above the knee, and a leathern strap buckled on it, to which, and to a staple before the limb, the pullies were fixed. The body was bent at right angles with the thigh, which crossed the upper part of the other thigh : then the extension with the pullies was begun, and gradually increased until it became as great as the patient could bear. An assistant was then directed to get upon the table, and to carry a strong band under the upper part of the thigh, by which he lifted it from the pelvis, so as to give an opportunity for the head of the bone to be turned into its socket. Mr. South, who held the leg.
78 PARTICULAR DISLOCATIONS.
was directed to rotate the limb inwards, and the bone, in thirteen minutes, was heard to snap suddenly and violently into its socket.
James Chapman,
Dresser at Guys Hospital. To whom I am indebted for the foreg'oing statement.
I believe that, in this case, I should not have succeeded in reducing the limb, but from attention to two circumstances : first, I observed that the pelvis advanced within the strap which was employed to confine it, so that the thigh did not remain at right angles ; and I was obliged to bend the body forwards to preserve the right angle during extension ; and, secondly, the extension might have been continued for any length of time, yet the limb would never have been reduced, but by the rotation of the head of the thigh-bone towards the acetabulum.
Mr. Wickham, jun. of Winchester, has had the kindness to inform me of a case of this dislocation which had been admitted into the Winchester Hospital, under the care of Mr. Mayo, one of the surgeons of that Institution, whose permission I have to state the following circumstances.
CASE IV.
Winchester, August 10, 1819. John Norgott, aged forty, was brought to the hospital on the 27th of December, 18175 from the neighbourhood of Alton, with
PARTICULAR DISLOCATIONS. 79
an injury of the hip ; twelve days had elapsed since the accident, without his being aware of the nature of the injury. He reported that his horse had fallen with him and on him, so that one leg was under the horse, whilst his body was in a half-bent position, leaning against a bank. He was of middle stature, but very muscular ; the leg was very inconsiderably shorter than the other, and but little advancing over it ; in fact, the immobility of the limb was the chief criterion of the dislocation ; for the head of the bone was thrown into the ischiatic notch. The mode of reduction was simple : Mr. Mayo had the limb extended by the pullies, so as to bring the head of the bone to the edge of the acetabulum, over which it was then tilted by a towel, fastened round the patient's thigh and the neck of an assistant. The man remained three or four weeks before he was allowed to leave the house ; but on the 4th of February he was discharged, cured.
The following case was communicated by Mr. Worts, dresser to Mr, Chandler, surgeon to St. Thomas's Hospital.
CASE V. James Hodgson, a sailor, aged thirty-eight years, a strong- muscular man, was admitted into St. Thomas's Hospital, on Tuesday, the 18th of February, for an injury which he had received in his left hip ; his foot was raised from the ground upon a chest of fruit, when another fell upon his thigh, striking the knee inwards ; he fell, and being taken up extremely hurt, he was directly brought to the hospital. Upon examination, I conceived that it was a dislocation of the hip-joint, and that the
80 PARTICULAR DISLOCATIONS.
head of the bone was thrown into the ischiatic notch. Some difference of opinion, however, arose upon the subject ; and as considerable tension existed, which prevented the head of the bone from bein^ distinctly felt, I ordered an evaporating lotion, and left the case for future investigation. Upon further consider- ation, my opinion was strengthened concerning the nature of the injury, as it was clearly pointed out by the diminished length of the leg, which was three quarters of an inch shorter than the other, and by the inversion of the foot ; although there was in this case more power of flexion in the limb than might have been expected, but no rotation outwards. Mr. Chandler saw the case on Saturday the 12th, and, on account of the tension, he ordered some leeches to be applied to the part, and the lotion to be continued. Mr. Cline saAV it this afternoon, and thought it a dislocation in the ischiatic notch.
Monday morning, the 14th. The swelling had greatly subsided, and I thought I could now feel the head of the bone on rotation of the limb. Mr. Chandler saw the case again this morning, and expressed a wish for Mr. A. Cooper to see it. Mr. Cooper, at my request, very kindly saw it in the evening, and immediately declared it to be a dislocation into the ischiatic notch ; and upon his rotating the thigh, I could much more distinctly than before feel the head of the bone in the ischiatic notch. Mr. Cooper recommended me to take away blood, which I did the next morning, to the amount of sixteen ounces ; this considerably relieved the pain the man had previously suffered, and the tension continued to abate till the Saturday morning following, when Mr. Chandler again saw him, and he thought it had sufficiently
PARTICULAR DISLOCATIONS. 81
subsided to justify the attempt at reduction. I accordingly made preparations in the following manner : — at about half-past two o'clock, I took sixteen ounces of blood from the patient, which produced no sensible effect ; at ten minutes past three, I took about twenty-seven ounces more, and while the blood was flowing, gave him a grain of emetic tartar ; this I repeated till he had taken five grains at intervals of a few minutes ; and as he was becoming faint, he was taken into the theatre. I applied the bandages and puUies to the pelvis and to the knee, bringing the thigh over the other; we kept up the extension about ten or twelve minutes before we used the strap to raise the head of the bone, and until I thought it had made some progress towards the acetabulum. We then continued the extension, gradually increasing it, at the same time endeavouring to raise the head of the bone and turning the knee outwards, for about fifteen minutes. I had now lost the head of the bone, but still, as it had not made the usual noise in its reduction, I thought that it would be wrong to remove the puUies, as the action of the muscles, if the bone had not been reduced, would have again drawn it up, in which opinion Mr. Martin, who assisted me, concurred. The man was now very faint, the extension was therefore continued for about twenty-five minutes longer, when the strap at the knee getting rather loose, we removed the pullies, upon which it was found that the thigh could now be moved in any direction, and that its position was perfectly natural. The bone was replaced, but at what time it had gained its situation no one could judge, neither could the man describe any feeling that could have indicated it ; he was carried to bed in a very faint state.
M
82 PARTICULAR DISLOCATIONS.
He had no sickness during' or after the extension. I gave him a grain and a half of opium at night, which procured rest.
Sunday morning. — He had some pain remaining, but it was greatly abated, and the thigh could be moved in any direction.
W. Worts, Feb. 22, 1820. Dresser to St. Thomas's.
Mr. Worts naturally expresses surprise that the bone was reduced without its entering the acetabulum with the usual noise; but when the muscles have been some time contracted, and when the patient is rendered faint by bleeding, and by the nausea of tartarized antimony, they do not act with the same violence as in the first few hours after the accident.
Cause.
DISLOCATION ON THE PUBES.
This dislocation is more easy of detection than any other of the thigh. It happens when a person, while walking, puts his foot into some unexpected hollow in the ground ; and his body at the moment being bent backwards, the head of the bone is thrown forwards upon the os pubis. A gentleman, who had met with this dislocation in his own person, informed me that it happened whilst he was walking across a paved yard in the dark : he did not know that one of the stones had been taken up, and his foot suddenly sunk into the hollow, and he fell backwards. When his limb was
PARTICULAR DISLOCATIONS. 83
examined, the head of the thigh-bone was found upon the os pubis.
In this species of dislocation the limb is an inch shorter than symptoms. the other, the knee and the foot are turned outwards, and cannot be rotated inwards, but there is a slight flexion forwards and out- wards ; and in a dislocation which had been long* unreduced, the motion of the knee backwards and forwards was full twelve inches; but the striking criterion of this dislocation is, that the head of the thigh-bone may be distinctly felt upon the pubes, above the level of Poupart's ligament, on the outer side of the femoral artery and vein ; and it feels as a hard ball there, which is readily perceived to move by bending the thigh-bone.
Although this dislocation is apparently easy of detection, I have Not detected known three instances in which it was overlooked, until it was too late for reduction ; of one, we have now a preparation at St. Thomas's Hospital; another occurred to a gentleman from the country, in whom it was not discovered until some weeks after the accident, who then submitted to an extension which did not succeed, and came to London to ask my opinion, when I advised him against a further attempt ; and, indeed, he himself was disinclined to any other trial. The third was a patient in Guy's Hospital, who was admitted for an ulcerated leg, and was found to have a dislocation upon the pubes, which had happened some years before. It really must be great carelessness Avhich leads to this error, as the case is so strikingly marked.
I dissected one of these dislocations, and we have it preserved Dissected. in our anatomical collection. It shews changes of parts nearly equal to those of the dislocation into the foramen ovale. The
M 2
84 PARTICULAR DISLOCATIONS.
original acetabulum is partially filled by bone, and in part occupied by the trochanter major, and both are much altered in their form. The capsular ligament is extensively lacerated, and the ligamen- tum teres broken. The head of the thigh-bone had torn up Pou- part's ligament, so as to be admitted between it and the pubes. The head and neck of the bone were thrown into a position under the iliacus internus and psoas muscles ; the tendons of which, in passing to their insertions over the neck of the bone, were elevated by it, and put on the stretch. The crural nerve passed on the fore part of the neck of the bone upon the iliacus internus and psoas muscles. The head and neck of the thigh-bone were flattened, and much changed in their form. Upon the pubes a new acetabulum is formed for the neck of the thigh-bone, for the head of the bone is above the level of the pubes. The new acetabulum extends upon each side of the neck of the bone, so as to lock it laterally upon the pubes. (See plate.) Poupart's ligament confines it on the fore part ; on the inner side of the neck of the bone passed the artery and vein, so that the head of the bone was seated between the crural sheath and the anterior and inferior spinous process of the ilium. Distinguish- This accidcut might, by an inattentive observer, be mistaken
ed from /• /• p . /.
fracture. for a fracturc of the neck of the thigh-bone ; but the head of the bone felt upon the pubes will decide its nature.
In the reduction of this dislocation, the patient is to be placed on his side on a table; a girt is to be carried between the pudendum and inner part of the thigh, and fixed in a staple a little before the line of the body. The pullies are fixed above the knee, as in the dislocation upwards, and then the extension
Reduction.
PARTICULAR DISLOCATIONS. 85
is to be made in a line behind the axis of the body, the thigh- bone being drawn backwards, (See plate.) After this extension has been for some time continued, a napkin is to be placed under the upper part of the thigh, and an assistant, pressing with one hand on the pelvis, lifts the head of the bone, by means of the napkin, over the pubes and edge of the acetabulum.
The following case, which occurred in Guy's Hospital at the time when my friend, Mr. now Dr. Gaitskill, was dresser to Mr. Forster, will best exemplify the mode of reduction. He was a dresser in the years 1803 and 1804.
Bath, August 13, 1817. Dear Sir,
The report of the case of dislocated thigh, which I have sent you, contains every material circumstance within my recol- lection ; it will afford me much pleasure if you can extract any thing from it useful or conducive to your purpose.
I remain your's most sincerely,
Joseph A. Gaitskill.
CASE.
A. B. with a dislocation of the os femoris upon the pubes, was admitted into Guy's Hospital, under Mr. Forster, during the time I was one of his dressers.
The length of the limb was somewhat diminished ; the foot and knee were turned outwards ; but the circumstance which
86 PARTICULAR DISLOCATIONS.
more clearly evinced the nature of the accident was, that the head of the thigh-bone could be distinctly perceived under the integuments near the groin, where its shape could be ascertained, as well as its motion felt, when the thig'h was moved. The accident had happened from a slip or fall he had sustained about three hours before.
With respect to the reduction; as the man was brought into the hospital in the evening, when Mr. Forster was absent, I considered it to be my duty to attempt to replace the bone im- mediately. I therefore ordered the patient to be carried into the operating theatre ; whilst this was doing, I invited my three brother dressers into the surgery, informed them of the accident, and, to avoid confusion, requested each to take some particular part in the process of reduction. The patient was placed on his sound side on a table, the pullies applied to the thigh in the usual manner, and extension began in a straight line, with the design of raising the head of the bone into its socket, but without suc- cess. Reflecting then a moment on the mechanism of the bones, and their new relative situation, I changed the line of extension to a little backwards and downwards, and passing a towel over my own shoulders, and mider the superior part of the man's thigh, raised it by extending my body.
The leg being kept bent, as from the beginning of the opera- tion, nearly to a right angle with the thigh, I requested one of the dressers to take hold of the ancle, and raise it, keeping the knee at the same time depressed, by which means the thigh was turned over inwards, and in a very short time, the head of the bone snapped into its acetabulum.
J. A. G.
PARTICULAR DISLOCATIONS. 87
The following case was admitted into St. Thomas's Hospital, under the care of Mr. Tyrrell.
CASE.
Guildhall, February/ 7th, 1823.
My dear Sir,
I take this opportunity of giving you the particulars of the case of dislocation on the pubes, which you wished for.
Charles Pugh, aged fifty-five, a cooper, about the middle size, on the evening of the 23rd of January, during the time he was making water at the corner of a street, was struck on the back part of the right hip by the wheel of a cart ; and the blow knocked him down. He was taken up by some persons passing, who, finding that he was not able to walk, took him to St. Thomas's Hospital. The accident happened about nine o'clock in the evening, and I was sent for between twelve and one o'clock, when I found a dislocation of the right femur on the pubis, the particulars of which were as follows : —
The head of the bone could be distinctly felt below Poupart's ligament, immediately on the outer side of the femoral vessels. The foot and knee were turned outwards, with very little altera- tion in the length of the limb. The thigh was not flexed towards the abdomen, and was almost immoveable, admitting only of partial adduction and abduction. The limb could be rotated outwards, but not at all inwards. I immediately had the man taken into the operating theatre, and speedily succeeded in reducing the dislocation by the following means : — the patient
88 PARTICULAR DISLOCATIONS.
was placed on his left side, a broad band was passed between the thighs, and, being tied over the crista of the ilium on the right side, was made fast to a ring fixed in the wall. A wet roller having been put on above the right knee, a bandage was buckled over it, and its straps attached to the hooks of the pullies, by which a gradual extension was made, drawing the thigh a little backwards and downwards. When this extension had been kept up a short time, I directed another bandage to be applied round the upper part of the thigh, close to the perineum, by means of which the head of the bone was raised, and in the course of a few minutes the reduction was easily accomplished. The patient had not been bled or taken any medicine, he suffered but little after the reduction, and was able to walk without pain or incon- venience five or six days afterwards. On the day following the accident, he could move the limb freely in all directions with- out pain, but did not attempt to walk until the period I have mentioned.
If I have omitted any points, or if you have any wish for further particulars, a message or a note by post, will much oblige
Your's very sincerely,
Frederick Tyrrell, Surgeon to St. Thomas's Hospital.
From what I have had an opportunity of observing on the subject of dislocations, I believe that the relative proportion of
PARTICULAR DISLOCATIONS. 89
cases will be in twenty as follows : twelve on the dorsum ilii ; five in the ischiatic notch ; two in the foramen ovale ; and one on the pubes.
The cases I have here detailed, with the dates at which they occurred, shew the frequency with which these accidents happen. The manner in which it escaped the observation of surgeons of eminence of former times, can only be accounted for by the diffi- culties which then existed in the pursuit of anatomy, and more especially of morbid anatomy : and it is a curious circumstance, that Mr. Sharpe, formerly surgeon of Guy's Hospital, author of a Treatise on Surgery, and in many respects an excellent surgeon, who had a large share of the practice of this town, did not, as I was informed by Mr. Cline, believe that a dislocation of the thigh- bone ever occurred.
It is really gratifying to observe the difference of knowledge in the profession at the present period compared with that of fifty years ago. What should we think of a surgeon in the metropolis in the present day, with all his opportunities of seeing disease in the large hospitals of this city, who doubted the existence of a dislocation of the thigh, when we find that our provincial surgeons immediately detect the nature of these injuries, and generally succeed in their attempts to reduce them ? Let them never for- get, however, that it is to their knowledge of anatomy, and, more especially, of morbid anatomy, that they are indebted for this superiority.
N
90 PARTICULAR DISLOCATIONS.
Mr. Charles H. Todd, surgeon to the Richmond Surgical Hos- pital, and Professor of Anatomy and Surg-ery at Dublin, has lately published "An Account of a Dissection of the Hip-Joint after recent Luxation, with Observations on the Dislocations of the Femur upwards and backwards ;" from which the following case is extracted :
CASE.
In the summer of 1818, a robust young man, in attempting to escape from his bed-room window, in the second floor of a lofty house, fell into a flagged area ; by which accident, his cranium was fractured, and his left thigh dislocated upwards and back- wards.
The dislocation was reduced without difficulty ; however, an extensive extravasation of blood having taken place on the brain, the patient lingered in a comatose state for about twenty-four hours, and then died. On the next day, dissection was performed, and the following appearances were observed in the injured joint and the parts contiguous to it :
On raising the gluteus maximus, a large cavity, filled with . coagulated blood, was found between that muscle and the poste- rior part of the gluteus medius : this was the situation which had been occupied by the dislocated extremity of the femur. The gluteus medius and minimus were uninjured. The pyriformis, gemini, obturatores, and quadratus, were completely torn across. Some fibres of the pectinalis were also torn. The iliacus, psoas^ and adductores were uninjured. The orbicular ligament was entire at the superior and anterior part only, and it was irre- gularly lacerated throughout the remainder of its extent. The
PARTICULAR DISLOCATIONS. 91
inter-articular ligament was torn out of the depression on the head of the femur, as in Dr. Scott's case, its attachment to the acetabulum remaining- perfect. The bones had not sustained any injury.
The following case, which has recently appeared in one of the Medical Journals, from JVir. Cornish, surgeon at Falmouth, I have thought proper to subjoin, though I must observe, that there is reason to suspect some mistake in the relation, not of the narrator of the case, but of the man himself ; as I have carefully examined the books of both hospitals at the period specified, and can find no such name. It is, however, possible that the patient may be able to explain the difficulty ; but I wish Mr. Cornish to make further enquiries.
CASE.
In 1812, Mac Fadder, a seaman, about twenty years of age, in coming up from Greenwich to London on the outside of one of the stages, fell from the coach and injured his hip. He was carried into St. Thomas's Hospital, and became Mr. Cline's patient. His case was treated as fracture of the neck of the thigh-bone. Having, after the lapse of some months, experienced no relief from the means that were adopted, he was dismissed with the assur- ance, that the limb would be useless to him as long as he lived.
The man was subsequently taken into Guy's Hospital. Sir A. Cooper, whose patient he became, thought the head of the femur out of the socket ; and after bleeding him, putting him into the warm bath, and administering nauseating doses of tartrate of
N 2
92 PARTICULAR DISLOCATIONS.
antimony, attempted to reduce the dislocation. The attempt was unsuccessful, as were also others that were afterwards made, and he was again dismissed as an incurable cripple.
In 1813, about twelve months after the accident, the man presented himself on crutches at the Falmouth Dispensary, when he gave me the foregoing history of his case. On examining him, I found the injured limb about two inches and a half shorter than the other, entirely useless, producing great pain on bringing it to the ground, and the knee and foot turned inwards. There was considerable distortion about the joint ; and the head of the bone appeared to have formed a bed for itself among the muscles on the dorsum ilii. In short, he had every diagnostic symptom of the dislocation upwards.
In consequence of the duration of the accident, and the failure of the attempts at reduction under the management of Sir. A. Cooper, I considered his case a hopeless one, and therefore did nothing for him.
In March, 1818, I met the man carrying a heavy basket on each arm, and walking without the slightest degree of lameness. Although I intimately knew his person, having seen him on crutches about the town for two or three years, I passed him, hardly believing it within the compass of possibility, that he could be my lame patient ; but after having walked twenty yards or more, I ran back after him to ascertain the fact. On satisfying myself of his identity, of which I entertained such doubt, and on enquiring into the cause of his cure, he informed me, that in the summer of 1817, five years after the accident, whilst on a passage from Falmouth to Plymouth, in a little
PARTICULAR DISLOCATIONS. 93
coasting vessel, " the ship made a lurch," by which he was thrown out of his birth. At the moment he fell, he heard a loud crack in his hip, and from that time he put aside his crutches, and recovered the perfect use of his limb. The man is now doing duty, as an able seaman, on board a ship which trades from this port to London.
The practical importance of this case is not, perhaps, equal to the curious character of its termination. " It proves," says Mr. Cornish, " the possibility of reducing a displaced joint, even after the lapse of years, when every impediment to reduction may be fairly supposed to exist (particularly the obliteration of the ace- tabulum), and when most surgeons would judge the attempt hopeless ; and it serves to illustrate the proposition, that * a slight effort, when the muscles are unprepared, will succeed in reduction of dislocation, after violent measures have failed.' "
FRACTURES of the OS INNOMINATUM.
Mistake. ^g thesG accidciits are liable to be mistaken for dislocations,
and as any extension made for them adds extremely to the patient's sufferings, and would be liable to produce fatal conse- quences if there existed previously a probability of recovery, I am anxious to say a few words upon them.
Symptoms. Whcu a fracturc of the os innominatum happens through the acetabulum, the head of the bone is drawn upwards, and the trochanter somewhat forwards, so that the leg is shortened, and the knee and foot are turned inwards : such a case may be readily mistaken for dislocation into the ischiatic notch. If the OS innominatum is disjointed from the sacrum, and the pubes and ischium are broken, the limb is a slight degree shorter than the other; but in this case the knee and foot are not turned inwards, but outwards. Of the first of these accidents I have seen two examples, of the latter only one.
FRACTURES OF THE OS INNOMINATUM. 95
These accidents are generally to be detected by a perceptible Detection. crepitus on the motion of the thig"h, if the hand be placed upon the crista of the ilium ; and they are attended with more motion than occurs in dislocations.
With respect to the appearances on dissection, they will be seen in plate seventh.
CASE.
A man was brought into St. Thomas's Hospital, in January, 1791, on whom a hogshead of sugar had fallen. Upon exami- nation the right leg was found about two inches shorter than the left, and the knee and foot were turned inwards ; these circum- stances induced the surgeon under whose care he fell to think the case a dislocation, although, as he stated, the limb appeared to be more moveable than usually happens in such accidents, and there was a great contusion and considerable extravasation of blood. The surgeon used the utmost caution in making a very slight extension, in order to bring the legs to an equal length, in which he did not succeed ; and whilst it was performing, a crepitus was discovered in the os innominatum. The man had a remark- able depression of strength, and paleness of countenance, and appeared to be sinking. In the evening he died.
Upon examination of the body the following appearances were observed : — The posterior part of the acetabulum was broken off, and the head of the thigh-bone had slipped from its socket ; the tendon of the obturator internus, and the gemini, tightly embraced the neck of the bone ; the fracture extended from the acetabulum across the os innominatum to the pubes ; the ossa pubis were
96 FRACTURES OF THE OS INNOMINATUM.
separated at the symphysis nearly an inch asunder, and a portion of the cartilage was torn from the right piibes, and adhered to that on the left side ; the ilia were separated on each side, and the puhes, ischium, and ilium broken on the left side ; the abdo- men contained about a pint of blood, and the left kidney was greatly bruised ; the integuments were stript off the patella and knee on one side, so as to expose the capsular ligament.
In a second case of this kind, which was admitted into St. Thomas's Hospital, having the appearance of the dislocation backwards, the patient lived four days. On examination, the fracture was found passing through the acetabulum, dividing the bone into three parts ; and the head of the thigh-bone was deeply sunk into the cavity of the pelvis.
The following case of fracture and dislocation of the bones of the pelvis lately occurred in Guy's Hospital : I am obliged for the particulars to Mr. Sandford, who attended to this patient as dresser.
CASE.
Mary Griffiths, aged thirty years, was admitted into Guy's Hospital at five o'clock in the afternoon of the 8th of August, 1817. Her pelvis had sustained a severe injury, from her body being pressed by the wheel of a cart against a lamp-post.
A small quantity of blood had been taken from her arm previ- ous to her admission ; and as she was very pale, her pulse extremely weak, and her feeces passed involuntary, no more blood was drawn.
FRACTURES OF THE OS INNOMINATUM. 97
Soon after her admission she was examined ; when, by placing her on the face, with one of my hands on the back of the right ilimn, and the other on the pubes of the same side, a distinct motion and crepitus could be perceived. The posterior spine of the ilium projected upwards, above its usual junction with the sacrum, and it was thought that the ilium was dislocated from the sacrum, with some fracture, either of the ilium, or the sacrum. When she was turned on the back, and examined per vaginam, the pubes were found passing more into the cavity of the pelvis than usual. A large quantity of blood was effused from the last rib to the upper part of the thigh, on the right side.
It was now a question whether this extravasated blood should not be discharged by making an opening through the integu- ments, as it appeared to be fluid ; but upon consideration, it was thought that the vessels would still bleed, that she could not bear the loss of blood in her weakened state, and that the blood, Avhen coagulated, would form the best security against further effusion. All that was done, therefore, was to roll a broad bandage round the pelvis to fix it firmly, to give tinct. opii. gt. xxx., and to draw off the urine from her bladder, which contained about a pint.
In the evening, the extravasation of blood was somewhat in- creased, and she complained of a pricking sensation in the right thigh and leg, which induced her to loosen the bandage. She had vomited ; her feet were cold : she had severe pain, and great thirst ; her pulse was 90, and small.
On the 9th, she complained of a sensation of one side tearing from the other; and, upon examination of the lower extremities, that on the right side was found shorter than the other ; there
o
98 FRACTURES OP THE OS INNOMINATUM.
was numbness also on that side. Her tongue was furred, but her pain and thirst somewhat less ; and she had not the same cold- ness in her feet as she had the night previous.
As her bowels had not been relieved since her admission, aperient medicine was given to her ; and the bladder being incapable of emptying itself, a catheter was employed. The ecchymosis was of great extent, and it was doubtful whether it could be absorbed. A pillow was placed against the right side to support the pelvis, and another was put under the knee, to pre- serve the limb in an easy position.
In the evening of this day, her pulse was 112. She complained much of pain in the right side and groin. The catheter was again obliged to be used, and aperient medicines to be repeated.
On the morning of the 10th, she complained of the bones of the pelvis moving upon each other, even more than at any former period, and that she had suffered severe pain ; the tongue was now furred, her pulse fuller, but her bowels had been relieved, and she had made water without assistance. At one o'clock this day, her pulse being fuller, and 120 in a minute, with great heat of skin, I bled her to the amount of ten ounces ; but the blood did not exhibit any signs of inflammation, nor did the loss of blood produce any apparent effect in relieving her symptoms.
In the evening, her pain and fever had increased ; and as she complained of the tightness of the bandage which still surrounded the pelvis, it was removed. The catheter was again obliged to be employed. Some saline medicine, with opium, was directed for her.
On the Uth, she stated that she had passed a good night. Her
FRACTURES OP THE OS INNOMINATUM. 99
pulse was 120 and softer; her tongue furred: she was directed to continue her medicines.
A stimulating lotion was ordered her on the 12th, to produce an absorption of the extravasated blood. Some spots appeared of a very dark colour, where the ecchymosis had been most severe, and the cuticle was abraded upon those parts.
On the 13th her report w^as more favourable; her bowels were open, and her bladder did not require the assistance of the catheter. However, she still complained of severe pain in the hip.
14th. As the excoriated parts seemed disposed to slough, a puncture was made through the integuments, nearly opposite to the trochanter major, and a quart of serum, mixed with the red particles of blood, and with a substance which appeared adipose, was discharged.
On the 15th the faeces and urine had passed into her bed, and she requested to be removed to another; her pulse was 112. The puncture made yesterday does not seem disposed to heal, and a poultice was directed for it.
16th. She expressed herself relieved by her removal into another bed; her pain is less severe; her pulse but 108. She was now directed a diet to support her strength, and some porter was given her ; but on the 17th, as she had been observed to be slightly delirious the preceding night, the quantity of porter was lessened.
On the 18th the sloughing of the part, which had been exces- sively bruised, had considerably increased ; yet her tongue was cleaner, and her skin of its natural heat.
o 2
100 FRACTURES OF THE OS INNOMINATUM.
On the foUowing^ day she appeared better ; had passed a good night : she was ordered a poultice of stale beer-grounds to the hip ; and as she strongly requested it, she was turned on her left side, as her impression was, it would relieve the pain she felt on the right side.
The sloughing of the superior and posterior part of the thigh had increased upon the 20th ; and she was ordered the decoction and tincture of bark, with saline medicine if her thirst became urgent ; and a more nutritious diet.
On the 21st, the sloughing had increased; the tongue was furred ; her pulse was 120. On the 22nd she was worse ; and on the 23rd, her stomach rejected every thing : she had a strong impression that she could not recover; she refused her medicine, and the slough had increased. In the evening of the 24th, she died.
Examination.
On the 25th, the body was examined. — A fracture was found passing through the body of the pubes on the left side, and through the ramus of the left ischium.
The right os innominatum was separated from the sacrum at the sacro-iliac symphysis, and a part of the transverse processes of the sacrum was broken off, and torn from the sacrum with the ligaments. The cartilage and ligaments of the symphysis pubis were torn, and the left sacro-iliac symj^hysis had given way ; the ligament over it being torn, and the bones separated sufficiently to admit of the handle of a scalpel being received between them. (See plate.)
FRACTURES OF THE OS INNOMINATUM. 101
Blood was found extravasated in the pelvis, behind the peri- toneum.
Jonathan Sandford.
I have known three instances of recovery from simple fracture of the OS innominatum : two of these were fractures of the ilium, and the nature of the accident was easily detected by the crepitus which was perceived upon moving- the crista of the ilium ; the third case was a fracture at the junction of the ramus of the ischium and pubes. In the two first a circular roller was applied upon the pelvis, and the patient was freely bled ; but in the latter no bandage was employed. I have also known a compound frac- ture of the OS innominatum recover; but Mr. Hulbert, surgeon, sent me a compound fracture of the ilium, which had proved fatal.
Several cases have also occurred within my knowledge of fracture of the pubes, near its symphysis, accompanied with laceration of the bladder, each of which proved destructive ; but when the bones have been broken without injury to the bladder, the patients have recovered.* The bladder is burst or not, in this accident, according to its state of distention or emptiness at the moment of the accident ; for, if empty, it escapes injury.
* There Is at this time (Sept. 1823), a case in Guy's Hospital, in which the bladder is believed to be ruptured below the reflexion of the peritoneum, and between it and the pubes, and the man appears recovering by wearing a catheter. But in cases where the injury is above the line of reflexion of the peritoneum, the urine escapes into the cavity of the abdomen, and excites general inflammation.
FRACTURES OF THE UPPER PART OF THE THIGH-BONE.
Before I enter into a description of the dislocations of other joints, it will be proper to point out the fractures incident to the upper part of the thigh-bone, as it is essentially necessary that these accidents should not be confounded with dislocations, or with each other, a mistake which has but too frequently happened. Indeed it must be confessed, that their discriminating marks are sometimes with difficulty detected, and that the different species of fracture are likewise frequently confounded ; for three distinct species, very different in their nature and in their result, have been described and classed under the indiscriminate appella- tion of fracture of the neck of the thigh-bone. Hence has arisen that difference of opinion, which has led to much discussion respecting the processes which nature employs for their cure, and which less hypothetical reasoning, and more attention to the development of such accidents by dissection, would have been
FRACTURES OF THE UPPER PART OF THE THIGH-BONE. 103
the means of preventing. Whilst one surgeon asserts that all attempts to cure them are unavailing, another maintains that they admit of union like fractures of other bones ; which latter opinion is only true as far as regards two species of these fractures.
I shall now, therefore, proceed to state the results of my obser- vations in living persons who have been the subjects of these accidents ; of my examination of the dead body ; and of some experiments upon inferior animals, which illustrate this subject.
These accidents are more frequent than dislocations of the thigh-bone ; for whilst we receive into our hospitals of Guy's and St. Thomas's (containing about nine hundred persons), not more upon an average than two such dislocations in a year, our wards are seldom without an example of fracture of the upper part of the thigh-bone.
Different Species of Fracture of the Upper Part
OF THE ThIGH-BoNE.
These are, as we have already observed, three in number.
First : That in which the fracture happens through the neck of the bone entirely within the capsular ligament.
Secondly: A fracture external to the ligament, through the neck of the thigh-bone at its junction with the trochanter major ; by which the trochanter is split, and the neck of the thigh-bone is received into its cancelli.
Thirdly : A fracture through the trochanter major, beyond its junction with the cervix femoris.
104 FRACTURES OF THE UPPER PART
FRACTURES OF THE NECK OF THE THIGH-BONE, WITHIN THE CAPSULAR LIGAMENT.
Appearances fhe appeavaiices which are produced by this fracture are as follows : — the leg becomes from one to two inches shorter than the other ; for the connection of the trochanter major with the head of the bone, by means of the cervix, being destroyed by the fracture, the trochanter is drawn up by the muscles as high as the ligament will permit, and consequently rests upon the edge
Difference in ^f ^jjg acctabulum, and upon the ilium above it. The difference
length. i
in the length of the limbs is best observed by desiring the patient to place himself in the recumbent posture on his back, when, by comparing the malleoli, it will be generally found that one leg is shorter than the other. The usual state of the limb is, that the heel on the injured side rests in the hollow between the malleolus internus and tendo Achillis of the other leg; but there is some variety in this respect ; a fork is sometimes formed in the trochan- ter minor, which catches the neck of the bone, and prevents a greater ascent than half an inch (see plate). Mr. Brodie informs me that he dissected a case in which the cervix was obliquely broken, and in which the upper part of the bone pre- vented the ascent of the lower. On the other hand, when the fracture has happened for a length of time, and the patient has borne upon the injured limb, the ligament becomes extended, and the leg is shortened four inches ; of this Mr. Langstaff mentioned to me an instance in a man of the name of Campbell, aged
OF THE THIGH-BONE. 105
eighty-two, in whom the heel was obliged to be elevated four inches to make the bearing of the limbs equal. I saw the frac- tured parts in this man, and the shoe he wore, which entirely verified Mr. L.'s statement. The retraction is at first easily removed by draAving down the shortened limb, when it will appear of the same length with the other; but immediately when this extension is abandoned, and the patient exerts himself, the mus- cles draw it into its former position ; and this appearance may be repeatedly produced by extending the limb. This evidence of the nature of the accident continues until the muscles acquire a fixed contraction, which enables them to resist an extension which is not of a powerful kind.
Another circumstance which marks the nature of this injury is. Foot turned
. . J? ^ c 11 outward.
the eversion ot the loot and knee ; and this state depends upon the numerous and strong external rotatory muscles of the hip- joint, which proceed from the pelvis to be inserted into the thigh-bone, and to which very feeble antagonists are provided : the obturatores, the pyriformis, the g-emini and quadratus, the pectinalis, and triceps, all assist in rolling the thigh-bone out- wards ; whilst a part of the g-lutseus medius and minimus, and the tensor vaginae femoris, are the principal agents of rotation inwards. It has been denied that this eversion is caused by the muscles, and it has been attributed to the mere weight of the limb ; but any one may satisfy himself that it arises chiefly from the muscles, by feeling' the resistance which is made to any attempt at rotation of the thigh inwards. This difllculty is also in some measure attributable to the length of the cervix femoris, which remains attached to the trochanter major ; because in
p
106 FRACTURES OF THE UPPER PART
proportion to its length, by resting against the ilium, the tro- chanter is prevented from turning forwards.
Directly that the bed-clothes are removed, two circumstances strongly arrest the attention of the surgeon : namely, the dimi- nished length of the injured limb, and the eversion of the foot and knee. In the dislocation upwards, the head and neck of the bone prevent the trochanter from being drawn backwards, whilst the broken and shortened neck of the thigh-bone, in fracture of this part, readily admits it ; and hence the reason that the foot is inverted in luxation, and everted in fracture. It is, however, proper to state, that an exception to this rule does now and then exist, and that the limb is found inverted ; but it is of extremely rare occurrence. Some hours must elapse before this eversion assumes its most decisive character, as the muscles require some time to assume a determined contraction ; and this is the reason that the accident has been mistaken for dislocation on the dorsum ilii. The surgeon having been called soon after the accident has happened, before the muscles had acquired that state of contraction to which they are liable, is led to mistake the nature of the injury, because the foot is not so decidedly everted as it afterwards becomes; and for this reason patients, even in hospital practice, have been exposed to useless and painful extensions. De^ee of In fractures of the neck of the bone within the ligament, the patient, when perfectly at rest in the horizontal posture, suffers but little; but any attempt at rotation is attended with some pain, because the broken extremity of the bone then rubs against the inner surface of the capsular ligament, upon which it is drawn by the action of the muscles. The pain is felt in this accident in the
pain
OF THE THIGH-BONE. 107
upper and inner part of the thigh, opposite to the insertion of the iliacus and psoas muscles into the trochanter minor, or sometimes just below this point.
The perfect extension of the thigh may be easily effected, but Degree of flexion is more difficult, and somewhat painful ; and its degree depends upon the direction in which the limb is bent ; for if the flexion be outwards, it is accomplished with but little comparative suffering ; but if the thigh be directed towards the pubes, the act of bending the limb is with difficulty accomplished, and is attended with greater pain ; for it is easier or more difficult, in proportion as the neck of the bone is shorter or longer.
In this accident the trochanter major is drawn up towards the situation of
... Ill 1^11 IT 1 1 ^^^ trochan-
ihum, but the broken neck of the bone attached to the trochanter tei major. is placed nearer the spine of the ilium than the trochanter itself, in which situation it afterwards remains ; and this alteration of position makes the trochanter project less on the injured side, because it is no longer supported by the neck of the bone, as in its natural state, but rests in close apposition with the edge of the acetabulum, and is, consequently, much more concealed than usual, until the muscles waste from the duration of the injury, when it can be distinctly felt upon the dorsum ilii; but there will be a greater or less projection of the trochanter, proportioned to the length of the fractured cervix attached to it.
If doubt exist of the nature of the accident, let the patient Appearance
I'i'i -1 • '" ''"' erect
be directed to stand by his bed-side, supported by an assistant, position. and to bear his weight upon the sound limb ; the surgeon then observes the shortened state of the injured leg ; the toes rest upon the ground, but the heel does not reach it ; the knee and
P2
108 FRACTURES OF THE UPPER PART
foot are everted; and the prominence of the hip is diminished. The least attempt to bear upon the injured limb is productive of pain, which seems to be occasioned by the tension of the psoas, iliacus, and obturator externus muscles, in the attempt, as well as by the pressure of the broken neck of the bone against the interior surface of the capsular lig-ament.
Crepitus. A crepitus like that which accompanies other fractures might
be expected to occur in this accident, but it is not discoverable when the patient rests on his back with the limb shortened ; if, however, the leg be drawn down, so as to bring the limbs to the same length, and rotation be then performed, the crepitus will be observed, as the broken ends of the bone are thus brought into contact; but the rotation inwards most easily detects the fracture. When the patient is standing on the sound leg, with the fractured limb unsupported, by rotating it inwards, the crepitus will some- times be perceived, as the weight of the limb brings the broken bones nearer in apposition.
More fre- Womcn arc much more liable to this species of fracture than
quent in
women. nicu : wc rarely in our hospitals observe it in the latter, but our wards are seldom without an example of it in the aged female. The more horizontal position of the neck of the bone, and the comparative feebleness of the female constitution, are the probable reasons of this peculiarity.
To the circumstances I have already mentioned, as strongly characterizing this accident, must be added the period of life at which it usually occurs ; for the fracture of the neck of the thigh- bone within the capsular ligament, seldom happens but at an advanced period of life, whilst the other fractures which I have
OF THE THIGH-BONE. 109
to describe happen at all periods: and hence has arisen the great confusion with respect to the nature of this injury ; for we find that surgeons of the hig-hest character have confounded fractures external to the capsular ligament with those which are within the articulation; and mention the latter as occurring at a period of life in which they scarcely ever happen.* It has been also said, that in early life these bones will readily unite; an assertion which I notice only to shew the confusion which has arisen on this subject.
Old age, however, is a very indefinite term ; for in some it is as strongly marked at sixty, as in others at eighty years. That regular decay of nature which is called old age, is attended with changes which are easily detected in the dead body ; and one of the principal of these is found in the bones, for they become changes thin in their shell, and spongy in their texture. The process of absorption and deposition varies at different periods of life ; in youth the arteries, which are the builders of the body, deposit more than the absorbents remove, and hence is derived the great source of its growth. In the middle period of life the arteries and absorbents preserve an equilibrium of action, so that, with a due portion of exercise, the body remains stationary; whilst in old age the balance is destroyed, because the arteries act less than the absorbents, and hence the person becomes diminished in weight ; but more from a diminution of the arterial than from an increase of the absorbent action. This is well seen in the natural changes
* I allude particularly to Dessault.
age in the bones.
no FRACTURES OF THE UPPER PART
of the bones, their increase in youth, their bulk, weight, and little comparative change during the adult period, and the lightness and softness they acquire in the more advanced stages of life ; hence the bones of old persons may be cut with a pen-knife, which is incapable of making any impression on those of adults. Even the neck of the thigh-bone in old persons is sometimes under- going an interstitial absorption, by which it becomes shortened, altered in its angle with the shaft of the bone, and so changed in its form as to give an idea, upon a superficial view, that it has been the subject of fracture, thus leading persons into the erroneous supposition, that the bone has been partially broken and re-united ; but it requires very little knowledge of anatomy to distinguish in the skeleton, the bone of advanced age from that of the middle period of life. Age at The ae'e at which fractures of the neck of the thig-h-bone
within the capsular ligament generally occur, is a most important consideration ; and as it is one on which the practice of the surgeon very much hinges, I shall take the liberty