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AN INQUIRY 
 
 DIFFICULTIES ENCOUNTERED 
 
 REDUCTION OF DISLOCATIONS OF THE HIP. 
 
 BY 
 
 OSCAR H. ALLIS, M.D., 
 
 FELLOW OF THE COLLEGE OF PHYSICIANS AND OF THE ACADEMY OF SURGERY, PHILADELPHIA ; 
 FELLOW OF THE ACADEMY OF SUPvGERY, ALTOONA ; HONORARY MEMBER OF THE 
 PATHOLOGICAL SOCIETY OF HARRISBURG ; MEMBER OF THE AMER- 
 ICAN SURGICAL ASSOCIATION AND OF THE AMERICAN 
 MEDICAL ASSOCIATION ; SURGEON TO THE 
 PRESBYTERIAN HOSPITAL. 
 
 THE SAMUEL D. GROSS PRIZE ESSAY. 
 
 PHILADELPHIA: 
 
 1896. 
 
DOR X AN, PRIXTEK, 
 PHILADELPHIA. 
 
THIS LITTLE VOLUME IS DEDICATED 
 TO 
 
 Dr. W. C. B. FIFIELD 
 
 OF DORCHESTER MASSACHUSETTS 
 
 WHOSE CORDIAL, EARNEST EXPRESSIONS OF APPRECIATION 
 
 AND APPROVAL FOR MANY YEARS HAVE BEEN A 
 
 SOURCE OF GRATEFUL ENCOURAGEMENT 
 
 TO THE 
 
 AUTHOR IN HIS WORK 
 
1429 Walnut Street, 
 Philadelphia, February 5. 1895. 
 Oscar H. Allis, M.D. 
 
 My dear Doctor : As Chairman of the Trustees of the S. D. Gross Fund 
 and Library of the Philadelphia Academy of Surgery, I have the pleasure to 
 inform you that the prize of one thousand dollars has been awarded you for 
 the best original essay among those entered for competition January 1, 1895. 
 
 Permit me to offer my congratulations upon the success you have achieved, and 
 
 believe me 
 
 Very truly yours, 
 
 J. EwixG Mears, 
 
 Chairman. 
 J. EwiXG Mear-S, 
 W. W. Keen, 
 John Ashhurst, Jr., 
 
 Trustees of Gross Fund aud Library. 
 
 The conditions annexed by the testator are that the prize " shall be awarded 
 every five years to the writer of the best original essay, not exceeding one hun- 
 dred and fifty printed pages octavo in length, illustrative of some subject in 
 surgical pathology or surgical practice, founded upon original investigations, 
 the candidates for the prize to be American citizens." 
 
 It is expressly stipulated that the successful competitor shall publish his essay 
 in book-form, and that he shall deposit one copy of the work in the .Samuel D. 
 Gross Library of the Philadelphia Academy of Surgery. 
 
REMINISCENCES. 
 
 In one of my visits to the Presbyterian Hospital in July, 1873, I 
 found a man suffering from a recent dorsal dislocation of the femur. 
 He had walked in his sleep from a second-story window, and in his 
 descent had struck a clothes-line, which changed the direction and 
 possibly modified the severity of the fall. In the erect posture the 
 deformity was pronounced and typical ; the right knee bent strongly 
 inward toward its fellow, the foot turned inward, and the great toe 
 could with difficulty be made to touch the floor. After full anaes- 
 thesia the patient was placed upon the floor, and various ineff"ectual 
 efibrts were made to reduce the dislocation. Reduction was finally 
 accomplished by traction upward. 
 
 This was the first dislocation that I had ever seen, and, instead of 
 being elated at my success, I was rather deeply mortified to think 
 that success had crowned efforts put forth with no clear understand- 
 ing of the nature of the accident or of the proper steps to repair it. 
 I accordingly determined to lose no time in familiarizing myself 
 with this subject, and, procuring Bigelow on' The Hip, I took it 
 with me to the dissecting-room, and there wrought out, over and 
 over again, the problems of that justly celebrated monograph. 
 Having satisfied myself, and thinking that I would profit by a 
 demonstration, I invited the members of my quiz class to the 
 dissecting-room, and readily convinced them, as I myself Avas fully 
 convinced, that a knowledge of the Y-ligament was all that was 
 necessary to enable one to diagnosticate or restore any form of dis- 
 location at the hip-joint. My class was so well pleased with the 
 
vi REMINISCENCES. 
 
 demonstration that I was induced to repeat my work with another 
 class a year later. 
 
 Although this was more than twenty years ago, 1 recall the pleasure 
 and satisfaction the work afforded me as vividly as if it were but yes- 
 terday. I speak of the pleasure, for it was an entirely new field to 
 me; of the satisfaction, because, whatever I might lack in other 
 departments of surgery, of this I was confident, that Bigelow knew 
 all about the hip . . . and that I knew as much as Bigelow. 
 
 Six years passed by before I had an opportunity of putting my 
 new attainment to a test ; with what result will be seen in the history 
 of the following case : 
 
 Simultaneous Dislocation of both Hips. Peter J., colored, 
 aged forty-two years. While removing ballast from the hold of a ship 
 a mass of earth and stone fell upon him, partly burying him. He was 
 removed in a condition of extreme shock, and was taken home. After 
 a few weeks he was able to crawl out of bed, and later on was taken 
 from one hospital to another, but, as he would not consent to what was 
 deemed best, he was always refused admission. Finally, eighty-one 
 days after the accident, he appeared at the Howard Hospital, at the 
 clinic of Dr. Livingston, who detected a dislocation of the hip, and 
 referred him to Dr. Willard, then in charge of the surgical clinic. 
 On the following Saturday I met my colleague, Dr. Willard, who 
 etherized the patient, and in a few seconds reduced by manipulation 
 a typical dorsal dislocation of the left femur. The head went into 
 the socket with the sound so characteristic of successful reductions, 
 and with the immediate restoration of normal appearance. But 
 when, to satisfy ourselves fully of the symmetry of the limbs, we 
 compared them, the restored (left) limb was found markedly shorter 
 than its fellow. This discrepancy threw grave doubt upon the suc- 
 cess of the reduction ; and the doubt was increased when a distin- 
 guished surgeon, standing by, pointed out a fulness in the thyroid 
 region of the right limb that was absent in the one we supposed had 
 just been successfully treated. To remove all doubt, Dr. AVillard 
 
REmXISCEXCES. vii 
 
 redislocated the femur, and by manipulation, as in the first instance, 
 restored the head vvitli the audible thud so clear and the disappear- 
 ance of deformity so sudden and complete as to dispel every misgiv- 
 ing as to the success of the manipulation. Then for the first time 
 there flashed across our minds a full appreciation of the situation. 
 Both femurs had been simultaneously dislocated. Dr. Willard had 
 restored the left femur, the right still lay in the thyroid depression, 
 thus enabling us to account for the fulness already alluded to, and 
 the apparent lengthening. 
 
 This being decided upon, Dr. Willard attempted reduction of the 
 right luxation, but failed, and sent the patient to the Presbyterian 
 Hospital, as there were no beds at the Howard Hospital at the time. 
 The patient then came under my care, and on the following Monday 
 I was met by Dr. Willard, and my colleagues, Dr. Porter and Dr. 
 Reed, and an earnest but fruitless attempt was made at reduction. 
 A few days later Dr. Porter and Dr. Hodge assisted me in a second 
 attempt. Manipulation, leverage, pulleys, and horizontal, oblique, 
 and vertical traction were employed, but to no purpose. The head 
 moved freely in all directions ; it passed from the thyroid region 
 backward to the dorsal, and from the dorsal again to the thyroid, and 
 could be made to approach the rim of the socket, but could not be 
 made to pass over it. 
 
 Had there been in this case only an irreducible thyroid dislocation, 
 I would have felt no special disappointment at not being able to reduce 
 it, since the time-honored apologies for failure would have abundantly 
 satisfied me. The time during which the dislocation had persisted 
 was now eleven weeks, and this, I would have argued, was ample for 
 the filling up of the socket and for the capsule to close in around it. 
 But no such argument could be urged in view of the fact that the 
 socket on the left side had not filled up, and that the capsule there 
 presented no greater obstacle to reduction than is found in recent dis- 
 locations. The left hip had entered with an audible thud, and this 
 was good evidence that the socket was empty and covered with glis- 
 
Vlll 
 
 REMIXISCEXCES. 
 
 tening, unaltered cartilage. The left femur had been easily and in- 
 stantly restored by manipulation in skilful hands, the right resisted 
 the skill, not only of Dr. Willard, but also that of the entire surgical 
 staff of the Presbyterian Hospital, even when that skill was supple- 
 mented by the most approved surgical appliances. 
 
 This experience led me to suspect that I had overlooked some im- 
 portant principle in my dissections and experimental work, though 
 not doubting for a moment the infallibility of Bigelow's principles of 
 reduction : I therefore again repaired to the dissecting-room, where 
 I carefully and deliberately reviewed the teachings of this author. 
 This work inspired in me new confidence, though it developed no 
 new principle. 
 
 Again I became impatient to test the system, confident now that 
 future triumphs would amply atone for my first somewhat mortifying 
 failure. How much of a triumph my next case proved will appear 
 in the following history : 
 
 Recent Dorsal Dislocation of the Left Hip. Mr. F., a 
 middle-aged man, had his left leg caught in the wheel of a wagon 
 drawn by oxen. He was riding between the wheels and the oxen 
 were walking. The accident occurred March 27, 1884. Dr. P. R. 
 Koons saw the man about two hours after the accident. There was 
 an apparent shortening of from two and a half to three inches. The 
 head of the femur was in the position of high dorsal displacement ; 
 the knee was rotated strongly inward with marked adduction. 
 Several efforts at reduction were made by Dr. Koons, with and 
 without ether, and at each attempt the deformity disappeared to a 
 very great degree. There remained, however, after each attempt a 
 considerable degree of flexion of the thigh upon the pelvis. Dr. 
 Koons accordingly brought his patient to the Jefferson Medical 
 College Hospital on March 30th, and through the courtesy of my 
 colleague, Dr. W. Joseph Hearn, the man was placed in my charge. 
 
 Upon examination I found no marked deformity. The thigh was 
 slightly flexed upon the pelvis, and the knee, a little flexed, rose 
 
REMINISCENCES. ix 
 
 above the level of the mattress. When the knee was depressed it 
 sprung upward again. 
 
 On April 11th, two weeks after the accident, assisted by Professor 
 Gross, Dr. Hearn, Dr. Barton, and Dr. Koons, after full anaesthesia, 
 I began the examination of the limb. Upon flexing and rotating it, 
 it suddenly changed its position and displayed all the signs of a 
 dorsal dislocation. The knee was semiflexed and bent strongly in, 
 and rested upon the right thigh above the other knee. All the 
 signs were typical of a dorsal displacement. I accordingly flexed 
 the leg on the thigh, the thigh on the pelvis, carried the knee 
 inward, then upward toward the umbilicus, then with an outward 
 sweep brought it down in extension. The result was that the head 
 went suddenly into a position in the neighborhood of the socket 
 with all the apparent signs of reduction, except that there were per- 
 sistent flexion of the thigh on the pelvis and a tilting forward of the 
 knee. All present exclaimed that the reduction was effected, but I 
 pointed out the slight but ominous symptom, and insisted that there 
 was still a radical defect, and that, while the head of the femur 
 might lie near the socket, it was not in it. Over and over again the 
 head was thrown into the dorsal region, and attempts were made by 
 each surgeon present to conduct the head into the socket without 
 any remaining deformity, but with no better success. Again, on 
 April 22d, aided by Professor Gross, Professor Brinton, Dr. Levis, 
 Dr. Hearn, Dr. Barton, and Dr. Koons, the whole work was care- 
 fully repeated. From a typical dorsal dislocation, with aggravated 
 deformity, the limb was made to assume suddenly almost normal 
 relations, and no eff"ort to convey the head through a new route was 
 any more satisfactory. Bigelow's plans of sudden upward jerking 
 and of enlarging the capsular rent were adopted, but the result of 
 .one method was identical with that of all others, and the poor fellow 
 was sent home with the same deformity that was present when he 
 was brought to the hospital. 
 
 It was the opinion of most of the surgeons present that the head 
 
X REMINISCENCES. 
 
 was restored ; that it was a subluxation — a radical defect — from 
 which the man would never recover, was my own opinion. The tilting 
 forward of the knee and the flexion of the thigh, I knew, should not 
 persist after a satisfactory reduction, and I therefore inferred that 
 the head still lay below the socket. 
 
 As months rolled by the condition of the unfortunate man was 
 kept fresh in my mind by correspondence with Dr. Koons, who 
 reported Mr. F. as a great sufferer, and that he feared the prolonged 
 use of morphine would lead to the formation of the morphine-habit. 
 The persistence of the pain confirmed me in the opinion that the 
 limb had not been properly restored, but I thought nothing but an 
 autopsy Avould clear up the mystery. It was cleared up, however, 
 much sooner than I expected, and in the following manner : 
 
 In February, 1885, nearly a year after the incident just related, 
 and while it was still fresh in my mind. Dr. Bley and Dr. Johnson, 
 who had returned to the Jeiferson Medical College for post-graduate 
 instruction, requested me to go with them to the Philadelphia School 
 of Anatomy, then under the care of Dr. George McClellan, and give 
 them practical instruction in reducing dislocations of the hip by 
 manipulation. After strapping a cadaver to the floor, Dr. Bley 
 eff'ected a dorsal dislocation by flexion, adduction, and rotation inward 
 without previous tenotomy of the capsule. I then requested him to 
 employ Reid's method. Accordingly he knelt, and grasping with 
 one hand the ankle and with the other the knee, he directed the 
 knee inward toward the upper third of the opposite thigh and cir- 
 cumducted it, moving the knee upward and outward over the pubes 
 and umbilicus and swinging it outward, and then brought the limb 
 down in full extension, and the reduction was effected as if by 
 magic, every vestige of deformity disappearing. I then requested 
 Dr. Johnson to make a trial. He did it in almost every particular, 
 as Dr. Bley had done, except that perhaps he pressed heavily upon 
 the knee as he directed it; but when he brought the limb down in 
 extension, instead of all deformity disappearing, I was delighted to 
 
REMINISCENCES. xi 
 
 see the same deformity present that persisted in the case of Mr. F. 
 The thigh was so much flexed upon the pelvis that the knee was 
 raised about a foot above the floor ; the thigh was also a little ab- 
 ducted and rotated outward, with every manifestation of constraint. 
 At my request the position was not disturbed, but the cause sought 
 for by dissection. This revealed the head in the socket, hut the 
 sciatic nerve was stretched over the neck. Thus I had been mis- 
 taken in insisting that the reduction in F.'s case was incomplete. 
 I was, however, right in demanding an explanation of the elastic 
 forward spring of the knee after apparent reduction, and that con- 
 dition no one present could explain. 
 
 This discovery infused new life into my study of dislocations of 
 the hip, and I again, by means of dissections, reviewed the subject 
 with increased interest. One point I certainly had gained, and I 
 was satisfied that in all subsequent cases I would know when a dis- 
 location of the hip was restored and when the great sciatic nerve 
 was involved. The vague notion that the head had been prevented 
 from entering the socket had been cleared up, and I felt an increas- 
 ing confidence that I was now prepared for any difficulty that would 
 present itself 
 
 That this confidence was no better founded than my former had 
 been will appear from the perusal of the following case : 
 
 J. H. M. , aged twenty-three years, a strong, well-developed young 
 man, fell on August 18, 1885, from a chestnut tree to the ground, a 
 distance of about twenty-five feet. Dr. Newcomet saw the patient 
 soon after the accident, recognized a dorsal dislocation of the right 
 femur, and made, without ether, an unsuccessful attempt at reduc- 
 tion. Five hours later, using anaesthesia, and assisted by two other 
 physicians, he again failed. The man was then taken to the Jeffer- 
 son Medical College Hospital, twenty-six hours after the accident, 
 and just before the hour for the medical clinic. Through the courtesy 
 of Prof. Da Costa, I was permitted to take the injured man before 
 the class immediately after his arrival. The symptoms were those 
 
xii REMINISCENCES. 
 
 of a dorsal displacement. When fully etherized the man was placed 
 upon a mattress upon the floor ; I then flexed the leg on the thigh, 
 the thigh on the pelvis, and seizing the ankle with my right hand, 
 and placing the bent elbow of my left arm beneath the popliteal 
 space, I adducted, rotated inward, lifted, rotated outward, circum- 
 ducting at the same time, and brought the limb down in extension 
 to complete the manoeuvre. I failed ; repeated my efforts ; failed 
 again ; and then asked Professor Brinton to make a trial. He did 
 so until, exhausted, he reluctantly desisted. Prof. Gross then un- 
 dertook the manipulation, and, after witnessing two failures, tried 
 hard not to make a third, but to no purpose. The man was then 
 removed to an adjoining room, where Dr. Richard J. Levis, Surgeon 
 to the Pennsylvania Hospital, Dr. Hearn and Dr. Barton, Surgeons 
 to the Jefferson Medical College Hospital, and others tried long and 
 earnestly, but ineffectually, to restore the dislocation. 
 
 A week later, aided by Prof Brinton, Prof. Gross, and Prof. Pan- 
 coast, Dr. Hearn, Dr. Barton, and Dr. Reed (the latter, surgeon to 
 the Presbyterian Hospital), a second long but fruitless effort at re- 
 duction was made. 
 
 With this failure vanished all the fancied acquisitions of my re- 
 peated studies on the cadaver, and with them all my reliance upon 
 the dogmatic assertions of authors and teachers upon the subject. 
 My disappointment was indeed great. What I had regarded as a 
 science and had pursued with ardor to its supposed mastery had van- 
 ished in a moment, and left me small compensation for the labor and 
 study I had expended upon it. I had failed after the fairest trials, 
 and had desisted, not for want of co-operation on the part of my pa- 
 tients, but for want of expedients on my own part. That which im- 
 pressed me more than anything else was, not that I could not reduce 
 dislocations, but that I could conceive of no rational cause for my 
 inability to do so. 
 
 Again I went into the dissecting-room, but found there no solu- 
 tion to my difficulties. Other failures, some in my own hands and 
 
REMINISCENCES. xiii 
 
 some in others, Avliich I need not record, confirmed my now settled 
 conviction that the rules for the reduction of dislocations of the hip- 
 joint were few and simple, and that when these failed in the hands 
 of a novice, he knew as much about the cause of failure as I did after 
 years of perplexing study. , 
 
 One who has experienced only success in the reduction of dislo- 
 cations may be surprised at these confessions, while he, in whose 
 hands reductions have taken place, that have resisted previous efforts 
 in other hands, may wish that he had had a chance at those cases. 
 But let such a one recall the case of J. H. M. The dislocation was 
 only a day old, and I failed before a well-filled amphitheatre. What 
 would I not have given for success ! I was followed by Prof. Brin- 
 ton, whose office it was to teach, and now he had an opportunity to 
 demonstrate, the proper means to overcome the obstacles to reduction. 
 Witnessing my own and Prof. Brinton's failure, would not Prof. 
 Gross have enjoyed our discomfiture, by skilfully dropping the head 
 into its socket ? And after we had failed, with four or five hundred 
 students as spectators, all eager for the result, what would have been 
 the exultation of Dr. Levis, Dr. Hearn, or Dr. Barton, if either 
 could have accomplished that which we had failed to do ?^ Certainly 
 there was every inducement for each man to do his best, and to try 
 some new expedient after the previously tried methods had failed. 
 
 Every surgeon is aware that the reduction of a dislocation is usu- 
 ally a very simple and easy matter. I saw an interne in the Phila- 
 delphia Hospital, fresh from the lecture-room, take hold of a recently 
 dislocated femur, trying to recall the method taught by the Professor 
 of Surgery, and, before he had decided what to do, and w^hile he was 
 aimlessly moving it about, the head sprang into its socket with the 
 characteristic audible thud. " I wish I had noticed how I did that," 
 
 1 After our failure, the young man was taken home, and, unwilling to go through life a 
 cripple, he wrote to Prof. D. Hayes Agnew, stating what had been done for his injury, and 
 asking his opinion about making further attempts at reduction at the Hospital of the Uni- 
 versity of Pennsylvania. The latter replied in terms so complimentary to those who had 
 failed that the young man never sought further advice. 
 
xiv REMINISCENCES. 
 
 was his regretful, half-mortified ejaculation. Cases of restoi'ation are 
 reported that occurred in the hands of experienced surgeons, the re- 
 turn taking place during a preliminary examination, and before any 
 intelligent effort had been put forth. 
 
 On page QQ will be found the reportof a case in which the patient 
 was deemed too ill to justify an effort at replacement, but in which 
 the reduction was unwittingly performed by the nurse, who was chang- 
 ing the patient's position in bed. All such cases are confirmed by 
 experimental study ; for, after effecting dislocations of the shoulder 
 and hip in the cadaver, I have often found the head hovering on the 
 confines of the socket, unwilling to stay out, and often returning 
 spontaneously or upon the slightest change of position. 
 
 The difference in different cases can also be illustrated from clini- 
 cal experience. I succeeded in my first case before I had made any 
 special study of the subject, and when I possessed only the meagre 
 impressions that students get from lectures. In my five succeeding 
 cases I failed, though I had made the subject one of thorough and 
 oft-repeated experimental study. Prof. Brinton failed before his 
 class in the case of J. H. M., whose right femur had been displaced 
 the day before. He succeeded in the next case he took before his 
 class, which was also a right dorsal dislocation, in a young man, injured 
 the day before ; and, to make the case still more nearly analogous, 
 he succeeded after others had failed. Dr. Reed failed in two of my 
 cases, but restored subspinous dislocation by the first manipulation. 
 
 The surgeons whose names I have mentioned were all practically 
 familiar with dislocations of the femur, and brought to bear all the 
 manoeuvres that a long hospital experience and extensive reading 
 could suggest. 
 
 Reflection upon the subject led me to believe that the true nature 
 of the obstacles that occasionally present themselves in dislocations of 
 the femur would always remain a matter of doubt, and that difficul- 
 ties arose in the living that had no counterpart in the dead subject. 
 
 With these conclusions I had almost dismissed the subject from 
 
REMINISCENCES. XV 
 
 my mind when, in January, 1892, a fatal result from an attempt to 
 reduce an old thyroid dislocation induced me again to return to the 
 dissecting-room, with the special design of studying the relation of the 
 femoral vessels to the subject of dislocations. I soon found that my 
 early enthusiasm in the subject had fully returned, and I now have 
 the satisfaction of saying that I believe I have seen the exact coun- 
 terpart in the cadaver of nearly every difficulty that I have ever en- 
 countered in the living subject. What I have seen I have tried to 
 depict, tried to show its peculiar mechanism and the rationale of 
 deliverance. Many difficulties that struck me at first as insuperable, 
 and which, before my studies were hopelessly inexplicable, are no 
 longer so.^ 
 
 In the Introductory Study which follows, clinical difficulties have 
 suggested and directed experimental work. To no class of affections 
 has clinical experience contributed so little. To anaesthesia, to the 
 knowledge gained from dissection, to the study of fatal cases of trau- 
 matic dislocations, and to experimental work in the dissection-room do 
 we owe all the progress we have made in this department of surgery. 
 The clinic has really been the amphitheatre for the display of skill 
 for the relief of the living which was gained upon the cadaver in the 
 dissecting-room. Some have fancied that they have found in exper- 
 imental work the solution of all conceivable difficulties, and have 
 spoken with confidence upon the subject. For my part, I have been 
 too often and too sadly disappointed in dogmatic assertions to ven- 
 ture upon the same course myself. I have everywhere striven to be 
 clear and candid. My oft-repeated failures have left me no room for 
 boasting. They have not, however, been an unmixed evil ; for, while 
 they have been a constant menace to over- confidence, they have also 
 been a constant spur to exertion. 
 
 1 N. B.— None of the foregoing remarks appear in the essay as handed in. All competing 
 writers were obliged to appear incog., and that necessitated the omission of Reminiscences. 
 —The Author. 
 
PART I. 
 
 INTRODUCTORY STUDY 
 
PROPOSITIONS. 
 
 The following propositions are discussed : 
 
 I. The Capsule is the most important agent against traumatic 
 dislocations of the femur. 
 
 II. For the laceration of the capsule and dislodgment of the head 
 of the femur, the femur is employed as a lever. 
 
 III. Every lever has a fulcrum ; the fulcra required in dislocations 
 of the femur are bony and ligamentous. 
 
 IV. Dislocation by thrust, if possible, is infrequent. 
 
 V. Reduction by Circumduction is the simplest, the most brilliant, 
 and the most hazardous of all modes of replacement. 
 
 VI. Method suggested for reduction of dislocation of the head of 
 the femur when associated with fracture of the shaft. 
 
INTRODUCTORY STUDY. 
 
 ANATOMY. 
 
 It is £1 matter upon whicli the medical student may "well con- 
 gratulate himself, that the study of dislocations at the hip-joint 
 has been reduced within a narrow compass. Thus, if I may be 
 permitted to divide the socket into three equal parts, I may say that 
 the havoc to capsule and muscles, attending dislocations, will almost 
 
 Fig. 1. 
 
 invariably be confined to the lower two-thirds, while that portion of 
 the capsule lying within the compass of the upper third, as well as the 
 muscles that cover it, will, with even greater certainty, escape in- 
 jury. Still more important are the now well-established facts that 
 we are indebted to the untorn remnant of capsule for the signs of 
 dislocation and for the most effective means for its restoration. 
 
4 INTRODUCTORY STUDY. 
 
 Certainly this is one of the departments of surgery in which the 
 labor of centuries is made readily available to the earnest student. 
 Knowledge that was at one time vague, diffuse, and theoretical has 
 approached the dignity of fact, and he who is willing to familiarize 
 himself with the subject will find himself able to do more, unaided, 
 in a few moments, than our learned Fathers in Surgery could accom- 
 plish with powerful auxiliaries in hours. 
 
 The Pelvis. 
 
 Throughout the Introductory Studies I shall speak of the pelvis 
 as lying upon its back. In this position we usually find our patient; 
 in this we administer an anaesthetic and make our attempts at reduc- 
 tion ; and in this we must determine our succers before the patient 
 returns to consciousness and can assume another posture. 
 
 If the pelvis be placed upon its back upon the floor, the pubes 
 becomes the highest and the sacrum the lowest part. In this posi- 
 tion the socket lies about midway between the level of the pubes and 
 the floor. 
 
 SAC/iUM 
 
 The situation of the socket is of great practical importance. 
 Rudely described, a transverse section of the pelvis is lozenge-shaped, 
 and at the extreme right and left of the lozenge lie the sockets. This 
 position puts the femur under the advantageous control of muscles 
 that arise from the pelvis, and gives the hips a wide separation for 
 a firm base of support. The socket looks upward and outward : in 
 the erect posture, downward and outward. It is situated at the 
 junction of two irregular bony surfaces : the inner, or pubo-ischiatic ; 
 the outer, or ilio-ischiatic. These, for want of a more appropriate 
 
THE PELVIS. 5 
 
 name, I shall denominate the inner and outer planes. These meet at 
 an angle of about 90°. The fact that the bony surfaces recede from 
 the socket, permitting it to stand out in bold relief, explains why 
 the femur can have so extensive a range of motion without danger 
 of bony collision. The socket lies chiefly upon the pubic aspect of 
 the pelvis ; it is excluded from the dorsal region by a high acetabu- 
 lar ridge. The head of the femur lies in the socket ; but the 
 trochanter (Fig. 3) projects over the outer rim. The retentive 
 apparatus exerts its influence chiefly upon the head ; the motor 
 power is attached to the trochanter and the shaft of the femur. 
 
 Fig. 3. 
 
 POBES 
 
 Planes of the Pelvis. I have alluded to the anatomical fact 
 that the socket lies at the junction of two irregular bony surfaces 
 or planes. These planes are caused by a sharp bend in the in- 
 nominate bone, which, while it gives great prominence to the socket, 
 makes the planes of the bony surfaces very distinct from each other. 
 The ridge, or dividing-line, between these two planes, passing from 
 the superior spine through the tuberosity of the ischium (Fig. 4, X, 
 Y), divides the sockets into two nearly equal parts. If the head 
 escapes upon the inner plane — no matter where — the whole lower 
 extremity will present an entirely different series of phenomena from 
 those of a dislocation upon the outer plane. Thus, at the outset, I 
 am led to give great stress to the anatomical shape of the pelvis, as 
 it gives us a rational classification of all dislocations into Outward 
 and Inward. 
 
 After the occurrence of a dislocation outward the socket can some- 
 times, in thin persons, be faintly outlined. The fingers are, however, 
 prevented from sinking into it by the remnant of untorn capsule 
 and the tendon of the ilio-psoas muscle, which are drawn obliquely 
 
6 INTROD UCTOR Y STUD Y. 
 
 and quite tensely across it. This muscle is relaxed by flexion under 
 normal conditions ; but after dorsal dislocation a part of the weight of 
 the limb would fall upon it, put it on the stretch, and prevent the 
 examiner from closely defining the socket. If the socket can be dis- 
 tinctly outlined, the dislocation is outward ; it cannot be inward. The 
 socket is deeply excavated at the expense of the ilium, ischium, and 
 pubes. I should not say at the expense of it, for the equivalent of 
 bony material is simply transferred from the middle to the periphery 
 of the socket. Thus a rim is formed, raised above the level of the 
 bone, which serves as a barrier against displacement, and may also 
 
 Fig. 4. 
 
 y ••. 
 
 constitute a formidable barrier to reduction. The tendency of the 
 head, in the normal functions of the joint, is to displacement up- 
 ward and outward ; but this tendency is so fully and effectually 
 guarded against by the depth of the socket and the unusual strength 
 of the capsule in this particular region that dislocations in this 
 quarter are, if possible, certainly very infrequent. 
 
 As no part of the socket is better guarded against displacement 
 than the upper and outer, so no part is better able to resist fracture. 
 Fracture of the rim of the acetabulum is very infrequent. It is 
 sometimes thought to be present when the head, after reduction, 
 
THE PELVIS. 
 
 readily becomes re-dislocated ; but this may be occasioned by a 
 socket partly filled by muscle and capsule. 
 
 Security of the Socket. An interesting study in connection 
 with the socket is the mechanism through which nature has com- 
 bined great freedom of motion with the greatest possible security. 
 Were the head held in the socket at all times by its ligaments, then 
 its ligaments must always be tense, and the area of motion would be 
 very limited ; with a large universal range of motion the capsule 
 can have no retentive function, except as a check to transgression. 
 
 Fig. 5. 
 
 Fig. 6. 
 
 In normal limits a retentive function largely independent of capsule 
 must be invoked, and this Weber has shown to be atmospheric 
 pressure. To accomplish this a firm yielding cartilage, known as 
 the cotyloid ligament, is strongly attached to the rim of the bony 
 socket. By this method the socket is deepened and the joint is 
 secured against the possibility of dislocation in its ordinary range of 
 motion. Had the socket been deepened by a bony instead of a car- 
 tilaginous rim, the range of motion would have been abridged and 
 the danger of fracture of the rim or femur would have been increased 
 manifold. Weber showed that, after the entire capsule had been 
 removed, it became a problem of mechanics to draw the head from 
 the socket. From this function the cotyloid ligament is often called 
 the sucker ligament. 
 
 Although the capsule, as a ligament, has no retentive function 
 during the ordinary movements of locomotion, it must not be in- 
 ferred that the security of the joint is wholly attributable to atmos- 
 pheric pressure. On the contrary, the joint's security is largely 
 due to muscular action. Thus the gluteus minimus and the iliacus 
 
8 INTROD UCTOR Y STUD Y. 
 
 internus have insertions into the upper half of the capsule which add 
 directly to its thickness and strength, while at the same time they 
 act as tensors of the capsule. The psoas magnus is attached partly 
 to the capsule, though in the main it passes over the part of the 
 capsule that is especially called upon to make pressure upon the 
 head of the femur.^ Thus, while the capsule in itself is a fibrous 
 structure, it becomes, under the action of these three powerful mus- 
 cles, an active barrier against displacement. At every step a man 
 makes, the head of the femur rises from the bed of the socket and 
 tends toward displacement. Such a rising would produce a vacuum 
 between the head and socket, the direct effect of which would be 
 to impede capillary circulation in the bed of the socket, were there 
 not a special provision against it. Such a mechanism designed to 
 equalize pressure exists. Beneath the inner border of the cotyloid 
 cartilage there is a canal leading to the central dome of the socket. 
 This canal is filled with loose connective tissue, through which the 
 vessels, nerves, and lymphatics find their way. Now, this loose, 
 movable, fatty material acts as an automatic valve or piston, sinking 
 into the canal whenever there is intra-acetabular exhaustion, and 
 bulging forth when this condition is relieved, thus preventing any 
 disturbances from altered atmospheric pressure, Avhich otherwise 
 must take place with every step. I have noticed a similar bulging 
 and recession of the loose connective tissue beneath the web in the 
 ischio-femoral band ; but such a function is hardly necessary in the 
 extra-cotyloid portion of the articulation. The retentive apparatus 
 of the hip is, therefore, a complex and widely distributed mechanism. 
 It embraces the capsule when the head tends to pass beyond its 
 normal limits, the psoas and iliacus when the joint is in active service, 
 the fascia lata, and atmospheric pressure. This provision has a 
 wider range than might be at first supposed, for when the poor 
 hemiplegic is bereft of all muscular support the security of the 
 joint is still preserved by ligaments and atmospheric pressure. 
 
 The Head of the Femur. 
 
 We are very apt to associate the security of the head of the femur 
 with the depth of the socket, but the truth is that in every useful 
 
 1 The retentive function of the fascia lata wiU be discussed in its appropriate place. 
 
THE LIGAMENTUM TERES. 
 
 9 
 
 position little more than half the head lies in contact with the socket. 
 The diagram (Fig. 7) represents the upper half of the head entirely 
 outside the bony socket and the lower quite within it. Indeed, the 
 positions in which the head would seem most secure are those in 
 
 Fig. 7. 
 
 which the femur is least serviceable. The reader will note that when 
 a part of the head is within the bony socket the neck does not come 
 in contact with the rim ; and this is true of all normal movements of 
 the joint. 
 
 The Ligamentum Teres. 
 
 The ligamentum teres is described as a tubular structure of vari- 
 able size and shape, extending from the dome and inner margin of 
 the socket to the dimple in the head of the femur. It is covered 
 with synovial membrane reflected from the fatty cushion in the 
 depths of the socket. A small vessel runs throughout its length, 
 distributing its branches on the periphery of the ligament. Accord- 
 ing to Gray (who quotes Struthers), " the teres checks rotation 
 outward and adduction of the flexed femur ; it assists in preventing 
 dislocations of the femur forward and outward, an accident likely 
 to occur from the necessary mechanism of the joint, if not provided 
 against by this ligament and the thick anterior part of the capsule." 
 This statement is very generally accepted by the profession. As a 
 theory, it is comprehensive and almost challenges a misgiving. For 
 my part, I join the few who believe that there are no adequate 
 grounds for calling this a ligament. Were it as strong as steel the 
 mechanism is such that it must rupture or tear loose from its attach- 
 ments whenever called upon to prevent a dislocation. Indeed, the 
 
10 INTRODUCTORY STUDY. 
 
 ligament rarely separates from the bead, but instead brings away a 
 thin lamina of bone. Hence, were the structure ten times stronger 
 than it is, the bones themselves must be proportionately stronger or 
 it would avail nothing. 
 
 The teres is absent in the orang-outang, in the anthropomorpha, 
 and in the South American sloth. These animals display their 
 wonderful activities in trees, moving from branch to branch and 
 from tree to tree with astonishing rapidity ; and if any animal 
 required a teres to establish a secure hip-joint, certainly it would be 
 present in these. It is also absent in the elephant, and sometimes 
 it is absent in man. 
 
 The alleged functions of the teres as a ligament are : 
 
 1. To check a tendency to dislocations ; 
 
 2. To suspend the head of the femur as in a sling, to prevent 
 shocks in runnincj and walking ; 
 
 3. To act as a channel of nutrition to the head of the femur. 
 
 4. It is alleged by Bland-Sutton that the structure has no special 
 function now, and is merely a retrogression from the pectineus 
 muscle. 
 
 Unlike the foregoing theories, and possibly no better than the 
 poorest, is my own, viz., that the teres when present is an accessory 
 lubricating agent to the joint. The chief source of synovia to the 
 head is from the synovial membrane that covers the fatty cushion 
 in the dome of the socket. Continuous with this is the teres cov- 
 ered by a reflection of the synovial membrane. To this membrane, 
 and not to the head of the femur, the artery that enters the base of 
 the teres is distributed. Were it not for the special provision of a 
 fatty cushion, covered with a synovial membrane, for lubricating the 
 head, all the synovia must be pumped up by the action of rotator 
 and other muscles^ that compress the capsule, and in man in the 
 erect posture gravitation would carry the lubricant away from and 
 not toward the articulating surface. It will be remembered that the 
 dome of the socket is covered with a loose fatty cushion, and such a 
 construction may be designed to enable it to follow the head through 
 the suction which its slight tendency to displacement creates, giving 
 it the function of a swabber to the movable head, while the liga- 
 
 • The psoas, gluteus minimus, and small rotators are the regulators of the cai>sule, and no 
 doubt contribute to the distribution of the synovia. 
 
THE LIG AMENTUM TERES. H 
 
 mentum teres, lying flat upon it, may have the additional function 
 of distributing synovia. 
 
 Tears from the Head. I think the ligamentum teres must 
 vary in length. I have cut away the capsule on its inner aspect 
 and dislodged the head by abduction upon the inner border. of the 
 socket without rupturing the teres, and at other times I have torn it 
 completely oflF from the head in eiforts at dislocation, and on dissec- 
 tion have found the head in the socket and the capsule not sufficiently 
 torn to permit the head to escape from the socket. From experi- 
 mental work I am quite disposed to think that the teres is often 
 ruptured in severe wrenches of the hip, which may tear the capsule, 
 but fall short of complete dislocation. 
 
 In my experiments it has been interesting to watch the teres tear 
 from the head of the femur. It is a fact, based upon the lesions of 
 fatal traumatic dislocations and verified by work in the dissecting- 
 room, that this structure is usually torn from the head of the femur 
 — rarely from the socket or in its continuity.^ If the inner part of 
 the capsule be removed and the thigh be abducted, the head will 
 gradually emerge from the socket, closely surrounded by the sucker 
 ligament (Fig. 8), which hugs the yet unbroken teres closely against 
 
 Fig. 8. Fig. 9. 
 
 T£/f£S 
 
 the head of the femur. As the head rises, traction is made, not on 
 all the fibres at once, but upon the uppermost fibres only. (Fig. 9.) 
 These fibres are the first to yield, after which the stress falls upon 
 succeeding fibres. Hence the attachment of the teres to the head is 
 its weakest part in accidents like dislocations ; because the violence 
 explodes upon the fibres separately and upon the most distant ones 
 first. A very common mode of separation is for the teres to bring 
 with it a thin lamina of bone from the head. The lamina tears from 
 
 1 I have seen it tear through the middle and also from its acetabular attachments. In two 
 cases in which the teres remained attached to the head it had, by its pelvic attachments, 
 torn the transverse ligament up by the roots and dragged it out of the socket. 
 
1 2 INTROD UCTOR Y STUB Y. 
 
 the bone, beginning always at the upper or most distant part, thus 
 demonstrating that the strain is greatest at this point and that the 
 strain does not fall equally upon the fibres under such a test. It 
 makes no difference whether the dislocation is primarily inward or 
 outward — the teres tears in the same manner from the head ; and the 
 ease with which it is torn off is a strong argument against its func- 
 tion as a ligament. 
 
 Summary of Functions. In conclusion, I think I can safely 
 say— 
 
 1. The teres does not prevent dislocations, since it is possible to 
 tear it from the head without completely dislocating the head. 
 
 2. The ease with which the teres can be torn after division of the 
 capsule is also proof that its function is not that of a ligament. 
 
 3. While it is true that the teres may be torn without a dislocation 
 taking place, it is also true that without rupturing it a complete dis- 
 location is possible. 
 
 4. If the teres escapes rupture in the process of dislocation, it is 
 highly probable that it will be ruptured during efforts at replacement, 
 if circumduction be employed. 
 
 5. As there is no evidence that the teres contributes to the normal 
 security of the joint, therefore insecurity or weakness of the articu- 
 lation after the reduction of a dislocation cannot logically be attrib- 
 uted to its loss ; nor can its absence be said to favor subsequent 
 dislocations. 
 
 6. After reduction, no unusual position of the limb or foot (such 
 as flexion, inversion, or abnormal eversion) can justly be attributed 
 to the lost function of the teres. 
 
 Query. Does the teres ever reunite after dislocation ? 
 
 From an anatomical standpoint, I would not deny the possibility. 
 The probability is slight when we think that coaptation of the torn 
 surfaces may be wholly or partially prevented by blood, muscular 
 debris, shreds of torn tendon. Pathology alone can enlighten us on 
 this point. 
 
 THE CAPSULE. 
 
 No single structure about the hip-joint stands second in importance 
 to the capsule. After dislocation, the remnant of untorn capsule, as 
 a short halter, contributes to the awkward constraint of the femur 
 
THE CAPSULE. 13 
 
 and can be made available as an important diagnostic agent; it may 
 also constitute a principal factor in accomplishing reductions. 
 
 The capsule cannot be studied too carefully. It is a strong mem- 
 brane, and extends like a sleeve or cuff from the rim of the socket 
 to the base of the neck of the femur. Its functions are : 
 
 1. To check the movements of the femur against a tendency to 
 transcend the limits of safety. If one will dissect every structure 
 from the joint but the capsule, he will be surprised at the resistance 
 this single structure will offer to displacement. 
 
 2. To offer a large surface for the attachment of muscles that 
 contribute toward the safety of the joint and preside over the move- 
 ments of locomotion. 
 
 3. To furnish a large surface for the display of synovial membrane. 
 
 4. To form a shut sac for the retention and distribution of synovia. 
 The pelvic origin of the capsule is from the bony margin of the 
 
 socket, except where the margin is deficient, and here the attachment 
 is to the transverse ligament. 
 
 The femoral attachment is to the base of the neck — anatomists say 
 that the attachment is to the base of the neck anteriorly and to the 
 middle of the neck posteriorly. I will explain this attachment fur- 
 ther when speaking of the ischio-femoral ligaments. Certain parts 
 of the capsule are worthy of special study in connection with our sub- 
 ject. Prominent among these is the ilio-femoral ligament. (Fig. 10.) 
 
 The Ilio-femoral Ligament. This is not a distinct ligament, but 
 only a remarkable thickening of the capsule anteriorly. Its pelvic 
 origin is below the anterior inferior spine of the ilium. At this point 
 it is thicker than the tendo-Achillis (Weber). From this point it 
 passes down to be attached to the anterior inter-trochanteric line. 
 In its passage to the femur it does not continue of uniform thick- 
 ness, but its fibres are divided into two columns or branches, leaving 
 a space between them where the membrane is thin and translucent.^ 
 As this is a very important part of the capsule, with a long and 
 unwieldy name, Bigelow has christened it the Y-ligament ; and this 
 name has been widely accepted by teachers. I have repeatedly dis- 
 sected it ; and while the branches are not always equally distinct, I 
 feel that I can unqualifiedly support the distinguished surgeon in 
 what he claims for it. The two branches are called by him the outer 
 
 1 See tn/ra— Strength of the Capsule, p. 17. 
 
14 
 
 INTR OD UCTOR Y STUD Y. 
 
 and inner branches ; and he attributes special functions to each.^ I 
 shall not confine myself to this name in these pages ; for experimental 
 work, supported bv pathology, proves that much more than the 
 Y-ligament is, as a rule, uninjured in dislocations ; and it is a fact 
 clearly susceptible of demonstration that the less the capsule is torn 
 
 the more restraint will be exercised upon the dislocated limb, the 
 nearer the head will lie to the socket, and usually the facility with 
 which reduction can be accomplished will be correspondingly greater. 
 Puho- or Pectineo-femoral Ligament. Continuous with the ilio- 
 femoral ligament, but further inward, is one known as the pubo- or 
 pectineo-femoral ligament. This structure arises from the pectineal 
 line as far inward as the spine of the pubes ; the fibres pass outward 
 to blend with the capsule. It presents a slightly prominent sickle- 
 shaped border, which extends from the spine of the pubic bone to 
 the femur just above the lesser trochanter. These fibres lie beneath 
 
 • The two branches of the Y are beautifully brought out by first dislocating the femur and 
 then looking toward the light from the inner surface ot the capsule. This will prove to any 
 one that the branching is not the work of a scalpel. 
 
THE CAPSULE. 
 
 15 
 
 the pectineus muscle and the sheath of the femoral vessels. The 
 fibres are made tense during abduction. When I have dislocated 
 the head inward — by hyper-abduction — this ligament has often 
 escaped injury, the head making its escape from the socket beneath 
 
 Fig. 11. 
 
 Dislocation inward— the head lying in the thyroid depression and partly covered 
 by the pubo-femoral ligament. 
 
 it. At other times it has been torn. It is torn in all attempts to 
 convert by rotation outward a direct inward dislocation into a sub- 
 spinous variety. It probably always escapes when the head is 
 dislocated downward and outward. It may constitute an obstacle to 
 reduction. 
 
 IscMo-femoral Ligament. This accessory band is called by Gray 
 the ischio-capsular ligament, but I think incorrectly. No two 
 anatomists describe it alike ; I Avill therefore describe it as I have 
 found it. It arises from the ischial portion of the rim of the socket 
 and sends its fibres to the capsule to be blended with them. As its 
 fibres extend upward they separate like two fingers or terminal pro- 
 cesses, the one extending forward to the base of the oblique line, the 
 other running backward to the digital fossa. Between these pro- 
 
16 
 
 INTBOD UCTOR Y STUD Y. 
 
 cesses is a web, like the web between the fingers of the hand, with 
 a distinct border and entirely free from attachment to the neck. 
 Anatomists say that the capsule attaches to the neck posteriorly 
 midway in its length. Now, it is true that above the web (Fig. 12) 
 there is no capsule, and that the synovial membrane reaches only 
 half-way the length of the neck posteriorly ; but there is a function 
 
 Fig. 12. 
 
 of the capsule that would be lost if the capsule attached directly to 
 the neck midway of its length ; and that function is strength. Were 
 the fibres lost in the capsule, as described by some anatomists, they 
 would confer no strength or barrier against dislocation. To gain 
 strength they must pass from bone to bone, from the rim of the 
 socket to the base of the neck. I have spoken of the web as having 
 
STRENGTH OF THE CAPSULE. 17 
 
 a free distinct border, and have said that this web does not attach 
 to the neck. I mean by this that it is not attached as a ligament. 
 It is loosely attached by a reflection of synovial membrane and by 
 connective tissue; but its only function in the attachment is to 
 retain synovia. The absence of capsular attachment in the middle 
 of the neck posteriorly does not weaken the joint, for any stress will 
 take the direction of one or the other of these processes, or of both. 
 
 Strength of the Capsule. 
 
 The crowbar is so constructed that its o-reatest strength shall be 
 at the point of greatest strain, i. e., a point over the fulcrum, and 
 the further we go from this point the less material do we find in the 
 bar. Now the capsule is constructed on this plan : it is thickest 
 where the strain is necessarily the greatest, and that is near the rim 
 of the socket. In every strain upon the capsule the pressure must 
 be exerted through the head of the femur and proceed from within 
 the capsule and extend outward. The capsule may be cut with a 
 
 Fig. 13. 
 
 bistoury from without inward, but it must be burst from within out- 
 ward. In every position in which the femur may be placed, if the 
 head is thereby brought against the capsule, it will be brought 
 against that part which is nearest to the pelvic attachment, and 
 hence everywhere the pelvic extremity of the capsule is thicker, 
 stronger, and more even in construction than the femoral extremity. 
 When we examine the femoral extremity of the capsule we find that 
 the ilio-femoral band splits and separates, making two attachments. 
 We see the pectineo-femoral making a single femoral insertion ; we 
 
 2 
 
1 8 INTBOD UCTOB Y STUB Y. 
 
 find the ischio-femoral — one at its pelvic origin — dividing into two 
 branches at the femoral ; and the question arises, What does it all 
 mean ? The answer is close at hand. The femur being a crooked 
 bone, enjoying universal motion, with capsular fibres of unequal 
 length, could not find a use for all the fibres were they inserted of 
 equal thickness into the neck. Not only is this true, but, were the 
 capsule of equal thickness at its femoral attachment, the directions of 
 strain would be interfered with, since some parts of the capsule by 
 its unwieldy thickness would be in the way of others. So far from 
 the gap between the legs of the Y-ligament being a cunning device 
 of a scalpel in the hands of Prof. Bigelow (as I have heard declared), 
 this gap is rather the conservation of material, being thin here, 
 with no other function than to retain synovia, while the branches 
 themselves of the Y are rather the expressions of normal hyper- 
 trophy due to healthful physiological activities. As in the case of 
 the mast of a ship, the strain may fall first on one rope, then on 
 another, and lastly on both together ; so the strain on the femoral 
 attachment of the ilio-femoral ligament falls, in the ordinary func- 
 tions of locomotion, first on one branch, then on the other, or upon 
 both together. In circumduction the strain would pass around the 
 base of the joint, starting, it may be, at the outer branch, extending 
 then to both, then to the inner, on to the pubo-femoral, and still on 
 to the ischio-femoral. Thus we can see that each end of the capsule 
 has a distinct function. At the pelvic, where the head of the femur 
 comes in direct contact with it, it is thick and strong, with no points 
 of attenuation that would easily permit the head to slip through ; at 
 the femoral attachment, the part unapproached by the head, the 
 material is gathered up in bundles that take the direction of greatest 
 strain. Thus is solved the problem of maximum strength with 
 minimum amount of material ; and the crucial test, that the femoral 
 attachment is as strong as the pelvic, is found in the frequency 
 with which dislocations are reduced — were the capsule uniformly 
 torn from its femoral attachment, restorations would be the excep- 
 tion. 
 
 The Femoral Vessels. 
 
 The femoral vessels are very rarely injured in dislocations. Their 
 immunity is due (1) to their anatomical relations to the joint; (2) to 
 the muscles that lift them out of tlie reach of danger at the instant 
 
THE FEMORAL VESSELS. 
 
 19 
 
 dislocation takes place ; and (3) to the relation of the femui' to the 
 vessels in the act of dislocation.^ 
 
 At their exit from the pelvis beneath Poupart's ligament the 
 femoral vessels lie on a plane a little anterior to the head of the 
 femur. They are not covered with muscles in Scarpa's triangle, but 
 
 Fig. 14. 
 
 lie upon muscles "which pass from the pelvis to the linea aspera. 
 The head of the femur approaches the femoral vessels only in dis- 
 locations inward ; and in dislocations inward the femur must be 
 flexed and abducted the instant the rupture of the capsule takes 
 place. Hence the muscles that constitute the floor of the femoral 
 
 ' In the only case that I have seen reported of fatal hemorrhage the femoral vessels were 
 ruptured by hyper-extension of the thigh upon the pelvis. In this position the vessels are 
 drawn tensely across the head of the femur at the instant when the head bursts through the 
 capsule. lu the case reported a cavalryman was thrown from his horse and the whole 
 thigh carried backward, so that the knee lay between the shoulders. Stimson's Treatise on 
 Dislocations. 
 
20 
 
 INTR OD UCTOR Y ST UD Y. 
 
 vessels are more or less tense, and lift them out of the way. In the 
 accompanying figure (Fig. 14) 1 have represented only a single 
 muscle — the pectineus. 
 
 If the head be dislocated inward, it will pass below the femoral 
 vessels and leave them and their sheaths wholly undisturbed. If 
 the limb is now permitted to descend by its own weight, the femoral 
 vessels will be found lying across the head or neck, the head being 
 internal to the vessels.^ (Fig. 15.) 1 believe this to be the usual — 
 
 Fig. 15. 
 
 Double dislocation of the femur inward. (Dissecting-room reproduction.) 
 
 not the occasional — relation of the head to the vessels in dislocations 
 inward. I doubt very much that the head is ever dislocated directly 
 upward and to the outer side of the vessels. The head can, however, 
 reach the outer side of the vessels by first being dislocated inward 
 and then shifting its position beneath and to the outer side of them. 
 Fig. 15 suggests the easy compression of the femoral vessels in a 
 thyroid dislocation. 
 
 The Fascia Lata. 
 
 This structure is not concerned to any material degree in the 
 subject of dislocations of the hip, and yet a knowledge of its normal 
 
 ' Sir Astley Cooper (Fractures and Dislocations) says: " Upon examining the seat of injury 
 it was found that the head of the femur had been thrown to the inner side of the femoral 
 vessels; " and in a case reported by James Douglas (Monthly Journal of Medical Sciences, 
 1843), it is stated that the head " lay internal to the bloodvessels, having passed beneath 
 them." Mr. Douglas cites this as an instance of the great force that was necessary to produce 
 such an injury. This prevailing opinion that the head was dislocated directly upward and 
 inward, external to the vessels, was due to the widespread influence of the eminent British 
 surgeon, who never thought that an easier mechanism of dislocations was possible. Had he 
 done so, he would ])robably have thought of an easier mode of reduction. 
 
THE FASCIA LATA, 
 
 21 
 
 relations may be of much diagnostic value in certain pathological 
 conditions, such as fracture of the neck of the femur and hip-joint 
 disease — injuries that have been mistaken for dislocations. I shall 
 not enter fully into its anatomical relations, but merely touch upon 
 parts that illustrate important conditions. 
 
 The chief function of this fascia is in the erect posture, as in 
 standing at rest, walking, and running ; hence it enjoys to a remark- 
 able degree the double function of 
 muscle and tendon. That part of 
 the fascia which especially concerns 
 us may be said to arise from the 
 crest of the ilium. From this cres- 
 centic bony origin the fascia, though 
 it extends around the entire limb, for 
 'Our present purpose may be said to 
 converge to a narrow band, and finally 
 to be inserted into the outer tuber- 
 osity of the tibia. (Fig. 16.) A 
 threefold function of this important 
 structure consists in its acting as a 
 tensor to fascise that sheathe the 
 muscles of the thigh, in acting as a 
 constant check to a tendency to dis- 
 placements, and in operating as an 
 important agent in supporting the 
 body at rest — thus relieving the over- 
 taxed muscles. 
 
 1. As a Tensor of the Fascia, 
 This is chiefly accomplished by the 
 tensor vaginae femoris and the pos- 
 terior half of the gluteus maximus. 
 Neither of these has a direct bony 
 attachment, but both are inserted 
 
 into this broad, dense, powerful fascia. In running and walking these 
 muscles make tense this fascia. Their action can be studied with 
 great ease as one ascends a flight of stairs, by holding the finger 
 against the tendon of the fascia just above the outer condyle of the 
 knee. 
 
 2. As a Chech to a Tendency to Displacement. With every step 
 
22 INTROD UCTOR Y STUD Y. 
 
 there is a tendency to displacement. Under the ordinary motions 
 of the hip the head of the femur is not retained in the socket by 
 arbitrary ligaments. The function of a ligament is to bind ; but the 
 hip has the freest motion in all directions. Hence an accommoda- 
 tive pressure, supplementary to atmospheric pressure, constant but 
 yielding, suiting itself to the varied changes that take place, is 
 required. This is accomplished in part by muscles that are inserted 
 directly into the capsule. But there is another entirely independent 
 and most important agency, hitherto possibly unnoticed, reserved for 
 the fascia lata. This fascia, under the control of the tensor vaginae 
 femoris and gluteus maximus, passes directly over the great trochan- 
 ter, exerting direct active pressure upon it. The fascia lata does not 
 have an attachment to the great trochanter. If it did, the femur 
 could not be flexed upon the abdomen. As it is, the trochanter 
 moves with every step beneath the fascia — to which action is prob- 
 ably due the large bursa always found beneath it. The first upper 
 attachment that the fascia makes to the shaft is through the tendon 
 of the gluteus maximus, and from this point down it is attached to 
 the linea aspera the whole length of the bone. As proof that the 
 fascia exerts pressure upon the head through the trochanter I adduce 
 the following personal experience : In December, 1884, I was seized 
 with a pain in the outer aspect of my right thigh which soon devel- 
 oped into an abscess beneath the fascia lata. In order to facilitate 
 drainage, I requested Dr. D. Hayes Agnew to cut the fibres of the 
 fascia transversely. This he did ; and, on my recovery after nine 
 weeks of recumbency, I was not a little surprised at the inse- 
 curity of the head of the femur, which became partially dislocated 
 with each step and returned with a decided jar and an audible sound. 
 This could not have been due to anything but the division of the 
 fascia lata and its consequent lengthening and changed relations, 
 which withdrew the normal pressure from the trochanter ; thus a 
 joint that had never exhibited the slightest disease or tendency to 
 insecurity before the division of the fascia, became subsequently, 
 upon my first use of it, so unstable that I feared for a time that a 
 synovitis would ensue from the constant concussions occasioned by 
 even the gentlest use. By degrees the tensor muscles shortened and 
 re-established their former control ; but the security has never fully 
 returned. 
 
 A further confirmation of the statement that the fascia, under the 
 
THE FASCIA LATA. 23 
 
 control of the tensor muscles, makes pressure upon the head through 
 the great trochanter is seen in the early symptom of abduction in 
 hip-disease. Adduction — the reverse of abduction — makes tense 
 the fascia and drives the head into the socket. In erect walking, 
 the fascia makes no pressure on the trochanter in its office as a ten- 
 don, but it does make pressure through the tensor muscles. There- 
 fore, in hip-joint disease the patient, to escape pressure from both 
 sources, abducts the thio;h and adds flexion to abduction to relax 
 still further the psoas, the tendon of which passes directly over the 
 head of the femur. The theory which is far too widely spread, 
 that lengthening exists in the early stage of hip-joint disease, and 
 is due to effusion in the joint, thus forcing the head out, cannot 
 be sustained. There is no lengthening ; the apparent lengthening 
 is due to asymmetry. Place both limbs in equal degree of flexion 
 and abduction (see Fig. 88), and the apparent lengthening will dis- 
 appear. 
 
 3. As a Support for the Body at Rest. Man in the erect posture 
 finds himself shiftino; his weight from one limb to the other. This 
 function of standing at rest has been attributed to the agency of the 
 capsule and the ligamentum teres. This is true only to a very 
 moderate degree, the chief agency being the strong, flexible, but 
 inelastic band of fascia that passes from the crest of the ilium to 
 the outer tuberosity of the tibia. (Fig. 17.) This tendon is not 
 tense as a ligament in the erect posture, i. e., when one is standing 
 equally upon both feet. When under such circumstances it is tense, 
 this tension is voluntary and due to the action of the tensor muscles. 
 Were the fascia tense in the erect posture, further adduction (so 
 important at times to preserve one's balance) would be impossible. 
 In standing at rest, man always throws his full weight upon one 
 limb, and the relation of this limb to the pelvis is that of adduction. 
 Adduction makes tense the' fascia, because it makes prominent the 
 trochanter, which, as it were, presses outward against it. In stand- 
 ing at rest, man tilts the pelvis toward the limb on which he stands 
 until it is finally arrested, the body balanced, and the muscles 
 rested.^ 
 
 Hammock Function. While the more important functions of 
 this fascia are exhibited in the erect posture, it enjoys a function in 
 
 1 I have been told that flamingoes sleep standing on one leg, and that one can tell which 
 of the flock is sentinel by noting which bird Is standing on both legs. 
 
24 
 
 INTRODUCTORY STUDY. 
 
 the horizontal position worthy of our consideration. This I shall 
 denominate the hammock function. In dorsal recumbency the toes 
 turn outward. Why do they do so ? It is not due to muscular 
 action, for it persists in sleep and is present in the paralytic. It is 
 due solely to the weight of the limb, which rotates outward on the 
 neck of the femur. It is simply an expression of external rotation, 
 the motor being gravity, and the radius of action being the neck of 
 the femur. But why does the rotation stop at the same j^/'ccise limit 
 each time ? Let a person stand erect, and, making a pivot of his 
 heels, rotate both limbs quickly outward. They both stop suddenly 
 and at the same precise point each time, no matter how often or 
 powerfully the motion is repeated. Why ? Because they are checked 
 by a ligament. This check is through the fascia lata, which supports 
 the limb as in a hammock. This support is of great value after the 
 reduction of a dislocation. When the surgeon in such a case ties 
 
 Fig. 17. 
 
 the ankles together he is practically adducting both limbs, and this 
 compels the fascia lata to make pressure upon the trochanter. Thus 
 a force, held in reserve and entirely unharmed by the traumatism of 
 dislocation, is made of great service during repair. Further proof 
 that this fascia influences rotation can be elicited in the following 
 manner. Place a person on his back, with his heels touching each 
 other, and note the degree of external rotation. Now, while the 
 patient is perfectly passive, let the surgeon abduct both the patient's 
 limbs. As the abduction increases — the knees being kept stiff — the 
 external rotation will increase, because the limbs are passing from 
 under the control of the fascia. Now let the surgeon approximate 
 the patient's feet. As he does so, the normal degree of rotation will 
 be resumed. In this manoeuvre the patient has been perfectly pas- 
 sive, and the change in rotation uninfluenced by muscular action. 
 
THE FASCIA LATA. 
 
 25 
 
 The same effect may be produced upon the cadaver. It is this auto- 
 matic mechanical control of the thigh which brings it down with such 
 a precise degree of external rotation that makes it possible for man 
 to run at a high rate of speed without danger of tripping or bringing 
 the foot down insecurely. 
 
 On page 29 I have noted the reasons why it is impossible to flex 
 the femur on the pelvis without first flexing the leg on the thigh. 
 At this point I wish to say that, even with the leg flexed on the 
 thigh and the ilio-tibial band thoroughly relaxed, hyper-flexion of the 
 
 Fig. is. 
 
 femur makes tense the upper fibres of the fascia that give support to 
 the head in this position and tend to check a tendency to displace- 
 ments. Fig. 18 indicates also how possible it is for the head to 
 wound or even transfix the gluteus maximus (p. 65, Case IV.) when 
 dislocation takes place during flexion, adduction, and inward rotation 
 of the femur. 
 
 A matter of great practical value is to note the deportment of 
 this fascia after fracture of the neck of the femur. All that I have 
 said about the fascia lata in regard to support depends upon an 
 unbroken femur. Let the femur be broken at any point in its con- 
 tinuity between the head and the condyles, and it is plain that it can 
 
26 
 
 INTRODUCTORY STUDY. 
 
 no longer make tense this fascia. Now, fracture in the shaft of the 
 femur is easy of detection. Not so with fracture of the neck of the 
 femur, and this is specially important, as its frequency increases with 
 adv^ancing years, rendering an easy means of diagnosis of inestimable 
 importance. To avail one's self of this principle, it is necessary to 
 note that the fascia during adduction is tense (Fig. 20) and can be 
 felt as a firm resistinor band between the trochanter and the crest of 
 
 Fig. 19. 
 
 ^^.-T- 
 
 :^^ 
 
 Abduction of both femurs. The arrows point to regions where the fascia lata will be 
 notably relaxed. 
 
 the ilium, and like a firm round cord, about the size of the little 
 finger, near the knee, above the outer condyle. The examiner can 
 first take the sound limb, and, adducting it, bring into prominence the 
 tendon, best felt above the outer condyle. He can then take the 
 suspected limb, and, gently adducting it, feel the resistance. If the 
 resisting band or cord be present in equal degree upon both sides, 
 there is strong presumptive evidence of a sound femur. If it be 
 absent, this, with the corroborative testimony that attends an acci- 
 dent, should have great consideration. 
 
THE FASCIA LATA. 
 
 27 
 
 Brief Resume of the Functions of the Fascia Lata. 1 . It 
 forms the sheath or envelope of the most important walking muscles 
 of the thigh ; during progression the tension of this fascia (through 
 the gluteus maximus and tensor vaginae femoris) is of the utmost 
 advantage; through the same muscles it steadies the head of the 
 femur in the socket. 
 
 Fig. 20. 
 
 2. It checks adduction of the extended thigh through the ilio- 
 tibial band. 
 
 3. It checks outward rotation of the extended thigh. 
 
 4. It assists the hamstring muscles and the sciatic nerve in check- 
 ing flexion of the extended limb. 
 
 5. It checks a tendency to hyper-flexion of the thigh upon the 
 abdomen. 
 
 6. It contributes largely to man's ability to stand at rest. 
 
28 I^TR OD UCTOR Y STUD Y. 
 
 7. After the reduction of a dislocation at the hip-joint the fascia 
 lata and the untorn portion of the capsule are our main reliance in 
 retaining the head of the femur in place. If the feet are tied 
 together, the fascia and nothing else presses the head into the socket. 
 
 8. After fracture of the neck this ilio-tibial band is relaxed during 
 adduction. 
 
 9. As adduction tightens the ilio-tibial band, and abduction re- 
 laxes it, the latter position is voluntarily assumed in the early stage 
 of hip-disease. 
 
 10. As flexion of the extended limb tightens the fascia lata and 
 drives the head into the socket, this manoeuvre elicits pain in the 
 early stage of hip disease. 
 
 THE SCIATIC NERVE AND HAMSTRING MUSCLES. 
 
 The sciatic nerve makes its exit from the pelvis at the lower 
 border of the pyriformis muscle (Fig. 21) and proceeds in a direct 
 line to the popliteal space. It passes between the great trochanter 
 and the tuberosity of the ischium, but its relation to the stable pelvis 
 is closer and more intimate than to the movable trochanter. The 
 latter can be rotated from or toward the nerve, but cannot pinch it. 
 It is covered by the thick, warm, fleshy gluteus maximus and the 
 hamstring muscles, and is thus protected against sudden changes in 
 temperature. 
 
 Since dislocations occur and are reduced with the femur in the 
 flexed position, I shall present the nerve in its relation to the socket 
 and muscles in this position. In the accompanying diagram the 
 nerve is seen emerging from the great sciatic foramen, in the inter- 
 space between the pyriformis and the obturator internus, then cross- 
 ing the quadratus femoris, and lying upon it and the adductor magnus 
 until it reaches the popliteal space, where it gives off a large branch. 
 The nerve is attached loosely to the muscles that surround it, but its 
 special guardian is the outer hamstring muscle, the biceps. The 
 nerve passes below the socket until it reaches the tendon of the biceps, 
 to which it becomes quite intimately attached. In adduction, abduc- 
 tion, and the various movements of the thigh, the nerve follows the 
 muscle. 
 
 As the nerve is large and practically incapable of being stretched, 
 
THE SCIATIC NERVE AND HAMSTRING MUSCLES. 
 
 29 
 
 it is interesting to notice how Nature, in the movements of the limb, 
 has phmned to throw the brunt of many an injury upon other and less 
 important structures. The structures that are made tense by any 
 attempt to flex the pelvis on the extended thigh and leg — or, what is 
 the same thing, to flex the extended limb — are : the fascia lata, the 
 hamstring muscles, and the sciatic nerve. I will describe only the 
 action of the hamstring muscles, since the mechanism is practically the 
 same in all. In Fig. 22 (p. 30) the femur and the hamstring muscles 
 
 Fig. 21. 
 
 are represented as parallel and of equal length. [Note in the dia- 
 gram that the origin of the muscle {B) is below and to the right of 
 the socket and that the insertion (Z>) is below and to the right of the 
 knee-joint.] If, now, we flex the femur to a right angle, the con- 
 dyles will reach as high as E^ while the muscle, though it be 
 equally long, will reach only to F. If an attempt were made to 
 raise the tibia to the perpendicular, F must rise as high as Cr. It 
 must be plain, therefore, that flexing the leg on the thigh, in walk- 
 
30 
 
 INTRODUCTORY STUDY. 
 
 ing or running, is not a voluntary or muscular action, but one of 
 pure mechanics ; for the instant the psoas and other muscles flex 
 
 Fig. 22. 
 
 e ... 
 
 m 
 
 N. T. F. Xeuro-tendinons fascia extending between the sciatic nerve and the tendon, 
 binding both together and normally exercising some constraint upon the nerve. 
 
THE SCIATIC NERVE AND HAMSTRING MUSCLES. 
 
 31 
 
 the thigh on the pelvis that instant the leg becomes flexed on the 
 
 thigh through the unstretchable fascia lata and the hamstring mus- 
 es o o 
 
 cles. The important principle to which I would call attention is, 
 that when the femur is flexed at right angles with the pelvis the leg 
 must he flexed to relax the nerve and the hamstring muscles. 
 
 I have already said that the nerve follows the hamstring muscles 
 in the various positions of the femur, as in abiuction, adduction, etc. 
 
 Fig. 24. 
 
 If the limb be abducted, the nerve and muscles will run parallel to the 
 shaft of the femur. (Fig. 23.) Now, if the femur is carried still further 
 outward, the head may burst through the capsule and be dislodged 
 inward. (Fig. 24.) In such a case it is plain that no injury will accrue 
 to the nerve. But suppose the head, from being in the position of thy- 
 roid luxation, should be shifted outward to that of a dorsal luxation, 
 how is it to get there ? Easily enough, but not Avithout danger to 
 the nerve, since there is but one possible path for a dislocation inward 
 to take in order to become a dislocation outward, and that is, be- 
 
32 
 
 INTR OD UCTOE T STUD Y. 
 
 tween the hamstring tendon and the socket. Xow the tendon of 
 origin of these muscles is within half an inch of the socket, and the 
 nerve is nearer, if anything. Under no circumstances can the head 
 he circumducted and carried outward without traumatism, more or 
 less severe, to the nerve. If the sweep of the knee through which 
 this may he effected be a large one, and especially if there he 
 sufficient extension of the leg on the thigh to shorten and make tense 
 the nerve, then there is great danger that the head will pass between 
 the nerve and the tendon, and that the result represented in the 
 diagram (Fig. 25) will take place. This condition was present in 
 
 Fig. 25. 
 
 Compare Fig. 2-5 with Fig. Zi, and note how completely the nerve may be torn from its 
 surrounding and controlling attachments through circumductive movements after dis- 
 location. 
 
 Quain's case (Fig. 50), and can be readily reproduced experi- 
 mentally. If such a condition be suspected, the fact may be ascer- 
 tained by having an assistant push upward upon the knee in the 
 direction of the long axis of the shaft of the femur, while the surgeon, 
 by extending and flexing the leg, will find the nerve made alter- 
 nately tense and relaxed in the popliteal space, if it be over the neck 
 and the head out of the socket. In such a case a successful reduction 
 of the head will release the nerve, but the traumatism may have been 
 80 severe that a prolonged neuritis, a partial or complete paralysis, 
 may result. Such a condition, if unrelieved by replacement, would, 
 of course, be one of prolonged suffering. 
 
 If the head, in its transit from within outward, pass between the 
 nerve and the socket, the former may be bruised a little, but not 
 
THE SCIATIC NERVE AND HAMSTRING MUSCLES. 
 
 33 
 
 detached from the tendon, and will lie, after dislocation, between 
 the head or neck and the tuberosity. This, taking all the varieties 
 
 Fig. 26. 
 
 of displacement into consideration, is, I think, the most frequent 
 condition, and when it occurs the danger of hooking up the nerve 
 through the efforts at reduction will be greatly increased if the 
 
 Fig 27. 
 
 head in passing outward catches up the nerve and tears it from its 
 attachments. This is no random statement, Bigelow, Morris, and 
 
34 INTBOD UCTOR Y STUD Y. 
 
 Johnson have caught it up in experimental work, and Koons did it 
 in actual practice.^ 
 
 If the nerve be hooked up during the reduction, the following 
 conditions will be present : The nerve will cross the front of the 
 neck and lie beneaih the untorn parts of the capsule and the tendon 
 of the psoas muscle (Fig. 27, p. 33) ; it then descends through the 
 rent in the muscular partition to the adductor magnus, beneath 
 which it descends to the popliteal space. At least three inches of 
 the nerve are taken up by this detour, and hence the thigh must be 
 flexed on the pelvis and the leg on the thigh to accommodate them 
 to the shortened nerve. 
 
 If the dislocation occur through flexion, adduction, and rotation 
 inward, the capsule may yield and the head may escape outward 
 and downward without touching the pelvis in the descent. In such 
 cases 1 have seen the head fall directly upon the nerve, from which 
 it can slip to either side. 
 
 Fig. 28. Fig. 29. 
 
 SCIATIC '/V£/fV£ ■ 
 
 I have already spoken of the guardianship of the nerve — i. e., 
 how the nerve is protected through attachment to the hamstring 
 muscles, and how it follows them in adduction and abduction. (Fig. 
 23.) As the adductor muscles are very powerful, it is highly probable 
 that more dislocations occur through flexion, adduction, and rotation 
 inward than in flexion, abduction, and rotation inward. Not that 
 these muscles bave any direct agency in producing a dislocation or 
 preventing one, but, simply by their power, place the limbs in a 
 state of adduction at the instant that the fatal flexion and rotation 
 inward produce the displacement. In hyper-adduction the nerve 
 skirts the border of the socket (Fig. 28), and the head may, in transit 
 
 1 Reminiscences, supra. 
 
TJTE HAMSTRING MUSCLES. 
 
 35 
 
 outward, scarcely touch it. In hyper-ahduction the nerve runs parallel 
 "with the shaft (Fig. 29), and the danger to it then from dislocation 
 outward is imminent and unavoidable. Thus we have two positions 
 in which, if dislocations take place, we have good reasons to predict 
 the condition of the nerve ; and hence when we read in accounts of 
 autopsies that the nerve was caught up over the neck — lacerated, 
 slightly bruised, or uninjured — we have a warrant for placing the 
 limb in a position between hyper-adduction and hyper-abduction that 
 will best fulfil the conditions. 
 
 That which I have said about the nerve does not apply to the 
 quadratus muscle. This muscle is always put on the stretch by 
 flexion, and the tension is increased by rotation inward. Hence, 
 when this muscle is torn in two with some of the fibres of the adduc- 
 tor magnus and the obturator externus, no other agency need be 
 invoked than hyper-tension. 
 
 The Hamstring Muscles. 
 
 I have already stated that these muscles become, under certain 
 circumstances, the guardians of the sciatic nerve. In their guardian 
 
 Fig. 30. 
 
 action they illustrate a principle inherent in all muscular fibre, viz.. 
 that when put upon the stretch it exhibits the property of tendon or 
 ligament. This is strikingly brought out in the following experiment ; 
 
36 INTBOD UCTOR Y STUD Y. 
 
 If a pelvis, resting prone, be securely bound to a strong table, and 
 the thigh with flexed leg (Fig. 30) be permitted to hang freely, 
 the thigh will hang nearly perpendicular. If now the support of 
 the leg be gradually removed, the leg will descend until arrested by 
 the hamstring muscles, whose tendons will stand out in bold relief in 
 the popliteal space. If the leg be again raised and suddenly let fall, 
 it will be so suddenly arrested as to jar the whole table, and a 
 rebound will take place proportioned to the height and suddenness 
 of the fall. The sudden checkino- of the leo- with an elastic rebound 
 demonstrates the important, long-established, but not sufficiently 
 well-recognized, principle already mentioned, that a muscle, when 
 it reaches the limit of extensibility, becomes a tendon or ligament, 
 and if the force continues, the muscle must rupture in some part or 
 tear from its bony attachments, or the bone must fracture or dislo- 
 
 FlG. 31. 
 
 cate. Those who hold that muscles, by their contractility, aid in 
 the reduction of dislocations, must depend wholly on theory, while 
 the agency of muscles put upon the stretch can be demonstrated 
 upon the cadaver. In experimental work, after removing every 
 vestige of the capsule, I have been able, by putting the psoas mus- 
 cle on the stretch, to restore the hip by the very principles of ma- 
 nipulation that Bigelow has so happily demonstrated as due to the 
 Y-ligament. In manipulation with a view to restore a dislocation 
 
THE HAMSTRING MUSCLES. 
 
 37 
 
 Fig. 32. 
 
 one often experiences a locking and a resistance, due in part to the 
 stretched muscles. 
 
 The sudden arrest of the falling leg in the experiment is pos- 
 sible only with normal soundness of the femur. If the latter be 
 bi'oken in any part or dislocated, the hamstring muscles will not 
 encounter resistance to the same degree. This fact can be turned 
 to good account, not only in investigating an injury, but also in 
 determining that a dislocated limb has been restored. To place the 
 tendons on the stretch, an assistant elevates both lower extremities by 
 the heels (Fig. 31), while the surgeon marks the gradually increasing 
 tension of the cords in the pop- 
 liteal space. In the normal limb 
 the tension of these cords will be 
 firm and resisting, wholly un- 
 influenced by muscular action. 
 It will be steady and the ten- 
 dons will feel almost like so 
 many wires. These cords will 
 be absent in case of fracture or 
 of dorsal dislocation. Again, 
 as the elevation goes on the 
 ascent will be arrested in the 
 sound limb, and, if the assistant 
 would bring the limb to the ver- 
 tical, he must flex the leg at the 
 knee. (Fig. 32.) Not so in case 
 of dislocation outward or of frac- 
 ture ; the extended limb can easily 
 be placed in a vertical position. 
 
 If the dislocation be inward 
 instead of outward, it will be 
 
 impossible to raise the extended limb to a vertical position. (This is 
 also true of the normal condition.) The reason is that, in dislocations 
 inward, the head rests on a bony foundation, just as when in the 
 socket, and flexion makes tense the fascia lata and the hamstring 
 muscles. To decide that the limb is dislocated inward one should 
 adduct the femur — this is impossible when the head lies in the 
 thyroid depression upon the inner plane. 
 
 In experimental work after I had restored the femur with the body 
 
3 8 I^^TB on UCTOR Y STUD Y. 
 
 prone (Fig. 30) I could readily assure myself that the restoration was 
 satisfactory by raising slightly the foot and letting it fall, while at the 
 same time my unoccupied hand rested upon the great trochanter. If 
 the limb were restored, the fall of the leg would simply jar the 
 pelvis ; but if it was dislocated, the trochanter would jump beneath 
 the hand. Although this experiment has little clinical value, yet it 
 illustrates well the principle under consideration, that a muscle when 
 made tense deports itself like a ligament. 
 
 A STUDY OF THE IMECHANISM OF DISLOCATIONS 
 ARTIFICIALLY PRODLX'ED. 
 
 Many of the earlier experimenters in this field of surgery found 
 it expedient, if not absolutely necessary, to divide the capsule sub- 
 cutaneously before they could effect dislocation. 
 
 To avoid the necessity of tenotomy I resorted to fixation of the 
 pelvis as a preliminary step in my investigations. 
 
 It may be objected that I have not imitated the mechanism through 
 which dislocation occurs any more exactly than those whose course 
 I wished to shun ; but upon a closer study it will be seen that, in 
 actual life, no dislocation ever occurs except on the principle of the. 
 lever and fulcrum, and, in the case of these agents, the former is 
 ahvays the movable and the latter alivays the fixed agent. It does 
 not afiFect the principle whether, in the causation of a dislocation, it 
 occurs when a man is slowly walking or when he is hurled from a 
 rapidly moving car ; whether it requires a minute or the hundredth 
 part of a second. In every case the lever must move and the fulcrum 
 must he fixed. 
 
 When a person steps into a deep hole, and, falling forward, dislo- 
 cates his hip, the mechanism is plainly that of motion and fixation, 
 lever and fulcrum. If a man suffers the same accident from getting 
 his leg caught in the wheel of a rapidly moving wagon, the same 
 mechanical principles are present, viz., motion and fixation — the lever 
 and fulcrum. In the latter case the inertia of the body represents 
 the fixation, while the rapidity of the revolving wheel twists the head 
 out of its socket before any of the dislocating energy has been com- 
 municated to the body. This is illustrated by the trick of snapping 
 a card poised upon the finger from beneath a penny, without dis- 
 
MECHANISM OF DISLOCA TIONS ARTIFICIALL Y PROD UCED. 39 
 
 turbing the penny. The penny is bound down by inertia, and the 
 solution of the problem is to communicate motion to the card with- 
 out communicating any to the penny. By a slow motion this trick 
 is impossible, since both card and penny move together. So, in my 
 early attempts at reduction without fixation, my tardy movements 
 w^ere readily communicated to the trunk, and I failed, because I was 
 not imitating the traumatisms of actual life. In mechanically secur- 
 ing the pelvis, i. e., in preliminary fixation, I was merely immobilizing 
 my fulcrum, and ifi this I was following to the letter the mechanism 
 of all traumatic dislocations. 
 
 Fig. 33. 
 
 Fig. 33 represents part of a dissecting-table. Above is a cross-bar of hickory, three and 
 a half feet long and one and a half inches in diameter. An oak strip, three inches wide 
 and of the same length, runs parallel beneath the table. The two are connected by iron 
 rods eighteen inches long. Two hooks slip along the hickory rod. At the end of the table 
 is a second oak board that passes beneath the end of the table and above the cross-bar. 
 Two iion rods, twelve inches long, with open hooks, are seen in this board. The apparatus 
 ■will fit any post-mortem or dissecting-table, and the cadaver can be fastened to any part of 
 it. If I desire to operate on the right hip, I bring the subject to the right-hand corner of the 
 table. This permits me to make any desired manipulation. The cross-bar crosses the lumbar 
 vertebrfe above the pelvis ; the lower hooks, which are between the thighs, are now con- 
 nected to the hooks on the cross-bar by means of a bed-cord, which secures the pubic por- 
 tion of the pelvis. Any further tightening can be done with the thumb-screws. With 
 this the pelvis ea,n be secured as in a vise, and the operator can watch the effect of every 
 manipulation. 
 
 No further advantage was anticipated from fixation than that it 
 would enable me to accomplish my purpose ; but in this I was agree- 
 ably surprised. It was indeed the initiatory step to a series of most 
 
40 
 
 INTROD UCTOR Y STUD Y. 
 
 instructive studies, each of which will be treated at length in its 
 proper place. 
 
 The instrument that I found of great service to me is seen on p. 39. 
 
 After fixation dislocations can be performed by unaided manual 
 effort, and the process may be carefully watched. The factors that 
 enter into the problem are simply the mechanical powers, viz., the 
 lever, fulcrum, power, and weight. These present interesting points 
 for consideration, and will be taken up in order. 
 
 The Lever. If a lever is straight and round (Fig. 34), it will 
 make no difference which surface is exposed to the fulcrum ; but if 
 
 Fig. 34. 
 
 Fig. 35. 
 B 
 
 m rr-l 
 
 ±1 
 
 HL 
 
 .n 
 
 W X Y Z 
 
 m n represents a plane surface ; w x y z, fulcra of equal height and distance from their 
 respective levers ; A and B are levers. If A be turned to the right or left, it will strike a 
 fulcrum. If B be turned to the right, it cannot touch a fulcrum, owing to the bend in it ; 
 but if it be turned to the left, it will strike the fulcrum sooner than if it had no bend in 
 it, while the bend in the lever taken together with the fulcrum will enable the lever to 
 raise a weight to a higher point than a plain lever could do. 
 
 it is bent and has a limited range of motion, as upon an even surface, 
 one position may make it wholly useless (Fig. 35, dotted line), while 
 another surface may make it more advantageous than a straight lever. 
 In the latter condition the outward prominence situated at the iunc- 
 tion of the two arms of the lever may itself constitute an additional 
 fulcrum and enable the operator to raise the weight much higher 
 than could be done with a straight lever. If the lever, in addition 
 to the bend, has a projection, then lever and fulcrum would be repre- 
 sented in one solid piece, and such an instrument could be made 
 available upon a plane surface. 
 
 Now, the femur is a lever whose shaft is long and straight, whose 
 neck joins the shaft at an angle of 130°, and is provided with a 
 trochanter — all of which elements may be the occasion of disaster 
 
MECHANISM OF DISLOCATIONS ARTIFICIALL Y PROD UCED. 41 
 
 to the joint and parts composing it. The shaft of the femur can 
 hardly be used as a lever in any other positions than in abduction 
 and extension. When dislocations take place through rotation, the 
 bent leg, like the handle of a crank, becomes the long arm of the 
 lever, and the neck and head the short arm. 
 
 The Fulcrum. Inseparable from the lever, without which the 
 very name lever would have no meaning, is the fulcrum. Every 
 quality of strength and reliability that is essential to the lever must 
 be present in the fulcrum. In one quality only does it differ from 
 the lever, and that is in fixation. The fulcrum is the pivot 
 upon which both arms of the lever move ; it is the arbitrary line 
 or division from which both arms take their origin. Its effective- 
 ness in levers of the first class depends upon its position — the nearer 
 it approaches the weight the greater the power that can be exerted. 
 
 Under the normal range of motion no part of the pelvis furnishes 
 a fulcrum, but in hyper-abduction (Fig. 36) the outer rim of the 
 socket becomes a most advantageous fulcrum. It is advantageous, 
 
 Fig. 36 
 
 FULCRUM 
 
 because it yields a very short weight-arm with a long power-arm, 
 and because the weight, i. e., the resistance to be overcome (that of 
 the capsule), lies almost directly over the fulcrum. In experimental 
 work the rupture of the capsule through hyper-abduction is easier 
 and more certain than in any other way. In simple hyper-extension 
 the rim of the socket forms quite an advantageous fulcrum ; but in 
 this instance the resistance is far greater, inasmuch as the anterior 
 part of the capsule is stronger than the internal part of it. 
 
42 
 
 IXTROD UCTOR Y STUB Y. 
 
 Other bony fulcra are to be found, though not one furnishes so 
 short a weight-arm. Thus, the sjreat trochanter is broufjht against 
 the tuberosity of the ischium in extension and rotation outward, 
 using the bent leg as a lever. In hyper-flexion the knee strikes 
 the abdomen before the neck strikes the rim of the socket.' 
 
 Fig. 
 
 In Fig. 37 is represented the principle just stated, that a beat lever may sometimes 
 be unable to secure a fulcrum. 
 
 In marked contrast to the conditions present in hyper-abduction 
 are those in adduction, Avhere we find the same lever, but bent so 
 that no part of the neck can come in contact with the rim of the 
 socket. Hyper-adduction will bring the shaft against the pubes, and 
 the result may be a fracture, but it cannot be a dislocation. I would 
 therefore emphasize the statement just made, that danger of dislo- 
 cation is inseparable from simple^ hyper-abduction, because an advan- 
 tageous bony fulcrum is always available, \^hile in simple hyper- 
 adduction it is impossible, from the absence of a fulcrum. 
 
 1 By the word simple I mean that no other motion or force, such as rotation, shall be added 
 to abduction or adduction. 
 
DISLOCATEON THROUGH LEVERAGE. 43 
 
 DISLOCATION THROUGH LEVERAGE, BUT WITHOUT 
 A BONY FULCRUM. 
 
 In all dislocations effected through leverage a fulcrum is indis- 
 pensable. When the femur is flexed and adducted no bony fulcrum 
 is available, and yet this is one of the situations most liable to 
 dislocation. To make a dislocation possible a new force must be 
 supplied. This will either be a thrust, i. e., a powerful force exerted in 
 the long axis of the shaft, or, if through leverage, it must he through 
 rotation. In all efforts at rotation the bones of the leg, bent at right 
 angles to the long axis of the femur, constitute the long or power- 
 arm ; the head and neck constitute the short or weight-arm. Ex- 
 ternal rotation has never, in my hands, in experimental work effected 
 rupture of the capsule, but, after rupture, through hyper-abduction, 
 external rotation with extension of the limb will bring about a 
 dislocation inAvard. Internal rotation, on the contrary, whether the 
 thigh be normally extended and the leg used as a crank and turned 
 outward, or the thigh be flexed and adducted, with similar rotation, 
 is an effective measure to bring about dislocation. The mechanism 
 is the same under all circumstances where internal rotation is con- 
 cerned — there is no bony fulcrum. Query, What are the nature and 
 position of the fulcrum ? If we remove every structure from the 
 joint but the capsule, it will be readily seen that by internal rota- 
 tion the strono; ilio-femoral ligament becomes wound across the neck 
 of the femur. (Fig. 38.) The trochanter has been rotated up and 
 the head is now pressing hard against the postero-inferior part of 
 the capsule. Under these circumstances it is impossible to tell what 
 will give way ; the pressure is great and increases as rotation ad- 
 vances. By this manoeuvre I have ruptured the ligaments of the 
 knee-joint, made twist fractures of the shaft and of the neck of the 
 femur, ruptured the capsule of the hip in its postero-inferior aspect, 
 with escape of the head downward and outward, but not in a single 
 instance has the ilio-femoral ligament been torn. This ligament 
 therefore acts as a fulcrum in all cases of rotation inward, and, as 
 rotation outward^ never enters into the problem of rupture of the 
 capsule, it can almost be put down as an axiom that, if dislocation 
 
 1 See Remarks, p. 46. 
 
44 
 
 INTR OD UCTOR Y STUD Y. 
 
 has taken place through flexion and adduction, rotation inward ac- 
 companied it.^ If the reader will now compare the mechanism of 
 dislocation brought about through abduction and a fixed bony ful- 
 crum with that of flexion, adduction, and a ligamentous fulcrum, he 
 will (I am inclined to think) decide that the former is by far the 
 easier. In six successive attempts to dislocate by the latter method, 
 
 Fig. 3S. 
 
 The design of Fig. as is to illustrate the relation of the ilio-femoral ligament to the neck ot 
 the femur during flexion and rotation inward. The femur is represented in the position of 
 abducticn, merely to give a better view of the ligament and its relations to the neck. 
 
 i. g., by rotation, the ligaments of the knee gave way. Failing in 
 this, dislocation was accomplished through abduction, with a bony 
 fiilcrum. 
 
 Po"wer. This, except under pathological conditions, is always an 
 external force, which must be exerted through the femur. The power 
 may be exerted directly upon the femur, in abduction or in hyper- 
 extension. It may be employed indirectly through rotation, in which 
 case the bent leg becomes the lever upon which the force is exerted, 
 
 "Weight, ^. e.. Resistance. This lies chiefly in the capsule. 
 Given a power capable of breaking the lever or rupturing the cap- 
 sule, and the result will depend, in a great measure, upon the mode 
 of attack : 
 
 > Refer to " Steps," p. 83. 
 
EXPERIMENTAL WORK. 45 
 
 1. If the capsule be attacked through abduction, there is the 
 highest probability that it will be ruptured. (Fig. 36.) 
 
 2. If it be attacked through flexion, adduction, and rotation in- 
 ward (Fig. 38), the ligaments of the knee may give way ; the femur 
 may yield through twist fracture, or the capsule will be torn. 
 
 3. If the attack be through flexion, adduction, and rotation out- 
 ward, the capsule will resist and fracture in some part will result. 
 
 EXPERIMENTAL WORK. 
 
 The following is a record of only a few of the many experiments 
 I have made. In many no new fact or principle .was brought out ; 
 when, however, anything unusual occurred a record has been entered 
 in its proper place. 
 
 Experiment I. Attempt made to dislocate upward and back- 
 ward, attacking the upper outer third of the capsule. 
 
 Subject : Male adult, muscular, about twenty-four years of age, 
 about forty-eight hours after death. Pelvis fastened securely, limbs 
 projecting over the end of the table. Right leg flexed on the thigh 
 to a right angle, thigh slightly flexed and adducted. Thigh rotated 
 outward {i. e., the ankle of the bent leg was turned inward and up- 
 ward). This brought the head against the upper and strongest part 
 of the capsule ; it brought the great trochanter against the ischium. 
 Result, fracture of the femur in the lower fourth. 
 
 Experiments II. and III. I repeated this experiment in two 
 other cases. In both the ligaments of the knee gave way, depriving 
 me of the bent leg as a lever. 
 
 Remarks. In these experiments the tuberosity of the ischium 
 was probably the fulcrum. By rotation outward the trochanter was 
 brought against it, while the head within the capsule Avas forced 
 against the upper front part, ^. e., the thickest and strongest part. 
 In the first instance the shaft broke through twist, and in the re- 
 maining two the ligaments of the knee gave way. In none was the 
 capsule ruptured. 
 
 Experiment IV. Attempt to dislocate outward by flexing the 
 thigh on the abdomen. Adduction and rotation outward. 
 
 Conditions : Recent cadaver, male, about twenty-five years of 
 age, body securely fixed. Right femur flexed, adducted, and rotated 
 
46 
 
 INTROD UC'TOR Y STUD Y. 
 
 outward, i. e., the bent leg was used as a crank and turned inward. 
 As I was not able to effect the displacement, the janitor assisted me, 
 using nothing but manual force upon the femur and bent leg.^ Re- 
 sult, fracture of the pelvis as indicated in Fig. 39. 
 
 Fig. 39. 
 
 Remarks. This was my fourth attempt to dislocate by means of 
 flexion, adduction, and rotation outward., i. e., by using the bent leg 
 as a lever and turning it inward. In two the ligaments of the knee 
 gave way ; in one the shaft of the femur was broken in the lower 
 third ; in one the pelvis fractured. A glance at the figure will make 
 it clear that no bony fulcrum can be made available in this mode of 
 
 ' The rcivder is asked to explain how a transverse fracture of the pubes and of the ilium 
 could result from a twist of the femur. The pelvis was fixed, and the only force exerted 
 was manual and exerted through the bent leg. Had this result occurred from a fall or 
 a crush the unanimous voice would be in favor of direct violence. In this case it was 
 unquc-tionably through twist, precisely as in other cases I produced twist fractures of the 
 femur. 
 
EXPERIMENTAL WORK. 47 
 
 attempting dislocation, unless the neck acts upon the upper part of 
 the rim of the socket. The resistance to dislocation lies chiefly in 
 the upper and outer part of the capsule ; and the result in four cases 
 (all young, in the prime of development, and in good state of preser- 
 vation as far as the ligaments were concerned) clearly shows that the 
 head cannot be made to escape through the thickest part of the cap- 
 sule by flexion, adduction, and rotation outivard. 
 
 Bigelow, who was of the opinion that the head emerged above the 
 obturator internus and pyriformis by a thrust in the long axis of the 
 femur when it was extended and adducted, was unable by any prac- 
 tical method to produce this variety ; and, therefore, he divided with 
 a bistoury the capsule above these muscles ; and then — strange to say 
 — dislodged the head by flexion, adduction, and rotation outivard, 
 and not hy an upward thrust. The fact that 7io expeiHmenter has 
 been able to dislocate directly upward without preliminary tenotomy 
 of the capsule, taken with the disastrous results of my four cases, 
 might suggest that, in actual traumatic dislocations, some easier ivay 
 is found for the head to reach a high position than through the 
 thickest part of the capsule. 
 
 In the foregoing attempts to dislocate the head of the femur the 
 resistance was solely from, the capsule, with the result of fracture of 
 the femur, rupture of the ligaments at the knee, and fracture of the 
 pelvis. Hence, when Sir Astley Cooper^ affirmed that ligaments 
 present little strength to prevent dislocations, he was in error. 
 
 Dislocation Produced by Rotation Inward. (See Mechan- 
 ism, Fig. 38.) 
 
 Experiment V. Female, about fifty years old. Pelvis secured. 
 Right femur flexed to a perpendicular. Leg used as a crank, and 
 turned outward [i. e., inward rotation). Capsule readily ruptured, 
 and head dislodged downward and outward. 
 
 Experiment VI. Left femur of the same subject. Hyper-flexion 
 of femur upon abdomen. Flexed leg used as a crank and rotated 
 downward and outward (?'. e., inward rotation of the femur). 
 
 Result, dislocation downward and outward, with complete rupture 
 of the obturator externus, quadratus femoris, obturator internus, and 
 pyriformis. In reducing this case, the great sciatic nerve was seen 
 to stretch over the head as it was passing into the socket. 
 
 1 Dislocations, pp. 20, 21. 
 
48 INTRODUCTORY STUDY. 
 
 Experiment VII. Male, sixty-one years old, a dissecting-room 
 subject that had been abandoned after dissection.^ Capsule and 
 muscles about the joint in good, supple condition. Pelvis secured. 
 Left femur flexed to a right angle and leg flexed on thigh. Knee 
 adducted a little and a little extended, so that by internal rotation 
 the head would tend to burst the capsule above the pyriformis. Re- 
 sult, fracture of the neck, partly intra- and partly extra-capsular. 
 The lesser trochanter remained upon a large spicule that adhered to 
 the head. 
 
 Experiment YIII. Right femur. Femur flexed to perpen- 
 dicular, leg flexed on femur, knee gently adducted and slightly 
 extended, as in previous case. Rotation inward, head made to press 
 against the capsule above the pyriformis. Result, fracture of the 
 neck of the femur, as in the previous case. 
 
 Remarks 07i Experiments VII. and VIII. The head was made 
 to attack the outer upper part of the capsule, and found the capsule 
 stronger than the agent that attacked it. 
 
 Experiment IX. Well-developed colored man, about thirty 
 years of age. Body secured, prone. Right limb. Femur flexed at 
 right angles to pelvis. Leg at right angles to femur, used as lever. 
 Rotation inward [i. e., ankle drawn outward). Result, ligaments of 
 knee crackled and gave way. Dissected everything away from the 
 hip-joint but the capsule. Limb placed in the same position. Rota- 
 tion inward. Rupture of capsule ^o&tev'mvl^ from femoral attach- 
 ment., hence a long sleeve. (Fig. 41.) 
 
 Experiment X. Left limb. Femur extended. Leg used as a 
 crank or lever, at right angles to femur. Rotation inward. Liga- 
 ments of knee gave way. After removing the gluteus maximus I 
 divided the capsule close to the femoral attachment, in the interspace 
 between the tendons of the pyriformis and obturator internus. Thus 
 weakened, the head was with difficulty dislocated outward by internal 
 rotation. 
 
 Observation 1. In both limbs the capsule proved to be stronger 
 than the ligaments of the knee. 
 
 Observation 2. The fact that dislocation was possible in the right 
 
 1 All the other experiments were upon fresh subjects in which the ligaments were in 
 almost perfect condition. In these two, although the body had been on the dissecting-table 
 for at least a month, the ligaments proved to be more than a match for the femurs. 
 
LESIONS PRODUCED IN EXPERIMENTAL WORK. 49 
 
 limb after removing the muscles would strengthen the assumption 
 that the muscles contribute to the safety of the articulation. 
 
 Observation 3. From experimental study, I incline to the opinion 
 that the chief agency of the muscles is to check any range of motion 
 that would place the joint in jeopardy ; but that, when the joint is 
 once put to the test, the ligaments are the main safeguard. 
 
 LESIONS PRODUCED IN EXPERIMENTAL WORK. 
 THE CAPSULE. 
 
 After dislocation some portion of the capsule still connects the 
 femur to the rim of the socket. It was formerly believed that there 
 was no special portion of the capsule that remained untorn after a 
 dislocation, since the head was supposed to pass directly to its points 
 of destination. The study of autopsies, on the contrary, presents a 
 most constant escape of the ilio-femoral ligament. In experimental 
 Avork it is easy to see why this portion of the capsule escapes, since, 
 by manual effort, the head can be dislocated only in situations that 
 do not subject the capsule to great strain. 
 
 The rupture of the capsule through rotation is due to torsion. 
 Were the femur a straight bone, and the capsule of equal length and 
 thickness, it would be diflScult to explain why one part should yield 
 through torsion before another, or why the whole should not rupture 
 at the same instant. But the femur is not a straight bone. The 
 neck joining the shaft at an angle of 130° cannot, in rotation, exert 
 equal strain on all parts of the capsule. When the capsule is torn 
 through torsion the lesion is invariably extensive. With the excep- 
 tion of the ilio-femoral ligament, all parts of the capsule have been 
 torn in pathological studies of dislocations. 
 
 A question of vital importance to decide is the possibility of dis- 
 locating the head through a slit in the capsule. It always has been, 
 and probably always will be, a very universal belief that the head 
 can be buttonholed by the capsule, and that this is one of the diffi- 
 culties that skill cannot overcome. 
 
 Morris,^ after making a series of dislocations and finding the 
 rent invariably greater than the diameter of the head, resorted to the 
 following expedient : Prior to any attempt at dislocation he slit 
 
 1 See a most instructive article on this subject in Medico-Chirurg. Trans., vol. Ix., by Henry 
 Morris, F.R.C.S.. 
 
 4 
 
50 INTBOD UCTOB Y STUD Y. 
 
 the capsule longitudinally, then dislocated, and found, instead of 
 buttonholing, a rent as capacious as in any previous experiment. 
 
 Not wishing to repeat Morris's work, I exposed the capsule, and, 
 instead of making a slit, I removed a circular disk from the capsule 
 nearly large enough to permit the escape of the head, thinking that 
 the borders of the opening would yield and let the head through 
 without further laceration ; but as pressure was brought against it 
 the tense marginal fibres snapped, fibre by fibre, and the head made 
 its escape through an opening ample for its easy return. I dare not 
 say that a fissure in the capsule is impossible, but I insist that it is 
 extremely improbable. I dare not say that it is impossible, but I 
 claim that no teacher has a right to enroll it among the obstacles to 
 the reduction of a dislocated hip until he has proved by experi- 
 mental work its possibility. I therefore join Morris in an earnest 
 protest against a most improbable theory, the legitimate fruits of 
 which are either unwarranted rudeness, with a view to enlarge the 
 rent, or despair and abandonment from an imaginary unsurmount- 
 able obstacle. Obstacles there really are to reductions, but the 
 sooner we abandon the chimerical slit in the capsule the sooner the 
 attention of the profession will be turned to the possible obstacles. 
 
 Experimental study will readily convince anyone of the correct- 
 ness of the views just stated, but the plausibility of the argument is 
 strengthened by the following considerations : 
 
 First, of the shape of the head of the femur. It must always be 
 the head of the femur that produces the laceration in the capsule. 
 Were the head narrow, square, triangular, or oblong the rent in the 
 capsule would necessarily vary greatly. On the contrary, the head 
 is spherical, and, no matter from what quarter the capsule is attacked, 
 the round, smooth surface of the head is the effective disruptive agent. 
 
 Second. The rupture-force is always exerted on the inner surface 
 of the capsule, ^. e., from within outward. While the leverage is 
 effected through the femur or leg, the head, which is the extreme 
 point of the short arm of the lever, is forced against the inner surface 
 of the resisting capsule. 
 
 Third. The structure of the capsule is fibrous. It cannot stretch 
 suddenly. The round head of the femur is forced against the short 
 resisting cylindrical capsule, and makes every fibre pressed upon 
 tense at the same instant. Often the first fibres to yield are those 
 overlying the greatest convexity of the head. As these yield the 
 
LESIONS PRODUCED IN EXPERIMENTAL WORK. 51 
 
 force falls upon succeeding fibres, and thus each fibre made tense 
 snaps before the resistless advance of the head. 
 
 When a dislocation takes place by a single uncomplicated force, 
 as by hyper- abduction, the rent is confined to the fibres pressed 
 upon, and represents a minimum degree of laceration, equal trans- 
 versely to the diameter of the head. Even this may render the 
 restoration difficult. When dislocations are due to a twist, as by 
 rotation, the rent is always extensive, embracing fully two-thirds 
 of the periphery of the capsule. 
 
 After dislocation takes place the head can do no more harm to 
 the capsule. Further efforts to enlarge the rent must be made 
 through rotation and circumduction, which bring the neck of the 
 femur ag-ainst the border of the rent. To enlarge the rent in the 
 capsule the head must be made to plow through any structure that 
 may lie in its path, doing much destruction to muscles without any 
 positive assurance of rendering reduction in the slightest degree 
 easier. A point that should always be borne in mind is, that when 
 the femur after dislocation presents marked deformity there is a 
 minimum laceration of the capsule, and the head lies near the 
 socket ; while, when the deformity (i. e., the constraint) is slight, 
 there has been free laceration of the capsule. 
 
 The INo-femoral Ligament. This I have never torn from its 
 pelvic attachment. Bigelow, in describing a subspinous disloca- 
 tion, expressed the belief that the head had reached that position 
 through direct upward dislocation, and in its ascent had stripped up 
 the (upper) pelvic attachment of the ligament. I record this only 
 to dissent from it. In experimental work I have produced a sub- 
 spinous luxation, but not through direct upward thrust. The lower, 
 or femoral, attachments of the Y-ligament are not so secure. I have 
 twice torn the outer and once the inner branch from its attachment. 
 In most instances the entire ilio-femoral ligament remains intact. 
 
52 
 
 INTR OD UCTOB Y STUD Y. 
 
 Position of Rent in Capsule. 
 
 A matter of the greatest practical importance is the position of 
 the rent in the capsule. All the j^ossible lesions may be arranged 
 under three general classifications : 
 
 1. Those in which the capsule is torn from its acetabular or pelvic 
 insertion. (Fig. 40.) I have torn capsule and periosteum from 
 the rim of the socket. In this class of lesions there can be no 
 possible obstruction from the capsule to an easy replacement, as 
 no part of it can be driven before the head into the socket. The 
 torn capsule, under such circumstances, must follow the femur in every 
 displacement inward or outward, and in all efforts at reduction. 
 
 Fig. 40. 
 
 2. Those in which the rent is between the attachments, or runs 
 obliquely from one attachment to the other. (Fig. 41.) In this 
 lesion the part of the capsule that is attached to the acetabulum may 
 Decome aetached from the surrounding muscles and driven before 
 the head into the socket during the act of replacement. In such a 
 case only a limited amount could be driven into the socket — scarcely 
 enough to be recognizable, yet enough to produce mischief. 
 
LESIONS PRODUCED IN EXPERIMENTAL WORK, 53 
 
 Fig. 41. 
 
 3. Those in which the capsule is torn from its femoral attach- 
 ment. (Fig. 42.) This I believe to be the most frequent obstacle 
 
 i^IG. 42. 
 
54 
 
 INTRODUCTORY STUDY. 
 
 to reduction. In this lesion the capsule remains entire or nearly so 
 at its acetabular portion, and as this is the easiest point of entrance 
 for the dislocated head the capsule is likely to resist reduction, and 
 if vigorous efforts are instituted the head will push the capsule before 
 it into the socket. 
 
 I have produced all these lesions in experimental work, and in- 
 cline to the belief that the character of the lesion must vary with 
 the nature of the vulnerating force. If dislocation be effected through 
 abduction^ the head of the femur tends to strike the capsule (Fig- 67) 
 at a point somewhat remote from its acetabular attachment, and 
 hence the greatest point of strain will be midway between the attach- 
 ments or near its femoral and thinnest parts, while, on the contrary, 
 when the femur is dislocated during adduction the head is driven 
 toward the socket and its greatest point of strain upon the capsule 
 is at its acetabular attachment. If in a given recent case of dislo- 
 cation of the hip in which perfect replacement was found impossible, 
 it could be clearly shown that the accident occurred through flexion 
 and abduction, I would incline strongly to the belief that the obstacle 
 was of the nature shown in class third — Fig. 42. 
 
 The three foregoing figures are reproduced in miniature to enable 
 the reader to contrast at a glance the three classifications of lesions. 
 
 I have considered this topic of sufficient importance to illustrate 
 it more fully. The reader will notice on the opposite page three series 
 of illustrations. In each, the first figure in the series represents the 
 head in the socket, and one variety of lesion of the capsule. The 
 second figure in each series represents the manner in which the cap- 
 sule will deport itself during any variety of displacement. The third 
 figure in each series shows the possible effect upon the capsule of 
 replacement. There is an important principle involved here ; and 
 unless it is fully comprehended, arguments later on will fail to con- 
 vince. 
 
lesiojs^s produced in experimental work. 
 
 55 
 
 Illustrated resume of the three varieties of lesions of the capsule, 
 showing : 
 
 X. The position of the rent in the capsule. 
 
 Y. The deportment of torn capsule during dislocation. 
 
 Z. The effect of dislocation upon the capsule. 
 
 Fig. 43. 
 First Series. 
 
 y. 
 
 Rent close to socket. 
 
 Capsule follows femur Capsule restored by reduc- 
 in displacement. tion. 
 
 Fig. 44. 
 
 Second Series. 
 
 Y. 
 
 Rent midway in capsule. Part must follow femur, Part attached to rim may be, 
 part cannot. and often is, inverted in 
 
 reduction. 
 
 Fig. 45. 
 
 Thirb Series. 
 
 Y. 
 
 Rent close to femoral Head escapes, leaving cap- Reduction extremely likely 
 attachment. sule as a sleeve behind, to place the head upon 
 
 covering the socket. capsule, not in socket. 
 
56 
 
 INTRODUCTORY STUDY. 
 
 Lesions in Muscles. 
 
 The lesions in the muscles are due either to overstretchincr or 
 to direct violence. 
 
 Overstretching-. Muscles are easily torn in manipulations upon 
 the cadaver. It is impossible after cadaveric rigidity to dislocate 
 without rupturing strong muscles, such as the adductors (Fig. 46), 
 which reach their limit of tension before the capsule is ruptured or 
 
 Fig. 46. 
 
 the head escapes from the socket. This condition would not be 
 present to the same degree in the living, and yet it affords an ex- 
 planation of many of the lesions. How else can we explain the rupture 
 in the middle of the adductor longus, the gracilis, or the pectineus ? 
 One of the most constant lesions found in autopsies and experimental 
 work is rupture of the pectineus ; and this muscle is not touched by 
 the head of the femur in dislocations either inward or outward. 
 
LESIONS PRODUCED IN EXPERIMENTAL WORK. 57 
 
 Rupture of Muscles from Direct Contact. By this I mean 
 the havoc produced by the dislocated head plowing through all mus- 
 cular structure within reach. It is possible for the head to be com- 
 pletely dislocated without doing material mischief beyond rupture of 
 the capsule.^ The head may be dislocated inward, and if any mis- 
 chief attend it, it may be a trifling laceration of some fibres of the 
 obturator externus. By a glance at Fig. 47 it will be seen that all 
 the muscles that extend from the antero-lateral aspect of the pelvis 
 to the shaft have their origins at the boundary and would not be 
 injured by a simple primary inward or outward displacement. Be- 
 sides, too, the direction of displacement when the thigh is abducted 
 is in the main nearly parallel with the muscles, which would favor 
 their escape. 
 
 Fig. 47. 
 
 After a dislocation occurs the head can be made to move in a circle 
 of which the untorn capsule and the neck constitute the radius. If 
 the thigh be kept nearly perpendicular and the knee be circumducted 
 through a small circle, the corresponding circle in which the head of 
 the femur will move will be near the margin of the socket ; while 
 larger sweeps of the knee will necessitate correspondingly larger and 
 more disastrous sweeps of the head. 
 
 In Fig. 48 I have represented two arcs of circles. Between them, 
 
 1 See case of Robert S— , p. 69. 
 
58 
 
 IXTR OD UCTOR Y STUD Y. 
 
 upon the ischium, I represent the strong tendon of origin of the 
 hamstring muscles — one of the important structures connected with 
 this subject. If the head take the smaller circle, it will go above 
 this tendon ; but if it take the greater circle, and if at the same time 
 the hamstring muscles are made tense by extension of the leg on the 
 thigh, the head would be arrested either in the perineum or upon the 
 ischium, as it could not pass the tendon. 
 
 If the head be dislocated primarily inward upon the pubic plane, 
 and then by rotation be turned outward upon the dorsal plane, it 
 
 Fig. 48. 
 
 The dotted lines represent arcs of circles, of which the remnant of untorn capsule and 
 the added length of the neck of the femur represent the radius. By varying the position of 
 the knee an infinite number of arcs could be described . (See Fig. 102.) 
 
 must burst through the great muscular septum that separates the 
 femoral vessels from the sciatic nerve. In Fig. 49 I have represented 
 the head dislocated inward, and about to be shifted by inward rota- 
 tion to the outer plane. Two muscles are in the way : the quadratus 
 femoris, which cannot escape when the head is shifted from an 
 inward (thyroid) to an outward (dorsal) position, and with it some of 
 the fibres of the adductor magnus. The adductor brevis is often 
 mentioned among the torn muscles ; but the lesion is probably always 
 
LESIONS PRODUCED IN EXPERIMENTAL WORK. 
 
 59 
 
 the result of overstretching, and not due to direct contact. As the 
 head forces its way outward, it strikes the obturator externus and 
 tears it in two ; then, in turn, the quadratus and short upper fibres 
 of the great adductor, all of Avhich lesions are unavoidable when a 
 primary inward dislocation is shifted to an outward. 
 
 Fig. 49. 
 
 In direct dorsal (i. e., outward) dislocations, those that I have 
 produced by rotation inward, the thigh being flexed or extended, the 
 capsule is rent in the postero-inferior aspect and the head may de- 
 scend between the obturator externus and internus (Fig. 51) without 
 rupture of either.^ If this accident occurs during hyper-flexion of the 
 thigh, though the obturators escape, the gluteus maximus, which must 
 be tense at the instant of escape, will be bruised, lacerated, or trans- 
 fixed.^ 
 
 Re'sume of Muscular Lesions. When dislocations occur 
 through leverage of the shaft of the femur — as, for instance, during 
 
 1 G. M. Humphrey thinks this the most frequent form of dislocation (Lancet, Nov. 27, 1886). 
 Although the position is frequent, the entire escape of the muscles must be very infrequent. 
 - See Case IV., p. 65. 
 
60 
 
 INTROD UCTOR Y STUD Y. 
 
 abduction — the long muscles are torn prior to dislocation. It is 
 possible for these muscles to be torn without dislocation taking place. 
 When dislocations occur through rotation inward, only the pyri- 
 formis, the two obturators, and the quadratus are put upon the 
 stretch. These may rupture through overstretching ; they may be 
 torn by the head of the femur as it bursts through the capsule. 
 
 Fig. 50. 
 
 The illustration represents the head restored to its socket after a primary inward disloca- 
 tion has been shifted to an outward and then restored. Note the area of the lesion and 
 how the nerve must he implicated in the reparative processes. 
 
 If the head escapes through rotation inward and strong flexion, 
 the gluteus maximus can hardly escape laceration. 
 
 If the head escapes inward, every rotator muscle may escape. 
 
 After a primary inward luxation an attempt to convert it into a 
 dorsal will rupture the obturator externus and quadratus femoris. 
 
 The head may escape outward between the obturators without 
 injuring either, through rotation inward. (Fig. 51.) Usually the 
 obturator internus is torn. 
 
 Muscles are torn in the steps of dislocation prior to, coincident 
 
PATHOLOGY. 
 
 61 
 
 with, and after the displacements. In rare instances they all escape. 
 (See p. 69.) 
 
 Fig. 51. 
 
 The sciatic nerve has been twice reported torn completely in two. 
 It has been lacerated, bruised, its fibres separated, and its sheath 
 filled with blood. It has been caught up repeatedly by experimenters 
 and carried across the neck in reductions. Partial persistent and 
 permanent paralyses are reported as sequelne of otherwise successful 
 reductions. The anterior cutaneous nerve would probably be stretched 
 across the head or neck if a thyroid were converted into a subspinous. 
 
 PATHOLOGY. 
 
 No better proof of the value of the foregoing experimental work 
 need be adduced than that it is fully and minutely corroborated by 
 dissections of actual traumatisms. The author has not striven to 
 make a large collection of cases. The few that follow illustrate im- 
 portant points; except in a few instances, duplicate injuries have 
 been rejected. 
 
 Case I. — A man, sixty years old, was killed by a fall from a ladder. 
 Symptoms : Right leg apparently, but not actually, much shortened ; was 
 inverted and separated from its fellow; the trochanter major was further re- 
 moved from the spine of the ilium than normal ; the head could be felt 
 toward the back of the pelvis ; the limb could be flexed, but could not be 
 rotated outward. 
 
 DissGction. On removal of the gluteus maximus the head was found below 
 the obturator internus (Fig. 52), which, with the great sciatic nerve, was 
 stretched over the neck of the femur. The obturator externus and quad- 
 
62 
 
 INTRODUCTORY STUDY. 
 
 ratus femoris were torn in two. Some of the deep fibres of the gluteus 
 medius were torn across. The capsule was rent at its inner and lower 
 aspect, where it was torn from the neck of the femur. The ligamentum teres 
 was torn from the head of the femur. — Richard Quain, Medical Times, 
 vol. xviii. p. 205. 
 
 Fk; 
 
 Remarks.^ The upward progress of the head was arrested by the 
 nerve and the obturator internus. Morris has asserted that the nerve 
 presents a more reasonable check than does Bigelow's position, 
 known as " dorsal below the tendon." The mode of rupture of the 
 obturator externus and quadratus femoris, with hooking up of the 
 nerve, can be explained in two ways : The head might have been 
 dislocated primarily inward, and then by unexpended force shifted 
 outward. If such was the case, the head tore its way through the 
 two muscles and hooked up the nerve. In the other — and to my 
 
 1 The " remarks" after cases in pathology are by the author of this work, and the reader 
 may give them whatever consideration he thinks them entitled to. 
 
PATHOLOGY. 
 
 63 
 
 mind the more plausible — the dislocation took place during forced 
 flexion with rotation inward. Forced flexion would make tense the 
 obturator externus and the quadratus femoris, and, at the same time, 
 draw the nerve down closely upon the quadratus as it crosses the 
 neck of the femur. Now, while in this condition, if rotation inward 
 be added — a manoeuvre calculated to luxate outward — the two mus- 
 cles would be torn either through overstretching, or through direct 
 contact, and the nerve would be readily caught over the neck as the 
 head fell outward. 
 
 Case II. — I. D., twenty-nine years old, was run over by a railroad train, 
 receiving injuries from which he died, with symptoms of septicaemia, four- 
 teen days after the accident. Injury to the hip. Symptoms : The left 
 
 Fig. 53. 
 
 thigh, leg, and foot were inverted ; the knee was directed inward, and the 
 thigh was slightly flexed. The shortening, if any, did not exceed half 
 an inch. 
 
 Dissection. On removing the overlying structures the head was found 
 with the obturator internus and gemelli above it, and below it w^-" " 
 ruptured obturator externus and quadratus femoris. The head W 
 
64 
 
 IXTR OD UCTOR Y STUDY. 
 
 vented from ascending upon the ilium by the obturator internus. It 
 pressed so tightly upon the head that it produced a distinct groove in the 
 cartilage. The capsule was rent in its posterior half and torn at its femoral 
 attachment. The mass of detached capsule, remaining attached to the 
 (Fig. 53) margin of the acetabulum, formed, as it became inverted by attempts 
 to reduce the head, some obstruction to its return. — Wm. Adams, Trans. Path, 
 Soc, London, vol. xxi. 
 
 Remarks. The reader will especially note the variety of rupture 
 of the capsule : it was from its femoral attachment, making a cuff 
 for the socket. (Fig. 42.) Although the difficulty was laid bare by 
 the scalpel, and the surgeon could use his eyes in efforts at restoration, 
 still the capsule would turn in before the head. The rupture of the 
 obturator externus and quadratus femoris was — as in the previous 
 case — probably due to rotation inward, which, with flexion, would 
 cause their rupture by tension. 
 
 Case III. — Cabman, crushed between cab and house, dying in a few 
 
 minutes. 
 
 Fig. 54. 
 
PATHOLOGY. 65 
 
 Dissection. On removing the gluteus maximus the head was found mid- 
 way between the socket and the great sciatic foramen. The head lay upon 
 the pyriformis, gemellus superior, and obturator internus muscles. All these 
 muscles retained their cellular and fibrous attachments to the torn capsule. 
 The quadratus femoris was but slightly torn on its upper border. The 
 gemellus inferior was completely raptured, and so were some inferior fibres 
 of the obturator internus. At least half of the fibres of the pyriformis were 
 torn. The obturator externus was but slightly injured ; some of its muscular 
 fibres were detached from its tendon. The tendon of the obturator in- 
 ternus was tightly stretched in front of, and the tendon of the obturator 
 exturnus tightly stretched behind, the neck of the femur. — Morris, Med.- 
 Chirurg. Trans., vol. Ix. 
 
 Remarks. If the reader will turn back, he will see how the head 
 may be dislocated between the two obturators without rupturing 
 either. This condition will also su2;o;est how, in the livincr, an 
 attempt at reduction by flexion and circumduction might readily fail. 
 
 Case IV. — J. A., injured by a great weight falling upon him, dying the 
 same day. At the autopsy there were found a rupture of the bladder, a 
 fracture of the ramus of the pubes into the foramen ovale of the right side, 
 and a separation at the symphysis pubis and at the sacro-sciatic junction. 
 On dissection, the gluteus maximus was found nearly torn through, with 
 the head imbedded in its substance ; the pyriformis was ruptured and the 
 superior gemellus was partly ruptured ; the gluteus minimus was so com- 
 pletely destroyed that its remains could with difficulty be recognized ; the 
 ligamentum teres was torn from the head ; the head lay upon the gemelli and 
 the sacro-sciatic nerve ; the capsule was extensively torn close to the ace- 
 tabular attachment. — James Syme, Lond. and Edin. Monthly, 1843. 
 
 Remarks. How did this dislocation take place ? Through direct 
 thrust? Under these circumstances the dislodgino; head would have 
 found the gluteus maximus in a state of complete relaxation and not 
 in a relation to it to oppose it. But if the man were " doubled up," 
 as is probable, then we can account for the fracture of the pelvis and 
 the rupture of the bladder, while a dislocation taking place when a 
 man is doubled up would find the gluteus stretched tightly over the 
 head, and rupture or transfixion probable. Note in this case that 
 the capsule is torn from the socket.^ 
 
 Case Y. — C. D., died a few hours after admission to the London Hospi- 
 tal. The dislocation had been reduced by manipulation, the head passing 
 from the dorsal position to the obturator, and thence into the socket. 
 
 On dissection, no external evidence of injury was found. On removing 
 
 1 See p. 88. 
 5 
 
Q Q INTR OB UCTOR Y STUDY. 
 
 the gluteus maximus, the bursa between it and the vastus externus was 
 found to be ruptured and filled with blood. The sheath of the great 
 sciatic nerve ivas distended with blood, and the nerve fibres were separated from 
 one another. The posterior fibres of the gluteus minimus were torn across, 
 and the cellular tissue beneath the muscle was filled with blood. The 
 quadratus femoris was torn completely in two, and the uppermost fibres of 
 the adductor magnus and some fibres of the gemelli and obturator internus 
 muscles were lacerated. The capsule was perfect in front and above, but 
 torn in its posterior part. The ligamentum teres was torn off close to the 
 head of the femur. — J. McCarthy, Lancet, 1874, ii. 13. 
 
 Remarks. How is it possible to have the capsule complete in front 
 and above, and yet have a complete rupture of the quadratus femoris 
 take place ? Answer. By flexion and rotation inward ; the laceration 
 being due to overstretching. It could not have been done by direct 
 contact with the head, for the capsule, not being torn in front, would 
 not have permitted the head to escape in that direction. By flexion 
 and rotation inward the nerve-injury could also be readily explained. 
 
 Case VI. — W. A., injured by falling timbers, admitted to the London 
 Hospital with the following symptoms : Right leg two and a half inches 
 longer than its fellow ; trochanter major less prominent ; foot and knee 
 widely separated from its fellow. No attempt at reduction was made, 
 owing to the patient's collapsed condition. When he rallied a little the 
 nurses, in changing his position in bed, restored the dislocation. Death on 
 the third day. 
 
 On dissection of the hip there was found evidence of contusion on the 
 outer aspect of the hip. Blood was found extravasated between the mus- 
 cles on the outer and posterior aspects of the hip and in the cellular tissue 
 about the great sciatic nerve. There was no laceration of muscular tissue. 
 The substance of the adductor magnus and the lower border of the ob- 
 turator externus were much ecchymosed. A large rent was found in the 
 capsule on the inner aspect, extending from the ilio-pubic eminence to the 
 upper border of the obturator externus muscle. The capsule teas torn from 
 its pelvic attachment. The ligamentum teres was torn from the head and lay 
 loose in the socket. The head could easily be redislocated upon the edge 
 of the obturator foramen ; and when this was done it pushed the obturator 
 externus before it, rendering it tense and bulging. — Curling, Med. Times, 
 vol. vii. N. S., p. 422. 
 
 Remarks. This was a dislocation inward. Note two points : 1. 
 There were no muscles torn, 2. The rent in the capsule was at its 
 periphery, and from the socket. Such a rent would favor reduction, 
 which took place while the patient was being gently handled by the 
 nurses. 
 
PATHOLOGY. 67 
 
 Case VII. — Dorsal dislocation. Young man, fatally injured by a fall from 
 a second story. Death in twenty-four hours. On dissection a large amount 
 of coagulated blood was found beneath the gluteus maximus ; the pyriformis, 
 gemelli, obturator internus, quadratus femoris, and obturator externus were 
 completely ruptured. The capsule was torn inferiorly and posteriorly; it 
 was intact at the superior and internal part. The ligamentum teres was 
 torn from the head. The head lay posteriorly upon the gluteus medius. 
 Some fibres of the pectineus were torn. — Charles H. Todd, Cooper on 
 Fractures ayid Dislocations, Case 40, 
 
 Remarks. There is no mention of injury to the nerve; and we 
 may infer that it escaped. As the capsule was not torn internally, 
 the quadratus and obturator externus were not torn by direct contact 
 with the head. The position of the limb, at the instant of rupture 
 of the capsule, was probably that of flexion and hyper-adduction, 
 with rotation inward. The two muscles mentioned above were torn 
 by hyper-tension. The hemorrhage and the traumatism to the other 
 muscles were probably due to direct contact. The pectineus was 
 torn by overstretching. 
 
 Case VIII. — Male, nineteen years old, strong and healthy, admitted to 
 Edinburgh Royal Infirmary. Railroad injury. Death in a few hours. Thy- 
 roid dislocation of left femur. On dissection, fourteen hours after death, 
 there was found an extensive extravasation of blood and many muscles torn 
 and bruised. The obturator internus was partly torn, and some of its sub- 
 stance had been forced into the socket. Its tendon was not ruptured. The 
 head had been reduced. The capsular rent was on the inner and lower 
 aspect. The ligamentum teres, with a thin scale of bone attached, had 
 been torn from the pit in the head. — Thomas Anxandale, British Medical 
 Journal, 1870, p. 101. 
 
 Remarks. The dislocation was inward, and I infer that it was a 
 clerical error to state that some of the fibres of the obturator internus 
 were driven into the socket. It is more probable that the muscle 
 referred to was the obturator externus. Two points are worthy of 
 emphasis: 1. Some muscular material was forced into the socket. 
 This is a fact, not a theory. 2. The teres was not torn from the 
 head ; it w^as peeled off from it with a scale of bone. Hence, if it 
 had been ten times as strong, its greater strength would have availed 
 nothing against luxation. 
 
 Case IX. — Thyroid dislocation. Young man, killed by a fall from a 
 window. Hip symptoms: Great trochanter less prominent than natural, 
 with an unusual fulness in the groin. Adduction of the thigh resisted; 
 
68 
 
 INTR OD UCTOR Y STUD Y. 
 
 abduction easy. No marked eversion on dissection ; the great sacro-sciatic 
 nerve was found to be ecchymosed and bruised ; the gracilis was torn 
 through ; the abductor longus and brevis were partly torn; the capsule was 
 extremely torn on the inner side; the ligamentum teres was ruptured. — 
 Shaw, Medical Times, vol. xvii. N. S., p. 459. 
 
 Remarks. In this case the head was dislocated internally ; but 
 it could not have touched the gracilis nor the adductor longus. How, 
 then, were they torn ? The explanation is simple. If we accept 
 the lesson of the dissecting-room, that internal dislocations are by 
 abduction, we see that on abduction to a point necessary to dislocate, 
 these muscles were put upon a severe strain, and the rupture was 
 due, not to contact with the head, but to overstretching. On the 
 same theory of overstretching the ecchymosis of the nerve may be 
 explained. 
 
 Case X. — A maniac jumped from a third-story window, receiving in- 
 juries that proved fatal in three hours. Thigh injured. Symptoms: Short- 
 ening and inversion ; shaft crossed the symphysis pubis, and was immovably 
 fixed in that position. On dissection, twelve hours after death, the gluteus 
 medius and minimus were found ruptured at their posterior edges ; the 
 
 Fig. 55. 
 
 pyriformis and the gemelli were partly torn, but the four portions of the 
 tendon of the obturator internus which pass through the lesser sciatic 
 notch were drawn out and separated from their connection with the muscular 
 fibres. The head of the femur presented through a rent in the capsule 
 
PATHOLOGY. 69 
 
 opposite the upper part of the tuber ischii above the quadratus, so that the 
 great sciatic nerve was somewhat displaced and pressed against the tuber 
 ischii. — Thomas Wormald, London Medical Gazette, vol. xix. 
 
 Remaeks. Bigelow lays great stress upon the anatomical struc- 
 ture of the obturator internus. He calls especial attention to the 
 separate fibres that make up its tendon, and assigns to this muscle 
 the province of arresting the head in its upward march. He has a 
 distinct class of dislocations which he calls " dorsal below the ten- 
 don." Now, before dissection, one would have assigned this disloca- 
 tion to that variety, since the head lay below the sciatic notch, and 
 the limb crossed its fellow at a high point. But, on dissection, the 
 obturator internus was found hanging in shreds from the trochanter, 
 and incapable of offering the least resistance to the upward progress 
 of the head. 
 
 This case confirms in a striking manner a result which I have 
 stated (p. 79), that in dislocations the tendon never gives way — it 
 tears from its insertion or from the muscle. This is easily explained 
 in experimental work, in which the bone, capsule, tendon, and fibrous 
 structure may undergo no change, while the muscular fibre has lost 
 its toughness. This case, due to traumatism, proves the truth of the 
 assertion. In experimental work I have drawn the tendons out of 
 the muscular part precisely as described above. 
 
 Case XI. — Robert S., forty-five years old, was knocked down and injured 
 while coupling railroad cars. He was unable to rise, and soon after was 
 taken to the Leicester Infirmary and placed under the care of Mr. Marriott. 
 Dislocation backward of right femur, with less advancement of the knee 
 and inversion of the foot than usual. No efforts at reduction, owing 
 to collapse. Death occurred on the following day. On dissection, the 
 head of the femur was found immediately behind the acetabulum, having 
 escaped below the pyriformis. No laceration of muscular fibre was any- 
 where detected. On manipulation, the muscles were found to be the main 
 obstacle to reduction. The ligamentum teres was torn from the head. The 
 capsule was freely torn all round, only a small portion remaining attached 
 to the femur in front and behind. The cotyloid ligament and the cartilages 
 were uninjured. — Samuel Lee, St. George's Hosp. Rep., 1872-4, vols, v.-vii. 
 
 Remarks. If the dislocation was below the pyriformis, the head 
 must have been between it and the obturator internus, as it is dis- 
 tinctly said there was no muscular lesion. It is impossible to repro- 
 duce this injury upon the cadav'er, owing to the brittle condition of 
 the muscles. It is this condition of head in chaneery that leads me 
 
70 
 
 INTRODUCTORY STUDY. 
 
 to classify it among the real obstacles to reduction from the usual 
 methods. 
 
 Case XII. — Stephen H., seventy years old, foundry laborer, crushed by 
 a heavy weight so severely as to drive a large quantity of intestines through 
 a rent in the scrotum. Death from peritonitis on the eighth day. Symp- 
 toms : Left hip inverted ; thigh flexed and rigid ; knee rested above patella 
 of sound side ; the head of the femur could with difiiculty be located near 
 
 Fig. 56. 
 
 the sciatic notch ; trochanter a little posterior to normal situation. On 
 dissection, the head was found to be dislocated almost directlj backward, 
 resting behind the acetabular ridge, opposite the middle and upper half of 
 the great sciatic foramen. The pyriformis was stretched above the head. 
 The gemellus superior was ruptured, and the obturator internus was intact. 
 — Wm. MacCormac, St. Thomas's Hasp. Rep., 1871. 
 
 Remarks. The fracture of the pelvis and the expulsion of the 
 intestines through a rent in the scrotum may be reasonably explained 
 on the theory of hyper-flexion; and this, Avith slight rotation inward, 
 would effect dislocation outward. 
 
PATHOLOGY. 71 
 
 Altered Relation of Parts After Dislocation. 
 
 Before Reduction. So long as the head remains out of the 
 socket all the structures that attach to the great and small tro- 
 chanters will be aifected, some being stretched and others relaxed. 
 If the head be dislocated inward, the great trochanter will approach 
 the socket, and may lie in it to a variable degree. When the knee 
 is abducted and the thigh flexed, the trochanter tends to sink down 
 into the socket. The tendon of the gluteus minimus will follow 
 the trochanter inward, and, with the tendons of the piriformis and 
 obturator internus (if untorn), will lie upon the outer edge of the 
 acetabulum or be stretched partly over it. Usually the part of the 
 capsule that remains untorn is that which is covered by and adher- 
 ent to the tendons of the ilio-psoas and gluteus minimus, and in 
 those cases where the capsule is actually torn beneath these ten- 
 dons the torn parts of the capsule will retain their attachments to 
 the overlying muscles. Both these muscles escape, as a rule. I 
 have never seen in experimental or pathological investigation any 
 injury to the psoas, but the gluteus minimus and medius are reported 
 as utterly destroyed. (See Cases IV. and V.) 
 
 While dislocation persists the edges of the capsule are held apart, 
 being separated to the extent of the full width of the neck of the 
 femur. Certain writers have permitted their imaginations to guide 
 their pens, and have stated that rapid healing of the capsule with its 
 consequent shutting oif of the socket is one of the insurmountable 
 obstacles to reduction. I cannot indorse such a sentiment, and be- 
 lieve that a persistent passage to the socket is not an infrequent 
 condition, or that, if adhesions take place, they are easily broken up. 
 
 If the dislocation be outward, the remnant of untorn capsule and 
 the tendon of the psoas will be drawn across the socket and rest 
 upon its outer rim. It is difficult to understand how any adhesions 
 of the capsule to the cartilaginous rim of the socket (both lined by 
 epithelium) could take place, or how, if they did occur, they could 
 be formidable. Such adhesions would shorten the remnants of the 
 capsule and must readily yield to manipulation. I am firmly of the 
 belief that capsular adhesion (the so-called shutting off of the socket) 
 in cases of unrestored dislocations is little w^orthy of serious consid- 
 eration, and should be given a much less prominent position in the 
 category of obstacles. 
 
72 INTRODUCTORY STUDY. 
 
 Conditions of the Head and Socket. The head and socket 
 may remain unaltered for years, or they may undergo rapid inflam- 
 matory and other changes. Something can be inferred from the 
 history of a case. If the dislocation has been effected by simple 
 leverage {i. e., if the head has been lifted out of the socket), the car- 
 tilages of the head and the socket escape without bruising. Such 
 dislocations, taking place in adult life, will not be followed by rapid 
 shrinking of the head or socket. Cases are reported in Avhich the 
 cartilages of the head and socket have been found smooth and glis- 
 tening years after a dislocation has taken place. Bernard E. Brod- 
 hurst found the cotyloid cavity to retain its full depth three years 
 after dislocation of the head of the femur. Fourier has placed a 
 dissection upon record in Avhich, after thirteen years of unrestored 
 dislocation, the socket preserved its size, form, and depth (St. 
 George's Hosp. Rep., 1868, vol. iii. Bigeloiv, p. 108). 
 
 In cases like those just described (i. e., in the class in which the 
 cartilages were not bruised) a new socket is formed and a new cap- 
 sule is created. The socket is formed by a thinning of the under- 
 lying bone, and probably by increased physiological activity at its 
 margins. There is little known about such capsular attachments ; 
 but there is no reason why the new capsule should not communicate 
 persistently with the old socket, as is the case with congenital dislo- 
 cations. 
 
 Dislocations occurring before puberty must, if unrestored, lead to 
 atrophy of all the constituents of the joints. 
 
 When dislocations are the result of direct violence (as when a 
 person, half-stooping, receives a crushing blow from a caving em- 
 bankment, or when one falls a distance, striking heavily upon the 
 knee) the concussion to the articular cartilages is likely to be followed 
 by inflammatory changes. If the head is not promptly restored, 
 such inflammation would produce direct adhesion between the head 
 and surrounding parts, and be followed — not by a new socket, but 
 by ankylosis. If, however, the head, under these circumstances, be 
 promptly reduced, the result will probably be synovitis with anky- 
 losis. In one of my cases of unreduced dislocation inward into the 
 thyroid depression, due to earth falling upon the man, the resulting 
 inflammation and adhesions between the head and the subjacent 
 parts were so intimate that a disturbance of the relations, in an effort 
 to restore the part, gave rise to a distinct sense of crepitus, and at 
 
AIDS AND OBSTACLES TO REDUCTION. 73 
 
 the autopsy it was found that the head was bare of" cartilage and of 
 the outer shell of bone, which had remained adherent to the floor of 
 the new bed. 
 
 If, in such a case, reduction is accomplished, ankylosis must ensue, 
 and the only gain would be a better position of the limb. 
 
 Osteophytes. The growth of new bone, as a sequence of dislo- 
 cations, is worthy of consideration. When the rent in the capsule 
 is between its acetabular and femoral attachments the periosteum is 
 not disturbed, and, unless a fracture be present, no bone repair will 
 be needed. Two possibilities, however, present themselves. Should 
 the capsule with periosteum be torn from the rim osteophytes might 
 oppose an obstacle to reduction, if this be long delayed ; or, if the 
 head be promptly restored, osteophytes, springing up around the 
 border of the socket, would greatly abridge, if not abolish, motion. 
 Should the capsule be torn from the neck, the osteophytes would 
 probably be less formidable, though new bone will grow, not only at 
 the points of denuded bone, but also at the detached border of the 
 capsule, which may be covered with periosteum. 
 
 Changes in the Socket and Head After Reduction. 
 
 These changes I shall not discuss. Those that have been noticed 
 are : Synovitis due to traumatism, with all the symptoms of rapid 
 inflammatory action ; subacute symptoms, followed by disuse and 
 atrophy, possibly due to turning in of the capsule or to a foreign 
 body in the socket, such as muscle or blood. Fibrous or bony anky- 
 losis is likely to follow under such circumstances. 
 
 AIDS AND OBSTACLES TO REDUCTION. 
 
 Anaesthetics have swept away every device that surgical ingenuity 
 has brought forward for the reduction of dislocations. Not a single 
 one remains in shop or hospital, and only in works on general sur- 
 gery can one still find the long catalogue of obsolete contrivances, 
 not one of which was constructed upon the true pathology of dislo- 
 cations. 
 
 The reduction of a dislocation is far from being a simple thing, 
 and no one who truly estimates the condition of his patient will 
 regard it as such. 
 
74 INTROD UCTOR Y STUD Y. 
 
 As a preliminary measure, therefore, and before the limb is 
 touched, I earnestly recommend fixation. The fixation of the pelvis 
 will be seen to be of the utmost importance, if we take into consid- 
 
 eration its shape. Had Nature given the pelvis a broad, flat dorsal 
 surface, reduction would have been easier ; but dislocations would be 
 more frequent. In giving to man a narrow dorso-sacral support, 
 Nature has thrown safeguards around the articulation, for the rocking 
 and tilting pelvis readily accommodates itself to motion from the 
 thighs, and thus circumvents many a vicious attack. 
 
 Fig. 5S. 
 
 With the tliigli bone dislocated, all efforts at its reduction are 
 applied through the thigh itself, or through the bent leg, and always 
 at the outer angle of the pelvis. Thus the femur, which we are 
 
AIDS AND OBSTACLES TO REDUCTION. 
 
 75 
 
 attempting to restore, becomes the direct agent or lever in moving 
 the pelvis, and contributes to our defeat. The chief advantages of 
 rotation and circumduction as methods of reduction are that they do 
 not communicate to the pelvis their motion in the same degree that 
 other methods do. But it is not difficult to show that reduction by 
 circumduction is both unscientific and dangerous. 
 
 A method of fixation that I have often advantageously adopted, 
 but whose only excellence is its simplicity, consists of three opened 
 screw-eyes and a long and strong bandage. (In the shops the screw- 
 eyes are screw-rings, but they can be readily opened.) I screw one 
 at the junction of the thighs in the perineum, and one at the iliac 
 flanges. (Fig. 60.) The prominences of the ilium and pubes are 
 protected with folded towels. 
 
 Fig. 59. 
 
 Fig. 60. 
 
 Whether the operator fixes the pelvis or not, he will find a large, 
 heavy, muscular thigh a very inconvenient thing to handle. After he 
 has flexed the thigh to a perpendicular he can readily grasp the ankle, 
 but he cannot grasp the knee. Many do not attempt to grasp the 
 knee, but, placing the hand upon it, steady it or circumduct it, while 
 the other hand guides the ankle. Now, though this procedure is 
 frequently successful, it is not without danger. Pressure upon the 
 knee drives the head, in rotation and circumduction, more irresist- 
 ibly against any obstacle within reach, and in my presence it once 
 hooked up the sciatic nerve. It is much more scientific (for it is 
 
76 
 
 INTR OD UCl OR Y STUD Y. 
 
 reversing the steps of a dislocation) to lift the thigh in the direction 
 of its long axis. This can be done by placing the bent elbow be- 
 neath the bent knee, though this is often done at great disadvantage 
 and is tiresome. To enable me to use my strength advantageously, 
 but not to increase it, I have often found the apparatus depicted in 
 Fis:. 61 of service. 
 
 Fig. 61. 
 
 /I 
 
 •^ 
 
 if ■ 
 
 11/ 
 
 11/ 
 
 The instrument is first thrown into a bucket of water to soften the sole-leather, and after 
 the two halves have been secured to the part by bandage the traction bars A are adjusted 
 and also secured by bandage. Finally the adjustable handle C is put in place. 
 
 The Shape of the Femur and the Effect of Traction and 
 Manipulation. In handling the femur we must bear in mind 
 three things : 1, that it is not a straight bone ; 2, that after dis- 
 location it does not revolve about the head as a centre, but upon the 
 axis of the shaft ; 3, that after dislocation the head is outside the 
 limits of the capsule, and that the remnant of untorn capsule ex- 
 tends between the upper part of the socket and the front part of the 
 base of the neck of the femur. If the femur were a straight bone, 
 traction in any direction Avould bring the head into line with the 
 socket after dislocation. The different effects of traction upon the 
 normal and dislocated head should be understood. If the head be 
 in its socket and the femur be flexed to a right angle, traction 
 
AIDS AND OBSTACLES TO REDUCTION. 
 
 77 
 
 upward (Fig. 62) will not be resisted by the capsule, for this is now 
 relaxed. The resistance comes from atmospheric pressure — not from 
 a taut capsule. In such a case the line of traction does not follow 
 the shaft, but runs from the knee through the socket (dotted line, 
 Fig. 62). But the instant the head escapes from the socket suction 
 has nothing more to do with it, and as the head is free from all 
 attachments traction upward will be resisted by the remnant of 
 untorn capsule and bring the shaft (not the head) in line with the 
 socket. If the head be dislocated inward, upward traction will bring 
 the great trochanter over the socket. (Fig. 63.) Under such cir- 
 
 FlG. 62. 
 
 Fig. 63. 
 
 Fig. 64. 
 
 cumstances it is folly to put forth great force in a direction perpen- 
 dicular to the pelvis with a view to draw the head over the socket, 
 for the greater the upward force the greater the difficulty in the way 
 of the head approaching the socket. 
 
 The same principle is involved in dislocations outward. Traction 
 upward (?'. e., vertically, with the body horizontal) brings the head 
 against the outer rim of the socket. The head must now go out- 
 ward (Fig. 64) before it can get into the socket. The instant it is 
 forced outward the remnant of capsule tightens, and the head is 
 blocked just at the moment when it should overstep the rim. Under 
 these circumstances the thigh should be adducted, or the head 
 rotated away from the projecting rim of the socket, when the 
 obstacle to reduction mav vanish. 
 
78 
 
 IXTROn UCTOB Y STUB Y. 
 
 The Crook in the Neck of the Femur becomes an Obsta- 
 cle in Rotation, Rotation winds up and of course shortens the 
 capsule. This obviously brings the base of the shaft (i. e., the great 
 trochanter, not the head) nearer to the socket, and when the opera- 
 tor hopes to turn the head into the socket the head or neck strikes 
 the border of the now tense and shortened capsule and is thus 
 prevented from entering the socket. Attention is directed to these 
 obstacles to reduction, because, as such, they are created by the ill- 
 directed efforts of the manipulator, and will all vanish under a proper 
 change in procedure. 
 
 The Rent in the Capsule. I have elsewhere discussed the im- 
 probability of a slit in the capsule ever occurring and thus becoming 
 
 Fig. 65. 
 
 Fig. 66. 
 
 an obstacle to reduction ; but while the head cannot escape through 
 a slit (since the smallest diameter of the orifice of exit must be, at 
 the instant of escape, equal to the diameter of the head), yet even 
 under these circumstances I have seen the neck of the femur so 
 cauf^ht by the borders of the rent as that this constituted a decided 
 obstacle to reduction. As soon as the head escapes new relations 
 between the orifice of exit and the head are created. For an in- 
 stant, while the head is escaping, the sides of the rent (Fig. 65) may 
 bulcre ; but the moment the head escapes and traction takes place 
 between the borders of the untorn portion the orifice of exit may be 
 narrowed, as in Fig. Q6. Obviously the head cannot be returned, 
 except that it be presented under circumstances similar to those 
 
AIDS AND OBSTACLES TO REDUCTION. 79 
 
 present at the moment of exit, as in Fig 65. I have demonstrated 
 this repeatedly in experimental work, restoring a dislocation with 
 ease in one position and by one method, that became impossible 
 under changed relations. 
 
 The Rotator Muscles as Obstructors. The obstruction may 
 arise from either of two conditions : The short muscle may not be 
 torn, and thus obstruct the way, or it may be torn and its detached 
 portion be pushed into the socket in advance of the head. As a 
 rule, if we may be guided by pathology and experimental work, one 
 or more of the short muscles will be torn. When I have attempted 
 to dislocate upward and outward, by flexion, adduction, and rotation 
 inward, I have torn the obturator internus before rupturing the 
 capsule. 
 
 The point of lesion in the three short rotators is worthy of note. 
 I have never torn the tendon from its bony attachment or ruptured it, 
 but the tendon may be torn from its insertion into the muscle (Case X., 
 p. 68), or the muscle may be torn in its fleshy part or from its origin. 
 Hence there will be two parts of the muscle to consider after the 
 lesion — viz., the part attached through tendon to the base of the 
 neck and the part attached to the pelvis. The first part — viz., the 
 part attached through tendon to the base of the neck — will follow the 
 femur, that is, will be dragged after it. In one of my experiments, 
 after a reduction, I found the tendons (with considerable attached 
 muscle) of the three short rotator muscles caught over the neck of 
 the femur, precisely as the nerve is caught up sometimes. In this 
 case I had made an everted dorsal from a regular dorsal disloca- 
 tion ; and, in restoring the head, the three torn muscles, dangling 
 from the neck through their attached tendons, were caught up and, 
 after reduction, lay across the neck beneath the untorn remnant of 
 the capsule. Their presence could not have been predicated from 
 any deformity or restriction of motion. The second part — viz., the 
 part attached to the pelvis — will not follow the movements of the 
 femur, but will be passive. It may, however, if it lie in front of the 
 head, be pushed into the socket. From experimental work I am 
 strongly of the opinion that no part of the pyriformis or obturator 
 internus can be pushed into the socket, for the simple reason that 
 the fragment will be too short to reach it. Not so with the muscle 
 that lies internal to the socket — viz., the obturator externus. I have 
 repeatedly found the body of this muscle, lying like a dead, inert 
 
80 INTRODUCTORY STUDY. 
 
 mass, at the door of the socket, unable to pull itself out of the way 
 or to resist the pressure from the head, and hence forced into the 
 socket. So much for dead muscle. Whether in the living the 
 stimulus of pain, from the pressure of the head, would excite con- 
 traction and thus clear the way is a matter of pure speculation. 
 Under the head of " Pathology " (Case VIII., p. 67), in the history 
 of one of the cases, it is stated that the obturator internus was pushed 
 into the socket. I take this to have been a clerical error. The evi- 
 dence of muscular structure driven before the head into the socket 
 is incomplete extension. This matter will be taken up again in the 
 chapter on " Cleaning Out the Socket." 
 
 The Sciatic Nerve. This, as an obstruction, has not received 
 the attention to which it is entitled. In the reports of cases I have 
 seen allusion to some unknown obstacle, the description of which 
 agrees fully with what I have witnessed in experimental work. In 
 reducinor a dorsal luxation bv rotation outward, I have seen the 
 head strike squarely against the sciatic nerv^e and flatten it out, 
 being thus debarred from entrance to the socket. In other cases 
 the head would catch upon the nerve which would first resist it, 
 then, slipping suddenly off, permit it to enter the socket, giving 
 the impression that a tendon or portion of the capsule had given 
 way. This has happened so frequently that I feel persuaded that 
 many surgeons have felt the arrest from and sudden disengagement 
 through letting go of the nerve in the circumductive sweep of Reid 
 and Bigelow. 
 
 STEPS OF DISLOCATIONS. 
 
 In the early part of this work I have endeavored to show that the 
 mechanism of dislocations demanded a fulcrum as well as a lever, 
 and have pointed out the positions and movements through which a 
 fulcrum could be obtained. I wish now to analyze the steps of a 
 dislocation. 
 
 This is an important subject, for no one can make a dislocated 
 head retrace its steps unless he knows and fully understands the 
 steps of the dislocation. 
 
 Dislocation inward presents by far the simplest mechanism. Its 
 three steps or stages are : 
 
 1. The rupture of the capsular ligament ; 
 
STEPS OF DISLOCATIONS. 
 
 81 
 
 2. The escape of the head beyond the limits of the socket ; 
 
 3. The shiftings that follow in the dislocated head. 
 
 1, Rupture of the Capsule. This is, of course, the initial lesion, 
 without which a traumatic dislocation cannot occur ; but before the 
 capsule yields in all dislocations dependent upon a bony fulcrum the 
 head must rise out of the bed of the socket (Fig. 67) and attack the 
 capsule, i. e., the dislocating force must act from within outward ; 
 for in no other way can the capsule be ruptured. The head rises as 
 the distal end of the shaft descends, and rises, like the short end of 
 any lever, upon its fulcrum. By its action the head tends to move 
 away from the further rim of the socket, and to bring its greatest 
 force upon the capsule at a point midway between the attachments. 
 Thus the capsule is ruptured. 
 
 Fig. 67. 
 
 savy ri/icftun 
 
 riPP£D WITH CARTILAGE. 
 
 2. Escape of the Head beyond the Boundaries of the Socket. 
 This would seem the natural sequence of rupture of the capsule ; 
 but it is not. The capsule may be fully ruptured by hyper-abduction 
 without the neck shifting its position upon the fulcrum. In experi- 
 mental work I have seen the fibres yield, as it were, one by one, and 
 after the head had emerged through the rent in the capsule, it 
 remained directly over the socket, and all that was necessary to 
 restore it was to raise the knee. In this class of cases, I repeat, the 
 relations of the lever to the fulcrum are not disturbed, and often the 
 slightest motion, such as lifting a person into a carriage or placing 
 him in bed, is sufficient to effect a restoration (Case VI., Pathology 
 p. 66). In this class of cases the luxation is probably the result of 
 
 6 
 
82 INTBOD UCTOB Y STUD Y. 
 
 force exerted slowly. When, in experimental work, I have found 
 such a condition present, I have been obliged to resort to a second 
 and independent force, to get the head bej^ond the region of the 
 socket, viz., to rotate outw^ard, in order to lift the great trochanter 
 over the brim of the socket, and then either bring the limb down in 
 extension or push it inward, to get the head beyond the socket and 
 into the thyroid depression. 
 
 But the fibres of the capsule do not always tear gradually, i. e., 
 one by one. They may all resist until the instant of maximum 
 violence, and all snap at once, freeing the head suddenly ; and in an 
 instant later it is found beyond the boundaries of the socket. 
 
 Now, let us analyze the process. The long, strong lever carried 
 outward, constitutes the primary force ; the bony rim is the fulcrum, 
 and the strong capsule offers the resistance. Note especially that 
 the bony resisting fulcrum is covered by an elastic cartilage, viz., 
 the peripheral cotyloid ligament, and that this cartilaginous covering 
 of the fulcrum is compressible. (Fig. 67.) Hence, as the lever is 
 being carried outward the cartilage is becoming more and more com- 
 pressed, thus creating a secondary force, while the capsule that can- 
 not readily stretch is fast reaching its limit of resistance. Suddenly 
 the capsule snaps with a loud report, the compressed peripheral car- 
 tilage recoils upon the neck which Avas pressing it down, and the 
 head, freed by the rupture of the capsule, is propelled as from a 
 gun, upward and inward, and lands clear beyond the confines of the 
 socket. 
 
 Fig. 68. 
 
 The reader can satisfy himself on this point by means of a very 
 simple experiment. Let him take a lever {AC, Fig. 08), tie the point 
 G down with a string and place a hard fulcrum at B. If power is 
 exerted at A, it will break the string without disturbing the relations 
 of the lever to the fulcrum FED. But if an elastic fulcrum be 
 
STEPS OF DISLOCATIONS. 
 
 83 
 
 substituted, the instant the string breaks the weight-end of the lever 
 will be thrown into the air as FE. 
 
 Rotation inward is an almost invariable accessory agent in pro- 
 ducing dislocations, and the query arises : Is there a special agency 
 in dislodging the head so constantly outward ? At first glance one 
 can see nothing in rotation to disturb the position of the head ; for 
 were the femur a straight bone and the capsule of equal strength and 
 length, the whole might be twisted off, leaving the head still in the 
 socket. Indeed, it seems a little strange, at the first glance, that the 
 head should not be as frequently displaced inward as outward by the 
 
 Fig. 69. 
 
 act of inward rotation. The solution, however, lies in the fact that 
 in rotation inward the ilio-femoral ligament, which is by far the 
 strongest part of the capsule, lies upon the inner aspect of the joint. 
 (Fig. 69.) As rotation increases the tension of the capsule increases, 
 until finally the lower outer portion, pressed upon by the head, gives 
 way, and the prevalent portion, feeling no longer any resistance, 
 throws the head outward. 
 
 There is another factor concerned in the leaping of the head from 
 beyond the boundaries of the socket, and that is found in its globular 
 shape. As the head is spherical, the pressure from the borders of 
 the rent increases until the maximum circumference is reached. The 
 instant that is passed, the tissues contracting, often very powerfully, 
 
84 INTR OD UCTOB Y STUD Y. 
 
 around the diminishing globe shoot it forward with a sudden spring. 
 Simple adduction and simple rotation may be quite enough to rup- 
 ture the capsule, but when the head is shot inward into the thyroid 
 depression or outward upon the dorsum (and that in the cadaver) an 
 agency independent of leverage or live muscle must be invoked to 
 explain it. 
 
 3. Shifting of the head to a point more or less remote from the 
 position it reached at the completion of the second stage. Few, 
 except in experimental work, see the head in the position to which 
 it originally escaped in the second stage. The unexpended force, 
 the weight of the limb, transportation, or prior unsuccessful attempts 
 at reduction, tend to shift the head to a secondary position. In 
 experimental work the hardest part is accomplished when the capsule 
 is ruptured ; after this any variety of dislocation may be easily and 
 perfectly reproduced. 
 
 An Examination into the Theory that Traumatic Disloca- 
 tions take Place through Thrust. 
 
 What I have said in the preceding pages about the steps of dislo- 
 cations in experimental work is not theory ; I have repeatedly wit- 
 nessed it. In traumatic, i. e., clinical, cases we are obliged to theorize. 
 Formerly all surgeons believed, and many still believe, that in trau- 
 matic dislocations the head passes directly to its point of destination ; 
 that a dislocation upon the dorsum ilii is produced by a thrust when 
 the thigh is extended and adducted, and that a thrust directly upward 
 with the limb extended will accomplish an infra-spinous luxation, 
 while a thrust inward as the thigh is abducted will produce a thyroid, 
 perineal, or pubic luxation. 
 
 I am free to acknowledge that it is not a sufficient argument in 
 refutation of such a theory to say that experimenters have never 
 been able to accomplish a dislocation bi/ tlirust^ or to say that 
 Nature need not adopt a difficult mode when there is an easier one. 
 I shall, however, ask the reader to examine with me the steps of 
 a few accidental dislocations which present fairly definite data, and 
 if he will do so without prejudice, I hope to convince him that dislo- 
 cations usually believed to be due to thrust are no exception to the 
 mechanism which I have just pointed out. 
 
 Problem 1. A man walking, steps into a long, narrow hole, falls 
 forward, and dislocates his right femur upon the dorsum. 
 
STEPS OF DISLOCATIONS. 
 
 85 
 
 What is the mechanism of dislocation ? Approximate data : 
 
 1. A long lever immovably fixed — i. e., the extended limb in a hole. 
 
 2. Weight, the body of the man. 
 
 3. Direction of the force forward — /. e., flexion of the body on 
 the thiorh. 
 
 4. Lever attached at the lower right-hand corner of the trunk. 
 
 5. Resistance to dislocation, the capsule. 
 
 The reader will please note that the body cannot fall forward 
 indefinitely upon the fixed and extended limb. It will be checked 
 by the hamstring muscles (Fig. 70, dotted line) before it reaches a 
 
 Fig. 70. 
 
 Fig. 71. 
 
 Fig. 72. 
 
 Flexion 
 
 Flexion, adduction, and 
 rotation inward. 
 
 right angle. Note also that the head of the femur is attached at one 
 corner of the body ; hence the instant the falling trunk is checked 
 at one point (i. e., in flexion) the unsupported part of the body (i. e., 
 the opposite corner) drops until checked ; and now, still under the 
 force gravity, it has yet only one direction open to it, viz., rotation 
 inward — three motions, all possible to a ball-and-socket joint. All 
 these are the direct result of falling forward upon one fixed and im- 
 movable thigh. The three motions that produced the luxation are 
 identical with forces that will accomplish the same end upon a cadaver 
 in the dissecting-room.^ 
 
 1 The order in which I have stated these steps is purely arbitrary. It would be equally 
 true if I had stated them in the order of adduction, rotation, and flexion. It is not the order, 
 hut the blending of these forces that acts so eflfectively in dislodging the head of the femur. 
 
86 
 
 ISTRODUCTORY STUDY. 
 
 Answer to Problem 1. The head was dislocated under three forces 
 acting together, viz., flexion, adduction, and rotation inward. 
 
 Problem 2. A tramp, sitting on the narrow foot-wide platform at 
 the rear of a freight car, with his left leg extended and resting upon 
 
 Fig. 
 
 a similar platform of the following car, has his left femur dislocated 
 upon the dorsum ilii by a sudden slowing up of the train and coming 
 together of the cars. 
 
 Fig 
 
 Query : What was the mechanism of dislocation ? Approximate 
 data : 
 
 1. The left limb was fully extended. (Fig. 73.) Had it been 
 flexed, or could it have been flexed by the impact, the knee would 
 have sprung forward and no injury would have been sustained. The 
 force was therefore transmitted directly from the foot to the pelvis. 
 
STEPS OF DISLOCATIONS. 87 
 
 2. The force does not strike the pelvis squarely, but explodes 
 upon one corner of it. (Fig. 74.) 
 
 3. The resistance comes from the perpendicular back of the car 
 against which the man Avas leaning. The man was not sitting erect. 
 Had he been he could not have fully extended his limb. The resist- 
 ance therefore comes from the dorso-lumbar vertebra. The dislo- 
 catino; force is directed from below and to the left ; the resistance is 
 above and to the right. (Figs. 74 and 75.) The resultant of these 
 
 Fig. 75. 
 
 three co-operating forces must be the answer to the problem, viz., 
 flexion, adduction, and rotation inward. 
 
 Problem 3. J. P., laborer, was engaged in shovelling out ballast 
 from the hold of a ship, standing on the bottom with his feet between 
 the ribs. While in the act of stooping a cave-in from above struck 
 him upon the back and pelvis. Result : Dislocation of both femurs : 
 one, dorsal {i. g., outward), the other, thyroid (inward). 
 
 Query : What Avas the mechanism of this double dislocation ? 
 
 Probable data. As the man was standing in a semi-stooping pos- 
 ture, with his feet between the parallel ribs in the bottom of the 
 hold, one effect of the cave-in was to drive him upon his knees. He 
 would thus have feet and legs fixed in a parallel position. A second 
 effect would be to flex still further the body on the thighs. If the 
 body had bent squarely upon the thighs, simple flexion would not 
 have dislocated either. As both legs were now fastened parallel, 
 whatever motion the thighs took, they also must move parallel. If 
 the body swayed, one thigh would be adducted, the other abducted. 
 If the body rotated, the rotation in one hip would be internal, and 
 that in the other of necessity external. If the legs were fastened 
 and the femurs compelled to move parallel, then flexion, adduction, 
 and rotation inward in one limb would require flexion, abduction, 
 
88 INTBOD UCl OR Y STUD Y. 
 
 and rotation outward in the other. Thus is brought about a double 
 dislocation, the one dorsal and the other thyroid, and by the appli- 
 cation of force in a way directly opposed to the theory of thrust. 
 
 There is a further argument in support of the theory that rotation 
 inward is a very constant, if not absolutely essential, element in the 
 mechanism of dorsal dislocations, viz., that rotation inward is an 
 almost invariable sign and accompaniment of dorsal dislocations. If 
 rotation inward is a factor in producing dislocations outward, the 
 instant the head bursts through the capsule a still greater degree of 
 rotation will take place, while the head falling outside the socket 
 falls in a state of inward rotation. It falls until arrested by 
 the iliofemoral ligament, and must remain in a state of inward 
 rotation until the neck is broken or the outer branch of the ilio- 
 femoral ligament gives way. Rotation outward is impossible, be- 
 cause any attempt to accomplish it is resisted by the remnant of 
 untorn capsule, which brings the head against some part of the outer 
 surface of the pelvis. 
 
 Let us, however, suppose a dislocation to be possible by thrust 
 through the extended femur. Let it be possible for the smooth head 
 to spring from the smooth socket, through the capsule, on the outside 
 of the socket. Why, I ask , if the thrust occurs during normal eversion 
 of the foot (Fig. 76), does not the foot remain everted ? and why, 
 if the usual mode of dorsal dislocations be through thrust with the 
 thiorh adducted and everted, is not the form of dislocation known as 
 dorsal with eversion the most common of all, instead of being very 
 rare ? How, I ask, will the holders of this opinion explain the 
 inward rotation of 90°, when they evoke no other agency to pro- 
 duce a dislocation than a thrust in the long axis of the extended, 
 adducted, and everted limb ? 
 
 In defence of the theory that direct thrust in the long axis of the 
 femur is competent to dislocate directly upon the dorsum ilii it has 
 been urged that velocity can perform wonders ; that while no one 
 can push a tallow-candle through a pine board an inch thick, the 
 candle can readily be shot through tlie board. Granting that cir- 
 cumstances alter cases, I urge against the theory of velocity that a 
 candle with a bend in it of 130° could not be shot through a pine 
 board, nor could a man projected with the velocity of a bullet sur- 
 vive the sudden arrest. So also, I would add, if a man sitting on 
 the end of a car were to receive a thrust from another car going at 
 
STEPS OF DISLOCATIONS. 
 
 89 
 
 the highest rate of speed, the strongest probabilities lie in the direc- 
 tion of fracture, not dislocation. 
 
 Fig. 7G. 
 
 Resume of Mechanism and Effect of Traumatic 
 Dislocations of the Femur. 
 
 1. All traumatic dislocations, unaccompanied with fracture, are 
 the result of leverage. 
 
 2. When the femur is the lever, the outer (or the lower) part of 
 the rim of the socket acts as a fulcrum. 
 
 3. Dislocations through leverage of the shaft of the femur occur 
 only in hyper-abduction and hyper-extension. 
 
 4. In dislocations through rotation the bent leg becomes the 
 long arm of the lever and the ilio-femoral ligament the fulcrum. 
 
90 lyTR OD UCl OR Y STUD Y. 
 
 5. In the mechanism of dorsal {i.e., outward) dislocations rota- 
 tion inward is a necessary factor. 
 
 6. Dislocations inward may result from simple adduction. Ad- 
 duction, rotation outward, with extension, will also produce it. 
 
 7. Dislocation through leverage pure and simple makes the small- 
 est opening in the capsule. 
 
 8. Dislocation through rotation usually tears all but the ilio-femoral 
 ligament. 
 
 9. The rent in the capsule may be extensive and the peri-capsular 
 muscles may escape entirely.^ 
 
 10. Dislocations through thrust exerted in the long axis of the 
 shaft are exceedingly improbable. 
 
 11. When the history of a case points to thrust the element of 
 fracture is highly probable. 
 
 12. In all injuries in which thrust is an element (as in earth fall- 
 ing on the bent trunk, or a blow in the long axis of the shaft) a 
 liability to subsequent inflammatory mischief must be borne in mind. 
 
 PHEXOMEXA OF DISLOCATIOXS-SIGXS AXD THEIR 
 
 CAUSES. 
 
 If we exclude pain (a symptom common to all aggravated trau- 
 matisms), there remains not a single symptom of dislocation. The 
 distinctive and peculiar deformities significant of dislocations can all 
 be accurately reproduced upon the cadaver. They should, therefore, 
 be called signs — certainly not symptoms. 
 
 In the following study I shall take up the simplest and most fre- 
 quent dislocations ; explain the rationale of signs peculiar to them ; 
 shoAV how by slight modifications other varieties may be made, and 
 how great a change at the periphery can be made by a slight central 
 change. I wish to repeat what I have already frequently brought 
 forward, viz., that, as we deal with lever and fulcrum in the produc- 
 tion of dislocations, so, by the changed positions in these levers and 
 fulcrums, we may interpret the positions of the two arms of the lever 
 as well as the nature of the fulcrum. I shall arrange the signs of all 
 dislocations under two general heads, viz., those that occur upon the 
 inner plane and those that take place upon the outer plane of the 
 pelvis. 
 
 1 See case of Kobert S— , p. 69. 
 
PHENOMENA OF DISLOCATIONS. 
 
 91 
 
 Signs Attending- Dislocations Inward. 
 
 In dislocations inward no part of the upper end of the femur can 
 lie upon as low a plane as is possible in dislocations outward. This is 
 best illustrated when the femurs are compared in the flexed position.^ 
 
 Fig. 77. 
 
 cV 
 
 XF indicates the level of the sockets (the limbs are placed vertical ; A, normal ; B, thjToid ; 
 C, dorsal). No dislocation inward can be below it ; no dislocation outward above it. 
 
 The student while investigating the persistency and cause of signs 
 must bear in mind the agencies under which dislocations take place; 
 and in dislocations inward he must remember the following facts : 
 
 1. All dislocations inward occur during abduction. Hence it is 
 not strange that, in the great majority of cases, abduction is a promi- 
 nent feature. 
 
 2. The shortest, closest, and by far the most controlling attach- 
 ment of the upper end of the shaft of the femur is the remnant of 
 untorn capsule, which binds the oblique line of the femur to the lower 
 spine of the ilium. This sole remnant of capsule has a one-sided 
 action. It is made tense by rotation inward, and resists it. It holds 
 the limb in a state of persistent outward rotation. This causes the 
 
 1 The author first called the attention of the profession to this mode of measurement in 
 establishing a diagnosis in an article published in the Medical Times, March 28, 1874. Dislo- 
 cation of the Hip — Sciatic Variety. 
 
92 
 
 INTRODUCTORY STUDY. 
 
 tendency of the capsule to hold the femur in a perpetual state of 
 abduction and rotation outward. These signs will not be invariably 
 present. They may be greatly modified, but in most cases they will 
 be typical of the injury. 
 
 Fig. 78. 
 
 /UOr£M.LIG 
 
 Dislocation is inward into the thyroid depression, below and internal to the bloodvessels. 
 The vessels in this position would cross the neck. The constraint is due to the trochanter 
 resting on the lower rim of the acetabulum, held in position by the remnant of untom 
 capsule. (See Kg. 15.) 
 
 In dislocations inward the trochanter, the head of the femur, and 
 the remnant of capsule enter largely into the characteristic deformity. 
 In a typical thyroid luxation (well represented in Fig. 78) the 
 marked constraint under the twofold heads of flexion and abduction 
 
PHENOMENA OF DISLOCATIONS. 
 
 93 
 
 are due, not to the head pressing into the thyroid depression, but to 
 the great trochanter resting (^'. e., impinging) upon the lower rim of 
 the socket. With the trochanter caught upon the lower rim of the 
 socket, the remaining part of the capsule is not long enough to per- 
 mit of full extension ; hence the weight of the thigh and leg is sus- 
 pended upon the remnant of capsule. (Fig. 78.) It must be observed 
 that the fulcrum, i. e., the ilio-femoral ligament, lies between the head 
 and the knee, i. e., that the femur lies obliquely beneath it. Under 
 these circumstances, the weight of the knee would naturally swing 
 it inward ; but to do so the head must swing outward. The latter is 
 impossible. Hence, in dislocations into the thyroid depression there 
 is a resistance to adduction of the knee. It is to be noted further, 
 that the position of the foot is midway between rotation outward and 
 inward, i. e., the outer and inner condyles are on the same level. In 
 such a case the great trochanter will be found on a level with the 
 head. 
 
 Fig. 79. 
 A. B. 
 
 Dislocation into thyroid depression. Fascia lata 
 relaxed. Great trochanter concealed. 
 
 Normal conditions. Trochanter 
 major prominent. 
 
 We may note again the concealment of the great trochanter, 
 and contrast it with the bold prominence in a normal condition. 
 (Figs. 78 and 79.) We may note also the angle of depression between 
 the crest of the ilium and the femur, due to displacement inward of 
 the upper end of the femur, and to the relaxation of the fascia and 
 muscles on the outer aspect of the hip. 
 
94 
 
 INTRODUCTORY STUDY. 
 
 Let us now attempt to flex the femur to a vertical position. The 
 head lies on the thyroid depression. There will be no obstacle to 
 flexion. But when the attempt is made to place the femur in a 
 vertical position the pelvis will be found to move with it. (Fig. 81.) 
 If vfe contrast Fis;. 80 with Fig. 81, we shall see that the abduction 
 has not been relieved ; that it is the same in each position ; that the 
 pelvis has been canted, and nothing more. Note in Fig. 80, in 
 which the abduction is apparent, that the sockets are on the same 
 level. Note in Fig. 81, in which the abduction is apparently over- 
 come, that the sockets are not on the same level. Two things should 
 be borne in mind: First, adduction in dislocations inward is resisted. 
 Second, if the two femurs are to be compared, see that the sockets 
 are on the same level, otherwise the dislocated limb will appear much 
 longer than its fellow. 
 
 Fig. 
 
 Fig. 81. 
 
 Should the troshanter slip ofi" the lower rim and into the socket (Fig. 
 82) there will be quite a marked change in the position of thigh and 
 leg. First, as to constraint. This will be decidedly less. The trochan- 
 ter lies nearer the socket, and the remnant of capsule Avhich supports 
 the weight of the thigh and leg is not put upon the stretch until the 
 thigh is more extended. The trochanter may lie well in the socket, 
 or but partially, according as it is empty or occupied by capsule or 
 muscle. The neck crosses, and may rest upon the inner rim of the 
 
PHENOMENA OF DISLOCATIONS. 
 
 95 
 
 socket. The head may rise and be a little more prominent ; or, if 
 the abduction is considerable, it may still remain in the thyroid 
 depression. In both of the conditions described the trochanter and 
 
 Fjg. 82. 
 
 
 Contrast this with Fig. 78. The head by rotation outward has been shifted upward ; it has 
 escaped from beneath the femoral vessels which now lie inward or they still cross the head. 
 {Cf. Fig. 15.) The trochanter now lies in the socket, and very much of the constraint has 
 disappeared. 
 
 the capsule give character to the deformity. In this, as in the former 
 case, the ilio-femoral ligament (fulcrum) lies across the two arms of 
 the lever. If the long arm (knee) is carried inward, it will be resisted, 
 because the short arm cannot move outward. With the exception of 
 
96 
 
 INTB OD UCTOB Y SI UD Y. 
 
 restraint, most that has been said of i\iQ first condition is present in 
 the second. The trochanter major is lost in both. Rotation may 
 make the head prominent, but not the trochanter. If the limbs are 
 compared vertically, all that has been said about adduction and the 
 
 Fig. 83. 
 
 The head is now entirely outside of the femoral vessels ; it has been rotated further upward 
 and outward. Trochanter is now in the thyroid space and caught beneath the overhanging 
 ledge of the ramus. 
 
 tilting of the pelvis must be borne in mind. In neither case is 
 rotation exajiserated. In both rotation inward will be resisted, but 
 rotation outward will be possible ; and in this way only can the head 
 be forced into prominence. 
 
 If, under the conditions just described, the ankle of the bent leg be 
 
PHENOMENA OF DISLOCATIONS. 
 
 97 
 
 raised and the femur be rotated upon its axis outward, the effect will 
 be to lift the trochanter out of the socket and to plant it in the thyroid 
 depression. (Fig. 83.) Once in the thyroid depression, it may abut 
 against the under surface of the horizontal ramus that forms the upper 
 boundary of the depression. Under these circumstances there is a little 
 
 Fig. 
 
 Originally a thyroid— now may be appropriately styled a reversed thyroid. All restraint 
 has now disappeared. Note the extreme pointing backward of the foot. 
 
 fixation. The weight of the limb is supported by the remnant of cap- 
 sule, but the fixed position in abduction and semiflexion is due to the 
 trochanter being caught beneath the pubic ramus. Note that the 
 inner malleolus and the inner condyle are looking upward. The head 
 must therefore look upward. Note that the foot looks outward and 
 
 7 
 
98 
 
 IN TROD UCTOR Y SI UD Y. 
 
 the heel inward. Look inward, then, for the great trochanter. The 
 ilio-femoral ligament crossed the lever in front in Figs. 78 and 82; 
 in Fiof. 83 it lies to the outside. Let the reader bear in mind that 
 the remnant of untorn capsule (the ilio-femoral ligament) is holding 
 the base of the neck of the femur to the lower spine of the ilium ; 
 that it may rotate about it, but cannot get away from it. Note that 
 the head is getting into greater prominence through rotation outward, 
 but that the trochanter major is still obscured. 
 
 The position of the trochanter beneath the ledge of the horizontal 
 ramus is precarious. The slightest rotation outward will lift the tro- 
 chanter out of the hollow, Avhen it will rise and rest upon the promi- 
 nence on the inner side of the socket. (Fig. 84.) Now all constraint is 
 at an end ; the femur hangs from the lower spine ; there is no flexion 
 or abduction. The most important clue to the position of the head 
 is rotation outward. Query. Where is the head ? the trochanter ? 
 the Y-ligament ? Answer. Look at the foot : the toes are looking 
 backward, the internal malleolus is looking outward ; then the head 
 must be looking outward, and the trochanter must lie inward and 
 
 rest upon the inner plane. It would not rest upon the inner plane 
 if it had been primarily a dorsal dislocation. It is therefore a dis- 
 location Avith extreme rotation outward, from an original thyroid, as 
 can be seen by a glance at the reduced figures of 82, 83, 84. 
 
 Study of the Signs Attending Dislocations Outward. 
 
 I began the explanation of the phenomena of dislocations inward 
 by stating that in this variety of displacement the trochanter major 
 
PHENOMENA OF DISLOCATIONS. 
 
 99 
 
 is brought into close contact with the pelvis ; that it, and not the 
 head, rests upon the bony platform ; and that the peculiar deformity 
 is mainly due to the trochanteric end of the shaft and the untorn 
 part of the capsule. 
 
 Not so in dislocations outward. In scarcely any position can the 
 trochanter be made to touch or rest upon the pelvis. In this variety 
 the head and neck abut against the outer side of the pelvis, and the 
 constraint brought about by the tense remnant of the capsule (ful- 
 crum) and the short end of the lever (head and neck) is of a very 
 different character from that which takes place in dislocations inward. 
 
 Two facts should be recalled at the outset : 
 
 1. That rotation inward is a prime factor in producing all dislo- 
 cations outward. 
 
 2. That the shortest, closest bond between the socket and the 
 femur is the remnant of untorn capsule — the ilio-femoral ligament. 
 
 Fig. 85. 
 
 If a dislocation outward and downward between the obturator 
 tendons could be arrested at the instant the head drops and the 
 whole weight of the limb is arrested by the ilio-femoral ligament, 
 the appearance would not be unlike that shown in Fig. 85. But the 
 limb cannot remain in this position ; it is not balanced ; the weight 
 of the leg drags the thigh downward. 
 
 As the knee descends it inclines inward toward the sound limb, 
 because the head and neck, which constitute the short arm of the 
 
100 
 
 INTRODUCTORY STUDY. 
 
 lever, lie outward, and the short fulcrum (the tense and strong ilio- 
 femoral ligament) compels the long arm of the lever to move inward 
 as it descends. 
 
 The full understanding of this inward tendency of the long 
 arm of the lever is of the utmost importance, and it is very easy 
 of comprehension. All depends on the situation of the fulcrum. 
 This lies between the two arms of the lever. If the long arm 
 (knee) would move outward, the short arm (neck and head) must 
 move inward. This is impossible. Under no circumstances can the 
 
 Fig. 86. 
 
 short arm move inward ; the outer wall of the pelvis prevents this. 
 So long as the fulcrum (the halter — the remnant of untorn capsule) 
 is short the knee cannot be moved out. If the neck of the femur 
 {i. e., the short arm of the lever) be broken or the fulcrum (halter) 
 be lengthened (<". e., if the ilio-femoral ligament be torn), then the 
 knee may be moved outward ; but under no circumstances can the 
 short arm of the lever move inward. 
 
 This accounts for the turning in of the knee. But how shall we 
 account for the rotation inward of the axis of the femur ? 
 
PHENOMENA OF DISLOCATIONS. 
 
 101 
 
 The immediate or temporary rotation may be explained from the 
 circumstance that, in all outward dislocations, rotation inward is an 
 efficient factor at the instant the capsule ruptures, and that a sudden 
 increase of rotation inward takes place, when the resistance from the 
 capsule ceases and the head drops outward. 
 
 The persistent inward rotation, however, rests on a very different 
 basis. This is not due to any original force in dislocation, or to any 
 muscular action after it. It can be readily demonstrated upon the 
 cadaver, and it persists during anaesthesia. The mechanism of this 
 is simple. In the accompanying diagrams I represent (Fig. 87) the 
 
 Fig. 87. 
 
 Fig. 88. 
 
 head in its socket and the ilio-femoral lio-ament extending from the 
 lower spine to the base of the neck of the femur. In Fig. 88 the 
 head is dislocated downward and the trochanteric end of the shaft is 
 now suspended upon the ilio-femoral ligament. If the head is to be 
 rotated, it must rotate upon the shaft as a centre, and the shaft must 
 rotate upon the attached capsule. Any such rotation brings the 
 head (see arrow) against the side of the outer wall of the pelvis, 
 which arrests it. The persistency of this sign, viz., rotation inward, 
 for years, or possibly for life, depends upon the persistency of the 
 elements that originally produced it. Time may modify it. Thus 
 the dislocated head may be flattened or the halter (untorn remnant 
 of capsule) lengthened by long-continued use. 
 
 A lad dislocated his hip with all the signs of dislocation outward. 
 
102 
 
 IXTE OD UCTOR Y STUD Y. 
 
 He grew up to be a man, and led an active life. The inversion 
 gradually changed, until late in life he had eversion instead of 
 inversion. 
 
 In Fig. 89 the upward progress of the hip is seen to be arrested 
 by the obturator internus. This is what Bigelow terms " dorsal 
 below the tendon." He lays great stress upon it, and makes a 
 distinct variety of it. "With Morris, I am of the opinion that the 
 eminent author laid too much stress upon this point. 
 
 'BJURHTOR 
 eXTERNUS 
 OBTUff^rO/l 
 
 Right hip dislocated outward. Xeck embraced between the two obturators. Compare Fig. 
 89 with Fig. 14-i. In the left hip, which is in place, the arrow indicates the path of the head 
 taken by the dislocated right hip. 
 
 If the head be arrested by the tendon of this muscle, it will lie 
 nearly opposite the lower half of the great sciatic foramen, and will 
 manifest considerable constraint. In the majority of cases this muscle 
 is torn in the act of dislocation, and yet the signs persist as if the 
 tendon enjoyed its fullest integrity. By a return to Case X. (p. ^^^ 
 
PHENOMENA OF DISL CA TIONS. 103 
 
 it will be seen that the limb was inverted and adducted, that it crossed 
 the symphysis pubis, and was immovably fixed in this position ; and 
 yet, on dissection, the tendon of the obturator internus lay across 
 the head, torn from the muscle of which it is a part. 
 
 I have described the two characteristic signs of outward disloca- 
 tion, viz., rotation inioard and adduction, and have shown that they 
 are both dependent upon the length and position of the fulcrum {i. e., 
 the remnant of untorn capsule). It will not, therefore, surprise the 
 student to learn that with a greater degree or total laceration of 
 this bond of union (in other words, with the removal of the fulcrum) 
 both these signs of dorsal dislocation vrould disappear. 
 
 We may thus have dorsal dislocation ivithout adduction, and dorsal 
 dislocation with e version. 
 
 ("Everted dorsal" will be discussed under Dislocations Practi- 
 cally Considered.) 
 
 Aids to Diagnosis — General Consideration. 
 
 It is obviously impossible for any one to diagnosticate a dislocation 
 of the femur who is not an expert in hip-joint disease and in fracture 
 of the neck. 
 
 I have little to say further than to put the inexperienced upon 
 their guard, lest they be too easily satisfied with first impressions. 
 
 If an experienced surgeon pronounces a fracture of the neck a 
 sprain, fails to recognize a dislocation, or gives an anaesthetic " to 
 set" a case of hip-joint disease, a young and inexperienced one has 
 reason to fear that he may fall into like errors. 
 
 I would guard the reader against some too-prevalent errors : 
 
 First. A snap diagnosis. This the most experienced have too 
 often occasion to regret. Give patient scrutiny to every detail of the 
 history of the accident. Remember that occasionally persons rise 
 up and walk after a dislocation, or after a fracture of the neck of 
 the femur. Patients sometimes purposely mislead by exaggerating 
 former injuries, or a drunken patient may not be believed, and an 
 old disorder may be mistaken for a recent injury. Such a mishap 
 is reported and had a fatal issue. 
 
 In the preliminary examination made with the patient conscious, 
 it would be a wholesome safeguard against error to have him out of 
 bed, standing, and naked. 
 
 Second. The use of an anaesthetic as an aid in diagnosis. Valuable 
 
104 
 
 INTRODUCTORY STUDY. 
 
 as this may be, do not resort to it until a careful study of the case 
 has been made; and during the examination do not forget that 
 serious, if not irremediable, harm may be done to a coxalgic joint or 
 to an impacted fracture of the neck. 
 
 Third. Do not place too high a value upon the data or information 
 that may be obtained from measurements. If you are dealing with 
 a thyroid dislocation, remember that in one instance lengthening, in 
 a second shortening, and in a third no difference, has been recorded. 
 In one instance of dorsal dislocation, Avitli apparently great dis- 
 crepancy in the lengths of the two limbs, the apparently shorter and 
 dislocated limb was, on measurement, found to be longer than its 
 apparently longer fellow. 
 
 Fig. 90. 
 
 Measurements may be deceptive on account of asymmetry of the 
 pelvis. If the head of the femur is ankylosed in an abducted posi- 
 tion, and the two ankles are compared in the horizontal position, 
 there will be marked shortening of the sound limb, or, what amounts 
 to the same thing, marked lengthening of the affected one. It is 
 
- PHENOMENA OF DISLOCATIONS. 
 
 105 
 
 therefore of vital importance that the pelvis and trunk be placed in 
 a normal position, and both limbs examined in corresponding rela- 
 tions to it. The accompanying outline-drawing is from a photograph 
 of a young man supposed to have dislocation of the right femur. A 
 consultation was called to reduce it. The diagnosis was made at a 
 renowned medical school, at which the patient sought relief. For- 
 tunately better counsel prevailed before an anaesthetic was adminis- 
 tered. In the figure the patient is standing on his abducted anky- 
 losed limb, assisted by his adducted limb. When the adducted limb 
 was abducted to correspond with its fellow (i. e., carried out to Z) 
 the asymmetry disappeared. 
 
 Fig. 91. 
 
 XY indicates the level of the sockets when the limbs are placed vertical, 
 inward can be below it ; no dislocation outward above it. 
 
 No dislocation 
 
 I have already stated that if the pelvis is placed on its back 
 the sockets are midway between the level of the pubes and the 
 sacrum. I have also stated that the bony pelvis slopes upward 
 toward the pubes and downward toward the sacrum. This condi- 
 tion can be turned to a valuable diagnostic service, if we examine 
 the limbs flexed upon the pelvis as indicated in the diagram (Fig. 91). 
 By reference to this it will be seen that if the head lies in the socket 
 (J-), or on the bony platform internal to it (B), that it (the head) will 
 
106 
 
 INTR OD UCTOB Y STUD Y. 
 
 have a support, while if it is dislodged outward (C), it will have no 
 bony support, and will hang from the socket by a remnant of capsule. 
 
 Fig. 92. 
 
 Another valuable point to bear in mind is, that the femur (thigh) 
 is about equal in length to the tibia and tarsus (leg and heel). 
 
 Fig. 93. 
 
 P(/B£S 
 
 Hence if the head is in the socket and the knee is vertical, the sole 
 of the foot will swing clear of the floor — i. e., it will be on a level 
 with the socket. The same will also be true if the head be dislo- 
 cated inward (Fig. 92); not so if the head is dislocated outward. 
 Under such circumstances, with the knee vertical, the sole of the 
 
PHENOMENA OF DISLOCATIONS. 107 
 
 foot will touch upon the floor, while the corresponding shortness 
 will show itself hy a comparison of the vertical knees. 
 
 A point which writers lay stress upon is that the great trochanter 
 is much depressed in dislocations inward (i. e., lies abnormally 
 inward toward the socket). While this is true, it is also true that 
 in most forms of dislocation the trochanter lies nearer the socket than 
 the head does. It should be constantly borne in mind that the head 
 is free after dislocation, but that the trochanter is bound by the 
 remnant of untorn capsule to the anterior inferior spine of the 
 ilium. Hence the mere fact of the trochanter lying near the socket 
 is not in itself diagnostic. The position of the trochanter should, 
 however, with the internal condyle, enable the examiner to locate 
 the head. 
 
 Cleaning- Out the Socket. 
 
 In experimental work muscular fibre becomes pulpified by manipu- 
 lation and is readily pushed before the head into the socket. Mus- 
 cular debris and muscular structure may be conveyed from the 
 pubo-ischiatic plane, and parts of the capsule from either plane. I 
 have not infrequently conveyed so much detached muscular material 
 into the socket as to give the restored limb a constrained position, 
 and, were it not that I could see and fully comprehend the difficulty, I 
 might have been led to accept the theory of partial reduction due to 
 some other cause. That which I have observed in my work has been 
 found to be present in deaths from accidents, in which the dislocated 
 head had been reduced, but in which the socket was found to be 
 partly filled with pulp or fragments of muscle. (See p. 67.) 
 
 When I first noticed this eff'ect of manipulation I was inclined to 
 believe there was no remedy, and that, though the head was nomi- 
 nally restored, dislocation would readily recur in some cases, while in 
 all the amount of foreign matter might ultimately lead to mischief. 
 Further consideration suggested that as the difficulty was one of my 
 ow^n creation a partial or complete remedy might be devised. The 
 reader will please note the following points : 
 
 First. The shape of the head and neck. 
 
 Second. The law of attachment of the foreign substance. 
 
 Third. The door of entrance of the foreign substance. 
 
 In the accompanying diagrams I represent the head joining the 
 neck by an abrupt offset in order better to illustrate my meaning. 
 
108 
 
 INTRODUCTORY STUDY. 
 
 By such a shape the edge or corner can be insinuated behind any- 
 thing that has been pushed before the head and which lies within 
 and upon the floor of the socket. Now anything that has been 
 pushed before the head (muscular fibre, parts of muscles, or capsule) 
 
 Fig. 94. 
 
 Fig. 95. 
 
 Fig. 96. 
 
 Capsule everted. 
 
 is attached, if at all, to the pelvis. Nothing attached to the femur 
 is likely to be pushed before it ; such material rather follows, or is 
 dragged after it, in the efforts of manipulation. Hence, if it be any 
 portion of the capsule that is turned in, it is the pelvic ; it cannot 
 be the femoral portion. As it is the pelvic, it can enter only a given 
 distance; it cannot extend indefinitely. Finally, all the foreign 
 substance that enters the socket must enter at its lowest segment. 
 At this part the head escaped, and here usually free access to the 
 socket was established. As the head drove the foreign substance 
 into the socket at its lower section during manipulation, so during 
 manipulation the foreign substance must be evicted by the head 
 and expelled at the door of entrance. It is important to note that 
 the side of the head that drives the capsule before it into the socket 
 cannot be made available to remove it. This must be done by the 
 opposite side, as shown in the diagram. Hence, if the capsule 
 
 Fig. 97. 
 
 Fig. 98. 
 
 has been pushed into the socket from the dorsal aspect, the first 
 step is to flex and abduct ; while, if the entrance has been made 
 from the thyroid aspect, the femur must be flexed and adducted to 
 accomplish the same end. After engaging the inverted capsule the 
 
ROTATION AND CIRCUMDUCTION. 109 
 
 femur should be rotated inward to tighten the Y-ligament and drive 
 the head down into the socket, while at the same time the knee is 
 raised and the foreign matter is removed from the socket. 
 
 The success of the manoeuvre Avill be apparent by the free and 
 unembarrassed motion of the femur. I have in experimental work 
 repeatedly pushed so much muscular fibre or capsule^ before the head 
 as to prevent extension within twenty-five degrees of the normal, and 
 to check adduction and extension. In some cases the infrincrement 
 was less marked, but in every case the socket was cleaned out, 
 and the full extent of motion was re-established by the method 
 just described. From an experimental standpoint only I would 
 urge upon every one the importance of testing the degree of extension 
 and adduction after every reduction, 
 
 Bigelow, after a reduction, found that the femur did not resume 
 normal extension, but remained semiflexed and abducted. He ac- 
 cordingly cut subcutaneously some tense fibres of the tensor vaginae 
 femoris, which only partially relieved the deformity. The subse- 
 quent history of the case was to the effect that the patient never 
 recovered the use of the joint. In this case the symptoms point to 
 a foreign substance within the socket. 
 
 ROTATION AND CIRCUMDUCTION: THEIR DEPORT- 
 MENT BEFORE AND AFTER DISLOCATION. 
 
 In rotation the entire shaft of the femur turns on its long axis 
 similarly to the motion of a gimlet. 
 
 In circumduction the knee moves in a circle, of which the head of 
 the femur is the centre. 
 
 Observation. It is possible to rotate without circumduction ; to 
 circumduct without rotation ; also to combine both movements in a 
 single manipulation. 
 
 Rotation : The term is derived from rota, a wheel. The spokes 
 of a wheel rotate about the axle, which is at rio-ht ansjles to them. 
 In a like sense Bigelow speaks of the bent leg as the spoke of a 
 wheel whose axle is the femur. Strictly speaking, the axis of motion 
 
 1 When I have reduced the head into a hooded socket (Figs. 42 and 45, Z) I have — during 
 efforts to get the rim of the head beyond the borders of the hood — experienced a sudden re- 
 lease which told me that the head was now at the bottom of the socket and beyond the 
 hood. I could then turn out the capsule and exult in an empty socket and freest motion, 
 and this, of course, entirely through manipulation. 
 
110 I^'TB OD UCTOR Y ST UD Y. 
 
 does not lie in the shaft, because the femur is not a straight bone. 
 The true axis of motion (Fig. 99, A B) is an imaginary line passing 
 through the knee and the head of the femur. This is not a foolish 
 refinement ; it is a fact of practical value. By a glance at the figui'e 
 it will be seen that the head being in the true axis, A B, does not 
 perceptibly move, but that the great trochanter, lying outside the 
 true axis, moves upon the arc of a circle whose radius equals in length 
 the length of the neck of the femur. This suggests a useful study. 
 Every student should familiarize himself Avith the amount of normal 
 movement of the trochanter in rotation, so that he may be able to 
 detect any defect in the shortened or impacted neck of the broken 
 femur or the restricted motion of an inflamed joint. 
 
 Rotation is of two kinds : internal and external. If the student 
 stands erect, he can rotate the femur inward by turning the toes 
 inward, and rotate outward by a contrary movement. Keeping 
 these two motions distinctly in mind, let him flex the leg on the 
 thigh to a right angle, and now, if he wishes to rotate imvard, he 
 must turn the foot and ankle as a crank outward ; if he wishes to 
 rotate outward he must carry the foot and ankle inward. 
 
 In the reduction of dislocations by manipulation the patient lies 
 on his back, the thigh is placed perpendicular, and the leg at right 
 angles to it. Now, remember that the terms "rotation inward" 
 and "rotation outward" have no reference to the position of the 
 head, but simply to the movement just described, and that, no matter 
 
ROTATION AND CIRCUMDUCTION. 
 
 Ill 
 
 where the head is, rotation inward requires the ankle of the bent 
 leg as a crank to be drawn outward, while rotation outward requires 
 the ankle of the bent leg to be carried inward. 
 
 After dislocation the head is no longer the pivotal centre. Now 
 the head, freed from all attachments, moves in the circumference of 
 a circle, of which the neck is the radius. The constraint (or ful- 
 crum) on which rotation depends is furnished by the untorn portion 
 of the capsule. The trochanter, bound to the inferior spine over 
 the socket by the ilio-femoral ligament, ceases to have its normal 
 range of motion, and may, without much inaccuracy, be regarded as 
 the pivot of motion. Now, though not strictly true, it may be said 
 that the true axis of motion runs through the shaft of the femur. 
 
 Fig. 100. 
 A' 
 
 Thus things are reversed. Before dislocation the trochanter rotated 
 about the head ; after dislocation the head rotates around the tro- 
 chanter. One point, which will bear many repetitions, is that, if 
 after dislocation the head revolves about the trochanter, the very 
 motion of rotation will bring the head or neck against any obstacle 
 that is close to the socket. 
 
 Circumduction means to lead around. Circumduction can be prac- 
 tised on the flexed or extended limb. As employed in attempts at re- 
 duction, the patient lying on his back, the thigh is flexed to a perpen- 
 dicular, while the leg is used at a right angle to it. (Fig. 101.) In the 
 normal joint only the head lies in the axis of motion, while the knee can 
 be made to sweep around in circles of gradually increasing diameter. 
 
112 
 
 INTRODUCTORY STUDY. 
 
 Circumduction may be either inward or outward, and, simple as it 
 may seem, it is often difficult to comprehend what an author means 
 when he says " circumduct inward " "or circumduct outward.'' If the 
 knee is abducted at right angles to the pelvis, circumduction inward 
 may mean upward and inward or downward and inward. If the 
 knee lies over the pubes, circumduction outward may be upward and 
 outward or downward and outward. As it is impossible to give 
 concise directions that cannot be misunderstood, surgeons should 
 always describe fully the manoeuvre, preferring the charge of pro- 
 lixity to that of ambiguity. 
 
 Fig. 101. 
 
 After dislocation a constraining force is pre.sent when rotation 
 and circumduction are employed, and this force is the untorn rem- 
 nant of capsule ; but the effect is widely diverse in the one from 
 the other. In rotation the ligament is wound up, and necessarily 
 draws the head nearer the socket. Very unlike this in princi- 
 ple is circumduction. In the latter, if the knee is moved in a 
 small circle, the head will move in a small circle ; but if the knee 
 
THE NOMENCLATURE OF DISLOCATIONS OF THE HIP. 113 
 
 be made to take a large sweep, then the head will take a cor- 
 respondingly large sweep, since it (the head) has a radius of the 
 entire length of the ilio-femoral ligament plus the length of the neck 
 of the femur. Such a sweep is most unnecessary and hazardous. 
 
 Fig. 102. 
 
 Unnecessary, because it drives the head away from, rather than 
 approximates it to, the socket. Hazardous, for it endangers the 
 sciatic nerve and the femoral vessels. 
 
 THE XOMEXCLATURE OF DISLOCATIOXS OF THE HIP. 
 
 There can be but one reason for assigning a name to a disloca- 
 tion, and that is, that it furnishes the key to its restoration. 
 
 Surgeons formerly believed that all parts of the capsule were 
 equally vulnerable, and that the head passed direct to its destina- 
 tion : hence as many varieties of dislocations as there are points to 
 the compass. 
 
 Formerly it was universally believed that in the muscles lay the 
 principal obstacle to replacement: hence depressants, depletives, and 
 powerful mechanical appliances. 
 
 8 
 
114 
 
 INTRODUCTORY STUDY. 
 
 To-day the surgeon believes 
 
 That the muscles are passive and play no active role as obstacles 
 to reduction ; 
 
 That after dislocation a portion of the capsule still connects the 
 femur with the socket ; 
 
 That all dislocations must be reduced with a distinct recognition 
 of the surviving portion of the capsule ; 
 
 And that most dislocations can be restored by unaided manual 
 effort. 
 
 The radical universal change in the method of reduction, logically 
 interpreted, implies a radical universal change of theory in the mech- 
 anism of dislocations. Whoever flexes a femur as the initial step 
 in reduction declares by so doing his abandonment of former theories 
 and his acceptance of others diametrically opposite. Hence the 
 question irresistibly follows. Why persist in a nomenclature that was 
 based on ignorance, has been proven to be false, and whose retention 
 can lead only to bewilderment and confusion ? Why should sur- 
 geons retain thyroid, perineal, pubic, and subspinous varieties of dis- 
 location of the hip when one name would do for all, and the same 
 rule for their reduction ? Physicians may with equal propriety 
 describe facial, colic, thoracic, and abdominal measles. 
 
 Fig. 103. 
 
 Fig. 104. 
 
 Fig. 105. 
 
 Thyroid. (Bigelow.) 
 
 Pubic. (Bigelow. 
 
 Subspinous. (Bigelow.) 
 
 When Bigelow illustrated his memorable monograph upon The 
 Hip he dissected a part, and, placing it in one position, his artist 
 photographed a thyroid ; then shifting it a little, the artist photo- 
 
IHE NOMENCLATURE OF DISLOCATIONS OF THE HIP. 115 
 
 graphed a pubic ; and then, by a further slight change, the prepara- 
 tion was posed for a subspinous. Why, while the author was arguing 
 for the supremacy of his Y-ligament ; why, when he was so elo- 
 quently demonstrating that the various signs of dislocation were all 
 dependent upon the remnant of capsule that still bound the neck of 
 the femur to the pelvis ; why, I ask, did he not with one stroke of 
 his trenchant pen blot out the whole list of subtle and meaningless 
 refinements, and unburden the memory of the student as he had 
 unburdened the closets of the surgeon and banished the cogwheels, 
 screws, ropes, and pulleys from the domain of surgery ? Why ? 
 There is but one answer, and that is, that it never occurred to him 
 
 Fig. 106. 
 
 Fig. 107. 
 
 Head in socket. (Bigelow.) 
 
 Dorsum ilii. Mortise rotated 
 inward 90°. (Bigelow.) 
 
 that variety in dislocations was brought about in the precise manner 
 in which lie was illustrating it ; that every variety of dislocation 
 inward must have been primarily into the thyroid depression. In 
 the formation of a pubic, how could the head reach this spot without 
 first being for an instant at least a thyroid ; and how, in the mechan- 
 ism of reduction, can a pubic be restored save through the gateway 
 of the thyroid depression ? Again, I ask in all candor, after the 
 specimen (Fig. 106) was placed in position to show normal relations, 
 was it converted into the high dorsal, as represented in Fig. 107, 
 hy an upivard thrust, even though every part of the capsule had 
 been removed except the Y-ligament? or was the femur flexed and 
 
116 INTR OD UOTOR Y STUB Y. 
 
 the head dislodged at a low point, and a low dorsal converted into a 
 high one ? The latter unquestionably. 
 
 If it be urged that what I am arguing for is a dissecting-room 
 theory, my answer is that it is the very dissecting-room theory that 
 has revolutionized the whole subject of reduction of dislocations ; but 
 when I turn upon my objector and ask him what his theory of direct 
 displacement is founded upon, he can only reply, theory ; and when 
 I ask what the logical result of such a theory has been, he can only 
 reply by pointing to a most humiliating chapter in the history of 
 modern surgery. 
 
 Were I to suggest a nomenclature for dislocations of the hip I 
 would base my action upon the firm conviction that all conceivable 
 dislocations are primarily either inward or outward, and that from 
 these primary positions the head may be secondarily shifted to any 
 point about the socket within reach of the remnant of untorn capsule 
 that binds the shaft to the rim above the socket. The primary 
 inward I would denominate thyroid ; the primary outward, dorsal. 
 My classification then would be : 
 
 Low thyroid, ^ All present the same general charac- 
 Mid. thyroid, V teristics, viz., abduction and rotation 
 High thyroid. J outward. 
 
 Reversed thyroid (Fig. 84). 
 
 Low dorsal, ^ All present the same general charac- 
 Mid. dorsal, V teristics, viz., adduction and rotation 
 High dorsal. J inward. 
 
 Reversed dorsal (Fig. 128). 
 
 I would reject the names "sciatic," "spinous," "interspinous," 
 and " subspinous," as I do not think they stand for distinct varieties 
 of dislocations. As the head can closely approximate positions de- 
 scribed by authors as "subspinous," "interspinous," or "spinous " 
 from either plane, if the names are to be retained, I would suggest 
 the prefix thyro or dorso. AVe would then have thyro-spinous, etc., 
 if the head reached the position from the inner plane, and dorso- 
 spinous, etc., if from the outer plane. By such terms the mechanism 
 of dislocation, diagnosis, and method of restoration would become 
 inseparably associated with the injuries. Preferably I would say 
 reversed thyroid and reversed dorsal, as given in the classification. 
 
PART II. 
 
 REDUCTION OF DISLOCATIONS 
 
 BT 
 
 MANIPULATION. 
 
 METHODS AND OBSTACLES CRITICALLY EXAMINED. 
 
REDUCTION OF DISLOCATIONS 
 
 BY 
 
 MANIPULATION. 
 
 That which follows upon the reduction of dislocations is based 
 wholly upon the assumption that all dislocations may be classified 
 under two general heads, viz., Internal and External. If the reader 
 is not willing to accept this statement as a matter oi fact, I ask him 
 to do so on the ground of the strongest -pr oh ability . 
 
 In the mechanism of all dislocations three distinct steps must be 
 recognized : ^ 
 
 1. The laceration of the capsule ; 
 
 2. The escape of the head from the confines of the socket ; 
 
 3. The shifting of the head from the position it occupied at the 
 instant of escape to its final destination. 
 
 It is important that these steps be accepted as final ; that they be 
 regarded as axioms, for upon them I base the time-honored proposi- 
 tion that every dislocation must he restored through steps in the 
 reverse order of its displacement. If there is a first, second, and 
 third step in the order of displacement, then, in the order of restora- 
 tion, the first step retraced should be the last step of displacement, 
 the second step retraced should be the second step of displacement, 
 and the third and last step to be retraced should be the first or 
 initiatory step of displacement. I shall begin with 
 
 " DISLOCATION INWAKD. 
 
 Reduction by traction — direct method — Method I. 
 
 First step. Retrace the last step in the order of displacement ; 
 locate the head and hring it hack to the position it occupied at the 
 instant of its escape from the socket. 
 
 1 For the demonstratiou of these steps, see p. 80. 
 
120 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 This will usually be easily accomplished. The flexion, abduction, 
 and rotation outward may all be characteristically present, indicating 
 that the head lies in the thyroid depression, with the great trochanter 
 in the region of the socket. (Fig. 78, p. 92.) Should the head lie upon 
 or above the ramus of the pubes, upon the pubes, or in the perineum, 
 it must be apparent that traction in the long axis of the femur and 
 directed toward the socket is indicated as the proper means for the 
 retracement of the last step of displacement. 
 
 But if the last step of displacement was accomplished by external 
 rotation, with extension of the femur, the unspent force continuing 
 after displacement will be controlled and guided by the remnant of 
 capsule that has escaped laceration. It is thus possible to have 
 several distinct degrees of rotation that might give rise to as many 
 named varieties, but all be the same in principle. From a disloca- 
 tion inward with scarcely any noticeable increase of rotation outward, 
 the rotation outward may be so great that the toes point backward^ 
 and the inside of the foot look outward. From the usual position 
 in which the ilio-femoral ligament lies upon the anterior surface of 
 the neck (Fig. 108) it may be so rotated as to lie behind it (Fig. 1 10). 
 It must be plain, therefore, that in order to retrace the last step 
 of displacement the operator should first distinctly locate the head, 
 notice the degree of constraint, the direction of the long axis of the 
 
 ' I. K., a flabby-looking man, rather fat, was admitted into Guy's Hospital, December 10, 
 1835. About one hour before his admission he was helping to carry a heavy crate down 
 stairs, when his foot slipped and he fell backward, receiving the weight on the groin. 
 The following are the appearances which the limb presented as he lay extended on his 
 back : The left leg was shortened at least two inches and the foot excessively everted so as 
 almost to give the toes a direction backward. [Had the patient been erect the turning back- 
 ward would not have been interfered with. — Author.] The injured limb had a tendency 
 to cross the sound one, so as to throw the heel of the former over the instep of the latter ; 
 nevertheless when the limbs were placed side by side they remained in that position. 
 The leg was susceptible of all the natural motions to some extent with the exception of 
 rotation, but the man complained of great pain while under examination. The projection 
 of the trochanter major was entirely lost, whilst the luxated head of the bone could be felt 
 under Poupart's ligament, just below and to thp inner side of the anterior superior spinous 
 process of the ilium, and apparently lying between the anterior inferior spinous process of 
 the ihura and the junction of that bone with the pubes. It thus nested on the brim of the 
 pelvis and projected upward to the abdomen. The femoral artery was not displaced, but 
 could be traced on the inner side of the dislocated bone. Reduction : Extension was made 
 downward by means of a jack-towel about the knee by three students, while Mr. Morgan, 
 sitting in the bed, made counter-extension with his foot in the perineum. After three min- 
 utes the man was told to raise his shoulders from the bed, at which time forcible rotation 
 inward accomplished the reduction with a snap. — Cooj)er on Dislocjitions, p. 124. 
 
 Bigelow quotes this case under everted dorsal.' but, I think, incorrectly. The signs are 
 those of a reversed thyroid, while the reduction by extension and rotation inward could not 
 reduce an everted dorsal, but would have been the correct manipulation for a shifted 
 thyroid. 
 
 1 The Hip, by Henry J. Bigelow. y. 101. 
 
DISLOCATION INWARD. 
 
 121 
 
 shaft, the degree of rotation as indicated in the foot. In one instance 
 simple flexion will retrace the last step, in another traction in the 
 long axis of the shaft, while if the displacement in the last step has 
 
 Fig. 108. 
 
 Fig. 109, 
 
 Fig. 110. 
 
 Y-ligament in front 
 of the neck. 
 
 Y-ligament to the outer 
 side of the neck. 
 
 Y-ligament behind 
 the neck. 
 
 taken place through adduction, extension, and external rotation, 
 then flexion, abduction, and internal rotation would conduct the 
 head to the position it occupied at the completion of the second 
 step of displacement. 
 
 Fig. 111. 
 
 Fig. 112. 
 
 Having retraced the last step of dislocation, viz., the shiftino- of 
 the head to a remote position, the next question to ask is, In what 
 'position luas the shaft the instant the head left the socket ? Answer. 
 The shaft was in a state of abduction at right angles to the trunk ; 
 and this is true, whether an instant later it was succeeded bv ex- 
 
122 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 ternal rotation or not. To produce a dislocation inward the capsule 
 must be put upon the stretch by means of abduction, and when, an 
 instant later, the head has sprung from the socket and lies in the 
 thyroid depression, the shaft is still in a state of abduction. It 
 must be plain, therefore, that as the head took the direction from 
 without inward while the femur was abducted, the thigh should be 
 drawn outward in the long axis of the shaft to retrace the second 
 step of dislocation. In retracing this step it must be borne in 
 
 Fig. 113. 
 
 mind that the trochanter or head may be caught upon some of the 
 bony irregularities of the socket or otherwise entangled. Hence, 
 in making traction outward accompany it, if the head or shaft 
 seems caught, with collateral movements, as slight rotation or rock- 
 ing — i, e., be sure that with traction the head leaves the thyroid 
 depression and takes its position over or near the socket. 
 
 The second step has been retraced — i. e., the head has been placed 
 over the socket. Query. Why will not simple traction outward 
 place the head in the socket ? Answer. The effect of traction out- 
 ward is to make tense the remnant of untorn capsule ; but when this 
 is tense through traction outward, the shaft and the two attachments 
 of the remnant are in the same line, and as the head stands oflF from 
 the shaft at an angle of 130°, it is plain that traction outward can 
 only bring the head to a position over the socket, but cannot possi- 
 bly replace it in the socket. To do this a new element must be 
 invoked, viz., direct pressure. But direct pressure alone is not the 
 reverse of the initial step of displacement, in that the shaft was 
 descending as the head burst through the capsule ; hence, to accom- 
 
DISLOCATION INWARD. 
 
 123 
 
 plish the last step, elevate the knee, while an assistant makes direct 
 pressure upon the head. (Fig. 115.) Query. Why will not simply 
 
 Fig. 114. 
 
 Fig. 115. 
 
 elevating the knee replace the head ? Answer. Because it is totally 
 unlike the first steps of displacement. In this, as the shaft descended, 
 the neck of the femur pressing on the rim of the socket (Fig. 116) 
 
 Fig. 116. 
 
 had a bony fulcrum, which forced the head out of the socket. In the 
 act of replacement the simple act of elevating the knee encounters no 
 corresponding fulcrum to force the head downward as the knee rises. 
 The necessary traction to bring the head over the socket has also com- 
 pelled the head to rise above the level of the socket, and as traction, 
 to hold the head over the socket, must be accompanied with the 
 elevation of the knee, we are compelled to invoke a new element, 
 viz., direct pressure to replace the head. 
 
 For the replacement of the head by direct steps I oifer the follow- 
 ing directions : 
 
 1. Flex and abduct the femur. 
 
124 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 2. Make traction outward. 
 
 3. Fix the head by digital pressure and adduct. 
 
 The medical profession has long practised with variable success 
 methods somewhat resembling that which has just been described. 
 Authors recommend : 
 
 1. To flex and adduct the thigh. 
 
 2. To make perpendicular traction upon the knee, and follow 
 traction by adduction. 
 
 3. To make traction with adduction, using the foot in the groin 
 as a fulcrum. 
 
 4. To place the patient astride a bed-post, using it as a fulcrum 
 while extension and adduction are made. 
 
 5. To make traction and adduction while an assistant with a fillet 
 passed between the thighs makes traction obliquely upward and 
 outward. 
 
 All of these have been recommended, but success in their employ- 
 ment does not depend upon the scientific application of the principle. 
 In all adduction is made a prominent feature ; but 
 adduction, if attempted too early, defeats its own 
 end. This can best be illustrated by means of a 
 diagram. In this, Fig. 117, adduction inward 
 makes tense the remnant of untorn capsule, which 
 acts as a fulcrum, about which both arms of the 
 lever revolve. As the long arm is carried inward 
 the short arm, head, and neck must move outward. 
 This is impossible under the circumstances, be- 
 cause the tense ligament drives the head against 
 the rim or into the thyroid depression. From 
 this it will be seen that the obstacle in this 
 case is created by the operator, who adducts 
 before he has made traction outward. It illustrates strikingly the 
 folly of violence or brute force. 
 
 I have entered into minute details in describing the direct method 
 of reduction, because it is the only method in which every step is 
 retraced. I may be going too far when I say that it is the safest, 
 surest, and only rational method. By means of it in one of my 
 experimental studies I reduced the head readily many times in suc- 
 cession from a dislocation inward, but when I resorted to rotation 
 I encountered obstacles that could only be overcome by further 
 
DISLOCATION INWARD. 125 
 
 laceration of the rent in the capsule — a most unnecessary expedient 
 when replacement was jjossible tvithout it, and a most dangerous 
 expedient token by enlargement of the rent through circumduction 
 and rotation the capsule is dissected from the rent in the muscles and 
 placed in such a condition that it is possible to drive some portion 
 of it before the head into the socket, and render a clean and abso- 
 lutely perfect reduction impossible. 
 
 Indirect Method — Reduction by Rotation. 
 
 The method just described I designate the direct method. There 
 is another in which rotation forms a prominent feature, and which 
 may properly be denominated the indirect method. Rotation may 
 or may not be associated with abduction during the first and second 
 steps of dislocation inward. The rotation recommended to effect 
 restoration is not employed to make the head retrace its steps on 
 the principle that it is the reverse of the agency that caused the 
 displacement. Its efficacy is entirely foreign to the laws of dis- 
 location, and rests for its means of success upon the utilization of 
 the Y-ligament, i. e., the remnant of untorn capsule. By the 
 proper employment of the femur as a lever this ligament becomes 
 a fulcrum and can be often used to great advantage. 
 
 We employ two varieties of rotation, viz., external and internal. 
 
 Reduction by means of external rotation — Method II. 
 
 First step. Flex the thigh, but not to a perpendicular. 
 
 Second step. Adduct, carrying the knee obliquely inward and 
 downward. 
 
 Third step. Rotate outward. 
 
 The object of the fi.rst step is to bring the head into the position 
 it occupied the instant it passed the confines of the socket. If the 
 head lies upon the pubes, in the perineum or above the socket, as 
 pointed out in the first method, then simple flexion will not effect 
 retracement, but other means must be employed to do so. Suffice it 
 to say that no second step is to be considered until the first step is 
 taken. In flexing the femur the operator is cautioned not to flex to 
 a perpendicular. The reason for the caution is that such a degree 
 of flexion tends to carry the head away from the socket and cause it 
 to sink deeper into the thyroid depression. 
 
 We are now ready for the second step, viz., "adduct and carry 
 the knee obliquely inward and downward.". Observe the position 
 
126 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 of the head : it lies below and internal to the socket. The remnant 
 of untorn capsule, which is to conduct the head back home, is at- 
 tached above the socket. When the knee is vertical or slightly 
 abducted this remnant is relaxed, but the instant the knee is 
 adducted and directed obliquely inward and downward the rem- 
 nant of capsule becomes tense and inclines to draw the head upward 
 and outward. To facilitate this, the third manoeuvre in the method 
 is resorted to — viz., rotation outward, i. e., turning the ankle of the 
 bent leg inward and upward. (Fig. 118.) 
 
 Fig. 118. 
 
 The head of the femur has been brought to the border of the socket ; the femur is abducted, 
 but not so much as is represented in the figure. The femur must be rotated outward by 
 means of the bent leg, which is turned inward as a crank; this makes taut the outer border 
 of the remnant of capsule, /. e., the outer band of the Y-ligament. 
 
 The operator must not regard adduction, extension, and rotation 
 outward as distinct and separable movements ; on the contrary, it is 
 the happy blending of the three that invites success. With the patient 
 lying flat on the floor and the femur flexed, the operator places his 
 bent elbow beneath the flexed knee and grasps the ankle with the 
 unoccupied hand ; he then extends,^ adducts, and rotates outward 
 ({. e., carries the bent leg inward), the combined movements some- 
 ■ times advantageously accompanied with a gentle spring. I have em- 
 
 1 Extension is the reverse of flexion, and can be accomplished with the bent elbow beneath 
 the knee. By this means traction in the long axis of the shaft can be combined with exten- 
 sion, and is never to be omitted. 
 
DISLOCATION INWARD. 
 
 127 
 
 ployed this method with gratifying success, both in experimental and 
 clinical work. In the case of a young adult who, from faulty diag- 
 nosis, had an unreduced thyroid dislocation, associated with fracture 
 in the upper third of the femur, the head was easily restored eight 
 weeks after the original accident by the method described. 
 
 Obstacles. In dislocations inward the pubo-femoral ligament (Fig. 
 119) often escapes uninjured. Now if the head is to be returned, it 
 
 Fig. 119. 
 
 Dislocation into the thyroid depression. The great trochanter rests against— i. e., is caught 
 upon— the rim of the socket. The head is partly covered by the pubo-femoral ligament. 
 
 must pass beneath this band. If adduction be made too obliquely 
 downward and inward, or if external rotation be too early attempted, 
 the head will strike against this band and be prevented from enter- 
 ing the socket, or the head may pass above the band and ascend 
 toward the horizontal ramus of the pubes. To avoid such a con- 
 tingency the knee should be elevated approaching the perpendicular, 
 and by combining adduction with rotation the reduction may often be 
 readily accomplished. The degree of adduction will vary with the 
 length and amount of the remnant of capsule. Whatever be the 
 nature of the obstacle it should not be essayed by violence. Vio- 
 
128 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 lence masks the nature and position of the obstacle which gentler 
 measures may detect and skill overcome. 
 
 Reduction by Means of Rotation Inward — Method III. Bige- 
 low puts this manoeuvre at the head of his ten rules. His directions 
 are : " Flex the limb toward the perpendicular and abduct a little 
 to disengage it from the bone, then rotate the thigh strongly inward, 
 adducting it and carrying the knee to the floor. The trochanter is 
 then fixed by the Y-ligament and the obturator muscle, which serve as 
 a fulcrum. While these are wound up and shortened by rotation the 
 descending knee pries the head upward and outward to the socket."' 
 Bigelow makes no reference to clinical support of this method, and 
 I am inclined to believe that his confidence in it rests entirely upon 
 experimental work. I have been delighted with it in certain ex- 
 perimental cases and disappointed with it in others. I have failed 
 with it in clinical trials. For the purpose of a critical study I shall 
 divide the method into three steps : 
 
 JRule. — First step. Flex the thigh, but not to a perpendicular. 
 
 Second step. Rotate strongly inward. 
 
 Third step. Adduct and carry knee to the floor. 
 
 The first step is identical with the preceding and needs no added 
 comment. 
 
 Second step — i. e., "rotate strongly inward." By this manoeuvre 
 the head is carried to the deepest part of the thyroid depression. 
 Now just at the instant when the head is fixed (i. e., wound up by 
 the tense ligament) Bigelow directs that the knee be suddenly and 
 strongly adducted with a view to prying the head over the acetab- 
 ular rim into the socket. In executing it the operator must not 
 separate " rotation inward " from "adduction and prying downward 
 and inward." The three distinct manoeuvres must be combined in a 
 single eflfort : with one hand^ grasping and controlling the knee, the 
 
 1 Henry J. Bigelow : The Hip, p. 77. 
 
 Sir Astley Cooper, in dislocations inward, combined rotation inward with the pulleys. 
 Bramsby Cooper, his nephew, fully believing that the only resistance to reduction lay in the 
 muscles, thus explain.^ the advantage of rotation inward : " Rotation inward elevates the 
 trochanter major and thereby places it in the most favorable position for the gluteus meJius 
 and minimus to draw the head of the bone toward the acetabulum." This statement ap- 
 pears in Guy's Hosp. Rep., 1X36, vol. i., just twelve years before Morton, by the introduction 
 of anaesthesia, struck the death-blow to the theory of muscular assistance or resistance. 
 
 - I feel that I cannot too often alluae to the danger of grasping and controlling the knee 
 Avith the hand. An insensible or voluntary pressure upon the knee accompanies this con- 
 trol, which drives the head downward upon anything with which it comes in contact. The 
 safest control is through traction with the bent elbow beneath the bent knee. 
 
DISLOCATION INWARD. 
 
 129 
 
 other grasping the ankle, the knee is directed inward and downward, 
 while the ankle is turned outward and upward, the combined action 
 resembling in some measure the movement of boring with an auger, 
 in which both hands seem to move in opposite directions. 
 
 There are objections to this method which the operator should 
 understand, for if properly appreciated it will not be persevered in 
 beyond a fair trial. The rotation is inivard. The object of this is 
 to bring the head directly beneath the fulcrum, viz., the Y-ligament,^ 
 
 Fig. 120. 
 
 Femur adducted': rotation of the femur inward, accomplished by turning the bent leg, 
 as a crank, outward. Notice that the socket, head, capsule, and shaft lie in the same 
 direction. 
 
 SO that when the knee is adducted and pried inward and downward 
 the head will be pried upward and outward. Note, however, that 
 while rotation inward brings the head beneath the fulcrum, it also 
 brings the head into the deepest part of the thyroid depression, a 
 condition at times very obstructive and unfavorable to reduction. 
 
 In some experimental work I have met with obstacles which could 
 be overcome, in others I have failed, and I am inclined to the belief 
 that the acetabular rim is more prominent and insurmountable in 
 some cases than in others. When in some cases I have used force, 
 as Bigelow directs, I have brought the head so strongly against the 
 rim of the acetabulum as to denude it (the rim) of periosteum and 
 tear the cotyloid cartilage from its attachment ; and when I have 
 persevered I have felt the head grate upon the denuded rim, and 
 upon examination have found the cartilaginous covering of the head 
 
 1 See p. 130, foot-note. 
 9 
 
130 RED UCTION OF DISL CA TIONS B Y MA NIP ULA TION. 
 
 deeply scored when it had been forced against the naked rim of the 
 socket. 
 
 A second defect in this method is that rotation inward often con- 
 veys the head outward, thus suddenly and unintentionally converting 
 a thyroid into a dorsal dislocation. It is to avoid this that Bigelow 
 recommends "strong rotation inward," holding the knee and ankle 
 well under command, lest it dodge at the critical moment. That it 
 is likely to do so may be learned from the fact that the head is round 
 and covered with a smooth and slippery cartilage, while the periphery 
 of the socket is crowning and not calculated to give a very stable 
 support to anything pressed against it. Indeed, the probability of 
 the head going into the socket is far less than that it slip to the right 
 or left of it. 
 
 I have failed clinically in two instances by this method, and 
 though in each I failed with other methods, the fact of failure is an 
 argument that it does not possess special superiority. Since the 
 memorable treatise of BigeloAv, in 1869, this method has had a fair 
 and impartial trial, and the verdict of the profession is in favor of 
 rotation outward, i. e., the first method of rotation. 
 
 In the opening of this chapter I designated the first method by 
 
 Fig. 121.1 Fig. 122. 
 
 Figs. 121 and 122, purely diagrammatic, introduced to illustrate the lever and fulcrum (sling), 
 and how in one case (Fig. 122) an obstacle may be overstepped by lifting the lever. 
 
 > While the capsule acts as a fulcrum, it is not in this case a pure one ; its function is rather 
 that of a sling. If the sling is short, depression of the lever will drive it strongly against the 
 obstruction. (Fig. 121.) I would therefore suggest that the operator, when he gets the femur 
 in the position he wishes by tirst flexing, then rotating inward to bring the head obliquely 
 below the socket, and, lastly, adducting a little to feel the tension of the sling ; that instead 
 of sudden and powerful depre.ssion of the lever he substitute a sudden jerk upward (Fig. 
 122) and inward to lift the head in a measure over the rim, and combine the jerking with 
 sudden depression. 
 
DISLOCATION OUTWARD. 131 
 
 traction as the direct^ and the following by rotation as the indirect, 
 method. Of the first I said that the steps in reduction were the 
 literal retracement of the steps of dislocation. But I cannot say the 
 same thing of the methods by rotation. In these the Y-ligament 
 acts as a fulcrum, but the fulcrum, instead of lying beneath the 
 lever, is attached above it, and may be said to suspend the lever ; 
 hence when the end of the long arm descends the end of the short 
 arm is, as Bigelow styles it, pried out of the thyroid depression, over 
 the rim, and into the socket. 
 
 If it be considered a cardinal principle in all efforts at reduction 
 to place the shaft of the femur in the respective stages of displace- 
 ment, then the first method (viz., by traction) meets every require- 
 ment, while that by rotation violates them. In the method by 
 rotation the Y-ligament as an agency that had no part in the act 
 of dislocation inward is invoked to participate in the reduction, and 
 that through adduction inward and downward, a force in no Avay 
 associated in the mechanism of this variety of dislocation. 
 
 DISLOCATION^ OUTWAKD. 
 
 First step. Retrace the last step in the order of displacement. 
 Locate the head and bring it back to the position it occupied at the 
 terminatio7i of the second step in displacement. 
 
 This may be a very simple thing. The dislocating energy may 
 have been spent in the second stage and the displacement in the 
 third stage may be simply due to the unsupported weight of the leg, 
 which drags the femur, and it inclines downward and inward. (Fig. 
 123.) In such a case the operator has simply to elevate the knee 
 to a perpendicular, when it will reassume the position (see Fig. 85) 
 it occupied at the completion of the second step of dislocation. 
 In most instances, either because the dislocating energy is unex- 
 pended after rupture of the capsule, or to exti'aneous causes, such 
 as transportation or manipulation, the head is displaced to a position 
 remote from its place of exit. It is important then to locate it, /. e., 
 study how it reached its destination and make it retrace its own path. 
 
 I have repeatedly stated that great constraint always betokens a 
 minimum degree of laceration of capsule, and the reverse of this is 
 equally true, that a slight degree of constraint may be regarded as 
 
132 RED UCTIOX OF DISLOCA TIONS B Y MANIP ULA TION. 
 
 the exponent of extensive laceration of capsule. Note especially 
 that the untorn portion of capsule that acts as the halter of the dis- 
 located head and neck lies on the inner side. This remnant of cap- 
 sule — the ilio-femoral ligament, the Y-ligament of Bigelow — is 
 attached to the lower spine above the socket by a single insertion ; 
 but below its fibres separate into two bundles, which Bigelow desig- 
 nates the outer and inner bands or branches. It stands to reason, 
 
 Fig. 123. 
 
 therefore, that the upper spinous attachments must be as strong as 
 the two combined lower attachments, and that it would require 
 double the force to rupture the upper that would be required to rup- 
 ture either of the lower attachments, providing the latter are of 
 equal size and length. They are not however of equal length, and 
 after dislocation a secondary force may act alone upon the shorter 
 outer portion, lacerating some of its fibres or completely tearing it 
 from its attachment. The same is true of muscles. If the head has 
 escaped Avith a minimum degree of laceration, the constraint will be 
 marked, but when the obturator internus and pyriformis are fully 
 torn the restraint will be greatly diminished. 
 
DISLOCATION OUTWARD. 
 
 133 
 
 The head may then lie upon the dorsum ilii, the whole limb may 
 be extended, suffer itself to be rotated outward, and still exhibit 
 nothing more than the freedom permitted by an extensive laceration 
 of the capsule and of the short rotator muscles. In all such cases 
 traction downward will bring the head into the region of the socket, 
 when flexion will place the femur in the position it occupied at the 
 close of the second step of dislocation. 
 
 But a change is possible that should be understood. The original 
 force, which was that of rotation inward, may be reversed after 
 dislocation takes place, and the third step of dislocation may yield 
 us the position of 
 
 Dorsal "with E version. 
 
 There is nothing in this condition to mystify the reader; it depends 
 upon physical laws and is easily explained. By a glance at Fig. 
 
 Fig. 124. 
 
 Fig. 125. 
 
 Fig. 126. 
 
 Fig. 124.— Inverted dorsal ; so-called because the knee is turned inward and the foot rotated 
 inward. In this the head turns inward and rests against the side of the pelvis. 
 
 Fig. 125.— Everted dorsal ; so-called in contradistinction from the primary or first condi- 
 tion of every outward dislocation, whicli is dorsal with inversion. In dorsal with erersion the 
 foot turns out, the trochanter (not the head) rests against the side of the pelvis, and the head 
 looks outward. To reduce an everted dorsal (Fig. 125), it must be first converted into an 
 inverted dorsal (Fig. 124). 
 
 Fig. 126 is only a shifted position from Fig. 125. 
 
 124 it will be evident that rotation outward would be possible by 
 still further adductins:; the knee ; or if the femur was extended 
 
134 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 and outward rotation instituted, the laceration of the outer branch 
 of the Y-ligament would readily liberate the head and permit of 
 eversion. The eversion will vary in degree and the position of the 
 head will vary! The foot may exhibit normal eversion (Fig. 125), 
 or it may even look slightly outward and backward (Fig. 126). 
 The head may lie against the dorsum (Fig. 125), or it may rise to a 
 level with the anterior border of the ilium, or it may extend over the 
 border^ its neck resting on the interspinous notch (Fig. 126). The 
 critical reader has not failed to notice a striking resemblance between 
 two very diverse conditions, viz., a dislocation primarily inward into 
 
 Fig. 127. 
 
 Fig. 128. 
 
 Fig. 127.— Thyroid reversed. I designate this a tliyroid, because it was originally a tbyroid 
 dislocation (Fig. 78), With the head pointing inward and the foot pointing forward. It is 
 reversed, for iiow the head points outward and the foot backward. I call it a thyroid re- 
 versed, and by the name indicate that it can only be reduced by converting it into a 
 primitive thyroid, i. e., into a dislocation inward, into the thyroid depression. For the 
 successive steps of causation, see Figs. 78, 82, 83, 84. 
 
 Fig. 128.— Dorsal reversed ; so-called in contradistinction from the primary dorsal disloca- 
 tion, which is always accompanied with inversion of the foot and rotation inward of the 
 axis of the shaft of the femur. The reversed dorsal is not a primary or original dislocation ; 
 it is a consecutive or secondary change from an original inverted dorsal. For its reduction 
 the first step must be to convert an everted into an imerled dorsal. 
 
 the thyroid depression, but which has by secondary influence been 
 rotated outward, so that the foot points outward and backward (Fig. 
 127), and another, dislocated primarily outward, but which by re- 
 versed action also yields a foot turned outward, or even slightly 
 backward (Fig. 128). 
 
DISLOCATION OUTWARD. 135 
 
 As these two conditions are the result of forces directly opposed 
 to each other, and that for their reduction they will require equally 
 diverse methods, must be apparent. 
 
 The diagnosis between these two conditions is a very difficult one, 
 a statement which is happily illustrated in the contradictory views of 
 Sir Astley Cooper and Henry J. Bigelow, the former of whom re- 
 garded the case recorded on p. 120 as "upward and forward," and 
 the latter as " dorsal with eversion." I shall not attempt to lay down 
 any rules by which these two conditions can be distinguished ; I shall 
 rather, first, show their general resemblances, and, second, offer some 
 general points of divergence. 
 
 (a) In neither form of dislocation ivill there he evidence of de- 
 cided fixation. In the thyroid reversed, shifted upward, the 
 Y-ligament will be seen (Fig. 127) to lie under (behind) the 
 neck. Hence, it cannot offer any constraint except against traction. 
 In the reversed dorsal (Fig. 128) the Y-ligament lies on the inner 
 side and may bind the head and neck with considerable force, but 
 even this constraint will vary with the integrity of the outer branch 
 of the Y-ligament, which is generally torn in the reversed dorsal, 
 
 (b) In neither form of dislocation luill the limb refuse to lie ^xir- 
 allel with its sound fellow. There may be a little tendency to ad- 
 duction, but in neither case will the limb show constraint when 
 placed in normal extension and abduction. There are three condi- 
 tions that might simulate the external rotation and parallelism, 
 VIZ.: Fracture of the neck of the femur ; reversed dorsal ; and a 
 reversed thyroid. Of these three conditions the former may be ex- 
 cluded if the patient is able to sit upon a chair. In such a posture 
 the fractured thigh would show shortening by comparison of the 
 knees, but the knees would look forward ; in the remaining two, 
 viz., in the dorsal reversed and in the thyroid reversed, the affected 
 knees would look outAvard in the sitting posture, and the bent leg, 
 resting on the toes, would lie behind its fellow. (Fig. 129.) 
 
 Although I cannot offer positive points of diagnosis, I will call 
 attention to the followino- : 
 
 (a) Extreme outward rotation in which the inside of the foot tends 
 to look outward — the heel forward and inward — is hardly possible in 
 any condition save that of a primary dislocation inward, with ex- 
 ternal rotation, the head being controlled by the Y-ligament, which 
 is untorn. The outward rotation of everted dorsal is rarely beyond 
 
136 REDUCTION OF DISLOCATIONS BY 3IANIPULATI0N 
 
 rectangular eversion. To [determine -whether the case in question be 
 an everted dorsal, let the operator make a gentle attempt to rotate 
 still further outward. This will be checked because the Y-ligament 
 
 Fig. 129. 
 
 Fig. 130. 
 
 Figs. 129, 130. Everted dorsal dislocation of left femur. Originally this injury was an in- 
 verted dorsal. The accident occurred in childhood, and was caused by a fall from a ladder. 
 The limb never gave any (Kscomfort, but by constant use, either through flattening of the 
 head of the femur, the deepening of the artificial socket, or the lengthening of the remnant 
 of untorn capsule, the inverted dorsal gradually became a well-marked everted dorsal. The 
 left, or injured, limb was the one on which he bore his weight when standing. This was 
 owing to the great shortening and the disparity between his limbs. It will be observed that 
 in sitting the left limb lies back of the right and rests upon the toes. If the reader turn to 
 Figs. 125 and 126, he will see that in these the knees look outward, and in them in the sitting 
 posture the inner side of the knee would look forward. 
 
 lies in front (Fig. 128), and external rotation will make it tense. 
 Not so Avith the " thyroid reversed." In this case the Y-ligament 
 lies behind (Fig. 127), and rotation, after the foot looks backward, 
 can still be increased. 
 
DISLOCATION OUTWARD. 
 
 137 
 
 (b) If the foot looks backward or outward, find the head ; to do 
 this locate the inner condyle ; it points in nearly the same direction 
 as the neck. After this locate the great trochanter, it will lie inter- 
 nal to the dividing line between the two divisions of the bone (Fig. 
 131, X, Y), when the head has been dislocated primarily inward; 
 but if the head were dislocated primarily outward, the trochanter 
 major cannot lie internal to this line. 
 
 Fig. 131. 
 
 Lastly, make direct pressure upon the head ; if it be a reversed 
 dorsal, the head Avill sink ; if a shifted thyroid, the upper end of the 
 femur will have a bony support ; if it be a dorsal with eversion only, 
 the head can be felt by direct pressure ; if it be a shifted thyroid, 
 the trochanter can be felt as well as the head. 
 
 It must be evident, therefore, that retracing the last step of dis- 
 location is not a simple or unimportant matter ; that a confident 
 rational procedure will only be based upon a knowledge of the path 
 taken by the head. As we are now dealing with dislocations out- 
 ward, the first thing to do if we are dealing with an everted dorsal, 
 is to convert it into an "inverted dorsal." To do this, flex (this 
 will relax the Y-ligament), abduct, and rotate inward. The opera- 
 tor should observe carefully that the head follows the manipulation ; 
 
138 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 if it does, he has retraced the last step of dislocation, and is ready 
 to undertake the second step. 
 
 Fig. ]32. 
 
 Fig. 132 represents the head of the femur beneath the overhanging capsule. The same in 
 cross-section in Figs. 133 and 134. 
 
 Retracing- the Second Step. In the second stage of disloca- 
 tion the head left the region of the socket and fell outward and 
 downward until arrested by the yet untorn part of the capsule ; 
 hence to retrace the second step — lift. 
 
 Fig. 133. 
 
 Fig 134. 
 
 If the surgeon lifts vertically upward, he will find that as the head 
 rises it is compelled to move outward to get from under the project- 
 ing rim of the socket, and this makes tense the remnant of untorn 
 capsule which checks the upward progress of the head at the instant 
 when it would pass over the rim and into the socket. To obviate 
 
DISLOCA TION UTWA RD. 
 
 139 
 
 this turn the Lent leg like a crank outward. This will compel the 
 head and neck to look footward (Fig. 135). Now tiie limb can be 
 lifted to a level with the socket, but on its arising it encounters an 
 
 Fig. 135. 
 
 obstacle worthy of our most serious attention. To complete the 
 second stage, the head must be turned inward to the region of the 
 socket, and now note that the tendon of the hamstring muscle and 
 its attendant, the great sacro-sciatic nerve, are directly in the way. 
 Fig. 136. 
 
 Fl(i. 136. 
 
 Notice that thd head is at a higher point than in Fig. 135. and rests against the tendon of 
 the hamstring muscles. 
 
 This, I say, is a most critical moment, for the head must be turned 
 into the region of the socket, and has no other path than between 
 
140 RED UCTION OF DISL CA TIONS B Y MA NIP ULA TION 
 
 the tendon and the socket. To do this while the limb is lifted ver- 
 tically with thfe leg flexed at right angles to the femur, which re- 
 laxes the tendon and nerve, turn the leg as a crank downward and 
 inward until the heel looks footward. Do not use violence. If ob- 
 struction be experienced, it cannot at this stage lie in the capsule, it 
 cannot lie in anytJiing over which violence will prevail. It will lie 
 in one of three things : Either the head strikes bone, in which case 
 it must be lifted higher ; or it strikes the tendon ; or the nerve. In 
 case it strikes the tendon it can be readily shifted, and the escape of 
 the tendon may be followed by a similar escape of the nerve. I have 
 frequently caught them in succession, and have so caught up the 
 nerve as to flatten it over the head, and being spread out twice its 
 
 Fig. 137 
 
 original size, it has barred my progress to the socket. Therefore, I 
 urge caution at this stage, for if the nerve be caught and force applied, 
 it (the nerve) has one of three destinies before it : it must eff"ectually 
 bar all entrance to the socket, or slip off the head and escape, or 
 slip off the head upon the neck of the femur, from which it can with 
 diflBculty be disengaged. I speak of this as a moment of peril, for 
 no one, when he undertakes to restore a dislocation, can tell what 
 degree of havoc attended the original traumatism, and whether or not 
 the nerve has been freely stripped from its attachment to the hamstring 
 (biceps), and lies dangling like a large cord in front of the socket. 
 
 If the iiead has met with no obstacle in rotation, it is now ready 
 for the last step. Please note the position of the head of the femur : 
 it rests upon a ridge between the outer and inner planes. It has 
 
DISLOCA TION UTWA RD. 
 
 141 
 
 readied its present position by being lifted to a level with the socket 
 and rotated obliquely beneath it (Figs. 137, 138). There are three 
 courses open to it now : it can fall outward, pass inward into the 
 thyroid depression, or ascend obliquely upward into the socket. 
 There are two ways for accomplishing a happy replacement : 
 
 Fig. 138. 
 
 The first is by traction. By this means the knee is lifted sky- 
 Avard, which relaxes the remnant of capsule, while an assistant 
 with his thumbs makes direct pressure upon the head in the direc- 
 tion of the socket. This may reduce it ; if not, the operator may 
 
 Fig. 139. 
 
 bring the knee down in extension, the assistant still keeping up the 
 pressure upon the head. The manoeuvre should not be attended 
 with violence or dispatch. The surgeon, if he encounters resistance, 
 should be warned by it, and retrace and modify his course. Usually 
 the head will pass noiselessly into the socket. 
 
142 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 The second, or indirect, method is to employ the Y-ligament of 
 Bi^elow as a fulcrum to drag the head into the socket. The reader 
 will bear in mind the position of the head: it lies (Figs. 137, 138) 
 below the socket, and must be directed obliquely upward and outward. 
 
 If, now, the knee, with the leg flexed, be carried directly down- 
 3vard in extension, the remnant of uutorn capsule (Y-ligament) will 
 be made tense, and the head be lifted into the socket. Should the 
 head slip outward upon the dorsal aspect, it must be replaced by lift- 
 ing, and, instead of extending the knee directly downward, it should 
 be a little abducted and then extended. If, on the contrary, the 
 head slipped inAvard into the thyroid depression, then the knee 
 should be adducted and the Y-ligament tightened a little by inward 
 
 Fig. 140. 
 
 rotation. (Note the position of the foot, Fig. 140.) If, now, ex- 
 tension be made, the head will be directed in the course of the 
 socket. 
 
 The reader will notice that this employment of the Y'^-ligament is 
 on the same principle that was given in the directions for reducing 
 dislocations into the thyroid depression, and the same cautions need 
 not be repeated. Having described at length the process by which 
 a femur dislocated outward may be made to retrace its steps, I will 
 briefly summarize it : Tiie patient lying supine, the surgeon kneels 
 by his side, and if the right femur is dislocated, he seizes the ankle 
 with his right hand and places the bent elbow of his left arm beneath 
 the popliteal space : (1) he now turns the bent leg outward by means 
 of the ankle and lifts upward (skyward) ; (2) then turns the bent leg 
 inward and brings the femur down in extension. 
 
 Often the reduction is extremely simple and can be accomplished 
 
DISLOCATION OUTWARD. 143 
 
 in a few seconds by this method without violence ; should it fail, the 
 method by traction should be adopted/ 
 
 It may be asked at this point, why Reid's method, which often 
 succeeds by magic, should not be recommended ? Reid's method is 
 through circumduction. He labored under the misapprehension that 
 muscular resistance was the chief obstacle to reduction, and that this 
 was overcome by relaxing the muscles in succession, and his unfor- 
 tunate success in three instances confirmed him in his belief and 
 checked his further researches. Bigelow doubting the theory, but 
 not knowing the true one, found it in the thick band of the capsule, 
 the ilio-femoral ligament, after he had dissected all the muscles away. 
 
 I will here analyze Reid's method, which was also adopted by 
 Bigelow, and has been accepted and taught almost universally. In 
 his first step he flexes the leg on the thigh, and carries the flexed 
 knee strongly over toward the pubes. The eff"ect of this is to make 
 a fulcrum of the pelvis, which raises the head of the femur to a level 
 with the socket ; now, Avhile the head is on a level Avith the socket, 
 the knee is carried upward toward the umbilicus, and outward toward 
 the side. As the knee goes upward and outward the head passes 
 downward and inward, and rises upon the pelvis below the socket. 
 Finally the knee is brought downward in extension, the head passes 
 into the socket, and all is accomplished in the twinkling of an eye. 
 
 Now the entire success depends on the remnant of untorn capsule, 
 as Bigelow has pointed out, but not simply upon the remnant of liga- 
 ment, hut, as Agnew lias pointed out, upon the shortness of it. For 
 if the untorn remnant of capsule compels the head to hug the rim 
 of the socket, then Reid's circumductive sweep will be effectual the 
 instant the head rises upon the pelvis below the socket and the knee 
 is brought down in extension. 
 
 But if the rent in the capsule is extensive, then this extensive 
 sweep will' place the head so far below the socket that any attempt 
 to bring the head upon the inner plane of the pelvis will be rendered 
 impossible by its striking against the tuberosity of the ischium and the 
 tendon of the hamstring muscles.^ While, then, I caution against 
 circumduction as a method of reduction, as its success is based on 
 error, and its employment both unscientific and attended with great 
 hazard, I do so with the most profound respect for one who, if not 
 
 ' For the advantages of the prone position as a means of reduction, see p. 147. 
 - See Figs. 48 and 102, and the accompanying text. 
 
144 ^ED UCTION OF DISL CA TIONS B Y MANIP ULA TIOK 
 
 the pioneer in the method of reduction by manipulation, was cer- 
 tainly the one to stamp it with confidence, and arrest the attention 
 of the world upon its possibilities. 
 
 I have said that the circumductive method is attended with danger. 
 The chief reason for saying this is that in the employment of this 
 plan, one hand seizes the ankle and the other is placed upon and 
 directs the course of the knee. It is leverage through the femur, the 
 power being exerted at the knee that elevates, i. e., pries the head of the 
 bone to a level with the socket, and to this manoeuvre may be added 
 
 Fig. 141. ■ 
 
 the effect of the remnant of untorn capsule. There is no direct 
 lifting by the operator in this method ; its employment does not 
 follow the reverse steps of displacement, and its success is always at 
 the hazard of catching up the nerve. 
 
 Obstacles. If the methods described do not succeed, failure in 
 recent cases may be ascribed to : 
 
 I. Lack of skill or facilities in the operator. 
 II. Obstacles that prevent the head from entering the socket. 
 
 III. Obstacles pushed into the socket by the head. 
 
 IV. The sciatic nerve hooked over the neck of the femur. 
 I. Lack of skill or facilities. 
 
 Upon this point I need have little to say. I would, however, 
 caution the operator not to get desperate and resort to rash measures 
 in the hope that by a lucky turn he may succeed. By skill and 
 well-directed measures the obstacles may be located and interpreted, 
 while if overcome by ignorance or force it may not be to the advan- 
 
DISLOCATION OUTWARD. 145 
 
 tage of the patient. There are conditions even worse than an unre- 
 duced dislocation. When I sent a man home with the sciatic 
 stretched across the neck of the femur permanent dislocation would 
 have been preferable.' When Bigelow restored a hip to a partly 
 filled socket, were the dry arthritis and subsequent ankylosis an 
 improvement upon permanent dislocation ? When — as has twice 
 happened in Philadelphia — the femur was broken in an attempt at 
 reduction, was fracture added to dislocation a condition preferable to 
 uncomplicated dislocation ? or did the result reflect creditably upon 
 the skill of modern surgery ? Hence do not, whatever you do, 
 become desperate : remember that obstacles about the socket are 
 like buoys in the channel — they not only point to danger and are to 
 be avoided, but, properly interpreted, they are guides to port. 
 
 Failure may be the result of lack of facilities. Anaesthesia, intelli- 
 gent assistants, and fixation are invaluable aids required by the most 
 expert ; therefore, do not prejudice your case by a premature attack. 
 
 II. Obstacles that prevent the head from entering the socket ; 
 closing the door of entrance or embracing the neck and holding the 
 head in chancery. 
 
 a. The capsule. While I persistently reject the very widespread 
 theory of " slit in the capsule" and "buttonholing by the capsule," 
 and hold firmly to the statement previously made, that the opening 
 of exit in the capsule is always ample for the return of the head, 
 I quite as firmly believe that the borders of the torn capsule 
 are capable of effectually resisting efforts at reduction whenever 
 those efforts are not made in harmony with the process of eviction. 
 I have repeatedly demonstrated that the rent in the capsule may be 
 ample and afford unobstructed passage for one method of reduction, 
 which by another mode of reduction would be impossible. I have 
 also demonstrated that a change in the relation of the femoral head 
 to the socket after dislocation is capable of creating a formidable 
 artificial buttonholing, but in no instance has resistance withstood 
 gentle, well-directed efforts at reduction. 
 
 There is, however, a rent in the capsule that may defy all possible 
 skill. It is that in which the capsule has been chiefly torn from the 
 femoral insertion, leaving the Y-ligament as the only remaining liga- 
 mentous band of connection between the socket and the base of the 
 neck of the femur. (See p. 52.) Of this special obstacle Bigelow 
 
 1 See Reminiscences, p. Ix. 
 10 
 
146 I^ED UCTION OF DISLOCA TIONS B Y MANIP ULA TION. 
 
 says that '* any difficulty can be easily obviated by carrying the 
 head of the bone toward the opposite side of the socket and thus 
 enlarging the slit."^ By such a statement Bigelow not only shows 
 that he has never had practical experimental dealing with such a 
 lesion, but his advice is that best suited for making such a difficulty 
 still more insurmountable. Bigelow errs in imagining that he is 
 dealing with a slit. The rent is not a slit in the long axis of the cap- 
 sule, but is peripheral, the capsule being chiefly torn from its femoral 
 
 Fig. 1-42. 
 
 attachment. It is the situation of the rent that makes it formidable 
 — not the size of it. The long detached capsule now covers the 
 socket like a hood, and no possible manoeuvre can " enlarge it." 
 But the manoeuvre suggested by Bigelow will have this serious dis- 
 advantage. When the rent is peripheral at the base of the neck — 
 if the cuff of the capsule is still attached to surrounding muscles, 
 which renders reduction, when properly attempted, still possible — 1 
 have repeatedly in rapid succession restored such a dislocation by 
 direct replacement with as much ease as could be desired ; but wdien 
 I have detached the muscles from the capsule by shifting the head 
 to the opposite side of the socket, as Bigelow directs, I have found, 
 upon returning to the method previously emploj^ed with success, that 
 
 1 The Hip, by Henry Bigelow, pp. 33-34. Philadelphia: H. C. Lea, 1867. 
 
DISLOCATION OUTWARD. 
 
 147 
 
 reduction was no longer possible except by pushing the capsule, now 
 loose and disengaged from its muscular attachments, before the head 
 into the socket. I therefore fully agree with Gelle, Malgaigne, Gunn, 
 and others that this is a complication that may be insurmountable. 
 The position I found most favorable for reduction under the 
 circumstances just mentioned is the one depicted below. It is 
 mentioned by authors, but its merit has not been sufficiently dwelt 
 upon. The subject was placed prone with the thigh hanging over 
 
 Fig. 143. 
 
 the corner of the table. In order to support the pelvis and sound 
 limb a second table was employed. In this position the pelvis can 
 be readily secured^ — a condition that I am certain contributed 
 greatly to my success. The prone position has this advantage 
 over the supine, in that it is assisted by gravity. The head, when 
 the thigh is flexed to a right angle, lies directly above the socket, 
 and the weight of the leg and thigh has a natural tendency in the 
 right direction. To favor the descent of the head the ankle may be 
 drawn outward and rocked a little, or pressure be made directly over 
 the head or in the popliteal space. The advantages of this posi- 
 
 1 Tlie mode of fixation I employed is, of course, not possible in actual practice, but my 
 success experimentally was largely attributable to it. 
 
148 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 tion are that limited circumduction can be practised, while the weight 
 of the limb, increased, if necessary, will always be an aid in directing 
 the head toward the socket. 
 
 h. Muscles. Dislocations that are readily reduced, i. e., that offer 
 no resistance, are probably accompanied with free laceration of cap- 
 sule and muscles. As already mentioned, the outward dislocations 
 are usually damaging to the obturator internus, while if the disloca- 
 tion were first thyroid and secondarily dorsal, then the obturator 
 externus and quadratus femoris are necessarily torn in two. It is 
 possible for dislocations to occur without destroying muscular fibre, 
 i. e., for a dislocation to occur between two muscles without injuring 
 either. In such a case it is hardly fair to say that the muscles es- 
 caped by a lucky dodge — it may be nearer the truth to say they 
 escaped by their own power of resistance. The endurance of a 
 strong, live, healthy muscle cannot be measured by contrasting it 
 with a dead, cold, rigid piece of lean meat. It is therefore impossi- 
 ble to arrive at the difficulties of actual life by investigations in the 
 dissecting-room. Probabilities are our nearest approach, and to 
 some of these I now ask attention. 
 
 Fig. 144. 
 
 In the pathology of recent dislocations the head has been found be- 
 tween the obturator internus and externus. (Fig. 144.) Now there 
 can be no possible buttonholing between these muscles, yet lam per- 
 suaded that by Reid's method — viz., by flexing the knee, carrying it 
 first toward the pubes, then up toward the umbilicus, then upward, 
 outward, and downward in extension — embarrassing difficulties may 
 
DISLOCATION OUTWARD. 
 
 149 
 
 be created. As the knee takes its upward and outward path, the 
 head passes downward and inward and will tend to rise upon the 
 ischium. Whether through circumduction the head will be arrested 
 
 Fig. 145. 
 
 by the tendon of the obturator externus, or whether the quadratus 
 femoris will become interposed, are speculative, but not improbable 
 obstacles. They would not, however, be possible if the method of 
 direct replacement were employed, as mentioned on p. 138 et seq. 
 
 Fig. 146. 
 
 Again, the head of the femur has been found in autopsies between 
 the obturator internus and the pyriformis (Fig. 145). And also 
 above the pyriformis (Fig. 146). The question I wish to propose is, 
 
150 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 Could either of these dislocations be restored by the usual modern 
 methods of manipulation? Flexion, circumduction, and rotation 
 might disengage the head and then reduce it — but what if they could 
 not disengage the head ? Would the conversion of a dorsal into a 
 thyroid rupture the tendon of the obturator internus or that of the 
 pyriformis ? Is it not a fair inference that muscles which could sus- 
 tain, uninjured, the strain put upon them of the head bursting 
 between them, could also sustain the strain of a much feebler force, 
 viz., the efforts of the surgeon at manipulation ? 
 
 Sir Astley Cooper, in attempting to reduce a dislocation, had it 
 suddenly slip into a position which he believed to be the sciatic notch, 
 
 Fig. 147. 
 
 from which he could not extricate it. Surgeons have tried in vain 
 to explain what Sir Astley meant by his advice to avoid this notch. 
 Some have even imagined that the head passed through the forma- 
 men or got entangled in the bony notch. Bigelow interprets it that 
 the head ascended behind the tendon of the obturator internus 
 (Fig. 144), which prevented the reduction by pulleys. It is difficult 
 for me to understand how the great London surgeon could so long 
 persevere in the use of pulleys if this most frequent variety of dis- 
 location should have baffled him. Be this as it may, Bigelow has 
 truly said that no such imaginary danger can exist if one adopts 
 flexion as a first step in reduction. But I have been baffled by the 
 very methods that the great advocate of flexion believed were invin- 
 cible. 
 
 I ask the reader now to turn back to the case of J. II. M., 
 
DISLOCATION OUTWARD. 151 
 
 Reminiscences, p. xi., and read it carefully. Here Avas a recent case, 
 in which in attempts at reduction the head passed repeatedly and 
 unobstructedly from the outer to the inner planes of the pelvis and 
 back again, but when the head approached the socket something 
 barred it. In this case there was no engagement in the sciatic 
 notch, no filling of the socket, and no obstruction from the capsule. 
 I have often sought an explanation of the difficult}^, and the only 
 one that is in the least degree satisfactory is that, in the dislocation 
 outward, the head passed directly between the obturator internus 
 and the pyriformis (Fig. 147) without rupturing either. That this 
 is possible can be shown by reference to pathology, p. 69, Case XI., 
 but it cannot be demonstrated upon the cadaver with stiff, brittle, or 
 disintegrating muscular fibre. While, therefore, I cannot substantiate 
 the theory I have adopted, my reasons for accepting it are these : If 
 those muscles had the strength to withstand, without rupture, the 
 head bursting between them, it seems not incredulous that they could 
 withstand a much weaker force, that of man's strength in his efforts 
 at reduction. The nature of the entanglement, which I denominate 
 in chancery, seems to me to account for our defeat. If the head 
 were clasped between the tendons of these muscles, none of the 
 ordinary efforts at reduction would avail. Sir Astley's extension 
 with pulleys would do no good. With circumduction the tendon of 
 the obturator internus might have been ruptured ; but if it were not, 
 it seems to be just in the position to bar etfectually all entrance just 
 at the door of the socket. In our efforts at reduction we circum- 
 ducted after Held, used Despres' method, jerked upward (Bigelow), 
 and everything that a full force of surgeons could, on two separate 
 occasions, suggest, but to no purpose. Acting on the supposition, 
 then, that the head lay in chancery, i. e., buttonholed between the 
 obturator internus and the pyriformis, I would suggest the following 
 method for dislodgement and restoration : 
 
 By a glance at Fig. 147, it will be evident that neither extension 
 with pulleys, circumduction, nor rotation could be instituted in answer 
 to the question, "how to make the head retrace its steps." To do 
 this the most feasible procedure would be to draw the head toward 
 the socket, but as the head rises the neck will be grasped all the 
 more strongly by the tendons of the muscles. Now, while the knee 
 is drawn inward toward the pubes, and the head made to approxi- 
 mate the socket, let an attendant hold the head in this position, 
 
152 RED UCTION OF DISL CA TIONS B Y MANIP ULA TION. 
 
 while the surgeon, using the upward pressure of the assistant as a 
 fulcrum, carries the knee outward. This will compel the head to 
 seek the interspace between the muscles, and, once that it has passed 
 through, the reduction is virtually accomplished. 
 
 I desire to state again that this is purely theory, but a theory only 
 put forward after other theories of this special obstacle to reduction 
 have been explained away. 
 
 III. Obstacles pushed before the head into the socket — subluxa- 
 tion. 
 
 I have never been able to comprehend what authors mean by sub- 
 luxations. There are but three possible positions for the head of 
 the femur, viz., entirely outside of the socket, on the rim of the 
 socket, and within the socket. If the head lie outside, the deformity 
 will be great ; if it lie upon the rim, the deformity will be greater ; 
 while the only position in which deformity disappears, or nearly dis- 
 appears, is when the head lies in the socket. In all the alleged 
 cases of subluxation the deformity has been trifling, and corresponds 
 to what I have experienced when in experimental work I have 
 pushed the capsule or portions of the obturator externus before the 
 head into the socket.^ 
 
 In experimental work I have known four conditions to interfere 
 with complete reduction. By incomplete reduction I mean any con- 
 dition that interferes with normal movements, as adduction and ex- 
 tension. These four conditions are (1) muscular debris, (2) portions of 
 muscles, (8) inversion of capsule, (4) hooking up the of sciatic nerve. 
 All of these have been discussed in the Introductory Study. 
 
 In the first three the head is prevented from sinking to its normal 
 depth into the socket. A few points are worthy of mention. 
 
 (1) Reduction of the head into a socket cushioned with muscular 
 or capsular material will not be accompanied with the report and 
 sudden succussion that take place when naked cartilage strikes 
 upon naked cartilage. 
 
 (2) If the socket is partially filled, the normal movements of ad- 
 duction and extension will be interfered with. Such embai'rassment 
 should be regarded as a valuable exponent of the condition present, 
 which, if properly considered, will not be met by forced extension of 
 the knee, a resort that temporarily helps the signs by mashing or 
 
 1 For the removal of portions of capsule or muscular fibre from the socket, see p. 107. 
 
DISLOCATION OUTWARD. 153 
 
 compressing the foreign substance, but will not aid the patient or 
 facilitate the removal of the foreign body. 
 
 (3) If the socket is partially filled, redislocation is extremely 
 probable. Redislocation may take place as the result of fracture of 
 the rim or imperfect reduction, due to a partially filled socket. 
 
 Points in regard to fracture of the rim : 
 
 (a) The fracture occurred prior to the dislocation. It could not 
 have taken place after it ; in other words, the dislocation was the re- 
 sult of the fracture. 
 
 {h) No rent in the capsule took place in its continuity, but the rent 
 was through the fractured rim, i. e., the capsule retained its attachment 
 to the fragment ; the main rent was peripheral, not longitudinal. 
 
 (e) Reduction would probably be easily accomplished, attended 
 with bony crepitus ; attended also with complete extension and ad- 
 duction. 
 
 (d) No constraint would attend reduction. 
 
 (e) Redislocation would probably attend the withdrawal of man- 
 ual support, and be accompanied with crepitus. 
 
 Points in regard to restoration into a partly filled socket : 
 
 (a) Reduction will be unattended with succussion or jar. This is 
 especially true when the material drawn before the head is consider- 
 able. 
 
 (b) Constraint. The incomplete reduction will make tense the ilio- 
 femoral ligament and arrest the femur at a point before normal ex- 
 tension or normal adduction is reached. 
 
 (c) Crepitus will be absent. 
 
 Observation. The importance of a proper diagnosis in such a case 
 is apparent, since in case of fracture of the rim rest and retention will 
 facilitate perfect recovery, while rest and retention with foreign 
 material in the socket will be attended by inflammatory processes or 
 redislocation on the first change of position. 
 
 See cleaning out the socket, p. 107. 
 
 IV. The sciatic nerve. 
 
 The implication of the sciatic nerve, Avith dislocations of the femur, 
 has never seriously engaged the attention of the medical profession. 
 In introductory studies I have quite fully explained the anatomical 
 relations of the nerve to the normal and dislocated hip. (P. 28.) 
 I. shall here refer to the signs and diagnosis, and suggest a course of 
 procedure in case the nerve is caught over the neck of the femur. 
 
154 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 The possible dangers to the nerve are from dislocations outward, 
 and these may be divided into two classes, viz. : 
 
 (a) Danger to the nerve from the mere act of dislocation. 
 
 (6) Dangers that arise from the eiforts at reduction. 
 
 Danger from dislocation. The nerve may be caught up by the 
 neck in the mechanism of dislocation. On p. 62 a pathological 
 representation is given. The nerve has been caught up with such 
 force as to cause its complete rupture. Every degree of impaired 
 function is recorded, from pain and feeble action to total paralysis. 
 I believe the mishap is likely to occur either when the dislocation is 
 primarily inward and consecutively by a continuation of the vulner- 
 ating force converted into a dorsal, or when a direct dorsal is produced 
 
 Fig. 148. 
 
 by flexion, abduction, and rotation inward. Under the former con- 
 ditions, if the thigh is made to take a large circumductive sweep, the 
 head will pass outward, rubbing strongly against the common tendon 
 of the hamstring muscles, and detaching, if not hooking up the nerve. 
 Such a mishap will not complicate in the least the ease of reduction, 
 but, if the nerve has been seriously injured, an acute neuritis or par- 
 alysis may ensue, and it would be greatly to the advantage and credit 
 of the surgeon if he could anticipate so grave a sequel. The possibility 
 of ascertaining that the nerve is hooked over the neck rests chiefly on 
 what can be felt in the popliteal space. When the hip is in its socket 
 the hamstring tendons can be made tense and prominent. After 
 dislocation they are relaxed. Tc push upon the knee in the direc- 
 tion of the long axis of the femur would still further relax these 
 
DISLOCATION OUTWARD. 
 
 155 
 
 tendons, but would tend to tighten the nerve if it had been caught 
 up over the neck. (Fig. 148.) Extension of, not traction upon, 
 the entire limb would not make the hamstring- tendon taut if the 
 head were dislocated, but such extension would make the nerve more 
 tense were it caught over the neck. It is, therefore, possible to as- 
 certain, before any attempts have been made at reduction, that the 
 nerve has or has not been caught up. 
 
 Fig. 149. 
 
 If the nerve has not been caught up, then the head lies outside of 
 it, and must cross or approach it in its passage to the socket (Fig. 149). 
 This is a matter of far more practical importance than it has ever re- 
 ceived, and here I wish, again, to call attention to Reid's method of 
 reduction. The underlying principle of this method is to relax the 
 muscles, and to accomplish this he directs the knee to be carried over 
 toward the pubes, thence toward the umbilicus, thence upward and 
 outward, and completing it by bringing the limb down in extension. 
 Gross and Agnew taught that the knee should be made to approach 
 well the body as it made its large circumductive sweep. The dan- 
 ger in this consists in the fact that the greater the circle taken by 
 the knee the larger will be the circle taken by the head. Such a 
 sweep will force the head well down upon the tuberosity of the 
 
156 REDUCTION OF DISLOCATIOXS BY MANIPULATIOS. 
 
 ischium, and as the knee is carried outward and the head moves 
 inward, the tendon of the hamstring muscles will be struck and 
 hugged as the head passes toward the socket. (See arrows, Fig. 149.) 
 I have demonstrated (Fig. 36) that one of the easiest, if not the easiest, 
 methods of producing a dislocation is by abduction, and if the disloca- 
 tion is primarily inward, and consecutively outward, the quadratus 
 femoris^ has been torn in two and its connection to the nerve destroyed. 
 
 Fig. 150. 
 
 Often when the head does not catch up the nerve in its outward prog- 
 ress, it tears it from its muscular attachments, and leaves it a loose, 
 lifeless, dangling rope, barring the entrance to the socket, and compel- 
 ling the head to strike it squarely, or slip to one side in its progress 
 to the socket. Under such circumstances, if the large circumduc- 
 tive sweep were designated for the especial purpose of catching up 
 the nerve, it would be most admirably adapted to the purpose. 
 
 At times the nerve thus disenojased becomes a veritable obstacle. 
 Over and over I have brought the head against the nerve, which, flat- 
 tened by pressure, refused to slip from the head, and thus offered a 
 formidable barrier to the socket. The normal nerve is often the size 
 of the little finger and may be flattened to an inch over the head, as 
 it presses against it. 
 
 When the nerve is hooked over the neck it off'ers no marked resist- 
 ance to reduction, and the head returns to the socket with suddenness 
 
 1 If the dislocations were directly outward, and due to flexion, abduction, and rotation in- 
 ward, the quadratus would probably be torn from overstretching. For the relations of the 
 quadratus and nerve to the socket, see Figs. 21 and 50. 
 
DISLOCATION OUTWARD. 157 
 
 and succussion, common to all successful reductions. It is, therefore, 
 extremely important in every case that the safety of the nerve should 
 be ascertained before the case is dismissed. 
 
 Signs. If the nerve has been caught up, the immediate effect will 
 be flexion of the thigh upon the pelvis, and of the leg upon the thigh, 
 owing to the sudden shortening of the nerve. The change in the 
 course of the nerve will take up three or four inches of it, and render 
 normal extension impossible. There will be imparted to the limb a 
 springing motion, which it can get in no other way. 
 
 Diagnosis. There are two conditions that will produce a flexion of 
 the thigh upon the pelvis as the result of imperfect reduction, viz. : 
 the nerve over the neck of the femur, and foreign material as capsule 
 or muscular fibre within the socket, and both will be influenced in the 
 same way by lapse of time. In both the flexion will be greatest imme- 
 diately after reduction. In case of the nerve it will stretch and let 
 the knee down ; in case of foreign matter in the socket pressure from 
 the weight of the limb will cause the limb to descend. The only 
 diagnostic point is that furnished by the tense cord-like nerve in the 
 popliteal space, which can be made to rise and disappear by extension 
 and flexion of the leg on the thigrji. 
 
 Treatment. I know of no more unpromising task than that which 
 proposes to disengage the nerve from its new position, and in this the 
 reader will agree with me when he considers : 
 
 1. The nerve has been detached from all its normal surroundino-s. 
 It is normally connected, after its exit from beneath the pyriformis, 
 to the gluteus maximus, hamstring tendon, the obturator internus, 
 quadratus femoris, and adductor magnus. From these it has been 
 torn, so that they can exercise no longer any control over it. 
 
 2. The nerve has been stretched and flattened over the neck, its 
 sheath torn, its fibres separated. 
 
 3. It lies in a region into which blood has been poured ; muscles 
 torn and minced by eff'orts at reduction. If there has been a delay 
 in discovering the position of the nerve, inflammatory products will 
 tend to srlue all the torn area together. 
 
 4. The only means available to disengage the nerve from the neck 
 is to put the neck of the femur in such a position that the nerve will 
 drop off"; and here we must remember that the adhesion through 
 fibrin and lymph to torn muscles will be far greater than the weight 
 
158 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 of the loose, flabby nerve, upon which one can only bring gravity to 
 aid in detaching and displacing it. 
 
 Hopeless as the situation is, the operator has but one course to 
 pursue — namely : 
 
 1. Redislocate the femur; patient supine. 
 
 2. Extend the thigh. 
 
 3. Flex the leg on the thigh to relax the nerve. 
 
 4. Turn the ankle of the flexed leg out until the leg is horizontal. 
 The head will now look perpendicularly downward. 
 
 5. Shake, rock, jar, adduct, and abduct, with a view to disengage 
 the nerve from the neck, and make it drop down below the level of 
 the head. 
 
 6. Rotate the head into the socket without making the nerve 
 tense — i. e., by not flexing the femur. 
 
 Assuming that no human skill can avail under the circumstances, 
 I would suggest the following course: Cut down upon the nerve in 
 the middle third of the thigh above the upper part of the popliteal 
 space, seize it and draw upon it. This will take up its slack and 
 make the nerve take a direct course from its exit from the pelvis to 
 the point of traction. This course will be below the level of the 
 head. The head can now be detached and rotated into its socket, 
 the nerve itself communicating to the finger its release or any further 
 entanglement. 
 
 Fig. 151. 
 
 The advantage of reaching the nerve at so great a distance from 
 the seat of injury is that it furnishes a clean wound and easy access 
 to the nerve without admitting air to the vast pulpified, disintegrated 
 area of traumatism about the articulation. After reduction the nerve 
 can be made to re-enter the wound by flexing the extended limb. 
 
DISLOCATION OUTWARD. 159 
 
 Dislocation of the Head of the Femur Complicated with 
 Fracture of the Shaft. 
 
 The diagnosis of such an injury will be difficult in proportion to 
 the high position of the fracture and the degree of swelling, fat, and 
 muscle surrounding it. Our chief reliance in detecting fracture must 
 be in locating the upper fragment and satisfying ourselves that it is 
 or is not affected by rotation of the shaft. If the fracture lies at 
 the junction of the upper and middle thirds, or just below the great 
 trochanter, the diagnosis of fracture will be facilitated by the pro- 
 jection of the lower end of the upper fragment. How, in addition 
 to fracture, to make a diagnosis of dislocation in a recent case 1 am 
 at a loss to state. I know of three instances — two in which the dis- 
 location was inward and one in which it was outward — in the practice 
 of surgeons of large hospital experience in which the element of dis- 
 location was entirely overlooked. Such an oversight cannot with 
 fairness be classed among "surgical blunders," nor justified by ttfe 
 rarity of the injury, but must be classed with injuries whose precise 
 nature, owing to their concealment, cannot be positively diagnosti- 
 cated by other than open methods. 
 
 In every case of which I have a knowledge the upper fragment 
 was conspicuous for its prominence and its intractability. In some 
 instances of uncomplioated fracture of the upper third of the femur 
 the upper fragment will transfix the vasti muscles which surround it, 
 and, thus transfixed, will successfully resist the usual efforts at appo- 
 sition. In one such case, after ansesthesia, I flexed the femur well 
 on the abdomen, and with my foot in the fold between the thigh and 
 the abdomen made counter-pressure while I exerted traction at the 
 knee in the long axis of the shaft. By this means I released the 
 fragment from the transfixed muscle, and when I brought it down in 
 extension the projection of the upper fragment had disappeared. 
 This, however, would not be the case if dislocation of the head of the 
 femur were present. Deformity would be persistent. I therefore 
 repeat, that while I know of no means other than palpation for 
 recognition of the dislocation, I would state that persistent deformity 
 under ether should lead to the suspicion of dislocation.^ 
 
 1 To facilitate diagnosis Agnew once suggested, in a public discussion of this difficulty, 
 the employment of a long needle to explore the acetabulum. Taking advantage of this 
 suggestion, I would not hesitate to make an incision over the region of the socket suffi- 
 ciently large to permit of digital examination. The incision need not go beneath the fascia 
 lata, would be perfectly harmless, and would enable the surgeon to establish beyond perad- 
 Yenture the presence of the head in or its absence from the socket. 
 
160 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 The difficulties of reduction of the dislocation will vary with the 
 position of the fracture. The reader must fully appreciate the prin- 
 ciple upon which success is based — viz., that the upper fragment, 
 the part extending from the head to the point of fracture, is our 
 entire lever now, and that the part of the femur from the fracture 
 to the knee is only the agent through which we apply our force. 
 If, as in Fig. 152, the head and neck, i. e., the weight-arm, were 
 
 Fig. 152. 
 
 three inches long to the position of the fulcrum (the insertion of the 
 Y-ligament), and the power-arm only two inches from the fulcrum 
 to the point of fracture, the short poAver-arm would act at a great 
 disadvantage, whereas, if the power-arm were equal to or longer 
 than the weight-arm, the power would act to better advantage. 
 Again, the only mode of acting upon the power-arm is through its 
 connection with the long fragment of bone. The connection, between 
 the fragments, partly periosteal, partly tendinous, and partly mus- 
 
DISLOGA TION WITH FRA CTUBE. 1 6 1 
 
 cular, enables us to make traction upon the power-arm in any direc- 
 tion, but precludes all efforts at rotation, circumduction, and leverage 
 through the agency of the lower fragment. In every dislocation of 
 the head of the femur complicated with fracture of the shaft the 
 mechanical powers upon which we are to rely for reduction are : 
 
 a, the power-arm of the lever extending from the fracture to the 
 fulcrum ; h, the fulcrum, viz., the ilio-femoral ligament, extending 
 from the lower iliac spine to the oblique line of the femur ; c, the 
 weight-arm of the lever, viz., the part extending from the fulcrum to 
 the extremity of the head ; and, d, the power exerted upon the extrem- 
 ity of the power-arm. So far as the power is concerned, it could be as 
 advantageously exerted through a strong cord attached to the free 
 end of the short fragment as through the part of the limb below the 
 injury. If, therefore, the operator would not attempt to make a 
 lever out of a dangling rope, nor with it attempt to rotate or circum- 
 duct, but confine himself simply to pulling with it, he will under- 
 stand what I am insisting upon, viz., that the only agency at our 
 command is traction. And yet with it this difficulty can be over- 
 come. 
 
 Reduction of Dislocation of the Head of the Femur Inward 
 Complicated with Fracture of the Shaft in the Upper 
 Third, 
 
 In such a case the head must be drawn outward until it lies as 
 near as possible to the socket. (Fig. 153.) Traction outward may, 
 with direct pressure, reduce the head. If not, the head must be held 
 in the position beneath the socket by an assistant (Fig. 154, A) to pre- 
 vent its slipping back into the thyroid depression, while the surgeon 
 reverses the direction of traction and makes it inward or obliquely 
 inward and downward. (Fig. 151, B.) The effect of this will be to 
 place the lever in an erect or semi-erect position, and while traction 
 compels the power-arm to follow it in the direction of the force, the 
 other extremity of the lever, viz., the weight-arm, will travel in 
 the opposite direction, viz., obliquely upward and outward into the 
 socket. 
 
 11 
 
1(52 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 Fig. 153. 
 
 Fig. 154. 
 
 Fracture of the Shaft with Dislocation of the Head of the 
 Femur Outward. 
 
 The principle is precisely the same as in the preceding. The 
 first question to be considered is, In what position was the shaft at 
 
DISLOOATIOy WITH FRACTURE. 
 Fig. 155. 
 
 163 
 
164 REDUCTION OF DISLOCATIONS BY MANIPULATION. 
 
 the instant the head left the socket and fell outward ? This cannot 
 be positively asserted beyond the belief that it was nearly vertical. 
 As the head fell outward and lies below the level of the socket, the 
 head must be lifted to a level with the socket as a preliminary step. 
 There is but one way of raising the head to a level with the socket 
 in complications of this kind, i. e., through traction directly upward. 
 (Fig. 157.) 
 
 There is no possible hope of retracing the last step if this is im- 
 perfectly done ; hence, in lifting upward the operator must be certain 
 that the head follows.^ Having lifted the head to a level ivith the 
 socket, it must he placed over it. To do this, traction obliquely 
 upward and inward must be instituted. (Fig. 158.) All this time 
 pressure upon the head or trochanter must be made by the assistant 
 as in the previous case — not with a view of pushing the head into 
 the socket, but with a view of preventing it from slipping back. 
 
 The head has now been brought to the rim of the socket, as in 
 the preceding case, and now as a last step the traction made upon 
 the end of the short fragment compels the tightening Y-ligament to 
 drag the head into the socket. (Fig. 159, p. 166.) 
 
 Although what I have said upon the reduction of dislocatioji ac- 
 companied with fracture is based entirely upon experimental work, 
 yet the principle is the same as that in which no fracture is present, 
 a principle that has established its correctness through universal 
 clinical experience. 
 
 If the head of the femur in any dislocation cannot be restored, 
 what course shall be pursued ? 
 
 I. Shall the case be abandoned ? 
 II. Shall the surgeon resort to tenotomy ? 
 III. Shall he be bolder and resort to open measures ? 
 I. Shall the case be abandoned ? If so, what will be the ulti- 
 mate result? Ans. A moderately useful limb with fixation, proba- 
 bly anchylosis. The efforts at reduction have pulpified the muscles, 
 have worn a bare-bone pathway from thyroid to dorsal ; have scored 
 and denuded the head of its covering; hence anchylosis is probable. 
 In abandoning the limb the surgeon may deposit it in the thyroid 
 region, if he desires to give his patient a useful walking limb, with 
 
 1 The advantage of immobilization of the pelyis as a preliminarj- step cannot possibly be 
 over-estimated. See p. 75. 
 
UNRED UCED DISL CA TION. 
 
 Fig. 157.1 
 
 165 
 
 I The arrows in Figs. 157 and 158 represent the assistant, who makes direct pressure upon 
 the head and follows it upward. 
 
 11* 
 
166 RED UCTION OF DISL CA TIONS B Y MA NIP ULA TION. 
 
 trifling limp ; but, from a comparatively small experience, I incline 
 to the belief that the dorsal region will yield the most active limb. 
 
 II. Shall the surgeon resort to tenotomy ? 
 
 I answer, no. The obstacles to reduction are so many and varied 
 that if the surgeon cannot divine the true nature or character of the 
 one that is opposing him, it is hardly likely that he will be fortunate 
 enough to overcome it by such a measure as tenotomy. The chief 
 argument in favor of tenotomy is that suppuration may be avoided. 
 
 Fig. 159. 
 
 A represents fixation of the extremity of the weight-arm, i. e., the head of the femur 
 after it has reached a favorable position below the socket (Fig. 158). B represents traction 
 upon the extremity of the power-arm. 
 
 This might be true were one dealing with a healthy area, but under 
 the present circumstances there is danger from such a procedure. In 
 the only case in which I attempted tenotomy — a dorsal of eight weeks' 
 standing, that had been subjected to repeated trials at intervals by 
 different surgeons — I succeeded in placing the limb in a position 
 simulating reduction, if I was not entirely successful ; but within a 
 few days, an extensive abscess formed, requiring open measures. 
 Were I to be called upon to decide between abandonment and ten- 
 otomy I would unhesitatingly choose the former. 
 
 III. Shall the surgeon resort to open measures ? 
 
 If he has the courage to do his work well and thoroughly, I be- 
 
UNREDUCED DISLOCATION. 167 
 
 lieve that open work will not endanger the life of the patient, and is 
 the only rational procedure. 
 
 Operation — Suggestion. Place the patient prone and locate the 
 head. If the dislocation be dorsal, draw a line from the head up- 
 ward, parallel with the long axis of the body. Draw a second line at 
 right angles to this, beginning at the selected point. Bisect this 
 angle, and it will show very closely the direction of the fibres of the 
 gluteus maximus, which should be the direction of the incision. 
 These fibres may be easily separated. The wound must be ample to 
 admit the hand. The obstacle must not only be overcome, but the 
 socket must be cleansed, and the pulpified muscular structure and 
 entire cavity cleansed out. Drainage with gauze for a day, then re- 
 moved and the wound permitted to heal. 
 
INDEX. 
 
 Anatomy, 3 
 Atmospheric pressure, 7 
 
 how prevented in the socket, 8 
 
 Capsule functions, 13 
 
 strength of, 17 
 
 resists external rotation, 45 
 
 size of rent dependent upon manner of attack, 51 
 
 rent in classified, 52 
 
 cuff of. 64 
 
 torn without injury to muscles, 66 
 Circumduction, danger of, 58 
 
 discussed, 109 . 
 
 Dislocations, general division of, 5 
 of both hips, vi 
 recent, J. H. M., xi 
 altered relations after, 71 
 after restoration, 73 
 steps, illustrated, 80 
 mechanism and effect, rfeume, 89 
 phenomena of, 90 
 signs and symptoms of, 91 
 diagnosis of, 103 
 measurement of, 105 
 nomenclature of, 113 
 dorsal, with eversion, 133 
 outward, manipulation of, 159 
 inward, manipulation of, 119 
 
 direct method of, 119 
 
 indirect method of, 125 
 
 Fasoia lata, diagnosis in fracture of neck of femur, contributes to the 
 security of the hip-joint, 22 
 voluntarily relaxed in hip-joint disease, 23 
 Femoral vessels, immunity from danger, 18 
 Femur, head in socket, 9 
 
170 INDEX. 
 
 Fixation, 75 
 
 apparatus used in experiments, 39 
 Fulcrum, femur as a, 41 
 
 wanting, 42 
 
 ilio-femoral ligament as, 43 
 
 Hammock function of fascia lata, 23 
 Hamstring muscles, guardians of sciatic nerve, 35 
 Head of femur, relation to socket, 9 
 
 Ilio-femoral ligament, 13 
 
 never torn from its subspinous attachment, 51 
 Ischio-femoral ligament, 15 
 
 Lesions in capsule, 49 
 
 Lever, when femur can be used as, 40 
 
 Ligamentum teres brings thin scale of bone away, 67 
 
 Muscles, how torn in dislocations, 56 
 obturator and quadratus, torn, 59 
 lesions, resume, 59 
 
 obturator internus, tendon torn from, 68 
 untorn in dorsal dislocation, 69 
 
 Pathology, (51 
 
 Pectineo-femoral ligament, 13 
 
 Pelvis, fixation of, for experimental work defended, 38 
 
 shape of, 4 
 
 fracture of, due to efforts at dislocation, 46 
 Planes of pelvis, 5 
 Propositions, 2 
 Pubo-femoral ligaments, 14 
 
 Reduction, aids and obstacles in, 73 
 Keminiscences, v 
 Rotation discussed, 10 
 
 Sciatic nerve hooked up through reduction, Dr. Koons' case, viii 
 Dr. Johnson's case, x 
 
 relations to dislocations of, 28 
 
 protected against overstretching, 28 
 
 hooked over neck, mechanism of, 33 
 
 how influenced by abduction and adduction, 34 
 
 caught, pathology, 62 
 
 manipulation to remove, 156 
 Socket divided into equal parts, 3 
 
 situation of, 
 
INDEX. Ill 
 
 Socket felt after dislocation, 5 
 
 security of, against displacements, 7 
 
 retentive function due to atmospheric pressure, 7 
 
 retentive function distributed between suction-ligaments and muscles, 7 
 
 security of, 7 
 
 vacuum prevented, 8 
 
 cleaning out, 107 
 Sucker ligament, 7 
 Suction. [See Atmospheric Pressure.) 
 
 Teres, ligamentum, anatomy of, 9 
 
 functions of, 10 
 
 how torn from the head, 11 
 
 summary of functions of, 12 
 Thrust, theory opposed, 84 
 
 Vacuum in socket prevented, 7 
 
 Y-LlGAMENT, 13 
 
 Prof. Bigelow's description of, 1 8 
 

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