NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland / THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. WITH THE REDUCTION OF THE DISLOCATIONS BY THE FLEXION METHOD. By HENRY J. BIGELOW, M. D., PROFESSOR OF SURGERY AND CLINICAL SURGERY IN THE MEDICAL SCHOOL OF HARVARD UNIVERSITY ; SURGEON OF THE MASSACHUSETTS GENERAL HOSPITAL ; MEMBER OF THE BOSTON SOCIETY FOR MEDICAL IMPROVEMENT, AND OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES J HONORARY MEMBER OF THE SOCIETY ANATOMIQUE J CORRESPONDING MEMBER OF THE SOCIETY DE BIOLOGIE, ETC. WITH ILLUSTRATIONS. PHILADELPHIA: HENRY C. LEA. 1869. Entered according to Act of Congress, in the year 1869, by WELCH, BIGELOW, AND COMPANY, in the Clerk's Office of the District Court for the District of Massachusetts. ► University Press : Welch, Bigelow, & Co., Cambridge. CONTENTS. Page Introduction...........3 Abstract...........4 Dislocation of the Hip.........9 Anatomy of the Hip. The Y Ligament......... 17 Capsule of the Hip.........20 Ligamentum Teres.........21 Obturator Internus Muscle . . . . . . .21 Other Muscles..........24 Dislocations............25 General Remarks upon Reduction......27 Position of the Patient and Surgeon.....31 The Y Ligament, with Reference to Reduction and to Subse- quent Treatment.........32 How the Limb is to be Held.......33 Capsular Orifice to be Enlarged......33 Fracture of the Neck........35 Flexion, Extension, Adduction, Abduction, and Rotation . , 36 Circumduction..........36 Regular Dislocations. Dislocation upon the Dorsum Ilii......37 Signs...........38 Dorsal Dislocation between the Rotator Muscles . . .43 Reduction of the Dislocation upon the Dorsum . . 46 Dorsal below the Tendon ........58 Signs...........62 The Mechanism of its Production, and Cause of its Irre- ducibility..........64 Reduction..........67 Thyroid and Downward Dislocations.....70 Thyroid...........70 Signs...........70 Vertical downward Luxation.......73 Dislocations near the Tuberosity or Perinjeum . . .74 Reduction ..........79 Dislocation upon the Pubes, and below the Anterior Inferior Spine of the Ilium. — Dislocation upon the Pubes . . .84 IV CONTENTS. Dislocation below the Anterior Inferior Spine of the Ilium, or Sub-spinous........86 Reduction..........89 Anterior Oblique Dislocation......92 Dislocations in which the outer Branch of the Y Ligament is broken. — Supra-spinous Dislocation . . ..95 Reduction..........99 Everted Dorsal Dislocation.......100 Reduction..........102 Irregular Dislocations.........103 Irregular Upward Luxation.......105 Irregular Downward Luxation......105 Reduction..........107 Special Conditions of Dislocation. Old Dislocations and their Reduction.....107 Dislocation from Hip Disease......110 Dislocation of the Hip, with Fracture of the Shaft of the Femur...........112 Spontaneous Dislocation.......112 Angular Extension..........115 Fracture of the Neck of the Femur. Impacted Fracture of the Base......118 Anatomical Structure of the Neck of the Femur . . . 120 Rotation...........122 Shortening...........123 True Neck..........123 Remarks...........125 Impacted Fracture of the Base of the Neck with Inver- sion ...........128 Impacted Fracture of the' Neck of the Femur near the Head...........131 Comminuted Fracture of the Trochanters without Impac- tion ...........135 Fracture of the Neck of the Femur resulting in False Joint............137 Crack in the Neck of the Femur.....137 Fracture of the Pelvis.........139 Fracture of the Rim of the Acetabulum .... 139 Fracture in which the Head of the Femur is driven through the Acetabulum.........142 Asserted Fracture of the Acetabulum, without Crepitus, from a supposed impossibility of keeping the femur in Place...........143 Fracture of other Parts of the Pelvis .... 144 INTRODUCTION. Some of the more important points in this paper are presented in the following abstract, which may serve either as a table of contents or as a list of propositions to be established by the evidence in the text. The comparatively few published autopsies of dislocation of the hip, and the still fewer conclusive ones, may indeed be insufficient for the complete analysis of its compli- cated mechanism; but the deficient evidence may in a great measure be supplied by experiments upon the dead subject, where the essential conditions are identi- cal with those of the living and etherized patient, not- withstanding what has been alleged to the contrary. The views here advanced may also be tested by the light they throw upon reported cases, of which I have carefully examined such as were accessible to me. If still deemed inconclusive, they may remain in doubt until established or confuted by further observation; but in the mean time it is certain that dislocated hips can be reduced upon the principles and by the rules laid down and explained in this paper. After reason- able attention to the subject, I confess that I can find no explanation so satisfactory as that here given. 4 INTRODUCTION. ABSTRACT. 1st. The anterior part of the capsule of the hip joint is a triangular ligament of great strength, which, when well developed, exhibits an internal and external fas- ciculus, diverging like the branches of the inverted letter Y. It rises from the anterior inferior spinous process of the ilium, and is inserted into nearly the entire length of the anterior intertrochanteric line. 2d. The Y ligament, the internal obturator muscle, and the capsule subjacent to it, are alone required to explain the usual phenomena of the regular luxations. 3d. The regular dislocations are those in which one or both branches of the Y ligament are unbroken; and their signs are constant. 4th. The irregular dislocations are those in which the Y ligament is wholly ruptured; and they offer no constant signs. 5th. In the regular dislocations of the hip, the mus- cles are not essential to give position to the limb, nor desirable as aids in its reduction. 6th. The Y ligament will alone effect reduction and explain its phenomena, a part of those connected with the dorsal dislocations excepted. 7th. During the process of reduction, this ligament should be kept constantly in mind. 8th. The rest of the capsule, except perhaps that portion beneath the internal obturator tendon, need not be considered in reduction, if the capsular orifice is large enough to admit the head of the femur easily. INTRODUCTION. 5 9th. If the capsular orifice is too small to allow easy reduction, it should be enlarged. 10th. The capsular orifice may be enlarged at will, and with impunity, by circumduction of the flexed thigh. 11th. Recent dislocations can be best reduced by manipulation. 12th. The basis of this manipulation is flexion of the thigh. 13th. This manipulation is efficient, because it re- laxes the Y ligament, or because that ligament, when it remains tense, is a fixed point, around which the head of the femur revolves near the socket. 14th. The further manipulation of the flexed thigh may be either by traction or rotation. 15th. The dorsal dislocation owes its inversion to the external branch of the Y ligament. 16th. The so-called ischiatic dislocation owes nothing whatever of its character, or its difficulty of reduction by horizontal extension, to the ischiatic notch. 17th. "The ischiatic dislocation" is better named "dorsal heloiv the tendon','' and is easily reduced by ma- nipulation. 18th. The flexion of the thyroid and downward dis- locations is due to the Y ligament, which, in the first, also everts the limb, until the trochanter rests upon the pelvis. 19th. In the pubic dislocation, the range of the bone upon the pubes is limited by this ligament, which, in the sub-spinous dislocation also, binds the neck of the femur to the pelvis. 6 INTRODUCTION. 20th. In the dorsal dislocation with eversion, the outer branch of the Y ligament is ruptured. 21st. In the anterior oblique luxation, the head of the bone is hooked over the entire Y ligament, the limb being then necessarily oblique, everted, and a little flexed. 22d. In the supra-spinous luxation, the head of the femur is equally hooked over the Y ligament, the ex- ternal branch of which is broken. The limb may then remain extended. 23d. In old luxations, the period during which reduction is possible is determined by the extent of the obliteration of the socket, the strength of the neck of the femur, and the absence of osseous excrescence. 24th. Old luxations may possibly require the use of pulleys, in order by traction to avoid any danger which might result to the atrophied or degenerated neck of the bone from rotation. 25th. Right-angled extension, the femur being flexed at a right angle with the pelvis, is more advantageous than that which has usually been employed. 26th. To make such extension most effective, a special apparatus is required. Fractures of the Neck of the Thigii-Bone. 1st. The terms intra- and extra-capsular, applied to these fractures, have little practical significance. 2d. When a fracture near the head of the femur shows bony union, it is often impossible to say whether such a fracture was originally inside or outside of the capsular ligament. introduction. 7 3d. These fractures are therefore better divided, for practical purposes, into: 1st, the impacted fracture of the neck into the trochanter; 2d, other fractures of the neck. 4th. In this impacted fracture, the limb is everted, because the posterior cervical wall is almost always im- pacted, the anterior very rarely, and in a less degree. 5th. These conditions mainly result from the rela- tive thickness of the two walls. 6 th. While eversion is due to the rotation of the frac- tured bone on a hinge formed in the anterior cervical wall, shortening is generally due to the obhquity of this hinge. 7th. In a well-formed bone, the posterior and thin surface of the neck of the femur is prolonged into the cancellous structure beneath the intertrochanteric ridge, and is the true neck. 8th. The posterior intertrochanteric ridge is a but- tress built upon the true neck, by which, when im- pacted, this ridge is sometimes split off. DISLOCATION OF THE HIP. The original object of the following paper was to show, that, in dislocations of the hip, the position of the limb depends chiefly upon a ligament which has been of late years imperfectly described, and that the reduc- tion of these dislocations should be managed accord- ingly. In connection with this subject, I also at- tempted to show how the anatomical structure of the neck of the femur leads to a common variety of fracture of that bone. These views have been, as I believe, so well estab- lished by repeated experiments upon the dead subject, and so corroborated by current pathological phenom- ena, and by the mass of reported cases and autopsies, that little doubt can exist of their correctness. Since about the year 1854 - 55, the four dislocations of the hip, as usually described, together with the method of reducing them by manipulation alone, have been annually shown to the classes attending the lec- tures at the Massachusetts Medical College. These four luxations were made in each case upon a single dead subject, which, notwithstanding the great laceration to which the capsule of the hip had been subjected, in no instance failed to exhibit, and to demonstrate in a striking manner, the appropriate and well-known atti- tude of each dislocation. In fact, the firm and persist- 2 10 dislocation of the hip. ent position of a joint displaced under such circum- stances is quite remarkable. In these experiments, the fixed attitude of the limb was at first attributed to the muscles, which, when fully extended, are capable of considerable resistance in the dead subject, as well as in the living one; but it was supposed that the action of their complicated mechanism would hardly repay the labor of its study. In the spring of 1861, having been led to expose a joint, the luxation of which had been the subject of a lecture, I was agreeably surprised to observe the sim- ple action of the ligament, — a simplicity which sub- sequent experience has confirmed, and which strik- ingly explains the phenomena observed in the living subject.1 The dislocated joint alluded to presented on exam- ination the following appearances. 1. Great laceration of the muscles about the joint. 2. The ligamentum teres broken. 3. Laceration of the inner, outer, and lower parts of the capsule. 4. The anterior and upper parts of the capsule uninjured, and presenting a strong fibrous band, fan-shaped and forked. The remaining tendinous and muscular fibres about the joint being now completely divided, with the excep- tion of the strong fibrous band above alluded to, it was found that the four commonly described dislocations of 1 Of the figures accompanying this paper, those of the impacted fracture and of the Y ligament, numbered 1, 6, 7, 8, 19, 24, 25, 27, 29, 31, 46, 47, were reproduced, in the spring of 1861, from photographs made from this hip after dissection. In June, 1861, a paper upon the subject was read before the Boston Society for Medical Improve- ment ; a second paper before the Massachusetts Medical Society, in May, 1864; another, in June, 1865, before the American Medical As- sociation. In the present paper the rarer forms of dislocation have been added, with references to the more interesting reported cases. dislocation of the hip. 11 the hip could still be exhibited without difficulty, and that in each of them the anterior portion of the cap- sular ligament, which alone remained, sufficed at once to direct the limb to its appropriate position and to fix it there. Assuming, then, first, that each of these dislocations may be produced, and that, however much it may vary in degree, it uniformly exhibits its proper and familiar diagnostic signs, — secondly, that the anterior portion of the ligament of the capsule far exceeds in strength any other part of it, and that, on this ac- count, it not only is less likely to be torn, but gener- ally remains intact, — thirdly, that, when this alone re- mains, it is itself able to give position to the displaced limb,— and lastly, that, when it is divided, the other parts of the capsule, the muscles, and other tissues do this very imperfectly, as will be hereafter shown,— the a priori evidence is strong, that a luxated femur assumes its attitude chiefly in obedience to the traction of the tense fibres of this part of the ligament. The resistance of a dislocated limb is unyielding, and unlike that of muscular action elsewhere; in illustra- tion of which a few cases may be cited, taken almost at random from Sir Astley Cooper.1 " Case XXXVIII. — .... He was bled thirty ounces in the recumbent posture, and small doses of tartarized antimony were administered, but without these means producing syncope. He was then placed upon a large table, and his pelvis fixed in the usual manner, by long jack-towels passed between the perinaeum and the injured joint; the extending apparatus, composed also of a round towel, was then applied above the knee, and to it were attached weights to the amount of one hun- 1 A Treatise on Dislocations and Fractures of the Joints. London, 1842. 12 dislocation of the hip. dred and twelve pounds, fastened to a rope, which was rove through a pulley; to the influence of this weight he was submitted for four hours, but without any effect being produced. He was therefore then sent to Guy's Hospital. At half past seven, p.m., he was taken into the operating theatre. The pelvis was fixed by the com- mon padded bandage, whilst to the knee was attached the circular bandage and pulleys, and gradual exten- sion was made across the lower third of the opposite thigh for the space of twenty minutes, during which period he was given three grains of tartarized antimony in solution." " Case L. — John Cockburn, a strong, muscular man, aged thirty-three, was admitted into Guy's Hospital on the 31st of July, 1819. While carrying a bag of sand at Hastings on the 24th of July, he slipped, and dis- located the left hip-joint. The foot on the affected side was plunged suddenly into a hollow in the road, which turned his knee inwards at the same time that his body fell with violence forwards. On the day of the accident two attempts were made to reduce the dislocation by pulleys, but without success; and on the 27th of July a third, but equally unsuccessful, trial was made, although continued for nearly an hour. " It was found, upon examination, that the thigh was dislocated backwards into the ischiatic notch. The patient was carried into the operating theatre soon after his admission; and when two pounds of blood had been taken from him, and he had been nauseated by two grains of tartarized antimony, gradually ad- ministered, extension was made with the pulleys in a right line with the body, and the upper part of the thigh was raised, while the knee was depressed; the extension was continued at least for an hour and a half, during which time he took two grains more of dislocation of the hip. 13 tartarized antimony, by which he was thoroughly nauseated; the attempts at reduction, however, did not succeed."1 To a surgeon accustomed to the comparative ease with which the powerful muscles of a recently frac- tured thigh may be extended by a moderate effort con- tinuously applied, these cases of enormous resistance in the reduction of a dislocated hip suggest a force more powerful and unyielding than that of muscular action. Indeed, the facility with which muscular contraction is overcome by ether, while the deformity and resistance of dislocation continue, should long ago have led to the conviction that muscular contraction is not a chief agent in this deformity. But modern writers, with few exceptions, have adopt- ed the theory of active or passive muscular resistance. Sir Astley Cooper says : — " With respect to the fixed position of the head of the femur, in the four dislocations which have been described, it is not to be considered as a mere matter of chance, but the natural result of the influence of the muscles, which draw the bone into these positions, and that therefore, under common circumstances, the con- dition is inevitable."2 "The capsular ligaments, in truth, possess but little strength either to prevent dislocation or to resist the means of reduction." " The difficulty of reducing dislocations arises neither from the bones nor from the ligaments, but from the resistance which the muscles present by their con- traction." 3 1 It is curious to remark that this case ultimately yielded, in the hands of Sir Astley, to the employment, unusual for him, of the flexion method, though combined with pulleys. In further illustration of the disadvantage of horizontal extension, let this case be compared with a similar one (dorsal below the tendon) where the reduction occupied three seconds (p. 69). 2 Op. cit., p. 100. 3 Op. cit., pp. 20, 21. 14 dislocation of the hip. Dr. Nathan R. Smith recognizes muscular contrac- tion as the chief agent in effecting both dislocation of the hip and its reduction.1 That similar views are still entertained by distin- guished surgical authorities is shown by the follow- ing reported remarks of M. Chassaignac at a meet- ing of the Societe de Chirurgie in 1865: "The em- ployment of chloroform in the reduction of disloca- tions had convinced him (M. Chassaignac) that obsta- cles to reduction said to be due to other causes than muscular contraction were chimerical,"2 — an observa- tion that seems to have passed unchallenged. Dr. Reid makes the following statement: " The chief impediment in the reduction of dislocation is the indi- rect action of muscles that are put upon the stretch by the malposition of the dislocated bone.....The limb or bone should be drawn in the direction which will relax the distended muscles."3 On the other hand, the theory of ligamentous resist- ance has been occasionally and distinctly recognized. Boyer expresses his conviction of the importance of the ligament in this relation, but without proof.4 Professor Gunn maintains, in a paper5 upon this subject, that any untorn or " undissected " portion of the capsular ligament is capable of producing the signs 1 Med. and Surg. Memoirs, by Nathan Smith, M. D. Edited by Nathan E. Smith, M. D. Baltimore, 1831. pp. 166, 167. 2 London Med. Times and Gazette, Dec. 1865. p. 661. 3 Dislocation of the Femur on the Dorsum Ilii reducible with- out Pulleys or any other Mechanical Power. By William W. Reid, M. D., of Rochester. Transactions of the N. Y. Medical Society. Albany, 1852. p. 41. 4 Traite des Maladies Chirurgicales, etc. Par M. le Baron Boyer. Paris, 1822. Tom. IV. p. 282. 6 Luxations of the Hip and Shoulder, and the Agents which oppose their Reduction. By Moses Gunn, A. M., M. D., Prof. Surg. Univ. Michigan. Detroit, 1859. dislocation of the hip. 15 of hip and shoulder luxation; while, since the reading of the present paper, Professor W. Busch,1 at the Bonn Clinic, has recognized the resistance to the reduction of dislocation as ligamentous and capsular, although he fails to identify the anterior ligament as its principal seat. There is no doubt that in luxation as well as frac- ture the muscles soon contract and adapt themselves to the new condition of things, so that the limb is steadied partly by the effort of the patient. In those luxations of the hip, for example, which exhibit great flexion, the muscles may thus contribute, when the patient is standing, to support the limb in a flexed position, while its own weight tends to straighten it; they may even help to convert a dislocation below the socket into one upon the dorsum, or into the foramen ovale, — or they may assist simply to reduce it. But there is no evidence that dislocations below the socket are capable of retaining their distinctive features, in an erect posture of the body, when the muscles are re- laxed, as in the dead or etherized subject. Again, some of the muscles are stretched and elon- gated by the luxated bone; and their passive strength under these circumstances, which is greater than might be supposed, has been well illustrated by Dr. Reid. But it is unnecessary to dwell upon the tenacity of the mus- cular fibre passively stretched to its extreme limit, be- cause this extreme tension does not occur in the usual dislocations, being prevented by the ligamentous ac- tion. It may be remarked, however, that muscle is far less strong than ligament, and that the muscles about the hip, which are inserted near the head of the femur, are acted upon at great advantage by this pow- erful lever, and might yield, were they unsupported. 1 Year-Book of Medicine, Surgery, etc., for 1863. Sydenham Soci- ety. London, 1864. p. 225. 16 dislocation of the hip. Moreover, the dislocated hip can be shown equally well upon a subject in which the muscles have become soft by decomposition; and when the four classical disloca- tions have been produced upon a single subject, most of the muscular tissue immediately surrounding the joint will be found to have been torn away, while the rest may be divided, without materially affecting the power of the limb to illustrate these four luxations. On the other hand, — a fact which is conclusive, — if the entire capsule of the hip joint be divided, and the muscles left intact, these dislocations are but imper- fectly represented. Without denying, then, that muscular fibre exerts both an active and a passive force, it is here assumed that the muscles play but a subordinate and occasional part either in hindering reduction or in determining the character of the deformity, and that this is chiefly clue to the resistance of a ligament, the power of which will presently be illustrated, and whose simple mechanism will explain the phenomena both of luxation and its reduction. Out of twenty-two recorded autopsies, while in two only is there any allusion to the rupture of the anterior portion of the capsule, in fourteen it is dis- tinctly mentioned that it remained wholly or in part unbroken : a large proportion, considering that atten- tion has hitherto not been directed to this point. It is not here maintained that this ligament will be found stripped clear of the remaining portion of the capsule : the comparatively few autopsies on record show that this is not the case: there is, however, reason to be- lieve that the thinner portions owe their immunity from injury to the protection of the main ligament. The theory here advanced recognizes the anterior portion of the capsular ligament as the exponent of the total agency of the capsule in giving position to the dis- dislocation of the hip. 17 located limb, and, what is more important, as so identi- fied with the phenomena of luxation, that reduction must be accomplished almost wholly with reference to it. It remains for future autopsies to show, by care- ful examination, how far the usual phenomena either of luxation or its reduction can occur after rupture of this ligament. The Y Ligament. The ilio-femoral ligament, known also as the liga- ment of Bertin, has been usually described as rein- forcing the capsule by a single fibrous band extend- ing from the inferior iliac spine to the inner extremity of the anterior intertrochanteric line, and playing no very important part in health or injury. This liga- ment is more or less adherent to the acetabular prom- inence and to the neck of the femur; but it will be found, upon examination, to take its origin from the anterior inferior spinous process of the ilium, pass- inp; downward to the front of the femur, to be inserted fan-shaped into nearly the whole of the oblique " spi- ral" line which connects the two trochanters in front, — being about half an inch wide at its upper or iliac origin, and but little less than two inches and a half wide at its fan-like femoral insertion. Here it is bifur- cated, having two principal fasciculi, one being inserted into the upper extremity of the anterior intertrochan- teric line, and the other into the lower part of the same line, about half an inch in front of the small tro- chanter. The ligament thus resembles an inverted Y, which suggests a short and convenient name for it. The divergent branches of the Y ligament are some- times well developed, with scarcely any intervening membrane. In other cases the intermediate tissue is thicker, and requires to be slit or removed before the 3 18 dislocation of the hip. bands are distinctly defined; and sometimes the whole triangle is of nearly uniform thickness. In the subject first dissected, and from which the accompanying wood- cut was designed, the external fasciculus of fibres was nearly as well developed as the inner band; in two other subjects it was actually wider and thicker. But as the internal and external branches exercise somewhat distinct functions,—the one being chiefly concerned in limiting the extension, the other the eversion, of the femur, — it is fair to infer that in a normal condition they would exhibit great- er development than the intermediate fibres. The Y ligament is of remarkable tenacity and strength, being at some points, when well de- veloped, nearly a quar- ter of an inch in thick- ness, and forming an un- yielding suspensory band, by which the femur, when in a state of extension, as in walking, is forcibly retained in its socket. In six by no means recent subjects, taken at random from the dissect- ing-tables and suspend- ed by the shoulders, the lower limbs being united to the pelvis by the Y ligament alone, this ligament Fig. 1. — The Y ligament, showing its inner and outer fasciculi. The for- mer is known as the ilio-femoral ligament, the ligament of Bertin, etc. This specimen showed the interval between the two fasciculi. (From a photograph in 1861.) Fig. 1. dislocation of the hip. 19 required for its rupture the attachment of weights to the foot varying in the several cases from two hundred and fifty to seven hundred and fifty pounds.1 The dissection of the Y ligament here represented, taken from a photograph made in 1861, first direct- ed my attention to the anatomical arrangement and strength of its fibres. A few months ago, I found, upon referring to works in the library of my distin- guished colleague, Professor 0. W. Holmes, the follow- ing passages, which show that a bifurcation of this ligament was known to some of the earlier anatomists, although it has since been generally overlooked. The first is from Winslow: — " It [the ligament] is very thick between the anterior inferior spine of the os ilium all the way to the small anterior tuberosity which unites, as it were, the basis of the great trochanter with the basis of the neck. It is likewise very thick between the same spine and the middle part of the oblique rough line observable be- tween the tuberosity and the little trochanter; and here likewise it is strengthened by a bundle of fibres connected to the passage of the tendon of the iliac muscle and to the inferior portion of the oblique rough line. The disposition of the ligamentous fibres of which these two thick portions are composed forms a sort of triangle with the oblique rough line which terminates the basis of the neck."2 1 Although autopsies show that the whole of this ligament has sometimes been torn asunder, it may be assumed that such a lesion is likely to be of rare occurrence. Its strength probably insures its immunity in a large majority of luxations, while the constancy of their signs, which will be shown to be best explained by the action of this ligament, testifies to its integrity. 2 An Anatomical Exposition of the Structure of the Human Body. By James Benignus Winslow. (Douglas's Translation.) Lon- don, 1776. Section II. 138, 139. 20 dislocation of the hip. Weitbrecht, an excellent, perhaps the best, authority upon the ligaments, referring in this connection to Winslow, distinctly recognizes a forked arrangement, which he thus describes : " Partim anterius versus col- lum femoris et trochanterem minorem procedit, .... partim vero lateraliter versus exteriora progreditur, et circa radicem trochanteris majoris in tuberculo laterali terminatur. Atque binae hae divaricationes, una cum linea obliqua, figuram .... triangularem .... constituunt,"1 The Webers describe the ligament as triangular, laying stress upon its thickness, which, as they as- sert, is greater than that of the ligament .of the pa- tella or the tenclo Achillis, and concluding thus : "With this great strength, we should expect that every other part of the capsule would be ruptured before this ligament, and that even the bone itself would first yield."2 Capsule of the Hip. In a front view of the cleanly dissected capsule of the joint, the Y ligament is distinctly seen, the tissue occupying its fork being sometimes a mere membrane, and sometimes thicker. The external band hinders eversion, especially when the leg is extended. Both bands limit extension. In abducting the leg, a band is raised (pubo-femoral) between the bony ridge above the thyroid foramen and the prominence at the inner part of the intertrochanteric line, hindering abduction in every position of the limb. Between this band and the Y ligament the capsule is compara- 1 Syndesmologia, sive Historia Ligamentorum, etc. Josias Weit- brecht, D. M. Petropoli, 1742. p. 141. 2 Traite d'Osteologie, etc. S. P. Soemmerring, and G. and E. Weber. Paris, 1843. pp. 3i3, 324. DISLOCATION OF THE HIP. 21 tivcly thin, and here the primitive pubic dislocation doubtless occurs. Behind and inside the pubo-femoral band, looking directly towards the thyroid foramen, is found the thinnest part of the capsule, which at this point resembles wet bladder, readily permitting the thyroid dislocation. Outside and behind the Y liga- ment, where the dorsal dislocations occur, the capsule is very strong, limiting adduction and rotation inward. There is also a fasciculus from the tuber ischii at its upper part to the upper part of the trochanter behind, arresting flexion and inversion. The principal liga- mentous bands are the two first described, no part of the capsule comparing in strength with the Y ligament and the tissue which lies immediately behind it, be- neath the tendon of the obturator internus muscle. Ligamextum Teres. Little can be added to the excellent paper of Mr. Struthersx upon the function of this ligament. When the limb is bent upon the body, it hinders eversion, thus opposing the action of the sartorius muscle, and hindering, in this position, dislocation upon the thy- roid foramen. It is not, however, possessed of much strength, is ruptured in all the complete and sudden dislocations, and, according to Cruveilhier, is often un- developed and sometimes wanting. Obturator Internus Muscle. It will hereafter be seen that this muscle, with which the gemelli are practically identified, is materially con- cerned in one variety of hip dislocation, and is impor- tant in relation to its reduction. There is an unde- 1 Edin. Med. Journal, Nov., 1858, p. 434. 22 dislocation of the hip. scribed peculiarity of the obturator internus which explains its strength. Its muscular belly is, in some subjects, mingled with tendinous fibres. This may be verified in dissection by reflecting the muscle from its pulley so as to expose its internal and fibrous surface. The four or five tendinous divisions which wind round the lesser sacro-sciatic notch, and which seem to dis- appear in the thickness of the muscular tissue, may then be traced in part to a bony origin, — some of their minute and ultimate fibres arising from the margin of the obturator foramen. The muscle, when extended, thus practically becomes a ligament, and by the attach- ment of its combined tissues acquires great strength. Again, the friction of the tendon over the pulley lessens the draft upon the extended muscle, and so increases its power of resistance that it is the strongest,1 as in relation to luxation it is the most important, of the small outward rotators of the hip. That portion of the capsule which lies directly beneath the tendon is also very strong, and while their fibres mutually rein- force each other, their mechanical action in the dorsal luxations is much the same. Arising within the pelvis, the obturator internus emerges from the pelvic cavity at a point several inches behind the great trochanter, into the back and upper part of which it is inserted. By its con- 1 The average weight required to rupture this and the adjacent muscles in four subjects is as follows : — Pyriformis 10 lbs. Obturator internus 401 " Obturator externus 36|- " Gluteus medius 17 " In the only recent subject among these, the obturator internus on one side parted at 64 lbs. and on the other at 60 lbs., the obtu- rator externus at 52 and 44 lbs., and the pyriformis at 16 lbs. DISLOCATION OF THE HIP. 23 traction it draws the trochanter backward, everting the thigh, when straight, and abducting it, if flexed. Upon the dead or etherized subject, it is rendered tense in the extended limb by rotation inward, adduction being then more limited ; but in the flexed limb, and especially in extreme flexion, it is relaxed, so that, in reducing a backward dislo- cation, when this muscle is still entire, it might be advantageous to flex the limb as much as pos- sible. A curious cor- roboration of the importance of this muscle, as well as of the external branch of the Y ligament, is seen in a prepa- ration1 of my own, the case having been one of old ununited fracture of the neck of the femur in a subject, the weight of whose body in walking had been suspend- ed chiefly between the outer branch of the Y ligament in Fig. 2. front and the obtu- 1 No. 2715, Warren Anat. Museum, Massachusetts Medical Col- lege. Fig. 2. — Ununited fracture of the neck of the thigh-bone, showing the hypertrophied outer fasciculus of the ligament supporting the weight of the pelvis in walking. The inner fasciculus is seen below. 24 DISLOCATION OF THE HIP. rator internus be- hind. (Figs. 2 and 3.) This is proba- bly the usual con- dition of patients after this injury, where the shaft of the femur moves freely upon the de- tached head of the bone. BBfe^ Other Muscles. It has already been stated that the restricted move- ments of the thigh in the various lux- ations are in part due to the active and passive resistance of several mus- cles which, like the psoas and iliacus, connect the femur with the pelvis and become more or less tense by its displacement; yet their action, in a practical point of view, is of secondary importance, whether consid- ered in relation to its direction or its extent. With- out the powerful ligament and the muscle already de- scribed, the regular femoral luxations would lose much of their present distinctive character; and regard being had to the action of these fibrous bands, the dislocations can be reduced with little reference to the muscles. It may, however, be briefly stated that the gemelli are practically identified with the obturator internus, while Fig. 3. Fig. 3. — The same seen from behind, to show the tense obturator ten- don bearing its share of the weight of the body; the inferior gemellus, hypertrophied, is seen below it. DISLOCATION OF THE HIP. 25 the obturator externus below it and the pyriformis above it are also outward rotators, the whole forming a deep muscular layer with interstices. The quadratus femoris muscle is below the usual range of dislocations, but is easily and frequently torn; and the three glutei have comparatively little efficacy in rendering the fe- mur immovable, even when its head is engaged, for example, beneath the medius. The psoas and iliacus exert a force in the direction of the Y ligament, es- pecially when that is ruptured; and if the limb is elongated, the adductors, the flexors of the leg, the tensor vaginae femoris, and the muscular fibres arising from the anterior part of the crest of the ilium, may all become more or less tense.1 DISLOCATIONS. Malgaigne is undoubtedly right in assuming that dislocation of the hip is sometimes only partial. These various degrees of dislocation give to the limb the slight differences of position observed in different cases of the same luxation. But the observation is not new. Hippoc- rates, in speaking of dislocation of this joint, remarks: u In a word, luxations and sub-luxations take place in different degrees, being sometimes greater and some- times less."2 Yet it cannot be denied that the general character of the deformity is the same for the same dislocation, and that the phenomena were on the whole well described by Cooper, and by preceding writers from the time of Hippocrates,3 in three or four now familiar 1 In a case of persistent flexion after reduction, I divided these fibres. (See p. 57.) 2 The Genuine Works of Hippocrates, etc., printed for the Syden- ham Society. London, 1849. Vol. II. p. 631. 3 Hippocrates describes the luxations on the dorsum, thyroid fora- 26 DISLOCATION OF THE HIP. varieties, with three or four rarer forms of displace- ment, considered to be anomalous. Accumulated experience has justified the practical value of this general division, which should not be lost sight of, either by exaggerating unimportant differ- ences or through needlessly obscuring what is plain by names of recondite derivation. Most surgeons have seen these dislocations in the living subject, and, although the rotation, the shortening, or other dis- placement, may have varied a little in each case, will concede that the general position of the limb is too constant and characteristic to be slighted either as a guide to the direction of the luxation or to the force appropriate for its reduction. I have therefore adhered as far as possible to the familiar names of hip luxation, which, as usually designated, are those upon the dorsum, the ischiatic notch, the thy- roid foramen, and the pubes. Great stress having been laid by most modern writers on a distinction between the two first, which, if reduced by the flexion method, are wholly unimportant variations of the same displace- ment, I shall endeavor to show how dorsal dislocations may be divided for practical purposes, — also, that cer- tain other less frequent luxations, hitherto classed as anomalous, are determined by the same mechanism as the rest, and with equal certainty. Assuming that the Y ligament exerts a uniform influ- ence upon the several dislocations, they will be here described, with a view to their practical arrangement, according to the following classification. men, and pubes, justly including with the first variety that which has since been called " dislocation upon the ischiatic notch," most of the cases so described by modern writers being only dorsal. In a fourth variety, the dislocation "backwards," — which has been, as I conceive, erroneously interpreted by his translators as " into the ischiatic notch," — Hippocrates describes at some length the disloca- tion directly downwards. DISLOCATION OF THE HIP. 27 r -«2 5S I. The Regular Dislocations, in which one or both branches of the Y ligament remain unbroken. 1. Dorsal. 2. Dorsal below the Tendon (ischiatic notch of Cooper). 3. Thyroid and Downward. Obliquely inward on the thyroid foramen, or as far as the perinceum. Vertically doivnward. Obliquely outward as far as the tuberosity. 4. Pubic and Sub-spinous. 5. Anterior Oblique. ' _ "L \ External branch broken} 7. Everted Dorsal. J II. The Irregular Dislocations, in which the Y ligament is wholly ruptured, and whose characteristic signs are therefore uncertain. General Remarks upon Reduction. When the patient lies upon his back, especially if ether- ized, the dislocated limb gravitates, and the Y ligament becomes more and more tense as the limb approaches 1 Although the anterior oblique, supra-spinous, and everted dorsal luxations resemble each other, it has been thought advisable to dis- tinguish between them for the purpose of more accurately classifying recorded cases. In the anterior oblique luxation the outer branch of the Y ligament is still entire, as seen in the figure illustrating this luxation, where the ligament is of uniform thickness. This, indeed, is a form of supra-spinous luxation, but the limb cannot be brought down to a perpendicular, and corresponds in position with that in a case reported by Cooper. If the limb is forcibly brought to a perpen- dicular, the external branch is ruptured, and to such a case the term " supra-spinous " is here assigned. The term " everted dorsal" is intended to imply a power of eversion more or less complete. In such a case the limb may be everted at various angles, which can happen only after a rupture of the external branch of the ligament. 28 dislocation of the hip. nearer and nearer to a state of complete extension. If, now, as is here maintained, the chief obstacle to reduc- tion of the luxated hip is found in this ligament, it fol- lows that the method taught by Sir Astley Cooper, the weight of whose unquestioned authority has un- fortunately availed to give it currency1 during many years, is based upon an erroneous conception of the nature of the difficulty to be encountered. By that method the limb is placed as nearly as may be in the axis of the body, thus rendering the Y ligament tense and inviting its maximum of resistance before traction is made. Hence the necessity for pulleys, the tendency of which is undoubtedly to elongate, or partly detach, at its femoral insertion, this powerful ligamentous band, at great sacrifice of mechanical force, with proportionate violence to the neighboring tissues and uncertainty as to the result. By the flexion method, which dates from a remote antiquity, the Y ligament is relaxed, its resistance annulled, and reduction often accomplished with surprising facility. The following is the statement of Hippocrates on this subject: "In some the thigh is reduced without preparation, with slight extension, di- rected by the hand, and with slight movement; and in some the reduction is effected by bending the limb at the joint, ivith gentle shaking."2 In view of this observation 1 See Edin. Med. Journal, May, 18G7. On the Reduction of Dis- locations of the Hip-Joint by Manipulation, by Thomas Annandale, Lecturer on Surgery, etc. " Its adoption in this country " (reduction by manipulation) " is as yet by no means general." 2 Dr. Adams, in his Sydenham Translation of Hippocrates, renders this passage, "bending the limb at the joint, and making rotation.'" (Vol. II. p. 643.) Mr. Sophocles, the distinguished Professor of Greek in Harvard University, has kindly furnished me the following conclu- sive note, defining precisely the character of this movement. " Your question has reference to the meaning of the word KiyKkiais, the formation of which is as follows : Kiyi<\os, wag-tail, a well-known bird in Greece, called also cre«ro7rvyis, the Latin motacilla. KiyKkifa, DISLOCATION OF the hip. 29 of the Coan sage, 450 b. c, the indiscriminate use of pul- leys hardly testifies to the progress of modern science. Flexion lies at the foundation of success in the reduction of femoral dislocation, and compared with this the rest of the manipulation is of secondary im- portance. It may be taken as a safe and general rule, that, after the thigh has been flexed at a right angle, the head of the bone is to be at once guided towards the socket, and that, if the capsular orifice is large enough, the operator will in general succeed, — while it is equally certain that in the extended position of the limb the chances are all against him. When the femur is flexed, reduction may be effected in either of two ways. In the first (traction), the head is drawn, or forced, at once in the desired direction. In the second (rotation), the same result is accomplished by a rotation of the femur, which, in winding1 the Y ligament about its neck, shortens it, and thus compels the head of the bone, as it sweeps round the socket, also to ap- proach it. In reducing a hip, the success of rotation, adduction, abduction, and extension depends upon this ligament, while the whole manipulation must be con- ducted with reference to it. In modern times the flexion method has com- mended itself to the good judgment of various sur- geons. Many cases of successful reduction by this method are to be found in the journals, and many more to wag (in the original sense of the term), as the bird aforesaid wags its tail. " Klytchiais and KiyK\i