REDUCTION OF DISLOCATIONS. 
BV r ' 
WM. WARREN GREENE, M.D. 
PROFESSOR OF SURGERY IN THE MEDICAL SCHOOL OF MAINE, ETC. ETC. PREFATORY NOTE. 
To the Editor of the Boston Medical and Surgical Journal. 
Dear Sir,—Nearly two years ago I began the preparation of a paper upon the Reduction of Dislocations, 
which ill health prevented my finishing. 
This work was undertaken both from an inclination on my own part to place before the profession doctrines 
which I deem of great importance, and also in accordance with the often expressed wish of many of my pupils that I 
should put on record views which they have found so valuable after testing them in practice. 
With returning health I find my disposition for the work revived, while my conviction of its importance has 
been deepened by additional reflection and experience. 
I have, therefore, written this paper, which, imperfect as I know it to be in its treatment of the subject, having 
been prepared amidst the constant pressure of other labor, contains ideas that I feel sure are worthy of the careful 
Attention of my professional brethren. w. a. 
Portland, Oct. 25, 1869. REDUCTION OF DISLOCATIONS. 
In the discussion of this subject I shall 
confine myself to the consideration of two 
main questions. 
1st, What is the principal obstacle en- 
countered in our efforts at reduction ? 
2d, What rules of procedure should guide 
us in the treatment of these injuries ? 
If an answerto the first question is sought 
for in the surgical text books of the day, it 
will be seen that muscular resistance is uni- 
versally deemed to be the great hindrance 
to reduction, and upon this idea are based 
the various methods of treatment recom- 
mended by surgical writers, from Hippocra- 
tes down to the present time. It is true 
that some authors admit other subordinate 
agencies, and Gross, with a characteristic 
breadth of view, attaches much importance 
to the great ease with which luxations are 
occasionally reduced even in muscular sub- 
jects, and on the other hand to the great 
difficulty oftentimes experienced in reliev- 
ing these deformities even after complete 
muscular relaxation has been produced by 
venesection, nauseants and amesthetics ; 
and he argues that the catching of the head 
of the bone under the muscles and tendons, 
the Bmall size of the aperture in the capsule 
through which it has escaped, and the in- 
terlocking of the various prominences and 
depressions so common in the vicinity of 
articulations and so marked in certain lo- 
calities, must occasionally prove serious ob- 
stacles to reduction. Still he does not, 
nor, so far as 1 know, do any of the syste- 
matic writers on surgery recognize these 
conditions as other than occasional and mi- 
nor in their operation. I think conclusive 
evidence of professional opinion on this 
subject, at the present time, may be found 
in the last edition of Erichsen’s Surgery, 
the American reprint of which Mr. Lea of 
Philadelphia has issued within four months 
past. This really excellent work, which in 
most respects is fairly up to the times, may 
be assumed to teach the modern views and 
practices of the great majority of surgeons ; 
and in the chapter on Dislocations, under 
the head of Treatment, page 291, the author 
makes this plain and unqualified statement. 
“The great obstacle to reduction is the 
tonic contraction of the muscles inserted into 
or below the displaced bones, and the sur- 
geon’s efforts are chiefly directed to over- 
come this contraction.” 
As my own belief and corresponding 
practice is diametrically opposed to this 
statement, I will first state it, and then in- 
dicate the line of thought through which I 
was brought to my conclusions. 
Since February, 1856,1 have believed and 
taught, for the last nine years publicly, as 
my classes in Berkshire Medical College, 
the Medical School of Maine and the Uni- 
versity of Michigan can testify :— 
1st, That the main opposing force to the 
reduction of dislocations is the untorn portion 
of the capsular ligament. 
2d, That in our efforts at reduction the 
primary object should be the relaxation of 
the untorn portion of this ligament, and that 
whatever mode of procedure accomplishes 
this ivith most facility is the best. 
3d, That occasionally the small size or pe- 
culiar shape of the rent in the capsule, or, in 
peculiar conditions of the nervous system, 
muscular contractions, may constitute the ma- 
jor forces with ivhich we have to deal; but 
that these cases are so extremely rare as not 
at all to invalidate the general rule. 4 
REDUCTION OF DISLOCATIONS. 
I desire at this point to call attention to 
the fact that these propositions are not 
restricted to special dislocations, either as 
regards locality or variety, but apply to 
this class of injuries generally. 
When a student of medicine in 1852 I be- 
came acquainted with Dr. Reid’s views, 
then just published, upon reduction of the 
upward and backward dislocation of the 
head of the femur by manipulation. In a 
conversation upon the subject with my 
venerable friend, the late Dr. Young B. 
Walker, of Waterford, Me., he informed 
me that he had repeatedly effected reduc- 
tion by a similar procedure which he learned 
from his preceptor, Prof. Nathan Smith, 
whom he had seen practise it successfully. 
He also said that l)r..Smith’s explanation 
of the success of the method, as well as his 
own, accorded with that of Dr. Reid in at- 
tributing it to muscular relaxation. 
In the winter of 1854-5 it was my privi- 
lege to be under the instruction of that ex- 
cellent surgeon and teacher, Prof. Moses 
Gunn, now of Rush Medical College, Chi- 
cago. 
He taught at that time that in the several 
luxations of the head of the humerus, and in 
the upward and backward displacement of 
the capxd femoris, the untorn portion of the 
capsule was the main obstacle to reduction, 
and so far as the hip was concerned, he de- 
monstrated his theory before his class upon 
a cadaver, having the articulation entirely 
cleared of surrounding muscles. Professor 
Gunn took, and ably defended the same po- 
sition, in a paper published in the Peninsu- 
lar Journal of Medicine in September, 185/, 
also published in the New York Journal of 
Medicine, and in a subsequent article, in 
which a part of the first paper was repro- 
duced, which appeared in the Peninsular 
Journal in May, 1855. 
It will be observed that while Dr. Gunn 
applied the same principle to the several 
luxations of the shoulder as to the one of 
the hip above mentioned, and while he dif- 
fered entirely from Smith and Reid in his 
explanation of the remarkable ease of reduc- 
tion by manipulation, putting ligamentous 
tension in place of muscular contraction, he 
yet like them confined the application of the 
principle, in the coxo-femoral articulation, 
to the upward and backward and 
in reply to my question whether the other 
dislocations of this joint might not be treated 
upon the same theory, he[said he thought not. 
These were the sources and this the ex- 
tent of my knowledge upon the subject of 
reduction by manipulation and the claim 
of untorn ligament for consideration when 
I entered upon practice ; nor have I from 
that time to this seen or heard anything 
farther about the matter, outside of my own 
investigations, except the remarks of Prof. 
Busch in the Year Book of the Sydenham 
Society for 1863, in which he attributes the 
resistance in hip luxations to ligament in- 
stead of muscle. I should add, that while 
I have no knowledge of such fact from Prof. 
Gunn himself, I have been told by several 
students that he now extends the principle 
to the several coxo-femoral displacements. 
I became firmly possessed with the idea 
that so important a principle as this had 
been shown to be in connection with cer- 
tain luxations, must have a more general 
application, and within a few months after 
graduating I had a case of dislocation of 
the caput femoris forward and upward upon 
the pubis, that I reduced with my own hands 
without the aid of antesthetics. 
A. few weeks later I saw a backward and 
outward luxation of the elbow in a lady 40 
years old. I directed extension to be made, 
in the line which the forearm then occupied, 
being the ordinary angle of flexion seen in 
this injury ; this was done by first one, then 
two and finally three men pulling upon a 
towel attached at the wrist, while counter 
extension was made upon the arm just 
above the elbow, but without avail, the pa- 
tient being meantime profoundly etherized. 
I now directed the assistants to cease their 
efforts, and seizing the arm firmly just 
above the elbow with my left hand, and the 
forearm with my right, 1 flexed the limb, 
making at the same time slight extension 
and rotation, and the deformity was imme- 
diately relieved. I argued with myself that 
if the resistance was principally or entirely 
muscular the powerful extension was cer- 
tainly sufficient to overcome it, and that at 
any rate its action upon the muscles sim- 
ply, was greater than the subsequent effec- 
tual movements of the limbs made by my 
own hands. Soon after this, in conversa- 
tion with Dr. Daniel Towne, he 
alluded to the case of a man killed'by ma- 
chinery, who with other injuries sustained 
a dislocation of the elbow. The Doctor 
was called to put the mangled remains in 
as decent condition as possible for burial, 
and among other things reduced the luxa- 
tion, - and,” said he, “ it required as much 
force to set those bones as if he had been 
alive.” He also assured me that he saw 
the body before rigor mortis occurred. 
These several cases strengthened my sus- 
picion that in all forms of dislocation liga- 
ment and not muscle was the offending 
agent, and in the following winter 1 iin- REDUCTION OF DISLOCATIONS. 
5 
proved an opportunity to make such obser- 
vations pout mortem upon the articulations 
of the elbow, wrist and phalanges as con- 
vinced me of the truths embodied in the 
propositions already laid down. 
In considering the relative importance of 
ligamentous and muscular resistance to re- 
duction the following facts should be well 
pondered:— 
1st. The shafts of the long bones are, as 
a rule, surrounded by groups of muscles 
quite as powerful in their combined action 
as are those that envelope their articulations. 
2d. In fractures of the shaft, with dis- 
placement of its mobile fragments whose 
sharp and ragged ends are constantly pro- 
voking muscular spasm, which increases 
its own cause, the amount of “ contrac- 
tion ” is at least equal to that resulting 
from the displacement of its smooth and 
rounded articular extremity, which occu- 
pies a fixed position. 
3d. In the various fractures (not impact- 
ed) occurring in the arm, forearm, thigh 
and leg, the eases are very rare in which 
the surgeon is not able, with his own 
hands, to make sufficient extension for the 
relief of the deformity, thus overcoming, 
of course, muscular contraction, even with- 
out anaesthetics, his main difficulty being 
to retain the fragments in proper apposi- 
tion ; while in dislocations, effective ex- 
tension in the ordinary mode often requires 
the force of several men or of the com- 
pound pulleys. 
4th. Profound anaesthesia annuls muscu- 
lar resistance. But while it allows the 
fragments of a fractured bone to be re- 
placed with the utmost facility, it often- 
times fails to diminish in any appreciable 
degree the difficulty of reducing disloca- 
tions, the most powerful extending force, 
if applied in the ordinary manner, still be- 
ing required. 
5th. It frequently happens that disloca- 
tions occurring in strong men, where there 
is no evidence of extraordinary muscular 
injury, are reduced with great ease by the 
rules laid down in the books, without anaes- 
thetics, and when the muscles are seen and 
l’elt to be in a state of positive resistance. 
It would seem that such considerations 
as these should long ago have taught sur- 
geons that an opposing force so constant 
under the varying conditions of muscular 
activity and repose, and again occasionally 
found wanting where vigorous muscles are 
known to be in a state of resistance, must be 
ligamentous. But I apprehend that hero, 
as in other departments of thought, pro- 
gress has been hindered by that too prova- 
lent habit of observation and reasoning by 
which selection is made of such evidence as 
seems to substantiate a theory, while facts 
which, viewed in the light of the theory, 
occupy equivocal or mysterious ground, 
are ignored or passed lightly by. The 
world is full of doctrines, both in and out- 
side of Medicine and Surgery, that can 
claim only this kind of support. 
Upon the theory that muscular contrac- 
tion is the most powerful opposing force to 
reduction, a very large proportion of the 
difficult cases must remain unexplained. 
But upon the assumption that the untorn 
portion of the capsule is the principal agent 
with which we have to deal, everything be- 
comes clear, even from a theoretical stand- 
point alone, the exceptional cases, as will 
be clearly seen, I trust, before I close, prov- 
ing the rule ; and when we add the posi- 
tive demonstrations upon the cadaver, strip- 
ped of its muscles, that, excluding such 
cases as have already been and will here- 
after be alluded to, and which are equally 
important as corroborating this view, un- 
torn ligament does accurately and constant- 
ly determine the characteristic deformity 
of the various luxations, and that, before 
reduction can be effected, this firm, dense, 
inelastic structure must either be torn through 
or relaxed; and furthermore, that by the time- 
honored method of extension and counter- 
extension the laceration is necessarily com- 
pleted before the deformity can be relieved, 
the proof would seem complete. 
With the exception of two years, I have, 
since 1856, annually repeated these demon- 
strations in the dissecting-room, under the 
observation of private students and of mem- 
bers of the profession, and in ten succes- 
sive courses of lectures have given the 
same illustrations more or less fully before 
my classes in the lecture-room. 
Among many gentlemen who have kindly 
assisted me while pursuing these studies, 
I am especially indebted to my former pu- 
pils, Drs. E. B. Lyon of Palmer, Mass., F. 
K. Paddock of Pittsfield, Mass., Geo. E. 
Frothingham, Michigan University, and 
II. II. Kimball, Minneapolis, Minn., for 
valuable aid ; also to Dr. II. S. Cheever, of 
the University of Michigan, who, while 
Demonstrator of Anatomy in that institu- 
tion in 1867-68, very kindly afforded me ex- 
tensive opportunities for experimentation. 
As 1 have already said, these observations 
have abundantly confirmed the truth of the 
propositions already laid down, and which 
in general terms answer the two questions 
under consideration. I shall now state, as 
briefly and concisely as possible, the points 6 
REDUCTION OF DISLOCATIONS. 
of greatest interest, both pathological and 
therapeutical, in relation to the several ar- 
ticulations, as noticed upon the subject 
stripped of muscles. 
The Shoulder.—In this articulation the 
three luxations downward, forward and 
backward are readily produced by dividing 
the corresponding portions of the capsule 
to an extent sufficient to admit of the pas- 
sage of the head of the humerus through 
the opening, when it is found that if the 
scapula and chest are covered with canvass 
sufficiently tense to represent the tegumen- 
tary, fascial and muscular coverings in the 
antero-posterior varieties, the positions that 
the limb assumes on the living subject in 
the several forms of this injury are accu- 
rately produced; and that if the limb is 
carried in such a direction as to relax the 
undivided portion of the ligament, reduc- 
tion is at once effected. 
The proper mode of procedure for restoring 
the displaced caput humeri may be stated in 
very few words. Raisethe arm to a horizon- 
tal position, whatever the position of the 
head of the bone ; then, if the head be in the 
axilla, make extension with a slight rotato- 
ry motion directly outward. If there is 
any delay in reduction carry the arm slow- 
ly upward, continuing the extension, if 
necessary, until it attains a perpendicular 
position. If the luxation be primarily for- 
ward under the clavicle, the elbow, already 
pointing somewhat backward, is carried 
still farther backward, gentle extension be- 
ing made as in the first instance, until the 
posterior ligamentous band is so far relaxed 
that the bone slides into place. If the an- 
terior position is only secondary to an axil- 
lary displacement, then as, by the move- 
ment last described, the head glides into 
the axilla, the limb is to be carried upward, 
outward and forward a little, and the re- 
duction to be completed as in case of prima- 
ry dislocation downward. If the luxation 
be the very rare one posteriorly upon the 
border or dorsal surface of the scapula, then 
the elbow, now pointing somewhat forward, 
is to be carried still further forward and 
upward also, for the reason that to attain 
this posftion the head of the bone has pass- 
ed downward as well as backward, and the 
proper route through which the displaced 
bone returns to its socket is the one it 
travelled in leaving it. 
But I have been often asked why it is, if 
these views are correct, that in the common 
dislocation into the axilla reduction is so 
often effected with facility by the ordinary 
method of extension downward, using at 
the same time the arm as a lever over a 
fulcrum of some sort placed in the axilla. 
The answer is easy. Without noticing at 
present the cases of extraordinary laxity of 
the capsule, of which I shall speak further 
on, it is to be remembered that the scapulo- 
humeral articulation is more prone to luxa- 
tion than any other. With its shallow gle- 
noid cavity, which is hardly a cavity at all, 
and its room}' lax capsule admitting of such 
a wide range of motion, the head escapes 
with great facility, the limb constantly as- 
suming, within the limits of ordinary mo- 
tion, positions in which the axis of the hu- 
merus points over the edge of the shallow 
cup in which its articulating extremity 
rests, when but little more force is requi- 
site for the production of the displacement 
than that which will tear the ligament; 
and it is for the reason that the capsule is 
of such amplitude, and that the glenoid 
cavity is so small in diameter and lacks the 
bony ridge which so securely guards the 
head of the femur, that in this injury the 
abduction is oftentimes so slight, the arm 
hanging almost straight by the side ; and 
these same conditions facilitate reduction. 
Yet it is true that, while as compared with 
other joints the amount of tension of the 
untorn capsule is small, requiring propor- 
tionally less relaxation, it nevertheless ex- 
ists as the main opposing force, which must 
be annulled either by tearing or relaxation 
before reduction can take place. How, then, 
if it is not torn, is the requisite relaxation 
effected in the common procedure referred 
to ? I answer, by the accommodation of 
the scapula to the surgeon’s efforts. Were 
this bone immovable this method would be 
unavailing, unless sufficient force were 
used to complete the laceration of the liga- 
ment ; but it is very mobile, and as the 
surgeon, putting his heel in the axilla, 
makes extension downward, the shoulder- 
blade glides forward upon the thorax, and 
as the extending force is continued, and 
the humerus used it may be as a lever over 
the axillary fulcrum, the posterior and up- 
per border of the bone is tilted from the 
ribs, the glenoid cavity being turned in the 
opposite direction forwards and inwards, 
until by this change of position the tension 
of the ligament is so far relieved as to al- 
low the head of the bone to return to its 
place. But while, for the reasons given, 
the old method often succeeds, it always 
involves unnecessary force, and oftentimes 
an amount that seriously injures the axil- 
lary vessels and nerves, and occasionally 
it fails altogether. 
With the manipulations I have described, 
I believe the surgeon will never fail in a re- REDUCTION OF DISLOCATIONS. 
7 
cent dislocation ; the force required is tri- 
vial, and as no injury is done to the parts, 
the danger of subsequent inflammation is 
much diminished. 
The Elbow.—By dividing tho posterior 
and lateral portions of the capsule surround- 
ing this joint and flexing the limb, but lit- 
tle force is required to drive the heads of 
the radius and ulna into their ordinary po- 
sition in the backward luxation on the liv- 
ing subject. It is then found that the an- 
terior fibres of the ligament hold the fore- 
arm in the position which it ordinarily 
occupies in this accident. The outward and 
inward varieties of the backward luxation 
are obtained by dividing in addition the 
inner or outer portion of the anterior liga- 
ment, the inner to produce the outward and 
the outer to produce the inward form. 
If the anterior and lateral ligaments are 
divided, leaving the posterior bands intact, 
after freeing the olecranon, the backward 
dislocation can be produced by forcibly ex- 
tending the forearm upon the arm, at the 
same time pushing it upward. In this case 
the forearm, instead of being flexed more or 
less upon the arm, as in the common form 
of injury, remains extended, nor can it be 
flexed to any extent without completing 
the division of the ligament posteriorly. 
In the first and common variety in which 
the anterior part of the capsule is untorn, 
reduction is effected by Hexing the limb 
and making pressure upon the anterior 
surface of the forearm, near the elbow, 
while an assistant steadies the arm—the 
same indication, i. e. relaxation of the un- 
torn ligament, is fulfilled by the ordinary 
plan of flexion over the surgeon’s knee—but 
in the rare form of luxation in which the 
posterior portion of the capsule remains 
untorn, tho forearm being extended upon 
the arm, and not admitting of flexion, re- 
duction is accomplished by extending the 
limb still more, or if necessary, bending it 
a little backward, when with a little lateral 
or rotatory motion tho deformity is readily 
relieved. 
I have referred in another part of this 
paper to two cases of dislocation of the el- 
bow, one in my own practice and another 
seen post mortem by a medical friend, both 
of which, and especially the latter, gave 
decided evidence to my mind that here, as 
elsewhere, we have to deal principally with 
untorn ligament. 
1 have since seen a case in tho practice 
of the late I’rof. Timothy Childs, of Pitts- 
field, Mass., in which the man’s arm being 
caught in a belt, the forearm was badly 
lacerated, and the entire group of muscles 
around the humerus, except a small portion 
of the triceps, were torn through, exposing 
the bone midway between the elbow and 
shoulder ; the elbow joint was not exposed, 
but was dislocated backward and outward. 
At my suggestion it was undisturbed until 
after amputation at the shoulder, when we 
found that myself making the extension and 
Dr. Childs the counter-extension in the line 
which the forearm occupied, our united 
strength was insufficient to reduce it; but 
I at once effected reduction by the manipu- 
lation I have described. An examination 
revealed a considerable portion of the ante- 
rior ligament untorn. Unfortunately, the 
prejudices of friends would not allow us to 
retain the specimen. Such cases need no 
comment. 
Of the unusual condition in which the 
ligamentous tension is posteriorly, I have 
seen two cases in the living subject; one 
in private practice, and one which was 
brought to my clinic in Michigan Universi- 
ty, by Dr. Andrews, of Detroit, and exam- 
ined with me by Prof. Armor. In both in- 
stances the limb was straight, and the mal- 
position of the bones easily detected. In 
the first case I very readily rectified the 
displacement by bending the forearm back- 
ward a little, and making gentle extension, 
the patient being etherized. 
In the second case the luxation had ex- 
isted several weeks, and the patient declined 
interference. 
The Wrist.—Antero-posterior disloca- 
tions of the carpus upon the bones of the fore- 
arm are produced by dividing corresponding 
portions of the investing ligaments, and 
forcing the bones into malposition. But 
the capsule is so lax and the articulating 
surface so small, that the tension is slight, 
and the reduction of this exceedingly rare 
displacement is effected with but little ma- 
nipulation—a fact rather difficult to explain, 
I think, upon the old theory, when we re- 
flect what powerful groups of muscles send 
their tendons below this articulation for in- 
sertion. 
Metacarpo-phalangeal Articulations.—Lux- 
ations of these joints are, in a majority of 
cases, readily reduced by simple extension, 
for the reason in some cases that the cap- 
sule is entirely torn, in others that it is in- 
ordinately large, allowing of displacement 
without tension, so that in either the oidy 
resistance is muscular. But a minority of 
these cases have always been recognized 
as exceedingly and mysteriously difficult to 
manage. Every now and then a case is 
met with where the most powerful extend- 
ing force compatible with the safety of tho 8 
REDUCTION OF DISLOCATIONS. 
member is necessary, and various contriv- 
ances have been instituted for the purpose 
of making the extension efficient. Even 
then it sometimes fails. An explanation of 
these cases is simply impossible upon the 
theory of muscular resistance ; but an ex- 
amination of these articulations stripped of 
everything but the capsules reveals the fact 
that untorn ligament determines, here as 
everywhere, the deformity, and constitutes 
the resistance, and the simple rule is here, 
as in all luxations, relax the untorn ligament. 
Prof. Crosby, senior, of Dartmouth College, 
many years ago described a method of re- 
duction in these difficult cases by forcibly 
bending the phalanx backward upon the 
dorsum to a right angle with the metacar- 
pal bone, when, by pressure with the thumb 
or fingers, the head of the phalanx is made 
to slide forward into its place. This ma- 
noeuvre, which is usually effectual, owes its 
success to the fact that it relaxes tense 
ligament, but that it may prove efficient it 
is necessary that the capsule should be 
torn in a certain direction, while at the same 
time something depends upon the original 
size of the ligament, and it therefore hap- 
pens occasionally, as has been the case in 
my own and the hands of several surgeons 
of my acquaintance, that this procedure 
fails, and it fails in these rare instances be- 
cause in those particular cases it does not 
relax the offending fibi’es. There is a great 
difference in different individuals in the size 
of these articulating surfaces and of the in- 
vesting capsule, the capacity of the latter 
often being much greater than is requisite 
for the ordinary range of motion. Bearing 
this in mind, suppose a dislocation of the 
metacarpo-phalangeal joint of the index fin- 
ger, the base of the phalanx resting on the 
dorsal surface of the metacarpal bone. Now 
it may be that in reaching this position the 
bone has completely lacerated the capsule. 
If so, simple extension will suffice for re- 
duction. If the bone has escaped through 
a rent in the dorsal portion of the capsule, 
leaving a portion of palmar ligament intact, 
this will of course be upon the stretch more 
or less, according to its length, and it is 
upon its length that the success of Prof. 
Crosby’s method depends. If the untorn 
palmar portion of the ligament bo long 
enough to admit of the movement practised 
in this method, reduction will be accom- 
plished. If the tense fibres are too short 
for this, then the manipulation will fail, un- 
less sufficient force is used-to lacerate them. 
It is probable that this laceration often oc- 
curs when but a small portion of the capsule 
remains uninjured, as the lever power ap- 
plied is very considerable. In this class of 
cases the better manipulation, because it 
constantly relaxes the palmar ligament, is, 
Jlexion of the finger upon the palm, at the 
same time making extension. 
Again, it may be that the capsule is so 
roomy as to allow the head of the phalanx 
to rest upon the metacarpal covered in 
by the dorsal ligament, with or without 
rupture of the anterior portion. In this 
case, if simple extension does not readily 
overcome the difficulty, Prof. Crosby’s 
method will. And yet again, in these 
different conditions of the antero-posterior 
ligaments, certain remaining fibres of the 
lateral ligaments may require some modifi- 
cation of the manipulation to relax them. 
A patient examination of a large variety 
of subjects will convince any one of the 
importance of careful attention to these 
several points, and of studying thoroughly, 
in a difficult case, the locality and extent of 
ligamentous rupture, and the degree of ten- 
sion of the remaining portion. This may 
be readily ascertained by determining in 
whichdirectionsthefingermoves, passively, 
most easily. The distal end will be carried 
most readily away from the side where the 
rupture exists, and with proper attention to 
these conditions and manipulations, in ac- 
cordance with them. I believe that in re- 
cent cases subcutaneous division as so often 
practised by some surgeons will never be 
necessary, unless possibly in some peculiar- 
ly shaped and small-sized aperture, which in 
this joint I can hardly conceive possible. 
I once saw a case with Dr. Oliver Brews- 
ter, of Pittsfield, in which he had tried ex- 
tension and Crosby’s method without ef- 
fec.t, and was about to tenotomize, as he 
told ine he had done several times in other 
cases, when it was found that by varying 
the procedure so as to relax some lateral 
fibres, reduction was accomplished, and ho 
afterward told me that he believed if he had 
to go over the ground of the former cases 
again he could dispense with the knife. 
Whether or not the knife be occasionally 
indispensable, it is important to notice the 
fact that, when used, so far as I know, no 
surgeon thinks of dividing tendon, but finds 
it sufficient to divide some ligamentous 
band ; thus practically, whether consciously 
or not, admitting the truth, for this locality 
at least, of the first proposition stated in 
this paper. 
The Hip.—In the luxations of this ar- 
ticulation, the questions under discussion 
receive most emphatic answer. I have 
already referred to Prof. Gunn’s able teach- 
ings and decisive demonstrations, with re- REDUCTION OF DISLOCATIONS. 
9 
gard to the upward and backward displace- 
ments of the caput femoris. 1 have only to 
add that the dislocation forward upon the 
pubis and downward upon the thyroid fora- 
men, and the various modifications of these, 
are produced with as much accuracy and 
fidelity as regards Rymptoms as are the 
luxations upon the dorsum ilii—the differ- 
ence in operating being that we divide that 
portion of the capsule in the direction of 
the luxation, or in other words, opposite 
the point where the head of the femur is to 
rest. This fact is, however, to be borne in 
mind. With the varying capacity of the 
capsule in different subjects, I have often 
found it necessary to divide the ligament 
more extensively than is necessary to mere- 
ly allow of the passage of the head of the 
bone, in order to produce these deformities 
in a well-marked degree, and sometimes in 
making the luxation downward to cut the 
upper part of the ligament directly opposite 
the opening made for the escaping caput; 
and in the pubic dislocation 1 have found 
a corresponding manoeuvre sometimes ne- 
cessary. It is not necessary in either in- 
stance to divide the anterior and stronger 
portion of the capsule. I do not, in fact, 
feel quite clear as to what portion of the 
ligament is constantly or generally torn, or 
1 might better say how extensively it is 
usually torn in these luxations. That ac- 
complished and renowned anatomist, Prof. 
C. L. Ford, my former teacher and present 
colleague, who yearly demonstrates to his 
classes the influence of the untorn, anterior 
part of the capsule in the iliac displace- 
ments, long ago called my attention to the 
importance of considering the great differ- 
ence in strength between the anterior and 
other portions of the capsule ; a fact no- 
ticed by the various anatomical writers. 
In 1804, when Dr. Lyon, of Palmer, Mass., 
then Demonstrator of Anatomy in Berkshire 
Medical College, was examining a hip joint 
in which I had cut away all the capsule ex- 
cept the anterior portion, he, after conside- 
rable effort, succeeded in throwing the head 
of the bone both upon pubis and thyroid 
foramen, producing the characteristic symp- 
toms without injuring the anterior band. 
In a compound dislocation forward ex- 
amined post mortem by myself and the late 
Dr. Geo. Collins, the anterior and lower 
portion was untorn, as was also a band 
stretched above the neck, attached to the 
upper edge of the acetabulum. In a man 
who was killed by falling from a great 
height, and who, otherwise horridly muti- 
lated, sustained a downward luxation, it 
was found by Dr. F. K. Paddock, of Pitts- 
field, Mass., aud myself, in company with 
several medical men, that the inner and 
anterior portion was intact; also that a 
band ran from the posterior part of the neck 
to the posterior lip of the acetabulum. All 
these facts make me a little uncertain, with- 
out further investigation, which I hope 
soon to give the subject, as to the exact lo- 
cality and usual extent of ligamentous in- 
jury in the several varieties of this injury. 
This is an important field for study. But 
while I feel somewhat uncertain as to the 
usual condition of the anterior portion of 
the capsule in these injuries, I am none the 
less certain of the application of the gene- 
ral principles I am endeavoring to estab- 
lish. 
In reduction of the iliac displacements I 
have used Reid’s manipulation, now fami- 
liar to all surgeons, with satisfaction, and 
it must be admitted that it relaxes the un- 
torn portion of the capsule; but 1 have 
found Prof. Gunn’s rule equally efficient, 
and, as being still simpler, 1 prefer it—that 
is, adduct the limb still further and invert 
still more, when with a little extension the 
head returns to its socket. 
I have reduced the pubic and thyroid 
forms of luxation, with my own hands, in 
accordance with the following rules :— 
In the pubic or upward and forward luxa- 
tion, abduct, evert and extend the limb, car- 
rying it backward. 
In the dislocation doivnward upon the. ob- 
turator foramen, abduct and evert the limb 
generally, carrying it backward. In somo 
cases the ligamentous tension is such that 
the latter movement is unnecessary, and a 
forward movement, with strong abduction, 
is better. It will be noticed that these 
movements, as those in the luxations upon 
the dorsum ilii (by which I mean the dor- 
sal and so-called ischiatic), carry the limb 
to the position it must necessarily have oc- 
cupied before the head of the bone could 
escape ; and a most significant fact is, that 
this direction is the only one in which the 
limb can be carried without extraordinary, 
or at least unnecessary force. The inter- 
mediate forms of luxation, if I may use the 
term, depending upon variations of the ordi- 
nary ligamentous laceration, are to be reduc- 
ed by the same general rules, varied accord- 
ing to the position of the limb which indi- 
cates the portion of the capsule on the 
stretch, it being always borne in mind that 
this determines the character of the defor- 
mity. 
The Knee.—Partial dislocations of this 
joint are sufficiently common without liga- 
mentous laceration, as we see oftentimes 
in the remarkably lax capsules of “ hyste- 
rical knees ” ; aud partial displacement 10 
REDUCTION OF DISLOCATIONS. 
may occur, the one Condyle occupying the 
place of its fellow, with partial or complete 
rupture of ligament on one side. In these 
cases reduction is effected by extension, 
the leg being at the same time adducted or 
abducted upon the thigh—adducted if the 
condyles are thrown outward, and abduct- 
ed if the reverse position obtains. Com- 
plete dislocations of the knee, however, 
are rare. Yet they do happen occasionally, 
and nowhere in the body do the views set 
forth in this paper find more forcible illus- 
tration than in these injuries. When we 
consider the powerful group of muscles 
whose tendons surround and find insertion 
below this joint, and the marked promi- 
nences and depressions pertaining to the 
articulation, it may certainly be claimed 
that in complete luxation of the condyles 
of the femur upon the tibia, the conditions 
for “muscular resistance” are fully present. 
And yet the fact has been, in my own cases 
and in all those of which I can find a re- 
cord, that the reduction has been remarka- 
bly easy. I have had two cases in my own 
practice, and both were readily reduced 
with my own hands, the patients being 
etherized. In the first instance, so readily 
was replacement effected that I fully sym- 
pathized with my friend Dr. 0. S. Root, of 
Pittsfield, Mass., who saw it with me, when 
he remarked that if he had thought it would 
“ go in so easy” we would have studied 
the rare phenomenon a little more before 
attempting reduction. The second case 
was equally amenable to treatment. Now, 
how upon the old and common theory can 
these things be explained ? If it be said 
that ruptured tendons might give a solu- 
tion, it would be very difficult to reconcile 
this assumption with another remarkable 
feature of my own and other reported 
cases (and which has an important bearing 
upon the influence of complete laceration 
of capsule upon the reparative process), 
which is, that these cases recover with 
wonderful rapidity. My first case walked 
one quarter of a mile to my office, using 
only a cane, and with hardly a limp, in 
three weeks from the day of his injury ; 
and this although he sustained a severe 
scalp wound and an amputation near the 
shoulder. The second case walked easily 
in four weeks. 
But upon the ground that difficult reduc- 
tion implies ligamentous tension, all be- 
comes plain ; for the articular surfaces are 
here expanded to such size in proportion 
to the laxity of their ligamentous invest- 
ments, that I have never found it possible 
upon the cadaver to produce a complete dis- 
location without entire division of the liga- 
merits around the joint, so that there is no 
untorn portion left to be put on the stretch 
in these accidents. 
I have thus briefly and in general terms 
stated the results of my investigations upon 
this subject. Much remains to be done in 
detail in the critical study of the various 
dislocations in the light of the theory here 
advanced, and, I could hope, established ; 
but while more minute knowledge shall 
render our work still more easy and cer- 
tain, I am confident that an adoption of 
the general principles I have laid down will 
rob surgical practice of much that has been 
unpleasant and formidable. For myself I 
can say that, in a practice of fifteen years, 
in which it has been my lot, I think, to see 
a fair proportion of luxations, I have never 
failed, in a recent dislocation, with the pa- 
tient etherized, to relieve the deformity 
without any aid except from counter-exten- 
sion ; and I am sure this has been from no 
unusual skill on my part, but simply due to 
the recognition of ligament instead of mus- 
cle as the agent with which I had to deal. 
I have been unusually fortunate in escap- 
ing those rare cases of small and peculiarly 
shaped rent in the capsule which, button- 
ing around the neck of the bone, sometimes 
necessarily embarrasses the surgeon. In 
the only case where I diagnosticated such 
a condition — a backward and upward 
dislocation of the head of the femur—I 
somewhat timidly and very cautiously used 
the femur as a lever, forcibly flexing and 
extending the thigh, thus endeavoring to 
enlarge the opening, which I apparently 
accomplished, as afterward the bone re- 
turned readily to its socket upon carrying 
the limb across the sound one, extending 
and inverting it. I say timidly, for I am 
not sure whether sometimes the neck of the 
femur might not yield before the capsule. 
In addition to my own experience, I am 
happy to know that my pupils everywhere, 
so far as heard from, testify to the value 
of these doctrines as they test them in 
practice. 
In conclusion, I desire to remind the 
reader that in this discussion neither is 
muscular resistance ignored on the one 
hand, nor on the other is it claimed that 
untorn ligament is always present, or, if 
so, is invariably an obstacle to reduction. 
On the contrary, for the muscles, it is ad- 
mitted that they may operate with as much 
force—no more—in opposing the reduction 
of a dislocation as in the adjustment of a 
fracture, and in very rare cases, as in teta- 
nic conditions, this may be extreme ; but 
it is claimed that as an almost universal 
rule the surgeon’s personal efforts are suffi- REDUCTION OF DISLOCATIONS. 
11 
tions of this joint—I shall rejoice to learn 
that he extends its application to the other 
articulations—and he maintains that it is 
the anterior portion of the capsule, with 
its strong ilio-femoral reinforcement, which 
he describes as a distinct structure under 
the name of the Y ligament, that is the 
constant factor determining the position of 
the limb and opposing the reduction in the 
various forms of luxation. I have already 
alluded to my indebtedness to Prof. Ford 
for suggestions upon this point, and to 
doubts that had arisen in my mind in con- 
nection with my own and Dr. Lyon’s ob- 
servations, and 1 have therefore been espe- 
cially interested in this portion of Prof. 
Bigelow’s book; but while it is undoubt- 
edly proven that the ilio-femoral ligament 
maxj accomplish all this, I do not feel quite 
sure that it is so constantly the offending 
agent to the exclusion of other portions of 
the capsule, as the author maintains. If 
so, I do not see clearly how the pubic and 
thyroid dislocations were so easily reduced 
in my own cases by the manipulations I 
have described. Nor is the anterior por- 
tion of the capsule always so dense and 
strong. It is only yesterday that I found 
the ilio-femoral bands almost entirely want- 
ing. The subject was a female, in a good 
state of preservation, upon which I was 
demonstrating the “ ligamentous theory ” 
before the class of the Portland School for 
Medical Instruction, and having cut away 
the posterior and upper portion of the cap- 
sule, I found myself able with my own 
strength, an assistant making counter-ex- 
tension, to tear the anterior portion by sim- 
ple extension. This was witnessed not 
only by the class, but by Drs. Foster and 
Weeks of this city, Bates of Yarmouth, 
Hall of Cumberland, and other members of 
the profession. This of course was an ex- 
ceptional case, but, together with the rea- 
sons already given, makes me somewhat 
doubtful whether the “ Y ligament ” may 
not be more frequently torn than Dr. Bige- 
low supposes. Upon this question hinges 
another, as to the propriety of the general 
rule for flexing the thigh in all cases. But 
I have no disposition to discuss these points 
without farther observations, and can only 
hope that the attention of the profession 
will be so drawn to them that they may be 
speedily settled beyond question. 
Upon the enlargement of the capsular 
opening by circumduction, Prof. B.’s expe- 
riments seem conclusive, and have given 
me great relief; for it seems well establish- 
ed that in a healthy bone the capsule will 
yield without danger of fracture. 
January 27, 1870. w. w. g. 
cient to overcome this muscular contraction, 
while anaesthesia practically abolishes it. 
Again, it is admitted that very often the 
ligaments are entirely torn through, leav- 
ing nothing but muscles to encounter; and 
again, that the capsule in rare cases is so 
lax as to admit of complete displacement 
without tension of the untorn portion, or 
even without any rupture at all. This is 
important to remember in studying this 
subject upon the dead body. I have seen 
subjects upon which it was hardly possible 
to produce a complete luxation of any 
joint in the body without entire severance 
of the capsule, so short and tense were the 
ligaments in proportion to the unusually 
large articular surfaces; and again, I have 
found the capsule of the hip, even, so large 
and roomy that in one instance, much to 
my surprise, I was unable to demonstrate 
the position of the limb and the resistance 
of the untorn ligament in the upward and 
backward dislocation. In this instance, 
but for the teres ligament, I think sponta- 
neous luxation would have been possible 
during life without rupture of the capsule 
at all. But it is affirmed that when the 
capsule is entirely destroyed or is extraor- 
dinarily loose, there is no great opposing 
force to overcome, and that the fact of easy 
reduction by extension in the position 
which the limb occupies is proof that one 
or the other of these conditions exists ; and 
it is further claimed that where any great 
amount of resistance is present, with the 
exceptions already made, it is ligamentous, 
and that before reduction can be effected 
the offending fibres must either be ruptur- 
ed or relaxed. The laceration can be ac- 
complished by brute force only, while the 
requisite relaxation can be attained by in- 
telligent manipulation. 
Within a few days after the completion 
of the foregoing paper, in October last, I 
received the excellent and classical work 
on “ The Hip,” recently published by 
Prof. Henry J. Bigelow, of Boston, which 
I have read with pleasure and profit. It 
came early enough to give me the pleasant 
opportunity of giving him full credit for 
his views in a discussion upon this subject 
in the Cumberland County Medical Society, 
and 1 have until now hesitated whether or 
not to re-write some portions of my paper. 
But, upon consideration, I prefer to publish 
the article as originally prepared. I am 
most happy to learn, what I regret not to 
have known before, that this accomplished 
surgeon has for several years recognized 
and taught the doctrine of ligamentous re- 
sistance as applying to the several disloca-