THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY I. THE MECHANISM OF DISLOCATIONS AND FRACTURE OF THE HIP II. LITHOLAPAXY; OR, RAPID LITHOTRITY WITH EVACUATION BY HENRY JACOB BIGELOW A.M., M.D., LL.D. MEMBKR OF THE MASSACHUSETTS MEDICAL SOCIETY ; EMERITUS PKO- EESSOK OP SURGERY IN HARVARD UNIVERSITY; SURGEON OB' THE MASSACHUSETTS GENERAL HOSPITAL; MEMBER OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES ; MEMBER OF THE BOSTON SOCIETY FOR MEDI- CAL improvement; member of THE BOSTON St)ClETY OF NATURAL history; foreign honorary member of the clinical society of london; MEMBRE CORRESPONDANT ETRANGER DE la SOCIETY DE CHI- RURGIE DE PARIS; MEMBRE HONORAIRE DE LA SOCIETE ANATOMIQUE DE PARIS ; MEMBRE CORRESPONDANT DE LA SOCi:^TE BIOLOGIQUE DE PARIS; SOCIUS EXTRANEUS SOCIETATIS MEDIC.E NOR- VEGICiE ; ETC., ETC. ?Vmi « BOSTON LITTLE, BROWN, AND COMPANY 1900 729 University Press : John Wilson and Son, Cambridge, U.S. A Biomedical Library THE First Part of this volume contains Dr. Bigelow's Treatise on the Mechanism of Dislocations and Frac- ture of the Hip, which has been long out of print. The Papers appended thereto comprise his other contributions to the literature of these subjects. They are reproduced with only such changes of the original text as their author had indicated a desire to have made. The Second Part includes Dr. Bigelow's published articles on Rapid Lithotrity, arranged in chronological order, and unmodified except by his own annotations. Boston, 1894. 593274 n ■ ■ CONTENTS. part £. THE MECHANISM OF DISLOCATIONS OF THE HIP. Page Introduction 3 Abstract 4 Dislocation of the Hip • . 9 The Y Ligament 1« Capsule of the Hip 20 Ligamentum Teres 20 Obturator Internus Muscle 21 Other Muscles 23 General Remarks upon Reduction 26 Position of the Patient and Surgeon 30 The Y Ligament, with Reference to Reduction and to Subse- quent Treatment 30 How the Limb is to be Held 32 Capsular Orifice to be Enlarged 32 Fracture of the Neck 34 Flexion, Extension, Adduction, Abduction, and Rotation . . 34 Circumduction 35 Regular Dislocations 35 Dislocation upon the Dorsum Ilii 35 Signs 37 Dorsal Dislocation between the Rotator Muscles ..... 42 Reduction of the Dislocation upon the Dorsum .... 44 Dorsal below the Tendon 56 Signs '5^ The Mechanism of its Production, and Cause of its Irre- ducibility ^1 Reduction ^4 Vlll CONTENTS. Regular Dislocations, — continued. Page Thyroid and Downward Dislocations 66 Thyroid 66 Signs 67 Vertical Downward Luxation 69 Dislocations near the Tuberosity or Perinseum 71 Reduction 75 Dislocation upon the Pubes 80 Dislocation below the Anterior Inferior Spine of the Ilium. — Sub-spinous 82 Reduction 84 Anterior Oblique Dislocation 87 Dislocations in which the Outer Branch of the Y Ligament is Broken. — Suprarspiuous 90 Reduction 94 Everted Dorsal Dislocation 94 Reduction 96 Irregular Dislocations in which the Y Ligament is wholly Broken 97 Irregular Upw^ard Luxation 99 Irregular Downward Luxation 100 Reduction 101 Special Conditions of Dislocation 101 Old Dislocations and their Reduction 101 Dislocation from Hip Disease 104 Dislocation of the Hip, with Fracture of the Shaft of the Femur 105 Spontaneous Dislocation 106 Fracture of the Pelvis 108 Fracture of the Rim of the Acetabulum 109 Fracture in which the Head of the Femur is driven through the Acetabulum Ill Asserted Fracture of the Acetabulum, without Crepitus, from a supposed Impossibility of keeping the Femur in Place . . 112 Fracture of other Parts of the Pelvis 113 Angular Extension 114 On Dislocation of the Hip 118 CONTENTS. ix THE MECHANISM OF FRACTURES OF THE NECK OF THE FEMUR, Page Fracture of the Neck of the Femur 13iJ Impacted Fracture of the Base of the Neck, with Eversiou . . 189 Anatomical Structure of the Neck of the Femur 141 Rotation 142 Shortening 142 True Neck 143 Remarks 145 Impacted Fracture of the Base of the Neck, with Inversion . 147 Impacted Fracture of the Neck of the Femur near the Head • 150 Comminuted Fracture of the Trochanters without Impaction . 154 Fracture of the Neck of the Femur resulting in False Joint . 155 Crack in the Neck of the Femur . 156 The True Neck of the Femur : its Structure and Pathol- ogy 158 Anatomical Structure of the Neck of the Femur 161 True Neck 162 Pathology : Impacted Fractures 167 Posterior Impacted Fracture of the Base of the Cervix . . . 167 Impacted Fracture of the Head of the Femur 170 Impacted Fracture of the whole Base of the Cervix, with Inver- sion 172 Unimpacted Fractures 172 Fracture of the Small Part of the Cei'vix of the Femur . . . 172 Comminuted Fracture of the Trochanters and Shaft .... 172 Treatment 173 Fracture of the Neck of the Thigh Bone 175 CONTENTS. IPart H. RAPID LITHOTRITY, WITH EVACUATION. Pagk Rapid Lithotrity 191 Rapid Lithotiuty, with Evacuation 229 LiTHOLAPAXY 235 LiTHOLAPAXY 242 LiTHOLAPAXY ; 254 LiTHOLAPAXY 258 LiTHOLAPAXY 261 LiTHOLAPAXY; OR LiTHOTRITY WITH IMMEDIATE EVACUATION 264 LiTHOLAPAXY. An IMPROVED EVACUATOR 274 LiTHOLAPAXY 282 De LA LiTHOLAPAXIE : OU LiTHOTRITIE AVEC EVACUATION IM- MEDIATE EN UNE SEULE SeAXCE 285 Modern Li'thotrity 296 LiTHOLAPAXY 320 Lithotrity, with Evacuaton 323 A Simplified Evacuator for Litholapaxy 332 Index 347 PART I. dislocatio:n^ akd feacture of THE HIP. 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 conclu- sive ones, are perhaps insufficient for the complete analysis of its complicated mechanism; but the defi- cient evidence may in a great measure be supplied by experiments upon the dead subject, where the essential conditions are identical with those of the living and etherized patient, although the contrary has been alleged. 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 accessi- ble to me. If still deemed inconclusive, they must re- main 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 reasonable attention to the subject, I confess that I can find no explanation so satisfactory as that here given. 4 INTRODUCTION. ABSTRACT. The points which were new to science in the first edition are here printed in italics. 1. The anterior part of the capsule of the hip joint is a triangular ligament of great strength, which, when well devel- oped, exhibits an internal and external fasciculus, 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. 2. 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. 3. The regular dislocations are those in which one or loth tranches of the Y ligament are unbroken ; and their signs are constant. 4. The irregular dislocations are those in which the Y liga- ment is wholly ruptured ; and they offer no constant signs. 5. In the regular dislocations of the hip, the muscles are not essential to give position to the limb, nor desirable as aids in its reduction. 6. The Y ligament will alone effect reduction and explain its phenomena, a part of those connected with the dorsal dislocations excepted. During the process of reduction, this ligarnent should be kept constantly in mind. 7. 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 8. If the capsular orifice is too small to allow easy reduction, it should he enlarged. 9. The capsular orifice may he enlarged at will, and with impunity, hy circumduction of the flexed thigh. 10. Recent dislocations can he hest reduced hy manipulation. 11. The hasis of this manipulation is flexion of the thigh. 12. This manipulation is efiicient either hy one method, he- cause it relaxes the Y ligainent, or hy another method, hecause that ligame7it, remaining tense, is a fixed point, around which the head of the femtir revolves near the socket. 13. TJie further manipulation of the fiexed thigh may he either hy traction or rotation. 14. The dorsal dislocation owes its inversion to the external hranch of the Y ligament. 15. The so-called ischiatic dislocation owes nothing what- ever of its character, or its dijfflculty of reduction hy horizontal extension, to the ischiatic notch. 16. The ischiatic dislocation is hetter named dorsal below the tendon, and is easily redticed hy manipulation. But the term "ischiatic" might hetter he suppressed. It is the dorsal dislocation with the least shortening. 17. TJie flexion of the thyroid and downward dislocations is due to the Y ligament, which, in the first, also everts the limh, until the trochanter rests upon the pelvis. 18. In the puhic dislocation, the range of the hone upon the puhes is limited hy this ligament, which, in the suh-spinous dis- location also, hinds the neck of the femur to the pelvis. 19. In the dorsal dislocation with eversion, the outer hranch of the Y ligament is ruptured. In the ahsence of this fulcrum, this dislocation may need pulleys for its reduction. 6 INTRODUCTION. 20. In the anterior oblique luxation, the head of the hone is hooked over the entire Y ligament, the limb being then necessarily oblique, everted, and a little jlexed. 21. In the supraspinous luxation, the head of the femur is equally hooked over the Y ligament, the external branch of which is broken. The limb may then be fully extended. 22. 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. 23. Old luxations may possibly require the aid of pulleys, in order by traction to ayoid any danger which might result to the atrophied or degenerated neck of the bone from rotation. 24. Right-angled extension, the femur being flexed at a right angle with the pelvis, is more advantageous than that which has usually been employed. 25. To make such extension most effective, a special apparatus is required. FRACTURES OF THE NECK OF THE THIGH-BONE. 1. The terms "intra" and "extra" ca.psular, applied to these fractures, have little practical significance, because 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 the capsular ligament. 2. These fractures are therefore better divided, for practical purposes, into (1) the impacted fracture of the neck into the trochanter ; and (2) other fractures of the neck. INTRODUCTION. 7 3. In this impacted fracture, the litnh is everted because the posterior cervical wall is almost always impacted, the anterior very rarely, and in a less degree. 4. These conditions mainly result from the relative thickness of the two walls. 5. While eversion is due to the rotation of the fractured hone on a hinge formed in the anterior cervical wall, shortening is generally due to the obliquity of this hinge. 6. 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. 7. The posterior intertrochanteric ridge is a buttress built upon the true neck, by which, when impacted, 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 imper- fectly described, and that the reduction of these dislocations should be managed accordingly. In connection with this subject, I also attempted to show how the anatomical struc- ture of the neck of the femur leads to a common variety of fracture of that bone. These views have been, as I believe, so well established by repeated experiments upon the dead subject, and so corrobo- rated by current pathological phenomena, and by the mass of reported cases and autopsies, that little doubt can exist of their correctness. Since about the year 1854-55, the four dislocations of the hip, as usually described, together with the method of redu- cing them by manipulation alone, have been annually shown to the classes attending the lectures at the Medical School of Harvard University. These four luxations were made in each case upon a single dead subject, which, notwithstanding the great laceration to which the capsule of the hip had been subjected, in no instance failed to exhibit, and to demonstrate in a striking manner, the appropriate and well-known attitude of each dislocation. In fact, the firm and persistent posi- tion of a joint displaced under such circumstances is quite remarkable. In these experiments, the fixed attitude of the 10 DISLOCATION OF THE HIP. limb was at first attributed to the muscles, which when fully- extended are capable of considerable resistance in the dead subject as well as in the living one ; but it was supposed that the action of their complicated mechanism would hardly repay the labor of its study. In the spring of 1861, having been led to expose a joint, the luxation of which had been the subject of a lecture, I was agreeably surprised to observe the simple action of the ligament, — a simplicity which subsequent experience has confirmed, and which strikingly explains the phenomena observed in the living subject.^ The dislocated joint alluded to presented on examination the following appearances : — 1. Great laceration of the muscles about the joint. 2. The ligamentum teres broken. 3. Laceration of the inner, outer, and lower parts of the capsule. 4. The anterior and upper parts of the capsule uninjured, and presenting a strong fibrous band, fan-shaped, and slightly forked. The remaining tendinous and muscular fibres about the joint being now completely divided, with the exception of the strong fibrous band above alluded to, it was found that the four commonly described dislocations of the hip could still be exhibited without difficulty, and that in each of them the anterior portion of the capsular ligament, which alone 1 Of the figures accompanying this paper, those of the Y ligament num- bered 1, 0, 7, 8, 19, 24, 25, 27, 29, 31, and of the impacted fracture, 1, 2, 3, were reproduced, in the spring of 1861, from photographs made from this hip after dissection. In June, 1861, a paper upon the subject was read before the Boston Society for Medical Improvement; a second paper before the Massachusetts Medical Society, in May, 1864; another, in June, 1865, before the American Medical Association. In the present paper the rarer forms of dislocation have been added, with references to the more interesting reported cases. DISLOCATION OF THE HIP. 11 remained, sufficed at once to direct the limb to its appropriate position and to fix it there. Assuming that each of these dislocations does occur, and that, however much it may vary in degree, it uniformly exhibits its proper and familiar diagnostic signs ; that the anterior portion of the ligament of the capsule far exceeds in strength any other part of it, and that on this account it not only is less likely to be torn, but generally remains intact ; that when this alone remains, it is itself able to give position to the displaced limb ; and that when it is divided, the other parts of the capsule, the muscles, and other tissues do this very imperfectly, as will be hereafter shown, — then the a 'priori evidence is strong that a luxated femur assumes its attitude chiefly in obedience to the trac- tion of the tense fibres of this part of the ligament. The resistance of a dislocated limb is unyielding, and unlike that of muscular action elsewhere, — in illustration of which a few cases may be cited, taken almost at random from Sir Astley Cooper.^ " 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 hundred and twelve pounds, fastened to a rope, which was rove through a pulley. To the influ- ence 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 operat- ing theatre. The pelvis was fixed by the common padded bandage, while to the knee was attached the circular bandage and pul- 1 A Treatise on Dislocations and Fractures of the Joints, London, 1842. 12 DISLOCATION OF THE HIP. leys, and gradual extension was made across the lower third of the opposite thigh for the space of twenty minutes, during which period he was given three grains of tartarized antimony in solution." ''Case L. — John Cockburn, a strong, muscular man, aged thirty-three, was admitted into Guy's Hospital on the 31st of July, 1819. While carrying a hag of sand at Hastings on the 24th of July, he slipped, and dislocated the left hip-joint. The foot on the affected side was plunged suddenly into a hollow in the road, which turned his knee inward at the same time that his body fell with violence forward. On the day of the accident two attempts were made to reduce the dislocation by pulleys, but without success; and on the 27th of July a third, but equally unsuccessful, trial was made, although continued for nearly an hour. ''It was found, upon examination, that the thigh was dislocated backward into the ischiatic notch. The patient was carried into the operating theatre soon after his admission; and when two pounds of blood had been taken from him, and he had been nause- ated by two grains of tartarized antimony, gradually administered, extension was made with the pulleys in a right line with the body, and the upper part of the thigh was raised, while the knee was depressed. The extension was continued at least for an hour and a half, during which time he took two grains more of tartarized antimony, by which he was thoroughly nauseated. The attempts at reduction, however, did not succeed." ^ To a surgeon accustomed to the comparative ease with which the powerful muscles of a recently fractured thigh may be extended by a moderate effort continuously applied, these cases of enormous resistance in the reduction of a dis- located hip suggest a force more powerful and unyielding 1 It is curious to remark that this case ultimately yielded, in the hands of Sir Astley, to the employment, unusual for him, of the flexion method, though combined with pulleys. In further illustration of the disadvan- tage of horizontal extension, let this case be compared with a similar one (dorsal below the tendon) where the reduction occupied three seconds (p. 69). DISLOCATION OF THE HIP. 13 than that of muscular action. Indeed, the facility with which muscular contraction is overcome by ether, while the deform- ity and resistance of dislocation continue, should long ago have led to the conviction that muscular contraction is not a chief agent in this deformity. But modern writers, with few exceptions, have adopted the theory of active or passive muscular resistance. Sir Astley Cooper says : — ' ' With respect to the fixed position of the head of the femur in the four dislocations which have heen described, it is not to be con- sidered as a mere matter of chance, but the natural result of the influence of the muscles, which draw the bone into these positions; and that therefore, under common circumstances, the condition is inevitable.^ . . . The capsular ligaments, in truth, possess but little strength either to prevent dislocation or to resist the means of re- duction. . . . The difficulty of reducing dislocations arises neither from the bones nor from the ligaments, but from the resistance which the muscles present by their contraction." ^ Dr. Nathan R. Smith recognizes muscular contraction as the chief agent in effecting both dislocation of the hip and its reduction.^ That similar views are still entertained by distinguished surgical authorities is shown by the following reported re- marks of M. Chassaignac at a meeting of the Societe de Chirurgie in 1865 : " The employment of chloroform in the reduction of dislocations had convinced him [M. Chassaignac] that obstacles to reduction said to be due to other causes than muscular contraction were chimerical," * — an observation that seems to have passed unchallenged. 1 A Treatise on Dislocations and Fractures of the Joints (p. 100). London, 1842. 2 Ibid., pp. 20, 21. 3 Medical and Surgical Memoirs (pp. 166, 167). By Nathan Smith, M. D. Edited by Nathan R. Smith, M.D. Baltimore, 1831. * London Medical Times and Gazette, December, 1865 (p. 661). 14 DISLOCATION OF THE HIP. Dr. Reid makes tlie following statement : — "The chief impediment in the reduction of dislocation is the indirect 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." ^ On the other hand, the theory of ligamentous resistance has been occasionally and distinctly recognized. Boyer expresses his conviction of the importance of the ligament in this relation, but without proof.^ Professor Gunn maintains, in a paper ^ upon this subject, that different untorn or "• undissected" portions of the cap- sular ligament are capable of producing the signs of hip and shoulder luxation ; while, since the reading of the pres- ent paper, Professor W, Busch,* 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 in fracture 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 while active may contribute, when the patient is standing, to sup- port the limb in a flexed position, while its own weight tends 1 Dislocation of the Femur on the Dorsum Ilii reducible without Pulleys or any other Mechanical Power, (p. 41). By William W. Reid, M. D., of Rochester. Transactions of the N. Y. Medical Society. Albany, 1852. 2 Traite des Maladies Chirurgicales, etc. (tom. iv, p. 282). Par M. le Baron Boyer. Paris, 1822. * Luxations of the Hip and Shoulder, and the Agents which oppose their Reduction. By Moses Gunn, A. M., M. D., Professor of Surgery in the University of INlichigan. Detroit, 1859. * Year-Book of Medicine, Surgery, etc., for 1863 (p. 22.5.) Sydenham Society. London, 1864. DISLOCATION OF THE HIP. 15 to straighten it ; they may even help to convert a dislocation below the socket into one upon the dorsum, or into the fora- men 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 relaxed, as in the dead or etherized subject. Again, some of the muscles are stretched and elongated by the luxated bone ; and their passive strength under these cir- cumstances, 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 muscular fibre passively stretched to its extreme limit, because this extreme tension does not occur in the usual dislocations, being prevented by the ligamentous action. 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 powerful lever, and might yield were they unsupported. 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 dislocations 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 imperfectly 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 due to the resistance of a ligament 16 DISLOCATION OF THE HIP. the power of which will presently be illustrated, and whose simple mechanism will explain the phenomena both of luxa- tion 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 distinctly mentioned that it remained wholly or in part unbroken, — a large proportion, considering that attention has hitherto not been directed to this point. It is not here maintained that this ligament will be found stripped clear of the re- maining portion of the capsule, — the comparatively few autopsies on record showing that this is not the case; there is, however, reason to believe 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 dislocated limb, and, what is more important, as so identified with the phenomena of luxation that reduction must be accomplished almost wholly with reference to it. It remains for future autopsies to show, by careful 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 ligament of Bertin, has been usually described as reinforcing the capsule by a single fibrous band extending 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 ligament is more or less adherent to the acetabular promi- nence and to the neck of the femur ; but upon examination it will be found to take its origin from the anterior inferior spinous process of the ilium, passing downward to the front DISLOCATION OF THE HIP. 17 of the femur, to be inserted fan-shaped into nearly the whole of the oblique spiral line which connects the two trochan- ters 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 bifurcated, having two principal fasci- culi, one being inserted into the upper extremity of the anterior intertrochanteric line, and the other into the lower part of the same line, about half an inch in front of the small trochanter. The ligament thus resembles an inverted Y, which sug- gests 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 bands are distinctly defined, and sometimes the whole triangle is of nearly uniform thick- ness. In the subject first dissected, and from which the accompanying woodcut 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 1 The Y ligament, showing its inner and outer fasciculi. The former is known as the ilio-femoral ligament, the ligament of Bertin, etc. This specimen shows the interval between the two fasciculi. 2 Fig. 1.1 18 DISLOCATION OF THE HIP. 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, and also in producing inward rotation in dorsal dislocation, — it is fair to infer that in a normal condition they would exhibit greater development than the intermediate fibres. The Y ligament is of remarkable tenacity and strength, being at some points, when well developed, nearly a quarter of an inch in thickness, and forming an unyielding 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 dissecting-tables and suspended by the shoulders, the lower limbs being united to the pelvis by the Y ligament alone, this ligament required for its rupture the attach- ment 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 directed my attention to the anatomical arrangement and strength of its fibres. Some seven years after this Y was photographed, I found upon referring to works in the library of my distinguished colleague. Professor 0. W. Holmes, the following 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 : — 1 Although autopsies show that the whole of this ligament has some- times 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, testi- fies to its integrity. DISLOCATION OF THE HIP. 19 ''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 between 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."i Weitbrecht, an excellent, perhaps the best, authority up- on the ligaments, referring in this connection to Winslow, distinctly recognizes a forked arrangement, which he thus describes : — " Partim anterius versus collum femoris et trochanterem mino- rem procedit, . . . partim vero lateraliter versus exteriora progre- ditur, et circa radicem trochanteris majoris in tuberculo laterali terminatur. Atque binae hae divaricationes, una cum linea obli- qua, figuram . . . triangularem . . . constituunt." ^ The Webers describe the ligament as triangular, laying stress upon its thickness, which, as they assert, is greater than that of the ligament of the patella or the tendo 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. "^ ^ An Anatomical Exposition of the Structure of the Human Body (sect. 2, pp. 138-139). By James Benignus Winslow. (Douglas's Trans- lation.) London, 1776. 2 Syndesmologia, sive Historia Ligamentorum, etc. (p. 141). Josias Weitbrecht, D. M. Petropoli, 1742. 3 Traite d'Osteologie, etc. (pp. 323, 324). S. P. Soemmerring, and G. and E. Weber. Paris, 1843. 20 DISLOCATION OF THE HIP. 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 comparatively thin ; and here the primitive pu- bic dislocation doubtless occurs. Behind and inside the pubo- femoral band, looking directly toward the thyroid foramen, is found the thinnest part of the capsule, which at this point resembles wet bladder, readily permitting the thyroid dislo- cation. Outside and behind the Y ligament, where the dorsal dislocations occur, the capsule is very strong, limiting adduc- tion 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, beneath the tendon of the obturator internus muscle. LIGAMENTUM TERES. Little can be added to the excellent paper of Mr. Struthers ^ 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, dis- location upon the thyroid foramen. It is not, however, pos- sessed of much strength ; is ruptured in all the complete and 1 Edinburgh Medical Journal, November, 1858 (p. 434). DISLOCATION OF THE HIP. 21 sudden dislocations, and, according to Cruveilhier, is often undeveloped and sometimes wanting. OBTURATOR INTERNUS MUSCLE. It will hereafter be seen that this muscle, with which the gemelli are practically identified, is materially concerned in one variety of hip dislocation, and is important in relation to its reduction. There is a peculiarity of the obturator internus, hitherto undescribed, which explains its strength. Its mus- cular 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 disappear in the thick- ness 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 attachment 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, as in relation to luxa- tion it is the most important, of the small outward rotators of the hip.i That portion of the capsule which lies directly beneath the tendon is also very strong ; and while their fibres mutually reinforce one another, their mechanical action in the dorsal luxations is much the same. 1 The average weight required to rupture this and the adjacent mus- cles in four subjects is as follows : — Pyriformis 10 lbs. Obturator externus 36-| lbs. Obturator internus 40| " 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 obturator externus at 52 and 44 lbs., and the pyriformis at 16 lbs. 22 DISLOCATION OF THE HIP. 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 vrhich it is inserted. By its contraction it draws the trochanter back- ward, everting the thigh when straight, and abducting it if flexed. Upon the dead or etherized subject it is ren- dered tense in the extended limb by rotation inward, ad- duction being then more limited; but in the flexed limb, and especially in extreme flexion, it is relaxed ; so that in reducing a backward disloca- tion, when this mus- cle is still entire, it might be advanta- geous to flex the limb as much as possible. A curious corroboration of the importance of this muscle, as well as of the external branch of the Y ligament, is seen in a preparation ^ 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 suspended chiefly 1 Ununited fracture of the neck of the thigh-bone, showing the hyper- trophied outer fascicuhis of the ligament supporting the weight of the pelvis in walking. The inner fasciculus is seen below. 2 No. 2715, The Warren Anatomical INIuseum of Harvard University. Fig. 2.1 DISLOCATION OF THE HIP. 23 between the outer branch of the Y ligament in front and the obturator internus behind (Figs. 2 and 3). This is probably the usual condition of patients after this injury, where the shaft of the femur moves freely upon the detached head of the bone. OTHER MUSCLES. It has already been stated that the restricted move- ments of the thigh in the various luxa- tions are in part due to the active and passive resistance of several muscles which (like the pso- as and iliacus) con- nect the femur with the pelvis, and be- come more or less tense by its displace- ment ; yet their ac- tion, in a practical point of view, is of secondary importance, whether considered in relation to its direction or its extent. Without the powerful ligament and the muscle already described, the regular femoral luxations would lose much of their present distinctive character; and regard being had to the action of these fibrous bands, the dis- locations can be reduced with little reference to the muscles. 1 Fig. 2 seen from behind, to show the tense obturator tendon bearing its share of the weight of the body. The inferior gemellus, hypertrophied, is seen below it. ,, Fig. 3.1 24 DISLOCATION OF THE HIP. It may, however, be briefly stated that the gemelli are practically identified with the obturator internus, while 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 femur 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, especially when that is ruptured ; and if the limb is elon- gated, 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.i DISLOCATIONS. Malgaigne is undoubtedly right in assuming that disloca- tion of the hip is sometimes only partial. These various de- grees 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. Hippocrates, in speaking of dis- location of this joint, remarks : " In a word, luxations and sub-luxations take place in different degrees, being sometimes greater and sometimes less." ^ 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 1 In a case of persistent flexion after reduction, I divided these fibres. (See p. 55 of this volume.) 2 The Genuine Works of Hippocrates, etc. (vol. ii. p. 631). Printed for the Sydenham Society. London, 1849. DISLOCATION OF THE HIP. 25 time of Hippocrates,^ in three or four now familiar varieties, with three or four rarer forms of displacement 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 differences, or through needlessly obscuring what is plain by names of recondite derivation. Most surgeons have seen these dislocations in the living sub- ject, and although the rotation, the shortening, or other displacement may have varied a little in each case, will con- cede 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 thyroid foramen, and the pubes. Great stress having been laid by most modern writers on a distinction between the first two, which if re- duced by the flexion method are wholly unimportant varia- tions of the same displacement, I shall endeavor to show how dorsal dislocations may be divided for practical purposes ; also, that certain 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 influence upon the several dislocations, they will be here described with a view to their practical arrangement, according to the follow- ing classification : — 1 Hippocrates describes the luxations on the dorsum, thyroid foramen, 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 " backward," — which has been, as I conceive, eiToneously interpreted by his translators as " into the ischiatic notch," — Hippocra- tes describes at some length the dislocation du-ectly downward. O 26 DISLOCATION OF THE HIP. I. The Regular Dislocations, in which one or both branches of the Y ligament remain unbroken. 1. Dorsal. 2. Dorsal below the Tendon (ischiatic notcli of Cooper). 3. Thyroid and Downward. Obliquely inward on the thyroid foramen, or as far as the perinseum. Vertically downward. Obliquely outward as far as the tuberosity. 4. Pubic and Sub-spinous. 5. Anterior Oblique. 6. SUPRA-SPINOUS. ) , , , rr -ny T\ r -Eixtemal branch broken. ^ 7. Everted Dorsal. ) 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 etherized, the dislocated limb gravitates, and the Y ligament becomes more and more tense as the limb approaches nearer and nearer 1 Although the anterior-oblique, supra-spinous, and everted dorsal luxa- tions resemble one another, it has been thought advisable to distinguish between them for the purpose of more accurately classifying recorded cases. In the anterior oblique luxation the outer branch of the Y liga- ment 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 perpendicular, 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. DISLOCATION OF THE HIP. 27 to a state of complete extension. If, now, as is here main- tained, the chief obstacle to reduction of the luxated hip is found in this ligament, it follows that the method taught by Sir Astley Cooper, the weight of whose unquestioned authority has unfortunately availed to give it currency ^ 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 liga- mentous band, at great sacrifice of mechanical force, with proportionate violence to the neighboring tissues and uncer- tainty as to the result. By the flexion method, which dates from a remote antiquity, the Y ligament is relaxed, its re- sistance 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, directed by the hand, and with slight movement; and in some the reduction is effected by bending the limb at the joint, with gentle shaking." ^ 1 See Edinburgh Medical Journal, May, 1867, — " On the Reduction of Dislocations 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 conclusive note, defin- ing precisely the character of this movement : — "Your question has reference to the meaning of the word /cty/cXt- o-ty, the formation of which is as follows : KtyAcXoy, wag-tail, a well-known 28 DISLOCATION OF THE HIP. In view of this observation of the Coan sage (450 B. c), the indiscriminate use of pulleys 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 importance. It may be taken a,s 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 toward the socket, and that if the capsular ori- fice 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 (rotatiori) the same result is accomplished by a rotation of the femur, which, in winding ^ the Y ligament about its neck, shortens it, and thus compels the head of the bone, as it sweeps round the socket, also to be guided toward the socket. In reducing a hip, the success of rotation, adduction, abduction, and extension de- pends upon this ligament, while the whole manipulation must be conducted with reference to it. In modern times the flexion method has commended itself to the good judgment of various surgeons. Many cases of successful reduction by this method are to be found in the bird in Greece, called also areia-onvyis, the Latin motacilla , KiyKki^ca, to wag (in the original sense of the term), as the bird aforesaid wags its tail. " KiyKXiais and KiyKXia-ixos, a wag-tail movement, or shaking rapidly within narrow limits; gentle shaking. The words circumaction and rotation are out of the question, — for the former is tts ptayw-yTj, and the latter kvkXo- (f)opia, — unless rotation be used in a peculiar sense. " Erotian, in his Hippocratic Glossary, and Galen, define KiyK\i Fig. 8.2 46 DORSAL DISLOCATION. place, is in or near the thyroid foramen. The rent in the capsule being thus enlarged, restore the thigh to a perpen- dicular, and proceed as in the last method. 4. Place the patient face downward on a table, the thigh, flexed at right angles, hanging over its edge, and bear the limb downward, with or without rotation.^ Fig. 9.^ By Rotation. — Flex the thigh and abduct or circumduct it outward, at the same time rotating it outward. The head of the bone, revolving about the great trochanter, which is fixed ^ A little girl of twelve years, upon whom six or seven attempts of an hour each had been made to reduce this luxation by straight extension, was thus placed on a board, when the head of the femur immediately slipped in. (Collin, These Inaugurale. Montpellier, 1833.) In 1830 Colombot had employed this method with rotation. (Docu- ments sur la ]\Iethode Osteotropique. Paris, 1840.) 2 Dorsal dislocation. Reduction by rotation. The limb has been flexed and abducted, and it remains only to evert it, and render the outer branch of the Y ligament tense by rotation. DORSAL DISLOCATION. 47 by the outer branch of the Y ligament, rises over the edge of the socket into its place unless the capsule is interposed, in which case enlarge the opening, as in the third method. This is a very effective manoeuvre for the reduction of the dorsal luxations, and has been described in the words, "Lift up, bend out, roll out." An imperfect comprehension of this empirical rule has led to confusion in its application.^ It should be remembered that if the thigh is everted before it is abducted, it may be locked below the socket. For this reason it is well, especially in an old dislocation where the parts are unyielding, to invert the limb until the final abduc- tion, when it may be everted. When the thigh is forcibly flexed upon the abdomen, the head of the bone is lifted out from beneath the socket.^ A little inward rotation favors the same result. If the thigh be now slowly abducted or depressed outward, it is plain that 1 An English journal terms this method " a knack." Mr. Cock, in a case of dorsal dislocation, gives the rule, " Lift up, bend out, roll in " (Medical Times and Gazette, June 30, 1855, p. 644), — a nianceuvi-e which may succeed, although the method, also mentioned by INIr. Cock, of flexion, abduction, and rotation outward, is perhaps the more correct one. (Lancet, July 7, 1855, p. 6.) The thigh being flexed, outward rotation and outward circumduction both carry the head of the bone toward the socket. In a case of dorsal dislocation reported by ]\Ir. W. J. Square, j)ul- leys were applied for twenty-five minutes unsuccessfully; and again twenty-five minutes longer, with no better result, when they were aban- doned. The thigh was now flexed at right angles, and easily reduced by circumduction outward. (Medical Times and Gazette, Nov. 13, 1858, and American Journal of the Medical Sciences, January, 1859, p. 2.58.) 2 Dr. George Sutton of Aui'ora, Ind., relates a case of dorsal dislocation in which, after a failure from some cause to reduce the hip by the ordi- nary flexion method, a roll of cloth was placed in the groin, as a fulcrum, by which the head of the flexed femur was pried out from beneath the socket, and afterward reduced by abduction while the limb was lifted. (Western Journal of Medicine and Surgery, September, 1868. American Journal of the Medical Sciences, October, 1868, p. 588.) 48 DORSAL DISLOCATION. the head of the bone, suspended by the Y ligament, must rise toward the socket ; and that when the shaft is thus abducted, outward rotation assists the entrance of the head. If the head of the bone is above the tendon of the internal obturator, this outward circumduction also ruptures the small rotator muscles. It may be needless to say that were the head of the bone sus- pended by the dissected Y ligament alone, as shown in some of the annexed woodcuts, a lateral movement of the knee would perhaps cause the head of the bone to swing from side to side, instead of giving to it the desired upward tilt. This movement is hindered by the unruptured fibres of the capsule on each side of the Y ligament, which continue to a greater or less extent in the different dislocations, and contribute to the varying facility with which different cases are reduced. This is especially true of the dislocation behind the tendon of the obturator internus, where the posterior part of the capsule not unfrequently remains uninjured. I have thus reduced the dislocated femur in living subjects by a single slow circumduction occupying from a quarter to half a minute, and also by a first rapid sweep of two seconds. The manoeuvre may be perfectly accomplished without lifting the limb toward the ceiling, but is more effectual when ter- minated with an upward jerk.^ If it fails, repeat the process once or twice, and then, if necessary, enlarge the opening. Or if the limb is too much flexed, and the Y ligament too much relaxed, then the limb may be slowly extended from the perpendicular position, when, as the Y ligament becomes 1 This upward jerk is a very efficient manceuvi'e, both alone and when assisted by rotation. Annibal Parea is said to have availed himself of it. " He placed the patient on his back, the pelvis being confined by assist- ants ; he flexed the knee, raised the thigh almost vertically, grasped its lower extremity with both hands, gave it a jerk as if to raise it perpen- dicularly, and the luxation was instantaneously reduced." (Malgaigne's " Traite," etc., p. 823.) DORSAL DISLOCATION. 49 tightened, the head of the femur will rise into its place (see p. 31),^ especially if the weight of the limb be sustained by the operator. The flexed femur is thus reduced by abduction and rotation with less flexion.^ If the laceration is large, and the head of the bone inclines to slip toward the thyroid foramen during abduction, this ten- dency is easily counteracted by the upward jerk or lift already described. But if upon examination the flexed thigh cannot be abducted beyond the perpendicular, the head of the bone has either escaped by a small orifice in the capsule (which is then comparatively sound), or has also passed above the obturator or pyriformis (which are then unbroken), and is suspended just behind the edge of the socket, midway between these muscles and the Y ligament. In the former case the luxation may perhaps be reduced by flexion with abduction and outward rotation ; in the latter, it is possible, but not easy, to disen- gage it by traction across the symphysis, the bone being lifted by a towel round the thigh at its upper part.^ If these attempts do not succeed, the obturator muscle and the capsule can be ^ See a case of " ischiatic " dislocation treated in this way by Greorge W. Callender, Esq., Assistant Surgeon and Lecturer on Anatomy at St. Bartholomew's Hospital. (Lancet, March 14, 1868, p. 343.) Mr. Callen- der believes, however, that the capsule " never can offer any obstacle to the reduction of dislocations of the hip." 2 In the extreme flexed position of the limb, the Y ligament is so re- laxed that it may not afford a firm centre of rotation. (See p. 34 of this volume.) A case reported by IVIr. Jones (Medical Times and Gazette, April, 1856, p. 362) may serve to illustrate this point. In reducing a dorsal dislocation, the thigh was flexed as far as possible, abducted, and rotated outward. The attempt failed ; but in gTadually bringing the limb down while the same forces were applied, the head of the bone snapped into its socket when the thigh had reached a semi-flexed position. (See also Mackenzie, London Hospital Reports, 1866, vol. iii. p. 207.) 3 To dislocate the bone above the obturator tendon in the dead sub- ject, the posterior capsule should be divided high up toward the Y ligament, and the bone then strongly flexed, adducted, and rotated out- ward. By inward rotation it may be reduced. 4 50 DORSAL DISLOCATION. ruptured by outward circumduction of the flexed limb, — an expedient also to be resorted to whenever the limb is especially fixed and unyielding, — after which the hip may be reduced as usual. The following case will illustrate the method by traction. I was requested by Dr. E. A. W. Harlow, Oct. 5, 1861, to see, with him, a stout, middle-aged Irishman whose hip had been dislocated an hour or two before. In climbing the ladder of a freight car while the train was moving, his thigh was bent to a horizontal position just in time to be caught between this car and the next one. The flexed hip was thus dislocated backward primarily upon the dorsum, by a force very exactly applied to the knee in front and the pelvis behind, probably with slight laceration of the capsule. The limb was short- ened, the toes were firmly inverted across the instep of the other foot, the head of the femur being felt upon the dorsum. On flexion the thigh could not be abducted as far as the perpendicular, and was unusually immovable, — the latter condition being perhaps due to the comparative integrity of the capsule. This would formerly have led to the belief that it was engaged in the ischiatic notch. It is also pos- sible that the head of the femur may have escaped between the Y ligament and the obturator or pyriformis muscle. The patient being etherized, I flexed the limb, and made several efforts to reduce it by angular traction, but was unable to do so, the failure being doubtless due to the small size of the capsular and perhaps the muscular opening, which under the same circumstances I should now not hesitate to enlarge by circumduction. The attempt was abandoned till the next morning, when, the patient being again etherized and the limb flexed as usual, a rectangular metallic splint was applied beneath the knee, and so held by assistants as to suspend the pelvis a few inches from the floor. I then placed my foot upon the anterior superior spine of the pelvis, DORSAL DISLOCATION. 51 and at the first effort depressed the latter into its place. ^ During the patient's stay in the hospital this limb was a little longer than the other, — an appearance I have observed in several instances, and which is perhaps due to a portion of 1 I venture to publish the following note from Dr. Mann, of Roxbury, in illustration of the above manoeuvre : — Roxbury, Jan. IG, 1867. Prof. H. J. Bigelow : Dear Sir, — I take pleasure iu sending you the following brief account of a case of dislocation of the right femur upon the dorsum ilii, in which I used the method for its reduction pointed out by you at the annual meeting of the Massa- chusetts Medical Society, in May, 1862. At that time you demonstrated a liga- ment described as the Y ligament, and the part performed by it in giving position to the limb and in preventing the return of the bone to its socket, together with the best means of overcoming that resistance. I was much surprised at the ease with which the reduction was accomplished, ... for I am sure in no other way could it have been accomplished with so much ease to the patient and to myself. I was called, July 10, 1862, to James Stump, a stout, muscular man, about fifty years of age, who while picking cherries lost his hold and fell from the tree, a dis- tance of about twenty feet, to the ground. He complained of great pain in his hip, and was incapable of rising. He was picked up and conveyed to his home (a distance of three miles), where I saw him about an hour after the accident. I found him lying on a mattress on the floor. The right leg was two inches shorter than the left, with the toes resting upon the opposite instep, the knee and foot turned inward, and a little advanced upon the other. The limb could be bent upon the other, but could not be moved outward. The trochanter major could be felt near the anterior superior spinous process of the ilium, and the head of the bone moving upon the dorsum ilii during rotation of the knee inward. He was just in the position I desired, and I determined to try your method of reduction. Having etherized him, I placed my left foot (the boot having been removed for that purpose) upon the pelvis of the right side, and bending the leg of the patient upon the thigh, and the thigh upon the pelvis, thus relaxing the Y ligament, and placing my left arm under the knee, and grasping the ankle with the right hand, I had perfect conmiand of the limb. Keeping the pelvis firmly fixed with the foot, I made a firm and pretty forcible extension with the left arm, and with a slight rotatory movement with the right hand the bone instantly slipped into its socket with a smart snapping noise which could be distinctly heard by every one in the room. In two days the patient was able to walk about his room and resume his work (which was that of fancy-basket maker). I met him upon the street three weeks after the accident, and he assured me he could walk as well as ever, saying that he had walked five miles that afternoon without fatigue. Very truly yours, Benjamin Mann. 52 DORSAL DISLOCATION. the capsule being engaged between the head of the bone and the acetabulum, — but in 1869 it was shortened half an inch, everted, and the power of rotation impaired, apparently by dry chronic arthritis. In another case which I have lately examined, of dislocation reduced fifteen years ago by the late Dr. Hayward, this deformity of the hip from the same cause was much more strongly marked. The subject of the following case of dislocation of four weeks' standing was sent to me by Dr. Thomas, of Scituate. Four weeks ago a large door, weighing half a ton, fell upon the patient, — a man, aged fifty, — dislocating his left hip. An irregular practitioner etherized him, and with the assist- ance of two men drew the leg down, and told him that it was reduced. The left leg is now two inches shorter than the right, the foot inverted over the right instep, the trochanter higher and more prominent than it should be, and the head of the bone felt upon the dorsum ilii. The reduction was effected as follows. The patient was etherized and laid upon the floor. The thigh was slowly flexed upon the abdomen, and then moved laterally, to loosen the tissues about the joint. It was then returned toward the perpendicular, and jerked upward, with a little simultaneous abduction and rotation outward, but without success. Recog- nizing the comparatively untorn or reuniting capsule as the cause of the failure of this effort, I slowly circumducted the flexed thigh outward until the head of the bone was carried from the dorsum nearly to the thyroid foramen. After the capsular orifice was thus enlarged, and the head of the bone re- placed below the socket, the first upward jerk reduced the dis- location, — the whole manipulation having occupied scarcely a minute and a half. The following cases were reduced by rotation. In the first case the reduction was easy, and occurred in the wards of Dr. Cabot, who kindly submitted the case to me. DORSAL DISLOCATION. 53 A man, aged twenty-four, had his left hip dislocated by the caving in of a bank of earth. The usual signs of dislocation on the dorsum were presented. To reduce it, the thigh was flexed to a perpendicular, and in order to enlarge the capsular orifice it was then slowly abducted with a little rotation out- ward, during which it snapped into its place. The manoeuvre occupied scarcely ten seconds. It will be observed that this movement is equally suitable for extending the capsular laceration in the direction of the thyroid foramen, or, if the laceration be already sufficient, for prying the head of the bone into the socket, with the aid of the Y ligament as a fulcrum. The following was a case of dorsal dislocation of eight months' standing, which had occurred in consequence of a fall on the floor. The patient, a woman twenty-seven years of age, had remained in bed for several months, and after- ward walked with great difficulty. The limb then presented the usual signs of dorsal dislocation, and was reduced by flexion, abduction, and eversion. I first saw her sixteen days after this operation, when the bone had again become dis- placed. The limb was an inch or more shorter than its fellow ; and though its patella looked directly forward, and the foot was not inverted, yet the latter could not be everted like that of the sound limb, and the head of the bone was felt near the sciatic notch. By forcible flexion, abduction, and eversion 1 brought the head of the bone into the socket with a snap; but when the limb was again extended, a very slight inversion sufficed to reproduce the dislocation, — in fact, the limb could not be trusted to itself. After the bone had thus repeatedly slipped out, the patient was placed in bed on her back, and the dislocation again reduced by flexion, abduc- tion, and eversion, which brought the flexed thigh and knee down to the mattress on their outer side. The knee was then tied to the bedstead in this position with a towel, and the 54 DORSAL DISLOCATION. foot secured to the knee of the sound side until the socket should be excavated by absorption. In two weeks she was allowed to sit up, and in two weeks more was discharged, well.i In the following case of dorsal dislocation of the hip of six weeks' standing, after reduction a muscle was subcutaneously divided. The patient while driving a railroad hand-car was thrown upon the track in front of it, the car passing over his body. On examination under ether, the head of the femur was felt " near the sciatic notch." After the thigh was flexed and rotated to break up the old adhesions, the dislocation was reduced by flexion, abduction, and extension. Eight days after this operation the bone had again slipped out ; and at that time I first saw the patient, and made the following record in the Hospital books (vol. cxxxii., August, 1867) : " In the recumbent position the limb is flexed at an angle of about 40°, shortened the length of the patella, but not inverted. The trochanter is very prominent, the head of the femur being movable upon the dorsum. The dislocation is dorsal, but without inversion. The knee cannot be depressed without raising the loins. The patient, when erect, can bear about ten pounds' weight on the limb, which can be brought down by the side of the other, if the pelvis be laterally tilted to make up for the shortening, and thrown out behind to compensate the flexion. The buttock is flat- tened and widened, as in hip disease. The feet can be everted equally, each to an angle of about 45°." At the close of the above examination, the bone was brought into the socket by flexion, abduction, and vertical extension, though it easily slipped out of place. The next day, as the record states, " the limb is found to be less flexed, and the head of the bone is in the socket. There is still, however, a 1 Massachusetts General Hospital, Surgical Records, May, 1868 (vol. cxxxiii). DORSAL DISLOCATION. 55 widening and flattening of the nates on the affected side, show- ing that the thigh is displaced laterally, as if the socket were partially occluded, although engaging the head of the femur, while the knee is still raised about four inches above its fellow, the tensor vaginae femoris being quite tense. The knee can be depressed, but is flexed by some elastic force, rising again," Under these circumstances, it was decided to divide the last- named muscle subcutaneously, near the anterior superior spinous process, which, when done, allowed a considerable though not complete extension of the thigh. The limb was now brought nearly straight, and placed in a Desault's splint until the socket should be excavated by absorption. This extension was continued until September 8, when the pa- tient began to sit up ; on the 13th he was moving about on crutches, and on the 23d he left the Hospital, there being no lengthening of the leg, and only some atrophy of the muscles of the thigh. That the luxation was unequivocal in this case is attested by the presence of the head of the bone upon the dorsum, — the femur being flexed, although the foot was straight. If the bones were sound, this absence of inversion would indicate rupture of the outer fasciculus of the Y liga- ment. But the marked lateral displacement, resulting from the inability of the bone fairly to enter its socket, even when placed and held there, implies some anomaly, — either the callus of fracture, the remains of capsule, or the presence of cicatricial tissue, partially occluding the socket. A little girl three and a half years old entered the Massa- chusetts General Hospital with unequivocal signs of dorsal dislocation of twelve days' standing. I flexed and abducted the limb, rotating it outward, and after some little effort, by pressing the head of the bone toward the socket, between the fingers applied to the superior spinous process and the thumb upon the trochanter, succeeded in reducing it. 56 DISLOCATION BELOW THE TENDON. DORSAL BELOW THE TENDON. It has been before remarked that when the flexion method is universally adopted it will be practically needless to classify separately the dorsal luxations. Their varying relation to the small rotator muscles has, however, been already shown, and the strength of one of these muscles may entitle it to separate consideration. The dislocation hitherto distinguished as " upon the ischiatic notch," and unnecessarily associated with it, is characterized by Sir Astley Cooper as differing from the dorsal displacement chiefly in producing less shortening of the limb. I believe that no dislocation upon the ischiatic notch is worthy of the name ; that no satisfactory or practical result can be based upon this distinction alone ; and that it is also an error to suppose that during reduction the femur ever notably " slips into the sciatic notch," ^ or that the sciatic notch ever offers any obstacle to its reduction. A little more or less shortening and a varying degree of inversion depend both on the position occupied by the head of the femur upon the dorsum and on the degree of laceration of the capsule. In cases of this vari- ety which have been recorded the signs were intrinsically the same, and reduction, if by pulleys, was usually effected in one and the same way, — unless we seek an exception to this statement in a slight variation of the angle of traction, quite as likely to occur in one case as another, and even to vary much in different attempts upon the same patient. But there is one remarkable feature in some of the recorded instances of " ischiatic " dislocation. They were erroneously supposed to have been " irreducible." Sir Astley Cooper says ^ See, for a recent statement of this erroneous notion, Holmes's " Sur- gery" (vol. ii. p. 644): "That in our attempts to reduce a dislocation upward Ion the dorsurn] the head of the bone may slip into the sciatic notch, there is abundant evidence." DISLOCATION BELOW THE TENDON. 57 " the reduction of this dislocation is in general extremely dif- ficult ;"i and this has thrown a shadow of uncertainty over a large number of other cases, where the observer, being per- suaded that the reduction was more difiicult than usual, or the limb less shortened, has taken it for granted that the head of the bone was engaged in the sciatic notch and forcibly detained there, but which were in reality simple dorsal dislocations. In view of these facts, I propose to separate the dorsal dis- locations into two varieties, of some practical importance in relation to their reduction. The first has already been con- sidered. The second includes only those cases in which the head of the femur is engaged behind the internal obturator tendon and the capsule lying beneath it, and which sometimes absolutely require the flexion method for their reduction. This is also a secondary dislocation, in which the bone, by a movement of more or less inversion, reaches its final position behind the tendon after occupying one below it, and is doubt- less of frequent occurrence, as this is the point at which the luxations below the socket are first arrested in their ascent upon the dorsum. I have ventured to call it, for simplicity, dorsal below the tendon, because, although the head of the femur lies behind the tendon, as it does in dislocation between the rotators, it is below it also, and not above it, as then happens (see p. 42). The following are classical examples of this accident. The first is from Sir Astley Cooper. "Case XLIII. A boy sixteen years old had a dislocation of the thigh into the foramen ovale ; he was placed upon his sound side, and an extension of the superior part of his thigh was made per- pendicularly; the surgeon then pressed down the knee, but the thigh being at that moment advanced, the head of the hone was thrown backward, and passed into the ischiatic notch, from which situation it could not be reduced." 1 Treatise, etc., p. 73. 58 DISLOCATION BELOW THE TENDON. It was probably this case that led Sir Astley to enjoin " great care," in reducing the thyroid luxation, " not to ad- vance the leg in any considerable degree, otherwise the head of the thigh-bone will be forced behind the acetabulum into the ischiatic notch, from whence it cannot afterward be re- duced ; this accident," he says, " I once saw happen." ^ In other words, by flexing the thigh the Y ligament was relaxed, and the head of the bone was allowed to descend below the socket,^ where there was an equal chance whether, in again extending the limb, the head would return inward to the thy- roid foramen, or slip outward upon the dorsum behind the obturator tendon, as actually happened. A second is from Malgaigne.^ A laborer, thirty-eight years of age, had dislocated his hip backward. The next day Lisfranc, with eight assistants, endeavored to reduce it by straight extension. At the end of an hour their efforts were abandoned, the patient being in a state of collapse. He died on the eleventh day of sup- purative inflammation of the hip, resulting doubtless from the operation. At the autopsy the bone was found to lie behind obturator tendon, and was easily reduced by flexion.* 1 Treatise, etc., p. 63. 2 This movement is identical with that elsewhere described in connec- tion with the three downward luxations. A similar result of relaxing the Y ligament by flexing the thigh occurred in a case of Verneuil, whose patient dislocated his hip a second time, fifteen days after the original accident, by suddenly rising to a sitting posture. The same thing hap- pened also to a patient of Malgaigne (" Traite," etc., p. 840), and is not uncommon. 8 Traite, etc., PI. XXVI. * For two autopsies of this dislocation see the cases of M. Bidard (Malgaigne, " Traite," etc., p. 835). In both these cases, of which the second seems to have been a more complete luxation than the first, the obturator internus was intact. In Queen's case, the sciatic nerve was engaged upon the neck of the femur (Medico-Chirurgical Transactions, 1868, vol. xxxi. p. 338). For a case in which the head of the bone had escaped just below the socket, and was arrested there on its way toward DISLOCATION BELOW THE TENDON. 59 SIGNS. The distinctive signs of this dislocation, dorsal below the tendon, may be thus stated. the obturator tendon, see Ollivier's " Archives Generales de Medecine," 1823, torn. iii. p. 545 ; also Lenoir, quoted by Malgaigne (" Traite," etc., p. 873). In an interesting case, reported with its autopsy by Thomas Wormald (London Medical Gazette, 1837, vol. xix. p. 657), the dislocated limb was shortened and inverted, forming about half a right angle with the body, while the shaft of the femur, crossing the symphysis pubis, was fixed immovably in this situation. The head of the femur had escaped above the quadratus, through a rent of the capsule opposite the upper part of the tuber ischii, compres- sing the sciatic nerve, and had plunged beneath the obturator ex- ternus muscle so as to engage this muscle upon its anterior face. The obtm-ator internus was completely ruptured; the pyriformis and ge- melli were partially so ; also the gluteus medius and minimus at their posterior edge. In this case the head of the bone, escaping between the two muscles, had passed forward beneath the external obturator, instead of retreating backward behind the tendon of the internal obturator. The luxation probably occurred when the limb was flexed and extremely inverted, to which position may also be referred the rupture of the obturator internus muscle. By de- pressing the knee the head of the bone would have been carried upward and backward, and the laceration so extended that reduction would have been easy. If the flexed knee had been circumducted outward, the exter- nal obturator muscle would have been partially ruptured ; and this lesion probably occurs when the head of the bone is carried from the dorsum to the thyroid foramen, or vice versa. The regular thyroid luxation, how- ever, occurs above this muscle, the upper edge of which only need then be ruptured. The external obturator and much of the quadratus are torn in the common dorsal dislocation, C) Wormald's case. Copied from the London Medical Gazette, 1837. The head of the bone, a, is seen engaged beneath e, the obturator externus muscle ; /, sciatic nerve j b, obturator internus; c, i, trochanters; d, socket; h, gluteus. EiG. 10.(«) 60 DISLOCATION BELOW THE TENDON. The limb is extremely inverted. It crosses the opposite thigh, even as high as the middle of it, although in the Fig. 11.1 Pig. 12 2 1 Dislocation below the tendon. The inversion is here seen to be greater than in the common dorsal luxation, and would be still further exaggerated in the recumbent posi- tion. 2 Profile view of. the same, show- ing the leg advanced. 3 Dislocation downward and out- ward toward the tuberosity. This may be considered a first step to luxation behind the tendon, which it inclines to become when the pa- tient is upright. The limb may oc- cupy any interval between these two luxations, the quadratus muscle readily yielding. (See Fig. 10.) Fig. 13.3 DISLOCATION BELOW THE TENDON. 61 upright position it may gravitate to a lower point. It is considerably in advance of the sound limb. By manipulation the capsular and muscular fibres may be so relaxed or torn that this dislocation may be made to resemble one higher up on the dorsum, or be actually converted into one by rupture of the obturator muscle. THE MECHANISM OF ITS PEODUCTION, AND CAUSE OP ITS lEREDUCIBILITY. In this luxation the bone first escapes below the socket^ or on its thyroid aspect, when the thigh is flexed, as it gene- rally is. The limb being extended by subsequent vio- lence, while the neck of the bone is unyieldingly sus- pended beneath the socket by the Y ligament, the head slips upward, not only behind the acetabulum, but also behind the capsule and the internal obtu- rator muscle. The fibres of the latter, instead of lying transversely behind the head, as when in place (Fig. 14), now lie obliquely in front of it, — a tendinous wall, interposed be- tween it and the acetabulum (Fig. 15).^ Fig. 14. 1 A case of dislocation behind the tendon, with fracture of the socket, exhibited much the same signs : the right leg was two inches shorter than 62 DISLOCATIOX BELOW THE TENDON. The difficulty of reducing this luxation by extension in the axis of the body will be readily understood. In the absence of both posterior ^x;?*^^-' capsule and inter- nal obturator mus- cle, the head of the '\ bone might be ili slipped forward 4/ over the lower mar- gin of the socket by rotation outward, after the pulleys liad sufficiently elongated or de- tached the Y liga- ment, especially if the pulleys were "■^^ then relaxed and / , . . the thigh flexed a little. But as the obturator tendon Fig. 15.1 the left, the knee and foot turned inward. An autopsy showed the pos- terior part of the acetabulum broken off, and the neck of the bone tightly emVjraced by the tendon of the obturator internus and the gemelli. (See Cooper'.s "Treatise," etc.. Case LXXI. p. 113.) ^ Figs. 14 and 1-5, — the mechanism of the dorsal dislocation below the tendon. Fig. 14 shows the head of the bone in it.s socket, with the obturator tendon in its natural position behind it. The part of the capsule which lies beneath the tendon and behind the Y ligament has been slit, both to demonstrate its thickness and to allow the head of the bone to rise as high as the ischiatic notch. Fig. 1.5 shows the head of the l:)one dislocated below the tendon into the neighborhood of the sciatic notch. If the tendon were not pres- ent, the capsule would produce much the same effect in binding the head of the bone close upon the ilium, without the intei'position of the muscle. DISLOCATION BELOW THE TENDON. 63 and its subjacent capsule now lie between the head of the bone and the socket, they oppose the entrance of the head by a firm tendinous wall, which is drawn down as the head descends, and which no extension or rotation, short of its ru})ture, can displace or overcome. The muscle is tense, and in its turn renders the ligament more tense, carrying the head of the bone backward and upward toward the ischiatic notch. The inversion, flexion, and adduction of the limb are thus augmented by the com- bined and reciprocal action of the ligament and the obturator muscle, — the latter being aided by the subjacent capsule, when that remains untorn.^ 1 It has been before said that if the neck of the femur be farther driven upward so as to rupture the obturator tendon and capsule, the luxation will become simply dorsal. Malgaigne correctly says that "the ischiatic luxation leads frequently to the iliac luxation ; " but he fails to identify the mechanism of the change when he asks, " May not the for- mer also be consecutive to the latter, in view of the fact that by flexion or strong traction the head of the bone may be drawn downward from the dorsum to the notch?" ("Traite,"etc., p. 831.) In the high dorsal dislo- cation the small rotators would be so lacerated by the ascent of the bone or by di-awing it down to reduce it, when engaged in their interstices, that the luxation " on the ischiatic notch " would lose its distinctive fea- tures. In an interesting discussion upon a pathological specimen of hip luxation of five months' standing, where an unsuccessful attempt had been made to reduce the bone by longitudinal traction, M. Tillaux main- tained that " in backward luxation of the hip the capsule, and not the muscles [notably the obturator], limits the movement of the head of the fenmr." (Societe Imperiale de Chirurgie, I'*'" Juillet, 1808. L'Union Medicale, No. 79, p. 57.) It is true (see pp. 2, 63) that the obturator tendon and the posterior part of the capsule, which is next in strength to the Y ligament, mutually reinforce each other, so that when the head of the bone rises behind the socket it is generally engaged behind both these fibrous walls. But their mechanical action being identical, it is unneces- sary to decide which under these circumstances would first be ruptured. The capsule yields fibre by fibre to the ascending bone, while the com- parative elasticity of the tendinous muscle preserves it (Fig. 1-5), until at the moment of the final rupture of the tendon the dislocation has become practically iliac, and can now be reduced, though disadvantage- 64 DISLOCATION BELOW THE TENDON. REDUCTION. The reduction is simple.^ The head of the bone, having reached its present position by circumduction of the flexed limb inward, must be reduced by circumduction of the ex- tended limb inward. When the thigh is raised perpendicu- larly to the floor, the head of the bone is unlocked and lies below the socket, and needs only to be jerked upward into its place ; or the suspended pelvis may be depressed, or the thigh abducted and rotated outward, as in the common dorsal dislo- cation.2 The laceration of the capsule is probably already suf- ficient, and will not need to be enlarged. It will be observed ously, with pulleys, by straight traction through the slit thus made behind the capsule. It may be safely asserted, first, that the tendon is usually present in these cases of the iliac luxation by inversion, unless the bone has risen so high iipon the dorsum that the posterior capsule also has been ruptured ; and, secondly, that the tendon resists longest, and best characterizes the luxation. 1 Mr. Nunneley, in the paper before quoted, expresses the contrary belief, that in this luxation reduction by manipulation will be more diffi- cult, and will more frequently fail, than in any other form of dislocation to which the hip is liable. - M. Lisfranc readily reduced a luxation " upon the sciatic notch " by the method of Despres, twelve days after the accident. The pelvis being fixed, " he adducted the limb, at the same time flexing the thigh and leg ; placing his fore-arm under the ham, and with his right hand grasping the ankle in order to use the leg as a lever, he instantaneoiisly reduced the luxation by extension, outward rotation, and abduction." For this case, which embraces the principles of flexion, abduction, out- ward rotation of the thigh, and the upward lift, see " Observations sur Luxations," etc., M. Malespine, Archives Generales de Medecine, Paris, 1839. See also Bulletin de la Societe Anatomique, 18-35, p. 4, and 1836, pp. 45, 169. Mr. Travers (London Medical Gazette, Nov. 22, 1828) relates a case of dislocation "upon the ischiatic notch," of six months' standing, which was reduced by pulleys, but in which the bone slipped out again while the thigh was flexed in bed during the night, — the obvious result of relaxation of the Y ligament. In subsequent unsuccessful efforts at reduction, the neck of the bone was fractured. DISLOCATION BELOW THE TENDON. 65 that by the flexion method this luxation and that upon the dorsum are reduced in the same way, and with equal facility. I have had but two opportunities of satisfactorily identify- ing this dislocation in the living subject. The usual extended position of the luxated limb so endangers the obturator that its condition must often be a matter of uncertainty, although this luxation cannot be uncommon compared with that higher up on the dorsum. In the first case alluded to, which did not occur in my own practice, the patient (a middle-aged female) had fallen down stairs, and the limb had thus been subjected to a variety of forces. It was flexed, greatly inverted, and so advanced and adducted across the middle of the other thigh that I did not hesitate to recognize it at sight as a dislocation behind the obturator tendon ; and yet it is possible that the bone may have been thrust between the rotators. With a view to its reduction, the limb was flexed, and a variety of movements were communicated to it, during which the bone slipped below the socket, — a change of position accompanied by a sharp report, probably due to the rupture of some fibrous band, or possibly the tendon of a rotator muscle.^ It was afterward lifted into its socket. The following case admits of no doubt. While correcting these sheets, I was called to the Hospital to see a middle-aged man who had three hours before been struck upon the hip by a bale of hay. Having fallen over on his left side, the bale dropped from the story above, striking upon his right femur below the trochanter a little in front, dislocating it outward and downward. He said that two physicians had unsuccess- fully tried for an hour, with ether, to reduce it. He was in pain, sitting up in bed, the luxated thigh greatly inverted, and flexed so that it crossed the sound limb near the groin. (See Fig. 13.) After he was etherized and laid flat, the dislocated 1 In the dead subject the muscular fibres yield noiselessly. 66 THYROID AND DOWNWARD DISLOCATIONS. thigh, when drawn down, crossed the other at the junction of the middle and lower third, but still with great and firm inver- sion. This position of the bone, in connection with the facility of its reduction and the manner of the accident, indicated that the head, suspended at the trochanter by the Y ligament, was prevented from rising on the dorsum so as to permit the de- scent of the knee, by some obstacle, which could be no other than the obturator tendon and the subjacent capsule, stretched across its neck ; also that the luxation was secondary, the bone having escaped below the socket before rising behind the tendon. After etherization, the knee came down somewhat, as the head rose behind the tendon. The hip was reduced by flexion, abduction, and eversion, with a slight upward jerk, at the first effort, and in three seconds from the moment the limb was grasped for flexion. THYROID AND DOWNWARD DISLOCATIONS. 1. Obliquely inward and downward on the thyroid foramen. 2. Obliquely inward and downward as far as the perinaeum. 3. Vertically downward below the acetabulum. 4. Obliquely outward and downward as far as the tuberosity. These dislocations, if we except that upon the thyroid fora- men, are comparatively rare. In view of the frequency of accidents dislocating the bone while flexed or abducted, this rarity may be explained by the readiness with which the extreme downward luxations are converted into those upon the thyroid foramen or the dorsum. THYROID. The bone escaping obliquely downward and inward beneath the socket by a laceration of the inner side of the capsule, where it is thin and membranous, tends to follow the inclined THYROID AND DOWNWARD DISLOCATIONS. 67 plane of the pelvis toward the thyroid foramen, where it finds a lodgement.^ SIGNS. The limb is unequivocally flexed and abducted, the heel being raised from the floor, and the toe pointing outward and Fig. 16.2 Fig. 17. forward. The trochanters being arrested and suspended by the Y ligament, while the head of the bone descends from the socket, the thigh is flexed to an angle of about 35° and also abducted, until the great trochanter, by swinging outward, 1 For a case of thyroid dislocation occurring in a child six months old, see Lancet, May 16, 1868. ■2 Thyroid dislocation, — Fig. 16 showing the front view, Fig. 17 the side view, and Fig. 18 the back view of the leg. The limb is seen advanced, abducted, and a little everted. 68 THYROID AND DOWNWARD DISLOCATIONS. gets a bearing on the acetabulum, and the adductor muscles become tense. The head of the femur likewise rests upon the pelvis (enabling the patient sometimes to walk tolerably well), and is hindered from rising toward the pubes, and even from Pig. 18. Fig. 19.1 re-entering the socket, by the inner margin of the acetabulum, the falciform edge of the lacerated capsule above, perhaps, con- tributiner its resistance.^ 1 The mechanism of the thyi'oid dislocation, showing the Y ligament suspending the trochanters, while the head of the bone is lodged in the thyroid foramen, the trochanter resting on the acetabulum. (From a photograph taken in 1861.) 2 In a case of M. J. Ronx, the head of the bone had passed the thyi'oid foramen and reached the ischium ; the leg was elongated, slightly flexed, and inclined outward. The thigh could be flexed, adducted, and abduc- ted, but not extended. After unsuccessful traction, the luxation was reduced by flexion. (Revue Medico-Chirurgicale, torn. iv. p. 364.) THYEOID AND DOWNWARD DISLOCATIONS. 69 The internal obturator muscle is not necessarily broken even in the complete dislocation. That part of the capsule which is attached near the ilio-pectineal eminence may assist the Y ligament in suspending the limb, the thigh becoming in all cases more flexed when forcibly inverted. If the inner branch of the Y be ruptured, the bone is suspended by the great tro- chanter, and the eversion is diminished. Although it might be supposed that the extended psoas and iliacus muscles are concerned in the flexion, yet after the Y ligament is divided the tense fibres of these muscles produce a less degree either of flexion or eversion, and can be broken by depressing the knee. The long muscles of the anterior part of the thigh also become somewhat tense, and the head of the bone tends to escape toward the perinaeum. VERTICAL DOWNWARD LUXATION. Escaping directly downward, the head of the bone may remain upon the lower margin of the socket, — the limb ex- hibiting less eversion than in the thyroid dislocation, but the luxation being practically of the same general character, provided the Y ligament be not ruptured. In Gurney's first case ^ the eversion was slight ; the flexion moderate, but if carried beyond tlie sitting posture, painful ; the knee length- ened by about an inch, standing and sitting ; the foot capa- ble of rotation inward and outward; and the limb able to support the weight of the body in walking, the patient hav- ing walked two hundred yards on the day of the accident and a mile six days after. In a second similar case the patient could walk ; the foot could be rotated outward and inward freely, but the limb could not be flexed to the sitting posture ; the head of the bone was felt behind and below the acetabu- 1 See two interesting cases of dislocation of the thigh downward, by Edwin Gurney, Esq., Surgeon, Camborne, Cornwall. Lancet, 1845, vol. iii. p. 412. 70 THYROID AND DOWNWARD DISLOCATIONS. Fig. 20.1 lum. In these cases the bone obviously had a firm bearing below the acetabulum, which while it was capable of support- ing the weight of the body in walking allowed rotation upon its convex surface. Flexion may have been hindered by the elon- gated extensors. Hippocrates probably refers to a case of this sort (and not, as has been supposed, to luxation on the ischiatic notch) when he speaks of " the leg and foot ap- pearing pretty straight, and not much inclined toward either side; . . . the sole of the foot on its own line, and not inclined out- ward." Of the limb he says : " It becomes much shorter, and the patient can hardly reach the ground with the ball of his foot, — and not even thus, unless he bend himself at the groins, and also bend with the other leg at the ham ; or, if resting upon the foot, the hips protrude backward far beyond the line of the foot." With a crutch the patient "will walk indeed more erect, but will not be able to reach the ground with the foot ; or if he wish to rest upon the foot, he must take a shorter staff, and will require to bend the body at the groins." ^ This description indicates great flexion of the limb without inversion or eversion ; and if it applies to a recent luxation, and not to an old one where the foot has been straightened by time, or unless we suppose the lesion here described to be the result of old hip disease, — an hypothesis which can hardly 1 Dislocation downward. The bone has descended toward the tuber- osity, the flexion of the thigh being proportionate to the descent of the bone. "^ Hippocrates, " Genuine Works," etc., art. 71. THYROID AND DOWNWARD DISLOCATIONS. 71 be considered possible in view of the practical experience of the writer, — these signs are compatible only with dislocation beneath the socket. DISLOCATIONS NEAR THE TUBEROSITY OR PERIN^UM.^ When the thigh is thus strongly flexed, it is easy to imagine that the head of the femur, suspended by the Y ligament be- neath the lower mar- gin of the socket, pauses there, hesitat- ing between the thy- roid and the dorsal luxations. It has been found at various — points in the interval Fig. 2\.^ 1 For a case of dislocation near the tuberosity, see Cooper's " Treatise," Case LXX. The limb was " considerably shortened and inverted," form- ing half a right angle with the body, — the shaft of the femur crossing the symphysis, and being fixed there. At the autopsy the head was found on the tuberosity ; the obturator internus was ruptured, and the ischium and ilio-pubic symphysis were broken, — complications which would not, however, necessarily modify the character of this dislocation. For a case of perineal luxation, with autopsy, see Transactions of the London Pathological Society, vol. x. p. 211. The thigh was much flexed and abducted, any attempt to adduct or depress it being met by resist- ance and pain. The head was felt in the perinseum. Reduction was effected by drawing the thigh vertically down from the pelvis, with lat- eral extension by a towel, aided by the knee of the operator in the groin. The capsular ligament was extensively detached, so that the head of the femur easily protruded. The " ilio-femoral ligament was detached at its outside, and partially separated from the neck of the femur ; and a small rent extended from that point into the capsular ligament." Flexion here was doubtless due to the remaining inner band of the Y ligament. 2 Dislocation downward and inward toward the perinseum. As in the other regular downward luxations, the flexion is proportionate to the descent of the head of the bone. 72 THYROID AND DOWNWARD DISLOCATIONS. between these luxations, and directed into the one or the other in attempts to reduce it. In extreme flexion the head may reach as far as the tuberosity on one side and the ascending ramus of the ischium, and even the perinseum, on the other. In short, in the dead subject the ligament permits the head of the bone to descend until the edge of its articular surface sweeps the centre of the tuberosity and the ascending ramus of the ischium. When found in these positions in the living subject, — so far as may be inferred from the reported cases, — the ligament was not ruptured. Such being the position of the head of the femur in the dislocations with extreme flexion, the knee would occupy the extremity of the opposite spoke in an imaginary wheel of which the Y ligament should be the centre. The signs obviously vary with the position of the bone, the limb being always flexed ^ in proportion to the downward displacement of the head of the femur and the length of the ligament, — inverted when the femoral head is directed to the outside of the socket, and everted when it inclines to its inner aspect. If the head of the bone inclines a little to the inside, resting near the groove of the external obturator tendon, the limb is a little abducted, elon- gated, and rotated outward, this being a first advance toward the thyroid foramen. If the head of the bone rests a little 1 In some of the reported cases of downward dislocation where the head was felt near the tuberosity, it is impossible not to recognize the fact that the flexion of the thigh was less than it should have been if the Y liga- ment was sound, — as it was in the case of Stanski, for example (see note, p. 73). Such a case is that of Bouisson, where the head was on a level with the tuberosity, and the thigh is said to have been but slightly flexed (Gazette Medicale, 1853, p. 664). The ligament may have been here rup- tured in whole or in part, and if so the dislocation was irregular. On the contrary, in a fatal case reported by Mr. Luke (Medical Times and Ga- zette, vol. xvi. p. 12), the flexion of the leg is not alluded to, although the limb was lengthened one inch without inversion or eversion, and at the autopsy the head of the bone was found just below the acetabulum, and the capsule was lacerated only heloiv. If so, the limb must have been flexed. THYROID AND DOWNWARD DISLOCATIONS. 73 outside and behind the axis of the acetabulum, the rotation of the limb inclines proportionately inward, this being a step toward dislocation behind the tendon (Fig. 13), into which this luxation may be easily converted by depressing the knee. If the head of the bone is thrust down near the tuberosity, the limb is in extreme flexion, with perhaps adduction. If it is forced inward upon the perinseum, we naturally find also, with extreme abduction, the thigh standing out at right angles with the body ; ^ and as there is no firm bearing for the trochanter in the perinasum, as in the thyroid foramen, the toes may be inverted or everted.^ 1 The following case of perineal luxation is reported by WiUard Parker, in the New York Journal of Medicine, March, 1852, p. 188. A man was standing beneath a canal boat, his legs apart, and received the weight of the falling boat upon his back. The left leg and thigh were found ex- tended at a right angle with the body, and a little inverted ; while the head of the femur could be felt in the perinseum behind the scrotum. Extension outward and downward carried the head of the bone into the thyroid foramen, whence it was reduced by carrying the femur across its fellow. A similar accident happened to Pope's patient (Ibid., p. 198), upon whom a bank of earth fell while he was standing under it with his legs widely spread. The thigh was found to be at right angles with the body, inclined a little forward, the head of the bone projecting beneath the skin in the perinseum. Reduction was effected by lateral extension applied with pulleys to the upper part of the thigh, the leg being used as a lever. The case of Amblard (quoted by Malgaigne, " Traite," etc., p. 876) was attended with a good deal of local pain, and with I'etention of urine. The lesion was caused by a fall from a cart upon the leg, which is sup- posed to have been already luxated by some twist before the patient reached the ground. The thigh was spread at a right angle to the body, with a little outward rotation. To reduce it, the leg was drawn down- ward and outward, and the head of the bone lifted outward with a towel. The head entered its socket by the way of the foramen ovale. The case of Amblard showed eversion, while that of Parker exhibited inversion. 2 The annexed woodcut (Fig. 22) represents the specimen of Stanski {Bulletin de la Societe Anatomique, 1837, p. 296), and is taken from Mal- gaigne (" Traite," etc., PI. XXVIL, Figs. 4 and 5), whose description is more complete than that of Stanski. It shows the anchylosed bones in a 74 THYROID AND DOWNWARD DISLOCATIONS. The obvious affinity and resemblance between these down- ward luxations, of which the thyroid is frequent and the others luxation of long standing, occasioned by the falling of a bank of earth upon a man while stooping. Although the dislocation is classed as thyroid by both these writers, the great flexion of the femur indicates that the head of the bone had passed down- ward and inward near the tuberosity, while the Y ligament remained en- tire, — "a mass of bony stalactites, which seem to prolong the inferior iliac spine downward to join the internal face of the femur, to which they adhere to the extent of four centimetres, bending round its anterior face, and even behind it, to join the great trochanter" (Malgaigne), being, if we may judge from the fig- ure, the tense and anchylosed Y ligament, beautifully illustrating this form of luxation. (Compare with Figs. 19 and 20.) Or it may have been that in this case the external ligamentary band was broken, pro- ducing greater eversion and more flexion. I have examined only Malgaigne's lithograph of this specimen, in which the origin of the bony plate from the inferior spinous process is so clearly given that, if cor- rectly represented, there can be little doubt of its real character. Yet it is proper to say that M. Houel alludes to it as a part of the tendon of the psoas muscle (" Manuel d'Anatomie Pathologique," etc., par Ch. Houel, Professeur Agrege, etc., Paris, 1862, p. 231). See also the case of Keate (London ^ledical Gazette, vol. x., p. 19). The accident happened to a gentleman, who while riding fell into a ditch, his horse falling upon him and widely separating his legs. The limb was three and a half inches longer than its fellow, " much flexed," with very great abduction and eversion. The head of the bone was close to the tuberosity, and freely movable. It was reduced by the way of the fora- men ovale, — the route of the luxation, as stated by the patient. This case may have been " irregular," because the operator was able to elon- FiG 22. THYROID AND DOWNWARD DISLOCATIONS. 75 rare, need not be urged. The bone is suspended by the Y ligament, and when the head is displaced to one side of the socket the limb passes to the other ; or if the head is arrested directly beneath the cotyloid cavity, the limb is in simple flexion, — the position of the limb thus indicating that of the head of the bone, which can then generally be felt, sometimes very distinctly, as in the perinaeum. In the downward dislocations, if the inner fasciculus of the Y ligament is ruptured, the head of the bone is inclined down- ward by an inward rotation of the limb still suspended at the outer trochanter, — the head of the femur being then com- paratively lower and the limb less flexed than if the inner fasciculus were unbroken. Such a state of the parts might exhibit the head of the bone in the neighborhood of the tuberosity without excessive flexion, but the limb would be greatly inverted. REDUCTION. The thyroid dislocation is usually not difiicult of reduction ; but the following methods will illustrate the variety of expe- dients to which the surgeon may have recourse, — it being remembered that the rent of the capsule, which is here thin, may be enlarged at discretion by circumduction of the flexed thigh inward. 1. Rotation. — Flex the limb toward a perpendicular, and abduct it a little to disengage the head of the bone ; then rotate the thigh strongly inward, adducting it, and carrying the knee to the floor. The trochanter is then fixed by the Y ligament and the obturator muscle, which serve as a fulcrum. While these are wound up and shortened by rotation, the de- scending knee pries the head upward and outward to the socket. As in reducing the secondary pubic dislocation, the gate or pull down the limb after reduction, — a circumstance which he attributed to a supposed fracture of the socket. 76 THYROID AND DOWNWARD DISLOCATIONS. last half of this manoeuvre is an inward circumduction of the flexed limb accompanied with rotation, and is practically the reverse of the flex- ion, abduction, and eversion by which a dorsal disloca- tion is reduced from the opposite side of the socket. In this manoeuvre the action of the ligament may be aided, if necessary, by a towel passed round the upper part of the thigh, to draw the head of the femur up- ward and outward. Rotation outward Fig. 23.1 may be substituted for inward rotation. ^ 1 The surgeon is here represented in the act of rotating and circum- ducting the flexed thigh inward. 2 In the paper akeady quoted, Dr. Markoe cites the two following cases of thyroid luxation reduced by rotation : — (Case 8) Dr. Buck here reduced the bone by inward rotation, after two failures. In the third and successful attempt, the thigh was brought down from entire flexion to a little below a right angle, and again rotated inward, when the head of the bone slipped into its place. (Case 9) Markoe, in imitating Buck's method by rotation inward, unintentionally carried the head of the bone round the socket to the sci- atic notch, from which position it was returned to the foramen ovale, and reduced by rotation outward, the knee being at the same time strongly adducted toward and behind its feUow. These cases are instructive, as showing that the head of the bone is directed toward the socket when the Y ligament is wound upon the shaft by rotation, tvhether inward or outward; and they correspond to the THYROID AND DOWNWARD DISLOCATIONS. 2. Traction. — Flex the limb toward the abdomen, and draw the thigh outward by a towel passed round the upper part ; or thrust it out- ward by applying the foot to the in- side of the groin. 1 3. Flex the thigh upward and out- ward, and drag or jerk it in that di- rection toward the socket. (Fig. 25.) 4. Lay the pa- tient on his belly on the edge of a table, the injured thigh hanging, and the results of iny own experiments, made before I had read the report of these cases. In the first case, the operator in finally placing the thigh a little below a right angle tightened the ligament and directed the head upward, while at the same time a passage was left for the head of the bone between the trochanter and the socket. In the second, the surgeon, starting the limb at right angles, relaxed the ligament, engaged the head at its lowest point beneath the socket, and cai'ried it by inward circumduction to the ischiatic notch. Had the thigh been now again placed in a vertical position it could have been jerked up into the socket. It was, however, returned to the thyroid foramen, and reduced by outward rotation. In these cases, the head entered the socket while the knee was being depressed obliquely inward. It may be superfluous to say that in Markoe's case inward rota- tion would probably have reduced the bone had the thigh been less flexed, or the manipulation been aided by oblique or vertical traction with a towel round the thigh at its upper part. 1 In reducing a dislocation of this sort, flexion with lateral traction was successfully employed by M. Vertu. (P. A. Vertu, These, No. 116, Archives Generales de Medecine, 1836, p. 379.) 2 The mechanism of the manoeuvre shown in Fig. 23 is here seen. The inner branch of the Y ligament being wound round the neck, the head must rise toward the socket as the femur is depressed inward. 78 THYROID AND DOWNWARD DISLOCATIONS. leg bent to relax the flexors ; then draw the head of the femur outward with the aid of a towel. 5. Place him in a sitting posture, with a log or post or bedpost between his thighs, and pry the head outward over this fulcrum by means of the shaft of the femur as a lever. ^ 6. Let him lie on a table, the limb flexed as usual. Then let an assistant, turn- ing his back to the patient, carry the flexed knee over his own shoulder, grasping the foot, and endeavoring thus to lift the pelvis, while the surgeon draws the thigh outward by a towel in the groin. 7. Let the surgeon, facing the patient, place the flexed limb upon his shoulder, and embracing the thigh near the pelvis, lift and direct the head of the bone toward the socket.^ Fig. 25.-2 1 In illustration of the flexion method, see Cooper (" Treatise," etc., Case XLVI.) Eight hours after a thyroid dislocation, attempts were made to reduce it by traction in the usual way, and were continued un- successfully until late at night, when, the pulleys breaking, further pro- ceedings were deferred until the next day. The patient, having then taken two doses of tartar emetic, was carried into the operating the- atre at 2 p. M. Attempts at reduction were again made, and powerful extension employed for upward of an hour without success. The tartar emetic was rei>eated in large doses, and the man, becoming faint, was placed in a sitting posture. Extension was then made, and after a short time the head of the bone slipj^ed into the acetabulum. 2 Thyroid dislocation. Reduction by traction. The limb is flexed, abducted, and everted, relaxing completely the Y ligament. (From a photograph taken in 1861.) 3 Method of Larrey. (See Malgaigue's " Traite," etc., pp. 853-855.) THYROID AND DOWNWARD DISLOCATIONS. 79 8. Let the capsular orifice be enlarged by a little circum- duction of the flexed thigh inward, as if to convert the thyroid into a dorsal luxation ; and let the pelvis, suspended by the limb, be then depressed by the foot of the surgeon, while the thigh is drawn outward, if necessary, with a towel. 9. Convert the thyroid into a dorsal luxation, and proceed accordingly. 10. Most of these manoeuvres may be executed while the patient lies on his sound side, if counter-extension be applied as a substitute for the weight of the body. To reduce the other varieties of downward luxation, the femur should be flexed and its head drawn and guided toward the socket, — during which manoeuvre these dislocations are sometimes converted into that upon the thyroid foramen, or upon the dorsum below the tendon. For the dislocation downward we may employ vertical trac- tion, rotating the femur a little inward to disengage the head; for the dislocation downward and outward, traction upward and inward, with abduction and rotation outward if required to tilt the head ; for the dislocation downward and inward, traction upward and outward. In these three injuries the femur is of course to be kept flexed, its head drawn and guided toward the socket by local pressure, or lifted with a towel if necessary, with rotation outward, and abduction when the bone is directly below or outside the socket, and with circum- duction at discretion when required to enlarge the capsular opening. See also the methods, 6, 7, and 8. 80 DISLOCATION ON THE PUBES. DISLOCATION UPON THE PUBES, AND BELOW THE ANTERIOR INFERIOR SPINE OF TEE ILIUM. (Sub- spinous.) dislocation upon the pubes. In this dislocation the head of the bone is felt upon the pubes ; the limb is a little shortened and everted, abducted Fig. 26.1 Fig. 27.2 and advanced. A laceration of the inner aspect of the cap- sule allows the bone to escape obliquely upward, to a point 1 Pubic dislocation. The foot is everted, the thigh advanced and abducted. 2 Pubic dislocation. The head of the bone is seen in the groin, sus- pended by the Y ligament. (From a photograph taken in 1861.) DISLOCATION ON THE PUBES. 81 upon the pubes distant in proportion to the violence of the force displacing it.^ Complete pubic dislocation is impossible unless the capsule beneath the obturator internus is ruptured,^ after which this muscle everts the limb until the trochanter bears upon the pelvis. If this muscle is ruptured, the psoas and iliacus, bind- ing the neck of the bone to the pubes, may produce a degree of eversion ; but the principal agent of eversion even then is the Y ligament, which also embraces the neck. The untorn capsular fibres and tlie obturator muscle are agents in prevent- ing flexion, their insertions being lower than the head of the displaced bone, which then becomes a fulcrum, the lever in flexion being the shaft ; but in pubic dislocation nearer to the iliac spine, the obturator is not tense, and flexion is then prob- ably hindered by the outer and inferior parts of the capsule, when they still exist. Both the muscle and the capsule act in preventing inversion. Dislocation to the neighborhood of the symphysis implies a rupture of the inner branch of the Y ligament.^ ^ Larrey is said to have seen a case of pubic dislocation in which the femm- was flexed at nearly a right angle with the body. (Hamilton, " Practical Treatise," etc., p. 655.) It is fair to suppose that it could have been brought down to the usual position. 2 In an autopsy of a case of pubic dislocation, recorded in a paper by Mr. Bransby Cooper (Guy's Hospital Reports, 1836, vol. i., p. 82), the gemini and quadratus femoris had suffered from laceration and subse- quent ulceration, implicating all the outward rotators of the thigh. ^ A careful autopsy of pubic luxation is recorded in a communication of M. Aubry, read by M. Maisonneuve, to the Societe de Chirurgie (Ar- chives Generales de Medecine, Paris, 1853, p. 35.5). The head of the bone projected in the groin ; the limb was rotated outward with flexion, a little abduction, and shortening to the extent of one quarter of an inch. The autopsy showed the psoas and the crural nerve upon the anterior surface of the neck. Half the anterior circumference of the capsule was torn at a quarter of an inch from its cotyloid insertion, the neck of the femur being held in a sort of button-hole between its fibrous edge and the co- tyloid rim. Flexion of the thigh obvioiisly relaxed this fibrous band, liberating the neck ; extension produced the contrary effect, strangulat- 6 82 DISLOCATION ON THE PUBES. DISLOCATION BELOW THE ANTERIOR INFERIOR SPINE OF THE ILIUM, OR SUB-SPINOUS. The head of the bone ranges along the pubes, displaced ac- cording to the violence and direction of the injury. If thrust Fig. 28.1 Fro. 29.2 directly upward, the bone may lie beneath the Y ligament and the inferior iliac spine ; but this displacement requires that ing the neck. Of the muscles, the external obturator was relaxed ; the pp'iformis, internal obturator, and gemelli appeared elongated. 1 Pubic dislocation nearer the spine. The limb is here seen everted, but is usually a little more advanced and abducted. Nelaton, however, describes a similar absence of flexion (" Clinical Lectures on Surgery by M. Nelaton." from Notes taken by W. F. Atlee, M.D., Phila., 1855, p. 213). 2 Sub-spinous dislocation. The neck of the bone is seen lying beneath the Y ligament, which is tightly stretched across it. (From a photograph taken in 1861.) DISLOCATION ON THE PUBES. 83 the upper part of the capsule should be completely detached from the edge of the socket. The firm bearing of the neck against the Y ligament may then explain how the patient has in some recorded cases been able to walk immediately after this accident.^ The limb is still everted, but less abducted or advanced, and the head of the bone is plainly felt in its new position, — in the absence of which evidence the shortening and eversion might possibly be mistaken for fracture of the neck.2 When the bone has been thus displaced, the psoas and iliacus tendon is sometimes thrown off the neck of the femur toward the pubes where it then lies slack. But even when in place, the action of this tendon is wholly secon- dary to that of the Y ligament in producing either flexion or eversion, as may be shown by its division, after which the position of the dislocated bone Fig. so.^ 1 See Malgaigne's " Traite'," etc , pp. 844, 845. 2 The above figure (Fig. 30) from Malgaigne ("Traite," etc., PI. XXVII. Fig. 1) represents a specimen elaborately described by M. Gely (Bulletin de la Societe Anatomique, 1840, p. 303). The accident oc- curred to an insane person, a long time before death. The neck of the bone rides upon the inferior spine, and the leg is much everted. This eversion may perhaps be referred to pathological changes, but may have occurred at the time of the accident. Gely rightly supposes the weight of the body to have been supported by the upper part of the capsule, reinforced by the tendon of the rectus muscle (Bulletin, pp. 320, 327). 8 Sub-spinous dislocation. 84 DISLOCATION ON THE PUBES. remains unchanged ; while if the Y ligament be divided without the tendon, the bone drops to a position near the thyroid foramen, with little flexion, — an attitude of the limb resembling the irregular dislocation toward the perinaeum or on the tuberosity.! REDUCTION. I have never met with pubic dislocation in the living sub- ject, and am therefore unable to speak of the extent of a difficulty in flexion alluded to by some writers as character- istic of this luxation. But there is ample evidence that this difdculty is neither insuperable nor constant. The pubic dislocation has often been reduced by flexing the limb ; and if the obturator tendon and its subjacent capsule resist flex- ion in the living as in the dead subject, the limb needs only to be drawn down toward the socket while in the act of being flexed. If the bone has been thrust upward between the Y ligament and the pubo-femoral band, and the capsular orifice be small, this band may be ruptured by circumduction or even rotation of the flexed thigh inward. But well-marked pubic disloca- tion usually implies a rupture of the capsule which extends to its inner and lower aspects. (See p. 81.) It is difficult to reduce the pubic dislocation by straight extension, and various accidents have happened in attempt- ing it. 1 If the head of the bone be still further displaced outward, it lies beneath the inferior spinous process, as in the case of Wormald (London Medical Gazette, January, 1837, p. 164), where the limb being somewhat everted, abducted a little, and shortened half an inch, the new cavity was formed in part by the upper portion of the cotyloid ligament. The patient, who died twenty-six years after the accident, was said to be able to walk well, being " engaged in carrying out beer for a publican in Portugal Street," — a statement which Malgaigne oddly translates, *'■ pour porter un mort au cimetiere" (" Traite," etc., p. 871). DISLOCATION ON THE PUBES. 85 The reduction may be accomplished in a variety of ways, among which are the following, combining angular traction and rotation. 1. By Traction and Rotation. — Flex the limb to a right angle, while drawing it down ; rotate either inward or out- ward, and directing the head of the bone by its shaft, rock it downward into its place.^ 1 Two cases of pubic dislocation skilfully reduced by manipulation are reported by Dr. E. J. Fountain, of Davenport, Iowa, in the New York Journal of Medicine, etc., January, 1856, p. 69. In the first case, the patient was laid upon the floor on a quilt, made insensible with chloro- form, and the limb was rotated outward. The leg was then flexed and carried across the opposite knee and thigh, the heel kept well up and the knee pressed down. This motion was continued by carrying the thigh over the sound one as high as the upper part of the middle third, the foot being kept firmly elevated ; then the limb was carried directly upward by raising the knee, which was gently oscillated, when the head of the bone dropped into its socket. The time of this operation was from twenty to thirty seconds, and the force slight. In a second case, rota- tion and fiexion produced greater pain, and the limb was less movable. Here also the knee and foot were rotated outward, the leg then fiexed across the sound thigh, the heel kept up and the knee pressed down. The whole was carried in this position across the sound thigh directly upward to the flexed position, the operator holding the foot firmly up and making oscillations with the knee, when the head of the bone slipped into the socket. About twenty seconds sufiiced for the operation, which was performed without the use of chloroform. It wdll be observed in these cases that no real difficulty was encoun- tered in flexion. The limb was flexed, and the vertical femur, rotated outward, was rocked down into its place. The outward rotation of the flexed femur made the outer branch of the Y ligament tense, with an interval through wdiich the head of the bone, already rotated to a point just above the socket, descended into it. Perhaps, as Dr. Fountain recom- mends, the whole manoeuvre should be commenced with an outward rotation, to be maintained till the reduction is accomplished; but it seems to me that this rotation is unnecessary until after the limb is flexed. Devilliers and Aubry each reduced a pubic dislocation by flexion and rotation inward instead of outward, and Larrey by simple downward pressure at the groin, with the knee over his shoulder (Malgaigne, " Traite," etc., pp. 853, 854). 86 DISLOCATION ON THE PUBES. Fig. 31.1 2. While extending the limb horizontally, with counter- extension by the foot in the peringeum, raise the patient to a sitting posture, coun- ter-extend against the pubes, and rotate in- ward. 3. The same method may be pursued, the patient lying on his belly on the edge of a table, or on his sound side. 4. See Reduction of the Thyroid Dislocation, Nos. 7 and 8. 5. Flex and abduct the limb and draw it outward, at the same time pressing the head downward and outward. By Rotation. — Reduction by rotation is to be accomplished by much the same method as in the thyroid dislocation, ex- cept that in the pubic luxation the flexed limb should be carried across the sound thigh at a higher point. First, semi-flex the thigh to relax the Y ligament, at the same time drawing the head of the bone down from the pubes. Then semi-abduct and rotate inward, to disengage the bone com- pletely. Lastly, while rotating inward and still drawing on the thigh, carry the knee inward and downward to its place by the side of its fellow. As in the thyroid luxation, this manoeuvre guides the head of the bone to its socket by 1 Pubic dislocation. Reduction by traction. The limb has been here flexed and abducted, for reduction by traction and local pressure. The abduction is rej)resented as greater than necessary. (From a photograph taken in 1861.) ANTERIOR OBLIQUE DISLOCATION. 87 a rotation wliich winds up and shortens the ligament, enabling the operator, by depressing the knee, to pry the head of the bone into its place. Brieiiy, while drawing upon the thigh, flex and abduct it to disengage the head ; then rotate inward, and when the bone leaves the pubes, continue the rotation while straightening the limb ; or circumduct the bent limb inward.^ Aid these manoeuvi-es by drawing the flexed groin outward with a towel, or otherwise depressing it.^ If by these combined movements of traction, leverage, and rotation — of which the Y ligament and the obturator tendon, when it is unbroken, are the centre — the luxation is not re- duced, it will perhaps be converted into one near the thyroid foramen, the rules for the reduction of which will then apply here.^ ANTERIOR OBLIQUE DISLOCATION. The remaining luxations imply a free laceration of the tissues about the joint, and sometimes of a part of the Y ligament itself. 1 See case of Dr. J. M. Iivme (British- American Journal, March, 1861, p. 282). A complete pubic dislocation of the right hip was reduced by flexing the thigh wpon the pelvis, carrying the knee over the umbilicus to the left side of the body, and thence to a state of extension, when the head slipped in. 2 Baron Larrey has reported a case of dislocation in front of the hori- zontal portion of the pubes, which he reduced by suddenly raising with liis shoulder the lower extremity of the femur, while with both hands he pressed the head of the bone downward. (Hamilton, " Practical Treat- ise," etc., p. 657, and London Medico-Chirurgical Review, December, 1820, p. 500). 3 Mr, Annandale, after some unsuccessful manipulation, succeeded by flexion in reducing a pubic dislocation of three days' standing, but used pulleys to withdraw the head of the bone from the pubes by outward extension. (Thomas Annandale, F. R. S. E., etc.. Assistant Surgeon of the Royal Infirmary ; Edinburgh Medical Journal, 1867, p. 997.) 88 ANTERIOR OBLIQUE DISLOCATION. In a common dorsal dislocation, let the leg be carried across the symphysis, so that the outer and convex surface of the Fig. 33.2 1 Figs. 32, 33, 34, — anterior oblique dislocation. The limb is here extremely everted, crossing the other above the knee. The general ana- tomical character of the luxation is seen in Fig. 33, vi^here the Y ligament is still entire, the limb crossing the other high uji. As the limb descends toward a perjiendicular the outer fibres of the ligament yield, until, as it reaches the position seen in Fig. 37, only the inner fasciculus remains. The head of the bone is then hooked over this inner fasciculus, as seen in the dotted line (Fig. 37), and the supra-spinous luxation is complete. If now thrust back upon the dorsum, the dislocation is simply the everted dor- sal, as shown in Fig. 40, where, however, the toes may be inverted at will. 2 Anterior oblique luxation. By depressing the shaft of the femur the head rises over the inferior spinous process, as the external part of the ligament yields. ANTERIOR OBLIQUE DISLOCATION. 89 socket shall correspond to the hollow beneath the neck of the femur. With some force the thigh can now be everted, and afterward brought down across the upper part of its fellow. It is here firmly locked, with great shortening and some ever- sion, the limb facing forward and obliquely crossing the oppo- site thigh, while the toe points outward, — a position not wholly ungraceful, and suggesting some attitudes in dancing. (Figs. 32 and 33.) i If in this position it is desired to bring the limb toward a perpendicular, the outer branch of the Y ligament must be ruptured. Thus liberated, it hangs suspended by the inner ligament, and becomes capable of lateral motion and of rota- tion ; and this is probably the condition under which supra- spinous luxation, although rare, usually occurs. (Fig. 35.) The anterior oblique dislocation may be reduced by inward circumduction of the extended limb across the symphysis, with a little eversion, if necessary, to disengage the head of the 1 For a description of the annexed woodcut, taken from Cooper, and which exhibits the position of the anterior oblique luxation, see case of Oldknow (Guy's Hospital Reports, No. 1, p. 97), also Cooper (" Treatise,' etc., Case LXVII.). The foot is said to have been very much everted, only the toes touching the gi'ound. But the patient had lived twelve years after the accident, and something may be , allowed for pathological changes. For a larger figure representing this dislocation, see a paper of Bransby Cooper, Guy's Hospital Reports, 1836, vol. i. p. 81. Fig. 34.(«) («) Anterior oblique luxation. 90 SUPKA-SPINOUS DISLOCATION, bone. Inward rotation then converts this into the common luxation upon the dorsum. Fig. 35.1 DISLOCATIONS IN WHICH THE OUTER BRANCH OF THE Y LIGAMENT IS BROKEN. SUPRA-SPINOUS DISLOCATION.^ The head of the bone has been found above the inferior spinous process, the neck lying across the edge of the pelvis, the trochanter turned back, and — d.6 is said — not readily 'discovered. The limb was shortened two or three inches, a 1 This figure is intended to show in diagram the external portion of the Y ligament detached, as in the supra-spinoiis and everted dorsal luxations. '^ See case of Cummins (Guy's Hospital Reports, vol. iii.). Cooper (" Treatise," etc.. Case LXV.) cites this case as anomalous, illustrating it with a figure which represents the head of the bone as projecting farther upon the abdomen than the context indicates. The leg was shortened three inches, and could not be drawn down. The limb, which SUPRA-SPINOUS DISLOCATION. 91 little abducted, and everted, — this eversion being sometimes so great that the toes pointed backward, although in one of was much everted, could not be rotated inward. Cooper considers this to be " a variety of dislocation hitherto unknown." Travers (Medico-Chirurgical Transactions, vol. xx. p. 113) thus de- scribes a case : " The trochanter is felt below and to the outer side of the anterior superior spinous, process of the ilium. The neck of the bone lies apparently between the two anterior spinous processes, so that when the patient is erect the limb seems as it were slung or suspended from this point." Sir Astley Cooper (" Treatise," etc.. Case LXII.) cites a case of old dislocation " on the pubes." An accurate account of the autopsy, with the annexed figm-e, is given by N. Cadge, F. R. C. S., Xorwich (Medico-Chirurgical Transactions, vol. xxxviii. p. 88). The left leg was full an inch and a half shorter than the right; the toes were turned outward ; and while the body lay on its back the foot rested completely on the outer border. A large, globular, bony tumor was felt in the groin, close to the superior spine of the ilium. On dissection, the head of the femur was found in the interval between the anterior superior and anterior inferior spinous processes of the ilium. The head of the fe- mur was covered with a complete bony cap, lined with a dense, pearly- white tissue, resembling fibro-carti- lage (Fig. 36). The edge of the new cavity was connected with the neck of the thigh-bone by a thick capsular ligament. The rectus muscle, which had been torn from its origin, was inserted into the edge of the new cavity, — a condition that suggests the ascent of the bone above the inferior spinous process of the ilium at the time of the injury, with rupture of the Y ligament. This luxation may have been supra-spinous or irregular. («• Supra-spinous dislocation, r^, bony cap; &, fractured margin of ditto ; c, socket; d, superior spinous process of ilium. Fio. .36 "" 92 SUrPtA-SPINOUS DISLOCATION. the cases related by Cooper they could be brought forward again to the side of the other foot. Another important fea- ture was that the shortened limb could not be drawn down. In this luxation the neck was doubtless hooked over the Y, and perhaps over the tendon of the rectus muscle also; so that direct extension, short of the rupture of this ligament, was worse than useless. The head of the bone had been thrust above and outside the Y ligament, upon which in its return the neck of the femur had engaged itself, the main Fig. 37.1 Fig. 38. branch of the Y then lying behind the neck, and so wound around it as to produce great shortening. In the supra-spinoiis luxations cversion is due to the inter- nal obturator, when it remains entire, but also to the tense ligament. 1 Figs. 37 and 38, — suiira-spinous dislocation. (See note, p. SS.) SUPRA-SPINOUS DISLOCATION. 93 The muscles inserted into the back of the trochanter, es- pecially the obturator internus, hinder the head of the bone from advancing upon the spinous process ; but when they are divided, the head advances toward the abdomen. The first degree of supra-spinous luxation, which is represented in the woodcut (Fig. 37), requires the rupture of only the outer fibres of the Y ligament, and is but a slight exaggeration of the anterior oblique luxa- tion (Fig. 33). But when the bone projects fairly upon the abdomen (as illustrated by the dotted line. Fig. 37), only the in- ner fasciculus remains. It may be remarked that the anterior oblique disloca- tion, while it is also supra- spinous, differs from it in the comparative soundness of the ligament, which compels the limb to assume an oblique position. In the latter luxa- tion the outer band is broken, and the limb is more mova- ble ; the term " supra-.spinous " has been reserved for this, as probably the more common of these two rare varieties. ''M^ Fig. 39.1 1 This woodcut is intended to show the possibility of a posterior ob- lique luxation, the Y ligament being entire, the head of the bone thrust across it, and the shaft locked behind the tuberosity. In the dissected bones it will be found that the femur is firmly locked, the limb being dii-ected backward, and the foot somewhat everted. But there is no authority, so far as I am aware, to show that such a position of the leg has been found in the liAnng subject. By forcibly advancing the knee the outer branch of the ligament is ruptured, and the luxation then becomes supra-spinous. 94 EVERTED DORSAL DISLOCATION. REDUCTION. After extension bv pulleys in the axis of the body has failed, reduction of this luxation has been accomplished by extension downward and outward, with some manipulation of the head of the bone and probably with rupture of the ligament. It is obviously a better plan to unhook the neck by circumduction of the extended limb inward, with eversion enough to disen- gage it from the edge of the pelvis. The head then lies upon the dorsum, and if the outer branch of the Y is broken, is not inverted. The reduction may then be accomplished as usual in the dorsal dislocation, although rotation would be less effectual than if the ligament were entire.^ EVERTED DORSAL DISLOCATION. It has been before stated that inversion of the limb in the dorsal luxations is due to the tense outer branch of the Y ligament. "When the injury has been such as to rupture these fibres, the limb may still be inverted ; but it can also be freely everted. Having escaped from the socket under 1 The following case well illustrates the mechanism of the supra- spinous luxation, and is taken from Hamilton (" Practical Treatise," etc., p. 649) : " Lenta relates a case [of ischiatic luxation] under the care of Dr. Hoffman, in the New York City Hospital, in which, when the extension was suddenly relaxed by cutting the cord, and the thigh at the same instant was abducted and rotated outward, the head of the femur left the ischiatic notch and rose upon the dorsum ilii, assuming a position directly above the acetabulum and below the anterior supe- rior spinous process, from which position it was with great difficulty subsequently returned to the socket." If this luxation was really " ischiatic," as stated, and therefore " below the tendon," the forcible outward rotation of the thigh ruptured both the tendon and the outer part of the Y ligament, or in any case the latter ; after which the head of the bone was free to turn forward and rise on the ilium toward the spine, the limb being of course everted, and the head of the bone perhaps engaged above the remaining ligament. EVERTED DORSAL DISLOCATION. 95 these circumstances, the bone may occupy any point upon the dorsum within the range of the inner fasciculus. The limb is then shortened in proportion to its upward displacement, the foot being sometimes everted a little, sometimes lying flat upon the bed, or even directed backward, the head of the femur facing accordingly, and — as has been else- where remarked — in the direction of its internal condyle. The femur is sus- pended midway between the inner branch of the Y and the obturator ten- don. Theoretically it may be luxated either below or above this tendon ; but in the former case the degree and nature of the force required to break the outer band would be likely to rup- ture the tendon also. If the head of the femur is driven upward and back- ward above the obturator tendon, the same forced eversion which would sever the inner branch of the Y ligament would relax this tendon, and so contribute to prevent its rup- ture. The tendon may then lend its aid in giving position to the limb.2 ^ Everted dorsal dislocation. (See note, p. 88.) 2 For an old case of this sort, with an analysis of the muscular action, see a paper by Dr. Gordon in the Dublin Hospital Gazette, Nov. 1, 184.5, p. 87. Mr G. R. Symes has described a case (" On an Unusual Form of Dis- location of the Hip Joint," by Glasscut R. Symes, one of the Surgeons of Stevens's Hospital, Dublin Quarterly Journal of Medical Science, 1864, vol. xxxviii.) in which the right leg was shortened two inches, the foot extremely everted, the buttock flattened, and the head of the femur two inches below the anterior superior spinous process of the ilium. The limb remained unreduced after protracted efforts by manipulation and Fig. 40.1 96 EVERTED DORSAL DISLOCATION. REDUCTION. The limb should be flexed and inverted, with adduction if necessary, to make room for the head of the bone to slide upon the ilium ; and the dislocation is then practically a simple dorsal dislocation, and easily reduced. Or if not, perhaps the whole upper part of the capsule is detached, making the luxa- tion irregular. The rupture of the outer fasciculus of the Y ligament deprives the operator of much of the advantage of rotation. The limb, after flexion and rotation inward, may be reduced by direct traction toward the socket, with local guidance.^ pulleys, during which it was repeatedly inverted and everted. The fail- ure to reduce the limb was attributed by Mr. Symes to a " button-hole " laceration. In a similar case, or even if the head of the femur were engaged in the interstices of the rotators, I should attempt to liberate it by cu'cumducting it to the thyroid foramen. A case of everted dorsal dislocation has been reported by Dr. Van Buren ("Contributions to Practical Surgery," by W. H. Van Buren, M. D., etc., Philadelphia, 1865, p. 157). The limb was shortened an inch, and slightly everted, there being some obstacle to inversion. The tro- chanter was an inch and a half behind and above its usual position, and the head of the bone was obscurely felt in the back part of the sciatic notch. After repeated attempts at reduction by manipulation, the bone was reduced by pulleys applied to the thigh in a flexed position. For a case probably everted dorsal, but classed by Cooper as anoma- lous, see Morgan (Guy's Hospital Reports, No. 1, p. 82). The left leg was shortened two inches, the foot excessively everted, so as almost to give the toes a direction backward, but when placed side by side with the other foot remained in that position. The leg was to some extent sus- ceptible of all the natural motions, with the exception of rotation. The trochanter could not be felt ; but the head of the bone was apparently lying between the anterior inferior spinous process of the ilium and the junction of that bone with the pubes. Traction was made from the knee against counter-extension with the foot in the perinaeum. The patient was then directed to raise his shoulders from the bed, extension was suddenly increased with forcible inward rotation of the thigh, and the head snapped into the socket. 1 The following interesting case (reported by Dr. Shrady in the New York Journal of Medicine, March, 1860, p. 255) occurred in the hospital IRREGULAR DISLOCATIONS. 97 IRREGULAR DISLOCATIONS. IN WHICH THE Y LIGAMENT IS WHOLLY BROKEN. In rare instances the Y ligament may be completely rup- tured by forced extension of the limb, or by an upward thrust, while the lower half of the capsule remains comparatively sound. But it has been shown that the position of the great majority of dislocations is determined by this ligament ; and until it is likewise shown that when it is broken the luxated limb will be compelled, in obedience to other mechanical agents, muscular or capsular, to assume positions equally constant, it is fair to consider such luxations as irregular. When any mechanism shall be shown always to give to a lux- ated limb, after the Y ligament has been torn asunder, the same position under the same circumstances, the luxation may be withdrawn from the present category, and classed as " regular." When the Y ligament is wholly broken, and the head of the femur is dislocated upward upon the edge of the socket, either ■wards of Dr. Willard Parker. The patient was crushed to the ground by a gravel car falling upon the small of his back. The left limb was rotated outward and shortened three inches, the thigh slightly adducted and flexed, the knee slightly advanced and semi-flexed, and the toe so everted that the heel rested against the inner aspect of the opposite leg, just above the ankle. Passive rotation was very painful ; the buttock of the affected side was much fuller than the other, and the post-trochanteric depression was obliterated. Only the tips of the toes touched the floor. The vertical distance from the trochanter to the crest of the ilium was shortened three quarters of an inch. (If this statement is correct, the apparent shortening of three inches was probably due to the flexed knee.) The head of the bone could be felt, but not very distinctly, in a direction forward and upward from the trochanter. Several efforts to reduce the limb by flexion and adduction were unsuccessful. The thigh was at last rotated inward, extension made in the direction of the socket, and the head of the bone guided by direct manipulation into its place. 98 IRREGULAR DISLOCATIONS. inside or outside the iliacus tendon, there is little or no short- ening, and no flexion ; but the eversion of the foot is marked. The head is felt in the groin, and is reduced by flexion and inversion. If the head of the bone under these circumstances be dis- placed toward the thyroid opening, there is abduction of the leg, produced chiefly by the fascia lata, with some flexion due to the adductors ; but the flexion is less than in the regular thyroid dislocation, and the knee can be depressed, with a little effort, to the natural position. It is possible that such a dislocation might simulate the thyroid displacement ; but it may be distinguished from this by the greater abduction and less considerable flexion of the limb. If the head be now carried farther downward, the flexion becomes more considerable, though less than if the Y ligament were entire. Such may have been the condition of the parts in some of the cases of downward dislocation before referred to, where the head was said to have been felt near the tuber- osity, and where the flexion was inconsiderable. If the head of the bone be now carried behind the tendon of the obturator internus muscle, there is a flexion of the femur at an angle of 45°, but with such exaggerated inversion as to distinguish it from the regular dislocation below the tendon. The thigh then faces completely inward, and instead of cross- ing its fellow is even a little abducted. The leg, which is bent by the tense flexors of the thigh, stands at right angles with it. If the head of the bone be carried upward upon the dorsum, the limb, while it faces directly inward toward its fellow, is no longer flexed, as in the regular dorsal dislocation, but lies flat upon the table. The head, being now detached from the socket, may be carried round upon the dorsum and hooked above the rectus muscle in front, — a position of the parts which, owing to the great strength of the Y ligament, is prob- IRREGULAR DISLOCATIONS. 99 ably less frequent than the regular supra-spinous and everted dorsal luxations, where a portion of this same ligament still remains intact. The Y ligament being destroyed, an upward and back- ward dislocation, if attended with accidental inversion, may be held in that position by the lower part of the capsule, which, however, is readily ruptured by outward rotation or circumduction. IRREGULAR UPWARD LUXATION. The bone may be thrust upward upon the inferior spine or above it, with rupture of the Y, but can then be drawn down as far as the remaining capsule will allow, unless detained by being hooked over the muscles arising from that point.^ 1 For several cases, of which the description is incomplete, but in which the limb was rotated outward, the head of the femur being outside the anterior inferior spinous process of the ilium, see Malgaigne's " Traite," etc., p. 869. In a patient at St. George's Hospital, the head of the bone was dislocated upward upon the inferior spine of the ilium, and a little to the outside, the upper half of the capsule being largely torn. (Lancet, 1840-41, vol. ii. p. 281.) In Gerdy's case, reported by Baron, the upper haK of the capsule was torn, but the round ligament was only half broken. In this case the limb was reduced by flexion, the head of the bone being pressed toward the socket. (" Traite," etc., p. 870.) See also the case of Adam Hunter (Edinburgh Medico-Chu'urgical Transactions, 1824, p. 171.) The limb was shortened one inch, and the toes turned inward. The head of the bone was over the sciatic notch, the gluteus minimus, pyriformis, obturator internus, and other small muscles being ruptm-ed. The capsule was entirely detached from the femur, so that when the ilio-femoral muscles were divided the limb was separated from the trunk. The head was said to have been bound down firmly on the sacro-sciatic notch by the gluteus medius, which passed over the neck of the bone. In the absence of the capsule, it is quite possible that the gluteus medius, beneath which the head of the bone was found, together with the anterior flexors of the thigh, exercised a certain controlling influence on the position of the limb ; and yet after dividing the whole capsule in a recent subject, and engaging the head of the femur fairly under the gluteus medius muscle, I have found that rotation ruptured its fibres with little effort. 100 IRREGULAR DISLOCATIONS. IRREGULAR DOWNWARD LUXATION.^ This variety should be distinguished from that in which the Y remains entire, — described in connection with the thyroid luxation. In the latter case the thigh will be forcibly flexed by the Y, and either adducted or abducted, while the head descends even to the tuberosity or perinaeum, — afterward, perhaps, returning to be lodged near the thyroid foramen, or on the dorsum. But if the Y be wholly broken, the limb is suspended by the remaining and comparatively slender cap- sule, which in such a case would probably be ruptured, thus abandoning the limb to the muscles. Of these, the psoas and iliacus offer a resistance most resembling that of the capsule, and produce an imperfect flexion. The biceps and other extensors may in certain positions interfere with flexion, as they doubtless do in the regular dislocation downward, while the adductors and flexors are also put upon the stretch when the limb is extended or abducted. It has been elsewhere stated that the muscles inserted immediately about the hip are subjected to the very powerful leverage of the femur, and are readily ruptured when unsupported by the ligament of the capsule. The same is true in a less degree of the long muscles, which are liable to laceration from the great violence necessary to sever the entire capsule. When this happens, the bone may be considered as fairly torn from the socket, — a grave accident, which rarely occurs, and in which the limb assumes no uniform position. The head of the bone might possibly, in such a case, be found on the tuberosity or in the perinaeum, even when the limb is extended. 1 The case of Keate (see p. 74) may have been irregular, because the operator was able to " elongate or pull down the limb " after reduc- tion, — a possibility supposed to depend on a fracture of the socket, but which may have resulted, if correctly reported, from a rupture of the Y ligament. OLD DISLOCATIONS. 101 REDUCTION. An irregular dislocation, with rupture of the Y ligament if not the whole of the capsule, cannot be reduced by any ro- tation which depends for its efficiency upon the integrity of these ligaments. On the other hand, their ligamentous fibres can no longer interfere with a direct traction of the femur toward the socket, aided by local guidance if required. SPECIAL CONDITIONS OF DISLOCATION. OLD DISLOCATIONS AND THEIR REDUCTION, Cooper ^ cites a case of dorsal dislocation said to have been reduced after the lapse of five years by a fall from a berth on shipboard. Such an occurrence is by no means impossible, but would depend upon the condition of the acetabulum, and of the head of the bone, the changes in which would be influenced by the age and tendencies of the patient.^ So long as the socket was still excavated, and the bones were not deformed by osse- ous growths, I should feel quite confident of breaking any adhe- sions, lacerating the newly formed capsule, and replacing the bone by the great power of the femoral shaft as a lever, and of the flexed leg in rotating the head of the bone around the main ligament.-'^ I am unable to understand why Malgaigne, ^ Treatise, etc., Case LXIY. 2 For a case of dorsal dislocation reduced after eight months, see p. .5.3. 3 The following passage corroborates the views here advanced, al- though its writer does not recognize the capsule as a source of resistance to reduction : — " It is doubtful if the capsule is ever an obstacle to the return of the •dislocated bone. Certainly the altered shape of the head of the bone never can prevent the retui'u of the head to its articular cavity ; and it is probable that where the articular cavity is partially obliterated, it is 102 OLD DISLOCATIONS. as quoted by my distinguished friend M. Broca,^ in the dis- cussion elsewhere alluded to, should assign an indefinite period of two years or more as the limit for reducing a dorsal dislo- cation, and only fifteen days for that upon the ischiatic notch. By the flexion method, the latter luxation should, theoretically, be reduced with even more facility than the former, and after as long an interval. A difficulty that may be seriously considered is the risk of breaking the femoral neck, if it has undergone fatty degene- ration or atrophy from long disuse ; and it might be well in such a case to rely rather on traction, or other force exerted longitudinally upon the bone, than on rotation, where from the immense power thus laterally applied the neck is taken at great disadvantage. The angular traction, to be hereafter described, would be especially suitable, — although, from the greater facility of such an application of power, a better result might be anticipated in a dorsal or downward than in an old pubic or even thyroid luxation. Yet should fracture of the neck, or separation of a previous fracture, occur during such attempts at reduction, it may be fairly said that the patient will generally have a better limb after its inversion has been thus corrected than with an unreduced luxation. An illustration of these points is afforded by a case in the Chelsea Marine Hospital, under the charge of Dr. Graves. The patient, a man twenty-three years of age, about six the ]-esult of extraordinary violence and consequent inflammation. I have found the cotyloid cavity retaining its depth and covered with carti- lage after the head of the femur had been dislocated for three years ; and Fournier has placed a dissection on record where the head of the femur had been dislocated during thirteen years, and in which the ace- tabulum retained its form and depth and cartilage. (Bulletin de la Societe Anatomique, 1855.)" — Bernard E. Brodhurst : On the Re- duction of Old Dislocations (St. George's Hospital Reports, vol. iii. 1868. London. 1 Union Medicale, No. 79, p. 57. OLD DISLOCATIONS. 103 months before entering the Hospital, had fallen from the mast-head, seventy-five feet, striking the thwart of a boat (which was broken by the fall) and dislocating his left hip. No attempt was made, at the time of the accident (Nov. 8, 1862) to reduce the displacement. At the time of entering the Hospital the patient was wholly unable to walk, being carried and placed in bed, where he remained. The limb was shortened about two inches, slightly flexed, and inverted to such a degree that the patella faced the inside of the opposite thigh, and the toes of the affected limb were more easily placed behind the heel of the other foot than upon the instep. The patient could partially flex the thigh, and also extend it nearly flat upon the bed, and could rotate the limb inward, but could not evert it. The head of the bone was readily felt upon the dorsum. Dr. Graves having kindly placed the man under my charge for the reduction of the dislocation, I flexed the limb once slowly upward upon the abdomen, — a move- ment which was attended with a continued fine crepitation about the hip. Upon examination, the head of the bone was now felt to be detached from the neck, and freely movable, like a grape-shot, among the muscles of the haunch. The patient was thereupon placed in bed, the position of the extended limb being much the same as before manipulation. In the course of a week the foot was gradually everted, after which extension was applied and maintained during three months, being increased by degrees from seven pounds to about twenty-one. In two weeks from this time the patient began to move about on crutches, which after six weeks more were abandoned, and at the end of two years he was able to walk without a cane. The limb is now, six years after the accident, an inch and a half shorter than its fellow, but other- wise in proper position, and moves freely in all directions, although it cannot be everted much beyond the perpendicular. The head is firmly attached to the femur behind the trochanter, 104 DISLOCATION FROM HIP DISEASE. and seems with the latter to cover the acetabulum. The manipulation in this case was conducted in the presence of a considerable number of medical gentlemen ; and the manner in which the head was detached from the shaft left no doubt upon their minds that the neck, as the result either of an original fracture or of subsequent inflammatory action, had not its normal strength. On the other hand, the present con- dition of the patient is much better than it would have been had not the dislocation been treated. He walks freely and firmly, with but little lameness, runs up and down stairs, and can swing the limb in all directions. DISLOCATION PROM HIP DISEASE. In the dorsal luxation which follows aggravated hip disease, the anterior part of the capsular ligament usually supports and inverts the shortened limb. On the other hand, the head of the femur, which rests upon the dorsum of the ilium, pro- duces, when disintegrated by disease, less inversion than if it were of normal size. Again, the displacement is generally a sub-luxation ; but it may sometimes be complete. In a case of hip disease, occurring in a boy about ten years of age, which terminated fatally, I excised the head of a femur (the first instance of this operation in the United States) that was completely dislocated upon the dorsum. The following is an instructive case of dislocation, perhaps connected with hip disease, and reduced by manipulation. The patient was a feeble and slender boy thirteen years of age, who was said to have dislocated his hip upon the dorsum by a fall upon a barn floor about three months before, and whom I was requested to see in consultation. The head of the bone could be plainly felt upon the dorsum, the limb being as usual inverted, shortened, and a little flexed. I found that in abducting the limb after it was flexed, a very considerable force was required to raise the head over the socket, and still DISLOCATION FROM HIP DISEASE. 105 more in outward rotation to make it enter, which it did only after the capsule and other attachments had been freely lacer- ated. After reduction, the head of the bone readily and repeatedly escaped, and could be kept in place only by the expedient, elsewhere alluded to, of confining the limb. The foot was secured to the inside of the sound knee, and the limb, thus flexed, was abducted down to the level of the bed, where it was bound to the side of the bedstead by a folded sheet under the knee. In this constrained position of flexion, abduction, and eversion, the patient remained for two and a half weeks, when I again saw him, and found the bone in place. But soon the hip-joint became stiff and painful, and sinuses slowly formed and opened in the groin, as if from hip disease. Upon inquiry, it was ascertained that the child had suffered from pain near the hip after a fall the preceding year, and had also lately recovered from protracted and grave dis- ease of the bone near the ankle. The dislocation may or may not have been facilitated by this tendency to disease of the bone; but there can be little doubt that serious inflammatory action was awakened by the presence of the reduced femur in the socket. DISLOCATION OF THE HIP, WITH FRACTURE OF THE SHAFT OF THE FEMUR. Cases have been reported of fracture, even of the upper third of the shaft, in which an accompanying dislocation was reduced by manipulation. There seems to be no good reason why, after the firm application of lateral splints to the thigh, the attempt should not be made with entire success,^ — reli- ance being especially placed upon flexion and the local man- agement of the head of the bone, which may be guided into its socket by the hands of the operator applied directly to it, or by a towel in the groin. Angular extension of the lower 1 See Hamilton'.s " Practical Treatise," etc., p. 666. 106 SPONTANEOUS DISLOCATION. fragment of the femur may draw upon its upper muscular insertions, and likewise make room for the upper fragment to follow it ; but it is obvious that nothing can be effected by its rotation. SPONTANEOUS DISLOCATION. Cases have been cited of individuals who could partially luxate and reduce the head of the thigh-bone at will, b}* the action of the muscles of the hip, Hamilton has collected three such cases. ^ I have had an opportunity of examining two, and Dr. Lyman, of Boston, has communicated to me the details of a third, all of which were dorsal luxations. In the first of these cases, — that of a soldier under the charge of Dr. Langmaid, to whom I am indebted for the opportunity of examining it, — the hip was dislocated while the legs were crossed, a wagon in which the man was riding having pitched into a hole. In a few hours the hip was reduced by flexion. Eight days after the accident, in attempt- ing to walk upon the limb, it was again partially luxated, — when the patient himself replaced it by pushing against it with one hand and pressing with the other against his knee. Since that time both luxation and reduction have been com- paratively easy, and the patient now displaces the head of the bone backward upon the edge of the socket by muscular action, and reduces it by " throwing the leg out sideways." The luxation is sometimes attended with pain, and the promi- nence caused by the head of the luxated bone is sensitive to the touch. In this and the following case, the displacement is rather a sub-luxation ; and the limb exhibits slight flexion, shortening, and inversion. In the second case, — that of a gentleman formerly of Boston, — the phenomena are much like those just described ; the bone being slipped out and in upon the dorsal edge of the socket by muscular action at will. ^ Practical Treatise, etc., p. 644. SPONTANEOUS DISLOCATION. 107 A third case was under the care of Dr. E. M. Moore, of St. Mary's Hospital, Rochester, N. Y., who has published photographs of it, from which the annexed figures are taken. The following account of this case has been kindly furnislied me by Dr. G. H. Lyman, of Boston, who obtained it from Dr. Moore : — Fiff. 41.1 Fig. 42. "John B. Parker, private, Co. H, 148th New York Volunteers, while on the march from Bermuda Hundred to Drury's Bluff, May 13, 1864, was skirmishing up a hill, and sprang back suddenly to avoid the gun of a comrade in advance. His left foot became entangled, and his weight dislocated his hip. He felt the injury, and supposed it out of joint. Some comrades pulled it in. He immediately resumed his skirmishing, and marched seven miles, from 10 A. M. till 6 p. m. He lay down at night, and went on duty the next day, sharp-shooting, crawling all day. He con- Spontaneous luxation of the thigh. Dr. Moore's case. 108 FRACTURE OF THE PELVIS. tinued this kind of duty five da^'^s, and returned to camp, when he was immediately put on intrenchments, and worked two days and nights. Afterward he went on picket, and entered the hospital May 28. At present he can luxate the hip-joint at any time, and does it by pressing the foot on the floor to fix it firmly, contract- ing the adductors, and throwing out the pelvis. The head suddenly leaves the acetabulum, and goes on the dorsum ilii." Although the lateral displacement and slight inversion show that this is only a sub-luxation, with the head upon the edge of the socket, yet the flexion of the limb, due to the elas- ticity and comparative integrity of the living tissues, makes it perhaps a better representation of a common dorsal luxation than Fig. 4, which was photographed from the dead subject, and where the limb was purposely extended as far as the Y lio-ament would allow. FRACTURE OF THE PELVIS. The following remarks on fracture of the pelvis are intro- duced here, chiefly with the view of showing how far this injury may be mistaken for regular dislocation of the hip. With this view the subject has been divided into four heads, comprising, respectively : (1) Fracture of the rim of the ace- tabulum ; (2) Fracture in which the head of the bone is driven through the acetabulum into the pelvis ; (3) kSuspected fracture of the acetabulum ; (4) Fracture of other parts of the pelvis. A few cases are given in illustration of each of these lesions. The more instructive of these are, of course, such as have been verified by autopsy. But there are some which are au- thenticated only by well-marked crepitus, and perhaps by mo- bility of the detached fragment; and it is then important that crepitus should not be confounded with the grating which results from the attrition of unbroken bone or cartilage. FRACTURE OF THE PELVIS. 109 Finally, there are still others, and by far the most numerous, in which a fracture of the socket has been inferred only from a supposed impossibility of reducing the luxated femur, or of retaining it in place after reduction. It need not be said that these last cases are more conclusive to the observer than to the reader. FRACTURE OP THE RIM OF THE ACETABULUM. To afford satisfactory evidence, cases of this sort should have been identified by autopsy, or at least by crepitus. Unfortunately, but a small part of the reported cases are thus elucidated, and fracture has been generally inferred because the head of the bone could not be restored to the socket, or could not be kept there. It is probable that when the rim of the socket is broken on the side either of the dorsum or of the foramen ovale, the signs of the displacement do not vary materially from those of the regular luxations. The regular backward displacement, for example, may be complicated with a detached rim, which, if enough be left to engage the head of the bone, in no way interferes with its conditions as a luxation, except that the bone tends to slip backward after being reduced. The same principle probably holds true in the case of fracture of the rim on the side of the foramen ovale, and also of the upper part of the socket, unless the fracture involves the upper insertion of the Y ligament, in which case the detached frag- ment might be so displaced as materially to modify the position of the limb, especially so far as its flexion or inversion was con- cerned. Such a luxation would be irregular. These displacements, especially the displacement backward, demand the usual attempts at reduction by flexion. Although the bone inclines to slip from the socket, it can be retained there, in cases of a sort heretofore considered difficult of treat- ment, by angular extension, with an angular splint attached to the ceiling or some other point above the patient ; or if any 110 FRACTURE OF THE PELVIS. manoeuvre has reduced the bone, the limb should be retained, if possible, in the attitude which completed the manoeuvre.^ The following case occurred at the Massachusetts General Hospital, under the care of Dr. Gay. The patient, aged thirty- six, a robust and healthy man, fell from the roof of a building, striking upon the right hip. In the recumbent position the leg was shortened and inverted, the toes crossing the opposite instep. Being etherized, the thigh could be flexed at a right angle with the abdomen, there being crepitus in the region of the neck of the femur. The limb, when drawn down, was still shortened half an incli. The patient having died of other injuries, the autopsy showed the head of the bone partially dislocated backward, and resting upon the posterior fractured edge of the socket, the whole posterior wall of the socket hav- ing been broken away in a mass. The detached fragment measured one and a half inches square. The posterior surface of the head of the bone was deeply indented by the fractured edge of the acetabulum, against which it had impinged after displacing the portion broken off. A transverse crack ex- tended through the acetabulum from the upper sciatic notch to the foramen ovale. The position of the limb in this case did not differ from that in the usual partial dislocation behind the tendon, and was determined by the same mechanism.^ 1 See p. 53. - In a case of dorsal luxation with inversion, reported by Maisonneuve (Clinique Chirurgicale, 186;], p. 168), the autopsy showed fracture of the posterior part of the border of the socket. Sir Astley Cooper's Case No. LXXI. is one of regular dislocation below the tendon of the obturator internus, which tightly embraced the neck of the bone, with shortening and inversion of the limb, although the pos- terior part of the acetabulum was broken off, and there was other extensive fi-acture of the pelvis. Dr. M. Tyer's third case was shown by the autopsy to be a regular backward dislocation with inversion, — the posterior and inferior margin of the acetabulum being detached, and displaced toward the coccyx. On the other hand, in Dr. Tyer's first case, the limb was everted while FRACTURE OF THE PELVIS. Ill FRACTURE IN WHICH THE HEAD OF THE FEMUR IS DRIVEN THROUGH THE ACETABULUM. In regard to this accident Hamilton well remarks : — ''There seems to be no certain rule in relation to the position of the limb ; but it is found to take the one direction or the other, flexed and shortened, an inch and a half of the rim being completely detached at the upper and posterior margin of the acetabulum. The remaining portion of the rim may not have been sufficient to turn the head backward, and thus compel inversion of the limb. In a second case, the toes crossed the tarsus of the other foot, and the autopsy showed a fracture of the upper margin of the rim of the acetabulum, (Glasgow Medical Journal, February, 1830 ; American Journal of the Medical Sci- ences, 1831, vol. viii. p. 517.) For a case of dorsal luxation with shortening, inversion, crepitus, and diflicvilty of retaining the reduced bone in the socket, see Cooper's "Trea- tise," etc., Case XXXIX. In the following case of fractured acetabulum, the upper insertion of the Y ligament was detached. The patient, fifty-eight years of age, was caught by a revolving belt. The right limb was shortened a quarter of an inch, and so far everted and straight that the internal condyle of the left femur lay in the popliteal space of the injured one. The right groin was filled up. Toward its middle, and outside the femoral artery, was a hard, resisting, and obscurely spherical tumor, masked by the glands and swollen tissues. Flexion with outward rotation and local downward pressure failed to reduce the luxation ; but on a third trial, flexion and downward pressvire during slight abduction, instead of outward rotation, succeeded. Seven months afterward, the death of the patient from another cause showed a united fracture of the socket, comprising the external and anterior third of the rim with the two anterior spinous processes of the ilium. (M. Beraud, Bulletm de la Societe de Chirurgie, 1862, torn. iii. p. 185.) • In the above case reported by M. Richet, the trochanter was rotated toward the median line, with the head of the femur facing directly for- ward, and probably with displacement of the detached bone. But the fact that the round ligament was unbroken would seem to indicate that the luxation was only partial, as might indeed have been inferred from the position of the limb, which, though everted, was not much displaced. In this connection, M. Richet (Bulletin, p. 226) refers to a case of luxa- tion of Maisonneuve (Re\T^ie Medico-Chirm-gicale, tom. xvi. p. 48) in which a fragment of a broken acetabulum had in twenty-seven dajs united with the rest of the rim so firmly that the fracture could hardly be discovered. 112 FRACTURE OF THE PELVIS. probably according to the direction of the force which has inflicted the injury, and perhaps in obedience to circumstances not always to be explained." ^ In two of the recorded cases the patients recovered, beins^ able to walk ; in one of these the head of the femur had become almost completely inclosed in a bony shell. In two other cases the patients died of the injury, which in all was the result of great local violence.^ It may be remarked that when the head of the femur is thus thrust completely within the pelvis, the capsule and sur- rounding muscles are relaxed, and would not determine the position of the bone. ASSERTED FRACTURE OF THE ACETABULUM, WITHOUT CREPITUS, FROM A SUPPOSED IMPOSSIBILITY OP KEEPING THE FEMUR IN PLACE. It has been already remarked that the evidence in this class of cases is unsatisfactory ; and it is not unlikely that the bone could have been kept in place by angular extension when other means had failed, or by confining the leg in the position of the final manoeuvre by which it was reduced, as before described.^ 1 Practical Treatise, p. .34-3. 2 In the case of Lendrick, and that of Morel-Lavallee, the accident was supposed to be that of fracture of the neck, from which it may be inferred that the foot was everted. In Case LXXII. of Cooper, the appearance was that of dislocation backward, probably involving inversion. In that of Moore the limb was shortened two inches, slightly flexed and abducted, but without rotation in either direction. Cooper, " Treatise," etc.. Cases LXXII. and LXXIII. ; Lendrick, American Journal of the Medical Sci- ences, August, 1839, vol. xxiv. p. 481 (from London Medical Gazette, March, 1839); Morel-Lavallee, Malgaigne, "Traite," etc., tom. ii. p. 881; Moore, Medico-Chirurgical Transactions, 18.'51, vol. xxxiv. p. 107. 3 See p. 53. In the case of Keate (Cooper, " Treatise," etc.. Case LXIX.), the fact that the limb could be drawn down, together with doubt- ful crepitus, was regarded as evidence of fracture of the socket. For a FRACTURE OF THE PELVIS. 113 FRACTURE OF OTHER PARTS OF THE PELVIS. A fracture of the pelvis not especially involving the aceta- bulum can hardly be mistaken for luxation of the hip ; and yet the following case under my care may be cited as an in- stance of a limb the position of which, when first seen, was identical with that of a dislocation, and as in similar cases was probably due to an effort of the patient to relieve the pain of injured tissues.^ The patient, a young man of seventeen years of age, entered the Massachusetts General Hospital, having been caught be- neath a heavy piece of machinery which fell from a wagon, striking upon the front of his left thigh just below the groin. Upon examination the thigh was found to be flexed upon the pelvis, and the foot everted. The knee was widely separated case of Mr. Brodie, of twelve weeks' standing, where failure to reduce a dorsal dislocation was attributed to fractvu'e of the socket, although none of its indications were present, see the Lancet, vol. xxiv. p. 671. The following case of supposed fractured socket without crepitus is one of several reported by M. Richet. A young man fell in dancing, while endeavoring to fling up his leg to the level of his partner's face. The leg was much inverted, and three quarters of an inch shortened, the head of the femur being felt upon the dorsum. The bone was repeatedly reduced, and as often escaped. The patient was ultimately placed in a fracture apparatus with extension, and two years after walked lame, the head of the bone rising upon the ilium at each step. No crepitus was felt, the diagnosis being based upon the supposed impossibility of keeping the head in the socket. (Bulletin de la Societe de Chirurgie, 1862, tom. iii. p. 251.) 1 A case of fracture of the ilium yielded crepitus under pressure upon the anterior and upper part of the ilium, the leg being shortened three quarters of an inch, and the foot slightly everted. After extension by the double inclined plane for several weeks the deformity disappeared. (Lan- cet, vol. xliv. J). 877.) In a case of fracture of the ilium, the right leg was half an inch shorter than the left, and slightly everted, with flattening of the region of the trochanter, the knee being also abducted. Pressure on the anterior supe- rior spine produced crepitus attended with acute pain in the joint. (Lan- cet, vol. XV. p. 575.) 114 ANGULAR EXTENSION. from the other, any attempt to approximate them causing pain. The pubes was tender when pressed. Under ether the leg resumed its normal position. No crepitus was discovered, although the patient had complained of a sense of grating in the perinaeum. A broad strap was placed around the pelvis, and in six weeks the patient was well enough to be discharged, walking on crutches. It is difficult in this case to account for the position of the limb before etherization, except on the sup- position that it may have afforded relief to pain. To the eye its position was that of a thyroid luxation.^ ANGULAR EXTENSION. PouTEAU^ first remarked upon the disadvantage of traction with counter-extension in the perinaeum, which brings the thigh into a straight line with the trunk. Most surgeons have observed the tendency of the pelvis, when pulleys are used, to escape from the counter-extending bands in the direction of the applied traction. It is believed that the apparatus here described will be found efficient, both in con- fining the pelvis and in enabling the operator to apply ex- tension to a limb which has been flexed for the purpose of relaxing the Y ligament. Lateral extension, with or with- out pulleys, can then be made in any desired direction by a towel passed round the thigh at the groin. The patient being laid upon his back, the pelvis is secured to the floor by a T band passing across it laterally in front, between the superior and inferior spinous processes of each side, and vertically over the pubes and perinaeum. The three extremities, each terminating in a strap and buckle, are fastened to the floor beneath the margin of the pelvis by 1 Massachusetts General Hospital Records, vol. cxxvii. p. 210. 2 Malgaigne, " Traite," etc., p. 867. ANGULAR EXTENSION. 115 common dislocation-hooks. The entire band, with the excep- tion of its extremities, is cyhndrical, about two inches in diameter, well padded and covered with buckskin. It firmly holds the pelvis by its pressure between the spinous processes on each side and upon the pubes. To apply it, the three pointed hooks are screwed into the floor, one near each tro- FiG. 43.1 chanter, and one near the perinaeum ; the band is then adjusted, and the pelvis buckled to the floor, after which it will be found that the thighs can be freely flexed. A tripod is now erected over the pelvis, consisting of three stiff poles about eight feet high, and held together at the top by a coni- 1 Apparatvis for angular extension. This woodcut represents the coni- cal leather cap and rings, the angular splint, with rings above and below the knee for the passage of a transverse wooden lever, and of a longitu- dinal one beneath the calf, the padded T pelvis band, and the hooks to attach it to the floor. 116 ANGULAR EXTENSION. cal leather cap, with three short, dependent straps and rings from which the pulleys are suspended. It remains only to attach the pulleys to the limb. This is effected by means of a strong right-angled splint of sheet-iron, extending nearly from the hip to the ankle, made concave so as to embrace the under surface of the thigh and leg, and padded, within which the limb, flexed at right angles, is confined by ban- dages or straps. Two iron rings riveted to the splint near the condyles of the femur receive a wooden rod about two feet in length and an inch in diameter, which crosses the ligament of the patella transversely above the head of the tibia ; and to this rod, between the rings, the pulleys are attached by a strap or cord. Vertical traction is thus made exactly in the axis of the shaft of the femur. Powerful rotation can be made by grasping the extremities of this transverse rod, while another useful movement, called by the French bascule, or tilt, may be effected by a similar 1 Angular extension. The pelvis is buckled to the floor. The flexed leg is suspended from the cap at the summit of the tripod by pul- leys which are attached to a transverse wooden rod across the patella. This rod passes through rings on the angular splint, and serves to rotate the limb. A similar rod is seen beneath the leg. Fig. 44.1 ANGULAR EXTENSION. II7 rod in the axis of the leg below the knee, passed through two rings beneath the splint, — one near the ham, the other near the heel, beyond which it projects a foot or more, — to afford a handle. By vertically raising this rod at its extremity we carry the head of the bone from the dorsum, or pubes, in the direction of the tuberosity. Oblique extension may be made by changing the position of the tripod. Although the need of this apparatus may be rare, it will prove occasionally efficient in reducing a luxation of long- standing or complicated with fracture. At any rate, I can- not believe that the period is remote when longitudinal extension by pulleys to reduce a recent hip luxation will be unheard of. 118 DISLOCATION OF THE HIP. ON DISLOCATION OF THE HIP.i The simplicity of the principle which controls hip reduction is as yet scarcely appreciated by the majority of practitioners into whose hands the scattered cases fall. Writers also, until very lately, have seemed disposed to consider " manipulation " as but one of several means of reduction of equal value, — oc- casionally available, indeed, but complicated with many meth- ods, and by conflicting opinions regarding its essential features, — by perplexing talk of abduction and inversion, of flexion and partial flexion, of rotation and circumduction. I have, perhaps, myself unintentionally contributed to this erroneous belief. But my paper upon this subject ^ was based upon the analysis of a large number of dissections, experiments, and cases of reduction, which could neither be condensed advan- tageously nor yet omitted ; while its object was to show the relation between hip dislocation and the ilio-femoral ligament, then generally unrecognized. The whole matter is really very simple. The word " manipulation " is an unfortunate one ; "flexion" is .better. The modern method of hip reduction, whether by lifting or by mere abduction, is the " flexion method ; " and it supersedes all others. A common way of describing dislocation is by the terms " backward," " forward," " in front," and " behind." It should be borne in mind that when the body is erect the pelvis is ob- lique, — the acetabulum standing in like manner obliquely, at an angle of about 45° , facing the front and outside of the thigh, at a point an inch or two below the trochanter ; so that what 1 The Lancet, June 15, 22, 29, 1878. 2 The Mechanism of Dislocation and Fractvu'e of the Hip. (Henry C. Lea, Philadelphia, 1869.) DISLOCATION OF THE HIP. 119 is behind the socket may be either below or outside of it. In fact, it is not easy immediately to place an os innominatum, or even a pelvis, in the normal erect attitude to which alone these terms should refer. As preliminary to reduction, the patient should be etherized to relaxation, and, in order to give the surgeon control of the limb, laid on the floor. It is well to remember that the head of the femur always faces the same way as the internal condyle. If there is any single and best rule for reducing a recent dislocation of the hip, it is to get the head of the femur directly below the socket by flexing the thigh at about a right angle, and then to lift or jerk it forcibly up into its place. This rule applies to all dislocations except the pubic, and even to that when secondary from below the socket. I have taught it many years. A case reduced by this method under the care of the distinguished surgeon, Mr. Erichsen, will be found in " The Lancet " for 1872 (vol. i. p. 10). Of the various ways which incorporate the essential principle, this one was placed first in my paper in connection with the common dor- sal dislocation ; and I elsewhere showed how it was applicable to other dislocations. The reduction by the lifting method is usually instantaneous ; and flexion is at the basis of its success. But if after one or two trials it should appear that the hip cannot be jerked into place, let the rent in the capsule be enlarged a little by moving the flexed tliigh, not up and down, but from one side to the other, so as to sweep the head of the femur across below the socket.^ No danger need be appre- 1 The following case is interesting in this connection : A short and very fat elderly woman was suspected of thyi'oid dislocation. Attempts already made to reduce the bone had so loosened the capsule that the limb was now lying parallel with the other. While the foot could be everted or inverted, the head of the bone could be nowhere felt. In 120 DISLOCATION OF THE HIP. hended from this expedient of circumduction; the added injury is a very slight one. So long as air is not admitted to the wounded parts the lesion is no more serious than often occurs in a simple fracture of the thigh. The laceration which resulted from the old longitudinal traction with pulleys was often much greater, and that from ill-planned and pro- tracted efforts by flexion is always so. Indeed, such addi- tional laceration may sometimes advantageously occur without the knowledge of the surgeon during unsuccessful efforts to reduce the bone, especially in executing the manoeuvre de- scribed in the rule "• Flex, abduct, evert." ^ consultation I was quite unable to satisfy myself about the lesion until it occurred to me to flex the limb and circumduct the head of the bone, as if it had been dislocated upon the thyroid foramen to the dorsum. Then the characteristic inversion at once demonstrated the dislocation. The thigh was again brought to a perpendicular, and readily lifted into place, — circumduction here affording a valuable means of diagnosis as well as of reduction. 1 Flexion dates from Hippocrates. He combined with it a movement which, by a literal translation of the original, is the " wagtail shake " ((cty/cXio-t?). (See "The Mechanism of Dislocation," etc., p. 27, footnote). But Hippocrates seems to have relied mainly on direct extension, aided by the rude application of levers and other mechanical expedients. The method concisely expressed in the words "flex, abduct, evert," a method the paternity of which has sometimes been in doubt, belongs to an in- vestigator of fifty years ago, a man of highly original mind, — the late Nathan Smith, Professor of Medicine in Dartmouth College, New Hamp- shire, and afterward Surgical Professor in Yale College. He attended lectures in Edinburgh under the elder Monro and Dr. Black, and studied also in London. In a Biograj)hical Memoir published in 1831, soon after his death, it is stated that "his mode of reducing dislocations of the hip is new, philosophical, and ingenious." In a posthumous volume of "Medical and Surgical Memou-s" (Baltimore, printed by William A. Francis, 18.31), edited by his son, Nathan R. Smith, M.D., twenty pages are devoted to a detailed description of his method, from which the fol- lowing is taken (pp. 180, 181): " The first effort which the operator makes is to flex the leg upon the thigh, in order to make the leg a lever with which he may operate on the thigh-bone. The next movement is a gen. tie rotation of the thigh outward, by inclining the foot toward the ground and rotating the knee outward. Next, the thigh is to be slightly ab- DISLOCATION OF THE HIP. 121 This familiar rule, until I explained its mechanism, was an empirical one. Flexion is indeed the essence of it ; but besides this, the femur is rotated around the ilio-femoral ligament as a centre. When the knee, abducted by this rotation, descends on the outside, the head of the femur rises on the inside, like an opposite spoke in the wheel, and is thus pried into place by the shaft of the bone as a lever, with the outer band of the ligament as a fulcrum. Eversion is of less importance, but helps the movement by inclining the head of the abducted femur toward the socket. It is best effected by keeping the foot of the flexed limb stationary while the knee is pressed outward. By the great power it gives the operator, this method, or rather the circumduction connected with it, is especially useful in breaking the adhesions of an old dislo- ducted by pressing the knee directly outward. Lastly, the surgeon freely flexes the thigh upon the pelvis by thrusting the knee upward toward the face of the patient, and at the same moment the abduction is to be increased. Professor N. Smith regarded the free flexion of the thigh upon the pelvis as a very important part of the compound movement. He believed that it threw the head of the bone downward, behind the acetabulum, where the margin of the cup is less prominent, and over which, therefore, the adductor muscles would drag it with less difficulty into its place. The operator may slightly vary these movements as he increases them, so as to give some degree of rocking motion to the head of the os femoris, which will thereby be disengaged with the more facility from its confined situation among the muscles." This covers the ground of priority of invention. It belongs to Nathan Smith. But surgeons were not as yet prepared for so considerable an innovation. In the words of Professor N. R. Smith (p. 174), "the propriety of em- ploying pulleys, for the purpose of multiplying power in the treatment of dislocations of the hip, appears to be so tacitly and universally ad- mitted at the present time that one who contends against it can scarcely expect to obtain a favorable hearing." The method by flexion and abduction had been taught by Nathan Smith long before 1831. In 1835 Despres, and in 1852 Dr. Reid, of Rochester, N. Y., enunciated the same views. The practice was good ; but both Professor Smith and Dr. Reid based the method and sought its mechanism in the erroneous theory of muscular resistance. The rule, it should be added, applies only to dorsal dislocation. 122 DISLOCATION OF THE HIP. cation. It might be called the abduction method, to distin- guish it from the lifting method. Abduction sometimes succeeds at once. It does not answer, however, when there is much laceration of the capsule. Then the head of the bone will not rise. Suspended by the ligament which is attached at the trochanters, it slips backward and forward below the socket, from the dorsum to the foramen ovale. The upward lift then becomes absolutely essential. In one of the figures of a standard and very excellent modern English surgical work, which has done me the honor to refer to my views, the engraver has placed the hand of the surgeon above the knee, adding to the weight of the limb, and bearing the head down below the socket, where it might even hook up the sciatic nerve. The weight of the limb should be sustained with the hand in the ham. Such are the simple principles of hip reduction, which are still often buried beneath unimportant details, and sometimes under a flood of technical language. By the lifting method I have reduced, without haste, a dor- sal dislocation of both hips in the same man in less than two minutes. With an effort to do it quickly, I reduced in two seconds a dorsal dislocation that had just been vainly " manipulated " under ether by two medical practitioners for an hour. A few months ago I forcibly lifted into its place from the dorsum, in a few seconds, a dislocated hip, which required traction with the whole strength of the elbow engaged under the knee, against the foot upon the pelvis. By the lifting method combined with abduction I have lately, in the case of a little girl of seven years, reduced a dorsal dislocation of five months' standing, said to have oc- curred during the delirium of typhoid fever. To keep the bone in place when reduced it was necessary to tie the knee to the side of the bedstead, in extreme abduction, after secur- DISLOCATION OF THE HIP. 123 ing the foot to the knee of the sound side, in order to main- tain the limb in the final position that reduced it. Since this occurred I have reduced by simple abduction, and in a moment, a recent dorsal dislocation in a little boy of four years. Prom these and other cases may be gathered the following rules for reduction. In the dorsal dislocation, — 1. Flex, and forcibly lift. If this fails, — 2. Flex, and lift while abducting. If this fails, it will be found that abduction has carried tlie head of the bone from the dorsum nearly or quite to the thyroid foramen, and that the capsular rent has been so enlarged that the first method may now prove successful. Lifting the femur abducts it if it raises the pelvis on the lifted side. In thyroid dislocation adduction of the flexed thigh reverses this movement and carries the head from the thyroid foramen to the dorsum, also enlarging the opening and making the first rule effective. The pubic dislocations may be generally brought down, after flexion, without difiiculty from above the socket. If they are secondary, the head of the bone will fall, after flexion, to its previous position below the socket, and may be reduced from there like the thyroid. My belief has long been expressed that the flexion method is the only rational one, and that pulleys are practically obso- lete, unless perhaps to steady the limb in some rare case, by rectangular, not longitudinal, traction. Then alone is the tri- pod apparatus possibly useful. But why flex the thigh ? Be- cause it relaxes a part of the ilio-femoral ligament. When the limb is straight, this ligament is rigid and the bone fixed ; when it is flexed, the inner band is slackened, — as also the whole ligament if the limb be lifted, — and the head is brought down below the socket, level with the cap- sular rent, becoming movable for reduction as it was pre- viously for escapa 124 DISLOCATION OF THE HIP. Now, flexion, with adduction or abduction, is the habitual attitude of the thigh, especially in action or for self-defence ; and the ligament is thus habitually relaxed. On this account, and also because the capsule is weak and thin below " like wet bladder," and the socket margin notched on that side, the dislocation downward is the most common one. All this I have elsewhere shown, and also that the head of the bone, thus escaping primarily below the socket, generally at once slides up to a second position on one side of it or the other. In fact, downward dislocation is so frequent, and the route from below to the dorsum is rendered so easy both by mus- cular contraction and by the conformation of the bone, — by the latter especially, — that in a very large proportion of cases the displacement is found to be dorsal. The result has been to extend the application of any rule for reduction which applies to dorsal dislocation, and to make it comparatively familiar. These secondary dislocations from below the socket are well known ; and all the regular dislocations (if we except those between the small rotator muscles) may be secondary. On the other hand, there can be no question that the bone may be primarily dislocated in various directions. Flexion does not in all dislocations return the limb to a point below the socket without increased laceration of the capsule, as it would if they had all come from there. Just as the downward dislo- cation may take place during extreme flexion, especially with rotation inward, and through a comparatively small aperture, so the dislocation on the pubes may occur during extreme extension ; and it is usually reduced from above the socket. A direct thrust backward may produce dislocation upon the dorsum when the ilio-femoral ligament is relaxed. Primary dislocations are not rare, in various attitudes of the limb. But in order to compare the regular dislocations more readily, let us for the time consider them all as secondary DISLOCATION OF THE HIP. 125 from a common point below the socket, and follow the pro- gress of the bone from the moment of its original escape downward to this point. The femur is, then, sometimes held below the socket in extreme flexion, firmly, as if the neck were embraced in the capsular rent. Such dislocations have been considered anom- alous, and described as " upon the perinajum," and " upon the tuberosity." I have shown them to be regular. But it oftener happens that from after-violence, or by its own weight, the knee falls, the thigh is straightened, and the head of the bone, suspended at the trochanters, is pried upward on one side or the other of the socket, lacerating the capsule. In this view the downward dislocation is a first stage of the others, the head pausing below the socket and hesitating which side to go, — whether to the thyroid foramen, or above it to the pubic region, or even to a higher point, where the dislocation is still a regular one (the sub-spinous), all these being internal to the socket ; or, which is more common, external to and behind the socket on the dorsum, where, as I have shown, the limb is at once inverted by the outer band of the ilio-femoral liga- ment. The first serious obstacle the bone then encounters in its dorsal ascent is the strong obturator internus muscle and the subjacent capsule. This is one of the more common dislocations. If the bone ruptures the obturator and the capsule, it rises to the pyriformis, and if this be broken, to the gluteus minimus, retaining the usual features of a dorsal displacement.^ If, however, the outer band of the ligament be ruptured, the limb is no longer necessarily inverted, but capable of eversion, and the dislocation is then the everted dorsal. The head of the bone, still suspended by the remaining inner band, can now be hooked over it above the spinous process ; the dislocation is then supra-spinous, the limb being still 1 See an account of the autopsy in Todd's case, No. XL. of Cooper. 126 DISLOCATION OF THE HIP. straight. But if the femur has been hooked over the entire ligament, instead of the inner band only, the limb cannot hang straight ; it assumes a very oblique attitude across the axis of the body. This I have called the anterior oblique dislocation. These three positions of the bone were described by Sir Astley Cooper as anomalous ; but the explanation here given of their essential mechanism shows that they occur under prescribed conditions of the ilio-femoral ligament, and that they are therefore constant and regular. In short, all regular dislocations, including those upon the perineeum and the tuberosity, as well as the everted dorsal, the anterior- oblique, and the supra-spinous varieties, have constant and distinctive signs which they owe to the ilio-femoral ligament ; and eversion in dorsal dislocation signifies that the outer band of this ligament has been severed. Nothing can be more simple than the reduction of secondary dislocations from below the socket. If dorsal, and the flexed thigh has fallen to a horizontal position by a spiral movement downward and inward, reverse the movement and reduce the limb by a spiral upward and outward. If thyroid or pubic, and the knee has followed a spiral downward and outward, reduce it by a similar movement upward and inward. But the spirals of reduction practically amount to mere flexion ; there- fore, in either case, flex the limb and jerk it upward ; and in the thyroid luxations it is well to aid the process by outward traction with a towel, or by a fulcrum in the groin. Finally, if the capsule offer resistance, sweep the flexed femur from side to side to separate its fibres and get the head below the socket, before jerking the bone up into place. There is another point, which is now of less practical im- portance. By the now obsolete straight traction with pulleys reduction from the dorsum was sometimes difficult, or failed. Surgeons then called the dislocation " ischiatic." There was a superstition about the ischiatic notch. It was the mael- DISLOCATION OF THE HIP. 127 strom of the hip-bone. There was obviously in those days some real difficulty, which does not occur with the flexion method. Its most frequent source was the strong obturator intcrnus muscle combined with an unusually sound and tense falciform edge of the subjacent capsule, interposed between the head of the bone and the socket, occluding the latter. On this account I substituted for the term " ischiatic " the phrase " below the tendon," as explanatory of the manner of the displacement, the relations of the bone, and the general character of the difficulty of its reduction. The phrase " below the tendon " was desirable to distinguish this disloca- tion from those in which the head emerges above the tendon. In either case the head of the bone may reach and occupy a place " behind " the tendon (see " The Mechanism of Disloca- tion," etc., Fig. 15) J When my paper was written, the bugbear of the ischiatic notch was still feared, because the practice of reduction by straight extension was still in vogue. In fact, surgical works are still illustrated with pulleys from Sir Astley Cooper. For more than fifteen years I have neither employed nor taught reduction by straight extension, and I have long 1 The dorsal dislocation between the small rotator muscles, or any other which offered exce|)tional resistance, was no doubt sometimes mistaken for the "ischiatic" dislocation. I still incline to believe that my explanation of the old difficulty in " ischiatic " reduction is the correct one. The dislocation formerly called " dorsal " differs from the "ischiatic" in having the thick capsule which is behind the ilio-femoral ligament and beneath the obturator tendon, including the ischio-femoral band, so torn as to allow a greater shortening of the limb than used to be described as a sign of " ischiatic " displacement. During reduction by straight extension, the head of the bone could pass through the torn capsule to the socket as soon as it had slipped over the obturator tendon. The injury may be accompanied by the rupture of muscles, even of the obturator internus. In short, the classical dorsal and ischiatic disloca- tions differ from each other only in the extent of the laceration of the posterior capsule and muscles. 128 DISLOCATION OF THE HIP. abandoned any especial description of the so-called ischiatic dislocation, whose chief and distinctive sign was that it resisted straight extension. For practical purposes this dis- location is dorsal, and may be called so. It is easily reduced by flexion. So, also, it is useless to distinguish from the common dorsal dislocation those which lie between the small rotators ; because, although interesting to the anatomist and the pathologist, it is very doubtful whether they will ever be diagnosticated with certainty during life. They exhibit, as 1 have shown, more inversion, more immobility, and more elasticity ; but these signs are not pathognomonic. When these dislocations occur, the head of the bone is thrust di- rectly backward through the capsule, and escapes this time, not below the tendon of the strong internal obturator, but above it, by the muscular interstice between this muscle and the pyriformis, or even higher, between the pyriformis and the gluteus minimus. The bone may possibly be reduced from these positions by vertical traction, or pried back through the interstice by the abduction method or by out- ward rotation ; but I think such attempts will generally end in rupturing the muscles. The dislocation would then offer no distinctive features, and would belong to the common dorsal variety, in which we can only guess what rotators are ruptured. Indeed, it is the rule in dorsal dislocation that the quadratus or some of the rotators are torn, — which of them we need not know. Our business is to reduce the bone by flexion, — and by circumduction also, if that be necessary to rupture the capsule and muscles, and so to clear the way to a point below the socket, from which the femur can be lifted into place. If, in accordance with these views, we suppress any distinct mention of the inter-rotator dislocations, — which indeed have never been separately classified (although, if it were possible DISLOCATION OF THE HIP. 129 always to identif}' them, they would deserve to be separately considered), — and of the obsolete ischiatic dislocation, by whatever name we call it, we have the following classifica- tion of regular dislocations, based on their direction from the socket : — External to the socket, — the dorsal, and the everted dorsal. Internal to the socket, — on the perinaeum, the thyroid foramen, and the pubes. Below the socket, — the dislocation toward the tuberosity. Above the socket, — the sub-spinous, the supra-spinous, and the anterior oblique dislocations. Of these, by far the more common are the dorsal, the thyroid, and the pubic, which offer the most convenient division for practical purposes. It leads to the following practical grouping of dislocations, based on the usual me- chanism of their occurrence and of their reduction : — Dorsal, — the dislocation on the tuberosity, the dorsal, the everted dorsal, the anterior oblique, and the supra-spinous. Thyroid, — that on the perinaeum, and on the thyroid foramen. Pubic, — the pubic and the sub-spinous.^ The ilio-femoral ligament is unbroken in these regular dislocations, — excepting only the everted dorsal and supra- spinous varieties, in which its outer band is severed, while the inner band remains. All may be readily reduced after 1 This is perhaps the best practical classification. Although the sub- spinous and the supra-spinous dislocations lie directly above the socket, the former is essentially a pubic dislocation, and after flexion needs only to be worked directly down into the socket. The supra-spinous disloca- tion on the contrary, like the anterior oblique, must be first unhooked from the ligament, and then circumducted to the socket by the way of the dorsum. It is essentially dorsal. In a regular dislocation the bone does not pass the ilio-femoral ligament, whether it approaches it from the inside or the outside. 130 DISLOCATION OF THE HIP. flexion, with or without circumduction, — the thyroid and pubic ^yith a towel or fulcrum in the groin if need be, in the one for outward, in the other for downward and outward traction. This method covers the reduction of the primary as well as the secondary forms of luxation. It may here be added that a broken socket makes reduc- tion difficult or impossible ; and that if the femur tends to escape after being reduced, the flexed thigh should be ab- ducted down to the bed, and confined there at right angles with the body, to take advantage of the tense ilio-femoral ligament in holding the bone in place, as in an instance be- fore mentioned. In illustration of some of these points, let me cite a few cases. 1. The classical case. No. XLIII. of Cooper. In this case, during straight thyroid reduction, the knee was raised, and the ligament, of course, relaxed. The head of the bone was thus unintentionally dropped from the thyroid foramen to a point below the socket. In this position it should have been jerked up into place ; but unfortunately the limb was again straightened. The head of the bone rose, this time not to the thyroid foramen, but upon the dorsum, where it was engaged behind the close-fitting capsule, and probably the obturator muscle. From this position it could not after- ward be drawn by straight extension, and was therefore pro- nounced irreducible. This case led Sir Astley Cooper to warn surgeons not to flex the thigh. In reality, flexion with an upward jerk was what the case required. 2. The similar case of Lisfranc,^ — a dorsal dislocation, which that surgeon, with eight assistants, failed for an hour to reduce by straight extension. The patient then col- lapsed, and afterward died. The autopsy showed a state 1 Malgaigne's "Traite," etc., torn. ii. pp. 818-829. Plate XXVI. DISLOCATION OF THE HIP. 131 of things which doubtless existed in the case of Cooper. The neck of the bone was closely tied by the capsule ; the head had emerged below the obturator internus, and was Ije- hind it. It was easily reducible by flexion. 3. Parmentier's case of dorsal dislocation between the rotators.^ The posterior half of the capsule was largely torn. The head had escaped by a muscular buttonhole above the internal obturator, between that muscle and the pyriformis, which is next it. 4. The similar case of Servier, above the latter muscle.^ Here the articular capsule was completely torn behind, the head of the bone having escaped by the " posterior notch of the acetabulum" (beneath the tendon of the pyrifor- mis), emerging above the pyriformis, which closely con- fined it. 5. The case of Dr. Fenner, of New Orleans, quoted in Pro- fessor Hamilton's valuable and comprehensive treatise on " Fractures and Dislocations." ^ The head was on the dorsum. The limb was shortened an inch and a half, and the toes turned inward. The capsule was torn through one half its extent. Portions of the obturator externus, pyriformis, and gemelli were ruptured and lacerated. " Dr. Fenner now proceeded to cut away the muscles ; and when all the external muscles about the joint had been removed, the thigh could not be brought down. The iliacus internus and psoas magnus were then severed, which per- mitted it to descend a little, but the head could not be replaced ; the triceps adductor was then divided without effect ; the ilio-femoral ligament was found tensely stretched. All the muscles between the pelvis and the thighs were then severed, and still it was impossible to reduce the dislocation ; 1 Bulletin de la Societe Anatomique, p. 176. 1850. 2 Bulletin de la Societe de Chirurgie, p. 485. 1863. 3 Fifth edition, p. 676. 132 DISLOCATION OF THE HIP. the head of the femur could not be forced back through the rent in the capsule from which it had escaped, and it was not until the opening was enlarged from one half to three quarters of an inch that the reduction was accomplished. Dr. Fenner infers that the capsule possesses sufficient elasticity to allow the small head of the femur to pass out through a lacerated opening, which might at once contract so as to offer con- siderable resistance to its return, and that occasionally this is the true explanation of the difficulty in reduction." Although the existence of this degree of elasticity may be questioned, there can be no doubt that a close-fitting rent in the capsule is practically a " buttonhole," whether in the straight or flexed limb. Among the details of these few cases will be found evidence of the efficacy of the flexion method, of its mode of action, and of the character of a difficulty which was sometimes insuperable by the old method of straight extension. They show that this difficulty may result from the interposition of capsule or muscle, or both, between the head of the bone and the socket, — or from a want of free aperture in the capsule ; and that then the obvious resource of the surgeon is to enlarge the slit by circumduction. They show also the character of the intermuscular aperture between the rotators, which may require similar enlargement ; and that it may sometimes be difficult to distinguish between these different impediments to reduction, — all of which yield to flexion, with circumduction if needed. All this is of the first interest to the surgeon, because it bears upon the question of reduction. The cases also contain evidence upon one or two points of minor interest and importance ; namely, that dislocation may occur, not only with abduction as an element, as writers agree, but also by a direct thrust ; and that in this case the socket need not be broken, as has been alleged. Upon the ilio-femoral ligament I have based my theory of DISLOCATION OF THE HIP. 133 hip dislocation, its classification, its mechanism and its re- duction. Other bands of fascia, of capsule, and of muscle may indeed be incidentally concerned in confining the neck of the femur ; but their action is a changing one, and second- ary in importance. Divide the ilio-femoral ligament, leaving the rest of the tissues, and the mainstay of the characteristic deformity is gone. It is not difficult, indeed, still to work the limb into the semblance of a regular dislocation ; but such displacements are exceptional, and their attitude is not con- stant. In short, they are irregular. All that is most essential about hip dislocation and re- duction may be learned from a pelvis and thigh-bone from which everything has been removed except the ilio-femoral ligament, with perhaps the obturator internus muscle and its subjacent capsule, although the last two can be spared. The dissected capsule is a combination of membrane with fasciculi beautifully adjusted for universal motion, limited in all directions. The vessel-bearing and so called " liga- mentum " teres within it is never strong, and is sometimes wanting; it is therefore unimportant in dislocation. Of the capsule itself the posterior part combines strength with great mobility, its pelvic insertion being far stronger than its femoral insertion. A general notion of the arrangement of the posterior part of the capsule may be had if we suppose that it is extended from the socket half way to the femur, being there reinforced by a thickened edge and tied to the trochanters by bands. The thick edge is represented by a fasciculus which is said to be " annular." It is parallel with the rim of the acetabulum, and midway of the capsule. It aids the pelvic half of the capsule in its effort to retain the head of the femur, and in the extended limb tightens it. It is tied to the trochanters by the ischio and pubo (or pectineo) femoral bands, which, as they pass from the pelvis to the trochanters, cross the annular ligament and are incor- 134 DISLOCATION OF THE HIP. porated with it.^ In these cross-bands lies the main strength of the femoral insertion of the posterior capsule. Between them, at a point between the trochanters, is its weakest part, — a mere membrane, supported bj^ these fasciculi. It is often accidentally opened in dissection ; and when torn along its margin, as sometimes happens in dislocation, after the bands are ruptured, the wide flap may occlude the socket as eifectually as in Fenner's case. But among these minor anatomical details connected with the posterior capsule, it is important not to lose sight of the main surgical facts. To these facts the ilio-femoral ligament is the key. It lies mostly in front. In an anterior view it is triangular, narrowest above. Its inner part, the ligament of Bertin, limits extension of the limb ; its outer part limits eversion, while to the latter alone belongs the inversion of dorsal dislocation. The functions of its outer and inner por- tions are therefore largely distinct. The habitual action of the thigh tends to develop them separately. In fact, they can be easily distinguished by the direction of their fibres, some of the fibres of one branch being inserted into the other half way up. They are separated by a cribriform in- terval for vessels, corresponding to a frgenum of soft capsule inside the joint, which adds to the thickness though little to the strength of the ligament. They vary in development in different subjects ; the outer band is not unfrequently the more voluminous, and, as is stated in my paper, the whole ligament is sometimes of uniform thickness. In that case its margin acts as bands. ^ The pubo and ischio femoral bands are best seen in extreme flexion, which in the recumbent subject brings the back and lower part of the capsule to the front, with the lesser trochanter above. Parallel lines then drawn from points on the pubes and the ischium, just above the socket and just below it, horizontally outward to the two trochanters respectively, will sufficiently indicate the two fasciculi, and the rec- tangular shape of the posterior capsule they enclose. In the extended limb they become oblique, and are no longer parallel. DISLOCATION OF THE HIP. 135 In recent times the narrow ligament of Bertin has been generally described and recognized as the ilio-femoral liga- ment. It is but the inner part of it. Its outer band and even its triangular shape were scarcely known to modern anatomists, and were unknown in their surgical application to dislocsttion when I came across them in dissection.^ I afterward found that while the Webers describe the liga- ment as simply triangular, the anatomist Winslow, and es- pecially Weitbrecht, — still perhaps the highest authority on ligaments, — had described the " binae divaricationes" a cen- tury and more ago. Thus much for the lower and sometimes distinctly forked insertion of the ilio-femoral ligament along the anterior intertrochanteric line of the femur. The upper or pelvic insertion of this ligament is into the front of the inferior spinous process of the ilium, and also into the outside of this process, along a rough depression existing beneath the reflected tendon of the rectus, three- quarters of an inch or more in length.^ All this part is thick, and arrests displacement directly upward. From this pelvic insertion the outer margin of the outer band runs to the trochanter major, and the inner margin of the inner band toward the trochanter minor. Together the two bands constitute the strongest ligament in the body. While it is not difficult by circumduction to tear the whole capsule on 1 The only modern anatomy in which I find an allusion to the fan- shaped outline of the ilio-femoral ligament is that of Sappey, Paris, second edition, 1867. The first edition (1862) figures and describes only the ligament of Bertin. My photograph was taken in 1861 and published in 1869. 2 This roughened surface, extending from the inferior spinous pro- cess outward, and in the normal oblique attitude of the pelvis a little upward, has been sometimes assigned by anatomists to the reflected tendon of the rectus. It belongs to the wide outside insertion of the powerful ilio-femoral ligament, to which the tendon is often attached by connective tissue only, having a comparatively small bony insertion beyond it. 136 DISLOCATION OF THE HIP. either side up to the margin of the bands, these resist. In a strictly surgical point of view, the exact extent of their varying interval may have little importance ; but in order to emphasize their separate normal functions, and especially the fact that the characteristic attitudes, the mechanism, and the reduction of hip dislocation are essentially dependent semetimes upon one of these sets of fibres and sometimes upon the other, I have given to the whole — as brief, and sug- gestive of its " binse divaricationes " — the name (inverted) Y ligament. THE MECHANISM OF FRACTURES OF THE NECK OF THE FEMUR. FEACTURE OF THE NECK OP THE FEMUR. IMPACTED FRACTURE OF THE BASE OF THE NECK, WITH EVERSION. The injury known as the " impacted fracture of the neck of the thigh-bone " has been well described by various writers. When it occurs, the neck, broken at or near its broad inser- tion into the head of the shaft, is driven into the loose cancel- lated tissue of the latter, and so fixed there that it sometimes requires a considerable force to withdraw it. That it may be a severe lesion, especially in the latter part of life, the numer- ous recent specimens to be found in museums sufficiently attest. In my own observation, while it is at least as frequent among elderly people as fracture of the neck within the cap- sule without impaction, the accident is comparatively common in middle life, and even later; and the bone is sometimes capa- ble of uniting after a few months, with little deformity. This fracture is characterized by shortening and eversion of the limb, sometimes so inconsiderable that we are obliged to accept a diagnosis based upon an almost imperceptible eversion, and a shortening of half an inch or less, by careful measurement. The Museum of the Medical School of Harvard University contains a valuable collection of impacted fractures of the hip ; and having through these specimens become familiar with the eversion exhibited by them in various degrees, I had my attention more carefully directed to the subject by the followinsr not unusual case. 140 FRACTURE OF THE NECK OF THE FEMUR. A gentleman slipped upon the ice before his door, and fell upon his hip. He walked up stairs with assistance, and was placed upon his bed. His attending physician, in the absence of any obvious shortening or eversion of the limb, entertained some doubt in regard to the nature of the injury, but after ten days, finding no improvement in the symptoms, — the pain and soreness having in fact increased, — requested me to see him. The local tenderness and pain on motion, together with a very slight eversion, — best seen on attempting to invert comparatively the two feet, — and a shortening of less than half an inch, led me to the conviction that the bone was slightly impacted ; and I conceive this view to have been cor- roborated by callus subsequently felt about the trochanter, and by the length of time required for the recovery, — the patient having been confined to his bed a little more than two months, and unable to walk without crutches until after the lapse of four months. Since that time I have had sufficient opportunities to satisfy myself that though this accident may be serious when it occurs late in life, it is by no means so to a middle-aged and healthy subject ; that the impaction is sometimes slight, and its indications proportionably so ; and that the following signs may be relied on as generally pathognomonic, — disabil- ity ; pain and tenderness resulting from local violence, es- pecially when applied laterally, as in a fall upon the hip ; shortening and eversion, however slight ; absence of crepi- tus ; and lastly, the rotation of the trochanter through an arc of a circle of which the head of the bone is the centre, instead of upon the axis of the shaft, as in detached fracture of the neck. The practical importance of readily identifying this fracture lies in the fact that its progress, as regards both time and good union, is in general more favorable than that of the unimpacted fractures ; that though it is a comparatively FRACTURE OF THE NECK OF THE FEMUR. 141 common and disabling accident, it may exhibit little deform- ity ; and lastly, that the object of extension in its treatment is to steady the limb, and not to draw it down. The followmg details of the ana- tomical structure of the femur sus- tain the foregoing statements in respect to the shortening and ever- sion incident to this lesion. ANATOMICAL STRUCTURE OF THE NECK OF THE FEMUR. Let a well-developed femur be placed in a vice with its back toward the observer, in its natural upright position, but obliquely, as if the legs were widely separated, the shaft be- ing so far inclined that the neck is horizontal. Let a first slice be now removed from the top of the head, neck, and trochanter by a saw car- ried horizontally through the neck. Let a second and third slice be re- moved in the same way, so that the neck shall be divided into four hori- zontal slices of equal thickness.^ It will be found that the upper section exhibits the anterior and posterior walls of nearly equal thickness ; but that as we 1 If the head of the bone be now vertically transfixed by a wire, the sections may be spread for examination like a fan. 2 Fig. 1 exhibits a bird's-eye view of a horizontal section of the neck of the femur, showing the posterior wall plunging beneath the inter- trochanteric ridge, at the angle where the neck joins the shaft. The posterior wall is of the thinness of paper, and here impaction occurs. The anterior wall, on the contrary, is seen to be quite thick, and forms by its fracture a hinge which is very rarely impacted. Fig. 1.2 142 FRACTURE OF THE NECK OF THE FEMUR. Fig. 2.1 approach the lower surface of the neck the anterior wall becomes of great thickness and strength, while the posterior wall remains thin, especially at its insertion beneath the posterior in- tertrochanteric ridge, where it is of the thinness of paper. ROTATION. The result of this conformation is obvious. In impacted fracture, the thin posterior wall is alone impacted, while the thick anterior wall, refusing to be driven in, yields only as a hinge upon which the shaft rotates to allow the posterior impaction. This phenomenon, varying a little with the injury, is constant in every specimen of simple impacted fracture I have examined ; and in fact it must be so from the arrange- ment of the bony tissues, which at once invites and explains the eversion.2 SHORTENING. The hinge before alluded to is oblique, following the ante- rior intertrochanteric line. Were it vertical, by bending this 1 The same as Fig. 1. The section of tlie shaft near the lesser tro- chanter shows the lower extremity of the septum, where the wall is thicker and changes its direction. (From a photograph taken in 1861.) 2 M. Robert, in a memoir upon impacted fractures of the neck of the fenim", attributes the posterior impaction to the supposed fact that the tangential plane of the external surface of the trochanter is inclined obliquely backward to the axis of the neck, and that a force applied to its centre would tend to increase the obliquity of this angle, and thus to produce outward rotation of the shaft. The shortening of the limb he attributes to the fact that the impaction is greatest at its lowest part. (IVIemoire sur les Fractures du Col du Femur accompagnees de Penetra- tion dans le Tissu Spongieux du Trochanter. Par Alphonse Robert, Prof es- seur Agrege, etc. Memoires de I'Academie de Medecine, torn. xiii. p. 487.) FEACTUEE OF THE NECK OF THE FEMUE. 143 hinge we should produce rotation without shortening. On the other hand, if it were horizontal and transverse, bending it would produce shortening without rotation ; but as it stands at an angle of 45°, the shaft rotating upon this broken inter- val is shortened in proportion to its rotation, — or, what is the same thing, the neck is reflected upon its hinge downward and backward till its axis normally oblique may become even transverse, with great outward rotation of the shaft and a shortening of perhaps two inches. This is probably the most common cause of shortening, although the head of the bone may be otherwise depressed.^ TRUE NECK. Upon examining the lower of the above sections in a well- marked bone, the posterior or papery wall of the neck will be seen to be prolonged by radiating plates into the cancellous structure beneath the intertrochanteric ridge. That the thick- est of these (Fig. 1) is a continuation of the true neck may be shown in another way. Let the whole of the posterior inter- trochanteric ridge, including the back part of both trochanters, be removed by a narrow, thin saw. (Fig. 3.) The bone being now laid upon a table, let a chisel, or what is better a gouge, be held perpendicularly upon the cancellous structure thus exposed, and lightly twirled until the friable and spongy tissue is removed and the instrument arrested by the septum, or wall, alluded to. To expose its inner surface, the shaft should be split by a vertical and curved section behind this wall, and the cancellous structure removed in the same way. The septum will then be distinctly seen as a thin, dense plate of bone continuous with the back of the neck and reinforcing it, plunging beneath the intertrochanteric ridge in an endeavor to reach the opposite and outer side of the shaft. At its lower 1 See pp. 157, 161, 163. 144 FRACTURE OF THE NECK OF THE FEMUR. extremity it curves a little forward, so as to take its origin when on a level with the lesser trochanter from the centre, instead of the back, of the cylindrical cavity, — a disposition easily seen in a transverse section of the shaft just above the trochanter minor. (Fig. 2.) Or it may be said that the posterior wall of the neck forks before reaching the intertro- chanteric line, one layer being seen upon the surface, while the other dives beneath the intertrochanteric ridge in a vain "" W«i'Nl.ll'«l||| Fig. 3.1 attempt to reach the outer wall of the shaft. If these views be correct, the intertrochanteric ridge is simply a buttress erected for the insertion of muscles upon and over the true neck, by the impaction of which it is in fact often split off and detached in a mass, — the force exerted by the true neck, though slight, being nevertheless an effort to resist such impaction. 1 Anatomy of impacted fracture. The intertrochanteric ridge has been removed, and the cancellous structure so excavated as to exhibit the true neck beneath. The rod is placed in a longitudinal fissure by which the shaft of the bone has been split, in order to exhibit the true neck from within. (From a photograph taken in 1861.) FRACTUKE OF THE NECK OF THE FEMUR. 145 REMAEKS. Surgical writers have been at some pains to indicate the distinguishing marks and tendencies of the so-called fractures "within" and "without the capsular ligament," — names which have but little practical significance. While the im- pacted fracture of the base of the femoral neck unites by bone, if at all, there seems to be a decreasing tendency to osseous union as we approach the smaller portion of the neck near its head, — a circumstance probably due in part to the feeble nu- trition of the detached extremity, and in part to its mobility. The fact, which Sir Astley Cooper did not deny, that bony union is possible " witbin the capsular ligament " ^ and at the slenderer portions of the neck, is now sufficiently attested by existing specimens, our University Museum possessing two of these. But in examining specimens of such bony union it is often difficult to say just how far the fracture was originally within or without the capsule, because the exact position and limit of the capsule itself are variable ; ^ and if we except the impacted fracture at the base, it is impossible during life, by any justifiable examination, to decide what part of the neck is broken, or whether the fracture has occurred within or without the capsule. Nor is it a matter of importance in the treat- ment, which is one and the same in both cases, or in prog- nosis, if the so-called varieties cannot be distinguished. In lecturing upon this subject, I have been in the habit of divid- ing the injuries of the neck of the femur into the impacted fracture of the base of the neck and the unimpacted fracture of the rest of the neck, without regard to the capsule, — a practical classification embracing a majority of cases, and to which the other lesions may be regarded as exceptional. 1 Treatise, etc., pp. 137, 138. 2 The Insertion of the Capsular Ligament of the Hip-Joint, and its Relation to Intra-Capsiilar Fracture. By George K. Smith, M.D., Demon- strator of Anatomy, etc. New York, 1862. 10 146 FRACTURE OF THE NECK OF THE FEMUR. It is indeed possible for the small extremity of the neck to be impacted into the detached head, and so steadied by it as to favor union. Such was the injury in the specimens in our Museum described below. It is also possible for the base of the neck to be impacted with inversion ; but in the large majority of cases, if there is a serious injury to the neck of the bone, it is either a common impacted fracture of the base of the neck, easily diagnosticated by the signs already described, or some other fracture, about which it is of no practical consequence in its treatment to know anything, except that it exists and needs .extension. In brief, the presence of excessive pain on motion leads to the suspicion of sevei^ injury. The age of the patient ; the shortened, everted, loosely hanging, and uncontrollable limb; crepitus, which when once felt is as satisfactory as if felt, to the detriment of the patient, many times, — and, lastly, the head of the trochanter rotating on the axis of the shaft and not through an arc, readily and quickly identify the unim- pacted fracture. On the other hand, the impacted fracture of the base, which occurs in the adult at all ages, though more frequently in the latter half of life, is characterized by less local pain and disability, by shortening and eversion^ (which may be slight), and by the absence of crepitus, while the trochanter rotates through an arc upon the articulation as a centre. The importance of distinguishing between the different frac- tures of the neck of the femur is not so great as to justify any protracted or considerable examination. Flexion of the thigh, its repeated rotation, or other unscrupulous or unskilful hand- ling, is liable to lacerate the remaining capsule, to displace the bony fragments, or, by loosening and detaching an impacted fracture, to render its union more difficult, — adding, perhaps, ^ As before stated, a slight eversion is perhaps best indicated by a comparison of the extent to which the two limbs can be inverted. FRACTURE OF THE NECK OF THE FEMUR. 147 to the accuracy of the diagnosis, but directly diminishing the chances of the patient. The treatment of all these fractures is similar, — the unim- pacted fracture obviously requiring extension, the purpose of which in the impacted fracture is to steady, not to elongate, the limb. Among the many expedients presented to the choice of the surgeon, I have for my own part found as good results, even in bad cases, from a flat bed, with a book or other weight attached to the foot for extension, and perhaps a broad band about the hips to steady the parts, and a cushion or pillow under the broken hip to prevent its eversion, as from more complicated and less comfortable apparatus. The prognosis of these fractures it is difficult to give. Elderly people may die of them at the end of a few weeks, or may linger many months. On the other hand, when the fracture is near the base of the neck, cases occur of recovery, with little lame- ness, both from the impacted and the unimpacted varieties, especially the former. To facilitate a differential diagnosis, the principal lesions of this region will now be described. IMPACTED FRACTURE OP THE BASE OF THE NECK WITH INVERSION. This accident is of rare occurrence. Smith and Hamilton each cite but one case. Indeed, the structure of the bone, as has been shown, is such as to insure an almost uniform ever- sion of the shaft. A specimen from a dissecting-room has enabled me to examine this rare lesion, and to identify the conditions under which it probably occurred. In this subject (an old woman) the limb was flexed a little, shortened to the extent of three inches, and inverted so that the patella faced inward ; the limb was in slight abduction, and could neither be everted nor brought to the median line. The trochanter 148 FEACTUKE OF THE NECK OF THE FEMUR. was felt to be much thickened. Upon examination of this exceptional specimen, the neck of the bone was found to be firmly united at right an- gles with the shaft, which was split open and spread so widely as to receive the whole impacted neck, leav- ing a fissure an inch or more long and a quarter of an inch wide between the anterior wall and the neck, and extending nearly to the outer wall of the shaft, while another similar fissure ex- isted behind the neck. The principal posterior fragment comprised the two trochan- ters with the intertrochan- teric ridge, and also a large fragment of the external portion of the shaft, — while above, the region of the great trochanter seemed to have been comminuted and driven downward and inward. Anteriorly the fracture had occurred, as usual in impacted fracture, along the oblique spiral line, although differing from that injury, the neck being deeply driven in behind this wall, from which it had slipped instead of turning upon it as a hinge. The whole upper part of the bone above the trochanter minor seemed to have been bent inward, so that the posterior inter- trochanteric line, instead of inclining obliquely to the axis of the shaft, was vertical. The inversion was due to the extent 1 Figs. 4 and 5, — impacted fracture with inversion. Fig. 4, posterior view ; Fig. 5, anterior view. The foreshortening fails to show the length of the tapering prolongation of the trochanter minor. Fig. 4. 1 TRACTURE OF THE NECK OF THE FEMUR. 149 of the comminution, whicli had separated the walls of the shaft so as to receive in the interval the whole neck instead of the posterior wall only, as commonly occurs, — thus producing an ante- rior as well as a posterior impaction. The shorten- ing resulted both from the horizontal position of the neck and from an ad- ditional upward displace- ment of the shaft caused by the comminution. A good deal of callus had been thrown out in va- rious directions, and the movements of the limb must have been quite re- stricted. A curious spicula stood at right angles with the shaft near the lesser trochanter, and may have been a dis- placed fragment or the ossified insertion of the psoas tendon. The same bony spicula exists in another specimen before me, and is not uncommon. In examining the accompanying illustrations, it will be seen that the intertrochanteric ridge is split off, as often hap- pens ; but in this case it has carried with it the outer and posterior walls of the shaft, with the two trochanters. Smith! (^Case XLVI.) cites a similar case of inversion, which the accompanying figure shows to have resulted from a similar cause. The posterior intertrochanteric ridge, with the greater part of the two trochanters, has been detached in a 1 A Treatise on Fractures in the Vicinity of Joints, etc. By Robert William Smith, M.D., M.R.I. A., etc. Philadelphia and Dublin, 1850. (See also Case XXXVII.) Fig. 5. 150 rRACTURE OF THE NECK OF THE FEMUR. mass, and so widely that the neck of the bone has slipped from its anterior hinge. In both specimens the impaction is arrested near the outer wall of the shaft. The entire neck in my specimen can be seen through the lateral fissures, while in that of Smith its extremity is detected through an interval of the fragments near the great trochanter. A similar specimen, numbered 248, in the Mutter Museum in Philadelphia, shows neither inversion nor eversion. IMPACTED FRACTURE OF THE NECK OF THE FEMUR NEAR THE HEAD. The following cases of impacted fracture of the femur near the head, — one resulting fatally, the other in complete recov- ery, with the exception of persistent pain, — may be regarded as instances of fracture fairly within the capsule. They illus- trate not only the possibility of bony union of the detached articular extremity, but also the circumstances which con- tribute most frequently to its occurrence, — if, indeed, they are not essential to it. In two specimens (Nos. 2111 and 1540) in the Museum of the Medical School of Harvard University, of undoubted bony union after fracture of the femoral neck, the line of separation is near the head, which is tilted obliquely downward toward the lesser trochanter, as in the following cases. A man aged seventy-six entered the Massachusetts General Hospital, March 9, 1863, under the charge of Dr. Gay, who has kindly furnished me with a record of this interesting case. The patient fell in the evening upon the sidewalk, striking the right trochanter. Feeling only that he had received a severe bruise, he crawled upstairs alone, and sat in his chair long enough to read his newspaper before going to bed. Two days after, he entered the Hospital. Upon examination, it appeared that the right leg was shortened half an inch ; the FRACTURE OF THE NECK OF THE FEMUR. 151 foot was everted, and could not be inverted beyond the per- pendicular ; the thigh could be flexed and extended without difficulty, but with pain ; the trochanter was less prominent than that of the other side. At the end of two weeks he died of pneumonia, at two o'clock in the afternoon ; but at half past ten in the morn- ing of that very day he had asked to have the splints re- moved, saying that the leg felt well, and at the same time lifting the whole limb several inches from the bed without assistance. In this interesting case, of which an excellent illustra- tion is here given, the head was found to be broken from the articular extremity of the neck, which was short and thick, the fracture behind being almost at the line of junction of the articular cartilage and the bone, while in front it ran irregularly across the neck, 1 Dr. Gay's case of impacted fracture near the head. In this speci- men the neck of the bone was originally short and stout. Below and behind it the fracture follows, as nearly as may be, the line of the articular cartilage, while anteriorly and above it is about half an inch distant from this line. The impaction in the recent state was firm, the thin surface of the neck at its lower and posterior part having been driven into the cancellous structure of the head to the depth of about half an inch, while the cancellous structure of the head of the bone has penetrated to the depth of three quarters of an inch into that of the neck, this mutual impaction being very firm. The head rests obliquely upon the lower fragment, as if the shaft had been rotated outward, opening the anterior part of the fracture to the width of neai'ly a quarter of an inch. Fig. 6. 152 FRACTURE OF THE NECK OF THE FEMUR. from a quarter to half an inch below this line. The head was bent on the neck obliquely backward and downward toward the lesser trochanter, — the tilting of the head open- ing the fracture on the outside of the neck, — and was so firmly impacted that considerable force was required to withdraw it. The impaction was double, the shell of the neck being driven to the depth of half an inch into the head behind, while the centre of the head had entered the cancel- lous tissue of the shaft, being much the more dense of the two. The patient was evidently not aware of the existence of fracture, and it would have been impossible for the surgeon to infer before death the exact nature of the injury. It is fair to suppose that two bony fragments thus mutually impacted and held in apposition would have united by bony union had the patient lived, and in this case it cannot be doubted that the fracture was wholly within the capsule. An additional interest attaches to this specimen in connection Avith the sub- joined case of fracture, almost identical with it in character, and presenting unequivocal bony union.^ The following case of bony union, in a fracture curiously resembling the preceding, occurred in the practice of Dr. Gush- ing, of Dorchester, Mass., — a practitioner of large experience, whose opinion in respect to the general character of an injury of this sort would be entitled to weight, even were it not cor- roborated by the specimen here represented, the section of which shows unequivocal evidence of fracture. A woman seventy years of age, while reaching to wind up a clock, fell upon her side. Dr. Gushing, being called at once, found that although the limb was not obviously displaced, it was so dis- 1 For a case of mutual impaction of the neck and head, but compli- cated with a second impaction, old or recent, of the base of the neck, see a paper by Thomas Bryant, F. R. C. S., etc., in the Medical Times and Gazette, May 1, 18G9. As the result of this double impaction, there was "some shortening of the limb, but no eversion of the foot." FRACTURE OF THE NECK OF THE FEMUR. 153 abled as to leave no doubt of the existence of a fracture. The patient was laid upon her back, with the knee flexed and two pillows beneath it. For two and a half or three months she kept her bed, and then began to sit up with the limb extended. Crutches were used for six months longer ; then a crutch and a cane ; but for the last two and a half years neither, the patient being able to go about the house and a little way out of doors. There was little, if any, shortening, and she limped but slightly. During the first few weeks she had much pain at the seat of the injury and in the limb, which was gradually atro- phied. Her health was generally good until near her death, four years and eleven months after the accident, from internal disease. In this instance, also, the neck of the femur is short and thick, — the line of fracture corresponding very nearly with that of tlie articular carti- lage. The head of the bone has been depressed so that the neck is now nearly transverse, — the head being also bent obliquely backward and downward toward the lesser trochanter, and the shaft rotated outward. In front the neck of the bone projects beyond the articular cartilage, while behind it is buried beneath it, as in the preceding specimen. The neck is thus posteriorly impacted into the head, which in bending backward opens a fissure in front, filled with an irregular bony callus. It was not observed in this case that the limb was everted, as the specimen implies. At the time of death the foot was 1 Dr. Cushing's case of impacted fracture near the head, with bony union. Fig. 7.1 154 FRACTURE OF THE NECK OF THE FEMUR. straight. Smith records a case (No. LVIII.) in which there was slight inversion. COMMINUTED FRACTURE OF THE TROCHANTERS WITHOUT IMPACTION. Tlie alleged injury thus described detaches the entire neck from the shaft, and is generally represented in museums by specimens, the comminuted fragments of which are reunited in their normal position. Museum specimens of this frac- ture are less frequent than those of the common impacted fracture, and might be still more rare were it not that the impaction, which I conceive to be the rule in fracture at the base of the neck, docs not always persist, being sometimes liberated by the extensive comminution of the bone, or by force subsequently applied. The impacted bones are un- doubtedly separated, in many cases from want of care both in the examinatioji and in the subsequent treatment of the patient, and likewise in the process of their preparation as specimens. It is fair to suppose that local crepitus can be felt in the trochanteric region, so extensively comminuted. The lines of fracture present great variety. The anterior and posterior trochanteric walls, or either of them, may be detached entire or in fragments. The posterior intertrochanteric ridge may be split off partially or wholly, and the trochanter minor broken off by itself. The summit of the outer trochanter, and in fact the whole upper region of the shaft, may be comminuted and driven in as by a blow from above. As in other fractures of this part, inversion of the limb is here the rare exception, and eversion the rule. Smith cites twenty-eight cases of extra-capsular fracture, of which four only were inverted. Assuming that anterior impaction is essential to inversion, we may seek the cause of the latter FRACTURE OF THE NECK OF THE FEMUR. 155 both in the direction of the blow received and in the action of the muscles. The influence of these is well illustrated in the case already detailed (Figs. 4, 5), where the mass of large and small rotators evert the upper fragment only, leaving the shaft to be inverted by the anterior fibres of the gluteus medius, and especially of the gluteus minimus, which is inserted lower down. This occurs when both the trochan- ters are detached, whether separately or (as in this specimen) in a single piece. Smith's four cases of inve)'sion ^ sufficiently illustrate these points, as does also a specimen in the Chatham Museum, 2 where, in addition, " an arch of new osseous matter . . . extends from the anterior inferior spinous process of the hannch-bone across the joint to the upper part of the shaft of the thigh-bone," and which, it may be inferred from its inser- tions, was the Y ligament and the neighboring fibres (see Fig. 22, page 74 of this volume). Shortening not unfrequently results from mere depression of the neck without correspond- ing rotation of the shaft, as in the regular impacted fracture ; and the transverse neck may then be displaced outward upon the shaft, so as to resemble a hammer upon its handle, FRACTUEE OF THE NECK OF THE FEMUR RESULTING IN FALSE JOINT. The frequency of this lesion is attested by the common museum preparations, showing the hemispherical head of the bone slipping upon the absorbed and shortened neck, or upon a broader surface with more restricted motion nearer the shaft. In the latter case the lower surface of the neck ^ A Treatise on Fractures in the Vicinity of Joints, etc. Cases XXIX., XXXVII., XXXIX., XL VI. 2 See the third Fascicuhis of Anatomical Drawings, etc.. Army Medical Museum of Chatham; also, A Case of Fracture of the Neck and Trochanter of the Thigh-bone with Inversion, etc. By George Gulliver. Edinburgh Medical and Surgical Journal, vol. xlvi. p. 312. 1836. 156 FRACTURE OF THE NECK OF THE FEMUR. not unfrequently rests upon a bony projection near the lesser trochanter. False joint is a frequent result of unimpacted fracture, and is not to be averted by any special form of apparatus. CRACK IN THE NECK OF THE FEMUR. It is obvious that while a simple crack or fissure of the femur would produce no immediate deformity, it might yet give rise, as in the radius at the wrist, to lameness and inflam- mation of long duration, with corre- sponding obscurity of diagnosis. The tendency of glass tubes and other brit- tle cylinders to crack in a spiral line is well known ; and M. Gerdy has re- marked upon the occurrence of oblique or spiral fissures in the long bones, producing at their intersection acute angles like the letter V. Those of the tibia sometimes exhibit a singular symmetry and mutual resemblance.^ The annexed woodcut (Fig. 8) repre- sents a portion of a left femur from a patient who died under my care at the Massachusetts General Hospital, of fracture and internal injuries. The specimen is now in the Museum of the Medical School of Harvard Uni- versity, and has been described by Fig. 8.2 1 See Pratique Journali^re de la Cliirurgie, p. 67. Par Adolphe Richard, Cliiruroien de I'llopital Beaujon, etc. Paris, 1868. 2 Crack of tlie femoral neck. Near the lesser trochanter is seen the hook-like extremity of the fissure, separated by a narrow interval of bone from the main line of fracture. FRACTURE OF THE NECK OF THE FEMUR. 157 Dr. J. B. S. Jackson, Dr. Mussey, and Dr. Hamilton. The femur is large and well marked. A spiral fracture ascends the shaft and winds round the neck, completely detaching it, except at a narrow isthmus in front half an inch wide. The shaft is broken transversely, eight inches below the trochanter. Here a spiral fissure begins, near the linea as- pera, and winds upward and inward to the front of the bone, crossing the anterior intertrochanteric line midway between the trochanters ; thence vertically upward to the outer edge of the cartilage ; thence transversely across the top of the neck to its posterior surface, here touching the cartilage again ; thence vertically down behind the neck to a point half an inch from the lesser trochanter, terminating on the under side of the neck in an S-shaped extremity, half an inch from the point where the fissure crosses the intertrochanteric line in front. The elastic bony pedicle thus formed allows a slight springing motion of the head, but maintains it firmly in place. 158 TRE TRUE NECK OF THE FEMUR. THE TRUE NECK OF THE FEMUR: ITS STRUC- TURE AND PATHOLOGY.i I. STRUCTURE. Some of the later numbers of Virchow's Archives contain a protracted yet interesting discussion upon the interior struc- ture of bones, notably of the head of the femur. According to Merkel,2 G. H. Meyer, in 1867, pointed out certain arching fibres in their cancellated structure as "a well-marked archi- tecture, which stands in the closest relation to the static and dynamic forces of the bones." In 1870,3 Wolff made further investigation of this subject ; and in addition, this writer incorporated into his paper certain elaborate mathematical calculations of Culmann, of Zurich, showing that interior braces intended to aid in supporting a weight upon the end of a cylinder, curved like the thigh-bone, or like a crane or derrick, should be placed, in order to act to Ijest advantage, precisely where the trabeculse of the spongy tissue of this bone actually exist. " Nature," says "Wolff, " lias built the spongy bones as an engineer would construct a truss bridge, mathematically." This recent German investigation, apart from the mathe- matical calculation which Merkel avows his inability to follow, was anticipated, so long ago as 1850, by the late Professor 1 The Boston Medical and Surgical Journal, Jan. 7, 1875. 2 Virchow's Archives, 1874 ; vol. lix. p. 237. « Ibid., 1870; vol. 1. p. 389. ITS STRUCTURE AND PATHOLOGY. 159 Jeffries Wyman, who, in a comprehensive article upon this subject,^ reached the following conclusions : — "1. The cancelli of such bones as assist in supporting the weight of the body are arranged either in the direction of that weight, or in such a manner as to support and brace those cancelli which are in that direction. In a mechanical point of view, they may be regarded in nearly all these bones as a series of * studs ' and 'braces.' "2. The direction of the fibres in some of the bones of the human skeleton is characteristic, and, it is believed, has a definite relation to the erect position, which is naturally assumed by man alone. " These structures are most clearly defined in adult and middle- aged skeletons." Dr. Wyman illustrates his paper by diagrams alone suffi- cient to demonstrate, even to a common mechanic, an advan- tageous adaptation of means to end. An internal structure, shown to be rectangular in the vertebrae, radiating in the tarsal bones, and arched in the neck of the femur, obviously offers economical resistance to the weight it is designed to carry. But if doubt be still entertained, the laborious calcu- lations of Culmann, assumed to be correct, establish the fact absolutely, so far as the femoral neck is concerned. Thus much for the spongy structure of the bones in general (Fig. 1). We are now to consider an arrangement peculiar to the interior of the neck of the thigh-bone. According to Merkel, a section of this may be seen in an illustration designed for another purpose, many years ago, by Pirogoff, who, how- ever, does not allude to it. In 1870,^ Wolff speaks of it as " a compact tissue beneath the trochanter minor." In 1874, in an able paper largely devoted to its description, 1 Boston Journal of Natural History, 1850 ; vol. vi. No. 1, p. 125. Report of the Committee on Medical Sciences ; Transactions of the American Medical Association, 1850. 2 Virchow's Archives, 1870 ; vol. 1. p. 389. 160 THE TRUE NECK OF THE FEMUR. MerkeP calls this compact tissue the " schenkelsporn," or thigh-spur. The " calcar femorale,'* special object of Merkel's paper is to prove the pre- dominant impor- tance of this tissue in sustaining the weight of the body, and to show that the strength of the neck of the femur is mainly due to this dense tissue, and not to the braces of Wolff and Culmann. Although a little embarrassed by variations of the " spur," as it ap- pears in different preparations, "be- ing in some straight, in others curved," he insists strongly 1 Virchow's Archives, 1874 ; vol. lix. p. 237. 2 A specimen showing repair of the acetabulum after hip disease is here figured. The subject in which it was found, a boy of a dozen years, was from the dissecting-room. Large sinuses still remained open. The head and neck of the femur had disappeared, and the trochanters were united to the ilium by a narrow isthmus of bone, an inch above and be- hind the socket. The latter is filled with a curious right-angled net-work, extending to some depth, the explanation of which is not obvious; and whether it be sought in the influence of a neighboring rectangular spongy tissue toward the spine of the ischium, or in prolonged fibres of the ver- tical ramus of the ischium and the horizontal one of the pubes interlaced beyond their normal boundary in the healthy socket, or lastly in some accidental traction upon tissue afterward ossified, the interpretation is equally unsatisfactory. At the bottom of the figure is the tuberosity. A perforation near the socket was in the track of a sinus. Fig. 1.2 ITS STRUCTURE AND PATHOLOGY. 161 upon its teleological importance ; doubting whether the ar- rangement of the spongy tissue possesses the same signifi- cance, because the calcaneum of man and that of the ox, as shown by Wolfermann, really perform very different func- tions, although they offer a similar internal structure, — a statement equally true of the spongy system generally. On the other hand, Wolff, in a second paper,^ replies that "the calculations of Culmann prove that the ' spur ' is not at the point of greatest strain, nor yet where strength is most needed ; " that " Merkel's theory in no way agrees with Cul- mann's calculations, which may be accepted as beyond con- troversy ; " and that " Merkel has ascribed to the ' spur ' a wholly erroneous importance." In the following foot-note,^ Merkel again insists upon his views : — "While these sheets are being printed, I have received the work of Bigelow upon the Mechanism of Dislocation and Fracture of the Hip, translated by Pochhammer (Berlin, Hirschwald), in which the schenkelsjjom is both described and figured ; he does not, however, follow out the significance of the structure." Before again expressing my own opinion of the purpose of the bony plate in question, it may not be amiss to cite here the description alluded to by Merkel, especially as I do not discover that anything of importance has been added to it since its publication in 1869: — ANATOMICAL STRUCTURE OF THE NECK OF THE FEMUR. ^ Let a well-developed femur be placed in a vice with its back toward the observer, in its natural upright position, but obliquely, as if the legs were widely separated, the shaft being so far inclined 1 Virchow's Archives, 1874 ; vol. Ixi. p. 417. 2 Ibid., 1874 ; vol. lix. p. 251. 3 Mechanism of Dislocation and Fracture, etc., p. 120. Philadelphia, Henry C. Lea. 1869. (See p. 141 of this volume.) 11 162 THE TRUE NECK OF THE FEMUR. that the neck is horizontal. Let a first slice be now removed from the top of the head, neck, and trochanter, by a saw carried horizon- tally through the neck. Let a second and third slice be removed in the same waj-, so that the neck shall be divided into four horizontal slices of equal thickness.-^ It will be found that the U2:)per sec- tion exhibits the anterior and posterior walls of nearly equal thickness, but that, as we approach the lower surface of the neck, the anterior wall becomes of great thickness and strength, while the posterior wall remains thin, espe- cially at its insertion beneath the pos- terior intertrochanteric ridge, where it is of the thinness of paper (Fig. 2). TRUE NECK. Upon examining the lower of the above sections in a well-marked bone, the posterior or papery wall of the neck will be seen to be prolonged by radiat- ing plates into the cancellous structure beneath the intertrochanteric ridge. That the thickest of these is a continu- FiG. 2.2 ation of the true neck may be shown in another way. Let the whole of the posterior intertrochanteric ridge, including the back part of both trochanters, be removed by a narrow, thin saw. The bone being now laid upon a table, let a chisel, or what is better a gouge, be 1 If the head of the bone be now vertically transfixed by a wire, the sections may be spread for examination, like a fan. 2 Exhibits a bird'.s-eye view of a horizontal section of the neck of the femur, showing the posterior wall plunging beneath the intertrochan- teric ridge, at the angle where the neck joins the shaft. The posterior wall is of the thinness of paper, and here impaction occurs. The anterior wall, on the contrary, is seen to be quite thick, and forms by its fracture a hinge which is very rarely impacted. ITS STRUCTURE AND PATHOLOGY. 163 held perpendicularly upon the cancellous structure thus exposed, and lightly twirled until the friable and spongy tissue is removed, and the instrument arrested by the septum, or wall, alluded to. To expose its inner surface, the shaft should be split by a vertical and curved section behind this wall, and the cancellous structure removed in the same way (Fig. 4). The septum will then be distinctly seen as a thin, dense plate of bone continuous with the back of the neck, and reinforcing it, plunging beneath the intertrochanteric ridge in an endeavor to reach the opposite and outer side of the shaft. At its lower extremity it curves a little forward, so as to take its origin, when on a level with the lesser trochanter, from the centre, instead of the back, of the cylindrical cavity, — a dis- position easily seen in a transverse section of the shaft just above the trochanter minor (Fig. 3). Or it may be said that the posterior wall of the neck forks before reaching the intertrochanteric line, — one layer being seen upon the surface, while the other dives be- neath the intertrochanteric ridge in a vain attempt to reach the outer wall of the shaft. If these views be correct, the intertro- chanteric ridge is simply a buttress erected for the insertion of muscles upon and over the true neck, by the impaction of which it is in fact often split off and detached in a mass, — the force ex- erted by the true neck, though slight, being nevertheless an effort to resist such impaction. Fig. 3.1 As regards ordinary spongy tissue, the teleological question is satisfactorily answered in either of two ways. We may attribute its architecture to that immediate necessity which in pathology builds a buttress to support a bone curved by 1 The same. A section of the shaft near the lesser trochanter shows the lower extremity of the septum, where the wall is thicker and changes its direction. (From a photograph taken in 1861.) 164 THE TRUE NECK OF THE FEMUR. rickets or weakened by fracture, or explain it by a general principle of conformation, in a measure automatic, developed in the lapse of generations by a frequently recurring neces- sity, and still continuing to act without immediate stimulus. But the purpose of the osseous plate, whose structure and pathology it is the main object of this paper to discuss, may be at first a little less obvious. It plainly adds a certain strength to the bone ; and yet in most bones it terminates be- neath the trochan- ters in papery la- mellae wholly in- adequate to lend it material support. It is usually united, even to the tro- chanters, only by a delicate wall and spongy tissue. It obeys the laws of similar bony structure, being feebly developed in childhood ; while later in life, its absence in the femoral neck impresses us, as do bone-sections generally, with the truth of the observation of Henle, — that the so-called brittleness of age depends not so much on the loss of animal substance as upon the atrophy of the bony walls and anterior structure. These varying appearances might well leave us in doubt as to the purpose of this osseous plate ; but no doubt can exist * "Anatomy of impacted fracture. The intertrochanteric ridge has been removed, and the cancellous structure so excavated as to exhibit the true neck beneath. The rod is placed in a longitudinal fissure by which the shaft of the bone has been split, in order to exhibit the true neck from within. (From a photograph taken in 1861.) Fig. 4.1 ITS STRUCTURE AND PATHOLOGY. 165 in the mind of one who examines an exceptionally well- marked adult bone. Such a bone fell under my observation in 1861 (Fig. 4). The dense plate is there a continuation of the neck, com- pleting the interval everywhere except at its upper part. In this form it adds greatly to the strength of this part of the femur, while the trochanters and their ridge erected upon it both rein- force it and give attachment to the muscles. This may be again shown. In a back view of the femur (Fig, 5) the neck appears as a pyramid, with its base to the trochanters. Fig. 5.1 Fig. 6.2 1 Rear view of left femur with and without the trochanters. The removal of these, in the left-hand figure, exposes the true neck. 2 Side view of the same. While these views are designed to exhibit the true neck, it is not denied that the trochanteric shell helps to stiffen the curving shaft and to sustain any weight resting upon the head of the bone; especially through the intervention of the upper and horizontal part of the neck. 166 THE TKUE NECK OF THE EEMUR. The cylindrical shaft also spreads as it rises to meet the tro- chanters. In a side view (Fig. 6) it is seen that both these cylinders, joined at their bases, are flattened from front to back, and are continuous in shape and direction, although surmounted at their junction by the trochanteric promi- nences. If we now remove the trochanters with their con- necting ridge (Figs. 5 and 6), it may be again observed that what we have called the true neck maintains the continuity of the shaft. It no longer resembles a " spur," with its edge exposed by excavating the wall, as in Merkel's preparations. Thus denuded, the shaft has an air of symmetrical strength. It is flattened to resist weight, like a bone curved by disease, while the trochanters seem to have been added for a different purpose (Fig. 7).^ Unfortunately, bones like that above alluded to are rare. The true neck is often at best but an ineffectual attempt to bridge the interval beneath the trochanters, as seen in Mer- kel's figures ; while in the latter half of life it degenerates 1 Diagram of a section of the head of the femur of a sheep, showing a deep trochanteric fossa. If this fossa were filled with spongy tissue (as seen beneath the dotted line), the posterior neck would be partially concealed, as in the human femur. The analogy, whether true or not, is too striking to be overlooked. A deeper fossa ex- ists in certain animals, especially South African ruminants, of which I examined sections in the Hunterian Museum in 1868. In this specimen the tendon inserted at the bottom of the fossa is prolonged into the spongy tissue by radiating lamellae, which intersect concentric arches as represented in the diagram, and resist traction to great advantage. In examining a number of preparations lately made by my friend Dr. Dwight, I am satisfied that the tendency of what I have called the true neck is to attach itself below, where it becomes thin, as a tangent to the inside of the cylinder of the shaft ; and also that it may be tolerably well pronounced in a subject six or eight years of age. ITS STRUCTURE A^^D PATHOLOGY. 167 into papery plates, radiating downward from a point near the lesser trochanter. Weakened in this way both by its own tenuity and by its slender union to the trochanteric ridge, the true neck has great practical interest for the surgeon. Even the adult femur is generally defective in construction at this point ; and here occurs the most common form of fracture, — namely, the posterior impacted fracture of the base of the neck. II. — PATHOLOGY. IMPACTED PRACTUEES. POSTERIOR IMPACTED FRACTURE OF THE BASE OF THE CERVIX. The posterior impacted fracture of the base of the cervix often occurs in old people. I have met with it also in middle life, and do not hesi- tate to express the be- lief that it is the most common of the frac- tures of the neck of the thigh-bone. That ^ Front view of right femm-, showing the frac- tured cervLx bending like a hinge at the anterior intertrochanteric line, to allow the posterior im- paction. The head of the bone leans more dis- tinctly from the observer than the perspective in- dicates. 168 THE TRUE NECK OF THE FEMUR. it has not been so considered may be explained by the fol- lowing considerations : — 1. It has been generally recognized only of late years. 2. The injury may be a comparatively slight one. 3. Its signs are in some cases a short- ening and eyersion hardly perceptible. 4. When it unites, there may be no lame- ness to attract subse- quent attention. 5. When it proves fatal before union, the impaction may have been disengaged by manipulation or other- wise, during life or after death, -'—espe- cially by macerating the specimen for pres- ervation. 6. On the other hand, unimpacted fracture of the small part of the neck, usually supposed to be most common, is marked by prominent symptoms. It entails great and persistent lame- ness, inviting attention and examination after death, however remote, and the specimen when obtained is unmistakable. The displacement varies greatly in degree. One wall only — the posterior one — is impacted at the intertrochanteric ^ Rear view of same, showing the cervix impacted beneath the pos- terior intertrochanteric line. The head of the bone leans toward the observer. Fig. 91 ITS STRUCTURE AND PATHOLOGY. 169 line, where the bone is a mere shell, driving the true neck, or the remains of it, farther beneath the trochanters, and some- times detaching the latter. The firm anterior wall resists impaction, but bends at the line of fracture as a hinge. If this hinge were ver- tical, the shaft would y"" be only everted; while if it were transverse, the neck would be only bent and the leg short- ened. But as the hinge stands at an angle of about 45°, shortening and ever- sion are nearly equal (Figs. 8,9,10). Im- paction, when slight, is detected by a dif- ficulty of inverting the foot rather than by actual eversion ; and the shortening may seem doubtful. It is needless to say that the rotated trochanter still sweeps through an arc of which the head of the femur is the centre, and that there is no crepitation. 1 Horizontal section of the same, showing the anterior hinge and the posterior impaction. The dotted line shows the normal position of the head. The patient who furnished the specimen from which these figures were taken was seventy-two years of age. It will be seen that the prolon- gation of the true neck has disappeared by senile atrophy, leaving only a few radiating lamellae. The specimen is of exceptional interest as show- ing this form of impaction with little comminution or other injury of the bone. Fig. 10.1 170 THE TRUE NECK OF THE FEMUR. Shortening and eversion, however inconsiderable, point di- rectly to this lesion. A large number both of cases and of specimens are referrible to this type, — impaction behind, with a hinge in front, each at its respective intertrochanteric line. In some of these specimens the neck is bent down nearly to a right angle with the shaft. The remaining varieties of fracture of the femoral neck are susceptible of classification, and deserve, for the purpose of comparison, to be mentioned in this connection. IMPACTED FRACTUKE OF THE HEAD OF THE FEMUR. The impacted fracture of the head of the femur is rare, and I do not believe it possible to distinguish it from that just described, even if it were de- sirable to do so. In three cases I have known there was the same shortening and eversion, and the same com- parative ability to move the limb. A woman who died of the injury was able at all times to get into and out of bed with but little assistance, and the trochanter, when ro- tated, swept through its arc. There was no union. The small extremity of the cervix was rather " rebated " than impacted with the head of the femur, and the fracture was "within the capsular ligament "^ (Fig. 11). 1 Impacted fracture of the head of the fennxr. The patient who fur- nished this specimen died of pneumonia in two weeks. 2 See extracts from the Proceedings of the Society for Medical Improve- ment; Boston Medical and Surgical Journal, No. 1 (1875), p. 20. 11.1 ITS STRUCTURE AND PATHOLOGY. 171 The firmness of the fragments in such a case is chiefly due to the dense central cone of spongy tissue which projects from the head of the bone and impacts itself in the friable cavity of the cervix. If the cylinder of the cervical portion is simulta- neously impacted into the head of the femur, around the base of the cone, immobility is doubly insured. I have elsewhere expressed the opinion that these condi- tions are essential to the very exceptional occurrence of bony union of the small part of the cervix. In default of anchylo- sis the neck is doubtless absorbed, presenting after a time the familiar conditions of an old " ununited fracture." So that permanent lameness may result from a fracture which, by simulating impaction of the base, promises, at first, bony union, with comparatively little deformity. 111 ^ .„Jif^ . Fig. 12.1 Fig. 13. 1 Figs. 12 and 13, — impacted fracture of the base with inversion. The anterior view (Fig. 12) shows the neck slipped off its thick hinge, into the cavity of the shaft. To allow this, the whole trochanteric mass must have been detached, as seen in the rear view (Fig. 13). 172 THE TRUE NECK OF THE FEMUR. IMPACTED FRACTURE OF THE WHOLE BASE OF THE CERVIX, WITH INVERSION. The very rare impacted fracture of the neck with inversion, instead of eversion which is the rule, occurs when the neck in front slips off its hinge into the cavity of the shaft. This is hardly possible, as I have elsewhere shown, unless the whole posterior intertrochanteric mass, including the trochanters, is fairly detached (Figs. 12, 13). UNIMPACTED FRACTUEES. FRACTURE OF THE SMALL PART OF THE CERVIX OF THE FEMUR. The fracture of the small part of the cervix of the femur, which has been usually described as the most common frac- ture of elderly persons, and erroneously as deriving impor- tance from being within the capsular ligament, is a loose fracture, with no interlocking to maintain the immobility of the small extremities, even were they disposed to bony union. Familiarly characterized by increased motion, great pain and disability, much shortening, marked eversion, and the rotation of the shaft upon its axis instead of through an arc, it is not likely to be mistaken even at first sight. But its relations to the capsular ligament are probably un- certain, owing to differences in the size and insertions of the latter. COMMINUTED FRACTURE OF THE TROCHANTERS AND SHAFT. Lastly, when the trochanteric portion of the femur is com- minuted, the detached neck and head of the bone may be very variously placed in bony union, both as to angle and as to the part which becomes subsequently attached to the shaft. ITS STRUCTURE AND PATHOLOGY. 173 In completing the list of injuries to be borne in mind while examining a hip with reference to impacted fracture, we may enumerate dislocation, sprain, crack, the rare separation of the epiphyses, and the fracture of the acetabulum into the pelvis. TREATMENT. A few words of a practical character may be added here. Apart from dislocation, the main object of examination is to decide, with reference to treatment, whether a fracture is loose or impacted. I have demonstrated here and else- where the following points, illustrating the difficulty of fur- ther diagnosis : — 1. The common impacted fracture of the base of the neck and the rare one of the head may be indistinguishable from each other. 2. A fracture seemingly impacted and promising bony union may yet result in ligamentous union with correspond- ing lameness. 3. In loose fractures with great shortening, it may be some- times difficult to distinguish a fracture of the small part of the neck, which does not promise bony union, from that of the trochanters, which does. But while an accurate diagnosis of such cases is some- times absolutely impossible, no embarrassment need be felt in the treatment of these injuries. Their treatment is simple. If to extend a limb means to draw it down, impacted frac- ture and whatever resembles it should never be extended, but only steadied by weight or splint. On the other hand, a loose fracture with decided shortening should be first drawn down to something like its normal length. Or, more briefly, treat- ment consists in immobility, with the previous extension of a loose fracture. 174 THE TRUE NECK OF THE FEMUR. A careful review of these injuries thus leads back to a prac- tical rule already usually adopted. But it leads further, and demonstrates conclusively that prolonged and active flexion and rotation of the hip, in search of positive signs, is more than superfluous. Without anesthesia it entails needless suffering ; and with or without it, by loosening impaction or lacerating tissues, it may be disastrous. Tlie question of dislocation settled, a very brief and gentle examination is alone admissible, — chiefly to determine (1) the degree of shortening ; (2) whether the shaft rotates through an arc or on its axis. The most useless and damaging exam- ination is that by quick and persistent rotation, and by flexion of the thigh as far as a right angle. The prognosis, if the patient lives, is favorable for bony union, except in the case of loose fracture of the small part of the cervix, which, if not readily distinguished, should be disturbed as little as possible. Familiarity with the posterior impacted fracture of the base of the neck will remove the most frequent source of doubt in the diagnosis of injuries of this region ; and the sooner the old classification of " intra and extra capsular fractures " is abandoned, the better it will be for science, for diagnosis, and for treatment. In the interest of the patient and of treat- ment the question should be, " Is the fracture loose or impacted ? " and science is often compelled to rest satisfied when this is settled. FRACTURE OF THE NECK OF THE THIGH-BONE. 175 FRACTURE OF THE NECK OF THE THlGH-BONE.i Few accidents are more common or more important than this ; and few give rise to greater doubt in diagnosis. I aim in this lecture at such a general view of the subject as will be useful to you in practice. The fractures of the head of the femur, or, as they are usually called, of " the hip," are tolerably well recited in the books. The principal ones are three in number. First, the so-called fracture within the capsular ligament, which I call fracture of the middle of the neck ; and, second, two others, — the impacted fracture of the base of the neck, and the im- pacted fracture of the upper end of the neck; the one being an impaction of the neck into the trochanters, the other an impaction of the neck into the head of the bone. This leaves for further consideration only the irregular fractures, or set of fractures, about the trochanters, which though not susceptible of classification fortunately do not need to be classified in treatment ; they may be considered as one. Contrary to the usual belief, I regard the impacted fracture of the base of the neck into the trochanters as the most fre- quent fracture of the head of the femur. Let us first, how- ever, consider the one usually known as "the fracture of old people," — that "within the capsular ligament" as it has been usually called, — or, as I term it, "the fracture of the middle of the neck." We have in the hospital wards four cases of injury to the hip ; three are the usual impacted fracture, and one the frac- 1 A Clinical Lecture. January, 1880. Now first published. 176 FRACTURE OF THE NECK OF THE THIGH-BONE. ture I am now about to speak of. It usually occurs in late life, when the outline of the neck of the femur is no longer w^hat it was in the young adult. In the perfect femur the neck is a flat pyramid, with its apex above, and its base spreading from one trochanter to the other. Its smallest part is next the head. Later in life the neck changes in shape, and is smallest at the middle, where it breaks. Its texture does not become more brittle, as usually stated, but there is less bone. Its interior is so changed that the neck is but a thin and almost papery shell, which may yield to slight injury. Sometimes the patient is even supposed to have broken his, or rather her, hip (for the injury occurs more frequently in women) before falling. The neck yielding near its middle, the limb is left at the mercy of the muscles, hangs loose, and, in an erect posture, swings. The muscles of the haunch evert the trochanter, and of course the toe. There may be a considerable shortening, — two inches and more. I have often mentioned a patient I once saw in the street, — a lady who fell, and when raised and supported by the bystand- ers had a swinging leg, everted toe, and the limb so shortened that I diagnosticated a fracture of the neck of the thigh-bone across the street. Such a patient placed upon a bed is usually in great pain, because the muscles are nipped by the displaced fragments, the pinching of the soft parts being the usual cause of pain in a fracture. So great is the eversion that the foot generally lies upon its outside. Under these circumstances it is useless to try to get crepitus; the effort is not only produc- tive of pain, but also damages the part. The evidence is suffi- cient without it. Crepitus can be got, however, by drawing the limb down until the fragments rub together in apposition. The prognosis of this fracture is unfavorable as to union, perhaps in proportion to the displacement ; also to the age of the patient and her health. The accident is sometimes grave, and may be a fatal one. The patient may die in a period vary- FRACTURE OF THE NECK OF THE THIGH-BONE. 177 ing from a few days to a year after the accident, gradually worn out. On the other hand, the bone generally unites by ligament, and the patient is able to walk with crutches, or a crutch and a cane. If such a patient is finally able to walk with a cane, the accident was probably not the one we are considering, but rather one of the impacted fractures, or a fracture of the tro- chanter. The ligament which unites the bone may be longer or shorter, and the mobility greater or less. The neck will eventually become absorbed, and the head of the bone may after a while rest directly upon the shaft of the femur. The explanation of non-union is to be found in the mobility of the fragments and the impossibility of keeping them in apposi- tion ; and there is also something in the fact that the upper fragment does not contribute its share to the mutual union, being suspended from the pelvis by the capsular ligament only, for the ligamentum teres is not a true ligament, but merely a fasciculus for the passage of vessels. I have already said that the fracture of the middle of the neck is not the most common one. It is, however, the most striking and the most persistent in consecutive results. This subsequent persistence of deformity or lameness directs atten- tion to the hip bone at an autopsy, and the specimen is saved; while other fractures resulting in bony union are forgotten, or if the head of the bone is procured it is so repaired as to leave the exact character of the injury in doubt. Consequently fractures of the middle of the neck are, or have been, the most familiar by reason of their frequency as museum specimens. It is also the fracture most easily diagnosticated. In fact it can hardly be mistaken even when seen for the first time. The most common fracture is the impaction of the base of the neck into the trochanters. It deserves to be thoroughly considered, because its signs are sometimes not at all satisfac- tory to the surgeon who is unfamiliar with them. They de- pend upon an anatomy comparatively new, and which was first 12 178 FRACTURE OF THE NECK OF THE THIGH-BONE. described by myself. We have seen that the neck of the femur is seated upon the oblique line of the trochanters. When the fracture is impacted the neck is driven into the trochanters. But there is a rule about this ; and that is, the neck is always impacted more behind than in front ; and the head of the bone is in this way bent backward, or — which is the same thing — the shaft of the femur is rotated outward. From this results the eversion which belongs to the accident. The cause of the unequal impaction is a difference in the thickness of the walls of the neck in front and behind. In front the bone is thick ; behind it is exceedingly thin ; and it is behind that it yields. The bone has a thickness of per- haps an eighth of an inch along the front of the neck, and in some cases more ; behind it has only the thickness of paper. The head and neck of the femur have been repeatedly sawed longitudinally and vertically ; and anatomists (notably the late Jeffries Wyman) have given details of the very beauti- ful cancellous structure, whose fibres are arranged in radii, arches and stringers, to support and suspend the head of the bone from the trochanter. But a transverse section of the head remained to be made. For this purpose the femur should be placed with its back toward you, upright, but as if the patient were straddling, so as to bring the neck of the femur to a horizontal position. Now, if you slice off the top of the femur, neck, and trochanters, and then take a second, a third, and perhaps a fourth horizontal slice, you will find as you get toward the bottom of the neck that the anterior wall is so thick, and the posterior wall so thin, as to leave no doubt of the facts I have mentioned. The posterior wall which yields actually starts thick from the head ; but instead of being inserted thick into the trochanters, it plunges beneath them in the direction of the shaft of the femur. If it were inserted there, it would be strong ; but in an attempt to gain the shaft of the femur it becomes more and more FRACTURE OF THE NECK OF THE THIGH-BONE. 179 attenuated until it loses itself and disappears in a series of radiating papery plates. This construction was first pointed out in my paper on " The Mechanism of Dislocation and Fracture of the Hip," and was some years afterward again described by Merkel, as the " Schenkelsporn," in a paper in Virchow's Archives ; and since by Dr. Dwight, of Boston. The anatomy of this part of the femur illustrates and ex- plains the important signs which enable us to identify the impacted fracture of the base of the neck. The anterior wall of the neck being thick is not impacted ; the posterior wall being thin is crushed and driven together. The thick ante- rior wall rocks upon its broken edges as a hinge, but is rarely otherwise displaced. You see this in these museum speci- mens, of which ours has a dozen or twenty. Specimens in other museums also show that this impacted fracture obeys a constant law. The neck bends only at its anterior hinge, while it is impacted posteriorly. This explains eversion. The whole limb is everted. A word as to shortening. If we hold a common hinge horizontally, a femur attached to the lower part of the hinge would be shortened by just so much as we shut the latter. If on the other hand the hinge-joint were vertical, there would be no shortening, but the shaft of the femur would be everted when the hinge was bent. Now, as the inter-trochanteric line is neither vertical nor horizontal, but oblique at an angle of forty-five degrees, the hinge which it represents is half verti- cal and half horizontal. Its movement is one of half eversion and half shortening, — of shortening in proportion to the eversion, and eversion in proportion to the shortening. A limb much everted is a good deal shortened, and when it is little everted it is but little shortened. Suppose the impaction is great. There is no difficulty in determining its existence ; the eversion and the shortening both announce it. But suppose that the impaction is slight. 180 FRACTUEE OF THE NECK OF THE THIGH-BONE. In this case you have hardly any eversion and hardly any shortening; so that in fact you may be in doubt whether the limb is shortened or not. Now, here is a rule for determining the existence of an impacted fracture where the impaction is slight. Let the patient be directed to evert the feet, — first the sound one, and then the other. One is everted as easily as the other. But let him be directed to invert them, and you will find that while he can invert the sound one, the affected limb, by reason of its impaction behind, cannot be inverted quite as much. So that in the very common accident of a slight impaction of the base of the neck of the femur you may accept as its pathognomonic sign an undemonstrable or hardly perceptible shortening, with only a diminution of the power of inversion. In other words, inability to invert is eversion. This throws light upon many cases of injury to the hip, about which even good surgeons not unfrequently differ. Cases we have now in the hospital illustrate these fractures. A patient upstairs, a female, whom you saw on Saturday, sixty-five years of age, fell upon her hip on a slanting, icy sidewalk. She came in here five hours afterward. She had pain at the trochanter, increased by motion, and tenderness on pressure. She was disabled so far as the use of the limb goes. The eversion was in this case obvious, the foot stand- ing at an angle of about forty-five degrees, and the shorten- ing being three-quarters of an inch. There was no crepitus. These signs indicated impaction. In another case the injury is less marked. It illustrates better what I have said of slight impaction. The patient, also a woman, is twenty-nine years old. She fell upon the side- walk, upon her hip, two days before coming here. There was pain over the great trochanter and its neighborhood, much increased by motion, and of course tenderness on pressure, and disability. There was an inability to invert the foot FRACTURE OF THE NECK OF THE THIGH-BONE. 181 beyond the perpendicular, — whicli was as pathognomonic as if the patient had an everted foot. There was little or no shortening-, because there was little or no e version. But I have no doubt that it was a case of impacted fracture. A third patient, thirty-eight years old, fell a distance of five feet upon his right hip. There were the usual pain and ten- derness over the great trochanter. The disability was not very great ; he could move his limb. The eversion was only shown by the absence of power to invert. There was little or no shortening, and no crepitus. You will anticipate me in the diagnosis. We may contrast these cases with another, — a male pa- tient, sixty-one years of age, whom you saw in the large ward. There was well-marked crepitus ; the shortening was nearly an inch, and the eversion was very pronounced. Here the injury was doubtless a fracture of the small part of the neck of the bone, leaving only a doubt whether it was not originally an impacted fracture in which the fragments had been de- tached and drawn apart by unjustifiable examination, — which is a matter we shall come to. So that the point important to remember is, when a pa- tient meets with an injury, however slight, about the hip, as indicated by pain and disability there, and upon examina- tion has no crepitus, next to no shortening, and but little apparent eversion, and you ask yourself. Is this only a sprain ; can he have a fracture of the hip ? — the answer is, Unquestionably he can. He may have a very slight impac- tion of the base of the neck into the base of the trochanter, which may disable him for two or three months, which may heal without difficulty, and leave little or no traces in the bone of its existence ; or, on the other hand, the impaction may be such — the parts so firmly locked together — that if you had the specimen in your hands, you could not draw the neck of the bone out of the trochanters. Do not for- 182 FRACTURE OF THE NECK OF THE THIGH-BONE. get, however, that it may be quite the reverse when you resort to the powerful leverage of the bent leg held at the knee and ankle in a futile search for crepitus. You may then twist the fragments apart, doing the patient a serious damage, which he would have escaped had you been more familiar with the signs of the accident and avoided an un- necessary examination. The impaction of its base being the most frequent accident to the neck of the femur, there is, on the other hand, an im- paction at the other end of the neck, which, so far as speci- mens testify, is very rare ; namely, that in which the neck is driven into the head. An illustration of this is seen in a specimen I show you from a case of the late Dr. Gay, ob- tained from a patient who died in the hospital, — a case I have mentioned in my paper on this subject. This man slipped at the foot of his steps on the sidewalk, but nevertheless got into his door, climbed one flight of stairs, went to bed without assistance, and only sent for Dr. Gay on the next day. He was removed to the hospital, where about ten days after he died of pneumonia. A few hours before his death he said, " Doctor, I am getting along well with my leg," lifting it off the bed, without help, to justify the assertion. There is no reason why he should not have been able to lift his broken leg if the parts were firmly impacted. A man can walk with a dislocated hip where the bone is firmly supported by the ligaments, and he can also sometimes bear weight on the common impacted fracture. In this case the fact of the frac- ture was established by the specimen. The neck was driven into the head, and the head was bent backward toward the trochanter minor, — which I believe to be the rule, although a case is recorded where the head was tilted a little the other way. In this remarkable and interesting case, cited by Pirrie,^ the limb was flexed and inverted across the abdomen, as in the 1 The Lancet, 1879, p. 5. FEACTURE OF THE NECK OF THE THIGH-BONE. 183 first stage of dorsal dislocation. Here the capsular ligament proved to be sound ; and it probably aided in maintaining the deformity, the neck being broken near the head. These cases explain others. Dr. Gushing, of Dorchester, had a pa- tient, an elderly lady, who fell while winding up a clock. He wa^ sure from all the signs that she had a fracture of the neck of the thigh-bone. She lived a number of years, and got about, walking pretty well. The articulating surface, as you see, was broken off like a watch crystal, tilted back, as in Dr. Gay's case, and united by bone in its new position. We have a third specimen of this same sort. This last named fracture, far rarer than the impaction of the base, cannot be distinguished from it. Indeed, there is no advantage in making such a distinction. If a patient has an impaction of the neck of the bone you need not know any more ; the chances are that he will have bony union. I believe that all the specimens of bony union of the neck of the thigh-bone within the capsular ligament — as they were called in old times — are cases where the summit of the neck was impacted into the head of the bone, and the parts were fixed and at rest. If mobility is one great obstacle to union, it should follow that where the fragments are kept at rest by impaction there will be a tendency to union ; and we find this to be the fact. In corroboration of this you will observe that in the vertical section of almost all specimens of intra-capsular fracture with osseous union, such as the books usually figure, there is a dense white line of bone. This is the posterior wall of the lower fragment imbedded in new material, and is usually long enough to show that the fracture was at the upper part of the neck. Here, then, are three lesions, — the most common being the impacted fracture of the base of the neck ; the least common the impacted fracture of the other end of the neck, which 184 FRACTURE OF THE NECK OF THE THIGH-BONE. need not and cannot be distinguished from it ; the third and familiar one being the fracture at the small part of the neck, — the fracture of old people. Let me now suppose another state of things. I have said that the impacted fracture of the base of the neck is attended with eversion, due to the bending of the neck upon an anterior hinge. Let us suppose that impaction has been so great that the neck is displaced from this hinge, and driven squarely in between the walls of the trochanter. When this happens the whole inter-trochanteric mass, including the greater and the lesser trochanter, is split off. The anterior hinge no longer exists. There is no longer any cause for eversion, and there may be actual inversion instead of the usual eversion. This injury is a rare one. A subject in the dissecting-room was transferred to me a dozen years ago as a case of unreduced dislocation upon the dorsum, the knee being greatly inverted. Upon examination I found that instead of a dislocation there was an impacted fracture of the neck, with inversion. In this instance the neck had penetrated between the anterior and the posterior walls of the inter-trochanteric mass, splitting them apart, and had finally united, presenting a specimen of the very rare fracture of impaction of the neck with inversion. I have seen very few such specimens, and I have looked over many museums. Smith, of Dublin, mentions their exceptional occurrence. It only remains for us to consider the group of fractures that occur about the head of the shaft. We may class them together as fractures of the trochanters. There is here no rule for the position of the limb. It is generally everted. There is no rule for the line of the frac- ture, nor advantage in knowing it ; there is no limit to the extent of the comminution. The neck of the bone may lie transversely instead of obliquely, and may be displaced so far outward that it becomes united by its middle to the FRACTURE OF THE NECK OF THE THIGH-BONE. 185 shaft, as in the letter T, and the femur looks like the handle of an old man's cane. Of course you get crepitus; you find a certain mobility ; you detect shortening, and in its treatment you would instinctively draw the limb down and keep it there. I cannot see how you should mistake such a loose fracture for an impacted fracture. But you might mistake it for frac- ture of the middle part of the neck, — fracture of old people, — and so err, not in treatment, but in prognosis ; inasmuch as the former usually unites by bone, — the latter, so far as I know, never. And now as regards treatment and its results. If the injury is not a dislocation, — which you ought to be able to deter- mine, — you can do nothing better than to draw the limb down and keep it steady. But if there is no great shortening, — as in the case of an impacted fracture, — then obviously you need not draw the limb down, because it is not much drawn up. In fact, if you try to draw it down you may do great damage by separating the impacted fragments. So that the treatment reduces itself to a very simple matter. If there is much shortening and mobility, draw the limb down, correcting as far as you can the usual tendency to eversion ; if not, only steady it. I again repeat, in impacted fracture you should be careful not to draw or twist the fragments apart. You saw the case in the wards where a surgeon had probably detached the frag- ments, and I have said that you get great leverage by taking hold of the ankle and the bent knee. In this way you can almost break a sound bone. No surgeon is justified in twist- ing such an injured limb about — especially if, employing ether, he is unrestricted by the pain he gives the patient — in persistent attempts to get crepitus. Much less is it desir- able that a number of surgeons, one after the other, should do so. 186 FRACTUKE OF THE NECK OF THE THIGH-BONE. In a person of an age liable to " the fracture of old people," great shortening, eversion, and mobility usually mean fracture of the middle of the neck, and you can say to the patient, " You will probably be lame ; " and yet a case of this sort occasionally happens which you cannot distinguish from one of fracture of the trochanters, likely to result in bony union with some lameness, — perhaps only that which follows from a shortening which the spine cannot compensate, or from bony callus about the joint. Late in life shortening of the femur is not, however, readily corrected by a spinal curve. In a robust or young subject a fracture about the head of the bone, not attended with great shortening or eversion, is probably impacted, and will in all likelihood unite by bone, leaving the patient not very lame. An inch and a half shortening after a fracture in the region under consideration is no great mat- ter ; a man may walk nearly as well with it as without it. After a while the pelvis tilts, and you may not be able to determine by tlie gait which limb is the shortest. I have just intimated that a comminuted fracture of the trochanters sometimes leaves a mass of bony callus, produc- tive of lameness ; and as this fracture cannot always be dis- tinguished from loose fracture of the small part of the neck by any justifiable examination, it is safest, where there is much shortening, eversion, and mobility, to give a guarded prognosis. If the patient ultimately walks better than you predicted, he will not object. You should always see that an effort is made to correct eversion in every case of fractured femur. I do not know any more effective means to this end than long sandbags packed under the trochanter from the outset, — in fact, out- side the whole limb ; indeed, you had better put sandbags on both sides of it. And you must watch the patient, who is always trying to ease his limb. The patella and the great toe should look directly upward. A sole-piece and splint FRACTUKE OF THE NECK OF THE THIGH-BONE. 187 may be attached to the foot and leg, which can so be kept vertical. Extension, whether for the purpose of drawing down a loose fracture or of merely steadying an impacted one, is best applied by the familiar expedient of adhesive straps, a pulley, and a weight of five to eight pounds, upon a bed without a foot-board, — its lower end being raised six inches, if necessary, to secure counter-extension. PART II. EAPID LITHOTKITY, WITH EVACUATION. KAPID LITHOTRITY. When Sydney Smith asked, " What human plan, device, or invention two hundred and seventy years old does not require reconsideration ? " he would no doubt have regarded with favor an occasional reconsideration of the theory and practice of medicine and surgery, — especially in view of the current belief that their traditions had been kept alive and their rules prescribed in part by authority. The surgical literature of Lithotomy, both French and English, so long showed the influence of the early specialists, that we have hardly now escaped from its exaggerated circumstance and detail ; and yet, with attention to a few precise rules, the operation of lithotomy is quite a simple one, — much less difficult', for example, than the dissection of tumors. It is not impossi- ble that convictions in some degree traditionary may prevail in regard to certain points connected with the practice of the more recent art of Lithotrity. Civiale was among the first to inculcate the excessive sus- ceptibility of the bladder under instruments. Later surgeons, perhaps influenced in part by his teaching, have continued to invest the operation of lithotrity with precautions which though by no means groundless, because under certain condi- tions both the bladder and urethra actively resent even slight interference, are nevertheless greater than this operation gen- erally requires. As a rule, there is little mechanical difficulty in its performance. The stone is readily caught and broken into fragments, of which a few are pulverized ; a large-eyed catheter is then sometimes introduced; a little sand and a 192 KAPID LITHOTRITY. few bits of stone are washed out ; after which the patient is kept quiet, to discharge the remainder and to await another " sitting." Under favorable circumstances such an opera- tion, lasting a few minutes, is not only simple, but, if skil- fully performed, safe. On the other hand, it is not always safe. This is the fact that seems to have arrested so strongly the attention of surgeons. It may happen that during the night succeeding the operation the patient has a chill, — not the chill of so- called " urethral fever," which sometimes follows the mere passage of a bougie, and which is of little consequence ; but one followed by other symptoms, such as tenderness in the re- gion of the bladder, a quickened pulse, an increasing temper- ature, and the frequent and painful passage of urine. These symptoms may insidiously persist rather than abate. Others may supervene. The surgeon vainly waits for a favorable moment to repeat his operation ; it becomes too evident that the patient is seriously ill, and it is quite within the range of possibilities that in the course of days or weeks he may quietly succumb. An autopsy discloses a variety of lesions, some of them remote or obscure, others of more obvious origin, — and among them, not the least common, an inflamed bladder, upon the floor of which angular fragments and chips of stone are resting. It is then evident that during a certain interval before death the bladder was not in a condition for further instrumental interference; and although, in view of the fatal result of delay, lithotomy or active lithotrity, to both of which I have resorted, might have been deemed on the whole the less dangerous, still it is plain that either operation would have furnished in itself an additional cause of progres- sive inflammation. Such cases have been supposed to point to the necessity of extreme precaution, as well as of extreme remedies. It is evident that the purpose of interference at an unfavorable RAPID LITHOTRITY. 193 moment is the removal of the offending fragments as a last resource. But if at the first operation the bladder could have been completely disembarrassed of every particle of stone, even with the risk of irritating its lining membrane, we can hardly doubt that the relief would then have been fol- lowed by comparatively ready repair. In short, it is difficult to avoid the conviction that in an average case damage to the mucous membrane is as likely to result from irritation by angular fragments, added to the injury inflicted by an opera- tion, as from the use of instruments protracted beyond the usual time for the entire removal of a stone, if this result can be accomplished. It is probable that injury from the use of instruments has been confounded with that resulting from the presence of frag- ments in the bladder. That the average bladder and urethra have no extreme susceptibility is attested by the generally favorable results of lithotrity, and even of catheterism, which are practised with very varying skill everywhere ; also by the singularly innocuous results of laceration of the contracted urethra, by an instrument like that of Yoillemier, for example; so, too, by the recovery of these organs from the considerable injury inflicted during the extraction of a large and rough stone in lithotomy. The bladder is often also to an extraordinary degree tolerant of the presence even of a mulberry calculus. If we remember that in this case it clasps the stone at every micturition, often with a persistent gripe, the comparative immunity of its tender mucous membrane is quite remarkable. But when after an operation sharp fragments are thus em- braced, presenting acute angles, which do not soon become blunted, and to which the bladder is unaccustomed, it is still more remarkable that serious consequences are the exception and not the rule in lithotrity. Polished metallic surfaces carefully manipulated can hardly do such damage as the other agencies here mentioned. 13 194 RAPID LITHOTRITY. Gentleness, dexterity, and experience are especially to be valued in lithotrity. If the bladder is pinched, the patient may die. A false passage or a lacerated inner meatus is a serious complication. It has been well said that no novice should undertake this operation. Civiale, with an almost un- paralleled experience, introduced a small lithotrite with much less pressure than its own weight, and with uniform and great slowness ; and yet in a healthy urethra it is only at the tri- angular ligament and beyond it that such extreme care is called for. The same author, who had no means of evacuating fragments in the bladder, restricted the length of his operation to two or three or perhaps five minutes. The like solicitude seems to have led Sir Henry Thompson, in his admirable and standard work upon this subject, to assign two minutes as the proper average duration of a sitting, — a period which his exceptional skill has often in his own practice enabled him materially to reduce. I have been gratified to find, however, that since he has availed himself of the advantage of etheriza- tion he recognizes the benefit to be derived from somewhat more prolonged manipulation. My own conviction is that it is better to protract the operation indefinitely in point of time, if thus the whole stone can be removed without serious injury to the bladder. I believe that in any case as favorable to lithotrity as the average, in these days when stones are de- tected early, this can be effected, — and tliat if the bladder be completely emptied of detritus, we have as little to apprehend from the fatigue of the organ consequent upon such manipula- tion as from the alternative of residual fragments and further operations. The duration of the longest sitting among the cases reported at the end of this paper was three hours and three quarters. The same result can be now accomplished in a very much shorter time. In a majority of cases the bladder can be completely and at once evacuated. But has not this result been already attained by evacuating RAPIIJ LITHOTRITY. 195 instruments variously devised and modified ? The following quotations from the latest authorities sufficiently answer this question in the negative : — "We may here say, without fear of being accused of exag- geration, that evacuating injections j^ractised after sittings of lithotrity have no apology for their use. The whole surgical arse- nal invented for their performance is absolutely useless. . . . It should be tvell understood that the best of evacuating catheters is worthless. ^^ ^ '■'■The practice of injecting the bladder to xoash out detritus is obsolete. . . . This ajiparatus of Mr. Clover should not be em- ployed if it is 2)ossible to dispiense tvith it, as its use is quite as irritating as lithotrity itself."^ ''Having used it [Clover's api^aratus] very frequently, I would add that it is necessary to use all such apparatus with extreme gentleness, and / ^9?'e/er to do ivithout it if possible.^^ ^ " All these evacuating catheters are little employed. They require frequent and long manoeuvres, which are not exempt from dangers ; besides, they give passage, as a rule, only to dust, or to little fragments of stone, ivhich xoould have escaped of them,- selves without inconvenience to the urethra.'''' '^ M. Voillemier here states the precise difficulty. The " evacuating apparatus " and the evacuating method hitherto •employed do not evacuate. This fact is beyond question. Such apparatus is not of recent contrivance. From the •earlier days of lithotrity, the operation of breaking the stone has been followed by the obvious expedient of introducing a large and special catheter, through which water was injected and allowed to escape, bringing away a little sand, with a 1 Article Lithotritie, by Demarquay et Cousin, in the Nouveau Dic- tionnaire de Medecine et de Chirurgie Pratique, pp. 693, 694. Paris, 187.5. 2 S. D. Gross: Diseases, etc., of the Urinary Organs, p. 232. Phila- delphia, 1876. 8 Sir H. Thompson : Practical Lithotrity and Lithotomy, p. 215. 1871. * Article Lithotritie, by M. Voillemier, Dictionnaire Encyclopedique ■des Sciences Medicales, p. 733. 1869. 196 KAPID LITHOTKITY. small fragment or two. This attempt at evacuation was aided by suction. With this object, and before the year 1846, Sir Philip Crampton employed an exhausted glass globe. ^ For the same purpose a rubber enema-syringe has been used, or a hydrocele bottle, with which fluid could also be injected and the bladder washed. By entering the catheter well within the bottle, or syringe, fragments were dropped inside the neck, where, lying below the current, they remained when the bottle was again compressed. When this neck was made of glass by Clover, the fragments became visible, as in Crampton's globe ; and to this neat arrangement the accomplished litho- tritist. Sir Henry Thompson, refers as Clover's bottle. But neither the previous practice nor the efficiency of evacuation by suction through a tube had been materially advanced. In the mean time the syringe was modified in France by a rack and pinion attached to the piston, so that water could be injected and withdrawn with great force, — a procedure not only useless, but detrimental to the bladder, if inflamed and thickened. Before describing my own instruments, it may be well to say a word in regard to the introduction of large instruments 1 The apparatus here aUuded to was intended more particularly " for clearing the bladder of detritus, in cases in which the expulsive power of that organ has been, as so frequently happens in old persons, im- paired or destroyed." In Sir Philip's own words : " The apparatus con- sists of a strong glass vessel of an oval form and six or eight inches in length by three in diameter, and capable of holding about a pint and a half of water ; to this vessel is attached a tube of about half an inch bore, furnished with a stop-cock. The air being exhausted by means of an exhausting syringe, and one of Heurteloup's wide-eyed steel evacu- ating catheters being introduced into the bladder, it is next attached to the exhausted vessel ; the stop-cock is then turned, and a communication being thus established between the bladder and the glass, the pressure of the atmosphere is by this means brought to bear on the bladder, and supplies an expulsive power, which may be increased to any required amount." — The Dublin Quarterly Journal of Medical Science, vol. i. p. 22. 1846. RAPID LITHOTRITY. 197 into the bladder. The successful introduction of the large straight tube is so important that it deserves especial mention. It throws light upon the successful passage of the lithotrite, and also of the large-sized curved tubes. Urethra to he measured. — In order to ascertain the maxi- mum calibre of the urethra before introducing a tube, it should be measured by an instrument which will enter more readily than the tube. Such instruments we have in Van Buren's Sounds, which are slightly curved at the end and a little conical. Being made of solid metal and nickel-plated, they traverse the urethra with singular facility. Both Otis's Sounds and the conical probe-pointed elastic bougie also an- swer admirably for this purpose. How to pass a straight instrument into the bladder. — A syringe facilitates the copious use of oil both in the urethra and within the tube. Into the normal urethra a straight instrument can be introduced with more accuracy than a curved one. Either may be passed rapidly as far as the tri- angular ligament, unless the instrument is very large, in which case great care is required not to rupture the mucous mem- brane. Having reached this point, which implies that there should be no premature endeavor to turn the instrument, but that it should be passed as far as it will go in the general direction of the anus before its direction is changed, the ex- tremity of the instrument depresses the floor of the urethra in front of the ligament. How to pass the triangular ligament. — Traction upon the penis next effaces this depression, and adds firmness to the urethral walls ; so that if the instrument be withdrawn a little, and again advanced after lowering the handle until it is almost horizontal, it can be coaxed without difficulty through the ligament in question, — a natural obstruction which phy- sicians often mistake for a stricture. The straight tube may be advantageously rotated through the aperture like a cork- 198 RAPID LITHOTRITY. screw. This obstruction passed, the rest of the canal is short, and corresponds to the axis of the body, to the line of which the instrument is now depressed. Presence of an enlarged prostate. — Even the enlarged pros- tate can often be traversed with facility by a straight instru- ment. In fact, the metallic prostatic catheter, before it was superseded by the modern rubber one, consisted essentially of an inch or two of straighter tube added to the extremity of a common catheter, to reach through the unyielding prostate before the hand was depressed and the beak turned up. Obstruction hy Jissnre in the prostate. — An occasional diffi- culty in passing the enlarged prostate deserves mention here ; namely, that resulting from a series of cracks or fissures, hav- ing their apex at the verumontanum, and radiating toward the bladder. I have a specimen of large prostate where these fissures readily engage a medium-sized catheter. In such a case a large instrument may pass more readily than a small one. The finger in the rectum is liere also of especial service. The handle of the tube may be also lowered to tilt up the tip in passing the inner meatus. Obstruction at the inner meatus. — In passing either a sound, catheter, or lithotrite, the extremity of a straight instrument, and curiously enough the convexity of a curved one, is sometimes arrested just at the entrance of the bladder by the firm lower edge of the inner meatus. The fact that water now dribbles through the inner meatus thus dilated, or that a stone is felt with the tip of the curved instrument which has really entered the bladder, may lead the operator into the mistake of supposing that the instrument is fairly within ; and I have known its further entrance, after sliding over this obstacle, to be erroneously explained by assuming the exist- ence of a second or hour-glass cavity in the bladder itself. How to overcome it. — To obviate this difficulty, and so soon as the triangular ligament is passed, a catheter, if RAPID LITHOTEITY. 199 curved, should be pressed fairly through the indurated neck, or prostate, in the direction of the axis of the body, by the hand on the perineum, — a most efficient manoeuvre when the prostate is large. If there be further difficulty, the tip should of course be sought and guided in the rectum (see p. 206). After introduction, a straight tube, or the shaft of a curved one, often returns to an angle of about 45° with the recumbent body; and if the patient is not etherized, a feeling of tension may then be relieved by depressing, with the hand upon the pubes, the suspensory ligament of the penis, — an expedient also useful during the passage of the instrument. Ancesthesia in lithotrity . — My own practice has always been to etherize for lithotrity. Position of the operator. — Each operator prefers the position to which he is accustomed ; and when the urethra is healthy, this is of very little importance. But if there be obstruction, a position at the patient's left side enables the operator to in- troduce a catheter or lithotrite to advantage with the right hand, leaving the left hand free to act in the perineum. After the instrument is introduced and both hands are re- quired above the pubes, they are most available if the surgeon changes his position and stands upon the patient's right. I also introduce the straight tube on the right side. Passage of a lithotrite. — The lithotrite is to be passed as a straight instrument, and not as a curved catheter. When it reaches the triangular ligament, the tip is insinuated into its aperture, and then the handle previously perpendicular, or nearly so, is depressed to an angle of about 45°. In this posi- tion it should remain, with but little further depression, while the blades are gently urged forward through the prostate. The convexity of the heel thus depresses the lower wall of the canal as it moves along and makes room. It moves as a boat, rising neither at prow nor stern (see Fig. 19, p. 313). 200 EAPID LITHOTRITY. Water to be injected before crushing. — In injecting water before using the litliotrite, the capacity of the bladder may be estimated by the tension of the urethra behind the point of constriction. By attention to this indication we prevent over- distention. In the etherized subject a short pipe or nozzle suffices for introducing water. I have usually employed a common Davidson's syringe. An unetherized patient may for a moment resist this injection through a short tube, by con- tracting the sphincter of the bladder ; but this readily yields. A distention by five or six ounces suffices. The smaller the injection of water the more readily, indeed, do crushed frag- ments fall into the blades of the instrument ; but unfortu- nately so also does the mucous membrane. In fact, with too little fluid in the bladder the use of a litliotrite in unpractised hands is attended with danger ; and in a long sitting an injec- tion which will separate the walls is the only really safe way of keeping the bladder from between the blades. A careful ex- amination of the action of a litliotrite through an opening in the summit of the bladder has confirmed me in this opinion, which was that of the older writers on this subject. From time to time the diameter of the collapsing bladder should be estimated by slowly opening the blades of the litliotrite. Water may be introduced as often as necessary; but care should be taken to guard against the serious injury to a con- tracted bladder which might result from suddenly injecting the contents of the syringe or aspirating bottle when it is already distended. On the other hand, distention of the bladder is a common symptom of retention. When extreme, it is often followed by inflammation and atony. But in a common case we do not anticipate such serious results, even when micturition has been frequent, and the bladder by infer- ence small. It has occurred to me whether a moderate forced distention might not be of service in certain cases of con- tracted bladder, as it is in a permanently contracted anus. RAPID LITHOTRITY. 201 Water retained ly an elastic hand. — A tape or an elastic band wound lightly once or twice around the penis near the scrotum retards the escape of injected water, and yet allows the movements of the tube or lithotrite. The successful evacuation of the bladder depends upon seve- ral conditions both in the appa- ratus and in its use, which for distinctness may be enumerated separately. 1. A large calibre of the evacu- ating tube. 2. The shape of its receiving extremity. 3. Manipulation of the bulb. 4. Capacity of the bladder. 5. Evacuation of the fragments. 6. Immediate recognition and removal of any obstruction in the tube. 1. A large calibre of the evac- uating tube. — Whether or not we adopt the view of Otis that the average calibre of the normal urethra is about 33 of Charriere, there can be no question that it will admit a much larger tube than that commonly attached to either Clover's or the French apparatus. The efficiency of the process of evacuation depends much upon using the largest tube the urethra will admit. This fact has been stated by Sir Henry Thompson, Fig. 1.1 1 Evacuating Apparatus. 1. Elastic bulb. 2. Curved rubber tube. 3. Curved evacuating tube of silver. 4. Straight evacuating tube, which is preferable to the cui'ved one. 5. Front view of same. 6. Glass recep- tacle, with bayonet joint for debris. (Tiemann and Co., Xew York.) 202 RAPID LITHOTRITY. but with a different significance. He recommends for the glass cylinder or trap which is to admit this tube a " perfo- ration at the end the size of only a No. 14 catheter," = 25 Cliarriere.^ This perforation is too small; and the tube which is designed to enter it is further reduced by its collar to the diameter of only 12, = 21 Charriere. In fact, this is the calibre of the evacuating catheters now attached to Clover's instrument, and is of itself fatal to their efficiency. An effective tube has a calibre of 28 to 31 or even 32 Char- riere, and the meatus, which is the narrowest part, may if necessary be slit to admit it, if the urethra is otherwise capa- cious. Again, in the instrument as sometimes constructed by Weiss a joint is made by inserting an upper tube into a lower one, thus obstructing the calibre by a shoulder. The joints should become larger as the tube approaches the bottle, so that the tube may deliver without difficulty fragments of its own calibre. Whatever be the size of the catheter, the rubber tube with its metal attachments should have a calibre of at least seven sixteenths of an inch, = 81 Charriere, and there should be nowhere any approach to a shoulder inside. My evacuating tubes are of thin nickel-plated metal of sizes 27, 28, 29, 30 and 31 jiUere Charriere, respectively. These are the sizes, including also perhaps 26 and 32, which I have designated as " large " in distinction to the calibre 21 of pre- vious apparatus. 2. The shape of its receiving extremity. — The receiving extremity should depress the bladder wlien required to do so, and thus invite the fragments, while its orifice remains unob- structed by the mucous membrane. Upon the floor of the bladder when not indented a fragment of stone lying at the distance of half or even quarter of an inch from the tube extremity may not be attracted by the usual exhaust of the expanding bottle, which requires that the fragment should 1 Diseases of the Prostate, p. 337. Fourth edition, 1873. EAPID LITHOTRITY. 203 lie almost in contact with the tube. A very slight obstacle impedes the entrance of a fragment; and this fact renders inefficient all tubes like catheters with orifices along the side or upper wall. The orifice of a tube cut square is at once occluded by drawing in the vesical wall, while the spoon-shaped beak of the French instrument, made like the female blade of a lithotrite, allows fragments to lie too far from the opening in the tube. The best orifice is at the extrem- ity, and is made by bending the tube at a sharp right angle, care- fully rounding the elbow, and then cutting off the bent branch close to the straight tube (Fig. 2 a). The tube is then prac- tically straight, while the orifice, which is slightly oval, delivers its stream laterally. The edge should be thick- ened and rounded to slide smoothly through the urethra; any rim inside the orifice should be masked by a false floor, but the calibre should be nowhere contracted. If the side walls of this orifice be removed a little, it gives an unguiform ex- tremity to the tube, which is advantageous ; and in introduc- ing such a straight tube, this tip should be insinuated through ^ Evacuating tubes, with unguiform extremity. a. Straight tube. h. Curved tube. The dotted lines show the false floor of the extremity. The tubes are here of a diameter 31 Charriere. The straight tube is preferable. Fig. 2.1 204 RAPID LITHOTRITY. the triangular ligament by rotation. If a couple of inches of the end of such a tube be bent, it may be inverted after intro- duction, and will bury itself in the floor of the bladder, which it depresses, while the orifice looks forward and is unobstructed (Fig. 2 b') ; or it may be used as introduced. An effective instrument may be made of a straight tube cut square at the end, if a disk convex outwardly, to repel the bladder, be attached to it at the distance of a diameter from the orifice. This was the original of the straight tube already described. When such an instrument is introduced, the interval can be filled by a rod. Indeed, the orifice of a tube should be con- trived with a view to its introduction. Too large an orifice impairs the suction and admits fragments that become wedged higher up. Whatever be added to the extremity of the tube, in order to facili- tate its introduction or to repel the bladder, should not prevent the orifice from lying, if re- quired, in the floor of the bladder at the apex of an inverted tunnel. 3. 3Ia7iipulaf.ion of the bulb. — The bulb, to- gether with its tubes, contains about ten ounces. If compressed with one hand until the sides meet, only about five ounces are displaced. If half compressed and then worked with a shorter movement, about two ounces are moved back and forth ; so that, provided the tube itself be handled care- fully and skilfully, the bladder is not greatly disturbed. The N9 3a Fig. .3.1 1 Tlie outline here given of the orifice and extremity of the tubes I use is more correct than that of Fig. 2. If the straight tube be closed by an extremity symmetrically round or ovoid, to facilitate its introduction, the orifice a d should have a length but little greater than the diameter a c of the tube. Tlie curve of the inside floor h is a quarter circle described upon a as a centre. The tube is then proved by a close-fitting ball rolled through it from a])0ve. At a the edge is a little thickened on the outside, and at d rounded to protect the urethra. KAPID LITHOTRITY. 205 object of more water is to prolong suction when fragments are passing freely ; also occasionally to stir up the debris, and especially to relieve obstruction in the tube when it occurs. The best position for the surgeon is at the right hand of the patient, resting his left wrist on the pubes to steady the tube, while the bulb is supported in a stand on the table between the thighs (Fig. 4). 4. Capacity of the bladder. — It is desirable, in each case, to form an idea of the habitual capacity of the bladder. The previous frequency of micturition throws some light upon it. Better than this, the tension of the urethra behind the elas- tic band is a valuable indication of the fluid pressure in the bladder during evacuation. If the patient strains for a moment, the bladder may become very tense, and I think it then important to let the water escape through the hose (see p. 278). The bladder can be immediately replenished. Without a hose this manoeuvre is impossible. PROCESS OP EVACUATION. Quantity of tvater needed during evacuation. — Unless the amount of debris is very abundant, there should be just enough water in the bladder to prevent the thud, or fish-bite, hereafter described (p. 217). While more than this needlessly scatters the fragments, a smaller amount allows the bladder to be con- stantly drawn into the catheter, giving rise to the quivering sensation above alluded to as the fish-bite. Nothing so facili- tates evacuation as the power exactly to regulate the amount of water. in the bladder and apparatus; and no contrivance so well accomplishes this desideratum as the hose. 5. Evacuation of the fragments. — Evacuation of the frag- ments is quite an entertaining art, requiring as much skill to accomplish the desired result in the shortest time as does the act of crushing. Dexterity in the process will hardly be 206 RAPID LITHOTRITY. acquired without practice outside the bladder.^ No jerk is required in pumping. The compression and expansion of the bulb equally divide a second or two of time. While the tube is held just above the debris, the fragments should fall Fig. 42 * The bladder may be imitated by the lower two-thirds of an ox-bladder (carbolized for cleanliness) suspended inside a vessel having a mouth of four or five inches diameter, to which it is tied. The vessel should be previously nearly filled with water. To show the efficient action of circular currents in the closed bladder, the ox-bladder may be tied to the evacuating tube, and held before a bright light. With a tin funnel secured to the summit of a human bladder (in situ) to aid in replacing the fragments, the process of evacuation can be rapidly repeated. Such practice is very instructive. Calculi may be imitated by coal of varying hardness, or by a bit of old grindstone ; a lighter and tough material for crushing, and liable to impact, is the cheap compressed meerschaum. 2 The trap is here placed in a stand upon the table. The remaining fragments are few, and the capacious bladder is depressed to assemble them. The operator stands on the patient's left, and supports his right hand firmly upon the pubes. This position is, on the whole, the most advantageous. RAPID LITHOTRITY. 207 in a shower into the trap. The operation may be divided into a first and a last half. During the first half, while the fragments are numerous, the secret is to separate and float them by the injection, so that they may enter the tube as they fall, in single file, without obstructing it. This is accomplished by keeping the orifice of the tube away from the floor, aspirating the fragments quickly while on the wing, just above the commi- nuted mass. In the latter part of the process, and after the smaller debris has been removed, by raising its outer extremity the tube may be made to indent the floor so as to gather instead of separating the 1 The operator is here supposed to sit between the thighs of the patient. The bulb has been compressed, and by its immediate expansion will aspirate a part of the abundant debris suspended in the fluid above the fragments. This Figure illustrates the advantage of dispersing the fragments for aspiration, when too abundant. But the same result can be better accomplished by withdrawing the tube a little from the floor, with the hand supported on the pubes as in Fig. 4. (From a photograph of a frozen section, in which the rectum and the bladder were previously distended with plaster.) 208 . KAPID LITHOTRITY. fragments. Some of the chips are apt to collect about the tube orifice ; but the tube thus raised is carried behind them. It is important occasionally to turn the orifice forward to wash the fragments from beneath the shoulder of a high prostate. A very slight movement of the tube sometimes makes much difference in the rapidity of the evacuation ; so that when it is on the floor of the bladder or quite near it, and steadied by the hand upon the pubes or the thigh, if any one expansion of the bulb proves more successful than another, the precise position then occupied by the tube should be carefully maintained. On the other hand, when the tube is choked at each expansion, if it be withdrawn, or tilted up a quarter or even an eighth of an inch, it may happen that a shower of debris at once appears in the trap. Higher in the cavity, while the debris is abundant, the orifice may be turned downward or partly sideways, so as to project horizontal currents around the bladder, the fragments being aspirated as they whirl. At the different stages of the pro- cess there is opportunity for a little tact in placing the tube, just as there is in discovering fragments with a lithotrite. 6. Immediate recognition and removal of obstruction in the tube. — If a short interval elapses without the fall of debris, it may be presumed that there is obstruction. This happens not only when the bulb will not expand, when its dimple dis- appears reluctantly, and when compression is difficult, but also when the current passes so freely that an impediment would hardly be suspected. Obstruction occurs in several ways : — (1) In the elastic tube, which may be accidentally bent at an angle or compressed. This should be looked at first. A bit lodged in the elastic can be displaced by pinching it. (2) In the bladder, the most common obstruction is at the orifice of the evacuating tube. A little practice will enable the operator to distinguish the encouraging rattle of debris RAPID LITHOTEITY. 209 passing this tube to appear at once in the trap (if held upright) from the valvular click of fragments too large to enter it. This click is quite constant at the end of the pro- cess, after the smaller chips have been aspirated off. If the orifice be choked, an effort should be made to expel the frag- ments in the ordinary way, — first raising the tube into clear water above the debris, and then compressing the bulb with a short and forcible squeeze. A half-dozen such efforts rarely fail ; but the rod may be introduced, if necessary. (3) It sometimes happens that nothing appears in the trap, although the current passes quite freely and the click of the abundant debris is still felt. A scale is then wedged higher in the evacuating tube, which admits water but ex- cludes fragments. This is worth remembering. The rod removes it. (4) A source of obstruction, and the most common one, is the wall of the bladder when drawn against the tube orifice with a dull thud, or a rapid succession of jerks not unlike the bite of a fish. It naturally interferes with the process, and if the patient has not been etherized is painful. The tube orifice may be moved to another part of the bladder where aspiration is more free. Perhaps the orifice has been acci- dentally turned sideways ; it then readily engages the floor. But the usual explanation is that the walls of the bladder are slack, and more water is needed to distend them. This will be further noticed. After a dozen or more aspirations it may be found that all the fragments which can pass the tube have done so, and that many of them have its full diameter. The passage of debris has ceased, and the larger bits are clicking against the cathe- ter. The lithotrite should now again be introduced. When no click has been heard for several minutes the bladder may be considered as practically cleared, and the patient should be remanded for subsequent examination. 14 210 RAPID LITHOTRITY. LiTHOTRiTE (Fig. 8). — It would be plainly desirable, if it were easy, to crush the whole stone before attempting to evacuate it ; but this is rarely possible. The lithotrite be- comes so choked with impacted debris that the convex surface of the mass prevents the engagement of other fragments between its blades. The character of this impaction varies. The powder of some varieties of soft stone, compressed in this way with mucus, is singularly hard, being scarcely in- dented with a sharp probe. A clean lithotrite always works to best advantage ; and the operator frequently withdraws the loaded instrument to evacuate it, sometimes with fatal injury to the neck of the bladder. It would be obviously better if the instrument could be emptied at will within the bladder, especially if we distinctly recognize that what can be withdrawn in a litliotrite would come better through a tube, and that the province of the lithotrite should he to pul- verize, or indeed merely to comminute, and not to evacuate. Fergusson's operation consisted largely in bringing away the finer debris, a pinch at a time, between the blades of the lithotrite. I cannot understand why, when a tube is to be introduced into the urethra to distend and protect it, and to deliver the debris at once, such a practice should still find advocates. Although all lithotrites are made a little loose for the pur- pose of working out the debris, and although I have had one constructed with an especial device for this motion, I do not find it easy to clear the female blade by a lateral movement of the male blade, chiefly because the impaction is so firm that the dense mass, instead of yielding, twists the female blade from side to side. Nor does an instrument like that of Reliquet fulfil the indications. It is like the old fenes- trated brise-pierre ; but, as in the hrise-pierre, its high sides are an obstacle to the approach of fragments. The male blade also of Reliquet's instrument is that of the lithoclast, RAPID LITHOTRITY. 211 and we need only close the blades between the thumb and finger to be satisfied of their scissor-like action upon the bladder. Lastly, it does impact badly. The instrument about to be described keeps its blades clear, and secures certain other desirable ends pertaining to the lock, handle, etc. Lock. — The general acceptance of the wheel-shaped handle of Thompson's instrument testifies to its convenience as a 1 Figs. 6 and 7, — position of the hands in holding and locking this lithotrite. Fig. 6, lithotrite unlocked ; Fig. 7, lithotrite locked by a quarter rotation of the right wrist. 212 RAPID LITHOTRITY. Fk;. 8.1 hold for the left hand. But it is always a little awkward to disengage the thumb of this hand, or indeed of either hand, in order to close the lock of a lithotrite at the critical moment of grasping the stone. This objection I have ob- viated in closing the lock by rotation of the right wrist, without relaxing the grasp or displacing the fingers of either hand (Figs. 6 and 7). Wheel. — In a protracted sitting the wheel is an inconvenient handle, its chief merit being that it affords so insecure a grasp that the ope- rator is supposed to be unable, with its pre- scribed radius, to break the blades. But in a larger instrument these blades are stronger, and a ball may be substituted for the wheel (Fig. 8 a). Injecting Tube. — If the sitting be protracted, as proposed, the water dribbles away, and the collapsing bladder, especially if trabeculated, is liable to serious damage from the lithotrite. To meet this difficulty, the injection of water, by means of a short, flat tube introduced into the urethra from time to time by the side of the lithotrite, is a valuable resource in a long operation. Blades. — The blades of this lithotrite consist of a shoe, or female blade, the sides of which are so low that a fragment readily falls or slides upon it ; while the male blade, or stamp, offers 1 Lithotrite by Collin et Cie., from a working model, a, Ball which turns the screw, b, Revolving cylinder-handle attached to the screw- guard, which also revolves. This guard consists of two rods, which slide through notches in the cap of the lock. By their revolution the cylinder- handle turns the cap and operates upon the lock, c. Cap of the lock, which by its revolution wedges up the screws. RAPID LITHOTRITY. 213 a series of alternate triangular notches by whose inclined planes the detritus escapes laterally, after being crushed against the floor and rim of the shoe. At the heel of the shoe, where most of the stone is usually comminuted, and where the impact is therefore greatest, the floor is high and discharges itself laterally, while its customary slot (Fig. 9/) is made to work effectively. It may be unnecessary to say that the female blade of the common lithotrite, when drawn from a thin, flat plate as in the French instrument, has a disadvantageous cavity at the heel, where the greatest im- paction occurs by gravitation. One of the dangers of lithotrity, which has been already emphasized, is the liability of the bladder to be nipped in the instrument. The common lithotrites,even the best, have thin extremi- ties which seize the bladder like forceps. I have known a strip of mucous membrane brought away in the instru- ment from the floor of the bladder without serious harm ; but my belief is that if the face-wall of the bladder be included in the firmly closed jaws the patient will die. It cannot be too carefully provided against, not only by skill in the opera- tor, but also in the construction of the instrument itself, and especially during a protracted operation, while water is escap- ing and the bladder collapsing. With this object, the shoe is here wider and longer than is usual, to repel the vesical walls (Fig. 9). 1 e, Male blade, presenting on alternate sides triangular notches. The small portion of debris not discharged laterally by these notches is driven through the slot in the female blade. /, Slot in the female blade. Fig. 9.1 214 RAPID LITHOTRITY. It can hardly be doubted that in practice dexterous opera- tors secure most stones and fragments as they gravitate into the female blade while it depresses the floor of the bladder, perhaps a little to one side or the other, where the stone is felt. A simple and efficient manoeuvre, especially for a small fragment, is that of opening the blades of the litho- trite widely in the vertical position, then slowly turning them to one side and closing them along the floor of the bladder. If in attempting this the instrument be opened after it is turned, the male blade displaces the fragment without secur- ing it ; and it is of course understood that in opening the lithotrite the blade in contact with the bladder, commonly the female blade, is stationary. The inverted lithotrite works efficiently in a depression, if the bladder be kept out of harm's way by a special device ; but with the common litho- trite it is essential to turn the blades up before crushing, and move them, in order to be sure they are free. Indeed, whatever be the position of the lithotrite, it is important al- ways to give it a little rotation before screwing down, to see if it is free from the mucous membrane. This habit also keeps the operator informed whether he has room, or needs more water in the bladder. In the exceptional case of a stone behind the prostate, it may be necessary to invert the lithotrite and seek it. Fragments, however, are readily washed from this region within reach of the evacuating tube by occasionally turning the orifice and directing the stream from the tube upon tliem. While, many years ago, I had not infrequently prolonged lithotrity to ten or fifteen minutes, and longer, it is only within two years that I have aimed at the evacuation of a considerable stone during a single sitting ; and although experience will perhaps be necessary to determine precisely what cases are unfavorable to such an operation, there can now be no question that it is practicable to remove at once RAPID LITHOTRITY. 215 a far greater quantity of debris than has hitherto been con- sidered possible. The conditions most favorable to lithotrity are obviously most favorable to this modification of it, — a stone neither very large nor hard, and especially a large urethra, promising its best results. But if the preceding views are correct, the future of lithotrity lies in the direction of a fast-working lithotrite, which while it effectually pro- tects the bladder is more powerful than the usual mstru- ment, and better proportioned to the work it is to do, — a rapid comminution of the stone. This is necessary in order to secure its immediate and complete evacuation by means of a large tube with an efficient orifice. It will he no longer essential to pulverize the stone, hut only to comminute it; and if in so doing the lithotrite can be kept free from impaction, the process will be more rapid and efficient. During the last year I removed by lithotomy two soft stones, weighing 1272 and 1230 grains, from two male adults, aged forty and twenty-four respectively, who recovered after various risks. I cannot but think that with a tolerably sound blad- der, a urethra of good size, a large lithotrite, and a large tube, the operation might have been performed with less risk by the method of lithotrity now described. We get a useful view of the interior of the bladder by exam- ining it in position through an opening in its summit. This part of the organ with the free and thin posterior wall is mainly concerned in distention. The floor of the bladder is compara- tively firm and flat, and if the subject be in good condition adheres to a thick mass of cellular tissue in and near the ischio-rectal fossae upon which it rests. This mass is trav- ersed by the rectum variously distended ; and this canal in a thin subject may be advantageously filled with air during an operation to facilitate its indentation by an instrument, — reversing for the operation of lithotrity one of the precepts of lithotomy. 216 RAPID LITHOTRITY. Note. — Figs. 10 to 14 show plaster casts of bladders variously dis- tended, and holding instruments to show the effect of a slight pressure in indenting the floor of the bladder in order to facilitate the approach of fragments. The dotted line near the summit of each represents the level of an air cavity, which makes it possible to place the cast in the exact position it occupied in a horizontal subject. Fig. 11.2 Fig. lla. 1 Figs. 10 and 10 a present side and front views of a distended bladder of singular symmetry. The original suggests in profile the torso of a Sile- nus, the pectoral pouches overhanging the pubes, the abdomen beneath the symphysis, while the hollow loins were cushioned on the sigmoid flexure which indented them. The extremity of a curved tube is seen below, at the apex of an inverted tunnel, and just above it is a trace of the vesical valve. These figures are one fifth larger than the others - Figs. 11 and 11 a show a less distended bladder, containing a straight tube which indents the posterior wall. RAPID LITHOTRITY. 217 Fig. 12.1 Fig. 12 a. Fig. 13.2 lit.. 13 a. Fig. 14 a. 1 Figs. 12 and 12 a, — a bladder with a curved tube brought forward behind the prostate, slightly indenting the floor. 2 Figs. 13 and 13 a, — a bladder containing a large lithotrite, which has so depressed the floor that the posterior wall rises perpendicularly. « Figs. 14 and 14 a, — a bladder with a very small injection, imprison- ing a lithotrite. 218 KAPID LITHOTRITY. The sigmoid flexure is largely concerned in compressing the bladder behind. The posterior wall of this viscus may be so crowded by the intestines as to become flat or even concave. A horizontal section of the bladder is then transversely oval, flattened between the intestines behind and the piibes in front, each of these indenting it. A well-filled or tense abdomen tends so to sliorten the antero-posterior diameter of the blad- der, that, while a large stone may gravitate backward into that part of the bladder which is compressed by the intestines, carrying the thin wall with it, it is not so with a small frag- ment, which unless the floor be artificially depressed may lie on one side or the other of the vesical orifice more readily than at a considerable distance behind it. So, in sounding with a curved sound, it may sometimes be a little diflicult to move the instrument back and forth in the urethra, although its extremity may be readily turned down upon the floor of the bladder on either side. It is seen also (Figs. 11,13,14), as a result of this conformation, that a lithotrite, or straight tube, standing at an angle of forty-five degrees with the recumbent body, abruptly buries its extremity in the floor of the bladder near the foot of the posterior wall, which then becomes more upright, and that it does not lie upon the centre of an extended concave surface as sometimes repre- sented. The deep pit at the extremity of the straight tube and the similar depression made farther forward by the curved and inverted tube (Figs. 10 and 12) show how readily fragments can be made to gravitate to the lithotrite, or to the tube orifice, provided the latter be not plugged by the mucous membrane. The curved tube when inverted rests on the adherent floor; but a straight tube bearing upon the free and thin posterior wall (Fig. 11) should not be urged too forcibly against it. In either case, the nearer the instru- ment approaches a vertical position the deeper will be the indentation. A pit of this sort formed in the elastic floor by RAPID LITHOTRITY. 219 an almost insensible pressure of the instrument explains the observation of Thompson, that when a fragment is caught by the lithotrite many more are likely to be caught, like fish in a pool, in the same place. A central indentation of the floor also explains how in certain cases of large stone a lithotrite or sound may be passed back and forth beneath it without touching it, unless the beak is tilted up. The stone may then seem to adhere to the upper wall of the bladder, and to be suspended from it. During an operation of lithotomy, I have myself been deceived in this way up to the moment of introducing the finger into the bladder. I am not aware that this common source of error in diagnosis has been be- fore pointed out. An adherent stone is rare. Case I. — December 14, 1875. Age, sixty-four. Date of symp- toms, six 3'ears. Two or three stones measuring from half an inch to more than three quarters. Three sittings. First sitting: no frag- ments were removed through a tube. Second sitting: interval, seven days; duration, forty-five minutes under ether; quantity removed, "a large mass of fragments;" size of tube, twenty-seven. Third sit- ting: interval, twelve days; quantity removed, "a, few fragments." Result : the patient was discharged well one week after. Case IL — May 15, 1876. Age, sixty. Date of symptoms, twenty years. Two stones of one and one quarter inches and three quarters of an inch diameter respectively. One sitting : duration, one hour and a half under ether ; lithotrite introduced three times; quantity removed, one hundred and sixty-seven grains ; size of tube, twenty- nine; there was afterw^ard a slight cystitis; no fragments were passed; in two weeks the patient w^as again sounded, and no frag- ments were found. Result: discharged well. Case III. — August 6, 1876. Age, sixtj^-two. Date of symp- toms, eighteen months. Several stones, none larger than three quarters of an inch. The patient was confined to the house in great pain, drawing his w-ater every half-hour or less. The prostate was unusually large. One sitting : duration, about one hour and three quarters under ether; size of tube, twenty-nine. He afterward passed a few grains of sand only. Result : no unfavorable symp- 220 RAPID LITHOTRITY. toms ; almost entire relief from pain ; later, no difficulty in retaining water, but continues to pass a catheter; gained ilesli and former health, and resumed avocation. Case IV. — December 14, 1876. Age, sixty-six. Date of symp- toms, two years. Single stone. One sitting: duration, about an hour under ether; quantity removed, one hundred and eleven grains; size of tube, twenty-eight. Eesult: the patient did well for two days; then there was a chill with higher temperature, pain in the back, and pain referred to the left hip; a gradually failing pulse; moderate meteorism, with but little tenderness; death on the sixth day. An autopsy was not permitted. Case V. — January 8, 1877. Age, fifty-five. Date of symptoms, one year. Single stone. " A severe chill followed the primary ex- amination." Seven days after, the meatus was incised and enlarged from twenty-eight to thirty-one. One sitting: diameters of stone, ten to twenty millimetres; duration, one hour under ether; size of tube, thirty-one. Result : no sand or fragments were afterward passed; nor were there any subsequent symptoms. Case VI. — April 21, 1877. Age, forty-three. Single stone with nucleus of dead bone. Five vears ago the pelvis of this patient was crushed. Sinuses discharging dead bone opened on both hips. Six months after the injury symptoms of stone ex- isted. One sitting: duration, one hour and a half under ether; meatus incised; size of tube, thirty; quantity removed, sixty-six grains, and also three small pieces of bone, doubtless nuclei, one of which was incrusted; an indurated spot was detected by the tube where the bladder seemed to adhere to the pelvis. Four days after, under ether, the lithotrite brought away with difficulty through the urethra a square scale of bone too elastic to be bro- ken, measuring five eighths of an inch by seven sixteenths, but no sand or fragments. Eesult: there were no unpleasant symp- toms at any time ; and after another careful examination for bone the patient was discharged well. Case VII. — (Dr. T. B. Curtis's case.) March 6, 1877. Age, fifty-four. Date of symptoms, two years. Single stone. One sit- ting: diameter of stone, one inch and a quarter; duration, one hour and twenty-five minutes under ether; lithotrite introduced three times; size of tube, thirty-one; quantity removed, when dry, two KAPID LITHOTRITY. 221 hundred and fifty-seven grains; the six largest fragments weighed together twenty -four grains; the strained urine yielded during the next week two and one half grains. Result : rapid recovery, with no subsequent symptoms. Case VIII.— (Dr. C. B. Porter's case.) August 19, 1877. Age, sixty-one. A large, flabby man, with a feeble pulse. Date of symp- toms, twenty-six years. Two stones : one so large that it was barely possible to lock the lithotrite. Passes water every fifteen or twenty minutes. Three sittings. First sitting : duration, one hour and a half under ether; size of tube, twenty-eight; quan- tity removed, two hundred and twenty-eight grains; passed after- ward one hundred and eight grains. Second sitting: interval, four days; duration, three hours under ether; size of tube, thirty; quan- tity removed, seven hundred and forty-four grains; passed afterward sixteen grains; no after symptoms of importance. Third sitting: interval, five days; duration, three and three quarter hours under ether; size of tube, thirty-one; quantity removed, seven hundred and six grains; no pain or discomfort afterward; total number of grains after drying, one thousand eight hundred and two. Re- sult : discharged well two weeks from the date of the first opera- tion; after a few weeks the patient could retain his water from three to four hours. The details of the earlier of these operations are expressed with less exactness than I might now desire, but were dictated by myself at the time, and are within the fact as to the dura- tion of each operation and the size of the stones. The cases, all of soft stones, — that is, not oxalate of lime, — are the only ones by which the method that is the subject of this paper has been tested. As statistics, they are not so numerous as to have importance. But they abundantly illustrate what this operation is able to accomplish in removing at once a large quantity of stone by the urethra. The fatal case without an autopsy, the absence of which is greatly to be regretted, must pass for what it is worth. The other cases demonstrate a tol- erance by the bladder of protracted manipulation which has not hitherto been recognized. 222 RAPID LITHOTRITY. Since the above was published, six cases have been success- fully treated by the new method, — making fourteen cases in all, with one death, which is about the proportion of fatality in Sir Henry Thompson's list of four hundred and twenty-two cases, with sittings of three minutes' duration. Among the later cases, two of the three which occurred in my own prac- tice offered exceptional interest. In the first case, a calculus lodged deep in the urethra was removed. A contracted ure- thra was then enlarged by divulsion with Voillemier's in- strument, a No. 31 tube was introduced, and a considerable quantity of thick mucus was immediately evacuated. This was found to contain twenty-five grains of phosphatic frag- ments, the whole mass being so voluminous that it could not probably have been otherwise as well withdrawn. In the second case, the extremity and wings of a red rubber cathe- ter had been lost in the bladder. After the stone of which these formed the nucleus was broken, the fragments of cathe- ter came through the tube at once. The following are the cases : — Case IX. — Patient aged fifty. Twenty-five grains of phosphatic deposit evacuated; time, four minutes. 1861, the urethra was opened to remove impacted gravel. 1863, he was cut for stone, and has occasionally passed gravel since. 1876, he was o^jerated on for stricture, and has passed a No. 12 sound until within two weeks ; one week ago he voided a stone ''as large as the end of his little finger." Now he has frequent micturition, and an impacted stone is felt in the urethra just behind the scrotum. This stone was bro- ken, and ten grains were removed with long forceps. The rigid and cicatricial urethra was next divulsed. The bladder was evacu- ated through a twenty-nine tube, yielding about one and a half ounces of mucus and gravel, the latter weighing when dry twenty- five grains. The walls of the urethra were now scraped with the female blade of a small urethral lithotrite, to remove an abundant and closely adherent calculous deposit. During the succeeding five days the temperature and pulse remained nearly normal, frequent micturition being somewhat relieved by opiates. For a dull pain RAPID LITHOTRITY. 223 in tlie urethra after urinating, water was injected to wash the pass- age after each micturition, — an expedient I have long employed in the treatment of gonorrhcea, and also, in imitation of the usual practice after strong applications to the eye, to terminate abruptly the action of strong gonorrhoeal injections in the urethra. The patient did well. At the end of three weeks, a single phosphatic concretion as large as a small pea was discovered and removed through a twenty-six tube. Case X. — Patient's age fifty. Eighty-two grains of stone with a rubber catheter nucleus were evacuated; whole time, twenty-jEive minutes. Eighteen weeks ago, daring the treatment of a traumatic laceration of the urethra, a winged rubber catheter was kept in the bladder. A portion of this was broken off and remained there, causing in a few days frequent micturition and cloudy urine. Five weeks ago a stone was discovered. Now there is frequent micturi- tion, and abrupt stoppage followed by pain in the glans penis. The bladder was filled and emptied, — the fluid measuring half a pint, which quantity was again injected. By the lithotrite the stone measured nearly an inch and a quarter, being doubtless caught lengthwise. A certain elasticity of the closed blades led to their withdrawal with a small fragment of brittle rubber. This with- drawal was twice repeated with bits of rubber, including the two wings and also twenty-seven grains of stone. The whole operation had now lasted nine minutes. A straight evacuating tube, No. 31, was next introduced, and the bladder pumped during four min- utes, after which it yielded no more foreign material. Almost all the stone thus evacuated (fifty-five grains), together with three bits of rubber catheter measuring respectively three fourths, seven eighths, and one fourth of an inch in length, and No. 23 Char- riere in diameter, came through the tube within the first min- ute. The lithotrite was now again introduced, but nothing more discovered; after which the bladder was again washed out. The entire operation lasted twenty-five minutes, much of which was occupied in determining the fact that the bladder had been evac- uated. The next night the patient had no pain, and micturated but twice instead of six times as habitually before. Two days after, the temperature suddenly rose to 102° Fahrenheit, but as quickly subsided without other sign or symptom, the patient be- ing entirely relieved. 224 KAPID LITHOTRITY. Case XI. — Patient's age, sixty -two. Date of symptoms, three 3^ears. Two stones, lithic ; largest diameter, thirty millimetres. One sitting: duration, one hour and twenty minutes; size of tubes, twenty-nine and thirty; quantity removed, three hundred and nineteen grains; urethra somewhat contracted in front of scrotum. In evacuating these stones the time was found to have been occupied as follows: crushing, twenty-nine minutes; evacu- ating, twenty-four minutes ; the rest of the time being consumed in passing and withdrawing the instruments, renewing the water, etc. As usual, most of the fragments passed the tube early in the operation, and readily, much of the time occupied by the evacua- ation being consumed in making sure that no fragments were left behind. Micturition before the operation once every hour and a half; after the operation about once an hour, and obstructed by purulent mucus. The j)atient had a large though yielding pros- tate. The water was drawn during eight days; at the end of which he was generally able to relieve himself, the purulent mu- cus having diminished in quantity. The testicles were some- what swollen. Though still under treatment, the patient is fairly convalescent. A discussion of the relative values of lithotrity and lithot- omy, at a recent meeting of the Royal Medical and Chirnrgi- cal Society ,1 has interest in this connection, because it exposes the current English views upon this subject, while it gives prominence, by contrast, to the advantages of the new method of lithotrity over the old one. It is evident that the large tubes offer a ready means for preventing the recurrence of stone by either nuclei or fragments, which is " by no means uncommon " after lithotrity, as Mr. Cadge remarked, and " one of its serious defects ; " also, for removing the phos- phatic deposits which, in the words of Sir Henry Thompson on that occasion, are " not unfrequently left after lithotrity," " being due to the injury done to the mucous membrane by sharp fragments of stone, and by continued instrumentation." Sir Henry looked iipon them as " unavoidable, and as a price 1 March 12, 1878. See " The Lancet," March 16, 1878. RAPID LITHOTRITY. 225 paid for the greater security to life which lithotrity affords." Again, Sir Jaraes Paget said " he must confess to a general feeling in favor of lithotomy over lithotrity," unless "the calculus can be got rid of in two or three sittings." Sir Henry Thompson on this subject said, " Three, or at most four sittings, at which point he should distinctly prefer to cut." The obvious question then is whether in adult patients, when the stone requires more than three or four sittings of a few minutes each, by the old method, it is safer to cut, or to employ the new and rapid lithotrity, with evacuation. The latter must be preferred to lithotomy, in cases now rejected by the lithotritist, unless it can be shown that its mortality amounts to one in three, — this being the death-rate of lithot- omy in such cases, as stated during the discussion. So great a mortality from the new operation is improbable. There can be no doubt of the importance of the complete evacuation of final fragments, renal nuclei, phosphatic masses, and foreign bodies. In the matter of crushing, stress was justly laid upon the difficulty of withdrawing the impacted lithotrite from the bladder, — both Sir Henry Thompson and Mr. Coulson speak- ing of fragments actually " preventing the withdrawal of the instrument," and " requiring in one case incision in the peri- ngeum." This difficulty is obviated by the new notched litho- trite, which effectually clears itself. It also permits more expeditious work. The larger size, as made by Collin, is much more powerful than the usual lithotrite, while it can readily be introduced into a bladder that will admit a No. 27 tube. As the female urethra is so easily dilated, the new lithot- rity will doubtless prove to be tlie easiest way to dispose of calculi in the female, the tubes being made shorter and larger than for the male urethra. 15 226 RAPID LITHOTRITY. I may again say, in conclusion, that since its first an- nouncement this method of evacuation has been, by repeated experiment, so modified and reduced to a system, as to have become much more rapid and efficient. The time then con- sumed by the operation, although it showed a surprising to- lerance of the bladder, is no criterion of the time now required for accomplishing the same result. The improve- ments relate chiefly to the systematic dispersion or collec- tion of fragments in the bladder, to the position of the tube, and to the recognition and immediate removal of obstruc- tion. A considerable part of the time is still consumed in ascertaining whether the stone is wholly evacuated, — a large part of it being usually removed at the beginning of the operation. The following are the chief points connected with the modification in lithotrity which I have described : — 1. The calculus, although not necessarily pulverized, is crushed as rapidly and completely as is practicable. The dust and fragments are immediately evacuated, and a serious source of irritation is thus removed. 2. This can be generally effected in a single operation. 3. The operation (performed of course under ether) may be, if necessary, of one or two hours' duration, or even longer. 4. The method applies to larger stones than have been hitherto considered to lie within the province of the lithotritist. It also applies to small stones, nuclei, phosphatic deposits, and foreign substances. 5. Evacuation is best accomplished by a large tube, preferably straight, — with a distal orifice, the extremity of which is shaped to facilitate its introduction and (during suction) to repel the bladder wall, — and by an elastic ex- hausting bulb which acts partly as a siphon. Below the latter is a glass receptacle for debris. RAPID LITHOTRITY. 227 6. The best size for the tube is the largest the urethra will admit. 7. Such a tube is usually introduced with facility, if passed vertically as far as it will go toward the anus before chang- ing its direction, and afterward directed almost horizontally, and passed by rotation through the triangular ligament. The first part of this rule applies also to the introduction of a lithotrite, and even a curved catheter. A free injection of oil is important. 8. A small meatus should be enlarged, or a stricture di- vulsed, to allow the passage of a large tube. 9. If the bladder be not small, a large and powerful litho- trite is always better than a small one. 10. That this may have room for action, the escaping water should be replaced occasionally through a tube inserted a few inches into the urethra by the side of the lithotrite. But the bladder should not be over-distended. 11. To save time, and also to prevent undue dilation of the vesical neck, a non-impacting lithotrite is desirable. The jaws of a non-fenestrated instrument will not impact if the male blade is furnished with alternate triangular notches by which the debris is discharged laterally, and also with a long thin spur at the heel fitted to a corresponding slot in the female blade, — provided the floor of the female blade, especially at the heel, be made nearly on a level with its rim. To repel the bladder, tfce female blade should be longer and a little wider than is usual. It should have also low sides easily accessible to fragments, — relying for strength less upon these than upon a central ridge below the heel. In the male blade of such a lithotrite, the apices of the triangles should be a little blunted. Lastly, a non-fenestrated female blade protects the floor of the bladder during a long sitting. A fenestrated instrument directs sharp splinters against it. The latter also delays the process of disintegration by 228 RAPID LITHOTRITY. delivering through its opening the same fragments many times. 12. In locking and unlocking a lithotrite repeatedly in a long operation, it takes less time and is easier to turn the right wrist, as in my instrument, than to displace the thumb of either hand in search of a button or a lever, as in previous instruments. The efficiency of evacuation has recently been further illus- trated by the removal through the urethra, under ether, with- out crushing, of thirty-five small calculi, daring a single sitting of half an hour, in which the bladder was completely emptied. The patient was sixty-five years of age, the prostate large. The stones were lithic, nearly spherical, and almost destitute of facets. The two largest had a diameter = 34 of Charriere. Of these stones thirteen were drawn through a tube of the calibre 31 Charriere. Twenty-two were arrested in the tube, — the smaller being detained by other larger stones simultaneously engaged in its extremity, into which they closely fitted. Thus obstructed, the tube was withdrawn ten times, always with one or more calculi. The stones, when dry, weighed two hundred and forty grains. I used in this instance a tube having a long oval orifice with a thick edge, passing the latter through the meatus, and especially the prostatic portion of the canal, with facility, by rotating the tube. Such an operation can hardly be called lithotrity. I have therefore proposed for the new method the name Litholap'- axy, — \ldo