functions of the muscles, be must understand thoroughly the ligaments,
he must have experience, tact, and fertility of resource.

Without these qualifications a man will do better never to under-
take to treat dislocations, since he is constantly liable to mistake frac-
tures for dislocations, and dislocations for fractures ; he will submit a
sprained wrist to violent extension, under the conviction that the
joint is displaced ; he will mistake natural projections for deformities,
and fail to recognize the real deformity when it actually exists ; be
wiU leave bones unreduced, fully believing that they are reduced; and
he will, all in all, within a few years, accomplish vastly more evil than
he can ever do good. Let a man practise any other branch of surgery
if he will, without experience or scientific knowledge, but he must
not attempt to reduce dislocated bones. The most learned and the
most skilful we shall find falling into error, embarrassed by the un-
certainty of the diagnosis, or successfully resisted by the power of the
opposing agents; what then can be expected of those who are both
ignorant and inexperienced, but failures and disasters ?

As a m^ans of disarming the muscles, or of placing them off their
guard, we often practise successfully the diversion of the mind of the
patient. At the very moment that the limb is moved or extension is
made, a question is addressed to him, or he may be suddenly surprised
by some unexpected intelligence.

Extension and counter-extension, made with our own hands or with
the hands of assistants, constitute the second resort where manipula-
tion alone has failed. The surgeon seizing upon the limb firmly with
his hands, makes the extension, while the assistants make the counter-
extension ; or, instead of grasping the limb directly, the operator may



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500



GENERAL CONSIDERATIONS.



Fig. 235. use for this purpose circular and longitudinal

bandages, or the bandage or handkerchief tied
in the form of the clove hitch. Extension is
thus applied in connection with manipula-
tion, aided, perhaps^ by direct pressure upon
the head of the displaced bone. Failing in
tbis, we employ some one of the various
mechanical contrivances which, while they
are capable of exerting much more power,
possess also the important advantage of
operating gradually and steadily, by which
mode the resistance of the muscles is always
more speedily and more completely over-
come.

For this purpose surgeons employ gene-
rally in the case of the large limbs, the com-
pound pulleys or the simple rope windlass,
which latter is thus described by Dr. Gilbert,
of Philadelphia: ''Place the patient, and
adjust the extending and counter-extending
bands as for the pulleys; then procure an
ordinary bed -cord or a wash-line, tie the ends
together and again double it upon itself, pass it through the extending
tapes or towels, doubling the whole once more, and fasten the distal
end, consisting of four loops of rope, to a window-sill, door-sill, or
staple, so that the cords are drawn moderately tight; finally, pass a
stick through the centre of the double rope, then by revolving the
stick as an axis or double lever, the power is produced precisely as it
should be in such cases> viz., slowly, steadily, and continuously."

Fig. 326.



C10T6 hitch. (From Erlehsen.)





Componsd pnlleyt, and ring to which one end of the pnUej rope it fiMtaned.

Jarvis's adjuster, although very complex, possesses some advantages
over the pulleys, which may, perhaps, entitle it to the preference in a
few cases.

Among the constitutional means, ether and chloroform occupy the
first rank ; indeed they are, at the present day, almost the only means



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DOUBLE OR BILATERAL DISLOCATION. 501

of this class to which surgeons resort, and their value in this point
of view can scarcely be overestimated. Only when some unusual
circumstance or condition of the patient forbade the use of an ansss-
thetic, would the surgeon return to the ancient practice of bleeding
ad deiiquium, of prostrating the system with antimony, or to the use
of those vastly less efiBcient agents, opium and the warm bath.



CHAPTER II.

DISLOCATIONS OP THE LOWER JAW.

There are two principal forms of this dislocation, namely, the
double or bilateral dislocation, and the single or unilateral ; in both
of which the direction of the displacement is forwards. To these
there has been added one example of an outward displacement
accompanied with a fracture.^

§ 1. Double or Bilateral Dislocations.

This form of dislocation of the lower jaw is much the most frequent,
being met with in about two out of every three cases. It appears also
to occur oflener in women than in men, and usually between the twen-
tieth and thirtieth year of life. In infancy and extreme old age it is
exceedingly rare ; yet Sir Astley Cooper mentions a case in which
''two boys" being at play, one had an apple thrust into his mouth,
producing a double dislocation ; and Ndlaton saw the same accident
in an old man of seventy -two years, who was toothless.

This comparative immunity in youth and old age has been ascribed
to certain peculiarities in the form of the jaw at these periods of life.
K^laton attributes its more frequent occurrence in middle life to the
great length and strong anterior inclination of the coronoid process.

In a majority of cases the direct or immediate cause has seemed to
be muscular action alone. Malgaigne fpund this cause to prevail in
twenty-five out of forty cases ; and of the twenty-five cases fifteen
were occasioned by gaping, five by convulsions, four by vomiting, and
one by rage. Dr. Physick, of Philadelphia, found both condyles dis-
located in a woman in consequence of the violent gesticulation of her
jaw while scolding her husband. But in a more remarkable case still,
this surgeon found the jaw dislocated after recovery from a profuse
salivation, and of the cause of which, or the- time of its occurrence,
the patient, a young girl, could give no account. Dr. Physick made
several ineffectual attempts at reduction, and only succeeded at last
after he had made her completely intoxicated with ardent spirits.^

» Robert, Journal de CUr., 1844.

* Physick, Dorsey's Elements of Surgery, yol. i. p. 202. Philadelphia, 1818.



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602 DISLOCATIONS OF THE LOWER JAW.

Dr. E. Andrews, of Michigan, found both condyles dislocated by a
lobelia emetic. The patient bad often taken these emetics before, and
had frequently experienced a sensation "of catching" at the joint, bnt
the jaw had always until this time resumed its position spontaneously.^

Among the causes from outward violence, the introduction of some
foreign body into the mouth, and the extraction of teeth, occupy the
most important place. In fifteen cases, seven were from the former
and six from the latter cause.

My former pupil, Dr. A. W. Gilbert, has related a case which came
under his own observation, produced by a similar cause. During his
apprenticeship with Dr. Parsons, a dentist, he was requested to insert
a set of teeth for a young man residing in Cattaraugus Co., N. Y., and
while opening his mouth to take an impression of his gums, he dislo-
cated " both condyles forwards, under the zygomatic arches f but so
perfectly were the muscles relaxed, that he immediately reduced them,
without the least difficulty, by placing his thumbs as far back as pos-
sible upon the molar teeth, depressing the back part of the jaw, and
at the same moment elevating the chin.'

Prof. James Webster, of Itochester, N. T., dislocated the jaw of a
lady while attempting to pry out a root of one of the molars.

Pathology. — In order that we may better understand the pathology
of this accident, it will be proper to say a few words in relation to the
anatomy of the temporo-maxillary articulation and the other parts
concerned in the dislocation now under consideration.

The articulation is formed by the condyloid process of the inferior
maxilla and the glenoid fossa of the temporal bone, in front of which
fossa, and at the root of the zygomatic arch, is a slight elevation, called
the articular eminence. Between the joint surfaces, both of which are
covered with cartilage of incrustation, is placed an interarticular car-
tilage, which divides the joint into two cavities, one corresponding to
the condyle of the inferior maxilla, and the other to the glenoid fossa,
each of which is furnished with a distinct synovial membrane.

Properly there is but one ligament — namely, the external lateral—
which passes from the outer surface of the articular eminence to the
corresponding surface of the neck of the condyle. What is called the
internal lateral ligament arises from the apex of the spinous processor
the sphenoid bone, and is inserted into the margin of the dental fora-
men, and has therefore no immediate connection with the articulation,
although it tends to strengthen the joint. The same is true of the
stylo-maxillary ligaments.

The lower jaw is drawn upwards, or closed upon the upper jaw by
the action of the temporal, masseter, and internal pterygoid muscles;
it is drawn downwards by the action of the digastricus, mylo-hyoideus,
and genio-hyoglossus muscles ; forwards by a few fibres of the masseter
and by the external pterygoid muscles; and laterally by the alternate
action of the external and internal pterygoid muscles.

When the mouth is open to its utmost extent, the maxillary condyle

I Andrews, Peninsular Jonm. Med., vol. iii. p. 101. 1855.

> Gilbert, Thesis on Dislocation of the Inf. Max. University of Boflalo, 1858.



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DOUBLE OK BILATEKAL DISLOCATION.



608



xises upon the articular eminence until it rests upon its very summit.
3ndeed, it is probable that in most persons it advances rather in front
of the centre of the eminence; so that in order to become actually dis-
located it only needs that the capsule shall be somewhat relaxed, or
Ihat it shall actually give way in front, when the condyles slide for-
-wards and occupy a position directly in front instead of behind this
eminence.

It is easy to comprehend how the combined action of the two ex-
ternal pterygoid muscles, with a portion of the fibres of the masseter,
may alone produce the dislocation when the mouth is wide open, and
especially when, in consequence of a slight blow upon the chin, the an-
terior portion of the capsule becomes lacerated; for it must be noticed
that the ascending ramus, with its
prolonged condyloid process, con- Fig. 237.

stitutes a lever of the first kind,
in which the temporal muscle,
attached to the coronoid process,
the masseter, and even tne mas-
toid process, constitute the ful-
crum, the anterior portion of the
capsule, the weight, and the force
acting against the front of the
chin, the power.

In this position of the condyle,
drawn upwards and forwards by
the action of the pterygoid and
temporal muscles, the chin de-
scends toward the neck, and the
coronoid process rests against the back of the superior maxilla, or
against the malar bone at the point of its junction with the upper
maxillary. The temporal, masseter, and internal pterygoid muscles
are very much upon the stretch, if not more or less lacerated.

Symptoms. — The mouth is widely open and the jaw nearly immov-
able. It has been noticed generally that, by pressure, the chin may be
slightly depressed, but that, owing probably to the pressure of the coro-
noid process against the body of the upper maxilla, or against the
malar bone, it is generally impossible to elevate the jaw in any degree
whatever.

The jaw is also slightly advanced; a depression, covering a con-
siderable space, exists between the auditory canal and the posterior
margin of the condyle. A slight fulness is observed in the temporal
fossa, and also upon the side of the cheek in the region of the masseter
muscle.

Ordinarily the patient suffers considerable pain, but not always, from
the pressure of the condyles upon the branches of the temporal nerves.
There is a constant flowing of the saliva from the mouth; the patient
is unable to articulate, and even deglutition is performed with great
diflSculty.

Prognosis. — When the dislocation remains unreduced, the lower jaw
gradually approximates the upper, and its anterior projection sensibly




Double dUlocftUon of the iaferior maxilla.



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604: DISLOCATIONS OF THE LOWER JAW.

^g- 338. diminishes, the saliva ceases to drib-

ble from the mouth, deglutition and
speech are restored, mastication is
performed with considerable ease,
and, in short, the patient comes at
length to experience no great incon-
venience from the displacement.

Bobert Smith relates the case of a
woman whose lower jaw was dislo-
cated during an epileptic convulsion.
She was at the time in one of the
metropolitan hospitals, but the acci-
dent wa^not noticed by the surgeons,
and it remained ever afterwards un-
reduced. At the end of a year she
could close the lips perfectly, but was
able to open the mouth only to a
limited extent; the teeth of the lower
jaw remained advanced, the involun-
tary flow of saliya had ceased, and

Double dUlocaUon of tbe Inferior maxilla, ^^q faculty of SpCCCh had beCD re-

gained.^ In Professor Webster's case,
to which I have before referred, although the jaw was immediately
and easily reduced, after the lapse of several years, when I saw the
lady, she still complained that it hurt her whenever she ate, and that
she often felt the condyles slip in their sockets.

Reduction has been accomplished by Physick in the case already
related after the lapse of several weeks; Sir Astley reduced a double
dislocation after one month and five days, which had been overlooked
by the surgeon in attendance;^ and Donovan succeeded after ninety-
five days.*

Treatment. — Eeduction may generally be accomplished with ease in
cases of recent luxation, in the following manner: The patient being
seated upon the floor with his head between the knees of the operator,
a couple of pieces of cork, gutta percha, or pine wood are placed as
far back between the molars as possible, when the surgeon seizing
upon the chin draws it steadily upwards, taking care not to draw it
forwards at the same time, since by this movement he would resist
the action of the muscles which naturally tend to restore it to place
whenever the condyloid processes are lifted sufficiently from the
zygomatic fossad. Many surgeons prefer to sit or stand in front of
the patient, and depress the condyles by means of the thumbs placed
insiae of the mouth and upon the tops of the molars. If the thumbs
are used in this way, it would be well to protect them with a piece of
leather, or to slip them oflF from the teeth suddenly when the condyles
are gliding into their places, as the muscles sometimes close the mouth

> Robert Smith, on Fractures and Dislocations. Dublin, 1854, p. 288.
« Sir Astley Cooper, on Disloc. and Frac, Amer. ed., p. 316.
• Donovan, Amer. Journ, Med. Sci., Oct. 1842, p. 470, from Dublin Med. Press,
May 25, 1842.



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SINGLE OK UNILATERAL DISLOCATIONS. 505

ivith sufficient violence to braise severely anything which might at
this moment be interposed between the teeth.

The method practised by Bavaton, of simply lifting the chin gradu-
ally and forcibly toward the tipper jaw, was essentially the same, but
far less efficient; for although he placed nothing between the molars
to serve as a fulcrum, the backmost teeth themselves must in some
degree perform this service whenever the lower jaw being dislocated
and drawn upwards, the chin is ^forcibly approximated toward the
upper.

In other cases it has been found necessary first to disengage the
coronoid process, by depressing the chin gently, and then pressing
backwards in the direction of the articulation ; a method which would-
oertainly deserve a trial in case of the failure of that first described.
This was the method practised by Hippocrates.

A more effectual expedient, however, consists in reducing one side
at a time; taking gooa care always that the side first reduced is not
relaxated while the attempt is being made to reduce the other, a
thing which happened in one of the cases treated by Sir Astley
Cooper, and has happened many times in the practice of other sur-
geons.

Finally, if all other expedients fail, we ought not to hesitate to
resort to anssthetics, nor indeed could any objection exist to their
employment at any period of the treatment, were it not that in a large
majority of cases the reduction is effected so easily and promptly as
to render their employment wholly unnecessary.

After the reduction is accomplished, it will be a matter of wise pre-
caution to sustain the jaw by a double-headed bandage passed under
the chin, and secured upon the top of the head, so as to prevent the
mouth from being accidentally opened too far, especially during sleep,
since experience has shown that a tendency to a reproduction of the
dislocation remains for some time. It will be prudent to continue
these measures of protection for at least one week ; after which the
danger of anchylosis should be borne in mind, and the extent of
passive motion should be gradually and cautiously increased. In
illustration of this tendency to reluxation, Malgaigne refers to the
case mentioned by Put^gnat of a woman whose jaw for many years
became luxated at least once a month ; but she was always able to
reduce it herself.

§ 2. Single ob TJnilatxral Dislocations.

The causes of this accident are in general the same as those which

5 reduce double dislocations, and it occurs most oft^en in middle life,
'artra has seen one exceptional example in a child only fifteen
months old, and Levison saw a case in an old man who had lost all
his teeth.'

Symptoms. — ^The mouth is open, but not so widely as in double dis-
location; the jaw is nearly immovable ; the teeth are advanced; the

> LeTison, Boston Med. and Surg. Joum., vol. xxxiv., 1846, p. 888, from London
Lancet.

83



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506 DISLOCATIONS OP THE LOWER JAW.

condyloid process can be felt in front of the articular eminence, leav-
ing a depression in its natural situation, and the coronoid prooess is
more prominent than in the bilateral dislocation.

It will be remembered that we have already pointed out an impor-
tant diagnostic mark between a fracture of the neck of the condyloid
process and a dislocation of one condyle. In the latter the chin in-
clines to the opposite side, while in the former it falls toward the aide
upon which the accident has occurred. According to Hey, this lateral
deviation of the chin is not always present in dislocations; and Bobeit
Smith mentions one case in which the surgeon was misled by this
circumstance so far as to attempt a reduction upon the left side when
the dislocation was upon the right.

Trealment. — The same rules of treatment which we have established
for dislocations of both condyles will be applicable to the single dislo-
cations, with only such modifications as will be naturally suggested to
the surgeon.

In the case mentioned by Levison, the dislocation was constantly
recurring upon the left side; and it was especially liable to happen
when just awakening from sleep. " He would then pull his jaw, press
it backwards, when, after about half an hour's work, bang it seemed
to go^ and all was right again." This old gentleman was finally
relieved of these annoyances by a band fastened under the chin. In
such a case, an apparatus constructed after the same plan as my lower-
jaw fracture apparatus might perhaps serve a useful purpose.

§ 3. Conditions of the Jaw simulating Luxations.

There is a condition of the temporo-maxilla.ry articulation called by
Sir Astley Cooper "subluxation of the jaw," in which it is assumed
that the condyles slip before the anterior margins of the interarticular
cartilages, and thus for the time render the jaw immovable. No posi-
tive evidence, however, has ever been presented, either by Sir Astley
or others, that any such derangement of the joint apparatus does acta-
allv take place, the opinion being based, not upon dissection^ but
only upon the symptoms which are known to accompany the aocident
It is quite probable that this explanation of the phenomenon in ques-
tion is the true one, yet it is not impossible that it has no relation
whatever to the interarticular cartilages, but that it indicates a true
subluxation of the inferior maxilla upon the zygomatic eminenoes.

It occurs mostly in young people, and in those of a feeble or scro-
fulous diathesis. Relaxation of the capsule, ligaments, and muscles
about the joint may, therefore, be regarded as the principal predispos-
ing cause. The exciting causes are generally yawning, or biting upon
some very hard substance.

The symptoms are a sudden arrest of the motions of the jaw, with
the mouth about half open, the arrest of motion being accompanied
or preceded generally with a sensation of slipping in one of the arti-
culations. The chin is slightly inclined to the opposite side. The
condyle may be felt somewhat advanced in its socket, and while it
remains in this position the patient experiences some pain.



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CONDITIONS OF THE JAW SIMULATING LUXATIONS. 507

Frequently the condyle resumes its place spontaneously, or after a
slight lateral motion of the jaw; but at other times it requires some
little manual force to replace it.

I have myself, during several years of my early life, while pursuing
my studies at college, experienced this accident many times. It was
peculiarly prone to occur in the morning, and it became necessary
that I should eat with some care at my first meal. Sometimes the
locking of the jaw was upon the right and sometimes upon the lefl
side; it was always painful. Generally the condyle was made to fall
into place by a voluntary lateral motion of the jaw, but occasionally
I was obliged to press gently against the chin with my hand. I never
adopted any measures to remove the predisposition, but as I became
older the annoyance gradually ceased.

Benevoli, in a dissertation published at Florence, Italy, in the year
1747, describes another condition very analogous to this which we
have now described, but which evidently depended upon a contrac-
tion of the muscles. A priest having opened his mouth very widely
ia gaping, found himself unable to close it. A surgeon who was
called diagnosticated a dislocation of the jaw, and attempted to reduce
it, but failing, Benevoli was called, who, observing " that the jaw was
not absolutely immovable, that the articulations were not separated,
and that the chin did not incline outwards or toward the sternum,"
concluded that it was only a contraction of the depressing muscles.
He therefore prescribed fomentations and oily unctions. The same
night the temporal muscles had acquired the size of a couple of eggs,
from contraction, but the next day the patient could shut his mouth,
and by the following day the tumefaction of the temporal muscles
had also disappeared,, and the restoration of the functions of the
mouth was complete.

Malgaigne, to whom I am indebted for the above case, relates two
others, one in the person of the surgeon Mothe, and the other in a
young man who was suffering from paralysis and spasmodic contrac-
tions of the muscles. Mothe observes that it had occurred to him
very often, and that it still continued to happen sometimes, that when
be gaped pretty widely, the genio-hyoid and mylo-hyoid muscles
contracted with so much force as to render it impossible for him to
close his mouth ; these muscles being thus in a state of cramp, their
bellies became hard under 'the chin, and so painful that he was
obliged immediately to press upwards against the under surface of
the chin in order to oppose their action. This condition would last
from one to three minutes, and was relieved, generally, by frictions
made with the hand over the contracted muscles. Sometimes he
actually believed that the lower jaw was dislocated, although the
result always convinced him that it was not.



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508 DISLOCATIONS OF THE SPINB.



CHAPTER III.

DISLOCATIONS OP THE SPINE.

Delpech ftDd Abernethy denied the possibility of a dislocation of
the spine, either in the cervical, dorsal, or lumbar region, withoat the
concurrence of a fracture.

Says Sir Astley Cooper: "I have never witnessed a separation of
one vertebra from another through the intervertebral substance, with-