Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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must lay one hand on the thigh, and the other on the patient^s leg, and
having somewhat extended it toward the sound leg, he most suddenly
force the knee up toward the belly, and press back the head of the
femur into its acetabulum, and it will snap in. For there is no need
of so great extension in this kind of luxation; for the most collider-
able muscles being upon the stretch, the bowing of the knee as afore-
said reduceth it ; yet in rough bodies it may require stronger ext^i-
sion."*

Bichard Boulton repeated, in 1718, almost the same instmctionak
affirming that this plan was applicable especially to dislocations in-
wards, in the case of " young and tender children."'

In 1742 Daniel Turner declared that he had reduced three disloca-
tions of the hip, one of which was a backward dislocation, by a
method combining extension with manipulation, but alone '' by the
strength of the arm or without any other instrument" Extension
and counter-extension being made by assistants, and " as soon as the
surgeon perceives the bone moving out," says Turner, " let him take
his opportunity, giving orders to the extenders below suddenly to lift
up the patient's thigh toward his belly, pressing with his bands,
either to the right or left, as the situation of the same requires, and
therewith force back its head toward the acetabulum, whereonto it
will, flipping over the tip of the cartilage, snap sometimes with a load
noise."*

Thomas Anderson, surgeon, of Leith, in Scotland, was oalled, in
Sept. 1772, to see a man who had dislocated his left femur into the
foramen tbyroideum. When he arrived four other surgeons were
present, and prepared to use the pulleys, which they did in his pre-
sence several times, but to no purpose. After examining the limb
carefully, " I was convinced," says Mr. Anderson, " that attempting
the reduction in the common method, with the thigh extended, was
improper, as the muscles were all put on the stretch, the action of
which is, perhaps, sufficient to overbalance any extension we can ap-
ply. But by bringing the thigh to near a right angle with the trunk,
by which the muscles would be greatly relaxed, I imagined that the
reduction might more readily take place, and with much less exten-
sion.

** When I made this examination, he was lying on a table on his

» Works of Hippocrates, Syd. ed., vol. ii. p. 648.

' Ei^ht CMrurgical Treatises. By Richard Wiseman, Seijeant-Chirorgeon to
King Charles II. London, 1676. Book vii. chap. vili.

» A System of Rational and Practical Surgery. By Richard Boalton. London,
1718, p. 846.

* The Art of Surgery, by Daniel Turner, London, 1742, vol. ii. p. 839.



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UPWARDS AND BACKWARDS ON THE DORSUM ILII. 643

back. I raised the thigh to about a right angle with the trunk, and,

with my right hand at the ham, laid hold of the thigh, and made what

extension I could. From this trial I found I could dislodge the head

of the bone. At the same time that I did this, with my left hand at

the head and inside of the thigh, I pressed it toward the acetabulum,

while my right g^ve the femur a little circular turn, so as to bring

the rotula inwards to its natural situation ; and on the second attempt

it went in with a snap observable to the gentlemen standing around,

hot more so to the poor man, who instantly cried out he was well and

free from pain. His knees could then be brought together; the legs

were of the same length, and the foot in its natural situation. The

knees were kept, together for some time, with a roller, to confine the

motion of the thigh ; and in three weeks he was at his work, without

the least stiffness in the joint."

Subsequently Mr. Anderson reduced by a similar method a dislo-
cation upon the dorsum ilii in a child eight years old, and which had
been out nineteen days.^

Says Pouteau, in a memoir on dislocations of the thigh upwards
and outwards : '* We observe then, first, that the thigh ought to be
flexed fo a right angle with the body during the extension and coun-
ter-extension ; second, that we ought to rotate the thigh from within
outwards, when the extension appears to be sufficient ; third, that this
position puts into relaxation, as much as possible, the triceps and
gluteal muscles which oppose the chief resistance to the extension,
thus saving the patient from excessive pain ; fourth, that the flexion
of the thigh places the head of the bone in the best position for a re-
turn to the cotyloid cavity during extension ; fifth, that feeble exten*
sion suffices for the reduction, because all of the muscles of the thigh
are relaxed."*

On the 7th of Jan. 1811, Dr. Philip Syng Physick, of Philadelphia,
reduced an outward dislocation of the hip, after extension had failed,
by flexing the thigh to a right angle with the body, and then giving
to the limb *' an outward circular sweep."*

So early as 1815, and perhaps much earlier, Nathan Smith, Prof, of
Surgery in the New Haven Medical College, taught that the only cor-
rect mode of reducing a dislocation upon the ilium was to flex the
leg upon the thigh, the thigh upon the pelvis, and then to carry the
limb diagonally to the opposite side, from whence it was to be brought
outwards and downwards;* and in 1824, Dr. Smith, being under oath,
affirmed as follows : " I do not think that the mechanical powers, such
as th^ wheel and axle, or the pulleys, are necessary to reduce a dislo-
cated hip, or any other dislocation." He further adds that he once
reduced a dislocation upon the dorsum ilii after he had pulled in every
direction but the right, " by carrying the knee towards the patient's

1 Anderaon, Medical Commentaries, Edinburgh, 1776, vol. il. pp. 261-4.
I Vidal (de Cassis) ; from (Euvres posthumes de Pouteau, Paris, 1788.

• Physick, Dorsey's Surg., 1813, vi. p. 242. Mem. of Nathan Smith, 1881, p. 173.
Phelps's paper, in Trans. New York State Med. Soc, 1856, p. 169.

• Trans. N. H. St. Med. Soc, 1854, p. 55.



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644 DISLOCATIONS OF THE TH-IGH.

face "^ Subsequently the son of Dr. Smith, Nathan R. Smith, the
present distinguished teacher of surgery in the Medical College at
Baltimore, gave a more full account of his father's method, illustrating
his views of the pathology of these dislocations, and the mechanism
of their reduction, by several drawings. It must be noticed, however.
that Dr. Nathan Smith left no written explanation of his views and
practice, exoept that which is to be found in the aflBdavit already
quoted, and that the account published by his son is from memory,
and it is given as follows: "The patient being prepared for the
operation by whatever means may be deemed necessary, may be placed
in an attitude convenient for the operation, with the body securely
fixed, by placing him in the horizontal posture, on a narrow table
covered with blankets, and on the sound side. To the table his body
should be firmly fixed, and this can be conveniently done by folding
a sheet several times, lengthways — then applying the middle of the
broad band thus made to the inner and upper part of the sound thigh
^-carrying its extremities under the table, crossing them beneath it
and then carrying them obliquely up and crossing them firmly over
the trunk, above the injured hip. The ends may then be secured
beneath the table. To support the trunk the more firmly, a pillow may
be placed on each side of it upon the table, and be incluaed in the band-
age. Should the operator design to employ any degree of extension,
a counter-extending band may be placed in the perineum, and carried
up to the extremity of the table, be fixed to some more firm body, or
held by the hands of assistants.
'' The operator now standing on the side to which the patient's back

E resents, grasps the knee of the dislocated member with his right
and (if the left femur be dislocated — vice versd^ if the right), and the
ankle with the left. The first effort which he 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 gentle rotation
of the thigh outwards, by inclining the foot toward the ground, and
rotating the knee outwards. Next the thigh is to be slightly abducted
by pressing the knee directly outwards. Lastly, the surgeon freely
flexes the thigh upon the pelvis by thrusting the knee upwards
toward the face of the patient, ano? at t/ie 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 downwards, behind the
acetabulum, where the margin of the cup is less prominent, and over
which, therefore, the abductor muscles would drag it with less diffi-
culty 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.'"

» Report of the Trial of an Action for Malpractice. Lowel «. Faxon and Hawks,
Machias, Maine, 1824; also Buff. Med. Joum., vol. xiii. p. 515.
< Medical and Surgical Memoirs, by Nathan Smith, late Prof, of Surgery, &c.,



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UP^W-AKDS AND BACKWARDS ON THE DORSUM ILII. 645

Dr. Liuke Howe, of Boston, who was a pupil of Nathan Smith's,
gives the following account of the method practised by him success-
fully, about the year 1820, and which method, he says, was recom-
mended by his preceptor : " The patient was permitted to lie on his
back on the bed where I found him, the knee of the luxated limb
turned in and over the other. I raised the knee in the direction it
inclined to take, which was toward the breast of the opposite side,
till the descent of the head of the bone gave an inclination of the
knee outwards, when I made use of the leg, being at right angle with
the thigh, as a lever to rotate the latter and turn the head of it in-
wards. It then readily returned to its socket, with an audible snap.

Fipr. 278.




Nathan Smith's method of rednetion by manipalation. (From Smith's '* Memoirs.")

During this operation, the two assistants who had been placed to
make the lateral extension and counter-extension, if ultimately re-
quired, were directed to draw moderately at their towels. How much
of the success of the operation is to be imputed to their extension, and
the rotation of the thigh by the leg, I am unable to determine ; but as
Dr. Smith succeeded without the aid of either, and as the head of the
femur seemed to descend by an easy and natural process, I am inclined
to believe that all that is necessary, in su^h cases, is to elevate the
knee, when the ilium, the muscles attached to it, and perhaps the
ligament, become the natural fulcrum, over which the thigh, as a
lever, acts to bring the head down and inwards into the socket."*

in Yale College. Edited by Nathan R. Smith, Prof, of Surgery in Univ. of Mary-
land. Baltimore, 1881, pp. 108-182.
' Howe, Boston Med. and Surg. Joum., vol. xxii. p. 249, May, 1840.



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646 DISLOCATIONS OP THE THIGH.

Kluge, in 1825, combined moderate extension with manipnlatioD,
by flexing both the leg and thigh, while at the same moment the
thigh was abducted and the knee rotated inwards.^ Wathman, in
1826, directed that in this dislocation the limb should be seized bj
the knee and ankle and slowly lifted forwards until it came to a right
angle with the long axis of the body ; when, if the outward " self-
twisting of the thigh" occurs, " which cannot be prevented by fast
holding," the movement of the head of the bone is declared, and it
will only remain for the surgeon to let down the thigh gradaallj
upon the bed so that the two limbs will come side by side, and the
reduction will be accomplished.'

Bust recommended also, in 1826, a similar plan, combining mode-
rate extension by the hands, with flexion and abduction of the thigh.'

Colombat, whose opinions date from 1830, suggested that the pa-
tient should lay himself forwards upon a bed or table, no higher than
his hips, with the sound leg and foot resting upon the floor, and that
then the surgeon seizing the foot with one hand, so as to flex the le^
should, with the other hand, exercise a moderate degree of extension,
and at the same time move the limb to the right or to the lefl, backwards
and forwards, in order to disengage the head of the femur ; and, finally,
' that he should communicate to the thigh a sudden movement of cir-
cular rotation, either from within outwards, or from without inwards,
as the surgeon may choose.*

Collin states that, in 1833, he had reduced four dislocations of the
hip by a method very similar to this recommended by Colombat*

Dr. William Ingalls, of Chelsea, Mass., reduced a compound dislo-
cation of the femur, in which the head of the bone rested upon the
pubes, after an unsuccessful attempt had been made to reduce it by
extension. ''An assistant, taking the ankle of the dislocated limb in
his right hand, and placing his left in the ham, bent the leg at right
angles upon the thigh, and the thigh upon the pelvis, then lifting with
a power little more than sufficient to elevate the whole limb, he car-
ried it to its greatest state of abduction, at the same time rotating the
femur inwards, while Dr. Ingalls passed his thumb through the wound,
and pressing upon the head of the femur, directed it toward the ace-
tabulum. At this moment he directed the limb to be forced toward
its fellow, by which the reduction was effected with the greatest pos-
sible ease and elegance."*

Similar methods of reduction, with only such slight variations as
scarcely deserve a special notice, have been suggested and practised
from time to time by Palletta, in 1818;^ Desprez, in 1835;* Vial, in
1841 f Fischer, Mahr, and Clark, in 1849.^°

^ Ghelius^s Surg., by South, ^mer. ed., vol. li. p. 241.
« Chelius's Surg., by South, Amer. ed., vol. ii. p. 239.
« Ibid., p. 241, note by South.
* Malgaigne, op. cit. vol. ii. p. 825.
B Malgaigne, op. cit., p. 828.

5 Ingalls, Bransby Cooper's ed. of Sir Astley's English ed., 1842, and Amer. ed.,
1852.
^ Chelius's Surg: ; note by South. » Malgaigne. • Ibid.

'0 Dublin Med. Press, Dec. 3, 1851. New York Journ. Med., March, 1852.



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UP-WARDS AND BACKWARDS ON THE DORSUM ILII. 647

In 1851, Dr. W. W. Eeid, of Eochester, N. Y., published an account
of the method practised by himself successfully in three cases of dis-
location upon the dorsum ilii, the first of which dated from the year
1844. His method, as applied to a dislocation upon the dorsum ilii,
consists in ''flexing the leg upon the thigh, carrying the thigh over
tbe sound one, upwards over the pelvis, as high as the umbilicus, and
then abducting and rotating it."^

I>r. Markoe, of New York, adopts the same procedure, except that
when the limb has been sufficiently flexed and abducted, he directs
that the limb shall be gradually brought down, and he affirms that it
is during this last manoeuvre that he has usually found the bone re-
sume its place in the socket.'

BigeloW; of Boston, declares, as has already been stated, that in all
tbe regular dislocations, that is to say, in all those dislocations in
which the ilio-femoral ligament is not torn, the thigh must be first
flexed, in order to relax this ligament, and then reduction may be
efifected by extension directly forwards, the thigh being at a right
angle with the body, or by rotation. In some cases, where there is
probably only a button-hole slit in the capsule, free circumduction
may be required in order that the capsule may be torn more freely.

Fig. 279.



Relaxation of the ilio-femoral ligament by flexion. (BIgelow.)

His method of reducing the dislocation upon the dorsum ilii, is to
flex the thigh upon the abdomen, abduct and then rotate outwards ;
or, to flex, then adduct and rotate a little inwards, to disengage the
head of the bone from behind the socket, then abduct and pull di-

» Reld, Buffalo Med. Joum., vol. vii., Aug. 1851, pp. 129-148.
* Markoe, New York Joum. Med., Jan. 1855.



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618 DISLOCATIONS OP THE THIGH.

rectly upwards. When necessary, circumduction is practical to la-
cerate the capsule more completely.

Reduction by extension dates from a period equally early with re-
duction by manipulation. Hippocrates recommended, when other and
gentler means had failed, to make extension and counter-extension ;
the extending bands being made fast above the knee and above the
ankle, so as to distribute the points of pressure ; and the counter-ex-
tending bands being secured around the chest under the armpits, and
also, if thought necessary, in the perineum of the sound side.

Fig. 280.



Hippocrates** mode of redncing dislocations of the hip bj extension.

Among the methods recommended and practised by Hippocrates,
was sitting across the upper round of a ladder with a weight attached
to the thigh of the dislocated limb ; or suspending the patient from a
sort of gallows with the head downwards, and if the weight of the
patient's own body proved insuflScient, the surgeon might add his also ;
a method which Hippocrates characterizes as " a good, proper, and
natural mode of reduction, and one which has something of display in
it, if any one takes delight in such ostentatious modes of procedure.r^

With various modifications as to the position of the limb, and as to
the points upon which the extending and counter-extending forces are
to be applied, and with diflferently constructed appliances, surgeons
have continued to employ extension down to this day.

The great majority have regarded flexion of the thigh as essential
to success ; some holding the limb only slightly flexed, and others in-
sisting that a flexion should be increased to a right angle with the
body.

The French surgeons, including Boyer and Vidal (de Cassis), prefer
generally to apply the extending bands to the feet, in order that the
muscles of the thigh may not be stimulated to contraction by the pres-
sure of the bandages. Mr. Skey adopts the same method.

Sir Astley Cooper, Samuel Cooper, B. Cooper, Fergusson, Miller,
Pirrie, Erichsen, and the English surgeons generally, make fast the
lacq above the knee. J. L. Petit and Duverney, among the French,
and Dorsey, Gibson, with most of the American surgeons, recommend

> Works of Hippocrates, Syd. ed., London, vol. il. p. 641.



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UPWARDS AND BACKWARDS ON THE DORSUM ILII. 649

"tbe same, but Gerdy seeks to multiply the points of application, and
for this purpose secures the extending band to the whole length of
t;he leg, and to a small portion of the thigh above the knee.

The counter- extending bands are now almost universally made to
operate against the perineum of the dislocated limb, but Boux, follow-
ing the practice of Hippocrates, places it in the perineum of the sound
limb. Gibson recommends the same practice.

Lizars recommends that sometimes the reduction should be attempted
by simply placing the heel in the perineum and making the exten-
sion with the hands, very much as Sir Astley Cooper advises us to
proceed in dislocations of the humerus. Morgan and Cock, of Guy's
Hospital, have reduced six cases of dislocation of the hip-joint by
placing the foot between the thighs, so that it pressed against the
upper part of the dislocated bone, and thrust it away from the pelvis;
extension and rotation of the limb being made at the same time by
assistants.^ Three of these were examples of dislocation upon the
dorsum ilii, two upon the pubes, and one into the foramen thyroideum ;
and most of them had occurred in weak or elderly persons.

Ambrose Par^ was among the first to recommend the use of pulleys
for the reduction of dislocations. Most surgeons since his day have
employed them for the purpose of making extension more energetic
and steady, and that it might be longer continued. Sir Astley Cooper's
plan of procedure is as follows : —

The patient having been bled freely and the muscles still farther

Fig. 281.




R«dnetloa of a dislocation on the donnm ilii, by pnlleye. (Sir Astley Gooper*s method.)

relaxed by nauseating doses of antimony and by the hot bath, he is to
be placed on his back upon a table of convenient height between two
staples; a strong padded leathern girth or perineal band, constructed
so as to receive the thigh and to press at the same moment against the
perineum and the outer surface of the pelvis, is then applied and made
fast to one of the staples situated behind the patient in the direction of
the axis of the limb. A wetted linen roller is next to be tightly
applied just above the knee, and upon this a leathern strap is to be
buckled, having two short straps with rings at right angles with the

I Cock and Morgan, Chelias, opt cit., yol. ii. p. 242, note by South.
42



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650



DISLOCATIONS OF THE THIGH.



circular part; or, instead of this, a round towel made in the kaot
called the clove-hitch. The knee is to be slightly bent, but not quite
to a right angle, and brought across the opposite thigh a little above
the knee. The pulleys ^ing now attached, the extension is to be
commenced.

A very simple and efficient mode of making the extension, if one
has not the pulleys, is to employ for this purpose a small rope» t^
ends being tied together and the rope being then doubled upon itself
once or twice, so as to make four or eight parallel cords. The oppo-
site ends of this bundle of ropes being made fast to the limb and tite




piiti? fm' «iii^



Reduction of a disIoeaUon oa the dorsum illi, hj the Spanish wlndli



(Gilbert)



Staple, the extension is made by thrusting a stick through its centre
and twisting it.

I have several times bad occasion to resort to this plan ; and indeed
it has been for some time known and practised among surgeons in this
country,^ having been first, according to Prof. Gilbert, introduced by
Fahnestock, of Pittsburg, Pa.

Jarvis's adjuster, to which I have already made allusion when speak-
ing of dislocations of the humerus, has been often used with success in
dislocations of the hip as well as in dislocations of the shoulder.' Its
power is equal to that of the pulleys, while the direction of the force
can be varied with much greater ease. The most serious objectioDs
to the instrument as employed for the reduction of dislocations, are its
complexity and its expensiveness.

Mr. Fergusson says that the Lancet for July 26, 1845, contains a
description of a similar apparatus constructed by Goxeter at the
suggestion of G. N. Epps ;* and L'Estrange, of Dublin, has invented
a *' windlass" for making extension, with a " forceps" by which the
extending power can be instantly disengaged.^ Mr. Bloxham's "dis-

* Gilbert, of Philadelphia, note to Pirrie^s Surg.; also Amer. Joom. Hed. 8cL,
vol. XXXV., April, 1846.

« Crandall, Bost. Med. and Surg. Joum., vol. xxxix. p. 77; Atlee, Traiu. Amer.
Med. Assoc, vol. iii., 1850, p. 367.

» Fergusson, 4th Amer. ed., p. 200. * Ibid., p. 198.



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UPWARDS AND BACKWARDS ON THB DORSUM ILII. 651

location tourniquet" is also very simple, and Mr. Erichsen affirms that
by it " any amount of extending force that may be required can be

Fig. 283.



JarTis's adj otter applied for reduction of a dliloeatlon of the hip.

readily set up and maintained."^ Sedillot> a French surgeon, has sug-
gested that when pulleys are used, we should measure the exact power

Fig. 284.



Bloxham's "dieloeation toarniqaet" applied for rednotldn of a dislocation on the pabes.

employed in the reduction, by an ingeniously contrived apparatus
called the dynamometer.' Such an instrument might occasionally
be useful in preventing the application of excessive force, especially
when the patient is under the influence of an ansBsthetic.

I Erichsen, Amer. ed., 1858, p. 242.
" " ^ !i., TOL



« Amer. Joum. Med. Sci., toL xv. p. 580.



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652 DI8L0CATI0:^S OP THE THIGH.

Finally, without attemptiog to determine the precise relative valoe
of these different procedures, all of which claim for themselves the
testimony of experience, we are prepared to admit that no one of them
is without merit, and that each may in certain cases possess advantages
over the others. Precisely what the cases are to which each individual
method may be especially applicable, we believe it would be impossi-



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 75 of 100)