Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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ble to declare unless the cases were actually before us; and even then
it would probably be found difficult often to say which was the best
until a fair trial of one or more, and a final success, had determined
the question. The time has not yet arrived in which we may institute
a rigid comparison between the relative merits of the two leading
plans of reduction, manipulation and extension, for while it is true
that reduction by manipulation has been practised from the earliest
day, it is equally true that extension has been generally preferred and
practised by surgeons in all ages. Indeed, it was not until Dr. Beid,
of Rochester, again called the attention of the profession to this sub-
ject, illustrating his views by the results of several successful experi-
ments and bv ingenious arguments, that reduction by manipulation
could be said to have been fairly introduced as an established method
of practice ; a large majority of all the cases upon record of redaction
by manipulation having been reported since the year 1851, the
period of Dr. Reid^s first communication to the Buffalo Medical

The following summary of a paper prepared by myself, with the
view of determining, if possible, the relative value of the two methods,
and exhibiting an analysis of sixty-four cases in which manipulation
was employed, will enable the reader to form some estimate of the
difficulty in which this subject is involved ; and if it does not actually
decide a moot-point, it will at least demonstrate that the method by
manipulation is not without its hazards.^

'* Of forty-one cases in which the fact is stated, twenty -eight were
reduced on the first attempt, seven on the second, four on the third,
and two on the seventh. In seven examples the head of the femar
has been thrown from one position to another upon the pelvis, travel-
ling from the dorsum of the ilium to the ischiatic notch, and from
thence to the foramen ovale ; or directly from the dorsum to the fora-
men, and back again ; or in other directions, according to the character
of the original dislocation; in some instances these changes being
made as often as seven times in succession. In the majority of cases
no evil consequences seem to have followed upon these changes of
position. One of my own cases will especially serve to show with
what impunity sometimes these changes may be made.

"John Caswell, aet. 2«, was admitted to the Buffalo Hospital of the
Sisters of Charity on the 13th of January, 1858, with a dislocation ot
the left femur upon the dorsum ilii, which had occurred six days be-
fore. His own account of the accident was that he was standing at
the bottom of a well, bent forwards until his body was at a right angle

» Reduction of Dislocation of the Femur by Manipulation. By the Author.
Buffalo Medical Journal, Nov. 1857 ; Feb., March, June, 1859. With tobies con-
structed by my very intelligent pupil, Lucien Damainville.

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witli bis thighs, when a bucket holding five hundred pounds of earth
fell upon his back and hips. No attempt had been made to reduce
the dislocation. Five times in succession manipulation made by my-
self failed, leaving the head of the bone each time upon the dorsum
ilii ; the sixth attempt, made with the addition of moderate extension
by tbe hands, threw the head into the foramen thyroideum. By revers-
ing tbe movements, it was easily replaced upon the dorsum ilii. The
seventh trial was made in the same manner, except that when I sup-
pK>sed the head of the bone to be opposite the lower margin of the
socket I did not permit the limb to turn either outwards or inwards,
but ^while lifting at the knee with my hands, with sufficient power to
raise his hips from the table, I brought the limb down gradually to a
line parallel with the opposite, and thus finally the reduction was
accomplished. No pain or inflammation followed, and in two weeks
be left the hospital ; but whether he was able to walk or not at that
time, I am unable to say."^

Since this paper was written, the following cases have come to my
knowledge. December 9th, 1865, Dr. James R Wood attempted, at
tbe Bellevue Hospital, the reduction of a dislocation of the femur
upon the dorsum ilii of five months' standing, in a man sixty years
of age, in the presence of Dr. Sayre, myself, and the class of medical
students. The patient was under the influence of ether. Manipula-
tion alone was employed. Probably half an hour had been consumed
in the various efforts, when, at a moment when the thigh was being
forcibly abducted, the neck was broken within the capsule, and very
close to the head. I was able to feel the head of the bone distinctly,
after the fracture, and to move it freely separated from the neck.

Dr. David Prince, of Illinois, who was present at the time, informed
me that he had himself fractured the neck of the femur in attempting
the reduction of an ancient dislocation of the hip by manipulation.

In Markoe's paper, published in the New York Journal for January,
1855, several cases similar to that of Caswell are reported, in which
the results have been equally fortunate ; but the case mentioned as
having been under the care of Dr. Post, had a more serious termina-
tion. This patient, John Kelly, .adt. 21, had a dislocation into the
ischiatic notch, and on the same .day the reduction was attempted by
manipulation. On the first trial the head of the bone was thrown
into the foramen ovale; and, after having been moved backwards and
forwards between these two points several times, it was finally carried
directly from the foramen ovale into the socket by manual extension
applied in the ordinary way, but without, pulleys. " In this case," says
Markoe, "the cure was very slow, and he left the hospital with some
degree of pain and swelling about the joint. I learned abscess
formed in or about the joint, which was opened, and when I saw him,
a year after, there was every appearance of seated morbus coxarius."
In Case 14, of Markoe's paper, the thigh was broken at the neck
after manipulation had been employed, but while extension was being
made by the hands, united with *' a lifting outwards." Whether the

1 Buffalo Medical Journal, vol. xiii. p. 6S2.

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fracture was due to the extension, or to the manipulation, seems not
to be clearly determined. The dislocation had existed seir^i weeks
when this attempt at reduction was made.

Dr. Bigelow has reported a case of dislocation upon the dorsum,
of six months' standing, in a man 23 years of age, which he attempted
to reduce and caused a fracture of the neck of the femur. His ac-
count of the manner in which the accident occurred is as follows: "I
flexed the limb once slowly upward upon the abdomen — ^a meyement
which was attended with a continued fine crepitation aboat the hip."
Upon examination, the head of the bone was found to be sepanted
from the neck.

Assisted by my pupil, Mr. Hodge, I have also succeeded in collect-
ing sixty -two cases of attempts at reduction by extension ; a great
majority of which, we find, were reduced in the first trials ; but fiye
cases of recent dislocation were not reduced until after several attempts
had been made.

In five cases the femur was broken. The first occurred in St
Thomas's Hospital, London. Ben. Whittenburg, 89t. 40, was admitted
Nov. 4, 1827, with a dislocation into the ischiatic notch, of twenty-two
weeks' duration. After bleeding, &c., had been practised, an attempt
was made to reduce the bone by pulleys, in which the reporter pro-
fesses to believe they were successful, but on the following day it was
plainly enough not in place. Mr. Travers again resorted to extension,
and while extension was kept up and the assistants were rotating the
limb outwards, the neck of the femur gave way.' Malgaigne mentionB
a ease in which, while he was himself directing the operation, the thi^h
was broken through its lower third. He was attempting to reduce the
bone by extension, but it was not until he gave the signal for rotation
outwards that the bone gave way.* Gibson says that Dr. Physick, at
the Pennsylvania Hospital, while engaged in reducing a dislocated
thigh by the pulleys, broke the femur in consequence of exerting too
much force upon it in a lateral direction by an additional pulley; and
that a similar accident is supposed to have happened to Drs. Harris
and Randolph in the same hospital, in the year 18S8, while using the
pulleys upon a boy twelve years of age; for during extension and
counter-extension, at the moment of rotating the limb, and of drawing
it forcibly outwards by a towel, a sudden crack was heard.'

The fifth case is related by Sir Astley Cooper as having occurred
at the Brighton Hospital, under the care of Mr. tJwynne ; the dislo-
cation was upon the dorsum ilii, and was supposed to have existed
about one month. The neck of the femur was broken in the first at-
tempt at reduction, and while the surgeon was making extension, with
gentle rotation.*

Sir Astley says : " There are plenty of cases upon record, of fatal
abscesses from violent attempts at the reduction of dislocated hips."
We presume that this remark has reference to attempts at reduction

» London Med.-Chir. Rev., Kor. 1828, p. 389.

s Malgaigne, op. cit., vol. ii. pp. 146 and 830.

» Gibson^ 8 Surgery, sixth ed., vol. i. p. 389.

* Sir Astley Cooper on Disloc., &c., Amer. ed., p. 88.

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by extension, since, in his day, this was almost the only mode in use
among surgeons. He adds, moreover, that Mr. Skey has mentioned,
in the Jjancet,^ a fatal case of phlebitis following protracted extension
of the hip.

Mal^igne has collected no less than eight similar examples, with
several more in which serions consequences and even death followed
promptly upon violent attempts at reduction by mechanical means.*

The bead of the bone has been repeatedly thrown from the dorsum
ilii into the ischiatic notch, and B. Cooper mentions a case in which
the bone was carried from the foramen ovale into the ischiatic notch,
from ^hich latter position it could not afterwards be changed.'

As to the relative chances of failure by the two methods, the testi-
mony of the recorded cases is equally unsatisfactory. Of the failures
by extension, the experience of almost every surgeon, the journals, and
the treatises furnish a sufficient number of examples; while among
the sixty-four cases of attempts at redaction by manipulation collected
by me, and excepting the cases in which the bone was broken, only
two were positive failures. It is somewhat remarkable, however, that
these two cases occurred in the experience of the New York City Hos-
pital ; and that they are taken from a total of fifteen, this being the
whole number which had been treated by this method at the date of
these observations, in the New York Hospital. One had existed one
month, and, after repeated trials by manipulation and frequent changes
of position, it was finally reduced by pulleys. The other, a dislocation
into the ischiatic notch, had existed only a few hours. At least seven
or eight trials were made to accomplish the reduction by manipulation,
but without success. The first attempt by extension failed also, but
in the second attempt the femur was kept at a right angle with the
body, and the bone was soon brought into its socket.^

We have in these two examples not only a record of failure by
manipulation, but an equal record of success by extension ; while, on
the other hand, we find in an analysis of the sixty-four cases, sixteen
triumphs of manipulation over extension.

We must not omit to mention, in order that the reader may form
a just estimate of the value of these statistics, that the great majority,
^ especially of the cases treated by manipulation, have occurred in
private practice, and it is unnecessary to say that such statistics do
not furnish the most reliable basis for conclusions. As a general rule,
unsuccessful cases are not published by private practitioners, but suc-
cessful cases are pretty certain to be made known ; while, on the other
hand, a series of cases furnished by^any single hospital will generally
be found to have given both unsuccessful and successful cases. The
writer has heard lately of a complete failure to reduce by manipulation
in a recent luxation of the hip, after repeated efforts on several succes-
sive days, and where skilful surgeons were in attendance; but it is
believed that no account of the result has been published.

« Op. dt, vol. I. p. 787, 1840-41. Cooper on Disloc., p. 69.

* Malgaigne, op. cit., vol. ii. p. 164 et seq.

* Sir Astley Cooper on Disloc. By Bransby Cooper, Amer. ed., p. 96.
« Van Boren, New York Med. Times, Jan. 1856, p. 126.

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We have already called attention to the fact that, in the New York
City Hospital, two of the fifteen cases reported were failares; a cir-
cumstance of remarkable significance, especially when we consider the
skill of the several gentlemen who were the operators in these cases;
and it plainly renders a new series of statistics necessary, drawn solely
from the experience of one or more similar large establishments, before
we shall be prepared to decide positively upon the relative valoe of
the two procedures.

Nevertheless, we shall not hesitate to express our present conyic-
tions upon this subject, reserving to ourselves the right of a change of
opinion whenever the proofs shall warrant it.

Manipulation, owing to the greater power which may be brought
to bear upon the neck and head of the bone through the action of the
shaft of the femur as a lever, is most liable to throw the head of the
bone into new positions, and consequently most liable to rupture the
various soft tissues about the joint, to produce inflammation, suppura-
tion, and caries. For the same reason it is most liable, also, to fracture
the neck of the femur. It is not certain in our mind but that^ when
the principles which control the reduction are more completely under-
stood, these evils may be lessened ; yet we can scarcely persuade oar-
selves that by any future observations the state of the question will
ever be greatly changed. We cannot but think, also, that some con-
clusions ought to be drawn from the circumstances that^ since the time
of Hippocrates to the present day, manipulation has been occasionally
recommended and successful examples reported ; the reduction being
accomplished in most instances by processes identical, or nearly so,
with those now adopted ; yet generally the writers appear to have
been ignorant of what had been done before, and, indeed, they have
generally avowed their belief that the method suggested by themselves
was altogether new and original. Possibly this slowness to establish,
and total inability to sustain and perpetuate a reputation, was not the
fault of the method, and had no relation to its failures. Until within
a few years, the number of surgical books, and especially of medical
journals, was comparatively very small, so that valuable truths often
died with their discoverers, or were known and remembered only by
a few ; but it is possible, also, that it has a deeper significance, and that
it implies some defect in the procedure, or serious danger, in conse-
quence of which it has from time to time lapsed into desuetude and
finally into complete oblivion.

The rules which the author would give for the employment of
manipulation are very simple. •

The patient being laid on his back upon a mattress, the snrgeoo,
assuming that it is a dislocation upon the dorsum ilii, should seize the
foot with one hand and the other he should place under the knee;
then, flexing the leg upon the thigh, the knee is to be carefully lifted
toward the face of the patient until it meets with some resistance; it
must then be moved outwards and slightly rotated in the same direc-
tion until resistance is again encountered, when it must be gradually
brought downwards again to the bed. We do not know that the
whole process could be expressed in simpler or more intelligible terms,

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than to say, that the limb should follow coDstantlj its own inclina-

All writers have united in the necessity of flexion ; and, indeed,
with very few exceptions, the advocates of extension have insisted
upon carrying the dislocated limb more or less across the sound one ;
or of making the extension at right angles with the body. They
have also been nearly unanimous in their statements that the thigh
should then be abducted and finally brought down. Nathan Smith
has added the injunction to rotate the shaft of the femur outwards,
and to press gently upon the inside of the knee while the thigh is
being flexed upon the body, so as to compel the head of the bone to
hug the outer margin of the acetabulum and to prevent its falling
into the ischiatic notch ; a suggestion which has been erroneously in-
terpreted by some writers to mean that he would carry up the limb
abducted, a thing which is simply impossible until the reduction is
accomplished. In adopting this practice, however, we must not forget
the danger which we incur when the limb is completely flexed, and
the head of the femur is below the edge of the acetabulum, of throwing
it over into the foramen ovale. Dr. Nathan Smith has also noticed
the advantage which sometimes may be gained by giving to the limb
at this moment a slight rocking motion.

These movements of the limb, with perhaps other slight modifica-
tions, such as lifting the knee moderately or forcibly when the bone
refuses to mount over the margin of the acetabulum, pressing with
the hand or foot upon the pelvic bones, and violent circumduction,
are all which have been usually practised in successful manipulation.

We repeat, however, that as a general rule, in the first trial, the
knee must be carried only in those directions which offer no resistance,
and these will be found almost always to be the same ; the knee of the
dislocated femur hanging over the sound one will be made easily to
ascend to about a right angle with the body, we can then carry it out-
wards a short distance, probably not more than four or five degrees ;
at this moment, frequently, the thigh will begin to rotate outwards of
itself, and with considerable force, or, as Wathman says, " a self-twist-
ing of the thigh occurs, which cannot be prevented by fast holding."
When this action takes place, the reduction is immediately accom-
plished ; and it is in fact at this moment, before the limb begins to
descend, that the bone most frequently resumes its socket. If it does
not, then as soon as the limb begins to fall the reduction occurs,
generally with a loud snap. It is pretty certain that this manipula-
tion is to fail if the knee has descended more than a few inches with-
out the reduction having taken place ; and it will be better to repeat
the manoeuvre at once, rather than to bring the limb completely down.

Generally ansesthetics ought not to be employed, since the opera-
tion, if successful, is not usually painful, and we need that the patient
should preserve bis consciousness, in order to admonish us when we
are using improper violence. It is probable, also, that the action of
certain muscles sometimes affords material assistance in the reduction.
If, however, the patient is very sensitive, or the parts about the joint

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are very tender, or manipulation without anaBSthetica has failed, tben
certainly these agents may be properly and advantageously employed.

If we propose to attempt reduotion by extension, it is no longer
necessary to resort to the lanoet» antimony, and the hot bath, as pre-
liminary measures, since the muscles can be at once overcome by the
much more certain and more powerful agents, chloroform, ether, Ac.

The method recommended by Sir Astley Cooper, and most often
practised by surgeons of the present day, is essentially as follows : —

The patient is placed upon a bed of suitable height^ reclining on
his back, but partly over upon the sound side. Curving now the
line of the axis of the dislocated thigh, one strong staple is to be
secured into the wall upon one side of the room, and another upon the
opposite side, both of which shall correspond as nearly as possible
with the line of the shaft of the femur. The staple in front of the
body will be higher than the bed, and the staple behind will be, in
the same proportion, lower than the bed. The limb being stripped,
two pieces of strong factory cloth, each about four inches wide and
two feet long, should be laid parallel with and on each side of the
limb ; the centre of each strip being about opposite that portion of
the thigh which is just above the two condyles. Over the centre of
these strips, above the condyles and patella, a strong roller, three
inches wiae and at least three yards long, previously wetted in water,
is to be turned as tightly as it can be drawn until the whole roller is
exhausted ; the extremity of the roller being made fast with a needle
and thread rather than with pins. The upper ends of the side strips
are then to be brought down, and tied to the lower ends^ forming
thus two lateral loons, upon which one of the hooks of the compound
pulleys is to be made fast, while the other hook is secured to the front
staple in the wall. Instead of these rollers we may employ, if we
choose, a leathern thigh-belt. For the purpose of counter-extension
a sheet is folded diagonally, and its centre being applied to the peri-
neum of the dislocated limb, the ends are tied firmly into the back
staple. To prevent the body from moving laterally, under the action
of the pulleys, one assistant should be seated upon the bed, with his
back against the side and back of the patient, and his right arm
thrown over the body ; it is well also to station another beside the
sound limb, so as to retain it also in its place upon the bed. Under-
neath the upper part of the dislocated limb a strong and broad band-
age should be placed, of sufficient length to tie over the neck of the
surgeon when he is standing about half bent over the body of the

Everything being arranged, and all portions of the apparatus having
been sufficiently tested to make sure that nothing will give way daring
the operation, the ansdsthetic is to be administered, and as the patient
falls gradually under its influence, the action of the pulleys should
commence, and be slowly but steadily increased; a third assistant
managing the rope, so as to leave the surgeon unembarrassed, and
able to direct his whole attention to the position of the trochanter
major and of the head of the femur. In order to this, he should

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place one hand upon eaoli of these prominences, and watch carefully
their descent.

The length of time which will be required to bring down the limb
mtist differ greatly in different persons, according to the peculiar cir-
cumstances of the case, and the condition, age, &c., of the patient; but
it mast never be forgotten that a slow and steady action is much more
effective than rapid and irregular tractions, and it is in this especially,
rather than in the relative amount of power, that the pulleys possess
al way s so great an advantage over the hands.

mT hen the surgeon finds that the head of the bone has nearly or
quite reached the socket, if it does not take its place spontaneously,
he may place his neck in the noose which passes underneath the thign,
and lift upwards and outwards, in order to raise the trochanter major,
and thus enable the head to rotate toward the acetabulum. It is in
this part of the manoeuvre, and especially when at the same moment
one of the assistants, after bending the leg upon the thigh so as to
make of it a lever, has rotated the thigh outwards, that the fracture
of the neck has generally taken place ; and we cannot be too cautious,
therefore, particularly in old persons, not to bear very strongly upon
the noose, nor to permit the assistant to rotate outwards with great

If the bone does not enter the socket, we may increase the flexion,
or suddenly release the tension, or, in fine, again resort to manipula-
tion alone.

When the reduction is accomplished, the patient should be laid

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 76 of 100)