Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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marine wards at the Hospital of the Sisters of Charity, and was placed
under the care of Dr. Wilcox, through whose politeness I was per-
xxiitted to see him frequently.

The wound in the leg healed kindly, with only a slight amount
of inflammation and suppuration. Violent inflammation, however,
occurred in the thigh, followed by extensive suppuration and slough-
ing. This, in fact, proved to be by far the most serious injury, and
that which most endangered his life and delayed his recovery.

After about two months, the ankle was in such a condition as to
require little or no further attention. The fragments of the fibula had
shortened upon each other and were united, so that the tibia rested
upon the astragalus. It was nearly two months, however, before he
"began to walk, owing to the condition of his thigh.

Aug. 24, 1856, fourteen months after the accident, Adamson called
at my office. He was then employed again as a sailor on board the
schooner Sebastopol, and performed all the duties of an ordinary deck-
hand. His leg is shortened one inch and a quarter ; from which, it
seems, that there has been some deposit upon the end of the bone,
which has compensated for one-quarter of an inch of that which I
removed. The ankle is perfect in its form, being neither turned to the
right nor to the left, and he treads square and firm upon the sole of
his foot. There is considerable freedom of motion, especially in flexion
and extension. Occasionally it becomes a little swollen and painful.

In a case of compound dislocation of the upper end of the humerus,
occurring also under my own observation, and recorded in the Trans-
actions of the New York State Medical Society for 1855 (p. 27, Case 14),
in which reduction was followed by death, I have now much reason
to believe that if I had practised resection before the reduction, my
patient's chances for recovery would have been greatly increased;
perhaps also the case of compound dislocation at the wrist-joint re-
corded in the same vol. (p. 68), in which, having reduced the bones,
I was subsequently compelled to amputate, may equally illustrate the
hazard to which the practice of reduction without resection must often
expose the patient.

The same remarks I will venture to apply to the case of compound
dislocation of the hip, of which I have already spoken as having oc-
curred in the practice of Dr. Walker, of Charlestown, Mass. Had the
head of the femur been resected before its reduction, I cannot doubt
but that the unfortunate man's chance for recovery would have been
very greatly improved.

Thus, if we consider the question of the life of the patient only, the
argument and the testimony seem to favor resection in a great ma-
jority of cases of compound dislocations occurring in large joints, and
in a considerable number of cases of similar accidents in the smaller
joints. It is certainly more safe than non-reduction or reduction
without resection, and it is probably quite as safe as amputation or
tenotomy.



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756 COMPOUND DISLOCATIONS OF THE LONG BONES.

But there is another question, which is, in our estimation, secondary
to the one now considered, but which is often in the estimation of the

Eatient himself of the first importance, namely, by which method will
e suffer the least maiming or mutilation?

This question I do not find it difficult to answer. Certainly it is
not by non-reduction or by amputation; and, putting tenotomy aside,
it is now a question only between reduction without resection, and
reduction with resection. These two methods, one of which experi-
ence has shown to be fraught with danger, and the other of which
experience has shown to be relatively safe, are now to be compared in
a point of view in which their antagonisms are perhaps less conspicu-
ous, yet sufi&ciently marked.

First. In either case the inflammation consequent upon the injury
may be violent, and the recovery slow and tedious. The same argu-
ments, however, which we have applied to the question of the com-
parative danger of the two modes, must apply with nearly equal force
to this question of maiming ; since the amount of maiming must often
be governed by the intensity and duration of the inflammation, and
upon this point the testimony has been shown to be in favor of re-
.section.

It will be observed that not only is the danger of maiming render©!
more considerable by reduction without resection, because the inflam-
mation is so much more likely to extend to the tendons and muscles,
causing them to adhere to each other, and to become subsequently
atrophied, a condition from which they often never completely recover,
but also because the ligaments and capsules of the joints, with the
synovial surfaces, are in consequence encroached upon, and the free-
dom of motion is ever afterwards greatly restricted, if not completely
lost. This marked impairment of the functions of the joint does not
always happen, but it cannot be denied that it does generally. Indeed,
it is by no means uncommon for these accidents to be followed, after
ulcerations of the cartilage, by copious bony deposits in and around
the joints.

How is it, on the other hand, with thesfe joints after resection? I
have thus far heard of no cases in which complete anchylosis resulted:
but in all considerable freedom of motion has returned, and in some
the restoration in this respect has been nearly or quite as complete as
before the accident.

Says Dr. Kerr, of Northampton: "Several cases of compound
dislocation of the ankle have fallen under my care, and it has been
uniformly my practice to takeoff the lower extremity of the tibia, and
to lay the limb in a state of semiflexion upon splints; by this means
a great degree of painful extension, and the consequent high degree
of inflammation, are avoided. The splints I used are excavated wood,
and much wider than those in common use, with thick movable pads
stuffed with wool. I keep the parts constantly wetted with a solution of
liquor ammonias acetatis, without removing the bandage. In my very
early life, upwards of sixty years ago, I saw many attempts to reduce
compound dislocations without removing any part of the tibia ; but,
to the best of my recollection, they all ended unfavorably, or, at least,



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COMPOUND DISLOCATIONS OF THE LONG BONES. 757

ill amputation. By the method which I have pursued, as above men-
iioned, I have generally succeeded in saving the foot, and in preserving
SL tolerable articulation."

Sir Astley Cooper has made a valuable experiment to determine
the condition of the new joint under these circumstances; and the vast
number of cases in which rwection has now been practised in cases of
caries of the articulating surfaces, and their results, add still more
substantial proofs as to the usefulness of the joints after such opera-
tions.

" I made an incision upon the lower extremity of the tibia, at the
inner ankle of a dog, and cutting the inner portion of the ligament of
the ankle-joint, I produced a compound dislocation of the bone in-
wards. I then sawed off the whole cartilaginous extremity of the
tibia, returned the bone upon the astragalus, closed the integuments
by suture, and bandaged the limb to preserve the bone in this situa-
tion. Considerable inflammation and suppuration followed ; and in a
week the bandage was removed. When the wound had been for
several weeks perfectly healed, I dissected the limb. The ligament
of the joint was still defective at the part at which it had been cut.
From the sawn surface of the tibia there grew a ligamento-carti-
laginous substance, which proceeded to the surface of the cartilage of
the astragalus to which it adhered. The cartilage of the astragalus
appeared to be absorbed only in one small part; there was no cavity
between the end of the tibia and the cartilaginous surface of the astra-
galus. A free motion existed between the tibia and astragalus, which
was permitted by the length and flexibility of the ligamentous sub-
stance above described, so as to give the advantage of a joint where
no synovial articulation or cavity was to be found. This experiment
not only shows the manner in which the parts are restored, but also
the advantage of passive motion ; for if the part be frequently moved,
the intervening substance becomes entirely ligamentous ; but if it be
left perfectly at rest for a length of time, ossific action proceeds from
the extremity of the tibia into the ligamentous substance, and thus
produces an ossific anchylosis."

Second. Is it not probable, moreover, since the limb can be retained
in place so much more easily after resection, that it will actually, in a
majority of cases, be found to have been retained in place more per-
fectly ? Even after simple dislocations, especially in those occurring
at the ankle-joint, great deformity and much maiming are the not un-
frequent results, and that too when all diligence and care have been
employed. It has been impossible always to maintain a perfect appo-
sition in the articulating surfaces. How much greater must be this
difficulty in cases of compound dislocations.

Third. The only argument which remains in favor of reduction
without resection is the necessary shortening of the limb after resec-
tion. But this need seldom perhaps to exceed three-quarters of an
inch, and often not more than half an inch ; an amount of shortening
which, as I have had occasion to prove when treating of fractures^
does not necessarily produce a halt, and which indeed is often not
known to exist by the patient himself.



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758 CONOBNITAL DISLOCATIONS.

Finally. It must not be inferred that the author intends to recom-
mend resection as a universal practioe in cases of compound disloca-
tions of the long bones. He has only sought to determine in a general
manner its relative value as compared with other modes of procure;
and especially has it been his intention to bring more prominently
into view the importance of rest and rel^ation to the muscles, as an
element in the treatment most essential to success. To declare its
special application to cases would demand a treatise more elaborate
than it was proposed to write. If, however, one were to speak of the
individual bones only, there seems sufficient authority in the facts and
arguments already presented to conclude that resection is applicable to
certain compound dislocations of the clavicle, humerus, radius, and ulna,
fingers, femur, tibia, fibula, and toes ; in short, to a certain proportion
of all these accidents occurring in the long bones of the extremities.

If an attempt is made to save the limb without resection, it is scarcely
necessary to say that the success will depend, in a great measure, upon
the care, attention, and skill bestowed upon the treatment. Cool or
tepid water-dressings, according as the indications or the sensations of
the patient seem to demand, are among the most valuable remedial
agents. The limb must be maintained in a position of rest^ combined
with moderate elevation; and the bran-dressings, recommended in
compound fractures, will be found occasionally useful



CHAPTER XXVI.

CONGENITAL DISLOCATIONS.

§ 1. Oknxeal Obssbyations and Histobt.

Wb have omitted, until this moment, to speak of Congenital Dislo-
cations, because, whatever theory of causation we adopt, dissections
have shown that they are generally, in some senlse, pathologic, or are
accompanied with such essential modifications of the anatomical struc-
tures as to separate them entirely from ordinary traumatic luxations,
which alone constitute the proper subjects of consideration in the pre-
sent treatise. In relation to congenital dislocations^ we shall find it
necessary to establish systems of etiology, symptomatology, prognosis,
and treatment, having very few points in common with traumatic dis-
locations. Exceptions to this rule will occur, in examples of intra-
uterine traumatic luxations, existing at birth without either original
or accidental malformations of the articulations, or of the adjacent
muscular, tendinous, or ligamentous structures; yet only in sufficient
numbers to warrant the intrusion of the subject in this place.

It is probable that congenital displacements may occur in all the
articulations of the skeleton ; and in most of them their existence has
been already established by dissections. Until within a few years,
however, the attention of surgeons has been almost entirely directed
to congenital dislocations of the shoulder and hip.



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OOKGENITAL DISLOCATIONS. 759

Hippocrates, in his treatise " De Articulis," speaks expressly of dis-
locations of the hip occurring in the mother's womb, comprising them
u^nder the same order with the different varieties of club-foot.

Avicenna and Ambrose Pard have each mentioned original disloca-
tions of the hip ; but the first to record an example with any degree
of accuracy was Kerkring; in which case, death having occurred
during infancy, he was able to verify his opinion by an autopsy.
Chaussier has reported, in the Bulletin de la Faculte et de la Societe de
JUidecine, An. 1811 and 1812, the case of an infant, upon which he
discovered, at birth, two dislocations, one at the scapulo-humeral arti>
culation, and the other at the coxo-femoral. In 1788, Palletta, of Milan,
published, under the title of Adversaria Chirurgica, a collection of
observations, in which, among other things, he has described certain
congenital malformations of the hip-joint; and in 1820 he published
another work, entitled Exerciiationea Pathologicse, where he enters into
a more complete exposition of the nature and causes of these de-
formities.

In 1826, Dupuytren read, before the Academy of Sciences, a memoir '
upon the lameness produced by the original displacement of the
femur; and in the Leqons Orales, published in the collections of the
Sydenham Society, may be found a full record of the views and obser-
vations of this distinguished surgeon.

The writings of Dupuytren seem, more than anything previously
written, to have directed the attention of surgeons and pathologists to
this interesting subject, and to have given a new impulse to investi-
gation.

From this time various treatises have been written by eminent sur-
geons, many of which are characterized by profound thought, careful
investigation, and practical experiment.

Among those who have furnished us lately with elaborate treatises,
or with more precise practical information upon this subject, the fol-
lowing names deserve to be especially mentioned : Breschet,^ Caillard-
Billionifere,^ Lehoux,' Sandiforte,* Duval and Lafond, Humbert and
Jacquier, Bouvier,* S^dillot,* Gerdy, Polini^re, Wrolik,^ Gu^rin,^ Pa-
rise,* Pravaz,**^ Carnochan," and Bobert Smith."

> Brescbet, Repertoire d^Anatomie et de Physiologic,
s CaiUard-Billioniere, These Inaugurale, 1828.

* Lehoux, These Inaugurale, 1884, Paris.

* Sandiforle, Thesis, sustained before the Faculty of Med. of Leyden.
' Duval and Lafond, Humbert and Jacquier, Bouvier. See Prayaz.

6 SMillot, Joum. de Gonnais. M6d.-Chirurg., 1838.
' Gerdy, Polin6re, Wrolik. See Pravaz.

* Gu^nn, Recherches sur les Luxations Cong^nitales ; par Jules Gu6rin, Paris,
1841.

* Parise, Archiy. G^n. de M6d., 1843.

» Pravaz, Traits Th^orique et Pratique des Luxations Cong^nitales du Femur,
suivi d'nn Appendice sur la Prophylaxie des Luxations Spontandes ; par Gh. G.
Pravaz, Lyons, 1847.

" Garnochan, A Treatise on the Etiology, Pathology, and Treatment of Con-
genital Dislocations of the Head of the Femur ; by John Murray Garnochan, New
York, 1850.

u R. Smith, A Treatise on Fractures in the Vicinity of Joints, and on Gertain
Accidental and Gongenital Dislocations ; Dublin, 1854.



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760 CONGENITAL DISLOCATIONS.

§ 2. Etiology.

Hippocrates says that the bones of the extremities may be disar-
ticulated during intra-uterine life by falls or blows, or by injuries of
any kind, inflicted directly upon the abdomen of the mother.

Ambrose Par^, while admitting the efficiency of the several causes
named by Hippocrates, believed also that the contractions of the
womb, and violence employed by the accoucheur, were occasionally
adequate to the production of the same results. He taught, moreover,
that the position of the foetus itself might favor the displacement;
and that, in some instances, an articular abscess, insufficient depth of
the socket, with a laxity of the ligaments, were competent to determine
the expulsion of the head of the femur from its natural position.

S^dillot regards a softening and relaxation of the ligaments as the
most frequent cause.

Parise and Malgaigne are disposed to attribute a majority of these
cases to hydrarthrosis, or water in the joints. Says Malgaigne : "For
myself, after having long meditated upon this subject, I have come to
think that inflammation of the joints enjoys a grand role, both in
coxo'femoral dislocations and in many others, and even also in various
congenital malformations generally ascribed to arrest of development"
This writer admits, however, that it will not do to generalize too much
in this matter, and that the etiology of congenital luxations is probably
as complex as that of luxations after birth.

Chaussier seems to have regarded muscular contraction, or the
occurrence of an intra-uterine convulsion, as the cause of the example
of congenital dislocation of both humerus and femur seen and recorded
by him. Since whom Gu^rin has greatly extended the application
of this doctrine, having embraced in the same etiologic formula all
or nearly all congenital dislocations. Gu^rin ascribes to muscolar
contraction in one form or another, and to corresponding muscular
paralysis, not only dislocations of the femur and other long bones,
but also club-foot, torticollis, and various other deviations of the spine.
He affirms, moreover, that he has established incontestably the depend-
ence of this abnormal state of the muscular system upon the absence
or disappearance more or less complete of corresponding portions of
the central nervous systems.

Breschet and Delpech maintained similar views, especially in rela-
tion to the dependence of the several varieties of club-foot upon some
morbid condition of the cerebro-spinal axis. While Carnochan re-
marks as follows: "It appears most in accordance with science to
refer the muscular spasmodic retraction, upon which congenital dis-
locations of the head of the femur from the cotyloid cavity depend,
to a perverted condition of the excito-motor apparatus of the medulla
spinalis, and more especially of that portion of it which is in direct
relation with the reflex-motor nervous fibres, distributed to the pelvi-
femoral muscles surrounding, and in connection with, the ilio-femoral
articulation."

Palletta ascribes these deformities solely to an original defect of the
germ ; and Dupuytren also declares that, in the case of a congenital



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CONGENITAL DISLOCATIONS OF INFEBIOB MAXILLA. 761

dislocation of the hip, the caases are coeval with the earliest organiza-
tion of the parts, and that the displacement is due rather to a defect
in the depth or completeness of the acetabulum, than to accident or
disease.

Sreschet and Delpech, both of whom, as we have already stated,
refer them to some morbid condition of the cerebro-spinal axis, ima-
gine that in consequence of this morbid condition of the nervous
centres, there exists an arrest of development in the bones, muscles,
ligaments, sockets, and, in short, through all the apparatus of the joint
vrbich is the seat of the deformity.

If we proceed to analyze these various opinions, we shall find that
tbey are so far susceptible of classification, as that they may be
arranged under the three following divisions: —

First, the physiological doctrines ; according to which congenital
dislocations are due to an original defect in the germ, or to an arrest
of development.

Second, the pathologic doctrines ; which refer them to some sup-
posed lesion of the nervous centres, to contraction or paralysis of the
muscles, to a laxity of the ligaments, to hydrarthrosis, or to some other
diseased condition of the articulating apparatus.

Third, the mechanical doctrines ; which recognize no intra-uterine
dislocations except those which are strictly traumatic. The causes
being understood to be the peculiar position of the foetus in utero,
violent contractions or the constant pressure of the walls of the uterus,
falls and blows upon the abdomen, and unskilful manipulation of the
child in delivery.

After a full and careful consideration of this subject, we are pre-
pared to admit the occasional agency of all the causes enumerated,
and the probable concurrence of two or more in many instances ; nor
do we see the propriety of rejecting, as Malgaigne has done, all that
large class of malformations, which seem to depend upon an arrest of
development, or those which appear to be due mainly or solely to
intra-uterine paralysis, of both of which many examples have been
reported.

§ 3. Congenital Dislocations of the Infebiob Maxilla.

Malgaigne affirms that " we know of no congenital dislocation of the
jaw," and that we are " not to take seriously the pretended luxation
observed by Gu^rin upon a d^renc6phalous infant." The example
recorded by Bobert Smith he rejects also, declaring that he does " not
comprehend how one can see in it a luxation."

For myself, I know of no reason why we should not take " seriously"
the case mentioned by Gu^rin, since, so far as appears in his very brief
report of the same, it might have been a true luxation. The specimeu
was before the academy, and if Malgaigne, from a personal examina-
tion, has become satisfied that a dislocation did not exist, he ought to
have so informed us. But since he does not speak of having made it
the subject of especial examination, we shall feel compelled to accept
of it as reported by Gu^rin.



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762 CONGENITAL DISLOCATIONS.

As to the objection offered to Mr. Smith's case, namely, that "aside
of the complete absence of its history, the subject did not present the
characteristic signs of luxation, and the dissection discovered neither
maxillary condyle nor glenoid cavity," we must reply, the dissectioD
seems to us to have furnished such evidence that the deformity was
congenital as to render its history unnecessary ; the signs were charac-
teristic, not indeed of a traumatic luxation, but of a congenital disloca-
tion, such as may be supposed to have been the result of aa arrest of
development, or of an original aberration of the germ.

The following is a summary of the very complete accouot of this
case given by Bobert. Smith.

On the fitlh of May, 1840, Edward Lacy, 89t 88, an idiot from in-
fancy, died at the Hardwick Hospital, in consequence of gangrene of
the lungs. While making the autopsy, a singular deformity of the
face was discovered. The right and left sides seemed as though they
did not belong to the same individual, the left being in every respect
more fully developed. Upon removing the integuments, the muscles
of the right side were found to be much smaller than those of the left,
and especially the masseter. These latter having been removed also^
the condition of the right temporo-maxillary articulation was carefully
studied.

When the mouth was closed, the^external lateral ligament, instead
of being directed backwards, was seen descending obliquely forwards,
to be attached to a very imperfectly developed condyle situated at
least one-quarter of an inch in front of its natural position. There
was neither an inter-articular cartilage nor cartilage of incruslatioo,
the joint surfaces being invested by a thick periosteum alone; nor was
there any distinct capsular ligament.

Nearly the whole of the right side of the inferior maxilla was
smaller than the left. The condyle was short and curved, being
directed nearly horizontally inwards, and resembling much more the
coracoid process than the condyle of the inferior maxilla. The core-
noid process was very small and thin, and the sigmoid notch could
scarcely be said to exist

The articular eminence of the temporal bone was absent^ there being
in its place nearly a flat surface destitute of cartilage; which surface
presented upon its inner side a shallow and semicircular sulcus where
the hook-like condyle of the lower jaw had played.

The malar, superior maxillary, and sphenoid bones of the right side
had also suffered corresponding changes of form and relative size.



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 88 of 100)