SECT. CXVIII.—ON DISLOCATION AT THE HIP-JOINT.
The other bones of the human body sometimes undergo subluxation, and sometimes complete luxation, but the articulations at the hip and the shoulder are subject only to complete luxation, more especially the hip-joint, because it has a deep and round cavity which is further strengthened by a strong brim. The limb, then, being subject to displacement from its cavity by some great violence, many differences arise according to the greater or less degree of the dislocation. Dislocation at the hip-joint takes place in four ways, or rather places; for it is dislocated either inwards, outwards, forwards, or backwards; inwards and outwards frequently, more especially inwards; but forwards and backwards very rarely. When the dislocation is inwards, the affected leg, if compared with the sound one, appears longer, the knee is more prominent, the patient cannot bend the leg at the groin, and a swelling is clearly felt in the perineum, from the head of the thigh being lodged there. When the dislocation is outwards, the symptoms are the contrary to these; for the leg appears shorter, there is a hollow in the perineum, a protuberance about the nates, the knee is turned inwards, and the leg can be bent. When the dislocation is forwards, the patient can stretch the leg without pain at the knee, but when he attempts to walk he cannot turn the foot inwards; the urine is retained, the groin is swelled, the buttocks appear wrinkled and destitute of plumpness; and in walking he supports himself upon his heel. Those who experience a dislocation backwards can neither extend the ham nor the knee, nor can they bend the limb before bending the groin also. The leg appears shorter, the groin looser, and the head of the thigh is to be felt at the buttock. When, then, from infancy, or simply, when for a length of time the limb has been neglected after being dislocated, and allowed to remain so, the cure is impracticable, callus having been already formed. But when the luxation is recent, it may be managed in the way recommended by Hippocrates. We must, then, proceed immediately to the reduction, for dislocations at the hip-joint, when allowed to remain long, are wholly irremediable. In general, then, in all the four kinds of dislocation, the reduction may be accomplished by rotating it, by bending the limb, and by extension. For if the accident be recent and the patient young, we may sometimes succeed in reducing the limb by grasping and rotating the thigh this way and that. When the dislocation is inwards we may sometimes accomplish our purpose by bending the limb at the groin inwards frequently and strongly. If the dislocation does not yield to these means we must have recourse to extension, first with the hands, certain assistants grasping the thigh and leg and pulling the limb downwards, while others grasp the body at the armpits and pull upwards. Or, if a stronger extension be required, the leg may be bound with twisted cords or thongs, above the ankle, and a little higher than the knee, lest it suffer injury; but it is not necessary to secure the breast in this manner, for, as has been said, the hands may be put under the armpits for this purpose. And the middle of a soft and strong thong is to be applied to the perineum, and brought up to the shoulders anteriorly by the groins and clavicles, and posteriorly along the back, and the two ends are to be given to an assistant to hold. Then, all pulling together so as to raise the patient’s body, extension is to be thus made. This mode of extension is applicable generally in all the four varieties of dislocation. But the manner of replacement varies according to the nature of the dislocation. If the bone has been dislocated inwards, let the patient be stretched by having the middle of a thong applied to the perineum between the head of the bone and the perineum, and let the thong be brought upwards by the adjoining groin and the clavicle, and let a young man with both his arms grasp the thigh which is affected in its thickest part, and pull strongly outwards. This mode of reduction is easier than any of the others. When the limb does not thus yield we must have recourse to other contrivances more complicated but more efficacious than these. Let the man be stretched upon a large board, or bench, like that upon which we stretch those who have dislocation of the spine, and along nearly its whole length let certain gutters be scooped out, in breadth and depth not more than three fingers, and not more than four fingers distant from one another, so that the extremity of the lever being inserted into them may impel the limb wherever it is required. In the middle of the board, or bench, let another piece of wood be fastened about a foot in length, and in thickness like that which is inserted in the extremity of a spade, so that when the man is pulled along, this piece of wood may come between the perineum and the head of the thigh, so as to prevent the yielding of the body when pulled by the feet, and thereby often obviating the necessity of making counter-extension; and at the same time when the body is extended this piece of wood will push the head of the thigh outwards. The extension is to be made in the manner described above, more particularly by the foot. But if it is not thus reduced, the erect piece of wood is to be taken away, and two other pieces of wood fastened on the sides of it like posts, not more than a foot in length, and let another piece of wood be adapted to them like the step of a ladder, so that the figure of the three pieces of wood may resemble the Greek letter Η; the middle piece of wood being fixed a little below the upper extremities. Then the man being laid on the sound side, we bring the sound leg between the two posts below the piece of wood corresponding to the step of a ladder, while the affected one is brought above it, so that the head of the thigh is to be adapted to it; but a folded garment is to be first wrapped about it to prevent the thigh from being bruised. Then another board of moderate breadth, and of such a length as to extend from the head of the thigh to the ankle, is to be bound along the inner side of the thigh. Then extension being made either by the pestles mentioned in treating of the dislocation of the vertebra, or some other instrument, the leg is to be pulled downwards along with the board which is fastened to it, so that by the force exerted the head of the thigh-bone may return to its proper place. There is another mode of reduction without making extension upon a board, which is much commended by Hippocrates. The patient’s hands, he says, are to be bound loosely to the sides, and a soft but strong thong put round both his feet at the ankles and above the knees, four fingers distant from one another, so that the affected leg when stretched may come two inches lower down than the other. The man is afterwards to be suspended with the head two cubits distant from the ground. Then an expert young man is to seize the affected thigh in his arms, at its thickest part, where the head of the thigh is lodged, and suddenly suspend himself from the man, by which means the joint will readily return to its place. This mode of reduction is simpler than any of the others, being performed without much apparatus, but many now reprobate it as dangerous. If the dislocation is outwards, the extension is to be made as above, but the thong at the perineum is to be passed by the opposite parts, I mean the groin and clavicle. The surgeon is to propel the limb from without inwards, the lever being fastened into one of the furrows formerly prepared, and an assistant fixing the sound nates that the body may not yield. In dislocations forwards, the patient being stretched, a strong man is to apply the palm of the right hand to the affected groin, and press down with the other hand, so that the depressing force may be exerted downwards, and to the knee. In dislocations backwards, the man is not to be stretched so as to raise him up, but he is to lie upon a hard body as in dislocations outwards; and, as we mentioned with regard to dislocations of the vertebra backwards, the man is to be laid on his face upon a board or bench, and the ligatures are to be applied, not to the loins, but to the leg as mentioned a little above. But the depression, by means of a board, is to be applied at the buttocks, where the dislocated bone is lodged. And thus much respecting dislocations at the hip-joint occasioned by some external cause. But since dislocation sometimes takes place at the hip-joint, as at the shoulder, owing to a collection of humours, we must, in this case, as we mentioned in the other, have recourse to burning.
Commentary. Although the descriptions given by the medical authorities who preceded and followed our author will be found in the main exactly the same as his, we are induced to give a brief outline of them, in order to illustrate by every means in our power a subject so important as the one now on hand.
Every subsequent author is indebted to Hippocrates for his lucid and correct exposition of dislocations at the hip-joint. He says truly that the thigh-bone is dislocated in four directions, namely, inwards, which occurs frequently; outwards, the most frequently of all; backwards and forwards, both very rarely. The following are the symptoms of dislocation inwards, as described by him. The leg is longer than natural, the buttocks outwardly appear hollow; the knee, foot, and leg are turned out; the patient cannot bend his thigh at the groin; and the head of the thigh-bone occasions a tumour in the perineum. This appears evidently to be the variety described by modern surgeons as the dislocation inwards and downwards, the head of the bone being lodged near the thyroid foramen. The symptoms described by modern authors are exactly the same as those mentioned by Hippocrates. Having seen cases of it, we can bear testimony to the correctness of Hippocrates’s description. The symptoms of dislocation outwards as enumerated by Hippocrates are, shortening of the limb, relaxation of the inner part of the thigh, and projection at the buttock, inclination of the knee, leg, and foot inwards, with inability to bend the limb. This case is described by modern authors as a dislocation upon the dorsum of the ilium. From personal experience we can also testify to the accuracy of the description of it given by Hippocrates. The next variety is the dislocation backwards, which, he remarks, is of rare occurrence. It is rather obscurely marked by inability to extend the leg at the hip-joint and ham, relaxation of the flesh in the groin, distension of the nates, a slight degree of shortening and inclination of the limb. He states that the head of the bone is situated below the flesh of the nates. This assuredly is the dislocation backwards upon the tuber ischii, the symptoms of which are admitted by Sir Astley Cooper to be sufficiently obscure. Hippocrates describes with great accuracy the appearance which the limb puts on afterwards when the dislocation is not reduced. (De Articulis.) Reduction, he says, may be accomplished by the hands, with a bench, or with a lever. All these modes of reduction are mentioned by our author, and therefore we shall not take up time in describing them. (Ibid. and De Vectiariis, 15.) The figure of the bench of Hippocrates, given by Littré, would appear to us excellent, and it renders the description easily understood. (Hippocrat. Op. t. iv, 44.) Littré also gives an excellent figure of the reduction by suspension. (Ib. 291.)
Apollonius Citiensis gives a most elaborate and interesting commentary on the methods of reduction recommended by Hippocrates in cases of dislocation at the hip-joint. These methods, however, may be best learned by examining the figures given in the Index Galeni, or in H. Stephens’s Latin Translation of Oribasius (Ap. Med. Art. Princip.), or in Littré’s Edition of Hippocrates (iii, and iv.) There is one curious passage in the commentary of Apollonius, which we must not pass by. He says that Hegetor, one of the followers of Herophilus, had maintained that dislocation of the thigh being attended with rupture of the tendon fixed into his head (ligamentum teres) it was impossible ever afterwards to keep the ball of the femur in the acetabulum. This, Apollonius correctly argues, is contrary to experience and the authority of the ancients. (Ed. Dietz, p. 35.)
Celsus describes the different modes of dislocation at the hip-joint in the following terms: “Femur in omnes quatuor partes promovetur, sæpissime in interiorem; deinde in exteriorem; raro admodum in priorem, aut posteriorem. Si in interiorem partem prolapsum est, crus longius altero et valgius est: extra enim pes ultimus spectat. Si in exteriorem, brevius varumque fit, et pes intus inclinatur; calx ingressu terram non contingit sed planta ima; meliusque id crus superius corpus, quam in priore casu, fert, minusque baculo eget. Si in priorem crus extensum est, implicarique non potest; alteri cruri ad calcem par est, sed ima planta minus in priorem partem inclinatur: dolorque in hoc casu præcipuus est, et maximè urina supprimitur. Ubi cum dolore inflammatio quievit, commodè ingrediuntur, rectusque eorum pes est. Si in posteriorem, extendi non potest erus, breviusque est; ubi consistit, calx quoque terram non contingit.” His statement, however, that dislocations inwards are of most frequent occurrence of any is at issue with that of Hippocrates, who more correctly states that the dislocations outwards are the most common of all. He likewise describes clearly the methods of reduction. If the muscles of the limb be weak, it will be sufficient to make extension by means of thongs applied at the groin and the knee; but if strong, it will be better to fasten them to the upper extremities of two sticks loosely fixed in the ground, and to make counter-extension by pulling the ends of the sticks in opposite directions. A more powerful method is by stretching the limb upon a board having axles at both ends with thongs fastened to them, by turning which such powerful extension could be made as would be sufficient even to break the muscles and tendons. When these are stretched, if the bone is dislocated forwards, some round body is to be placed in the groin, and the knee is to be suddenly carried over it, for the same reason and in the same manner as in dislocations at the shoulder. In the other cases the surgeon is directed to push the bone towards its place, while an assistant propels the hip-joint.
Oribasius mentions the four varieties of dislocation at the hip-joint. In three of them, he says, the leg is extended and cannot be bent; but in the dislocation backwards, it is bent and cannot be extended. He has described the method of reducing these dislocations by machines, of which he gives plates.
Albucasis describes the four varieties of dislocation and the methods of reduction in much the same terms as Paulus. His modes of reducing them are: 1st. By rotating the limb in all directions. 2d. By making extension and counter-extension with the aid of two assistants. 3d. By suspending the patient, and getting a strong assistant to grasp the affected leg and swing himself by it. 4th. By making extension with ropes fastened to two sticks or pieces of wood as recommended for dislocations of the spine. When the dislocation is forwards, the surgeon is to press down the prominent part with his hands; but if backwards, a board is to be used in the manner described by our author.
Avicenna agrees with Hippocrates, in opposition to Celsus, that dislocation outwards (on the dorsum of the ilium) is of more frequent occurrence than the dislocation inwards (on the foramen ovale.) His description of the modes of reduction is evidently taken from Paulus.
Haly Abbas describes the four varieties mentioned by Hippocrates, and recommends much the same treatment. The account of them given by Rhases is exactly the same.