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.
The earlier modern writers on surgery, describe the four varieties of dislocation at the hip-joint in the same terms as the ancients. They evidently follow the Arabians. See Theodoricus (ii, 51); Guido de Cauliaco (v, 2, 7.) From the contents of this section it will be clearly seen how erroneous is the statement made by the late Sir Astley Cooper, that the profession was entirely ignorant of the nature of these accidents until within these last few years.
SECT. CXIX.—ON DISLOCATION AT THE KNEE.
The knee is dislocated in three ways: inwards, outwards, and towards the ham; for it is prevented by the patella from being dislocated forwards. Using, then, the same modes of extension, sometimes by the hands alone, and sometimes by cords, we must have recourse to suitable bandages, and the other suitable treatment, the part being in particular preserved free from motion.
Commentary. Hippocrates, like our author, mentions three directions in which the bones of the knee-joint may be dislocated: namely, inwards, outwards, and backwards. He has not noticed the dislocation forwards, which is, in fact, a very rare case. Celsus mentions, however, that Meges had related a case of dislocation forwards, which was successfully treated by him. But most of the other authorities, he says, have denied the possibility of such an occurrence. He directs the surgeon to reduce dislocations at the knee upon general principles, by making extension and counter-extension. Hippocrates represents dislocations at the knee as being of more frequent occurrence, but less dangerous, than those of the elbow.
Oribasius, like our author, treats only of three kinds of dislocation at the knee. Albucasis denies the possibility of a dislocation forwards. He directs the surgeon, in making reduction, to turn his back to the patient, and take the limb out between his knees; then while an assistant makes extension at the foot, he is to replace the bones with his hands. This seems a very proper method of reduction.
Avicenna likewise mentions only three modes of dislocation. He has described dislocation of the patella, a case omitted by our author. He directs us after making reduction, to fill the hollows with compresses, and then to apply splints and bandages. He says that the knee is often dislocated in walking. He must surely allude to a species of sub-luxation first well described by the late Mr. Hey, of Leeds; for a complete luxation is a very rare occurrence, and is never occasioned but by great violence.
Haly Abbas and Rhases describe only three kinds of dislocation at the knee, and deny the possibility of a dislocation forwards. Both evidently copy from our author.
The earlier modern surgeons, as usual, adopt the views of the Arabians, and accordingly deny the possibility of a dislocation forwards. See Theodoricus (ii, 52.) They would appear to have been wholly unacquainted with the works of Celsus, and to have derived all their information from the Arabians.
Dislocations at the knee-joint are now found to be of much rarer occurrence than they are represented to be by the ancient authorities. In fact only a very few cases have been reported in modern times. We would beg, therefore, to refer our readers to a case related in the ‘Medical Gazette,’ Dec. 16, 1842, by the author of this Commentary. It is necessary to remark, however, that several typographical mistakes occur in the Report, which are partly corrected in a subsequent number of the same periodical.
SECT. CXX.—ON DISLOCATION AT THE ANKLE, AND ALSO OF THE TOES.
The articulation at the ankle, if but a little displaced, is remedied by moderate extension; but if completely dislocated, it requires greater force. We may endeavour therefore, in this case, to make strong extension by the hands; but if reduction does not take place, having stretched the man on the ground in a supine posture, we are to fasten into the floor a long and strong peg, between his two thighs, so as to prevent the body from yielding to the extension by the foot; or rather let the peg be fastened before the man is laid down; or if we have the large board at hand on the middle of which, as we said, a wooden peg a foot long is fastened, we may make the extension upon it. An assistant then grasping the thigh, and making counter-extension, another assistant is to pull the foot with his hands or by a thong, and the surgeon is to rectify the dislocation with his hands, while some other person keeps the other foot down below. After the reduction it is to be bound carefully, some folds of the bandage being carried along the front of the foot, and some towards the ankle; but we must take care not to include the posterior tendon which is inserted into the heel. And the man is to be kept from walking for forty days; for those who attempt to walk before the cure is completed impair the actions of the part. If from a leap, as commonly happens, the bone of the heel is moved from its place, or if any inflammatory state is brought on, it is to be remedied by gentle extension and reduction, anti-inflammatory embrocations and secure bandages, the man being kept also in a quiet state until the part is restored. And dislocation of the toes, as we said with regard to the fingers, may be remedied without difficulty by moderate extension. In all these luxations and sub-luxations, after the reduction, and rest for a suitable number of days, any inflammation or swelling which may remain in the joints, and occasion a protracted impairment of the function thereof, is to be cured by emollient applications, the materials of which must be known to every one who is conversant with the matters relative to our art.
Commentary. Hippocrates states that dislocation at the ankle is generally produced by leaping from a great height. He remarks that the accident gives rise to excessive swelling of the part. When the parts have been reduced, he directs us to apply a bandage to retain them properly in position, which, he says, it requires some address to perform in a suitable manner. He recommends us to reduce dislocations of the toes and of the bones of the foot like those of the hand. His account of dislocations of the astragalus and of the os calcis is curious, but there is some difficulty in clearly apprehending his views. We need scarcely say that it is a subject still requiring elucidation.
According to Celsus, dislocations at the ankle-joint may take place in all directions. He recommends us to reduce them with the hands, by making extension and counter-extension. He advises us to make the patient lie in bed longer than in ordinary cases.
Oribasius makes mention of only three modes of dislocation at the ankle; namely, inwards, outwards, and backwards.
According to Albucasis, dislocation at the ankle can only take place inwards or outwards. When the bones of the tarsus are displaced, he directs us to restore them by making the patient put his foot upon the ground; and the surgeon, by placing his foot upon it and standing erect, is to push them into their place. After reduction, a splint is to be put under the sole, and secured with bandages. Rhases, Avicenna, and Haly Abbas evidently copy from our author. They give the same account as Hippocrates of dislocation of the astragalus.
Luxations of the tarsal bones are described in Sir Astley Cooper’s ‘Surgical Lectures,’ and other modern works. Modern authors are agreed that dislocations may take place in all directions, and that they may be complete or incomplete. It will be remarked that Paulus makes mention of sub-luxations.
This is the place where we shall be expected to give some account of the knowledge possessed by the ancients of the nature and treatment of Club-foot. It is singular that Hippocrates is almost the only ancient author who has treated of the subject in an interesting manner, and of him one need have little hesitation in affirming, that he displays more practical acquaintance with it than any other writer until the time of Stromeyer. He states that there are more than one variety of this impediment; that it is not, properly speaking, a dislocation, but a declination of the foot from its natural position; and that most cases of congenital club-foot admit of cure, if it be attempted before the limb is much wasted. He gives minute directions for restoring the limb to its proper shape by the fingers, and for securing it with waxed bandages and compresses, above which a piece of stout leather or a plate of lead is to be bound. Over all a leaden boot, like the Chian shoes, may be applied if necessary. By these means, he does not hesitate to declare that the deformity may be generally overcome more readily than one would have believed, “without cutting or burning, or any other complex mode of treatment.” (De Articulis, 62.) Galen’s commentary on this chapter is of use in illustrating the text of Hippocrates, but supplies no additional information for any practical purpose. (v, 642, ed. Basil.)
SECT. CXXI.—ON DISLOCATIONS WITH A WOUND.
In the case of dislocations with a wound the utmost discretion is required. For these, if reduced, occasion the most imminent danger, and sometimes death, the surrounding nerves and muscles being inflamed by the extension, so that strong pains, spasms, and acute fevers are produced, more particularly in the case of the elbows, knees, and joints above, for the nearer that they are to the vital parts the greater is the danger they induce. Wherefore, Hippocrates, by all means, forbids us to apply reduction and strong bandaging to them, and directs us to use only anti-inflammatory and soothing applications to them at the commencement, for that by this treatment life may sometimes be preserved. But what he recommends for the fingers alone, we would attempt to do for all the other joints: at first, and while the part remains free from inflammation, we would reduce the dislocated joint by moderate extension, and if we succeed in our object we may persist in using the anti-inflammatory treatment only. But if inflammation, spasm, or any of the afore-mentioned symptoms come on, we must dislocate it again if it can be done without violence. If, however, we are apprehensive of this danger (for perhaps if inflammation should come on it will not yield,) it will be better to defer the reduction of the greater joints at the commencement; and when the inflammation subsides, which happens about the seventh or ninth day, then, having foretold the danger from reduction, and explained how, if not reduced, they will be mutilated for life, we may try to make the attempt without violence, using also the lever to facilitate the process. We are to apply the same treatment to the ulcer as recommended for fractures with a wound.
Commentary. Hippocrates, as stated by our author, was decidedly averse to immediate reduction in cases of dislocation complicated with an external wound. Hence, in compound dislocations at the ankle, he forbids us to interfere at first, as attempts at reduction will certainly bring on convulsions or gangrene. Modern experience agrees with that of the father of medicine as to the danger attending these accidents. Compound luxations at the wrist, he says, prove fatal if reduced, but if let alone they generally get better. (De Artic. 64.) Compound dislocations at the knee are said to be particularly dangerous. (Ibid. 66.)
Celsus follows the line of practice recommended by Hippocrates. In cases of compound dislocations at the shoulder and hip-joint, he states that the danger is great if they are left unreduced, but pronounces death to be certain if they are reduced. Like Hippocrates, he approves of immediate reduction only in dislocations of the bones of the feet and hands. Even these, however, are not to be interfered with while the parts are in an inflamed state. He approves of bleeding, a spare diet, and rest. When a naked bone protrudes and cannot be got restored to its place, he advises it to be sawed off. (viii, 25.)
Galen gives his unqualified sanction to the practice of Hippocrates. See his commentary on the work ‘De Articulis’ and ‘Nicetæ Collectio.’
Albucasis, like our author, recommends gentle attempts at reduction before swelling and inflammation come on, and soothing treatment afterwards.
The practice of Haly Abbas differs nothing in principle from that of our author and Albucasis. If reduction has not been performed early, he forbids it until the inflammation has subsided.
Rhases appears to have copied his rules of treatment from our author. He recommends us, if possible, to replace the parts before inflammation comes on, but forbids it while they are in that state, for fear of occasioning convulsions and death.
SECT. CXXII.—ON DISLOCATION COMPLICATED WITH FRACTURE.
If a dislocation be attended with fracture without a wound we must apply the common extension, and replacement by the hands, as described for simple fractures. But if complicated with a wound, we must apply the suitable treatment from what has been said of fractures with a wound, and dislocations in particular.
Commentary. Haly Abbas says that when a wound, a fracture, and a dislocation are combined in one case, each is to be treated upon general principles.
Albucasis directs us to remove any spiculæ of bone which may protrude in such cases. He exhorts the surgeon to act cautiously but confidently, as such conduct will prove most pleasing in the sight of his Creator, and redound to his own glory.
END OF VOL. II.
C. AND J. ADLARD, PRINTERS,
BARTHOLOMEW CLOSE.