have found that extension of the lower extremity on the affected side, especially if the thigh is well flexed, adds much to the comfort of the patient and reduces apparently

Fig. 118.-Attitude in bed of a patient with fracture of the pelvis (Kurek, 1895), with a circular extension dressing. On the 14th of May, 1895, Kurek sustained a severe injury by the giving way of the floor of a barn loaded with about 25 tons of oats. The joists and other parts of the wood work fell on his left side. Great extravasation of blood in the region of the left hip and pelvis; pain elicited by lateral compression, with indistinct crepitation and abnormal mobility. The seat of greatest pain was in the region of the left sacro-iliac articulation. The urine was voided spontaneously and was not mixed with blood. There was a large ecchymosis in the scrotum. The pelvis was dressed as shown in the illustration and the patient recovered. He was discharged on the 19th of July, 1895. The left innominate bone is about 2 cm. higher than the right. The region of the posterior superior spines of the ilium is thickened by new-formation of bone and still sensitive to pressure. Patient wore a circular plaster-of-Paris dressing when he was discharged.

the resultant shortening of the limb. A Smith's anterior splint provides the most convenient method of extension. In four cases of fracture of the pelvic ring I have observed a

moderate degree of shortening of the limb on the affected side due to the elevation of the pelvis. The leg is also slightly adducted. If not carefully examined, the deformity might be mistaken for an old fracture of the neck of the femur. The functional result is always good. Fracture of the wing of the iliac bone is not infrequently associated with extensive hemorrhage and the formation of a large hematoma. In one instance I found it necessary to make an incision and pack with gauze the bleeding fractured surface of the cancellous bone. The hemorrhage was profuse and checked with great difficulty. If at hand, Horsley's wax would probably check the hemorrhage better than gauze.-ED.]

The treatment of a laceration of the urethra does not, as a rule, present any unusual difficulties. If, however, the bladder is lacerated at some inaccessible point,―as, for example, behind the symphysis, the management of the case may become very difficult. The dribbling of the urine irritates the skin over the back of the pelvis and bed-sores develop which are very difficult to control. If possible, the patient should be placed in a permanent bath.1

2. HIP-JOINT

Dislocation of the hip-joint is rather a rare injury, and requires severe violence for its production. The force acts indirectly through the trunk or the thigh, as when the injury is produced by a cave-in, by being run over, by a fall from a great height, etc. Dislocation by direct action on the region of the hip must be extremely rare. The most important forms are backward and forward dislocations, but they are very much more rare. Since the investigations of Bigelow in Boston we know that the mechanism and the fixation of the luxated bone are determined by the iliofemoral ligament (or Bertini's ligament) [the Y-ligament.-ED.], which in all regular dislocations remains in

1 See Mitchell's article (l. c.) for use of bath.

An irregular dislocation without characteristic symptoms is possible only when that ligament has been torn.

(A) Backward Dislocation (Luxatio postica sive retrocotyloidea). (Plates 50, 51, 52.)

If the flexed and slightly abducted thigh is rotated inward, the posterior portion of the capsule is put on the stretch. If the movement is continued, the neck of the femur catches on the edge of the acetabulum and a fulcrum is provided so that by means of the long arm of the lever (the shaft of the femur) enormous power can be exerted on the short arm-the head of the femur. The head is forced against the capsule, which gives way at its posterior portion, and the head escapes from its articular connections, the ligamentum teres being torn. Thus the backward dislocation is completed.

We distinguish two forms: iliac and ischiatic dislocation. In the former the head is found on the iliac bone; in the latter it occupies a deeper position on the upper segment of the ischium. The position of the tendon of the obturator internus in relation to the head of the femur is an important anatomic distinction. In the iliac form the

head of the femur is above, in the ischiatic form below, the tendon. An ischiatic dislocation may be produced experimentally by rotating the strongly flexed thigh inward. The iliac form is also produced by inward rotation, but with the thigh in less pronounced flexion.

In the living subject posterior dislocation is brought about in the same way, either by movement of the leg (rare), or, more frequently, by movement of the trunk or pelvis while the leg is fixed, the head of the femur becoming displaced above or below the tendon of the obturator muscle. Or the head may first escape from the acetabulum in its postero-inferior segment and, by secondary dislocation, approach the position characteristic of iliac dislocation, until the Y-shaped ligament and the external

PLATE 50.

Backward Dislocation of the Thigh.-Fig. 1.-Ischiatic dislocation artificially produced in the cadaver. The gluteus maximus has been split, each part being held aside by retractors, so that the head of the femur and deeper-lying soft structures are exposed. Immediately below the gluteus maximus is a strip of tissue, belonging to the gluteus minimus, and under the latter, the pyriform muscle. The obturator internus occupies a position above the head of the femur, but lies at some depth, so that little is to be seen of it. Below the head, and surrounding it like a cravat, we see first the obturator externus, and lower down the quadratus femoris, some of the fibers of which are lacerated. On the median side of the head of the femur is the sciatic nerve; between it and the edge of the lower portion of the gluteus maximus are the tuberosity of the ischium and the tendon of the biceps femoris, which has its origin at that point.

Fig. 2.-Anatomic preparation of the hip region seen from behind; the conditions are normal. The plate is explained by figure 119.

Fig. 3.-Iliac dislocation, artificially produced in the anatomic specimen (see Fig. 2). The head of the femur is above the obturator internus.