Under the most minute antiseptic precautions" an incision ten centimetres long was made, beginning at the anterior inferior spine of the ilium, and carried through the fascia and muscles to the same extent; the great trochanter was found fixed against the cotyloid cavity, and a thick layer of fibrous tissue, thought to be the anterior portion of the capsule, extended from the upper rim of the acetabulum to the upper border of the neck of the femur; this was divided, and the finger could then be introduced into the articular cavity. Reduction being still impossible, the muscles inserted upon the front of the great trochanter were in part detached, and the head and neck separated from the soft parts as freely as possible by a blunt elevator. The thigh was then flexed upon the abdomen, rotated inward, and extended, by which the head of the femur was carried behind the acetabulum, and then by traction it was brought into the socket.

Two days later the parts adjoining the wound were infiltrated with fetid gas; several sutures were removed; the tissues were gray and had the odor of putrefaction; on the fifth day, December 20th, the patient died.

Dr. McBurney's case has not yet been published; the patient, about seven years old, was admitted to St. Luke's hospital, New York, in 1886, with a dorsal dislocation of several months' standing. A longitudinal incision was made above and along the great trochanter, and the iliofemoral ligament divided close by its attachment to the femur. Reduction was then made. The patient was kept in bed for several months because of the persistence of a sinus in the wound; as the probe disclosed the presence of bare bone the sinus was enlarged, and as the head of the femur was found to be carious it was excised. Sufficient time has not yet elapsed for the ultimate result to become known.

This showing is far from favorable; of six cases reduction was accomplished in only two; and of these two one died of the consequences of the operation, and in the other the head of the femur became carious. Still, it should be said that in MacCormac's case the length of time that had elapsed left no reasonable ground for the hope that the operation could be successful, and in Volkmann's case it does not appear that the adherent muscle which covered the cotyloid cavity could not have been detached. The fatal result in Polaillon's case may perhaps be fairly attributed to the repeated violence inflicted in the preceding attempts to reduce, from which the tissues had apparently not entirely recovered at the time of the operation. The caries of the head which spoiled the result in McBurney's case is, I fear, a consequence which may frequently follow and which may prove to be the most important objection to undertaking the operation.

Excision of the head, or of the head, neck, and great trochanter has been done in nine cases, in eight of which the dislocation was traumatic, and in three spontaneous, having occurred in the course of acute articular rheumatism or typhoid fever. The traumatic cases are those of Delagarde, Volkmann, MacCormac, Quénu, and Severano, already quoted,

1 Delagarde: St. Barth. Hosp. Rep., 1866, vol. 2, p. 183.

2

and Sydney Jones; the spontaneous cases are those of Bruns, Rawdon,3 and William Adams. In connection with these may be considered the cases of Bryck, Czerny, and Post, above mentioned, in which the head of the femur became necrosed after fracture of the neck accompanying or following dislocation and was removed; and it may further be added that, according to Krönlein, Roser excised the head of the femur in 1874 in a case of congenital dislocation.

Delagarde's patient was a man fifty-one years old, who, five months before the operation, had been crushed under a fallen wall, receiving a dorsal dislocation of the left hip and fracture of the femur in two places; the fractures had united. The slightest attempt to move the thigh made the head of the femur press on the sciatic nerve, producing throughout the limb a most peculiar and intolerable numbness. The head was deeply lodged in the upper part of the sciatic notch.

A deep incision was made from the trochanter to the sacrum through the gluteus, which laid bare the head and neck of the femur; the ligamentum teres had been strained, but not broken; the tendon of the pyriformis passed under the neck. By means of a trephine a hole was made in the neck of the femur at its junction with the shaft, and the remaining strip of bone on each side was sawn partly through with a narrow saw, the division completed with bone forceps, and the head and neck removed. The sciatic nerve was laid bare for an inch and a half, it was curiously flattened and moulded to the head of the femur. The relief was immediate. The wound healed in six weeks, and the patient was discharged four months after the operation with a serviceable limb.

Jones's patient was a boy eleven years old with a dorsal dislocation of six months' standing. "On Nov. 25, 1879, Mr. Sydney Jones excised the head of the femur, corrected the malposition of the limb, and drew down the upper end of the shaft to the acetabulum, which was filled up with condensed cellular tissue and inflammatory material. Now, five years after the excision, the boy has a straight limb an inch shorter than the opposite one. He can run, jump, play cricket, and ride a tricycle." Volkmann's and MacCormac's cases have been given in detail above; both were obturator, but Volkmann's had been transformed into a dorsal dislocation before operation. Quénu's was dorsal.

Bruns's case was a "double spontaneous or pathological dislocation of the hip forward and downward (obturator and perineal)." The patient was a boy eight years old, who had suffered two years previously with acute articular rheumatism affecting all the joints in turn, but persisting after two months only in the hips and knees. The limbs gradually became abducted, and large abscesses formed and were opened below the groins; the suppuration persisted for many months.

Both thighs were abducted at a right angle with the trunk, so that the knees and toes looked directly outward. The head of the left femur could be distinctly felt resting at the junction of the rami of the pubis and ischium; that of the right femur lay upon the obturator foramen.

Sydney Jones: Lancet, 1884, ii. p. 870.

2 Bruns: Abstract by Tillmanns, Centralblatt für Chir., 1879, p. 697.

:

3 Rawdon Liverpool Med. Chir. Journ., 1882, p. 22.

Adams: Lancet, 1884, ii. p. 775.

Both hips were immovable, and the knees could not be extended beyond a right angle. Locomotion was possible only upon all fours and sidewise. Bruns treated the case by excising the head of the left femur, and making a subtrochanteric osteotomy on the right side.

The excision of the head was done through an incision through the adductor muscles in the long axis of the thigh, down upon the head of the bone. The detachment of the head from the soft parts could not be completely effected, and it had to be removed piecemeal after the neck had been sawn through. The position of the limb could not at the time be corrected, because of the tension of the contracted muscles, but after the wound had almost healed the limb was straightened under anæsthesia by the employment of moderate force, although with rupture of the tensor vaginæ femoris; the upper end of the femur remained in a position corresponding to that of an iliac dislocation. The knee also was straightened, and continuous traction applied. This forcible straightening was followed by suppuration at the place where the muscle had been torn, and the pus burrowed all along the back of the thigh down to the knee, greatly reducing the patient's strength.

Five months after the first operation, the abscess having completely healed, the second operation, subtrochanteric osteotomy, was done upon the right side; the bone was chiseled through three-fourths of its circumference, and the remainder broken; the limb was at once made straight, and the knee extended, and continuous traction applied to both limbs. The wound healed without incident, and in four weeks the fracture was consolidated.

Three months after the last operation the condition of the patient was very satisfactory; both hips and knees extended, the right hip ankylosed, the left quite movable, dislocated upon the ilium, rotated outward, and shortened five centimetres. The boy had already learned to stand upright and walk quite well with a thick sole on the left foot and a cane.

66

Rawdon's patient was a girl eight years old, whose right hip had become dislocated backward during an attack of typhoid fever, which ended about two months before she came under observation. Very free painless flexion was possible, extension to 135°, abduction and outward rotation almost entirely lost. An incision two and a half inches long was made, parallel with the shaft of the bone a little behind the trochanter; reaching the neck, the muscular coverings were dissected off the head, cutting upon its rotundity with the thumb pressing back the tissues which embraced it, until the head could be turned out, and the neck divided with a blunt-pointed metacarpal saw." Antiseptic treatment discontinued after six days because of the abundance of the discharge and accidental wettings; no fever; wound healed in a month. Continuous extension by weight and pulley was begun on the third day, and maintained for four weeks; the limb was then found to be "capable of all the natural movements, freely and without pain." One inch shortening on measurement. Two months after the operation she could walk quite naturally without crutches.

Adams's patient was a boy eleven years old, with a dorsal dislocation that had taken place during a rheumatic fever. He made "a T-shaped incision with the long arm two and a half inches in length directly over

the head and neck of the bone, and the small arm one inch in length transversely over the head of the bone, which was at once exposed. It was found that the capsular ligament had been ruptured, and the torn margins of the rent passed on either side of and closely embraced the neck of the bone. After dividing the margins of the capsular ligament the operator passed his small subcutaneous saw to the neck of the bone, and cut through it a little below the margin of the articular cartilage, and withdrew the head. There was not much suppuration, and the wound was completely healed two months after the operation. A fortnight later the patient walked with crutches, and four months later without them. "The limb was perfectly straight, and the movement at the hipjoint was free in all directions."

Subtrochanteric osteotomy has been done, in addition to Bruns's case above mentioned, by Van Wahl and Koch. The latter's patient was a man forty-one years old, with a dorsal dislocation that had existed for twenty months, and in which the flexion was so great that the patient could not use the limb in walking. October 3, 1881, a wedge of bone was removed from the outer and posterior portion of the femur on a level with the lesser trochanter; the wound healed in two weeks, and the bone was then broken under anæsthesia, and the limb placed in a gypsum dressing in the position of extension, abduction, and outward rotation. The fracture united in three weeks, and it was then found that, owing to the intractability of the patient, the position had not been preserved, but that the limb was flexed 40°, and equally abducted. The functional result was nevertheless good.

He mentions a case of dislocation twenty-five days old treated by Van Wahl in like manner, except that the fracture was made at the time of the removal of the wedge, in which the result also was good.

Subcutaneous fracture of the neck has never, so far as I know, been intentionally done to correct a vicious position of the limb, but in a number of cases in which it has occurred during an attempt to reduce it has been utilized for this purpose and with good results, although, as above mentioned, necrosis of the head of the femur has twice ensued. The objection to it, and also to subtrochanteric osteotomy is that, unless the dislocated head is movable the limb is fixed in the position of extension, and while that position is advantageous in walking, it is very inconvenient when the patient is sitting. In this respect excision of the head is to be preferred.

CONGENITAL DISLOCATIONS. (See Chapter IX.)

SPONTANEOUS OR PATHOLOGICAL DISLOCATIONS.

Almost all the different kinds of spontaneous dislocation have been observed at the hip, and many of them with a frequency that has not been observed at other joints. The weight of the body in walking is a factor of much importance and constantly at work, the effect of which is well

1 Koch Berlin. klin Wochenschrift, 1882, vol 19, p. 492.

shown in three cases reported by Lücke,' in which the dislocation followed rachitic changes in the shape of the femurs and the spinal column. The patients were children who, at birth and during infancy, showed no sign of dislocation; after a time rachitic changes occurred, the displacement appeared, and walking became difficult. Lücke found a marked lumbar lordosis and anterior curvature of the femurs; the trochanters were displaced far back ward, and the dislocation was evident. He thought the curvature of the femurs was the primary change, and the lordosis compensatory of it, and that the dislocation was due to changes in the acetabulum following the consequent pressure at an unusual point.

Of similar character are those cases in which the dislocation has taken place in a healthy joint in consequence of the prolonged maintenance of some exceptional attitude, as in a case reported by Franks of a child five years old, who had been confined to the bed for many months by an arthritis of the left hip, and had lain upon its left side with the knees and hips flexed, and the right hip adducted; a dorsal dislocation took place without pain in the right side. Here the contraction of the muscles takes the place of the weight of the body in producing the dislocation when the limb is long held in a favorable attitude, and many examples of this effect have been reported in cases in which the joint was the seat of an arthritis, as in acute articular rheumatism, or in continued fevers, typhoid, scarlatina, in which usually there are indications of inflammation of the joint, although in some cases attention was first called to the joint by the appearance of the deformity. As the individual usually lies with the thigh flexed and adducted, the dislocation almost always takes place backward and upward; but in a case observed by Stromeyer,3 a man eighteen years old, affected with acute articular rheumatism, especially of the hip, during the entire course of which he had lain on his side, the dislocation was into the obturator foramen.

It is believed that in these cases, at least in those in which there is any inflammation of the joint, the quantity of synovial liquid is increased, the ligaments and the capsule are softened and, perhaps, lengthened, and thus the dislocation is favored. The immediate cause of the dislocation is the persistent contraction of the muscles which connect the femur with the trunk, a contraction which is stimulated by the pain in the joint.

"Paralytic" or "myopathic" dislocations of the hip, those in which the displacement is effected by the unopposed contraction of certain muscles or groups of muscles, whose antagonists are paralyzed, have been most frequently seen as a consequence of infantile paralysis. As has been shown in Chapter X. they were formerly confounded with congenital dislocations, and were first clearly separated from them by Verneuil, and afterward studied in detail by some of his pupils, especially Reclus." When the paralysis involves all the muscles of the hip the joint becomes loose, and the femur may be displaced and replaced at will, but when

1 Lücke: Quoted by Forgue and Maubrac, Luxations pathologiques, Paris, 1886,

p. 15.

2 Franks: Lancet, 1883, ii. p. 15.

3 Stromeyer: Handbuch der Chir., 1844, vol. i., quoted by Forgue and Maubrac. Verneuil Bull. de la Société de Chirurgie, 1866.

5 Reclus: Revue de Méd. et Chir., 1878, p. 176.