physician, was thrown from a wagon, striking upon and dislocating his right shoulder. While continuing his journey and suffering severely, he attempted to get a flask of brandy from his valise that lay upon the seat beside him; with the hand of the injured arm he grasped the handle of the valise to steady it while he opened the lock with the other; a sudden jolt threw the valise from the seat, and by the involuntary effort to arrest its fall its weight was brought upon the injured arm and the bone slipped back into place with a distinct snap and immediate relief of the pain. Malgaigne gives several examples of spontaneous reduction of dislocation of the hip. In one, a dislocation downward and forward, the operation for reduction was postponed and the patient placed in bed; during the night he sought to turn upon his side and raised the limb with his hands, the pain caused him suddenly to loose his hold, a snap was heard, the pain ceased, and the dislocation was found to be reduced. In another, many fruitless attempts had been made to reduce a dislocation inward, and the case had been abandoned. One day the patient was getting into a wagon and had placed the sound foot upon the step, while raising the other he heard a dull sound, and the bone was found to be in place. In another1 a young man fell from a height with his legs apart, and at once suffered great pain in the upper part of the thigh and felt a hard lump there. Without changing his position he pressed upon this lump, and it disappeared with a distinct sound. It was thought to have been a dislocation of the femur downward and forward. A case observed by Cornish and quoted by Sir Astley Cooper2 is very remarkable because of the length of time, five years, between the occurrence and the reduction of the dislocation. It was a dislocation of the hip upon the dorsum; the patient went on crutches for five years, and then, while making a voyage, was thrown from his berth to the deck, and the dislocation was reduced with a loud snap; he was afterward able to walk easily and without a limp. Cornish, who fully appreciated the remarkable character of the case, lived in the same town with the patient, and knew and examined him both before and after the reduction. In other cases spontaneous reduction, without the aid of external force, has followed shortly after attempts to reduce which have been unsuccessful but which may be thought to have made spontaneous reduction possible by rupture of adhesions, or laceration of the tissues, or fatigue of the muscles. This variety was termed consecutive reduction by Léveillé, and the term was adopted by Malgaigne, who applies it both to cases in which spontaneous reduction takes place after complete failure of the efforts to reduce and also to those in which an incomplete reduction spontaneously becomes complete or is gradually made complete by the prolonged action of some force applied by the surgeon-such as pressure. The following examples are quoted from Malgaigne: A man fifty-four years old came to Palletta with a dislocation of the shoulder a week old; many fruitless attempts to reduce had been made, and the elbow and forearm were prodigiously swollen. After some days of preparatory treatment Palletta tried to reduce with Freke's machine and failed; the attempt was repeated four days later, and this time the head of the bone shifted its place somewhat, with the accompaniment of a cracking sound; the patient was replaced in bed, and the arm supported in a sling. Two days afterward the bone was found apparently in place and the movements of the joint had become much more free, but still something was lacking in the form of the region, and it was not until after three or four days more that the reduction became complete. A similar case came under Malgaigne's own observation: a very marked intra-coracoid dislocation of the humerus which had resisted twenty-one attempts to reduce it before the patient came to Malgaigne. The swelling being enormous, he instituted a preparatory treatment and then applied the pulleys, but the pain was so great that he was obliged to desist. A week later he tried again, and while engaged in the effort he drank by mistake an emetic prepared for the patient, and was thereby again obliged to abandon the attempt after having brought the head of the bone somewhat nearer the glenoid cavity. The elbow was supported in a sling, and the shoulder covered with poultices. The next day the shoulder was found to have regained, in great part, its natural form, and during the following days the reduction became complete. Other cases involving the hip are mentioned by different authors, but without exact references. The obstacles to the reduction of recent uncomplicated dislocations arise from inflammatory swelling of the soft parts, muscular contraction excited by pain or the fear of pain, the inextensibility of untorn portions of the capsule or ligaments of the joint, the interposition of portions of the capsule between the head of the bone and its cavity, and the size and position of the rent in the capsule. All of these are not present in every case, and they vary in importance. For a long time the muscles were deemed the most important, but observations and experiments upon the cadaver carried on at about the same time by several different personsGunn' in 1851, Gellé2 and Bigelow in 1861, Streubel in 1862, and Busch in 1863-fixed the attention of surgeons upon the relations between the bone and the capsule, showed the nature and importance of the opposition commonly offered by the latter, and established the basis of treatment by systematic manipulation. An account has already been given of the part played by the untorn portion of the capsule in determining the position assumed by the limb, a part so important that in "regular" dislocations (the term given by Prof. Bigelow to those in which the rent in the capsule is only partial and occupies a certain definite place in it) the muscles surrounding the joint may all be divided without thereby modifying the position of the limb or increasing its range of motion. At the hip the portion which remains untorn in all the typical forms is the anterior portion or Yligament; at the shoulder it is the thicker anterior portion forming the so-called coraco-humeral ligament. It is more correct to speak of the 1 Gunn: Peninsular Journal of Med., July, 1855, p. 27. ? Gellé: Archives générales de Méd., April and May, 1861. Streubel: Vierteljahreschrift für prakt. Heilkünde, 1862, ii. p. 59. obstacle offered to reduction by this untorn portion of the capsule as an obstacle not to reduction in general, but only to reduction by certain. methods, for when properly managed it offers no opposition, and may A FIG. 7. possibly even be of assistance. It may be compared to the link of a sleeve-button, which in some positions absolutely prevents the button from passing back through the button-hole, while in other positions the passage is easy. Thus, if the head of the bone is displaced, for example, to the right and lodged behind a projecting portion of the rim of the articulation, the ligament (Fig. 7, A) is tense, and traction in any direction which tends to separate its points. of attachment is effectually opposed by it; but if these points are brought nearer together by moving the shaft of the bone in the direction indicated by the arrow, the ligament is thereby relaxed and its opposition to the movement of the head of the bone toward its cavity annulled. The position of the untorn portion of the capsule or ligament must be inferred from the posture of the limb and the directions in which motion is strongly opposed. Diagram to illustrate the action of an untorn ligament or portion of capsule in opposing reduction. In "irregular" dislocations, those in which a characteristic attitude ist not taken by the limb and in which the mobility is marked, these differences are due to extensive rupture of the capsule; and this, by removing the restraint imposed in other cases by the untorn portion of the capsule, makes reduction remarkably easy without much attention to the position in which the limb is held during the attempt. In addition to this opposition to movement or traction in certain directions, the capsule may offer other obstacles arising from the form and position of its rent and from its own possible interposition between the head of the bone and the cavity in which the latter is to be replaced. The tearing of the capsule is caused by the pressure of the head upon it, consequently the rent is on the side toward which the head is displaced, and it may be longitudinal or transverse at either attachment, or present a combination of the two forms. In order that either of these obstacles should be present, it is necessary that the head of the bone should have passed entirely through the rent-that, in other words, its displacement should be marked. As the rent, under these circumstances, is large enough to allow the head to pass out through it, it is large enough to allow it to be brought back through it if it is not made too narrow and its sides too tense by traction upon them. The effect of traction to narrow the opening can be demonstrated on the cadaver (Streubel, loc. cit., p. 70) by producing a subcoracoid dislocation of the humerus or an obturator or ischiatic dislocation of the femur, exposing the region by removal of the muscles, and then making traction in the extended position. As the capsule is made tense the sides of the longitudinal part of the rent are drawn together, and their lateral separation, which alone would allow the globular head of the bone to pass back, is prevented. The narrowness of the gap is at once relieved by changing the position of the limb in such manner as to bring the points of attachment of the capsule nearer together, and the transverse portion of the rent can be lengthened by rotating the limb. Interposition of the capsule between the head and its cavity may exist whenever a secondary displacement has succeeded the primary one and the head has moved from the point at which it escaped along the outside of the capsule, but unless the capsule has been so torn as to form a flap adherent by its base to the edge of the articular cavity, this interposition can be readily avoided by moving the head of the bone back to the position of primary displacement. If, on the other hand, such a flap has formed and has fallen between the articular surfaces (as in Fig 4, p. 47), there is no means, short of an operation that directly exposes it, of certainly getting it out of the way; it is attached to only one bone, and consequently cannot be acted upon by moving the other or changing the relations to each other of the two. Another obstacle, similar in character to that offered by a narrow rent in the capsule, may be occasioned in dislocations backward of the thumb upon the metacarpal bone by the passage of the head of the latter between the flexor tendons that are attached to the base of the phalanx; the tendons, after separating to allow the head of the bone to pass between them, embrace the narrower neck tightly, because they are overstretched, and the attempt to reduce by drawing the phalanx downward only makes them more tense. The difficulty can sometimes be overcome by unbuttoning the head, as it were, by pressing the phalanx to one side and then, by a movement of rotation and circumduction, slipping the tendon of that side past the head of the bone. Swelling of the soft parts interferes with reduction by increasing the bulk of the limb within the fascia and thereby mechanically opposing changes in position. If it is very great it may be proper to defer reduction and combat it by rest, cooling lotions, and pressure; it will usually subside so promptly that the loss of time thus incurred will not add. appreciably to the difficulty of reduction when it is undertaken. Contraction of the muscles, provoked by the traumatism or the fear of pain, opposes reduction by preventing the preliminary changes of position and neutralizing to a greater or less extent the traction that is made upon the limb. It may be overcome by gentle and long-continued traction, or forcibly, or by anæsthesia, or it may be avoided by taking the patient unawares or distracting his attention at the critical moment. The methods formerly employed of weakening the patient by emetics or bloodletting, or stupefying him with alcohol or opium, have now been entirely abandoned. Other methods that have been recommended-the passage of the constant galvanic current through the muscles (Remak) and compression of the main artery (Rist)-have been entirely neglected because of the superiority of anesthesia by ether or chloroform. Anæsthesia is far from being needed in all cases, and as there are certain discomforts and even dangers in its use an attempt to reduce without its aid should usually be made. In New York, and, I think, in most of the large cities of the United States, ether is habitually used in preference to chloroform, and although chloroform is still used in Europe, the greater safety of ether is almost universally admitted. The collected cases of death under chloroform apparently prove the correctness of an opinion quite generally held that its use in dislocations is especially dangerous, although no satisfactory explanation of the fact has yet been given. Of 101 fatal cases collected by Kappeler' between 1865 and 1876, 11 were dislocations, 20 amputations, and 11 operations upon the eyes; of 134 cases collected by Marchand2 17 were dislocations, and 15 extractions of teeth. It is not always necessary to push the use of ether to complete anesthetization, for the relaxation is sometimes sufficient during the stage of primary anaesthesia, if care is taken not to excite the patient unduly. Gentle traction may be made upon the limb as the anæsthetization is begun, and its direction gradually changed or merged into the desired manoeuvres as the muscles are felt to yield. Since the nature of the obstacles to reduction has been more correctly understood the methods by forcible traction have been so far superseded by the methods of manipulation that they now possess only an historical interest. They consisted essentially in extension (traction), usually in the line of the dislocated limb, and counter-extension to bring the head of the bone down to the level of its cavity, followed then by measures of "coaptation" to force it into place. The traction was made through bands attached to the lower segment of the limb, and the force was exerted either directly by the hands of several assistants or indirectly through pulleys or screws. The amount of force sometimes exerted by these means can be inferred from the disastrous and even fatal consequences that occasionally ensued, including rupture not only of muscles and ligaments but also of the principal nerves and blood vessels, and even complete avulsion of the limb. Suppuration of the joint, followed by the death of the patient, an accident which is now very rare, was formerly quite common, and in very many of the cases which recovered the record plainly shows the violence of the reaction and how narrowly the patients escaped with their lives. The occasion for the exertion of so much force arose from the faulty direction in which it was frequently applied, one in which the head of the bone could not be brought down to the level of the cavity without preliminary rupture of the opposing soft parts. The laceration caused by the dislocation was increased by the treatment, in order to enable the bone to follow a course which the ligaments, if untorn, would effectually bar. The method was directed against an obstacle, the resistance of the muscles, which was only one, and not the chief, of those which opposed reduction, and was pursued in ignorance of the principal one; violence was used to overcome an obstacle which correct anatomical knowledge would have enabled the surgeon to avoid. It must not be understood that this extreme violence was exerted in every case. In many the traction was made in a proper direction, or at least in one in which the already existing laceration of the capsule allowed the bone to be moved; hence, many dislocations were reduced with comparative facility, especially those of the shoulder and those of 1 Krönlein: Loc. cit., p. 66 2 Marchand: Des accidents qui peuvent compliquer la réduction des luxations traumatiques, 1875, p. 134. |