oedema of the arm disappeared simultaneously with the development of numerous varicose veins in the arm and shoulder. Syncope and sudden or early death; fat embolism.-Besides the numerous cases already quoted in this chapter which show the dangers to the life of the patient that may arise in the course of an attempt to reduce a recent or an old dislocation, there are still others which indicate that life may be seriously threatened, or even destroyed, by other accidents or complications than the rupture of important vessels or nerves or excessive reaction and suppuration. In some of the fatal cases the failure to make an autopsy leaves the cause of death obscure, but the symptoms point to rupture of a vessel as a possible cause. An example of this kind is the case of the mayor of Nîmes, operated on by Delpech' for a dislocation of the shoulder. Traction was made by ten assistants; at the moment of reduction the patient grew pale, became unconscious, and immediately died. This syncope seems to have differed only in its result from that accompanying rupture of a vessel or nerve in some cases (e. g., Agnew, Sands, and Flaubert, quoted above). Quite recently E. Boeckel' has reported a case the autopsy of which suggests another explanation, not only of some of the deaths by syncope, but also of some attributed to the anaesthetic. The patient was a man fifty years of age, with a recent ilio-pubic dislocation, who was brought to the hospital after an unsuccessful attempt to reduce. Chloroform was given and reduction made in seven minutes; the patient grew pale, his respiration weakened and promptly stopped. The autopsy showed the heart to be atrophied, both pulmonary arteries plugged by non-adherent clots, rounded like emboli, in the medium-sized branches and those of the third and fourth order, and also fat embolism of the lungs very wide-spread and intense. The iliac and femoral veins. were free, but there was a thrombus in the popliteal vein from which it was thought those in the pulmonary arteries had been broken off. Before the use of anaesthetics, in the times when muscular resolution was sought to be obtained by measures which depressed and weakened the patient, and when the efforts to reduce were made with great violence and sometimes prolonged for hours, exhaustion of the patient habitually followed, and death was sometimes the consequence. Malgaigne refers briefly to several such cases and gives one in detail: an athletic man, forty years old, with an old dislocation of the humerus. After having made a free venesection, Lisfranc reduced the dislocation by traction on the fourth attempt. The patient returned unaided to his bed and seemed well, although pale; two hours later he called the nurse, said he felt ill, uttered a cry, and died. The autopsy showed the vessels, nerves, and spinal cord intact, the viscera in good condition, and only an excessive injection of the vessels of the pia mater and a serous effusion in its meshes. Malgaigne: Loc. cit, p. 152. 2 Bockel: Mort subite par embolies pulmonaires, simulant la mort par le chloroform après réduction d'une luxation de la cuisse. Rev. des Sciences Méd., Oct. 15,. P. 687. 1881. Death by the action of an anesthetic, especially chloroform, is thought to occur in a larger proportion of cases of reduction of dislocation than in other operations, but no satisfactory explanation of the greater risk, if it actually exists, has been given. Of 134 cases of death by an anæsthetic collected by Marchand, in 17 the operation was the reduction of a dislocation; of these 11 were of the shoulder, 3 of the hip, and 1 each of the knee, elbow, and thumb. PART II. NON-TRAUMATIC DISLOCATIONS. CHAPTER IX. CONGENITAL DISLOCATIONS. UNDER the term non-traumatic may be included all dislocations which exist at birth (congenital), although it is claimed that some of them are due to violence inflicted upon the foetus in utero, or even during delivery, and those which appear subsequent to birth as the result of non-traumatic changes in one or more of the constituent parts of the joint ("spontaneous," "symptomatic," "inflammatory," "paralytic," "myopathic," "chronic," "tardy," "dislocation by distention," "by relaxation," "by destruction," "by deformity"), and those which may be reproduced at will by the individual, "voluntary." The existence of dislocations (at least of the hip) in the newborn child, and their non-traumatic character, have been recognized since the earliest times, but the accurate study of the subject may be said to have begun in 1818, with Schreger, who examined, post-mortem, two specimens in a girl two and a half years old and a woman of forty-eight. A few years later, 1826, Dupuytren brought the subject before the Académie des Sciences, and called attention especially to the facts that the affection was often inherited, and often bilateral. Since then the subject of congenital dislocation of the hip has been actively studied by many, and the similar but much rarer affections of other joints have received due attention. Statistics.-Dislocations have been observed at birth in many joints, but not only do those of the hip far exceed all others in number, but the latter are actually, as well as relatively, so rare that their statistics have not much value. Next to that of the hip the most common dislocation is apparently of the shoulder, and then that of the head of the radius. Krönlein says that the records of Von Langenbeck's Polyclinic show 90 congenital dislocations of the hip, 5 of the shoulder, 2 of the head of the radius, and 1 of the knee. It is not exceptional to find several dislo The use of the term congenital to classify certain dislocations is objectionable for several reasons, which will appear in the course of the discussion of the subject. It includes forms that radically differ in their etiology and pathology, but as these forms cannot well be distinguished from one another during life, a classification based upon other points cannot be realized in practice, but must be confined to the deadhouse and museum. cations present in an individual, or one or more dislocations associated with such congenital defects as spina bifida, club-foot, ventral hernia, encephalocele, and exstrophy of the bladder. As will appear in studying the etiology of this affection, the statistics of congenital dislocation of the hip include cases widely different in their origin, and even some which are acquired and not congenital, that is, some which have been produced during the first few months of life, perhaps before the patient began to walk, by the unopposed action of certain groups of muscles after paralysis of others. It seems probable, however, that the error thus arising is not a large one, but still, for this and for other reasons, I shall here quote only the more recent statistics, believing them to be the most nearly correct. These are Drachmann's,' Pravaz's (quoted by Krönlein) and Krönlein's.2 TABLE VI.-CONGENITAL DISLOCATIONS. Prahl's, quoted above in Chapter I., are not given in sufficient detail to be included in the table; they comprise 18 cases; 3 were males, 15 females, making with those in the table a total of 292, of which 38 were males, 13 per cent., and 254 females, 87 per cent. Angots says that of about 20 cases observed by him at the Hôpital des Enfants malades in 1882, all were girls. Of 11 cases of congenital dislocation of the knee collected by Hibon, 7 were girls, 3 boys, and in 1 the sex was not recorded; of these, 3, 1 girl and 2 boys, were stillborn, and presented other very marked deformities. 5 According to a remark made by Broca in a discussion on this subject in the Société de Chirurgie, Parise, while interne at the Hôpital des Enfants trouvés, dissected the hips of all the children that died there during his term of service, 332 in number, and found single and double dislocations in 3. This would indicate a far greater frequency of the affection than clinical records do. Etiology. The discussion of this branch of the subject, which was taken up with much interest after the publication of Dupuytren's memoir, was not fruitful of positive results because of the lack of anatomical material and minute examination, and of the failure distinctly to dis 1 Drachmann: Schmidt's Jahrbuch, 1881, vol. clxl. p. 170. Krönlein: Deutsche Chirurgie, Lief. 26, p. 82. Angot: Luxations congénitales de la hanche. Thèse de Paris, 1883, p. 11. Hibon: Luxations congenitalés du tibia en avant. Thèse de Paris, 1881, p. 7. 5 Broca: Bulletins de la Société de Chirurgie, 1866, vol. vii. p. 331. criminate between different forms and between the original bony defects and the changes produced by long use of the deformed limb. Since the affection is one which often escapes recognition until the child begins to walk, it was sometimes confounded with dislocations resulting from infantile paralysis, and as it is one which does not destroy life, the opportunities for direct anatomical investigation were almost entirely restricted to two classes of cases, the stillborn and those that died shortly after birth in consequence of other important congenital defects, and those in which the original changes had been masked or supplemented by subsequent ones produced by the further displacement of the head of the femur and its abnormal relations to the adjoining parts. In the former, incorrect inferences were drawn from the associated defects, as when the irritation of an over-full urinary bladder, or the separation of the symphysis pubis, was deemed the immediate cause of the arrest of development of the acetabulum; and in the latter the attention was led far astray by prominent changes in the bones. The history of the theories advanced has not only an historical value, but it serves also to indicate certain varieties and prominent features of the affection, and therefore I append the following résumé made by Krönlein. It must be remembered that most of the theories deal exclusively with dislocations of the hip. 1. The so-called congenital dislocation is traumatic, and arises: a, through external violence acting upon the foetus in utero, or through the action of the muscles of the foetus itself. Hippocrates and the early writers held that mechanical injuries of the belly of the mother could produce dislocation in the foetus. Cruveilhier did not entirely reject this theory in some cases. Chatelain, Kleeberg, Zielewicz, even specify in their three cases the injury, a fall in the seventh month, which, in their opinion, had caused the dislocation. Chaussier claims even that a dislocation can be caused by the contraction of the muscles of the foetus, and narrates in support the case of a young woman who, during the ninth month of pregnancy, felt on three occasions such violent movements of the child that she almost became unconscious. When delivery took place at term, the child had a complete dislocation of the left forearm. b, during delivery. Capuron (1834) held that some congenital dislocations of the hip had been produced during delivery, by traction with the finger on the groin in breech-presentations. Chelius and d'Outrepont (1839) maintained even that none of the so-called congenital dislocations of the hip were congenital in the sense that they were due to a faulty development of the acetabulum, but that all were caused by traction on the foot during delivery. 2. Congenital dislocation (of the hip) is a spontaneous dislocation, and is occasioned: a, by softening and laxity of the ligamentous portion of the joint (Sédillot, 1836). This opinion was held in part by Stromeyer (1840). |