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It is maintained that the disease goes on and commonly runs its course; but it is admitted that it is occasionally cut short, and that it is almost always rendered comparatively free from high fever, pain, and swelling; that heart damage is less liable to occur and is less serious; and that relapses are less frequent.
It is needless to multiply examples to show that great progress has been made in the acquisition of definite agents and in the knowledge of how to use them; and, should the next ten or twenty years prove as fertile in the resources of the medical art as is indicated by the progress of the past, the profession will occupy a much higher position in the estimation of the public than it now does.
It should not be inferred from the above that all the prominent changes in relation to the materia medica within the past few years have been improvements or have been for the good of either the profession or the public; for much doubtful medication has grown into common use with large numbers of physicians who do not seem to stop to think where the mercantile enterprise of the manufacturer is carrying them.
NOTES ON DISLOCATION OF THE HIP, BASED UPON TWO HUNDRED AND SEVENTY-THREE CASES OCCURRING IN NEW YORK STATE.
By FREDERICK HYDE, M. D., of Cortland County.
Read by Title, November 18, 1884.
ALTHOUGH dislocations of the hip are rare, their written history dates from early times, and the old masters in anatomy and surgery have left records of their observations upon these important lesions. It is not, therefore, true that the infrequency of the dislocations in question can be urged in extenuation of errors in diagnosis and of the consequent bad results of their treatment. On the contrary, luxations of the head of the femur have been regarded, from an early period of the history of surgery, as entailing great responsibility upon those who have charge of their treatment.
There are many diseased conditions in which an incorrect diagnosis, or its too tardy correction, would not make so great a difference in the future welfare of the patient, the reputation of the surgeon, or the credit of surgery, as would be involved in a diagnostic error regarding luxations of the hip. Sometimes the surgeon removes a morbid growth which he considers benign, and the operation is followed by rapid and kindly healing; but recurrence of the neoplasm, after weeks or months, accompanied with well-marked cachexia and glandular involvement, often disproves the operator's early diagnosis, and he becomes convinced of the cancerous nature of the tumor. Under these circumstances, however, he can console himself with the thought that he may have helped to prolong life, and that his operation may have mitigated suffering, and such errors in a surgeon's record are not serious obstacles to his professional progress; but, when his faulty diagnosis has resulted in deformity or in lasting disease of an important organ, his surgical reputation may sustain such a shock that he will need all the counterbalancing resources at his command to reinstate himself in popular favor. It is for the purpose of aiding his fellow-practitioners to avert the sad consequences of errors in the diagnosis of luxations of the hip-joint, that the author has prepared this paper.
It is said that both the symptoms and signs are so well marked, in the four regular dislocations of the hip, that ordinary care can not fail to detect the site of the displaced articular head. Would this be equally true of each form of the different luxations? In the dorsal and the thyroid dislocations, the degree of shortening in the former and of elongation in the latter, with their corresponding signs, can scarcely fail to be recognized; but, in the variety generally called ischiatic, the signs are not always plain. Whether, however, the head of the bone be upon or in the ischiatic notch, I think that the deformity, the degree of shortening, and the inversion are less marked than in dorsal dislocations. In some cases, indeed, the discrepancy is so slight between the affected and the sound limb as to require the most careful examination for its detection. In the ischiatic form of dislocation, the thigh is so nearly on a plane with its fellow that the foot seems not to be inverted; but close observation will detect slight inversion of the patella, and if, with this sign, resistance to eversion of the foot be present, and pressure on the knee raises the loins, luxation surely exists.
Bigelow holds that there is no sacro-sciatic dislocation. Sir Astley Cooper, however, said that the ischiatic luxation was “extremely difficult to reduce”; but whether he meant because of the forcible detention of the bone in the ischiatic notch or not, I can not say. I think that it would be difficult to convince surgeons who have treated many luxations of the hip, that they have not seen and felt the head of the femur imbedded in the ischiatic notch; and I am scarcely prepared to believe, with Professor Bigelow, that there “is no dislocation into the ischiatic notch worthy of the name," or that “it is an error to suppose that during reduction the femur's head ever notably slips into the ischiatic notch.” Having more than once had the hand upon the head of the femur when it was high upon the dorsum, during attempted reduction, and having followed the movements of the head until it dropped into the notch, I could see and touch it in that situation. On continuing efforts at reduction, I have felt the head rise from its abnormal position and move into its socket. I am, therefore, not justified, on the basis of personal experience, in subscribing to the doctrine advocated by Bigelow.
In the dislocation which we term ischiatic, the shortening and the inversion of the foot will depend upon the definite situation of the head, which may either be deeply fixed in the notch or may merely rest upon its margin. This accounts for the varying degree of shortening, the slight inversion of the foot, the trifling adduction of the limb, and, in some cases, for the close resemblance to the sound limb, as well as for the mobility of the injured member. We should keep in mind that, in the other three forms of luxation, the distance between the head of the bone and its socket varies so much that the degree of lengthening or shortening alone will not accurately define the situation of the head, even when taken in connection with the degree of adduction, abduction, or flexion of the limb. These conditions will be better determined by the direction in which the dislocating force was applied, by its violence, and by the position of the patient at the time when the articular head was driven from its socket. The site and extent of the rupture in the capsular ligament will also aid in disclosing the direction taken by the head of the bone and its distance from the acetabulum. The ligaments of the hip and their functions should be clearly in the mind of the surgeon. He should know that the capsular ligament is stronger and more dense in some parts than in others, and that it includes the margin of the acetabulum above, and incloses the neck of the femur below. It is much thicker at the upper and anterior part of the joint than below, near the thyroid foramen, where its comparative thinness and looseness
oppose only a slight obstacle to the escape of the head of the bone. The ilio-femoral ligament is described by anatomists as intimately connected with the capsular ligament, and as extending obliquely across the front of the joint, being attached above to the inferior spinous process of the ilium, and below to the anterior intertrochanteric line. It is this ligament which Professor Bigelow describes under the name of the Y ligament, in his work on “The Mechanism of Dislocation and Fracture of the Hip,” published in 1869, a book which should be possessed by every surgeon.
On page eighteen of the volume just referred to, the author says :
The Y ligament is of remarkable tenacity and strength, being at some points, when well developed, nearly a quarter of an inch in thickness, and forming an unyielding suspensory band by which the femur, when in a state of extension, as in walking, is forcibly detained in its socket.” Professor Bigelow next cites certain experiments to prove the strength of the ligament, which can be ruptured only by weights varying from two hundred and fifty to seven hundred and fifty pounds. Some of the earlier anatomists speak of this ligament and of its bifurcation, but later anatomical teachers and writers did not do
before the convincing demonstration by the distinguished surgeon to whom reference has just been made. Modern surgeons have now, so far as I know, unanimously adopted Professor Bigelow's views regarding the important relations of this ligament to the diagnosis and treatment of dislocations of the hip.
Professor Bigelow describes the Y ligament as more or less adherent to the acetabular prominence and to the neck of the femur; but it will be found to take its origin from the anterior inferior spinous process of the ilium, and, passing downward to the front of the femur, to be inserted into nearly the whole of the oblique spiral line which connects the two trochanters in front. It is about half an inch wide at its iliac origin, and but little less than two inches and a half wide at its femoral insertion. At the latter point it is bifurcated, having two principal fasciculi, one of which is inserted into the upper extremity of the anterior intertrochanteric line, and the other, into the lower