A BRIEF ACCOUNT OF THE 
MECHANISM OF THE HIP-JOINT, 
WITH 
DIAGNOSTIC POINTS UPON DISLOCATION AND FRACTURE OF 
THE NECK OF THE FEMUR. 
BY OSCAR II. ALLIS, Al . IL, 
SURGEON TO THE PRESBYTERIAN HOSPITAL. 
Read before the Philadelphia County Medical Society, February 28th, 1877. 
(Reprinted from the Medical and Surgical Reporter, of April 7, 1877.) 
Gentlemen :-One year ago I offered some 
remarks before this Society, upon the mechanism 
of the shoulder joint. I mentioned the func- 
tion of the capsular ligament, and stated that 
the retention of the head of the bone in the 
socket was not due to ligaments, but to the 
peculiar arrangement of the muscles about the 
socket and head of the bone. As proof of this 
it is only necessary to recall cases of paralysis 
of these muscles, or the falling of the head of 
the bone from its socket, under complete anaes- 
thesia. 
The hip-joint presents a marked contrast in 
this respect. This articulation Js the only true 
enarthrodial one in the body, and the head of 
the bone being more than half received into its 
socket, is retained by atmospheric pressure. 
Neither the so-called ligaments nor the 
muscles contribute to this retention. It is done 
by the cartilaginous rim about the socket, 
which is called by some anatomists the sucker 
ligament. This is easily shown upon the cada- 
ver, since the head of the bone is drawn with 
difficulty from the socket after all the muscles, 
the capsular ligament, and the ligamentum teres 
have been entirely cut away. If, in the gen- 
eral acceptation of the term, the joint were held 
in place by ligaments, then, in the ordinary 
functions of the limbs in walking, stooping, 
rising, turning, and the like, we would find our- 
selves suddenly arrested the instant any por- 
tion of the ligament became tense. As it is, 
the limb enjoys circumduction to a remarkable 
extent. 
It cannot be said to owe its security to 
muscles, else in paralysis, anaesthesia, drunken- 
ness, and in sleep, we would have constant dis- 
placements.* 
The ligaments about this articulation have 
been carefully studied and described. I can 
only repeat that which is familiar to you all ; 
still, a brief review of their functions will not 
be uninteresting. The capsular ligament is 
firmly attached to the rim of the acetabulum, and 
passes from this to the neck of the femur. 
Posteriorly, it is but loosely attached to the neck 
* I have heard it stated that in typhoid fever the 
hip becomes occasionally spontaneously dislocated. 
I have no experience in this, and doubt the truth of 
it. It is not at all improbable that the weak condi- 
tion of one recovering from such a prolonged illness 
might predispose to accidents in falling, but that 
there is any spontaneity about the case is very im- 
probable. 2 
of the femur, and fits it like a collar.* By this ar- 
rangement it offers no impediment to the motions 
of the joint. It is at this part, too, that the cap- 
sular ligament is thinnest, and the part most 
usually torn when the head of the bone escapes 
from the socket. The anterior portion of the 
capsular ligament is the thickest, strongest, and 
most serviceable portion of it, and is kbout half 
an inch longer than the posterior portion. In 
order to enable man to perform in the erect 
position the various functions for which he is 
designed, this joint has special strength given 
to it. Thus the fibres of the capsular ligament 
have accessory fibres, making it nearly double 
the thickness at the anterior than at the pos- 
terior part. To these must be added the tendons 
of the psoas, iliacus, and rectus muscles, that 
pass directly over and are blended with the 
capsule. Hence it is that man is enabled to 
stand erect, for without this special support the 
head of the bone would leap from its socket at 
each step. The special strength of this portion 
of the protective apparatus of the joint can be 
better imagined when one notices the mounte- 
bank, throwing his hands backward and turn- 
ing his back-hand spring, without ever ruptur- 
ing the capsule or displacing the head of the 
bone. Besides this, the same symptoms of de- 
formity hold good that were pointed out cen- 
turies ago, showing that the same cause pro- 
duces the same effect, and this cause is now 
known to be the untorn (anterior) portion of the 
capsule. 
But man is not only designed to work in the up- 
right posture, but also to rest in the same posture. 
If one but watch the motions of soldiers under 
command, he will see that standing erect is 
a muscular action and hard work, and that 
as soon as the word comes to rest, they quickly 
assume a posture that rests the weary muscles. 
This they do unconsciously, but if one imitate 
the action, he will find that he first balances his 
wteight on the ankle, then locks the knee-joint, 
and then, leaning a little forward and outward, 
finds himself at rest, i. e., balancing himself 
upon one leg. Two, and possibly three, liga- 
ments contribute to this relief of the muscles- 
the ligamentum teres, ilio-femoral, and the ilio- 
tibial, a strip of the fascia lata. 
The function oT the ligamentum teres has 
been the theme of warm and earnest discussion. 
It has been assumed that the function of this 
fibrous band, that extends from the edge of the 
socket to the centre of the head of the femur, 
is to suspend the body, allowing the weight 
of the body to fall upon it, rather than upon 
the head of the bone. Ingenious, as such a 
theory may be, and partially supported by 
the anatomy of the articulation, still there are 
good reasons that stand out against it. 
1. This ligament forms a protecting sheath* 
to the nerves and vessels that nourish the head 
of the joint, and is in the most favorable posi- 
tion for conveying the blood when the limbs are 
employed in supporting the body. If its func- 
tion were to support the trunk, and prevent 
concussion between the head of the bone and 
the acetabulum, then it would be too tense for 
a protecting sheath to blood vessels. 
2. Holden, and others, say that it limits ad- 
duction. Certainly, then, it cannot be tense, 
when the limb is in a line with the trunk, i. e., 
in the upright posture. 
3. The head of the bone fitting accurately 
the socket, and being retained by atmospheric 
pressure, there can be no space between the 
head of the bone and the socket, as would ne- 
cessarily be the case if the weight were sup- 
ported by this ligament. 
In the resting posture, i. e., in a state of ad- 
duction of the limb, the round ligament may 
contribute, in a slight degree, towards fixing the 
head of the bone. This, however, must not be 
too firmly insisted upon, as Henle has observed 
that adduction to a much greater degree is possi- 
ble after the capsular ligament is cut away.f It 
is highly probable, then, that this ligament 
(that only approaches the tense condition in the 
state of adduction) does not contribute to the 
strength or security of the joint, but is the 
protector of the nutritive supply to the head of 
the femur. • 
The anterior portion of the capsular ligament 
does, however, contribute largely in securing 
the joint, when one is standing at rest. It is 
strong, short, forms a cup for the partly pro- 
jecting head of the bone, and fixes it securely 
when one is in the resting posture. 
But the structure that contributes most largely 
to the standing at rest attitude is the thick, 
strong portion of the fascia lata, that extends 
from the crest of the ilium to the outer side of 
the head of the tibia. If this fascia is exam- 
* Sappey, Traite d'Auatomie, Vol. I, p. 653. 
f Cruveilhier and See, vol. i, p. 408. 
• " Holden's Manual of Anatomy," p. 746. 3 
ined, it will be found to have not only an 
attachment to the ilium and tibia, but to the 
linia aspera almost through its extent, and hence, ' 
from its position, admirably adapted to the I 
support of the body. As the fascia passes over 
the great trochanter a bursa is formed, to give 
the freest motion in its ordinary functions. 
It is not necessary to go to the dissecting 
room to verify the accuracy of this statement. 
All that need be done is to stand erect and feel 
the prominent tendon-like structure on the 
outer aspect of the knee, about an inch from 
the patella (See Fig. 1, left side, dotted line). 
If we do this we will feel a round cord on each 
limb. Now, if we throw the weight of the 
body on the right limb we will find that this 
cord is much more prominent, tense and hard 
than it was when we were standing erect, and 
that the cord on the left limb has disappeared. 
Try, now, the other limb. Throw the weight 
upon it, and the same result will take place. 
If the weight is thrown upon one foot, then 
upon the other in rapid succession, the ob- 
server will notice the suddenness of his arrest. 
If this were muscular it would not be so sudden. 
If muscular it would not always be at the same 
point. If muscular there would be a corre- 
sponding fatigue to the muscles brought into 
action. As it is, all the muscles of the body 
participate in the resting attitude. If mus- 
cular, the experiment could not be successfully 
tried upon the cadaver. The latter proof can 
easily be made by securing the knee in splints, 
to imitate the condition in life, and the resting 
attitude can be most perfectly counterfeited.* 
Having briefly invited your attention to the i 
great strength of the. ligaments about the joint, 
and to the part they play in the workings of 
the joint, let mfe now invite your attention to 
the most frequent injuries of the hip joint, i. e., 
fracture of the neck, dislocation, and fracture of 
the acetabular portion of the pelvis. 
Let us suppose a man in the vigor of life to 
fall from a height, upon his feet, or in such a 
manner as to bring the greatest force upon the 
structures of the joint when the femur is in a 
line with the trunk. 
First, I will say that the pelvis is least likely 
to be injured by such a fall. The upper part of 
the acetabulum recedes into the thick, strong 
flange of the ilium, and escapes fracture, prob- 
ably from its superior strength. Clinical ex- 
perience yields here valuable negative testi- 
mony. A fracture of the pelvis is one of the 
rarest injuries when the person falls upon the 
feet. Such a fall will most probably produce a 
fracture below the knee ; next in frequency, a 
fracture of the shaft or neck of the femur; while 
the pelvis, protecting, as it does, vital organs, is 
rarely broken save by a force directly applied. 
The injury, if at the joint, will lie between the 
laceration of the ilio-femoral ligament, with 
anterior displacement of the bone, and fracture 
of the neck of the femur. When every tissue is 
at its fullest strength, it is hard to decide which 
of these two will yield first. The mechanism of 
the neck of the femur, and its wonderful adapt- 
ability to overcome the various shocks, has 
been a matter of careful study and mathemati- 
cal computation, and as competent observers 
have witnessed a directly upward displacement, 
it cannot be said that the neck of the bone may 
not be stronger than the anterior portion of the 
capsule. In such a case, were the limb to be 
examined, it would be found that the neck of 
the femur was short, large, and obliquely grafted 
upon the shaft. Clinical experience, however, 
stands decidedly in favor of the ligament, and 
in such a fall as under consideration, a fracture 
of the neck of the femur is the more probable. If 
a similar injury occur to one in feeble strength, 
and especially to one in advancing years, then 
the probability of fracture of the neck is 
very great indeed. By disease and age, the 
texture of the bone changes. In its loss of 
weight may be seen the loss of the constituents 
that contributed to its toughness, hardness and 
strength. Not so with the ligaments ; even into 
old age their functions remain unimpaired, so 
that beyond sixty a dislocation is exceedingly 
rare, but fracture of the neck correspondingly 
frequent. 
Let us suppose a man, now, to fall with the 
thighs flexed, or semi-flexed. Under such circum- 
stances, the weight of the body, with its mo- 
mentum, will act most powerfully upon the 
shaft of the femur, as upon the long arm of a 
lever, and, as in this instance, the head of the 
bone is brought against the lower segment of 
the capsule, its rupture and a dislocation is 
exceedingly probable. Thejreasons that lead me 
to think that dislocations occur most frequently 
in this position are- 
1. (As Bigelow has shown) That almost all 
* For a fuller description of this, see Medical Times 
No. 229. 4 
the characteristic deformity in dislocations that 
have been pointed out for centuries are due to 
the untorn portion of the capsule, i. e., the 
ilio-femoral ligament. Hence, if the anterior 
(upper) portion of the capsule is intact, the es- 
cape of the bone has been elsewhere. 
2. The flexed condition (as has been already 
mentioned) takes the lower segment of the cap- 
sule at great disadvantage. I have frequently 
displaced the head of the femur, in the dissect- 
ing-room, by taking advantage of this position. 
Hence, in delivering a child in head last labors, 
and especially when resort has been had to the 
blunt hook, a careful examination should be 
made to see if any injury has been done to the 
joint. A case of dislocation from this cause has 
been related to me, which, however, was hap- 
pily rectified shortly after birth. 
3. Bigelow has shown that, when' restora- 
tion of the limb takes place from the applica- 
tion of pulleys, and the limb extended, even 
this success is due to the integrity of the ilio- 
femoral ligament. 
4. He has also shown that the flexed posi- 
tion is the most favorable to the reduction of all 
dislocations-depending, as he does, on the ilio- 
femoral ligament to draw the head of the bone 
into its socket, during the process of circumduc- 
tion. In this flexed position, man is placed in 
an attitude not unlike the quadruped, and 
among the expedients for restoring a dorsal dis- 
placement Bigelow recommends one that the 
farriers avail themselves of. Thus, he says,* 
" while assistants suspend the pelvis a few 
inches from the floor, by a strip of board passed 
transversely under the calf, near the ham, the 
surgeon may, with his foot, thrust the pelvis 
down into its place." The farrier reverses this 
manoeuvre. He suspends the horse by means 
of the four feet, and if the weight of the animal 
does not restore the displacement, he lets him 
drop a foot or more, and the first trial is often 
crowned with success. 
In making out a diagnosis of injuries of the 
hip, it is of the utmost importance that the 
patient be made to assume the upright position. 
In this position the affected limb suffers no such 
constraint as when lying on a bed, and a com- 
parison between £fre two limbs is easily insti- 
tuted. Such a position is not always practicable. 
Still, in doubtful cases it should be resorted to. 
Whenever this is attempted, the patient should 
have a strong chair or table to rest upon, to 
secure himself from falling. If this position is 
to be assumed, it is obvious that it should be 
done before the administration of an anaesthetic. 
In the erect position- 
1. In fracture (complete) of the neck, 
there will be no marked deformity, no want of 
parallelism between the limbs, and both feet 
oan be brought flatly upon the floor. This is 
really the most important feature to note. As 
long as the symmetry of the two limbs is main- 
tained, there cannot possibly be a dislocation. 
In all cases of dislocation the femur will 
have a fixed position ; the knee inward, out- 
ward, above or in advance of its fellow, and 
the heel drawn upward. In no case of disloca- 
tion can the knee be brought into a similar 
attitude with its fellow and the foot placed flatly 
upon the floor. 
2. In fracture within the capsule, or partly 
without the capsule, there is nothing to create 
deformity when one stands erect. The capsule 
is untorn and the limb is now suspended by 
ligament and muscles. Hence, by mere gravity, 
it hangs by the side of its fellow. 
In dislocations, the head of the femur lies in 
an abnormal, constrained position. This holds 
good in all varieties, whether recent or old, 
whether from accident or disease. The degree 
of deformity will be greatest when the rent in 
capsule and laceration of the muscles and 
their tendons is least. 
When the head of the bone has escaped 
through the posterior segment of the capsule, 
and the entire anterior portion is untorn, then 
the head of the bone will be fixed and held 
firmly upon the rim of the acetabular cavity, 
and the greatest contrast between the two limbs 
he manifest. This deformity will measurably 
subside, however, after unsuccessful manipula- 
tion, for by circumduction the tendons of mus- 
cles are severed and the rent in the capsule 
increased. It is in just such a condition as this 
that the erect position is so valuable in a diag- 
nostic point of view ; for then all restraint 
has been removed and the limb left to obey the 
traction that is exerted upon it about the joint. 
3. In fracture of the neck the patient can 
rotate the limb almost as completely as in 
health. This is owing to the fact that the in- 
sertion of the rotator tendons has been undis- 
* "The Hip," Henry J.jBigelow, p. 47. 5 
turbed, the capsule intact, and no impediment 
placed upon the free motion of the limb. Very 
different will be the result in dislocation. 
It matters not what may be the variety of the 
dislocation, voluntary rotation is lost, the hip 
is fixed and held by a stronger power than the 
muscular. 
4. In fracture of the neck there is no longer 
the firm union between the limb and the trunk 
that is to be found in the sound limb. 
Three observations have been made upon this 
head. Dr. Levis has pointed out, as a diagnos- 
tic feature, the possibility of bending the thigh 
backward to a greater extent than its fellow. 
It will be remembered that I spoke of the great 
strength of the ilio-femoral ligament, and the 
part it played in enabling us to stand at rest. 
This ligament is nearly tense when we stand 
erect, and will only permit the limb to be 
carried back but a slight degree, when sound. 
When a fracture of the neck is present, and a 
patient be placed on his belly upon a table, the 
greater elevation of the broken limb will estab- 
lish the diagnosis. Dr. Cleemann has observed I 
<hat, in this peculiar injury, the function of the 
quadriceps muscle has been so disturbed that a 
wrinkle may be noticed in the tendo patellae. 
He adds further, that this feature is of practical 
importance in determining the amount of weight 
necessary to keep the limb equally extended 
with its fellow. The little wrinkle is due to 
shortening. Hence, extension is only perfect 
when the limb is made equal to its fellow, and 
this can be easily known, he states, by the ex- 
amination of the tendo-patellae. The third 
point (and one which I have already alluded 
to), is the relation of the fascia lata to the 
act of standing at rest. The portion that 
forms a sheath for the muscles of locomotion 
is, when we stand erect, or walk, drawn tense 
by two muscles, the tensor vaginae femoris 
and the gluteus maximus. This tense condi- 
tion depends, of course, upon the integrity of 
the femur. The latter broken, there would no 
longer be the resistance to the action of these 
muscles, and hence the unequal degree of ten- 
sion of the fascia lata in the broken and sound 
limbs. 
The standing posture is the only one in which 
this can be verified, as in the reclining the 
muscles that make tense the fascia lata are both 
relaxed. 
FIG. 1. 
The dotted line Indicates the course of this strip 
of the fascia lata that has been alluded to. In the 
left leg it is tense. In the right, the handt show 
where it will be most lax, in case of fracture. 
In regard to measurements, I have only to add 
to what has been so often said, that every pre- 
caution should be taken to guard against error. 
This can only be done by measuring from dif- 
ferent points, as the anterior superior spine of 
the ilium, the symphisis pubis, the point of the 
coccyx, etc. Unless such a precaution is taken, 
a serious mistake may be made. Permit me 
here briefly to illustrate this point. A man was 
brought to the Presbyterian Hospital, with 
symptoms of dislocation of the right hip, which 
disappeared with appropriate manipulation, ac- 
companied by the audible sound. Nearly a year 
later he returned, with an apparent shortening 
of the same limb, of about two inches. Upon 
the most careful measurement from the anterior 
superior spine of the ilium to the inner side of 
the knee, the apparently shorter limb was half 
an inch longer than its fellow, and this was 
verified, by frequent and careful measurements, 
with every care to avoid error by any want of 
similarity of position of the limbs, On measur- 6 
ing from the symphisis pubis, the apparently 
shorter limb proved to be so in reality. 
The degree of shortening will, in cases of dis- 
placement, depend largely upon the untorn ilio- 
femoral ligament. If this is complete, then the 
head of the bone, though escaped from its 
socket, must lie in close proximity to it, and 
the shortening be more apparent than real. 
The shortening, in fractures of the neck of the 
femur, will be due to retraction of the muscles, 
and may vary from 0 to | of an inch. 
Should there be any doubt, after the adminis- 
tration of an anaesthetic, of the return of the 
limb to its socket, the limbs may advantageously 
be compared at right 
angles to the trunk. 
If both are in their 
sockets, their lengths 
will be the same, but 
if either is displaced 
(Fig. 2), this manoeu- 
vre will readily deter- 
mine it. This change 
in position may serve 
as an aid in the diag- 
nosis between dorsal 
dislocation and frac- 
ture. With the limbs 
compared in this po- 
sition, in case of frac- 
ture, the limb can be 
lifted to the level of 
its fellow, and on 
letting go it will sink 
half or three-fourths 
of an inch. But in dorsal dislocation the short 
ening will be greater, will not disappear until 
the limb is restored to the socket, and then it 
will not reappear on removing the support. 
Dupuytren relates the following case, which 
illustrates two points very forcibly-first, the 
importance of making a correct diagnosis ; and 
second, the importance, in a dislocation, of 
knowing that it has been restored.* 
Case 7.-Dislocation of the Thigh Upward and 
Outward Mistaken for Fracture of the Neck 
of the Femur-Reduction on the ninety- 
Ninth Day. 
Madame R., aged twenty-five, of slender, ner- 
vous temperament, threw herself from a third 
storv window. Besides slight iniuries to the 
trunk, "the left thigh was much flexed on the 
pelvis, with the leg placed across the opposite 
thigh, and it was impossible to restore the 
affected limb to its natural position without 
occasioning extreme pain in the hip. The knee 
and point of the foot were very much inverted, 
and on the dorsum of the left ilium a large 
globular tumor was felt, which it was presumed 
was the head of the femur, and the great 
trochanter was sensibly approximated to the 
crest of the ilium. 
" From the above signs, the surgeon who first 
saw the patient, together with two others who 
were subsequently called in, concluded that 
there was a dislocation of the femur, which ad- 
mitted of easy reduction ; but no sooner was the 
patient put into bed, with every necessary pre- 
caution, than the shortening of the limb made 
itself again apparent, together with the inversion 
of the poini of the foot. They then abandoned 
their first impression, and set down the injury 
as fracture of the cervix femoris, grounding the 
opinion on the facility of reduction, the imme- 
diate recurrence of the symptoms, and the 
relief experienced by the patient from the semi- 
flexed position." They accordingly 
dressing suitable for fracture of the cervix fem- 
oris, and the patient was retained in bed 
three months, and as the characteristic signs 
of dislocation reappeared on removal of the ap- 
paratus, appropriate measures were immediately 
taken, and the limb restored by Dupuytren on 
the ninety-ninth day. • 
This comparison of the limbs at right angles 
to the trunk may admit of quite a wide range 
of practical use. Thus I have seldom failed to 
elicit crepitus in fracture of the neck, and that, 
too, without resorting to any but the gentlest 
manipulation, when under other circumstances 
this element in the diagnosis was wanting. 
When placed at right angles to the trunk 
the limb has nothing to support it when the 
fracture is complete, and sinks until the cap- 
sule supports it. In sinking the fractured sur- 
faces touch, and convey to the ear and hand the 
true condition of the joint, while in the extended 
posture (the limb being examined in a line 
with the trunk) the weight of the limb causes 
I the fractured surfaces to separate, and thus 
renders crepitation impracticable. 
Again, there is an important point, in case of 
I impaction. These cases, if properly managed, 
I will recover with bony union. Hence it is in>- 
FIG. 2. 
* Dupuytren on "Diseases and Injuries of the 
Bones," p. 375. I have not given it verbatim, as it 
is unnecessarily long for my purpose. 7 
portant to establish the diagnosis without dis- 
turbing the impaction. 
In impaction there will be shortening and a' 
possible change in the position of the foot. It 
has been everted and at times inverted. With 
inversion of the foot we may suspect dorsal dis- 
placement of the limb. Still, however, this 
must not outweigh the position of the knee, 
which will tend to cross and override its fellow in 
all cases of dorsal displacement, while in im- 
pacted fracture with inversion, the entire limb 
will lie flat on the mattress or floor. In case of 
impaction, a comparison of the two limbs in a 
line with the body and at right angles to it 
will show the same results, since both limbs 
move upon a like centre, i. e., the acetabulum, 
while, in dorsal displacement, if we compare 
the attitude of the two knees, the difference in 
length will be greater when taken at a right 
angle to the trunk than when takfcn in a line 
with it. The reason of this may still be 
referred to the rfile played by the ilio-femoral 
ligament. When in dorsal displacement the 
limbs are compared in a line with the trunk, 
this ligament is tense, and must limit the amount 
iff shortening. If, now, the limbs are com- 
pared at right angles to the trunk, this liga- 
ment has been relaxed, and will let the limb 
drop toward the sciatic notch until it becomes 
tense and supports the weight of the limb. 
Hence, it will be found that the difference in 
the length of the limbs will be more noticeable 
in dorsal dislocations, when the limbs are com- 
pared at right angles to the trunk, than when 
compared in a line with the trunk. 
I have twice alluded to the proximity of the 
head of the bone to the socket when the mus- 
cles and anterior portion of the capsular liga- 
ment are untorn. My attention has been 
repeatedly called to this in experiments in the 
dissecting room. In attempting to study the 
various attitudes of the foot when the limb was 
elevated or circumducted, I have often found it 
difficult to prevent the head from going back 
into its socket. 
While I was an interne in the Philadelphia 
hospital, one of my colleagues received a patient j 
with dorsal displacement. I shall never forget 
his puzzled manner as he tried to recall the in- 
structions of the professor of surgery upon that 
point. " Let me see. How did he tell us to 
carry the knee ?" and while he was trying to 
recall it, and at the same time carrying the 
limb around in an uncertain, aimless way, it 
suddenly went in with a report, when he ex- 
claimed, " I wish I had noticed how I did that." 
A curious story is told of a laborer in a grist 
mill. He was lifting bags of grain, and by 
some means not quite clear was thrown to the 
ground and was unable to rise. His physician 
was summoned, and told him that he had torn 
across the great muscle of the back, and that 
he must lie in bed for months, until it should 
grow together. 
The minister called to see him, and gave 
such words of comfort as were befitting one in 
his circumstances. He evidently thought that 
here was a weekly pastoral visit for him to 
make for a long time to come, when, to his 
utter surprise, he saw the man walk late into 
church on the following Sabbath, and appar- 
ently as straight as ever. As soon as service 
was over he made his way to his parishioner 
and asked him how this had happened. " Why," 
said he, " as soon as everybody had left home 
and gone to church I thought I would venture 
out of bed, as I felt no pain and didn't think 
that there was anything the matter with me. 
I got out of bed, but found that I couldn't 
stand well, and took hold of a chair to steady 
me, but the chair gave way and I fell with full 
force upon my buttocks, and immediately got up 
and walked as well as ever." Here was evi- 
dently a displacement luckily restored by a fall, 
and I think that there are those of experience 
in dislocations that will not question the proba- 
bility of my statement when I assert that dislo- 
cation and restoration of a joint may take place 
as successive steps in an injury, and that, 
though at the visit of the surgeon the relations 
of the joint may be perfect, it is not safe to say 
that there has not been a dislocation or exten- 
sive laceration of the capsular ligaments. 
A case in point came under my care at the 
Presbyterian Hospital. A man had been re- 
ceived who had sustained a severe injury to the 
shoulder. Though the part was greatly swollen, 
I made an examination under ether, and found 
that though the head of the bone was in the 
socket, I could, by circumduction, easily dis- 
lodge it, and throw it into the axilla, accompa- 
nied with moist crepitus. 
March 23d, 1877, 1328 Spruce Street,