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LUXATIOlNrS
HIP  AND  SHOULDER:
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   MOSES UU>\\, M. ]).,
rnofi:-o[; of surgery in the university of Michigan.
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HIP AND  SHOULDER:
   MOSES GUM, M. D.,
PROFESSOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.
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H'	ANN ARBOR:
■,	E. B. POND, PRINTER, ARGLS OFFICE,
	1855.
 
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3%-'  2-7-3  *~~ 
LUXATIONS  OF  HIP AND SHOULDER.
   The object of the present paper is to elucidate more fully certain
views relative to  luxations of the hip and shoulder joints,  which
were contained in a short article originally read before the Detroit
Medical  Society, and subsequently published in  the Peninsular
Journal of Medicine.  An  article on dislocations of the hip, by Dr.
Markoe,  of  New York,  Published in the January number  of the
New York Journal of Medicine, induced me to re-peruse the  article
by Dr. Reid, of Rochester, published in the Transactions of the
State Medical Society of New York, and I was pleased to see how
illustrative of the views  contained in my former article,  were two
experiments, one made by each of these gentlemen.  This, together
with further experiment  on my own part, led to the preparation of
the present paper; in the construction of which, I shall here intro-
duce my former article, published in September, 1853 :
   " The  views here advanced I have taught  for the past two years
to the gentlemen composing the Medical  Class in the University;
and I shall offer no apology for calling the attention of the Society
for a few moments this evening to the subject of Dislocations of the
Hip  and  Shoulder, and  more particularly to that form of  the acci-
dent, which, from the anatomical peculiarities of  the joint, is one
exceedingly difficult to reduce ; and for the reduction of which Dr.
Reid has recently proposed a novel and efficient mode.
   " It is  not my intention  to discuss the question of priority which
has been raised in reference to  this subject, for there can be no
doubt that Dr. Reid arrived at his conclusions by a course of rea-
soning and experiment;  and that those  conclusions were most es-
sentially  novel to  a large majority of the profession.  I propose 
4
 rather, briefly to consider the prominent peculiarities of the joint,
 and the relation of the parts in a state of dislocation ; the structures
 which oppose the return of the head of the femur to the acetabu-
 lum ; the manner in which Dr. Reid's manipulations overcome this
 opposition; and lastly, the application of the principle involved, to
 the reduction of  some other dislocations.
   " The encircling ridge which gives depth to the cotyloid cavity.
 presents upon its outer slope a plane, the inclination of which varies
 in different parts.  At its posterior portion this inclination is very
 great, and it  would seem in dislocation in this direction,  impossible
 to return the head of the bone to the cavity without lifting it com-
 pletely over  the ridge ;  upwards and backwards it is more gradual,
 and would seem to afford a much more easily surmountable obstacle;
 yet when we examine the relation of the parts in a dislocation in
 this direction, we find that applied to this surface, we have the an-
 terior and inferior surface of the head and neck of the femur, the
 rotundity of the head corresponding with the curvature of the slope,
 while the edge of the acetabulum corresponds with the curvature
 described by the anterior and inferior  surface of  the neck.  Al-
 though thus seemingly locked together, comparatively slight exten-
 sion in the line of dislocation  would cause the head to ride over the
 edge of the cavity, were it not bound down  in this position by the
 surrounding  tissues.   Which particular tissue constitutes these
 bonds is  an  important question to him who seeks to relax them.
 Dr. Reid, in common with the profession generally, considers the
 muscles the agents which thus oppose our efforts at reduction, and
 his manipalations are conducted with a view to relax them, while
 the femur, acting as a lever, raises the head of the bone clear of the
 edge  of the cavity.   With this same  view  we have the directions
 of the books and public teachers to apply extension and counter-
 extension slowly  and uniformly, in order to tire out the rebellious
muscles.  Blood-letting, antimony, and the hot bath are also called
in to aid in this laudable crusade against these wicked organs.
  " In this view, I would respectfully differ with Dr. Reid, the
teachers, books and profession, and state my honest belief that the
muscles oppose our efforts very little more than they do the progress
of our earth in its orbit.  This belief I have repeatedly verified by
experiments upon the dead subject, and the members of the medical
elass of 1851-2 in the University will remember those  conducted 
5
 before them.   A subject was placed upon the table, the lower bor-
 der of the gluteus maximus was raised, and a scalpel carried through
 the subjacent  muscles, and  an opening made  in the posterior and
 superior portion of the capsular ligament.   The round ligament was
 then divided, and the head of the femur luxated upon the dorsum
 of the ilium.  The usual indications of this dislocation were present.
 The subject was placed in the proper position, a counter-extending
 band applied to the perinseum, and fixed ;  the strength of two men
 exerted now  upon the extending bandj while endeavor was  made
 to raise the head of the bone clear of the acetabulum  with a jack
 towel, was insufficient to reduce the luxation.  Reid's method of
 manipulation readily replaced the bone.  This experiment was re-
 peated many times, and uniformly with the same result.  As muscu-
 lar, action could not ha^e opposed our efforts and prevented success
 in this case, the question naturally presents itself, what structure
 stood between effort and success?*   I  answer, the untorn portion of
 the  capsular ligament.  In support of  this  view, let us consider for
 a moment the position  of the limb at the instant of escape of the
 head from the socket during  the process of dislocation.  To do this
 we must bear in mind that force applied to the knee or foot while
 the  limb is in a state of  adduction, constitutes the most  frequent
 cause of this dislocation.  Force thus applied adducts the limb still
 more  powerfully before dislocation takes place, and at the moment
 of the escape of the head of the bone from the socket, the limb is in
 a direction which crosses the thigh of the opposite side.  Immedi-
 ately that the head of the bone has cleared the edge of the acetab-
 ulum it settles into its position upon the dorsum of the ilium, and
 the  limb assumes the position and direction  indicative of the acci-
 dent.  During the dislodgement of the  bone, the superior and pos-
 terior portion of the capsular ligament  is ruptured, through which
 the  head protrudes;  while from the position of  the limb at the in-
 stant of protrusion, the anterior and inferior portion is very much
 relaxed, thus allowing the head to rise  easily over the acetabulum.
 As soon as the head settles into its position upon the dorsum of the
 ilium,  the direction of the limb is changed,  and the untorn portion
 of the ligament Incomes more tense, and for this reason the head of
the  bone  cannot be readily  returned to its place, till the limb is
again placed in a position to relax it.   Dr. Reid's method does this
* Doct. Reid would answer, passive muscular fibres. 
(j
most effectually, and I  conceive that any other plan which does not
accomplish this, as for  instance extension and counter-extension by
the pully, or Jarvis' apparatus, in the usual direction, succeeds only
by lacerating much  more extensively, if not by actually tearing
the ligament completely asunder, before the head of the bone will
ride over the edge of the cavity.
   " The principle, then, I would seek to establish, is  this—that in
luxations of the hip and shoulder the untorn portion of the capsular
ligament, by binding down the head of the dislocated bone, prevents
its ready return over the edge of the cavity to its place in the socket ;
and that this return can be easily effected by putting the  limb in
such a position as will  effectually approximate the two points of at-
tachment of that portion of the ligament which remains untorn.
   " This principle can be successfully  applied to the reduction of
the backward luxation  of the femur into the ischitic  notch, and also ^£
to the several luxations of the shoulder.  It hasseveral times been
my guide in the reduction of  the downward  dislocation of the hu-.
merus into the axilla.  The patient is seated  upon the floor, an as^-
sistant slowly raises the arm to an angle of forty-five degrees to the
plane upon which the patient is sitting; and now while the assistant
makes extension in this direction, the surgeon makes pressure  with
the hand upon the top  of the shoulder, the bone readily returns to
its place, and the arm is dropped to the side and secured in a sling.
   " White's method of reducing this luxation, which is figured in
Druitt, is essentially the same,  the only difference being in the posi-
tion of the patient.  According to his plan the patient lies upon his
back, the  scapula is fixed by a counter-extending band applied to
the top of the shoulder, or by the hand of an assistant, while  ' the
arm is raised from the side, and drawn  straight up by the head, till
the bone is thus elevated into the socket.'  In either method it will
be seen that the upper and untorn portion of the capsular ligament,
by the elevation  of the arm, is very much relaxed, thus giving a
latitude of motion to the head which greatly facilitates its return,
and which could not be obtained by any manipulation in which this
relaxation was less perfect.  Nine-tenths of the force spent in exten-
sion and counter extension may be spared, in the reduction of all
those dislocations in which, by alteration of the position of the limb,
such relaxation is effected; and in the several luxations above spe-
cified, this end is undoubtedly attainable." 
   Further thought and experiment upon this subject have convinced
me that dislocations of the hip joint cannot occur, except in certain
positions, and these, are positions of very great distortion.   In sup-
port of this view I would call attention to the great security against
this accident provided by nature in the anatomy of the joint,   The
great depth of the acetabulum, surrounding on  all sides the head of
the femur, renders its escape  nearly, if not absolutely, a  physical
impossibility, so long as the legs are  parallel to each other, and on
a line with'the body. 3§ Fracture of some of the bony structures of
the joint,  would be the result of great violence, in this position  of
the  limbs, but dislocation  without  fracture,  I  apprehend,  never.
Before dislocation can take place, the  limb must be so distorted
that the walls  of  the acetabulum will afford  no longer protection
against the escape of the head of the femur,  the dislocating force
throwing the head, in this changed direction, against some portion
of the capsule of the joint, which gives way before it, permitting the
rupture of the round ligament, and the escape of  the bone.   It is
evident that while the changed direction of the limb, throws the
head wholly against some portion of the capsule, the opposite side
of this capsule must be relaxed, and by its relaxation facilitate the
riding of the head over  the edge of the cotyloid cavity.   Taking,
for example, the upward and backward form of luxation, in my ex-
periments, I have found it impossible, by my own strength, to pro-
duce luxation, even when the direction of the limb  was changed to
that which distinguishes this  form of the accident after it has oc-
curred, although the upper and posterior portion of the capsule, and
the round ligament, were divided.  In the course of my instruction
during the last winter, I introduced the following experiment: A
fresh, whole,  and muscular subject was selected, and a circular in-
cision was made around the middle of the  thigh down to the bone;
another, from the tuberosity of the ischium around the inner aspect
of the thigh, and over the dorsum of the  ilium to the point of com-
mencement, and all the tissues cleanly removed from the bone and
capsule of the joint.   The upper and posterior half of the capsule
was then cut away, leaving the anterior and inferior half, whole, and
the round ligament was divided.   In this state it will be seen that
all tissues were  entirely out of the way, (and  could neither  afford
protection against dislocation, or impediment to reduction,) except
the anterior and  inferior half of the capsular ligament.   I now 
8
placed the limb in the position which characterizes the dislocation
upon the dorsum, viz:  the knee in advance of the other, and the foot
inverted; and the pelvis being fixed, I attempted to produce dislo-
cation, but failed  to do  so, and I believe that no  force, however
great, applied to  the  knee, would  be sufficient to accomplish the
escape of the head of the bone without fracture of  the acetabular
walls, so long as the limb remains in this direction; for in this po-
sition,  the head presses perpendicularly against the superior and
posterior portions  of  the acetabular walls.  But on carrying  the
limb to a  position  in which the thigh crossed that of the opposite
side, at a point just above its middle, slight pressure was sufficient
to dislocate the bone, for the acetabular walls, in this position, pre-
sented to the head of the  bone an inclined plane, while from the
same reason of position, the undivided portion  of the capsule was
relaxed, thus permitting the head to  slide easily up this inclined
plane and ride over the acetabular edge.  At the moment, however,
during which the head rested upon the edge of the cavity, this un-
divided portion of the capsule became tense, relaxed again as the
head settled down upon the outside of the cavity, and upon dropping
the limb down to the position which characterizes this dislocation,
it became again tense.    Efforts at reduction by  extension and
counter-extension in this direction were now made, but were unsuc-
cessful, for this tense, undivided portion of the capsule bound down
the head so that it could not ride back over the edge of the acetab-
ulum ;  but on carrying the limb across the other, to the position in
which is was at the moment of escape, the reduction was easily ac-
complished.
  Upon the limb of the opposite side the experiment detailed in iny
former article was repeated, and with the same result.
  The following  case illustrates  also the practical bearing of the
principle under consideration: In February of the present  year I
was called into the interior of the  State to reduce a dislocation of
the hip of four days standing, which had resisted the efforts of two
very efficient professional  gentlemen.  They  had  extended with
Jarvis' adjuster,  and practiced Reid's manipulations, but without
success.   Reid's method, they informed me, only altered the form
of luxation,  carrying the head downward and forward upon the ob-
turator ligament.   The  luxation had been  primarily upon the dor-
sum, but upon examination I found the head  of the  bone in the 
9
     ischiatic notch.   I placed the patient upon his back, and attempted
     reduction after Reid's plan, but with the  same result that had at-
     tended the efforts of the gentlemen in attendance.  By inverting
     the foot, I slipped the head  back to its position in the notch, and
     repeated my efforts,  but with like result.   I thus four times essayed
     reduction, but succeeded only in making the head travel from one
     position to the other.  I adopted this plan  with confidence, from
     the fact that the luxation had originally been upon the dorsum, but
     failing to replace  the bone, I applied Jarvis' adjuster, and made ex-
     tension after the usual method, and carried it to the extent of bend-
     ing the extending bar to the form of a very considerable curve, but
     was not able to reduce the luxation.  Opposed, as I was before, to
     violence, I removed the instrument, and straightening the extending
     bar, resolved to adopt Blundell's obstetric motto, artenon vi.  After
     some  deliberation, I armed  the  adjuster with the shoulder fork,
     flexed the  thigh  at  right angles with the body,  and adducted it;
     and applying the  shoulder fork to the pubis and ilium, and attaching
     the extending bar  to the knee, a few  turns of the instrument
Getevolved the head into the socket.
      Although Doct. Reid attributes to the muscles the difficulties of
     reduction, he is explicit upon the fact that it is not muscular activity
     which opposes our efforts, and points  triumphantly to the ease with
    which muscular contraction is overcome in fractures of the neck and
     shaft  of the femur.   He conceives that the muscular tissues imme-
    diately surrounding the joint, are the  means of binding down the
    head of the bone in its new position,  thus preventing  reduction.
    He says, "the true condition of the muscles  is this: the six, rota-
    tor, adductor, and abductor muscles, viz :  the obturator externus
    anteriorly; the pyriformis, obturator intemus, gemelli and quadra-
    tus, posteriorly, are  all in a state of  extreme tension,  while the
    other  eleven muscles, larger and smaller, are  shortened, and in one
    sense, contracted, but in another,  and  in fact, theyj-elaxed—that   ^-Vt-
    is, in a recent dislocation.  Now it is evident on the slightest inspec-
    tion, that the six muscles, that are put upon the stretch, being in an-
    tagonism to each other, that is, the short, strong obturatur externus,
    anteriorly, being  opposed by the other five posteriorly, and all
    acting at nearly right angles to  the axis of the femur, must hug,
    with great power, the head of the bone, upon the dorsum, and by
    the same force, oppose its ascent over the brim of  the acetabulum, 
10
in any direct attempt to replace  it by traction towards its socket.
These six muscles, then, so violently stretched, constitute the real
and only impediments to the reduction by the usual mode, and not
the shortened and contracted triceps and glutei, as has always been
believed and taught by all authors and professors of surgery."
  So forcibly  impressed is Dr. W. with  the idea that  " tltesc six
muscles constitute the real and only impediment,'"  that even in an
experiment of his own, which he  details in his paper, he foils to see
the fact which he actually relates, that there is another structure
which forms an  impediment.   His experiment was upon a subject
considerably advanced in decomposition, and  in  the course of its
relation he holds the following language :
  "After carefully noting the relative position of bone and muscles,
we made  traction on the femur downward and  inward over the
sound limb, as we are directed by  most authors;  but the moment
the attempt was made, the muscles already named as being in  a
state of tension became more tense, although all the muscles about
the joint Avere separated from each other—were loose, without vi-
tality, and almost in a state of decomposition, yet it was with great - • ^ %*y
difficulty that we  could bring down the head into its socket; and
when we did so, we carried away a part of the capsular ligament."
  It seems hardly probable that  muscles  " almost in  a state of de-
composition," could form the " real and only impediment," particu-
larly, when in accomplishing reduction, he  " carried away a part
of the capsular  ligament."  In  this  connection, I quote from my
first article :  " Extension and counter-extension by the pully, or
Jarvis' apparatus, in the usual direction,  succeeds, only by lacera-
ting much more extensively, if not actually tearing the ligament
completely asunder, before the head of the bone will ride over the
edge of the cavity."
   Dr. Markoe, who adopts Dr. Reid's views relative to the nature
of the impedipient, seems to have had a similar illustration, in one
of his experiments,  and like Dr. R., fails to see that the untorn
portion of the capsular ligament  forms an " impediment."  His ex-
periment is as follows:
   " I removed all the muscles, leaving  the capsular ligament only,
and then endeavored to dislocate the head of the bone.  I first tried
adduction, and carried the limb  so forcibly  over the abdomen that
the  knee touched the anterior  surface of the thorax, but without 
11
producing luxation.  In making more  violent efforts in the same
direction, the cervix fractured, or rather cracked across within the
capsule, and soon after the ligament itself tore across at its superior
and posterior part, just opposite the point of yielding of the cervix.
The laceration was directly across the ligament, and occupied about
one half of its circumference.  As soon as this took place, the dis-
location was easily effected.  The neck of the femur and the tro-
chanteric portion of  it were now seen to be kept in their place by
the untorn portion of the capsular ligament, which acted as a sort of
fulcrum, upon which, by using the limb as the long arm, we could
make the head, as the short arm, move about in any direction upon
the surface of the dorsum of the ilium."
   Does the untorn portion  of the  capsular ligament  form an im-
pediment ?   My own views  are that it constitutes  the chief, if not
the only opposition to our efforts at reduction.  If it is urged, that
in this view, I am exclusive and ultra, I ask  only that before such
judgment is passed, the  experiment of removing all the tissues
about the joint, in the manner detailed  above, may  be  made.
   Detroit, May 15, 1855 
 
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