Ars chirurgica a compendium of the theory and practice of chirurgery in seven books ... shewing the names, causes, signs, differences, prognosticks, and various intentions of curing all kinds of chirurgick diseases ... : to which is added Pharmacopoeia chirurgica, or, The medical store, Latin and English ... / by William Salmon ...

CHAP. XXII. Of a DISLOCATION of the HIP or THIGH BONE.

I. IT is called in Greek, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. in Latin, Dislo∣catio, vel Luxatio Ossis Femoris; and in English, A Dislocation, or Luxation of the Hip; or rather, of the Thigh-Bone.

II. The Thigh-Bone is the largest, or longest and thickest in the whole Body; before it is round, behind a little depressed or hollow: on its upper part it has a round head, with a slender part under∣neath it, called the Neck; which is pretty long, and oblique.

III. The Neck is an Apophy∣sis, or Process to the Bone it self; and the round Head an Epiphysis or Appendix to the Neck: this Head is received by the large Acetabulum of the Coxendix, and is detained therein by two strong Ligaments: one which encom∣passes the lips of the Acetabulum; and another which springs out of its bottom, and is inserted into the tip of this Epiphysis or round Head.

IV. At the lower end of the Neck, there spring two Prominen∣ces from the Bone: which because the Muscles called Rotatores are fastned to them, are called Tro∣chanteres: the hinder and lower is the lesser Trochanter; and the lateral or uppermost, the bigger.

V. The lower end of the Thigh-Bone, grows thicker gradatim, and has two indifferent large Apophy∣ses or Heads; having a Cavity in the middle between them, which receives the Apophysis of the Tibia; which is tied therein by a Ligament; as the upper end, or head of this Bone is tied to the Acetabulum of the Cox∣endix.

VI. The Acetabulum of the Os Coxendicis (which is a large Cavity, tipt round its Lips with a Cartilage called Supercilium) receives the Apophysis or Head of the Os Femoris, by that kind of Articulation which we call En∣arthrosis.

VII. Now as the Thigh-bone is join'd by Enarthrosis to the Bosom of the Hip-bone; so that Sinus is fully large and deep enough to receive its Head: and as it is strongly united to it by a most firm Ligament arising from the bottom of the Hip, which is im∣planted into the narrow Sinus of the Apophysis of the Os Femoris; so thereby, it is much the more safely, readily and casily ex∣tended, turned or moved any way, and will not easily slip forth.

VIII. The Kinds. The Dislo∣cation of the Thigh-Bone, is either perfect, or imperfect, which is called a Luxation; yet some Au∣thors will not allow of an imper∣fect Luxation in this Joint.

IX. To which it is answered, That tho' Aegineta, de Re Med. lib. 6. cap. 118. will only allow of a perfect Dislocation, and not of a Subluxation; yet this only is to be understood where it is caused from external force and violence.

X. But if it is caused from a Flux of Humors to the Part, those Humors sometimes so relax and mollify the Ligaments, that they cannot retain the Head of the Thigh-Bone firmly in its Cavity, whence follows a certain Sub∣luxation.

XI. The Causes. Out of what hath been said it appears, That a Luxation or Subluxation is cau∣sed, the first from External Vio∣lence, the latter from Fluxion; as in an inveterate Sciatica, where the violence of the Pain induces a Flux of Humors upon the Part; where thickning and concreting, they by degrees thrust the Bone out of its place.

XII. The Differences. They are drawn from the several Ways by which the Dislocation may be made, 1. Inwards. 2. Outwards. These two happen very often, because at those places the lips of the Acetabulum are lower than in other places. 3. For∣wards. 4. Backwards. These two happen very rarely, because the Lips of the Cavity are in those places higher than in others.

XIII. The Signs. If the Disloca∣tion is Inwards; the Leg is longer, and moves with difficulty; the Knee, and Foot stand outward, (for if one end of a thing in∣clines one way, the other end must recline the contrary way:) the Head of the Thigh-Bone may by the Hands be felt under the Groin; but the Thigh it self cannot be bent towards it, because the Musculi Inflexores are straitned and hindred, that they can neither lift up, nor bend the Thigh: and in the Perinaeum, viz. the Region between the Testicles and Anus, a manifest Tumor appears.

XIV. If the Dislocation is Out∣wards; the Leg is made shorter, and the Knee, Leg, and Foot are turned inwards; the Sick can then indeed bend his Leg, but scarcely bring it to the Ground: in the Perinaeum there is a cavity and leanness; and on the con∣trary, in the Butrocks a certain Tumor: the Heel touches not the Ground, and the Patient when he endeavours to walk, goes on tiptoes.

XV. If the Dislocation is For∣wards; the Groin is swelled, for the head of the Thigh-Bone leans to the Pubes; the Buttock is fallen, hollow, and wrinkled; because the whole Thigh with the Processes is slipt forwards: the Leg is neither shorter nor longer; nor can it be bent, but with trouble; because the Mus∣culi Inflexores are hindred, and pressed by the Head of the Thigh: the Urine is stopt also, because the Head of the Thigh-Bone presses upon the Bladder: nor can the Toes of the Foot be easily extended, or turned to the Ground, and the Patient is for∣ced to tread only on the Heel.

XVI. If the Dislocation is Back∣wards; the Patient can then

neither stretch out, nor bend his Leg; because the Musculi Ex∣tensores which are behind, are prest, so that they cannot be drawn towards their proper Principles: he cannot bring his Heel to the Ground; which if he should force himself so to do, he would fall backwards: the Member affected is shorter than the other, because the head of the Bone is got above the Acetabulum: there is a hollow∣ness in the Groins; and if the Buttock is pressed upwards, you will find an unusual Tumor, because the head of the Thigh-Bone sticks out at the Buttock.

XVII. The Prognosticks. These Luxations are never without dan∣ger, because they are hardly redu∣ced; and being reduced, are in danger of falling out again. The reason why they are difficult to reduce is, because of the ex∣ceeding strength of the the Muscles, which are not easy to be extended.

XVIII. An inveterate or old Luxation of the Thigh-Bone, which has contracted a Callus, and whose Sinus or Acetabulum is filled up with Humors, or a Gelly, is incu∣rable: and tho' in this case, the Bone should be reduced, yet it will not stay in its place, but fall out again. See Celsus, lib. 8. cap. 20.

XIX. The same will come to pass, if that the Ligament in the Cavity is preternaturally relaxed or extended, or by any means is broken.

XX. If the Luxation is not reduced, the Parts adjacent will waste and consume by degrees; be∣cause the Veins and Arteries will be so straitned and compressed, that a free passage for the Blood, Nutriment, Vital and Animal Spirits will be wanting: and because the Part will not have its due motion, its heat will decay; whence an Atrophy or Paralysis may be feared.

XXI. If the Dislocation is In∣wards, it is difficult to reduce, and as easily slips out again; whereby the Part affected is wasted, and the Sick lamed: if it is not re∣duced, when they go, they wheel about their Thigh outwardly; because it is too long, and they cannot well bend, so that they are forced to wheel it about.

XXII. If the Dislocaiton is Out∣wards, if it is not right set, yet the pain will vanish of it self, and the Sick will in time be able to go without Crutches. If it is not well restored in those that are of ripe age, the Flesh into which the head of the Joint falls will grow callous; after which the pain will go away, and he will be able to walk without a Staff.

XXIII. If the Dislocation is Forwards, tho' it be not rightly set, yet the Patient will in length of time go indifferently well upon it, tho' oftentimes it is so, that he is forced to trail his Leg after him. But Sennertus, Med. Pract. lib. 5. part. 6. cap. 9. says, That tho' it be not reduced, yet the Sick will be able forthwith to go upright upon it, and perfectly upright, with∣out a Staff: for by reason of the inflexibility of the Groin, they use the whole Thigh more straight in going, than before it was dislocated.

XXIV. If the Dislocation is Backwards, tho' it be not reduced, yet the pain will vanish in time also; because the part which touches the head of the Bone will grow callous, and the the Leg may be bent again: but it will be shorter, yet streight, for that the Foot will be turned neither inwards nor outwards.

XXV. The Cure. The Way of Reducing the Luxation is almost the same with that of Reducing the Shoulder; and truly the manner of Extension may be common to all the four Species of a dislocated Thigh: but the manner of for∣cing and restoring the Head of the Thigh-Bone, must be, ac∣cording to the variety of the places into which it is fallen: for that which is fallen inwards, must be forced outwards; and that which is fallen outwards, must be forced inwards, &c.

XXVI. The Thigh-bone may also be reduced either without Ex∣tension, or with it: without Ex∣tension it may be done two ways: but not at all, unless the Luxation be recent, and in a Patient who has soft Flesh, and moist Liga∣ments, and where the Bones stands but a little way from its Sinus, and it be also in a Childs Body.

XXVII. The first way is to turn round the head of the Thigh, about the Ilium (as we do some∣times when the Arm is out of Joint) and not to separate it, if it gets into the Sinus, or Cavity: But this way is not accounted safe, for fear the head of the Bone should rub against the edges of the Acetabulum.

XXVIII. The second way is, to bend the Thigh suddenly; for so sometimes it is replaced, as Pau∣lus, lib. 6. cap. 98. has told us. These ways possibly may do in Children, but to reduce the Bone with Extension, is certain∣ly the safest and best way, which we now are a going to teach you.

XXIX. The General Method. Lay the Patient down upon a Table on the Back, or whole side, for the three first Species; but on the Belly if the Luxation is backwards: then between the Legs put a strong Staff, wound about with Linnen, which with Ropes, Reins, Girts, or some such like, let it be drawn strong∣ly upwards, by one or two Men; or you may do it by Swaths or Bandages above.

XXX. In the mean season, let another draw out strongly the Leg: and while the Extension is mak∣ing and made, let the Artist with his Hands put the head of the Bone into its place, thrusting that outwards which is fallen in∣wards, and contrariwise; and that backwards, which is fallen forwards, and contrariwise.

XXXI. If it cannot be reduc'd by the former means, you must be forc'd to make use of Engins or In∣struments; as the Reductive Lad∣der, the Glossocomium of Galen, the Table of Hippocrates, or the Pully of Vitruvius, all which In∣struments, together with their several uses, we have at large described and delivered in lib. 6. cap. 2. of this Work aforegoing.

XXXII. The Bone being redu∣ced, you must apply proper Medica∣ments, with fit Bandage and con∣venient

Situation, as we have large∣ly taught in the proceeding Discourse of Fractures: and both Thighs must be bound, that the Luxa∣ted Bone may be kept in its place, which must not be loosed before the fourth day: the Pa∣tient must also continue long enough in Bed, and not walk too soon, lest straining the Part whilst it is yet weak, it should be put out of the Joint again.

XXXIII. The particular Me∣thods of Reduction, are as follows. If the Luxation is inwards, let the Patient be laid with his Back upon the Scamnum Hippocratis, or some other Table, in which a thick Wooden Pin, about a Foot long is to be fixt, which is to be set between his Thighs, to detain the Body when the Legs are drawn down: then a Strap or Girt is to be passed above the Joint of the Thigh, to draw the Ischion upwards; and the Thigh is to be drawn down∣wards, with another Bandage fastned about the Knee: mean season, the Artist is to thrust the Thigh-Bone upwards and out∣wards, to reduce it to its Aceta∣bulum; upon which, the Exten∣sion is to be somewhat slackned, to facilitate the Operation.

XXXIV. If the Luxation is Outwards, the Patient is to be laid upon his Belly, and the Extension is to be made after the same manner, as we have even now shewn: in the mean time, the Thigh-Bone is to be forced from the outside inwards, to re∣duce and set it right in its Sinus.

XXXV. If the Luxation is For∣wards, the Patient is to be laid upon the opposite side to that which is dislocated; and the Extension is to be made by drawing upwards and down∣wards, as before; then the Head of the Bone must be for∣ced strongly with the Knee, a Ball being first laid thereon; and so reduced to its proper place.

XXXVI. If the Luxation is Backwards, the Patient may be laid upon his his Belly, and the double Extension, upwards and downwards, is to be made; and with the Knee, the Bone is to be forced back again into its pro∣per place.

XXXVII. These things being done, a Bolster or Splenium is to be applied, with strengthning, Bal∣samick, and Spirituous Medica∣ments; and it is to be bound up like in anner, as we have taught in the Binding-up of a Disloca∣ted Shoulder.