On the Articulations (51-55)

There are four modes of dislocation at the hip-joint: of which modes, dislocation inward takes place most frequently, outward, the most frequently of all the other modes; and it sometimes takes place backward and forward, but seldom. When, therefore, dislocation takes place inward, the leg appears longer than natural, when compared with the other leg, for two reasons truly; for the bone which articulates with the hip-joint is carried from above down to the ischium where it rises up to the pubes, upon it, then, the head of the femur rests, and the neck of the femur is lodged in the cotyloid foramen (foramen thyroideum?). The buttock appears hollow externally, from the head of the thighbone having shifted inward, and the extremity of the femur at the knee is turned outward, and the leg and foot in like manner. The foot then being turned outward, physicians, from ignorance, bring the sound leg to it and not it to the sound leg; on this account, the injured limb appears to be much longer than the sound one, and in many other cases similar circumstances

lead to error in judgment. Neither does the limb at the groin admit of flexion as in the sound limb, and the head of the bone is felt at the perineum too prominent. These, then, are the symptoms attending dislocation of the thigh inward.

When, then, a dislocation has not been reduced, but has been misunderstood or neglected, the leg, in walking, is rolled about as is the case with oxen, and the weight of the body is mostly supported on the sound leg, and the limb at the flank, and the joint where the dislocation has occurred is necessarily hollow and bent, while on the sound side the buttock is necessarily rounded. For if one should walk with the foot of the sound leg turned outward, the weight of the body would be thrown upon the injured limb, but the injured limb could not carry it, for how could it? One, then, is forced in walking to turn the leg inward, and not outward, for thus the sound leg best supports its own half of the body, and also that of the injured side. But being hollow at the flank and the hip-joint, they appear small in stature, and are forced to rest on a staff at the side of the sound leg. For they require the support of a staff there, since the nates inclines to this side, and the weight of the body is carried to it. They are forced also to stoop, for they are obliged to rest the hand on the side of the thigh against the affected limb; for the limb which is injured cannot support the body in changing the legs, unless it be held when it is applied to the ground. They who have got an unreduced dislocation inward are forced to put themselves into these attitudes, and this from no premeditation on their part how they should assume the easiest position, but the impediment itself teaches them to choose that which is most conformable to their present circumstances. For persons who have a sore on the foot, or leg, and cannot rest upon the limb, all, even children, walk in this way; for they turn the injured limb outward in walking, and they derive two advantages therefrom, to supply two wants; the weight of the body is not equally thrown upon the limb turned outward, as upon the one turned inward, for neither is the weight in a line with it, but is much more thrown upon the one under the body; for the weight is in a straight line with it, both in walking and in the shifting of the legs. In this

position one can most quickly turn the sound limb under the body, by walking with the unsound limb outward, and the sound inward. In the case we are now treating of, it is well that the body finds out the attitudes which are the easiest for itself. Those persons, then, who have not attained their growth at the time when they met with a dislocation which is not reduced, become maimed in the thigh, the leg, and the foot, for neither do the bones grow properly, but become shortened, and especially the bone of the thigh; and the whole limb is emaciated, loses its muscularity, and becomes enervated and thinner, both from the impediment at the joint, and because the patient cannot use the limb, as it does not lie in its natural position, for a certain amount of exercise will relieve excessive enervation, and it will remedy in so far the deficiency of growth in length. Those persons, then, are most maimed who have experienced the dislocation in utero, next those who have met with it in infancy, and least of all, those who are full grown. The mode of walking adopted by adults has been already described; but those who are children when this accident befalls them, generally lose the erect position of the body, and crawl about miserably on the sound leg, supporting themselves with the hand of the sound side resting on the ground. Some, also, who had attained manhood before they met with this accident, have also lost the faculty of walking erect. Those who were children when they met with the accident, and have been properly instructed, stand erect upon the sound leg, but carry about a staff, which they apply under the armpit of the sound side, and some use a staff in both arms; the unsound limb they bear up, and the smaller the unsound limb, the greater facility have they in walking, and their sound leg is no less strong than when both are sound. The fleshy parts of the limb are enervated in all such cases, but those who have dislocation inward are more subject to this loss of strength than, for the most part, those who have it outward.

Some tell a story how the Amazonian women dislocate the joints of their male children while mere infants, some at the knee, and others at the hip-joint, that they may be maimed, and that the male sex may not conspire against the female, and that

they use them as artisans to perform any sedentary work, such as that of a shoemaker or brazier. Whether these things be true or not I do not know, but this I know, that matters would be such as is represented, provided their children, while infants, were to have their joints dislocated. The consequences of dislocation inward at the hip-joint are much greater than of dislocation outward at the hip-joint, but at the knee, although there be some difference, it is less; but the mode of either impediment is peculiar, their legs are more bandied when the dislocation is outward, but those who have dislocation inward stand erect on their feet with less freedom. In like manner, when the dislocation is at the anklejoint, if outward they become vari (their toes are turned inward?), but they can stand; but if the dislocation be inward they become valgi (their toes are turned outward?), but they have less freedom of standing. The proportional growth of their bones is as follows: in those cases in which the bone of the leg is dislocated, the bones of the feet grow very little, as being very near the injury, but the bones of the leg increase in size, and with very little defect, but the fleshy parts (muscles?) are wasted. But when the ankle-joint is in its natural state, but the knee is dislocated, in these cases the bones of the leg do not grow in like manner, but become shortened, as being nearest the seat of the injury, and the bones of the feet also are atrophied, but not in the same proportion; because, as was said a little while ago, the ankle-joint is safe, and if they could use it, as in the case of club-foot, the bones of the foot would be still less atrophied. When the dislocation takes place at the hip-joint, the bone of the thigh, in this case, does not generally grow in like manner, as being the one nearest the seat of the injury, but becomes shorter than the sound one; but the growth of the bones of the leg is not arrested in like manner; nor of those of the feet, for this reason, that there is no displacement between the bones of the thigh and leg, nor between those of the leg and foot; in those cases, however, the fleshy parts of the whole limb are atrophied; but if they could make use of the limb, the growth of the bones would be still more developed, as formerly stated, only the thigh, although its flesh would be much less wasted, would still be by no means so fleshy as the sound limb. The following observations are a proof of this: those persons who are weasel-armed (galiancones) from birth, owing to dislocation of the humerus, or when the accident has happened to them before they have attained their full growth, such persons have the bone of the arm shortened, but those of the fore-arm and hand are little inferior in size to the sound, for the reasons which have been stated, because the humerus is the bone nearest to the joint affected, and, on that account, it is shorter than natural; but the fore-arm is not equally affected by the accident, because the joint at which the bones of the arm and forearm are articulated remains in its natural condition, and the hand is still further distant than the fore-arm from the seat of the injury. Such are the reasons why certain of the bones in this case increase in growth, and certain do not. The laborious office of the hand contributes much to the development of the flesh in the fore-arm and hand, for whatever work is done by the hand, these weasel-armed persons strive to do no less effectually with the other hand than with the sound; for the arms do not support the weight of the body like the legs, and the work performed by them is light. From exercise, then, the fleshy parts on the hand and fore-arm are not atrophied in weasel-armed persons, and by these means the arm, too, gains flesh. But in dislocation inward at the hip-joint, whether from birth or from childhood, the fleshy parts, on that account, are much more atrophied than those of the hand, because the patients cannot exercise the leg. Another proof will be given in the observations which will be presently stated, that these things are such as I things are such as I have represented.

When the head of the femur is dislocated outward, the limb in these cases, when compared with the other, appears shortened, and this is natural, for the head of the femur no longer rests on a bone as in dislocation inward, but along the side of a bone which naturally inclines to the side, and it is lodged in flesh of a pulpy and yielding nature, and on that account it appears more shortened. Inwardly, the thigh about the perineum appears more hollow and flabby, but externally the buttock is more rounded, from the head of the thigh having slipped outward, but

the nates appear to be raised up, owing to the flesh there having yielded to the head of the thigh-bone; but the extremity of the thigh-bone, at the knee, appears to be turned inward, and the leg and foot in like manner, neither does it admit of flexion like the sound limb. These, then, are the symptoms of dislocation outward.

When such a dislocation is not reduced in adults, the whole limb appears to be shortened, and in walking they cannot reach the ground with the heel, but they walk with the ball of the foot on the ground, and the points of their toes incline a little inward. But the injured limb, in this case, can support the body much better than in dislocation inward, both because the head of the femur and the neck of its articular extremity, being naturally oblique, have formed a bed under a considerable portion of the hip, and because the extremity of the foot is not forcibly turned outward, but is nearly in a line with the body, and is even inclined more inwardly. When, then, the articular extremity of the femur has worn out a socket for itself in the flesh where it was lodged, and the flesh is lubricated, it ceases to be painful in the course of time, and when it becomes free from pain, they can walk without a staff, if so inclined, and they can support the body on the injured limb. From usage then, in such cases, the fleshy parts are less enervated than in those which have been mentioned a little before, still, however, they lose their strength more or less; but in general there is more enervation when the dislocation is inward than when it is outward. Some of them, then, cannot wear their shoes, owing to the unbending state of their leg, and some of them can. But when this dislocation takes place in utero, and when the dislocation having occurred at any time before manhood, from violence, has not been replaced, or when from disease the articular extremity has started from its socket, and is displaced (for many such cases occur, and from some of them, if the femur become necrosed, obstinate suppurations requiring the use of tents are formed, and in certain of them the bone is laid bare), whether the bone become necrosed or not, the bone of the thigh is much shortened, and does not usually grow like the sound one, the bones, too, of the leg, become shorter than those

of the other, but in a small degree, for the same reasons that were formerly stated; such persons can walk, some of them in the same fashion as adults having an unreduced dislocation, and some of them walk with the whole foot on the ground, but limp in walking, being obliged to do so by the shortness of the limb. Such is the result, even though they be carefully and properly trained in the attitudes before they have strength for walking, and in like manner also, after they have acquired the necessary strength; but those persons require the most care who were very young when they met with the accident, for, if neglected while children, the limb becomes entirely useless and atrophied. The fleshy parts of the entire limb are more wasted than those of the sound limb, but this is much less apt to happen in their case than in dislocation inward, owing to usage and exercise, as they are speedily able to make use of the limb, as was stated a little before with regard to the weasel-armed (galiancones).