There are persons who, from birth or from disease, have dislocations outward of both the thighs; in them, then, the bones are affected in like manner, but the fleshy parts in their case lose their strength less; the legs, too, are plump and fleshy, except that there is some little deficiency at the inside, and they are plump because they have the equal use of both their legs, for in walking they totter equally to this side that. Their nates appear very prominent, from the displacement of the bones of the joint. But if in their case the bones do not sphacelate (become carious?) and if they do not become bent above the hip-joint, if nothing of this kind happen to them, they become otherwise sufficiently healthy, but the growth of all the rest of the body, with the exception of the head, is arrested.

In dislocations of the head of the femur backward, which rarely occur, the patient cannot extend the leg, either at the dislocated joint, or at the ham, to any extent, and of all the dislocations, this is the variety in which the patients have the least power of making extension at the groin and the ham. But, moreover, this also should be known (for it is a valuable piece of knowledge, and of much importance, and yet most yet most people are ignorant of it), that persons in health cannot extend the joint at the ham, if they do not extend the joint at the groin at the same time, unless they raise the foot very high, for in this way they could do it; neither also could they bend the joint at the ham, but with much greater difficulty, if they do not bend the joint at the groin at the same time. There are many other things in the body which have similar connections, both with regard to the contractions of nerves (ligaments?), and the positions of muscles, and many of them more worthy of being known than is generally supposed, and with regard to the nature of the intestine and that of the whole internal cavity, and with regard to the displacements and contractions of the uterus; but all these things will be treated of elsewhere, in a work akin to the present one. But with regard to the matter on hand, they cannot make extension, as has been already stated; and the limb appears shortened, for two reasons-first, because it cannot be extended, and also because the bone has slipped into the flesh of the nates; for the head and neck of the femur, in this dislocation, are carried downward from their natural situation, to the outside of the nates. But yet they can bend the limb, unless prevented by pain, and the leg and foot appear pretty straight, and not much inclined toward either side, but at the groin the flesh, when felt, appears looser, from the bone of the joint having slipped to the other side, but at the nates the head of the femur may be felt to be more prominent than natural. Such are the symptoms accompanying dislocation of the thigh backward.

When this dislocation occurs in an adult, and is not reduced, he can walk, indeed, after a time, and when the pain has abated, and when he has been accustomed to rotate the articular bone in the flesh; he finds it necessary, however, to make strong flexion at the groin in walking, for two reasons, both because the limb, for the causes already stated, becomes much shorter, and he is far from touching the ground with his heel, and he can barely reach it with the ball of his foot, and not even thus, unless he bend himself at the groins, and also bend with the other leg at the ham. And in this case, he is under the necessity of supporting the upper part of the thigh with his hand at each step: this also contributes, in a certain degree, to make him bend the body at the groins; for, during the shifting of the feet in walking, the body cannot be supported on the unsound be supported on the unsound limb, unless it be pressed to the ground by the hand,-the end of the femur not being placed properly under the body, but having slipped backward to the nates; and if he should try to rest the weight of his body for a little, upon the foot, without any other support, he would fall backward, for there would be a great inclination in this direction, from the hips having protruded backward far beyond the line of the foot, and the spine inclining toward the hips. Such persons can walk, indeed, without a staff, if so accustomed, for because the sole of the foot is in its old line, and is not inclined outward, they do not require anything to balance them. Such, however, as, instead of grasping the thigh, prefer resting their weight upon a staff introduced into the armpit of the affected side, these, if they use a longer staff, will walk, indeed, more erect, but will not be able to reach the ground with the foot, or if they wish to rest upon the foot, they must take a shorter staff, and will require to bend the body at the groins. The wasting of the fleshy parts is analogous to what happens in the cases formerly described, for the wasting is greatest in those cases in which the patients keep the limb up, and do not exercise it, whilst those who practice walking, have the least atrophy. The sound leg, however, is not benefited, but is rather rendered more deformed, if the injured limb be applied to the ground, for it is forced to cooperate with the other, being protruded at the hip, and bent at the ham. But if the patient does not use the injured limb by applying it to the ground, but carries it up, and rests upon a staff, the sound leg thereby gains strength, for it is employed in its natural position, and further, the exercise gives it strength. But it may be said, these things are foreign to medicine; for what is the use of enlarging upon cases which are already past remedy? This is far from being the case, for it belongs to the knowledge of medicine to be acquainted also with these, and they cannot possibly be separated from one another; for to such as are curable, means are to be used to prevent them from becoming incurable, studying how they may best be prevented from getting into an incurable state. And incurable cases should be known, that they may not be aggravated by useless applications, and splendid and creditable prognostics are made by knowing where, how, and when every case will terminate, and whether it will be converted into a curable or an incurable disease. When then, from birth, or during one’s youth, this dislocation backward occurs, and is not reduced, whether it be connected with violence or disease (for many such dislocations occur in diseases, but the nature of the diseases in which dislocations take place, will be described afterward); if, then, the dislocated limb be not reduced, the bone of the thigh becomes shortened, the whole limb is impaired, is arrested in its growth, and loses its flesh from want of use; the articulation at the ham is also impaired, for the nerves (ligaments?) become stretched, from cases formerly stated, wherefore those who have this dislocation, cannot make extension at the knee-joint. In a word, all parts of the body which were made for active use, if moderately used and exercised at the labor to which they are habituated, become healthy, increase in bulk, and bear their age well, but when not used, and when left without exercise, they become diseased, their growth is arrested, and they soon become old. Among these parts the joints and nerves (ligaments?), if not used, are not the least liable to be so affected; they are impaired, then, for the reasons we have stated, more in this variety of dislocation than in the others, for the whole limb is wasted, both in its bones and in its fleshy parts. Such persons, then, when they attain their full growth, keep the limb raised and flexed, rest the weight of the body on the other leg, and support themselves with a staff, some with one, and others with two.

In dislocations of the head of the thigh-bone forward (they are of rare occurrence), the patients cannot extend the leg completely, but least of all can they bend it at the groin; they are pained, also, if forced to bend the limb at the ham. The length of the leg, if compared at the heel, is the same as that of the other; but the extremity of the foot inclines less to project forward. But the whole limb has its natural direction, and inclines neither to this side nor to that. These cases are particularly attended with severe pain, and they are more apt to be accompanied with retention of urine at first than any of the other dislocations; for the head of the thigh-bone is lodged very near to important nerves. And the region of the groin appears swelled out and stretched, while that of the nates is more wrinkled and flabby. The symptoms now stated are those which attend this dislocation of the thigh-bone.

When persons have attained their full growth before meeting with this dislocation, and when it has not been reduced, upon the subsidence of the pain, and when the bone of the joint has been accustomed to be rotated in the place where it is lodged, these persons can walk almost erect without a staff, and with the injured leg almost quite straight, as it does not admit of easy flexion at the groin and the ham; owing, then, to this want of flexion at the groin, they keep the limb more straight in walking than they do the sound one. And sometimes they drag the foot along the ground, as not being able to bend the upper part of the limb, and they walk with the whole foot on the ground; for in walking they rest no less on the heel than on the fore part of the foot; and if they could take great steps, they would rest entirely on the heel in walking; for persons whose limbs are sound, the greater the steps they take in walking, rest so much the more on the heel, while they are putting down the one foot and raising the opposite. In this form of dislocation, persons rest their weight more on the heel than on the anterior part of the foot, for the fore part of the foot cannot be bent forward equally well when the rest of the limb is extended as when it is in a state of flexion; neither, again, can the foot be arched to the same degree the limb is bent as when it is extended. The natural state of matters is such as has been now described; and in an unreduced dislocation, persons walk in the manner described, for the reasons which have been stated. The limb, moreover, is less fleshy than the other, at the nates, the calf of the leg, and the whole of its posterior part. When this dislocation occurs in infancy, and is not reduced, or when it is congenital, in these cases the bone of the thigh is more atrophied than those of the leg and foot; but the atrophy of the thigh-bone is least of all in this form of dislocation. The fleshy parts, however, are everywhere attenuated, more especially behind, as has been stated above. If properly trained, such persons, when they grow up, can use the limb, which is only a little shorter than the other, and yet they support themselves on a staff at the affected side. For, not being able to use properly the ball of the foot without the heel, nor to put it down as some can in the other varieties of dislocation (the cause of which has been just now stated), on this account they require a staff. But those who are neglected, and are not in the practice of putting their foot to the ground, but keep the limb up, have the bones more atrophied than those who use the limb; and, at the articulations, the limb is more maimed in the direct line than in the other forms of dislocation.