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Displacement upon the Back of the Hip-bone.Signs.- If the patient stand upon the sound limb, it will be noticed : First-The limb is rotated inward, so that the great toe rests upon the instep of the other foot. Second- The knee is bent and is held in front of that of the other leg. Third-The bony prominence at the upper end of the thigh-bone, outside of the joint, projects more than that on the uninjured side. The distance between this prominence and the front of the hip-bone is less on the injured than on the uninjured side. Fourth - The limb is fixed and rigid ; the hip-joint cannot be moved by the patient nor by a second person. Fifth - The injured member is shorter than the other limb. If the patient be very fleshy, some of these signs may be scarcely perceptible. If, on the other hand, the subject of the injury be thin, it will often be possible to see and feel the displaced bone, or at least to perceive distinctly the unnatural swelling on the back of the hip of the uninjured side. This dislocation is recognized at once by an experienced surgeon. To non-professional persons it may at first seem that the patient has suffered a fracture of the neck of the thigh-bone, rather than a dislocation. In order to enable one to detect at once the difference between these two conditions, Dr. Hamilton arranges the points of distinction in the following tables : DISLOCATION UPON THE BACK OF THE HIP-BONE. 1. Very rare in aged persons. 2. Never caused by a fall upon the prominence on the outer side of the upper end of the thigh-bone, called the " great trochanter. " 3. Absence of grating. 4. Unnatural stiffness, or loss of motion. 5. Limb always shortened. 6. Limb almost always turned inward, drawn toward sound limb, and bent. FRACTURES OF THE NECK OF THE THIGH-BONE.1. Very frequent in old age.2. Often caused by a fall upon the " great trochanter. " 3. Grating sensation present. 4. Limb can be moved freely, except when motion causes pain. 5. Limb not always shortened. 6. Limb never turned inward, but is almost always slightly turned outward, and generally lies in the same direction with the other limb. Dislocation of the head of the thigh-bone forward toward the groin is often caused by some force which draws the knee or foot outward and downward. Signs. - If the patient stand on the sound limb it will be noticed : 1. The foot of the injured limb is advanced and the toes, turned somewhat outward. 2. The body is bent forward and toward the injured side. 3. There is an unusual flattening at the point where the other side of the body exhibits the prominence of the upper part of the bone. 4. There is an unusual prominence in the groin. 5. The limb is shorter than the sound one. In many cases it is possible to feel a movement at the prominent point in the groin when the thigh is rotated. In the other varieties of dislocation of the hip, the symptoms are very similar to those presented by the two forms just described. The symptoms vary somewhat under different circumstances, but in every case the deformity, the loss of motion and the shortening of the limb are sufficient to indicate the nature of the complaint. The non-professional observer can in almost every case, by the exercise of care and attention, recognize a dislocation of the hip ; in most cases this knowledge must suffice, since the detection of the individual and separate dislocations requires an intimate knowledge of the anatomy of the parts concerned, and a practical acquaintance with the signs of these affections. A simple means for recognizing a dislocation - a means applicable to all varieties of displacement - is said to be the following: A line is drawn with ink or lead pencil along the skin of the limb from the bony prominence at the front of the hip to the bony projection at the back of the haunch. If the limb be uninjured, that is, if no dislocation has occurred, the upper end of the thigh-bone should touch the lower border of this line ; if, on the other hand, the hip has been dislocated, the upper end of the thigh-bone lies above this line. Dislocations of the hip are often complicated with fractures of the neck of the thigh-bone ; and some of these fractures - those in which the fragments are driven into each other or impacted - frequently simulate a dislocation of the hip to a considerable degree. The latter can, however, usually be distinguished from dislocations by the fact that the limb can be moved, while in displacements of the bone the limb is fixed and immovable. Dislocations of the hip-bone in children are sometimes accompanied by a separation of the head of the bone from the neck. This occurs in children only, because during early life the head of the bone is not firmly attached to the narrow part which connects it with the shaft. Treatment.- The treatment of dislocations of the hip has undergone a radical modification in the last few years. In former times it was supposed that the chief obstacle to the restoration of the bone to its proper place consisted in the contraction of the powerful muscles constituting the hip and the thigh. Hence mechanical appliances were employed whereby the limb could be pulled away from the body with extreme force. Systems of pulleys were attached to rings in the wall or to the bed, and several men exerted their utmost strength in pulling the thigh away from the body. In one unfortunate instance, this feat was literally accomplished, the thigh being torn from the body. A more careful study of the anatomy of the parts showed however that the chief obstruction in the reduction of these dislocations was not muscular contraction, but a certain ligament which formed part of the capsule or sac surrounding the joint. This fact was brought to the notice of the profession largely by two distinguished surgeons, Dr. Gunn, of Chicago, and Dr. Bigelow, of Boston. It was demonstrated that there is a ligament which extends from the hip-bone to the head of the thigh-bone, having a shape much resembling that of the letter Y. It is hence called the " Y " ligament. It was found that the head of the bone often escaped from the sac of the joint through this ligament, and that the presence of the ligament constituted the obstacle to the restoration of the head of the thigh-bone to its socket. The recognition of this fact is followed by a change in the methods of treatment, for it became evident that the object was no longer to overcome the contraction of the muscles, but merely to manipulate the bone so that the head should be slipped through the opening, and should at the same time avoid the obstacle caused by the twisting of the Y ligament. The present methods consist, therefore, merely in such movements of the thigh as shall secure the passage of the head of the bone through the the capsule of the joint. These methods will be described, although their successful execution requires a certain amount of experience and acquaintance with anatomy, There is, however, a method which can be readily employed, even by non-professional persons, and which often succeeds in reducing dislocations. This method, which was first described by Dr. Allen, of Vermont, is essentially as follows : The patient is placed upon his back upon the floor; the operator stands over him, holding the injured limb between his legs. The patient's leg is bent at the knee, so that the ankle comes between the thighs of the operator ; the latter then clasps his hands below the knee of the patient and lifts gently until the latter's body is raised from the floor. In this way the weight of the body is made to pull away from the thigh. After the patient has been held in this position for a few seconds there often occurs a movement of the head of the thigh-bone into its socket, accompanied by an audible click. If this method fail, another attempt may be made by lifting both legs of the patient instead of one ; after the limbs are thus held for a few seconds, the head of the bone often slides back into its socket. If both of these measures fail, it will be necessary to resort to the methods by manipulation. These vary according to the particular dislocation which it is desired to reduce. In most of these cases it becomes necessary to administer ether ; first, in order to prevent the unconscious resistance of the patient; and, second, to relax the muscles. If no ether be administered, an extra amount of force must be employed, which may occasion injury to the tissues or to the bone itself. The patient is placed upon some blankets spread upon the floor or upon a hard bed. If the dislocated limb be the right one, the operator grasps the ankle with his right hand and places the left under the knee. The leg is bent to a right angle at the knee, and the thigh to something more than a right angle with the body. Care should be taken not to bend the limb at the hip so much as to bring the thigh in contact with the body, since the tissues about the joint may be lacerated by manipulations of the limb in this position. The thigh is then turned outward away from the body, while at the same time it is rotated upon itself by pulling the ankle away from the other limb. At this point of the manipulation the direction of the leg is therefore obliquely outward, while the thigh itself is inclined inward. The limb is then slowly extended, that is straightened at both the knee and the hip-joint. It will often be found even at the first attempt that the head of the bone drops into its socket during the manipulation. Sometimes, indeed, the reduction occurs quite unexpectedly before the maneuver has been completed. Backward dislocation of the hip - the variety in which the head of the bone lies behind its socket - is recognized by the symptoms and signs already mentioned. The treatment consists essentially in the measures already described, though the attempt to reduce a dislocation by a manipulation requires some modification. The leg is bent at the knee at a right angle, and at the thigh so that this forms about a right angle with the body. The thigh is then turned outward from the body, while at the same time the entire limb is rotated outward by means of the hand, which is applied to the ankle of the patient. The limb is then slowly straightened at the knee and at the hip. During this movement the head of the bone usually slips into place. Dislocation of the thigh-bone forward and inward under the groin often results from violence applied to the foot while the limb is placed obliquely to the body. It has repeatedly happened to individuals walking upon icy pavements, and is an occasional unpleasant incident in skating. The body is bent forward; the foot of the injured limb is turned somewhat outward, the heel being raised and placed against the ankle of the other limb ; the knee is slightly bent, and cannot be straightened without extreme pain ; the leg is shortened to a greater degree than usually happens in the other dislocations. If the individual be not supplied with much fat, the head of the thigh-bone can usually be felt in its new position. Treatment.-One of the best methods for reducing this dislocation is that practiced by Dr. Hamilton. The patient lies upon the floor or on a hard bed. A folded sheet is passed under the hips, the ends being crossed in front of the body and held by two assistants on either side of the bed. A third assistant stands by the uninjured side of the patient, passes his hand under the sound leg and seizes the ankle of the other limb. The operator stands by the injured side of the patient, a folded sheet is passed over his shoulders and carried between the patient's thigh as high as possible under the injured limb. The assistants who hold the ends of the sheet draw upon these and thus hold the hips firm. The third assistant, standing by the uninjured side of the patient, pulls the injured thigh toward him. The operator raises his shoulders, and thus lifts the head of the thigh-bone toward the head of the patient. The method by manipulation is somewhat simpler, in that fewer assistants are required. It is performed as follows : The patient lies upon his back on the floor. The operator, standing upon the side of the dislocation, grasps the ankle with one hand and places the other under the knee. The limb is bent so that the thigh stands perpendicularly to the body. The leg is then turned outward by carrying the foot away from the opposite limb. The leg is then rotated toward the other leg, while at the same time the limb is carried across the front of the body so that the knee is brought to the floor. In this way the head of the bone is lifted upward and forced somewhat outward. In the hands of an experienced and skillful surgeon, dislocations of the thigh-bone, when not complicated with fractures or extensive injuries to the flesh, are reduced without much difficulty. Any other individual will probably find much trouble in effecting the reduction. In every case a non-professional person should first try the method introduced by Dr. Allen, described above. If this fail, he may attempt to use the appropriate method by manipulation ; in all his efforts, however, he should be careful not to employ much force, for the proper manipulation can be executed with but a gentle amount of muscular effort on the part of the operator ; any greater force usually causes harm and not good. If these efforts be unsuccessful, it will be better to await the arrival of a surgeon, even though a day or two must elapse, than to experiment with the injured limb. If a much longer delay be unavoidable - and this may sometimes happen in a thinly-settled country-another attempt may be made while the patient is under the influence of ether. After the reduction has been accomplished, the thighs should be tied together for a week, and the patient should not rest the weight of the body upon the limb for two weeks at least, for after the hip has been once dislocated, a repetition of the accident may occur even after slight violence. In most cases it will be necessary to envelop the hip in hot fomentations for several days, in order to reduce the swelling and palliate the pain. It occasionally happens that dislocation of the hip is followed by more or less complete paralysis of the limb. This results from pressure upon a large nerve which passes out from the body just behind the hip-joint; the displaced head of the bone is pressed against this nerve and drawn firmly upon it by the contraction of the powerful muscles composing the hip. The ultimate result is doubtful, dependent upon the amount of injury which has been sustained by the nerve. The treatment of this complication must consist in frictions of the limb with the hands and with stimulating liniments (such as the soap or ammonia liniments), and in the use of electricity. After the hip has been dislocated for several weeks, it can be reduced only with great difficulty and with some danger, for the violence necessary to break up the bands and adhesions which have been formed since the displacement of the bone, often causes a severe and dangerous inflammation. These old dislocations should, therefore, never be meddled with by non-professional persons. 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