The Classic: Congenital Dislocation of the Hip

This month we highlight developmental dysplasia of the hip. The entity is one known since the beginning of recorded history, although until relatively recently it was known in the English language as congenital dislocation of the hip. Our Classic this month reproduces an article published in 1891 by AM Phelps describing a patient with an unusual congenital anterior dislocation of the hip and also outlines the then-current ideas regarding the etiology [1]. Despite considerable searching, I have unfortunately been able to uncover little information (including his first name) about this apparently prolific writer: he published at least 11 articles in the Transactions of the American Orthopaedic Association (later The Journal of Bone and Joint Surgery), and others in various journals such as Medical Record and the New England Journal of Medicine. All articles I could locate note he was from New York, but as was customary at the time, no additional information was provided regarding his address or institution or other contact information. According to records at the American Orthopaedic Association he was admitted in 1890 (only a few years after its founding in 1887) and he died in 1902. According to Weinstein [9], Phelps delivered the 1994 Presidential Address of the AOA, so he undoubtedly would have been prominent well before his induction into the AOA. Weinstein recognized Phelps’ prescient thinking about the education of orthopaedists of the future: they would be ‘‘thoroughly schooled in all the departments of medicine...he will secure for our specialty the subjects which are rightfully ours...colleges will want professors of orthopedic surgery.’’ (Readers will recognize Phelps was writing before the Flexner report resulted in more uniform medical schooling and at a time when orthopaedics was not well established as a specialty and all training was via an apprenticeship system.) Like most surgeons who focused on the musculoskeletal system at that time, Phelps had broad interests. He published a paper, ‘‘A New Operation of Hernia [4],’’ and according to Read [8], he reinforced hernia repairs with silver coils. However, he published on posterior congenital dislocation of the shoulder [5], surgical treatment of clubfoot [2], deformities of the knee [3], scoliosis [6], and infection [7]. Perhaps most astonishingly, he described the transplantation of tissue from lower animals to humans (found on Google Scholar without further reference). In the article we reproduce this month, Phelps had the unusual (if unfortunate) opportunity to confirm the pathologic findings in his patient with an anteriorly dislocated hip: the patient died at age 41⁄2 years from meningitis. The autopsy specimens (Figs 3 and 4) confirmed the anterior dislocation. It was common in those days to make inference of etiology based upon structural changes, many of which were secondary. Phelps cited Cornigan who ‘‘believed that the dislocation was a primary one, due to reflex spasm of the muscles in utero, caused by some central nerve lesion in early fœtal life [1].’’ In referring to his case, he then remarked, ‘‘It seems to me that dislocation of this bone could not take place by the contraction of...muscles...’’ based on the directions of muscle pull. Phelps summarized the then postulated causes of congenital dislocation of the hip. He quoted Ambrose Paré, from his book in 1678, ‘‘Hippocrates himself avers that infants in the very womb may have their joints dislocated by a fall, a blow, or compression [1].’’ ‘‘Heredity,’’ Phelps commented, ‘‘no doubt has much to do with producing this deformity.’’ He again cites Paré, on the role of heredity: