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AN 
 
 Inaugural Cjrtsis 
 
 
 CERVIX FEMORIS. 
 
 SUBMITTED TO THE PUBLIC EXAMINATION OF THE TRUSTEES AND FACULTY OF MEDI- 
 CINE OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF THE 
 
 UNIVERSITY OF THE STATE OF NEW YORK. 
 THOMAS COCK, M.D., President. 
 
 Sox tl)e JDegrse of doctor in itteoicine., 
 
 March. 12, 1857. 
 
 BY JOHN GEO. JOHNSON, 
 
 OF THB STATB OF MA98ACDD8 
 
 l*to |;0il: 
 
 BXILLER & HOLMAN, PRINTERS, CORNER OP CENTRE AND WHDHE STREETS. 
 
 1857. 
 
«SS 
 
 -AO 
 
 /p:<r, 
 
JAMES R. WOOD, M.D., 
 
 SURGEON TO BELLEVUE HOSPITAL; PRESIDENT TO^THE NEW YORK 
 PATHOLOGICAL SOCIETY, ETC., ETC. 
 
 fins firms h g*&uat*&, 
 
 ^ ' 
 
 As an humble tribute to that distinguished Surgeon for his noble endeavors to 
 
 elevate the Profession by his public teachings and private example, and 
 
 as a feeble acknowledgment of the debt of gratitude due to him 
 
 for the interest he has manifested in the advancement 
 
 of his pupils in professional information ; by 
 
 one of his private pupils, 
 
 JOHN GEO. JOHNSON. 
 
-t 
 
Sv Inba-Capsnlar Jrofam of % Cafe Jfmork /'^ ^ 
 
 Until within a few years, much diversity of opinion has 
 existed upon this question. Lately, the preponderance of 
 opinion has inclined strongly toward the affirmative. In the 
 conviction, however, that it is an open question, we desire to 
 submit to the profession the results of our investigation of 
 the subject. 
 
 The first question which presents itself is — Can intra-cap- 
 sular fractures be diagnosed with certainty during the life of 
 the patient ? 
 
 Fractures of the cervix femoris present themselves in three 
 varieties : — 1. Those entirely within the capsular ligament. 
 2. Those entirely without the capsular ligament. 3. Those 
 partly within and partly without the capsular ligament. 
 
 The subjective symptoms are : — 1. Pain. 2. Loss of vol- 
 untary motion. The objective symptoms are : — 1. Swelling 
 and deformity at the hip. 2. Approximation of the tro- 
 chanter major to the anterior superior spinous process of the 
 ilium. 3. Shortening. 4. Crepitus. 5. Eversion. 6. Forma- 
 tion of callus. 7. The direction in which the force is 
 applied. 
 
 It is hardly necessary to refer to the first of the subjective 
 symptoms as a means of diagnosis, for in all cases of fracture 
 of the cervix femoris, there is more or less injury to and 
 laceration of the soft parts — and, consequently, pain. 
 
 It is generally admitted that in all these cases the patient 
 feels pain in the whole vicinity of the joint. 
 
 2. Loss of voluntary motion exists in all fractures of the 
 cervix femoris where there is displacement, whether the 
 fracture is within or without the capsule. The only excep- 
 tion is in cases of impacted fractures, where the shaft of the 
 bone is driven into the cancellated portion of the head, in 
 which cases the power of voluntary motion may still remain. 
 
 Of the objective signs, the amount of shortening immedi- 
 ately attendant on the injury has been insisted upon as the 
 most conclusive in the diagnosis of intra from extra-capsular 
 fractures. 
 
 Those that insist that they can distinguish between these 
 kinds of fractures during the life of the patient, maintain 
 that the amount of immediate shortening in the cases of 
 
extra-capsular fractures is so much greater than in intra-cap- 
 sular fractures, as to furnish conclusive evidence as to which 
 class the fracture belongs. First, they maintain that imme- 
 diate shortening is greater in extra-capsular fractures, from 
 physiological principles ; second, as a matter of experience. 
 The physiological reason is, that the cervix femoris is sur- 
 rounded by a capsular ligament, which, in health, is ex- 
 tremely powerful, and closely embraces the head and cervix ; 
 thereby preventing the shaft from slipping so far in intra as 
 in extra-capsular fractures. If the capsule was in every case 
 uninjured, this would be satisfactory ; for it must be admitted 
 that the capsular ligament is very strong, and acts power- 
 fully in retaining the fractured parts in their places. If, how- 
 ever, the capsular ligament is torn, the shaft of the bone 
 may slip through the rent, and thus afford an amount of 
 shortening as great as in cases of fractures entirely without 
 the capsule. All authorities admit that laceration of the 
 capsule may, and often does, occur. Again, if the head of 
 the femur is comminuted, shortening to an indefinite extent 
 may occur. The head of the femur may be comminuted, as 
 this fracture usually occurs in persons past the prime of 
 life, when all the bones are fragile. Further, we can not 
 diagnosticate oblique intra-capsular from transverse extra- 
 capsular fractures, for it is quite impossible to feel the direc- 
 tion of the fracture, imbedded as it is. Again, the shock is 
 sometimes so great as to cause a paralysis of the muscles, 
 and in these cases the shortening does not immediately occur, 
 even though the fracture be extra-capsular. The fracture 
 may also be impacted, and yet extra-capsular. In these 
 cases there will not be as much immediate shortening, as 
 is claimed for all cases of extra-capsular fractures. 
 
 From these considerations, we conclude that unless the 
 condition of the capsule, or the precise nature of the frac- 
 ture can be determined, the amount of shortening is not a 
 diagnostic mark to be relied on. 
 
 2. Opinion of Authorities. — It is surprising to find the 
 amount of difference among authorities upon this point. 
 The most eminent surgeons, not of this country alone, but 
 English, Irish, and French, hold directly opposite opinions. 
 
 Sir Astley Cooper says, that intra-capsular fractures gives 
 the greatest amount of shortening. Mr. Stanley is opjjosed to 
 him. He states that extra-capsular fractures have the great- 
 est shortening. Amesbury claims the greatest shortening 
 for intra — and Earle, for extra-capsular fractures. Robert 
 
Wm. Smith, of Dublin, claims the greatest shortening for 
 extra-capsular ; while Chassaignac, and Vidal, (de Cassis) 
 are opposed to Desault, Boyer, Dupuytren, and Cloquet. 
 
 How can these contradictory opinions be reconciled or har- 
 monized ? Only by considering that, in some instances, the 
 intra-capsular fractures have given the greatest amount of 
 shortening, and in other instances the extra-capsular fractures 
 give the greatest shortening ; and that the surgeons who 
 have seen the cases of the first class, hold the opinion that 
 extra-capsular shortening is the greatest ; while those who 
 have seen cases of the second class, hold the opinion that 
 intra-capsular shortening is the greatest ; accepting this, as 
 the true explanation, and there is none other we can accept 
 without charging either the one side or the other with ignor- 
 ance or with intention to mislead, (neither of which charges 
 we are willing to make,) we are compelled to conclude that 
 this symptom does not present itself with sufficient regu- 
 larity to be of weight as a diagnostic sign. This is the opinion 
 entertained by the French Surgeon, M. Eodet, who says : — 
 " Cette opposition formelle entre les opinions de ces grands 
 chirurgiens vient sans doute de ce qu'il n'y a rien de constant 
 dans le degre du raccourcissement, qui accompagne de ces 
 deux espices des fractures." With this difficulty, both in 
 theory and in experience, we are compelled to exclude the 
 amount of shortening as diagnostic of the character of the 
 fracture. 
 
 Crepitus. — This will, depend on two conditions : first, 
 whether there is anything interposed between the ends of 
 the bone, as muscle, capsular ligament, etc., to prevent the 
 rubbing of the ends together ; second, whether there is im- 
 paction. If there is no impaction, and nothing interposed 
 between the ends of the bones, there is no reason why crepi- 
 tus should not occur, whether the fracture is intra or extra- 
 capsular. 
 
 Eversion. — This will depend, if the fracture is intra-cap- 
 sular, much on the amount of laceration of the capsule. If 
 the capsule is lacerated, there is no reason why the foot may 
 not be everted as fully as in cases of extra-capsular fractures. 
 Until it is determined whether there is, or is not, laceration 
 of the capsule, it is certain that we can not make the amount 
 of eversion a diagnostic sign. 
 
 Again, if the fracture is extra-capsular and impacted, there 
 may be as little eversion as in cases of intra-capsular frac- 
 ture, where the capsule is not lacerated. So, whether we 
 
8 
 
 have intra-capsular fracture with, laceration of the capsule, 
 or extra-capsular fracture without laceration; whether we 
 have intra-capsular fracture without laceration, or extra-cap- 
 sular fracture with impaction, we can not form a diagnosis 
 from the eversion. 
 
 Callus. — It has been thought that the existence of cal- 
 lus furnished a means of diagnosis, because there would be 
 no callus formed around the ends of the bone, if the frac- 
 ture was intra-capsular. This is true ; there is no callus 
 formed within the capsule, but there is a formation of callus in 
 cases of intra-capsular fracture. The callus is formed pre- 
 cisely where the law that governs plastic exudations would 
 teach us to look for it, viz. : external to the capsule, where 
 there are tissues capable of effusing it. It is effused external 
 to the capsule precisely where it is effused in cases of extra- 
 capsular fracture. This fact is beautifully shown in the spe- 
 cimen of intra-capsular fracture, now in the possession of Dr. 
 William H. Van Buren, of this city. A minute description 
 of which will hereafter be given. The simple formation of 
 callus, therefore, can not be considered a diagnostic sign of 
 extra-capsular fracture, as it may be found in the same place 
 in both kinds of fracture. 
 
 Approximation of the Trochanter Major to the Anterior 
 Superior Spinous Process of the Ilium. — This can not be a diag- 
 nostic sign, for there will be approximation in every case of 
 fracture of the cervix, and the degree of approximation will 
 depend on the direction of the fracture ; an oblique fracture 
 giving us more approximation than a transverse ; and this 
 rule will hold true, whether it is an intra or extra-capsular 
 fracture. 
 
 Swelling and Deformity at the Hip. — This will occur in 
 both cases ; the amount of deformity depending on the direc- 
 tion of the fracture. 
 
 M. Kodet having come to the conclusion, that none of thesa 
 signs were diagnostic, rejected them ; and maintained thet 
 the direction in which the force was applied was the only 
 diagnostic sign ; and that the fracture will be intra or extra- 
 capsular, oblique or transverse, according as the force has 
 been received in a vertical, lateral, or transverse direction. 
 Mr. Smith thus sums it up : 
 
 Force acting vertically, Fracture will be oblique, and intra-capsular. 
 
 antero-laterally, transverse, and intra-capsular. 
 
 postero-laterally, . . . mixed, 
 
 transversely, extra-capsular. 
 
Thus, if the person fell upon the knees, we should have the 
 first class, oblique and intra-capsular ; and in regard to this 
 argument, Mr. Smith, of Dublin, makes the following very- 
 just remarks : " With respect to Rodet's diagnostic sign, it 
 will be admitted as a general principal, that the mode of appli- 
 cation of the force and the direction in which it acts, will 
 determine the situation and direction of the fracture ; but I 
 contend that it is seldom available in practice in determining 
 the seat of a fracture of the neck of the femur with respect 
 to the capsule, for it would be extremely difficult, if not im- 
 possible, in the generality of cases, to obtain from patients 
 a description of the direction in which the force was applied, 
 as accurate as would be necessary before we could avail our- 
 selves of it as a means of diagnosis. It is not probable that 
 a person of advanced age, who had just suffered so severe an 
 injury as fracture of the neck of the thigh bone, would be 
 able to inform us whether the shock was sustained by the 
 external surface of the trochanter, or whether there was a 
 deviation anteriorly or posteriorly from a directly lateral fall." 
 (Smith on Fractures, Page 21.) It might be quite impossi- 
 ble to determine the point of injury from an examination of 
 the hip, as it may have been so protected by the clothes, that 
 no ecchymosis occurred, or the contusion and ecchymosis 
 maybe so extensive as to lose all value as indications of 
 the precise spot of the application of the force. Mr. Smith 
 also gives an instance (page 21) in which, according to this 
 rule, we should have an extra-capsular fracture, and in which 
 dissection proved that the fracture was intra-capsular. So 
 much for this diagnostic sign, beautiful in theory, but value- 
 less in practice. 
 
 I have thus reviewed each of these symptoms of fracture. 
 They are all extremely obscure, and the one upon which the 
 ' greatest stress has been laid — shortening — must be excluded 
 altogether. Taken separately, no one of them will enable 
 us to form a diagnosis ; taken collectively, there are so many 
 different conclusions that may justly be deduced from them, 
 that no positive diagnosis can be given between the two 
 kinds of fracture during the life of the patient. 
 
 If this difficulty attends the diagnosis of the two extreme 
 classes of extra and intra-capsular fractures, still greater dif- 
 ficulty must attend the diagnosis of the third class, which is 
 a mixture of the other two, partly intra and partly extra- 
 capsular ; and when we come to diagnose this third class 
 from the other two, it is impossible. As no accurate opinion 
 
10 
 
 can be formed of the precise nature of the injury during the 
 life of the patient, so no conclusion can be drawn as to the 
 osseous or non-osseous union of fractures within the capsule 
 from those patients who recover. This limits the decision 
 of the question to the conclusions derived from an examina- 
 tion of post-mortem specimens. 
 
 Before entering on that question, it may not be improper 
 to consider the probability of the osseous union of intra-cap- 
 sular fractures, in the view of the anatomical and pathological 
 conditions existing. The first point is the effectjrf the injury 
 on the capsule. 
 
 Violence sufficient to fracture the cervix femoris, must 
 be sufficient to cause injury to the synovial membrane of 
 the capsule. The result of that injury will be inflamma- 
 tion of the synovial membrane, and the result of that in- 
 flammation will be the effusion of a superabundance of sy- 
 novial fluid ; or, if the inflammation continues long enough, 
 of plastic lymph. Now, when the synovial fluid is poured 
 out, there must be distention of the capsule by it, and if this 
 occurs, then there must be separation of the ends of the bone, 
 for they are attached to the capsule. If the ends of the bone 
 are separated, we can not have osseous union ; for even the 
 most ardent advocate of osseous union (R. W. Smith, of Dub- 
 lin) claims it only in cases of impacted fractures. Now, as 
 long as the inflammatory action continues, so long shall we 
 have synovitis, effusion, distention of the capsule, and con- 
 sequent separation of the ends of the bone. If the inflam- 
 matory action ceases, we shall not have union by bone, for 
 the first thing nature does is to get up an inflammatory 
 action in and around the ends of the bone, whereby plastic 
 exudation is poured out. That we do have synovitis in all 
 cases of intra-capsular fractures is evident from the autop- 
 sies, for the capsule is always reported thickened. This 
 thickening is evidently due to inflammation of the synovial 
 membrane, so long continued that not merely synovial fluid 
 had been effused, but plastic lymph, and that lymph had be- 
 come organized. 
 
 2. There is no sufficient means left, after the fracture, 
 to nourish the head of the bone, and furnish material for 
 ossific union. The only possible means of nourishing the 
 head of the bone, are four in number : — 1. From the 
 branches of the nutrient artery of the femur. 2. From 
 the periosteum. 3. From the synovial membrane. 4. 
 From the vessels of the ligamentum teres : — 1. If the bone 
 
11 
 
 is fractured, the probability is that the branches of the 
 nutrient artery are torn from the head of the femur. 2. The 
 periosteum . will probably be torn, because it is the most 
 delicate upon the head and cervix. 3. The synovial mem- 
 brane would produce synovial fluid and lymph, but not 
 ossific matter. 4. The vessels of the ligamentum teres are 
 so small as to be imperceptible to the unassisted eye, and it 
 is not possible that these should be able to carry a sufficient 
 amount of nutrition to support the bone, and afford ossific 
 union. Grant, for the sake of argument, that the vessels of 
 the ligamentum teres were capable of performing this func- 
 tion. If they did perform it, they would become much 
 enlarged from this increased action, in the same manner that 
 the anastomotic vessels are enlarged -in the case of aligated 
 artery ; but in every one of these cases, of so-called osseous 
 union, where the ligamentum teres has been spoken of, it 
 has been described as natural. If it was natural, then its 
 vessels could not have performed this increased function. If 
 it was not natural, then the notes have not been faithfully 
 reported. 
 
 3. Another difficulty in the way of osseous union is to be 
 found in the difficulty of maintaining the ends of the bone 
 in coaptation. Nature's splint does not work here ; there is 
 no provisional callus around the ends of the bone to main- 
 tain them in apposition. There is effusion into the capsule, so 
 that no external splint can be applied which will be able to 
 control the upper end of the fractured bone ; for, if it is firmly 
 applied, the pressure will increase the synovitis ; if it is not 
 firmly applied, it is of no use. 
 
 We conclude, therefore, that bony union of the intra-cap- 
 sular fracture does not occur, for the following reasons : 
 
 1. The separation of the ends of the bone by the 
 synovitis, which synovitis continues so long as there is 
 inflammatory action in the part. 2. The lack of tissues 
 capable of producing ossific matter. 3. The lack of means 
 of nourishment. 4. The impossibility of retaining the bone 
 in coaptation. 
 
 Before leaving this part of the argument, another point 
 must be briefly considered, because some writers lay great 
 stress upon it. It is the "Argument from Analogy;" or, 
 the bony union of fractures of bones within synovial mem- 
 branes, as in fractures of the patella and olecranon. This 
 argument seems to many to be conclusive, and it is urged, 
 as such, by men of eminence in their profession. A slight 
 
12 
 
 examination will, however, show points of difference suf- 
 ficient to destroy all analogy and all arguments derived from 
 analogy. 1. The patella is not a part of the skeleton. It is 
 a sesamoid bone developed in the tendon of the quadriceps 
 extensor muscle, to afford this muscle greater leverage. 
 2. It is a flat bone, while the head of the femur is sphe- 
 roidal. 3. It is more fully nourished than the head of the 
 femur. The head of the femur, in cases of fracture, derives 
 its nourishment entirely through the ligamentum teres, a 
 small rounded tendon ; while the flat, strong band of tendi- 
 nous fibres, composing the ligamentum patella, passes over 
 the entire length of the patella. This ligament is so large 
 that it would be more fitly denominated the tendon of the 
 quadriceps extensor muscle. The whole anterior surface is 
 covered with synovial membrane, and there is a fold of syno- 
 vial membrane reflected behind the patella, termed the liga- 
 mentum mucosum. The knee joint is the largest joint in 
 the whole body, and the patella being a flat bone, there is a 
 greater amount of surface in proportion to the size of the 
 bone to receive nourishment from the synovial membrane and 
 fluid, than is the case in the head of the femur. Again, the 
 knee joint is more abundantly nourished than the acetabu- 
 lum. We find five arteries of considerable size passing to 
 the joint — so large as to be described by anatomists. They 
 are the two upper articular arteries, the two lower articu- 
 lar arteries, and the middle articular artery. Of these, the 
 middle branch or external articular artery, goes directly to 
 the patella; and the lower internal articular artery sends 
 branches directly to that bone. These five arteries form 
 a net- work of vessels at the front and sides of the joint, 
 so that the patella has an abundant supply of blood in 
 cases of fracture — unless these vessels are destroyed. Most 
 fractures of the patella occur from a sudden strain, rather 
 than from direct violence, so that in the majority of cases 
 there will be abundant nourishment to the fractured patella. 
 The olecranon has scarcely more analogy with the cervix 
 femoris than the patella. Instead of being attached by a small 
 ligament, like the ligamentum teres, there is the powerful liga- 
 ment of the triceps extensor muscle — a tendon far more capa- 
 ble of supporting a bone as large as the head of the femur than 
 the ligamentum teres. But it has no such work to perform. 
 The olecranon has other and ampler sources of nourishment, 
 being covered on one side by cartilage, and on the other by 
 the synovial membrane of the joint. The synovial mem- 
 
13 
 
 brane of the elbow joint is far larger, in proportion to the 
 size of the olecranon, than is that of the hip joint to the size of 
 the head of the femur. We regard it as established, there- 
 fore, that the prospects of union are far more favorable in 
 cases of fracture of the patella and olecranon, than in cases of 
 fracture of the cervix femoris. But what results are obtained 
 in cases of fracture of the patella and olecranon ? Almost in- 
 variably union by ligament. The union by bone is the ex- 
 ception, and so rare an exception that the specimens are 
 preserved in museums, as curiosities. These reasons place 
 the improbability of union beyond a reasonable doubt. 
 
 Again, the non-union of cases, where everything was favor- 
 able, affords a strong probability that union does not occur. 
 I will quote two of these cases for illustration. 
 
 I am indebted to Dr. James E. Wood, of this city, for the 
 following history, which he has kindly furnished me, of a 
 case which occurred in his own practice, and I take great 
 pleasure in acknowledging the favors I have received from 
 him, both in the privileges of his museum and also in his 
 library, and the facilities he has afforded me in the investi- 
 gation of this subject: 
 
 Case 1. — History. — M. J., a young lady, eet. 16 years ; of 
 vigorous constitution; perfectly free from any constitu- 
 tional taint either of scrofula, syphilis, or cancer; was caught 
 between the wheels of two carriages, the one stationary, the 
 other in motion. The blow was received directly on the tro- 
 chanter major of the right side. The symptoms which pre- 
 sented themselves showed conclusively that there was a 
 fracture. There was shortening, loss of voluntary motion, 
 and eversion ; by placing the finger on the trochanter major, 
 and the thumb in the groin, a well-marked crepitus could be 
 felt on extension and rotation being made. There was no 
 laceration or other complication of the injury. She was 
 placed on Amesbury's splint, with side splints accurately 
 adjusted, and eveiy precaution taken to ensure a perfect 
 union. The limb was kept on this splint without being dis- 
 turbed for six weeks. At the end of that time, it was taken 
 from the splint, and examined with care. The signs of frac- 
 ture still remained; the limb was replaced on the splint, and 
 the dressings as before ; everything was attended to in the 
 general management of the case which the doctor thought 
 would be conducive to perfect union. The patient was 
 kept for three weeks longer on the splint, which was then 
 removed. It was found that there was no union. Patient 
 
14 
 
 lived for three years, and was so lame that she was always 
 obliged to use a crutch in walking. At the expiration of 
 three years she died of an acute disease. 
 
 Post-Mortem Examination. — On examination of the cervix 
 femoris, it was found that there had been a transverse frac- 
 ture of the bone just at the junction of the head and neck. 
 The head of the bone was still attached to the acetabulum by 
 the ligamentum teres. The process of absorption had been 
 going on, and the head of the bone had already been ab- 
 sorbed below the level of the acetabulum, and what remained 
 was soft and spongy, easily broken with the handle of the 
 scalpel. The neck of the bone was rounded off, and covered 
 with a fibrous deposit. This was not a case of diastasis, as 
 has been suggested by an eminent surgeon, who judged sim- 
 ply from the age of the patient. She was full sixteen when 
 the accident happened, and over nineteen when she died. 
 
 Remarks. — This case makes a very strong argument against 
 union by bone. Here, every circumstance was favorable. 
 The age of the patient, her constitution, the immediate diag- 
 nosis of a fracture, and the subsequent treatment, were 
 favorable to osseous union, if it were possible that such 
 union could take place under any circumstances where the 
 fracture was within the capsule. She was not an old patient, 
 past the prime of life, in whom the vital energies were nearly 
 exhausted, as .are most of the patients in whom osseous 
 union is claimed to have taken place, but at the most vigor- 
 ous period of life, just after ripening womanhood has given 
 full strength and power to all her functions ; a period when 
 nature is prodigal in her endeavors to aid, and when her re- 
 cuperative powers are the strongest. She was not broken 
 down by constitutional disease, produced either by her own 
 or her parents' errors, but in perfect health, free from all 
 constitutional taint, either of scrofula, syphilis, or cancer. 
 
 There was no mistake in the diagnosis of the case, as in 
 one of Mr. Smith's so-called cases of osseous union. Here 
 the diagnosis was made at once, and made correctly. The 
 treatment, also, was adapted to the nature of the fracture. 
 The patient was at home, among her friends, where every 
 wish of her attending surgeon could be carried out. And to 
 those acquainted with the surgeon in attendance, his name 
 alone would be a guarantee that everything requisite in the 
 treatment was attended to, even had no mention been made 
 of the dressings in the case. 
 
 Those dressings were Amesbury's splint, with side splints ; 
 
15 
 
 a form of dressing insuring perfect rest of the parts. These 
 dressings were kept on for six weeks undisturbed, then the 
 limb was carefully examined, dressings replaced, and continued 
 for three weeks longer ; everything, meanwhile, being attend- 
 ed to which the surgeon in attendance thought conducive to 
 union. Under these most favorable circumstances for osseous 
 union, this result was not obtained ; the patient remained a 
 cripple for life ; the process of absorption of the fractured end 
 of the bone went on, and at the time of her death the parts 
 were found as already described. If this was the only case of 
 the kind which could be adduced, then it might be regarded 
 as a rare exception ; but cases of the kind can be easily mul- 
 tiplied, quite as conclusive as that just mentioned. 
 
 There is in the museum of Prof. William H. Van Buren, of 
 the University Medical College, a specimen precisely in 
 point. I am under obligations to Prof. Van Buren for the 
 history of the case, which he furnished me, and also for the 
 privilege of fully examining the specimen. 
 
 Case 2. — History. — The patient was a man, set. 25 years ; 
 robust ; in good health. He was dancing at his sister's wed- 
 ding ; while cutting a pidgeon wing, he struck the foot 
 upon which he was resting from under him, and fell, striking 
 directly upon the trochanter major. He was unable to rise ; 
 a carriage was called and he was taken directly to the New 
 York Hospital. There he came under the charge of Dr. J. 
 Kearney Rodgers. A fracture was immediately diagnosti- 
 cated, and for a few days he was kept on the double inclined 
 plane. The straight splint was then used, and the dressings 
 kept up for six weeks, at the end of that time they were 
 taken down and the limb examined : there was no union. 
 The limb was continued in the straight splints for three 
 weeks longer, and again examined — there was still no union. 
 The patient was again replaced in the straight splint for two 
 weeks longer, but no union occurred. At the end of three 
 months from his admission, he was discharged ; he was in 
 good health, but so lame that he was obliged to use two 
 crutches in walking. After his discharge, the patient became 
 very intemperate ; and, in the course of a few weeks, he 
 applied for admission to Bellevue Hospital. He was much 
 debilitated, and had an exhausting diarrhoea. Shortly after 
 his admission, an immense abscess formed over the joint, 
 which discharged profusely. The man died shortly after, 
 from exhaustion, and the specimen came into Dr. Van Buren's 
 hands, the patient having been in his service. Dr. Van 
 
16 
 
 Buren was aware of the patient's previous history, the treat- 
 ment, etc., at the New York Hospital, and a careful exam- 
 ination was made. 
 
 Post- Mortem Examination. — The capsular ligament was 
 destroyed entirely by the suppurative process j there was a 
 formation of callus upon the trochanter major ; the ligamen- 
 tum teres was entirely absorbed ; the head of the bone was 
 spongy, as if worm eaten ; the direction of the fracture was 
 oblique, commencing just at the articulating surface of the 
 head and ending just within the capsule ; the upper end of 
 the shaft of the bone showed this same appearance that was 
 marked in the head. These points are beautifully shown in 
 the specimen at the present time. The opinion of Charles 
 E. Isaacs, M.D., the able Demonstrator of Anatomy of the 
 University Medical College, is, that this fracture was entirely 
 within the capsule. 
 
 Remarks. — Here was a strong, healthy man, in the prime 
 of life, with no constitutional taint, with an immediate diag- 
 nosis of his fracture, and immediate and proper treatment, 
 and that treatment continued for three months, under the 
 supervision of Dr. J. Kearney Eodgers, with all the advan- 
 tages of the New York Hospital, where more fractures are 
 treated than in any other institution in this country ; every- 
 thing being attended to that would facilitate union. The 
 patient's general health was carefully attended to as is 
 shown by his condition at the time of his discharge. Not- 
 withstanding all these advantageous conditions, there was 
 no union. If health, constitution, youth, and good treat- 
 ment give no such results, what are we to hope for from 
 age and debility? 
 
 We shall now proceed to analyze the specimens which 
 have been brought forward to prove the union of intra-cap- 
 sular fracture of the cervix femoris. If there is a single speci- 
 men, about which there could be no doubt of there having been 
 a fracture entirely intra-capsular, and of that fracture unit- 
 ing by osseous union, that specimen would settle the possi- 
 bility of osseous union in* cases of intra-capsular fractures of 
 the cervix femoris. But is there a single specimen of this 
 kind in existence ? Eobert W. Smith, of Dublin, in his ex- 
 cellent work on Fractures, claims to have collected facts 
 which settle this question. He has searched the museums 
 of England, Ireland, and France, for their choice specimens, 
 and has been able to collect only seven which have any pre 
 tense of this kind. Prof. Willard Parker, of this city, has 
 
17 
 
 one ; Philadelphia claims to have two; and Prof. E. D. Mus- 
 sey, of Cincinnati, has three specimens, which he alleges 
 are perfect illustrations of the osseous union of intra-capsu- 
 lar fractures of the cervix femoris. 
 
 The greatest number collected are in the work of Robert 
 W. Smith, of Dublin, on Fractures ; they are seven in number. 
 The first of these cases is that of Mr. LangstafF's, which is 
 the strongest case ; the notes of this case, both as published 
 in the Medico-Chirurgical Transactions, vol. 13, page 49 1 , 
 No. 242, and in Mr. Smith's work on Fractures, page 57, are 
 extremely meagre. Mr. Smith's report is as follows (page 
 57) : — " In this case, the patient was a female, aet. 50 years, 
 when the fracture happened. She was confined to her bed 
 for nearly twelve months after the occurrence of the acci- 
 dent, and during the remainder of her life, a period of ten 
 years, w T alked with crutches. On dissection, it was found 
 that the principal part of the neck of the bone was absorbed ; 
 the head and remaining portion of the neck were united, 
 principally by bone, and partly by a cartilaginous substance. 
 On making a section of the bone, it was evident that there 
 had been a fracture of the neck within the capsular ligament, 
 and that union had taken place by osseous and cartilaginous 
 media. With a view of ascertaining whether there was real 
 osseous union, the bone was boiled many hours, which, by 
 destroying all the animal matter, satisfactorily proved the 
 extent and firmness of the osseous connection, and exhibited 
 the spaces which had been occupied by cartilaginous matter." 
 
 No mention is made of the treatment adopted in the case. 
 The only statement that can in any way be considered as 
 bearing on this point, is that she was confined to her bed for 
 twelve months. This was probably because she could not 
 get up, for if Mr. LangstafF had required her to be kept in 
 bed, as a part of the treatment, he would doubtless have men- 
 tioned it. He does not state whether any splints were used, 
 or any other means adopted to keep the parts in coaptation. 
 These are important particulars ; for Mr. Smith says (page 64) 
 it is by contact and rest, that we are to hope for bony con- 
 solidation. 
 
 Again, all the proof of there ever having been a fracture 
 must be derived from the statement of Mr. LangstafF; for 
 there is not a single symptom, nor a single fact mentioned, 
 to lead to such a conclusion, except that the woman kept 
 her bed for twelve months after the accident, and was after- 
 wards lame for life. Nor does he give us any reason where- 
 
18 
 
 by he came to this conclusion from the autopsy. There are 
 no measurements given to show how far within the capsule 
 the fracture was ; or, how near to the capsule the fracture ap- 
 proached at its nearest point of approximation. In fine, the 
 capsule itself is not preserved, or even the smallest portion 
 of it, from which to furnish points of measurements. Noth- 
 ing is given but the simple statement of Mr. Langstaff, that, 
 " On making a section of the bone, it was evident that there 
 had been a fracture of the neck within the capsular liga- 
 ment, and that union had taken place by osseous and carti- 
 laginous media." In all cases of controversy, the public have 
 the right to know the reasons upon which an opinion is 
 founded, especially if they are called upon to believe that 
 opinion. In this particular case, it was of the utmost im- 
 portance that, instead of mere assertion, a systematic state- 
 ment of the case should have been given, with measurements 
 from certain fixed points, and minute descriptions of the 
 various abnormal peculiarities ; that, from these measurements 
 and descriptions, logical conclusions might have been drawn. 
 Mr. Langstaff makes the statement that the head of the 
 bone was united to the shaft by bone, and that the neck was 
 absorbed. The same objection exists to this which did to his 
 first statement ; he gives us none of the reasons whereby 
 he came to the conclusion that this was the head of the bone 
 which remained ; he does not inform us whether the liga- 
 mentum teres was attached to it or not ; he does not men- 
 tion whether the vessels of the ligament um teres were en- 
 larged or not, as they would be had they sustained the head 
 of the bone, and also furnished the osseous union existing. 
 In fine, the notes are so carelessly taken, that he does not 
 mention whether there was a ligamentum teres or not. There 
 is no ligamentum teres represented in the engraving ; it is 
 presumed that the engraving is a fair representation of the 
 specimen, — for it is presented for that purpose by Mr. Smith. 
 As nothing is said of a ligamentum teres, and none is shown 
 in the plate that represents the specimen, it is right to con- 
 clude there was no ligamentum teres. This was probably a 
 case of the absorption of the head of the bone, from the 
 results of the injury. This is rendered probable from analogy 
 and from the facts in the case. Illustrations of this absorp- 
 tion of the head of the bone are abundant ; we find them in 
 this same article of Mr. Smith's, page 71, Case 6. (Esther 
 Christie.) In that case we are told : " The upper fragment 
 has been absorbed as far as the acetabulum, and the ligamen- 
 tum teres was the sole remaining attachment of the bone." 
 
19 
 
 Here the process of absorption of the fractured head of the 
 bone is going on, the head of the bone is absorbed as far as 
 the acetabulum, while the surface of the lower fragment is 
 becoming "covered with a fibrous deposit, though still rough," 
 to enable it to fulfill its new function. Case 7, page 72 
 (Mary Lamb), gives the same process of absorption going on. 
 In this case, the patient died twelve months after the injury, 
 yet the head of the bone is absorbed as far as the acetabulum, 
 and fibrous structure formed, all of which had been accom- 
 plished in the space of twelve months. If, in this old woman, 
 eighty years of age, absorption had gone on as rapidly as here 
 stated, is it improbable that the whole head of the bone 
 should have been absorbed in the case of Mr. LangstafT, when 
 the patient lived, not merely twelve months after the injury, 
 but nearly eleven years, and was only fifty years of age in- 
 stead of eighty ? If further illustrations of this absorption 
 of the head of the bone were desired they could easily be 
 multiplied. The case of Dr. Wm. H. Van Buren's is in point ; 
 in that the ligamentum teres was absorbed besides the pro- 
 cess in the head of the bone. The case of the girl M. J., 
 under Dr. Wood's charge, is another case in point. There 
 is still another specimen in the museum of Dr. James R. 
 Wood, that illustrates this point ; it was taken from a woman 
 fifty-four years of age ; all the usual signs of fracture were 
 fully made out ; the limb was immediately placed on a double 
 inclined plane, and retained so for nearly two months; the 
 woman had no control over the motions of the limb, she was 
 unable to walk without a crutch, and when she died, two 
 years after the occurrence of the injury, the specimen came 
 into Dr. Wood's possession. At his clinical lecture at Bellevue 
 Hospital, Saturday, January 3, Dr. Wood exhibited the speci- 
 men to the students. The patient, he stated, died of pneu- 
 monia two years after the injury. The autopsy exhibited the 
 fracture entirely within the capsule ; on cutting into the thick- 
 ened capsule, the head of the bone was found lying loose in the 
 cavity ; the ligamentum teres was entirely absorbed ; the head 
 of the bone had become exceedingly light and soft, easily 
 broken up with the handle of a scalpel, the neck of the bone 
 was becoming rounded off to fulfill its new function, and the 
 neck was becoming covered with fibrous matter. These 
 cases demonstrate conclusively the fact that, in fractures of 
 the cervix femoris within the capsule, the head is often under- 
 going the process of absorption, and it is not unreasonable to 
 conclude that, in this patient of Mr. Langstaff, where she 
 
20 
 
 lived for so long a time after the injury, this process was com- 
 pleted. 
 
 In the case of Mr. Langstaff's, the patient was confined to 
 her bed for twelve months, and lived ten years, during which 
 she was lame ; if the head of the bone remained, as is claim- 
 ed, and the union was by bone, if the ligamentum teres re- 
 mained, as it must have done to have produced this bony 
 union, then the patient should have had the use of the limb ; 
 but, on the contrary, she was lame for life — so lame that she 
 had to walk with crutches, though she lived for a period of 
 nearly eleven years after the injury ; a circumstance easily 
 understood, if this process of absorption of the head of the 
 bone was going on during this time. 
 
 The next case adduced by Mr. Smith to support this view. 
 is that of Dr. Brulatour, page 58 of Mr. Smith's work ; also, 
 vol. 13, page 512, Med. Cfflrurg. Transactions. 
 
 Dr. James, an English physician, residing at Bordeaux, ast. 
 47 years, was thrown from his horse, on March 29, 1826. 
 He fell directly on the great trochanter, but got up and 
 walked a step or two, which occasioned such acute pain in 
 the hip joint that he instantly fell again; on examination 
 immediately after the accident, Dr. Brulatour observed the 
 principal signs of fracture of the neck of the femur, such as 
 shortening of the affected limb, eversion of the foot, and a 
 feeling of crepitation in the joint when counter extension was 
 made ; extension of the limb was kept up for two months, 
 so as to preserve it of its natural length. Three months after 
 the receipt of the injury, Dr. James was able to walk with 
 only the assistance of a cane, and subsequently recovered the 
 full use of the limb. On the 20th of December, nine months 
 after the accident, he was attacked with hgematemesis, which 
 proved fatal in two days. The post-mortem examination of 
 the right hip joint showed the capsule a little thickened ; the 
 cotyloid cavity and inter-articular ligament in a natural state; 
 the neck of the femur shortened ; an irregular line surround- 
 ing the neck, denoting the direction of the fracture, and con- 
 siderable bony deposit at the bottom of the head of the 
 femur, and at the external and posterior part. A section of 
 the head of the femur was made, in a line drawn from its 
 center to the bottom of the great trochanter, so as perfectly 
 to expose the callus. The line of union, indicated by the 
 callus, was smooth and polished as ivory ; the line of callus 
 denoted also, that the bottom of the head of the femur had 
 been broken off at its superior and posterior part. 
 
21 
 
 If these notes prove anything, they prove too much ; for 
 it is stated that " an irregular line surrounding the neck, de- 
 noting the direction of the fracture, and considerable bony 
 deposit at its external and posterior part." " The line of 
 callus, denoted, also, that the bottom of the head of the 
 femur had been broken at its superior and posterior part.' 1 
 If this statement is true, what must have been the nature of 
 the injury ? Evidently a comminuted fracture entirely 
 within the capsule ; for, the first line denoted that the head 
 of the bone had been fractured off from the shaft of the 
 bone, a second line indicated that the bottom and pos- 
 terior part of the head had been fractured off from the 
 remainder. If the periosteum was injured, and I can not 
 imagine it to be otherwise, how would it be possible that 
 this third portion of the bone should be nourished? If 
 the head was nourished by the ligamentum teres, and 
 the portion connected with the shaft by the nutrient 
 artery of the femur, how would this third piece be sus- 
 tained? Yet it had been nourished, and was united to the 
 remainder "by callus as smooth and polished as ivory." An- 
 other point : the report states that " the ligamentum teres 
 was in a natural state," and we are informed that the head 
 of the bone was fractured off in such a way, that the larger 
 part of it could only be nourished by the ligamentum teres. 
 The ligamentum teres had in addition to its usual functions 
 nourished this, and had assisted in the formation of the ex- 
 isting callus. When an artery performs an additional func- 
 tion, that artery becomes enlarged. This is constantly seen 
 in the anastomotic circulation of a ligated vessel — the inoscu- 
 lating branches soon enlarge to the size almost of the original 
 vessels, whose place they have supplied. In this case the 
 vessels of the ligamentum teres had to perform their own 
 functions, and in addition to nourish this fractured head, and 
 assist in the formation of callus, yet they were found in a 
 natural state. We may add that Mr. Smith is in error in 
 stating that " It is highly probable that they have all been 
 examples of impacted fractures ;" "the displacement of frag- 
 ments has been prevented ;" for in this case the limb was at 
 first shortened, and then by dressings drawn down to its natu- 
 ral length. 
 
 The third case is that of Mr. Stanley, of which the notes 
 are as follows : — A young man, aet. IS years, fell from the top 
 of a loaded cart upon his right hip, the injury of which was 
 attended with the following symptoms : — he was wholly una- 
 
22 
 
 ble to move the limb ; the thigh was bent to a right angle 
 with the pelvis, and could not be extended; abduction was 
 difficult ; the limb was everted ; but there was no shorten- 
 ing, nor could crepitus be felt in any motion of the limb. 
 The patient died of what was supposed to be small pox, 
 about three months after the occurrence of the accident. In 
 the examination of the joint after death, the capsule was 
 found thickened, the round ligament uninjured; a line of 
 fracture extended obliquely through the neck of the femur, 
 and entirely within the capsule ; the neck of the bone was 
 shortened, and its head approximated to the trochanter major. 
 The fractured surfaces were in the closest appositon, and 
 firmly united nearly in their whole extent by bone ; there 
 was an irregular deposition of bone upon the neck of the 
 femur, beneath its synovial and periosteal covering, along 
 the line of the fracture. At the end of his report, page 59, 
 Mr. Smith refers to the Medico- Chirurgical Transactions, vol. 
 18. On reference to this volume, we find the following impor- 
 tant facts which Mr. Smith has omitted in his extract : — " The 
 age of the patient was unfavorable to the occurrence of a frac- 
 ture at the neck of the thigh bone. The general opinion, there- 
 fore, of the several surgeons to whose judgment the case 
 was submitted, favored a belief of a dislocation into the fora- 
 men ovale. Forcible extension of the limb was made by pul- 
 leys, and the thigh then moved in several directions by which 
 the head of the bone might be replaced in its socket." These 
 facts which Mr. Smith has omitted, bear directly against the 
 position he has assumed. For immediately after giving the 
 seven cases, of which this is one, he says (page 64) " The 
 preceding cases furnish ample evidence of the possibility of 
 osseous union in cases of intra-capsular fracture of the neck 
 of the femur, and it is highly probable that they have all 
 been examples of impacted fractures. Certainly, in all those 
 of which delineations have been given, there has been either 
 penetration of one fragment by a portion of the other, or 
 else the irregularity of the line of fracture has been such, 
 that the displacement of the fragments has been prevented. 
 They have been maintained in contact and at rest, and it is 
 under such circumstances alone, that we are to hope for the 
 occurrence of bony consolidation." These are singular com- 
 ments upon a case in which the limb was forcibly extended 
 by pulleys, and then rocked. If this was a case of impacted 
 fracture, how long would it remain so, after forcible exten- 
 sion by pulleys and rocking ? Yet, according to Mr. Smith, 
 
23 
 
 it must have remained an impacted fracture ; for under those 
 circumstances alone, does he believe we are to hope for bony 
 union. 
 
 To an intelligent surgeon, it will be a sufficient refutation 
 of Mr. Smith's assumptions, by simply stating the following 
 facts. The case was at first treated for a dislocation, and not 
 till the second month was the patient brought to the hospi- 
 tal. Shortly after his admission, he was attacked with an 
 exanthem of which he died. Is it probable that a fracture 
 within the capsule of the cervix femoris, mistaken for dislo- 
 cation, would have that perfect contact and rest (a sine qua 
 non of ossificunion with Mr. Smith), without which we can 
 not hope for bony consolidation, when the limb is first 
 forcibly extended by pulleys and rocked, then the patient is 
 removed to a hospital, where he soon after dies from an attack 
 of acute disease, and all this occurring within the space of 
 three months, from the injury ? 
 
 Case 4 — (Mr. Swan's case). — Mr. Smith's notes are as fol- 
 lows : — " Mrs. Powel, above SO years of age, fell down, No- 
 vember 14, 1824. Sir Astley Cooper, who saw her soon 
 after, believed that there was a fracture of the neck of the 
 femur, although there was no appreciable shortening of the 
 limb, and only a slight inclination of the toes outward ; crepi- 
 tus could not be perceived ; the patient died about five weeks 
 after the accident ; upon examination of the joint after death, 
 the fracture was found to have been entirely within the cap- 
 sular ligament, and the greater part of it was firmly united. 
 A section was made through the fractured part, and a faint 
 white line was seen in one portion of the union, but the rest 
 appeared entirely of bone. The cervical ligament had not 
 been injured." (Smith, page 59.) In this case, the patient 
 was an old lady, above SO years of age, with the fracture 
 not certainly made out ; there was no appreciable shortening 
 of the limb ; no crepitus ; and only a slight inclination of the 
 toes outward. The strongest point in favor of there having 
 been a fracture, was the opinion of Sir Astley Cooper, which 
 opinion is entitled to great weight ; but there are no sat- 
 isfactory facts given upon which he formed that opinion. 
 This slight eversion of the foot might be given by the patient 
 to relieve the tension on the bruised and inflamed part. We 
 may well queiy if the vessels of the ligamentum teres would 
 not have shown evidences of having performed an increased 
 function ? Would five weeks have been sufficient time for 
 them to furnish osseous union, and resume their original size ? 
 
24 
 
 Again, the old woman died in five weeks after the receipt 
 of the injury. Now, it seems to us quite improbable, nay, 
 impossible, that bony union of an intra-capsular fracture of the 
 femur in an old woman, above eighty years of age, in whom 
 there was not left vitality enough to sustain life, should take place 
 in five weeks after the injury — in less time than is allowed for 
 the ordinary union of a fracture of the shaft of the femur in a 
 healthy person in the prime of life. 
 
 Case 5 — (Mr. Adams' case). — This case is reported more 
 fully and is accompanied with an engraving, illustrating it, 
 page 61. The engraving must be considered correct — for it is 
 fair to presume that it would not be made to represent the 
 case any more unfavorable to the side of the question Mr. 
 Smith argues than the facts in the case required. Now, this 
 engraving shows the line of union to extend nearly to the base 
 of the trochanter minor, a point far without the capsule. 
 (See second engraving, on page 61, Smith on Fractures.) 
 This makes it a case of fracture partly within and partly 
 without the capsule — a class of fractures which every one 
 admits may readily unite by bone. 
 
 Case 6 — (Mr. Jones' case). — Of this case Mr. Smith makes 
 the remark, page 63 : " this specimen was sent to Sir Astley 
 Cooper for examination ; Sir Astley was of opinion, that the 
 fracture was ' in part within, and in part external to, the cap- 
 sular ligament ; in part united, and in part not ; and the neck 
 of the thigh bone absorbed.' " This excludes it from the class 
 of intra-capsular fractures. 
 
 Case 7 — (Mr. Chonly's case). — Mr. Smith says of this case, 
 " A portion of the upper fragment extended in one situation, a 
 little external to the capsule, this portion was not united." 
 Mr. Smith adduces this to prove that intra-capsular fractures 
 unite, and yet admits it does not belong to the class, and is 
 not an intra-capsular fracture. 
 
 This completes the specimens adduced by Mr. Smith, to 
 prove this ossific union of intra-capsular fractures of the 
 cervix femoris. It will be remembered these are not the speci- 
 mens of one country alone, but the choice specimens culled 
 from the museums of all Europe. In this country, the largest 
 number of specimens are in the possession of Prof. Mussey, of 
 Cincinnati. He claims to have three specimens which prove 
 this. 
 
 Of these three, the most valuable one is that about which 
 Prof. Mussey and Dr. Dalton, of Lowell, Mass., maintained 
 so long a controversy. The circumstances of the case, as far 
 
25 
 
 as we have been able to gather them from Prof. Farker's lec- 
 ture, and from the statements of Dr. Morrell, of Borodino, 
 N. Y., who was one of Prof. Mussey's students shortly after 
 the controversy, are as follows : — The patient was a team- 
 ster, away from his home in Northern New Hampshire when 
 he met with the accident; Dr. Dalton became satisfied there 
 was a fracture, and treated him for it. The man became dis- 
 satisfied. Dr. Dalton boxed up the leg and sent the man home, 
 a distance of more than one hundred miles, in one of the or- 
 dinary country wagons, over the rough roads of that hilly 
 country ; on his arrival home, the man's limb was examined 
 by Prof. Mussey, about three weeks after the injury, the 
 dressings removed, yet no fracture could be found ; Prof. Mus- 
 sey maintained this opinion till he came in possession of the 
 specimen, which he thought showed conclusively there was 
 a fracture within the capsule, and which had united by bone, 
 when he made the amende honorable. If we had only these 
 facts to rely upon, they would be sufficient to throw a doubt 
 on the nature of the injury. No matter how skillful the 
 surgeon might have been, or how favorable the circumstances 
 surrounding the patient, it would have been impossible to 
 have obtained an union of a fracture entirely within the cap- 
 sule in four weeks' time. Dr. Dalton may have boxed up 
 the limb in the most skillful manner, and he is a surgeon of 
 high repute in Eastern Massachusetts, yet, it would have been 
 impossible to have applied his pressure so equally as to keep 
 the head of the femur still — jolted, as the man must have 
 been, in one of those old-fashioned, springless wagons, over 
 the half-built mountainous roads of Northern New Hamp- 
 shire, for a distance of a hundred miles — and yet have, at the 
 end of that journey, an union of an intra-capsular fracture, so 
 perfect that Prof. Mussey denied there ever had been a frac- 
 ture there. 
 
 But these are not the only facts in the case ; Dr. Black- 
 man (editor of Velpeau's Operative Surgery,) has given us 
 the true explanation of the case. In his review of Malgaine 
 on Fractures, while discussing this question of intra-capsular 
 fractures, states (New York Journal of Medicine, Sept., 1S55,) 
 that Prof. Mussey took this specimen to 4 Sir Astley Cooper, to 
 convince him of the possibility of bony union of intra-cap- 
 sular fractures ; but Sir Astley decided this to be a case of 
 fracture, partly within and partly without the capsule. 
 
 Of Prof. Mussey's two remaining specimens I have been 
 unable to procure histories. I have conversed with a surgeon 
 
26 
 
 of eminence of this city, who has examined them carefully, 
 and he says they are no more satisfactory than the one already 
 referred to. Dr. Bauer, of Brooklyn, has also recently examin- 
 ed them, and is very strongly of the opinion that they are not 
 specimens of intra-capsular fracture. 
 
 Since the above was written, we have received the Ameri- 
 can Journal of Medical Sciences, for April, 1857. The lead- 
 ing article is by Prof. Mussey, detailing his cases of " Frac- 
 ture of the Neck of the Thigh Bone." 
 
 We are gratified to find the facts of Case 1, as above stated, 
 corroborated by Prof. Mussey in all essential particulars. In 
 this article, Prof. Mussey admits his inability to convince Sir 
 Astley. He details his interview as follows : — 
 
 " On my presenting it for inspection to Sir Astley Cooper, 
 he remarked, ' this bone never was broken,' I said, ' Sir 
 Astley, please to look at the interior of the bone ;' he sepa- 
 rated the two halves and said, ' this does look a little more 
 like it to be sure, but I do not think it is wholly within the 
 capsular ligament.' It is well known that Sir Astley Cooper, 
 for some years, had taught the doctrine that bony union does 
 not take place in intra-capsular fracture ; his views, among 
 the surgeons of Great Britain, were extensively admitted as 
 correct." 
 
 This last remark, following, as it does, his account of his 
 interview with Sir Astley^would appear to be Prof. Mussey's 
 assigned reason for his own success. 
 
 It is possible that Sir Astley Cooper was so prejudiced as 
 not to admit as facts, points that, at best, were but doubtful, 
 but it will hardly be presumed that Sir Astley Cooper would 
 deny facts about which there could, be no reasonable doubt. This 
 is not the only occasion in which Sir Astley's motives have 
 been impugned. A distinguished lecturer of this country 
 has, in his public teachings, declared that Sir Astley Cooper, 
 by teaching this doctrine of the non-union, " had done more 
 harm than he had ever done good in his life," but those who 
 have studied Sir Astley's works, with an unprejudiced mind, 
 would prefer to believe that he lived alone for truth, for 
 science, and his profession. 
 
 Sir Astley Cooper, is not the only surgeon of distinction 
 whom this specimen has not convinced. Prof. Mussey men- 
 tions John Thompson, of Edinburgh, a surgeon of eminence 
 as well as an author of a work upon inflammation, as one who 
 was not convinced by this specimen. 
 
 As to Prof. Mussey's sweeping statement : — " The profes- 
 
27 
 
 sional gentlemen of our country, who have examined these 
 specimens, unhesitatingly pronounce this to be a case of union 
 by bone of intra-capsular fracture," if he will take the trouble 
 to ascertain the opinion of many of the New York surgeons, 
 who have examined this specimen, he will find that this as- 
 sertion will admit of essential modifications. 
 
 Prof. Mussey details several other cases in his own and in 
 other's practice — but this is his best specimen. He also makes 
 some valuable suggestions as to the manner of union and his 
 method of measurement. And we refer, with pleasure, those 
 interested to the American Journal of Medical Sciences, for 
 April, 1857, for a further elucidation of his views. 
 
 In regard to, the Philadelphia specimens, my only source of 
 information is the brief notice of them in the new work on 
 Surgery, by Prof. H. H. Smith, of Philadelphia. His state- 
 ment is as follows (page 399) : — "There is in the Wistar and 
 Horner Museum of the University of Pennsylvania, a femur, 
 apparently of an old woman, in which the neck has been frac- 
 tured near the head, yet, in which complete osseous union, 
 though with some degree of shortening, has taken place. I 
 have, moreover, in my own cabinet a specimen in which the 
 bone has been fractured through the neck near the head, the 
 fragment having slid down beneath its natural position, and 
 the fracture traveled obliquely down the neck, though still 
 within the capsule, splitting it off in the line of the inter- 
 trochanteric ridge. In this case, which must have produced 
 marked shortening of the limb, there is complete osseous 
 union." This report is so exceedingly brief that no in- 
 ference can be drawn from it, in fact, the writer does not 
 appear to know whether the specimen is from a male or fe- 
 male. If this is true, then he knows nothing of the history 
 of it. He does not give us the direction of the fracture, or 
 a drawing of it, or even a positive statement that it is en- 
 tirely within the capsule. In regard to his own specimen, 
 he is more explicit ; he gives a drawing and shows that the 
 fractured head has slipped down, and even now the line of 
 fracture can be traced to the inter-trochanteric line. If this 
 is so now, it is probable that the end of the fractured bone 
 extended below the capsule in the first place, as in all cases of 
 fracture, where there is not perfect coaptation, the rough points 
 become absorbed. If we allow for this absorption, it would 
 make the end of the bone below the trochanteric line, a point 
 without the capsule, thus excluding it from this class. If we 
 adopt Prof. Smith's view, that this was entirely within, we 
 
28 
 
 meet with an objection ; he states that the head of the bone 
 has slipped down beneath its natural position, and the frac- 
 ture has traversed it obliquely. This, of course, could not 
 have been an impacted fracture, for in an impacted fracture 
 we should have had the shaft of the bone driven into the 
 cancellated portion of the head — not the head of the bone 
 " slipping down" along the shaft. If this was a case of slip- 
 ping down of the head, we leave Prof. Smith, of Philadelphia, 
 to controvert the position taken by Mr. Smith, of Dublin, 
 where he says that only impacted intra-capsular fractures can 
 have an osseous union. 
 
 There remains but one more specimen to examine. This 
 belongs to Prof. Willard Parker, of this city. I am under 
 obligations to Prof. Parker, for his kindness in explaining to 
 me the various points which he considers the case presents. 
 He loaned me the specimen to examine at my leisure, that 
 I might become thoroughly acquainted with all the facts of 
 the case. According to the description of the case given by 
 Prof. Parker, in his lecture, the patient was an old maid, of 
 about sixty years of age, an inmate of the almshouse, of Bar- 
 nard, Vt. One morning, while going out of doors, she fell 
 striking upon her hip. The doctor in attendance, who did 
 not pretend to be a surgeon, or accurate in his diagnosis, 
 came to the conclusion that there was a fracture. He was 
 of the opinion that he obtained crepitus, accordingly he 
 dressed the limb with the straight splint for six weeks, and 
 at the end of that time found half an inch shortening. The 
 specimen afterwards came into Prof. Parker's possession. The 
 points Prof. Parker relies on to show that this was a fracture, 
 are : — 1. The supposed crepitus. 2. A ridge of bone along 
 the inter-trochanteric line, termed the " callus." 3. The 
 neck of the bone shortened on the outer side one-third of an 
 inch more than on the inner side, this being accounted for 
 on the supposition that it was produced by the position the 
 limb was allowed to retain. 4. No such changes are to be 
 found in the femur of the opposite side, which is pronounced 
 healthy. These specimens were procured four years after 
 the injury. The capsule is entirely gone, and there is noth- 
 ing to show positively where it was inserted ; a line is pointed 
 out about three lines below the so-called callus, as the line 
 of insertion of the capsule. On examination of the interior 
 of the specimen, there is nothing to indicate the line of frac- 
 ture ; no callus as is shown on internal examination of other 
 fractures of long bones. There is one point very marked on 
 
29 
 
 the inner edge of the compact structure of the shaft, it is 
 what Sir Astley Cooper terms a " buttress of bone " shoot- 
 ing up from the body into the neck and head, evidently as a 
 support to the head in the new angle which it has assumed, 
 with respect to the shaft. This buttress is formed appa- 
 rently by the cancellated structure being more compact than 
 in other points. On comparing this specimen with the femur 
 of the well limb, a very marked difference is observable : 
 this line or buttress is stronger, better developed, and is evi- 
 dently for the purpose of giving support to the head of the 
 bone in this new position. The specimen is far from being 
 satisfactory. If this rough line extending along the inter- 
 trochanteric line, is in reality the line of callus, then it is ex- 
 tremely probable that the fracture was partially extra-capsu" 
 lar. For if the capsule extended along the line which runs 
 below this line that is pointed out as the line of fracture, then 
 the insertion of the capsule must have been as low down as 
 the middle of the trochanter minor, an anomaly in regard 
 to insertion of the capsule. If this really was the line of 
 insertion, it is extremely unfortunate that the capsule was 
 not left to show really where it was inserted. 
 
 Again, there is no callus on the inside of the bone corre- 
 sponding to this so-called external callus, but throughout 
 the whole line corresponding to this external " callus," the 
 cancellated structure is perfect. If it should be admitted that 
 crepitus was here obtained, a point which is extremely doubt- 
 ful, as we have only the opinion of a doctor who practiced 
 many years ago in the small town of Barnard, Vt., a town 
 which now numbers less than two thousand inhabitants,— if it 
 should be admitted on such authority that this was a frac- 
 ture, still it is by no means established that this was an intra- 
 capsular fracture ; for this so-called callus extends along the 
 inter-trochanteric line. The capsule itself is gone, so that 
 it can not be shown positively where it was inserted, and it 
 is probable if there was a fracture, it was partly extra-cap- 
 sular. 
 
 Again, the view which Prof. Parker takes of his specimen 
 conflicts with that taken by Robert W. Smith, of Dublin, on 
 fractures of this class, in his work already quoted. For if 
 there was crepitus, then there must have been motion of one 
 fragment or the other ; and if there was motion, then the 
 fracture was not impacted ; and it is only this latter class 
 which Mr. Smith contends can unite. My own impression 
 is that there never was a fracture here at all. I think this 
 
30 
 
 is a case of interstitial absorption of the neck of the bone ; 
 the cause of this absorption being the contusion received by 
 the fall. This view is sustained by analogy. Sir Astley 
 Cooper says this is common in old people ; in his work on 
 Surgery, vol. 2, pages 314 and 315, Lee's edition, we 
 find the following : — -"As the shell becomes thin, ossific 
 matter is deposited on the upper side of the cervix, opposite 
 the edge of the acetabulum, and often a similar portion at 
 its lower part, and thus the strength of the bone is in some 
 degree preserved. This state of things may be frequently 
 seen in very old persons." " When the absorption of the 
 neck proceeds faster than the deposit on the surface, the 
 bone breaks from the slightest cause; and this deposit wears 
 so much the appearance of an united fracture, that it might 
 be easily mistaken for it before the bone thus alters. We 
 sometimes meet with a remarkable buttress shooting up from 
 the shaft of the bone into its head, giving it additional sup- 
 port to that which it receives from the deposit of bone on 
 its external surface." 
 
 Mr. Liston, in his Practical Surgery, says : — " Gradual 
 shortening of the lower extremity often ensues upon contusions 
 of the hip in persons advanced in life, in consequence of in- 
 terstitial absorption of the neck of the thigh bone, and altera- 
 tion of the angle in which it is set upon the shaft. The head 
 of the bone undergoes a change in form ; it becomes flat- 
 tened and expanded, and the cotyloid cavity is made to 
 correspond. This cause of lameness ought to be kept in 
 view. The risk of its occurrence ought to be explained to 
 those who have suffered injury of the hip, and, if possible, it 
 must be prevented. 
 
 Mr. Grulliver, in the Edinburgh Medical and Surgical Jour- 
 nal, No. 128, July, 1836, et seq., has written very fully on 
 this subject of interstitial absorption ; and has adduced cases 
 which we would copy, if our limits would allow. He shows, 
 by his specimens, that the head is enlarged at its lower part ; 
 that these cases may occur in young persons ; that it is not 
 disease of the joint, from the fact that there is no anchylosis ; 
 and that the cartilages are not involved. The cases of John 
 Lynn, J. McGj-ath, and J. Fox, etc., are adduced, and the 
 specimens preserved from autopsies. We have abundant 
 evidence of interstitial absorption occurring from contusion in 
 persons like this old maid, and Mr. G-ulliver says this short- 
 ening may take place as rapidly as in five or six days. Now, 
 Prof. Parker's specimen corresponds to the facts we have 
 
31 
 
 given : — 1. There is a ridge formed along the lower part of 
 the neck, as Sir Astley Cooper states, occurs in these cases of 
 interstitial absorption. 2. There is the buttress of bone shoot- 
 ing up from the shaft into the head as a means of support ; this 
 is clearly shown by comparing the two specimens, the one 
 from the well limb, and the one from the contused limb. 
 
 3. There was a contusion sufficient for an exciting cause. 
 
 4. This occurs in one limb and not in the other, as shown in 
 the case of J. Fox, reported by Gulliver, where one limb 
 was in every respect natural, and iu the other interstitial ab- 
 sorption had taken place. This, we believe, is the case in 
 Prof. Parker's specimen. If this specimen is in reality a 
 fracture, it was most probably partly extra-capsular ; if not, 
 it was a case of interstitial absorption. 
 
 I have thus reviewed all the cases of supposed osseous 
 union. All of them are defective in points of great import- 
 ance ; no one of them places the question beyond a reasonable 
 doubt, and it should be remembered that these are the choice 
 specimens of all Europe and America. 
 
 There is a single point more worthy of notice ; it is the 
 extreme difficulty there appears to be, in all these specimens, 
 of deciding whether they are intra-capsular, or only partly 
 within. The mere fact that a surgeon of such eminence as 
 Prof. Mussey should have been misled, and should have been 
 so deceived as to take a specimen across the Atlantic, to con- 
 vince Sir Astley Cooper of the possibility of the ossific union 
 of intra-capsular fractures, by whom it was conclusively 
 shown that he was in error, is sufficient to prove the difficulty 
 of deciding on these specimens. All such specimens should 
 be preserved in the wet state with the capsule still attached, 
 when there could be no doubt of their character. 
 
 The argument may be thus summed up: — 1. It is abso- 
 lutely impossible to form a certain and unmistakable diagnosis 
 of all these fractures during the life of the patient. 2. That 
 the probabilities are all against union by bone, from lack of 
 nourishment to the fractured parts of the head, from impos- 
 sibility of perfect rest, and from synovitis. 3. The argument 
 from the analogy of fractures of the patella, olecranon, etc., is 
 an argument against, instead of for, osseous union. 4. Cases 
 where every circumstance was favorable to union, if any frac- 
 tures of this kind could unite, yet which failed to unite. 5. 
 The cases given to prove this union not having proved it. 
 
 The treatment of these cases is obvious. It has been shown 
 that a positive diagnosis can not be formed. It may be a case 
 
32 
 
 of those kinds which do have a bony union. The patient is 
 entitled to the benefit of this chance. If his age and health 
 will permit, the straight splint should be used ; while, at the 
 same time, the surgeon should protect himself, by showing 
 the patient and his friends what an unfavorable result there 
 may be. If the fracture is impacted, it should by all means 
 be kept in the impacted state, and all attempts to extend the 
 limb to its proper length should be abstained from. 
 
 If the patient is past the prime of life, or of enfeebled con- 
 stitution, then the double inclined plane splint should be used ; 
 and if the patient can not bear that, then simply let the limb 
 rest over a pillow. 
 
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 s on intra -capsular 
 *e cervix femoris 
 
ii>i