A careful review of these injuries thus leads back to a practical rule already usually adopted. But it leads further, and demonstrates conclusively that prolonged and active flexion and rotation of the hip, in search of positive signs, is more than superfluous. Without anesthesia it entails needless suffering; and with or without it, by loosening impaction or lacerating tissues, it may be disastrous.

The question of dislocation settled, a very brief and gentle examination is alone admissible, chiefly to determine (1) the degree of shortening; (2) whether the shaft rotates through an arc or on its axis. The most useless and damaging examination is that by quick and persistent rotation, and by flexion of the thigh as far as a right angle.

The prognosis, if the patient lives, is favorable for bony union, except in the case of loose fracture of the small part of the cervix, which, if not readily distinguished, should be disturbed as little as possible.

Familiarity with the posterior impacted fracture of the base of the neck will remove the most frequent source of doubt in the diagnosis of injuries of this region; and the sooner the old classification of "intra and extra capsular fractures" is abandoned, the better it will be for science, for diagnosis, and for treatment. In the interest of the patient and of treatment the question should be, "Is the fracture loose or impacted?" and science is often compelled to rest satisfied when this is settled.

FRACTURE OF THE NECK OF THE

THIGH-BONE.1

FEW accidents are more common or more important than this; and few give rise to greater doubt in diagnosis. I aim in this lecture at such a general view of the subject as will be useful to you in practice.

The fractures of the head of the femur, or, as they are usually called, of "the hip," are tolerably well recited in the books. The principal ones are three in number. First, the so-called fracture within the capsular ligament, which I call fracture of the middle of the neck; and, second, two others,the impacted fracture of the base of the neck, and the impacted fracture of the upper end of the neck; the one being an impaction of the neck into the trochanters, the other an impaction of the neck into the head of the bone.

This leaves for further consideration only the irregular fractures, or set of fractures, about the trochanters, which though not susceptible of classification fortunately do not need to be classified in treatment; they may be considered

as one.

Contrary to the usual belief, I regard the impacted fracture of the base of the neck into the trochanters as the most frequent fracture of the head of the femur. Let us first, however, consider the one usually known as "the fracture of old people,”—that "within the capsular ligament" as it has been usually called, or, as I term it, "the fracture of the middle of the neck."

We have in the hospital wards four cases of injury to the hip; three are the usual impacted fracture, and one the frac

1 A Clinical Lecture. January, 1880. Now first published.

ture I am now about to speak of. It usually occurs in late life, when the outline of the neck of the femur is no longer what it was in the young adult. In the perfect femur the neck is a flat pyramid, with its apex above, and its base spreading from one trochanter to the other. Its smallest part is next the head. Later in life the neck changes in shape, and is smallest at the middle, where it breaks. Its texture does not become more brittle, as usually stated, but there is less bone. Its interior is so changed that the neck is but a thin and almost papery shell, which may yield to slight injury. Sometimes the patient is even supposed to have broken his, or rather her, hip (for the injury occurs more frequently in women) before falling. The neck yielding near its middle, the limb is left at the mercy of the muscles, hangs loose, and, in an erect posture, swings. The muscles of the haunch evert the trochanter, and of course the toe. There may be a considerable shortening, - two inches and more.

I have often mentioned a patient I once saw in the street,a lady who fell, and when raised and supported by the bystanders had a swinging leg, everted toe, and the limb so shortened that I diagnosticated a fracture of the neck of the thigh-bone across the street. Such a patient placed upon a bed is usually in great pain, because the muscles are nipped by the displaced fragments, the pinching of the soft parts being the usual cause of pain in a fracture. So great is the eversion that the foot generally lies upon its outside. Under these circumstances it is useless to try to get crepitus; the effort is not only productive of pain, but also damages the part. The evidence is sufficient without it. Crepitus can be got, however, by drawing the limb down until the fragments rub together in apposition.

The prognosis of this fracture is unfavorable as to union, perhaps in proportion to the displacement; also to the age of the patient and her health. The accident is sometimes grave, and may be a fatal one. The patient may die in a period vary

ing from a few days to a year after the accident, gradually worn out. On the other hand, the bone generally unites by ligament, and the patient is able to walk with crutches, or a crutch and a cane. If such a patient is finally able to walk with a cane, the accident was probably not the one we are considering, but rather one of the impacted fractures, or a fracture of the trochanter. The ligament which unites the bone may be longer or shorter, and the mobility greater or less. The neck will eventually become absorbed, and the head of the bone may after a while rest directly upon the shaft of the femur. The explanation of non-union is to be found in the mobility of the fragments and the impossibility of keeping them in apposition; and there is also something in the fact that the upper fragment does not contribute its share to the mutual union, being suspended from the pelvis by the capsular ligament only, for the ligamentum teres is not a true ligament, but merely a fasciculus for the passage of vessels.

I have already said that the fracture of the middle of the neck is not the most common one. It is, however, the most striking and the most persistent in consecutive results. This subsequent persistence of deformity or lameness directs attention to the hip bone at an autopsy, and the specimen is saved; while other fractures resulting in bony union are forgotten, or if the head of the bone is procured it is so repaired as to leave the exact character of the injury in doubt. Consequently fractures of the middle of the neck are, or have been, the most familiar by reason of their frequency as museum specimens. It is also the fracture most easily diagnosticated. In fact it can hardly be mistaken even when seen for the first time.

The most common fracture is the impaction of the base of the neck into the trochanters. It deserves to be thoroughly considered, because its signs are sometimes not at all satisfactory to the surgeon who is unfamiliar with them. They depend upon an anatomy comparatively new, and which was first

described by myself. We have seen that the neck of the femur is seated upon the oblique line of the trochanters. When the fracture is impacted the neck is driven into the trochanters. But there is a rule about this; and that is, the neck is always impacted more behind than in front; and the head of the bone is in this way bent backward, or which is the same thing-the shaft of the femur is rotated outward. From this results the eversion which belongs to the accident. The cause of the unequal impaction is a difference in the thickness of the walls of the neck in front and behind. In front the bone is thick; behind it is exceedingly thin; and it is behind that it yields. The bone has a thickness of perhaps an eighth of an inch along the front of the neck, and in some cases more; behind it has only the thickness of paper.

The head and neck of the femur have been repeatedly sawed longitudinally and vertically; and anatomists (notably the late Jeffries Wyman) have given details of the very beautiful cancellous structure, whose fibres are arranged in radii, arches and stringers, to support and suspend the head of the bone from the trochanter. But a transverse section of the head remained to be made. For this purpose the femur should be placed with its back toward you, upright, but as if the patient were straddling, so as to bring the neck of the femur to a horizontal position. Now, if you slice off the top of the femur, neck, and trochanters, and then take a second, a third, and perhaps a fourth horizontal slice, you will find as you get toward the bottom of the neck that the anterior wall is so thick, and the posterior wall so thin, as to leave no doubt of the facts I have mentioned. The posterior wall which yields actually starts thick from the head; but instead of being inserted thick into the trochanters, it plunges beneath them in the direction of the shaft of the femur. If it were inserted there, it would be strong; but in an attempt to gain the shaft of the femur it becomes more and more