ABNORMAL CONDITIONS OF THE HIP-JOINT. 



812 



culars of a case of fracture of the neck of the 

 femur, which were read before the Medico- 

 Chirurgical Society on the 5th of June, 1827. 

 The following is an abstract of it. Dr. James, 

 an English physician, aet. 47, in good health, 

 was thrown from his horse on the 20th of March, 

 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 im- 

 mediately after the accident, Dr. Brulalour 

 observed the principal signs of fracture of the 

 neck of the femur. Extension of the limb was 

 kept up for two months so as to preserve it of 

 its natural length. He recovered the full use 

 of the limb so as to be able to walk without 

 any assistance, even that of a cane. Dr. James, 

 on the 20th of December, about nine months 

 after the accident, was attacked with haernate- 

 mesis, which in two days terminated fatally. 

 The post-mortem examination of the right coxo- 

 femoral articulation shewed 1st, the capsule 

 a little thickened; 2d, the cotyloid cavity 

 sound; 3d, the inter-articular ligament in a 

 natural state; 4th, the neck of the femur 

 shortened, from the bottom of the head to the 

 top of the great trochanter was only four lines, 

 and from the same point to the top of the small 

 trochanter six lines ; 5th, an unequal line sur- 

 rounded the neck, denoting the direction of 

 the fracture; 6th, at the bottom of the head of 

 the femur and at the external and posterior part 

 considerable bony deposit had taken place. A 

 section of the bone was made in a line drawn 

 from the centre of the head of the femur to the 

 bottom of the great trochanter so as perfectly 

 to expose the callus. The line of union indi- 

 cated 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 at its superior and posterior part. 



Case 3. Mr. Stanley, surgeon to St. Bar- 

 tholomew's Hospital, in May 1833 read before 

 the Medico-Chirurgical Society of London a 

 case of bony union of a fracture of the neck of 

 the thigh-bone within the capsule, occurring in 

 a young subject set. 18. In the examination of 

 the body of this young man, who died of what 

 was considered to be small-pox about three 

 months after the accident of the hip-joint, no 

 other morbid appearances were discovered 

 besides those of the injured hip-joint. The 

 capsule of the joint was entire but a little 

 thickened, the ligamentum teres was 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, in consequence, approximated to 

 the trochanter major. The fractured surfaces 

 were in the closest apposition 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. 

 Mr. Stanley adds, " the foregoing case is re- 

 markable from the occurrence of a fracture of 

 the neck of the femur within the capsule at an 

 early age, and it is, I believe, the only example 

 of it on record." 



Sir A. Cooper has published a letter in the 

 Medical Gazette, April 1834, vol. xiv., which 

 is intended to explain his sentiments upon this 

 subject, and to set the profession in general 

 and the French surgeons in particular right as 

 to the conceptions formed of the doctrine he 

 held as to the susceptibility of the bony con- 

 solidation of the intra-capsular fracture. In it 

 we find the following case. 



Case 4. Mrs. Powell, aged above 80 years, 

 fell down in the afternoon of the 14th of No- 

 vember, 1824. Sir Astley Cooper saw her soon 

 after, and found her complaining very much of 

 pain in the left hip. The limb could be moved 

 in every direction, but this motion produced 

 excessive pain. She lay on her back with the 

 limb extended, and nothing whatever was done, 

 except to apply fomentations, in the first few days. 

 He believed there was a fracture of the neck of 

 the thigh-bone although the limb remained 

 quite as long as the other, and he could per- 

 ceive neither a crepitus nor any altered appear- 

 ance in its position, except a slight inclination 

 of the toes outwards. She had more constitu- 

 tional irritation than Sir Astley ever observed 

 from a similar accident. She suffered much 

 pain in the hip, and was in consequence obliged 

 to take an opiate, but she got very little rest. 

 She generally had much thirst. There was the 

 utmost difficulty in keeping her bowels open, 

 and she had great pain and difficulty in making 

 water. She had no appetite for common food, 

 and for three weeks appeared so weak that she 

 was under the necessity of taking wine and 

 brandy. For some time all her urine and 

 stools were passed in bed, but not involuntarily, 

 and only because she could not be persuaded 

 to use proper means; in consequence her back 

 became very sore. Latterly she complained of 

 pain in the abdomen, which was very tender 

 on pressure, and even the weight of the bed- 

 clothes was inconvenient. Her tongue became 

 very dry and brown, and the last twenty-four 

 hours she was insensible. She died on the 

 morning of the 19th December about five. 



Examination. This took place at seven in 

 the evening. There was some ecchymosis 

 amongst the muscles about the injured part 

 and in the cellular membrane about the sciatic 

 and anterior crural nerves. The greatest part 

 of the fracture of the neck of the thigh-bone, 

 which was entirely within the capsular ligament, 

 was firmly united. A section was made through 

 the fractured part, and a faint white line was 

 perceived in one portion of the union, but the 

 rest appeared to be entirely bone. This case, says 

 Mr. Swan, beautifully shews the principle which 

 Sir A. Cooper has advocated, viz. that when the 

 reflected ligament remains whole, and the bones 

 are not drawn asunder, the nourishment to the 

 head of the bone continues, and union will be 

 produced even in the short space of five weeks, 

 by only placing the knee over a pillow, and in 

 other respects leaving the case to nature. 



We find Mr. Samuel Cooper is of opinion 

 that a bony consolidation of the intra-capsular 

 fracture is proved. He says,* " Sir A. Cooper 



* Surgical Diet. p. 575, last cd. 



