753 
SURGERY. 
at the extremity of the fracture. On dissection, we find the 
Iigamentum teres holding the head in the cavity, and upon 
this small v'hite spots covered with the articular cartilage. 
The cervix broken transversely or obliquely; the cancellated 
structure of the inner portion hollowed or rendered smooth 
by the pressure of the extended pieces of the cervix. “ The 
cancella are rendered firm and smooth by friction, as we 
see in other bones which rub upon each other when their 
articular surfaces are absorbed, giving the surface the ap¬ 
pearance of ivory. Loose portions of bone covered with li¬ 
gamentous matter are formed on the joint. When, how¬ 
ever, these excite no inflammation, the external portion of 
the head of the bone is much absorbed, its surface is yellow, 
and bearing the character of ivory. Some ossific deposition 
often takes place round the trochanter cervix and even shaft 
of the bone. The capsular ligament is thickened, and the 
synovial membrane covering it, as well as the portion which 
covers the external cervix, is also very much thickened. 
Serous synovia is secreted in abundance, and flakes of liga¬ 
mentous matter are seen proceeding from the synovial sur¬ 
face and uniting it with the edge of the head of the bone. 
The membrane separating from the cervix sometimes forms 
a bond of connection between this part and the inner frac¬ 
tured portion, and bands of ligamentous matter passing 
from one end of the fracture to the other, an union by liga¬ 
ment ensues. The head becomes lighter and more spongy 
than ordinary when macerated, except its smooth ivory 
surface.” 
The same want of union takes place in fractures of the 
condyles of the humeri and the coronoid process of the ulna 
within the capsule. In experiments on rabbits and dogs, it 
was found that union did not take place when the fracture 
was made within the capsule, but if it was across the cervix, 
in part within and part without the capsule, union took 
place (but then apposition was of course maintained, which 
could not be done in the other cases). This accident is 
distinguished from dislocation on the dorsum ilii or in the 
ischiatic notch, by the eversion of the limb, and from the 
dislocation forwards on the pubes, by the absence of the 
head under Poupart’s ligament—from all these by the mo¬ 
bility of the limb. It is distinguished from fractures ex¬ 
ternal to the capsule by its occurring at a- very advanced 
age, by the limb being considerably shortened, by the 
absence of crepitus if the limb be not drawn down and 
rotated, by the slight causes which induce it, and by the 
absence of much constitutional irritation. To produce union 
these plans have been used.—First, a double inclined plana 
has been placed under the limb, by which means it has 
effectually stretched to the proper length, and a broad ban¬ 
dage thrown round the pelvis to keep the fractured portions 
in apposition. Secondly, a broad board has been fixed to 
the foot of the bed, and the sound leg rested against it to 
prevent the descent of the body. A cord was then put 
through a hole in the board with one end tied to a weight, 
and the other by bandage to the diseased foot, and thus gra¬ 
dual extension was maintained. Thirdly, both limbs have 
been extended and tied together with a roller, or an iron 
plate may be appended to the sole of the shoe on the sound 
foot, and by means of a screw through it, a bandage round 
the knit limb may be tightened ad libitum. Boyer’s splint, 
which has been used for the same purpose, is hurtful, on 
account of the pressure of its band on the inner and upper 
part of the thigh. Mr. Amesbury’s apparatus is doubtless the 
best that has been contrived, but, hitherto, it has not been ap¬ 
plied to any case with success.—Union takes place when the 
head only is broken, so that the cervix remains in the ace¬ 
tabulum, or when the periosteum is unbroken, and in nei¬ 
ther of these cases is the bone much drawn up. The limb 
should be kept extended for ten days or a fortnight, and 
then the patient may rise and sit in a high chair. A patient 
with the aid of crutches or a stick, may recover so far as to 
walk with a little sinking on the affected side. The acci¬ 
dent is sometimes fatal on exhausted frames. Lameness is 
sure to follow, but the degree is various. 
' Vox,. XXIII. No. 1605. 
Fracture of the cervix external to the capsule.—This frac¬ 
ture, like the former, has the leg shortened and everted—has 
pain at the hip and on the inner and upper part of the 
thigh, and the joint loses its soundness; but it is thus distin¬ 
guished. 1st. It happens in the young and in the old till 
under 60. 2dly. It requires much severer force to effect it, 
as violent blows, falls from a great height, or the passage of 
heavy weights over the pelvis. 3dly. It is attended by cre¬ 
pitus when we rotate the limb, even when we do not draw 
it down. 4thly. There is much severer pain, especially on 
motion, the thigh and leg are swelled, and there is an high 
degree of irritative fever—recovery is tardy. The limb is 
not shortened so much as in the accident before noticed, 
rarely more than an inch; but this, of course, is subject to 
variation, according to the obliquity of the fracture and 
the degree of laceration in the muscular parts. On dis¬ 
section, the fracture-has various situations, but most com¬ 
monly it is at the root of the neck of the femur. 
Fracture through the trochanter, without injury of the 
cervix, occurs at any period of life.—Symptoms. The 
leg is very little or not at all shortened; the broken part of 
the bone sometimes is drawn forwards towards the ilium, 
sometimes it falls towards the outer ischii. The portions are, 
however, widely separated; the patient cannot sit; the foot 
is extremely everted; crepitus is with difficulty discovered by 
rotation. It unites firmly and quickly. 
Fractures below the trochanter.—The iliacus internus and 
psoas magnus, as well as the pectinalis and top of the triceps, 
draw up the fractured portion of the bone in this accident to 
near a right angle with the body. If pressure be made on 
this fractured portion, it only adds to the pain of the suf¬ 
ferer, without at all depressing the bone. To prevent horrid 
distortion, the knee should be elevated very much over the 
double inclined plane, and the patient placed, well sup¬ 
ported by pillows in the sitting position. Then the com¬ 
mon splints may be used, or, what is better, a strong leather 
belt should be buckled round the limb. 
Fractures of the patella are almost always transverse; sel¬ 
dom oblique ; and still more rarely longitudinal, or perpendi¬ 
cular. The bone, however, is sometimes broken into three 
or four pieces. 
There is no difficulty in ascertaining the existence of a 
transverse fracture of the patella. When the patient is stand¬ 
ing up at the period when the force of the muscles breaks the 
bone, the subsequent fall is a consequence of the accident. 
In this case, as well as in the example in which the bone is 
broken by the fall itself, the patient cannot get up without 
succour; and if, when he is put upon his legs, he endeavour 
to walk a few paces forwards, he falls down again. But, if 
he be assisted with an arm, and keep his limb straight, he 
may hobble along a good way, drawing the member after 
him, and meet with no other fall, especially, if the ground 
be not too irregular. The transverse division of the bone, 
and the interspace between the two fragments, can be plainly 
distinguished under the integuments. Instead of the pro¬ 
minence of the patella in front of the knee, a flatness or even 
a depression may be remarked. When the leg is extended 
and the thigh bent, the two pieces of bone are brought near 
together again, and a very little pressure will then suffice 
for putting them in contact with each other. When 
this has been done, if they be moved laterally in opposite 
directions, they will rub against each other, and a crepitus 
be felt. 
Fractures of the patella are very rarely united by bone, the 
connecting medium being in almost all cases a fibrous liga¬ 
mentous substance. The possibility of a bony union, how¬ 
ever, is admitted. 
For the cure of fractures of the patella, Boyer employed a 
very simple, but effectual apparatus. It consists of a hollow 
wooden splint, long enough to reach from the middle of the 
thigh to below the calf, sufficiently deep to embrace two- 
thirds of the thickness of the limb; broader above, than be¬ 
low; and lined with wool, or other soft materials. On the 
outside of the edges of this splint, little round-headed pegs, 
9 F or 
