No. 2286.

JUNE 22, 1867.

LecturesON

FRACTURES OF THE NECK OFTHE THIGH-BONE.

Delivered at St. Thomas’s Hospital,

BY SAMUEL SOLLY, ESQ., F.R.S.,SENIOR SURGEON TO THE HOSPITAL.

GENTLEMEN’,—The following case of fracture of the neck ofthe thigh-bone, which you have lately had an opportunity ofobserving, will enable me to call your attention to several im-portant points in the diagnostic marks of this injury, and theproper treatment to be adopted. Many a superficial surgeonimagines that the distinction between fracture of the neck ofthe thigh-bone and dislocation is so clear that a man must bea downright fool who cannot immediately diagnose the twodifferent injuries. Such is not the fact ; and though you maynot have the opportunity of seeing all the obscure forms ofinjury, even at this hospital, which, notwithstanding itscribbed and confined condition, affords for observation a vastamount of accidental surgery, you have just seen one case

in illustration; but with your own unaided sight you will not,perhaps, draw all the instruction from that which it is capableof rendering. You will, then, I am sure, follow me attentivelyin the brief practical deductions that I shall make. That youmay not think I am making mountains of molehills, or ex-aggerating the importance of the subject merely for the pur-pose of riveting your attention, I shall strengthen my ownauthority by reference to that of others.Mr. R. W. Smith, of Dublin, who has published a most in-

structive book, entitled "Fractures in the Neighbourhood ofJoints," says: "These are truly embarrassing cases; for weare expected to pronounce at once our opinion as to whetherthe bone is broken or not. The recollection of every surgeonwill furnish him with instances in which he has experiencedthe utmost difficulty in coming to a conclusion in his own mindnnilm’ fbt-. fr.nTTist;aT)r’fBc: which ba.v<=t haan dpHfnbed * HTid it ie

certain that not only cases of impacted fracture of the neck ofthe femur have often been mistaken for contusion of the hip,but also that numerous instances of the latter injury have beenrecorded as examples of fracture of the cervix femoris, curedwithout lameness or deformity resulting."CASE.-William L--, aged seventy-nine, admitted into

Accident ward, St. Thomas’s Hospital, April 8th, 1867. Hewas a delicate-looking and feeble old man, so intensely deaf thathe was unable to give any account of himself. His friendsgave the following description of the accident :-Immediatelybefore his admission, on attempting to sit down in a chair, hemissed his seat and fell on the floor, striking the right hip.The distance, therefore, was not great, and, except in old age,the force scarcely sufficient to produce fracture. You will dowell to bear this fact in mind when in practice, if you get apuzzling case like this, and not say, when reasoning on iteither alone or in consultation, " But the man did not fall farenough to produce fracture." He was examined by the house-surgeon and dressers on admission, but no fracture could bedetected either bv the Droduction of creDitus or the aDDear-ance of shortening or abnormal movement at the seat of -frac-ture. My dresser, Mr. Dobson, from whose notes I am nowlecturing, informs me that though he complained of great painwhen the limb was examined, there was no sign of contusionof the soft parts. This in itself does not bear upon the dia-gnosis of fracture, but it bears upon the diagnosis of manyrailway injuries. Thus, when, called upon by a railway com-pany to examine an individual who claims compensation forinjuries received, you find no appearance of contusion on thepart which he states has been seriously injured, and which healso describes as the seat of severe pain, at rest, in motion,and on pressure, you must not conclude, as I have known sur-geons do, the absence of a bruised appearance of the skin to bea proof that the statement of the claimant is false. It is well

Ithat your attention should be called to such things, because avery considerable nart of vour dutvin surmfs.1 nrantiff will bp

to distinguish between the truthful sufferer and the malingerer;and this duty will be equally urgent whether you are consultedby the patient or by the railway company. Your duty in eachcase is of course to discover the truth, and it is your policyalso. If you make a mistake in your diagnosis, it will in allprobability be exposed in cross-examination, and you willappear in the eyes of the world as either a knave or a fool.But to return to our patient. This poor fellow, as you will

soon learn, had fractured the neck of the thigh; but the skinwas unscathed, and gave no surface evidence of the severityof the lesion. There was no appreciable shortening of the limbwhen measured from the anterior spine of the ilium to theinner malleolus. A little difficulty attended this measurement,in consequence of the naturally bowed form of the leg. Therewas no shortening from the anterior superior spine of thehaunch bone to the upper point of the trochanter major. Therewas no eversion of the limb. No crepitus could be detected bythe most careful manipulation of the hip-joint.

I came into the ward very soon after the admission of thispatient, and I remember remarking that, considering the age ofthe patient, the nature of the accident, and the extreme pain thathe experienced on the slightest movement of the limb, I wasafraid that he had fractured the thigh-bone. The entire ab-sence of shortening and creuitus made me sav to the nunils .that I would not inscribe on his ticket fracture of the neckof the femur," but that we would wait a little. In the meantime we would treat it as such an injury ought, in my opinion,to be always treated.

In the first place, I ordered him to be placed on the doubleinclined couch, which I call, from the name of the maker," Alderman’s couch." And I am happy to say that we do atlast possess one such bed for the use of the hospital. Indeed,I ought to add, in justice to our worthy treasurer, that as soonas I explained to him that these fractures could not be treatedproperly without the assistance of this couch, he gave me per-mission to order it.The splint and bandage which I always use in these cases,

and which I must now describe, I have found more useful for

several reasons than the old straight splint. It consists of a.bandage made of strong linen, and, for private patients, linedwith silk. It is composed of a well-fitting pelvic bandage anda thigh-piece, as may be seen in the accompanying woodcut.Mr. Millikin, of Southwark-street, has always made it for me.I used to have a small wooden splint, about the size of thepalm of my hand, to catch the trochanter major, stitched inthe bandage. Mr. Millikin proposed substituting a piece ofthick, stiff leather, previously moulded, in a soft state, to thetrochanter major. There is a strong elastic band connectingthe pelvic bandage with the thigh, ensuring strength andadaptability. I have found the leather answer as well, if notbetter than the wood. This splint, however perfect it maybe, would be of little service if you did not place your patientupon the couch.

I remember when I was attending the lectures of Mr. Aber-nethy the controversy regarding union or non-union of fractureof the neck of the thigh-bone was at its height ; and as I hadalready listened to the excellent lectures of Sir Astley Cooper,1 was not ignorant of his views and arguments regarding thissad injury. Johnny Abernethy, as we used to call him inthose days, said: "X 0, gentlemen, fractures of the neck of the

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thigh-bone never have united yet, and never will until surgeons Ifix the pelvis as well as the thigh. It is no use putting a splint (upon the thigh when the pelvis remains unfixed. Every timethat the bed-pan is thrust under the bottom of the patient, hispelvis, with the head of the femur closely attached to thesocket, is jerked up, and the rest which is essential to theformation of the uniting callus is prevented." These wordsof Abernethy made a great impression upon me, and as soonas I could carry his principles into practice I did. I soon dis-covered that the only way in which you can fix the pelvis is toplace your patient on a bed with a hole in it opposite the anus,under which there is a movable bed-pan. Then you may con-’6ne the pelvis to that spot by means of a broad pelvis-strap.This arrangement is best carried out by means of the couch Ihave mentioned, and thus, and thus only T believe, is Aber-nethy’s objection got over, and the fractured surfaces securedin apposition with any certainty.But we must continue our narrative of Mr. L&mdash;&mdash;.On the 9th, or following day, the patient seemed much as

usual; but, not having micturated, a prostatic catheter waspassed, and healthy urine drawn off.

10th.-Continued about the same until the middle of theday, when he was suddenly attacked with hiccup, pain in theabdomen, and a little vomiting. The house-surgeon orderedhim a draught of sulphuric acid and chloric ether, which relievedhim for the time; but at eight P.M. he just passed gently outof this world.The post-mortem examination revealed no positive lesion of

.any of the viscera sufficient to account for death. The spleenwas somewhat congested, very small and pulpy, its investingmembrane unusually tough and inelastic; kidneys small andcontracted. The lungs were congested but crepitant through-out, containing a few cretaceous tubercles at their apices. Theheart was somewhat flabby, with atheromatous deposits on the

valves on the left side (the exact valves were not named in theofficial report). The brain was healthy.

This abbreviated account of the post-mortem examinationreally proves nothing regarding the cause of death. I supposewe must attribute it to shock. If, however, his life had beenspared, there was nothing, so far as the nature of the fracturewas concerned, which would have prevented a perfect unionunder the adoption of the plan of treatment which had beencommenced.

I never saw a more perfect specimen of impacted fracture.I learnt from my dresser that the impaction was so completethat even in the dead-house neither the house-surgeon nor thedresser could produce any crepitus. The whole bone-shaft

FIG. 2.

and head and neck-rotated as one; so much so that until thecapsule was divided and the soft parts dissected down to thebone, they did not discover that there was any fracture. Iam much indebted to these gentlemen for their observationand report to me of this most important fact, which otherwise1 should not have heard. I was not present at the examina-

tion. Be so good, gentlemen, as to mark this pathologicalfact well, and remember it all your life. What does it teachyou, that I am so anxious you should attend to it ? That youmust treat such a case as a case of fracture, though you cannotdetect separation of the bone, either by the head of the bonenot following the movements of the shaft, or by that rubbingof the separated surfaces which the surgeon calls crepitus.The extreme pain in this case, the nature of the accident, withthe age of the patient, ought to have been enough to determinethe line of treatment. If this poor fellow had been in goodhealth, he would, with proper treatment, have obtained a per.fect union and a useful limb. But with improper treatment,resulting from imperfect diagnosis that impaction which yousaw in the dead-house, and which you see portrayed in thisdrawing (Fig. 2), would have availed him nothing. After afortnight or three weeks the impaction would have been dis-solved, the parts would have been loosened, and the fracturedsurface no longer adherent; and if the patient had been per.mitted to leave his bed, he would, to the great astonishmentof the surgeon, have fallen. Then at last the fracture wouldbe detected, but too late for any curative treatment, and theinjured man would be for life an incurable cripple.

I have many more observations to make on this interestingsubject, but I must postpone them to our next meeting.

ON MORBID RELIGIOUS THOUGHT.

BY FORBES WINSLOW, M.D., D.C.L. Oxon.(Continued from p. 663.)

THE psychological, philosophical, and historical investigationof the phenomena of Epidemic as well as Sporadic insanity,associated with morbid fanaticism, and allied to disorderedecstatic enthusiasm, will necessarily form part of this inquiry.

It is impossible to regard without feelings of profound in-dignation the frightful cruelties characteristic of the primitivehistory of the Church which were practised not only upon sanebut insane persons, particularly on those whose mental aberra.tion was manifested by some form of religious delusion or per-version of the moral sense. When contemplating the barbari-ties perpetrated in ancient as well as in more modern timesunder the subterfuge of sanctity, well might a distinguishedwriter exclaim, "Religion ! religion ! what crimes have beencommitted in thy name !" But the religion of the epoch towhich I refer had no legitimate title to so holy a designation.It was a false, a hollow, and a pseudo religion-a fanaticaland ignorant religion-a religion based upon a degrading,brutalising superstition, originating in a frenzied or bighlyper-verted imagination, supported and promulgated by knavishcharlatans, mercenary, crafty, licentious, and besotted priests,who with unparalleled effrontery and zeal did their utmost toenslave the soul and subjugate the mind, obstructing the pro-gress of all useful knowledge, and obliterating from the intel-lect the glorious light of God’s truth, thus blinding the eyesof the understanding to all matters concerning man’s eternalinterests.

It is painful to dwell upon the enormities practised in thesetimes, under the protection of an ecclesiastical garb, and inthe sacred name of religion, on the human race in general, andparticularly on wretched lunatics, whose state of mentaldisorder unhappily escaped all recognition. The gross ignorancewhich then enshrouded and obscured the intellect, destroyingall right appreciation of scientific truth, led men of no ordinaryintelligence to deal with the insane as if they were demons,fiends, or possessed of devils. These notions were in the mainthe result of the defective knowledge of the time, combinedwith the debasing and demoralising teaching of a bigoted andnarrow-minded priesthood, which then held in galling subjec-tion the human understanding.

It is true, as I shall endeavour to prove, that at a subse-quent ecclesiastical period lunatics were kindly housed, pro.tected, and cared for in various charitable asylums, superin.tended by priests and other persons officially connected withthe Church. After the dissolution, at the time of the Reforma-tion, of what were called the "religious houses," the insanebecame a wandering body. Deserted by their friends, theseunhappy persons were permitted to ramble about the country,: often naked, exposed to every conceivable kind of insult andhardship. These lunatics were known by the name of