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the nature of the injury. In these cases the surgeon is apt to allow greater freedom to the patient than is advisable, or, it may be that, in his anxiety to establish the nature of the injury by producing crepitation, he employs too much force in rotating the femur; in either case it is highly probable that the sudden occurrence of shortening of the limb will establish the nature of the lesion which the joint has suffered; the eversion of the foot now becomes decided, and the trochanter altered in position. These phenomena may take place long after the occurrence of the accident. In these instances it is most probable that, at the time of the receipt of the injury, the cervical ligament, having escaped laceration, prevented the retraction of the limb, but that subsequently it was torn, either in consequence of some imprudent exertion upon the part of the patient, or too eager a desire upon that of the surgeon to produce crepitus by forcible extension and rotation of the limb; the retraction then takes place as the immediate result of the laceration of this important membrane." P. 12.

Mr. Smith states, that if there be any one fact in surgical pathology more certain than another, it is this-that in cases of fracture of the neck of the femur within the capsular ligament, there is scarcely any callus ever effused; it certainly is never formed in such quantity as to be at all capable of counteracting the causes which produce shortening of the limb. We shall not follow our author in his rather tedious refutation of the views of M. Rodet on the subject of shortening after fractures, to which undue attention seems to have been bestowed by him. The position of the foot is not subject to as much variety as the shortening of the limb; in general it is turned outwards. Mr. Smith's experience would lead him to say that inversion of the foot is most frequently seen in cases of extra-capsular fractures. He has seen several examples in which the foot was turned inwards, in five of which the fracture was external to the capsule. He

remarks

"There is one remarkable circumstance which appears to have escaped the observation of those who have described injuries such as those now alluded to, accompanied by inversion of the foot, and which appears to support the opinion that this symptom is to be ascribed to the relative position of the fragments, rather than to the influence of muscular action. I have observed it several times, and it is this: the deformity having been removed, and the limb restored to its natural length by extension, as soon as the extending force ceases to act, though the limb is again shortened, the foot will be found to remain everted." P. 25.

In every case of fracture of the neck of the femur, accompanied by inversion of the foot, which Mr. Smith has had an opportunity of examining after death, the inferior has been placed in front of the superior fragment. He gives the best description that we have hitherto met with of that remarkable but not uncommon species of fracture of the neck of the femur, termed the impacted fracture, in which the broken cervix is driven into the shaft of the femur between the trochanters. Our author justly ob

serves :

"This peculiar form of fracture is the only one, the diagnosis of which is attended with difficulty, for it rarely happens that the limb is shortened to the same extent as in the ordinary examples of extracapsular fractures; in general the amount of retraction is nearly the same as in cases of fracture within the capsule. Between these two forms of injury, therefore, the shortening of the limb is not available as a means of differential diagnosis; upon further examination, however, it will generally be found that crepitus cannot be elicited upon

rotating the limb, because upon the one part the neck of the femur is so firmly wedged into the cancellated tissue of the shaft, that the fractured surfaces cannot be moved upon each other; and upon the other the integrity of the strong fibrous and tendinous structure which invests the whole of the region traversed by the second fracture, which has been already alluded to as being always present, is such that the detached portion of the trochanter, whether large or otherwise, in general moves with the shaft of the bone, and it is only by submitting the patient to an examination unjustifiably severe, that we are occasionally enabled to produce this characteristic evidence of fracture. When we endeavour to extend the limb, we usually find that no force which it is safe to employ will restore it to its normal length, and in general the dislocated head of the femur will return into its socket more readily than the impacted cervix will leave the cavity between the trochanters, into which it has been driven.

"More remarkable deviations than these, from the ordinary symptoms of fracture of the neck of the femur, sometimes attend this particular lesion; and cases have occurred in which the patient has not only raised himself from the ground after the fall which caused the fracture, but has even walked a considerable distance, bearing his weight upon the injured limb." P. 29.

These cases are very liable to be mistaken for contusion of the hip. The evidence of the existence of an impacted fracture of the cervix femoris is of a negative rather than of a positive character, and is thus briefly stated. "1. Slight shortening of the limb. 2. Slight eversion of the foot. 3. Absence of crepitus. 4. Great difficulty in all cases, and in the majority of instances an impossibility, of removing the shortening of the limb by extension; and lastly, less loss of power than in other forms of fracture of the neck of the femur." The anatomical characters of this form of fracture, as well as of the fracture of the neck with the capsular ligament, are well described by Mr. Smith, and obviously from extensive observation of specimens of those injuries.

Our readers are probably aware that a peculiar form of injury of the neck of the femur, termed " partial fracture," has been described by the late Mr. Colles and also by Mr. Adams of Dublin. The former author has spoken of its occurrence in cases of fracture within the capsular ligament, and the latter has described the symptoms and the morbid appearances supposed to characterize it in extra-capsular fractures. Mr. Smith, after quoting the observations of Mr. Adams on this form of fracture, states that he has examined the specimens referred to by both these pathologists, and for reasons which are alleged he can come to no other conclusion than that the doctrine of partial fracture has not yet been proved to be correct.

In reference to that long-agitated question, the possibility of osseous union taking place in cases of fracture of the neck of the femur within the capsular ligament, Mr. Smith, after briefly stating and repeating the chief objections which have been made to the occurrence of such an event, gives a concise summary of the cases which constitute the evidence by which the possibility of osseous union taking place has in his opinion been established. Seven cases, most of them well known to surgical pathologists, are adduced. Our author thinks it 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

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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."

Mr. Smith, after noticing the unfavourable nature of the prognosis in cases of fracture of the neck of the femur, the injury in many instances soon proving fatal, and in all the functions of the limb being for ever impaired, makes a remark which we can fully confirm, viz., that the form of fracture which is most rapidly and most frequently fatal is the extra-capsular fracture, when it is accompanied by a comminuted fracture with displacement of the trochanters. Our author next gives a brief account of the preparations which seem to warrant the conclusions he has deduced from them, accompanying the description with a concise history of the symptoms which each case presented during life. The preparations amount to sixty in number, and are nearly all illustrated by woodcuts. He subjoins a table shewing the age of the patient, the degree of shortening of the limb, and the position of the foot in these cases, as well as the length of time which elapsed between the receipt of the injury and the death of the patient. He terminates this elaborate investigation of fractures of the neck of the femur with the following conclusions :

"1. A slight degree of shortening, removable by a moderate extension of the limb, indicates a fracture within the capsule.

"2. The amount of immediate shortening, when the fracture is within the capsule, varies from a quarter of an inch to one inch.

"3. The degree of shortening, when the fracture is within the capsule, varies chiefly according to the extent of laceration of the cervical ligament.

"4. It also varies according as the fracture is impacted or otherwise.

"5. In some cases of intracapsular fractures, the injury is not immediately followed by shortening of the limb.

"6. This is generally to be ascribed to the integrity of the cervical ligament. "7. In such cases, shortening may occur suddenly, at a period more or less remote from the receipt of the injury.

"8. This sudden shortening of the limb is in general to be ascribed to the accidental laceration of the cervical ligament, previously entire, and is indicative of a fracture within the capsule.

"9. The deposition of callus around the fragments is not necessary for the union of the intracapsular fracture.

10. When osseous consolidation occurs in the intra-capsular fracture, it is effected by the direct union of the broken surfaces, which are confronted to each other.

"11. The osseous union of the intracapsular fracture is most likely to occur when the fracture is of the variety termed 'impacted.'

"12. In the intracapsular fracture, the mode of impaction is different from that which obtains in the extracapsular.

"13. The degree of shortening, when the fracture is external to the capsule, and does not remain impacted, varies from one inch to two inches and a half. "14. When a degree of shortening occurs immediately after the receipt of the injury, we usually find a comminuted fracture external to the capsule. "15. The intracapsular fracture is accompanied by fracture with displacement of one or both trochanters.

16. The extracapsular impacted fracture is accompanied by fracture without displacement of one or both trochanters.

17. In such cases, the fracture of the trochanters unites more readily than that of the neck of the bone.

"18. The degree of shortening, in the intracapsular impacted fracture, varies from a quarter of an inch to an inch and a half.

"19. The exuberant growths of bone met with in these cases have been erroneously considered to be merely for the purpose of supporting the acetabulum and the neck of the femur.

"20. The final cause of their formation is the union of the fracture through the posterior intertrochanteric space.

"21. The difficulty of producing crepitus, and of restoring the limb to its normal length, are the chief diagnostic signs of the impacted fracture.

"22. The position of the foot is influenced principally by the obliquity of the fracture, and the relative position of the fragments.

"23. Inversion of the foot may occur in any of the varieties of fracture of the neck of the femur.

" 24. When the foot is inverted, we usually find that either a portion or the entire of the extremity of the lower is placed in front of the superior fragment. "25. In cases of comminuted extracapsular fractures, with fracture and displacement of the trochanters, the foot will generally remain in whatever position it has been accidentally placed: it may be turned either inwards or outwards, or there may be inversion at one time and eversion at another.

"26. Severe contusion of the hip-joint, causing paralysis of the muscles which surround the articulation, is liable to be confounded with fracture of the neck of the femur.

“ 27. Severe contusion of the hip-joint may be followed, at a remote period, by shortening of the limb and eversion of the foot.

"28. The presence of chronic rheumatic arthritis may not only lead us to suppose that a fracture exists when the bone is entire, but also, when there is no doubt as to the existence of fracture, may render the diagnosis difficult, as to the seat of the injury with respect to the capsule.

"29. Severe contusion of the hip-joint, previously the seat of chronic rheumatic arthritis, and the impacted fracture of the neck of the femur, are the two cases most likely to be confounded with each other.

"30. Each particular symptom of fracture of the neck of the femur, separately considered, must be looked upon as equivocal; the union of all can alone lead to the formation of a correct opinion as to the nature and seat of the injury." P. 112.

In Chapter II. there is an account of the disease of the hip-joint termed by Mr. Adams "Chronic Rheumatic Arthritis." The symptoms of the disease, as described by Mr. Smith, are those of a chronic rheumatic affection with which we have long been familiar, though we have not hitherto connected them with the remarkable changes in the neck and head of the femur described and represented in the work before us. Since our attention has been called to these changes by the interesting observations of Mr. Adams in the Cyclopædia of Anatomy, we have been led to question whether the shortening of the neck, and the curious alteration in the form and depression of the head, occasionally met with, are altogether dependent upon a peculiar morbid change. We are satisfied that they may take place in advanced life as the result of the degeneration to which the bones are liable, without being attended with any rheumatic affection or marked symptom of disease. In this natural decay, the animal parts sometimes waste faster than the earthy, and thus the bone becomes so brittle that it is liable to fracture from the slightest violence; whilst in other cases the earthy parts are removed before the animal, so that the bone, being softened, becomes depressed and changed in shape by the

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pressure to which it is subject. This latter change may, and indeed is very liable to be precipitated in chronic rheumatism of the joint,-the state of rest consequent on the painful nature of the affection, being favourable to the natural process of degeneration. The exuberant growths of bone, and eburnation of the bared head of the femur, combined with the other changes, are very probably the result of chronic rheumatism. There are some excellent woodcuts, illustrating the various alterations in the femur described in this chapter. Our own experience leads us to coincide with Mr. Smith in the following practical remarks :

"It is an affection amenable to treatment in a very slight degree, and although its anatomical characters would lead us to suppose that it depended upon chronic inflammation affecting all the tissues entering into the composition of the joint, yet it is not found that antiphlogistic treatment produces any material alleviation of pain, nor is any permanent benefit derived from local bleeding or counter-irritation. Patients labouring under this affection not unfrequently present themselves at hospitals and dispensaries, in whom the entire of the region of the hip is covered with the marks of leeches, cupping, moxa, &c., but the disease has, notwithstanding, steadily progressed, totally uninfluenced by such treatment. Rest, anodyne embrocations, keeping the joint protected by new flannel or carded wool from the influence of cold and damp, together with the free and long-continued use of hydriodate of potass, combined with the compound decoction of sarsaparilla, and small doses of colchicum, constitute the mode of treatment from which I have seen most benefit derived." P. 128.

The subject of Chapter III. is Fractures of the Bones of the Fore-arm in the vicinity of the Wrist-joint. In by far the most common form of fracture in this situation the lower end of the radius is broken and its lower fragment displaced backwards. This is an obscure form of injury until recently not well understood, to which the attention of the profession was called by an accurate description of it, published by Mr. Colles, in 1814, in the 10th volume of the Edinburgh Med. and Surg. Journal.* It has been particularly noticed by Dupuytren, and is also described by Chelius. Mr. Smith, after quoting Mr. Colles' account of this injury, gives some minute particulars of the symptoms which characterize it. The marked deformity at the wrist is well shown in the accompanying woodcuts. It has been supposed, from the symptoms of the injury, that the fracture is in many instances oblique. This is not the opinion of Mr. Smith. He states :

"I have lately examined upwards of twenty specimens of the injury, and have not found one in which the bone had been broken with any considerable degree of obliquity from above, either downwards and backwards, or downwards and forwards; in all of them the anterior and posterior margins of the fractured surface have been nearly upon the same level and the surface plane; there is, however, an obliquity which the fracture not unfrequently presents, and which is directed either from

* Mr. Smith finds fault with the learned author of the Surgical Dictionary for not alluding to Mr. Colles' account of this fracture, remarking that it is the duty of every person who undertakes to write upon a given subject, to make himself, as far as possible, acquainted with, and also to acknowledge, the labours of those who have preceded him in the same field of enquiry. The observation is a just one, but it is one, we think, particularly applicable to many of the writers of the Dublin School, though not to Mr. Smith.