chine whose movements are effected by a peculiar volatile fluid known as "æther," whose chief reservoir and center is in the medulla. This æther was supposed to circulate with the blood and also through the nerves. Atony and plethora were the two chief causes of disease, according as the circulation of the æther is diminished, or on the other hand is too active. Fever was supposed to be due to spasm of the arteries and veins arising in the spinal cord. All this seems to us fanciful and foolish, and I have outlined it as a type of the systems, which seemed to be inseparable from the study of medicine, even in the minds of the greatest thinkers of the times. After all, it was but the earnest seeking for an explanation of the phenomena of the various normal and pathological precesses, which their crude methods of investigation were as yet insufficient to clearly reveal.

A celebrated English, or rather Scotch, physician was William Cullen, born at Lanarkshire in 1712. He was of humble parentage and his early education was meagre. He was successively a barber, an apothecary, a ship surgeon, and finally surgeon of a small Scotch village. Early in his career he became acquainted with William Hunter (elder brother of John Hunter), who was also in poor circumstances, neither of them having sufficient means to obtain a university degree. They accordingly formed. a unique and curious partnership arrangement, by means of which each agreed to earn by practice money enough to allow the other to attend the university. Cullen, being six years the senior received the first advantage of this arrangement and was thus enabled to take his degree in 1740. He soon afterwards became professor of chemistry at Glasgow and in 1755 he was called to Edinburgh as professor of medicine, where he continued during his life as an active and successful teacher and gained a great reputation as a medical author. He apparently made little effort to obtain private practice and he died in 1790, a poor man. He attributed great importance to the nervous system and advanced a theory of nervous pathology which contained much that was original and correct. He speaks of a "nervous force," a "nervous activity," and a "nervous principle" as being the active vital element as opposed to the æther of Hoffman's system. Perhaps his most popular and widely known book was his "First Outlines of the Practice of Physics," published in London in 1777It soon became recognized as an authority and was republished in America in 1793. Čullen made an elaborate classification of fevers and advanced the most rational theory which had yet appeared concerning the nature of gout, which he maintained to be a general disease depending chiefly upon digestive derangements, and that

the joint inflammations were reparative efforts on the part of nature. Cullen was of a most generous and charitable disposition, and although from his teachings and his books he gained a considerable income and his own tastes were simple and inexpensive, he left a very small estate. Cullen's reputation extended to all the medical centers of the world and his views were held in the very highest esteem.

(To be continued.)

ORIGINAL ARTICLES.

MECHANICAL AND SURGICAL TREATMENT
OF FRACTURES OF THE NECK
OF THE FEMUR.*

By Arthur J. Gillette, M. D.,

St. Paul.

In 1888, Lewis A. Stimpson, of New York, reported because of its rarity a case of intracapsular fracture of the hip with bony union in a woman aged 65, treated by Thos. F. Raven. Sir James Paget in commentating upon the case, stated that he had never seen so thorough a repair of this kind of fracture, and the specimen was presented to the Royal College of Surgeons, where it may be found in the Pathological Mu

seum.

Prior to this and since, scattering cases of this fracture have been reported as united, and we have looked upon the reports in as charitable a light as possible, believing that they were extracapsular instead of intracapsular fracture.

Since then to the present time all surgeries have clung to the old tradition, and stated that intracapsular fracture of the hip seldom if ever united.

While this has been a great consolation to many of us, it has lessened our ardor in our attempt to get a bony union by persistent reduction of the fracture and its thorough immobilization and perfect apposition of the fractured ends.

Then, too, we have been told that it is distinctly a fracture of the aged. This is disproved by Dr. Royal Whitman in the Annals of Surgery, 1897, Vol. 25, where he reports ten cases of fracture of the neck of the femur in childhood.

The old theory of the structure of the bone in the neck of the femur and the peculiar physiological changes in the aged as a cause for nonunion, is disproved by the many cases of union where proper mechanical and surgical means

*Read before the Interurban Medical Society, at West Superior, Wis., June 20, 1898.

position and mutual interlocking of the uneven fractured surfaces. No matter how snugly a plaster of Paris dressing is applied, as a result of shrinkage in a few days it becomes loose, and without some means of making lateral pressure it would become necessary to change it from time to time in order to render it efficient. But by incorporating a splint as shown in Fig. I. in the plaster dressing (Fig. II.) this is obviated, and the lateral pressure is regulated from day to day by moving the set screw, the proximal end of which rests in an oval depression in the center of the pad. From time to time the pad is removed and the skin washed with diluted alcohol for the purpose of guarding against decubitus."

In the Annals of Surgery, 1892, Dr. John Ridlon reports twelve cases of fracture of the neck of the femur treated by means of the so-called Thomas hip splint, the ages ranging from 43, the youngest, 70 and 80, the oldest, all with fairly good

to

created where the fulcrum (the origin of the abductors) is between the power (the lower end of the limb) and the resistance (the seat of the fracture). The entire limb is now placed on an inclined plane at an angle of about 135°.

"Thus the traction maintains the length of the limb, and the abduction of the thigh approximates the fragments. To still further increase the lateral pressure a tourniquet is passed over the padded surcingle, thus absolutely controlling the lateral pressure. When the patient is moved in bed for any purpose, or when the traction is modified in any way, or when the perineal pads are loosened the tourniquet pressure is carried up to the point of toleration. At other times the tourniquet pressure is modified. This pressure does not give rise to any trouble, nor does it seriously interfere with the circulation."

Two of the cases reported by Dr. Shaffer were ununited fractures, and they came under his care because the conventional method had failed.

results. In May, 1897, Dr. Newton M. Shaffer read before the American Orthopædic Association an article on "The Mechanical Treatment of Ununited Fracture of the Neck of the Femur with Traction Apparatus Producing Abduction of the Thigh and Direct Lateral Pressure over the Trochanter Major," in which he employs a modified long straight Taylor hip splint. (Fig. III.)* "In addition to this splint a belt about three and one-half inches wide, made of surcingle material, such as is used by saddlers, is passed around the pelvis, a crescentic shaped horse hair pad being placed over the trochanter major. This belt is firmly buckled at the opposite side of the pelvis.

"The limb is placed in abduction at an angle of about 20°, the origin of the abductor muscles being used as a fixed point to throw the distal toward the proximal fragment. A lever is thus

*Fig. III. represents the splint recommended by Dr. Shaffer but without some of the details.

I have employed Dr. Shaffer's method with the long traction hip splint but once, and only varied. from the treatment in that I did not find the tourniquet over the padded surcingle necessary. It was in the case of a man, aged 45, who had sustained not only a fracture of the neck of the femur but a fracture of the middle third of the thigh, the fracture demonstrated by etherization. No fracture-bed was used, and the bed pan could be easily placed in position, and there was no discomfort or pressure from plaster or perineal pads

in a word, no irritation in any way. The result, so far as union was concerned was perfect, although there was some shortening, and the man is now employed as a day laborer.

Notwithstanding the reports of eight cases by Dr. Senn, twelve by Dr. Ridlon, seven cases by Dr. Shaffer, and four cases by Dr. Myers, making a total of thirty-one cases of fracture of the neck of the femur united by these methods, our surgeries still repeat the old story of non-union

and make little, if any, reference to these reports. In a work on surgery placed upon the market within the last six months, highly recommended by reviewers, and claiming to be up to date, we find the following statement regarding fracture of the neck of the femur: "Union in old and enfeebled persons is doubtful. Should they show

the bad effects of confinement to bed, we must make the treatment of the fracture a secondary matter and attend to their general health. Traction should be employed gently, and impaction, if existing, should not be disturbed. Make the patient as comfortable as possible, and guard against bed sores. Sandbags or cushions may be used to steady the limb, or a plaster of Paris cast to include the whole limb and the pelvis. Buck's extension, with a five-pound weight will

were given special instructions regarding these particular cases, yet time and again I have gone there and found that my patient, while asleep, had gradually slipped down in the bed until the foot would be against the pully, notwithstanding the elevation of the foot of the bed. I have repeatedly found the trochanter major above Nelaton's line. It is impossible to place the bed pan under the patient and a fracture-bed must be used.

The idea of the Hamilton splint is to prevent rotation. It makes a very pretty picture as shown in surgeries, but when applied, because of the lack of contour of the leg, it is impossible to adjust it snugly, from foot to axilla, and the very parts which prevent its snug adjustmentviz: the ankle, trochanter major, crest of the

allow the patient to sit up in bed, and will keep up just enough traction to make him comfortable."

What he says of Buck's extension is true, and it is a comfort to the patient so far as pain is concerned, but it does not immobilize the hip sufficiently to permit union, and the plaster of Paris cast, including limb and the pelvis will not come as near immobilizing it as the Buck's extension, for you must have both limbs, the pelvis and the body to at least the eigth rib, included in the plaster, and the lateral pressure as mentioned by Dr. Senn.

I have had four cases where I employed the conventional Buck's extension, supplemented by Hamilton's long splint, and met with complete failure in all but one. Three of them were treated in one of the best of appointed hospitals, where we had house surgeons and nurses who

ilium and ribs, will not bear pressure as they are so slightly padded by muscular tissue. Often after I felt sure the splint was well applied, and adjusted with bandages and adhesive straps to toleration, I have visited my patient the following morning and found my Hamilton's splint on top of the leg, crossing the abdomen and chest, or slipped around and the upper portion of it under the body.

All of these conditions are obviated in the long extension hip splint, as suggested by Dr. Shaffer, the extension made by adhesive straps attached by buckles to the foot piece of the brace and the counter extension by the perineal straps. Extension can be made until the fractured ends are brought in apposition by the use of the ratchet and key to extend the leg. It is still more firmly fixed by the abduction of the leg and the surcingle about the pelvis making lateral

pressure over the trochanter major. There is no occasion to guess at the amount of extension necessary as we do with Buck's extension. In the long traction hip splint when the fracture is reduced, you have sufficient extension and it can be locked there.

If mechanical measures fail we are justified in surgical procedures, now that surgery has reached such a point that we enter the various cavities of the body with impunity.

Prior to the report of cases cured by the long extension hip splint I had three cases in which an operation for ununited fracture of the neck. of the femur was performed.

Case I. On Feb. 2, 1897, with Dr. Edouard Boeckmann, of St. Paul, I saw Michael C., age 36, who gave the following history:

of the limb, which treatment was continued for one month.

He was then again examined under an anæsthetic, which examination showed that there had not been the slightest attempt at union.

Dr. Boeckmann operated, making a horse shoe shaped incision (Fig. IV.) beginning it an inch below and an inch posterior to the anterior superior spine of the ilium, carrying it down two inches below the trochanter major, and bringing it up the buttocks to about the center of the gluteus maximus muscle; the skin, superficial and deep fascia were dissected en masse. chain saw was then passed between the posterior border of the tensor vaginæ femoris muscle and the gluteus medius, hugging the neck of the femur and the base of the trochanter major; it

A

On Sept. 15, 1897, nearly five months before, he was thrown from a wagon, the wheel of which struck his hip; the injury was such that his physician kept him in bed for five weeks. It was impossible to find what diagnosis was made at the time of the injury. When he entered Bethesda Hospital he was able to go about only on crutches. Even with this protection to the limb he suffered great pain whenever the limb or foot came in contact with an object that disturbed it in the least. He suffered great pain at night especially upon any attempt to move.

He was given an anesthetic, and it was easily demonstrated a case of intracapsular fracture of the hip.

The hip was forcibly manipulated and the patient placed on a hard bed with extension by weight and pully, and sand bags on either side

was brought out between the posterior surface of the gluteus medius and anterior surface of the gluteus maximus (Fig. V) thus sawing off the trochanter major and its muscular attachments which were then turned back, making an exposé of the capsule of the joint. Then by making a longitudinal incision in the capsule of the joint, the line of the fracture through the neck of the femur could be easily seen. The surfaces of the fractured ends were denuded and a bone peg was driven through the neck of the femur (Fig. VI), thus holding the fractured ends together. The capsule was then stitched with cat gut, the trochanter major nailed. with a small bone peg back to its original position, the skin and fascia flap sutured and a silicate spika applied.

Very little pain followed 'the operation, and the only constitutional symptom was a tempera