PROFESSIONAL ETHICS.

TO THE EDITOR OF THE MEDICAL TIMES AND GAZETTE.

SIR,-Will you be so good as to favour me with your opinion on two questions of Professional ethics, touching the taking of fees from the relatives of our brethren?

1. A. is a consulting Practitioner in a city. B. is a country Practitioner residing ten miles off. B.'s father, who lives near him, is ill, and B. wishes a consultation on his case with A. A. accordingly meets B. for that purpose at the house of the father, going by road. Is A. entitled to the usual fee given by an ordinary patient, or to any portion of it, or should he decline a fee in toto?

2. C. is a consulting Practitioner, as in the former case. D. is a retired Indian Practitioner, residing twenty miles off, near a railway station of easy access. D. sends for C. on the occurrence of any serious illness in his family. How should C. act as to fees?

In each case ample means are supposed to exist.
March 31.

I am, &c.

X. Y. Z.

Both cases, we think, should be determined by the consideration of whether or not the patients be dependent on the Medical men, B. and D. Mere relationship to a Medical man does not confer the privilege of obtaining Medical journeys and advice gratis. But if the patient be dependent for support on a Medical man, then the consulting Practitioner should either not take a fee, for it would come indirectly from his brother Practitioner's pocket, or be content with a small honorarium to cover expenses. In any case, however, in which a consulting Practitioner is expected to attend and to take no fee, the thing should be clearly explained beforehand, so that he may have the option of refusing a long and fatiguing journey without recompense-a thing which it may be the duty of a consulting Practitioner to decline.

COMMUNICATIONS have been received from

Mr. W. H. DAVIS; Mr. A. L. Fox; Dr. LETHEBY; Dr. JAMES CUMMING; Dr. FREDERIC BATEMAN; Dr. J. BURTON; Dr. DAY; Dr. WOLFE; Dr. F. J. BROWN; Dr. CHARLES KIDD; Dr. HUXLEY; Mr. C. J. Fox; Dr. FELCE; A CLOSE OBSERVER; Mr. W. W. CORBAN; Mr. B. WILLS RICHARDSON; Dr. MACKEY; Mr. F. REYNOLDS; Dr. Ross; Mr. J. B. CURGENVEN; Mr. J. C. GALTON; Dr. J. N. VINEN; Mr. FREDERICK JEEVES-Mr. C. F. MAUNDER; Mr. J. CHATTO; Mr. J. HUTCHINSON; Mr. T. M. STONE; Dr. WILKS; Mr. C. Godson.

BOOKS RECEIVED

Untersuchungen über Psychologie, von Dr. F. A. v. Hertzen-Elliott's Druggists' Price Book-Sanitary Record, No. 2-Pharmaceutical Journal, No. 118-Haughton's Laws of Vital Force - Quarterly Journal of Microscopical Science, April-British and Foreign Medico-Chirurgical Review, April-"Does Education Lessen Crime?" By W. H. Groser, B.Sc., F.G.S.-A Pastoral for the Times, by a Cambridge Undergraduate -Human Nature, No. 25-Monthly Microscopical Journal, April-Smallpox and Vaccination Hospital Report-Philadelphia Medical and Surgical Reporter-Westminster Review, No. 70-Gamgee's Researches on the Blood-Glamorgan County Lunatic Asylum Report-Barter's Report on the Sanitary Condition of Bath.

in the week was 29'574 in. The barometrical reading decreased from 29.77 in. on Thursday, April 1, to 29 21 in. by the end of the week. The general direction of the wind was N.E. and S.W.

Note. The population of Cities and Boroughs in 1869 is estimated on the assumption that the increase since 1861 has been at the same annual rate as between the censuses 1851 and 1861; at this distant period, however, since the last census it is probable that the estimate may in some instances be erroneous.

April 10. Saturday (this day).

Operations at St. Bartholomew's, 1 p.m.; St. Thomas's, 9 a.m.; King's,
2 p.m.; Charing-cross, 1 p.m.; Royal Free, 1 p.m.
ROYAL INSTITUTION, 3 p.m. Mr. A. Geikie, On the Origin of Land
Surfaces."

12. Monday.

Operations at the Metropolitan Free Hospital, 2 p.m.; St. Mark's Hospital for Diseases of the Rectum, 1 p.m.; St. Peter's Hospital for Stone, 24 p.m.

MEDICAL SOCIETY OF LONDON. 8 p.m.: Casual Communications. Dr. Morell Mackenzie, "On Syphilitic Diseases of the Throat." 13. Tuesday.

p.m.:

Operations at Guy's, 14 p.m.; Westminster, 2 p.m.; National Orthopedic, Great Portland-street, 2 p.m. ETHNOLOGICAL SOCIETY, 8 p.m. Opening Address by Prof. Huxley, F.R.S. Mr. William Blackmore, Notes on some of the principal Tribes of the Indians of the United States, with a brief Account of the late Indian War." A. W. Bell, M.D., "On the Aztec Tribes of New Mexico and Arizona." Mr. Morton C. Fisher, "The Arapahoes, Kiowas, and Comanches." Mr. E. T. Stevens, "Some Characteristics of the Stone Implements and Objects found in the Mounds of Ohio." A Series of Photographs of Views in the Indian Country, with Portraits of many of the principal Chiefs, will be exhibited.

ROYAL MEDICAL AND CHIRURGICAL SOCIETY (Ballot, 8 p.m.), 8 p.m. Dr. Barnes, "On the Operations for Relief of Chronic Inversion of the Uterus." Dr. Kelly, "On the Spontaneous Cure of Hydatid Cysts." ROYAL INSTITUTION, 3 p.m. Prof. Grant, "Stellar Astronomy."

14. Wednesday.

Operations at University College Hospital, 2 p.m.; St. Mary's, 14 p.m.; Middlesex, 1 p.m.; London, 2 p.m.; St. Bartholomew's, 14 p.m.; Great Northern, 2 p.m.; St. Thomas's 14 p.m.; Ophthalmic Hospital, Southwark, 2 p.m.; Samaritan Hospital, 2.30 p.m.

EPIDEMIOLOGICAL SOCIETY, 8 p.m. Dr. E. D. Dickson, of Constantinople, "On Cholera in Persia, 1866, '67, and '68." Dr. Milroy, "On the Analogy between Epiphytics and Epidemics."

HUNTERIAN SOCIETY (Meeting of Council, 7 p.m.), 8 p.m. Dr. Beigel will read a Paper On Chorea," and will show a "Case of Ruptured Vocal Cords by the Laryngoscope.”

15. Thursday.

Operations at St. George's, 1 p.m.; Central London Ophthalmic, 1 p.m.;
Royal Orthopaedic Hospital, 2 p.m.; West London Hospital, 2 p.m.;
University College Hospital, 2 p.m.

HARVEIAN SOCIETY, 8 p.m. Mr. Gascoyen, "On Varicocele."
ROYAL INSTITUTION, 3 p.m. Prof. Tyndall, "On Light."

16. Friday.

Operations at Westminster Ophthalmic, 14 p.m.; Central London Ophthalmic Hospital, 2 p.m..

ROYAL INSTITUTION, 8 p.m. Mr. Carruthers, "Cryptogamic Forests of the Coal Period."

THE angular or caudate nerve cells are characteristic of the great central nerve organs of vertebrata, the brain and spinal cord, and attain their maximum of development in the highest mammalia and man. If we examine those in the grey matter of the spinal cord, we see lines traversing the cells from cach of the many fibres connected with them, and passing to every other fibre. (Proceedings of the Royal Society, 1864.) I endeavoured to show that these lines, which were rendered evident by the slow action of acetic acid, indicated the paths taken by the nerve currents which traversed the cell.

FIG. 15.

FIG. 15.-Angular and caudate nerve cells from the anterior cornu of the grey matter of the spinal cord. Human. x 130.

Deiters, Boddaert, and other observers have stated that one dark-bordered fibre enters each of these cells. If this be so, we may consider the axis cylinder as splitting up into a number of branches, some of which pass into every one of the other granular "protoplasm" fibres which leave the cell. My own observations lead me to conclude that all the fibres are composed of the same material and exhibit the same structure and refractive power, but that one fibre (Deiters's darkbordered fibre) does not divide until it has passed some distance from the cell, while the others give off branches very close to it (Fig. 15).

Connected with the cells of the grey matter of the brain, particularly of the sheep, is one long fibre which may often be followed for the distance of the tenth or twelfth of an inch without giving off a single fibre (Fig. 16). The other fibres, on the contrary, break up into a great number of branches quite close to the cell. I cannot agree with Deiters and Max Schultze in regarding these fibres as of a totally different nature from the long one. Although in Deiters's figures the long darkbordered fibre is represented as if it were altogether different in structure from the other fibres of the cell, I do not discover this difference indicated in the beautiful photograph of Boddaert, from which it appears to me all the fibres of the cell possess the same refractive power. This could not be VOL. I. 1869. No. 981.

dark-bordered" and all the rest consisted

the case if one were 66 of " protoplasm." (a) The germinal matter of the nerve cell is embedded in the material which exhibits the lines crossing in all directions, and no doubt this substance is formed from it; but, as far as I have been able to ascertain, no nerve fibre arises from, or is connected with, the nucleus or nucleolus. It appears probable that these cells are the stations at which nerve fibres pursuing many different directions decussate and change their course. It is an interesting circumstance, and strongly corroborative of the truth of the views just advanced, that at the very time I was making out the peculiar anatomical fact recorded in my paper, Professor Alexander Bain, looking at the subject from a totally different side, was led to conclusions concerning the arrangement of the nervous mechanism agreeing in all important particulars with my own, which had been deduced from facts of observation.

It is possible that the caudate nerve cells may not be sources of nerve force. These cells are fewer in number and of small size in the lower vertebrata, particularly batrachia and fishes. In the invertebrata they do not exist at all, and it is very questionable if any cells precisely corresponding to them are to be found in their stead.

Of the Spherical, Oval, and Pyriform Nerve Cells.-The nerve cells belonging to this class have a structure very different from that of the caudate or angular nerve cells. The fibres, instead of radiating from the cells and appearing as if drawn out from them, encircle them, and pursue a very circuitous course. They are curved and coiled, and are of much greater length than is necessary simply to traverse the space through which they may be traced. The matter of which the fibres are composed is continuous with that of the cell, and the facts observed justify the inference that the fibres are continually growing, or, in other words, the matter at the outer part of the cell gradually undergoes conversion into fibre, and this process continues during the life of the cell (Figs. 17, 18). The fibres, even in that part nearest to the cell, contain numerous small masses of germinal matter. In many cases the fibre seems to unwind itself from the outer part of the cell, and in this situation the gradual multiplication of the oval masses of germinal matter which are ultimately seen in the unwound fibre may be demonstrated, and the youngest may be seen growing in the substance of the cell itself, near the surface.

In man and the higher vertebrata these cells are found in all the ganglia of the so-called sympathetic, and in the ganglia on the posterior roots of the nerves, the Gasserian ganglion, etc., which belong to the same class. They are nearly spherical, and are usually represented as spherical cells or globules lying amongst the fibres of the ganglion. Even to this day these cells are stated in many text-books to be invested with a capsule of connective tissue, sometimes as thick as the cell is wide, in which numerous nuclei are represented. These are supposed to have no connexion whatever with the nerve fibres passing near them. Nothing could be more unmeaning or more unintelligible than many of the statements made concerning the structure of the sympathetic ganglion cells. Nevertheless, they are repeated again and again, and the old draw

(a) This word has been employed most loosely, and matter in different states and exhibiting very different properties has been called "protoplasm." Only recently we have been told of "protoplasm" extending for miles in the depths of the Atlantic, and roast mutton has been called protoplasm (Huxley). The contractile material of muscle, the axis cylinder of nerve, and certain nerve fibres are all considered to be protoplasm. In short, living growing matter has been called protoplasm, the formed matter or tissue of living beings has been called protoplasm, and the lifeless material obtained from roast or boiled meat has been regarded as "protoplasm." Protoplasm may therefore be living and moving or still and non-living; it may exhibit structure or be structureless, may be active or passive, and is supposed to retain its characters not only in the raw but in the cooked state!

imperfect and unsatisfactory specimens. One might fairly expect that before an author ventured to upset the observations of another, he would take proper steps to obtain good preparations. It is, however, quite unnecessary for me to reply to objectors or to try to convince sceptics, as the actual specimen from which my most complex ganglion cell was copied is under the microscope.

The oval and spherical cells characteristic of the sympathetic, of the ganglia on the posterior roots, etc., are seen at a very early period of development, and the ganglia in which they are found are very large and advanced in development in proportion to other parts of the nervous system. At a time when these cells are well defined and probably active, the caudate nerve-cells are but small masses of germinal matter which may be easily passed over. In the lower vertebrata, when fully grown, these cells are many times larger than the caudate cells of the spinal cord, and in the ganglia of most invertebrata we find spherical and oval nerve-cells which, I believe, correspond with those under consideration. The early development of these cells and their large size at a time when the caudate nerve-cells are not to be distinguished, their constant presence, their growth and multiplication in the adult and probably at an advanced age, and their peculiar structure at least in some animals, their situation as regards the nerves to which they belong, and especially the fact that these are the only cells constituting the nerve-centres upon which the rhythmic contraction of detached portions of the cardiac muscular tissue depends, (b) have led me to look upon these cells as the sources of nervous power, while I consider that the caudate nerve-cells are more probably concerned in the distribution and radiation of the nerve-currents.

ORIGINAL COMMUNICATIONS.

CLINICAL SURGERY.

ON THE

IMPACTED FRACTURE OF THE NECK OF THE THIGH-BONE,

MORE PARTICULARLY IN REFERENCE TO ITS DIAGNOSIS.

By THOMAS BRYANT, F.R.C.S.,
Assistant-Surgeon to Guy's Hospital.

THERE are few cases which cause more anxiety to the Practitioner of Surgery than injuries to the hip, and there are none which demand more careful clinical observation and anxious thought; for the difficulties of diagnosis in certain instances are not despicable, nor are the dangers of error insignificant.

To recognise the presence of an ordinary fracture of the neck of the thigh-bone may not be difficult when the solution of continuity between the broken portions is well marked; nor is the diagnosis of the more ordinary forms of dislocation of the head of the femur usually obscure, for these injuries are characterised by definite symptoms which are readily interpreted by the Practitioner of Surgery.

It might also be thought by the uninitiated that it could be no difficult task to make out the fact that a simple contusion of the hip alone exists in any given instance, and that no fracture of the bone complicates the case. Still, experience tells us that the solution of this latter problem is far from simple, and that it is under such circumstances errors of diagnosis and errors of practice are frequently committed. As a proof of this, amongst the cases of fracture I am about to relate several will be detailed which had been diagnosed and treated as cases of contusion.

It will not be doubted, therefore, that, as a question of clinical importance, the diagnosis of the impacted fracture of the neck of the thigh-bone can hardly be placed too highly; for it is not to be disputed that the recovery or lameness of many a patient rests entirely upon a correct appreciation of the value of such a combination of symptoms as usually exists in this variety of fracture, and that, too, in the very critical period of the case; for should an error in diagnosis be made, and the case as one of impacted fracture be overlooked, violent manipulative efforts will probably be made to reduce the supposed dislocation, or to set the supposed fracture, or, what is

(b) See a paper by me in the Microscopical Journal for April, 1869.

equally probable, to decide the question between the presence of the two by the detection or non-detection of crepitus, when, as a consequence, the impacted bones will to a certainty be loosened, if not dislocated, and the case changed from being one in which the bones are placed favourably for union and for recovery into another in which a very different condition of circumstances has to be encountered, and a less favourable prognosis given.

To Professor R. W. Smith, of Dublin, the thanks of the Profession are unquestionably due for having given a prominence to this class of cases, and in his valuable work on fractures in the vicinity of joints, published in 1850, will be found nearly all that is known about the subject. Still, the great body of the Profession are not sufficiently alive to the importance of the points involved in its clinical consideration, and by overlooking cases of impacted fracture they occasionally commit errors of diagnosis of grave and serious importance; for the treatment of a case of impacted fracture is not one of difficulty when fairly understood-the main importance rests in its diagnosis.

I propose, therefore, in my present communication to draw the attention of the Profession to this subject in its clinical aspect to illustrate it by the details of several cases treated during life, and by some few pathological specimens taken from cases the histories of which are tolerably complete.

But first of all it may be well to ask whether the impacted fracture of the neck of the thigh-bone be in reality an accident of rare occurrence; is it so rare as to render it right in practice to regard the existence of such a form of fracture in any case of injury to the hip as an improbability? Would it not be a wiser-nay, safer-practice, to look upon all cases of fracture of the neck of the thigh-bone as more or less complete examples of the impacted fracture, the degrees of solution of continuity in the bone and the mobility of the broken parts varying from the most perfect impaction of the neck of the femur within the shaft to the most complete mobility of the broken bones?

I am disposed to think that such a mode of looking at every case of injury to the neck of the thigh-bone would practically be the safest, and this opinion is supported both by clinical experience and by pathological investigation.

With reference to pathological investigation, I may state that the opportunities I have had of examining morbid preparations enable me cordially to agree with Professor Smith (a) "that all extra-capsular fractures are in the first instance also impacted fractures.' I believe, moreover, that many intracapsular fractures and all the mixed forms are primarily of a like kind. I agree also with Professor Smith "that it depends principally upon the violence with which the injury has been inflicted whether the neck of the bone shall remain implanted between the trochanters, or whether these processes shall be so completely separated from the shaft of the femur as to allow of the escape of the cervix from the cavity which it had formed in the reticular tissue of the lower fragment. If the force has not been very great, the neck of the femur remains wedged in between the trochanters, and one or both of these processes are split off from the shaft; but if the fibrous structures around the neck of the bone and trochanters have not been injured, these broken portions of the trochanters are still held firmly in their places, and the impacted cervix does not become loosened; but if the force has been considerable, the impulse prolonged, the bone in a state of senile atrophy, or if, as frequently happens, the patient in endeavouring to rise falls a second time, then, under these circumstances, the trochanters are not only broken from the shaft of the femur, but are so far displaced and separated from the connexion with the soft parts that the cavity or socket, as it were, into which the superior fragment has been received, is destroyed; the impacted cervix thus set free no longer opposes the ascent of the inferior fragment, and the case then presents the characters of the ordinary extra-capsular fracture with great shortening of the limb."(b) In fact, the ordinary fracture of the neck of the thigh-bone is an impacted fracture, the impacted bones being loosened in some cases by a second fall, in others by excess of violence received in the original accident, and in too many instances by the Surgeon in his anxiety to make out the presence of a fracture by the detection of crepitus. Indeed, this looking for crepitus in all cases of fracture is a practice of considerable danger; in fractures of the neck of the thigh-bone it is not only unnecessary, but unjustifiable. It is unnecessary because the diagnosis of the case can be made out without the help of such a symptom; it is unjustifiable because in every case of impacted fracture the attempt to find it is attended with irreparable mischief.

How, then, it may be asked, is an impacted fracture of the neck of the thigh-bone to be made out? I shall attempt to indicate this by the quotation of the following cases which have been under my care. I shall then give the details of the cases from which the specimens I now illustrate were taken after death, and conclude by a general analysis of the symptoms as a whole in the form of conclusions.

Case 1.—Impacted Fracture of the Neck of the Femur-Recovery. On November 16, 1864, I was requested by Mr. Langmore, late of Finsbury-square, to visit with him a Mr. B., aged 44, of the Kingsland-road, for some injury to his right hip which he had sustained the evening before. The patient was an epileptic and a confirmed spirit drinker, and it was from a fall on to his right hip that the injury had been sustained. Mr. B. was playing at billiards at the time, and fell with his whole weight upon the trochanter; he was a tall and muscular man.

He

had been unable to stand or raise the limb since the accident. I found him in bed and in some pain. There was external evidence of injury to the right hip, as indicated by a bruise and some swelling; the limb was slightly everted, but not more so than the sound leg, and measured about one inch shorter than the left. On rotating the limb gently as it was resting on the bed, the head of the femur clearly rotated in the acetabulum, and the trochanter also moved with it. Pressure over the trochanter caused severe pain, and the trochanter was clearly nearer to the anterior superior spine of the ilium than on the sound side. No amount of extension caused the slightest elongation of the shortened limb. The man being very muscular and extremely sensitive to pain, a complete examination was a task of difficulty; consequently chloroform was given, and an impacted fracture of the neck of the thigh-bone was made out. For it was tolerably clear that the head of the femur was in the acetabulum and could be rotated in it, the trochanter also moving with it. The trochanter was clearly nearer to the anterior superior spinous process of the crest of the ilium than on the sound side, and nearer also the median line of the body. The limb was about one inch shorter than its fellow, and that shortening was in the thigh. The foot was slightly everted, but to nothing like the extent generally present in the ordinary forms of fracture, and less so than on the sound side. These symptoms were the immediate result of a direct fall upon the trochanter in a sound limb. No crepitus could be felt, nor was it looked for, since such a symptom could only have been produced by a dislocation of the fractured and impacted bone. A long splint was applied and kept on for six weeks, when it was removed, a good limb being the result. It was still, however, about an inch shorter than its fellow. The trochanter also still occupied a position nearer the median line of the body than in the sound limb, and about the neck of the bone there was some thickening. Good movement, however, existed in the joint. Five months subsequently this patient had perfect power in his limb, the shortening being the only point about which complaint was made. This case was complicated with an attack of delirium tremens at first, and subsequently by true gout in the foot of the affected limb. One other point of interest also must be mentioned. During the administration of chloroform for the purpose of making an examination of the thigh, this patient had two severe epileptic fits, and during these fits, in which the whole muscular system of the body was affected, the injured limb remained at rest. The arms and left leg were moved with great power, the muscles of the right leg were also very rigid, but the limb was not raised.

Case 2.-Impacted Fracture of the Neck of the Thigh-boneRecovery.

On the evening of February 25, 1865, I was called down to Enfield by Dr. Benjamin Godfrey, of that town, to see a Mrs. T., aged 51, who had received an injury to her right hip at 5 p.m. It appeared that this lady had gone into her farmyard to see a favourite cow, who greeted her roughly, and butted at her. In attempting to save herself from the attack, she suddenly turned round to the left side, and fell with her whole weight upon the left trochanter. She was unable to move after the accident. When I saw her with Dr. Godfrey five hours subsequently I found her in bed; her left leg was lying powerless, and the foot everted. The limb was one inch shorter than the sound one, the shortening clearly existing in the thigh; and extension failed to elongate the limb. The soft parts over the trochanter were bruised and much swollen. It should be stated also that this lady was tolerably stout, and had unusually broad hips. The limb could be rotated gently, and the head of the bone clearly moved in the acetabulum; the tro

chanter also moved with it. There was some thickening about the neck of the bone, with great tenderness on pressure, and indistinct crepitus was once felt during the examination. Chloroform was given in this case, as in the last, to allow of a complete examination being made, when all doubt as to its nature was cleared up, and an impacted fracture of the neck of the bone was diagnosed. The limb was put up in a long splint, and absolute rest enforced. Everything went on well, and on April 28, two months after the accident, Dr. Godfrey reported that the patient was out of bed and walking the room with help, that the limb was less than one inch shorter than the other, and that every movement existed. At a later date a good and useful limb was reported to exist.

Case 3.-Impacted Fracture of the Neck of the Thigh-boneRecovery.

Mr. Frederick Toulmin, of Upper Clapton, asked me, on October 3, 1865, to see with him a lady, aged 64, who had received that afternoon an injury to her right hip. The accident was produced by a direct fall on to her right trochanter on getting out of an omnibus. I found her in bed with the right limb powerless, and the foot everted. The thigh measured one inch less than the left from the anterior superior spinous process of the crest of the ilium to the patella, and extension failed to elongate the limb. The head of the bone rotated in the acetabulum, and the trochanter moved with it. Some thickening was felt about the neck of the bone, and deep pressure caused pain. No crepitus could be felt. From the nature of the injury and the character of the symptoms there was no difficulty in arriving at the conclusion that an impacted fracture existed. A long splint was consequently applied, and a good recovery ensued. Her injured limb, however, remained about three-quarters of an inch shorter than the sound one.

Case 4.-Impacted Fracture of the Neck of the Thigh-boneRecovery with Good Limb.

Mary C., aged 56, a heavy woman, was admitted into Guy's Hospital on September 21, 1868, under my care, for an injury she had sustained one hour previously to her right hip. That injury was a fall upon the right trochanter. It took place at 7 p.m., and at eight o'clock she was admitted. She was unable to stand or use the limb after the accident. On admission she was seen by the dresser, Mr. Ticehurst, who found the right lower extemity shorter than the left, and the foot everted. The limb was useless though movable, but yet no crepitus could be made out. The dresser confessed that he could not make out the case, that it was not one of dislocation, and yet he could not determine it was one of fracture, as no crepitus could be felt. He accordingly fixed the limb on a pillow and left it for my visit the following day. When I saw the case, and learned its history, the suspicion of its true nature was at once raised. The limb was one inch shorter than the left, and the shortening was in the thigh; no moderate extending force could diminish this amount. The head of the bone clearly rotated in the acetabulum, and the trochanter moved with it. This projection of bone was also three-quarters of an inch nearer the anterior superior spinous process of the ilium on the right than on the left side; it was also nearer the median line of the body. Under these circumstances the diagnosis of the impacted fracture was very simple. A long splint was accordingly put on and left for six weeks; at the end of that time it was removed, and good union was secured. There was a good deal of new bone thrown out about the neck of the bone. The patient left the Hospital at the end of two months with a sound limb, but she was afraid to use it freely.

Case 5.-Impacted Fracture of the Neck of the Thigh-bone, loosened by want of Care-Separation of Parts-Recovery. The following case is a good example of the impacted fracture and forcibly illustrates the evils of not preserving absolute quiet in the treatment, for there is no doubt in the case I am about to relate that the impacted fracture was subsequently dislocated from the constant moving of the patient, and that an impacted fracture was turned into the ordinary fracture of the neck of the thigh-bone.

On November 9, 1865, I was requested by a Medical man to visit a lady aged 65, who had sustained some injury to her right hip some twenty-four hours previously by being knocked down by a horse and falling on to her right trochanter. She was unable to move the limb after the accident, and had been in much pain ever since. When I saw her I found her in bed with her left leg lying motionless, and the foot everted. The left thigh measured three-quarters of an inch less than the right, and extension failed to make any difference in its length. The