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the patient is resting on his back with the limb shortened; but if the leg be drawn down, so as to bring the limbs to the same length, and rotation be then performed, the crepitus is sometimes observed from the broken ends of the bone being thus brought into contact, but the rotation inwards most easily detects it.'

"Now, if the generality of Sir Astley's patients, and particu larly those in Guy's Hospital, have had all these indications of fracture demonstrated upon their persons, It is not difficult to un-. derstand the great degree of shortening of the limb, and destruction of the fibrous periosteum, which he has found in fractures within the capsule. I have already commented on the worse than inutility of such examinations in another part of this work, and only revert to the subject to explain one source of failure in Sir Astley's practice.

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"The next circumstance is the prejudice which he acknowledges has existed in his mind for the last thirty years on this subject, which may fairly be supposed to have prevented him from making any very effectual attempt to remove the difficulties attending the treatment, the greatest of which he acknowledges to be the securing the pelvis during the operations of nature. So very far indeed has this prejudice carried him, as to induce him to express himself in the following strong language: It is gratifying to find opinions, which have been for thirty years delivered in my lectures, confirmed by the observations of intelligent and observing persons; and therefore it was with pleasure I read the account of Mr. Colles of Dublin, who found a similar want of ossific union in fractures within the capsule.' It would, I humbly conceive, have been somewhat more gratifying to have found that this opprobrium had been removed from our profession, and that the deformity, lameness, and misery of our patients had been diminished or prevented.

"This strong bias has, indeed, evidently influenced the practice which Sir Astley recommends to be pursued, and which is the third source of his want of success. This consists in the placing a pillow under the whole length of a limb, and another rolled up under the knee, and thus extending the limb for ten days or a fortnight; at the end of which period the patient is to rise daily, and sit up in a high chair, to prevent any painful flexion. Our hospital patients,' he says, 'treated in this manner, are allowed in a few days to walk with crutches; after a time a stick is substituted for the crutches, and in a few months they are able to use the limb without any adventitious support,' but of course with the limb shortened for the remainder of their lives. When the fracture is ascertained to be exterior to the capsule, he adopts a different practice.

"It must be very apparent, that under such treatment no patient can recover without lameness, and that ossific union is quite impossible. How long he has adopted this plan of treating, or, more properly speaking, of abandoning patients, he does not, state." Earle, p. 81.

It is not surprising that' Sir Astley should take offence at parts of the foregoing statement. The reflection upon the examinations to which patients are subjected at Guy's Hospital might have been spared or softened. But these doctors, after all, are the very best of controversialists. Accustomed to the use of the knife and the cautery, they cut and burn without remembering that flesh can feel; and until "the indications" of suffering "have been demonstrated upon their own persons" they seem to have no compassion for the persons of others. Sir Astley's powers of dissection are not inferior to those of his antagonist, witness the following criticisms upon Mr. Earle's statement.

"To proceed. Our author says, page 22.-' Diagnosis.—Where a person, previously in full possession of the locomotive powers of, his limb, after the receipt of any injury, and particularly a fall upon his trochanter, becomes suddenly deprived of that power; accompanied by a remarkable consciousness of incapacity in the injured member; and when, from the position and direction of the limb, it is obvious that there is no dislocation, a strong presumption must arise that a fracture has taken place.'

"Again, page 23. 'I cannot quit this subject without deprecating, in the strongest terms, the cruelty and impropriety of what is termed satisfying yourself that there is a fracture, and its precise situation.'

Page 24. To return, then ;-This symptom of a total and sudden privation of the power of motion, after a fall on the trochanter, should always be regarded as diagnostic of a fracture.'

"Good God! is this written by an English surgeon? in the land of John Hunter, the minute investigator of nature, whether in health or disease? This is, indeed, cutting the gordian knot! What! shall not the surgeon satisfy himself there is a fracture, and its nature, before he exposes his patient to a confined position of great duration? for, if the surgeon be not suffered to examine the limb, when is that confinement to terminate? Are such doctrines to be taught, such advice to be given to young men just embarking in their profession, that they need learn nothing of these cases? For if a man has a fall, and a consciousness of inability, his limb is decided to be fractured! Certainly it will save a great deal of time in studying the profession. and a great deal of trouble in knowing the nature of the case the surgeon is called upon to treat.'

"If the advice which the author has given in the foregoing quotations, is adopted by young men, who come to London for instruction, when they return into the country, to settle in practice, they would all be ruined." Cooper, p. 10.

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These remarks are very unfair, and, with the strong case which their writer has in store, it was not necessary to mis

represent his opponent's meaning. Mr. Earle has expressly declared, in words not quoted by Sir Astley, "that a few days will declare whether the suspicion of fracture be well or ill founded," and that, at all events, "it is better that a few persons should be confined for a somewhat longer period than is absolutely necessary, than that many should have their sufferings increased and their recovery prevented or retarded." The writer of these sentences is not entitled to the censure contained in our last extract.

Taking leave, however, of these bony excrescences upon the works of both our anatomists, let us proceed to the real matter in dispute. Mr. Earle offers the following proofs of the possibility of reunion within the articulation.

"But it may be urged, that I have hitherto only adduced arguments in opposition to the reasons which have been assigned for the want of bony union, and that the onus probandi rests with me to show that bony union has taken place. It is not sufficient, it may be said, to point out the circumstances which have hitherto interrupted the union by bone, but I must prove that ossific union has actually taken place.

"That such an occurrence, without any lameness, or perceptible shortening of the limb, has happened several times in the course of my experience, I am perfectly satisfied of in my own mind; but as the individuals are either now living, or have died without affording me an opportunity of ascertaining the actual state of their limbs, I cannot reasonably expect to gain implicit credence to all the testimony which I might offer upon this subject. By actual dissection, however, I have proved the possibility of fracture existing without the periosteum and synovial membrane being completely torn through. By dissection, also, I have proved that union has taken place within the capsule, and that so firm and rigid, as to be inseparable even after maceration, and which required boiling for a considerable time before it could be overcome.

"The following are the particulars of the case in which this occurred:One of the nurses belonging to the hospital, aged 74, was knocked down in the street by a horse, and fractured the neck of the thigh, in the year 1808. She was an old emaciated woman, and had been much addicted to drinking. I did not attend her until nearly three weeks after the accident, when I found the limb retracted and foot everted. Very little attention had been paid to her during this interval. By gentle and continued extension I drew down the limb nearly to its proper length, when a very evident crepitus was perceptible. The limb was maintained in this situation by means of a splint, of a peculiar make, which I had constructed for cases of this description, and which I shall mention hereafter. The patient was placed on a double bed, which admitted of her

VOL. XXI. MARCH, 1824.

X

passing her motions without moving the pelvis. She was kept in this position for seven weeks, when the apparatus was removed. She had an old ulcer in her leg, which the peculiar construction of the splint admitted of being dressed daily without inconvenience. She was allowed to move the limb about in bed, and at the end of a week was permitted to rise for a short time. Considerable œdema of the leg took place, the wound became irritable, and erysipelatous inflammation spread up the limb, and eventually carried her off; she died exactly thirteen weeks from the receipt of the accident. On examination, two fractures were found; an oblique one extending through the greater part of the trochanter major, which was split into two portions, and reaching to the trochanter minor; the other a transverse fracture within the articulation. Both of these had very firmly united, as it was believed by bone; but as much discussion arose out of the case, it was submitted to the test of boiling, when the union became loosened; prior to which, no force that was applied could move one portion from the other. The obliquity of the neck was lost in this case, and the limb shortened about three quarters of an ich. Had the patient lived for some time longer, there is every reason to believe that the union would have been still more consolidated." Earle, p. 94.

"I have reserved to the last the highly interesting specimens in the possession of Mr. Abernethy, which were found by Mr. Stanley in the body of a subject in the dissecting-room. As it is Mr. Stanley's intention to publish a description of these bones, I will only so far anticipate that gentleman's account by stating, that they were both found in the same subject; that the fracture on the right side was entirely within the articulation, and on the left side partially; that there was very little shortening of the limbs, arising only from the loss of obliquity in the neck; and lastly, that the most perfect osseous union has taken place, which can be traced through the whole substance of the neck, in the different sections which Mr. Stanley has made.

"This case must, I think, be admitted by the most sceptical, and must at once place the possibility of such an ocurrence on the firm basis of actual demonstration. Nothing is known respecting the case, either as to the mode of treatment, or whether both the bones were fractured at the same time.

"If it were allowable to hazard an opinion on the subject, I should feel disposed to attribute the accident to a perpendicular fall which may have broken both necks at the same time; and I think it is highly probable that the firm and perfect union which has taken place may be referrible to the total inability to move either the pelvis or extremities, which must have been the necessary consequence of such an accident; for it is hardly possible to conceive a more totally helpless state than that to which a person under such circumstances would be reduced.

"Whether this opinion be correct or not, the fact of bony union

cannot be controverted; and one single fact of the possibility of such an occurrence is sufficient; for

"The first great cause,

Acts not by partial, but by general laws;"

and we may hence conclude, that bony union is possible under more favourable circumstances than have usually occurred."— Earle, p. 99.

Sir Astley Cooper dissects these cases minutely, and shews clearly enough, that they do not establish Mr. Earle's case. We prefer, however, quoting the summary of his opinions contained in the following passage.

"As a proof that the general principle which I have stated is correct, in the appendix to the second edition of my work I have produced the following forty-three cases, from different collections, of non-union by bone, of fractures of the neck of the thigh-bone.

In St. Thomas's collection
In the College of Surgeons

...

7 specimens

1 ditto

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"To these I have now to add another, from an experiment upon a living animal: while, upon the opposite side of the question, only a single instance, upon which the mind can for a moment dwell, has yet been produced; and in this, the same appearances were found in both the thigh-bones, and even these resembled what I have several times observed in the dead body, arising from a softened state of the bones. I have given a plate of some of these appearances, and the preparations I shall at all times be happy to shew to any of my professional brethren who may wish to see them.

"But in speaking of fractures of the neck of the thigh-bone within the capsule of the joint, I have been necessarily led to describe those which are external to it, as well as that to which the trochanter major is subject; and as the descriptions which I have given have been objected to, it is proper I should examine these objections in detail.

"But first let me observe, that I did expect an experience of near forty years would have been attempted to be contradicted by numerous dissections of these cases, and by experiments upon living animals, as these are the only modes by which the point can be determined.

"Is it a fact, or is it not, that fractures of the neck of the thigh

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