FRACTURES OF THE NECK OF 
THE FEMUR, 
WITH SPECIAL REFERENCE TO BONY UNION AFTER 
INTRA-CAPSULAR FRACTURE. 
N. SENN, M.D , 
BY 
OF MILWAUKEE, WISCONSIN. 
Extracted from the 
Transactions of the American Surgical Association, 
Vol. I. 1883. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1883. FRACTURES OF THE NECK OF 
THE FEMUR, 
WITH SPECIAL REFERENCE TO BONY UNION AFTER 
INTRA-CAPSULAR FRACTURE. 
/BY 
N. SENN, M.D„ 
OF MILWAUKEE, WISCONSIN. 
Extracted from the 
Transactions of the American Surgical Association, 
Vol. I. 1883. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
i 883- TO 
GEHEIMERATH von NUSSBAUM, 
IMS ponagrftirb 
IS DEDICATED 
IN ADMIRATION OF HIS SUCCESS AS A TEACHER, 
AND OF 
HIS ABILITY AND SKILL AS A SURGEON, 
HIS 
FRIEND AND FORMER PUPIL, 
THE AUTHOR. FRACTURES OF THE NECK OF THE FEMUR, 
With Special Reference to Bony Union after 
Intra-capsular Fracture. 
I. Experiments on Animals. 
These experiments were undertaken with a view of obtaining 
information concerning the following questions : 1st. What is 
the mode of repair after non-impacted intra-capsular fracture of 
the neck of the femur? 2d. What becomes of a bone or metallic 
nail when driven into the neck of the femur and retained per- 
manently? 3d. What is the effect of such a nail upon the adja- 
cent bone tissue? 4th. Can we, in cases of intra-capsular fractures 
of the neck of the femur, by immediate or direct measures, as 
by nailing the fragments together, obtain such accurate coapta- 
tion and retention as to secure union by bone? 
A great many difficulties were encountered in performing 
these experiments, prominent among them I will enumerate 
shortness of the femoral neck, difficulty in carrying out the 
antiseptic treatment, and in providing additional means for 
securing immobility of the fractured bone, and the great danger 
to life in using anaesthetics. After I had lost a number of 
animals from the administration of chloroform and sulphuric 
ether I relied exclusively on hypodermic injections of morphia 
in preventing pain during the operation. The experiments were 
made on cats, dogs, and rabbits, embracing in all thirty-three 
operations upon thirty animals. In the first thirteen operations 
the capsule of the hip-joint was exposed by a small posterior 6 
incision, and the neck was rendered more accessible by forcibly 
rotating the thigh inward; the bone was perforated a sufficient 
number of times with a small drill close to the head, and usually 
fractured by forcible abduction and rotation outward of the limb. 
The fracture usually took place with a distinct snap, and was 
followed by all the characteristic symptoms of fracture through 
the neck; preternatural mobility, shortening, and crepitus. The 
incision was closed with catgut sutures, and the wound covered 
with iodoform and salicylated cotton. In all of these cases the 
fractured bone was replaced as nearly as possible in the normal 
position, and a plaster-of-Paris dressing applied, which included 
the pelvis and both extremities. Two of these animals died of 
pyaemia, and in not a single instance out of the whole number 
could be found the slightest attempt at bony union at the post- 
mortem examination. In one instance (a young Newfoundland 
dog) the hip-joint presented evidences of severe inflammation 
without suppuration; the head of the femur, having necrosed, 
was found completely detached in the acetabulum. In some 
cases ligamentous union had taken place, while in others the 
fractured surfaces were covered with healthy granulations. In 
all the specimens the lower fragment had become shortened. 
Having satisfied myself that the antiseptic treatment could not 
be followed with sufficient accuracy in these cases to protect the 
animals against infection, I determined to fracture the neck sub- 
cutaneously. In the next six cases, after shaving and disinfect- 
ing the hip, and rotating the thigh inward and sliding the skin 
forward, I made a puncture down to the neck of the femur from 
behind with a narrow tenotome, and inserting the drill into the 
passage made, divided and fractured the neck as before. The 
skin retracting made the operation entirely subcutaneous. A 
plaster-of-Paris dressing was applied in the same manner as in 
the first series of experiments. No inflammation or febrile re- 
action followed these operations, and the post-mortem examina- 
tions showed evidence of ligamentous repair. In the absence 
of bony union, the functional result in several cases appeared 
remarkable. With few exceptions, all of the fractures produced 7 
so far were proved to be purely intra-capsular at the post-mortem 
examinations. 
In Experiment No. 21 the neck was fractured subcutaneously 
and no retaining dressing applied. The animal was killed five 
weeks after the operation, and an examination of the hip-joint 
showed that a firm and short ligamentous union had taken place. 
After the first three weeks little or no lameness could be detected. 
Having failed in all cases so far in obtaining union by bone 
I determined to secure immediate and direct coaptation by nail- 
ing the fragments together. 
The fracture was produced subcutaneously in the same way 
as in the preceding series of cases, and, after replacing the limb 
in its natural position and sliding the opening in the skin to a 
point corresponding with the centre of the base of the femoral 
neck, the drill was introduced, and a perforation made in the 
direction of the centre of the femoral head, and a wire-nail or 
bone-peg of proper length was driven into the opening made by 
the drill so that the outer extremity of the nail should not pro- 
ject beyond the surface of the bone. 
The first two animals progressed very favorably after the 
operation and appeared to suffer but little pain, but unfortu- 
nately escaped before an examination could be made to ascertain 
the result. 
Expeiimcnt No. 24.—Young cat; fractured the right femoral 
neck subcutaneously, and nailed the fragments with a bone-nail. 
Animal killed ten weeks after operation. Neck of femur almost 
entirely absorbed; capsular ligament thickened; vertical section 
through head, neck, and upper portion of shaft shows that the 
head is almost in contact with the trochanteric portion of the femur; 
posterior portion of neck shows line of fracture near the head, and 
fractured surfaces in close contact, but movable upon each other; 
anterior portion firmly united by a dense compact callus, the upper 
fragment apparently impacted into the lower; no trace of the bone- 
peg can be found. The perforation in the trochanter major can 
be followed to a distance of about two mm. In this specimen the 
lower fragment appears to have become almost completely absorbed, 
as the upper fragment remains unchanged, and appears to be almost 8 
in direct contact with the trochanteric portion of the femur. Liga- 
mentum teres normal. 
Experiment No. 25.—Adult cat; subcutaneous fracture of neck of 
right femur; direct transfixion of fragments with wire-nail. Animal 
killed eighteen weeks after operation. Fracture within capsule close 
to the head ; fragments in close contact, slightly movable upon each 
other, but united by a very short ligament. Nail had slipped out- 
ward, and projected from the trochanteric surface about one-third 
of an inch, and could be felt as a sharp point immediately under 
the skin. The projecting portion of the nail is invested by a firm, 
dense, fibrous capsule, while the implanted portion is firmly and 
immovably fixed in the bone. Vertical section through the head, 
neck, and trochanteric portion shows that almost the entire neck 
has disappeared by interstitial absorption, the upper fragment being 
almost in contact with the trochanteric portion. The trochanteric 
portion has almost entirely lost its cancellated structure, its interior 
being filled with compact tissue ; this change is conspicuous more 
particularly in that portion traversed by the nail. Capsular liga- 
ment thickened ; ligamentum teres normal. 
Experiment No. 26.—Adult, large Maltese cat; subcutaneous 
fracture of right femoral neck; direct coaptation of fragments with 
wire-nail. Animal killed ten weeks after operation. Neck of femur 
shortened; capsular ligament thickened; ligamentum teres normal; 
vertical section .through the upper portion of the femur shows line 
of fracture within capsule, with impaction of upper fragment into 
lower; fragments movable upon each other, but broken surfaces in 
immediate contact. A new compact layer of bone was formed on 
the outer surface of the compacta in the region of the lesser tro- 
chanter. Nail firmly imbedded in bone, outer extremity on a level 
with compact layer of trochanter major; it is seen to traverse the 
trochanteric portion in a backward direction, entering the cavity of 
the hip-joint, and being in close contact with the posterior surface of 
the femoral neck; its sharp point being on a level with the highest 
point of the head. No inflammation in the hip-joint. During life 
the function of the joint appeared to be perfect. As the point of 
the nail was firmly fixed in the capsular ligament, and impaction had 
taken place during the nailing process, immobility was tolerably 9 
well attained, and there is every reason to believe that bony union 
would ultimately have taken place. 
Experiment No. 27.—Adult Maltese cat; subcutaneous fracture 
of left femoral neck ; fixation of fragments by means of bone-peg 
made from compacta of tibia of an ox. Animal killed fourteen 
weeks after operation. Neck of femur only slightly shortened ; 
capsular ligament nearly normal; ligamentum teres normal; ver- 
tical section shows a slight curve in the upper portion of the neck, 
the head being slightly depressed. Perfect and complete bony 
union, the spongiosa being restored nearly to its normal condition. 
Bone-peg has disappeared completely. 
Experiment No. 28.—Old Maltese cat; subcutaneous fracture of 
left femoral neck ; direct adjustment of fragments by bone-peg. 
Cat died of fatty degeneration of liver and kidneys five weeks after 
operation. Vertical section through upper portion of femur reveals 
line of fracture partly within and partly without the capsule; no 
union; fragments in good apposition; outer extremity of bone-nail 
beneath the compacta, direction of nail downward and inward, the 
point terminating a little beyond the line of fracture in the lower 
portion of the neck. The saw has divided the nail obliquely at the 
juncture of the outer with the middle third. No evidences of in- 
flammation or repair. 
Experiment No. 29.—Adult cat; fractured neck of left femur 
subcutaneously, and used bone-peg for nailing fragments together. 
Animal died of pyaemia twelve days after operation. Hip-joint 
filled with pus; fracture intra-capsular; outer extremity of nail on 
a level with compacta, its point was in the cavity of the joint on a 
level with the foveola of the head. A piece of the posterior portion 
of the head is split off, an accident which occurred either by the 
drill or driving in of the nail. 
Experiment No. 30.—Adult cat; subcutaneous fracture of right 
femoral neck, and direct transfixion of fragments by wire-nail. 
Animal died, four weeks after operation, of pneumonia. No in- 
flammation of joint; fracture intra-capsular; fragments slightly 
separated but well transfixed by nail; no callus. Experiment No. 32.—Young cat; subcutaneous fracture of neck 
of right femur ; direct fixation of fragments with bone-peg. Animal 
killed four months after operation. During life function of the 
joint was perfect; vertical section through the head, neck, and 
upper portion of shaft, shows that the line of fracture must have 
been entirely within the capsule, as no thickening of bone or liga- 
ment could be seen; capsular ligament normal. Accurate measure- 
ment shows only an appreciable shortening of neck ; compact tissue 
within neck more abundant than in the opposite bone. Spongiosa 
restored to nearly its natural perfection. No trace of track of per- 
foration or bone-nail. 
In no case did I feel crepitation more perfectly than in this 
case, and the sudden giving way of the bone the moment it was 
fractured was well marked, and heard by several witnesses, and 
as the post-mortem examination shows a most perfect restora- 
tion of the continuity of the bone, I am convinced that this case 
represents a typical and perfect recovery of union by bone after 
intra-capsular fracture of the neck of the femur. 
In all cases, twenty-one in number, where no direct means of 
fixation were used, there was not the slightest evidence of bony 
union, the best result attained was a short ligamentous band. 
In Experiment No. 21, no retention dressing was applied, and 
the result was equally good, if not better, than in the cases 
where the plaster-of-Paris dressing was used. 
In all of these cases the tendency to shortening was not as 
well marked as in man, while eversion occurred seldom, and 
only to a slight degree. 
The weight of the limb evidently counteracted muscular 
action, while the conditions which produce eversion in man are 
absent in animals. The results obtained by immediate trans- 
fixion of the fragments stand in direct contrast to those treated 
by external fixation. Bony union, or union by short ligament, 
was the rule, non-union the exception. 
These experiments would also tend to prove that aseptic 
ntetallic nails, when implanted subcutaneously into living bone, 
remain firmly in its substance for an indefinite period of time 
without giving rise to suppuration, and from one of the experi- 11 
ments it will be seen that the point of the nail was within the 
cavity of the joint for many weeks without materially interfering 
with the normal function of the joint, or producing more than a 
slight synovitis. 
Iron- and bone-nails, if driven into living bone, produce osteo- 
plastic inflammation, and are, on this account, not only useful in 
the treatment of pseud-arthrosis, but are equally beneficial in 
accelerating the reparative process in recent fractures. Bone- 
nails are completely absorbed, the time required for absorption 
to take place depends upon the vascularity of the tissues, which 
are in immediate contact with the nail. 
According to Gurlt, the time required for bony union to take 
place is proportionate to the diameter of the fractured bone, 
being much shorter in case of slender bones as compared with 
those of greater diameter. 
It appears that the shortest time for the slender neck of the 
femur in cats to unite by bone is at least two months; hence in 
man the time required for bony consolidation of fracture of the 
femoral neck must be at least from one hundred to one hundred 
and twenty days. As in two of the specimens, well-marked im- 
paction occurred during the nailing process, the question arises 
if the same desirable conditions could not be obtained in man by 
using sufficient lateral force at the time direct coaptation is 
attempted; in other w'ords, would it not be prudent to use suffi- 
cient force to produce artificial impaction. 
In nearly all the specimens the upper fragment underwent 
but little change, while the lower fragment always, without 
exception, suffered a diminution in length from osteo-porotic 
inflammation and interstitial absorption. 
Interstitial absorption, as the consequence of inflammatory 
osteo-porosis, takes place to a greater or less extent in every 
case of fracture through the femoral neck, and precedes and 
accompanies the reparative process. In all cases of bony union 
the posterior attachment of the cervical portion of capsular liga- 
ment was displaced outward, an occurrence which can only be 
explained satisfactorily by assuming that during the osteo-porotic 
inflammation, the periosteal investment of the femoral neck is 12 
loosened and transplanted toward the femoral shaft, carrying 
with it the femoral insertion of the capsular ligament. These 
experiments also illustrate the difficulty of transfixing the upper 
fragment in the process of nailing, a circumstance largely due 
to the diminutive size of the bone, the incomplete anaesthesia, 
and the want of fixation of the parts in their relative normal 
positions previous to the operation. 
II. A Case of ’ Bony Union after Impacted Intra-capsular 
Fracture of the Neck 'of the Femur. 
At our last meeting I presented a specimen of bony union 
after an intra-capsular fracture of the neck of the femur, and gave 
a full description of the case and specimen (see page 167). In 
the discussion which followed, it became npt only evident that 
in the opinion of the speakers the specimen was not what I had 
claimed for it, but that such a favorable occurrence was not 
possible, and that a well-authenticated case had never been 
observed. These criticisms induced me to look up the litera- 
ture on the subject with care and impartiality, and to resort to 
experiment to verify my position. I will ask the Fellows to 
examine the specimen once more, and will call their attention 
to a few prominent points in the case. The patient was a 
female, aged seventy-five years, and was under my observa- 
tion at the Milwaukee Hospital. She was in good health at 
the time of the accident, hence there can be no possibility 
that the extensive changes in the neck of the femur were the 
result of senile coxitis or interstitial absorption. The fracture 
was produced by direct violence by a fall upon the greater tro- 
chanter. Fractures of the neck produced in this manner are 
very apt to be impacted. Loss of function was complete imme- 
diately after the injury, and remained so for several months. 
The patient suffered great pain in the groin and the region of 
the trochanter minor, a symptom which is always indicative of 
injury within the capsular ligament. For the purpose of exclud- 
ing asymmetry of the bones, all the long bones of both legs 
were measured separately, and on comparing the measurements the injured limb was found shortened one-half of an inch. The 
limb was strongly everted. Gentle traction had no effect on the 
length of the limb. On comparing the movements of the tro- 
chanter major on both sides by rotating the limbs it was found 
that the neck of the femur on the affected side was perceptibly 
shorter. No crepitation could be felt. As the impaction appeared 
to be firm no treatment was employed, except rest in bed on a 
smooth even mattress, and the limb supported on each side 
with sand-bags. In this position the patient remained for three 
months; at the expiration of this time she was allowed to walk 
on crutches. After the third week the shortening gradually in- 
creased until it reached an inch and a half, when the treatment 
was suspended. The secondary shortening I attributed to in- 
flammatory osteo-porosis and interstitial absorption in the lower 
Fig. i. 
Bony Union after Iutra-capsular Fracture. (Anterior view.) 
a.—Line of Fracture. 
, b.—Capsular Ligament. 14 
fragment. The patient eventually was able to walk quite well 
with the aid of a cane. Two years after the accident she died 
of pneumonia. The post-mortem appearances I will quote from 
the former report:—• 
“The capsule of the joint, especially the tipper portion, was 
thickened and firm, and bridges of fibrous bands connected the 
line of fracture with the anterior portion of the ligament. On the 
anterior surface of the neck the direction of the fracture could be 
clearly traced from below upward, and from within outward, but 
not extending beyond the insertion of the capsular ligament. The 
line of fracture is elevated, and presents a serrated appearance. 
Posteriorly the head of the bone was in close proximity to the 
posterior inter-trochanteric ridge. A slight depression on the 
articular cartilage marked the point of contact with the inner surface 
of the capsular ligament. Impaction had evidently taken place at 
Fig. 2. 
lfony [Jniun after Intra-capsular Fracture. (Posterior view.) 
a.—Capsular Ligament. ' the expense of the posterior compact portion of the neck. A 
portion of Adam’s arch, which had been implanted into the lower 
fragment, could be distinctly seen in the spongiosa, on making a 
vertical section (Figs, i, 2, 3). 
F'g- 3- 
Bony Union after Intra-capsular Fracture. (Vertical section.) 
a —Compact Plate of Bone. 
“A vertical section through the neck, head, and trochanter re- 
vealed a white line of very compact bone traversing the cancellous 
tissue of the neck near the shaft in an oblique direction, correspond- 
ing to the line of fracture on the anterior surface of the neck. The 
anterior half of the specimen has been submitted to the boiling test 
without affecting the union of the fragments, hence there can be no 
doubt as to the union by bone. 16 
“The bone outside of the capsular ligament presents no sign of 
callus or any other evidences of injury or disease.” 
III. Anatomy of the Neck of the Femur. 
The neck of the femur is that portion of the upper extremity 
of the bone located between the head and trochanters. It is a 
continuation of the shaft, and springs from an oblong rhomboidal 
surface from the inner side of the trochanteric region, and is 
directed obliquely upward, inward, and a little forward. Its base 
is limited anteriorly and posteriorly by the inter-trochanteric 
lines; above and behind it reaches the summit of the greater 
trochanter, while below and in front it extends to the upper 
margin of the lesser trochanter. In animals the neck of the 
femur is exceedingly short, and usually set almost at a right 
angle with the shaft. The great length and obliquity of the neck 
is peculiar to man. It is this which gives elasticity, freedom, and 
grace to the motions of the body, but at the same time its great 
length increases the liability to fracture. The decided inclination 
of the neck forward naturally turns the lower limb a little out- 
ward, and constitutes an important determining element in the 
production of posterior impaction and eversion of the limb in 
case of fracture. The length and obliquity of the neck vary at 
different ages and under different circumstances, in harmony 
with the requirements of age or conditions. In children it is 
very oblique, short, and slender, and the bony prominences 
about the hip are not well defined. As old age advances, the 
neck in some instances undergoes remarkable changes in struc- 
ture, contour, and direction ; its obliquity in many instances 
diminishes to such an extent that the head descends below the 
level of the superior border of the greater trochanter, at the same 
time its length is greatly diminished. During adult life, when 
the femur represents the most perfect degree of development 
and maximum power of resistance, the neck forms an obtuse 
angle with the shaft varying in degree from 120° to 1300.1 
1 Fr. Merkel, Betrachtungen uber das os femur. Virchow’s Arcliiv f. Pathol. 
Anat. Band 50, Heft. II. Viewed from the front or from behind, it is seen that the neck 
is widest at its base or trochanteric portion, gradually becoming 
narrower until its most contracted part near the head is reached, 
when it abruptly expands into the corona of the head. The 
posterior surface is smooth for the play of muscles, especially 
the obturator extern us; convex in the vertical and concave in 
the longitudinal direction. 
The anterior surface is rough, flat from above downward, and 
slightly concave from without inward. On account of the direc- 
tion of the neck forward the anterior surface is somewhat shorter 
than the posterior. According to Heppner this difference 
amounts to two and two-and-a-half lines.' 
The under surface is smooth and forms with the inner side of 
the shaft a well-marked curve or arch nearly three inches in 
length, the upper surface is rough and only half the length of 
the lower. 
The thin compact layer of bone on the anterior and upper 
surface is perforated by numerous foramina for the passage of 
nutrient vessels. Seen from above, the neck appears much nar- 
rower than from an anterior or posterior view. The proportion 
of the diameter of the neck from above downwards, and from 
before backwards, at the trochanteric portion is as two to one. 
From the general anatomical description, it becomes apparent 
that the neck of the femur is constructed strictly on purely 
mechanical principles, in order to resist the greatest amount of 
vertical pressure, but this becomes more evident if we study the 
inner architecture of the upper portion of the femur, and more 
particularly the neck. On making a vertical section through 
the head, neck, and upper part of the shaft of the femur, it may 
be seen that the thick compact layer of the shaft, as it approaches 
the trochanteric region, gives off from its inner surface cancelli 
at regular intervals, which build up the interior or spongy tissue 
of the bone. As the spongy tissue is formed at the expense of 
the compact layer, the latter gradually becomes thinner as it 
approaches the head, which it supplies with a delicate layer of 
' C. L. Heppner, Beobachtungen u. Untersuchungen iiber eingekeilte Schenkel- 
halsbrueche. Med. Jahrb. Band XVIII. p. 106. 18 
uniform .thickness. The most important part of the cortical 
layer in relation to fractures of the neck is the lower and inner 
portion, which, from the support it gives to the head and neck 
has been called Adam’s arch, or femoral brace. It is a continua- 
tion of the cortical layer of the inner portion of the shaft, pre- 
serving its thickness and strength to a level with the upper 
margin of the trochanter minor, where it is gradually broken 
up into spongy tissue, until at the corona it is lost in the thin 
cortical layer surrounding the head. The trochanter major is 
surrounded by a thin layer of compact tissue. Transverse sec- 
tions made through the neck at different depths show that while 
the anterior and posterior layers are of the same thickness in the 
upper part of the neck, the posterior wall gradually loses in 
thickness, until near the lower surface it is reduced to the thin- 
ness of paper, while the anterior wall becomes of great thickness 
and strength.1 The direction of the neck, the concavity of the 
posterior surface, and the thinness of the posterior compact wall 
as compared with the anterior, afford abundant and satisfactory 
explanations concerning the frequency of posterior impaction in 
fractures of the neck, and outward rotation of the limb in the 
non-impacted form. 
Of great interest to the surgeon is the arrangement of the 
cancelli of the spongy tissue in the upper part of the femur. It 
is true that some of the peculiarities of the structure of the 
spongiosa in this locality were known to surgeons for a long 
time, still the credit is due to H. Meyer of having first, in 1867, 
called attention to the regularity of its construction, and out of 
this deduced distinct and positive laws governing its mechanical 
construction.2 
He describes three distinct systems of cancelli which traverse 
the neck in different directions. The first begins on a level 
with the lesser trochanter, and reaches in parallel curves the 
lower segment of the head of the femur. The second system 
1 H. J. Bigelow, M.D., The True Neck of the Femur, its Structure and Patho- 
logy. Boston Med. and Surg. Journ., Jan. 7, 1875. 
2 H. Meyer, die Architectur der Spongiosa, Archiv f. Anatomie, von Reichert 
und Du Bois-Reymond, 1867, p. 624. commences on the opposite side on the same level, and traverses 
towards the outer side of the trochanter major, and in such a 
way that the points of intersection of the curves form a series of 
arches. The third system springs from the commencement of 
Fig. 4. 
Meyer’s Pressure and Fraction Curves. (Meyer.) 
the femoral brace, and extends to the upper and inner circum- 
ference of the head of the femur, is the strongest, and transfers 
the weight of the body at once upon the femoral brace on the 
inner and lower side of the neck. According to Meyer’s descrip- 
tion and drawings, a triangle exists between the curves of the 
first and second systems, the apex of which corresponds to the 
base of the neck. This triangular space is occupied by an irre- 
gular network of cancellated tissue, or by curves from the second 
or third system. This space, however, does not exist in all 
specimens, but is usually present in the bones of aged people, 
where the spongiosa has undergone rarefaction. 
In specimens from adults the interior of the bone is filled with 20 
arches from the inner and outer compact layer/or some distance 
below the point indicated by Meyer. In another paper1 Meyer 
dwells at length on the mechanical function of these curves, 
which he calls pressure and traction curves. It seems as though 
the compact layer is gradually lost in the spongiosa. This is 
well seen in a horizontal section through the long bones, more 
especially of the lower extremity. The lamellae are so arranged 
as to correspond to pressure and traction curves, a construction 
by which the least possible amount of bone tissue can resist the 
greatest amount of force. The spaces between these curves are 
filled with loose cancellated tissue, which does not add materially 
to the strength of the bone, but serves more the purpose of 
forming a framework for the medullary tissue. The spongiosa 
appears, therefore, as the primary typical structure of bone, and 
the compact tissue as an accidental modification of the spongiosa 
constructed by local concentration of resistance curves. 
Heppner divides the cancelli of the spongiosa into two strong 
and two less dense portions. Among the first he includes the 
fibres connecting the neck of the femur with the femoral brace, 
and from the other side extending to the base of the femoral 
neck. To the second portion belong the fibres in the space be- 
tween the first two portions and those of the trochanter major. 
About the same time that Meyer was investigating this sub- 
ject, Dr. J. H. Packard published a very interesting paper on 
“ Fractures of the Neck of the Femur,”2 in which he calls atten- 
tion to the architecture of the interior of the neck of the femur, 
and accurately describes and delineates the arching fibres pass- 
ing from the femoral brace to the upper segment of the head of 
the femur. He says: “A careful examination of vertical sections 
of the head and neck of the femur shows, as several writers have 
pointed out, that a number of the cancellous columns, beginning at 
the upper end of the inner wall of the shaft of the bone, diverge 
upward to the concavity of the thin articular lamella of compact 
substances of the head, so as to receive the weight of the body 
1 Die Statik u. Mechanik des menschliclien Knochengerustes, 1873. 
2 O11 some Points relating to Fractures of the Neck of the Femur, by John H. 
Packard, M.D., Amer. Journ. of Med. Sciences, Oct. 1867, p. 379. upon their extremities. Another series of columns are found to 
run outward from the same point, and from a line running up- 
ward from it, to meet other columns running up inward from 
the outer wall of the shaft; and these two sets of columns form 
a series of groined arches culminating at the upper wall of the 
neck of the bone, a little to the inner side of the greater tro- 
chanter. 
“ By this arrangement the shifting of the weight towards the 
outer or upper portion of the head of the bone is provided for, 
the pressure coming in greater degree on the outer wall of the 
shaft, the inner wall, however, receiving its share through the 
inner columns of the arches. The remainder of the cancelli run 
in various directions, not capriciously or at random, but so as to 
afford in the aggregate a very strong support to the solid wall 
of the bone. Sometimes it may be clearly seen that they are 
so placed as to run as nearly as possible in the line of muscular 
traction; an arrangement, the mechanical advantage of which 
must be at once evident.” 
In 1870, Julius Wolff1 published the result of his studies of 
the spongiosa, which he considered as standing in the closest 
relation to the static and dynamic forces of the bones. In his 
researches he made use of the mathematical calculations of Cul- 
mann, showing that interior braces intended to aid supporting a 
weight upon the end of a cylinder, curved like the femur, or 
like a crane or derrick, should be placed, in order to act to the 
advantage, precisely where the trabeculae of the spongy tissue of 
this bone actually exist. 
“ Nature,” says Wolff, “ has built the spongy bones as an 
engineer would construct a truss bridge, mathematically.” 
A compact plate of bone (Schenkelsporn, septum) is usually 
found imbedded in the cancellous tissue of the neck, and to it 
an important function has been assigned by Merkel and Bigelow. 
Merkel2 described a structure in the interior of the neck of the 
femur which he called “Schenkelsporn.” It consists of a wedge- 
1 Julius Wolff, Ueber die innere Architectur der Knochen und ihre Bedeutung 
fur die Frage von Knoclienwachsthum. Arcliiv f. Palh. Anat. u. Phys. Band 50. 
2 Der Schenkelsporn. Centralbl. f. d. Med. Wissensch. No. 27, 1873. 22 
shaped solid projection of the cortical layer, which springs from 
its inner surface on a level with the trochanter minor towards 
the median line, and penetrates into the interior of the spongiosa 
to the depth of i cm., and is lost immediately under the head 
of the femur on the anterior surface of the neck. It is not found 
in the foetus, is fully developed in the adult, and again disappears 
completely during old age. 
Bigelow, after describing the necessary manipulations for ex- 
posing it, says : “ The septum will then be distinctly seen, as a 
thin dense plate of bone continuous with the back of the neck, 
and reinforcing it, plunging beneath the inter-trochanteric ridge 
in an endeavor to reach the opposite and outer side of the shaft. 
At its lower extremity it curves a little forward, so as to take its 
origin, when on a level with, from the centre, instead of the back, 
of the cylindrical cavity; a disposition easily seen in a transverse 
section of the shaft just above the trochanter minor. Or it may 
be said that the posterior wall of the neck forks before reaching 
the inter-trochanteric line, one layer being seen upon the surface, 
while the other dives beneath the inter-trochanteric ridge in a 
vain attempt to reach the outer wall of the shaft. If these views 
be correct, the inter-trochanteric ridge is simply a buttress erected 
for the insertion of muscles upon and over the true neck, by the 
impaction of which it is in fact often split off and detached in a 
mass; the force exerted by the true neck, though slight, being 
nevertheless an effort to resist such impaction.” 
The importance of this septum, when in a perfect state, be- 
comes evident as the same author continues: “ The true 
neck is often, at best, but an ineffectual attempt to bridge the 
interval beneath the trochanters, as seen in Merkel’s figures, 
while, in the latter half of life, it degenerates into papery plates, 
radiating downward from a point near the lesser trochanter. 
Weakened in this way, both by its own tenuity and by its own 
slender union to the trochanteric ridge, the true neck has great 
practical interest for the surgeon. Even the adult femur is gene- 
rally defective in construction at this point; and here occurs the 
most common form of fracture, namely, the posterior impacted 
fracture of the base of the neck.” 23 
Bigelow looks upon the septum as a continuation of the 
“ True Neck,” while Merkel has described the same structure as 
a projection of a portion of the posterior and inner compact wall 
into the spongiosa; hence, he has called it Calcar femoral or 
Schenkelsporn. 
The relation of the septum to the trochanter minor is such as 
to isolate its spongy tissue, and on that account Wolff alludes 
to it as “the compact tissue upon which the trochanter minor 
rests.” 
The importance of this structure in preventing and determining 
the location of fractures has, undoubtedly, been over-estimated. 
It is absent in children, and is subject to the same degenerative 
changes as the remaining portions of the cortical layer and the 
spongiosa. 
In conclusion it may be stated that the spongiosa of the upper 
extremity of the femur is derived directly from, and at the ex- 
pense of, the compact.layer, that it is constructed upon a definite 
plan in a series of arches arranged in such a manner as to resist 
the greatest amount of vertical pressure according to well-estab- 
lished architectural laws ; at the same time by expanding the 
bone it furnishes a more extensive surface for muscular attach- 
ments, and imparts to it a greater degree of elasticity. 
The exact point of insertion of the capsular ligament into 
the femoral neck has been a frequent source of dispute among 
anatomists and surgeons to decide the location of fractures in 
this locality. Great discrepancies on this point may be found 
in our anatomical text-books. 
To Dr. Geo. K. Smith much credit is due for the light he has 
thrown on this subject.1 By injecting the capsule of the hip- 
joint with air or plaster of Paris he was enabled to make very 
careful dissections, and by measuring accurately the distance 
between the corona of the head and the insertion of the liga- 
ment, and from this point to the inter-trochanteric lines, he 
could locate the exact point of insertion. Alter preparing and 
1 The Insertion of the Capsular Ligament of the Hip-joint, and its Relation to 
Intra capsular Fracture. New York, 1862. 24 
measuring sixty-one specimens in this manner he came to the 
following important conclusions:—■ 
“ ist. That scarcely any two specimens of the normal capsule, 
taken from different subjects, are alike in their insertion into the 
neck of the bone; consequently no definite description of its 
insertion can be given. 
“2d. That the normal capsules of the opposite femurs of the 
same subject are alike in their insertion. Having measured 
twenty-four pairs I have yet to see a single variation from this 
rule. Moreover, it is just what we must expect to find in obedi- 
ence to that law of symmetrical conformation which pervades 
the animal economy.” 
Morris1 locates the femoral insertion of the capsular ligament as 
follows: “At the femur the capsule is fixed to the anterior portion 
of the upper border of the great trochanter, and to the tubercle 
of the femur close to the insertion of the gluteus minimus and the 
origin of the vastus externus, with slips from each of which it is 
blended. Thence it runs along the upper and outer part of the 
anterior inter-trochanteric line, but it soon gets below it, and at 
the inner border of the femur is on the level of the lower surface 
of the small trochanter. It is then inclined upward and back- 
ward along an oblique line, two-thirds of an inch in front of the 
small trochanter, to reach the back of the neck; here it is 
attached above the posterior inter-trochanteric line at a distance 
varying from half an inch, at the lower and upper ends, to over 
two-thirds of an inch opposite the middle of that line. 
After laying open the capsule it is seen that some of the deeper 
fibres of this ligament are reflected upward along the neck, so 
as to be attached to the femur much nearer its head. These 
reflected fibres occur at three places, one corresponding in posi- 
tion to the middle of the ilio-femoral ligament, another to the- 
pectineo-femoral, and the third on the upper and back part of 
the neck. A thin fold of synovial membrane stretches between 
the reflected and the unreflected fibres of the capsule.” 
These strong bands of reflected fibres have been called reti- 
1 The Anatomy of the Joints of Man. Philadelphia, 1879, P- 322- 25 
nacula by Weitbrecht. Packard, in his paper previously alluded 
to, has called attention to the existence of pockets, usually three 
in number, between the reflected fibres. 
Riidinger,1 in speaking of the fibrous capsule of the hip-joint, 
says : “ Its attachment to the lateral portions of the neck is in 
such a manner, that anteriorly it reaches the anterior inter-tro- 
chanteric line; posteriorly, on the other hand, it reaches only as 
far as the middle of the neck.” 
Practically, we can safely say, that the anterior portion of the 
capsular ligament, as a rule, is inserted into the anterior inter- 
trochanteric line, reaching its lowest level on the lower surface 
of the lesser trochanter, while the posterior portion is usually 
inserted at or near the middle of the femoral neck. A close 
inspection of the posterior segment of the capsular ligament will 
usually reveal the existence of more or less fibres running from 
the insertion of the ligament proper towards the inter-trochan- 
teric ridge. For our purpose it is also proper to mention that 
the largest nutrient vessels to the neck pass beneath the reflected 
portions of the ligament. 
The ligamentum teres will receive mention only as far as it 
serves as a carrier of bloodvessels to the head of the femur. In 
infants it contains a number of bloodvessels which enter the 
head of the femur at the point of insertion of the ligament in 
the fovea. That the blood supply from this source is not essen- 
tial for the growth and development of the upper extremity of 
the thigh-bone, is apparent from the fact that it is wanting in 
many animals, as the Bradypus, Echidna, Cholaepus, elephant, 
rhinoceros, and others. According to Savory, two hip-joints 
were examined at the St. Bartholomew’s Hospital, where 110 
trace of this ligament could be found, but the head of the femur 
presented a depression, not covered with cartilage, at the usual 
point of insertion of this ligament. There can be no doubt that 
in infants the vessels of this ligament penetrate the bone and 
furnish material for ossification to the epiphysis of the femur. 
After the growth of the bone has been completed, the vessels 
1 Topographisch-chirurgische Anatomie des Menschen, Stuttgart, 1873, p. 142. 26 
diminish in size with advancing age, and disappear entirely at 
their point of entrance into the bone in a certain percentage of 
cases. Hyrtl has asserted that the vessels from the capsule 
which pass along the ligamentum teres to the surface of the 
head do not communicate with the vessels of the medullary 
substance, but return in the form of loops. 
In one-third of the specimens examined by Welcker,1 no fora- 
mina nutritia could be found in the fovea capitis; hence, he 
concluded that the round ligament is not destined to act as a 
carrier for nutrient vessels. Sappey, on the other hand, attri- 
butes to the ligamentum teres the function of protecting the 
vessels and nerves that nourish the head of the femur. 
Langer2 has made careful injections of the vessels of the hip- 
joint, and has observed that not all of the vessels of the liga- 
mentum teres return in loops on reaching the bone, as described 
by Hyrtl, but that some of them penetrate into the spongiosa of 
the head of the femur. I have examined a number of specimens 
with reference to this point, and have been able to detect with 
the naked eye nutrient foramina in the fovea capitis in more 
than one-half of them. When the foramina were of considerable 
size, I have been able to trace them for some distance into the 
bone. In such specimens there can be no doubt as to the 
presence of bloodvessels from the round ligament in the interior 
of the spongy tissue of the head of the femur, and in this the 
vessels from the round ligament enter into anastomosis with 
vessels from the bone, and render material assistance in main- 
taining the circulation in the head of the femur. In some speci- 
mens the foramina may be so small as to elude detection with 
the naked eye, but may nevertheless admit small vessels which 
may be of some importance in furnishing material for nutrition 
in the bone. The absence or destruction of the vessels of the 
ligamentum teres may not interfere with the growth and deve- 
lopment of the bone as long as the normal supply through the 
neck of the femur is not impaired; but in case of fracture of the 
1 Virchow u. Hirsch’s Jahresbericht, 1875, vol. i. p. 9. 
2 Riidinger, op. cit., p. 144. 27 
neck they are of great importance, and assume a compensating 
function in harmony with similar processes in other parts of the 
body. Rudimentary small vessels may assume vicarious action 
for the purpose of answering an increased demand, and thus 
supply a sufficient amount of blood, not only for maintaining 
the vitality of the upper fragment, but likewise to furnish mate- 
rial for repair. 
IV. Classification of Fractures of the Neck of the Femur. 
Since the teachings of Sir Astley Cooper on this subject, it has 
been customary to classify fractures of the cervix femoris accord- 
ing to the relative position the capsular ligament bears to the seat 
of fracture, into the intra-capsular and extra-capsular fractures, 
to which has been added a third variety, fractures partly within 
and partly without the capsular ligament. The mixed variety 
has given rise to a good deal oficonfusion, as some have included 
it among intra-capsular fractures, while others class it with extra- 
capsular fractures. Since it has been ascertained that many of 
the fractures of the neck of the femur are impacted, those who 
have placed great prognostic and therapeutic importance upon 
this condition, have made impaction the basis for a new classifi- 
cation, and speak of impacted and non-impacted fractures of the 
neck of the femur. Among those who favored this classification 
may be enumerated Cloquet, Josselin, Duplay, Bigelow, Bryant, 
Hueter, and Lossen. 
The distinction into impacted and non-impacted fractures is 
important in a clinical, diagnostic, prognostic, and therapeutic 
sense, while the division into intra-capsular and extra-capsular 
fractures has a very important pathological significance. Frac- 
tures of the neck of the femur with impaction will unite by bony 
union irrespective of the situation of the capsular ligament, pro- 
vided the impaction is maintained for a sufficient length of time. 
Fractures, impacted or non-impacted, outside of the capsular 
ligament will unite in the same manner as fractures in any other 
locality, if the fractured ends are kept in apposition and immo- 
bilized for the necessary length of time. Fractures at the narrow 28 
part of the neck, and entirely within the capsule, can only unite 
by bone, if the penetration is such as to secure apposition for a 
number of weeks, or if the same degree of apposition and im- 
mobilization is affected by surgical procedures. The frequency 
with which impaction occurs in the femoral neck, and the im- 
portant part it performs in the reparative process, entitle it to a 
permanent place as a basis for classification. 
When we are able to diagnosticate the existence of an impacted 
fracture of the neck of the femur all efforts to locate the exact 
seat of fracture are perfectly useless, as it could have no influence 
*in selecting therapeutic measures, and might eventuate dis- 
astrously by abolishing the most favorable conditions for a 
fortunate issue. If we adopt the proposition, that fractures of 
the femoral neck with penetration can, and often do, unite by 
bone, irrespective of their relative position to the capsular liga- 
ment, then the distinction between fractures within and without 
the capsular ligament can only find a practical application in the 
examination of specimens to prove or disprove the correctness 
of the proposition. This holds the more true as, in vivo, all 
known diagnostic means have proved unreliable in locating the 
exact point of fracture. The sooner the profession can be con- 
vinced that intra-capsular fractures also unite by bony union 
under certain favorable conditions, the better will it be to aban- 
don the old classification, which has proved to be incorrect ana- 
tomically, and unwarranted by pathological facts. Practically, 
then, it is always important to ascertain the presence of impac- 
tion, and not to interfere with it when found; theoretically, and 
for the purpose of adopting therapeutic measures, it is desirable 
in non-impacted fractures to locate as nearly as possible the seat 
of fracture without inflicting unnecessary violence. 
In the light of recent anatomical investigation and pathological 
research, and for the purpose of avoiding unnecessary confusion, 
it would be advisable to limit the term intra-capsular to all frac- 
tures that do not extend beyond the insertion of the capsular 
ligament, and include among the extra-capsular fractures the so- 
called mixed and purely extra-capsular fractures. Remembering 
the attachment of the anterior portion of the capsular ligament 29 
we would naturally infer that purely extra-capsular fractures, 
without further injury to the shaft of the femur, if possible at all, 
must be exceedingly rare. The greatest number of extra-cap- 
sular fractures, as described by our text-books, have belonged to 
the mixed variety; intra-capsular in front, extra-capsular behind. 
In speaking of extra-capsular fractures, Ur. R. W. Smith says : 
“ All extra-capsular fractures are, in the first instance, also 
impacted fractures, and all impacted fractures are necessarily 
accompanied by a fracture traversing some part of the trochan- 
teric region. I have omitted no opportunity of investigating this 
point, and have now examined here and elsewhere upwards of 
one hundred specimens of the extra-capsular fracture, and have 
found in all, without a single exception, a second fracture travers- 
ing some portion of the inter-trochanteric space.” 
In commenting upon the paper of Dr. G. K. Smith,1 Dr. Post 
suggested to substitute the terms intra-cervical and extra-cervical 
for intra-capsular and extra-capsular, the latter designation to 
indicate an impacted fracture at the base of the neck with more 
or less injury of the femoral shaft. As under this classification 
intra-cervical fractures would include intra-capsular and mixed 
fractures, and the term extra-cervical would imply the existence 
of a fracture rather beyond than in the cervix itself, these terms 
do not convey sufficiently accurate anatomico-pathological pre- 
cision to recommend themselves for general adoption, although 
they are full of practical significance. Inasmuch as the principal 
object in writing this paper has been to prove that bony union 
after intra-capsular fractures can take place, the terms intra-cap- 
sular and extra-capsular have been retained, but will be applied 
in the sense previously suggested. 
V. Relative Number of Intra- and Extra-capsular Fractures. 
The inability to accurately locate the fracture during life, the 
existing confusion and uncertainty as to the meaning and appli- 
cation of the terms intra- and extra-capsular in the description 
1 Op. cit., p. 35. of specimens have rendered the statistics on this point unsatis- 
factory and unreliable. Although the cervix femoris may be 
broken at any point between the head of the femur and the 
inter-trochanteric ridges, there are certain points where it is 
more liable to give way. The exact location of the fracture is 
determined to a great extent by the seat and degree of senile 
osteo-porosis, and the direction of the fracturing force. Senile 
osteo-porosis,aswe have seen, begins in the spongiosa and reaches 
its maximum degree soonest at the contracted portion of the neck; 
hence fracture nearest the head is most likely to take place in 
decrepit old people. Fractures at this point are exceedingly 
rare in persons less than fifty years of age; only a very few well- 
authenticated cases being on record. Rodet, in a series of ex- 
periments on the femur and on plaster-of-Paris casts of the upper 
extremity of this bone, has demonstrated the important fact, that 
the situation and direction of a fracture of the neck of the femur 
may be predicted to almost a certainty by a knowledge of the 
direction in which the force was applied. Thus, a force acting 
vertically will produce an oblique intra-capsular fracture; a force 
acting from before backward a transverse intra-capsular fracture; 
one from behind forward a fracture partly within and partly 
without the capsule; and a force applied transversely a fracture 
entirely without the capsule. Clinical evidence has repeatedly 
verified the correctness of these observations. The traction 
fractures described by Linhart, Riedinger, and Hueter, from the 
powerful traction of the ilio-femoral ligament, when the thigh is 
over-extended and adducted, invariably fall outside of the limits 
of the capsule. 
Bonnet believed that the line of fracture was almost always 
without the capsule, and Nelaton contended that in the great 
majority of cases he made the same observation; while many 
authors, equally competent, among them Sir Astley Cooper, 
Ashhurst, and Druitt, claim that intra-capsular fracture occurs 
more frequently in persons above fifty years of age. Of twelve 
specimens examined in the museum of St. Bartholomew’s Hos- 
pital by Stanley, six were supposed to be intra-capsular, and six 
extra-capsular. 31 
Malgaigne1 examined one hundred and three specimens from 
different sources to determine the relative frequency of these 
fractures, and found that sixty-one belonged to the intra-capsular 
to forty-two of the extra-capsular variety. 
M. Mercier, at Bicetre, found in eight autopsies three intra- 
capsular to four extra-capsular fractures, and one below the tro- 
chanters; while Malgaigne himself, in the same hospital, found 
in eight other autopsies one fracture below the trochanters, five 
within the capsule, and only two outside of it. Stimson2 made 
a post-mortem examination in six cases, and ascertained that in 
two of them the fracture was purely intra-capsular, and in four 
the fracture was at the junction of the neck and shaft. 
Heppner3 gives a description of five cases of impacted fractures 
of the neck of the femur, of which number three were extra- 
capsular and two intra-capsular. Of twenty-three specimens of 
fracture of the neck of the femur, in the Museums of the College 
of Physicians, Philadelphia, and the University of Pennsylvania, 
examined by Agnew,4 ten were within and thirteen without the 
capsular ligament. 
Mussey’s collection contains twelve examples of fracture of 
the femur without the capsule, and ten within. The above 
statistics embrace one hundred and eighty-five post-mortem 
specimens, of which number ninety-nine were fractures within, 
and eighty-six without the capsular ligament; figures which 
would tend to prove that intra-capsular fractures are more fre- 
quent than fractures without the capsule. It must, however, be 
remembered that many of these specimens were collected for a 
special purpose, and on that account the numbers do not repre- 
sent the true proportion as it actually exists. If the statistics 
obtained by the examination of post-mortem specimens are not 
reliable in ascertaining the relative frequency with which these 
fractures occur, the information derived from clinical observation 
1 Treatise on Fractures. Translated by J. H. Packard, M.D., 1859, p. 533. 
2 A Treatise on Fractures, 1883, p. 491. 
3 Beobachtungen u. Untersuchungen iiber die Schenkelhalsbrueche. Oestr. 
Med. Jahrb. Heft. 3 u. 4, 1870. 
4 Principles and Practice of Surgery, 1878, vol. i. p. 931. 32 
must prove still less satisfactory in deciding this question, as the 
symptoms during life are not sufficiently well marked to enable 
the surgeon to locate with certainty the exact seat of fracture. * 
Billroth1 refers to twenty-seven cases of fracture of the neck 
of the femur, of which number thirteen were diagnosticated as 
intra-capsular, and fourteen extra-capsular. In Dr. Hyde’s table 
of three hundred and twenty-one'cases of fracture of the femur, 
we find that the neck was involved thirty-one times, these were 
supposed to be located fourteen times within and seventeen 
times without the capsule. 
Hamilton2 has recorded eighty-four cases of fracture of the 
femoral neck from his own personal observation ; of these, forty 
were believed to be without the capsule, and thirty were believed 
to be within, the remainder were undetermined. These statistics 
furnish one hundred and twenty-eight cases with fifty-seven intra- 
capsular, and seventy-one extra-capsular fractures, a majority in 
favor of the extra-capsular variety. 
Combining the figures from the museum specimens and those 
taken from bedside observation we obtain three hundred and 
thirteen cases of fracture of the neck of the femur, of which 
number one hundred and fifty-six were supposed to be located 
within, and one hundred and fifty-seven without the capsular 
ligament. 
VI. Incomplete Fractures of the Neck of the Femur. 
The structure of the neck of the femur in the aged furnishes con- 
ditions unusually favorable for the occurrence of partial or incom- 
plete fracture. Although this form of fracture has received but 
little attention on the part of surgical writers, receiving at the best 
only brief mention, it would appear from the cases reported dur- 
ing the last few years, that the accident is not as rare as has been 
supposed. Colies3 was the first to call attention to this variety 
of fractures as it occurs in the neck of the feriiur, and described 
1 Chirurgische Klinik. Wien, 1879. 
2 A Practical Treatise on Fractures and Dislocations, 1880, p. 393. 
3 Dublin Hospital Reports, vol. ii. 33 
three cases. Dr. J. B. S. Jackson, of Boston, described a case 
of incomplete fracture (fissure), the line of fracture extending 
from the junction of the upper border of the neck with the head 
downward to within a quarter of an inch of the inferior and 
internal wall of the bone. Gurlt1 mentions three cases. In 
Tournel’s case the infraction took place at the upper portion of 
the base of the neck, the line of fracture running from the digital 
fossa downward. 
. In the case reported by P. Wilkinson King, the line of frac- 
ture was near the head of the femur, a bridge of compact tissue 
on the anterior and upper portion of the neck, one-third the 
circumference of the compacta remained intact. The third 
described he found in the Pathological Museum in Giessen. 
The transverse infraction affects the entire posterior half of the 
femoral neck about its middle, while the anterior wall is not 
affected. The margins of the fractured surfaces are in immediate 
contact. Koenig2 described two specimens. In the first speci- 
men the line of fracture occurred on the upper and posterior 
surface of the neck, near the head, with impaction of the cer- 
vical portion into the head, while the compact tissue on the 
anterior and inferior surface remained entire. In the second 
specimen, the line of infraction took place at the lower surface 
of the neck, at the most constricted portion, with penetration of 
the apex of Adams’s arch into the interior of the head, while the 
upper portion of the neck had yielded without being broken. 
(Figs. 5 and 6.) These two varieties Koenig considers as repre- 
senting typical forms of this fracture, the mechanism of their 
production being the same as in complete fractures of the neck. 
In the first variety from the direction of the impaction the limb 
is rotated outward, while in the second form the foot remains in 
its natural position but the limb is shortened in proportion to the 
extent of the impaction. Koenig is of the opinion that many of 
the cases of complete recovery after supposed intra-capsular frac- 
tures, were cases of incomplete fracture with impaction. At the 
1 Knochenbrueche, vol. i. p. 31. 
'l Verhandlungen der Deutschen Gesellsehaft f. Chirurgie, 1877, p. 131. 34 
same meeting, Billroth reported two cases where he made the 
diagnosis of incomplete fracture during life, in both instances 
recovery was imperfect. 
Fig- 5- 
Fig. 6. 
Partial Fracture of Neck of Femur. (Koenig.) 
Incomplete fractures of the neck of the femur, as well as of 
other bones, consist of a loss of continuity of a certain number 
of cancelli, forming the substance of bone. It may exist in 
every degree from a fracture almost complete to one in which 
the number of severed cancelli is so small as to elude detection 
by the naked eye. The location and direction of the line of 
infraction, as in complete fractures, must necessarily vary accord- 
ing to the direction in which the force is applied which produces 
the fracture. Stimson1 says : “ The line of fracture is transverse 
and upon the concave side, and is produced by crushing, not by 
overbending.” Incomplete fractures are repaired by the forma- 
tion of intermediate callus between the fractured surfaces which 
restores the continuity of the bone. The unbroken portion of 
the bone and periosteum serve as a perfect splint, which secures 
complete rest and apposition until the injury is repaired. The de- 
1 A Treatise on Fractures, 1883,p 41. 35 
formity attending this accident is necessarily always very slight, 
and as the symptoms at the same time are not pronounced, the 
diagnosis must always remain uncertain. The cases are most 
likely to be mistaken for contusion of the hip; hence, we should 
always examine the severer injuries about the hip with unusual 
care, and if any doubt exists, give the patient the benefit of such 
doubt, and treat the case as one of incomplete or complete frac- 
ture with impaction. 
VII. Impacted Fractures of the Neck of the Femur. 
Impaction, penetration, implantation, and incuneation, are 
synonymous terms, which are used to describe a fracture when 
one fractured end is driven into the other, an occurrence which 
secures perfect coaptation and fixation. In some instances im- 
paction is mutual. Impaction may be complete or incomplete, 
according to the tissue-structure at the seat of the fracture, or 
the direction and intensity of the fracturing force. Impacted 
fractures are most frequently met with in the spongy portions of 
the long bones, and in persons suffering from osteo-porosis from 
any cause. These fractures have only quite recently become 
the object of special investigation, and are at the present time 
receiving the attention their importance merits. 
Robert was the first to give a good description of impacted 
fracture of the neck of the femur and explain its mechanism. 
He specified the following conditions which must be present for 
penetration to take place. In the first place the penetrating 
bone must have a conical shape, and must be placed opposite a 
spongy section of bone, and must have been broken off close 
to the insertion of the same. The impacting force must be 
applied in the direction of the long axis of the incuneated bone. 
All these conditions are presented in fractures through the neck 
of the femur. Adams regarded the inner and lower compact 
tissue of the neck of the femur as the principal element of im- 
paction ; the direction of the fracture through the neck being 
oblique from above downward fractures the arch in such a way 
that the apex, sharp and pointed, is placed opposite the loosely 36 
cancellated tissue of the shaft into which it is driven by the same 
force which fractured the bone. 
Streubel looked upon senile osteo-porosis as the main cause 
of impaction. It is necessary, however, that the compacta of 
the fractured neck retains sufficient firmness to penetrate the 
bone without being comminuted. Some authors assert that 
impaction follows fracture in such a way that the neck of the 
femur gives way to indirect violence from a fall upon the foot 
or knee, the impaction following by the patient falling upon 
the trochanter. Heppner assumes that the relation existing be- 
tween the neck of the femur and the trochanteric portion of the 
femur is the cause of impaction, and takes into special consider- 
ation the spongiosa in which he distinguishes two distinct layers, 
of which the one possesses a greater degree of density than the 
other. He believes fracture at the base of the neck with impac- 
tion is always the result of force applied to the trochanter major, 
which expends itself at the origin of the femoral brace, and 
fractures the entire base of the cervix. Aside from the diminu- 
tion in the obliquity of the cervix, and the presence of senile 
osteo-porosis, he finds another cause for this fracture in the 
general atrophy of the aged, rendering the trochanter major 
more prominent and thus more directly exposed to external 
violence. 
This last assertion, however, is not in accord with experience, 
as corpulent aged females furnish the largest number of fractures 
of the femoral neck. Streubel made some experiments on 
cadavers to determine the seat of fracture on the application 
of direct and indirect violence. To test the effect of violence 
applied in the axis of the femur, he amputated the thigh and 
applied the force directly to the sawed surface of the femur, and 
succeeded only in one instance in producing an intra-capsular 
fracture. By applying the force to the trochanter major he pro- 
duced one extra-capsular impacted fracture, while in all other 
cases the trochanter major was fractured. Heppner repeated 
these experiments with the same results. He then reversed the 
direction of the force. Taking a femur, stripped of its soft parts, 
and resting the outer surface of the trochanter major upon a 37 
table, he struck the head of the femur with an axe, and produced 
in every instance a fracture of the neck resembling an impacted 
fracture. He repeated the experiment thirty times, and in five 
of the cases the impaction was typical. From these experiments 
he has drawn the deduction, that the fracture is produced by 
contre-coup, whether the force is applied to the trochanter major 
or through the axis of the femur. 
In regard to impaction of intra-capsular fractures he could 
find nothing in the literature on the subject of fractures of. the 
femoral neck. Vollemier speaks of them at length, but only for 
the purpose of denying their occurrence. But, inasmuch, as he 
relates having seen several specimens where the end of Adams’s 
arch was found to terminate in the interior of the spongy portion 
of the head of the femur, he contradicts himself, as the descrip- 
tion corresponds with impaction of the lower wall of the femoral 
arch into the head. The question at issue is not the degree of 
impaction, but whether it can secure mutual fixation of the frag- 
ments. In most cases only the lower edge of the outer fragment 
is impacted, but the contrary may take place, as is evident from 
the description given by Koenig under the head of partial frac- 
tures. 
For one of the best contributions to our knowledge of impacted 
fractures of the neck of the femur we are indebted to Riedinger.1 
He has studied this subject by way of experiments and examina- 
tion of museum specimens. In speaking of intra-capsular frac- 
tures, he says that, as a rule, the lower and more particularly 
the posterior wall of the lower fragment is driven into the spon- 
giosa of the head. As a necessary consequence of this form of 
impaction, the head of the femur is depressed and inclines back- 
ward sometimes to such an extent as to come in contact with 
the posterior inter-trochanteric line. The cortical portion of the 
lower fragment can often be traced into the interior of the head 
to a distance of two centimetres. At the anterior line of fracture 
the denticulated margins retain such a firm grasp as to add 
materially to the firmness of the impaction. At the base of the 
1 Studien iiber Grand and Einkeilung der Sclienkelhalsbraeche, Wiirtzburg, 
1874. neck of the femur the conditions for impaction are most favora- 
ble. If sufficient force is applied over the trochanter major, the 
neck fractures in such a way that the femoral brace is detached 
near its origin, and constitutes a sharp projection, which, when 
slightly dislocated, is placed vis-a-vis to the spongy tissue of the 
outer fragment, and is implanted into the same by the fracturing 
force. The upper portion of the inner fragment, although not 
possessed of an analogous dense structure as the femoral brace, 
follows in the penetrating process the more readily as the whole 
inner fragment is wedge-shaped. The spongiosa between the 
cortical layers forms a somewhat sharp projection. Impaction 
of the base of the neck is carried to its fullest extent in case 
the fracturing force is sufficient to fracture also the trochanteric 
portion of the femur. In such instances the apex of the inner 
fragment splits the shaft of the femur sometimes into a number 
of fragments, and presents itself on the outer surface of the bone 
beneath the soft parts. 
Mr. Bryant1 has published a table of fourteen cases of impacted 
fracture of the neck of the femur, and from an analytical study 
of these cases he draws the following conclusions:— 
“ i. That in all the cases the injury to the hip-joint was com- 
municated through the great trochanter. 
“2. That, as a result of the injury, there was more or less loss 
of power in the limb; in some cases it was complete, in as many 
the patient could rotate the limb slightly on the couch; and in 
two cases partial flexion of the thigh could be performed. 
“3. That in all the cases immediate shortening of the injured 
limb was the direct result of the accident; and that this shorten- 
ing was about an inch or less, and it was irremediable by 
extension. 
“4. That the foot of the injured extremity was either straight 
or slightly everted, although in several cases this eversion was 
less marked on the injured than on the sound side. 
“5. That the great trochanter was placed nearer the median 
line of the body, and also nearer the anterior superior spinous 
process of the crest of the ilium than on the sound side. 
1 Medical Times and Gazette, April 17 and May I, 1869. 39 
“ 6. That the head of the femur could be made to rotate 
smoothly in the acetabulum, and the great trochanter moved 
with it. 
“7. That crepitus was either absent or indistinct in all cases. 
“ 8. That all the cases, with one exception, occurred in patients 
past middle age.” 
Bardeleben1 maintains that, in intra-capsular fractures, longi- 
tudinal displacement is opposed by the untorn portions of the 
capsular ligament. 
In this fracture the ends of the fragments are often interlocked 
in such a manner as to prevent dislocation, and may even enable 
the patient to walk on the limb for a few hours, or for several 
days. 
The more important elements in retaining the fragments are, 
however, the presence of impaction, and the untorn portions of 
the reflected capsule, the retinacula of Weitbrecht. 
S. D. Gross2 believes that impaction is rare, and, when present, 
it is almost exclusively extra-capsular. The distance of pene- 
tration varies from a few lines to one-half or three-quarters of 
an inch. 
Hueter3 places great importance in recognizing the presence 
of impaction. He regards the schenkelsporn as the most im- 
portant agent in the process of impaction. Anatomically he 
distinguishes two varieties : either the upper end of the lower 
fragment is displaced inward, so that the termination of the 
schenkelsporn penetrates the soft tissues below the upper frag- 
ment, or the lower fragment is displaced outward in such a 
manner that the schenkelsporn is driven into the spongiosa of 
the neck. Impacted fractures are not so frequent as non-im- 
pacted fractures, but they are sufficiently common to render 
them of the greatest importance in diagnosis, prognosis, and 
treatment of fractures of the neck of the femur. 
H. H. Smith4 believes that in the majority of cases the neck 
1 Lehrbuch der Chirurgie, 1871. Band II. S. 473. 
2 System of Surgery, 1864, vol. i. p. 965. 
3 Grundriss der Chirurgie, 1882. B. II. S. 883. 
4 The Principles and Practice of Surgery, 1863. 40 
of the femur is fractured by indirect violence, impaction following 
subsequently by a fall upon the trochanter major. 
R. W. Smith says: “ That all extra-capsular fractures are, in 
the first instance, also impacted fractures.” 
Robert1 was of the opinion that fractures of the neck of the 
femur were nearly always impacted, and as such should be 
disturbed as little as possible to obtain the best results, as the 
impaction furnishes the best possible conditions for bony union 
to take place. 
MacNamara2 affirms that fractures of the neck of the femur 
are usually impacted, the fragments being jammed into one 
Fig- 7- 
Posterior Impaction of Femoral Neck. (Bigelow.) 
another; the smashed cancellated tissue must be removed, ren 
dering the process of repair tedious. 
1 M6moire sur les Fract. du col de F6mer, 1845. 
2 Diseases of Bones and Joints, 1881. 41 
Bigelow,1 who has devoted a great deal of time and attention 
to the subject of injuries about the hip-joint, from the views he 
entertains as to the architecture of the femoral neck, is con- 
vinced that fracture takes place most frequently at the base of 
the neck, and is usually accompanied by impaction of its poste- 
rior wall. (Figs. 7 and 8.) These cases present outward rota- 
tion of the limb, and slight shortening, and may be followed by 
complete repair without lameness. 
Fig. 8. 
Posterior Impaction of Femoral Neck. (Bigelow.) Transverse Section. 
Impaction at the constricted portion of the neck is not fre- 
quent. Impaction of the entire base of the neck with inward 
1 The True Neck of the Femur, Boston Med. and Surg. Journ., Jan. 7, 1875. 42 
rotation of the limb is very rare, and is hardly possible without 
fracture of the trochanters. 
The same author, at a meeting of the Boston Society for 
Medical Improvement, held November 23, 1874, exhibited a 
specimen of a fracture within the capsular ligament with imper- 
fect impaction, which, during life, had simulated impaction at 
•the base of the neck, and induced him to express a favorable 
prognosis. “ The autopsy showed that the fracture was not 
through the base of the neck, but through the neck itself, close 
to the head, and that the fragments were ‘rabbeted’ together. 
There was motion enough to have worn away the thin walls of 
the neck, and to show that any bony union, had the patient 
lived, was not to be hoped for. In this respect it differed from 
Dr. Gay’s case of impacted fracture into the head, where the 
patient, on the day of his death from pneumonia, a week or two 
after the accident, lifted up his leg and said that as far as that 
went, he was getting well. Had that man lived, he would un- 
doubtedly have had bony union and a serviceable leg. The 
rabbeting of the fragments was shown here very well in the 
present specimen. It was due to a conical mass of compara- 
tively dense bony tissue projecting from the head fragment, 
which was driven into the loose cancellated structure of the 
portion of the neck in the shaft fragment. This dovetailing, 
although sufficient while the fragments were surrounded by the 
capsule and soft parts to prevent crepitus, and to cause the neck 
and head to rotate in the socket as a whole, did not prevent 
such attrition of the fragments as would hinder bony union.” 
Koenig1 locates fractures of the neck of the femur either near 
the head or the trochanteric portion, localities which correspond 
to intra- and extra-capsular fractures. From anatomical reasons, 
after a fall upon the trochanter major, the anterior wall of the 
neck (the convex side) fractures first, and the fractured end of 
the neck is directed forward. In most, if not in all cases, the 
wedge-shaped end of the inner fragment is implanted into the 
trochanteric portion, producing impaction. 
1 Lehrbuch der Speciellen Chirurgie, 1879. B. II. S. 837. 4 3 
Adams’s arch, the densest and strongest portion of the neck, 
penetrates the deepest. The greater the inclination of the inner 
fragment forward the more extensive the impaction. As a ne- 
cessary result of this impaction, the head of the femur descends 
and approaches the posterior inter-trochanteric line, the disloca- 
tion of the head in the'se directions satisfactorily accounts for 
the shortening and outward rotation of the limb. 
Accurate statistics as to the frequency with which impacted 
fractures occur as compared with non-impacted fractures, are 
still wanting. The individual experiences of surgeons are so 
widely at variance on this point, that a final decision can only 
be rendered after the accumulation of more positive knowledge 
from accurate bedside observation and post-mortem exami- 
nations. 
From a study of the literature on this subject it is apparent, 
however, that the more recent authors advance the opinion that 
it is of frequent occurrehce. It is also evident that impaction is 
not limited to any particular part of the femoral neck, but that 
it can follow any fracture, although the most favorable condi- 
tions for its occurrence are found at either extremity of the 
femoral neck. The direction and extent of impaction depend 
on the density of the tissues which are penetrated, and on the 
direction and intensity of the fracturing force. Impacted frac- 
tures within the capsule may occur from the application of 
indirect violence, as the capsular ligament will offer the neces- 
sary resistance; on the other hand, impacted fractures without 
the capsular ligament can only take place from direct violence. 
It is also possible in cases of this kind, as suggested by several 
authors, that a simple fracture is produced in the first place by 
force applied through the axis of the femur, and impaction takes 
place subsequently by a fall upon the trochanter major. Impaction 
from indirect violence would necessarily take place at the lower 
portion of the constricted portion of the neck by the apex of the 
femoral brace penetrating the soft spongiosa of the head, while 
if produced by a fall upon the trochanter major, the compacta 
of the posterior surface is also implanted into the head. Impac- 
tion outside of the capsule, from the normal position of the neck 44 
and the direction of the fracturing force, always takes place at 
the expense of the posterior portion of the neck, except in cases 
where the fracturing force is so severe as to drive the entire 
neck wedge-like into the upper portion of the femoral shaft, 
splitting the latter into two or more fragments. Impaction im- 
plies the destruction or crushing of more or less of bone tissue; 
and, in case the fragments are unlocked, a vacuum is formed, 
which must be filled by the interposition of fluids or the adjacent 
soft tissues. It is well known that intra-capsular fractures are 
often produced by very slight injuries, and it is equally certain 
that these are the cases which furnish the most unfavorable 
prospects for a good result, and the question might naturally 
arise, had the violence been sufficient to produce deep penetra- 
tion, would it not have enhanced the prospects for a more favor- 
able issue? In fractures of the neck of the femur the prospects 
for a favorable result are better if the exciting cause acts with 
sufficient intensity to produce impaction, as this condition is the 
most favorable for repair by bony union. 
VIII. Predisposing Causes. 
Fractures of the neck of the femur is one of the rarest accidents 
during childhood and adult life, while after the fiftieth year they 
constitute a high percentage of all fractures. Between the 
twenty-first and thirtieth year they constitute -Jy of all fractures; 
between thirty and forty ;’ between fifty and sixty nearly 
and over seventy Their frequency increases steadily with 
the advance of old age. A number of explanations have been 
advanced to explain this clinical fact. Thus, Richter2 mentions 
the following predisposing causes: 1. Spongy texture of neck, 
and diminution in thickness of compact layer. 2. Diminution 
in the obliquity of the neck. 3. Prominence of trochanter major 
by which the fracturing force is transmitted directly to the neck. 
Walther3 assigns to syphilis an important part. Sex has also 
1 Guilt, Handbuch der Lehre von den Knochenbrueche, 1862, vol. i. p. 30. 
2 Lehrbuch von den Bruechen, etc., 1833. 
3 System der Chirurgie, 1852. B. VI. S. 348. 45 
been mentioned as a predisposing cause; aged females furnish a 
greater number of fractures, and it was claimed that this could 
be explained by the more horizontal position of the neck in the 
former than in the latter. As the strength of the femoral neck 
is derived from the peculiar architectural arrangement of the 
spongiosa, the simple diminution of its angle w'ould not render 
it more liable to fracture, as Julius Wolff has shown that, even 
in fractures that have healed with considerable deformity, the 
structure of the spongiosa is perfectly restored in accordance with 
the original plan. If the neck is placed at a right angle to the 
shaft, it would give way more easily at the constricted portion 
on the application of indirect violence, while from a mechanical 
standpoint it ought to resist force more advantageously in case 
it is applied in the direction of the axis of the neck. The pre- 
disposing cause is intrinsic—inherent in the bone itself—a de- 
generation or diminution of bone-tissue. All influences which 
affect nutrition, and that of bone in particular, as insufficient or 
improper food, wasting diseases, prolonged confinement in bed, 
etc., hasten the degeneration of bone, consequent upon senile 
marasmus. Senile osteo-porosis then is the only known predis- 
posing cause; an assertion which is abundantly confirmed by 
clinical experience. 
IX. Exciting Causes. 
Fractures of the neck of the femur are produced by— 
1. Force applied in a vertical direction through the axis of 
the femur. 
2. Force applied in a horizontal direction over the trochanter 
major in the axis of the femoral neck. 
3. Traction force transmitted through the capsular ligament 
when the limb is forcibly hyper-extended and adducted and 
rotated outwards. 
A fall upon the foot or knee, as a rule, will fracture the neck 
at its narrowest portion ; and, if the fracture is complete, no 
impaction will take place, unless it follows as a secondary occur- 
rence from transmission of force through the trochanter major. 46 
Most authorities who believe that intra-capsular fractures are the 
most frequent, assert that indirect violence is the most frequent 
exciting cause. 
Experiments and clinical observation have shown that the 
majority of fractures of the neck are produced by force applied 
in the direction of the axis of the neck by falls upon the tro- 
chanter major. It is also an established fact that in most 
instances of this kind the neck gives way at its trochanteric 
portion, and that the posterior wall is crushed or fractured first. 
Impaction takes place more frequently from direct force with 
deeper penetration of the posterior than the anterior wall of the 
neck. 
Of thirty cases of fracture of the neck examined by Desault1 
for the purpose of learning the exciting cause, twenty-four were 
produced by a fall upon the trochanter major. All the cases 
reported by Sabatier appear to have been produced in a similar 
manner. Sabatier ascribed to the prominence of the greater 
trochanter an important part in the production of fracture, and 
believed that fracture of the femoral neck does not occur in 
children on account of the imperfect development of the upper 
extremity of the femur. 
Although direct force through the axis of the neck generally 
expends itself near the femoral shaft, causing a fracture of the 
expanded portion of the neck with posterior impaction, there 
are a number of cases recorded where the fracture occurred 
within the capsule. Intra-capsular fractures produced in this 
manner are often impacted. 
The last manner in which a fracture may be produced of the 
femoral neck is by forcible hyper-extension and rotation outward 
of the limb, movements by which the ilio-femoral ligament is 
put upon its utmost stretch; and, when this bone has become 
so fragile that it is unable to resist the traction of this powerful 
ligament, a fracture, the so-called traction fracture, takes place at 
the junction of the neck with the femoral shaft. This fracture 
1 A Treatise on Fractures, etc., 1817. 47 
is always extra-capsular, and was first described by Linhart, and 
subsequently experimentally studied by Riidinger.1 Riidinger 
believes the fracture takes place before the patient falls upon the 
ground ; comminution of the trochanter major and impaction 
may subsequently result from direct violence. 
X. Senile Osteo-porosis. 
Senile osteo-porosis is an affection of the bones in the aged, 
characterized by diminished elasticity and increased fragility as 
compared with healthy bones. It is an excentric atrophy of 
bone, due to impairment of the physiological functions which 
preside over digestion and assimilation. During the incipient 
stages the bone retains its volume, but loses in density and 
weight, owing to an actual loss of bone-tissue, which necessarily 
results in increased porosity. This affection appears first in the 
spongiosa of the head and neck of the femur, anti it is here 
where its most advanced stages are observed. In the upper end 
of the femur this senile degeneration weakens the support to 
vertical pressure, allowing the head gradually to descend in 
some instances below the summit of the great trochanter, at the 
same time diminishing the oblique angle of the neck to almost 
a right angle with the shaft. Senile, in connection with this 
subject, however, is a relative term, as this condition of the bones 
may be found in comparatively young people, provided atrophic 
changes peculiar to old age, the senile marasmus, from any cause 
manifests itself; and, on the other hand, even very old people, 
when otherwise in good health, may remain exempt from this 
form of senile degeneration. I have in my possession a femur, 
taken from a gypsy 104 years of age at the time of his death, 
which illustrates this assertion. The neck of the bone retains 
the normal obliquity, the compact layer is firm and thick, while 
the spongiosa, although somewhat more porous, presents the 
different systems of arches in a degree of perfection unsurpassed 
at any age. Senile atrophy of bone, and the diminution in the 
1 Studien liber Gruntl u. Einkeilung d. Schenkelhalsbrueche, 1874, p. 63. 48 
obliquity of the neck of the femur resulting from it, have justly 
received so much attention on the part of pathologists and sur- 
geons, to explain the frequency of fracture, that I may be par- 
doned for entering more fully into a consideration of this subject. 
All authorities agree in assigning to the structural degenera- 
tion of the neck of the femur an important, if not the only pre- 
disposing cause in the production of fractures in this locality in 
the aged. The increased brittleness of bones during advanced 
age has been explained in different ways. Bichat attributed it to 
an excess of the inorganic constituents of the bone with a corre- 
sponding decrease of the organic matter. This view found 
almost universal acceptance among surgeons, and is still taught 
in many of our text-books on surgery. 
Henle was among the first to assert that the fragility is not 
caused by a disproportion of the earthy and organic constituents 
of bone, but that it is th6 result of an actual loss of bone tissue, 
a genuine atrophy of bone. Ribbert1 has made special inquiries 
into the pathology of senile atrophy of bone, and from the pre- 
valence of this affection along the lower regions of the Rhine, 
he has been enabled to study this process under the most favor- 
able circumstances. On examining sections of osteo-porotic bone 
stained with carmine he invariably found an osteoid red zone 
upon the surface of the lamella varying in size, extent, and 
number in proportion to the severity of the process. These 
zones presented very delicate parallel lines, and bone-cells with 
very fine or spindle-shaped projections. The margins of the 
osteoid layers towards the unchanged portion of the lamella are 
not very irregular, and usually devoid of lacunae. The medulla, 
as a rule, is pulpy, hypersemic, and often infiltrated with blood, 
the medullary spaces dilated, and the lamellae correspondingly 
reduced in thickness. In one case he found the latter completely 
destroyed and converted into osteoid tissue, forming cyst-like 
cavities filled with pulpy medullary tissue. Ribbert regards the 
process as being due to an impairment of nutrition, which of 
1 Ueber senile Osteo-malacia u. Knochenroorption im Allgemeinen. Archiv. 
f. Path. Anat., LXXX. S. 436. 49 
necessity is attended by chemical changes of the basis substance 
of bone, which is followed again by a separation of the earthy 
phosphates from the basis substance. The earthy salts are ren- 
dered soluble by acids (perhaps carbonic acid) contained in the 
fluids of the body. As an evidence that the earthy phosphates 
are separated from the organic tissues, the author mentions that 
he has seen a granular opacity at the junction of the osteoid 
spaces with the normal bone, which cleared up on the applica- 
tion.of an acid. 
Insufficient or improper food has an important influence in 
impairing the nutrition of bone, as has been abundantly shown 
by reliable observations. Roloff1 made experiments on animals 
for the purpose of studying the pathology of fragility of bones. 
He was able to produce this condition artificially by depriving 
the animals of all food containing phosphate of lime. He ascribes 
the condition primarily to a diminution of the earthy constituents 
of bone, and during the more advanced stages of decalcification 
a metamorphosis of osteoid into myeloid tissue takes place. The 
walls of the canaliculi appear more transparent and wider, and 
present the appearance of light stripes with dark edges. The 
walls of the bone-cells or spaces become translucent. During 
the further progress of the metamorphosis the appearances are 
such as would indicate that the bony tissue over greater or less 
areas had been entirely destroyed, and its space filled up with 
new myeloid cells from the adjacent myeloid spaces. A close 
examination, however, showed that the myeloid cells originated 
from the bone-cells. 
Maresch observed an epidemic of fragility of bones among 
cattle and pigs in Bohemia, which lasted for three years, and was 
attributable to a prolonged drouth, and consequent upon it poor 
quality of food. He invariably found that the disease showed a 
predilection for the extremities of the long bones, which were 
softened to such an extent that they could be readily cut with 
the knife. The interior of the spongiosa was filled with a white 
pultaceous mass, while the compacta was reduced to a thin shell. 
1 Ueber Osteo-malacia u. Rachitis. Virchow’s Archiv, B. XXXVII. Hft. 4, S. 
434- 50 
M. Mercier observed that in all specimens of senile atrophy 
the alveolar spaces were enlarged, rendering the tissue more 
porous. 
Kblliker1 believes that giant-cells are the agents which pro- 
duce absorption of bone in normal and pathological conditions. 
These cells, when found in bone, he calls osteo-klasts. They 
originate from osteo-blasts, and are found on the surface and in 
the interior of the lacunae. 
Humphry,2 in mentioning the causes of fracture of the femoral 
cervix, alludes to the subject as follows: “ In the aged the 
arrangement of the cancelli, which in the young and middle 
aged are so admirably adapted to support superimposed weight, 
becomes imperfect from senile degeneration, a process which 
begins earliest in the upper end of the femur.” 
Herman Meyer3 advanced the idea that senile osteo-porosis 
appears under the form of a non-suppurating periostitis, the pro- 
duct of which as yet remains unknown. 
Gurlt’s4 description of senile osteo-porosis may be condensed 
as follows: The medullary canal is enlarged, the cortical layer 
very thin or entirely absent, and the spongiosa exceedingly 
porous, the meshes being filled with myeloid tissue of a dark 
color. 
Kassowitz5 affirms that absorption of bone takes place as a 
consequence of increased vascularization, the loss of bone-tissue 
being the direct result of absorption. 
G. Pommer8 has studied the process of resorption in diseased 
bones with a view to determine the formation of Howship’s de- 
pressions and the function of the osteo-klasts. His observations, 
based upon thirty cases of bone atrophy, due either to old age 
or pressure from any cause, has induced him to accept Kblliker’s 
views as mentioned above. 
1 Die Verbreitung und Bedentung d. vielkernigen Zellen d. Knochen u. Zaeline. 
Virchow u. Hirsch Jahresh., 1872, vol. i. p. 21. 
2 Treatise on the Human Skeleton, 1871, p. 471. 3 Op. cit. 
4 Handhuch von der Lehre der Knochenbruechen, 1861, vol. i. 
5 Virchow u. Hirsch’s Jahreshericht, 18S1, vol. i. p. 262. 
6 Ueber die lacunaere Resorption im erkrankten Knochen, Wiener Sitzungs- 
bericht. B. 83, Abth. III. S. 17. 51 
Morisane has made histological examinations to ascertain the 
minute processes which take place in the destruction and ab- 
sorption of bone in cases of rarifying osteitis. He believes that 
the normal exudation which takes place from the minute vessels 
in bone in a state of health, is destined to perform the essential 
part in the production of bone, but when inflammation is pre- 
sent, chemical changes take place in the exuded material, which 
annihilate the bone producing properties of the cells. He dis- 
tinguishes an acute and chronic.form of the disease. In the 
chronic form the destruction of the compact tissue is the result 
of a progressive diminution of its earthy phosphates, during 
which the basis substance is reduced to fibrillae, which unite 
with the connective tissue of the marrow spaces, and undoubt- 
edly materially assist in the formation of the connective tissue 
framework of these spaces. In the acute form, where nutrition 
is seriously impaired, the stroma undergoes rapid granular dege- 
neration, while the earthy salts are absorbed, the bone-cells are 
destroyed instead of being converted into connective tissue, as 
is the case in the chronic form. In the chronic as well as the 
acute variety of rarefying osteitis, the death and absorption of 
bone-tissue is dependent in an intimate manner on the numerical 
increase and degree of dilatation of the small vessels; and, to a 
certain extent, it also results from a chemical change which the 
products of exudation have undergone; to this latter must be 
assigned an important role as a dissolving agent. 
I have called attention to inflammatory osteo-porosis of bone 
under the head of senile osteo-porosis, in order to explain the 
rapid absorption which takes place after fracture of the neck of 
the femur. In all of these cases, and more particularly in the 
intra-capsular variety, more or less of the neck is removed by 
absorption, in some instances almost the entire neck disappears. 
This process of absorption after fracture expends itself more on 
the lower than the upper fragment, and more upon the posterior 
than the anterior portion of the neck. Interstitial absorption of 
the neck of the femur in young adults, as described by Gulliver,1 
1 Interstitial Absorption of Neck of Femur without Fracture, Medico-Chirur- 
gical Review, vol. xvii. p. 543. 52 
can only be explained on the hypothesis that inflammatory soft- 
ening and absorption were induced by traumatism. Only in 
two cases of the four reported by Gulliver was the diagnosis 
verified by the autopsy. Both were young men who had suffered 
contusion of the hip on the affected side, in both the neck was 
shortened, and almost at a right angle with the shaft; in one of 
them the cancellated tissue of the neck was more compact, and 
some adventitious bony material on its surface near the shaft; 
while in the other case, “ the cancelli of the neck were filled 
with caseous matter, in some nearly colorless, in others tinged 
with dark grumous blood.” 
Similar specimens have been brought forward as cases of bony 
union after intra-capsular fracture; there is, however, in all of 
these cases a symmetrical atrophy of the anterior and posterior 
portion of the neck of the femur, while in cases of intra-capsular 
fracture with bony union, there is almost without exception a 
greater loss of substance of the posterior than of the anterior 
portion of the neck. 
Interstitial absorption of the neck in young adults is always 
the result of rarefying osteitis, which eventuates in loss of bone- 
tissue, but after the disease has subsided regeneration takes 
place, the spongiosa becomes more dense by deposit of new 
bone, while the same process takes place beneath the perios- 
teum, giving rise to adventitious bone, which might easily be 
mistaken for callus, as in Case III. described by Gulliver; in 
other instances the process of destruction is not followed by 
repair, the products of inflammation remain in the cancelli, as in 
Case IV., mentioned by the same author: 
There has been considerable difference of opinion in regard to 
the particular structure which is the primary or most important 
seat of senile osteo-porosis. Authors have located it in the 
structures which, in accordance with the views they entertained, 
were supposed to furnish the principal support to vertical pres- 
sure; thus Meyer found it in the spongiosa, Merkel in the calcar 
femoral, Bigelow in the compact tissue of the neck. Senile 
degeneration, in preference, affects the spongy bones, and the 
spongy portions of the long bones, hence, there can be no doubt 53 
that it first attacks the spongiosa in the interior of the head and 
neck of the femur, from where it gradually invades the different 
parts of the compact tissue. With a view to prove this assertion 
I have examined a number of sections of the upper extremity of 
the femur from persons advanced in years, and have repeatedly 
observed the spongiosa atrophic and porous, while the femoral 
brace and the calcar femoral retained their normal strength. 
During the advanced stage of the affection the compacta may 
be reduced to the thinness of paper, or disappear entirely, the 
periosteum coming in contact with the spongiosa; in such cases, 
fracture takes place on the slightest application of force, and the 
bone can be readily cut with a knife. The myeloid spaces are the 
starting points of the process of degeneration; they are enlarged 
and become distended by the accumulation of myeloid cells and 
granulation tissue; the cancelli are broken down, and thus spaces 
of considerable size are created at the expense of the regular 
system of arches which make up the structure of the spongiosa. 
Giant cells and granulation tissue possess the property to disin- 
tegrate and absorb bone, they are the destructive agents, while 
the broken-down tissue is removed by the bloodvessels. When 
sections of a bone, the seat of senile atrophy, are examined dur- 
ing the earlier stages of the process, they present a vascular and 
red appearance, on account of increased vascularization and an 
abundant deposit of red marrow. When degeneration has pro- 
gressed to the highest degree, the compacta has disappeared 
almost completely, the spongiosa is exceedingly porous, the 
alveoli large and filled with fat, the bone presents a yellow ap- 
pearance, imparted by the free fat derived from the fatty degene- 
ration of the histological elements. 
As long as the bone is supplied with an abundance of myeloid 
tissue and bloodvessels, its bone-producing capacity is not im- 
paired; on the other hand, it is said to be increased, irrespective 
of the degree of softening and fragility; but if fatty degeneration 
has progressed to the extent just mentioned, and the vascular 
supply is greatly diminished, as is the case in the most aggra- 
vated forms of senile osteo-porosis, no attempt at production of 
bone can reasonably be expected in the event of fracture. We 54 
are then justified from a consideration of the foregoing remarks 
in adopting the following conclusions:— 
1. Senile osteo-porosis is the only predisposing cause of frac- 
tures of the neck of the femur in the aged. 
2. Senile osteo-porosis, except in the most advanced stages of 
fatty infiltration, does not impair, but hastens the production of 
myeloid, or permanent callus. 
XI. Symptoms of Fracture of the Neck of the Femur. 
As the very best authorities are forced to admit that during 
life it is impossible to locate accurately the precise seat of frac- 
ture, there exists no longer the necessity of considering the 
symptoms separately under the head of intra- and extra-capsular 
fracture. In practice, the greatest care should be exercised to 
ascertain the presence of impaction; but even impacted fractures 
present the most important symptoms in common with non- 
impacted fractures; and they may be conveniently, and I think 
profitably, grouped together to prevent unnecessary repetition. 
The symptoms presented by a fracture through the neck of 
the femur, as in any other fracture, are: I. Subjective; 2. Ob- 
jective. 
The subjective symptoms are: I. Pain; 2. Loss or impair- 
ment of function. 
I. Pain.—The pain is due either to the immediate effects of 
the traumatism, laceration of the contiguous soft tissues, irrita- 
tion produced by the movements of the fractured ends, or the 
inflammation of the bone or surrounding tissues succeeding the 
injury. The pain is variable, almost absent, and of short dura- 
tion in some cases, excruciating and continuous for months and 
sometimes years in others. If the fracture is located in the 
narrow portion of the neck, the pain is usually referred to the 
groin about the insertion of the ilio-psoas muscle; if at or near 
its base, it is more diffuse, and referred to the seat of injury. 
There has been considerable discrepancy of opinion as to the 
severity of the pain in fractures within, as compared with frac- 
tures without the capsule. Sir Astley Cooper maintained that 55 
it is less severe in the former variety, while Malgaigne claimed 
that the reverse was true. As fractures of the narrow portion 
of the neck are the result of less violence than when they occur 
near the shaft, it is undoubtedly true that the pain attending 
them immediately after the traumatism is less than in the latter 
class of injuries, while the reverse may be true during the 
subsequent history of the case. In impacted fractures, where 
the favorable conditions for bony union are not disturbed, and 
the process of repair is initiated at once, and progresses uninter- 
ruptedly, the pain, as a symptom, is referable only to the trau- 
matism; and as such, as a rule, is more severe in fractures where 
the greatest amount of tissue has been lacerated, that is, in extra- 
capsular fractures. 
In cases of non-impacted fractures within the capsule, with 
motion of the fragments upon each other, a certain amount of 
inflammation springs up, which is always attended by its most 
prominent symptom—pain. When pain, the result of inflam- 
mation, is present, it assumes the characteristic features as wit- 
nessed in coxitis independent of fracture. It is then no longer 
a symptom of fracture, but indicates the accession of traumatic 
coxitis. The presence of no inconsiderable amount of inflam- 
mation has repeatedly been verified at post-mortem examina- 
tions, in the form of thickening of the capsule, adhesions, and de- 
struction of the synovial membrane and cartilage. Any attempt 
at motion or pressure against the trochanter major aggravates 
the pain. In some old inveterate cases the pain assumes a 
neuralgic type, which would indicate that some of the nerves 
about the hip-joint were encroached upon by the displaced frag- 
ments, or exuberant callus, or the products of inflammation. 
2. Loss or Impairment of Function.—This symptom is present 
in all fractures of the femoral neck. As a general rule, it may 
be stated, it is prominent as a symptom in proportion to the 
degree of separation of the fragments. In impacted fractures 
the patients are often not only able to move the limb, but even 
walk for hours and sometimes days. The impairment of volun- 
tary movements does not depend alone on the direct loss of 
support, but is also influenced by the pain incident to such 56 
movements; hence, this symptom will present itself in the 
highest degree in nervous, excitable patients. Laceration of the 
soft parts, the periosteum, and capsule, in the absence of impac- 
tion, will also counteract voluntary motion, not only by allowing 
a greater degree of disjunction of the fragments, but likewise by 
increasing the pain on any attempt at motion. 
In the great majority of cases the patient, as he lies in bed, is 
unable to raise or move the limb in any direction, it remains 
perfectly helpless in the position it was left after the accident, or 
in which it has been left by the displacing elements. In some 
cases where interlocking of the fragments exist, or where a slight 
amount of impaction has taken place, the patient has control 
over a certain amount of voluntary movements for a number of 
days, or until disjunction of the fragments takes place as a result 
of injudicious examination or inflammatory osteo-porosis, when 
the limb is placed in the same conditions as if no impaction had 
taken place. 
The objective symptoms are: i. Swelling and deformity at 
the hip. 2. Suggillation about the hip. 3. Eversion of limb. 
4. Shortening. 5. Change of position of trochanter major. 
6. Either increased or diminished mobility of the hip-joint. 7. 
Loss of tension of fascia lata between the trochanter major and 
the crest of the ilium. 
1. Swelling and Deformity.—In all cases there is an appre- 
ciable fulness in the fold of the groin corresponding to the seat 
of fracture. This swelling is caused by the hinge-like projection 
of the anterior portion of the neck, effusion of blood or inflam- 
matory products, and, lastly, by the over-riding or impaction of 
the fragments. When impaction takes place at the base of the 
neck, the trochanteric portion of the femur is enlarged from im- 
plantation of the upper fragment. The swelling is larger when 
the fracture is located without the capsule from the more exten- 
sive bone injury and the more copious effusion of blood. 
2. Suggillation appears earlier and more constantly the nearer 
the fracture is seated to the femoral shaft. As this symptom is 
the result of the presence of blood at the point of fracture, it is 
more extensive if the hemorrhage has been considerable and 57 
outside of the capsule. If the hemorrhage has been within the 
capsule, and the capsule is ruptured at some point, the discolor- 
ation will usually show itself along the inner side of the thigh. 
The same force which produced the fracture may also contuse 
the soft parts sufficiently to give rise to superficial discoloration 
independent of the fracture. 
3. Eversion.—The lower limb in a natural condition is slightly 
everted on account of the forward obliquity of the femoral neck. 
This normal eversion is increased during sleep when the muscles 
are at rest, or when they have been completely relaxed by an 
anaesthetic, or when their action has been permanently suspended 
by paralysis. In the normal condition, then, the weight of the 
limb effects outward rotation until arrested by muscular action, 
or the resistance offered by the ligament of the hip-joint. As 
the posterior wall of the neck is usually the seat of more exten- 
sive comminution or impaction than the anterior, and as the 
fracturing force in the majority of cases is applied in the antero- 
lateral direction, it is only reasonable to expect that outward 
rotation of the limb is the rule. And this expectation has been 
verified by clinical observation. Until recently it has been gene- 
rally supposed that eversion is the result of muscular contraction, 
and in support of this view it has been suggested that in non- 
impacted fractures it increases after the muscles have recovered 
their contractility. 
Edmund Owens, on the ground of anatomical demonstrations 
and carefully made experiments, as well as accurate clinical 
observation, holds that eversion of the limb takes place indepen- 
dent of muscular contraction, that it is invariably the result of 
the impacting force or the weight of the limb as the case' may 
be. In intra-capsular fractures it is especially true that eversion 
is more marked a few days after the injury, but this fact can be 
interpreted more satisfactorily from a different standpoint. In 
such cases the fragments are often kept in apposition by an 
interlocking of the broken surfaces or unlacerated portions of 
the fibrous investment of the neck ; either of these supports may 
give way to the constant traction from the weight of the limb, or 
the same result may take place from reflex muscular contractions, 58 
or careless handling of the limb. The great mass of muscles, the 
external rotators of the hip, after the fracture, are relaxed from 
the approximation of their points of origin and insertion, and it 
is difficult to conceive in what way they could effect outward 
rotation. Dupuytren believed that eversion may also be due to 
the action of the adductor muscles, and in some instances to the 
obliquity of the fracture itself. It is also necessary to mention 
that eversion is not a constant symptom. Cases have been de- 
scribed by reliable observers where the limb remained normal so 
far as the position of the foot was concerned, and in some even 
the reverse, inversion occurred. Cases of fracture with inversion 
have been described byAmbroise Pare, J. L. Petit, Guthrie, Stan- 
ley, Dupuytren, Desault, Cruveilhier, Hamilton, R. W. Smith, 
and others. Desault thought that it occurred in about one case 
out of every four. Stanley observed one case where the autopsy 
showed that the fracture was purely intra-capsular, and no 
satisfactory explanation could be found for the inversion. Wm. 
Pirrie mentions a case of intra-capsular fracture where the limb 
was not only inverted but also strongly flexed and adducted, a 
position he ascribed to the tension of the ilio-femoral ligament. 
Of the one hundred and thirty cases of intra-capsular fracture 
of the neck of the femur which came under Pirrie’s observation, 
and where the accuracy of the diagnosis was verified by dissec- 
tion, this was the only case with flexion, adduction, and rotation 
inward of the limb. Of the remaining number, in one case only 
existed inversion, the limb in other respects occupying the usual 
straight position. Malgaigne1 reports an exceedingly interesting 
case. “In 1833, having found the foot inverted in a fracture of 
the neck of the femur, I ascertained that it was easily everted 
and again inverted at will, and that it remained as readily in one 
position as in the other; whence I concluded that whatever incli- 
nation is given to the part upoyi the supporting plane it keeps by 
its own weighty2 This observation is exceedingly valuable, and 
would lead us to the conclusion that whenever the support 
derived from the cervical portion of the femur is lost, the limb 
1 A Treatise on Fractures. Translated by J. H. Packard, M.D., p. 543. 
2 Italics my own. 59 
will follow the natural law of gravitation, and will turn outward 
by its own weight, unless opposed by some special conditions at 
the seat of fracture, or by external influences. 
4. Shortening.—The significance of shortening as a symptom 
of fracture of the neck of the femur has received additional 
interest, since it has been ascertained that in many persons there 
is naturally a difference in the length of the lower extremities in 
the same individual. Dr. J. S. Wight, of Brooklyn, has made 
a valuable contribution to surgery relating to the comparative 
length of the inferior extremities in the same individual. His 
first published table comprised the measurements of sixty persons, 
of varied nationality, pursuits, and ages. In these sixty there 
were ten persons who presented a parity of length in the two 
legs, and fifty who showed a difference varying from one-fourth 
of an inch to one-and-three-eighths inches. The right leg was 
the longer in eighteen, and the left in thirty-two instances. A 
second table comprises forty-two measurements, and shows a 
parity of length in thirteen, and a difference in twenty-nine 
instances, the difference varying from one-fourth of an inch to 
one inch. In nine cases the right, and in twenty the left limb 
was the longer. Hamilton has corroborated these statements 
by his own researches. Gurson1 has made some further investi- 
gations which tend to establish the correctness of these observa- 
tions. He examined seventy skeletons of different sexes and 
ages, and belonging to different races. He found that among 
this number only in seven were the lower extremities of the 
same length, and among these the femur, tibia, and fibula were 
of the same length on both sides in two, while among the 
remaining five the tibia and fibula and the femur equalized the 
difference in length. In 54 per cent, of the cases the left ex- 
tremity was longer than the right, the average difference being 
4.8 mm., and the maximum difference 13 mm. The right ex- 
tremity was longer than the left in 55.8 per cent., with an average 
difference in length of 3.3 mm., and a maximum of only 8.0 mm. 
1 Inequality in Length of the Lower Limbs. Journ. of Anat. and Phys., vol1. 
xiii. p. 26. These measurements not only prove that the lower limbs differ 
in length in a majority of cases examined, they likewise point 
out the importance of measuring the long bones separately for 
the sake of comparison when measurements are made for diag- 
nostic purposes. 
More or less shortening will take place in every case of frac- 
ture of the neck. M. Lisfranc and M. Lallemand1 each have 
reported a case where the limb was longer. It is impossible to 
conceive in what manner the fracture could add to the length of 
the limb; and still the observations were undoubtedly correct, 
and an explanation can only be given by assuming that the 
amount of actual shortening was slight, and the patient’s limbs 
were of unequal length. The amount of shortening depends on 
the degree of disjunction, the greater the longitudinal displace- 
ment, the greater the shortening. The shortening is always the 
direct result of muscular contraction or longitudinal displace- 
ment by impaction. In impacted fractures the maximum is 
reached at once, and the degree of shortening depends on the 
depth of penetration or mutual inter-penetration of the fractured 
ends. In cases of impaction the shortening remains stationary, 
as the fracture is not disturbed, and can only increase on the 
advent of inflammatory interstitial absorption. In fractures with- 
out the capsule, all resistance to muscular contraction is lost, and 
the maximum amount of shortening is reached as soon as the 
muscles have become contracted. If the capsule is intact, and 
remains attached to the lower fragment, shortening takes place 
gradually by stretching of the capsular ligament. In case the 
fragments are held in contact by the denticulated fractured sur- 
face shortening can only proceed after this medium of apposition 
has been removed by displacement of the bones, or after inflam- 
matory osteo-porosis has removed the projecting spiculae. This 
condition is often met with in intra-capsular fractures. The 
degree of shortening immediately after a fracture has been relied 
upon by some in determining the seat of fracture. Among sur- 
geons there has been, however, such discrepancy of opinion in 
1 Dupuytren, Injuries and Diseases of Bones. this respect, that no reliable deductions can be drawn from this 
circumstance in rendering a decision. 
Sir Astley Cooper and Amesbury claim the greatest shorten- 
ing for intra-capsular fractures, while Stanley, Earle, and R. W. 
Smith entertained an opposite opinion. Impaction and the in- 
tegrity of the capsular ligament are such important factors in 
determining the amount of shortening and the time when it 
takes place, that these conditions must be carefully considered 
in estimating the value of shortening as a diagnostic aid. 
5. Change of Position of Trochanter Major.—The trochanter 
major is displaced upward and backward, in proportion to the 
amount of shortening and eversion. When shortening has taken 
place, its upper border has passed beyond Nelaton’s line. When 
the limb is rotated, it describes a smaller arc of a circle. It is 
less prominent when impaction has taken place, or when the 
lower fragment is not in apposition with the upper. 
6. Alteration of Motion.—A false point of motion is always 
established in non-impacted fractures. Preternatural mobility 
is most marked if the fracture is not impacted and located out- 
side of the capsule. It is probably in cases of this kind that 
Gerdy has been able to rotate the limb outward until tl\e toes 
looked backward, and that Maisonneuve brought into requisition 
his test of hyper-extension. If the fracture is within the intact 
capsule, the latter will serve as a retentive measure, and limit 
the motion between the fractured bones. Dr. Levis has found 
that in non-impacted fractures the limb can be extended beyond 
its normal length. In case firm impaction has taken place, the 
neck has become shorter and thicker, conditions which neces- 
sarily impair the natural mobility of the hip-joint. 
7. Fascia Lata.—Dr. Allis,1 of Philadelphia, has added another 
symptom, which indicates fracture through the neck of the 
femur, namely, the existence of a relaxed condition of the fascia 
lata between the crest of the ilium and the trochanter major on 
the injured side, produced by the loss of resistance, which is 
furnished by the neck when not broken. As the presence of 
1 Mechanism of the Hip-Joint, Med. and Surg. Reporter, vol. xxxvi. p. 303. 62 
this symptom depends on the dislocation of the lower fragment 
upward and inward, it is only met with when such changes have 
taken place. The standing position is the only one in which 
this test can be applied, as in the reclining position the muscles 
that make tense the fascia are relaxed. 
Bezzi1 has called attention to a sign which he considers as 
pathognomonic of fracture of the neck of the femur. In examin- 
ing the space between the trochanter and the crista ilii, it will 
be found that while on the same side the muscles occupying this 
region (the tensor vaginae femoris and the gluteus medius) are 
tense, and offer to the hand a considerable feeling of resistance, 
they present on the affected side a deep, well-marked depres- 
sion, a flaccidity, and diminution of tension, from displacement 
upwards of their points of insertion. This sign appears under 
the same circumstances, and possesses the same significance as 
the one described by Dr. Allis. 
I have intentionally omitted to mention crepitus as a symp- 
tom, as more harm than benefit has accrued from the efforts of 
the anxious surgeon to establish a positive diagnosis on the 
presence or absence of this sign. A careful study of the other 
symptoms will usually enable us to arrive at a correct conclusion 
without exposing the patient to the risks incident to the mani- 
pulations necessary for the purpose of eliciting this symptom. 
XII. Diagnosis. 
All manipulations, during the examination of a supposed 
fracture through the cervix femoris, should be performed with 
the utmost care and gentleness. The so-called “ thorough 
examinations,” the search for positive symptoms, has been the 
source of incalculable mischief. In many instances careless 
handling of the limb has resulted in disjunction of impacted 
fractures, or in tearing of periosteal or ligamentous bands, thus 
precluding most effectually possible union by bone or the forma- 
1 Centralbl. fur Chirurgie, July 31, 1880. 63 
tion of a short fibrous union. Years ago, Davis1 entered his 
protest against such reckless examinations in the following 
emphatic manner: “ Now, while we willingly concede the im- 
portance of a correct diagnosis in its bearings upon the suc- 
cessful treatment of any case, we hold that too much handling 
and manipulation of the limb in intra-capsular fracture is liable to 
eventuate in irreparable injury to the patient.” Again: “When 
this connecting link of periosteum and capsular ligament is not 
severed by officious handling on the part of the surgeon, in his 
zealous, but often mischievous efforts to ascertain to the fullest 
extent the details of the injury, then we may hope for better 
results than have usually followed this accident.” 
Bryant’s2 caution is equally strong: “ In fact the ordinary 
fracture of the base of the neck of the thigh-bone is primarily 
an impacted fracture, the impacted bone in some cases being 
loosened by a second fall, in others by excess of violence received 
in the original accident, and in too many by the manipulations of 
the surgeon in his anxiety to make out the presence of a fracture 
by the detection of crepitus. Indeed, this seeking for crepitus in 
cases of fracture is a practice fraught with danger.” 
I shall not allude to crepitus as a diagnostic sign; as a satis- 
factory diagnosis can usually be made without, by a careful con- 
sideration of the other symptoms. In every case of suspected 
fracture we should make careful search for evidences of senile 
osteo-porosis, and ascertain as nearly as possible the amount of 
force applied, and the direction in which it was applied. If the 
general appearances of the patient indicate the existence of senile 
osteo-porosis far advanced, the amount of force has been slight; 
and inflicted in the direction of the axis of the thigh-bone, it is 
more than probable that the fracture has occurred within the 
capsule. If the fracturing force has been greater, and applied 
transversely in the axis of the femoral neck, we have reason to 
expect that the fracture has taken place, at least partly, without 
the capsule. The sudden and complete loss of function of the 
limb after an injury to the hip in a person over fifty years of age 
1 Conservative Surgery, 1867, p. 23. 
2 Bryant’s Practice of Surgery. Edited by J. B. Roberts, p. 842. 64 
speaks strongly in favor of a fracture through the femoral neck. 
We can say with Hodgson : “ If an elderly person, after a fall 
upon the hip, is unable to use the injured limb, it is very probable 
that a fracture of the neck of the femur has been sustained, and 
this is more likely to be the case, if, during the fall, no such 
great force has acted upon the greater trochanter as would be 
necessary to produce a contusion sufficiently severe to render 
the limb useless.” 
Aside from a general consideration of the case, the diagnosis 
will depend on the presence or absence of the two most important 
symptoms, shortening and eversion. Many of our best surgeons 
depend almost exclusively on accurate measurements in render- 
ing a diagnosis. The amount of immediate shortening will vary 
according to the presence or absence of impaction, from a few 
lines to two inches. In impacted fractures the shortening is 
immediate, and remains stationary unless displacement takes 
place, or, during the reparative process, the femoral neck is 
shortened by interstitial absorption. The progressive shorten- 
ing, a few days after the accident, is due to a loosening of the 
fragments which have been in mutual contact by denticulated 
projections, and to a gradual stretching of untorn portions of the 
capsular ligament. Mr. Bryant, in speaking of the utility of his 
“test-line,” says : “ Indeed, as a proof of its use, I may add that 
twenty-five consecutive cases of fracture of the neck of the thigh- 
bone, admitted into my wards to the end of 1877 (the average 
age of the patients being 74), left the hospital with union of the 
broken bones and useful limbs.” 
Dr. J. S. Wight, of Brooklyn, has written an exceedingly 
interesting and practical paper on diagnosis of fractures of the 
femoral neck, based on the report of twenty-one cases.1 For the 
purpose of avoiding errors, which might accrue from asymmetry 
of the lower extremities, he directs that the following measure- 
ments should be taken : “ 1. Inside measurements from the supe- 
rior anterior spines of the ilium to the lower ends of the internal 
1 The Diagnosis of Twenty-one Cases of Fracture of the Neck of the Femur. 
Proceedings of the Med. Soc. of the County of Kings, Oct. 1881. 65 
malleoli. 2. Outside measurements from the superior anterior 
spines of the ilium to the lower ends of the external malleoli. 
3. Measurements from the tops of the great trochanters to the 
lower ends of the external malleoli. 4. Measurements from the 
bases of the tibiae to the lower ends of the internal malleoli. 
5. Measurements from the superior anterior spines of the ilium 
to a line drawn transversely in front between the tops of the 
great trochanters.” 
The object of all these comparative measurements is to deter- 
mine the possibility of original asymmetry of the two limbs, and 
to find out, as far as possible, if the injury to the hip has caused 
any shortening of the limb on the injured side, so that we can 
infer the probability of there being a fracture of the femoral neck. 
He gives the results of examination of twenty-one such fractures, 
where a diagnosis was made without eliciting crepitus. In eight 
of these cases there was probably impaction. The average 
shortening was of an inch, as shown by the inside and out- 
side measurements. In no case of fracture of the femoral neck 
does he use force to find crepitus. He considers the other evi- 
dences of fracture as sufficient to come to a practical conclusion. 
His concluding statements contain so many practical and useful 
suggestions that I do not hesitate to quote them in full. 
“ 1. Moving the outer fragment when it is in contact with 
the inner fragment, will generally carry the inner fragment with 
it, and there will be no crepitus. And, when there is impaction, 
ordinary manipulation will not cause crepitus to be felt. Yet 
crepitus may, at times, be felt when there is impaction of the 
neck of the femur. 2. Moving the outer fragment when it is 
not in contact with the inner fragment, of course will not give 
crepitus. 3. Hence unwarrantable force will be required in order 
to get crepitus in many cases of fracture of the neck of the femur, 
and more than this—an impacted fracture of the neck of the femur 
may be broken up by severe manipulation, and a patient that would 
have had a usefid limb may be quite completely disabled for life— 
for a?i impacted fracture of the neck of the femur is the best setting 
of the bony fragments that a surgeon can have. 
“ In a suspected fracture of the neck of the femur, I examine 66 
all the witnesses of fracture except crepitus, and if these wit- 
nesses agree substantially, I pronounce a verdict in favor of 
fracture of the neck of the femur; and if there is a doubt as to 
the correctness of such a verdict, I give the patient the benefit 
of that doubt by treating the case as if there was a fracture of 
the neck of the femur, and then the surgeon receives a benefit 
from the doubt. But if there is no fracture, the patient has had 
some days of needful rest, and has had a contused hip well 
treated.” 
The instrument recommended is an accurate steel tape- 
line, with feet and inches on one side, and meters and cen- 
timeters on the other side. This tape-line will not elongate 
under tension. It is superfluous to mention that the -patient 
should be placed in the recumbent position, on an even surface, 
when the measurements are taken. It is to be hoped that the 
text-books of the future will say less of crepitus as a sign of 
fracture, and will substitute for it accurate methods of measure- 
ment. 
Eversion of the limb is the next most reliable symptom. In 
impacted fractures the position of the limb depends on the direc- 
tion of the fracturing force. If the force acts in the direction of 
the axis of the cervix, and is severe, causing implantation of the 
whole base of the neck into the trochanteric portion of the 
femur, the limb will retain its natural position. If the anterior 
wall is impacted by force applied against the outer and posterior 
aspect of the trochanter major, the limb will remain in a position 
of inward rotation. From the anterior obliquity of the neck, 
and the usual manner of falling (forwards and-on the side), and 
the thinness of the compacta of the posterior concave surface of 
the neck, as compared with the anterior, we would naturally 
infer that posterior impaction takes place in the great majority 
of cases. This supposition has been abundantly verified by 
clinical observation. Impaction, then, is usually attended by 
eversion. If the fracture is located within the capsule, eversion 
frequently will increase for a few days, or weeks, after the acci- 
dent, from the same causes which give rise to secondary shorten- 
ing. In cases of posterior impaction, where the fragments 67 
remain firmly implanted during the process of repair, eversion 
increases from the weight of the limb and the inflammatory 
absorption of the impacted fragments, permitting increased rota- 
tion outward of the lower fragment. The abnormal position of 
the trochanter major is also an important diagnostic sign. If 
we can exclude dislocation of the hip upward and backward, the 
application of Nelaton’s test may decide the diagnosis. In 
cases of fracture of the neck of the femur, the upper border of 
the greater trochanter will be found above Nelaton’s line, the 
distance corresponding with the amount of shortening. In non- 
impacted fractures, the false point of motion diminishes the axis 
of rotation which the greater trochanter describes in rotating the 
limb. This symptom is mentioned simply to be condemned, as 
the manipulations necessary to apply this test, like the search 
for crepitus, have done a great deal more harm than good. In 
doubtful cases, more particularly when dislocation is suspected, 
the patient should be carefully placed in the erect position, 
when the position of the limb and an examination of the con- 
tour of the hip, as well as an inspection of all the landmarks in 
that locality, will render material assistance in arriving at cor- 
rect conclusions. In case of doubt, if we err at all, we should 
err on the safe side, and treat the case as one of fracture. Many 
cases which were in a condition most favorable for union by 
bone to take place, have been rendered hopeless by not follow- 
ing this rule. The surgeon should ever bear in mind that the 
most favorable cases present the least degree of deformity, and 
that in our anxiety to make a correct diagnosis we sacrifice all 
the conditions which are essential for obtaining bony union. 
In response to my circular as to the possibility of bony union 
after impacted intra-capsular fracture, Prof. Alfred C. Post, of 
New York, after replying in the affirmative, kindly wrote: “But 
the difficulty in proving this proposition depends on two circum- 
stances : I. The want of absolute demonstration that fracture 
has actually occurred. II. The want of opportunity to demon- 
strate by autopsy that bony union has actually occurred. 
“ It is a common thing for a person of advanced age to meet 
with an accident rendering him or her unable to stand or walk, 68 
or to raise the affected limb from the bed. There is a certain 
amount of pain and lameness about the hip, with eversion of the 
toes, and a scarcely perceptible shortening of the limb. On 
careful examination, without using much force, neither crepitus 
nor abnormal motion can be detected. 
“ There is probable evidence, but not certain demonstration of 
impacted intra-capsular fracture. If the surgeon is contented 
with this imperfect diagnosis, he treats the case as one of frac- 
ture, and recovery takes place with a perfectly sound limb. But 
the proof of the fracture and reunion is incomplete. If the sur- 
geon in his anxiety to obtain a perfect diagnosis moves the 
limb freely in all directions, he overcomes the impaction, rup- 
turing the cervical ligament, demonstrates beyond all doubt the 
existence of the fracture, and effectually destroys all hope of 
reunion. For my part, I prefer an imperfect diagnosis for the 
surgeon, and a perfect limb for the patient, rather than a perfect 
diagnosis for the surgeon and a useless limb for the patient.” 
These remarks require no explanation. They are concise, 
plain, practical, and to the point. Unimpacted fractures of the 
neck of the femur seldom give rise to any difficulty in diagnosis; 
the symptoms attending them are so well marked that a correct 
conclusion can be reached without causing needless suffering or 
sacrificing important tissues in searching for any one particular 
positive sign. Fractures with impaction present the same symp- 
toms in a minor degree, their presence can usually be recog- 
nized by a careful consideration of symptoms, the elucidation of 
which does not necessitate the disengagement of the fragments ; 
and, finally, if we have reason to believe that a fracture with im- 
paction exists, although the symptoms are not sufficiently well 
marked to warrant the diagnosis, it is our duty to initiate the 
treatment in accordance with such a supposition. 
XIII. Production of Callus. 
In assuming an affirmative position concerning the possibility 
of bony union after intra-capsular fractures, it becomes necessary, 
from a theoretical standpoint, to allude to the results of recent 6 9 
researches on the production of callus. A brief historical review 
of this subject will be of interest to illustrate in how far the 
opinions of surgeons, regarding the mode of repair after frac- 
tures, have been influenced by the views they entertained as to 
the source from which callus is produced. Galen looked upon 
callus as a substance thrown out around the seat of fracture for 
the purpose of cementing the bones together, without, however, 
becoming changed into bone. Van Swieten claimed that the 
cement of Galen is transforme Ainto bone. J. L. Petit compared 
the healing process of bone with the repair of soft tissues. Du- 
hamel de Monceau attributed to the periosteum and endosteum 
the function of producing callus. Haller, and his prosector 
Detlef, believed that the periosteum took no part in the regene- 
ration of bone, but that callus is derived from the fractured 
ends of the bones, more especially the myeloid tissue. 
Dupuytren, from a clinical aspect, revived the theory of Du- 
hamel, and at the same time attributed to the soft tissues around 
the seat of fracture bone-producing functions. He also intro- 
duced the terms provisional and definitive callus. He made the 
assertion that the definitive callus does not make its appearance 
until four to five months after the injury, and is not complete 
before eight to twelve months. Cruveilhier did not recognize 
the different kinds of callus described by his teacher, and ascribed 
its source to the lacerated soft parts surrounding the fractured 
bone-ends, the periosteum, connective tissue, muscles, tendon, etc. 
Bransby B. Cooper defined callus as a plastic exudation from 
the inflamed ends of the broken bone. Lambron asserted that a 
broken bone can unite directly through the medium of an inter- 
fragmentary callus without the formation of a provisional callus. 
P. Flourens believed that the periosteum alone is capable of 
furnishing material for new bone. Subsequently, however, he 
modified his view, and made a distinction between the periosteal 
or permanent callus, and the temporary or muscular callus. 
August Voetsch speaks of callus as the product of traumatic 
periostitis. Rokitansky declares that callus is developed directly 
from bone and its connective tissue, including the periosteum. 70 
Reinh. Hein,1 who has studied this subject with great care by 
means of the microscope and experimentally, has come to the 
following conclusions : The regeneration of broken and resected 
bones commences, as a rule, from connective tissue. The pro- 
cess of regeneration is, at times, limited solely to the connective 
tissue of bone and periosteum, but in most cases the connective 
tissue of adjacent parts, more especially the muscles, contribute 
to it. 
According to Virchow, is produced from connective 
tissue outside of the bone, and as well as from myeloid tissue 
in the interior of bone. 
Preparatory to his studies on the production of callus, Hof- 
mokl2 has traced the histology of bone during foetal life. During 
the development of bone, cartilage-cells are transformed into 
bone-cells. The primary marrow spaces are formed in the inte- 
rior of cartilage-cells, which, with their contents, are transformed 
into marrow spaces. The normal development of callus appears, 
histologically, as a return of perfect bone into its primary stage, 
embryonal development. The periosteum, bone, and marrow 
are active in the production of callus. The neighboring soft 
tissues assist in the process of repair only in so far that they 
may become converted into bone. In point of importance, the 
callus-yielding tissues are arranged in the following order, peri- 
osteum, marrow, bone. The bone-cells take an essential part in 
the production of callus, since they become enlarged, multiply, 
and thus form marrow spaces with myeloid cells; changes which 
are observed very distinctly upon the surfaces of the ends of 
broken bone, on the periosteal, as well as on the medullary side. 
Ossification invariably begins from the margins of a medullary 
space. 
Gegenbauer3 takes the ground that bone is produced directly 
from connective tissue. Sharpey’s fibres, if traced carefully, 
1 Ueber die Regen. gebrochener u. resec. Knochen. Virchow’s Archiv f. Path. 
Anat. B. 15, 1858. 
2 Ueber Callusbildung. Virchow u. Hirsch, Jahresbericht, 1874, p. 294. 
* Ueber die Bildungdes Knochengewebes. 2 Mitth. Jenaische Zeitschr. f. Med. 
B. 3, S. 206. 71 
always spring from a bony point between the Haversian canals, 
from which point they radiate towards both sides into the lamel- 
lar systems. The fibres form networks; and, at points of inter- 
section, bone-cells are produced, and a deposit of lamellae takes 
place around connective-tissue fibres. The intercellular sub- 
stance is regarded by Gegenbauer as a product of secretion of 
cell elements, and not as a metamorphosis of cells, as was asserted 
by Waldeyer, who believed that the protoplasm of the cells is 
transformed in part or entire into basis substance. 
Kassowitz,1 in carefully studying the process of ossification, 
has come to the conclusion, that the deposit of earthy material 
in the fibrillary reticulum, as well as in the osteoblasts, is depen- 
dent on the condition of the circulation. The fact that the im- 
mediate neighborhood of the vessels does not ossify, and that 
the deposition of earthy material takes place in advance of the 
vessels, induced him to accept the theory that active circulation 
prevents the deposition of earthy material, while diminution of 
blood pressure favors ossification. 
Rigal and Vignal’s2 experimental researches on the formation 
of callus have an important and direct bearing on the process 
of repair after fractures. Their practical deductions may be 
summarized as follows: If periosteum is exposed to a moderate 
degree of irritation, new bone is produced from the marrow 
beneath the point of irritation directly, without passing through 
the stage of cartilage. If irritation is increased by displacing 
the fragments and rubbing the soft parts, the result is cartilage 
beneath the periosteum, which is subsequently converted into 
bone. If the periosteum is completely destroyed by scraping 
the bone, the defect is repaired by a connective-tissue cicatrix, 
which somewhat resembles periosteum. If a circular piece of 
periosteum has been thus removed, and the bone is broken after 
cicatrization has been completed, perfect union is the result. If 
the cortical layer of bone is scraped away down to the medullary 
canal, the defect is replaced by myeloid callus. If the medullary 
1 Die Normale Ossification, etc, Wiener Med. Jahrb., 1879, S. 145. 
* Virchow u. Hirsch’s Jahresbericht, 1883, vol. i. p. 263. 72 
canal is not opened, the process of regeneration is slower, as a 
considerable period of time will elapse until the resulting rare- 
fying osteitis opens the Haversian canals sufficiently to furnish 
the required amount of cellular elements from the medullary 
tissue for the reparative process. 
Mr. McNamara, in alluding to this subject, in his excellent 
work,1 as applied to the neck of the femur within the capsule, 
says : “ The ossification of the soft structures which grow from 
the medullary spaces of the broken bone is, in the human 
subject, a protracted process, and the tissues concerned are so 
delicate, that unless they are protected from injury by means of 
artificial splints, they seldom unite at all.” 
It is now generally conceded that the provisional or tempo- 
rary callus is the product of the periosteal and para-periosteal 
tissues, while the definite or permanent callus is produced 
directly from the osteoid and myeloid tissues. The provisional 
callus is nature’s splint, its only object being to immobilize the 
parts until the definitive callus firmly and permanently unites 
the fragments. The temporary callus is accidental, and appears 
earliest and most copiously where para-periosteal tissues are 
most abundant, and motion between the fragments greatest; the 
intermediate or permanent callus is produced later, and is most 
certain to take place in spongy bones. Fractures of the neck of 
the femur, partly within and partly without the capsule, unite with 
as much certainty as fractures in other localities in the usual way, 
by the formation of external and intermediate callus. In this 
variety of fractures an abundance of callus, sometimes bordering 
on deformity, designates the exact location of fracture. In intra- 
capsular fractures, as in fractures within any other joints, the 
conditions for the formation of external callus are unfavorable; 
hence, we find in all cases purporting to be bony union imper- 
fect, if any, attempts in this direction. Anatomy, physiology, 
and experimental research, all tend to prove that in cases of 
intra-capsular fracture we have all the conditions present which 
are necessary for the production of intermediate callus, provided 
1 Diseases of Bones and Joints, 1881. 73 
the fragments are kept in immediate contact for a sufficient 
length of time. The neck of the femur has been rendered vas- 
cular and porous by senile degeneration, and is supplied with an 
abundance of bone-producing myeloid tissue. The vessels in 
the red marrow, according to recent observation, are also ad- 
mirably adapted for the purpose of establishing early and free 
collateral circulation. In 1869, Hoyer made the discovery that 
the small veins in the red marrow are without walls, their lumen 
being bounded by the parenchyma of the marrow. Most of the 
capillaries are also without walls. The small arteries of the 
marrow consist of a delicate tube of endothelium, and a single 
layer of muscular fibres. Rindfleisch corroborated these obser- 
vations. From this peculiar structure of the vessels in marrow, 
it is easy to understand how readily the interrupted circulation 
could be re-established through immediate contact of the severed 
vessels, or by canalization through the medium of a blood-clot 
or mass of exudation material. That intermediate callus is 
thrown out in cases of intra-capsular fractures, where the frag- 
ments have not been kept in apposition, and bony union has 
failed to take place, is evident from examinations made of speci- 
mens where the broken surface of the upper fragment, and 
sometimes the connecting ligamentous band, presented well- 
marked spurs of hard compact bone; an appearance alluded to 
by many observers, but more particularly by Sir Astley Cooper 
and Mr. MacNamara. 
XIV. Can Loose Detached Pieces of Bone Produce Callus, and 
Aid in effecting Bony Union ? 
It has been urged against the possibility of bony union after 
intra-capsular fractures that the upper fragment is not furnished 
with a sufficient vascular supply to maintain nutrition, much less 
to produce callus. Clinical and post-mortem evidence, however, 
tend to prove that in the great majority of cases the fragment 
retains its vitality, and in many instances where bony union has 
failed to take place, the fractured surface shows evidence of callus 
production. In such cases where the fracture was complete, and 74 
the fibrous investment of the neck was completely torn across, 
the requisite vascular supply must have been furnished through 
the round ligament. If the upper fragment was not nourished 
from some source it would more frequently disappear by absorp- 
tion, or suffer necrosis, and act as a foreign body, than has been 
actually observed at the bedside or in the post-mortem room. 
The establishment of collateral circulation through the liga- 
mentum teres, in maintaining the vitality of the upper fragment 
after intra-capsular fractures, is, unquestionably, of more frequent 
occurrence and of greater importance than many are ready to 
admit. 
Taking it, however, for granted that the ligamentum teres 
furnishes no vessels to the upper fragment, I shall, nevertheless, 
endeavor to show that in case of impaction it can retain its 
vitality, assist in the formation of callus, and enter into the pro- 
duction of bony union. It has been known for a long time that, 
in compound fractures, perfectly detached splinters remain in- 
ocuous, and assist in the production of bony callus without giving 
rise to any particular symptoms of irritation. John Hunter1 
expressed himself as follows on this subject: “Adhesion of the 
detached splinters also takes place, not only in those which are 
attached to the soft parts, but even such as are entirely loose. 
(This was shown in a thigh-bone in which one of the splinters 
had moved quite around on its axis, and adhered by its outer 
surface to the bone.) I never examined a compound fracture 
without finding some of those loose pieces, which shows they 
must be common. Their union must be similar to that in the 
transplanted teeth.” 
Ollier and Philip Walther inform us that they have seen the 
disk of bone separated by the crown of the trephine, and, entirely 
removed, reunite with the surrounding bone when replaced. 
Prince,2 in speaking of the drilling operation for ununited 
fractures, says: “When the operation results in the effusion of 
plastic lymph without suppuration, there are new centres of 
> Works of John Hunter. Edited by James T. Palmer, vol. i. p. 502. 
2 Plastics and Orthopedics, 1871. 75 
ossification in the chips of bone cut off by the drill. These are 
left in the track of the drill; some of them in the soft callus 
between the ends of the fragments. That these minute frag- 
ments of bone become parts of the living tissue is certain; for, 
if they did not, they would, by the offensive emanations of dead 
bone, excite suppuration and work their way to the exterior. 
The importance of these little fragments cut off by the drill, as 
centres of ossification, may have received too little attention.” 
Cases, where fragments of bone from the internal table of 
the skull were completely isolated and yet became attached to 
the surrounding bone by permanent callus, are reported by 
Samuel Thomas, Soemmering, Bernhard Beck, von Bergmann, 
H. Demme, Cluston, Richet, and Ziegler. 
Lossen1 has studied this subject in connection with commit 
nuted fractures of the long bones, and has come to the conclu- 
sion that not all loose fragments necrose, but that many are 
incorporated in the callus and form part of the living ridge 
between the fractured ends. He is of the opinion that the 
vessels of the fragment, at some point, unite with other vessels 
in the lacerated district, thus establishing the circulation. In 
one of his illustrations may be seen a fragment, five centimeters 
long and one centimeter broad, completely isolated and denuded 
of its periosteum, which, with its wedge-shaped end, had been 
driven into the medullary cavity. The upper end was perfectly 
united with the bony mass filling the medullary cavity, and its 
lower end could be seen aside of the necrotic portion of the 
fractured bone. It can safely be assumed in this instance, that 
the vessels in the medullary cavity vascularized the fragment 
and preserved its vitality. Klebs gives a description of a similar 
specimen, and believes that the vitality of the medullary tissue 
and periosteum is sufficient to sustain the physiological activity 
of isolated fragments of bone under favorable circumstances, 
production of new bone taking place from the transplanted 
piece of bone. 
1 Kriegs-chirurg. Erfahrungen aus den Barackenlazarethen zu Mannheim, 
Heidelberg u. Karlsruhe, 1870, 1871. Deutsche Zeitschr. f. Chirurgie. Band II. 
S. 25. 76 
v. Bergmann describes a specimen of comminuted fracture of 
the femur, the result of a gunshot wound during the Turko- 
Russian War, where a fragment, 7.2 ctms. long, 15 mm. broad, 
and 6 mm. thick, had become completely detached from the 
soft tissues, and had been forced into the medullary cavity, 
where it became firmly united with the fractured ends of the 
bone and the intervening bony callus. 
Meek’ren made a series of experiments on animals for the 
purpose of establishing the fact that isolated fragments of bone 
devoid of periosteum would, under certain favorable conditions, 
retain their vitality, and were capable of forming an attachment 
to bone through the intervention of a bony callus. He removed 
by the trephine, from the skull of a dog, a disk of bone and re- 
placed it. On the twenty-second day he found this disk firmly 
united by bony callus to the surrounding bone. 
Flourens transplanted a piece of rib from a dog, under the 
periosteum of the tibia, of the same animal, and in due time 
found it united by bony callus. The well-known experiments of 
Ollier are familiar to every surgeon, but as he placed great im- 
portance on the preservation of the periosteum as an essential 
condition for success in bone transplantation, they are not of 
great importance for our purpose. The experiments of Kos- 
mowski, to ascertain the exact mode of repair in cases of fracture 
of the skull, indicate that the reparative process in general, and 
the union of loose splinters of bone in particular, are accom- 
plished by the osteo-genetic functions of the medullary tissue. 
Of great practical importance are the experiments of Jakim- 
owitsch.1 The experiments were made exclusively on the long 
bones of dogs, and the vascular connections of the transplanted 
or replanted piece of bone were demonstrated by means of 
gelatine injections stained with Berlin blue. To insure success, 
he places great importance on securing accurate apposition and 
perfect immobilization of the fragment by stitching the perios- 
teum or soft parts over it, and applying elastic pressure and a 
fixation splint of plaster of Paris. The operation was always 
1 Versuche liber d. Wiederanheilen vollkommen getrennter Knochensplitter, 
Deutsche Zeitschr. f. Chir. B. XV. 77 
done under strict antiseptic precautions. To prove that the 
detached bone had become a part and parcel of the living bone, 
some of the animals were fed on madder after the example of J. 
Wolff. This staining material is deposited during life in the 
new bone around the fragment in greatest abundance, while it 
also follows the new vessels into the transplanted piece. In 
almost all of the cases after death, the vessels of the limb ope- 
rated upon were injected with gelatine stained with Berlin blue, 
which afforded an excellent opportunity to follow the course of 
the vessels into the transplanted or replanted piece of bone. In 
other instances the examination was made even more complete 
by decalcifying the bone and submitting it to a microscopical 
examination. The results of his experiments induced him to 
conclude that replantation and transplantation of isolated frag- 
ments of bone can be successfully performed if the detached 
piece retains its former relations to its immediate vicinity. 
Under such circumstances the piece of bone becomes a living 
part of the bone through the medium of the intermediate callus, 
and the re-establishment of vascular connections with the sur- 
rounding vessels. 
Guilt1 describes and furnishes illustrations of two specimens 
of fracture of the femur, where a large fragment of the cortical 
layer near the centre of the shaft had become completely de- 
tached, and in one instance turned completely around, and yet 
they were found firmly attached by bony union. Both speci- 
mens are from the Museum of the Royal College of Surgeons 
of England, being numbered 108 and 454. He states further, 
that in comminuted fractures, where many loose fragments must 
exist, they furnish no obstacle to ready bony union. The frag- 
ments either take part in the formation of callus, or are im- 
bedded in the mass, and eventually are removed by a slow 
process of absorption. 
MacEwen2 resorted to transplantation of small pieces of bone 
to restore extensive pathological defects, believing that the 
blood-clot between the fragments served as a medium through 
1 Op. cit. 
2 Virchow u. Hirscli, Jahresbericht, 1881, vol. ii. p. 332. 78 
which the vascular connection between the detached bone and 
surrounding tissues is established. He operated successfully 
upon a case of necrosis of the humerus, with extensive loss of 
bone substance, by transplanting into a groove made in the bone 
numerous wedge-shaped pieces of bone derived from the tibiae 
of six rickety children, the fragments being supplied with perios- 
teum and marrow tissue. The bone grafts retained their vitality, 
united with, and grew with, the bone. 
Prof, von Nussbaum has introduced transplantation of bone 
as a legitimate operation in surgery, for the purpose of supply- 
ing bone defect in cases of ununited fracture, and his success, as 
well as similar operations by several other German surgeons, 
certainly prove that the vitality of even compact bone is sus- 
tained by a minimum amount of blood-supply through a narrow 
strip of periosteum. 
Spongy bone, containing an abundance of marrow tissue and 
a rich supply of bloodvessels, is endowed with a higher degree 
of vitality than compact bone; and is, consequently, better 
adapted to enter into union with surrounding tissues, in case it 
has become detached. 
It has also been established by way of experiment, that in 
animals marrow can be transferred to different parts of the body, 
and if the operation is successful, the transplanted marrow will 
produce bone. 
Baikow, Goujon, and Ollier were successful in their auto- 
transplantations of marrow, but failed when the tissue was trans- 
ferred from one animal to another. The most extensive and 
reliable experiments on marrow transplantation have been made 
by P. Bruns.1 He operated upon sixty chickens and six dogs. 
He failed repeatedly as long as he transplanted the marrow 
from animal to animal, but as soon as he limited his experiments 
to auto-transplantation, he succeeded in the great majority of 
cases. Of nineteen auto-transplantations, twelve proved sue- 
1 Uel>er Transplantation von Knochenmark, Archiv. fur Klinische Chirurgie. 
B. XXVI. S. 661. 79 
cessful, three failed on account of suppurative inflammation fol- 
lowing the operation, and in four the transplanted tissue was 
absorbed. 
The operation consisted in removing cylindrical pieces of 
marrow from the femur or tibia, 2 to 3 ctms. in length, and 
transplanting them under the skin of the same animal. After 
the fourteenth day foci of ossification could be distinctly seen, 
which enlarged and became confluent after the twentieth to the 
twenty-fourth day. Ossification is preceded by an active proli- 
feration of spindle-shaped cells. 
The formation of bone takes place from the pre-existing 
osteo-blasts in marrow, an opinion which is also supported by 
Waldeyer. The yellow and red marrow were used in these 
experiments, and proved alike capable of producing bone. 
The success attending bone and marrow transplantation con- 
stitutes a potent argument in favor not only of the possibility 
but probability of bony union after intra-capsular fractures, in 
the event that the fractured ends are in accurate and undisturbed 
apposition for the requisite length of time. The neck of the 
femur in a state of senile atrophy furnishes a number of favorable 
conditions for a speedy production of bony callus. It is very 
vascular, the compact tissue attenuated, the spongiosa exceed- 
ingly porous, and its meshes distended with an abundance of 
bone-producing myeloid tissue. If perfectly detached and de- 
nuded pieces of compact bone, and isolated masses of marrow, 
can be transferred to a distant part of the body, and when pro- 
perly transplanted, they not only retain their vitality, but become 
vascular and produce bone, I can see no reason why the upper 
fragment in intra-capsular fractures, which is still retained in its 
natural location, should not manifest the same power of self- 
preservation and repair. In impacted fractures the bone-tissue, 
marrow, and lacerated vessels are brought in such immediate 
contact, that the reparative process is taxed only to its minimum 
extent in restoring the continuity of.the bone. In these instances 
we have an example of bone and marrow transplantation under 
the most favorable conditions, and the reason it does not succeed 80 
oftener, is simply because these favorable conditions, as a rule, 
do not exist, or are not allowed to exist, for a sufficient length 
of time. 
XV. Specimens of Bony Union after lntra-capsular Fracture. 
It is not my purpose to enter into a discussion of the many 
specimens for which bony union has been claimed by their 
possessors. Many of them have been the object of the most 
rigid criticism, at different times and at the hands of different 
writers. While careful and competent men have brought these 
specimens before the profession as typical examples of union by 
bone within the capsule, equally good observers have failed to 
see the evidence which justified these claims. I have tabulated 
only the cases reported by competent observers, and where the 
diagnosis was verified by a post-mortem examination. No. 
Name of 
Reporter. 
Where mentioned or classified. 
In whoso possession. 
I 
Adams, K. 
Todd’s Cyclopedia, vol. ii. p. 813. 
Adams. 
2 
Adler, 
Am. Journ. Med. Sci., April, 1873. 
Adler. 
3 
Bardeleben, 
Lehrbuch d. Ohir. B. ii. p. 477. 
Govrand. 
4 
Hrulatour, 
Mod. Chit-. Transactions, vol. xiii. 
Brnlatour. 
s 
Brvant, 
Bryant’s Sargerv, p. 843. 
Museum Guy’s Hospital. 
6 
Callender, 
St. Barthol. Hosp. Rep., vol. i. p. 154. 
7 
ChaHsaignac, 
TlifeRe inaugurate. 
Van Iloute. 
8 
ChelliiR, 
Ilandb. d. Chir. B. i. p. 319. 
Chelius. 
9 
Cbelius, 
Handb. d. Cliir. B. i. p. 319. 
Soemmering’s collection. 
IO 
Cushing, 
Bigelow, The Hip, p. 133. 
11 
Earle, 
Practical Obser. in Surgery, 1823^.97. 
12 
Fawcington, 
Am. Journ. Med. Sci., vol. xv. p. 534. 
Fawciugton. 
J3 
Fischer, 11. 
Personal communication. 
Pathological Museum, Breslau. 
J4 
Fischer, H. 
Personal communication. 
Pouflck. 
15 
Field, 
Aniesbary on Fractures. 
Field 
16 
Beddings, 
Am. Journ. Med. Sci., Jan. 1847. 
Beddings. 
17 
G urlr, 
Knochen-braeche, vol i. p. 308 
Giessen Museum. 
18 
Hamilton, 
Hamilton on Fractures, p. 407. 
Hamilton. 
19 
Harris. 
Am. Journ. Med. Sci., vol. xviii. p. 246. 
Harris. 
20 
Holthouse, 
Holmes’s System of Surgery, vol. ii. 
Med. Cliir. Transactions, vol. xiv. 
St. George’s Hosp., Spec. N0.112. 
21 
How-hip 
Howship. 
22 
Hutchiusou, 
Illustr. Clin. Surgery, vol. ii. p. 8. 
‘‘Museum Notes” of Jan. 23, 1870. 
Leeds Hospital Museum. 
23 
llatchinson, 
Museum of Trinity Coll. Dublin. 
24 
Jones, 
Med. Cliir. Transactions, vol. xxiv. 
Jones. 
25 
Kocher, 
Personal communication 
Pathological Museum, Berne. 
26 
Kroenlein, 
Personal communication. 
Pathological Museum, Zurich. 
27 
Langstalf, 
Med. Chir. Transactions, vol. xiii. 
Langstaff. 
28 
Maas, 
Personal communication. 
Pathological Museum, Freiburg. 
29 
M algaigne. 
A Treatise on Fractures, 1859, p. 555. 
Musee Dupuvtren. 
3° 
March, 
Trans. Am Med Association, 1858. 
Museum Albany College. 
31 
March, 
Trans. Am. Med Association, 1858. 
Museum Albany College. 
32 
March, 
Trans. Am Med. Association, 1858. 
Museum Albany College. 
33 
Mussey. 
Am. Journ. Med. Sci., 1857, P- 299. 
Mussey. 
34 
Mussey, 
Am. Journ. Med. Sci., 1857, p. 299. 
Mussey. 
35 
Massey, 
Am. Journ. Med. Sci., 1857, p. 290. 
Mussey. 
36 
Pope, 
Hamilton on Fractures, p. 407. 
37 
Po st, 
l’ersoual c mmunicatiou. 
Destroyed in fire of Univ. Med. 
Col 
38 
Uiedinger, 
Studien iiber grund u. einkeilang der 
Scheukelhalsbrueche, 1874. PI. xi. 
Wiirtzburg Museum. 
39 
R oberts, 
Personal communication. 
Museum Pennsylvania Hospital. 
40 
Sands, 
New York Med. Record, June 1, 1869. 
Sands. 
41 
South, 
Clielius Surgery by South, vol. i p.621. 
South. 
42 
South, 
Quoted by Hamilton, Ed. 1871. p. 363. 
Museum St. Barthol. Hosp. 
43 
Smith, 11. II 
Priuc. aud Prac. of Surg., vol. ii. p 610. 
Wisteraud Horner Museum. 
44 
Smith, H. H. 
Priac. and Prac. of Snrg., vol. ii. p. 610. 
Smith. 
45 
Smith, R. W. 
Dublin Joara. Med. Sci., Jan. 1873. 
Museum Trinity College. 
46 
Smith, R. W. 
Dublin Joaru. Med. Sci.. Jan. 1873. 
Museum Trinity College. 
47 
Spalding, 
Bust. Med. & Snrg. Journ., Mar. 4,1858. 
Spalding. 
48 
Stanley, 
Med Chir. Review, vol. xii. p. 170. 
Stanley, 
49 
Swan, 
On Diseases of Nerves, p. 304. 
Swan. 
5° 
Selden, 
Trans. Virginia State Med. Soc., 1877. 
Selden. 
5i 
Selden, 
Trans. Virginia State Med Soc., 1877. 
Selden. 
52 
Parker, W. 
Johnson, Intracap. Fract., 1857. p. 28. 
W. Parker. 
53 
Zeiss, 
Hamilton, Fract. and Dial., 1880, p. 406. 
Hamilton, Fract. and Dial., 1880, p. 406. 
Zeiss. 
54 t 
Zeiss, 
Zeiss. 
I will only give a description of a few undoubted specimens 
for the purpose of illustrating the alterations which take place 
in the femoral neck during the process of repair. R. Adams 
(Table, No. i): “The round ligament was sound. The head 
and neck of the bone had lost their normal obliquity, and were 
directed nearly horizontally inwards ; the cervix presented, both 
anteriorly and posteriorly, evidence of a transverse intra-capsular 82 
fracture having occurred; the globule-shaped head was closely 
approximated behind and below to the posterior inter-trochan- 
teric line, and to the lesser trochanter, so that the neck seemed 
altogether lost, except anteriorly, where a very well-marked ridge 
of bone showed the seat of the displacement and of the union 
of the fragments. This ridge is evidently the upper extremity 
of the lower fragment of the cervix. The fracture of the neck 
posteriorly was found to have been closer to the corona of the 
head than anteriorly, and the fibro-synovial fold in the former 
situation remained unbroken. A section has been made of the 
bone through the head, neck, and trochanter; one portion has 
been subjected to maceration and boiling; and the bony union 
has been unaffected by these tests. Scarcely any portion of 
the neck can be said to have been left. The section shows the 
compact line which denotes the union of the fragments; the 
head and shaft seem to be mutually impacted into each other, 
and almost the whole of the cervix has been absorbed; the line 
of union is serrated, solid, and immovable; and the cells of the 
head and substance of the shaft seem to communicate freely in 
all places, except where the thin line of compact tissue here and 
there points out the seat of the welding together of the remain- 
ing portions of the head and neck of the femur.” 
As Mr. R. Adams, in his article, “ Abnormal Conditions of 
the Hip-joint,” in Todd's Cyclopcedia, took the ground that bony 
union was impossible, and commented unfavorably on the cases 
which had been reported as cases of bony consolidation, it is 
evident that this case must have presented convincing proof in 
order to change his views on this subject. The value of this 
specimen is increased by a full clinical history of the case. 
Chorley’s specimen, described by Jonathan Hutchinson (Table, 
No. 22): “The bone, which supplied the illustration I now pub- 
lish, is one of the many treasures of the Pathological Museum of 
the Leeds Hospital. The drawings were (by permission) made 
for me by Mr. Tuffen West, some years ago, at the time of the 
visit of the British Medical Association to Leeds. The specimen 
is the best example of union of an intra-capsular fracture with 
which I am acquainted, and, as it appears to be beyond all cavil, 83 
I have great pleasure in endeavoring to secure for it a wider 
recognition. The drawings show so exactly the condition of the 
bone that it is scarcely necessary to describe them. (Figs. 9, 10, 
11.) It will be seen that, whilst the transverse fracture is wholly 
Fig. 9. 
Anterior view of Bony Union after Fracture of Neck of Femur. (Hutchinson.) 
within the capsule, and nowhere more than half an inch from 
the articular head, yet, that on the back of the cervix, some 
'ragments have been detached, which pass much further out. It 
is worth notice, also, that in the section of the bone, the edge of 
the lower outer layer is seen to catch in the cancellous tissue of 
the articular fragment, thus constituting a degree of impaction, 84 
which, no doubt, much favored fixation and union. The speci- 
men was obtained by the late Mr. Chorley, formerly Surgeon 
Fig. IO. 
Posterior view of Bony Union after Fracture of Neck of Femur. (Hutchinson.) 
to Leeds Infirmary, from the body of a gentleman, aged seventy, 
whom he had attended several years before his death, with the 
diagnosis of fracture of the neck of the thigh-bone. The treat- 
ment had been by very careful immobilization and long-con- 
tinued confinement to bed. The recovery had been such that 
the patient had been able to walk well with a stick.” 
The well-known ability of Mr. Hutchinson is a sufficient guar- 
antee for the genuineness of this specimen. Fig. 11. 
Vertical section showing Bony Union after Fracture of Xeck of Femur. (Hutchinson.) 
Riedinger’s specimen (Table, No. 38): “The neck of the femur 
is considerably shortened, and the head inclines so far backward, 
that, superiorly, it comes almost completely in contact with the 
posterior inter-trochanteric line. From behind, only the carti- 
laginous surface of the head can be seen; downward, the neck is 
visible to the extent of 1 ctm. Above, the length of the neck 
is ctm. On the anterior surface, the well-marked denticulated 
line of fracture can be seen close to the head. Its length is 3 
ctm. A longitudinal section of the upper portion of the femur, 
into an anterior and posterior half, discloses the line of fracture 86 
in the loosely cancellated tissue of the spongiosa, and more 
clearly shows the impaction of the lower fragment into the head, 
Fig. 12. 
Anterior view of Bony Union after Intra-capsular Fracture. (Riedinger.) 
which is especially well marked in the lower cortical portion of 
the neck (Adams’s arch). The length of the implanted portion 
amounts to 2 ctm.” (Figs. 12, 13, 14.) 
As Riedinger has made fractures of the neck of the femur a 
special study for many years, no one would for a moment doubt 
the correctness of his description, or the authenticity of this 
specimen. 
Gurlt’s specimen (Table, No. 17): “The fracture runs obliquely 
through the neck of the femur; in front it is three-fourths of an 
inch from the base of the neck, posteriorly a little less. The 
head of the bone is displaced somewhat backward and down- 87 
ward, and is united by bone, although the line of fracture is still 
visible in places.” (Pigs. 15, 16.) 
Gurlt’s name occupies a position foremost among writers on 
fractures, present and past, and his decision admits of no appeal. 
Fig. 13- 
Posterior view of l!ony Uuion after Intra-capsular Fracture. (Riedinger.) 
To prove the validity of any specimen, it is necessary to exam- 
ine for evidences which will warrant an affirmative answer to the 
following questions: 1st. Has the bone been fractured? 2d. 
Was the fracture within the capsular ligament? 3d. Has the 
racture consolidated by bone? 
The first question can only arise in specimens without a clini- 
cal history. Post-mortem specimens have been brought forward 
as instances of bony union, when the changes in the bone were 
due to other causes, as rickets or senile coxitis. In all cases of 88 
interstitial absorption without fracture, the wasting of the neck 
takes place in a more symmetrical manner; the neck may 
become greatly shortened, and yielding to the vertical pressure, 
the head may descend to a level with the upper border of the 
Fig. 14. 
Vertical section showing Impaction with Bony Union after Intra-capsular Fracture, 
(Riediuger.) 
trochanter major, but does not incline backward, as is generally 
the case when fracture has taken place. In senile coxitis the 
head is enlarged, and presents the characteristic deep depression 
for the round ligament, at the same time its upper and anterior 
surface is deprived of cartilage, and presents an eburnated appear- 
ance. (Fig. 17.) If rickets, or senile osteo-malacia, has been the 
cause of the deformity, the disease affects both joints simultane- 
ously. An intra-capsular fracture always unites with some degree 
of deformity. Longitudinal sections of the specimens usually dis- 
close the direction and extent of displacement of the fragments. 
From causes which have been previously enumerated, absorption 
of the neck is more extensive in the posterior portion of the 89 
neck than in the anterior, permitting the head to approach the 
posterior inter-trochanteric ridge. If the fracture has been 
entirely within the capsule, little or no provisional callus is found 
over the seat of fracture, while in senile coxitis irregular bony 
Fig. 15- 
Fig. 16. 
Fig. 15. Anterior view of Bony Union after Intra-capsular Fracture. (Gurlt.) 
Fig. 16. Section through Neck showing Bony Union within Capsule. (Gurlt.) 
masses are found over different portions of the neck. The writer 
on fracture of the neck of the femur in Eiilenburg's Encyclopaedia 
says: “If bony union takes place, the femoral neck disappears 
almost completely by absorption, the head coming nearly in 
contact with the trochanteric region. Little or no callus is found 
upon the surface of the neck.” 
Bardeleben1 indicates the following appearances as charac- 
teristic of union by bone after fracture within the capsule: “If it 
can be ascertained with certainty that a fracture had occurred 
during life, and on post-mortem examination we find a bone 
cicatrix, that is a disk of dense bone through the intra-capsular 
portion of the neck, and there are no other evidences of syno- 
1 Lehrbuch d. Chirurgie, 1871, B. II. S. 473. 90 
vitis or osteitis, then we are justified in claiming for such a case 
that a fracture within the capsule has united by bone.” 
Fig. 17. 
Appearances of Head and Neck of Femur in Senile Coxitis. (Richardson.) 
Erichsen1 remarks: “ When bony union has taken place, the 
head will usually be found somewhat twisted round, in such a 
1 The Science and Art of Surgery, 1869. 91 
way that it looks toward the lesser trochanter, owing to the 
eversjon that has taken place in the lower fragment.” 
Gurlt1 states: Absorption of the fragments takes place exclu- 
sively in fractures involving joints, and proceeds hand in hand 
with the process of repair. In some joints, as in the hip-joint, 
it may be so extensive that almost the entire neck is absorbed. 
This is more likely to be the case if the fracture is within the 
capsule. In such cases the head of the bone may be very near 
the great trochanter at the base of the cervix femoris. The 
cause of this absorption is not known. 
The characteristic deformity presented by specimens of bony 
union of fracture through the neck of the femur corresponds to 
the direction of the displacing forces—shortening and eversion. 
The cause of the primary displacement is the fracturing force 
itself. The secondary displacement takes place upon the acces- 
sion of inflammatory osteo-porosis, and is the result of softening 
and absorption of the bone, muscular contraction, and gravi- 
tation. 
Exacting critics have questioned the validity of many speci- 
mens of bony union on the ground that the fracture was not 
purely intra-capsular. Indeed, this argument has been the main 
support of all modern believers in non-union. In all specimens 
of bony union, the point of attachment of the posterior portion 
of the capsular ligament is changed; instead of being inserted 
near the middle of the femoral neck, it is found attached at or 
near the posterior inter-trochanteric line, and on this account it 
has been asserted that the fracture extended beyond the capsular 
ligament. I believe, however, that this alteration in the attach- 
ment of the capsule admits of a more satisfactory explanation. 
All fractures are followed by inflammatory osteo-porosis in the 
ends of the broken bones, and this is especially well marked in 
the articular extremities of the long bones. During an inflamma- 
tion of this kind, the periosteal covering of the bone is loosened, 
and readily changes its relative position to the bone during the 
process of interstitial absorption, and carries with it the capsular 
1 Handbuch d. Lelire v. d. Knochenbruechen, 1862, vol. i. 92 
ligament with which it is intimately connected. Interstitial ab- 
sorption precedes and attends the production of callus, and is 
most active in that portion of the bone supplied with the greatest 
number of bloodvessels. The upper fragment being scantily sup- 
plied with bloodvessels, absorption, if it takes place at all, occurs 
at a later date, and progresses very slowly; while the reverse is 
the case in the lower fragment. The point of attachment of the 
capsular ligament is no indication as to the seat of fracture, as 
almost the entire femoral neck may disappear by absorption, 
and the capsule approaches the trochanteric region in propor- 
tion to the amount of bone absorbed. A more important sign 
is the presence or absence of new bone upon the outside of the 
capsule. In intra-capsular fractures little or no external callus 
is produced within or without the capsule; while extra-capsular 
fractures, from obvious anatomical reasons, yield an abundance 
of exuberant callus, part of which at least remains permanently. 
The last test is to ascertain the nature of the connecting medium. 
This can be done by submitting the specimen to a microscopical 
examination, or to the boiling process. In the first test the 
tissues at the seat of fracture will show the histological elements 
of true bone in all genuine specimens. The boiling process will 
destroy the ligamentous union between the fragments in all 
doubtful cases; and is, therefore, the simplest and most certain 
method to demonstrate the restoration of the continuity of the 
broken bone. 
In recapitulation, it may be stated, that the validity of a speci- 
men is established whenever the clinical history has revealed the 
existence of fracture during life, and the post-mortem examina- 
tion has demonstrated that the fracture has been within the cap- 
sule, and that the union is by bone. 
XVI. Non-union after Intra-capsular Fractures. 
Sir Astley Cooper enumerates the causes of non-union under 
the following heads: I. Want of proper apposition of the bones. 
2. Want of pressure of one extremity of the broken neck upon 
the other, even though the limb preserved its length, and the 93 
fractured parts are consequently not much displaced. 3. Ab- 
sence of nutrition in the head of the thigh-bone. 4. Atrophy 
of bone. 
The first cause can only apply to non-impacted fractures, 
where treatment has failed to keep the fractured ends in imme- 
diate and uninterrupted contact for a sufficient length of time 
for union by bone to take place, and as such constitutes the 
principal, if not the only, cause of non-union. There is no other 
fracture where immobilization is so difficult to accomplish. 
Every movement of the body disturbs the fractured ends. No 
apparatus yet devised has answered the first and principal indi- 
cation in the treatment of all fractures, namely, to secure immo- 
bility and permanent coaptation. 
Colies,1 who fully endorses the views of Sir Astley Cooper on 
the subject of fractures within the capsule, in speaking of the 
causes of non-union, remarks: “ However this may be, I think 
the difficulty of keeping the parts motionless on each other 
would be sufficient of itself to account for it.” Gurlt,2 who has 
studied the process of repair in fractures with the most assiduous 
care, says : “ There is no specific tendency to non-union in any 
form of fracture. If the ends of the broken bones can be kept 
in accurate apposition, union by bone will take place.” As 
illustrations of this statement, he mentions the following frac- 
tures : Neck of femur, patella, coronoid process of inferior 
maxilla, coracoid process of scapula, olecranon, coronoid process 
of ulna, trochanter major, tuberosity of calcaneus, spinous pro- 
cesses of vertebrae, and some of the sharp prominences of the 
pelvic bones. 
The second cause of non-union. Want of pressure of one 
fragment upon the other implies a want of apposition, expressed 
in other words. Dupuytren and Brainard were of the opinion 
that oblique resulted more frequently in non-union than trans- 
verse fractures, and the former applied this rule to fractures of 
the neck of the femur. Experience has shown that of all frac- 
1 Lectures on Surgery, 1845. 
2 Handbuch der Lelire von der Knochenbruechen, 1862, vol. i. 94 
tures within the capsule, none are so prone to result in non-union 
as transverse fractures through the narrowest portion of the 
neck. Lateral pressure applied over the trochanter major is an 
important measure for obtaining union by bone, but this desir- 
able result does not follow from the fact that pressure is made, 
but simply because by the pressure coaptation and immobiliza- 
tion are effected. 
Deficient vascular supply of the upper fragment is prominently 
mentioned by almost every author against the probability of 
union by bone. On the other hand, it is generally submitted 
that fractures of the anatomical neck of the humerus unite by 
bone, and that completely isolated pieces of bone, when properly 
replanted or transplanted, retain their vitality and physiological 
properties. It is also well known that traumatic or pathological 
epiphyseolysis may be repaired by bony callus. Why should 
the upper fragment in intra-capsular fractures, with at least a 
doubtful supply of blood through the round ligament, make an 
exception to this general rule ? Simply because, in this in- 
stance, coaptation, without impaction, is next to impossible, with 
the present method of treatment. On this point MacNamara1 
makes this statement: “ I hardly think the non-union between 
the ends of the bone in instances of intra-capsular fracture of the 
neck of the femur is most frequently due to the insufficient 
blood-supply of the head of the bone ; otherwise we should more 
commonly meet with examples, after fractures of this kind, in 
which the head of the bone had become absorbed ; but, as you 
will see in the specimen I now show you, the cancellated tissue 
of the head of the bone is supplied with blood through vessels 
passing along the round ligament and through the fibrous struc- 
ture uniting it with the trochanter major.” 
The fractured head of the humerus, deprived of all vascular 
supply, unites by bone like any other fracture, because the 
anatomical relations about the seat of fracture are such that 
coaptation is maintained without difficulty, and fractures within 
the capsule of the hip-joint will follow the same rule as soon as 
1 Diseases of Bones and Joints, 1881. 95 
the surgeon can successfully combat the obstacles which cause 
displacement. The last cause, atrophy of bone, is the weakest 
argument in favor of non-union. Clinical experience furnishes 
abundant proof that in persons suffering from fragilitas ossium 
fractures not only unite, but unite very promptly. Mr. Holmes, 
in his System of Surgery, quotes from Gibson the case of a 
youth of nineteen, who had twenty-four fractures, and from 
Esquirol another with as many as two hundred fractures. Earle 
records a case of eight fractures in a child of ten years, and 
Flemming observed a case where a person suffered fifty-three 
fractures between the ages of one-and-a-half and twenty-five 
years. In all of these cases union took place rapidly. Gurlt 
reports a large number of similar cases. He states very dis- 
tinctly that old age does not retard the process of union, as has 
been erroneously supposed; the reparative process is the same as 
during adult life} 
I believe non-union is more frequently, observed in young, 
robust persons than in old people. I have seen a fracture of 
the femur, at the junction of the middle with the upper third, in 
an old decrepit man, suffering at the same time from locomotor 
ataxia, unite firmly by bone in less than six weeks. Fracture 
of the lower end of the radius is common after middle life, inva- 
riably unites, and in a remarkably short time. Senile osteo- 
porosis is a condition of bone favorable to the production of 
intermediate callus. Atrophy of bone facilitates inflammatory 
osteo-porosis, an event which always precedes the formation of 
callus. Some authors mention still other causes for non-union, 
as the presence of synovia and the absence of a nidus for the 
formative material. Both of these conditions simply remind 
us that the bones are not in apposition, otherwise they have 
no significance in preventing union by bone. From this short 
review we are not only justified, but warranted, in asserting that 
the only cause for the non-union in cases of intra-capsular frac- 
ture is to be found in our inability to maintain perfect coaptation 
1 Italics my own. 96 
and immobilization of the fragments during the time required 
for bony union to take place. 
XVII. Bony Union after Intra-capsular Fractures. 
In a circular letter, I addressed to prominent surgeons in this 
country, England, France, Germany, and Switzerland, for the 
purpose of ascertaining the prevailing opinion on the subject of 
bony union after intra-capsular fractures, I asked this question : 
“ In your opinion does bony union ever occur after impacted 
intra-capsular fracture of the neck of the femur, and under what 
circumstances ? 
To this question I received fifty direct replies. The opinions 
were divided as follows: Yes, 27; no, 18; doubtful, 5. It is a 
significant fact that the replies from professors of surgery in 
German universities, 5 in number, were without exception, in the 
affirmative, while the greatest diversity of opinion appeared to 
exist in our own country; at least fifty per cent, of the correspon- 
dents replied with an emphatic “ No.” I believe the answers 
received reflect correctly the sentiments of the entire profession 
on this point. If we add the five doubtful correspondents to the 
eighteen negative, we have nearly 50 per cent, who do not believe 
it possible for bony union to take place within the capsule even 
under the most favorable circumstances. 
I consulted the text-books and monographs on this subject 
with about the same result. It would then appear that nearly 
one-half of the profession still doubt the possibility of union by 
bone in cases of intra-capsular fractures. 
Having shown that there are no anatomical and physiological 
impossibilities present to prevent osseous union after intra-cap- 
sular fractures, and having referred to a number of reliable and 
well-authenticated cases of this kind, I will quote the opinion on 
this subject of a few recognized authorities. 
Sir Astley Cooper, the originator of the controversy on this 
subject, and who is always quoted as authority on the negative 
side of this question, never denied the possibility of union by 97 
bone, as is evident from what he says on page 137 of his work:1 
“I have only met with one in which a bony union had taken 
place, or which did not admit of a motion of one bone upon the 
other. To deny the possibility of this union (bony union), and 
to maintain that no exception to the general rule can take place, 
would be presumptuous, especially when we consider the varie- 
ties of direction in which a fracture may occur, and the degree of 
violence by which it may have been produced.” He enumerates 
a number of conditions which would maintain permanent appo- 
sition, and then proceeds: “Such a favorable combination of 
circumstances is of very rare occurrence.” At the time this was 
written the process of repair in bone was but imperfectly under- 
stood, and the occurrence of impaction within the capsule was 
either unknown, or its importance as an essential element for 
bony union was not appreciated. 
Heister,2 nearly a century and a half ago, after explaining that 
the frequency of non-union in cases of fractures of the femoral 
neck was owing to the difficulty of keeping the broken ends of 
the bone in apposition, makes the following statement: “If an 
instrument could be invented which would keep such a limb so 
extended that during the cure, or at least during the first two or 
three weeks, it could be kept as long as the healthy one, there 
would be hope that the fracture could be cured more satisfactorily 
than has been the case heretofore.” Since we have learned that 
the production of the intermediate callus requires months instead 
of weeks, Heister would have to modify his statement by greatly 
extending the period of time required for maintaining apposition. 
Desault,3 in combating the popular idea of insufficient blood 
supply as a cause of non-union, states: “ The head of the bone 
separated from the soft parts, and attached to the acetabulum by 
the round ligament, receives a sufficiency of nutriment to enable 
it to live in that cavity; for there is no instance of its having 
suffered mortification in consequence of a fracture. Why, then, 
should it not partake of the properties of life, and particularly of 
1 Fractures and Dislocations. 2 Chirurgie, 1747, p. 193. 
* A Treatise on Fractures, etc. Edited by X. Bichat; translated by Chas.. 
Caldwell, 1817. 98 
the faculty of reunion when placed in regular apposition with 
the body of the bone?” 
The following quotation is from Syme:1 “But none of the 
arguments, which have been adduced to prove the impossibility 
of osseous junction, seems to be conclusive, and though the 
small extent and mobility of the broken surfaces, the absence of 
vascular tissues surrounding the fracture, and, perhaps, also the 
presence of synovial fluid, may render the cure very difficult, it 
ought still to be regarded as a possible occurrence.” 
Richter2 claimed that bony union could take place in impacted 
fractures, or where, by careful treatment, apposition and reten- 
tion were fully accomplished. He evidently was impressed with 
the importance of the bone-producing function of the periosteum, 
as he advanced the theory, that, in fractures of the neck with 
complete rupture of the periosteum under favorable conditions, 
bridges could be thrown across the line of fracture from one 
membrane to the other, from which bone could be produced. 
Dupuytren,3 in criticizing the treatment followed by the Eng- 
lish surgeons, and alluding to the secondary displacements fol- 
lowing the too early removal of retaining apparatus, gives the 
following advice: “But, if these surgeons had adopted the prac- 
tice of the H()tel-Dieu, in keeping their patients in bed for eighty 
or even a hundred days, they would have been convinced of the 
practicability of reunion and complete cure without deformity.” 
And again : “ I can only say, for my part, that, if the specimens 
at the Hotel-Dieu are insufficient to satisfy any one who may 
take the trouble to examine them, I am at a loss to know what 
amount of evidence such sceptics would require. For my part, 
I regard the osseous union of intra-capsular fracture as demon- 
strated and placed beyond d6ubt.” 
Malgaigne4 is a firm exponent of Sir Astley Cooper’s teach- 
1 The Principles of Surgery, 1832, p. 261. 
2 Lehrbuch von den Bruechen und Verrenkungen der Knochen, 1833. 
3 On the Injuries and Diseases of Bones. Edited and translated by F. Le 
Gros Clark, 1847. 
4 A Treatise on Fractures. Translated from the French by John H. Packard, 
1859. 99 
ings, and yet, after the most critical examination of specimens 
for which bony union was claimed, he is forced to acknowledge 
that three of them were genuine. He says : “When a fracture 
unites, the fragments do not undergo such enormous losses of 
substance as. we should be forced to admit in the neck of the 
femur; and in Swain’s case, which Sir Astley Cooper himself 
acknowledged as an instance of bony union, the neck of bone had 
not changed its form. It was so also in Stanley’s case; and, 
lastly, one femur (No. 188), in the Musee Dupuytren, has lost 
nothing, either in form or volume, except as the result of very 
trifling displacement. I admit that these three examples demon- 
strate quite positively the existence of consolidation; but I can- 
not say the same of the rest.” Loss of substance and change 
of direction of the neck can no longer be regarded as evidence 
against the existence of bony union, as they only indicate the 
presence of impaction followed by interstitial absorption, the 
consequence of inflammatory osteo-porosis. 
Nathan R. Smith,1 in recommending his anterior splint in the 
treatment of fractures of the neck of the femur, expresses his 
convictions as follows: “ This apparatus, with slight modifica- 
tions, is applicable to all fractures of the femur. To none is it 
more appropriate, and in none has it accomplished more satis- 
factory results, than in fractures of the cervix, the events of 
which are so justly regarded as an opprobrium of surgery. So 
uniformly has non-union and deformity resulted, that eminent 
surgeons have denied that bony continuity is ever restored 
within the capsule. We hope to show that these results are 
rather the consequence of insufficient treatment, than defect in 
the reparative power of nature.” 
H. H. Smith2 advocates the possibility of bony union in the 
following language : “ That osseous union has been seen, cannot 
reasonably be doubted, and from a careful analysis of the seat of 
fracture in these cases, I think it is evident that there are a com- 
1 Treatment of Fractures of the Lower Extremity, by the use of the Anterior 
Suspensory Apparatus, 1867. 
2 The Principles and Practice of Surgery, 1863. paratively limited number of cases in which osseous union does 
occur; and I suggest that, as a general rule, based on observation, 
it will be found that the nearer a fracture is situated to the head 
of the bone, or, in other words, the shorter the upper fragment, 
the greater will be the possibility of osseous union ; because the 
shorter the upper fragment, the greater the chance that the ves- 
sels which supply it with blood through the round ligament 
will be able to furnish it with an amount of material sufficient 
to enable osseous union to take place by a deposit of bone from 
the Haversian canals.” 
Samuel Solly1 writes: “If you can diagnose that the fracture 
is an impacted fracture of the cervix, then you may with toler- 
able confidence predict complete union and a sound limb. I 
have shown by reference to the preparations in the College of 
Surgeons’ Museum, and also in our own, that fractures of the 
cervix within the capsule will unite, though not so frequently as 
those without.” 
Chelius2 claims that bony union may have been observed less 
frequently in England than on the Continent, on account of 
neglected treatment in cases diagnosticated as intra-capsular 
fractures. 
Erichsen,3 in discussing this subject, remarks: “ In some 
cases, however, bony union takes place. This may happen 
when the cervical ligament remains intact, or when the fracture 
is impacted.” 
Holthouse4 says : “ Bony union in this fracture (intra-capsular) 
is rare, and by some has been considered impossible; but a suf- 
ficient number of undoubted cases have now been brought to 
light, both in Europe and America, to place the fact beyond a 
doubt.” 
Agnew,5 in speaking of Astley Cooper’s method of treatment 
of intra-capsular fractures, remarks : “ There have been recorded 
1 On Fractures of the Neck of the Thigh-bone, London Lancet, 1867. 
2 Handbuch der Chirurgie, B. I. S. 119. 
3 The Science and Art of Surgery, 1869. 
4 Holmes’s System of Surgery, 1875, vol. ii. p. 846. 
5 Principles and Practice of Surgery, 1878, vol. i. p. 938. 101 
a sufficient number of cases of bony union, after what was be- 
lieved to be intra-capsular fracture, to justify a hope that some 
of the cases encountered by the surgeon may have a similar 
termination.” 
Gant1 expresses a similar opinion: “ Bony union at one time, 
and for many years, thought never to take place, does assuredly 
in some rare cases; but only, it would seem, when the capsular 
ligament remains entire, or the fragments are impacted, whereby 
a due supply of blood can be speedily established.” 
Bryant2 makes use of the following language: “ In the im- 
pacted fractures union ought to be looked for if the broken 
fragments are left alone, and not loosened by a careless and too 
curious manipulation. In the purely intra-capsular fractures, 
union may take place, osseous in many cases, fibrous in more.” 
MacNamara3 affirms: “ I believe, if you can keep the parts at 
rest, in many cases of intra-capsular fractures, union of the ends 
of the bones will occur.” 
Koenig4 realizes the importance of impaction in the reparative 
process, as may be seen from his statement that intra-capsular 
fractures heal less frequently by osseous union than extra-cap- 
sular fractures, because they are less frequently impacted. 
Hueter,5 who classifies fractures of the neck of the femur into 
those with and without impaction, regardless of the attachment 
of the capsular ligament, lays it down as a rule that impacted 
fractures usually unite by bony union. 
Stimson,6 in discussing this subject, advances the following as 
one of his arguments in favor of the possibility of bony union : 
“ Even if we disregard all existing specimens of alleged bony 
union, the possibility of such union must, I think, be admitted, 
because of the demonstrated fact that the head preserves its 
vitality, and has shown its ability to produce granulations and 
1 The Science and Art of Surgery, 1878, p. 646. 
2 Principles of Surgery, edited by J. B. Roberts, 1881. 
3 Diseases of Bones and Joints, 1881. 
4 Lehrbuch der Speciellen Chirurgie, 1879, ti. II. S. 857. 
6 Grundriss der Chirurgie, 1882, B. II. S. 884. 
6 A Treatise on Fractures, 1883, p. 503. 102 
bone ; the former proved by the examples of fibrous union, the 
latter by eburnation or condensation of its spongy tissue.” 
I will close the list of witnesses who testify to the possibility 
of bony union after intra-capsular fractures, by quoting the last 
sentences of Jonathan Hutchinson’s description of the specimen 
in the Pathological Museum of Leeds Hospital. “ This speci- 
men is alluded to by Malgaigne and Hamilton, as if it were of 
doubtful validity; but neither of them had probably seen it. I 
cannot but hope that the publication of these life-size drawings 
of the bone will set at rest all scepticism as to the possible union 
of intra-capsular fractures. I trust, also, that it may lead to 
greater hopefulness in the treatment of these accidents, and thus 
to more systematic care in securing coaptation.” 
With such an array of unprejudiced, honest, and conscientious 
witnesses before us, who unanimously and most positively testify 
that union by bone can, and not infrequently does, take place, 
we are no longer warranted in denying its possibility. The 
number of well-authenticated specimens has been gradually in- 
creasing, and the knowledge derived from clinical observation 
and experimental investigations on this subject during the last 
few years, can leave no further doubt pertaining to the produc- 
tion of bony callus in intra-capsular fractures. In the interest 
of science, and for the benefit of the patients, this controversy 
ought and must be decided in favor of the affirmative, and then 
the profession will be prepared to seek for measures which will 
secure better results. 
XVIII. Treatment. 
In no other fracture are the indications for successful treat- 
ment so difficult to meet as in fracture of the neck of the femur. 
Every unprejudiced surgeon is forced to admit, that the usual 
bad result in these cases is owing more to the insufficiency of 
the treatment employed than to the anatomico-pathological con- 
ditions of the broken bone. The causes of non-union are not to 
be found in the broken bone, but in the difficulties encountered 
in the treatment. All the various methods of treatment, sug- 103 
gested and practised, have failed in securing perfect coaptation 
and uninterrupted immobilization. In all intra-capsular fractures 
union is effected by the production of an intermediate callus, 
from the broken surfaces; nature’s splint, the external callus, for 
well-known anatomical reasons, is always wanting, hence, the 
surgeon’s splint has a more important and prolonged applica- 
tion than in fractures in other localities. The time required for 
bony union to take place in fractures of the femoral neck is an 
unusually long one. Gurlt1 fixes the time at from 56 to 207 
days, and the average duration at 84 days. 
Dupuytren estimates the time at from 100 to 120 days, and 
states, that it has been customary at the Hotel-Dieu to keep these 
patients in bed at the hospital for 80 to 100 days. There can 
be no doubt that many cases, which promised well from the be- 
ginning, terminated .unfavorably by abandoning the treatment 
too early. To prevent secondary displacements, the retentive 
measures should not be removed for at least 80 to 100 days. In 
deciding upon a course of treatment to be pursued it is important 
to make a distinction between impacted and non-impacted frac- 
tures. In impacted fractures the fragments have been placed in 
the best possible condition for bony union to take place, and the 
object of treatment consists simply in maintaining the mutual 
penetration until the reparative process is completed, and the 
continuity of the bone restored. The surgeon must be satisfied 
with securing consolidation of the broken bone in the position 
in which it has been placed by the accident. Any attempt to 
correct the deformity is unjustifiable, and would necessarily result 
in loosening of the impaction, an event which would almost to 
a certainty be followed by non-union. Permanent fixation of an 
impacted fracture is necessary for the following reasons:— 
1. It maintains the impaction. 2. It prevents secondary 
shortening and eversion during the stage of inflammatory osteo- 
porosis. 3. By keeping the injured parts at rest, it serves as a 
preventive measure against the accession of arthritis and para- 
arthritis. 4. It enables the patient to leave the bed before com- 
1 Knochenbrueche, vol. i. p. 331. 104 
plete consolidation of the fracture has taken place. Extension 
is always contra-indicated in these cases, as it certainly can do 
no good, and may result in irreparable damage by loosening the 
impaction. The best dressing to accomplish permanent fixation 
is a plaster-of-Paris bandage. To insure complete immobility of 
the hip-joint, the bandage must include the injured limb from 
the toes upwards, the entire pelvis, and the sound limb from the 
pelvis to at least as far as the knee. For the purpose of greater 
durability and security of the dressing, a tin or wood splint can 
be incorporated in the plaster bandage. In the application of 
this bandage it is necessary to protect all prominent bony pro- 
jections, more especially the trochanter major over the affected 
side, with salicylated cotton, to guard against excoriations; a 
flannel bandage should be applied next the skin. During the 
application of the bandages, and until the plaster sets, it is neces- 
sary to place the patient on a pelvic rest, such as is described by 
Bardeleben. During the setting of the plaster, it is important 
to make lateral pressure over both the greater trochanters, in 
order to secure firm support to the broken bone. 
With such a dressing, the patient can be moved without fear 
of disturbing the fracture, and in a few days he can leave the 
bed, and in a few weeks can walk on crutches, if deemed neces- 
sary for the purpose of preventing complications. Unless indica- 
tions arise, it is advisable not to disturb the dressing until osseous 
union has become sufficiently firm to support the fragments. It 
is particularly dangerous to change the dressing from the third 
to the fifth week, as during this time the inflammatory osteo- 
porosis has a tendency to loosen the fragments. I am satisfied 
that a dressing of this kind is vastly superior to any splint in 
affording comfort to the patient and securing the best attainable 
result. 
In the treatment of non-impacted fractures the same principles 
should govern us as in the impacted variety. In this class of 
fracture, however, another important indication arises, namely, 
to effect coaptation of the fractured ends; at the same time 
retention is more difficult to accomplish. The nearer we can 
imitate impaction, the better the prospects for a favorable result. 105 
If we could keep the broken surfaces in perfect coaptation, and 
maintain retention and immobility, these fractures would heal 
in the same way as impacted fractures. That these indications 
have not been fulfilled by the usual treatment with different 
splints, extension by weight and pulley, and pelvic belt, nobody 
can deny. Even extra-capsular fractures have healed, as a rule, 
with so much shortening as to cripple the patients for life, while 
the results after intra-capsular fractures have almost universally 
been so bad, that many of the most distinguished surgeons have 
abandoned all active measures, limiting their treatment exclu- 
sively to palliation. Prominent among the advocates of the ex- 
pectant treatment in intra-capsular fractures, I will mention Sir 
Astley Cooper, Velpeau, Langlet, and Lavacherie. That the 
views of many surgeons on this point have undergone no material 
change since Sir Astley Cooper’s time is apparent from more 
than one recent work on surgery. I quote verbally from Gant’s 
surgery, page 647 : “No bony union taking place, as a rule, in 
intra-capsular fractures of the neck of the femur, it will generally 
be useless to adjust the fracture and apply any retentive appa- 
ratus with a view to such union; and the more so, in proportion 
to the years of the patient.” 
If the results attending the different methods of treatment 
have been so bad as to induce men of the highest professional 
attainments to abandon all active treatment as useless, the ques- 
tion naturally arises, are there any other means which are better 
adopted to accomplish the desired result ? The question as to 
possible bony union after intra-capsular fracture, in the light of 
recent researches, has been decided in the affirmative, and a 
more practical question arises, how can it be obtained? By 
what means can we keep the fragments in mutual coaptation 
during the process of repair? I would suggest the following 
points in the treatment: 1. Immediate reduction and coaptation 
of the fracture under the influence of an anaesthetic. 2. Fixation 
with a plaster-of-Paris splint. 3. Lateral pressure. 4. Direct 
fixation of fragments by bone-pegs. 
I. Extension by means of the weight and pulley overcomes 
the shortening only gradually, and seldom completely, at the 106 
same time it necessitates the recumbent position for a long time, 
and thus exposes the patient to all the risks and inconveniences 
incident to such position. If the patient is placed thoroughly 
under the influence of an anaesthetic, muscular action is tempo- 
rarily annihilated, and the limb can be extended at once to its 
natural length, while coaptation can be effected at the same time. 
The advantages arising from immediate reduction and coaptation 
are the following: i. The untorn portions of the joint structures 
are replaced at once into their normal relations; a procedure 
which cannot fail to influence favorably the circulation in vessels 
which may have escaped injury. 2. The sharp and irregular 
margins of the broken surfaces act as irritants to the surround- 
ing soft tissues; immediate reduction, by placing the bones at 
once in mutual coaptation, acts as a preventative against the 
supervention of undue inflammation in and around the hip-joint. 
3. With coaptation the process of repair is initiated at once, the 
blood and exudation material between the fragments act as a 
temporary cement substance, and at the same time serve a useful 
purpose in re-establishing the interrupted circulation. 5. Perfect 
reduction and coaptation prevent muscular spasms and diminish 
pain. 
II. Having reduced the fracture, retention should be main- 
tained in a similar manner, as in impacted fractures; with the 
exception, however, that eversion should be carefully corrected. 
The plaster-of-Paris splint is applied as for impacted fracture, 
only that over the trochanter major of the injured side a fenes- 
trum, about two inches wide and four inches long, is left open 
for the purpose of applying lateral pressure. 
III. Many fractures of the femoral neck are kept from be- 
coming displaced for a variable period of time by interlocking 
of the denticulated broken surfaces, a condition which has been 
called by Bigelow “ rabbeting.” Believing that the surgeon 
should imitate the reparative resources of nature wherever it is 
possible to do so, it appears to me that artificial rabbeting could 
often be produced by lateral pressure. The fractured surfaces 
being placed as accurately as possible opposite each other, 
lateral pressure would cause perfect coaptation and a mutual 107 
interlocking of the fragments. Lateral pressure, applied with 
this view, would be one of the most reliable means to prevent 
secondary lateral and longitudinal displacements. Pressure, to 
be effective, must be applied in the direction of the broken neck, 
that is, over the trochanter major, and in such a manner as not 
to interfere with the superficial circulation. Pressure with belts 
and strips of adhesive plaster encircling the whole pelvis, can 
exert but little influence on the fractured bone, at the same time 
it impedes the superficial circulation. With the fenestrated 
plaster-of-Paris splint, pressure can be applied directly over the 
trochanter major, by placing a well-cushioned pad, with a stiff, 
unyielding back, corresponding in size to the fenestrum, in the 
opening of the splint, and applying the necessary amount of 
pressure by means of a Petit’s tourniquet, or some other similar 
contrivance. A small amount of pressure, if well directed, would 
be sufficient to retain the fragments in apposition. By removing 
the pad from time to time, and washing the parts with dilute 
alcohol, there would be no danger of producing excoriation. 
The pad could also be made smaller, and the pressure surface 
changed as often as necessary, as an additional precaution 
against superficial excoriations. Lateral pressure and fixation, 
however, could be applied more directly and advantageously by 
means of a long, sharp, steel pin, regulated by a set-screw pass- 
ing through the centre of a curved steel bar, incorporated in the 
plaster-of-Paris bandage over the fenestrum, in such a way that 
the sharp point of the pin would perforate the soft parts over 
the centre of the bone of the femoral neck, and by penetrating a 
small distance into the bone, would, secure perfect immobility 
of both fragments. By removing the steel pin and adjusting 
the pad, this instrument can be used for applying ordinary 
lateral pressure. I present for your inspection an instrument of 
this kind. (Figs. 18, 19.) 
Heine1 has used a somewhat similar instrument in the treat- 
ment of ununited fractures of the femur and tibia. The super- 
1 Ueber operative Behandlung der Pseud - arthrosen, Verb. d. Deutsch. 
Gesellsch. fiir Chirurgie, 1877, p. 220. Fig. 18. 
Apparatus for treating Fracture of Neck of Femur. 
Fig. 19. 
Apparatus applied ; steel point of instrument fixed in Trochanter Major. 
ficial site of the greater trochanter would render this dressing of 
easy application, and from the absence of very sensitive struc- 109 
tures, the pain inflicted would not be as severe as in using 
Malgaigne’s hooks for fracture of the patella. Undue inflam- 
mation of the soft parts could readily be avoided by the use ol 
antiseptic precautions. It would probably not be necessary to 
continue this treatment for more than two to four weeks, when 
the ordinary pad for lateral pressure could be substituted for the 
steel pin. 
IV. Apposition of the fractured ends could be secured and 
maintained with the greatest degree of accuracy by measures, 
which are calculated to operate directly upon the fragments. 
Such measures have been successful on other joint fractures, 
where the usual prescribed methods of treatment had failed in 
effecting union by bone. In the case of fracture of the femoral 
neck, however, the injured parts are so inaccessible as to exclude 
the propriety of any cutting operation for the purpose of ex- 
posing the fragments to view and securing apposition through 
the wound. At the same time, this injury is limited almost 
exclusively to a class of patients whose general condition would 
forbid an operation of such magnitude for such a purpose. If, 
however, an operation could be devised which would be devoid 
of immediate or remote danger to life, and that would not incur- 
any loss of blood, nor add to the suffering of the patient, and at 
the same time would render substantial aid in maintaining per- 
manent apposition of the fragments, then our prospects for 
securing better results would indeed become more encouraging. 
I believe we have such an operation in subcutaneous drilling ot 
the neck of the femur, and nailing the fragments together by 
means of a bone-peg. 
The observations of Volkmann and Heine have shown that 
driving ivory-pegs into osteo-porotic bones will produce an 
osteo-plastic inflammation and osteo-sclerosis. The operations 
of drilling and insertion of bone-pegs have been resorted to for 
a long time, for the purpose of promoting the formation of callus 
in cases of ununited fractures, and it is only reasonable to assume 
that the same operations would have a similar effect in recent 
fractures. The operation offers no great technical difficulties in 
its execution, and if done under strict antiseptic precautions, does not expose the patient to any additional risks. The idea of 
immobilizing fractures by nailing the ends of the broken bone 
together is not a new one. It is alluded to by David Prince,1 
in treating of the subject of ununited fractures, when he says: 
“ Perhaps a bone might be drilled through both fragments, and 
held in apposition by a rivet of one of these metals. The pre- 
sence of the rivet after the completion of the healing process 
would do no harm, and if a permanent discharge should be the 
result, the metal could be readily removed.” 
As yet a discrepancy of opinion prevails as to the future fate 
of bone- and ivory-pegs when imbedded in living bone. Tren- 
delenburg2 operated for a very oblique ununited fracture of the 
femur at the junction of the lower with the middle third, by 
fixing the fragments with an ivory-peg. He had an oppor- 
tunity to examine the specimen two-and-a-half years after the 
operation. The fracture was firmly united, and the ivory-peg 
was found intact in the bone-tissue, having undergone no change 
whatever, except that a portion which had projected into the 
knee-joint had become detached, and was found imbedded in a 
cyst in the interior of the joint, surrounded by giant cells. 
Riedinger3 made similar Introducing ivory- or 
bone-pegs into the bones of animals, he found them after a 
variable period of time either entirely unchanged, or only 
slightly diminished in size. The diminution in size appeared to 
be in proportion to the vascularity of the living bone. The 
growth of the bones thus treated was stimulated, as was shown 
from an increase in their length as compared with the opposite 
bones. 
Bidder1 found that by boring a hole into the spongiosa of the 
epiphysis of the long bones in old rabbits, into the lower end of 
the femur, for example, that no regeneration of bone took place, 
the loss of substance being replaced by fibrous and myeloid 
tissue. In young adult rabbits a slight attempt at regeneration 
1 Plastics and Orthopedics, 1871, p. 220. 2 Ibidem. 
3 Virchow u. Hirsch’s Jahresbericht, 18S1, vol. ii. p. 333. 
4 Exper. Beitriige u. Anat. Untersuchungen d. Knochengewebe, etc., Archiv f. 
Klin. Chir. B. XXII. p. 155. 111 
was manifested. The process of regeneration, however, was in- 
creased by driving ivory-pegs into the perforations, or by inject- 
ing iodine or lactic acid. 
Brainard1 taught that simple perforation of bone increased the 
formation of callus, while insertion of ivory, wooden, or metallic 
pegs not only disminished it, but with few exceptions produced 
absorption of bone. 
Volkmann2 treated a pseud-arthrosis of the femur by ex- 
cision of the fractured ends, and immobilized the fracture by 
driving a peg made of a piece of fresh bone, taken from another 
patient, into the medullary cavity of both ends. The fracture 
united and the transplanted piece was not seen again. 
Riedenger’s3 experiments on animals have shown that ivory- 
and bone-pegs implanted into bone increase the nutrition of the 
bone, and remain without giving rise to any undue irritation, 
and are finally partially or completely absorbed. Metallic sub- 
stances remain firmly imbedded. Wood and rubber invariably 
gave rise to suppurative inflammation. Clinical experience and 
experimental investigations have sufficiently demonstrated that 
bone- and ivory-pegs, if implanted under antiseptic precautions, 
do not act as foreign bodies, and never give rise to suppuration; 
and can, therefore, be safely employed in securing accurate co- 
aptation of recent fractures, if this is deemed desirable and 
necessary, and not attainable by simpler measures. It has also 
been shown that these pegs produce osteo-plastic inflammation, 
and thus materially hasten the process of repair. The operation 
of direct immobilization of the fragments by means of bone- or 
ivory-pegs is, therefore, particularly adapted to the treatment of 
intra-capsular fractures, whenever it is decided to make every 
legitimate attempt to secure union by bone. A somewhat similar 
operation has been performed several times for the purpose of 
relieving the pain incident to pseud-arthrosis, following frac- 
tures of the femoral neck. Before the introduction of antiseptic 
1 Treatment of Ununited Fractures, Trans. Am. Med. Ass. 1858. 
2 Ueber Pseud-arthrosen der Vorderarm Knochen. Verh. d. Deutsch. Gesell. f. 
Chir., 1S81, ii. p. 167. 
3 Verhandl. d. Deutschen Gesellsch. f. Chir., 1877, p. 134. surgery, von Langenbeck1 operated by exposing the greater 
trochanter, and passing a silvered drill through it into the upper 
fragment so as to secure apposition. The fracture was oblique 
and extra-capsular in an aged female. The operation was fol- 
lowed by destructive inflammation, hospital gangrene, and death. 
Lister operated in a similar manner, but under the protection of 
antiseptic surgery, and secured a good result by a short fibrous 
union.2 In this case, however, it appears that the upper frag- 
ment was not transfixed by the screw. Koenig3 repeated Lan- 
genbeck’s operation under antiseptic precautions, and secured a 
favorable result. My experiments on animals have satisfied me 
that it is not always an easy task to find the upper fragment with 
the drill, and perforate it at the proper point. To overcome this 
difficulty, it has been suggested by Trendelenburg,4 to expose 
the seat of fracture by a small incision from behind, and after 
forcibly abducting the limb, perforate the lower fragment from 
within outward, and by reinserting the drill from without inward, 
guided by a finger in the wound, and, after straightening the 
limb, transfix the upper fragment. A silver screw is inserted in 
the hole made by the drill, and the two fragments are screwed 
together. The screw is to be removed after two weeks. For 
the purposes for which we have urged the operation, Trendelen- 
burg’s advice is too severe and dangerous. By using bone- or 
ivory-pegs no disastrous result would follow in the event the 
peg should miss the upper fragment and be driven into the joint. 
Trendelenburg’s case and my experiments on animals furnish 
positive proof that bone- and ivory-pegs driven into the interior 
of joints do not give rise to any serious results. The operation 
df drilling the femoral neck and the subsequent insertion of the 
ivory-peg is facilitated by placing the limb in its natural position 
and securing it by the plaster-of-Paris dressing. The drilling is 
done through the fenestrum over the greater trochanter in the 
plaster splint, by sliding the skin and making a passage for the 
1 Verhandlungen d. Deutschen Gesellsch. f. Chirurgie, 1878, p. 92. 
2 MacCormac, Antiseptic Surgery, 1880, p. 200. 
3 Verhandlungen d. Deutschen Gesellsch. f. Chirurgie, 1878, p. 93. 
4 Idem. drill through the soft tissues down to the bone with a tenotome 
at a point corresponding to the centre of the base of the femoral 
neck, and drilling in the direction of its axis toward and into the 
femoral head. The length of the bone- or ivory-peg should 
correspond to the distance between the outer surface of the 
greater trochanter and the centre of the femoral head. The 
advantages arising from the treatment as suggested above 
would be:— 
1. The most perfect degree of coaptation and immobilization 
of the fragments. 
2. The patient could be placed in any position in bed, or 
even be taken out-doors as soon as the dressing is applied, thus 
effectually preventing excoriations and the diseases incident to 
prolonged confinement to bed in the recumbent position. 
I do not advise, of course, that all the means suggested should 
be called into use in every case. When the general condition 
of the patient is such as to preclude any possibility of obtaining 
a good result, the severer measures, which aim at accurate 
adjustment and immobilization, are not to be used. In such 
cases, it is only necessary to adjust the parts as accurately as 
possible, and apply the plaster-of-Paris dressing, which, by keep- 
ing the parts at rest, secures for the patient the greatest degree 
of comfort, and, moreover, does not exclude the possibility of 
recovery by the formation of a short ligamentous union. If the 
patient’s health is fair, and the symptoms are such that point to 
the existence of the fracture within the capsule, then we are 
justified in resorting to the means which will insure the greatest 
accuracy in the approximation of the parts, and thus furnish 
nature with the only known means by which she can restore 
the continuity of the bone.