DIAGNOSIS OF OBSCURE DISEASES OF THE HIP. By O. H. ALLIS, M.D.,

OF PHILADELPHIA.

DR. ALLIS stated that in the March No. of the Philadelphia Med. Times he had called the attention of the profession to the relation the great sacro-sciatic notch bore to the acetabular cavity. That if a pelvis were placed in the position of one lying on his back the "notch" in the majority of cases will lie directly below the acetabular cavity; and from the conformation of the pelvis it would appear possible, and indeed very probable, that a dislocation in its direction might not be followed with any shortening of the limb when it is compared with its fellow in a line with the axis of the trunk. Now, if the limbs are compared at right angles to the trunk, a discrepancy will at once be produced for the very reason that the head of the bone lies in a new position an inch or more directly below its normal bed. [Here he exhibited the drawing of a pelvis.]

The importance of this anatomical feature would appear

1st. In enabling one to determine positively that his efforts at restoration had been successful.

2d. In determining complete intracapsular fractures.

3d. In determining severe contusions or incomplete and impacted fractures.

1. The limb cannot be regarded as restored until its measurements in the axis of the trunk and at right angles to it correspond.

2. In complete fractures the usual signs are eversion, shortening, and a doubtful crepitus. If in such a case we compare the limbs at right angles to the trunk while the weight of the sound limb will be sustained by the neck of the femur, the neck of the other being broken, the limb will sink until the trochanter end shall become arrested by its ligamentous surroundings, and thus produce a shortening similar in many respects to the preceding case. Now to determine that this is fracture and not dislocation, lift the limb to a level with its fellow, and if a force sufficient to overcome its weight

will effect this, and if on letting go again it sinks an inch or more, it may be confidently asserted that it is fracture of the neck, for if it were a dislocation it would require the strength of one or more strong men to bring the limbs to the same altitude.

3. Incomplete and impacted fractures. This he said was a feature of the utmost importance, as this variety of fracture was the only one, implicating the joint, that was likely to result in bony repair. Rude manipulation in such cases would endanger the impaction and hazard the chances of recovery. Hence he enjoined gentleness, warning against an attempt to obtain crepitus. In such a case, place the patient on a level surface and, with no obliquity of the pelvis, notice the relation the limbs bear to each other. Then compare them at right angles to the trunk, and if they still sustain the same relation it may be confidently assumed

a. That the head of the bone is in the acetabular cavity.

b. That no complete fracture is present.

c. That the injury is a severe contusion, or an impacted or incomplete fracture; and the nature of the injury, sex, age, persistence of pain, and degree of helplessness will point out an intelligent and rational course of treatment.

A NEW OPERATION FOR UNUNITED FRACTURE OF THE TIBIA. By WM. H. PANCOAST, M.D., Erc.

THE first case, in which I tried the following procedure, was that of Catharine Smith, an inmate of the Philadelphia Hospital, in November, 1870.

Three years previous to this date, in attempting to elope from the hospital, she fell from the wall, and fractured the tibia of her right leg, at the lower part of the middle third. She was of medium stature, very stout, and about thirty years of age. When I saw her for the first time in the surgical ward, I examined her leg, and found a loss in the continuity of the tibia, of about three inches, at the middle third of the bone. She begged me to do something for her, even to amputate the leg if I thought proper. Saying that she was tired of remaining in the hospital; that she had been there over three years, and wished to leave, even if she left one leg behind her; that she was tired of being operated upon; and wished something decisive done. I promised to do what I could for her, desiring not to amputate if possible. On inquiring, I found that she had been skilfully treated, and everything done for. her in the ordinary way of surgery. The fragments had been irritated by being rubbed firmly together; inflammation had been excited by perforating the ends of the fragments with an awl; a seton had been passed between them; an effort to establish union had been made by driving in ivory pegs; the integument had been laid open, and the fragments fastened together with silver wire, but all without success; and finally the integuments were again laid open, and the ends of the fragments resected, leaving the gap of three inches that I have mentioned.

On examining the leg, I found that the fracture had taken place, just below where the nutritious artery enters the bone, and had thus cut off the supply of arterial blood necessary for the proper effusion of plasma to make callus; this, I presumed to be one of the reasons of the formation of the false joint. The main cause, however, appeared to me to be, that the fibula, which had remained un

broken, acted as a splint to the broken tibia. It being fastened by its ligaments, above, to the head of the tibia, and to its lower end, where the external and internal malleoli project downwards, making the socket for the astragalus, forming the ankle-joint. The last operation of resection only increased the difficulty, as the upper and lower fragments being fastened to the fibula, were kept asunder the distance of three inches. At my next visit, the patient repeated her earnest request for an amputation. I answered her by saying that she had broken the tibia by a fall, and if she would tumble so as to break the fibula, I thought I could cure her. This she said she could not do, but she was willing that I should do anything I thought best for her. I asked her if she would permit me to break the bone. She said most cheerfully. On my next clinic day, having prepared her for the operation, I took her before my class. I described the case as above mentioned, stating that as the fibula acted as a splint, keeping the fragments apart, I p.oposed breaking it subcutaneously. Then forcing the lower fragments of both bones upwards, so that they would overlap the upper, I hoped that the fragments, thus approximated, would under the stimulus of the inflammation become united by callus.

I etherized the patient, and then with a strong gimlet, pierced the integument on the outside of the leg, and screwed it into the fibula, about three inches above the external malleolus, where this bone is still superficial. I withdrew the gimlet from the bone, but not from the integument, and slipping the point a little further upwards, I bored a second and a third hole in the same way. The fibula is narrow and does not give you much surface to work on, requiring for this purpose a gimlet, with a hard sharp point, that must be firmly and adroitly applied upon the bone. At the point where I had perforated and weakened the fibula, I now broke it; seizing the leg above and the foot below, and striking the leg at the perforated point on the edge of the bed. The bone broke with an audible snap. I then pushed up the lower part of the leg, endeavoring to make the bones overlap, avoiding too much force so as not to lacerate the arteries. The fragments approximated nicely, but did not overlap as much as I had hoped, owing to the amount of bone resected from the tibia, making the large gap, and from the pinching of the muscles, as I forced the fragments together. I decided, however, to wait, and see how much benefit would be derived, from what had been done. I placed the leg in a fracture-box, to obtain from its use, what is a disadvantage in its employment, when we wish to cure fracture of both bones of the leg, without much shortening; as by its weight, it holds the lower part of the leg and

foot fixed and immovable, while the body above, unless prevented, sinks down in the bed, causing the fragments to override each other, producing a tendency to great shortening as the fragments unite. I placed the patient in bed, supporting her back with pillows, and elevating the fracture-box also, so that between the two pressures of the fracture-box below, and the weight of the body above, the bones might be made to approximate as much as possible. She suffered no inconvenience from the operation, ordinary antiphlogistic treatment prevented any fever, and I soon gave her good nourishing food.

Union, however, did not take place rapidly, and motion could still be made at the point of fracture; so at the end of about four and a half weeks, I took the patient again before my class, etherized her, and broke up what adhesions had been formed, forcing the bones up yet more together, so as to make the fragments overlap, and then taking a long, thin, and highly tempered steel gimlet, made for the purpose, and with a movable handle, I pierced the integuments over the seat of fracture, screwed the fragments together, and removing the handle, let this pin remain for the purpose of exciting inflammation, so as to cause bony deposit, and at the same time to hold the fragments in as close juxtaposition as possible. The patient bore this operation well. I replaced her in bed as before, watching the inflammatory process which was now frankly excited in the leg, keeping it within proper limits so as to avoid erysipelas, with ointment of oxide of zinc and applications of lead water and laudanum. When the pin, at the end of ten days, became loosened in the bones, I removed it. I kept the patient in bed about six weeks, having the gratification of seeing the limb becoming stronger daily. At the end of that time, I let the patient get up on crutches, and in eight weeks from the last operation, she walked into my clinic room without any other support than a cane, and I then discharged her from the hospital.

I lost sight of my patient entirely, though I had frequently inquired after her, being desirous of knowing the ultimate success of my operation. In the fall of 1872, after the period, when the terrible fires swept over the great forests of the west, devastating that country, and rendering houseless and impoverished, so many unfortunates, who should walk into my office, but this very Catharine Smith, accompanied by a nice-looking young German, whom she presented to me as her husband. They were in great destitution, ragged, and almost shoeless. She told me that after she had left the hospital she married this young man, who was good looking and some years her junior. They then moved to Minnesota, where