The insertion of the capsular ligament of the hip-joint, and its relation to intra-capsular fracture / by Geo. K. Smith.

  • Smith, George K.
Date:
1862
Catalogue details

Licence: Public Domain Mark

Credit: The insertion of the capsular ligament of the hip-joint, and its relation to intra-capsular fracture / by Geo. K. Smith. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    I A A sometimes extends much further; I have seen half of the globular head of the bone thus re- moved, and a case has been recorded in -which the head of the bone was completely absorbed. In old cases the femoral fragment is likewise ab- sorbed to a greater or less extent; sometimes it disappears entirely to its base, and the portion of the shaft from which in the normal state, it springs, presents a smooth and even surface, lim- ited by the trochanters and their connecting lines.”* When fracture occurs entirely within the cap- sule and is followed by absorption of the neck, the process of absorption soon reaches that point on the posterior surface of the neck to which the capsule is attached. At this point the capsule is not only inserted into the bone, but also blended with the periosteum which covers the neck ex- ternal to this point. If the progress of absorp- tion continue, that portion of the neck to which the capsule is attached is soon removed, and the capsule is left, having no other insertion than its connection with the periosteum. If the whole of the neck be removed in this manner, the periosteum covering it is loosened, thickened by fibrous deposit, and constitutes, by its connection with the normal capsule, a part of the morbid capsule which now has its insertion into the shaft of the bone. If now the fragments be approximated and union occur, we shall have extra-capsular union of intra-capsular fracture, and yet the line of union will be included within the morbid capsule. It is highly probable that intra-capsular frac- ture is sometimes followed by union without the capsule, in this manner; but this, if it ever does occur, can never be proven, since the diagnosis of intra-capsular fracture cannot be made with posi- tive certainty during the life of the patient; and it is impossible, after absorption of the neck, to tell at what point the neck was broken. I have succeeded, by dissection ol the normal capsule, in illustrating the insertion of the morbid cap- sule into the shaft of the bone, as seen after re- moval of the entire neck by absorptiou. (See Fig. 10.) In the dissection I commenced just within the normal capsule, and, cutting through that portion of the capsule which is reflected upward on the neck of the bone, dissected the capsule loose from its insertion into the neck, leaving it attached to the periosteum covering the neck external to this point. Continuing my dissection outward to the shaft ol the bone, I raised the periosteum, which by its connection with the nor- mal capsule exhibits a lengthened capsule inserted into the shaft of the bone. Numerous specimens have been exhibited, both in this country and in Europe, as illustrations of bony union of intra-capsular fracture, yet but few if any of these furnish positive evidence that this desirable result has ever been obtained. Of the specimens found in European museums, Robert W. Smith recognizes seven, while Malgaigne ad- mits but three, and Sir Astley Cooper only one. The number of specimens in this country, for which this honor is claimed, is quite equal to the number recognized by Robert William Smith. Of these, Reuben D. Mussey, Professor of Sur- gery in the Miami Medical College at Cincinnati, Ohio, has three; Alden March, Professor of Sur- gery in the Albany Medical College, has two; Willard Parker, Professor of Surgery in the Col- lege of Physicians and Surgeons in the City of New York, has one; Daniel Holmes, M.D., of Canton, Bradford County, Pa., has one. Others will be mentioned hereafter. A review of the cases of fracture of the neck, reported by Robert W. Smith, will show us that this eminent writer has claimed, as illustrations of intra-capsular fracture, a large number of specimens in which the entire neck of the bone has been removed by absorption; therefore, we have a right, in discussing the subject of bony union, to regard with some skepticism his cases in which the exact location of the fracture is left dependent on an expressed opinion, and has not been given in the description of the specimen. In cases x., xi., xviii., xx., xxiii., and xxv.,Mr Smith states that “the fracture was within the capsule,” and that “ the entire neck of the bone has been removed by absorption.” We ask how ii is possible for him to tell the point at which the neck was fractured, after the neck has been re moved by absorption? We do not feel unde obligation to believe the expressed opinion o any surgeon until we know the facts on whicl that opinion is founded. The first case adducet by Mr. Smith in proof of osseous union withii the capsule, is that originally reported by Mi Langstaff.* The history of this case is quit unsatisfactory, inasmuch as Mr. Langstaff tell us that the bone was fractured, without giving u a single symptom which led him to such a con elusion. The following is the history:— i ii SI - ; i; i i - , -I i i . . Medico-Chirurgical Transactions, vol. xiii. p. 491.