FRACTURES OF THE NECK OF THE FEMUR

596 group was treated with intravenous strophanthin. Initial experiments with a dose of gr. 1/100, which would generally be considered quite a high one, showed no slowing of the heart-rate. Finally, a dose of gr. 1/33 was found usually to produce an adequate slowing within half an hour, any larger dose leading to toxic symptoms. The method appears to be a safe one when no digitalis has been given for two or three weeks, except under two conditions : if the patient is subject to paroxysmal fibrillation with high ventricular rates, and if cardiographic changes indicate considerable myocardial damage. Experiments made on the ability of atropine to abolish the slowing of the heartbeat produced by digitalis and strophanthin showed that these drugs act largely or entirely on the vagus. FRACTURES OF THE NECK OF THE FEMUR FRACTURES of the neck of the femur have an unfortunate tendency not to unite after the manner of most other fractures. Nowhere else in the body, excepting perhaps in the scaphoid bone of the carpus, is there anything like the same incidence of non-union. Dr. W. Eugene Wolcott, in a discussion at the 83rd annual congress of the American Medical Association in New Orleans, stated that in a series of 41 cases, all treated by the Whitman method of fixed abduction in plaster, 15 remained ununited. Subsequent speakers at the congress, while considering this figure unusually high, agreed that the average incidence of non-union was high enough to give rise to grave dissatisfaction. There have been various speculations and assertions about the causes of this failure to unite. The favourite teaching has been that the cause is primarily vascular. The blood-supply to the femoral epiphysis is said to be poor and, being damaged at the time of the injury, is no longer able to keep the head of the bone alive. The blood-supply to the head and neck of the femur reaches it by two routesthrough the ligamentum teres and along the retinacula of the neck. The neck of the femur is anatomically a part of the shaft ; its blood-supply is therefore carried to it by the periosteum. The vessels lie along the retinacula, give branches to the neck, and then, entering foramina at the junction of head and neck, are the main supply to the head. They are of the vessels than importance considerably greater entering along the ligamentum teres, which supply only the " core " of the head. Dr. Wolcott is investigating by injection methods, using fluid opaque to X rays, the anatomical connexions of these vessels. He has traced branches from the obturator and the internal circumflex arteries into the ligamentum teres, but has not had much success with the vessels of the neck. No anastomosis between the two sets of arteries has so far been demonstrated by him. By direct observation of four cases of non-union subjected eventually to open reconstruction operation by the Whitman method, Dr. Wolcott was able to show that the ligamentum teres had vessels of a respectable size, quite patent and spurting when cut across. Dr. Myron 0. Henry, in the same discussion, pointed out that the course of the decalcification of the femoral head demonstrates the presence of an active circulation. Less seems to be known about the fate of the vessels in the retinacula in these injuries, although it is by no means certain that their blockage or severance would of necessity interfere with union. Apart from vascular failure, non-union has at various times been attributed to lack of sufficient haemorrhage at the site of the fracture, to prolapse of the capsule between the bone ends, and to the action of the synovial fluid. Prolapse of the capsule was looked for by Dr. Wolcott. He did not find it in

any of the four

cases

which

on

operation

was

performed ; what he did find in growth of fibrous tissue over the

all of them was a end of the femoral neck on the distal side of the fracture. This fibrous tissue had a fairly good blood-supply and bled when incised ; its presence in one case and not in another may be of the utmost importance in determining whether union will take place. In attempting to assess the influence of the form of treatment on the occurrence of non-union, it is of interest to note Dr. Wolcott’s view that only 35 of his 41 cases were efficiently treated by Whitman plasters. Accurate reduction and immediate and prolonged fixation in extension may have an important bearing on the occurrence of union, despite the fact that callus formation in fractures of the shaft of the femur occurs quite readily without accurate and complete reduction. The Whitman method of reduction and retention in plaster is probably the commonest form of treatment at present in use for fractures of the neck of the femur. It would appear from the opinion expressed by American orthopaedic surgeons that its success is far from certain. Dr. Frederick Gaenslen made a useful suggestion. He has found that a position of slight valgus at the fracture favours a more rapid union. By practice on artificially produced fractures in the cadaver, Dr. Gaenslen has evolved a method of producing this position during reduction. He first flexes the hip-joint and knee-joint to 90°, and then uses upward traction in the line of the femur to reduce the fracture. Manual thrust in the region of the great trochanter produces the valgus deformity. The limb

finally brought into extension with a moderate degree of abduction and internal rotation. The question arises as to whether it is an impaction produced by the method which results in the success claimed for it, or some mechanical advantage in the position to the vessels running along the neck. Some surgeons, believing in the importance of an initial hsematoma, inject blood to the site of fracture. It is

is

obvious that the process of union and also of the formation of false joints in fractures of the neck of the femur still provides a field rich in problems. EPSOM COLLEGE

A

SHORT

time ago the

Epsom College

Act of 1932

the benefits of the Royal Medical Foundation of the College to medical women pari passu with medical men. The Council has now asked medical women to take up administrative

was

passed extending

responsibilities-namely, Dr.

Laetitia Hutchison (Mrs. Robertson Hutchison) as a member of the Council, and Dr. Christine Murrell as the representative of the Medical Women’s Federation on the Conjoint Committee of the College, which now elects the Pensioners and Foundationers. The Council of the College has acted promptly under its new opportunities, and will surely reap advantages, academic and material, from the course of action taken. Sir Charles

Sherrington

will deliver the

lecture, entitled Mechanism and Arts School at at 5

Cambridge

on

Rede

Brain, in the Wednesday, May 24th, the

P.M.

THE Lister memorial lecture of the Royal College Surgeons of England will be delivered in the theatre of the College by Sir Charles Ballance on Wednesday, April 5th, at 5 o’clock.

of

WE regret to record the sudden death at Cambridge Monday last of Mr. Arthur Cooke, senior surgeon and ophthalmological surgeon to Addenbrooke’s

on

Hospital.