The frequency of fractures of the hip in the aged, their high mortality and the unvariable disability that follows them, make them important. I wish to draw the attention of the members particularly to one variety, the Impacted ExtraCapsular Fracture; and although I may not be able to offer anything essentially new or entirely original, I do think the leading characters of this injury are not always made sufficiently clear by surgical writers.

That it is essentially an accident of advanced life is shown by the statistics of the specimens collected by R. W. Smith, Gordon and others. The average age in Smith's collection, sixty in number, was sixty-five. The predisposing causes of the fracture are probably senile, due to osseous changes this period of life. All extra capsular fractures are primarily impacted, and associated with injury-splitting up-of the trochanter. The mechanism of their production offers a simple explanation of their pathology. The injury being produced by force applied to the trochanter in the direction of the axis of the neck, the bone gives way at that part least capable of resisting this force, the base of the neck behind, just in front of the posterior inter-trochanteric line, and secondarily at the same point in front, and is driven into the trochanter, splitting it up into various fragments, generally two or

more.

In advanced life the degree of force necessary to produce the fracture not being great owing to the senile changes, already referred to, impaction remains, but where the force is great the frag

ments are liable to become disengaged, as they may also be by rough and unscientific manipulation made for the purpose of eliciting crepitus. In the young or in adults, the non-impacted extra capsular fracture is always the result of great violence, and is always readily recognized from the loud and distinct character of the crepitus, felt under the hand when the trochanter is grasped.

The injury to the trochanter produces local aberrations in this process that can always be recognized, and offers, as we shall presently see, most important and distinctive signs.

The force that fractures the neck, at the narrowest part-the intra capsularis transverse to its axis; that which produces the other variety is along the direction of the axis.

These are the facts as generally observed, but we know that extra capsular fractures have been shown to occur by falls on the feet, or on the knees, and by muscular effort, and intra capsular from falls on the trochanter. Bennett has cited a case where he claims to have demonstrated an extra capsular fracture without any injury to the trochanter. Sometimes the fracture is produced by the fall, sometimes the fall occurs as a result of the fracture, and we know that exceptions are frequent in the age at which both fractures occur. However, it is not with these exceptions we have at present to deal. We know that these injuries are prone to be followed by ab. sorptive and other changes, that seriously prejudice conclusions, based on their pathology if examinations are made at remote periods following their receipt,

and where it is extremely difficult to determine the original line of fracture; neither is it my intention to discuss the questions as to whether they are better termed intra and extra capsular, intra and extra articular, whether the extra capsular are not generally partly within. and partly without the capsule; but what I am desirous of advancing for the purpose of determining more clearly, if possible, is that the extra capsular impacted fracture has special features that should always lead to its recognition and proper treatment. These are my conclusions, and I respectfully submit them to the members for discussion.

That the extra capsular, impacted fracture of the cervix femoris, equally with the intra capsular fracture, is an accident of advanced life. Not probably so frequent in extreme old age as the intra, but comnion after fifty, and in my opinion the more frequent of the two.

2. That it is associated with a history of falls on the trochanter.

That there is an associated injury of the trochanter. This injury produces certain local signs that can nearly always be recognized and do not belong to any other accident.

4. These signs are broadening of the trochanter and prominence of the groin along the anterior-intertrochanteric line. These signs are, as I have said, peculiar to the fracture, and are best elicited by grasping both trochanters, for the purpose of comparison, so that with the thumbs in front and the fingers behind we can appreciate the difference in their antero-posterior diameters and the prominence in the groin. The trochanter is also rotated and placed further back in the injured side.

The increased breadth of the injured trochanter is explainable by the fact, that this process is split more or less apart by the wedge like action of the base of

the neck. It may be difficult to determine when there is much bruising and infiltration, but it usually presents itself sufficiently when sought for, and at any rate readily recognizable after swelling has subsided.

This alteration remains as permanent as the shortening that inevitably follows this fracture, and in thin subjects with a pair of calipers a difference of one to one and a half inches can be demonstrated between the two sides. The prominence in the groin or "lack of compressibility" as it has been described, can be felt inside the rectus and corresponds to the base of the neck, the fullness being due to the projection forwards of the anterior-intratrochanteric line.

The difficulties of making a diagnosis between intra and extra capsular fractures at times is very great and in a hip that has been the subject of chronic rheumatism, the difficulties are probably insurmountable. It has to be diagnosed fracture from dislocation: fracture of acetabulum and contusions, etc. Here the history of the accident will be the surest guide. I have nothing to add to what has already been written on the other symptoms-eversion and elevation of trochanter, as determined by Nelaton's & Bryant's test lines, these are common to several conditions of the hip-intra capsular fracture of the acetabulum, senile absorption following severe contusion, and dislocation, but in summing up the associated facts that characterize this fracture, I would emphasize the age, the direction of the force, and the alteration about the trochanter as being most important.

A word as to treatment:

Recognizing that it is always a grave accident, that it is often fatal, either directly from shock, or secondarily from affections of the respiratory or urinary organs or from bed sores, and remem

bering that the resulting impaction is not to be disturbed, no scientific reason can be advanced for retention apparatus. The impaction, of itself, secures the best result attainable, while the influence on the general condition of the patient cannot be otherwise than

harmful.

This rule admits of modifications, especially in young subjects, where, I think, the opposite rule should be adopted, that is, disengaging the impaction and retaining the fragments in apposition as in other fractures. Occasionally extension may be admissable to control spasm, or sand bags, to secure the limb against movement, both or, indeed, any apparatus must, only, be useful until such time as the local pain in the limb has subsided and, usually, not after the second week.

The best results that I have seen have been in cases that have been least interfered with. The more movement the

patient is able to give the limb, short of producing pain seemed to promote restoration of function, and protection from greater degrees of disability afterwards. In fact the advice, laid down by Sir Ashley Cooper, that the knee should be supported by a pillow and made as comfortable as may be, the patient kept in bed until movement is no longer painful to him, say a fortnight or three weeks, and then allowed, or as I would suggest, encouraged, to get up and move about as much as he can with ease, comprehends all that is necessary. I have found application of a long hot water bag, under the upper part of the thigh to support the trochanter, a great comfort, as I also find advantage from massage and later on local protection against alterations of temperature in a joint that has become permanently crippled, and is like all such joints in old people, subject to rheumatoid pains.

DISCUSSION.

Dr. J. Ford Thompson said: So far as the diagnosis between fracture and dislocation is concerned, I think there should be no difficulty even with an inexperienced man; but to diagnose an intra-capsular fracture or an extra-capsular fracture is more difficult. I have seen two cases in the last year where there was some impaction. No fracture had been detected, and the patients were advised to get about; in one case an extremely painful joint with a useless limb resulted; the other has no painful joint, but on walking the trochanter moves. Both cases are now incurable.

I do not agee with Dr. Kerr that a fracture should be broken up at any age. A weight of about ten pounds should be applied, for it will not be suf ficient to destroy the impaction, but it will overcome the contraction of the muscles and prevent shortening of the leg. There is no reason why a fracture at the base should not get well as well as a fracture anywhere else. The nutrition is sufficient, and everything is favorable to perfect consolidation of the limb, and I think the great mistake is that we let these cases go without any treatment at all.

Dr. T. C. Smith referred to the diffi culties of diagnosis of injuries about the hip, as shown in his own experience and reported an interesting case of fracture of the rim of acetabulum, where the crepitus was not discovered for several months.

Dr. Hobart S. Dye referred to a case of a fracture of the hip where crepitis was not discovered until two months later. There was no deformity and no pain on mater and the patient walked about.

Dr. J. Ford Thompson: The most important thing in these cases in my opinion is that treatment should not be neglected because all the symptoms of fracture are not present. Where you

have eversion of the foot and loss of function of the limb the safest thing is to treat as a fracture. I do not think that a surgeon who is in the habit of seeing these cases frequently requires all of the symptoms to make a diagnosis. It often happens that the most serious difficulty in the way of making a diagnosis is that there is no crepitus.

The President: Is it possible for an impacted intra-capsular fracture to get well without shortening.

Dr. Thompson: No; there must be

some shortening with every case of impacted fracture.

Dr. James Kerr, in closing the debate, said: The object of my paper was to draw attention especially to fractures occurring in old age, and I only spoke of fractures in the adult to justify breaking up impactions. Every impaction involves some shortening, and it is not justifiable to let a young adult go about lame. The breaking up of impacted fractures has been done by a surgeon of Manchester, who reported his cases at the last meeting of the British Medical Association. In such cases the impaction does not become disengaged it should be broken up in order to restore the normal length of the limb. I do not believe that any treatment by extension, is scientific, except just enough to relieve the spasm,

because impaction is the most favorable condition that can be obtained in old people, and all manipulation for the purpose of eliciting crepitus is unjustifiable. One of the saddest cases I saw was one of this kind, in which the impaction was broken up, and the patient died with symptoms of suppuration around the hip. Bryant says that it is important to know whether a fracture is impacted or not impacted. When there is impaction you get shortening, and when there is no shortening at first you may get it after two or three months. The special sign that I attach most importance to, is alterations about the trochanter, and I can generally diagnose a fracture by comparing the trochanters on both sides. În addition you have eversion of the foot, uselessness of the limb and some shortening.

It is well known that milk under ordinary conditions contains many bacteria. The large number is attributable to the multiplication of the bacteria which gain access to the milk either from the udder and the milk ducts themselves or from external contamination. Among the latter there is a great variety of fecal and purely saprophytic organisms, and occasionally the specific organisms of certain diseases peculiar to mankind which find. their way into the milk through contaminated water used in washing the milk utensils or otherwise. Among the former are the specific bacteria of certain diseases of cattle common to the human species, such as tuberculosis and anthrax which are transmitted from the diseased cow to her milk. There are furthermore the bacteria which get into the milk ducts and multiply there after each milking and which necessarily contaminate the milk subsequently drawn.

It is supposed, by certain milk bacteriologists, that disregarding the age, the number of bacteria present depend largely upon the amount of dirt and filth which find their way into the milk after it is drawn from the udder. Passing over the details concerning the well known channels through which external contamination takes place, we come to the still more interesting fact namely, that it has been found impossible, in the majority of cases, to obtain milk free from bacteria when it is drawn directly into sterile flasks and under rigid aseptic precautions. The nature of these bacteria which constitute the normal bacterial flora of milk and their effect upon the milk itself and indirectly upon the health of the consumer, have received comparatively little attention. The examinations to determine the number of bacteria in, milk as it is delivered by the milkman, are legion, but the inquiries into