engrafting of tubercular consumption on local lung disease. In the mines of Schuylkill County a large number of men inhale carbon and irritant gases, until at last, chronic bronchitis is established. For a considerable period the general system may remain. unaffected, but at length blood-poisoning occurs. Finally, they die with all the symptoms of phthisis, and tubercular deposits are found in their lungs. To these facts I alluded in a paper published in the Transactions of this Society for 1869, and I state them now with confidence, as an interesting proof of the local origin of this undoubtedly constitutional disease.

6. Scrofula has been considered to be an established constitutional affection, which gives rise to varied disease in different tissues and organs of the body. Does it not seem, in the light of preceding illustrations, worth consideration whether it may not be a consequence, and not a cause, of many affections ranked heretofore as scrofulous diseases? Consider one of the most thoroughly studied forms of this disorder, viz., coxalgia. Once it was the most unmanageable of so-called scrofulous affections. It was held to be of constitutional origin alone, and general remedies only were employed in its treatment. Long agony, perhaps anchylosis with deformity, and often caries, abscesses, constitutional infection, these were the results of that theory and practice. How is it now? Thanks to Prof. Sayre, this is one of the most curable of surgical maladies. It is cured by local measures, by skilful local surgery.

7. Again, what is pyæmia? A general disease, caused by general infection, but originating in a local nest.

Let purulent absorption occur from ever so small a wound or abscess wall, and there follows that fearful train of symptoms which so frequently ends only with life. Not many weeks ago I saw a patient die a protracted death after hectic fever, chronic abscess, and purulent deposits. It was a case of chronic pyæmia following a small lacerated wound below the knee-joint. It was a sad instance of the local origin of constitutional diseases. It was an instructive commentary upon the importance of opposing the beginning of a local malady.

8. Perhaps the most beautiful illustration of advance in pathological knowledge, and the removal thereby of an interesting class of so called general diseases into the domain of diseases of local origin, has been furnished by the "anæmias."

Until the independent discovery by Bennett and Virchow in 1845, of leucocythæmia, anæmia was held to be a constitutional disease of the blood, and no distinctions were made among the various disorders grouped together under that common title. In

deed, the true nature of the physiology of the blood was not known, much less its pathological conditions.

Leucocythæmia, in its three subdivisions, splenic, lymphatic, and medullary, became separated from the other anæmias through the researches of Wilks, Hodgkin, Griesinger, Ponfick, and H. C. Wood. But there still remains anæmia proper, described as idiopathic anæmia by Addison in 1855. Though the local origin of the leucocythæmias was established, this form of blood dyscrasia was not understood until the masterly analysis by Prof. Wm. Pepper cleared up the view, in an article printed in the Amer. Journ. of Med. Sciences for Oct. 1875. And now, under the generic title of “ anæmatosis," Dr. Pepper groups all these anæmias, which are so clearly proved to depend on defective elaboration of the blood, and to have their "locus" in one of the three tissues (splenic, lymphatic, or medullary), known now to be principally concerned in the renewal of the vital fluid.

To those of us who have ever watched a case of idiopathic anæ. mia, hopelessly through a tedious and distressing illness, with no rational view of its pathology, a great relief to our uncertainty has been afforded. And it may be that with clear views of the pathology there may yet be found a way to satisfactory therapeutics also.

Time warns me to conclude these imperfect and fragmentary illustrations. Hastily thrown together, they may still accomplish their purpose of calling attention to a long-neglected view of medi

cal truth.

It is probably about seventy years since Abernethy wrote his famous work upon the reverse of the subject which we have been considering; and, as we all know, his doctrine of the constitutional origin of local disease marks an era in medical teaching.

It is well to remember, therefore, that the shield of truth has two sides, and that we must consider the opposites of this subject if we would obtain complete and solid views of the relations to each other of local and constitutional disease. Opposing truths, if they be truths, must be harmonized. Let us then be medical philosophers as well as medical practitioners, thinkers as well as workers, and so accomplish our part in the solution of this difficult problem of pathology.

HISTORY OF A CASE OF DISLOCATION OF THE HIP, COMPLICATED

WITH FRACTURE OF THE FEMUR; WITH REMARKS.

By J. B. MURDOCH, M.D.,

SURGEON TO THE WESTERN PENNSYLVANIA HOSPITAL, PITTSBurg.

IT is too much the custom for physicians to report only their successful cases, and keep silence in reference to failures. This is not well. It is probable that our blunders, if honestly reported, would be of greater service to our professional brethren than the report of our most brilliant achievements. The following is the report of an unsuccessful case; I ask for it your patient attention, believing that you will find the case instructive in spite of its very clumsy recital.

W. D., aged 24, a flagman on the Pennsylvania Railroad, was injured August 16th, 1876, in the following manner: He was standing on the rear end of a train of cars, the train consisting of an engine and seven platform cars. The train was backing down the track in order to couple on another car. Mr. D. was leaning forward over the rear end of the car, with a pin in his hand, in order to make the coupling when the train should reach the stationary car. He, however, lost his balance before reaching it, and fell forward upon the track. The car on which he had been standing and another car then passed over him. He was between the wheels under the cars. The wheels did not injure him but he was struck, as he thinks, by the brake-rods.

When examined, three hours after the accident, it was easy to discover that he had sustained a fracture of the shaft of the right femur and a lacerated wound of the heel. As the patient lay upon the bed the injured limb rolled outwards and was one and one-half inches shorter than its fellow. He could not lift his foot from the bed. A false point of motion could be felt at the upper third of the thigh. The upper fragment was drawn upwards and inwards and its fractured extremity could be felt at a point two inches below Poupart's ligament. The direction of the fracture could be felt to be from above downwards and from before backwards. The

point, however, which distinguished this case from other simple. fractures at this point was the fact that the upper fragment was drawn more firmly up and was more fixed than is usual in this form of injury. It was, however, diagnosticated as a case of simple fracture of the shaft of the femur, and dressed according to the method of Dr. Buck. It was soon apparent that this apparatus failed to meet the indications. The upper fragment rebelliously projected forward, and no amount of compression applied to it, or extension of the limb, would bring it into place. During the first two weeks of the treatment I called in no less than six of my professional friends, and the case was regarded by them all as one of simple fracture. At the expiration of two weeks I removed the Buck's apparatus and applied a Smith's anterior splint. The splint was bent more at the knee and the limb more elevated than is custom

ary in the application of this instrument. It was thought that inasmuch as the upper fragment could not be brought down to the lower, the best way would be to lift the lower fragment to the upper. This splint approximated the fragments more accurately than it had been possible to do with the Buck's apparatus. It was kept on for six weeks, at the expiration of which time, and eight weeks from the time of the accident, the limb was carefully examined when it was discovered that no union had taken place.

It was then, Oct. 18th, put up in the plaster of Paris dressing, the thigh being well flexed upon the pelvis, in order to bring the lower fragment as near as possible into line with the upper. This was kept on until January 27th, more than five months from the date of the accident. The limb was again carefully examined, and it was still apparent that no union had taken place. As the patient's health was suffering from his protracted confinement, a soleleather splint was carefully moulded to the hip and thigh and the patient permitted to go about upon crutches. Under this management he continued to improve in his general health, was able to bear a little weight upon his limb, but did not have much control over its movements. Being of an active temperament, he became restive and impatient. He consulted various surgeons in this city, in the hope of getting advice which would be of benefit to him. Finally he visited various surgeons in New York State and was there advised to have the operation of resection performed. He returned to this city about the 1st of August, 1877, for this purpose, and applied to Dr. James McCann, then on duty as surgeon at the Western Pennsylvania Hospital of this city.

Dr. McCann, after pointing out the risks of the operation and

seeing that this had no effect in changing the man's determination reluctantly consented to undertake the operation.

Accordingly, on the 8th of August, with the counsel and assistance of the hospital staff, he performed the operation of resection. The patient being anesthetized, a straight incision was made on the outside of the thigh down to the broken ends of the bone. The fragments were found to be widely separated, the upper drawn upwards and inwards, and the lower backwards towards the tuberosity of the ischium. There was a thick band of muscular fibre between the fragments.

It was necessary to divide this muscular band with the knife and elevate the lower fragment before it could be brought into contact with the upper. The ends of the broken fragments were then sawn off, the ends perforated with a Brainard's drill, and the fragments bound together with four thickness of stout silver wire. The operation was skilfully performed, the patient not losing more than two ounces of blood. The limb was dressed upon a double inclined plane, and the patient placed in bed. But in spite of the greatest care he did not rally well from the operation, but continued weak and depressed in spirits. On the night of the 15th of August he was taken with a slight secondary hemorrhage, losing not more than six ounces of blood. This, however, was more than he could bear in his feeble condition, and he died on the morning of the 16th of August, 1877, just one year from the date of his injury.

On post-mortem examination it was found that there had been scarcely any effort at union. A dislocation of the head of the femur was now discovered, the head of the bone resting on the external surface of the body of the ischium in the groove between the lower lip of the acetabulum and the tuberosity. Ossific deposit had been thrown out and the head of the femur was attached to the ischium in the position which I now show you. It required a good deal of force to break up the union. It will be seen that the dislocation was directly downwards, so that the head of the femur rested on the ischium below the lip of the acetabulum. This is a rare form of dislocation. Erichsen in the last edition of his Surgery, vol. i. p. 502, says that two cases of this injury have been recorded by Gurney, of Camborne, and one by Luke; and Henry J. Bigelow in his work on the Hip, page 74, refers to a case of this kind mentioned by Hippocrates.

I have reported this case thus minutely, because dislocation of the hip complicated with fracture of the femur is a rare form of injury, and one which has received but little attention from surgical writers. The authors of our most voluminous surgical works