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cases of fracture of the femur upon the thigh itself, and upper part of the back of the leg; but we should think not, as we have seen him place a fractured neck of the thigh bone in the straight position; and this being the case, it appears, from what we know of his plans of treatment, that the extending means must be made to act first upon the foot in fractures through the cervix.
After adverting to the advantages which accrue to the patient from raising the limb upon an inclined plane, when the inflammatory action is considerable, the author goes on to enumerate the following indications, which, from his own observations and experiments, he thinks should be attended to in the construction of any machine for fractures of the lower extremity.
“ The instrument should— 1st. Fix the whole limb so as to admit of no motion whose centre is not in the hip-joint, or between the pelvis and the back. 2d. It should maintain the fractured ends in a natural position, and in perfect coaptation. 3d. It should lie upon the limb with ease to the patient. Ath. It should enable the surgeon to place the limb at any angle the case may require. 5th. It should allow of extension and counter-extension when the limb is fixed in the bent position. 6th. It should be entirely passive to the motions of the limb, and should allow the patient to place it in any position most congenial to his feelings, either on the heel or on the side, and to alter this position at pleasure. 7. It should enable the attendants to move the patient from place to place, without any danger of displacing the fractured ends. 8th. It should allow of being ada pted to limbs of different lengths and different sizes.. Oth. It should be applicable to fractures in any part of the limb, and of all kinds; whether simple, comminuted, or compound. 10th. It should be simple and easy of application. 11th. With all these advantages it should ensure to the patient a speedy recovery and a straiglat and perfect limb."
Mr. Amesbury has contrived a machine to answer these purposes, his own description of which we subjoin; and also his reasons for introducing into its composition each particular part.
“ To fix the limb and allow it to be bent and fixed at different angles, a piece of beech slightly hollowed out, to receive the back of the thigh, thrown a little out of a straight line, to answer to the natural curvature of the thigh bone, and gradually narrowed towards the lower end, was connected by means of a binge-joint, to another piece of beech, slightly excavated to receive the calf of the leg, and gradually narrowed towards the lower extremity, to answer to the natural form of the limb. From the situation for the calf to the inferior end this piece was made a little concave, simply to prevent the pad, upon which the limb is placed, from shifting its situation. Both of these pieces were cut out of one inch and quarter board; and that for the thigh was left one inch thick for two inches from its lower end, for the purpose of receiving, on each side, a brass-eyed screw; and that for the leg was left one inch thick, and the same width for six inches from its lower end. A bit of beech, a little longer and wider than the foot, was cut out at one end, to receive the legpiece at right angles. This was intended for a foot-board. It was one inch thick and one broad, where it lay in contact with the sides of the leg-board; and when they were placed at right angles, the receiving end of the foot-board, and the received part of the legpiece, were bored transversely, so that they may be fastened together by means of a bit of wire. That part of the foot-board which lay upon the concave part of the beech intended for the leg, was a little rounded off at the edge nearest the lower end of the leg-piece, so as to give it a hinge-like motion in a direction from right angles over the lower end of the leg-piece.
“ To fix the pieces of beech intended to support the leg and thigh, and to allow of their being placed and fixed at different angles, I had a thin rod of steel, connected at one end, by means of a binge joint, to a short pillar of brass, which was fixed by screws to the middle of the back part of the leg portion. To the other end of this rod was fixed, by means of a hinge-joint, a brass foot, about an inch and half long, and one-fourth of an inch thick, with a hole in its centre, a little narrower in the transverve than in the longitudinal direction; and another hole in its side, which traversed the one in the centre transversely. To the side of the brass foot was fixed a bit of brass with a spring, in the form of a flute key, and at that end of the key which answers to the part that stops the hole in a flute, was fixed a steel pin, which was made to pass into the hole in the side of the brass foot, and cross the hole in its centre. A narrow piece of brass, with six stays projecting from its surface, was fixed to the back of the thigh portion. Each of these stays was of the form and size of the hole in the centre of the brass foot, connected to the steel rod, and each had a hole in it transversely to the plate, upon which they were arranged, large enough to admit the pin made to traverse the hole in the side of the brass foot. They were placed at a distance sufficient to allow the thigh piece to be fixed to that intended for the leg, at any degree of flexion, from straight to right angles,
“ It will be seen that, by pressing the key, the pin attached to it, as above described, would be drawn out of the hole in the centre of the brass foot-piece, which could then be made to receive any ono of the stays placed on the back of the thigh-piece; and once received, we have only to take the finger from the key, and the steel pin is forced, by the reaction of the spring, through the hole in the centre of the stay, and, consequently, the two pieces of beech may be fixed at any angle the case may indicate.
“ To prevent the effects of moisture upon the steel rod, it is adviseable to have it coated with brass or tin, which may be easily done; but this is not required except for hospital practice.
.“ But it is proper that the instrunjent shonld be applicable to limbs of different lengths. The thigh and leg pieces must allow of being shortened more or less according to the length of the limb. To answer this purpose, as far as the leg piece is concerned, a number of holes of one size should be bored in a line transversely to this piece at its lower end ; and then we have only to draw out the wire Vol. III. No. 12.
which 6xes the foot-board to that intended for the leg, slide up the former upon the latter, and fix them where we please.
“ The lengua of the thigh portion, however, is not so easily altered; but this may be done by a thin plate of brass the width of the thighpiece, and five or six inches long, according to the size of the instrument. When hammered out to lie upon the hollow part of the thigh-piece, and turned off at its upper end, this plate had attached to it two this plates or bars of steel of its own length, and about half an inch wide. As much of one end of each of the steel plates as was equal to the wood of the thigh-piece, was bent at right angles. They were then placed upon the back of the brass plate in the longitudinal direction, and the bent extremities united to it, just below its upper end; and within half an inch of its sides. Having now placed the brass plate upon the thigh-piece, and the steel plates or bars behind it, I had nothing to do but unite the plate to the bass of steel through two long mortises in the wood, in such a manner as would enable me to slide the brass plate up and down, or fix it upon the wood at pleasure. To fix the brass plate and to allow it to slide, two small screws, with square heads, were passed through two holes at the lower end of the brass plate, opposite the steel plates or bars. These screws were then passed through the mortises in the wood; and through two holes of their own size made in the steel plates ; where they were fixed by female thumb screws. Ry means of the female thumb-screws the brass plate could be fixed or made to slide upon the wood, so as to enable us to lengthen or shorten the instrument, according to the length of the femur; but this plate is not required except for fractures of the thigh and fractures, &c. of the leg, attended with high action.
“ But legs are of different thicknesses as well as of different lengths; one man may have a larger calf or a longer
, heel than another, and these should engage our attention. To enable us to adopt the same instrument to different degrees of thickness in the calf of length in the heel, we may make use of a leather shoe, open from.. the toe with a wooden sole, suspended from the top of the foota board by means of a strap and buckle. The strap should be fastened to the bottom of the wooden sole in a groove, and made to pass over the top of the foot-board, which should be furnished with a buckle near the end that comes in contact with the leg piece, in order to receive it. The strap should be let a little into the top of the foot-board, that it may not shift its situation. The sole of the shoe should be confined closely to the foot-board by a strap and buckle passed round them. The same intention may be answered by making the sole of the shoe to slide in a groove in the foot-board, upon which it may be fastened by means of a thumb-screw. The leather of the shoe is intended to wrap over the instep, and to be confined upon it with straps or ribbons.
“ This shoe is intended to answer three indications : to raise the heel from the leg-piece, or lower it, as the case may require ; to prevent any lateral or rotatory motion between the fractured ends of the bones; and to form an easy bed for the heel.
* The whole of what I have described, is required for fractures of the thigh; and for fractures of the leg, attended with high inflammation; but when the instrument is used for common simple fractures of the leg, as we usually see them, the brass plate may bo dispensed with.
“Besides the parts I have mentioned, three common short splints are required for fractures of the thigh: one on the outer, another on the front, and another on the inner side of the thigh. The first should extend from the upper part of the great trochanter to the Jower part of the outer condyle; the second from the great trochanter to the patella ; the third should lie upon the triceps adductor femoris, and should extend from the pelvis to the lower part of the inner condyle. These, with the assistance of the thigh-piece, may be made gently and regularly to compress the muscles, and to prevent any straps or tapes, made use of to secure them, from injuring the soft parts. The splint placed upon the front of the limb answers another indication, that is to resist the action of the flexors of the thigh.
“ For fractures of the leg, three short splints are also required; one on the outer, another on the inner side of the leg, running from the head of the tibia or condyles of the femur to the sole of the foot. These differ but little from common short splints for fractures of the leg. Each of them has a small hole at the lower extremity, which corresponds with one on the same side of the foot-board. They are a little narrower, and the holes for the ancles are made to answer to the situation of the malleoli, the one for the inner ancle being nearer the anterior edge of the splint than that for the outer. These splints steady the foot more perfectly, and enable the patient to lay the limb upon the side. The third splint, which is composed of deal, one half of which is split, is turned up a little at either end, and is intended to lie upon the front of the leg. This prevents the upper fragment of the fracture from being at all displaced by pressure on the calf, and preserves the integuments on the shin from the action of straps or tapes.
" I have had an instrument constructed in the manner above deg. cribed, and have used it in a variety of cases, and have not yet been able to discover any thing material that militates against it. In confining the different splints upon the limb, I have made use of leather straps, armed with buckles, in preference to tapes; as the necessary
degree of pressure can be better and more easily regulated with the former than the latter; and as there is no danger of their giving way. In order to fix them to the instrument, or remove them at pleasure, I have usually had some studs put along the middle of the back of the instrument, and a strip of leather near each side, for the straps to pass under.
“ Having described the different parts of this instrument, we now pass on to its application. This is modified by the state of the soft parts, and the situation of the fracture. The surgeon should bear in mind the principles of bis science, and act up to them in every instance. If no particular angle is indicated, by the nature of the case, the semiflexed position is most easy to the patient, both in fractures of the leg, and fractures of the thigh. Whether the fracture be in the leg, or in the thigh, the limb should be placed upon the instrument, as soon as possible after the accident, and this is the more necessary, in proportion as the displacement is great, or the inflammation high ; but as long as the high irritation continues, it is not adviseable to apply the short splints closely upon the fractured bone. We may indeed defer the application of the short splints to the fractured part, till the first irritation is got under, unless the bone cannot be kept in apposition from the irritability of the patient, or other causes.
“ In a case of fractured leg, before the first irritation has subsided sufficiently for the application of the short splints, supposing no particular indication requires them to be immediately applied, the limb should be put up in the following manner :-The surgeon, having procured an instrument, should fit it to the sound limb. The hinge which connects the leg and thigh pieces should be placed under the knee-joint, and the foot board brought up close to the foot. He should then superintend the construction of a pad, made thickest at the part which is intended to lie under the small of the leg, and long enough to cover the leg and thigh-pieces, upon which the limb is to be placed.* A tape should be placed transversely upon the back of the foot-board near its loose end, under a strip of leather, placed there to prevent the tape from slipping down to the end of the leg-piece. The ends of this tape should then be carried from the sides of the foot-board, through the corresponding brass eyes connected to the sides of the thigh-piece, and left hanging. The instrument being now properly adjusted, two assistants should raise the fractured limb, one the foot, and the other the upper fragment, while the surgeon places the instrument, properly padded, beneath it. The instrument being in a line with the limb, and the hinge under the knee, the assistant should be directed to lower the limb gradually upon it, and place the heel in the shoe. Then, having placed a splint upon the front of the thigh, and another on the inner side upon the triceps, two or three straps should be carried round the thigh upon the splints, so as to make very little pressure upon the limb. One of the straps, drawn rather closer than the others, should pass over the condyles upon the femur, to keep the knee from rising from the instrument, when the limb is moved. The only use of the short splints, placed upon the thigh, is to prevent the straps that fix the thigh upon the instrument from injuring the soft parts. The tape, made to cross the loose end of the foot
• Mr. A. now uses a leather strap instead of a tape, as it supports the foot-board more steadily, and is more easily regulated. The strap is fixed to one of the brass eyes on one side of the thigh-piece; and the buckle to the other. In applying the instrument, the strap is carried from the side of the thigh-piece, round the toe of the foot-board, under the leather placed there to support it, and then along the opposite side of the instrument, where it is received by the buckle at the side of the thigh-piece.