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board, should now be drawn as tight as is comfortable to the patient, and tied upon its back. The tape is intended to keep the fooi-board close against the sole of the foot, which should be left extended a little beyond a right angle with the leg. The leather of the shoe should now be laid over the instep and toes, and secured as close as the patient can bear it with ease. The limb being thus put up, the foot of the instrument should be raised, and the patient left upon his back, with the limb upon the heel. In this state, leeches, cold lotions, &c. may be applied; the patient's bowels may be freely evacuated; he may have his bed made daily, &c. without any danger of disturbing the fracture, if care is taken not to turn the instrument to either side. When the inflammation and tumefaction have subsided, the surgeon should notice the bone particularly, to see whether the fragments continue in a line, and depress or raise the shoe upon the foot-board, as circumstances may require. The tape that supports the foot-board should now be gradually drawn sufficiently close to place the foot at right angles with the leg, taking care at the same time that the bones are not made to overlap, if the fracture is oblique. The short splints, properly padded, may now be applied to the leg, with the unsplit part of the front one upon the tibia, and confined moderately close with two or three circular straps. A tape should be passed through the small hole at the lower end of each of the side splints, and then through the corresponding hole in the foot-board. These tapes should be brought together on the back of the foot-board, and tied. The use of these tapes is to prevent the lower ends of the side splints from shifting when the patient moves the limb. The straps upon the thigh having been drawn a little closer, the patient may be furnished with a sling, which should be fixed so as to act upon the* heel of the foot-board and lower end of the leg-piece, and desired to get up and place his limb across a chair, or walk about at pleasure on crutches, with a caution not to move the limb but by means of the sling. The sling should not be taken off the instrument night nor day, during the period of cure, as it gives the patient perfect command over the lower part of the limb, and enables him to place it in any position he pleases.
“ In all cases of fracture of the thigh, it is necessary to make use of the apparatus for lenthening the thigh piece.
“ The instrument, with the sliding plate attached to it, should be placed under the sound limb and fitted to the leg and foot, as for fractures of the leg; and the thigh-piece should be regulated so as to reach from the bend of the knee to within half an inch of the tuberosity of the ischium. The pad should be made a little longer than the instrument, that it may fall a little over its upper end, where
It is of importance that this direction should be strictly attended to, for if the sling is fixed so as to move the foot-board, the motion will be communicated to the fracture, and a tardy union will be the conSequence.”
it should be fastened ; and should be thick enough at this part, when compressed, 10 fill up the space left between the jostrument and the tuberosity of the ischium. The surgeon should superintend the making of this pad, for it is of importance in two respects. If the thigh part be nicely adapted to the length of the thigh, the instrument will tend to keep the broken bone the same length as the found one, by its pressure against the tuberosity of the ischium, and upper part of the back of the leg; and if its upper end be sufficiently protected, it will not inconvenience the patient by its pressure upon the soft parts.
" When there is much contusion or inflammation of the soft parts, the instrument, properly adjusted to the length of the sound limb, should be applied in the following manner :-Two assistants should raise the limb from the bed, while the surgeon places the instrument beneath it. The limb being placed upon the instrument, the foot-board should be properly fixed with the tape, and the foot secured in the shoe, as described for fractures of the leg. A couple of straps should then be passed round the leg upon the instrument, and a bit of splint padded and placed upon the shin. The leg and foot being thus secured, and a long strap with a sliding pad attached to it being previously carried between the steel bars and the brass plate, one assistant should keep the upper end of the instrument close against the back of the thigh, while the other, by extending from the knee, draws down the instrument, and with it the lower frag. ment, ull the upper end of the instrument comes anterior to the tuberosity of the ischium, in the same manner as when it was placed upon the sound limb. The surgeon, having ascertained this point, and that the fractured ends of the bone are in apt and proper contact, the broad strap, placed at the upper end of the instrument, should now be made to cross upon the front of the thigh, pass round the pelvis, and buckle.
“ This strap keeps up the instrument against the back of the thigh, and serves to secure it to the pelvis, and therefore the instrument and lower part of the limb are made to follow those motions of the pelvis which tend to disturb the fracture.
“ The whole length of the thigh is left bare, except at its back part, and little or no impediment is given to the circulation. The limb thus put up should be left resting on the heel upon pillows, with the patient on his back. It is to be recollected that, if any particular indications require the limb to be secured more firmly, the short splints should be lightly applied
“ As soon as the high action is sufficiently got under, which is usually in the course of two or three days, the short splints, properly padded, should be placed upon the limb and secured with three or four straps. The broad padded strap, previously passed round the thigh and the pelvis, should now be carried under the leathers, placed upon the back of the short splints, made to cross upon the outer of these splints ; and again to pass round the pelvis, and buckle. This strap keeps the upper ends of all the splints firmly upon the upper fragment, and serves to connect them with the pelvis.
“ If the broken ends of the bone do not ride, and if the fracture be Aot 80 high up as to prevent the upper fragment from being held firmly by the splints, the patient may now be allowed to place his limb upon the side or upon the heel, and to alter the position at pleasure; not by means of a sling, as in fractures of the leg, but by placing his finger under one of the straps surrounding the lower end of he thigh, and at the same time taking care that the pelvis and the limb move together in the same direetion. The limbs however had better be allowed to lie principally upon the side with the toe and knee a little raised from the bed by means of pillows, if the bone is broken just below the trochanter minor, or if the fracture is oblique.
“ During the cure, it is necessary that the surgeon should attend to two points particularly. He must see that the instrument does not ride over the tuberosity of the ischium; he must take care that the patient does not move the limb by the exertion of its own muscles, but by the assistance of his hand, or by the assistance of another person. The reason of these two directions will immediately appear. The riding of the instrument would indicate that the fractured ends of the bone overlap; and if the patient attempts to move the limb, by its own powers, he would incur the danger of displacing the upper fragment; for the muscles surrounding the fracture are not of a; texture capable of opposing much resistance to lateral displacement, which their own contraction would tend materially to produce.
“ If more extension and counter-extension be required than the instrument itself is capable of effecting, which I am disposed to believe will seldom be the case, the patient should be placed on his back diagonally upon the bed. Extension may then be made by a tape, which should be fastened to the brass eyes in the sides of the thigh-piece, thrown over a pully at the foot of the bedstead, and made to suspend a weight sufficient for the purpose for which it was intended. The tape, before it passes over the pully, should take the line of the thigh part of the instrument at whatever angle it max be placed, and whether it lies upon the beel or upon the side; it will therefore be necessary for the pully to be suspended from the ceiling, the foot of the bedstead, by means of a forked stiek, or any other means suited for the purpose. Counter-extension may be kept up by means of a bandage, padded and passed round the upper part of the thigh. The two ends of this bandage should be made to cross upon the ilium of the affected side; and then one end may be carried under the pillows, and the other over the chest to the opposite side of the body, where they may be fastened to the bed-post.
We now come to the cases which were treated according to the plan above related.
“ I was favoured (says the author) by Mr. Travers, with the treatment of the following case of fracture of the thigh.
“ Case 1.-Thomas Barwick, æt. twenty-six, was placed under my care December 17th, 1821, for a simple fracture of the thigh across the middle. The injury was occasioned by the wheel of a cart, which passed over the limb, considerable contusion and tension followed che accident; but the muscles were tranquil, and the fractured ends of the bone did not appear to ride.
“ I saw him the fourth day from the time of the accident, and applied the machine. He had his bed made directly, and had it repeated during the cure as often as he wished; and placed his limb in any position most congenial to his feelings, either on the heel or op the sides, and altered the position at pleasure.
“ January 17th, 1822, he got up with the instrument on, and walked about on crutches, supporting his limb in a sling. At the end of five weeks from the time of the accident, the machine was taken off; and, at the end of six, the man was able to walk without crutch or stick, and had a straight and perfect limb. As there was still some weakness about the muscles of the thigh, he was desired to steady himself a little longer with a crutch or stick.
“ He has since informed me, that he was able to carry a sack of malt the distance of fifteen yards, ten weeks after the accident."
“ This case proves, as far as any one case can prove-Ist, that there is no necessity for confining the patient to one position, during the cure of a simple transverse fracture of the thigh across the middle. 2d. That allowing the patient to alter the position of the limb under the restrictions above stated, does not retard the union. 3d. That the treatment here laid down is more conducive to the comforts of the patient and to a speedy cure than any previously adopted.”
“ Case 2.-I feel indebted to Mr. Key, assistant-surgeon to Guy's Hospital, who kindly offered me the treatment of the following case:
“Mary Lovel, æt. forty-five, February 8th, 1822, slipped off the flag-stones, and, her foot twisting under her, she fell and broke the tibia and fibula just above the ancle-joint.
“ Fourteen days after the accident, I saw her. The tension and pain were then very great, and the foot was lying in the extended position, where it was kept by the spasmodic action of the gastrocnemii muscles ; there was an angle formed by the bones projecting forward at the seat of fracture; and the fractured end of the lower portion of the tibia threatened to come through the skin. I was informed that the symptomatic fever had run high. She had been out of bed in a delirious state. Leeches, fomentations, and cold lotions, had been applied, and had, in some measure, reduced the inflammation and tension.
“ The machine was now lightly applied upon the limb. 24th. The pain and tension having materially abated, the short splints were placed upon the leg; and, the straps having been drawn moderately tight, the woman was desired to sit up with her leg across a chair. In a few days, she was able to walk about the room with the assistance of crutches. Three weeks after the application of the machine, the bones were found firmly united; and the limb was straight and perfect. The machine was now taken off, and she was desired to walk about the room with the assistance of crutches, bearing lightly upon the foot at every step. In six weeks and two days she was able
to walk without crutch or stick; but did not throw aside her erutches altogether till the end of the seventh week."
66 Case 3.-T. C. æt. fifty-five, March 28th, 1822, fell from the step of a carriage, and his foot twisting under him, the tibia was fractured obliquely into the ancle-joint, and the fibula a little above it. He was put to bed with the limb upon the side. Ten leeches were immediately applied to the part, and the bleeding promoted by fomentation.
“ 29th. The machine was applied and the leg kept wet with sedative lotion. He had considerable symptomatic fever, which was removed by a strong purgative. 31st. The active inflammation having subsided, short splints were applied to the leg, and the man ordered to get up, and put his limb across a chair. April 1st, the fourth clear day of the accident; he was up yesterday, and has been walking about this morning with the assistance of crutches, supporting the limb in a sling, but not without considerable pain when the limb was hung down. The increase of pain in the fracture, occasioned by the pendant state of the limb, soon subsided, upon placing the linb in the horizontal position; and, in the course of a few days, it became immaterial to him whether the limb was placed upon the floor or upon a chair. 13th. He was seized with a pleuritic attack, which confined him to his bed three days. 22d. The twenty-fourth clear day after the accident, the instrument was taken off, and the bones were found straight and firmly united. 23d. Soap plaster and a bandage being applied, he was desired to walk about with crutches, bearing lightly upon the foot at every step. Five weeks after the accident, this man was able to walk across the room without crutch or stick, but as he had not yet full power over the muscles of the leg, he was desired to steady himself with one or the other a little longer.
“ Case 4.-A lady of rank and fortune, received a blow from the heel of a horse, as she was on horseback, on the lower part of her stirrup leg. The force fractured the fibula about two inches and a half above its lower extremity, and the tibia, an inch and a half above the point of the inner malleolus. She applied to her surgeon in the country, who placed her in the horizontal position, and did every thing he thought advisable. Eight weeks after the accident, finding she had no power over the limb, she came to town to consult Sir Astley Cooper, and hy his recommendation, requested my attendance. The fibula was, at this time, united close to the side of the tibia, and the leg deformed in consequence; but distinct crepitus and preternatural motion still remained between the fractured surfaces of the tibia. The machine was applied, and in five weeks and three days, the tibia, also, was found firmly united. During the cure, the lady walked about with the assistance of crutches, carrying the limb in a sling, received company, or took an airing in her carriage at pleasure.”
" These three cases, 2d, 3d, and 4th, prove that there is no occasion to confine a patient to his bed for simple fracture of the leg, from the mere circumstance of the bones being broken. Vol. III. No. 12.