ful, a manifest advantage is obtained. reduced fragments; they should be strong In fractures of the leg, the muscles of the enough to offer sufficient resistance, and cals are powerful in producing displace- long enough to remove constriction from ment; a semi-flexed position in which the part. They are made of wood, bark, they are relaxed, would certainly be the leather, iron, pasteboard, and other submost favourable to reduction, and also stances. They may be as long as the induring the after treatment.

jured bone, or as the limb itself; tber In the reduction of fractures, machines should not be directly in contact with for making extension are exploded; the projecting points. In some fractures a hands are almost always found to be single splint is used, in others two, in sufficient. Always extension should be others three, or even four. Pasteboard gradually and steadily made; if it be made splints are used in certain cases, wbere the suddenly and violently, the muscular fibres consolidation is long about. They are may be ruptured and otherwise injured. always moistened before they are applied; It is desirable, during the time extension they thus adapt themselves perfectly to the is making, to endeavour to distract tbe form of the limb, and in drying become patient, to direct bis attention to some. perfectly firm and hard, and partake much ihing unconnected with the business of of the character of the immoveable appa. reduction, as it tends to lessen muscular ratus. But probably the best form of contraction at the part. When extension paper splint is that which is formed by has been carried far enough, the hands applying upon the limb a certain number should be applied to the part. It may of layers of brown paper, between each of happen that the attempts to reduce a frac- which a layer of paste, gum, dextrine, or ture will be unsuccessful, either because some similar substance is applied, each extension bas been too suddenly applied, layer becoming dry before another is sp. and spasmodic action excited, or becausé plied; this becoming perfectly modelled muscular contraction is produced by pain upon the limb, can, therefore, make no or irritation. In the first case the remedy unequal pressure, and may be removed al is easily applied ; in the second it may be will. necessary to bleed or give opium.

Whether we apply the one or the other, Reduction, however, is not the difficulty (taking care that it is neither too lightly most commonly experienced in fractures, nor too tightly bound,) we should interfere but the power to maintain it until nature with it as rarely possible. Still it must shall have provided against displacement. be watched, tightened if necessary, and The means commonly employed for the the apparatus should even be removed to purpose, are a proper position, rest, ascertain wbether the fragments have been bandages, splints, and a great variety of properly sustained; this should be done apparatus. It is of great importance to at the end of ten days or a fortnight from place the patient and the limb in a con. its first application, and again before the venient position ; supposing the injury to apparatus is dispensed with. It is praeaffect the leg, it must be equally and com. tice alone which can teach us as to the fortably supported along its whole length; constriction which it is necessary to apply. if it be applied injudiciously, two accidents It often occurs, especially in fractures of may bappen, a new displacement and in the leg, that the patient experiences during flammation, or gangrene at the points the night spasmodic contractions, by which where pressure bas been so made. What he is awoke, by which the apparatus may ever be the position we give the limb, be somewbat deranged, and the fragments whether semi-flexed or extended, it must displaced ; this must be particularly albe maintained at perfect rest during the tended to. Some surgeons recommend aa time necessary for consolidation. If motion almost daily remoral of the apparatus, to be experienced at the fractured point, the be assured that all goes well. This prace formation of callus will be interfered with, tice I decidedly object to ; it is opposed to and the cure may be interrupted. Ordi. that important principle—the necessity of nary bandages are comparatively useless, absolute rest. Another treatment, the as means of maintaining quiet ; but they opposite to that, is the “immoveable treatare of use in supporting compresses, upon ment,” in use from a very early period which cold or other applications may be among the Arabs and Greeks, and climade. To maintain reduction, pillows, ployed in Switzerland, Spain, and other junks, splints, and certain other apparatus, countries. In France the principle bas are employed. The objection usually been largely tested by Larrey. lo this case made to junks is that they are cylindrical, the apparatus is not removed from the too narrow, and too easily displaced; but time of its application to the moment of this objection might be removed, for the cure, in conformity with that principle that cylindrical form is not absolutely necessary. the more complete the repose the more Splints variously modified are most com rapid will be the consolidation. 'The monly employed for maintaining the apparatus of Larrey, which is applied

equally to compound and simple fractures, of the inconveniences attendant upon conis formed by placing a couple of junks at finement. The method of Larrey has been the sides of ihe limb; they are secured much simplified by Seutin and others. by means of linen cloths of the length, or The method of Seutin was to place around rather more, of the fractured bone; these the limb tbree, four, or more layers of are wound around the limb, and secured bandaging, between each of which was a by ligatures. The whole apparatus is layer of starch. When dry, this constituted saturated with a mixture of white of egg, a firm splint exactly moulded upon the camphorated spirit, and goulard water. leg. The strip of paper plan which I have At the end of twenty-four to thirty-six alluded to is a modification of the same hours the apparatus, so applied, becomes system. So also is the mode employed in perfectly bard, and, as it were, a solid very early times, and revived by Dieffenpiece: to attain this quality, it must not, bach, of surrounding the limb with plaster of course, be covered up, or it remains of Paris. soft. Once dry, it effectually prevents dis- I am of opinion that in a considerable placement, being moulded on the part. number of cases it is desirable, from week

Certain objections, however, are made to week, to ascertain the condition of to this plan ; tbat, as thirty or more hours the part; at the same time I decidedly pass before the apparatus is firm, the frag- object to a frequent interference. Therements may during ibat time be displaced; fore it is that I am disposed to object to that, if applied when there is much tume- any system which places difficulties in the faction, when that subsides, there must be way of such supervision; and the plans of a considerable interval between the appa- Larrey, Seutin, and Dieffenbach, cerratus and the limb: there is clearly truth tanly are open to this objection, though, in these objections, but they are not at the same time, I readily admit that, in a weighty. In any mode of treatment, it is large number of cases, they are unexcepnot commonly during the first three days tionable. But I look to the strips of paper that displacement occurs; it is later, when or papier maché method as the one the patient gets restless; it is rarely which ought to be most generally used. that the subsidence leaves a very great We must now consider another system interval, and by that time the callus has of treating fractures which has has been, acquired some power; if there were force within a few years, much employed by in this objection, it might be obriated Sauter of Constance (Annweisung, &c. by allowing the swelling to subside before 1812, 8vo. fig.) and by Mayor, of Lausanne the apparatus is applied. And against (Memoire sur l'Hyponarthecie, 1821, 8vo.) any theoretical objection, as to gangrene, This method consists in the use of and so on, ihe results of the treatment may an instrument like one side of an old be opposed. Its advantages must be ob fashioned scales—that is, a flat oblong vious; it admits of moving the patient board suspended by four cords at its corfrom his bed by the third day, and gets rid ners ; upon this board a pillow is placed, and it is raised or lowered to the required the necessary applications to the part elevation by pullies. The board should be without in any way disturbing it, and it two or three inches longer than the limb, allows of a changing position without inand from six to nine inches wide-adapted convenience. Still it is doubtful whether to it is a small mattress stuffed with horse. this system will get into general use; for I hair, chaff, or other substance, which must cannot divest my mind of the conviction that be thick enough to prevent the possibility this mode, as well as a still more unsafe of improper pressure. The limb being one lately recommended in this country, placed upon it, it is .surrounded by a affords more facility for displacement than broad piece of linen, which is also passed the other methods of which I have spoken. around the apparatus, so as to prevent the The fracture has been reduced the one moving without the other. If the means of preventing displacement are fragments tend to ride, this may be pre- applied, but there are other circumstances vented by making extension, and securing to be attended to. You must anticipate ! both extremities of the limb to the extre- or watch the advent of accidents-consemities of the board. This apparatus is quences of the injury. If the patient be susceptible of various modifications by young or vigorous, and there be much which it may be adapted to the different tamefaction, it may be advisable to bleed; limbs. Munaret has proposed a modifi. but this should not be heedlessly done, por cation which seems to me a decided im. as a matter of routine, because it is proprovement. He substitutes for the board bable that callus is as much more promptly a gutter of painted iron adapted to each formed as the circulation is more energetic, limb. This is unquestionably a very and the strength good. As soon as inflamvaluable invention ; it admits of making matory symptoms begin to subside, the

diet should be improved. If there be con. hæmorrbage or extravasated blood, we stipation, which is commonly the case, it should endeavour to procure immediate must be relieved by the gentlest means, union, and reduce it to the condition of a because a frequent call to stool will be simple fracture; but in a majority of cases likely to displace the fragments. When the result will not be obtained, and long the consolidation is completed, it is always suffering will be the consequence. It is well to allow a couple of days to pass after not long since surgeons thought comthe removal of the apparatus before the pound fractures cases for amputation; limb is used. There is always a certain in the present day we regard them diffeseebleness and rigidity of the limb, depend. rently. And, although in this metropolis, ing, to a considerable extent, upon the the wholesale result may be very unfavourasplints and bandages which have inter- ble, it is not the case in the provinces. If fered with the circulation, and have pre- the wound have been occasioned by a vented muscular action. This state is fragment of bone, and the wound be not relieved by frictions, baths, and douches; large nor much jagged, we may attempt bat the effect is not soon got rid of. Occa: union. If the fragment of bone be large sionally a very uncomfortable symptom is and protruding, and the fracture translong felt after a fracture ; a pain is expe. verse, it may be reduced, and we may pur. rienced at the part after walking; and sue a similar course. If it cannot be resometimes the muscles of the part act duced, the wound may be enlarged longi. spasmodically. I have known two cases tudinally, in the course of the vessels and in which this state was very troublesome; nerves, as affording the best chance of but it yielded at last to blisters and an avoiding them. If the extremity of the issue.

fragment be reduced, it will be wise to reCOMPOUND FRACTURE.-In compound move it with the saw, being careful to profractures the treatment is different; the tu. tect the soft parts; if there be many loose mesaction and disorganization of the part fragments, much after mischief may be may be great, and may require a very de- prevented by removing them; and in either eided course of treatment. But here, at the case bring the parts together, so as to afford threshold, we are met by a much debated the best chance of union. If the wound question-should we at once proceed with has been caused by the passage, over the the reduction, or should we wait, until by limb, of a cart or other wheel,or indeed any antiphlogistic means this condition is similar contusing body, the bone will abated. It is thought by some persons probably be comminuted, and the soft that the displaced fragments are a constant parts may be so much injured as to render source of annoyance and irritation; others immediate amputation necessary.

Do believe that the violence which may be done not, however, proceed to amputaie until in attempting reduction, will be more in. you have well examined the injury, and jurious than useful, by greatly increasing estimated the probable power of reparathe inflammation. Like all other similar tion; and here à long experience is the questions the difficulty is got rid of by taking safest guide. It is astonishing what an a middle course, sometimes following one, extent of injury may be repaired in young sometimes the other; and it is difficult to people. In cases where the contusion is very lay down a rule on the subject. There is severe, the application of cold or iced water another point to which I must direct your for the purpose of subduing inflammatory attention, phlyctedæ are often seen in cases action, should not be heedlessly made; it of fracture; they contain a yellowish may induce gangrene; if the contusion be serous fluid, sometimes it brown or violent, it is a most valuableapplication. It bloody, but they do not indicate the ex- may be necessary to bleed generally and lo. istence or even the approach of gangrene, cally, for the purpose of subduing the misthey are only signs of contusion. You chief, but in doing so, you must not lose sight must not remove ibe pellicle which covers of my former caution. If the separation thera or they will be painful; they of a considerable slough lay bare a portion may be punctured with a fine 'needle, of bone, the suppuration will be abundant, and covered with simple dressing. If the periosteum will be bathed in pus, and ibe integument be disorganized, the in the probability of necrosis great; dressing flammation will excite suppurative ac- should be frequent, and dry lint applied tion; if it establish a communication with upon the part, to absorb the pus: with all the fracture, it may be serious; if not, it our care it may burrow or take the course may be treated like a common wound. 'In of tendons, and abscesses be developed at a the latter case it will be wise to limit the distance. In this case it is necessary, by inflammatory action as much possible, or bandaging, position, and counter-openings, it may interfere with the progress of con- to procure the escape of this fluid. Often, solidation. When the wound communi- after a long time, spiculæ of bone, necrosed cates with the fracture, if it be the result of or otherwise, will continue lo be thrown off. a cutting instrument, uncomplicated with It very often bappens, tbat after a pe: od

occurs.

of many weeks, a time arrires that many Callus.-It is now time to consider the patients are lost. A fragment of bone in formation of that substance by which the the thigh, for instance, has remained in fragments are preserved in contact, as well contact with the artery; at last it has ul. as ibat by which permanent union is accerated it, and a secondary bæmorrhage ,complished. This matter, termed callus,

Pelletan describes such an occur- is formed around the fragments in the folrence at the end of seventy-five days. Orlowing manner:- When a simple fracture the suppuration may be so profuse as to happens, there is always a slight, often a exhaust the patient; or it may infect the very considerable, displacement, and that system, and typhoid syimptoms will be de. displacement must occasion a certain quan. veloped, and it may then be too late to tity of injury to the soft parts, and rupture amputate. To succeed in these cases, it a certain number of vessels, from which must be practised immediately after the blood, in small or large quantity, will be injury; when the inflammation is followed extravasated, and will coagulate around by gangrene, when suppuration has become the fragments. Soon this coagulum is so excessive as to occasion hectic, by which broken down, and its more fluid part is the life of the patient is threatened, it is absorbed; the vessels then pour out another often too late.

kind of fluid, lymph; this lymph is poured Supposing the fracture to be complicated into the injured parts as well as those in by the wound of a large vessel, if ihere be their vicinity, and a homogeneous mass, no external wound, enormous tumefaction of a bulk corresponding very much with will be soon developed. This tumefaction the quantity of inflammation, is formed. will not be circumscribed, and the integu. This mass soon becomes pervaded by resment will rapidly acquire a violet colour. If sels, which deposit here and there osseous a vein be wounded, after a short time it matter; these increase in number until the ceases to make progress, and the fluid may whole mass becomes firm and gritty. A be absorbed, or it may be removed by in. similar matter penetrates to a certain excision; sometimes, if left to itself, it has ter- tent into the medullary canal, aequires & minated in abscess. Ifan artery be wounded, similar consistency; and thus are formed the extravasation continues, the tume. two natural obstacles to further displace. faction increases, and commonly a pulsa- ment, an internal plug and an external tion may be distinguished in it, isochronous splint. At first the deep-seated museles or with the motion of the heart. In this case tendons, and other organs, are implicated we are rapidly threatened with gangrene. in this exterval mass, gradually it lessens Forme surgeons were accustomed to am. in bulk, and these organs are restored to putate, but the success was not great; and freedom; as it lessens in bulk, it increases of late, the practice has been successfully in density,and effectually prevents displaceintroduced, of placing a ligature on the ment. As soon as this provisional medium artery, at a distance from the injury. of union is formed, the patient may use

But seldom it happens that nervous cords the limb without apprehension. But still, are injured in these accidents; and probably at this time, although the restoration has these are cases in which, now and then, we proceeded thus far, although the new perisee tetanus developed; if the injury have osteum has become continuous with the old, been sufficient completely to destroy the if we saw longitudinally through the callas nerve, we may have paralysis.

we shall find that the medium of union beLarrey and the Spanish surgeons apply tween the fragments is yet incomplete ; and the immoveable apparatus in case of com- it is not until that is perfectly accomplished pound fracture, and allow them to keep that the bone is reduced, by the absorbeats, iheir place up to the complete consolida

to its proper limits. tion; no maiter how much pus may be If the case be one of compound fracture exhaled or how offensive may be the appara- and suppuration be established, the process tus. There can be no doubt that to the of reparation varies ; the fragments are military surgeon it is a matter of the first covered with granulations; as soon as supe importance that the mode of treatment puration ceases they coalesce, lymph is should afford the greatest possible facility found upon their surface, and union is comfor removing the patient; and in the field pleted; this granular mass is a matris for this treatment may be the best, but cer- the reception of calcareous matter, which tainly it should be modified so as to admit gradually renders the mass of a bony conof frequent examination and dressing; forsistency. instance, the Arabs cut out a portion of In a common case of simple fracture, the their apparatus, corresponding to the mass of callus does not acquire much denwound.

sity before the end of three weeks or a When a fracture is very near an articu- month; therefore it is we do not allow a lation, it is wise to move the limb from patient to use the limb until after that time to time, to guard it against the chances period. But numberless circuinstances ocof anchylosis.