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required, as the gastrocnemius muscle draws the upper extremity of the lower fragment downward. The condyles themselves being broken, requires the straight position.
If the flexion does not overcome the overlapping of the bone, and means of extension become necessary at the foot, then either the inclined or straight should be employed.
I believe with Dr. Pope, whose language is: "In the treatment of fractures of the femur I employ neither the straight nor the flexed position exclusively, but the one or the other, according to the sight of fracture."
Dr. Pancoast suggests the use of the flexed position at first, in fractures near the ends of the femur, then, after the lapse of a few days, when the disturbed muscles lose their tendency to spasm, and the provisional callus about the fracture forms a bond between the ends of the broken bone, to gently bring the limb down to a straight position. This change of position affords rest and comfort to the patient, but with the ordinary methods of treatment the surgeon will seldom put himself to the trouble in devising the necessary splints; besides, he would be forced to an unnecessary handling of the limb.
Unnecessary punishment of a patient in the confinement to one position, deformity, and anchylosis, when they can be avoided by the surgeon, deserves consideration, and the want of the proper apparatus is often due more to the indifference of the surgeon than anything else.
THE ADJUSTABLE HINGE.
The splint which I have devised for the leg is represented in Fig. 3, and is free from the serious objections above-mentioned.
The same hinges used in Figs. I and 2 are now applied upon the leg bars. Two of Fig. I are applied to the knee; one of Fig. 2 is used at the hip, to give freedom of motion, and one of Fig. 2 at the foot-board.
The axillary bar, B, may be changed to the other side to suit the other leg, or if desired it can be left off at the hip. A, A, A, A, are thumb-screws to adjust the instrument to the length of the leg. G, G, is a rod setting in posts to widen the bars; there are also means to widen or narrow at the foot. O is the extension-screw made fast to the footboard, H. E, E, E, E, are the hooks by which the limb is suspended.
FIG. 4.-ADJUSTABLE HINGE JOINT SPLINT APPLIED.
In Fig. 4, the splint is adjusted to the leg. The foot-board is applied to the foot as a shoe, or it may be fastened with a
roller-bandage; the bars are placed in position, and strips of muslin, four to eight inches wide, are pinned to the bars. A little plaster of Paris will stiffen these bands and keep them from corrugating. These constitute the floor upon which the leg rests while in the suspended position. The strips can be changed one by one without disturbing the fracture. The bandage around the body holds the axillary bar and steadies the apparatus. The hooks are pushed upon the bars to the desired. place in order to balance the leg. The patient is allowed to sit up or lie down at pleasure. He can be fastened down, or in the sitting posture if desired. The splint is suspended to the ceiling, or to a frame over the bed; the pulleys seen in the ropes allow a movement in any way the body turns. The instrument can be changed on any of the planes without removal of the dressings. There is nothing to interfere with with the circulation, and no roller-bandages are required. It matters not where the bones are fractured, the apparatus is peculiarly applicable.
Having used this apparatus for a number of years, I most cheerfully recommend it to the profession, not because I am the author of it, "for the pride of genius I courteth not."
FRACTURE OF THE CLAVICLE.
The appliances for the treatment of fractures of the clavicle are numerous. The number has grown out of the difficulty in obtaining the objects desired. Many of them are defective, and some are absolutely worse than useless. The figure-ofeight bandage ought never to be applied; Velpeau's dextrine bandage is impracticable; Hunton's yoke-splint and Welch's apparatus are too expensive; Bartlett's, Fox's, and Hamilton's, admit a degree of relaxation of bandages, just enough to allow the broken bone to overlap and the shoulder to sink. Any apparatus that will hold the shoulder upward, outward and backward will accomplish the desired ends. I ask a trial of the following plan: Cut two adhesive straps (rubber adhesive is the best) about two inches in width and two and a half or three feet in length; make a ring to fit around the arm of the injured side, close up to the axilla, not over the
shoulder, but as seen at A. This ring may be made of muslin rolled up, with a little cotton enclosed, and this, by a roller wrapped around and sewed. The body of the ring should be about an inch thick, and soft enough to admit the circulation of the blood to the arm. This now slipped over the arm to the axilla, and the adhesive strap B is made to catch the ring A by slipping the end of the strap between the arm and the ring and then lapping it upon itself. The arm is now drawn backward, and while held in that position the adhesive strap B is drawn over the opposite shoulder and made fast to the skin. The next step will be to make a loop D by tying the
corners of a handkerchief together, or a piece of roller, and slipping it over the elbow. The other adhesive strap C is now made to catch this, the arm is drawn forward and upward while the strap is taken over the shoulder in front and secured to the skin. The hand may now be secured or held up by a handkerchief, which may be held by the end of the strap B. By the use of the adhesive straps you throw the shoulder upward, outward, and backward, and then hold it as long as you
desire just where you put it. The ring A acts as an axillary fulcrum, but ought not to be too large. Having used so many of the different kinds of apparatus, I can say that none gives me the satisfaction of this one. The straps join the bone where you want it, and keep it just where you put it, until you desire to let it loose.
FRACTURE OF THE PATELLA.
From the great variety of appliances devised to secure accretion in fractures of the patella, we are impressed with the fact that many difficulties lie in the way of treatment. Much ingenuity has been displayed in the appliances of Lonsdale, Hamilton, Sanborn, Eve and others, but the surgeon finds. them either too expensive, not available, or not efficient in holding the fragments together. The country surgeon, especially, will at the time of such accident have none of these on hand to meet such emergencies, and he is not disposed to send far away for a costly arrangement for an individual case.
James Cochran, aged twenty-eight, fell June 25th, 1874, striking his knee upon a curb-stone, producing a transverse fracture of the patella. After some deliberation I constructed the apparatus I now describe, and for its cheapness, ready application and effectual working it must recommend itself to all.
A board is cut long enough to reach from the middle of the femur to the middle of the lower leg. It should be a little. broader than the leg, that the bandages may not compress the superficial veins. An elastic band is now cut, so that when doubled and its ends are fastened together its length will be the length of the splint, plus the length of the projecting loop, as seen in Fig. 6. This band may be made of the rub