ON FRACTURES.

THE ARGUMENT.

THE work commences with an announcement of the general principle upon which all cases of fracture and dislocation are to be rectified, which is this, that extension should be made as straight as possible, the term straight being immediately afterward explained to be meant as applying to that direction which is most natural to the limb affected, that is to say, the position which will afford the patient most ease and comfort after the limb has been properly arranged. This principle of treatment he illustrates at considerable length, and with great force of argument, in the case of the fore-arm, and reviews the different positions in which it had been recommended that it should be placed, namely, the state of pronation, of supination, the intermediate, and, lastly, that of the archer when he is in the attitude of drawing the string of his bow. The author shows, in a very striking manner, the evil effects resulting from the practice of not putting the limb, during the process of bandaging, into the attitude in which it is meant that it should be kept afterwards, as by the change of position the whole apparatus will be in so far deranged. §§ 1-3.

Fractures of the fore-arm are next considered, and most minute directions are given regarding the whole process of managing it-the setting of the fractured bones-the application of the bandages, the compresses, and splints, and the arrangement of the limb after the process is completed. The general rules of practice laid down for the management of this case are meant to apply to all fractures, with a few exceptions. $84-7.

Fracture of the arm, or humerus, is next considered, and here our author's mode of procedure is highly deserving of attention, as being considerably different from the method now in use: he attaches much importance to the mode in which extension is made, and pointedly directs that the limb be placed in its proper position before the application of the bandages and the rest of the apparatus. § 8.

He then proceeds to the consideration of the foot and the injuries of the bones which compose it. § 9.

The displacement of the tarsal bones from those of the leg are next considered, by which luxations of the astragalus and os calcis are probably meant. §§ 10, 11.

in general terms, of luxations of the foot, and then describes very elaborately the process of reducing them, and of conducting the treatment afterward.

$$ 13, 14.

Fractures of the leg are then treated of at considerable length in § 15,

16, 17, 18

Fractures of the thigh-bone are next taken into consideration, and most minute directions are given for the management of them in $ 19, MYLMA Our author gives some account of the canals, or gutters, then used for receiving the limb in cases of fractured leg or thigh; he does not much approve of them, but gives it as his opinion that the beneficial eivers of them had been much exaggerated. OXWORK

Compound uns are next considered, and all the different modes dem which were then in name are discussed, and freely critPAMAMA A Theolarkin of the bones and the srason 2 gitle are text brought under native, and the treatment of sted cars bely considered. $3

k** **** Dimeters se gwa wadw a the webortion of berken Þves he mains of the levee, and the treatment stervel $LR

The mea mem; the ass in which in has been found Sportinble vměny de Serred bones sex divered mining maŢIŞOTRAZI Jersons “gating the exda seven of der is, and the resertina of them.

a considerable portion of the next work, which is more especially devoted to dislocations, is occupied with observations on fractures. It is difficult to account in a satisfactory manner for this want of arrangement, more especially as the two treatises are generally acknowledged to have constituted originally one work. The most plausible conjecture which I can form, in order to account for this mixing up together of the different matters in each, is this,-that when, for convenience sake, the work was divided into two, namely, one part "On Fractures," and another "On the Articulations," it was found necessary, in order to give a clear view of the subjects treated of in the one, to illustrate them by extracts relative to the cognate subjects treated of in the other. And, in fact, although the subjects here discussed be given rather confusedly, it will be found, in a practical point of view, very convenient, nay, indispensably necessary, to consider certain fractures and dislocations at the same time, in order to establish an accurate diagnosis between them. For example, how is it possible to understand dislocations at the elbow without a knowledge of fractures of the extremities of the bones which enter into the formation of it, namely, of the humerus and the bones of the fore-arm? And again, who could understand fractures at the lower end of the tibia and fibula without an acquaintance with dislocations at the ankle-joint? Altogether, then, it certainly appears to me, upon mature reflection, rather an advantage to the student to have these two classes of accident treated of together, as they are in this and the succeeding work. The complete manner in which the various subjects are handled, the admirable plan upon which our author proceeds from obvious and indisputable principles, cannot fail to command the admiration of every careful and intelligent reader. The whole treatise, also, is written in so lucid a style that, with the few foot-notes which I have added, the reader will find no more difficulty in availing himself of the contents of this work, although written twentytwo centuries ago, than if it had been a.publication of the present day. I shall now only make a few observations on certain subjects, either because they seem to require some elucidation, owing to their being treated. of very succinctly, or because I look upon them as being particularly deserving of attention.

The process of setting, bandaging, and arranging a fractured limb, although this truly is now a hackneyed subject, will be found described in this treatise with so much precision, that I am persuaded the surgeon of the present day may derive information from it, for it appears to me that certain of the rules of practice here laid down by Hippocrates, are sometimes improperly overlooked by the modern practitioner. For example, although the propriety of putting a fractured limb, before it is set, into the position in which it is to be kept afterwards, is so clearly stated in this work, it is often disregarded in modern practice, and the consequences here described follow accordingly, namely, the derangement of

of bone after the position of the limb is altered. I am also of opinion, after having repeatedly adopted the practice recommended by Hippocrates, that the rule here stated, not to apply the bandages and apparatus beyond the fractured limb, is consistent with sound principles, and that the departure from it in modern practice is, in many cases, anything but an improvement. This I have hinted in the annotations on the preceding treatise, and I am now glad to find that so distinguished an authority as M. Malgaigne joins me in expressing this opinion. Treating of the splints compresses, and bandages used in the Hippocratic system of bandaging a fractured limb, he adds: "Reste enfin leur longueur, qui choque nos habitudes; car où est le chirurgien qui se borne à recouvrir l'avant-bras fracturé, sans empiéter sur la main et avec les bandes et avec les attelles? Or, déjà l'occasion ne m'a pas manqué pour le dire, et je n'hésiterai pas à le répéter ici, ces bandes, ces attelles, prolongées sur la main, ne sont justifices par aucune considération sérieuse et légitime, et elles ont de graves inconvénients. En thèse générale, attelles ou bandages ne sont faits que pour remplacer par un squelette extérieur le squellette naturel fracture, qui donnait au membre sa longueur, sa forme, sa solidité, et ils ne doivent pas se prolonger au-delà, à moins d'indications toutes spéciales. Il faut ajouter cependant que tout membre fracturé, pour arriver à la consolidation, devant rester long-temps dans l'immobilité, a besoin d'une position stable qui la lui garantisse, et que l'appareil que nous venons d'étudier serait insuffisant à cet égard. Mais les moyens de remplir cette indication nouvelle sont divers pour chaque membre et pour chaque brisure du membre: ils pourraient être décrits sous le nom d'apparels complémentaires. Or, ces appareils complémentaires ne sont pas oubles par Hippocrate: charpe pour avant-bras, le bandage de corps pour le bras, les coussins ou les gouttières pour le membre inf rieur. And, in addition to the reasons here assigned by M. Malgaigne for coninng the apparatus, in general, to the fractured portion of the limb. I would again say, that I am inclined to think that bandaging the part below the injury, for example, the hand, in fractures of the fore-arm, has a tendency to increase the swelling above, which would otherwise be determined to the parts below, and thus relieve the seat of the injury.

I would beg lewe most particularly to direct attention to the zondemNatory remarks of þur author upon the method of treating compound fac‐ tures by ballonging the parts on both sides of the wound, and leaving it uncovered to win.t of iressings being appitel to t I may mention in this place, that the ast version on which I met with the lamented Mr. L.Son. we omersed on this abjeer, when he stated eclely that he agreed with Hipoceries in ondemning the prites, which, however, he

Des Apparens urle Tulement les Futures on eneral, etc.

tured portions Iso of opinion, ed by Hippocand apparatus iples, and that , anything but the preceding an authority as gof the splints of bandaging i choque nos ir l'avant-bras ec les attelles? n'hésiterai pas main, ne sont = elles ont de lages ne sont ellette naturel sa solidité, et -ations toutes acturé, pour immobilité, a reil que nous -vens de rem

abre et pour le nom d'ap

ne sont pas Lage de corps inférieur."" gne for conthe limb, I ng the part pre-arm, has wise be dejury. The condempound frac l leaving it mention in ented Mr. lly that he owever, he

etc.

often saw adopted in hospital practice. Our author's treatment of compound fractures is also deserving of much attention, as indicating the large amount of experience which he must have had in this way.

There are three surgical subjects which are very fully, but yet rather confusedly, treated of by our author in this and the two following works, namely, the accidents which befall the knee, the ankle, and the elbow.

On Dislocations of the Knee.

It strikes one as very remarkable, that the ancient surgeons should all speak of dislocations at the knee-joint as being of frequent occurrence, whereas they are now regarded as being among the rarest accidents of the kind to which the joints of the human body are subject. In this case, we must either suppose that the ancient surgeons had somehow been guilty of a mistake, or that the accident had been more common in ancient times than it is now. I have often wondered whether the difficulty might not be got over, by supposing that the wrestlers at the public games of his country, who, it is clear, furnished Hippocrates with a large proportion of his cases of fracture and dislocation, may not have been particularly liable to this accident. Having once met with a very interesting case of dislocation at the knee-joint, I persuade myself that I cannot better illustrate this subject than by giving a Report of it which I published in the London Medical Gazette, Dec. 1842. I do so the more readily, as it will enable me to correct some unfortunate typographical blunders which occur in the Report as it appeared in the Gazette.

"Case of Dislocation of the Knee-joint.-By Francis Adams, Esq., Surgeon; Sept. 10th, 1842. Alexander Robie, æt. 55, while in the act of carrying provender between two large bullocks in their stall, was knocked down by a stroke of one of their hind legs on the right knee; and while lying down on the ground, was severely injured by being trod upon in several parts of the body, especially near the middle of the right leg. I saw him about two hours after the accident, and found the bones of the right leg lying on the fore part of the femur; the articular cavities could be distinctly felt, while, below, the contour of the condyles could be traced in short, I never saw a case of dislocation in which the symptoms were so strongly marked. The patella was pulled considerably up the thigh; but it appeared pretty obvious that neither the ligamentum patella, nor the tendon of the triceps, was ruptured; but my impression at the time certainly was, that, in order to admit of so great a displacement, all the principal ligaments of the joint must be torn. The limb was immovably extended. By making proper extension and counter-extension, the reduction was effected with little difficulty. The limb was then bandaged loosely, from the toes to near the middle of the thigh, and laid half-bent on a thick pillow, and evaporating lotions were directed to be applied occasionally. For some days no severe symptoms occurred in the joint;