splints are most suitable for all fractures of large bones, as those of the lower extremities. Only in children, or in fractures of small bones, may flexible splints be used, which are fixed with a roller or with separate straps. Of the inflexible splints those made of firm wood, and which are quite straight, are the best. Between these and the limb, bags filled with chaff are to be applied throughout the whole length of the latter, to equalize their pressure (3). These splints should, if possible, be so large as to project over the neighbouring joints; on the lower limbs they should be applied on both sides, enclosed in a sufficiently large cloth, and fastened with several straps. They render the so-called straw splints quite superfluous (4).

The fracture-plasters (empl. catagmatica of the ancients) are to be rejected on account of their irritating properties. Many, however, employ empl. sapon., in order to dimini the pressure of the apparatus, especially in those bones which are merely covered with si [(1) No compress should ever be applied upon the seat of fracture; it is quite needed, as the position of the limb should put the broken ends in proper place; t very improper, as it may cause ulceration of the interposed soft parts.

Neither should any bandage, on any account whatever, be applied at first; the constriction it produces by becoming tightened, as swelling comes on, is at the leas inconvenient, as the bandage must be loosened again and again; for if not, severe and unnecessary pain will be produced to the patient, and gangrene may follow, of which I have seen examples. Even after all swelling has subsided, I think fractures do quite as well, if not better, without any other bandage than those necessary to confine the splints, as the limb is thereby less heated.

(2) As presently shown, the use of starched or gummed rollers, which drying exactly fit the limb, and form a firm strong case to it, are commonly used, in many fractures, in preference to any splints.

(3) The best material for padding splints, is thick flannel or blanket, in three or four layers, and covered with linen.

(4) The treatment of simple fractures by the immovable apparatus, as it is now called. has within the last few years greatly superseded the use of splints, except in very oblique and unmanageable fractures. A method of this sort was known to and men tioned by CHESELDEN (a), who says:-" I had learnt it from Mr. CowPER, a bonesetter of Leicester, who set and cured a fracture of my own cubit, when I was a boy at school. His way was, after putting the limb in a proper posture, to wrap it up in rags dipped in the whites of eggs and a little wheat flour mixed; this drying grew stiff, and kept the limb in a good posture. And I think there is no better way than this in fractures, for it preserves the position of the limb without strict bandage, which is the common cause of mischief in fractures." (p. 38.) Elsewhere, in speaking of the treatment of club-foot, CHESELDEN (b) gives a plate showing the application of this bandage, from which is appears he put on single strips of linen diagonally upon the leg, and crossing each other in various directions; and he makes one observation worth remembering: There is no bandage so equal as this for a fractured leg. I always use it, leaving that part upon the tibia very thin, that if it grows loose by the abatement of a swelling, I can cut out a piece and bend it closer. Upon a journey I once set the cubital bone of a gentleman's arm that was broke; and, making use of this bandage, he the two next days rode long journeys without any inconvenience." (p. 453.)

The reintroduction of an apparatus, on nearly the same plan, is due, I believe, to JoHN LAWRENCE of Brighton. Its advantage consists in the formation of light, close-fitting cases or moulds of the limb, which, as they dry, are amply sufficient to keep the bone and surrounding parts in proper place, and at the same time to permit free movement of the whole limb, and if it be the leg, even of bearing the weight of the body and walking upon it, without disturbance of the position of the bone, and without interference with the process of union. This treatment, as efficient as it is simple, has also the advantage of relieving the patient of the irksomeness of keeping his bed for several weeks, as so soon as the bandage has become dry, he may be allowed to get up and move about without fear of retarding his cure. There is also in this plan, whatever the modification of it may be, the advantage that the linen case fits much more perfectly than any wood or tin (a) The Anatomy of the Human Body, 11th DRAN'S Operations in Surgery by GATAKER, 3rd Edition, 1778. Edition, p. 1737.

(b) See his Additions to the Translation of LE

splint however carefully padded, and that the materials are always at hand in every house, and of the most trifling expense.

The first method I saw employed, and which I first used, was that of linen splints and a roller, according to LAWRENCE's plan. The splints are made by covering one side of the limb with a piece of linen or lint soaked in water, and of rather larger size than the splint is proposed to be. White of egg and flour well mixed, and of the consistence of very thick cream or batter, is spread over three or four strips of linen, each about three fingers' width, and of corresponding length with the limb; and these, one after another, are laid upon the lint with their spread surface downwards, and the edge of each, after the first, a little overlapping the other. All the air is to be got from beneath the linen, by gently passing the finger from one end to the other, but always one way, or the splint will not be even; and when the whole has become well applied to the lint, then a layer of short strips, also spread with the egg and flour, are to be placed across the long ones from one end to the other, and each a little overlapping the other, as in the first layer, and the whole to be carefully pressed down and the air discharged as before. A second layer of long strips is then to be applied, over this a second layer of cross strips, and then a third layer of long strips, all spread with the mixture, completes the splint. Great care must be used in pressing out all the air, otherwise the splint is weak; but if this be well done, then as the linen and the mixture dries, the splint becomes as tough and unyielding as a board, and fits like a mould to the limb. During the drying of the splint, which usually occupies twelve or sixteen hours, the patient must be careful to keep his limb in the position in which it has been placed, or the splint will be disturbed and harden awry. This constrained position, even for so short a time, is the principal inconvenience and objection to this mode of treatment. On the next day, if the splint be tolerably dry, it should be carefully removed, the edges cut smooth with a sharp knife, and then a little pressed out with the thumb, to prevent them digging into the skin and causing a sore. After this the limb is to be turned over and laid upon it, and then the other side of the limb to have a splint made like the former. Care must be taken that the edges of the splints should be at least half an inch asunder, so that they should not jostle each other, nor prevent a little pressure being made upon them by the roller, nor hinder their drawing together subsequently when the limb has shrunk, which it usually is after a fortnight. On the third day the last-made splint is to be removed, its edges pared and pressed out, and then replaced. The limb is now raised, being kept in place by the splints, and all are to be swathed, from end to end, in a roller of six yards length, which having been soaked in pretty thick starch, is first rolled up, and then carried round spirally, and with as many reflexes as may be necessary to make it lie even; after which the whole is to be gently pressed down, and brushed over with starch, and then the limb laid in an easy and convenient position to dry. On the fifth day the patient may leave his bed and move about, either carrying his foot in a sling, or bearing upon it as he may be disposed. The starched bandage generally needs renewal at the end of a week or fortnight, on account of the shrinking of the soft parts; but very commonly nothing more is requisite till the entire removal of the splints.

A much more simple, and equally efficient, treatment is a starched or gummed roller, without even linen splints, closely applied three or four times over the whole limb, which has been first covered with lint. The gummed roller is that which in our hospital practice is almost alone used in fractures of the leg, either of one or both bones, and in fractures of both the upper and fore arm.

In the employment of either of these methods care should be taken that neither should be used till the swelling has completely subsided, that is, not till the lapse of five or seven days after the accident, during which time the limb may either lie simply on a pillow, or be temporarily put up lightly in wooden splints. I do not think it prudent to put the apparatus on immediately after the accident, for very often the swelling and consequent pain from its tightness will compel its removal; or if left untouched there will be the same danger of mortification as from tightly-bound splints of the common kind.

Various materials have been proposed with which the roller should be spread, or in which it should be soaked, a number of experiments on the composition of which have been made by SMEE (a).

TAVIGNOT (b) has recently proposed the use of oil varnish in the treatment of fractures of the lower limbs of young children, where by the constant moisture of the urine the common apparatus falls to pieces. He first applies a starch bandage, and

(a) On the Composition of Moulding Tablets for Fractures, &c. ; in Lancet, vol. i. p. 833, 1838

39.

(b) Examinateur Médical, Aug. 1841; and FORBES' British and Foreign Medical Review, vol. P. 544.

xii.

when that is quite dry, brushes over its whole external surface, also the upper border and part of its internal surface with varnish; then dries it in the sunshine or by artificial heat, and, two hours after, repeats the varnishing. Over such bandage the urine passes without in the least softening or disturbing it; and TAVIGNOT says it has the further advantage of being removed without cutting the bandage, merely by putting the limb into warm water, which insinuating itself dissolves the starch, and allows the roller to be easily taken off.-J. F. S.]

584. This (the Simple Contentive) apparatus is sufficient in transverse fractures, and in such as are not very oblique. But if the fracture be very oblique, this apparatus will not, in the least, prevent the displacement of the ends of the fracture, as it affords them no support, and therefore they are always readily displaced by the action of the muscles. This especially happens in fractures of the lower limbs, where in order to counteract the contractions of the muscles, a continued extension of the limb by means of particular contrivances is most proper. It must, however, be remarked that the extending force, so far as possible distributed over the limb, shoul be applied above and below the neighbouring joints, and increased or di minished at pleasure, as otherwise inflammation, excoriation, and mortifica tion, are produced by the pressure.

585. The position of the limb during extension and counter-extension, (par. 582,) as well as during the cure, should always be that in which the muscles are most relaxed. Therefore in fractures in the middle of tubular bones, the straight position is to be preferred; but in fractures in the neighbourhood of joints, the half-bent position, because, as the flexor muscles are attached to the bones above and below the joints, they always drag in the direction in which they bend, and the two ends of the fracture are best kept close together if the joint be retained in a half-bent position. The exceptions which occur in reference to this rule will be noticed in the special treatment of fractures. Only when the fracture extends into the joint, and stiffness is feared, must the limb have that position during the cure, which, should stiffness take place, will least hinder its motions; there fore in the lower limbs the straight, in the upper limbs the half-bent, which also is the most suitable, as in that only can the arm be properly fixed.

[The rule laid down by CHELIUS in the beginning of this paragraph, in regard to putting the limb in a half-bent posture, so as to relax the muscles, is perfectly right; but the exception he makes at its conclusion is equally wrong. There is no reason to expect stiff joints to occur more frequently in the lower limbs than in the upper; and, indeed, experience proves that they rather more commonly happen in the upper than in the lower limbs. But in the latter, a bent posture is much preferable to an extended one, as the patient walks infinitely better with a bent knee than with a straight one. Stiff joints are, however, except when the fracture extends into a joint, and even then not always, rather uncommon. I admit that, generally, in fractures of the lower limbs, I prefer the straight position when the fracture is of the thigh, not, however, in regard to any consideration of the possible stiffness of the knee-joint, but because I believe it answers the purpose equally well as the bent position, and gives the patient the opportunity of vary ing his posture, which is not a trifling advantage and comfort to him.-J. F. S.]

586. When the apparatus is applied, and the limb put in a proper posi tion, care must be taken that it is neither neglected nor displaced From time to time it must be moistened with the resolvent wash, and the bandages tightened when they yield (1). When the apparatus becomes loose (mostly about the fifth or sixth day) it must be re-applied, and as often as it does not keep firm, at which times the broken ends of the bone must be always brought into their proper position, if they have become displaced. The general treatment requires attention only for the first few days, and should be antiphlogistic. In common cases after proper arrangement no peculiar

symptoms are observed. The apparatus must only be removed when the connexion of the bone is complete, otherwise the limb is distorted by the action of the muscles. The time during which the apparatus is to remain on, will depend upon the state of the fracture, upon the size of the bone, upon the power of the surrounding muscles, and upon the function of the limb. In fractures of the lower limbs it should always remain on longer than in those of the upper; in oblique longer than in transverse fractures. If at the proper time no firm callus be formed, the causes which prevent its hardening (par. 579) must be removed. General diseases require suitable treatment; the ends of the broken bone must be kept in the closest contact and at rest; the apparatus must be applied less tightly on the seat of fracture, and generous strengthening diet ordered. Many months may elapse before the callus becomes quite firm.

[(1) As a fracture should never be properly put up till all swelling have ceased, and the soft parts have almost entirely, if not completely, returned to their natural size, it is unadvisable to continue the use of any cold applications of any kind. It is better to leave the limb entirely alone as long as possible. On the upper limbs the bandages rarely require readjustment for ten days or a fortnight; and on the lower limbs, not for a fortnight or three weeks. Though it must not be forgotten, that one or other strap may require a little tightening daily for the first three or four days, till its woof have attained its utmost stretching; but it is rare that the whole apparatus needs re-adjustment before the time just mentioned. I have, indeed, often known the whole apparatus, bandages and all, untouched from their application till their removal, with the best results.-J. F. S.]

587. The earlier and more perfect the setting of the fracture is, the fewer symptoms follow; but if before the setting be effected, much inflammation and swelling have taken place at the seat of fracture, the patient must be prepared by suitable blood-lettings and dispersing applications for the setting, in which the limb is to have such position that all the muscles shall be properly relaxed, and, if possible, extension and counter-extension made above the neighbouring joints, by which the muscles passing over the fracture are not pressed and dragged by the hands of the assistants. The setting must not, under these circumstances, be long delayed, for the principal mode of diminishing the inflammation is setting the fracture, the ends of which then no longer irritate the soft parts.

Many moderns comply with the general maxims heretofore followed by the older Surgeons in reference to setting and to the application of apparatus after from the first four to eight days, to allow and to wait for the passing by of the inflammation, till the pain and swelling have diminished, and thereby a more secure position of the limb obtained. This advice is manifestly objectionable, and the putting off the setting to be restricted only to those cases where decided inflammation has set in.

[As a general rule, I do not at all agree with the principles here laid down by CHELIUS; I am quite certain that no fractures, excepting those of the collar-bone, and very oblique fractures, in which the ends of the bone threaten to penetrate the skin, should ever be set, that is, put in splints and bandaged, till after three or more days, or more correctly speaking, till the swelling has ceased and nearly or completely subsided. Nothing is gained by immediate application of splints and bandages, for the increasing swelling renders the latter so tight that they require loosening, in consequence of the severity of the pain caused by the constriction; and I have known mortification ensue from this cause, and amputation required to save the patient's life; and after this necessary relaxation of the bandages, when the swelling subsides, the whole apparatus becomes loose and useless, and requires to be re-adjusted. Therefore all that should be done at first is, to lay the limb upon a pillow, in a position which gives the patient the greatest ease, and soothes the irritability of the muscles; for which purpose a position intermediate to flexion and extension should be preferred; and in reference to the upper limb especially, such as will facilitate the return of the blood from its extremity, namely, raising the hand and elbow above the shoulder. A piece of linen moistened with an evaporating

lotion is commonly laid over the limb, and may, perhaps, tend to diminish the effusion, and check the action of the vessels of the part; but if there be not much disposition to swelling or pain, it is of little consequence, except to satisfy the patient's mind that something is being done for his relief. Generally, bleeding in town practice is totally inadmissible, and I much doubt its needfulness under any circumstances. Local bleeding with leeches is now and then required, but in general rarely called for, and I think best left alone; for after the lapse of a few days all the powers of the constitution, and of the part itself especially, are required for the reparation of the injury, and therefore should not be uselessly diminished.

In cases of fractured collar-bone, or of oblique fractures, something must be done st once, to counteract the muscular contraction, which tends to thrust the bone among the muscles or against the skin, and even to pierce it. But even under these circumstances, the object is not to set the fracture, but simply to quiet the muscles, and to arrest the irritation they excite by their continual forcing the ends of the fracture into themselves, and thereby increasing the disposition to that unsatisfactory proceeding, and worrying the patient's feelings. In these cases, therefore, extension should be employed, as CHELIUS advises; but nothing in the way of setting the fracture should be attempted till the swelling have subsided. Sometimes in oblique fracture position will be sufficient to allay these inconveniences without extension, but not always the same position. Two persons may seem to have a precisely similar oblique fracture, but in one the spasm will only be checked by the straight posture of the limb, whilst in the other this can only be effected if the limb be bent. The decision of these points must depend on the circumstances of each case, and upon the judgment of the Surgeon, but they are of the greatest importance to the patient, and must not on any account be overlooked.

In the employment of extension, any special apparatus is rarely required. A bandage fastened around the joint below the fracture, with a weight attached to its end and slung over the side or foot of the bed, is usually sufficient. Nor is a very heavy weight requisite; three or four pounds, or a brick, is amply sufficient for the purpose, as after a few hours the muscles soon tire of dragging at even so slight a weight, and, ceasing to act, no longer force the fractured ends of the bone into themselves, and the fracture drops into place.

Should the bowels be loaded, it is advisable that they should be cleared by a gentle dose of castor oil before the fracture is set. But when the setting has been perfected, it is best that they should be unmoved for several days, so that the fracture may not be disturbed by the patient's movements. If, however, he should become uneasy and feverish, they must be looked to, and relieved with as little disturbance of the limb as possible.-J. F. S.]

588. Little important as are the symptoms which generally occur in Simple Fractures, yet may they be very serious in Compound Fractures (1).

If considerable bruising or division of the soft parts be connected with fracture, the inflammation is always very great, and requires strict antiphlogistic treatment, blood-letting, leeches (2), cold applications, and so on, together with the simultaneous use of opium, if very severe pain and other nervous symptoms be present (3). In very great swelling and tension soothing applications should be employed (4).

The wounds accompanying fractures are either consequent on the external violence, or on the bony pieces being driven through the soft parts. In the former case the setting is usually not connected with any particular difficulty, and the wound may be brought together with sticking plaster, even although its state be such as to give little expectation of its being followed by quick union. In the latter case the difficulty of setting depends on the size of the wound, and on the projection of the pieces of bones, as well as on their direction. The wound is to be enlarged, if the piece of bone be firmly girt by it (5); the extension is always to be made in the direction of the protruded bone, till the broken ends no longer overlap, and then the limb is to be put in its straight position. If the fracture cannot be set in this way, it is necessary to saw off the protruding pieces of bone (6). Splinters, if quite loose, must be removed; those