the feet to the lower, and the upper part of the body to the upper part of the bed, and the simple contentive apparatus,) either permanent extension is produced by the extended position of the limb, or the limb is kept in a half-bent position with or without extension.

The simple contentive apparatus, and fastening with the spica cora (PARÉ); with two chaff pillows on both sides of the limb, fixed with straps (SABATIER); by tying both feet together with a pad between the thighs (GUYOT) (a) by concave splints of tin, wood, leather, and the like (FABR. HILDANUS, LA FAYE, ARNAUD, DUVERNEY, HEDENUS, THEDEN, BÖTTICHER); by a pelvis-belt, and bending the thigh on a splint placed in the ham, and binding the feet together (BERNSTEIN); by enveloping the limb with compresses and an eighteen-tailed bandage, by straw splints on both sides of the limb, enclosed in a wide napkin, fastening of the outer straw splint with a broad pelvis-girdle, and along the limb with bandages (LARREY) (b), are not sufficient in true fractures of the neck of the thigh-bone; they can only be employed in cases in which, for the abovementioned reasons, there is but little shortening or inlocking of the upper fractured piece.

676. To the machines for extension of the limb in the directly straight position belong

1. DESAULT'S Apparatus.-The essential point of which is, that after the whole limb has been swathed in SCULTETUS's bandage, a permanent extension is kept up by means of a splint reaching from the crest of the hip-bone to beyond the sole of the foot. At the upper end of this splint is fastened a long pad, which is applied on the inner upper side of the thigh, and at the lower end a similar one, which is applied over the ankle. Besides this, a second splint is to be placed on the inner side, and a third on the front of the limb, which last is to descend from the groin to the knee; between these splints and the limb chaff pillows are to be placed, and the splints fastened with five straps; the outer splint especially, by a girdle running round the pelvis.

VAN HOUTE'S alteration of DESAULT's splint is for the purpose of keeping up extension in the long axis of the limb by means of a cross board connected at right angles with the splint (c). Similar to this, except that to the cross board an inner splint is fastened, is VOLPE's machine (d). Also Josse's (e) apparatus, with a peculiarly arranged bed. MEYER'S (f) machine. PHYSICK'S (g) apparatus, in which the external splint is continued to the arm-pit; that of HOUSTON (h); also Alban's (i) machine, which consists of a strong splint fixed on the outside of the ailing limb and to the pelvis: the extension is effected by means of a kind of lever contrivance at the lower end of the splint. GRESSLEY'S (k) apparatus.

2. BrünninghauSEN's Apparatus.-A soft cotton strap is first applied upon a soft pad, over the ankle of the ailing limb, and carried like a stirrup around the sole of the sound foot. To prevent the rotation of the limb outwards, a suitable splint of padded tin or lacquered leather is to be applied on the outside of the thigh, and fastened with a padded bandage around the pelvis and knee. Bending of the knee-joint on the sound side is to be prevented by a gutter-like splint, which should extend from the middle of the thigh to the middle of the leg.

Heilung des Schenkelhalsbruches. Würzb. 1826; with one copper-plate. 4to.

(g) FRORIEP S Chirurg. Kupfert., ccxiv. f. 10. (h) Ib. pl. cccli. f. 1.

(1) LANGENBECK's neue Bibliothek für die Chirurgie und Ophthalmologie, vol. i. p. 262.

(k) Mémoire sur un nouvel Appareil pour les Fractures du Col du Femur. Paris, 1832.—VELPEAU, Examen d'un nouvel Appareil imaginé par GRESELEY. Paris, 1832.-FRORIEP's Chir. Kupf., pl. ccxc.

3. BOYER'S Machine.-This acts in the same manner as DESAULT'S apparatus, only the extension is kept up in a direction corresponding with the long axis of the limb; by means of a screw the extension may be increased or diminished, and the power of extension distributed over a large part of the leg. HEYNE has altered this machine.

4. HAGEDORN'S Machine consists of a strong wooden splint reaching from the crest of the hip-bone to the sole of the foot, and furnished with a transverse piece. It is applied on the side of the sound limb, and fastened with padded straps around the pelvis and extremity. The foot of the sound and that of the ailing side are both fastened to the cross piece, and thus the injured limb preserves its proper extension. DZONDI's (a) improvement of this machine consists in the splint extending above the crest of the hip-bone to the side of the chest, and the bandages for extending the ailing limb being applied above the ankle and below the knee. NICOLAI'S machine (b), that of KLEIN (c), and that of GIBSON (d), of BECK (e), SCHÜRMAYER (ƒ), and of WECKERT (g), are all to be considered as modifications of HAGEDORN'S machine.

677. Various plans have been attempted to keep the limb in the bent position.

1. By SAUTER'S (h) Suspensory Machine. The pelvis is thereby fixed; the tubercle of the haunch-bone is the special point for counter-extension; the extension is made from the foot with a long pad connected to the footboard.

2. After the setting of the fracture is completed, both feet are to be bound together, for which purpose a bandage is to be applied spirally, from the instep to the knee; a firm pillow is then to be put under the knee so as to bend the thigh at the knee and hip-joint, and the spiral turns are to be continued to the upper third of the thigh. The upper part of the body should be raised rather high, and inclined forwards (MURSINNA.) Or a firm pillow may be put into the ham of the limb, bent at the hip and knee joints, which is to be kept in this position by a folded cloth carried over the lower part of the thigh and leg, and fastened on both sides to the bed. (DUPUYTREN, RICHERAND.)

3. A. COOPER, in fracture without the capsular ligament, keeps the limb half bent, putting it upon a wooden machine, consisting of two pieces of board fastened together at an angle, and corresponding with the bend of the knee-joint. A long splint, laid upon the outside of the thigh, is to be fastened by straps on the side of the great trochanter, and buckled on above the knee, and around the pelvis. In fracture within the capsule, a pillow should be laid beneath the whole length of the ailing limb, and a well-rolled pad in the bend of the knee-joint, and in this manner the foot kept extended from ten to fourteen days, till the pain and inflammation have passed by. Then the patient should get up daily, and sit on a high stool, in order to diminish the painfulness in bending the limb. After some days he may go on crutches, subsequently with a stick, and in a few months he is generally capable of using his foot, without any further sup

(a) Beiträge zur ervollkommnung der Heilkunde, part i. Halle, 1816. 8vo.; with plates.

(b) Journal für Chirurgie und Augenheilkunde von v. GRAEFE und VON WALTHER, vol. iii. part ii. p. 260. pl. ii. f. 1-9.

(c) Ibid., vol. iv part i. p. 17; pl. i. f. 1-6. (d) Ibid., p. 189. pl. i. f. 7-13.

(e) FRORIEP's Chirurg. Kupfert., pl. 350, f. 7.

port. In every doubtful case the treatment should be as if the fracture were without the capsular ligament.

4. EARLE has proposed a peculiarly constructed bed for the bent position, in which, by the weight of the pelvis, counter-extension, and by the attachment of the foot to a foot-board, the proper length and position of the limb are preserved, and the relief of natural needs made possible, without moving the patient.

Hereto belong also the machines of AMESBURY (a), SMITH (b), KOPPENSTÆDTER (c), HAGER, and others, in which extension is connected with the double inclined plane.

678. Of all these modes of treatment, I consider the use of HAGEDORN's machine the best. It is more simple, its operation more certain than that of any other extending machine, and not more troublesome than the double bent position in one or other way, which, excepting the relaxation of certain muscles, has scarcely any advantage, and even renders the limb less secure against motion. DUPUYTREN, however, will have it that by the doubly bent position (par. 677) the results are more satisfactory than by any other treatment; inasmuch as in this posture, by the relaxation of the m. adductor femoris, the limb loses the disposition to roll outwards, and that this position is accompanied with less inconvenience to the patient than in the extending apparatus (d). A. CooPER's practice in fracture within the capsule, leaves the impression that the diagnostic marks which he proposes are not always to be depended on. In old persons also, and with all the signs of internal fracture, a perfect cure may be effected by HAGEDORN'S machine, on which point both home and foreign practice agree.

A similar contrivance to EARLE's bed for preventing motion whilst relieving the bowels, may be added to every mattress; it is however unimportant, as it may be advisable to move the patient daily into another bed (e).

679. As in fracture of the neck of the thigh-bone there is always much irritation and contraction of the muscles, if this come on subsequently, it must be attempted to moderate it by rest and antiphlogistic treatment before the application of the extending machine. If permanent extension of any kind be employed, we must always endeavour to keep it up to the same degree; it must only be slackened when the patient complains of pain, and if he cannot bear it another treatment must be resorted to. The patient should keep as quiet as possible during the treatment. The apparatus must not be removed before the sixtieth to the seventieth day, and then the limb should be enveloped in a circular bandage; the patient must remain some time in bed, and must only be allowed to stand up, and, supported by crutches, to move about very cautiously, when, with the leg straight, he can bend the whole limb at the hip-joint. DUPUYTREN assigns to the length of the cure eighty, one hundred, and even a hundred and twenty days.

The weakness and stiffness of the muscles and joint gradually subside; but volatile infrictions and baths may be ordered. Even in the most satisfactory cases, there commonly remains a little shortening of the extremity, which can often be alone observed, on close examination, in the straight posture, but may always be perfectly counterbalanced by a rather thicksoled shoe.

680. When the fracture passes obliquely through the great trochanter, (a) Medical Repository, vol. xix. p. 113.

(b) New York Medical and Physical Journal,

Oct. Dec. 1825. p. 474.

(c) Beschreibung einer neu erfundenen und ver

besserten Maschine für alle Arten Beinbrüche. Augsburg, 1823, p. 29.

(d) Above cited.

(e) DZONDI, Lehrbuch der Chirurgie, p. 590.

and the proper neck of the thigh-bone does not participate therein, (which fracture may happen at every period of life,) it is characterized by the fol lowing appearances:-the extremity is very little and frequently not at all shortened; it is stiff; the patient is incapable of turning himself in bed without assistance, and the attempt always causes great pain; the broken part of the trochanter is in many cases drawn forwards towards the hipbone, in others it sinks against the tuber ischii, but is ordinarily far sepa rated from that part of the great trochanter which remains connected with the neck; the foot is turned very much outwards, the patient cannot sit, and the attempt always causes severe pain; crepitation is difficult to be discovered, when the trochanter either sinks much backwards or is drawn much forwards. This fracture requires the same treatment as that for fractured neck of the thigh-bone, and unites firmly.

A. COOPER (a) gives a proper bandage, which consists of a broad cloth, enclosing the hips, and sewn together; at the point where it passes under the great trochanter, it is widened with a piece let in, and padded; behind the great trochanter a wedge-like pad is to be placed, so that when the bandage is sewn the trochanter may be kept in place. At the same time a thick wedge shaped pillow is to be put under the upper part of the thigh, and the foot fastened in such way that it cannot turn either inwards or outwards.

B.-OF THE FRACTURE OF THE THIGH-BONE BELOW THE GREAT TROCHANTER.

POTT, P., General Remarks on Fractures and Dislocations; in his Works, vol. i. Edition of 1783.

RICHTER, C. F., De situ femoris crurisque fracti laterali minus apto. Lipsia. 1788.

8vo.

DESAULT, Œuvres Chirurgicales, vol. i. p. 219.

BELL, C., A System of Operative Surgery founded on the basis of Anatomy. 2 vols. London, 1807-9. 8vo.

SAUTER, above cited.

681. This fracture happens either in the upper, middle or lower third of the thigh-bone; but is most common in the middle. Its cause is either violence acting directly on the thigh, or a fall upon the knee or foot; in the former case it is always accompanied with much bruising, frequently with splintering. The direction of the fracture is in old subjects mostly oblique; in young persons and children usually transverse.

682. The signs are, fixed pain at the seat of fracture, sudden incapability of the patient to move the thigh, unnatural motion in its continuity, deformity of the limb in reference to its length, thickness and natural direction; distinct crepitation on moving the thigh.

The upper fractured end is drawn less upwards and forwards in fracture of the upper than in that of the middle third; the lower end is drawn backwards and upwards at the same time; the lower end is turned outwards, partly by the contraction of the muscles, partly by the proper weight of the limb. If the broken surfaces do not touch, the limb is shortened, especially if the fracture be very oblique. In transverse fractures, specially in young persons, the broken surfaces often remain in actual contact, and the thigh is curved forwards by the contraction of the muscles. In fractures in the lower third, which are mostly oblique, the lower end is drawn backwards towards the ham and the condyle upwards, in consequence of which the knee assumes a peculiar form, and the point of the upper fractured end may penetrate the m. rectus and through the skin.

(a) Above cited, p. 158.

683. Fracture of the thigh-bone is always a severe accident, as the broken ends are retained in proper contact with great difficulty. The cure takes place most commonly with deformity and shortening of the limb, especially in oblique fractures, and those which occur in the upper and lower third of the thigh-bone. Compound fractures are so much more difficult to treat.

[In simple fractures of the thigh-bone except with great obliquity I have rarely found difficulty in retaining the broken ends in place, and in effecting the union without deformity and with very little and sometimes without any shortening. For the contrary results the medical attendant is mostly to be blamed, as they are usually consequent on his carelessness or ignorance.

Compound fracture of the thigh is a very serious accident; its danger depends upon the injury of the soft parts and extent of the wound, and also upon the obliquity of the fracture and its disposition to drive through the wound or among the muscles. These are points which must be well weighed in deciding whether amputation should be performed or not. If the patient be young and healthy we may often undertake the cure without amputating, and with fair prospect of a happy result.-J. F. S.]

684. The difficulty of retaining the broken ends in complete contact till consolidation is effected, has led to various modes of treatment.

1. The Contentive Apparatus, with splints, and the limb in a straight position. The setting is to be effected by extension and counter-extension, as in fracture of the neck of the thigh-bone (par. 674.) The Surgeon, standing on the outside of the thigh, endeavours, with both hands, to bring the broken ends into their proper place, and to equalize all irregularities. The apparatus is to be slipped beneath the limb, kept in a proper degree of extension. It consists of five double bands, a piece of linen, as long as the limb, and sufficiently broad to include the splints on both sides, of SCULTETUS's bandage, of three splints, and their corresponding chaff pads, of which one should extend from the crest of the hip-bone to beyond the sole of the foot; the second from the upper inner part of the thigh, just as far; and the third from the groin to the knee. At the seat of fracture two wetted compresses are to be applied, which should surround three-fourths of the thigh; the whole limb is then to be swathed in SCULTETUS's bandage, from below upwards, and the splints rolled up in the piece of linen on both sides, till they are brought to two to three fingers' breadth from the limb. The interspace is then filled up with the pads, the third splint laid with the chaff pad upon the front of the thigh, and the splints surrounded with the bandages, of which three are to be put on the thigh, and two on the leg. The foot should be supported in a stirrup (1). This apparatus is to be wetted from time to time with lead wash, replaced every six days up to the fiftieth, or, in old people, to the sixtieth day (2). If the callus have become sufficiently firm, which is known by the patient being able to raise the limb freely, rendering it some support with his hands at the fractured part, the apparatus may be removed, the whole limb enveloped in a circular bandage, and the patient allowed to go about carefully with crutches for several days.

[(1) In general, I think the straight position in treating fracture of thes haft of the thighbone is far preferable to either of the other methods. But the plan I employ is rather different from that here advised. I use four splints, flat pieces of deal about one-sixth of an inch thick, and three or four fingers wide, which any carpenter can quickly furnish; the hind one should reach from the tuberosity of the haunch-bone, against and immediately below which it should rest, to within four inches of the sole, so as to be quite free of the heel; the front one should extend from just below the groin, not quite so low as the bend of the ankle-joint, and should have two or three transverse saw-tracks