patient cannot bear them. To these belong the bandages and apparatus of BÜCKING (a), EVERS (b), MOHRENHEIM (c), B. BELL (d), BOYER (e), A. COOPER (f), BAILLIF (9), FEST (h), and many others.

697. If, as is generally the case, inflammation and swelling immediately set in together, they must be first got rid of by proper treatment, the joint being kept in the position already described, (par. 694,) before proceeding to set the fracture, and to the application of bandages. As often as the apparatus becomes loose, it must be reapplied; in seven or eight weeks' time it may be removed, but the patient must still be very careful in moving about. The longer the patient remains quiet, the sooner bony union takes place. A stiffness of the joint frequently continues, which only gradually subsides; often incurable anchylosis ensues (1). The latter seems to arise from the application of the bandages, before the inflammation of the joint is got rid of. If the intersubstance be very wide, the knee must be supported with an elastic bandage. The motions of the limb in these cases may be also often improved, if gradual and more violent motions of the leg be performed, by which the contracted m. rectus again lengthens itself to a certain degree (2).

[(1) I have never seen anchylosis of the knee-joint from fracture of the knee-cap, and can only imagine its occurrence under very peculiar circumstances.-J. F. S.

(2) JOHN HUNTER observes :-"Other things are to be done after the union has taken place. First, the accommodation of the muscles to their new situation, where less length is necessary, from the patella having become longer; secondly, the new contraction in this new situation; thirdly, acquiring sufficient strength in it. We have reason to believe that the greatest contraction in a muscle is somewhat greater than the joint will allow of; for we find them firm when the limb is stretched, as if the power was greater; and when the part is deprived of this firm band, we find the muscles draw the bone up higher than they should. Thus the upper part of the patella is always drawn up when the bone is broken. While the union is taking place, the muscles are accommodating themselves to the great length of the bones. After this it will be necessary to bend the limb and keep it so, in order that the muscles may be thus enabled to admit of an elongation equal to the flexure of the limb, by which means the patient will be enabled easily to bend the limb. Extension will not be so easy; still, by perseverance, it may be acquired." (p. 512.) He then mentions a case in which the broken pieces of bone having been left far apart, the patient had lost the use of her limb, although it could be swung backwards and forwards as she sat upon a high table; and he considered that he cured her simply by inducing her to direct her will to the excitement of the action of the rectus muscle. And he explained how this was effected, first, by reference to the condition of the muscle," that the space between the two attachments of the rectus being much shortened, while the muscle continued of the same length, the utmost degree of its contraction would scarcely be able to straighten itself, much less move the patella and leg also." And then, that "if the influence of the mind was frequently exerted on the muscle, it would gain this power of contraction, in which it would probably be aided by the interstitial absorption taking place, and actually shortening the muscle, and suiting its length to the office it was to perform." (p. 513.) In other words, and more briefly, the object is to produce in the rectus muscle a recovery of its tonicity, by educating it to contract and permanently shorten itself, so that it may re-acquire the power of acting on the knee-cap, and extending the leg which it previously had, but of which it is deprived by the ascent of the broken part of the kneecap rendering it lax instead of tort when the leg is straight.

I believe the best mode of recalling the m. rectus to its proper function is, after having kept the patient in bed five or six weeks, by which time it may be presumed whatever union will, has taken place, to get him up, place him on a table, with his ham on its edge, and direct him to swing the leg backwards and forwards, frequently during the

(e) Above cited, pl. iii.

(f) Above cited, pl. ix. f. 9, 10, 11.

(g) ORTALLI, De fracturâ Patellæ. Berol., 1827,

p. 52.

(h) Dissert. de fracturâ Patellæ. 1827. 4to.

day. At first he can do this very little, not because, as HUNTER and CHELIUS suppose, the m. rectus is too short and requires lengthening, but on the contrary because it is too long and must be instructed to shorten itself still more, so as to compensate for the ap proximation of its points of attachment by the unnatural space between the broken ends of the knee-cap. When the muscle has re-acquired sufficient power to throw the leg and foot forwards, then some weights must be attached to the foot, and the same exercise continued till the muscle can freely move it when so loaded. In this way the muscle becomes shortened, and capable both of sustaining the erect posture and throwing the leg forwards. It may be here observed, that if the fibro-ligamentous union of the broken pieces of the knee-cap be long, the patient's gait is very odd, the foot and leg are not carried forward steadily and set on the ground, but as it were jerked or thrown forward from the knee, and when the foot rests on the ground and the weight of the body is transferred to that limb, the knee is in an extreme state of extension, as if supported almost entirely by the posterior ligament of the joint.-J. F. S.]

698. The longitudinal fracture requires merely a common contentive bandage, which may compress the broken pieces on their sides, with a less elevated position than in transverse fracture.

The splintered fracture requires the same apparatus as the transverse, when the broken ends are displaced upwards, or as the longitudinal fracture if they be displaced at the side; but here also the inflammation and swelling must be first got rid of, before the aplication of the apparatus.

If fracture of the knee-cap be accompanied with wound of the joint, it must be treated according to the general rules of compound fractures. [Compound fracture of the knee-cap almost invariably requires amputation, as the injury producing it is so severe that there can be little expectation of a satisfactory issue.-J. F. S.]

699. If the ligament of the knee-cap be torn, the knee-cap ascends, and the treatment must be the same as in transverse fracture. I have employed this same practice in five cases with the happiest success. I once observed, in a weakly man, in whom the ligament was torn on the left side, and from improper treatment the bone was displaced upwards five inches, a tearing of the fleshy fibres of the m. rectus, which had occurred from a false step, and from the attempt at preserving the equilibrium of the body, consequent on muscular contraction. The seat of rupture is distinctly felt, of which the space becomes greater on bending the leg, and is diminished by straightening it. The application of the prescribed apparatus was successful.

Although the apparatus above mentioned is most suitable for transverse fracture of the knee-cap and rupture of its ligament, it must, however, be observed that its application must be made with the greatest accuracy and attention, as also its readjustment when the bandages are loosened, in which special care must be taken that the broken ends be not displaced, and the scarcely-formed union disturbed and destroyed. In this respect it were perhaps convenient to spread the above-described apparatus with plaster, and thereby render certain its lasting close application.

XVII. OF FRACTURE OF THE BONES OF THE LEG.

(Fractura Ossium Cruris, Lat.; Bruche der Knochen des Unterschenkels, Germ.; Fracture des Os de la Jambe, Fr.)

POTT, P., above cited.

DESAULT, above cited, p. 270.

BOYER, above cited, p. 324.

700. Both bones of the leg may be broken at once, or the shin-bone or splint-bone may be broken separately. The fracture is produced either by a fall upon the feet, or by the operation of direct violence.

701. If the shin-bone alone be broken, (Fractura Tibiæ, Lat.; Bruch der Schienbein, Germ.; Fracture du Tibia, Fr.,) the fracture has usually a transverse direction, and may happen in the middle or at either end. The broken ends are rarely displaced, and then only according to the thickness of the limb. This happens so much less frequently, the nearer the fracture is to the upper end of the bone. The diagnosis is, therefore, often difficult; the patient frequently can walk after the injury; he feels a fixed pain; an irregularity is often discovered at one part of the shin-bone, and often crepitation on moving the broken ends. The treatment of this fracture is easy; a slight extension is sufficient, if the broken ends be displaced, to put them right, and a simple contentive apparatus, as recommended in fracture of both bones of the leg.

702. Fracture of the Splint-bone (Fractura Fibula, Lat.; Bruch der Wadenbein, Germ.; Fracture du Péroné, Fr.) may be produced by an inward or outward turning of the foot, or by the immediate effect of violence; and the fracture may be either in the body of the splint-bone, or in the neighbourhood of the outer ankle. In fracture of the body of the splint-bone the limb is not shortened, and retains its natural direction; a slight yielding is scarcely felt at the seat of fracture in pressing the finger along the bone. The violence received on the outside of the leg, and the great ecchymosis assist the diagnosis. This fracture is frequently accompanied with dislocation inwards of the shin-bone, and if it be mistaken, the foot retains its disposition to dislocate after seeming reduction. The inner ankle always again leaves the joint surfaces of the astragalus, thrusts the skin violently inwards, which becomes inflamed, breaks, and even runs into mortification. The broken end may alone be displaced, and driven inwards against the shin-bone. If the seat of fracture be very low down, it may be discovered by the touch, which is not possible in the upper third of the splint-bone. Crepitation is often observed on pressing the fractured ends inwards, or in alternate adduction and abduction of the foot. The most striking sign is always the inclination of the foot outwards, so that its inner edge is downwards, and the outer upwards. If dislocation of the shin-bone inwards be connected with this fracture, the bone is shorter, its long axis falls on the inner side, the whole shin-bone lies obliquely from above inwards, and produces beneath the skin, especially at the lower part, a considerable prominence. The splint-bone follows the same direction as the shin-bone to the seat of fracture, from which it is directed obliquely outwards. The foot is not

only inclined outwards, but so turned upon its own proper axis, that its sole is turned up, and its inner edge directed downwards. Fracture of the splint-bone may also be connected with dislocation of the foot outwards, often simultaneously with fracture of the inner ankle or of the shin-bone, and other complication may exist, as, in dislocation of the ankle-joint, will be more particularly described.

703. The treatment of simple fracture of the splint-bone is unattended with difficulty. The foot must be kept bent inwards, to separate the broken ends from the shin-bone. This is effected by the same apparatus as that for fracture of both bones of the leg, with this difference, that the inner splint is applied only to the inner ankle, but the outer continued below the outer ankle. Or, upon the inside of the leg is put a folded chaff pad, the bottom of which rests on the inner ankle, and the upper end upon the inner condyle of the thigh-bone. A sufficiently strong wooden

splint is fixed upon this pad with a circular bandage, so that its lower end may project from four to five inches beyond the sole of the foot. With a second roller the foot is drawn inwards towards the shin, the bandage being turned like a ∞ around the shin, foot, and ankle-joint (a). This apparatus, however, has the objection that it frequently becomes displaced, or presses too tightly. In five or six weeks the fracture is consolidated. In fracture connected with dislocation of the foot, the splint-bone must, after reduction of the dislocation, be kept in place by the prescribed apparatus, and by a general and local treatment according to circumstances, to which often very important symptoms are opposed.

704. Fracture of both bones of the leg (Fractura Cruris, Lat.; Bruch der beiden Knochen des Unterschenkels, Germ.; Fracture des deux Os de la Jambe, Fr.) is either transverse or oblique, and may be either in the middle, upper, or lower third. The diagnosis is always easy. The displacement of the broken ends, according to the length of the limb, is more rare, than that according to its straight direction and circumference; but, in oblique fractures, the leg is always shortened, the lower end turned outwards and backwards, the upper inwards and backwards. Only when the fracture is near the top of the leg, is the upper fractured end drawn much upwards and backwards by the operation of the bending muscles. Very frequently, particularly in oblique fractures, the broken ends protrude through the skin.

705. The treatment varies as the fracture is transverse, oblique, in the neighbourhood of the knee-joint, or connected with injuries of the soft parts.

706. In Simple transverse Fracture the setting is always easy. One assistant holds the limb above the knee, and another at the heel and instep; slight extension is generally sufficient to bring the broken ends into place. As they have little disposition to displacement, the simple contentive apparatus is sufficient. Two moistened square compresses are to be put upon the leg, and to surround two-thirds of it; it is then to be swathed, from below upwards, with SCULTETUS's bandage, wooden splints, three fingers wide, are to be applied on both sides, which should reach beyond the knee and ankle-joints, in a sufficiently large piece of linen, and they should be two fingers distant from the leg. This space is to be filled with chaff pads, a smaller pad and splint are to be put on the front of the leg, which should reach from the tubercle of the shin-bone to the ankle, and the splints are to be fastened with three double bands, of which that on the seat of fracture should be first tied. A compress is to be put on the sole of the foot, and crossed on the instep, and by its ends attached to the apparatus. The leg should so rest on a chaff pad, that it may easily be bent at the knee-joint; and care should be taken that the heel lie in a proper hollow. At first the apparatus should be moistened from time to time with a dispersing lotion, and renewed every six or eight days. On the fortieth or fiftieth day the consolidation is perfected, when the leg may be enveloped in a circular roller.

707. The oblique Fracture of the leg is also generally set with ease, though the mere contentive apparatus is not sufficient to keep the broken ends in proper place, as they have not any opposite support, and are,

(a) DUPUYTREN, Mémoire sur la Fracture de l'extrémité inférieure du Péroné, les luxations et les accidens qui en sont la suite; in Annuaire medico

chirurgical des Hôpitaux et Hospices de Paris. Paris, 1819. 4to.-Leçons Orales de Clinique Chirurgicale, vol. i. p. 189.

therefore, very easily displaced. PoscH's (a) foot-bed or SAUTER'S (b) machine serves best for permanent extension.

708. In fractures of the leg near the knee-joint, the setting is best managed in the half-bent position, which is the most proper during the cure. The contentive apparatus is to be applied with this difference, that one splint is to be put in front, another upon the inner, and one upon the back of the leg, which should lie on the outer side, or on a double inclined bed. If the head of the shin-bone be broken obliquely into the kneejoint, the leg must be kept straight, fixed by the contentive apparatus, and stiffness prevented by early motion.

709. Fracture of the leg is frequently connected with a wound produced by external violence, or by tearing of the soft parts by pieces of bone being driven outwards. In the latter case the wound must be enlarged, and often the piece of bone sawn off, in order to effect the proper replacement. The seat and direction of the fracture determine the kind of apparatus. The simple contentive bandage has in these cases the disadvantage of requiring frequent renewal, on account of attending to the wound. Here the suspensory apparatus, in which the limb lies free, and the wound can be properly attended to, is best. BRAUN's (c) machine is merely a suspendor, and can therefore principally serve in those cases only in which the broken ends, after being set, have no disposition to displacement. When this is the case, PoscH's foot-bed, with EICHHEIMER'S (d) improvement, or SAUTER's machine, best answer the purpose. These two machines have the advantage that they not only suspend the leg, but also keep it permanently extended.

SEUTIN'S permanent apparatus for fracture of the leg may be easily modified from that for fracture of the thigh. The thigh part is not required; the apparatus, however, must be applied of sufficient length upon the broken parts. In fracture near the knee-joint, it must therefore reach over the lower part of the thigh-bone. As in the leg there is little danger of separation, the patient may lie in winter upon a sofa at the fire, and in summer he may sit in the sun, so that the bandages may dry in twelve hours, if there be no special disposition to inflammation in the joint.

[The treatment of fracture of the leg, when either one of the bones only is broken, is very easy, the unbroken bone forming the best and most efficient splint which can be provided. And indeed if the patient be quiet, there is no real necessity for splint or bandage of any kind, which, however, it is necessary to apply to quiet the anxiety of the patient and his friends. If, however, both bones be broken, they must be kept in place by apparatus of some kind or other. If wooden splints be used, one on each side is sufficient, and the leg is best laid upon the side, with the knee half bent to relax the muscles, and the tip of the great toe so raised as to be on the same level with the kneecap. I do not think that usually there is any necessity for the application of a third splint along the shin. Especial care must be taken that the edges and ankle-holes of the splints are well covered, so as to prevent their digging into the skin and forming tiresome sores. Some prefer the straight posture with the leg resting on the heel, but I think the bent is more agreeable to the patient. In the common transverse fractures of the leg, my colleagues and myself almost invariably use the gum roller, without either splints or fracture-box, and with very great success, as well as comfort to the patient, who is not then confined to his bed more than six or eight days, but allowed to be about on crutches. The plaster of Paris apparatus of SEUTIN, or the white of egg and flour splints with starch roller, may either of them be used in this fracture advantageously; but they occupy more time in their application, and we now seldom use them. Oblique fracture

(a) Beschreibung einer neuen, sehr bequemen Maschine, das Fussbett genannt, zur Heilung des Schienbeinbrüches. Wien, 1774. 8vo.

(b) Above cited.

(c) METZLER Beschreibung der BRAUN'schen Maschine zur zweckmässigen Lage einfacher und complicirter Beinbrüche der unteren Gliedmassen. Ulm, 1800.

(d) Beschreibung und Abbildung einer Maschine für einfache und complicirte Beinbrüche des Unterschenkels, welche nach der PoscH und BRAUN'schen Maschine construirt, die Vortheile desselben vereinigt, nebst einer Vorrichtung, welche bei dem Transportiren solcher Patienten gebraucht werden kann; with five lithographed engravings. München, 1821. 8vo.