FRACTURES OF THE LEG.

The two bones may be broken together, or they may be broken separately. The commonest fracture of the tibia is in the lower third; it is most frequently oblique, with the upper end directed downward and forward, so that it rides over the lower fragment; the fibula may give way at the same time, at a point nearly opposite. The tibia may also be broken transversely, at either the upper or lower half.

There are many methods of treatment: By the common splints; first reduce the fracture; apply the many-tailed bandage, and then use the shaped splints of Cline, supported by sand bags, or apply Macintyre's splint or Boyer's board and pillow dressing. The fracture box; the stiffened bandage, using the silicate of potash; paper and paste; plaster-ofParis; or chalk and gum bandage, are in general use, and commended in

turn.

FRACTURES OF THE FOOT.

These fractures are of rare occurrence, and result from severe crushes, and usually several bones are involved in the injury. The fracture is generally compound.

The os calcis is sometimes fractured as the result of a fall upon the heel.

Fractures of the metatarsal bones and phalanges are always the result of direct violence.

Treatment. In fracture of any of the bones of the foot, it should be kept at rest, either on a back splint with a foot-piece, or by means of some form of stiff bandage.

TREATMENT OF COMPOUND FRACTURES.

If the limb is put in a stiff bandage, an opening must be cut over the seat of fracture, in order to allow of the wound being examined and dressed when necessary.

If there is a mere puncture of the skin, caused by one of the sharp ends of the fragments, it may be closed at once, by applying a pad of lint dipped in the compound tincture of iodine or collodion. If under this treatment the temperature rises and the parts become hot, red, painful and swollen, the pad should be removed, and if there be evidence of suppuration, the wound must be opened, the parts carefully cleansed, and thoroughly syringed out with an antiseptic lotion.

If the wound is of a larger size, its edges lacerated, tissues bruised and

swollen, it should not be closed, but at once be treated antiseptically, by syringing with the bichloride solution (1-2000), and the parts must be dressed on strictly antiseptic principles.

If there be a compound fracture of a limb, apply a tourniquet; place bichloride towels under the part, then shave it, wash away any remaining soap with 1-1000 bichloride solution, and at the same time scrub the surface with a nail brush.

Be sure to place bichloride towels wherever instruments may possibly be laid, or wherever the operation may extend.

Freely enlarge the wound, if necessary, and constantly irrigate with 1-2000 bichloride solution.

Trim away all muscular and other soft tissues which are injured to such an extent that they cannot live; remove loose fragments and rough margins of bones, and shape the ends so that they will fit each other; then drill holes into them so that they can be fastened together with catgut, silver wire, or silkworm gut, and be careful not to irritate the parts with the ends of sutures, which are not to be removed.

The muscular tissue is to be united or approximated by catgut sutures. The ends of large nerves that are divided must be carefully trimmed, and brought together with fine catgut sutures.

Bleeding vessels are to be tied with catgut ligatures.

When hemorrhage is controlled, put in the wound a drainage tube of large calibre, making a free counter opening if necessary.

Finally wash out the parts with 1-1000 bichloride solution, and bring together the margins of the wound with catgut sutures.

Powder iodoform, or subiodide of bismuth over the wound. Put Lister's protective over the line of sutures, and cover the wound with a sufficient quantity of bichloride gauze; fasten it in its place with a bichloride gauze bandage. Wind five yards of bichloride gauze around the limb; keep this in place with a bandage of the same material, cover this with bichloride cotton two inches in thickness, the whole to be enveloped in wax paper. Then apply an ordinary roller bandage, and finish the dressing with a plaster-of-Paris splint. Sling the limb to a bar above the bed.

Change the dressings in a week, so that the drainage tube may be removed, and put in its place an absorbable bone drain, using at the same time bichloride irrigation.

Sprinkle iodoform about the wound, and dress as heretofore directed. The limb will probably not require to be again dressed for six weeks.

Hot and cold douche, massage, and passive motion will be required after removing the final dressings.

Amputation may be necessary where there is extensive destruction and laceration of the soft parts, with much splintering of the bone, especially if the main vessels of the limb are wounded, or an adjacent joint laid

open.

During the treatment, many complications may arise, such as ædema and swelling of the limb, ulceration and sloughing, spasms of the muscles, gangrene and venous thrombosis.

When oedema presents itself, the bandages should be slackened, and an evaporating lotion applied; if the tissues are bruised, paint the parts with tinct. benz. comp.; should bullæ form, they may be pricked, and their contents allowed to escape.

Ulcers are apt to form over bony prominences, and bed sores may appear over the sacrum, buttock, hips, etc. These must be treated antiseptically.

Gangrene, as a rule, is the result of tight bandaging, or other improper treatment. The part should be frequently examined, and if there be coldness, numbness, lividity or swelling of the limb, the bandages should be at once relaxed.

SPRAINS.

A Sprain is a violent stretching of the ligaments, tendons or fascia surrounding a joint, with or without rupture of some of their fibres and blood vessels.

It usually happens from the sudden extension of the joint in the direction for which the muscles are unprepared; the most common situations of these accidents are the wrist or ankle.

The pain produced is instant and severe, frequently attended with faintness; the parts begin to swell immediately, and there is great tumefaction and ecchymosis, and subsequently weakness and stiffness of the part. There is inability to bear any weight on the limb, and any attempt to move the joint surfaces on each other is attended with increased pain.

The remote effects of this lesion are often permanent pain and weakness; or stiffness and even ankylosis.

Treatment. The patient should at once go to bed, so as to ensure perfect rest; the part affected should be confined to a splint behind, held in place by a comfortably applied bandage, and the position of the limb should always be such as to relax the muscles. Warm fomentations or

cold affusions, whichever are most agreeable to the patient, should be used; acetate of lead and opium should be applied through the medium

of wet rags.

Should the pain and tumefaction increase, leeches should be freely applied, and if the patient is very plethoric, and the injury extensive, purgatives and general bleeding must be had recourse to.

Care should be taken not to use the part too early.

Should the disease become chronic, friction with moderate pressure should be used; stimulating liniments should be rubbed over the parts, which should be kept neatly bandaged; leeches and blisters should be resorted to, and good effects are often produced by pouring a continued stream of cold water over the part.

SYNOVITIS.

Synovitis, or acute inflammation of the synovial membrane, may be produced by local or constitutional causes, such as blows, strains, mechanical injuries, penetrating wounds, exposure to cold, syphilitic or gonorrhoeal poisons, and gout.

The knee is the joint most frequently affected.

Symptoms.-Severe aching pain in the joint, increased by motion, great swelling, redness of the surface, tenderness and fever, which is frequently violent.

The swelling, which is occasioned by a rapid effusion of fluid into the synovial cavity, is distinctive. There is evident fluctuation, if the joint is superficial. The shape of the joint is always altered.

When the knee is affected the patella is pushed forward, and there is great fullness on each side of it, and at the lower and front part of the thigh. The swelling, if at the elbow, is most distinct above and between the olecranon and the condyle; and in the hip there is general fullness of the surrounding parts, and tenderness on pressure.

Treatment.-Limb must be kept absolutely motionless. A splint must be applied, after being padded, so that it may be fastened some distance above and below the joint, and care must be taken that it does not touch the affected part.

Leeches to the joint, cups in the neighborhood, evaporating lotions or hot fomentations. Calomel purgatives should be administered; and opiates, to relieve pain. When there is a tendency to the disease becoming

chronic, iodide of potassium should be administered. And if the disease be connected with rheumatism, ammonia and potash should be prescribed. Where there is tendency to gout, colchicum with potash is to be employed. In syphilitic cases, mercury, in its different forms, is most to be relied upon.

COXALGIA, OR HIP-JOINT DISEASE.

This disease is most frequent from the third to the seventh year.

FIG. 56.

The first circumstance which indicates disease of this joint is some degree of lameness and pain in the knee, with more or less weariness, some eversion of the foot and dragging of the leg. The motions of the joint are impeded; extension is performed with difficulty; the knee is bent; the heel on the diseased side scarcely rests on the ground; there is great difficulty experienced in the flexion of the joint.

To ascertain whether disease exists, the patient is placed on his back and examined, to ascertain whether the sides of the pelvis are equal; the pelvis will be lower on the diseased side. Then bend the knee on the abdomen; if there be disease of the hip joint, considerable pain will be occasioned. In rotating the joint pain will be excited. If the patient is turned on his face, the nates on the affected side will be found lower.

If the surgeon presses on the hip joint, either in front, over the psoas and iliacus, or behind the great trochanter, or jerks the femur against the acetabulum by a sharp tap on the trochanter major or heel, pain will be felt in the hip, and that in the knee will be greatly aggravated.

COXALGIA.

Abscesses are frequently formed in this disease, which take various directions; as a rule, their course is down the thigh, where they break; they may, however, occur in the upper part of the thigh, the rectum or vagina.

The pain of complete extension of the joint, and the instinctive resistance of the patient to this position, when laid on a flat, hard bed, producing, when the knee is pressed straight, a sudden aching of the lumbar curve, is very characteristic of the disease, even in the earliest stages.