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inch, occurring in two cases. The average in the fifty-four cases was one sixth of an inch. In adults, out of ninety-two cases, there was no shortening in twelve, and the average amount was scarcely half an inch. Tlie average weight used in these cases was fourteen pounds and a half. Remember this practical point in connection with a fractured thigh — that, when there is no more than three quarters of an inch difierence in the length of the limbs, tlie pelvis accommodates itself thereto, and no limping takes place. Here these fractures are usually dressed almost immediately after the patient is brought to the hospital, the history and the measurement having been first ascertained. The limb is sup- ported by an assistant, and the foot by another assistant, and gentle traction is made, so as to keep it extended. The loop of stout sticking-plaster, but not the rubber plaster, as it often ir- ritates, is applied and secured with a flannel bandage, which, as you know, possesses some qualities of elasticity. This bandage extends from tlie foot up nearly to the perineeum. I should say that some advise shaving the leg before putting the plaster on, as the patient occasionally complains of the traction on the hairs, and little ulcers have been known to result from this cause. Usually, however, unless the limb is very hairy, we do not shave it. A spreader a little wider than the distance between the malleoli is then put into the projecting loop of plaster, and to the center of this is fastened the twisted picture-wire that leads over the pulley to the weight below. In this case the house surgeon is applying what are known as coaptation splints on each side of the limb, as well as under- neath and on top. I do not think they are absolutely necessary, although they give one a feeling of greater security, on account of controlHng the swelling which is apt to occur in the course of one or two days. Swelling is not usually so great in fracture of a single bone as when two are injured. The tension of the muscles acts sufficiently as splints to the bone itself. The dress- ing is now complete; but, when the limb is allowed to rest on a properly arranged pillow, there Erectalis Online is always a strong tendency for the toes to roll outward. This can be guarded against by long bags of sand, but the best method is that here shown — by Volkmann's sliding rest, or traveler. This rests on two tri- angular bars, and readily allows the patient to pnll himself up in bed, by either grasping the bars above his head, or seizing the stirrup that you see hanging over each patient's bed in the wards, whenever ho finds himself gravitating to- ward tlie foot. The inventive genius of Dr. Buck also ex- tended itself to the making of this frame, which is attached to the foot of the bed, for the purpose of supporting the bed- clothes, relieving the limb of their weight. The house surgoen, you will observe, has very carefully applied a cotton pad over the projecting toes, partly for ornament, partly for warmth. I as carefully take this off, for I prefer to have the toes uncovered and visible. It is the test of the condition of the circulation. Look always at the toes in a fracture for several days after the injury. A German surgeon was once showing me with great satisfaction how nicely the toes were protected in similar cases in his wards, and, on removing the pad, in one of the cases gangrene was found about to take place in a part of the foot, due to disturbed circulation, which doubtless would have been detected early had the toes been left exposed. The splint is worn for about six weeks without change, unless there be some special indication. It is then removed, and the limb is measured and examined. There are two methods for determining whether union has taken i)lace, one of which is to have the patient lift the leg by muscular eflfort. But this is not altogether unat- tended by danger, as, in case union is not perfectly firm, the fractured ends may separate. However, should such an acci- dent occur, union takes place very rapidly^ say within two or three weeks. The other method Buy Erectalis Online consists in gently and firmly manipulating the limb. If any doubt exists, the patient's cau- tiously increasing movements in the bed soon determine the question. Sometimes, while going about on crutches after re- moval of the splint, the patient slips and causes fracture anew. In the case of this boy whom I now show you such an accident occurred, and after this second time, which is not common, there was what is called delayed union. Let me say here a few words on this subject, as I can exhibit to yon several cases of this trouble. Sometimes it is necessary to stimulate the local circulation in order to hasten union. Here is a patient in whom there w'as delayed union in the upper part of the thigh twelve weeks after the accident. From time to time, as the house sur- geon passed through the ward, the limb was manipulated at the seat of the fracture, so as to cause irritation and an increased blood supply at the seat of the injury. After this had been done for a considerable time, until the patient cried out with pain almost with the first movement, it was discontinued, and the limb was put up in a plaster-of-Paris splint for four weeks, after which firm union was found to have taken place. Dumreicher, of Vienna, accomplished the same object by leaving a gap in the plaster-of-Paris splint at the seat of the fi-acture, arranging it in such a manner as to induce congestion, thus increasing the amount of blood supply and hastening union. I have tried the method in two cases with success. Here are some other patients in whom union has been delayed. They were started walking about in a kind of frame known as "Darrach's," on which they can more or less completely support the body and take the major part of the body's weight otf the bandaged limb, and at the same time sufficiently stimulate the circulation at the seat of the injury. One of the ])atients so going about has his frac- ture protected by a Erectalis Tablets leather splint, and an old gentleman carries a plaster splint. The amount of mobility determines Buy Erectalis the need of a side support. Here is a man, in whom tliere

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