lying upon his back suffering severe pain. Considerable inflammation had been excited by the attempts at reduction.

The leg was shortened from one to two inches, lying nearly paralell with the opposite limb, the toes everted.

The trochanter of the affected limb was between one and two inches higher than that on the sound side, and turned backward so as to lose the prominence seen in the natural position. It rotated with the limb, so as to describe the arc of a circle somewhat less than natural, but not to a marked degree. There was no effusion or apparent injury to the soft parts about the trochanter. In consequence of the previous attempts at reduction, the parts had become very sensitive. After chloroform was administered, I seized the limb and found it very mobile and easily extended to the full length, when its aspect became entirely normal. A dull crepitation was distinctly recognized in the joint.

The diagnosis of intra-capsular fracture of the femoral head was established, and the treatment adopted at the time, and subsequently continued, was as follows: The patient being placed upon his back on a smooth bed, the foot of which was elevated about four inches, a splint, made after the manner of Hodgen's extension apparatus, was applied to the limb which was elevated ten to fifteen degrees, or until the extending force became sufficient to overcome the shortening, so that when a straight rod four feet long was applied against both heels, it was perpendicular to the axis of the body. The hip now assumed a natural appearance, the trochanters corresponding in position and prominence, and the fragments were thus believed to be in apposition. A wide flannel bandage was then snugly applied about the hips. The lad now said he was free from pain and soon fell asleep. The extension was kept up continuously for fifty-five days. On the fortieth day, a plaster of Paris dressing was applied about the hip, so as to prevent motion, the extending apparatus being removed fif teen days later. The plaster dressing was removed on the seventy-second day, and he was furnished with a pair of crutches. His health remained good during the entire time of the confinement. Dr. Smith writes me that he saw the patient

on the 17th of March, 1877, when he was walking by the aid of his crutches. The injured limb was of the same length as the sound one, and no deformity of any kind was detected. On the 1st of May following, he was reported able to walk without crutch or stick. His friends, who were quite intelligent, appreciated the importance of the case, and expressed great satisfaction at the result.

The interesting features of this case are the age of the patient; the time from the original injury to the date of the complete fracture; the mode of treatment; and the result.

As to the age in which this fracture occurs, Dr. Gross says: "Experience has shown that it (the neck of the femur) is subject to fracture, as a general rule, only after the age of fifty, when its spongy and compact tissues suffer from atrophy and fatty degeneration, thus rendering it more or less brittle and incapable of withstanding injury."

In a collection of 250 cases made by Sir Astley Cooper, the youngest patient was thirty-eight years old.

Erichsen refers to a case reported by Mr. Stanley, occurring in a young lady of eighteen years.

Dr. F. H. Hamilton mentions four cases of suspected fracture, or separation of the epiphysis, in persons aged respectively eleven, eighteen, sixteen, and fifteen; but he remarks that "at least one dissection is required to confirm the diagnosis in any of them."

Authors in surgery inform us that the fracture may be denticulated, or the fragments so dovetailed together, that they may not separate for some days; or we may have an impacted or partial fracture, especially in younger persons, in whom the animal constituents of the bone are abundant. The latter injury is more apt to occur when the force is received in or near the line of the axis.

This patient received the force of the fall or jump upon his feet, he did not fall upon his side. The neck of the bone at his age forms an obtuse angle with the shaft of about 135 degrees, so that the force was spent upon the neck rather in a longitudinal direction, than transversely. There was probably a partial fracture at first; but whatever the injury may have

been, repair did not follow as soon as might be expected in a patient of his age; on the contrary, it was followed by pathological changes which rendered the bone brittle and easily broken, as it was.

In the treatment of this fracture, as of all others, two principal indications are to be kept in view; viz., apposition and fixation.

By suspending the limb in Hodgen's splint, the extension is principally made by its own weight, the counter extension being made by the weight of the body.

We can thus secure a constant and equable extension, and the patient can be allowed some liberty of motion and change of position, lessening very materially the danger from bed

sores.

The bandage was first applied about the pelvis, without the plaster, so that frequent observation could be readily made of the parts, lest erysipelatous inflammation might follow the injury after the several attempts at reduction.

The plaster dressing well applied will keep the joint quite immovable.

By the extension, and plaster dressing, the fragments were kept in apposition until bony union was complete.

THE PLASTER OF PARIS JACKET IN SPINAL DISEASES.

BY EDMUND ANDREWS, A. M., M. D.

[Prof. of Surgery in the Chicago Medical College.]

The repeated inquiries made by physicians respecting the use of plaster of Paris in constructing supporters for spinal disease, show a widely diffused interest in the subject. I have therefore prepared this article to answer the numerous questions addressed me from different sources.

The therapeutic principles involved in the use of the plaster of Paris jacket, are the same as for other spinal supporters, and may be stated as follows;

1. Pott's disease is an inflammation limited almost invariably to the bodies of the vertebræ, and not affecting the articular processes behind them.

2. Hence it is that the bodies only soften and yield to the compression of the vertebræ above, while the articular processes behind remain firm and unchanged, in consequence of which the spine bends at an angle or a short curve, with its concavity forward and its convexity backward.

3. Curative apparatus acts in three methods; viz., (a) as a splint to correct or arrest the deformity; (b) as a means of securing immobility; (c) as a lifting power to take off the weight resting on the diseased vertebræ.

Any firm, broad splint applied to the back may act favorably to prevent the further flexion, and to secure immobility. The action of the plaster of Paris jacket in this respect, like that of all other supporters, is too obvious to require explanation. There is, however, one curative element in the splint principle which is very generally overlooked. Inflammation. of the vertebral bodies is usually kept up solely by mechanical irritation; that is to say, by the jarring, the rocking and the pressure of the vertebræ above pressed down by the entire weight of the superior portion of the body. If this mechanical irritation be taken off, almost all cases will recover from the inflammation spontaneously. Now let it be borne in mind that the articular processes are free from inflammation, and are located on a line considerably posterior to the bodies of the vertebræ. It is evident at a glance, therefore, that if any supporter is so constructed that by its splint power it shall flex the spine firmly backwards, it will throw the weight of the vertebræ upon the articular processes, and take it off from the inflamed bodies of the affected bones.

The direct lifting power of spinal supporters is often overestimated. In small children it amounts to almost nothing, because their hips are smaller than their waists, and there is no basis on which to rest a support for the lifting power. In adults, however, and especially in women, the expansion of the hips gives a counter support, and lifting becomes possible. It may be well to remark, just here, that the old attempt to

In

lift by pressure in the axillæ is abandoned by all good surgeons. The axillary plexus of nerves is intolerant of all continuous pressure. A lifting force applied there with sufficient vigor to accomplish anything, soon paralyzes the arms. spite of this fact, however, the instrument sellers continue to vend, and physicians to buy absurd pieces of apparatus, even for young children with no expansion of the hips, pretending to lift by crutch pieces in the axillæ.

The only lifting power possible (except an occasional headstretch), is by embracing the double cone of the waist in something resembling a corset, and this the plaster of Paris jacket accomplishes in cases of adults. The principle is simply this The waist being the smallest part of the body, anything like a firm, well fitted corset, or the plaster jacket firmly laced on, tends strongly to crowd the cone of the hips downward, and the inverted cone of the rest of the body upward, thus making a decided extension on the middle of the spinal column. It is for this reason that firm corsets, well laced, are a comfort, and actually a benefit to women with incipient Pott's disease. The plaster of Paris jacket acts both as a corset and as a splint, thus fulfilling both indications, acting in that respect like the combination brace, which I have for years been in the habit of applying to cases of Pott's disease. The most approved method of applying the plaster jacket, requires the following articles to be prepared :

1. A pair of pulleys to suspend the patient.

2. A suspension bar, or rather a sort of whippletree of steel or strong wood, suspended by the pulleys in the centre, and having two notches or hooks on each side, one five inches and one eight inches from the centre.

3. A sort of band or collar of soft stuffed leather to surround the base of the skull, capping the end of the chin in front and passing beneath the occiput behind. Straps pass up from this on each side to the suspension bar.

4. A pair of axillary pads or bands suspended from the centre notches of the suspension-bar.

5. A quantity of roller bandages of coarse cross-barred crinoline, whose meshes are rubbed full of good, dry, fresh plaster of Paris.