and bandages were all removed for the first time since their application, and the fractures seemed to be united. Enlargement of the knee, without pain, however, was still present. On the following day it was ascertained that the union, especially at the upper seat of fracture, was not sufficiently firm, there being outward deformity and shortening, produced by muscular contraction. The retentive apparatus was again applied, after bringing the femur as nearly as possible into its normal line, and allowed to remain four weeks longer. After this removal, being seventeen weeks from the application of this apparatus, and twenty-four weeks after the occurrence of the fracture, the union was considered sufficiently consolidated, and the apparatus was not again applied.. By very careful measurement, at this time, the fractured limb was found to be scarcely one inch shorter than its fellow. In consequence of her protracted confinement, at such an advanced age, she was not able to leave her bed, however, until a week afterwards. Gradually she gained strength, and, by the aid of crutches, became able, at the end of the second week, to move about the room. The union, however, could not have been as perfectly consolidated as was supposed when the final removal of the apparatus took place, since, by a recent measurement, made January 14, the shortening has increased to 1 inch. She is, however, fully restored in every other respect, and is able to attend to her ordinary household duties. Notwithstanding the unusual amount of power which it became necessary to apply by the tourniquet, for so protracted a period, no complaint was made of pain at the seats of the application of this power, except when the anterior adhesive counter-extending bands became detached from the surface, and began to act as ordinary loose bands, this being promptly remedied by the application of new strips.

2. The next case is that of Thomas Stokely, aged 11 years, whom I attended, as consulting surgeon, at the request of Dr. Theophilus E. Beesley, the family physician. In this there was compound oblique fracture of both thighs, the bones piercing the pantaloons as well as the muscles and integument. Whilst I leave it to Dr. Beesley to present a full account of this case to the College, I furnish the accompanying drawing (Fig. 4, p. 297), which was very accurately taken from life by Kielman. The roller applied to the leg, and many-tailed bandages to the thigh, are shown as applied to the right limb only.

In the treatment of oblique fractures of the bones of the leg, requiring permanent extension and counter-extension, the adhesive plaster bands are quite as valuable as in fracture of the thigh. For simple oblique fracture, two splints, six inches wide, reaching from above the knee to about six inches below the foot, are sufficient (Hutchinson's modified). Each splint should have two holes at its upper and one mortise hole at its lower extremity. Those at the upper extremity are provided for the passage of the counter-extending adhesive bands, and the mortise below is for the reception of a cross-piece upon which the frame of the tourniquet rests. The tour

niquet in this, as in fracture of the thigh, furnishes the most convenient and efficient extending and counter-extending power. Junk bags, or wadding, to fill up the inequalities of, and give support to, the leg, adhesive plaster Fig. 4.

1, 1. Anterior adhesive counter-extending strips. 2. Distal extremity of posterior adhesive strip of left side. 3. Adhesive strip surrounding pelvis, binding the anterior and posterior strips to pelvis. 4. Inner extremity of the extending adhesive strip, forming stirrup under the foot to receive the strap of the tourniquet. 5. Cicatrix of left thigh. 6, 6. Holes made in the pantaloons by the protruding fragments of bone, full size. 7,7. The common tourniquet, by which the power was applied. bands, about two inches wide, and the roller, or the many-tailed bandage, complete the apparatus. For counter-extension four adhesive plaster bands are necessary, and for extension two are ordinarily sufficient. The former are applied spirally, so as to cross each other, the two anterior just below the tubercle of the tibia, and the two posterior at a point directly opposite. These, in their spiral course upwards, severally cross each other, externally and internally, opposite the joint; their proximate extremities are then passed through the holes in the splint, and securely tied outside. The

latter are applied to the foot and ankle so as to cross each other at the hollow of the foot, then over the tarsus anteriorly, and the upper part of the tendo-Achilles posteriorly. The strap of the tourniquet passes between the sole of the foot and the strips where they cross each other. After the extending and counter-extending adhesive bands are applied, they are bound to the surface by common bandages.

In cases of compound fracture a modification of the common fracture-box may be used very advantageously. In this the foot-board is omitted, and a cross-bar for the reception of the frame of the tourniquet is substituted. The sides of the box each consist of three separate segments. Of these the upper and lower are permanently screwed to the bottom-board, and the central one is attached by hinges. By this arrangement there is full access to the wound, which may be dressed from day to day without disturbing the extension and counter-extension maintained by the permanently attached upper and lower segments. This apparatus was used successfully in the case of Michael Gillis, who had compound comminuted fracture of both bones of the leg, in the winter of 1852-53, and is the sixth of the series of cases published in the Amer. Journal of the Medical Sciences, already alluded to. The following drawing represents this apparatus, omitting bandages and side-compresses.

1. The four counter-extending adhesive strips, as if encircling the knee and upper part of leg. 2. The two extending adhesive strips crossing at the bottom of the foot, ready to be applied to the foot. 3. Tourniquet.

Dr. BEESLEY then read the following note of the case of compound fracture of both thighs, referred to by Dr. Gilbert:

In the afternoon of the 27th of 10th mo. (October), 1858, I was called, as the family physician, to Thomas, son of Wm. S. Stokely, No. 58 N. Eighth St., and met Dr. David Gilbert at the bedside of the sufferer. He was a lad of 11 years of age, who had a compound fracture of both thighs, of the right a little below, and of the left a little above the middle of the femur, occasioned by his falling from a height of about 20 feet directly upon his feet. Subsequent examination of his dress showed that the upper fragment of one thigh, and the lower of the other, had protruded sufficiently to penetrate through his pantaloons in front. My friend Dr. Griscom had first seen the patient, and attended to the reduction of the bones. I assisted Dr. Gilbert in the application of such temporary splints as we had, and of the proper dressings. As a counter-extending band to each thigh,

two strips of adhesive plaster, each an inch and a half wide and two feet long, were so placed as to cross each other at the portion of the thigh where it joins the perineum, extending, the one in front and the other behind, to the upper part of the splint, and were there passed through two holes and were firmly fastened together, an outside splint only being applied to each limb. A broad adhesive strip was applied around the pelvis and over the counter-extending bands, so as to give them additional support. For the extending bands two broad strips of plaster were applied, from a little below the knees, along the legs, sufficiently long to leave a loop below the hollow of each foot for the strap of a tourniquet to pass through. Extension and counter-extension being then made, and the fractures properly adjusted, a common roller-bandage was bound on the adhesive strips from the ankles to the knees, and the many-tailed bandage was applied over the thighs. Between the splints and the thighs cotton wadding, folded in muslin, was used as padding. A compress and cold water dressing were kept to the wounds.

No complaint of pain at the seats of extension and counter-extension was made by our patient. The following day the temporary splints were laid aside, and a narrow board splint for each limb was substituted, extending along the outside from below the arm-pit opposite the nipple to about six inches below the foot. Extension was made and kept up by means of common tourniquets, the frames of which rested on blocks projecting inwardly from the lower extremities of the splints.

The wounds were inspected at the end of the third day, and were found sealed up by coagulated lymph, a slight oozing of bloody serum alone appearing. Dry compresses were now applied, and retained by the bandage of strips, and a flat bottle of ice-water was laid between the thighs, opposite the injured parts, and continued for a fortnight or more, to the apparent comfort of the patient.

After the first day there had been a considerable amount of swelling, which seemed more the result of effusion and congestion than inflammation. The general excitement was at no time great. It was highest about the fourth day, and subsided to a very moderate degree about the close of the first week. Anodynes were given from the commencement, about every four hours, to allay the spasms of pain which occasionally darted through the limbs, and to obtain sleep; they were found useful, in moderate doses, throughout the case. The neutral mixture, with a little tincture of rad. aconite, was administered, whilst there was febrile excitement; also occasionally, when needful, a cooling laxative or an enema. On the complete subsidence of the febrile symptoms, tonics were given, principally sulphate of quinia, with the tincture of the chloride of iron. The patient was placed from the commencement on a fracture-bed, consisting of a simple frame, about 4 inches deep, 5 feet long, and 2 feet wide, with strong ticking stretched tightly over it and firmly nailed to it; the ticking was furnished with a hole in the centre for the evacuations, and under this hole was placed

a cushion or pillow. On this fracture-bed, he could be lifted, without pain, to attend to his evacuations. The fracture-bed rested on a common mattress, and was supported, when desirable, by stools at the head and foot.

The first complaint he made of pain at the seat of the counter-extending bands was on the morning of the fourteenth day. On examination, it was found that, in order to relieve itching under the plaster, he had separated it for some distance from the skin on the previous evening, and that then this detached portion had acted as an ordinary loose counter-extending band in producing pressure and excoriation; to relieve this, his mother had stuffed cotton under the bands, but still the pain continued. We renewed the loosened portions of the bands, and little complaint was made during the remainder of the treatment until the fourth week, when it became necessary to apply fresh anterior and posterior counter-extending bands. The wound of the left thigh was fully cicatrized on the eighteenth day after the accident; that of the right not until the sixth week. After the first few days the discharge from each wound was very trifling in amount, proceeding only from the granulating surfaces.

We had reason to believe that firm union had taken place at the end of the fifth week; but, at the urgent request of the father of the patient, the splints were continued until the middle of the seventh week, or the fortysixth day from the accident, when all retentive apparatus was removed. The thighs have their natural form and length. The patient was free, during the entire period of treatment, from the usual suffering experienced at the seats of extension and counter-extension; the only exception to this was the very slight uneasiness above mentioned, induced by the patient's interference with the bands at and near the perineum. The strips of adhesive plaster, by which extension was made, remained without removal from the day they were applied to the end of the treatment.

In writing an account of this interesting case, I have drawn freely from the notes of it kept by Dr. Gilbert, to whose skill, under Providence, I attribute its completely successful result, the more remarkable from the age, nervous constitution, and active character of the lad. Of all the cases of fracture of the thigh which have come under my notice in the course of a pretty extensive practice of more than forty years, there has been none where the apparatus made use of was so simple, so painless, and yet so thoroughly efficient in retaining the injured limbs in their natural position. The fracture-bed, by its cheapness, lightness, and convenience for moving the patient without pain and allowing the necessary evacuations of the bowels, seemed almost all that was to be desired in such a case. At first there was some difficulty in urinating, and the catheter was used a few times; after that, however, a large-mouthed flattish phial was placed so as to receive the urine, when the patient desired to void it. In conclusion I may add, that now, at the end of three months from the accident, the boy walks with facility and without limping, there only appearing some stiffness in his knees.