from above downwards, two layers of many tailed bandage, and upon them a layer of cotton wadding, split so that the glazed surface was downwards. So arranged, the dressing is ready for use. Placing the limb gently upon it, more wadding is used, if need be; adapt the one to the outline of the other. The batting on the plane should be at least an inch thick under the tendo Achillis, and there should be none under the heel. The limb so placed, the next step is to attach to each side of the foot a strip of adhesive plaster, or, in lack of that, pieces of starched cloth which, when the dressing is complete, can be attached to the foot-board, and have the double purpose of maintaining the foot perpendicular and steady, and preventing pressure on the heel. The layer of split wadding is now wrapped smoothly around the foot and leg, and over that the first layer of bandage is neatly and snugly applied, beginning at the foot. The starch is applied with the hand to the overlapping ends only, as each strip of bandage is used; one layer on, the other covers it in the same way (I generally put between them, two or three folds of starched cloths lengthwise the leg to secure greater firmness). The foot is now supported by the adhesive plasters from the foot-board, and the dressing is complete. The foot should be so supported by this arrangement, that its inner border be on a line with the inside of the knee, and that the outline of the tibia be as projecting as possible. For that reason it is better done after the leg is in position, and before applying the bandage. The limb is kept steady till the bandage is dry, by a temporary bandage around the thigh and the upper arm of the plane. Under ordinary circumstances, the starch is dry in thirty-six or forty-eight hours. The drying may be hastened or delayed by facilitating or impeding evaporation. Once dry, the starch bandage is a snug and perfect envelope of the limb, perfectly moulded to every outline. For fractures of the leg or forearm it extends from the toes or fingers to the knee or elbow joints, the motions of which are unimpeded, and its anterior surface on the leg (posterior in the forearm) is hard and unyielding, while the posterior surface on the leg and anterior on the forearm is as soft and flexible as the cloth of which it is made. This is the peculiarity of construction to which I wish to call attention. That half of the bandage which lies over the extensor muscles and the arch of the bones is solid and unyielding, while that half which incloses the flexor muscles, vessels, and nerves is unstarched cloth, fitting the limb, and not easily displaced. A just objection to the ordinary form of starch bandage is in this way obviated, and perfect ventilation of the limb secured. I propose the use of the double inclined plane only as a convenient rest for the inner limb till the starch of the dressing is dry. It secures better flexion of the limb and perfect quiet, and by raising the foot of the plane, any required degree of elevation can be given to the whole limb by flexion of the hip joint alone. This I have found of advantage in case of great swelling, materially arresting the graduated pressure of the bandage, and the evaporation of the water of the starch in its removal. It permits also other changes of position, thus adding greatly to the comfort of the patient. After the starch is dry, I permit the feelings of the patient to decide as to its further use, except in fractures of the upper third of the femur, where it should be retained for about two weeks. Mrs. W. made a good recovery; was able to sit on a chair after the first week, and was on crutches after the third week. John Johnson, Swede, æt. twenty-six years. While chopping cord wood on the side of a bluff, felled a tree in such a way that his ankle and lower third of leg were crushed between it and a stone. He was alone, and worked his way down the bluff a half mile; then by the aid of another man he walked, or rather hopped, on one leg more than a mile, was put into a timber sleigh, and rode two miles further over a rough road to his home. I saw him about six hours after the accident and found the limb swollen to the capacity of the skin. There was a very severe contusion over the inner malleolus, and much discoloration of the skin of the leg from effusion of blood, with an occasional large watery blister, as appears in erysipelas. Motion of the fragments of bone on each other was impossible, even of the ankle, so great was the swelling. By measurement, the calf was much larger than the thigh. could only infer fracture from the history of the case and the evidence of injury. The starch bandage, as described, was snugly applied to the limb on the double inclined plane, the lower extremity of which was well elevated. The rapid evaporation of the starch was promoted, and in three days the splint was so loose that it had to be tightened, which the attendant did, as he was instructed, by passing from heel to knee around the leg over the dressing broad strips of bandage, and tying them in hard knots over the anterior hard surface of the dressing. I saw him in a week, slit up the unstarched bandage where necessary to get at the contusion and blisters, dressed them, and reapplied strips of cloth as at first, with starch. I saw him but three times at his home. I All the adjustment necessary was done by the attendant. Thirtyeight days after the injury, he rode eight miles over a rough road in a huckster wagon to my office. I removed the bandage by cutting it open in the unstarched portion; found all right, and reapplied it, retaining by a single long bandage, which the patient removes daily, and reapplies after a bath. Fracture of Femur.-Ole N., æt. twenty-four. Thrown from a wagon, two miles from town, producing oblique fracture of the femur at junction of middle and lower thirds. He was picked up and brought back on a load of hay. I found him in bed an hour or more after the injury; the thigh bent at nearly a right angle outward. He was in great pain, and unwilling to have the limb touched. Distracting his attention by a little banter as to his poor oxmanship (a pair of steers ran away with him) he became quite excited in his own defence, and, almost without his knowledge, and without his consent, the limb was easily straightened and placed in the inclined plane prepared as already described, the entire splint covered with wadding and the many tailed bandages, extending from the toes to the groins. The anterior surface was starched, and inclosed the condyles and trochanters of the femur, resting against the pubis on the inner side. He sat on a chair on the fourth day, was on crutches on the eighth day (the limb supported by a sling). In the fifth week, he rode home twenty miles, and reported himself in the eighth week as ploughing, with a limb as straight and as long as its fellow, but not quite so strong. A case of compound fracture just above the knee-joint was treated in the same way, and with equal success. The cases related are taken as fair illustrations of the method and success of the modification of the starch bandage used. I leave them, and the grouping of anatomical facts and principles of treatment stated in this paper, to speak for themselves, only asking a fair trial for the method proposed, before a judgment as to its merits. RED WING, MINNESOTA, May 2, 1872. VOL. XXIII.-37 |