cian must help himself. Openings are made over the wounds. During
defecation, the round pillow, which occupies the part of the splint corre-
sponding with the perineal region, is removed.
For compound fractures of the leg, previous to antiseptic times, Petifs
fracture box, introduced into Germany by Heistcr, was extensively used
(Fig. 247).
The leg is wedged in between straw cushions by means of the movable
side pieces ; for the change of dressings, each side of the lower portion of
the leg can be made ac-
cessible, one after the
other, without changing
the position of the leg.
By means of the mova-
ble supports, the angu-
lar position of the knee
joint can be easily regu-
lated
In England, Macln-
tyre s splint, improved ^^^- ^
by Listen and made of
sheet iron, is used in preference for the same purpose (Fig. 248). The same
has a movable foot board, which can be changed in various directions ; by
means of a screw on the back, the angular position of the knee joint can be
changed very gradually. The transverse board at the lower end gives the
splint a secure position. The portion for the thigh can be lengthened or
shortened.
Fialla s rod splint (Figs. 249, 250) con-
sists of a row of thin rods which, by means
of a screw, can be pressed together into
any desired position around a common
axis. It may serve as a substitute for the
leg splints and the double inclined planes,
especially since it can be easily folded,
occupies little space, and can be placed in various angular positions.
The fracture box devised by Scheiier has this advantage : it can be very
rapidly constructed with a few wooden laths (Fig. 251).
In modern times, the hollow straight splints with foot board (Fig. 155)
MacIntyre's Splint (improved by Liston) for Com-
pound Fractures of the Leg
^J-.
\\p
t4i
rlr
*-ft
XI
i
\
Fig. 249. Fi aula's Rod Splint
144
SURGICAL TECHNIC
are probably preferred by most physicians to all kinds of fracture
boxes.
Fig. 250. Fialla's Rod Splint
Fk;. 251. Scheuer's Fr.\cture Box
In compound fractures of the humerus and in injuries of the shoulder
joint, Stromeyer s arm pillow is very useful. This is a triangular soft
upholstered horsehair pillow, covered with some waterproof material (Fig.
252). The apex
of the pillow
edge is placed
in the axilla and
fastened in front
and behind with
safety pins to a
strip of bandage,
which is carried
over the opposite
shoulder. The
arm, bent at a right angle, and the pil-
low upon which it is placed are fast- V /£..,itm miir" ■^fer« - - - *-''tiss.?a
ened together with a sUng (Fig. 253). inu 253. biKoMi \Ek^ ak.m I'illunn
Fig. 252. Stromever's
Arm Pillow
THE TREATMENT OF WOUNDS
145
It secures rest for the arm by preventing the movements of breathing
from being conducted to the fracture.
In fractures of the upper end of the humerus with an obstinate abduc-
tion of the upper fragment, the whole humerus can be placed in an
abducted position by Middeldorpf s triangle, a triangular wedge-shaped pil-
low (Fig. 254), or a double inclined plane made of three boards (Fig. 255),
the base of which is fastened to the trunk with belts or bandages, while the
Fig. 254. Middeldorpf's Triangular Pillow
Fig. 255. Middeldorpf's Triangle
arm, bent at an obtuse angle, is placed upon the short sides and fastened
there. This triangle can also be made from wire splints. On account of
the dependent position of the arm, oedema is likely to ensue ; hence, the
whole arm must be very carefully bandaged from below upwards.
Lister's leather-covered wooden splint (Fig. 256), for resection of the wrist,
secures a proper position for the hand and the fingers during the after
treatment, when more frequent movements of the fingers become necessary.
Many of the hand splints described above are superior, consequently it can
almost be dispensed with. Modern surgery, especially in the case of injured
146
SURGICAL TECHNIC
limbs, rarely makes it necessary to resort to all of these position appliances,
and contents itself with the cleaner modern splints. For special and very
tedious cases, they might be used advantageously even to-day.
vWW>i'wv^ !;! y^?^>SS-;-'<-^^ -''-'^'"^^" "'""
I""iG. 256. Lister's Wooden Splint eor Resection of Wrist
EXTENSION DRESSINGS
(distraction dressings)
These permanently exert an extending force on some part of the body and
are frequently employed with great advantage : —
1. For removing great displacements in simple and compound fractures.
2. For correcting diseased cojitraction of the mnscles and the consequent
increased pressure upon diseased bones and joints and for the after treat-
ment of some resections.
3. For removing or rather stretching cnrvatnirs.
To the incomplete but simple extension appliances, which may eventu-
ally be used as a temporary dressing for transportation, belongs Desanlt-
Listons wooden splint iox femoral fractures (Fig. 257). A cloth fastens the
foot to the lower end — improved by Hayncs Walton (Fig. 257, a) — while
a second cloth conducted over the perineum secures counter extension. By
means of a third cloth (girdle cloth), the upper end of the spHnt is fastened
to the pelvis. By means of a fourth and a fifth cloth, the thigh and leg are
fastened laterally to the splint. Similar is Dupnytren' s splint for fracture
of the ankle. This splint, provided with a thick pad, is fastened laterally to
the calf of the leg, while by means of cloths or bandages, the foot is fastened
THE TREATMENT OF WOUNDS
14;
Fig. 257. Desault-Liston's Wooden Splint for Femoral Fractures
at the lower end in such a manner that the broken ends of the bone are
brought in proper position (Fig. 258). For extension, however, the use of
weigJits and elastic extensors is much better. To make these means effective
it is necessary, by a careful dis-
tribution of the points of attach-
ment over a large surface, to
make the permanent extension
endurable for the patient. This
has been accomplished by Cros-
by s adhesive plaster loop. Since
this method is preferably and most frequently employed in fractures of the
femur, the extension dressing for the thigh may serve as an illustration of
this method of treatment.
Crosby s adhesive plaster loop consists of a strong, broad strip of adhesive
plaster (spread upon canvas), which is applied along both sides of the leg
as far as the frac-
tured part of the
femur. In the loop
against the plantar
Fig. 258. Dupuytren's Splint for Fracture of
THE Ankle
Fig. 260. Applying Strips of Adhesive Plaster
259. Foot Board
surface of the foot is placed a small foot board provided with a ring (Fig.
259), to prevent pressure against the malleoli and furnish a point of attach-
ment for the cord, and by means of a second strip of adhesive plaster, which
encircles the leg spirally, the two strips of plaster are held in place (Fig. 260).
148
SURGICAL TECHNIC
Next, with a cambric bandage the whole leg is firmly bandaged from the
toes as far as the upper ends of the first adhesive plaster strip. These ends
are turned over the last turn of the bandage (Fig. 261 ). By means of a cord
Tk;. 261. Fastening Strips of Adhesive Plaster
running over pulleys, a weight is fastened to the ring of the foot board ; by
means of this weight, the leg is drawn toward the lower end of the bed.
The increase of the weight must be made very gradually ; preferably only
after 10 to 12 hours, in order that the adhesive plaster may become firmly
attached to the skin.
If the leg were left without any further support, it would sink into the
mattress, and the friction would either entirely or partly neutralize the effect
m
Fig. 262. Extension by Weight for Fractures of the Femur
of the extension. The fragments would, moreover, suffer a rotation from
the lateral movements of the foot.
To prevent both these results, the leg may be placed on ?fon Volkmaiui s
sleigh apparatus (Fig. 263), a short, hollow, iron splint provided with an
THE TREATMENT OF WOUNDS
149
opening for the heel, a foot board, and under the same a narrow transverse
bar, resting and sliding upon two smooth, triangular wooden bars.
If this splint is not at hand, a prismatic transverse piece of wood may be
fastened transversely to the dorsal side of the tibia by means of a plaster of
paris bandage, which is also carried around the foot ; this transverse piece
is allowed to slide on the two
wooden prisms connected by
parallel iron wires (Fig. 262).
In most cases, however,
von Volkniann s tin splints are
provided with such prismatic
transverse pieces of Avood.
In many patients, com-
mon adhesive plaster causes a
troublesome itching of the
Fig. 263. Von Volkmann's Sleigh Apparatus
skin and eczema; hence, it is better to use non-irritant adhesive plaster;
for instance, the excellent though expensive adhesive india-rubber plaster,
or the zinc plaster muslin.
In cases where not even this is well borne, or where no adhesive materials
can be used, a substitute must be found. The extension splint can be fast-
ened very well by two wet bandages, each double the length of the whole
leg, in the middle of which a small slit is cut for the ring of the foot board.
Two of the four ends hanging therefrom are carried in an anterior and the
other two in a posterior direction in serpentine turns around the limb (Fig.
264). If another dry bandage is carefully wrapped over them as far as the
fracture, considerable extension is secured without causing the bandages to
slip ; by coating the bandages with paste or flour, they can be made still more
Fig. 264. Fastening the Extension Splint i;v 'Y.\\^> Wet Landages
secure. By sewing ox fastening the several turns of the bandage with safety
pins, a firm hold is secured even with a common bandage.
Likewise, the trellis finger catcher, made of fibres of the palm leaf
(" Fingerfanger," " Madchenfanger "), which under tension becomes tighter,
ISO
SURGICAL TECHNIC
and which cannot be stripped again from the limb, can be used in case of
necessity as a substitute for adhesive plaster. Although a plaster of paris
bandage applied on the bare skin adheres, it is less to be recommended.
The traction by the attached weight varies from 2 to 12 kilograms, accord-
ing to circumstances ; for most cases 5 to 8 kilograms are sufficient. Very
powerful muscles sometimes cannot be overcome by means of weight
extension.
Counter extension is made by means of a padded cord carried over the
perineum and the groin, or by means of a thick India rubber cord wrapped
with cotton, and fastened laterally to the head of the bed ; this prevents the
patient from being drawn down in his bed by the weight. Or the weight
of the body is used for this purpose by raising the foot of the bed with
blocks of wood or bricks placed under it. In the treatment of coxitis by
extension, the counter extension is made in the abducted position of the
limb on the diseased side, and in the adducted position on the liealthy side.
After resection of the hip joint, extension must be made with the limb in
the abducted position.
Von DnnireicJicj- used the weight of the limb for an extension by
placing it upon a single inclined splint with rollers (railway apparatus).
Much simpler and more practical is
Konig's gliding stirrup (Fig. 265),
a dorsal splint which allows the leg
to be suspended upon two iron
arches fastened laterally. To pre-
vent outward rotation of the frag-
ments, the thigh is fixed with short
splints ; for instance, those of Gooch
(Fig. 140) and ^i'//(Fig. 151).
If the upper fragment is dis-
placed much anteriorly, or if on
account of uncleanliness the patient's dressings become greatly soiled from
the prolonged supine position (which is the case in fractures of the femur in
little children), it is advisable to make vertical extension. The leg is drawn
up straight on a gallows, so that the body exerts the extension (Schede).
For extension of the arm, the adhesive plaster strips are fastened on the
internal and external side of the arm, so that the cross-board is placed under
the elbow, with the forearm bent at a right angle. If the forearm is sup-
ported by a sling, the weight can be fastened to the cross-board, and the
patient can walk about. Or the arm is fastened on a suspension splint.
Fig. 265. k'onig's Glidinc; Stirrup
THE TREATxMENT OF WOUNDS
151
similar to von Volkmamis, at the elbow part of which the extension cord is
carried over a pulley ; the patient must then remain in bed.
For extension of the wrist in the treatment of inflammation, as well as
resection of the same, loops of equal length of adhesive plaster strips are
fastened to all the fingers in the form of a gauntlet (Fig. 88), and through
these loops a thin rod is inserted. A weight carried over a pulley is fast-
FiG. 266. Extension of the Wrist
ened to this by means of fine cords. The counter extension can be effected
by a large adhesive plaster loop, applied to both sides of the forearm, and
fastened by means of a cord with an India rubber ring to the head of the
bed. The arm rests on an inclined plane (Fig. 266).
Extension of the trunk is resorted to more especially in the treatment of
diseases or curvatures of the spine, and can only be accomplished by a
complicated apparatus. Among these numerous appliances, the following
will be mentioned briefly : —
Von Volkmann' s extension apparatus for the cervical portion of the spine
in the treatment of spondyHtis (Fig. 267).
Fig. 267. Von Volkmann's Extension Apparatus for the Cervical
Portion of the Spine
The head is extended in a horizontal direction by means of Glisson's
sling, which encircles the chin and the occiput ; to this sling, provided with
152
SURGICAL TECHNIC
Glisson's Sling
a curved iron cross-bar, the extending weight is fastened and carried over a
pulley at the head of the bed. If it becomes necessary to increase the exten-
sion, this can be done by attaching weights to both lower extremities.
Instead of the weights, counter
extension is made by raising the
head of the bed. For Glissons
suspension sling, two loops of
adhesive plaster may be substi-
tuted ; these are placed around
the chin and the occiput, united
over the head, and kept apart
by a transverse piece of wood.
With Glissons suspension
sling, according to Sayre, an extension can also be exerted
on the scoliotic spine. By means of a pulley the patient
lifts himself with both arms until only his toes touch the
floor, the weight of the body becoming thus the extending
force (Fig. 268). In this position, in which the spine is
stretched as much
as possible, a fixa-
tive dressing (plas-
ter of paris felt corset) is applied in
cases in which such treatment is
indicated. The extension is more
endurable and still more effective if
axillary extensors are added to Glis-
soji s sling (Fig. 269). By this com-
bined extension the whole upper
section of the vertebral column is
lifted (Fig. 270), so that the cur-
vature is diminished or corrected.
These suspension exercises are re-
peated daily, and the time is gradu-
ally increased.
Scoliotic curvatures may also be
removed temporarily by a lateral
extension. Barwell places the patient
with the prominence of the curva- ,, c , tt a
^ Pig. 270. Sayre's Extension Apparatus for
ture into a girth sling, which, when Scoliotic Spine
Fig. 268. Extension
FOR Scoliosis
THE TREATMENT OF WOUNDS
153
traction is made by weight and pulley, presses the curvature into its normal
position (Fig. 271). This position is also suitable for applying plastic corsets
in an " over correction" (^Peterson).
DRESSINGS WITH ELASTIC EXTENSION AND
WITH ADHESIVE PLASTER
Although elastic extension becomes very
effective on account of its active force, its
effect can be less easily gauged than that of
extension by weight and pulley ; on the other
hand, it has the advantage of being lighter
and more comfortable.
For elastic extension, either strong india-
rubber rings, such as can be bought every-
where, are used ; or, if such are not available, fig. 271. Barwell's Lateral "exten-
a piece of india-rubber hose. sion in Scoliosis
Small grooved wooden plugs, provided with hooks, are
fastened at both ends (Figs. 272, 273). The simple knot-
ting of the ends is less secure, since these knots easily
get loose.
For a distant transportation, the wounded person is placed at once 7tp07i
a stretcher and supplied with such an elastic extension by fastening with an
Fig. 272. Groca'ed
Wooden Plug
Fig. 273. India-rubber Hose with Hooks
india-rubber ring the carefully bandaged limb to the lower end of the
stretcher ; for counter extension, the belt of the patient, or, in case of neces-
sity, the leg of his trousers, cut open at the inner and the outer seam and
Fig. 274. Von Esmarch's Stretcher Extension Dressing f|^
for Transportation in Gunshot Wounds of the Femur
rolled up to the perineal region, is fastened with an elastic cord or a sus-
pender to the head of the stretcher (Fig. 274).
154
SURGICAL TECHXIC
For the same purpose, the separable wooden splint (Fig. 139) can be
used ; five sections of the same joined together are sufficient. An iron hook,
to which the extension ring is fastened, is
appHed, when used, at the lowermost part
(Fig. 275).
At the upper section are two slots, to
which are fastened both the pelvic belt
and, by means of a second india-rubber
ring, the perineal band. If the leg of the
trousers is not used for a counter exten-
sion, it is carefully folded and used as a
padding between the splint and the leg
(Fig. 276). The splint, which can be
taken apart and which is supplied with a hook and two india-rubber rings,
occupies very little space and can be easily packed.
Fig.
Irun Hook for Separable
Wooden Splint
Fig. 276. Von Esmarch's Separable Wooden Splint for Elastic Extension
OF the Thigh
In the same manner the ivrist can be provided with a very effective
elastic extension. The hand and the forearm, after having been bandaged
as described above (Fig. 266), are placed upon a hand splint provided in
front and behind with rollers. Next, the extension cords under the splint
Fk;. 277. Elastic Extension of the Wrist
are stretched tight by means of an india-rubber ring (Fig. 277). The
patient can walk about with this dressing.
THE TREATMENT OF WOUNDS
155
Fig. 278. Sayre's Adhesive Plaster
Dressing (First Strip)
Sayres adhesive plaster dressing for fractiurs of tJie clavicle is also an
extension dressing, as by lifting the shoulder outward, backward, and
upward, it corrects the overlapping of the
fragments. Cut two strips, 8 to 10 centi-
meters wide, of strong adhesive plaster
spread upon canvas, one strip long enough
to be carried around the arm and also around
the thorax, the other long enough to be car-
ried from the healthy shoulder over the
elbow of the diseased side, and thence back
to the healthy shoulder.
Apply the first strip below the margin
of the axilla around the arm ; next, on the
posterior side of the arm, sew it together to
form a loop wide enough to leave poste-
riorly a portion of the arm free ; this pre-
vents strangulation. By means of this loop,
draw the arm downward and backward, until
the internal sternal fragment of the clavicle
has been drawn sufficiently downward by stretching the pectoralis major
muscle. Fix the arm in this position by carrying the strip of adhesive
plaster around the chest and fasten its end posteriorly to the strip (Fig. 278).
Cut in the middle portion of the second strip a small longitudinal slit to
receive the olecranon process. Next, place the patient's forearm, bent at an
acute angle, upon his breast ; (while an assistant forces the elbow forward
and inward, completely reducing the fracture) fix the arm in this position
by the second strip, the middle of which receives the tip of the elbow.
Carry both ends across the breast and back over the opposite shoulder,
where they cross each other, and fasten them with a few safety pins (Figs.
279, 280). In the case of unruly children, apply over this a Desault
starched bandage.
Similar is Landerer' s adhesive plaster dressing iox fractures of the clavicle.
Sew a broad strip of adhesive plaster, cut several times lengthwise at one
end, together with another strip of equal length by means of a broad piece
of strong india-rubber bandage (Fig. 281). Next, apply the first strip upon
the diseased shoulder so that its fingerlike attachments come to lie anteri-
orly, carry it posteriorly and obliquely across the back, and apply the
second strip of adhesive plaster, under strong tension, like a girdle around
the healthy side, and fasten it there. The elastic bandage then draws the
156
SURGICAL TECHNIC
Fig. 279 Fig. 280
Sayre's Adhesive Tlaster Dressing (Second Strip)
diseased shoulder backward, and hence produces an extension force upon
the fragments.
In the same manner Landcrcr appHes his extcnsio7i dressing for genu
valgmn {knock-knee\ Two broad strips of adhesive plaster encircle the
thigh and the leg ; at the inner side of the knee a broad elastic band is
stretched tensely between them, or into the ends of the bands of adhesive plas-
ter, at the knee, transverse pieces of wood are fastened and are gradually
Fig. 281 P"iG, 282
Landerer's Adhesive Plaster Dressing with Elastic Extension
contracted more and more by india-rubber rings. The same end may be
obtained also by means of a buckle arrangement in the elastic middle piece.
THE TREATMENT OF WOUNDS
157
More effective, however, is Miciilicz s extension dressing for genu valgum
(Fig. 283). The whole leg is bandaged with a plaster of paris dressing,
into the posterior and the anterior sides of
which iron splints with hinges are incorpo-
rated, so that the hinges correspond to the
region of the knee joint; at the inner side
of the plaster of paris dressing, over the
thigh and leg, a hook is fastened with a
plaster of paris bandage ; after the dress-
ings have set, a wedge is cut out of the
dressings in the region of the knee with its
base inward ; thereby two plaster of paris
dressings are formed, which can be moved
laterally on the hinges of the splints; by-
means of an elastic extension connecting the
two hooks, the leg is gradually straightened.
Club-foot shoe with
elastic extension (Fig.
284), used in the after
treatment of corrected
club-foot, consists essen-
tially of a solid lace shoe,
with lateral steel braces, from the upper end of which an
elastic cord extends to the point of the shoe. This exten-
sion is to replace artificially the muscles which have
become atrophied. According to these principles, it may
be changed to meet the require-
ments of individual cases.
Finally, in connection with
more or less complicated appli-
ances, extension can be made by
means of screw splints ; as exam-
ples, may be mentioned here : —
Say re's extension dressing for
the knee joint (Fig. 285). Thigh
and leg are covered with adhe-
sive plaster strips in the manner
of Sciiltet ' s bandage ; these two
separate dressings are screwed
Fig, 283. MicuLicz's Extension Dress
iNG FOR Genu Valgum
Fig. 284. Club-foot Shoe
WITH Elastic Extension
Fig. 285. Sayre's
Extension Dress-
ing for the Knee
Joint
158
SURGICAL TECHNIC
apart by means of an iron splint, attached on both sides at
their extreme ends.
Sayrc's portable extension apparatus for the treatment of
cervical spondylitis (Minerva, Jurymast) consists of a curved
steel rod incorporated in the posterior median line of a plas-
ter of paris jacket, giving support to the head in a Glissons
sling. By means of screw action the rod can be raised and
lowered (Fig. 286).
Taylor s extension apparatus for the
ambulant treatment of coxitis (Fig. 287)
consists of a strong steel shaft as long as
Fig. 286. Sayre's ^^^ ^^^' ^^^^ ^ P^^^^^ ^^^^ ^^ ^^^ "PP^^ ^^^
JURYM.A.ST and a foot support at
its lower end. By means
of a screw, the splint can be extended,
thus stretching
the leg fast-
ened to it. The
apparatus is
fastened by
means of aiive-
headed strip of
adhesive plas-
ter, so that its
broad end
comes to lie in
a downward di-
r e c t i o n and
somewhat
across the in-
ner m a 1 1 e o-
lus (Fig. 288).
Over it, the
whole leg is covered with a bandage. After
the apparatus has been applied, the patient rides