Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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double-inclined plane. To the support of this system of Pott's, thus
modified, Sir Astley Cooper, 0. Bell, John Bell, Earle, White, Sharp,
and Amesbury lent the influence of their great names, and its triumphs,
so far as the judgment of British surgeons was concerned, soon became
complete.

Fig, 137.



Amaabury's splint.



In Prance, and upon the continent generally, the reception of this
system was more slow and reluctant ; but Dupuytren, now for once
taking ground with his great rival. Sir Astley, adopted almost without
qualification these novel views. The decision of Dupuytren deter-

Fig. 138.



Ameflbniy's splint applied.

mined the opinions of a large portion of the continental surgeons ;
and had it not been for the early and decisive opposition of Desault
and Beyer, the great surgeon of St. Bartholomew might have con-
tinued for a long time to have enjoyed a triumph upon the continent,
and perhaps throughout the world, equal to that which had already
been decreed to him in Great Britain.

On this side of the Atlantic, the practice of Pott, at least in so far
as it applied to the treatment of fractures of the thigh, never gained

Fig. 189.




Borer's splint.



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400



FRACTURES OP THE FEMUR'.



a distinguished advocate; and but few ever adopted the practice as
modified by White, Amesbury, Bell, A. Cooper, &c.

But whatever may have been the early success of these doctrines,
either here or elsewhere, it is certain that a strong reaction has taken
place, and that gradually, in all parts of the world, the opinions of
practical surgeons have been settling back into their old channel. It
would be difficult to find to-day, in France or Germany a dozen dis-
tinguished surgeons who adopt universally the flexed position in the
treatment of fractures of the femur ; and in England the reaction is,
if possible, even more complete.

In my tour of 1844, during which I visited very many of the hos-
pitala of Great Britain and upon the continent of Europe, I do not
remember to have seen the flexed position once employed in the treat-
ment of a broken thigh ; and I shall presently show that the straight
position is at the present moment very generally adopted by the best
American surgeons.

There have been, then, three grand epochs in the history of the
treatment of fractures of the thigh.

First. That in which the straight position was universally adopted,
and which reaches from the earliest periods to the period of the writ-
ings of Pott, or to about the middle of the last century.

Second. The epoch of the flexed position, which, inaugurated by
Pott, had already begun to decline at the beginning of the present
century, and which may be said to have been completed within less
than one hundred years from the date of its first announcement.

Third. The epoch of the renaissancej or that in which surgeons, by
the vote of an overwhelming majority, have declared again in favor
of the straight position. This is the epoch of our own day.

Although American surgeons have generally adopted the straight
position in the treatment of fractures of the thigh, yet the form and
construction of the splints employed have been greatly varied. The
simple long splint of Desault, and the more complicated apparatus of
Boyer (Fig. 139), have each their advocates ; but it is seldom that we
meet with these or with any of the other forms of apparatus originally
employed in foreign countries without noticing that they have been
subjected to considerable modifications; indeed, most of the straight

Fig. 140.




Mathan B. Smith's suspending apparatus, or doablo-lnellned plana.



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FRACTURES OP THE SHAFT OF THE FEMUR.



401



splints as well as double-inclined planes in use at present among
Araerican surgeons may fairly be regarded as, original inventions.

Nathan Smith, of New Haven ;^ Nathan R. Smith, of Baltimore;^
Say re, of New York; McNaughton, of Albany f and Nott, of Mobile,
are the only American surgeons of distinguished reputation, and with
whose practice I am familiar, who have recommended exclusively the
double-inclined plan^

Fig. 141.



JO8IAH C. Nott'B DOUBLE-IICCLIHBD PlAKB.

In this apparstns th« limb is secured to the splint by rertical pins and leather straps; the npper sur-
face of the thigh splint in carved ont a little, to fit the thigh ; the two portions are articulated by a joint
like that of a carpenter's rule, and this Joint may be steadied by a horizontal bar underneath. For the
rest, the drawing sufficiently explains itselt

Dr. Nathan R. Smith has introduced a modification of the double-
inclined plane in what is known as his "anterior splint," and which
is intended also as a suspending apparatus. I have seen it employed
lately a good deal in the treatment of gunshot fractures of the thigh
and leg in our various military hospitals. It is my opinion, how-
ever, that it is more applicable to gunshot fractures of the leg than
, to those of the thigh.

The splint, if splint it can be properly called, is simply a frame
composed of stout wire and covered with cloth, which being suspended
above the limb, allows the limb to be suspended in turn to it by rollers;
the rollers passing around both limb and splint from the foot to the
groin. Wire of the size of No. 10 bougie is usually employed. The

Fig. 142.




B. Smith's anterior splint.



length of the splint should be sufficient to extend from above the
anterior superior spinous process of the ilium to a point beyond the
toes, the lateral bars being separated about three inches at the top and
one-quarter of an inch less at the lower extremity.

' Amer. Med. Rev., published at Philadelphia, 1825, vol. ii. p. 855 ; also Medical
and Surgical Memoirs of Nathan Smith, published at Baltimore, pp. 129-141.

* Med. and Surg. Memoirs, pp. 148-162. See also Geddings, Baltimore Med. and
Surg. Joum., vol. i., 1883 ; and Sargent's Minor Surgery, p. 171

'Trans. Amer. Med. Assoc, vol. x. p. 317. Rep. on Defor. after Frac.



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402



FRACTURES OF THE FEMUR.



In the case of a broken thigh, the upper hook, to which the cord
for suspension is to be fastened, ought to be nearly over the seat of
fracture, and the lower hook should be placed a little above the middle
of the leg.

Fig. 148.



5. R. Smith's anterior splint, applied for a frletnre of the thigh.

Fig. 144.



Palmer's modification of the anterior splint.



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FRACTURES OF THE SHAFT OF THE FEMUR. 403

The modification of Smith's anterior splint suggested by Dr. James
Palmer, United States Navy, will be suflBciently explained by the
accompaDying wood-cut,^ Fig. 144.

Dr. J. S. Hodgen, of St. Louis, Mo., has invented a wire suspension
splint, which I much prefer to Smith's. The bars of wire are traversed
with a cotton sacking, upon which the limb is laid. He does not,
however, advocate its general use, but he has designed it especially
for gunshot fractures.^

Fig. 145.



Hodgen's saspension apparatas.

On the other hand, among the advocates of the straight position
are found the names of Physick, Dorsey, Gibson, Horner, J. Harts-
home, H. H. Smith, Neill, R. Ooates, H. Hartshorne, Norris, Gross.

Says Dr. Gross : "Many years ago, before I had much experience in
this class of injuries, I occasionally employed the flexed position, but
I soon found that it was objectionable, on account of the great difficulty
in maintaining so accurate apposition to the ends of the fragments. Of
late years I have confined myself entirely to the use of the straight
position, and I have never had any cause to regret it. In the adult, I
sometimes employ the apparatus of Desault, as modified by Physick,
but much more frequently one of my own construction, somewhat
upon the principle of that of Dr. Neill, described in the Philadelphia
Medical Examiner for 1855. I have used it for nearly twenty years,
and it has generally answered the purpose most admirably in my
hands. It consists simply of a box for the thigh and leg, with a foot-
piece and two crutches, one for the axilla and the other for the peri-
neum, to make the requisite extension and counter-extension. With
such an apparatus, an oblique fracture of the thigh can be treated with
great comfort to the patient, and with the assurance of a good limb.
In children, I have effected some excellent cures simply by means of
a sole-leather trough, well padded, and provided with a foot piece.

' Amer. Joum, Med. Sci., 1865; also, Mechanical Therapeutics, etc., by Philip
S.Wales, M.D., U.S.N., 1867.
* Hodgen, Treatise on Mil. Surg., by F. H. Hamilton, 1865, p. 411.



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404



FRACTURES OF THE FEMUR.



"The great objection to the flexed position is thedifiiculty of keep-
ing the ends of the broken bones in apposition ; the upper one having
a constant tendency to pass away from the inferior. Other objections

Fig. 146.



JoHK Nbill*! Steaioht Tbiob-Spuvt.— Extension and connter-eztension made at the same tioe.

might be urged against the flexed position, but this is quite sufficient
to induce me to reject it."^



Fig. 147.



Fig. 148.





Pel Tic belt, and perineal strap. (From drawings fur-
Bished by Dr. L. M. Sargent, Boston, Mass.)

Fig. 149.



Foot-piece and screw.



-^



H^



Lateral rlew of the apparatus, without the belt.
Fig. 150.



yi" >M ! ■ ! ! i '■ ■ ■ » 'in" i i



rOLi



«^



Front Tiew, with folded sheet laid across.



' Trans. Am. Med. Assoc, vol. x.; also System of Surg., by S. D. Gross, 1859,
p. 221.



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FRACTURES OF THE SHAFT OF THE FEMUR. 405
Fig. 151.



App»rataa applied.



I



Side view ofapparatas applied.

Fig. 153.




Fig. 154.




Figs. 153, 154. Mode of making extension with adhesive plaster.

Dr. Neill, of Philadelphia, has contrived a very ingenious mode of
making both extension and counter-extension at the same moment by
means of a twisted rope which is fastened by its two ends respectively
to the perineal band above and the extending bands below.

J. F. Flagg's thigh apparatus, as used in the Massachusetts General
Hospital, by Warren, Bigelow, and others (Figs. 147 to 154 inclusive).

" The belt is made of strong webbing, having pockets on each side,
to receive the long splint. It is also furnished with straps and buckles.
The perineal strap (Fig. 155), corresponding to the injured side, is
kept constantly buckled, while the other may be occasionally loosened,
or left off, as its purpose is only to steady the apparatus. Where the
straps pass under the perineum, they are covered with wash-leather.
Before applying the belt, a pillow-case or two may be passed around the
waist. The padlock is only to be used in case the patient persists in
unbuckling the straps. The splints being applied with also short
side splints, junks, containing bran or sand, &c., are to be secured
more firmly to the limb by bands of webbing and buckles."

The two Warrens, father and son, of Boston, Kimball, of Lowell,
Sanborn, of Lowell, Mass., Mussey, of Cincinnati, Ohio, J. B. Flint, of



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406



FRACTURES OP THE FEMUR.



Louisville, Ky., Armsby, of Albany,' have also recommended some
form of the straight splint. Says Dr. Mussey: —

" For all fractures of the thigh-bone I employ the extended position
of the limb. There are but few cases in which extending force is not



Fig. 155.



Fig. 156.




Perineal band secared with a padlock.

necessary to prevent the degree of deformity or
shortening which would occur without it. Of thirty
specimens of fracture of the shaft, in my collection,
only two are transverse. In fractures of the neck,
especially with old subjects, I sometimes avoid the
application of any kind of apparatus for permanent
extension ; but in all cases, whether of the neck or
shaft, where such extension is attempted, I have
found the straight position of the limb to be the
most reliable."

And Dr. Kimball, who employs generally San-
born's splint, uses the following emphatic lan-
guage :—

" If I should be asked under what circumstances
I would use the double-inclined plane in case of
fracture of the femur, I would unhesitatingly an-
swer, never 1 I have long since abjured the double-
inclined plane in every form of fracture of this bone,
finding the straight splint fully adequate to all pur-
poses for which any apparatus of this kind is re-
quired. In support of this statement, I could
furnish a great number of cases showing that the
locality of the fracture, the importance of which is
so much dwelt upon in the books, constituted in
no case a valid objection to its use."

Extension in Sanborn's apparatus is effected by means of adhesive
straps, and counter-extension by a perineal band; but the patient
may at any moment relieve the pressure in the perineum by resting
his axilla upon the head of the crutch.

Daniell, of Savannah, Georgia, recommends the straight position, the

» Trans. Am. Med. Assoc, vol. x. Report on Deformities after Fractures



Sakbobb*8 SpLnrr. a.
The morable cratch, b.
The screw which flexes
the crutch. c.TheeroK**
bar to which the ends
of the etrap are fkftened.
d. The moTlDg eerew.



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FRACTURES OF THE SHAFT OF THE FEMUR. 407

limb being laid in a kind of long box, and the extension being made
with a weight and pulley.* Dugas, of Augusta, Georgia, employs the
pulley and weight also, but uses the long side splint instead of the
box.* Howe, of Boston, recommended a similar method in 1824.*

Dr. Gurdon Back, of New York, uses the pulley, without the
long side splint. His perineal band is composed of India-rubber
tubing, "of one inch calibre, two feet in length," stuffed with bran or
cotton lampwick, and covered with canton flannel, which covering
may be renewed as often as may be necessary. The extending bands
or adhesive plasters terminating below the foot in an elastic rubber

Fig. 157.



Gardon Buck's apparatas.

cord. The weight necessary to make suitable extension will vary
from five to twenty pounds.

Wm. E. Horner, of Philadelphia, employed a long outside splint
extending into the axilla, and padded, so as to avoid the necessity of
junks; with fenestrsD, for extending and counter-extending bands;
and also a foot-piece; and a short inside splint, made to extend from
the perineum to the bottom of the foot. Across the excavated upper

Fig. 158.



W. E. Horner's thigh-splint.

end of this splint, a strip of leather is stretched to receive the pressure
of the perineum, while the perineal band is made to pass through two
firm leather loops on the outside of the splint.*

> Amer. Joum. Med. Sciences, vol. iv. p. 330, 1829.

* Southern Med. and Surg. Journ., Feb. 1854.
8 Howe, New Eng. Med. Journ., July, 1824.

* Treatise on the Practice of Surgery, by Henry H. Smith.



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408



FRACTURES OP THE FEMUR.



Dr. Joseph E. Hartsborne, of Philadelphia, rejected the perineal
band altogether, and sought to make the counter-extension by means
of the internal long splint alone; and for this purpose he cushioned
the head of the inside splint, as will be seen in the accompanying
drawing. The head of the outside splint may also be cushioned, but



Fig. 159.




Jbseph Hartshorne's thigh-flpUnt.



not for the purpose of employing it as a means of counter-extension.
The outside splint is so adjusted to the foot-piece, that it may be re-
Fig. 160.





D. GiLBRET*8 Modi op xakixq CouimB-BXTBirBiov, ahd Bxtbitsiov.
1. Anterior and posterior coantar-extendlDg adhesire bands, two and a half inches wide, croisiof each
other before they pass through the mortise holes. 2. The same crossing at the upper part of thigh aad
perineum. 3. Horizontal pelric band, which may be three Inehea wide. 4. Extending bands, reeelvisf
strap of tourniquet in the hollow of the foot. 5. Tourniquet.

Fig. 161.




Gilbert's Appabatub applibd ib a Casb op Fbactubb op both Tbiohi.
1. Anterior adhesire counter-exteudiog strips. 2. Distal extremity of posterior adhesive strip of
the side. 3. Adhesive strip surrounding pelvis, binding the anterior and po«terior.strlps to pelTis. 4.
Inner extremity of the extending adhesive strip, forming stirrup under the foot, to receive the strap of
the tourniquet. 6. Cicatrix of left thigh. 7, 7. Petil*s tourniquet, by which the power was applied.

moved in case of a compound fracture, without disturbing either the
extension or counter-extension.^

* Treatise on the Practice of Surgery, by Henry H. Smith.



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FRA(

Dr. David (
method of mc
had employed
of the leg ; e:
broad piece ol
bind down tl
Additional sti

H. L. Hod]
counter-extern
idea of Gilbei
body instead
which is mac
shoulders.*



Lente, of 1^
of an apparat
inconvenience
between the t
fore, supplied
line from the
body, to the c
is attached t
arrangement
from the groi
but also the <
axis of the b(
not to the up]
several inche
upon the und<
of the band i
a strong spin
and weight, s

» Gi
« H(
27



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410 FRACTURES OF THE FEMUR.

The splint is made in sections, for adaptation to different persons,
and for convenience in packing. It extends no higher than the ake
of the pelvis, and is secured to the body at this point by a padded
pelvic band. The accompanying illustration will sufficiently explain
the remaining features of the apparatus.

Fig. 163.



Lente*8 thigh*splint.



The apparatus invented by Dr. Burge, of Brooklyn, is both a frac-
ture-bed and a splint, and was constructed with the same view of
removing pressure from the front of the groin. The principles in-

Fig. 164.



Barge's spparatas.



volved and the general plan of construction will be sufficiently ex-
plained by a study of the accompanying wood-cuts.



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FRACTURES OF THE SHAFT OF THE FEMUR. 411

There are a few, however, of our most distinguished surgeons, who
retain the flexed position in certain fractures, such as an oblique
downward and forward fracture, occurring just below the trochanter
minor, and a similar fracture just above the condyles, or in certain

Fig. 165.



Barg6*« apparataa applied.

cases of fractures in children, or in very old people, but who, never-
theless, give a decided preference to the straight splint in those oblique
fractures of the shaft which constitute by far the greatest proportion
of all these accidents. Among these, I will mention the names of
Nott, of New York, Pope, of St! Louis, Mo., and Eve, of Nashville, •
Tenn.

The practice of Dr. Pancoast, of Philadelphia, is peculiar, and will
be best described by himself: —

" I treat all thighs, fractured in their middle part, by the long splint,
and in the straight position. In fractures occurring at either end of
the bone I resort at first to the angular splint and the flexed position,
and thus place the muscles more at rest ; in which position, also, there
is less tendency to angular displacement and shortening. After the
lapse of a few days, when the disturbed muscles have lost their ten-
dency to spasm, and the hardened cellular tissue about the fracture
has formed a sort of bond between the ends of the broken bone, I
gently bring the limb down to the straight position, and apply the
long splint."'

The practice of treating fractures of the thigh, as well as all other
fractures of the long bones, with the roller alone, and without either
lateral splints or extending apparatus, first suggested by Radley, has
found in this country but one distinguished advocate, the late Dr.
Dudley, of Lexington, Ky.* Nor, with all my respect for that truly
great surgeon, can I persuade myself that the practice is able to ac-
complish, in a majority of cases, the indications proposed, nor indeed
that it is, at least in the hands of inexperienced surgeons, wholly safe.

' Trans. Amer. Med. Assoc., vol. x. Rep. on Def., etc.

« Amer. Journ. of the Med. 8ci , vol. xix. p. 270 ; Transylvania Journal, April,
1836. Boston Med. and Surg. Journ., vol. xxxiv. p. 85.



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412 FRACTURES OF THE FEMUR.

Dr. D., of Aberdeen, Miss., has reported to me one example in which,
after the application of this bandage by a pupil of Dr. Dudley's, to a
negro slave, who had a fracture of the femur, death of the limb ensaed,
and amputation became necessary. The negro was sixteen years old,
and healthy ; the fracture was caused by the fall of a tree or of a
branch, and was simple. The bandage was applied from the toes up-
wards to the groin, and was not opened for several days, at which time
the whole limb was found to be in a state of dry gangrene, with the
exception of the upper two-thirds of the thigh, which was swollen
enormously, and partially gangrenous as high up as the groin.

Dr. D. says: "Having heard the history of the case carefully
stated, observing the leg and the lower part of the thigh to be ia a
state of dry gangrene, and seeing the marks of the bandage visibly
impressed on the surface, my opinion was made up at the time that
the gangrene had resulted from pressure of the bandage. The femoral
artery at the groin was in a sound and natural state, and if I mistake
not, after the limb was removed, it was traced to the point of oblite-
ration where the gangrene commenced, and where the impression of
the bandage was observed ; thus far, I think, it was of natural aiase
and calibre. Hence the conclusion is inevitable, that the death of
the limb resulted from the pressure of the bandage, and not of one of
the fragments.

" It was a curious specimen of dry mortification, and I regret that I
did not use the means of preserving it. I was then engaged in a very
laborious practice, thirty miles from- home, on horseback, and conse-
quently could not conveniently spare the time to attend to it as an
object of surgical curiosity. Dr. H. and myself cut into the leg in
various places, in order to examine the muscles, arteries, nerves, etc.,
but found the integuments so hard that it was really difficult to pene-
trate them with a knife ; the resistance to the knife was more like
that of dry hickory wood than anything else."^

I cannot think it necessary to do more than allude to the practice
of Jobert, of Paris, and of Swinburn, of Albany, who, rejecting side
or coaptation splints altogether, have relied solely upon extension as
a means of support and retention in the case of fractures of the shaft
of the femur.

The treatment of these and other fractures by plaster of Paris, paste,
starch, or dextrine has been already considered when speaking of the
treatment of fractures in general. Thus far my experience will not
warrant me in recommending the immovable apparatus as a general
plan of treatment in any other cases than fractures of the leg below
the knee. Yet I must in candor admit that in the hands of Drs.
Bryant, Synott, Alexander, O'Byrne, and St. John, house surgeons at
Bellevue, the plaster of Paris dressing for broken femurs has been
attended with a greater than average' success. I have before me a
paper now in preparation for the press, by Dr. J. D. Bryant, and from
which it appears that of 21 cases treated by this method at Bellevue,

I For a more complete account of this interesting case, see Buffalo Med. Journal,
vol. xiv. p. 193, Sept. 1858.



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rRACTURES OF THE SHAFT OF THE FEMUR. 413

11 united without auy apparent shortening, and 10 with an average
shortening of three-eighths of an inch. Of the 11 perfect results, 5
were obtained in persons over 18 years of age.

For the accuracy of the statements made in this paper I am pre-
pared to vouch ; but the facts are nevertheless inconclusive. Similar
results, or results very nearly equal, may be obtained in a hospital
where great care is exercised and the best skill is applied, by my owa
method, and without any possibility of accidents. At Bellevue, as
Dr. Bryant's report will show, accidents have occurred in the use of
the plaster, and of a pretty serious nature; and that, too, notwith-
standing the gentlemen in charge possess unusual qualifications, and
have been exceedingly vigilant.

Fig. 166.



Extension daring application of plaster of Paris.

Possibly, in some degree, the results obtained by these gentlemen
may be due to the mode adopted by them of making extension while
the plaster was being applied. In ten cases the patients were under
the influence of an anaesthetic during the reduction and dressing, and
of these, four united without shortening; in all the cases extension was



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 48 of 100)