Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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upon natural kindness of heart, and social education. The man of
refinement and sensibility will know instinctively how to proceed,
and needs no instruction. They who lack these qualities can never
learn, and it would be quite useless to undertake to teach them. I
sincerely wish such men as these latter would find some more suitable
employment than the practice of a humane art. .

Nearly all fractures present three principal indications of treatment,
namely : to restore the fragments to place as completely as possible;
to maintain them in place ; and to prevent or to control inflammation,
spasms, and other accidents.

It ought to be regarded as a rule, liable only to rare exceptions,
that broken bones should be restored to place, or to the position in



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GENERAL TREATMENT OP FRACTURES. 45

which we hope to maintain them, as soon as possible after 'the occur-
rence of the accident. If the patient is seen within the first few hours,
or before much swelling has taken place, we scarcely know the cir-
camstance which would warrant an omission to adjust the fragments
either end to end or side by side, as the one or the other might be
found to be practicable. We have before sufficiently explained the
general impossibility of again restoring to place, end to end, and fibre
to fibre, fragments which have been made to override. We are there-
fore in no danger of being understood to say that bones should in all
cases be immediately " set," in the popular sense of this term. They
ought to be " set," no doubt, if this can be accomplished through the
application of a prudent amount of force; but if they cannot be thus
placed end to end, they may at least be laid in such a manner side by
side as to restore, in some measure, the natural axis of the limb, and
prevent the points of the bone from pressing unnecessarily into the
flesh.

Experience has, indeed, furnished us with four or five very good
reasons why broken bones should be reduced as soon as possible.
When the injury is recent, the muscles offer less resistance; their
resistance being increased affcer a time not only by the reaction which
ensues upon the shock, but also by actual adhesion between their
fibres ; effusions distend both the muscles and the skin, and compel
the limb to shorten ; the constant goading of the flesh by the sharp
points of the broken bones increases the muscular contractions ; the
patient will submit readily to manipulation and extension at first, but
after the lapse of a few days it is very seldom that he will permit the
limb to be in any manner disturbed, even if he is assured that his
refusal entails upon him a great deformity. If it is true that no callus
or bony structure is deposited earlier than the seventh or tenth day,
it is also true that the renewed attempt to adjust the bones at this
period, by chafing and tearing again the tissues, reduces the fracture,
in some degree, to the same condition in which it was at first, and,
consequently, the time which has elapsed, or, at leasts a portion of it,
may be regarded as lost.

We cannot, therefore, understand the argument by which Brom-
field. South, and a few other surgeons have persuaded themselves
that reduction should never be attempted before the third or fourth
day; nor, indeed, do we fully appreciate the refinement which Mal-
gaigne has given to this question in itself so simple. To affirm that
we ought not to reduce the bones to their original positions during
the period of intense inflammation, or of great swelling, or while the
muscles are acting spasmodically, is only to affirm that we may not
do what is impossible ; and the attempt to do which, therefore, can
only be mischievous ; but to authorize their restoration to a better
position, by such manipulation, extension, and lateral support as they
may comfortably bear, is warrantable under any circumstances. The
practice is not only defensible, but imperative, and we do not think
any really sound and practical surgeon ever intended to teach the
contrary. We say still, if bones can be easily reduced, or the position
of the fragments improved at any moment or under any circumstances,



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46 GENERAL TREATMENT OF FRACTURES.
Kg. 5. Fig. 6.





AppUeafelon of tht "roU«r<
TerMd tariw.



bj dreuUr and n-



ICuj-UUed b«Ad««tt.

it ought to be done ; and if we fail
in accomplishing all that we wish
to do in the first instance, we
must remain incessantly watchful
to seize the earliest opportunity
which presents, to complete the
adjustment. No doubt our efforts
will prove fruitless very much in
proportion to the amount of swell-
ing, inflammation, or muscular
spasm which exists, and also in
proportion to the time which has
elapsed, but this will not excuse
us for omitting to do all which the
circumstances permit.
It has been the practice of most surgeons, for a long period, to cover
the broken limb with some form of a bandage or roller before apply-
ing the lateral splints.

Of these primary dressings there are two principal varieties : first,
the " roller" or simple bandage, applied to the limb in circular and
reversed turns; and, second, the "many-tailed bandage," consisting of
a piece of muslin, or other cloth, torn down from each side into a
suitable number of strips, leaving the centre, which is to be applied
to the back of the limb, entire.

A modification of this latter bandage consists of a number of separate
strips, so laid upon one another, commencing from above, as that each
strip shall overlap the other by one-third or one-half of its breadth.
This is called the bandage of Scultetus, and it possesses one advantage
over the many- tailed bandage just described, especially in the case of
compound fractures, in the facility with which each separate piece
may be removed and another substituted. Some surgeons prefer to
form the bandase of separate strips, and having overlaid them in the
manner directed, to unite them again into one by running a thread
through the whole mass along the centre.

Whichever of these several varieties of strips are employed, the
mode of applying them is the same. They are folded alternately



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GENERAL TREATMENT OP FRACTURES.



around the limb, being made to overlap and cross upon each other in
front, and only the last strip or two is fastened with a pin.



Fig. 7.



Fig. 8.




Appliestion of tht nuuij-Utiled tendage.



BandAge of Senltetiu.



The olgect proposed in the use of the roller or of the many-tailed
bandage is twofold : firsts to compress and support the muscles, by
which their tendency to contraction is in some measure controlled ;
and second, to protect the limb against the direct pressure of the side
splints.

A moment's consideration will convince us that the first of these
objects is in most cases fully attained by the lateral splints themselves,
and by the bandages by which they are retained in place ; and that
the second can be as well accomplished by a single fold of cloth, or bv
the compresses, which ought generally, even when the roller is used,
to underlie the splints. Nevertheless, we should hardly feel authorized
to reject these primary dressings solely because the splints and com-
presses furnish a convenient substitute, especially since we are com-
pelled to admit that they are occasionally useful, unless objections of a
more serious nature could be brought against them. Unfortunately
this latter supposition is actually true. By ligating the limb com-
pletely, leaving no point of the tegumentary surface to which the
pressure is not applied, they too often occasion congestion, inflamma-
tion, and gangrene. It is not until lately that the attention of surgeons
has been sufficiently called to this subject ; but the records of surgery
are to-day filled with these terrible accidents, formerly attributed to



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48 GENERAL TREATMENT OF FRACTURES.

the original injury or to the splints themselves, but now understood
to be plainly traceable to the too common employment of the primary
bandage. The roller is by far the most dangerous dressing of the two,
since it does not yield to the swelling so readily as the bandage of
strips, and it is more objectionable also on account of the inconve-
nience of applying and removing it; but even the bandage of strips
may be so confined as to produce the same consequences, as I have
myself seen in more than one instance. It is also all the more dan-
gerous in the hands of the inexperienced surgeon, because he feels
a confidence that it will not cause ligation.

Except in rare cases and for especial reasons, which we sh^all attempt
to indicate in their appropriate places, we cannot recommend the em-
ployment of any kind of bandages next to the skin.

In order to fulfil the second indication, namely, to maintain the
fragments in place, we employ usually what are called short, side, or
coaptation splints, and long or extending splints, or the weight and
pulley.

Side-splints may be constructed from various materials, according
to the size and circumstances of the limb, or according to the conve-
nience of the surgeon ; and as the surgeon cannot be expected to have
always on hand, at the bedside of the patient, such splints as he might
prefer to use, it is well for him to understand how to avail himself of
such materials as may be within his reach, in order that he may make
the most of his sometimes imperfect resources.

Lead, sheet-iron, zinc, and other metals have been occasionally em-
ployed, but especially tin and copper, which possess all of the requisite
firmness and malleability to allow them to be hammered, and thus
moulded to the limb. In general, however, they are unnecessarily
heavy, and demand too much labor to be wrought into shape. I have
sometimes employed tin splints perforated with large fenestrse to
diminish their weight and increase their flexibility, and found them
to answer an excellent purpose. The light perforated zinc splints,
introduced into the U. S. Army by the Sanitary Commission, through
the agency of Dr. E. Harris, of New York, were found exceedingly
useful.

Iron- wire splints, made from wire-cloth or coarse gauze, were first
publicly mentioned, so far as I can learn, in a communication to the
Mtmphis Medical Recorder j made by Dr. J. C. Nott, of Mobile ; but they
have been brought more particularly into notice, and their construction
perfected, by Louis Bauer, of New York.' These splints are moulded
upon " gypsum or wooden casts," of different sizes, and surrounded with
a stout iron wire frame, in order to give them the requisite degree of
firmness, and to preserve their forms ; after which they are tinned by
galvanism, and varnished, to prevent them from becominff rusted.
When applied. Dr. Bauer recommends that they shall be filled with
loose cotton, and that they shall be held in place by rollers. It is
claimed for these splints that they are light, flexible, permeable to air
and to the perspiration, and that they permit the application of cool-

1 Nott and Bauer, Buf. Med. Joum., vol. xii., April, 1857.



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GENERAL TREATMENT OF FRACTURES. 49

ing lotions without impairiDg their firmness ; the last of which is a
quality of questionable value, since lotions applied to permanent
dressings of any kind are only warm fomentations, and do not, there-
fore, in this respect serve the purpose for which they were intended ;
besides that they render the skin tender, and disposed to vesicate,
they give rise to a sensation of scalding, which is sometimes almost
intolerable; they soak into the bed, and in many other ways render
the patients uncomfortable. Cooling lotions are only applicable where
the dressings are open, loose, and temporary.

The same objections hold also to this as to all other forms of
moulded metallic, or carved wooden splint, namely, that they seldom
exactly fit the limb, even when the supply of assorted^sizes is com-
plete, and that they are not sufficiently flexible to adapt themselves
to anything but the slightest irregularity of surface. They are not,
however, without merit, and they deserve at least a qualified recom-
mendation in many cases. I shall refer to them again when speaking
of fracture of the thigh and leg.

Horn and whalebone may be employed in thin plates, or in the
form of narrow strips quilted into cloth ; but they are expensive, and
possess no special value except in an emergency. Beeds, the coarse
rank grass which grows in swamps, flags, willow branches, and
unbroken wheat straw, may be quilted between two thicknesses of
cloth in the same manner, and form very excellent temporary splints.
I have especially found it convenient to use wheat straw in the form
of junks. Gathering up a bundle of unbroken straws of the size of
my arm, I roll them snugly in a broad piece of cotton cloth, cut off
the projecting ends, and then stitch up the cloth neatly. We have
thus a splint of considerable firmness, and one which is cool and
especially adapted to the summer, allowing the perspiration to evapo-
rate freely. Straw splints were employed sometimes by Ambriose
Par^, by J. L. Petit, Larrey, and I have several times seen them in
the wards of certain European hospitals, although I am unable now
to say under whose direction. Mr. Tuffnell, of Dublin, has especially
recommended them in the form of junks.*

Wooden splints, made of pine, willow, white or linden wood, or of
some other light and easily wrought timber, are probably of more
universal application, and possess greater intrinsic value than splints
constructed from any other material ; but I wish at once, and for all,
to disclaim any intention of giving even a qualified approval of any
of those carved, polished, and generally patented wooden splints, which
are manufactured and sold by clever mechanics, and which one may
see suspended in almost every doctor's office, whether in the city or
in the country. Constructed with grooves and ridges, and variously
inclined planes, for the avowed purpose of meeting a multitude of
indications, such as to protect a condyle, to press between parallel
bones, to follow the subsidence of a muscular swelling, &c., they never
meet exactly a single one of these indications, whilst they seldom fail
to defeat some other indication of equal importance. They deceive

Tuflhell, New York Joum. Med., March, 1847, p. 264.



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60 GENERAL TREATMENT OF FRACTURES.

especially the inexperienoed surgeon into the belief that he has in the
splint itself a provision for all these wants, and consequently lead him
to neglect those useful precautions which he would otherwise have
adopted.

If carved wooden splints are employed, they ought to be made
especially for the case under treatment. But this requires time and
some more mechanical skill than can always be commanded; and
when accurately fitted, it is quite probable that the subsidence or
increase of the swelling will, within the next forty-eight hpurs, render
some change in the form of the splint necessary, or compel the sur-
geon to throw it aside.

We much prefer to use plain, straight strips of wood, of the re-
quisite width and length, which may be cut at any moment from a
shingle or a thin piece of board.

In order that these splints may adapt themselves to the inequalities
of the limb, and properly support the fragments, they may be under-
laid with pads or junks of a suitable thickness ; or, what is still better,
they may be covered with a muslin sack, open at both ends, into
which, and on the side of the splint which is to be placed against the
limb, bran, wool, cotton batting, or curled hair may be pressed, until
it is made to fit accurately. I generally prefer cotton batting. Bran
is liable to get displaced, and curled hair does not pack firmly enough.
When the sack is sufficiently filled, the two ends must be stitched up.
This mode of constructing the splint is simple and easy of accomplish-
ment ; the splint can be fitted very accurately ; the pad never becomes
displaced ; and when the bandages are applied, they may be pinned
or sewed to the cover in such a way that the^ shall not slide or loosen.

IS pads are employed separate from the splint — and for this purpose,
also, I generally prefer the cotton batting — they ought to be made and
fitted with the same care, and neatly stitched together at their ends,
rather than pinned. Cotton batting laid loosely next to the skin, or
underneath the splints at any point, will not keep its place so well as
when it is inclosed in covers — it is more liable to get into knots, and
it has altogether a slovenly appearance. The pads may be stitched
to the roller, and in this wav secured effectually in place, but loose
cotton is subject to no control.

When I speak of pads, it must not be understood that I intend to
recommend them for compresses, or for the purpose of pressing frag-
ments into place. Nothing could be a greater source of mischief in
the dressing of a broken limb. I have only directed their employ-
ment as a means of adaptation, and to protect the skin against the
direct pressure of the splint.

Dr. Jacobs, of Dublin, says that he has seen an excellent splint
made from the " fresh bark of a tree, taken off while the sap is rising."
"It fits admirably," says Dr. Jacobs, "just like pasteboard soaked in
water."* Dr. C. C. Jewett, of the 20th Mass. vols., recommends for
the same purpose the bark of the liriodendron, or tulip-tree.

Undressed sole-leather, cut into shape and soaked a few minutes in

1 Jacobs, New York Joum. Med., March, 1847, p. 265, from Dublin Med. Press.



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GENEBAL TREATMENT OF FRACTURES. 51

water, adapts itself easily to the limb and is sufficiently firm. It is
especially applicable to fractures of the larger limbs. At Bellevue
Hospital it has for several years taken the place of almost all other
materials.

A splint is also occasionally made of thin calfskin veneered with
some light timber, such as linden or white wood, the latter being sub-
sequently split into strips of from half an inch to
one inch in width, so as to combine a certain degree ^8- d-

of flexibility with the rec[uisite firmness.

The Turks use, according to Sedillot, in a similar
manner, the " nervures" of palm laid upon sheep-
skin and fastened with wooden thongs;^ and Dr.
Packard mentions that he has seen narrow slips of
some light wood glued in the same way upon soft
pieces of buckskin, and then fastened together with
two strips of buckskin, which were also glued to

ihe splints.* ^ wood and leather epUnt

Common, unpolished pasteboard, cardboard, or
the stoat milllx>ard usea by bookbinders, constitute invaluable do-
mestic resorts, since they can generally be found in the house of the
patient; and if in no other way, pasteboard may generally be had at
the expense of some paper box or of the loose cover of some old book.
For small bones, the thinner sheets afford a sufficient support ; but for
large bones the thick binders' board is necessary. In preparing the
latter for use, it ought to be moistened with water ; but if soaked too
mach it will separate and fall into pieces, or lose its firmness when
dry, in consequence of having parted with some of its paste. This
splint may be applied to the limb without the interposition of any-
thing but a few folds of muslin cloth, or a piece of flannel ; or we may
use instead a single sheet of cotton wadain^. It must be bound to
the limb by the roller while it is moist, and as it dries speedily it
forms a smooth, firm, and reliable splint.

Felt, made of wool saturated with gum shellac, and pressed into
sheets, makes an excellent moulding tablet for splints. This may be
obtained at any hat manufactory. Until recently they were manu-
factured, and moulded into a great variety of forms, by Dr. David
Ahls, at York, Pennsylvania. A much cheaper material, however,
and which has nearly all the qualities of the real felt, may be made
from old pieces of broadcloth, or from any similar closely woven
texture, by saturating it thoroughly with gum shellac, the gum being
dissolved in alcohol in the proportions of one pound of the former to
two quarts of the latter. Thus prepared, it is to be spread upon both
surfaces of the cloth with a common paint-brush. When this first
coat is well dried by suspending the cloth where the air will have
free access to both surfaces, a second must be spread upon one of the
sar&ces; and then a third; the cloth being allowed to dry after each
successive coat Finally, the sheet is to be folded upon itself, so as to

> Amer. Joam. Med. Sol., yol. zziii., Feb. 1889, p. 481.
• Packard's edition of Malgaigne, vol. i. p. 178.



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62 GENERAL TREATMENT OF FRACTURES.

bring the most thickly covered surfaces together, and pressed with a
hot flat. If it is necessary to have greater strength, more gum may
be laid upon the cloth, and it may be again folded and pressed. When
used, it is to be dipped into boiling water or held near the fire until
it becomes flexible. It hardens very rapidly in cooling, and demands,
therefore, some quickness in its application ; but once applied and
fitted, it forms a hard but smooth splint, well adapted for all the
purposes for which it is designed. It is well to mention, if one wishes
to keep any portion of the solution which is not used, that, in order to
prevent evaporation, the vessel in which it i« contained must be closely
covered.

The principal objection to all of those forms of splints which con-
tain gum shellac is, that they harden so rapidly after being made
flexible by exposure to heat, that it is often found difficult to give
them an accurate mould to the limb.

Dr. Jacobs says he has sometimes found an old hat to furnish a very
efficient splint in the small fractures of children.

It has been objected to the felt splint occasionally, that it is imper-
vious to air and moisture, and that it confines the insensible perspira-
tion ; an objection which may be obviated in some measure by rubbing
the surface which is to be laid against the limb, with pumice-stone,
until it is roughened or until a short nap is raised. But as I never
use splints of any kind without underlaying them with compresses
which act sufficiently as absorbents, I have never been aware of any
inconvenience from this source.

Within a few years, sheets of gutta percha have been brought into
the market, varying in thickness from one-sixteenth to one-quarter of
an inch ; the use of which for side splints was first suggested and
practised by Oxley, of Singapore. For fractures of the thigh, and for
the large bones generally, I prefer a thickness of about one-sixth or
one-fifth of an inch ; but for the fingers or toes it need not be more
than one-sixteenth of an inch in thickness. In its natural state, and at
the ordinary temperature of the body, it is nearly as hard and as in-
flexible as bone ; but when immersed in hot water it almost imme-
diately softens, and would become too soft to be conveniently handled
unless soon removed. It can therefore be adapted to any surface,
however irregular, and its form may be changed as often as may be
necessary. It does not harden as rapidly as felt, and it possesses,
therefore, in this respect, an advantage, since it allows the surgeon
more time for adjustment; while, on the other hand, it hardens much
more rapidlv than either starch, paste, or dextrine. Ten or twenty
minutes is all the time usually required for gutta percha to acquire
that degree of firmness which will prevent it from yielding under the
pressure of a bandage.

To use gutta percha skilfully requires some experience, and I have
known surgeons to reject it after a single trial; but by those who
have acquired the necessary skill it is generally regarded as an invalu-
able resource.

When constructing from this material a thigh-splint, we should
order a very large tin pan, or some open, flat tray, in which we may



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GENERAL TREATMENT OP FRACTURES. 58

lay the splint at full length. If the splint is required to be twelve
inches long, and six inches wide, we must cut it about fourteen inches
long by seven wide, so as to allow for the contraction which always
takes place more or less when the hot water is applied. It is then to
be laid upon a sheet of cotton cloth of more than twice the width of
the splint, in order that the cloth may envelop it completely when it is
folded upon it; and the cloth should be enough longer than the splint
to enable us to handle and lift it by the two ends without immersing



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 5 of 100)