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our fingers in the hot water. Beside, if the gum is not thus covered
and supported, it will adhere to the vessel, to the fingers, to the surface
of the limb, and indeed to whatever else it comes in contact with; it
may even fall to pieces, or become very much stretched and distorted
by its own weight. The cloth cover will generally adhere to the
splint, and may be permitted to remain upon it permanently.

Place the splint, thus covered, in the basin, and pour on the water
slowly. . As soon as it is sufficiently softened, lay it over the limb,
moulding it carefully with the hands, or by pressing it against the
limb with a pillow. If it does not harden rapialy enough, this process
may be hastened by sponging the outer surface with cold water; and
as soon as it has acquired sufficient firmness to support itself, it may
be removed and immersed in a pail of cold water or placed under a
hydrant ; after this, it is to be neatly trimmed and wiped dry, when
it is ready for use.

When gutta percha remains a long time exposed to the air, it
gradually oxidizes, its color becomes darker, it loses its tenacity and
flexibility. This may be prevented by keeping it constantly immersed
in cold water.

The same objection has been made also to gutta percha which is
occasionally made to felt, namely, that it confines the perspiration, but
to this we have already sufficiently replied.

There is scarcely any fracture demanding the use of a splint in
-which I have not demonstrated its utility, but it is especially valuable,
as I shall have occasion to mention again, as an interdental splint in
fractures of the jaw, and as a moulding tablet in all fractures occur-
ring in the vicinity of joints.

Sheets of gutta percha of any required thickness may be obtained
in this city, of Mr. Samuel C. Bishop, the manufacturer, at 118 Liberty
Street. One pound will make about four thigh-splints.

Benjamin Welch, of Lakeville, Conn., has contrived a very ingenious
application of gutta percha to the purposes of a splint, by veneering
a thin plate of the gum with equally thin plates of elastic wood. The
veneering is laid upon both sides, and then it is pressed into form in
moulds. The elasticity of the wood, together with the plasticity of
the gum, enables the surgeon to change its form somewhat at pleasure,
by dipping it into hot water. Its form cannot, however, be changed
to any great extent, and by frequent immersion in hot water the ve-
neering is apt to loosen from the gutta percha. Nevertheless, it is a
most excellent splint, and in very many respects it is superior to any
of the carved wooden splints which we have ever seen.



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54 GENERAL TREATMENT OF FRACTURES.

^«- 10. The moulding tablet of Alfred Smee,

composed of gum Arabio and whiting;
spread upon cloth/ has nothing special
to recommend it, any more than the
cloth splints, hardened with the whites
of eggs and flour, used by Larrey.*
Starch and alum, glue, pitch, and vari-
ous other materials of a similar character
deserve only to be mentioned as having
been occasionally employed, but which
have never succeedea in securing for
themselves the confidence of surgeons.

In 1834, Seutin, of Brussels, intro-
duced the use of starch as a means of
hardening the bandages; his method of
using which is essentially as follows : a
dry roller is first applied to the' skin,
and then smeared with starch ; all of
the bony prominences and irregularities
of the limb are filled up or covered with
cotton batting, charpie, down, etc.; strips
of pasteboara, or of binders' board,
moistened and covered also with starch,
are now laid alongside the limb, over
starch undagei, applied for a broken which again are tumcd in succcssioa
**»*«^ one, two, or three layers of the starched

roller; the number of rollers and the
thickness of the pasteboard being proportioned to the size of the limb
or to the required strength of the splint. The whole is completed by
starching the outside of the last bandage.

This dressing will generally become dry within from thirty to forty
hours; which process may be expedited by exposing its sides as much
as possible to the air, or by the application of artificial heat with bags
of dry sand, or with hot bricks. As a temporary support until the
drying is completed, some surgeons lay upon each side of the limb
additional splints, securing them in place with tapes.

As soon as the bandages are dry, they are to he cut along the front
to a sufficient extent to permit of an examination of the limb, and then
closed with an additional roller. For the purpose of opening the
bandages both at this period and subsequently, Seutin uses a pair of
strong scissors or pliers, such as are represented in Fig. 11.

On the third or fourth day, or as soon as the subsidence of the swell-
ing may render it necessary, the bandages should be cut open through
their whole extent, the edges pared off and brought together again
snugly with an additional roller.

1 Amer. Journ. Med. Sci., vol. xxvi. p. 220, May, 1840; from London Lancet,
Jan. 25, 1840.

« Amer. Journ. Med. Sci., vol. ii. p. 216, May, 1828 ; from Journal des Progers,
vol. iv.



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OBNEBAL TBBATXENT OF FBACTUBBS. 65
Rg. 11.




tentin't plion.

Erichsen, who uses the starch bandage in all fractures and from the
first day, advises that the limb shall be completely enveloped with
cotton wadding before the first roller is applied ; m consequence of
which, he does not think it necessary to apply the first roller dry.

Velpeau prefers dextrine (" British gum"), a kind of glue or jelly
obtained by the continued action of diluted sulphuric acid upon starch
at the boiling point. It is prepared for use by dissolving it in alcohol
or tinctare of camphor, or camphorated brandy, until it has acquired
about the consistence of honey ; at this point hot water should be
added, reducing its consistence to that of thin treacle, when, after one
or two minutes' shaking, it is ready for application. According to F.
D'Arcet^ the proportions most favorable to the drying and solidifying
of the apparatus are, one hundred parts of dextrine, sixty of cam-
phorated brandy, and fifty of water. Malgaigne, to whom I am in-
debted for this observation of D'Arcet, says, also, in a note, " as regards
dextrine, an important point was recently brought practically under
my notice, viz., that as sold in the shops, it is often unfit for making
an agglutinative mixture; it forms lumps with alcohol, as starch does
with cold water, without cohering ; and twice in succession I have
been obliged to change the supply at the Hdpital Saint Antoine. The
dextrine thus deteriorated is whiter and less saccharine; it crepitates
more in the fingers ; and on pouring a few drops of tincture of iodine
into the solution, there is produced a violet tint, indicating the pre-
sence of fecula; while true dextrine, treated with iodine, gives a
vinous red, or the color of onion-peel."

Yelpeau soaks his bandages with the dextrine before applying
them, but, like Seutin, he applies his first roller dry. He uses but one
bandage, which he carries first from below upwards, and then from
above downwards ; and he rarely thinks it. necessary to employ the
pasteboard as a collateral support.

For myself, I am quite as much in the habit of using wheat fiour
paste as either starch or dextrine, and, if properly made, it dries about
as quickly as the starch, and is equally as firm.

Whatever material is used in the construction of what is now usually
termed the " immovable apparatus," or, as Seutin has more lately called
it, the " movable immovable apparatus" (*' movo-amobile"), in reference
to his practice of opening it at an early period, it is jstill the same
apparatus in efiect, and is liable to the same judgment — a judgment
which we shall find it very diflBcult to declare, since, from the day in
which this practice was first recommended by Seutin, to the present
moment, it has been constantly experiencing the most extraordinary



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56 GENERAL TREATMENT OF FRACTURES.

vicissitudes in the public favor. At one lime, and by the most ex-
perienced surgeons, extolled as a method unequalled in its simplicity,
efficiency, and safety; and at another, and by surgeons of equal expe-
rience, denounced as eminently lacking in all of the true essentials of
an apparatus for broken limbs. These conflicting opinions, which it
is impossible to reconcile, have nevertheless some foundation in truth.
The immovable apparatus, of whatever materials constructed, is under
some circumstances a very simple, safe, and efficient dressing, while
under other circumstances it isf, as we think, eminently unsafe and
inefficient. Thus, in all of those fractures which are accompanied
with such injury to the soft parts as to render subsequent inflamma-
tion inevitable or probable, this form of dressing exposes to conges-
tion, strangulation, and gangrene. Whatever its advocates may say
to the contrary, the simple fact is before us, that the number of acci-
dents resulting from this practice is out of all proportion with any
other yet introduced. I have met with them myself in all parts of
my own country, and the journals abound with records of disasters
from this source.* Nor is it a sufficient reply to this statement, that,
with proper care and prudence, such accidents may be avoided. We
think they could not always be avoided. But admitting that they
could, it is still undeniable that in certain cases the immovable appa-
ratus demands extraordinary attention ; and what is the need of multi-
plying our cares when already they are more than sufficient? Many
circumstances, over which he has no control, may prevent the surgeon
from giving to the limb the full amount of attention which is required ;
and for this reason that apparatus is the best which, whilst it answers
the indications equally well, exacts the least amount of skill and
attention on the part of the surgeon.

Fig. 12.



Opening of the appanttas with Seatin's pliera.

Immovable dressings are not only liable to become too tight as the
swelling augments, but, on the other hand, the surgeon may omit to
notice that as the swelling has subsided it has become loose. Portions
of the limb may vesicate, ulcerate, or even slough, without the know-
ledge of the surgeon. If, however, the bandages are frequently opened,

• Amer. Joum. Med. Scl., vol. xxv. p. 460, Feb. 1840 ; also vol. xxxi. p. 212.



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GENERAL TREATMENT OF FRACTURES. 57

and all the proper precautions are taken, it is possible that these acci-
dents may also be avoided ; but unfortunately experience has shown
that they have not been avoided in too many instances.

The cases, then, to which this apparatus seems to be adapted, are a
few examples of transverse or serrated fractures in which the bones
have not become displaced, and in which little or no swelling is anti-
cipated ; and certain fractures which were origi-
nally more complicated, but in which a partial Fig. 18.
union, and the subsidence of the inflammation,
have reduced them to a more simple condition;
and especially is it adapted to cases of delayed
union. If now the dressings are applied care-
fully, the bandage being only moderately tight;
and a portion of the extremity of the limb is
left uncovered so that we may observe con-
stantly its condition, and at proper intervals the
apparatus is opened completely, in order that
we may subject the whole limb to a thorough
examination; in such cases as we have now
indicated, and with such precautions, we admit
that the "apparatus immobile" constitutes an
invaluable surgical appliance, and one of which
no surgeon can well afford to be deprived.

I have even met with examples of compound
fractures in which it has seemed proper to ap-
ply this dressing; and especially when a suffi-
cient time had elapsed to render it probable that
there would be no sudden accession of swelling
in the limb. In such casbs I have preferred ..'i^^Tl'l'^lufZ
ffenerally to lay the several turns of the roller tnr©.
directly over the suppurating wound in the
same manner as if no wound existed, and to make a valvular opening,
or window, with the scissors on the following day, in order to allow
the matter to escape, after which the valve may be laid down and
stitched, or the piece may be removed entirely, and a new piece of
bandage drawn closely around the limb at this point. This may be
repeated once or twice daily. If an opening is left by the roller,
and no additional bandage is laid over it, the margins of the wound
soon become oedematous and protrude, making an ugly-looking and
ill-conditioned sore.

Plaster of Paris moulds, employed occasionally from a very early
period, and moi^ lately recommended by Hendriksz, Hubenthal, Keyl,
and Dieffenbach, are not entitled to serious consideration. Heavy stone
coffins, they might serve well enough the purposes of interment, but
they are wholly unsuited to the purposes of a splint.

Plaster of Paris has, however, been of late employed in another
form, and in relation to which our judgment must be much more
favorable. I allude to the so-called " plaster of Paris bandages," which
were first introduced to notice by Mathiesen and Van der Loo, of
Holland, but the value of which has been more especially brought to
5



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68 GENERAL TREATMENT OF VBACTTTR^g^

notice by Prof. Nicliolas PirogoflF, of St* Petersburg) Surgeoa-in-chiet
at Sebastopol, during the Crimean war.

At Belle vue, during the last two or three years, plaster of Paris
bandages have been used quite extensively, and, after a careful ob-
servation of the results in my own wards and in the wards of my
colleagues, I find no occasion to recall anything I have said of this, as
one form of the immovable apparatus, in the preceding pages ; the
dangers have not been overestimated, yet I must say that in fractures
of the leg, whether simple or compound, when great care is exer-
cised in the management of the case, it is in several respects superior
to any other form of dressing. I shall describe the cases of fracture
of the leg to which it is applicable more particularly when speaking
of these fractures. I am not at present^ however, prepared to speak
of it so favorably in the fractures of any other long bones.

The manner of using gvpsum bandages generally preferred at
Bellevue Hospital, may be thus briefly described. Thin, rather coarse
unglazed cotton cloth, torn into strips, is laid upon a table and the
dry plaster rubbed into it until its meshes are full. It is then rolled
and made ready for use by immersing it a few minutes in hot water.
The limb, being held in a proper position, is first inclosed in sofl dry
flannel cloth, and the rollers are then applied. In most cases two or
three thicknesses of bandage are found to be sufficient.

Another method of using the gysum bandages is as follows : A dry
roller is first applied to the limb, or it may be covered with a single
piece of cloth of any kind, and the irregularities are filled up and pro-
tected with cotton-wool, the same as we have directed when about to
apply the starch bandage. The remaining dressings being now at
hand and ready for use, we proceed to mix the plaster. For this pur-
pose we must select the fine, fresh, well-dried, white powder. The
gray does not solidify well, nor that which has been a long time
ground, or is moist. The proportions of water and plaster usually
required are about equal parts by weight. For the thigh it may re-
quire, perhaps, seven or eight pounds of plaster, and for the leg or arm
much less. It is probably a better rule to direct the gypsum to be
added to the water until it is of about the consistence of cream. The
water should be cold and the gypsum thrown in not too rapidly, at
least not more rapidlv than it can be thoroughly mixed, otherwise we
shall not be able to aetermine precisely its consistence. If, while ap-
plying the paste, it begins to harden in the bowl, we must not add more
water, as this will again interfere with its final solidification upon the
limb. It must be thrown away and some fresh immediately prepared ;
or the crystallization may be retarded by throwing in a few drops of
carpenters' glue, or a little starch or dextrine ; but the plaster is apt
to be brittle after the addition of these articles. The solidification
may be hastened by adding a little salt to the water. When the
plaster is good, and it is properly mixed, we may allow ourselves from
five to eight minutes in the application. A large paint-brush is the
most convenient thing for spreading it^ but the hands will do very
well in an emergency.

Everything being ready, the limb is to be seized by assistants at



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GENERAL TREATMENT OP FRACTURES. 69

both of its extremities and held in a position of steady extension until
the dressing is completed, and for one or two minutes longer, or until
the plaster is hard. It will be sufficiently hard to support itself, even
when the dressings are quite moist. The surgeon then proceeds to lay
a long piece of linen — old sack will answer as well as any — folded
three or four times, and saturated with the paste, parallel to the two
sides of the limb, around which are to be immediately placed, horizon-
tally and at several points, short and wide strips of the same material.
These latter are intended to increase the strength of the apparatus, and
to bind on the side strips. Finally, the whole may be painted with
the solution. It is very well, however, not to cover the front of the
limb, or a narrow strip somewhere in the line of the axis of the limb,
with the plaster, as this will not diminish materially its strength, and
it will enable the surgeon to open it more easily with the scissors.
Pirogoff accomplishes the same purpose by laying a piece of narrow
tape, soaked in oil, along the line through which he wishes to make
the section of the splint.'

At Bellevue Hospital we also occasionally apply the plaster of Paris
by a method which is very simple. The limb being carefully shaven,
is enveloped with one single sheet of coarse woollen cloth, which is
previously thoroughly saturated with the plaster.

Dr. B. Harris, of this city, has ascertained that by mixing the plaster
in the following proportions the weight will be considerably dimin-
ished, namely, water 100 parts by weight, gypsum 76 parts, clear-
boiled starch 2 parts. By this method the process of crystallization
is retarded, and all the water, except about twenty per cent., is per-
mitted to escape. For the use of the surgeons in the U. S. Army, the
Sanitary Commission furnished the plaster in tin cans hermetically
sealed.'

Professor B. W. Dudley, of Lexington Ky., one of the most success-
ful surgeons in this country, but especially distinguished as a lithoto-
mist, for many years employed in the treatment of fractures nothing
but a roller, regarding both side-splints and extending apparatus as
not only useless, but absolutely pernicious.' This practice, which
seems to have originated with Badley, of England, has not found,
hitherto, in this country or elsewhere, many imitators.

Still more unscientific and irrational was the practice of Jobert,
of Paris, who employed neither side-splints nor bandages, but only
extension, in the treatment of all, or of nearly all fractures of the long
bones. The side or coaptation splints bring the fragments into more
complete apposition, and secure a more prompt and certain union.
• They ough^ therefore, never to be omitted, unless the condition of the
limb precludes their application.

As to the question of permanent extension in fractures, and the

> Weber on Plaster of Paris Bandage, New^York Jonm. Med., May, 1856, p. 841.

« Practical Lectures on Military Surgery, by Isidor Gluck, of New York, chief
surgeon to the Hungarian (Vilmos) Hussars, &c. &c., during the late war in Hun-
gary. Amer. Med. Monthly, Dec. 1855, p. 449, &c., vol. iv. New York Med.
Times, Dec. 7, 18^1.

• Dudley, Trans. Amer. Med. Assoc, vol. iii., 1850, p. 849.



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60 GENERAL TREATMENT OF FRACr^i^^.

means by which it may be most effectually accompifshed, nothing
need be said at this time, inasmuch as it relates only to the fractures
of certain bones, and to certain forms of fractures; we must therefore
refer its consideration to those chapters which treat of individual
bones.

In the treatment of comminuted fractures, no pains ought to be
spared to bring the fragments as nearly as possible into apposition ;
and if there exists at the same time an external wound, and the frag-
ments are small and loose, they ought to be removed carefully. Nor,
indeed, should we be deterred from the attempt to remove them by-
finding that they are somewhat adherent, if still they are very easily-
moved about with the finger.

In compound fractures, not unfrequently the end of one of the frag-
ments protrudes from the wound, and its reduction may be attend^
with considerable difficulty. My practice is usually in such cases to
attempt the reduction first, by simple extension and counter-exten-
sion ; but if this fails, I introduce my finger into the wound, and
endeavor to stretch the skin over the sharp point of bone ; or I make
use of a spatula formed, from a piece of shingle, or of any suitable
piece of metal which ma}^ be at hand ; finally, but not until all other
expedients have failed, I enlarge the wound sufiiciently to insure its
return.

There are some cases, however, in which the surgeon may feel
justified in sawing off the projecting end; as when the periosteum is
completely torn from it by its having penetrated a boot, or even some-
times when its extremity is very sharp, and there is reason to suppose
that it would prick and irritate the tissues. In these cases, also, sur-
geons have proposed to secure the fragments in apposition by metallic
ligatures or sutures. In a few instances the practice has been attended
with success, but in most cases the wires have failed utterly of their
purpose, and have cftxlj proved sources of additional irritation.

If arteries bleed freely and for a long time, we may make some
effort to find the open mouths in the wound; but in this we rarely
succeed, nor is it prudent always to tie the main branch which supplies
the limb. Fortunately, this bleeding, although at first profuse, gene-
rally ceases in a few hours under the steady employment of cold lotions,
moderate compression, and rest. If it does not, the chances are that
the case will call for amputation.

The rule generally laid down by surgeons, that we should at once
close the wound in compound fractures, with sutures and adhesive
straps if necessary, or with bandages, is far too absolute. This prac-
tice will do when there is no great contusion or extravasation of blood ; •
but if blood is flowing, it is much better to leave the wound open, so
as to permit it to jsscape freely ; and if the severity of the injury war-
rants the supposition that much inflammation is to ensue, the danger
of gangrene is greatly lessened by thus allowing the opening to remain
as a channel of exitlbr the inflammatory efiusions.

It has, however, been claimod of late by Mr. Lister, of Edinburgh,
and by many others who have adopted his practice, that by the use



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GENERAL TREATMENT OF FRACTURES. 61

of carbolic acid in the manner which will presently be described, we
may again return safely to the old practice of closing at once all
wounds connected with fractures, without regard to the degree of
contusion, laceration, or comminution ; indeed, it is affirmed that by
the adoption of this method of treatment we may avoid suppuration
and its consequences in a very large proportion of cases. It is be-
lieved by Mr. Lister that suppuration is mainly due to the presence of
certain germs which constantly float in the air, and which carbolic
acid is fully able to destroy. Every possible precaution is therefore
taken to exclude the air, and to disinfect that which is unavoidably
brought in contact with the wound. The interior of the fresh wound
is fully injected with carbolic acid of the strength of one part of car-
bolic acid to twenty of water ; nor does he hesitate to throw this into
wounds communicating with joints. The fluid being afterwards
carefully expressed, the surface of the wound is covered first by the
" protective," which is a piece of oiled silk coated with a thin layer of
a mixture composed of one part of dextrine, two of powdered starch,



Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 6 of 100)