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AN INQUIRY INTO THE 
 
 PRINCIPLES OF TREATMENT OF 
 
 BROKEN LIMBS 
 
FRONTISPIECE 
 
 The frontispiece is from a photograph showing a subject in 
 position upon the author's apparatus for use in applying an im- 
 movable splint to a fracture of the shaft of the femur. 
 
 The photograph was taken in 1873 before the days of offi- 
 cially known trained nurses and has historical value. 
 
 The seated assistant is the skilled and noted "Orderly of 
 Ward 16." 
 
 It will be observed that the anaesthetized patient has only 
 been moved crosswise of his bed. He has been spared the chance 
 of serious accident in being moved from his bed to the operating- 
 table as in the procedure shown in Plate V. The patient is so 
 placed that there is no obstacle to his freest surgical functioning^ 
 by which is meant that his position upon the apparatus imposes 
 no restrictions upon the use of medical or surgical measures of 
 relief for which sudden need might arise. The capacity for 
 extended surgical functioning may be compared with the re- 
 strictions imposed by the use of apparatus shown in Plate V, 
 By one who, like the author, has seen sudden demands made 
 upon the skill of the operator to meet the occurrence of serious 
 accidents the difference in attitude of the patient for surgical 
 functioning will be appreciated. 
 
 The author's method tends to forestall the occurrence of such 
 accidents and affords the best conditions for their treatment 
 should they arise. The procedure, by averting a disturbance of 
 the injured soft parts, also tends to obviate swelling of the limb, 
 an objectionable complication in the application of the splint. 
 
 The patient has only been shifted in position on his own bed, 
 and may very well in case of accident be treated upon the ap- 
 paratus, or, he may be easily returned in a few seconds' time to 
 his original position in bed. 
 
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I ' i: I \' 
 
 AN INQUIRY 
 
 INTO THE 
 
 PRINCIPLES OF TREATMENT 
 
 OF 
 
 BROKEN LIMBS 
 
 J PHILOSOPHICO-SURGICAL ESSAY 
 WITH SURGICAL NOTES 
 
 BY 
 
 WILLIAM F. FLUHRER, M.D. 
 
 OONStTLTIKQ SURGKON TO BBLLEVUB AND MOUNT SINAI BOSPITAM 
 
 NEW YORK 
 
 REBMAN COMPANY 
 
 141 West 36th Street 
 
Copyright, 1916, by 
 
 WILLIAM F. FLUHRER 
 
 New York 
 
 PBIKTED IK AMERICA 
 
PREFACE 
 
 Soon after the author had invented the method of 
 rapidly immobilizing broken bones by the use of per- 
 forated narrow tin strips, he explained the procedure 
 with the aid of photographic illustrations, to a dis- 
 guished physician from a distant city. His response 
 was: "What does Professor Blank [naming an emi- 
 nent surgeon] say of the merit of the method?" I 
 then realized that it was not enough to devise an im- 
 provement of existing procedure but that it was also 
 important to prove its value independent of the dic- 
 tum of personal authority. 
 
 In the following pages I have endeavored to sub- 
 stitute impersonal proof of values in place of the 
 pronouncements of personal authority or the expres- 
 sions of consensus of opinion. The furthest reach 
 of personal authority, often derived from adventi- 
 tious circumstance, is to cast a presumption in favor 
 of or against the correctness of a stated conclusion. 
 
 Some years ago in the discussion of a paper read 
 before the Academy of Medicine on the non-operative 
 treatment of recent simple fractures of the patella the 
 writer was one of a small minority speaking in favor 
 of the open method of suturing. The eminent author 
 of the paper of the evening in closing the debate, de- 
 clared he would be governed in his action by the prac- 
 tice of the most distinguished surgeons throughout 
 the world and the consensus of opinion as expressed 
 in surgical societies. In the field of empirical prac- 
 
VI PREFACE 
 
 tice no better rule of conduct could be formulated: 
 in scientific practice, however, in the writer's judg- 
 ment, the conclusions determining the conduct of the 
 surgeon should not be influenced by personal author- 
 ity or consensus of opinion. 
 
 In his advocacy of the open method of wiring 
 simple fractures of the patella the writer said: "The 
 value of a method of treatment is not to be deter- 
 mined by reference to the fluctuating standard of 
 professional opinion but by the comparison of the re- 
 sults of treatment to a single and invariable standard 
 of perfection." (See N, Y, Medical Record, June 
 14, 1890.) 
 
 In this essay small increments of variations, even 
 though sometimes derived from a consideration of 
 obsolete and discarded procedures of treatment, are 
 studied for the purpose of determining the trend of 
 the embodied principles toward a theoretical maxi- 
 mum of excellence. 
 
 In laying the foundation of impersonal proof of 
 value of methods of treatment, the author has seen 
 fit to reduce his argument to syllogistic form. 
 
 With a common interest he has sought to pro- 
 ceed hand in hand with his reader in this investiga- 
 tion of a particular phase of truth. 
 
CONTENTS 
 
 PAGE 
 
 A. Concrete Subject-matter . - - . l 
 
 B. Abstract Considerations - - - - 6S 
 
 SURGICAL NOTES 
 
 I. Septic Saturation of Bellevue Hospital in the 
 
 Seventies. Battle Against Sepsis - - 79 
 
 II. The Open Operation in the Treatment of 
 Simple Fractures Considered in its Relation 
 to the Assertion of a Negative - - 90 
 
 III. Treatment of Septic Wound Complications — 
 
 Compound Fractures and Primary Amputations 102 
 
 IV. Scope or Degree of Extension Considered in 
 
 Reference to Principles Embodied in Surgi- 
 cal Procedures - - - - - -110 
 
 Index - 123 
 
LIST OF ILLUSTRATIONS 
 
 Patient on apparatus in the application of a plaster-of- 
 Paris splint to a fracture of the shaft of the femur 
 
 Frontispiece 
 
 ITG. PAGE 
 
 1. A diagrammatic representation of a truss in the 
 median longitudinal plane of the leg in a fracture of 
 
 the tibia q 
 
 2. Plan of cutting blanket covering of thigh in fracture 
 
 of shaft of the femur 27 
 
 3. Ground plan of the position of the patient upon ap- 
 paratus for setting a fracture of the femur 30 
 
 4. Construction of the pelvic portion of the thigh splint, 
 rear view 3g 
 
 5. Hand crochet-drill and fork Ill 
 
 6. Use of fork in placing loop of silk in notch of the 
 crochet-drill 112 
 
 7. Drilling of an irregular fracture of the patella while 
 
 the knee-joint is extended 114 
 
 8. Ordinary curved bistoury for opening abscesses .... 115 
 
 9. Author's design of knife for opening abscesses 115 
 
 10. Author's design for a probe 118 
 
 11. Method of'probing a tortuous sinus 119 
 
 PLATES 
 
 PLATE 
 
 I. Rapid immobilization of the broken bones of the leg. 
 Upper figure. — Limb covered with protective. 
 Lower figure. — Tin strips in position on a foundation 
 layer of plaster-of-Paris bandage. 
 
 II. Rapid immobilization of the broken bones of the leg. 
 Upper figure. — Tin strips bandaged to lower frag- 
 ment. 
 Lower figure. — Finished splint. 
 ix 
 
LIST OF ILLUSTRATIONS 
 
 PLATE 
 III. 
 
 IV. 
 
 VI. 
 
 VII. 
 
 VIII. 
 
 IX. 
 
 XI. 
 
 XII. 
 XIII. 
 
 Pott's fracture near the ankle-joint. 
 Upper figure. — Tin strips in position upon a founda- 
 tion layer of plaster-of-Paris bandage. 
 Lower figure. — Tin strips being bandaged in position. 
 
 Fracture of the shaft of the humerus. 
 Left hand figure. — Tin strips in position upon a foun- 
 dation layer of plaster-of-Paris bandage. 
 Right hand figure. — Finished splint. 
 
 Setting of a fracture of the shaft of the femur with 
 tin strips and plaster-of-Paris bandages. The 
 patient has been moved to the operating-table. 
 
 Upper figure. — Tin strips bandaged to lower fragment. 
 
 Lower figure. — Reversal of tin strips at the upper 
 margin of the splint. 
 
 Suspension apparatus applied to a compound fracture 
 
 of the leg treated in a plaster-of-Paris splint. 
 Patient lying upon his back. 
 
 Suspension apparatus applied to a compound fracture 
 
 of the leg treated in a plaster-of-Paris splint. 
 Patient lying upon his face. 
 
 Suspension apparatus applied to a compound fracture 
 
 of the leg treated in a plaster-of-Paris splint. 
 Patient sitting up in bed. 
 
 Suspension apparatus applied to a compound fracture 
 
 of the leg treated in a plaster-of-Paris splint. 
 Patient sitting in a chair beside his bed. 
 
 Suspension apparatus applied to simple fractures of 
 both femora treated in a plaster-of-Paris splint. 
 Patient turned upon his side. 
 
 Suspension apparatus applied to simple fractures of 
 both femora treated in a plaster-of-Paris splint. 
 Patient exercising upon the apparatus. 
 
 Recent primary amputation at the thigh treated with- 
 out dressings, upon a supporting frame. 
 
 Recent primary amputation at the thigh, the same as 
 in plate xii, showing change of frame support — 
 no dressings upon the wound. 
 
LIST OF ILLUSTRATIONS 
 
 XI 
 
 PLATE 
 
 XIV, Recent primary amputation of the forearm treated by 
 suspension, without dressings upon the wound. 
 Upper figure. — Clean frame beneath soiled frame. 
 Middle figure. — Release of the wire of the soiled 
 
 frame. 
 Lower figure. — Limb resting upon the clean frame. 
 
 XV. Amputation at the ankle-joint (Syme's) and at the 
 middle of the leg (Stephen Smith's), treated by 
 suspension upon sectional supports, and without 
 dressings upon the wounds. 
 
 XVI. Upper figure. — Compound fracture of the leg treated 
 in a fracture-box. 
 Lower figure. — Same compound fracture of the leg as 
 in upper figure, treated in suspension apparatus 
 with sectional supports and no dressings upon the 
 wounds. 
 
 XVII. Upper figure. — Compound fracture of the leg treated 
 upon suspension apparatus with sectional sup- 
 ports. Two supports and a part of a third have 
 been removed and an abscess incised. No dress- 
 ings upon the woimds. 
 Lower figure. — Excision of the knee-joint treated 
 upon suspension apparatus with sectional sup- 
 ports. 
 
 XVIII. Oblique fracture of the lower third of the shaft of the 
 femur, with perfect union. Old osteophyte. 
 
 XIX. Hand-power mechanism of crochet-drill. 
 
 XX. A. Upper figure. — Pistol-shot wound of the brain. 
 Probe in the wound. 
 Lower figure. — Course of the ball. 
 
 B. Upper figure. — Pistol-shot wound of the brain. 
 
 Course of the ball. 
 Lower figure. — Course of the ball. 
 
 C. Upper figure. — Pistol-shot wound of the brain be- 
 
 hind the right ear. 
 Lower figure. — Course of the ball. 
 
 D. Upper figure. — Pistol-shot wound of the brain. 
 Lower figure. — Course of the ball. 
 
 E. Upper figure. — Median section of the head, show- 
 
 ing the falx cerebri in position. 
 Lower figure. — The inner face of the cerebral hemi- 
 sphere after the removal of the falx cerebri. 
 
PRINCIPLES OF TREATMENT 
 OF BROKEN LIMBS 
 
 While it is conceivable that in the long processes of 
 time there may be evolved such perfect adjustment 
 of man to the mechanical forces to which he is ex- 
 posed as to exclude the occurrence of fractures of the 
 bones, nevertheless it may be safely assumed that this 
 will never take place in measurable time. 
 
 "No serum or other agent will ever confer im- 
 munity against these injuries, nor will measures 
 directed to their prevention through the combating 
 of their causation ever be completely successful. 
 Their treatment, therefore, concerns one of the few 
 enduring fields of surgical practice. 
 
 It may be supposed that such striking injuries as 
 broken bones must have been the subject of thought- 
 ful treatment from ancient times, and it is very prob- 
 able that the procedures of long-continued and highly 
 developed empiricism will often have closely ap- 
 proached or may sometimes have coincided with those 
 demanded by compliance with exact theory. 
 
 In this essay the attempt is made to lift this lasting 
 field of surgical practice from empiricism to scientific 
 exactitude. The essay is mainly concerned in an in- 
 quiry into the principles of treatment of fractures of 
 some of the long bones, with the object of determining 
 the criterion of value of the results of treatment. In 
 
2 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 this effort we are carefully to discriminate observation 
 of the facts and their classification in defined catego- 
 ries, from the determination of their relative value in 
 an ideal scheme of values. Values attach to results, 
 and results may be even hypothetical without disturb- 
 ance of their comparison. Indeed, the surgeon is 
 always engaged in efforts to realize in the concrete 
 ideal values of greater worth that have appealed to 
 him in the abstract. 
 
 The determination of relative values is not to be 
 confused with skill required in their practical realiza- 
 tion. Skill is concerned merely in the practical be- 
 neficence of their realization and distribution. 
 
 Among the other advantages of a clear perception 
 of the method of determining relative values of dif- 
 ferent methods of treatment founded upon scientific 
 theory is the important one of conserving effort along 
 a line of progress, with a consequent resulting ten- 
 dency to uniformity of practice. 
 
 In this essay free use will be made of established 
 common logical expressions, partly for cogency, and 
 partly also to enable critics the more readily to expose 
 errors into which the author may have fallen. In the 
 use of ambiguous terms important to argument, the 
 particular connotation of the term in the sense in 
 which it is used, is sometimes substituted for the term 
 itself. 
 
 The various procedures of treatment peculiar to 
 the author's practice, some of which are avowedly ob- 
 solete, are nevertheless described for the purpose of 
 illustration. In their presentation the author par- 
 ticularly considers himself relieved of any charge of 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 3 
 
 ''begging the question" (petitio principii). The 
 various changes from usual methods of treatment 
 in vogue at the time, were made to meet needs for 
 the betterment of the patient which were pressed 
 upon his attention in each individual instance by 
 bedside experience, and were not designed for the 
 purpose of carrying out any preconceived theory of 
 treatment. If any of the author's methods are 
 adjudged of superior value, it is, so far as the argu- 
 ment is concerned, purely incidental. 
 
 While the author was a member of the House 
 StaflP of Bellevue Hospital in 1872, he was struck 
 with the difficulty in many (fractures of the long 
 bones of continuously holding the fragments in a 
 given desired adjustment pending their fixation in 
 permanent retention apparel. To overcome this 
 difficulty he devised a method of more speedy fixa- 
 tion of the fragments in adjusted relation, by means 
 of the use of roughened narrow tin strips. 
 
 In illustration of the practicability of the method 
 he collected into his service a large number of vari- 
 ous recent fractures, in which the Hospital abounded 
 and invited members of the Visiting Staff and other 
 surgeons present at the demonstration, to select ex- 
 amples as tests of the method. There were chosen, 
 a simple fracture of the shaft of the femur, a Pott's 
 fracture with great displacement of the foot, and a 
 fracture of both bones at the middle of the leg with 
 great mobility at the seat of fracture. To the satis- 
 faction of all present, these fractures were treated 
 in turn by the method, using plaster-of-Paris band- 
 
4 PEINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 ages for the construction of the permanent retentive 
 apparel. 
 
 The p'atient, with fracture of both bones of the 
 leg, before treatment suffered much pain upon the 
 slightest disturbance of his broken leg. As soon as 
 the tin strips had been fastened in position, no an£es- 
 thetic having been given, although the plaster-of- 
 Paris bandages were still wet, and the. plaster had 
 not begun to harden, to the surprise of the audience, 
 the patient delightedly waved his broken leg about 
 without pain, till he was told to desist. 
 
 Photographs of illustrative instances, together with 
 a very brief description of the mechanical principles 
 involved in the method, were a part of the exhibit of 
 Bellevue Hospital sent by the Commissioners of 
 Public Charities and Correction to the World's Fair 
 of 1873. The author having abundant opportunity 
 while in charge of the Reception Hospitals, which 
 cared for a very large emergency service, as well as 
 in other hospital services embracing a great number 
 of fractures, amply confirmed the utility of the 
 method. In those days, by invitation of Prof. Frank 
 H. Hamilton, and Prof. Lewis A. Sayre, practical 
 demonstrations of the method were given before their 
 college classes, as well as on other occasions. 
 
 If it be conceived that in a given longitudinal 
 plane of the leg a rigid truss extending between the 
 fragments is fastened to the bones, obviously the 
 fragments would be held immovable in that plane. 
 As by reference to the diagram Fig. 1 we perceive, 
 having to deal with soft living structures, it is pos- 
 sible to make rigid only the surface, or exposed mem- 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 5 
 
 ber of the truss; other members of the truss are 
 constituted by the soft tissues themselves. The same 
 is true of all splints as extrinsic apparel acting in 
 resistance to forces tending to displace the adjusted 
 fragments. However, there is a limit to the safe 
 compression of the soft tissues by the constricting 
 bandage and their consequent approach to rigidity, 
 therefore it is not practicable to hold the fragments 
 
 Fig. 1. — A Diagrammatic Representation of a Truss in the 
 Median Longitudinal Plane of the Leg in a Fracture of 
 the Tibia. Deep members of the truss are indicated by 
 dotted lines; the superficial member of the truss is the tin 
 strip. 
 
 of bone absolutely immobile in the presence of dis- 
 turbing forces by means of any extrinsic apparel 
 exerting its resistance through the soft parts. 
 
 An immovable plaster-of-Paris splint, encasing the 
 limb, is efficient in resistance to displacement of the 
 adjusted bony fragments in a degree proportional 
 to its compression of the soft parts. Even the best 
 applied, tightest fitting splint is incapable of holding 
 the fragments absolutely immovable when they are 
 exposed to active disturbing forces. In an instance 
 
6 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 of a compound fracture of both bones of the leg, the 
 author found immediately after applying a tight 
 fitting plaster-of-Paris splint that upon introducing 
 the finger through the wound down to the fragments, 
 they moved upon each other when the patient gave 
 the slightest cough, the leg lying upon the bed. 
 
 By reference to the diagram, to repeat, it will be 
 noted that the only member of the truss that can 
 be made rigid is the one located at the surface of 
 the limb, the other members being constituted by the 
 compressed living soft tissues. In the case of the 
 plaster-of-Paris splint as usually applied, the pros- 
 pective member of the truss located at the surface 
 of the limb, at first soft and yielding, becomes rigid 
 and effective by the hardening of the plaster-of- 
 Paris, which requires a certain interval of time, dur- 
 ing which the desired adjusted relation of fragments 
 must be maintained; the longer the interval of time, 
 the greater the probability of the disturbance of the 
 desired relation. 
 
 In the author's invention the rigid superficial mem- 
 bers of the truss, perfectly adapting themselves to 
 the contour of the limb and developing rigidity when 
 bandaged to the limb, were made of narrow tin strips 
 and became immediately effective as a resistance to 
 disturbing forces as soon as fastened by bandages 
 to the surface of the limb, thus securing the advan- 
 tage of limiting the required maintenance of the 
 adjustment of the fragments in desired relation to 
 a minimum length of time, thereby practically ex- 
 cluding the chances of a disturbance of that elected 
 adjustment. 
 
rPRINCIPLES OF TREATMENT OF BROKEN LIMBS 7 
 
 The tin strips are effective on account of the ab- 
 sence of extensibility and contractibility, neither 
 lengthening nor shortening when in action as a re- 
 sistance between the retaining layers of bandage. 
 In addition to the important advantage of immobiliz- 
 ing the fragments of bone in the briefest interval 
 of time, and under the most favorable conditions for 
 their correct adjustment, they present the further 
 advantage of scope of efficiency in affording an ex- 
 tended range of choice of the material that may be 
 used for the construction of the permanent splint 
 or apparel ; the strips are even effective when secured 
 between layers of dry bandage, but still more effi- 
 cient when used between layers of wet bandage. 
 
 While the author's experience in the use of the tin 
 strips as a means of rapidly immobilizing the bony 
 fragments has been limited to civil practice, their 
 superior utility in the exigencies of military practice 
 must be evident. In military practice the prompt- 
 ness of setting the fracture, and consequently the 
 quick preparation of the patient for safe trans- 
 port are paramount considerations and often, no 
 doubt, determine the question of preservation or 
 sacrifice of the injured limb. 
 
 The time element in the treatment of fractures 
 is so important that for "first aid," soldiers should 
 be provided with two or three flannel bandages about 
 three inches wide and eight yards long, two or three 
 muslin bandages of the same dimensions and three 
 or four antiseptic bandages of the construction orig- 
 inally devised by Lister. These last, apart from 
 their antiseptic value, have a special advantage in 
 
8 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 securing the tin strips in position. Being gummy, 
 their folds readily stick together. In addition to 
 the bandages, the soldier should be provided "vvith 
 four properly prepared tin strips. 
 
 In possession of this surgical equipment, there is 
 the important consideration that the broken hones 
 may he immohilized without the use of plaster-of- 
 Paris or even of water, both of which may be diffi- 
 cult to obtain. 
 
 The flannel bandages, which at least may be 
 sterilized, are an excellent substitute for the blanket 
 protective covering of the limb and can be quickly 
 applied. 
 
 The surgical material mentioned is of trivial 
 weight. The splint being made of the strips, when 
 fastened in position, fractures, perhaps excepting 
 those of the thigh, could be unmobilized immediately 
 after injury, even on the battle-field. In case of 
 fractures of the thigh, the benefit of some degree of 
 immobilization could be obtained. 
 
 As a part of his military training every soldier 
 should receive lessons in handagiiig, which education 
 may in an emergency he the means of saving his 
 own or a comrade's life. 
 
 The tin strips are cut one-quarter of an inch wide 
 from ordinary thin sheet tin. Additional length, 
 if necessary, may be obtained by soldering two or 
 more strips together. They are roughened that they 
 may be securely held between layers of bandage, by 
 punching holes along the centre line of their length. 
 These holes are made about one inch apart, alter- 
 nately on either side, by a round pointed awl. The 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 9 
 
 punching throws out little jagged points of tin 
 around the margin of each hole, which give to the 
 bandage an effective hold upon the strip. Care is 
 taken not to make the holes too big, throwing out 
 too large projecting points of tin which may inter- 
 fere with the smooth application of the retaining 
 bandage and thus obscure the outline of the limb, 
 one of the best guides to the correct adjustment in 
 line, of the fragments of bone. After being rough- 
 ened, the strips are carefully straightened for use. 
 
 The procedure of their use in detail is as follows : 
 taking, for an example, a fracture of both bones of 
 the leg about the middle, with great mobility at 
 the site of fracture. It is emphasized that the fixa- 
 tion of the adjusted fragments is to be accomplished 
 by means of the tin strips, and that the material used 
 for the construction of the permanent splint is for 
 the continuance of the initial fixation. The use of the 
 tin strips is not for the purpose of strengthening the 
 constructed splint, which no doubt to some extent 
 is a secondary effect; they are themselves the splint, 
 within the stated connotation of the term. 
 
 The guides for the correct adjustment of the frag- 
 ments at the time of their immobilization are: — ^the 
 assurance of the touch, palpation; the proper outline 
 of the limb as disclosed by its uninjured fellow; and 
 possibly tJie revelations of the fluoroscope or X-ray. 
 It is highly important that the adjustment of the 
 fragments shall be accomplished under conditions 
 wherein the guides are most helpful. 
 
 The limb is first covered with protective material 
 to prevent immediate contact of the plaster-of-Paris 
 
10 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 with the skin and in some slight degree to cushion 
 tissues overlying superficial bones in places intolerant 
 of undue pressure. In the case of the leg splint such 
 places are the point of the heel, the instep and the 
 tubercle and spine of the tibia. Care should be taken 
 not to make the protective covering too thick at these 
 designated places. No padding of cotton or other 
 such material should ever be used. It would deform 
 the important outline of the limb and interfere with 
 the efficiency of the splint. 
 
 To avoid undue disturbance of the sensitive broken 
 limb and a chance increase of swelling, it is better to 
 adapt a covering of thin old blanket, or similar ma- 
 terial rather than to force a stocking or other ready- 
 made covering, upon the limb. The covering should 
 be gently adjusted in position with such neatness and 
 skill that it does not obscure but preserves the dis- 
 tinctness of the outline of the limb. The protective 
 which covers the inner and anterior aspects of the 
 limb should overlap that portion which covers the 
 posterior and external surfaces. The overlying fold 
 where the covering joins, which is held by pins with 
 their points directed outward, should fall along the 
 outer aspect of the limb, away from the most im- 
 portant outline concerned in the adjustment of the 
 fragments, where the tibia is superficial and accessible 
 to the touch, and thus oppose no obstacle to the 
 scientifically made turns of the bandage. Except 
 in fractures at the very lowermost portion of the leg 
 it is well to have the splint include the knee-joint and 
 infringe upon the thigh. One layer of protective 
 covering, except in the places specified, is sufficient. 
 
PLATE I. 
 
 Rapid Immobilization of Broken Bones of the Leg. 
 
 Upper Figure. — Limb covered with protective. 
 Lower Figure. — Foundation layer of plaster-of-Paris band- 
 age; tin strips in position. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 11 
 
 In fractures of the leg, measurements are of little 
 value in aiding the efforts for the correction of the 
 shortening, which is usually inconsiderable and easily 
 sufficiently overcome, even without the use of an 
 anaesthetic. 
 
 In bandaging secundum artem, which should al- 
 ways be practiced, the turns of the bandage should 
 be made from the median line of the body outward 
 across the anterior surface of the limb; in conse- 
 quence, therefore, the right leg is bandaged left 
 handedly, the left leg, right handedly, the operator 
 standing at the patient's side with his face directed 
 toward that of the patient. The roller bandage made 
 of thin unbleached muslin should be rather narrow, 
 from two to three inches wide, and six to eight yards 
 long. A very little plaster-of-Paris is rubbed into 
 each side of the bandage, just whitening it, in order 
 that the bandage may be very easily wetted when 
 immersed in water. Should there be much plaster 
 upon the bandage it would be apt to form into lumps 
 and deform the outline of the limb. 
 
 It is always to be borne in mind that the initial 
 fixation of the adjusted fragments is to be accom- 
 plished by the action of the tin strips independently 
 of the setting of the plaster-of-Paris, the wet band- 
 age serving the purpose. The bandage is rolled 
 evenly but rather loosely so it will moisten readily 
 to the core without the plaster first setting on the 
 outer layers. No agent should be added to the tepid 
 water in which the bandages are immersed to hasten 
 the setting of the plaster, indeed, a too quick setting 
 of the plaster is to be avoided. Three or four band- 
 
12 PRINCIPLES OF TREATIVIENT OF BROKEN XIMBS 
 
 ages are immersed in the basin of tepid water. As 
 one is used a diy one replaces it till the requisite 
 number have been wetted. In using a bandage it 
 should be freed from an excess of water by pres- 
 sure upon it sides, avoiding pressure upon its ends. 
 All loose ravelings should be cleared away so as not 
 to embarrass or delay the surgeon while at work. 
 All these details, some of them apparently trivial, are 
 mentioned, as a regard for them contributes to the 
 making of the perfect splint. 
 
 An assistant, comfortably seated, seizes the broken 
 limb by the foot and drags it over the edge of the 
 bed, giving the surgeon plenty of operating space, 
 at the same time making moderate extension. 
 
 Commencing at the base of the toes, which are 
 left exposed, the surgeon snugly applies one layer 
 of bandage to the previously covered limb, as far 
 as the designed limits of the splint. For the best 
 construction of the splint the bandage is applied by 
 making figure of eight turns, the reverses, where 
 necessary, being made posteriorly, away from the 
 more imjDortant outline of the limb. As the bandage 
 is applied it fastens down the overlapping fold of the 
 protective covering, permitting the removal of the 
 retaining pins. 
 
 Practical skill in bandaging is a positive pre- 
 requisite to tJie construction of an immovable plaster- 
 of-Paiis splint. In preantiseptic days, when Bellevue 
 Hospital was saturated with infection, the ever-im- 
 minent probability of the infection of a wound, es- 
 pecially a recent one, was a great discouragement 
 to cutting operations. As a consequence, attention 
 
PRINCIPLES or TKEATMENT OF BROKEN LIMBS 13 
 
 was concentrated upon bloodless operations. In 
 these, as well as in the septic surgery, as then prac- 
 ticed, bandaging ^^laved a very important part. The 
 members of the House Staff of those days became 
 proficient in bandaging. A novice may be taught 
 how to make the necessary turns in bandaging, but 
 the degree of compression of the tissues to be exerted 
 by means of the bandage can never be adequately 
 taught. It must be acquired by experience. It be- 
 longs to the 'Hactus eriiditus" an acquirement upon 
 which the older surgeons very properly laid great 
 emphasis. To know just what amount of compres- 
 sion injured tissues can safely bear, an element of 
 their surgical functioning, is a matter of judgment 
 gained only by experience. When it is considered 
 that the greatest efficiency of the immovable apparel 
 is developed through the greatest amount of com- 
 pression that the soft tissues can safely tolerate, the 
 careful training of the judgment and the skill neces- 
 sary to insure that greatest efficiency may be ap- 
 preciated. 
 
 The first layer of bandage when applied is little 
 more than a covering of wet bandage. The splint 
 during its construction should be kept rather wet, 
 short of dripping. This layer of snugly and evenly 
 applied bandage preserves the outline of the limb 
 sharp and distinct. A little dry plaster is held in 
 the hand under water till thoroughly moistened and 
 then rubbed into the layer of bandage, smoothly 
 sticking the folds together and making the proper 
 basis for the strips to rest upon. If this basis should 
 be judged to be not firm enough as a foimdation for 
 
14 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 the strips, which is usually the fact, a second layer 
 of bandage is applied. 
 
 A few imaginary principal longitudinal planes of 
 the limb are located, in which, after correcting exist- 
 ing deformity, immobility is to be secured. 
 
 At least four or five tin strips, as in the illus- 
 tration, are used in said planes. The strips at first 
 are to extend beyond the limits of the finished splint, 
 from the toes to a line upon the thigh. One strip is 
 placed on either side of the anterior median line and 
 one in the posterior median line, respectively; the 
 latter strip starts from beyond the toes and extends 
 along the middle of the sole of the foot upward along 
 the limb in the posterior median line ; the former ex- 
 tends correspondingly along either side of the an- 
 terior median line of the limb. Two principal side 
 strips are used, one on either side in the principal 
 horizontal plane of the limb. They start upon the 
 sole of the foot from beyond the toes and extend on 
 either side of the posterior median strip to a point 
 upon the heel where they are directed by a reverse 
 nearly at a right angle into a general course up the 
 limb, on either side respectively, in its principal hori- 
 zontal plane. 
 
 The strips which may be prepared beforehand are 
 secured to the foot by two or three turns of bandage 
 and any errors in their general course along the limb 
 are corrected at the early start. The figure of eight 
 turns of bandage are continued, firmly securing the 
 strips in relation to the lower fragment, as far as the 
 place of fracture (see Plate II) . During this bandag- 
 ing the exposed portions of strips are uncontrolled 
 
PLATE II. 
 
 Rapid Immobilization of the Broken Bones of the Leg. 
 
 Upper Figure. — Tin strips bandaged in relation to the lower 
 fragment as far as site of fracture. 
 
 Lower Figure. — Finished splint. Strips bandaged in position 
 without deforming the outline of the limb. 
 
PRINCIPLES or TREATMENT OF BROKEN LIMBS 15 
 
 and allowed to hang free, and thus adapt themselves 
 to the contour of the limb as the bandaging pro- 
 gresses. The strips having been firmly secured to 
 the lower fragment as far as the point of false motion 
 at the site of fracture, the surgeon then carefully 
 directs his efforts to correcting the existing deformity. 
 The guides to effect the attainment of this object 
 have not been obscured and the conditions for mak- 
 ing a correct adjustment are of the best; the out- 
 line of the limb has been preserved sharp and dis- 
 tinct; there is no obstacle to the exercise of the 
 touch or the use of measurements. 
 
 Under the direction of the surgeon the assistant 
 now exerts the full force of extension. The surgeon 
 then makes the necessary corrective manipulation to 
 overcome any angular or other deformity and while 
 these procedures are continued in full play, he rapidly 
 extends the turns of bandage upward fastening the 
 exposed free portions of the strips home to their 
 base and in relation to the upper fragment. As soon 
 as this is done, which takes only a brief fraction of 
 time, a few seconds, the fragments are firmly held 
 in their given adjusted relation. Moistened plaster 
 is rubbed into the layer of bandage as was the case 
 with the first layer. 
 
 The ends of the tin strips extending beyond the 
 margins of the splint are trimmed to a length of two 
 or three inches, turned back upon the splint together 
 with a finishing turned over cuff of the protective 
 covering, and secured by plaster-of-Paris bandage. 
 
 While the splint should be strengthened by lengths 
 of plaster-of-Paris bandage, or pieces of old blanket 
 
16 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 saturated with a thin cream of plaster-of-Paris, 
 bandaged into position, in places especially exposed 
 to injury during the wear of a month's or six weeks' 
 duration, it should not be made so thick over the 
 portions of bones lying superficially and exposed to 
 pressure, but that if required, undue pressure may 
 be eased in such places by pressing the hardened 
 splint between the hands. 
 
 The splint is finished (see Plate II) by rubbing 
 into its surface moistened plaster and smoothing the 
 same with rather wet hands. This finishing process 
 should not be continued too long, otherwise it will 
 disturb the initial set of the plaster and cause it to 
 "flour." 
 
 When the splint is finished the patient is replaced 
 upon his bed till the splint hardens. 
 
 The exposed toes are carefully watched as the 
 tell-tale of the condition of the circulation. Being 
 assured that the circulation of the limb is in safe 
 condition, the surgeon should induce the patient to 
 leave his bed and walk with crutches as soon as 
 possible. 
 
 In the treatment of compound fractures of the 
 leg strict antiseptic measures should, of course, be 
 practiced. All compound fractures due to injury 
 should be regarded as infected and the surgeon should 
 never hesitate for a moment to enlarge the wound 
 communicating with the fracture to insure its com- 
 plete disinfection. Ample drainage of the wound 
 should be provided for under such circumstances. 
 In place of the protective covering of thin blanket 
 an antiseptic covering material should be specially 
 
PLATE III. 
 
 Pott's Fracture near Ankle-Joint. 
 
 Upper Figure. — Tin strips in position upon a foundation 
 layer of plaster-of-Paris bandage. 
 
 Lower Figure. — Tin strips being bandaged in position. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 17 
 
 prepared. This may be made of a layer, not too 
 thick, of 'antiseptic cotton, held between layers of an- 
 tiseptic gauze (bichloride) and quilted. The tin strips 
 are, of course, sterilized by immersion in an antiseptic 
 solution or by heat. The original Lister antiseptic 
 bandages, somewhat gummy from the resinous com- 
 bination used in their construction, are highly useful. 
 Bichloride bandages will, however, answer the pur- 
 pose. The tin strips are bandaged in position in the 
 same manner as if plaster-of-Paris bandages were 
 used. After the fragments have been immobilized, 
 layers of antiseptic gauze are bandaged about the 
 region of the wound in sufficient quantity to absorb 
 the secretions regardless then of deforming the out- 
 line of the limb. If desired, a more permanent 
 character may be given to the retentive apparel by 
 applying plaster-of-Paris bandages over all. 
 
 The author emphasizes the importance of using 
 antiseptic instead of sterile dressings to absorb the 
 wound secretions. Sterile dressings saturated with 
 such secretions and held in contact with warm tissues 
 furnish ideal conditions for germ growth. The use 
 of sterile dressings in septic surroundings instead of 
 antiseptic dressings to absorb wound secretion is in 
 the author's judgment an unjustifiable procedure. 
 
 In a Pott's fracture with displacement of the foot, 
 one of the tin strips is so placed as to correct the 
 deformity, secure inversion of the foot and prevent 
 motion in the plane of displacement. Said tin strip 
 starting upon the sole of the foot is reversed at the 
 heel so as to take a course diagonally across the 
 
18 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 anterior aspect of the ankle in a direction from within 
 outward, as shown in Plate III. 
 
 In a fracture of the humerus the tin strips may 
 be applied as shown in Plate IV, if the use of an 
 immovable splint is thought to be desirable, which, 
 however, has only exceptionally been the author's 
 practice. It is to be noted that the immovable 
 plaster-of-Paris splint, except in skilled hands, is a 
 highly dangerous apparel for fractures in the upper 
 extremity, where the delicate soft tissues are ex- 
 tremely intolerant of pressure. The author has been 
 called upon to amputate limbs in a number of in- 
 stances of traumatic gangrene caused by too tight 
 bandaging, but most frequently in cases of faulty 
 bandaging of the arm and forearm. Curiously, none 
 of these mishaps has been encountered in instances 
 of application of the plaster-of-Paris splint. 
 
 In the treatment of fractures of the shaft of the 
 femur more forcible extension to overcome the short- 
 ening of the limb must be employed than in the 
 case of fractures of the leg, in which manual exten- 
 sion, with or without anaesthesia, suffices to over- 
 come the moderate amount of shortening. 
 
 It will be instructive to briefly trace the evolution 
 of the special apparatus for the setting of fractures 
 of the femur in the plaster-of-Paris splint in use in 
 Bellevue Hospital during the seventies, when under 
 the great emulation in the practice of treating frac- 
 tures in such splints the art was brought to the high- 
 est pitch of perfection by the House Staff of the 
 hospital. 
 
 At first, counter extension was made from a 
 
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PLATE V. 
 
 Setting Fracture of the Shaft of the Femur with Tin Strips and 
 
 Plaster-of-Paris Bandages. The patient has been moved 
 
 from his bed to the operating-table. 
 
 Upper Figure. — Tin strips bandaged to foundation layer of 
 plaster-of-Paris bandage as far as the site of fracture. 
 
 Lower Figure. — Strips reversed downward from upper mar- 
 gin of the splint. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 19 
 
 straight upright perineal bar clamped to the edge of 
 a table. ( See Plate V. ) The patient was anaesthetized 
 in his bed, then transported to the table, and while 
 prone was placed astride the bar. His pelvis was 
 suspended by a folded sheet looped from a narrow 
 strip of wood, one end of which rested upon the end 
 of the perineal bar and the other upon a stool or 
 other support placed upon the table, beyond the 
 patient's head. The wood was always in the way of 
 the angesthetizer and frequently slipped from posi- 
 tion. One of the House surgeons substituted a band- 
 age for the sheet to suspend the patient's pelvis. 
 The bandage at the middle of its length was tied to 
 the perineal bar at about the place the perineum 
 would bear; about six inches from the bar it was 
 knotted together, the ends to be brought along each 
 side of the pelvis and attached to the overhead strip 
 of board. This bandage, suspending the pelvis, was 
 built into the splint during its construction and was 
 sometimes withdrawn when the splint was completed, 
 otherwise it was simply cut close to the splint, when 
 releasing the patient from the bar. The first im- 
 provement made by the author dispensed with the 
 troublesome overhead strip of board altogether, by 
 bending the upper portion of the perineal-bar at a 
 right angle and extending it about five inches hori- 
 zontally over the pelvis with a short lip or projection 
 on its upper surface, thus making the point of sus- 
 pension integral with the bar itself. 
 
 Under the great tractive force exerted by means 
 of the compound pulleys, the bracing of the table 
 would yield, or the edge of the table would some- 
 
20 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 times break. Furthermore, there was still the neces- 
 sity of transporting the patient back and forth from 
 his bed to the operating table with the chance of a 
 considerable disturbance of the broken limb while in 
 transit. In one patient under the author's observa- 
 tion, but not in his practice, the bending of the limb 
 during the struggles of the patient caused the frag- 
 ments to lacerate the femoral vein, resulting in his 
 death. The imperfect means of counter-extension, 
 the necessity of transporting the patient, and the pos- 
 sible accidents incident thereto, led the author to de- 
 vise the construction which he used ever after with 
 the greatest satisfaction and without the occurrence 
 of the slightest accident. 
 
 The apparatus could easily be made more portable 
 for use in military practice. 
 
 The contrivance, inexpensive and easy of construc- 
 tion, consists of a perineal-bar fixedly mounted in a 
 wooden tripod as shown in the frontispiece. The 
 perineal-bar is made of a length of half-inch of five- 
 eighths of an inch bore gas-pipe projecting above 
 the centre wooden block or body of the tripod into 
 which it is securely fastened. Into the free upper 
 end of this pipe is received for five or six inches a 
 smaller pipe which extends about six inches above 
 the larger pipe or perineal-bar and which is then bent 
 to extend horizontally about six inches, terminating 
 in an upturned lip. This piece is removable and 
 taken out when the patient is being placed astride the 
 perineal-bar. When fitted into the larger section of 
 pipe it holds its position by friction, the portion slid- 
 ing into the perineal upright is slightly bent out of 
 
'PRINCIPLES OF TREATMENT OF BROKEN LIMBS 21 
 
 its long axis so th'at it will hold by friction when 
 fitted into place. The perineal-bar is cushioned 
 where the perineum will bear, by being wound with a 
 strip of blanket or other material held in place by dry 
 bandage. It is advisable, for reasons that will be 
 given later, not to cushion the perineal upright to a 
 great thickness with the idea of saving the urethra 
 from pressure. 
 
 In older practice with the original perineal-bar, 
 operators sometimes padded the bar to a great thick- 
 ness, often to two inches or more in diameter. This 
 of necessity brought pressure upon the middle line 
 of the perineum. But even with this faulty practice 
 no harm ever came to the urethra. The bar of 
 smaller diameter, however, may be crowded against 
 the injured thigh past the middle line, thus saving 
 the urethra from pressure. A sufficient length of 
 medium-sized copper wire is fastened at its middle 
 to the perineal-bar at about the place the patient's 
 perineum will have a bearing when he is in position ; 
 the strands of this wire are twisted together for about 
 six inches and then allowed to hang free. Its us6 
 will be stated subsequently. 
 
 No bloodless operation comes to the writer's mind 
 that requires more skill in its successful performance 
 than the setting of a fracture of the shaft of the 
 femur in an immovable splint. Errors of skill in the 
 application of a movable splint may be corrected dur- 
 ing the early stages of treatment, thereby averting 
 the evil consequences of mistakes. In applying an 
 immovable splint, however, all the skill necessary to 
 eliminate the consequences of mis-steps must be con- 
 
22 PEINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 centrated in less than an hour's work. As an illus- 
 trative instance we will take for treatment a supposed 
 patient with a recent simple oblique fracture of the 
 shaft of the femur at the middle of its length with 
 marked shortening of the limb. 
 
 The immovable apparel should be applied as soon 
 after the patient has reacted from the shock of the 
 injury as the condition of the limb in reference to 
 swelling, will allow. The nearer the application of 
 the splint to the time of the receipt of the injury, the 
 more easily can a correct adjustment of the bony 
 fragments be made. 
 
 The time of setting a fracture in relation to the 
 time of the occurrence of the injury is a factor of 
 prime importance. This was well shown by many 
 instances of suture of simple transverse fractures of 
 the patella by open operation either performed or 
 witnessed by the author. In patients operated upon 
 very soon after fracture, the fragments could be 
 drawn together and held in position by a very slight 
 force. After delay, however, the fragments were 
 difficult to approximate and it required a stout suture 
 to hold them together. The very early operation 
 gave to the surgeon an extended choice of character 
 of suture ; procrastination gi-eatly limited that choice. 
 
 Upon the same principle the early treatment by the 
 surgeon (the earlier the better) enables him to ad- 
 just the broken long bone in position, especially in 
 fractures of the shaft of the femur. The illustrations 
 (Plate XVIII) show a sample of simple fracture of 
 the lower third of the femur of greatest obliquity 
 treated very soon after fracture in which the union 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 23 
 
 of the broken bone was obtained in best position. 
 Traction easily restored the length of the limb. On 
 the other hand, in an instance of mal-union with 
 over four inches of shortening, the most forcible ef- 
 forts at reduction, which were made immediately after 
 a refracture, only slightly diminished the shortening 
 of the limb. The soft parts, muscles, tendons and es- 
 pecially the fibrous skeleton of the thigh had grown 
 in accommodation to the new condition of shorten- 
 ing of the limb and the contractures could not be cor- 
 rected by sudden and great tractive efforts. It is in 
 such instances that long-continued traction would ap- 
 pear to be allowable in an attempt to correct the con- 
 firmed shortening. 
 
 The illustration (Plate XVIII) shows further the 
 capacity of the immovable apparel to maintain ex- 
 tension and counter-extension for a length of time 
 sufficient to achieve union in perfect position of the 
 fragments. That the immovable plaster-of-Paris 
 splint does exert extension and counter-extension was 
 well shown in an instance witnessed by the author 
 in which the splint was light and weak, no tin 
 strips having been used, and when the extension by 
 the compound pulleys was relaxed while the splint 
 was green and soft, it telescoped at the site of the 
 fracture to the extent of the amount of the shorten- 
 ing. Extension by the compound pulleys was im- 
 mediately reapplied, the telescoping of the splint 
 at the site of fracture was removed, the splint was 
 made of due strength and a satisfactory union of the 
 fragments was obtained. 
 
 The usual controlling local condition is the swell- 
 
24 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 ing. "While it is true that the plaster-of-Paris splint 
 may be applied at any time irrespective of the degree 
 of swelling, it can only be used as a continued or 
 permanent apparel developing its maximum effi- 
 ciency, while the size of the limb remains compara- 
 tively stationary. A confining and constricting 
 bandage has little control over a rapidly increasing 
 swelling. Certain necessitous circumstances may be 
 conceived and do occur, especially in fractures of both 
 bones of the leg, when the application of the splint 
 is imperatively demanded, notwithstanding the pres- 
 ence of advancing swelling. 
 
 If the swelling be acute and increasing, the applied 
 splint must immediately be cut open and eased or 
 the constricted limb, perhaps the life of the patient, 
 will be sacrificed. On the other hand, if a consider- 
 able swelling be rapidly subsiding, the splint will 
 soon be a loose fit and ineffective and need re- 
 application. In either instance the splint as applied 
 will be only a temporary apparel, the maintenance 
 of its efficiency with safety requiring successive re- 
 applications. 
 
 If the trained judgment assures the surgeon that 
 the swelling will be slight and the changes in the 
 size of the limb negligible, the splint may be applied 
 as a permanent fixation apparel very soon after the 
 occurrence of the fracture — the sooner the better. 
 Generally, however, the elective period of its appli- 
 cation as a permanent apparel is that of greatest 
 safety consistent with efficiency, namely, when the 
 swelling has passed its maximum and in recession has 
 reached a comparatively stationary limit, which usu- 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 25 
 
 ally is a matter of a few days after the receipt of the 
 injury, the limb meanwhile, of course, having been 
 under continual extension with weight and pulley. 
 
 The amount of shortening of the limb from the 
 fracture is ascertained by carefully made measure- 
 ments. In measuring the limb the operator avoids 
 prejudice and deceiving himself by having the blank 
 side of the measuring-tape turned toward him. He 
 measures from the anterior superior spine of the 
 ilium to the tip of the inner malleolus, the patient's 
 pelvis meanwhile being perfectly squared, so that 
 an imaginary line drawn transversely through the an- 
 terior superior spines of the ilia meets the median 
 longitudinal plane of the body at a right angle. For 
 confirmation, the measurements are repeated. Not 
 all surgeons are capable of making reasonably exact 
 measurements. One prominent surgeon known to 
 the writer would commit gross errors; the amount 
 of his personal error was, indeed, sometimes as great 
 as the amount of the shortening to be measured. 
 With such errors inherent in the personal instru- 
 ment the measurements were of course fallacious. 
 
 The patient is then prepared for ansesthesia. In- 
 asmuch as the degree of swelling is a large factor 
 affecting the mechanical efficiency of the splint, the 
 limb should at all times be carefully guarded against 
 a disturbance of the soft parts. While the use of an 
 anaesthetic is highly desirable, it is not absolutely 
 essential. With old and very feeble patients a stimu- 
 lant may be used instead. The writer has known 
 his skilful and rapidly working assistant to complete 
 
26 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 the whole operation in a most excellent manner in 
 less than half an hour. 
 
 The fractured limb should be most carefully pro- 
 tected against injury preparatory to the administra- 
 tion of the ansesthetic. Temporary splints should 
 be applied and extension meanwhile maintained. In 
 addition assistants should safeguard the patient, a 
 particularly trustworthy one having constant charge 
 of the broken thigh. The patient when anaesthetized 
 to complete relaxation should be held continuously in 
 the same degree of ansesthesra throughout the opera- 
 tion. This, like all well-conducted, important and 
 complicated surgical operations, should be constantly 
 supervised and coordinated by the operating surgeon. 
 
 The patient being fully under anaesthesia, the 
 operator removes all dressings from the limb, an 
 assistant, of course, constantly maintaining manual 
 extension. Other things being equal, the operation 
 to be well done should be speedily done. Even min- 
 utes should be economized. In the complex operation 
 which we are describing, careful forethought and 
 method in executing the different steps of procedure 
 will in the total economize the time and shorten 
 the period of ansesthesia. This is all the more desir- 
 able since it is not necessary to give time for the 
 setting of the plaster-of-Paris, under the anaesthetic, 
 the fixation of the fragments being immediately ac- 
 complished by the action of the tin strips when 
 bandaged in position. 
 
 A transverse mark is made upon the skin above 
 the inner malleolus of the injured limb, which will 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 27 
 
 serve as a point in measuring to correct the shorten- 
 ing of the limb. 
 
 The protective covering of thin blanket or other 
 material is carefully slid beneath the patient. One 
 free edge of the material which extends a short dis- 
 tance beyond the injured limb is cut to conform to 
 
 Fig. 2. — Plan of Cutting Blanket Covering of Thigh in Frac- 
 ture of Shaft of Femur. 
 
 the middle of its external surface (Fig. 2). This 
 is done by first making a number of guiding cuts in 
 the edge of the blanket. Beginning near the ankle, 
 with one hand the flap of blanket is held against 
 the middle line of the external aspect of the limb 
 and is then cut with scissors down to that point. 
 At intervals of a few inches similar cuts are made 
 in the blanket along the whole length of the limb 
 
28 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 and that portion of the pelvis that is to be covered. 
 The superfluous blanket, as shown by the guiding 
 marks, is cut away till the edge of the blanket, per- 
 haps with a little trimming, can, when brought into 
 position, be made to reach to the middle of the 
 external aspect of the limb throughout the whole 
 length to be covered. The patient's healthy thigh is 
 flexed at a right angle with his body, and the other 
 portion of blanket is cut diagonally from above 
 downward to a point opposite the anus. This cut is 
 so made that the portion of blanket above the cut 
 may be brought around the pelvis anteriorly and 
 temporarily held in position with a single pin. 
 
 The lower or thigh portion of blanket, below the 
 transverse cut, is brought across the inner and an- 
 terior surfaces of the injured limb, especial care being 
 taken to cover the groin and perineum. This por- 
 tion of blanket is trimmed to guiding cuts, as was 
 the case with that covering the posterior and outer 
 surfaces of the limb. The blanket covering the 
 inner and anterior aspects of the limb overlaps that 
 covering the posterior and outer aspects, the fold 
 thus formed lying along the external and less im- 
 portant aspect of the limb, and is pinned in posi- 
 tion beginning at the ankle. The loose edge of the 
 fold thus placed does not obstruct bandaging, but 
 is easily fastened in position by the successive turns 
 of the bandage. It is better to fasten the protective 
 covering by common pins than with needle and 
 thread. Little changes may then be made to make 
 the perfect fit and the pins may be removed as the 
 turns of bandage fasten the covering in position. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 29 
 
 The foot need not be covered till the splint is fin- 
 ished but during the operation the blanket for cover- 
 ing the foot may be left loose and turned back 
 from the ankle, out of the way. The protective 
 covering of the thigh and pelvis has been adapted 
 while the patient has been lying in bed under 
 anaesthesia, the assistant meanwhile preserving the 
 manual extension upon the limb; it having been so 
 snugly and neatly applied that the outline of the 
 limb has not been obscured or changed. The pa- 
 tient is now ready to be placed upon the special 
 apparatus necessary for extension and counter-ex- 
 tension to facilitate the construction of the splint. 
 It will be observed that the power (the com- 
 pound pulleys) is located between two fixed points, 
 the two inserted screw-eyes, the one from which 
 extension is made, and the other, the fixed point of 
 counter-extension. The. patient is not so immovably 
 fixed upon the apparatus but he may shift from 
 position. He is so conditioned, however, that for a 
 sufiicient though brief time he may be held in the 
 desired position of best adjustment of the frag- 
 ments. The assistant exerts control over the upper 
 fragment through acting upon the long arm of the 
 lever resting upon the perineal-bar as a fulcrum. 
 The same assistant controls the rotation of the 
 lower fragment. The surgeon avails himself of all 
 helps to secure correct adjustment of the frag- 
 ments, that is, he coordinates all the elements nec- 
 essary to secure that end, and then, while the pa- 
 tient is in position of election, quickly immobilizes 
 the fragments. 
 
30 PEINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 The surgeon locates an imaginary vertical plane 
 cutting the bed at a right angle at about the middle 
 of its length, which may be designated the plane 
 of counter-extension. (See Ground Plan, Fig. 3.) 
 In this plane, beneath the edge of the bed, is in- 
 serted at a slight angle in the floor a strong screw- 
 
 FiG. 3. — Ground Plan of the Position of the Patient upon the 
 Apparatus in the Application of a Plaster-of-Paris Splint in 
 the Rapid Setting of a Fracture of the Shaft of the Femur. 
 No. 1 is the median plane of the body. No. 2 is the plane 
 of counter-extension. No. 3 is the plane of extension. 
 
 eye which constitutes the fixed point of counter- 
 extension. The small piece of gas-pipe fitting into 
 the upper end of the perineal-bar serves well in 
 inserting the screw-eye into the floor. The movable 
 tripod, minus the smaller pipe, to be inserted later 
 into the upper end of the perineal-upright, is 
 
PBINCIPLES OF TREATMENT OF BROKEN LIMBS 31 
 
 brought near the edge of the bed, the rear leg ex- 
 tending under the bed, being located in the plane 
 of counter-extension three or four inches from the 
 inserted screw-eye; the other two legs of the tripod 
 (forward legs) are placed equidistant from this 
 plane, on either side respectively. A rather heavy 
 copper wire is caught at its middle over the screw- 
 eye in the floor and then very coarsely twisted to- 
 gether till it reaches the upper surface of the centre 
 block of the tripod. The ends of wire are wrapped 
 about the upright perineal-bar in opposite direc- 
 tions and made fast by twisting (see Frontispiece). 
 By means of this twisted wire the perineal-upright 
 is hitched fast to the screw-eye and is constituted 
 an unyielding resistance of counter-extension. In 
 other words, the fixed point for counter-extension 
 is transferred from the screw-eye in the floor to 
 the perineal-bar at the place of bearing of the 
 perineum. By pulling upon the perineal-bar any 
 slack in the wire is removed by stretching, and 
 the forward legs of the tripod which oppose a 
 counter-resistance under extension are made to 
 stand squarely upon the floor. 
 
 The principal assistant, always continuing his 
 extension upon the injured thigh, seizes the pa- 
 tient by both ankles while the ansesthetizer grasps 
 him by the shoulders and, acting in concert, under 
 supervision of the surgeon, they pivot the patient 
 upon the bed bringing the sound limb first toward 
 the perineal-bar. The sound thigh is sufficiently 
 flexed that it may be lifted over the end of the bar 
 and the patient so placed in position that the median 
 
32 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 longitudinal plane of his body shall be carried as 
 far as possible in the direction of the uninjured 
 side, at the same time being maintained parallel to 
 the plane of counter-extension. 
 
 The purpose of this is to increase the leverage 
 upon the upper fragment when traction is made 
 upon the uninjured limb, the perineal-bar acting as 
 the fulcrum upon which the pelvis may be tilted. 
 The further the median longitudinal plane of the 
 body is crowded over in the direction of the un- 
 injured side the greater will be the leverage and 
 command over the upper fragment. Added to this 
 advantage, the pressure will be away from the 
 median line of the perineum, the urethra thus es- 
 caping, and furthermore, a less total pressure will 
 be exerted upon the perineum. 
 
 The patient having been properly placed in posi- 
 tion it now becomes an additional duty of the an- 
 aesthetizer, under supervision of the operator of 
 course, to assist in the preservation of the patient 
 in correct position. 
 
 The smaller pipe fitting into the upper end of 
 the perineal-bar is then fitted into place. The bed 
 is pushed back from the perineal-bar just far enough 
 to give working space about the patient's pelvis. 
 The copper wire, previously attached to the perineal- 
 bar, is carried backward along the sacrum and the 
 ends are brought upward along each side of the 
 pelvis and attached over the tip of the horizontal 
 piece of the smaller pipe of the perineal-bar over- 
 hanging the pelvis. 
 
 The purpose of this wire is not so much to sus- 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 33 
 
 pend the pelvis as to prevent its displacement by 
 partial rotation on a longitudinal axis of the body 
 projected through it to its bearing against the 
 perineal-bar. It is therefore a guy-wire. The pel- 
 vis is sustained clear of the bed by the patient's 
 body resting upon the bed and by being held firmly 
 in its bearing against the perineal-bar under the 
 force of extension. Ample working room may be 
 gained about the pelvis by pushing the bed back 
 from the perineal-bar, without disturbing the ad- 
 justed position of the patient upon the apparatus. 
 A clove-hitch made sufficiently strong from a folded 
 bandage is now attached to the naked ankle above 
 the malleoli. The ends of the bandage are tied into 
 a loop into which may be caught one of the hooks 
 of the compound pulleys. The clove-hitch may be 
 so adjusted to the ankle that it will, in large de- 
 gree, control the eversion of the lower fragment. 
 
 The fixed point from which extension is to be 
 exerted is constituted by a strong screw-eye which 
 is screwed into the woodwork of the room at a point 
 where the prolonged long axis of the broken limb 
 under extension will touch. 
 
 Before the operation has been commenced, the 
 bed has been placed in proper position in reference 
 to the mechanical requirements of the operation and 
 the screw-eyes inserted in proper position. 
 
 As shown in the Frontispiece, the principal assist- 
 ant, comfortably seated, with one hand controls 
 the rotation of the lower fragment by so holding the 
 ankle that the foot is somewhat inverted; at the 
 same time grasping the ankle of the uninjured 
 
34s PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 limb he exerts sufficient traction to hold the pelvis 
 in position and control the upper fragment. The 
 importance of so placing the pelvis upon the peri- 
 neal-bar as a fulcrum as to favor the leverage upon 
 the upper fragment has been explained. Some- 
 times a clove hitch is attached to the ankle of the 
 uninjured limb and connected to the extension upon 
 the other limb, but with a trained skilful assistant 
 exerting control over the upper fragment this fea- 
 ture of practice may be generally dispensed with. 
 
 We may pass in review the steps of the procedure 
 to the present stage of the operation: — 
 
 The patient lying upon his bed has been pro- 
 tected from self -in jury during the administration 
 of the anaesthetic by having temporary splints ap- 
 plied to the injured limb. 
 
 The ansesthetic has been given. If the patient 
 is old and feeble a stimulant may be given instead. 
 
 The temporary splints have been removed and 
 the limb and pelvis covered with a protective of 
 thin blanket or other material. 
 
 Imaginary planes have been located for the guid- 
 ance of the surgeon in placing the patient upon the 
 special apparatus. 
 
 The fixed points for extension and counter-ex- 
 tension have been established and the special thigh 
 setting apparatus has been placed in position. 
 
 The patient has been placed upon the apparatus 
 and the extension by means of compound pulleys 
 has been substituted for manual extension which 
 has hitherto been constantly exerted. 
 
 All through the procedures the injured limb has 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 35 
 
 been disturbed as little as possible so as not to ex- 
 cite an increase of swelling. 
 
 Enough extension is for the time exerted through 
 the compound pulleys to straighten the thigh and 
 take out most of the sag at the place of fracture. 
 All through the operation the surgeon strictly co- 
 ordinates his assistants, supervising, with a full 
 sense of his responsibility, every feature of the 
 operation. All preparations that forethought could 
 suggest have been made so that there may be no 
 delay in the progress of construction of the splint. 
 
 As in the case of the leg splint, a foundation 
 layer of plaster-of-Paris bandage is applied to the 
 leg, thigh and about the pelvis covering the limits 
 of the prospective splint from the ankle to the 
 pelvic limit. Especial care is bestowed in the mak- 
 ing of the spica at the pelvis. One layer of band- 
 age even when closely imbricated does not make a 
 sufficiently firm foundation for the tin strips es- 
 pecially with the yielding soft tissues about the 
 groin. There, and at any other place where the 
 underlying soft tissues are too yielding to give a 
 good basis for the tin strips, either strips of plaster- 
 of-Paris bandage folded in reverses, or pieces of 
 blanket saturated with a thin cream of plaster-of- 
 Paris and cut to form will remedy the weaknesses. 
 Into the foundation layer, as in the construction of 
 the leg splint, a small amount of moistened plaster 
 is rubbed, smoothing all folds of bandages and 
 sticking them together. This foundation layer, 
 when completed, leaves the outline of the limb sharp 
 and distinct. 
 
36 PRINCIPLES OF TREATMENT OF BROKEN LIMES 
 
 The pelvic portion of the splint should not be 
 extended too high. The author has sometimes seen 
 it made so high as to infringe upon the lower ribs, 
 thus greatly hampering the movements of the pa- 
 tient, who could not even sit up in comfort. The 
 pelvic portion of the splint is for the purpose not 
 only of securing a hold upon the upper fragment, 
 but also for the purpose of controlling the rotation 
 
 Fio. 4. — Construction of Pelvic Portion of Thigh Splint (rear 
 view) in Fracture of the Shaft of the Femur. 
 
 (generally in eversion) of the lower fragment. The 
 proper construction is shown in Fig. 4. 
 
 The weak places where the splint is most likely 
 to give way from the wear of weeks are about the 
 groin, the buttocks, and the posterior aspect of the 
 thigh and leg. In construction, the strength of the 
 texture of the splint is proportioned somewhat to 
 the closeness of the imbrications of the folds of 
 bandage. 
 
 The tin strips for use in fractures of the shaft of 
 the femur are made no wider but longer than need 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 37 
 
 be the case for fractures of the leg; otherwise they 
 are of the same construction. They are easily made 
 longer by soldering two or more strips together at 
 their overlapping ends. About seven or eight strips 
 are used, and they are disposed in the principal longi- 
 tudinal planes of the limb as in the case of setting 
 the leg fracture, described. To reiterate, the tin 
 strips operate as a resistance to forces by reason 
 of their not changing in length, either by shorten- 
 ing or lengthening when nicely adapted to the con- 
 tour of the surface of the limb and firmly held in 
 position between layers of bandage. They resist 
 forces tending to displace the fragments in shorten- 
 ing of the limb or in angailar deformity, rotation 
 or any other mode of displacement that can be 
 resisted from the surface, operating upon the bony 
 fragments through the yielding medium of the soft 
 parts: they also develop some resistance by virtue 
 of their width, though very narrow. 
 
 \Miile they, no doubt, add to the strength of the 
 constructed plaster-of-Paris splint, their use was 
 not designed for that purpose. They are them- 
 selves the splint, constituting the resistance to forces 
 tending to move the fragments in relation to each 
 other, immobility ^vithin limits being the essential 
 attribute of all methods of treatment. Their action, 
 immediately operative ^ is rendered more surely per- 
 manent by the material used in the bandages by 
 which their primary and essential fimction is con- 
 tinued. The plaster-of-Paris splint in its construc- 
 tion is an infinitude of lines of resistance coming 
 into practical operation through the hardening of 
 
38 PRINCIPLES or TREATMENT OF BROKEN LIMBS 
 
 the plaster, which requires the lapse of a variable 
 period of time ; the tin strips develop their resistance 
 immediately. 
 
 To proceed with our operation, tin strips are 
 placed on either side of the anterior median line 
 and in the posterior median line and side strips, 
 internal and external, midway between them^ 
 Added strips are placed anteriorly and posteriorly 
 between the median and lateral strips. They ex- 
 tend from the ankle to a line far beyond the de- 
 signed upper pelvic margin of the splint. They 
 are held in position by a few turns of the bandage 
 at the ankle till their correct general course up 
 the limb is assured. The tin strips are firmly band- 
 aged home to their foundation as far as the site 
 of fracture. During the whole bandaging the ex- 
 posed portions of the strips are allowed to hang 
 free and uncontrolled that they may adapt them- 
 selves perfectly to the contour of the limb. 
 
 When they have been bandaged firmly in rela- 
 tion to the lower fragment as far as the site of 
 fracture, the surgeon carefully reviews the situa- 
 tion. He makes sure that the patient is in every re- 
 spect in correct position upon the apparatus. With 
 his tape he measures from the anterior superior spine 
 of the ilium to the mark made upon the skin of the 
 ankle, at the same time directing the assistant hold- 
 ing the rope of the compound pulleys to make 
 sufficient extension to overcome the known amount 
 of shortening of the limb; it is well to even over- 
 correct the shortening. He carefully regards the 
 outline of the thigh to see that all sag at the place 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 39 
 
 of fracture is removed, and that the normal outline 
 of the thigh is restored, using any manipulation 
 that may be necessary to secure that object. All 
 ihis is done with a strict regard to the preservation 
 of the patient in correct position upon the apparatus. 
 
 With a final word of warning to his assistants to 
 be alert in the performance of their duties, he rap- 
 idly, in a few seconds, by figure of eight turns of 
 the bandage, firmly bandages the tin strips home 
 to their foundation and in relation to the upper 
 fragment. By this rapidly executed manoeuvre the 
 fragments are fixed in their adjusted relation to 
 each other. He continues his bandaging to the 
 upper pelvic margin of the splint, where he re- 
 verses the tin strips sharply, bringing them down 
 ^gain upon the splint (see Plate V, lower figure) 
 in a direction downward and diagonally outward. 
 Most of the reversed strips reach down past the 
 site of fracture. The anterior strips he cuts short 
 l)efore the knee-joint is reached. The posterior 
 strips and some of the lateral ones reach down past 
 ihe knee-joint upon the calf of the leg. The re- 
 versed strips are not allowed to interfere with each 
 other; they hang free and uncontrolled and are 
 bandaged home from above downward, commenc- 
 ing at the upper pelvic margin of the splint. The 
 fixation of the adjusted fragments, although the 
 splint is wet and soft, has been accomplished under 
 ihe best conditions. The guides for correct adjust- 
 ment have not at any time been obscured or im- 
 paired. 
 
 The surgeon may now proceed to strengthen the 
 
40 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 splint without any fear of disturbing the adjusted 
 fragments, now already fixed in their relation to 
 each other. A little experience will teach just how 
 much and where the splint should be reinforced 
 posteriorly to stand a month's or six weeks' wear. 
 A skilful hand may so manipulate the plaster-of- 
 Paris bandage in making reverses to give all the 
 added strength in places otherwise weak, that is 
 required, or, pieces of thin blanket saturated with 
 plaster-of-Paris cream and cut to form, may be 
 bandaged in position. The protective covering of 
 blanket extending beyond the pelvic margin of the 
 splint is then trimmed to within two or three inches 
 of the margin of the splint, turned back upon it 
 as a cuff, and retained in position by plaster band- 
 ages and finally, while quite wet, moistened plaster 
 may be rubbed into the entire surface of the splint. 
 This finishing coat should not be too thick, nor 
 should the smoothing process be too long persisted 
 in, lest, to repeat, the initial set of the plaster be 
 interfered with, and the plaster "flour." 
 
 The construction of the splint having been thus 
 far completed, extension is relaxed, the compound 
 pulleys disconnected, and the clove-hitch removed 
 from the ankle. The protective covering having 
 previously been cut to form, the foot and ankle are 
 speedily covered, the covering of the foot having 
 been so well arranged that it may be retained by a 
 single common pin. This covering is so adapted 
 that the instep and tendo Achillis are covered by 
 a double layer. 
 
 In bandaging, care is exercised that the dorsal 
 
[PRINCIPLES OF TREATMENT OF BROKEN LIMBS 41 
 
 face of the instep, the point of the heel and the 
 skin over the tendo Achillis are not subjected to 
 an excess of pressure. From the lack of exercise 
 of skill in this regard the author has seen an ulcer 
 upon the heel give more trouble than the cure of 
 the fracture itself. 
 
 It is always to he remembered in bandaging that 
 the greatest support to the circulation by compres- 
 sion is to be given to the periphery of the body, the 
 strength of compression lessening as it approaches 
 the circulatory centre. The foot may be simply 
 bandaged with an ordinary dry bandage, but the 
 author's preference and general practice has been 
 to use the plaster-of-Paris bandage. 
 
 Some surgeons in applying splints that include 
 the foot have been at great pains to immobilize the 
 foot at right angles with the leg. The reasons for 
 this practice seemed to the author to lack force. 
 It is an unnatural position of the foot and there 
 is a greater risk involved from unequal and undue 
 pressure. It has never been practiced by the author 
 whose results have always been without the com- 
 plication of accidents, and perfectly satisfactory. 
 
 The inclusion of the foot and ankle in the con- 
 structed splint while not absolutely necessary, is 
 generally advisable. The construction of the splint 
 upon the foot and leg, preliminary to the making 
 of the thigh splint should never be practiced. When 
 extension is made from the leg piece of splint al- 
 ready applied it is liable to slip and the leg splint 
 will then act as a partially withdrawn tight fitting 
 boot, causing undue pressure at certain places, with 
 
42 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 great discomfort and probably troublesome sloughs. 
 Neither should the toes ever be covered in, as the 
 author has sometimes witnessed. The exposed toes 
 are the tell-tale of the condition of the circulation. 
 They should be always left free. 
 
 The patient is now ready to be freed from the 
 apparatus. It will have been observed that while 
 upon the apparatus the patient has always been in 
 the best position for surgical functioning, no re- 
 strictions having been imposed thereon. At any 
 stage of the operation, should necessity therefor 
 have arisen, he could easily have been freed from 
 the apparatus. This could have been done in a 
 few seconds' time and the patient re25laced in bed 
 in his original position. The aneesthesia is stopped. 
 The heavy wire connecting the tripod to the screw- 
 eye of counter-extension is untwined; in an emer- 
 gency, to gain a few seconds of time, this could 
 be cut with strong scissors. The guy wire con- 
 trolling the rotation of the pelvis, is cut on either 
 side. The patient is seized by the shoulders bj^ the 
 anassthetizer and drawn a short distance up on the 
 bed. While the ansesthetizer holds the patient by 
 the shoulders and the first assistant holds him by 
 the ankles, the tripod, its forward legs resting upon 
 the floor, is pulled over, withdrawing the pelvic 
 guy-wire from the splint, and the patient then 
 rests upon the bed, thus speedily freed from the 
 apparatus. The two assistants, protecting the splint 
 as much as possible, turn the patient as upon a 
 pivot, back into his original position upon the bed. 
 
 After the splint has set and hardened, and before 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 43 
 
 it is dry, the surgeon carefully inspects his work. 
 First of all, he notices the character of the circula- 
 tion. With a snug fitting splint the toes may be 
 at first a little puffy, but the circulation must be 
 distinct, bright and not retrograding. If com- 
 plaint is made of pressure over bony points it may 
 be eased by compressing the splint between the 
 hands. Continued complaints of pain should never 
 be masked with morphine but must receive respect- 
 ful attention, even if it results in the cutting down 
 of the splint. Under such circumstances the sur- 
 geon will wish he had moderated the pressure of 
 his bandage in the affected places, which attain- 
 ment was within the reach of skill. He specially 
 directs his observation to the delicate tender tissues 
 of the perineum. In a well-constructed splint, it 
 may happen that he will be obliged to trim away 
 the edge of the splint there, but he should be very 
 slow in taking away too much splint and leaving 
 the tissues unsupported, otherwise they will "bag," 
 become congested and ulcerate at the margin of 
 the splint. At first he may do a little trimming 
 in the perineum down to the blanket protective 
 covering. On the contrary, it will sometimes hap- 
 pen that he has not carried his construction far 
 enough or, perhaps, he has cut away too much of 
 the splint upon the permeum and that the tissues 
 will bag. To correct these conditions and the ten- 
 dency to ulceration he should not cut away the 
 splint but support the tissues with a well-applied 
 dry bandage applied over the splint, perhaps even 
 slightly padding the concerned supported tissues. 
 
44 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 All going well, the surgeon induces the patient 
 to move about as soon as possible. The operation 
 has been conducted in such a manner as to irritate 
 the lacerated soft tissues as little as possible thereby 
 forestalling any disagreeable reaction in the way 
 of increased swelling. The compressing splint hold- 
 ing the fragments comparatively still, and with- 
 drawing the injured muscles from functioning, bene- 
 ficently quiets the tissues. At the same time it 
 must be remembered that a continued shrinkage 
 in the size of the limb alters its physical and me- 
 chanical relations to the splint, lessening the re- 
 sistance of the latter to forces tending to move the 
 fragments. Consequently it is desirable, for me- 
 chanical reasons alone, to induce the patient to 
 move about so that the ensuing local oedema may 
 keep the splint packed and efficient as a resistance. 
 
 Within forty-eight hours, perhaps the next day, 
 the patient is urged to leave his bed to sit in a 
 chair and be propped up with pillows. Very soon, 
 within a day or two, he walks upon crutches, not, 
 of course, bearing any weight upon the injured 
 limb. In about a month, perhaps a little sooner, 
 the patient himself subjectively knows that union 
 of the fragments is well established. At the end 
 of a month or six weeks, the splint, pretty well 
 worn, is cut down anteriorly. A strip is moistened 
 with water in the anterior median line and cut down 
 with a common loiife with rather a coarse cutting 
 edge. Tin strips, as they are encountered, are cut 
 with stout scissors. Specially designed instruments 
 to cut down the splint are of little worth. When 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 45 
 
 the splint is removed, of course, great interest cen- 
 tres in the amount of shortening of the limb. Com- 
 parative measurements with the healthy limb are 
 taken and recorded. 
 
 When the use of the immovable plaster-of-Paris 
 splint in the treatment of simple fractures of the 
 shaft of the femur was much practiced, I think I 
 am safe from contradiction and very moderate in 
 making the general statement, that in expert hands 
 such treatment was at least as effective in overcom- 
 ing shortening as any other treatment then in vogue. 
 Indeed, many times I have found experts in measur- 
 ing, fail to find more than a negligible discrepancy 
 between the two limbs, say % or 1/4 of an inch. 
 And in some few instances I have heard an expert 
 declare his doubt that the thigh had ever been 
 broken and that he must have evidence that such 
 had been the fact, when of course it could be amply 
 proven to have been the case. 
 
 After the measurements have been impartially 
 taken, in the further treatment of the limb the 
 splint is treated as a movable one. It is taken off 
 as much as possible and used only when necessary 
 to protect the limb against the chance of accidental 
 injurj^ Every day the limb is douched alternately 
 with hot and cold water, gentl}^ shocked, and func- 
 tion stimulated by the patient's exercise of his will 
 and his own active efforts. Under such a line of 
 treatment the stiffness of the joints rapidly disap- 
 pears, the union is strengthened and the normal 
 function of the limb regained. 
 
 To overcome the stiffness of joints in the treat- 
 
46 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 ment of these injuries, as well as in the more ag- 
 gravated instances after the open suture of frac- 
 tures of the patella, the author has never practiced 
 passive motion. Overlooking the arguments that 
 might be made against it, he will declare that in 
 all instances the active efforts of the patient under 
 the stimulus of the will have been competent to re- 
 store full normal function to the joint. 
 
 From his experience and observation the author 
 avers that under good treatment a non-union of 
 the fragments must be a rare occurrence. 
 
 In the instance of the simple fracture of both 
 thighs, sho\^^l in Plates X and XI, two perineal-bars 
 were mounted in the wooden tripod instead of one, 
 thereby avoiding pressure upon the middle line of 
 the perineum. The lower limbs were brought to 
 the same length and enclosed in splints. The con- 
 structed splints were heavy and anchored the pa- 
 tient inmfiovable in bed. He at once began to lose 
 appetite and strikingly to lose strength. To af- 
 ford him a chance to exercise, the author rigged 
 for him the suspension apparatus shown in Plates 
 X and XI. The patient was at once delighted with 
 it. Whenever he felt disposed, which was often, 
 he would swing himself clear of the bed and exer- 
 cise like an acrobat. One evening he suspended 
 himself at eleven o'clock (as in Plate X), and after 
 exercising fell asleep and slept soundly till break- 
 fast time next morning. He soon recovered his 
 appetite and rapidly regained his strength. "While 
 undergoing treatment he was taken in the ambu- 
 lance to Bellevue Hospital, where he was exhibited 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 47 
 
 before the class of students. He was suspended 
 from the great dome of the amphitheatre and took 
 pleasure in going through his exercises. When 
 the splint was removed the lower extremities were 
 found to be without deformity and, by careful meas- 
 urements, of equal length. Soon after he recovered 
 function in the fractured limbs and went to his 
 former work, earning his livelihood. 
 
 It has been stated that the degree of efficiency 
 of the immovable plaster-of-Paris splint is related 
 to the degree of compression of the soft parts. In 
 some instances, where there has been great injury 
 of the soft tissues, their tolerance of compression 
 is very slight, with the consequence of a reduced 
 efficiency of the resistance afforded by the splint. 
 This is generally the case in compound fractures, 
 and also in some simple fractures where, in spite 
 of swelling, from special reasons, like imminent de- 
 lirium, the protection of a splint is rendered neces- 
 sary. Inasmuch as the line of safety in compression 
 of the soft parts must not be transgressed, it be- 
 comes advisable to moderate the effect of forces 
 tending to move or displace the fragments, which 
 is tantamount to increasing the resistance afforded 
 by the splint, 'and this is accomplished by the sus- 
 pension of the injured limb. The better to un- 
 derstand the principles of suspension embodied in 
 apparatus, it will be well to briefly trace the de- 
 velopment of the suspension apparatus formerly in 
 use in Bellevue Hospital. 
 
 The most primitive contrivance then in use was 
 the suspension of the limb in splints by loops of 
 
48 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 bandage from a cradle placed over the limb. This 
 in a limited degree withdrew resistance in 'a single 
 plane, principally acting upon the lower fragment. 
 
 A very decided advance was made by the device 
 of Dr. Van Wagenen, a member of the House 
 Staff. His contrivance consisted essentially of a 
 wooden gallows, made fast to the foot of the bed. 
 Its flat horizontal portion, overhanging the limb, 
 contained two slots, each about six inches long. 
 Upon an iron rod passing lengthwise of each slot 
 travelled a pulley from which depended a few inches 
 of rubber tubing, which carried at its lower end 
 another pulley whose plane of rotation was trans- 
 verse to the long axis of the suspended limb. The 
 limb in splint was suspended in loops of rope which 
 ran over the lower pulleys. In its action, this 
 apparatus withdrew resistance to motion in a ver- 
 tical plane, and also to rotation of the limb upon 
 its longitudinal axis. In practice, however, the two 
 upper pulleys would often approach each other, 
 bringing the suspending loops of rope together, 
 sometimes over the wound, and the even support 
 of the limb in balance would be destroj^ed. 
 
 These defects, among others, led the author to 
 design the construction shown in Plate VI, which 
 in action was very satisfactory. A triangular 
 w^ooden support was fastened to the foot of the 
 bed. Into a socket in its upper end was received 
 an iron gas-pipe, which turned freely. The pipe 
 extended perpendicularly upward, and was then 
 bent to extend horizontally. Into its free end was 
 received a piece of smaller pipe, which extended 
 
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PRINCIPLES OF TREATMENT OF BROKEN LIMBS 49 
 
 horizontally about six inches and was turned ver- 
 tically upward for a length of about two inches. 
 This smaller pipe was held in place by having its 
 received portion bent a little out of line, enough 
 to give sufficient friction. A pulley, about two 
 and a half inches in diameter, travelled freely upon 
 the smaller pipe, being checked in one direction by 
 the end of the larger gas-pipe, and in the other by 
 the upturned end of the smaller pipe. 
 
 To the lower end of the pulley from which the 
 screw had been removed was fastened a loop of a 
 few inches of elastic rubber tubing. At the lower 
 end of the tubing was a strong hook fashioned out 
 of strong iron wire. Inasmuch as under the strain 
 of constant use the loop of rubber tubing was apt 
 to break, the weak point was guarded by a safety 
 line of flexible braided wire picture cord. It was 
 fastened to the pulley above and the hook below, 
 sufficient slack being given to allow full play to the 
 elastic tubing under the weight of the suspended 
 limb. Under this arrangement, the author has known 
 the elastic tubing to break without awakening the 
 patient from sleep, the safety cord holding the sus- 
 pension rigging intact. 
 
 Into the hook at the lower end of the loop of elastic 
 was caught a short length of chain of pl'ain coarse 
 round links. This chain was for the purpose of ad- 
 justing the elevation or depression of the limb. Into 
 one of the lower links of the chain was caught the 
 hook connected with a square loop made of rather 
 heavy iron wire, which loop received loosely the 
 wooden bar from which the limb was directly sus- 
 
50 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 pended. The bar iVas of hard wood. On its upper 
 edge it was grooved transversely, near each end; the 
 grooves were about one inch apart and of a size and 
 depth to receive easily the wire loops of the pulleys 
 over which ran the ropes encircling the limb in splint. 
 On its lower edge, one side of the centre, the bar had 
 cut into it three or four notches, about an inch apart, 
 into which could be shifted the square iron wire loop 
 catching into the lower part of the chain. The 
 wooden bar spaced the pulleys carrying the suspend- 
 ing loops of rope which could consequently be held 
 in predetermined position. The notches in the upper 
 edge of the bar, at each end permitted an accurate 
 spacing of the loops of rope and those in the lower 
 edge, 'a nice balancing of the suspended limb. 
 
 The pulleys carrying the ropes suspending the 
 limb were treated in this way: The screw of each 
 pulley was cut off flush with the body of the pulley; 
 in its place a square loop of wire to slide back and 
 forth over the wooden bar was fastened to the body 
 of the pulley, the plane of the loop, of course, co- 
 inciding with the plane of the pulley wheel; this 
 loop was made sufficiently large so that when the 
 pulley hung in place from the bar there would be 
 left ample space between the upper surface of the 
 body of the pulley and lower surface of the bar so 
 the pulley could not only be shifted into position in 
 different notches in the bar, but might swing freely, 
 thereby accommodating its plane of rotation to any 
 inclination of the rope, which, were the pulley fast 
 to the bar, would ride off or block the wheel. The 
 limb was suspended directly from the pulleys by; 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 51 
 
 loops of small rope which rode easily in the pulley 
 grooves. In action, the limb was comfortably sus- 
 pended by the encircling loops of rope which were 
 accurately spaced, and balanced in the best position. 
 The elevation or depression could be regulated to a 
 nicety by the links of the chain. 
 
 Except for special reasons, as a general principle, 
 the limb should be lifted as little as possible from the 
 plane upon which its healthy fellow rests. Indeed, 
 the writer in observance of this principle has some- 
 times depressed the underlying portion of bed, rather 
 than elevate the limb. When the limb is much ele- 
 vated, the lower fragment tends by gravity to over- 
 ride the upper fragment and gives rise to the dis- 
 agreeable necessity of using some sort of extension 
 appai^atus to correct the difficulty, with a consequent 
 restriction of motion of the lower fragment. By 
 means of the apparatus the resistance to motion in 
 horizontal and vertical planes and to rotation upon 
 the long axis of the limb has been lessened. By virtue 
 of the elastic suspension from a single point, the re- 
 sistance to elevation of the limb is lessened, which 
 is sometimes, as in the delirium of the patient, of 
 material advantage. Given the wooden upright 
 bored to receive the iron pipe, and the wooden bar 
 shaped to form, all the materials can be assembled 
 in construction by the surgeon's own hands, at least 
 that was so in the writer's experience. Frequently 
 the author in making his rounds observed patients 
 who were able to walk about, sitting in their chairs 
 with the leg in splint resting in the suspension ap- 
 paratus described, fastened to the chair, rather than 
 
52 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 resting upon a pillow in an opposite chair. To in- 
 quiry, the answer was always given that it was the 
 more comfortable choice. It will be noted, of course, 
 that the suspension apparatus for the patient with 
 fracture of both thighs was an adaptation of the con- 
 struction in use for fractures of the leg. 
 
 In the preantiseptic days in Bellevue Hospital, 
 when that institution was saturated with infection, 
 it was customary in the treatment of compound frac- 
 tures to cut fenestr^e in the immovable plaster-of- 
 Paris splint, for the purpose of watching and treat- 
 mg the wound. It generally happened that there was 
 burrowing of pus, and the opening in the splint had 
 to be enlarged to increase the area under observation 
 and treatment. This led the author by rapid steps to 
 finally discard altogether the encasing and conceal- 
 ing splint, obstructive of surgical procedures, and to 
 adopt means of treatment which though opposing 
 feeble resistance- to forces tending more or less to 
 displace the fragments, gave freest access for obser- 
 vation and surgical treatment. The splint had be- 
 come restrictive of surgical treatment demanded by 
 the functioning of the injured tissues. 
 
 The limb was so circumstanced that while some 
 control was exerted over the immobility of the ad- 
 justed fragments, it was completely open to inspec- 
 tion and palpation and treatment of the wound com- 
 plications. All absorbent dressings were discarded. 
 No wound-dressings were used. The pus drained 
 away, and was not decomposed by being held in con- 
 tact with the warm limb. There was no squeezing 
 of tissues to evacuate sinuses, indeed in tissues that 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 53 
 
 were not handled but kept in absolute physical rest 
 the burrowing of pus was slight or did not occur. 
 The patient was spared the pain of the usual mode 
 of dressing. The dressing was only the substitution 
 of a clean for a soiled support, and this was so per- 
 formed as sometimes not to awaken the patient from 
 sleep. The success following the carrying out of 
 these principles was so great, especially with primary 
 amputations, that the wi'iter was slow to adopt the 
 antiseptic measures of treatment as at first practiced. 
 Later experience in the then highly septic wards 
 of Bellevue Hospital convinced the author that anti- 
 septic measures of treatment could fully protect pa- 
 tients against sepsis. He accordingly discarded the 
 method and apparatus which, though giving the ex- 
 cellent results in his hands in septic surgical practice, 
 afforded but feeble control over the maintenance in 
 position of the adjusted bony fragments. Strict anti- 
 septic measures having reduced the chances of septic 
 wound complications in compound fractures to the 
 vanishing point, such fractures could therefore be 
 placed in a category closely allied to simple frac- 
 tures, and a consequent greater control could be 
 exerted over the maintenance of the fragments in ad- 
 justed position, as already described in the use of tin 
 strips in conjunction with antiseptic measures of 
 treatment. 
 
 The illustrative instances that have been presented 
 might be largely increased in number from the 
 author's experience. It is thought, however, that 
 they provide ample subject-matter for the purposes 
 
54s PRINCIPLES OF TREATMEXT OF BROKEN LIMBS 
 
 of our induction, which has as its objective, the or- 
 ganization of the facts through the principles which 
 they embody. We therefore now pass from a con- 
 sideration of the concrete to a study of the abstract. 
 
 All methods of treatment of fractures of the long 
 bones to insure their union, however diverse in char- 
 acteristics, have one constant feature in common, 
 which may therefore be regarded as the essential fac- 
 tor or attribute. This attribute is maintained immo- 
 hility of the fragments. The essential nature of this 
 attribute is further shown by the demonstrable truth 
 of its contradictory, that disturbance of the continu- 
 ous immobility of the fragments beyond a certain 
 degree will prevent their union. 
 
 It has been pointed out that no extrinsic apparel 
 in opposing its resistance to disturbing forces through 
 the soft parts can completely immobilize the frag- 
 ments. While, therefore, maintained absolute immo- 
 bility under those conditions is unattainable, yet a 
 degree of immobility practically sufficient to insure 
 union, as has been amply demonstrated, can always 
 be achieved ; this attainable degree of sufficient immo- 
 bility may, therefore, be termed practical immobility, 
 in distinction from theoretical or absolute immobility. 
 
 Just what excursion of motion between the frag- 
 ments, disturbance of immobility, may take place 
 consistent with the fragments uniting, is not easy of 
 determination; it probably varies with individual pa- 
 tients. In view of this, it is incumbent upon the sur- 
 geon to bestow upon his patient a sufficient factor of 
 safety in restricting motion between the fragments, 
 to insure their uniting. 
 
PEINCIPLES OF TREATMENT OF BROKEN LIMBS 55 
 
 The maintained practical immobilization of the 
 fragments, in the realization of the essential attribute 
 common to all methods of treatment, is accomplished 
 by the adjustment of mechanical forces to resist me- 
 chanical forces acting to disturb their immobility. 
 The essential attribute is a mechanical one. The 
 measure of its value in a scheme of values is not re- 
 lated to the degree of attainable immobility per se, 
 said attainable immobility in turn being related to an 
 ideal standard of absolute immobility as a test of ex- 
 cellence. The measure of its value is determined 
 through the extension of that factor, in the relation 
 of the varying range of forces maintaining practical 
 immobility, to the incident forces tending to disturb 
 it. In other words the essential attribute, maintained 
 practical immobility, is treated as a constant, the 
 range of forces tending to disturb the immobility, as 
 the functioning variable. 
 
 The maintenance of practical immobility of the 
 fragments by the adjustment of mechanical forces to 
 oppose a varying range of forces tending to disturb 
 that immobility is proximately measured in its degree 
 of excellence by the varying range of coarse motion 
 of the organism, the test of excellence being shown 
 in the degree of practical realization in approach to 
 the ideal of largest range of coarse motion. In brief, 
 the efficiency of the essential attribute, sustained prac- 
 tical immobility, being granted, the measure of its 
 value is the varying range of coarse motion of the 
 organism, the essential attribute being preserved, the 
 highest value being assigned to the greatest range of 
 coarse motion of the concerned organism. Changes 
 
56 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 in coarse motion in their turn extend their effects to 
 all the various fields of function. 
 
 Xor does the ideal, it may be noted, propose as its 
 limit of excellence the restoration of the former or 
 so-called normal field of coarse motion, which, in re- 
 sults, may conceivably be even surpassed. 
 
 It may be further pointed out that the term "re- 
 sults" is not limited in its application to a certain 
 period of treatment, as, for example, the time of 
 union of the fragments. Such is an arbitrary limita- 
 tion in time of the application of the term. The esti- 
 mation of results should be extended to include any 
 period or all periods of treatment, even those during 
 which union is taking place. 
 
 Results, considered as immediate, remote and mul- 
 tiplied effects, have an indefinite extension of appli- 
 cation, not even being limited bj^, or ceasing with the 
 life of the individual, but extending their influence 
 to the effect on the welfare of the social organism 
 itself. Indeed, had we an all-embracing grasp, all 
 results, like all actions, from the smallest to the great- 
 est, should be determined in the measurement of their 
 value by this final of all tests. A proximate test, 
 however, is sufficient for our inquiry. In determining 
 the relative values of the essential attribute embodied 
 in various methods of treatment in its extension, the 
 degree of excellence is in the proportionate realiza- 
 tion by a given method of treatment of the ideal of 
 highest excellence, as sho'vvn by the increase in motion 
 of the affected individual. 
 
 The means by which the essential attribute is made 
 operative, in other words, methods of treatment 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 57 
 
 considered apart from the essential attribute itself 
 (which, to repeat, is a mechanical one), and consid- 
 ered in reference to their inseparable accidents or 
 characteristics, may be generalized under two heads: 
 
 First, in their local influence, affecting functioning 
 of the injured limb. 
 
 Second, in their particular, peculiar effect upon the 
 tissues ; in other words, in their therapeutic influence. 
 Both heads may be considered under the effect of 
 function, extending the connotation of the term func- 
 tion beyond its ordinary, arbitrary, accepted signifl- 
 cation, to include all responses of the concerned tis- 
 sues, whether normal or abnormal, to the distributions 
 of conditions to which they are exposed. 
 
 By parity of consideration with that of the essen- 
 tial attribute, it is evident that in the function of 
 variable responses to varying distributions of envir- 
 oning conditions, the theoretical maximum of excel- 
 lence must connote the largest response to distribu- 
 tions of environing conditions. It follows, therefore, 
 that the degree of excellence is necessarily propor- 
 tionate to the largest response, in practical realization 
 of approach to said ideal of largest response. Under 
 the same head may be included the variable results 
 of the so-termed therapeutic influence. To repeat: 
 The results following from the effects of the non- 
 essential attributes of treatment (the inseparable ac- 
 cidents or characteristics), considered apart from 
 those due to the realization of the essential attribute, 
 are to be measured in their excellence by their degree 
 of approach to the ideal of highest excellence, in terms 
 of function. 
 
58 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 In exhausting the subject-matter, both essential 
 and non-essential attributes of treatment inclusive 
 may be generalized in their results under the head of 
 functional responses of the organism to the distri- 
 butions of conditions to which it is exposed. The 
 comparative value of said responses in their imme- 
 diate, remote, and cumulative effects are measurable 
 as proportionate to the largest response, in approach 
 to the theoretical ideal of maximum response. 
 
 In the foregoing reasoning, which has been briefly 
 presented, and might be easily elaborated, and, it is 
 trusted, will be made clear by illustrations, the author 
 has been engaged in laying the foundation of imper- 
 sonal proof of value of any method of treatment, to 
 displace the bare empirical assertion of values rest- 
 ing on personal authority or consensus of opinion. 
 
 The voicings of personal authority may contradict 
 each other, or when made by the same individual may 
 vary at different times. The weight of the consensus 
 of opinion may sustain one conclusion to-day*, its 
 contradictory to-morrow. 
 
 Impersonal truth alone is authoritative. By truth 
 is meant that peculiar harmony of relations revealed 
 in the upbuilding of what Prof. Karl Pearson has 
 happily termed "the constructive field of the mind." 
 Said upbuilding is the constructive harmonizing of 
 continuous principles, abstractedly derived from the 
 complex, fluid, discontinuous, ever-varying phenom- 
 ena of the external world. Such organization of phe- 
 nomena through the harmonizing of their embodied 
 principles is, as the author conceives it, the final ob- 
 jective of all scientific endeavor. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 59 
 
 In the region of empiricism, the social organism 
 guided only by the weight of changing personal au- 
 thority or the consensus of opinion, gropes its uncer- 
 tain way ; in the realm of scientific exactitude, guided 
 by immutable principles, it confidently pursues a 
 direct and certain course, and by proper instrumen- 
 talities at its command, insures the betterment of its 
 constituent members. 
 
 While on the one hand the surgeon engages in his 
 individual work for the welfare of his patient, on the 
 other he should, through principles, instruct and equip 
 the social organism in the knowledge of the preven- 
 tion of the diseases and injuries he treats, always, 
 therefore, in acts of self-abnegation being engaged 
 in contracting the immediate field of his activity, as 
 it were, cutting the ground from beneath his own feet. 
 
 It should ever be borne in mind when the 
 asserted superiority of any method of treatment 
 is challenged, that the defendant, to prove his as- 
 sertion, should, avoiding all question of personal 
 authority or consensus of opinion, display the prem- 
 ises and the reasoning therefrom, upon which his con- 
 clusion depends. 
 
 So far as relates to separable accidents, the mere 
 proof that they are separable accidents and are 
 avoidable, is sufficient to expose their entire lack of 
 force in the argument. For example, the writer well 
 remembers an occasion when an immovable splint was 
 removed from a patient with a simple fracture of the 
 shaft of the femur. The fragments of bone were 
 united with no shortening or other deformity, indeed 
 with a perfect result. However, the point of a pin 
 
60 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 in the blanket protective covering had caused a very 
 small phlegmon upon the abdomen. This had caused 
 so little discomfort that the patient had made no com- 
 plaint and the pustule was only known when the 
 splint was removed. Yet, a distinguished surgeon, 
 an authority on fractures, who was present, made 
 careful note of the little mishap as furnishing, to his 
 mind, an argument against the use of the plaster-of- 
 Paris splint. The point of the pin might have been 
 turned outward, or the pin might have been removed 
 altogether. It was by no means a necessary element 
 in the construction of the splint. The irritation 
 caused by it was perfectly avoidable; it was a separ- 
 able accident and, of course, had no logical force in 
 an argument against the use of the apparel. 
 
 When the writer first entered upon his service as 
 a member of the House Staff of Bellevue Hospital, 
 the following incident occurred which made a deep 
 and lasting impression. A woman with simple frac- 
 ture of both bones of the leg in the middle third of 
 the leg was admitted into the Hospital soon after the 
 occurrence of the injury, and was seen by the Visiting 
 Surgeon, one of the greatest authorities on fractures. 
 He directed that the fractured leg should be treated 
 with leather side-splints, which was at once done. At 
 his visit next day, the patient said that she could not 
 sit up in bed without feeling the bones grate upon 
 each other. The Visiting Surgeon criticised the ap- 
 plication of the splints and reapplied them himself, 
 and also directed that the limb be suspended by loops 
 of bandage dependent from a simple cradle placed 
 over it. The next day the patient told the Visiting 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 61 
 
 Surgeon the same story, that she could not sit up 
 without feeling the fragments grate upon each other. 
 He then directed the House Surgeon to apply an 
 immovable plaster-of-Paris splint. The next day, the 
 Visiting Surgeon found the patient dressed and sit- 
 ting in a chair, beside the bed, the fractured limb rest- 
 ing upon a chair opposite. She told the Visiting 
 Surgeon that she had sat up in bed, was dressed with 
 assistance, and had otherwise moved about, without 
 feeling any grating of the hones. 
 
 In strict analysis, what had happened to the pa- 
 tient? As she was walking across the street, she 
 was knocked down by a passing wagon and her leg 
 broken. She was immediately removed by ambulance 
 to the Hospital. By the fracture, her field of coarse 
 motion, specialized in locomotion, had suddenly been 
 contracted to a very small one. With her leg in a 
 fracture-box resting upon the bed, she could not sit 
 up without disturbing the immobility of the frag- 
 ments, thereby destroying the essential attribute of 
 treatment necessary to their uniting. The support 
 of the limb, practically in only one plane, prevented 
 any but the smallest range of coarse motion. En- 
 cased in movable side-splints, she could move in a 
 very small range without disturbing the fragments. 
 There had been adapted a resistance to a small range 
 of disturbing forces, the fragments being meanwhile 
 held immovable. In the immovable plaster-of-Paris 
 splint, resistance was adapted to overcome a consid- 
 erable range of disturbing forces, that otherwise 
 would destroy the requisite immobility of the relation 
 of the fragments. This was shown by the greatlv 
 
62 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 enlarged field of coarse motion she enjoyed, without 
 interfering with the practical immobility of the frag- 
 ments in adjusted relation, and their consequent 
 union. 
 
 In the three separate distributions of conditions 
 constituting the three varieties of treatment, the es- 
 sential attribute of maintained practical immobility 
 of the fragments had been preserved with three dif- 
 ferent results as marked by three different degrees 
 of extension in functioning of the essential factor or 
 attribute. This extension was expressed by three dif- 
 ferent degrees of coarse motion, the essential factor 
 or attribute being preserved, as shown: — 
 
 First, by a very limited range of coarse motion. 
 
 Second, by an increase in the range of coarse mo- 
 tion, and 
 
 Third, by a still greater range of coarse motion. 
 
 These three degrees of enlargement of coarse mo- 
 tion derived their value in excellence measurable by 
 their degree of approach to a practical realization of 
 the ideal of greatest range of coarse motion. Assign- 
 ing highest excellence to the greatest enlargement of 
 the field of coarse motion in practical realization of 
 said ideal, then the second distribution of conditions 
 produced a result of higher value than the first dis- 
 tribution and the third distribution produced a result 
 of higher value than the other two. In the foregoing 
 illustration of comparative values, consideration has 
 been restricted to an extension of the essential factor 
 or attribute, as a functioning variable. 
 
 Limiting our consideration to the essential factor 
 or attribute, the term plaster-of-Paris splint is a 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 63 
 
 highly ambiguous one. It connotes a great variety 
 or range of resistances, as expressed in extension by 
 degrees of coarse motion of the concerned organism. 
 For example: a plaster-of-Paris splint may be so 
 loosely applied that it affords no greater resistance 
 to displacing forces than the simple fracture-box as 
 shown by the extremely limited range of coarse mo- 
 tion without disturbance of the fragments. At the 
 other extreme it may be so efficiently applied that it 
 gives a great resistance to otherwise disturbing forces, 
 as shown by a great range of coarse motion on the 
 part of the concerned organism, without disturbance 
 of the practical immobility of the fragments. It may 
 consequently be so applied as to develop all degrees 
 of resistance between the extremes, its inseparable 
 accidents or characteristics remaining the same. 
 
 Then again, the enclosed limb may so diminish in 
 bulk from recession of swelling as to greatly change 
 the resistance afforded by the splint. The author 
 has seen a well-applied splint upon a limb consider- 
 ably swollen allow the fragments to fall out of ad- 
 justed position in a short time on account of subsi- 
 dence of swelling, and the splint itself afford no more 
 resistance to disturbing forces than a roofed-in frac- 
 ture-box. 
 
 In any argument concerning the value of a plaster- 
 of-Paris splint applied in a given instance, the par- 
 ticular resistance to incident forces which it connotes 
 should be exactly specified ; better, indeed, the specific 
 connotation should be used rather than the term it- 
 self, which is so variable in its connotation. 
 
 In compound fractures, or simple fractures with 
 
64 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 much injury to the soft parts, forbidding that degree 
 of compression by the splint to afford resistance to a 
 large range of incident forces tending to disturb the 
 practical immobility of the adjusted fragments, in 
 other words limiting the extension of the essential 
 attribute or factor, the incident forces are so disposed 
 by suspension apparatus as to extend the functioning 
 of the essential factor, thereby increasing the range of 
 coarse motion of the concerned organism. 
 
 The more clearly to understand the use of suspen- 
 sion apparatus in its relation to the extension of the 
 essential factor, it will be instructive to trace in the 
 evolution of its functioning the forms of apparatus 
 that have been described, as formerly used in Bellevue 
 Hospital. 
 
 The simplest form of suspension apparatus is that 
 in which the broken leg is suspended by loops of 
 bandage dependent from a simple cradle placed over 
 the limb. This apparatus is a distribution of condi- 
 tions modifying the incident forces otherwise disturb- 
 ing the essential attribute (maintained practical im- 
 mobility) in such a manner as to extend the relations 
 of the attribute, as shown by the enlargement of the 
 field of coarse motion of the afflicted organism, mean- 
 while preserving the essential factor in its efficient 
 operation. 
 
 Dr. Van Wagenen's excellent appliance so modi- 
 fied the distribution of disturbing forces as to extend 
 the functioning of the essential factor or attribute 
 as shown by the greater enlargement of the field of 
 coarse motion of the concerned organism, the opera- 
 tion of the essential factor being preserved. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 65 
 
 The apparatus contrived by the writer still further 
 modifying the distribution of disturbing forces, in 
 such wise as to extend the functioning of the essential 
 factor, is shown by a larger range in the field of 
 coarse motion on the part of the organism. 
 
 In recapitulation. Appliance No. 1 modified the 
 incident forces acting upon the lower fragment prin- 
 cipally in a single plane so that the patient could 
 move the broken limb in a single plane without the 
 disturbance of maintained practical immobility of the 
 fragments, a resulting slight enlargement of the pa- 
 tient's field of coarse motion. 
 
 Appliance No. 2 (Van Wagenen's) modified in- 
 cident forces operating in more planes and especially 
 those forces operating upon the lower fragment to 
 prevent rotation of the limb on its longitudinal axis, 
 without disturbance of the fragments in adjusted re- 
 lation, a resulting decided increase in the patient's 
 field of coarse motion. 
 
 Appliance No. 3 (the writer's) modified the dis- 
 tribution of incident forces operating in more planes 
 and upon more axes: resulting in still greater in- 
 crease in the patient's field of coarse motion without 
 disturbance of the maintained immobility of the frag- 
 ments. 
 
 The three appliances respectively, were distribu- 
 tions of environing conditions affecting incident 
 forces tending to disturb the extension of the essen- 
 tial attribute common to all three methods of treat- 
 ment. They were extensions of the functioning of 
 that factor as shown by the increasing degrees of en- 
 largement of the field of coarse motion of the pa- 
 
66 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 tient, the action of the essential factor being always 
 preserved. 
 
 As a general principle, unless special reasons con- 
 tradict, the suspended linib should be elevated as little 
 as possible above the plane upon which its healthy 
 fellow rests. A notable exception is suspension in 
 vertical traction of a simple fracture of the femur in 
 a child, which strictly analyzed gives the greatest 
 range of coarse motion of the individual, the essen- 
 tial attribute of practical mimobility of the fragments 
 being preserved. 
 
 The elastic suspension acting from a single point 
 was advantageous in modifying the resistance to ele- 
 vating the limb, which was of importance in extend- 
 ing the range of coarse motion in certain critical 
 conditions of the patient, like delirium. 
 
 Having considered diverse categories of distribu- 
 tions of conditions in the influence upon the exten- 
 sion of the essential factor or attribute as expressed 
 by results interpreted in terms of degrees of coarse 
 motion of the concerned organism, we now compare 
 the various categories of distributions of conditions 
 in reference to their inseparable accidents or charac- 
 teristics in their influence upon the organism, apart 
 from the influence upon the essential factor. This is 
 expressed through a common medium of proof of 
 their value. We have divided this consideration 
 under two heads, one the modification of the con- 
 cerned organism expressed in terms of function, and 
 two, the special or therapeutic influence of such 
 distributions of conditions as exerted by extrinsic 
 apparel. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 67 
 
 One: It is to be understood in our consideration 
 that the signification of function is not arbitrarily 
 limited to modification of the responses usually ex- 
 pressed by normal or healthy tissue, but is extended 
 to include all responses of the concerned tissues. This 
 comparison is perhaps best made by a study of the 
 categories of distributions of conditions themselves, 
 taking for our study as illustrative examples three 
 different methods of treatment of a given fracture 
 of the leg, first, in a fracture-box; second, by mov- 
 able side-splints, and third, by immovable plaster- 
 of-Paris splint. 
 
 So far as relates to ordinary phases of functioning, 
 the first or simple support in the fracture-box (con- 
 sidered apart from the essential factor) imposes the 
 least limitation upon ordinary function. Such dis- 
 tribution also imposes the least restraint upon surgi- 
 cal relations of the injury. In the latter respect the 
 injury is open to inspection, palpation and extended 
 surgical treatment. 
 
 In the second category, that of movable side-splints, 
 there is greater restraint upon what is termed normal 
 functioning, and there is also greater restraint upon 
 the functioning of the limb in reference to surgical 
 relations. The tissues are not so readily open to in- 
 spection, palpation, or surgical treatment. 
 
 In the third category, that of the immovable plas- 
 ter-of-Paris splint, there is a still greater restriction 
 than in the other two categories, upon the normal 
 functioning of the limb. The tissues are withdrawn 
 from inspection, palpation, and are not open to a 
 range of surgical procedures. 
 
68 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 In recapitulation, the first category of conditions 
 imposes the least restraint upon, or limitation to 
 functioning responses, including surgical relations. 
 The second imposes a greater limitation of responses, 
 and the third and greatest of all limitations of re- 
 sponses, limiting the surgical relations to a near ap- 
 proach to the vanishing point. 
 
 In therapeutic influence, which is really a phase of 
 functioning, the first category of conditions imposes 
 no special therapeutic influence upon the tissues be- 
 yond physical rest; the second category imposes the 
 deleterious influence of more or less confinement and 
 withdrawal from the light; the third category accen- 
 tuates the effects of confinement and absence from 
 light and air, to which may possibly be added a special 
 influence from the material of the permanent apparel 
 itself. Broadly expressed, the therapeutic influence 
 of the environing distribution of conditions in the third 
 instance is at the maximum ; in the second category it 
 is in moderate degree; and in the first category it is 
 near the vanishing point. 
 
 The therapeutic influence of the plaster-of-Paris 
 splint is of such great importance as to demand ex- 
 tended consideration. It is not to be overlooked that 
 in the early stages of its application the plaster-of- 
 Paris apparel exerts a beneficent influence upon the 
 included tissues mainly by inducing rest and quieting 
 muscular action. The injurious effect of the splint is 
 cumulative, increasing with the duration of its appli- 
 cation. Great changes are induced in the skin as 
 shown by its anaemia and readiness to become oedema- 
 tous. Nor is the deleterious influence of the splint 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 69 
 
 limited to the skin, but extends to all soft tissues and 
 even to the bones themselves. The changes in the 
 soft parts are not only evident but also invisible, and 
 are strikingly illustrated by their behaviour under 
 infection. 
 
 In preantiseptic days when Bellevue Hospital was 
 saturated with infection, great care was exercised in 
 the removal of splints lest the skin be scratched and 
 infected with erysipelas. Nevertheless, erysipela- 
 tous infection frequently occurred. The destruction 
 wrought by such infection upon the tissues that had 
 been covered by the splint was wide-spread and in 
 some instances accompanied by unusually large and 
 deep sloughs of subcutaneous tissues. In some in- 
 stances the erysipelatous inflammation would rapidly 
 sweep over the limb affecting the portion formerly 
 encased in the splint, and then stop abruptly in a 
 sharp circular line, bounding the upper limit of the 
 splint. 
 
 The deleterious therapeutic influence of the splint 
 was in addition also otherwise shown in striking man- 
 ner as affecting the union of the bony fragments. In 
 one illustrative instance, a patient with a compound 
 fracture of both bones of the leg, had been treated 
 in a plaster-of-Paris splint without suspension of the 
 limb, for more than six weeks. Suppurating sinuses 
 connecting with the wound had formed, as was fre- 
 quently the case in such injuries. The wound was 
 not yet healed when the splint was removed. There 
 was no union of the bones whatever, and the limb 
 taken from the splint was placed in a fracture-box. 
 The exposed limb, enjoying its larger functional 
 
70 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 range, was then frequently sponged, and stroked with 
 the hand, the immobility of the fragments meanwhile 
 not being disturbed. To the astonishment of the 
 House Staff, in four days the leg began to stiffen and 
 heaHng progressed rapidly to a complete union of 
 the fragments. 
 
 A patient with a simple fracture of both bones of 
 the leg at the middle of the leg, was in the middle 
 period of pregnancy. After the limb had been en- 
 cased in a well-fitting plaster-of-Paris splint for six 
 weeks she came under the writer's care. There was 
 no union of the fracture whatever. There was free 
 angular motion at the site of fracture. The limb was 
 forcibly douched 'with hot and cold water alternately, 
 always leaving off with the cold douche. The limb 
 was gently massaged three times daily, and the pa- 
 tient was encouraged to exercise the muscles of the 
 affected limb under the stimulus of the will, the frag- 
 ments during all procedures being held immobile. 
 The splint, which had been cut down in the anterior 
 median line was used as a movable apparel, and w^orn 
 only when the limb was exposed to injury, and con- 
 sequently was very seldom upon the limb during the 
 day-time. In a very few days the fragments began 
 to unite; the bones stiffened and union progressed 
 uninterruptedly to solidity. 
 
 In other patients, where there had been long de- 
 layed union from prolonged confinement in immov- 
 able plaster-of-Paris splints, with apparently hope- 
 less prospect of union, indeed, in two cases that had 
 been condemned to operation, the same practice of 
 revivification narrated above (persistent invitations 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 71 
 
 to increase of function) was completely successful in 
 steadily effecting complete and solid union of the 
 fragments. 
 
 The measures were strikingly successful in one re- 
 markable case in private practice, of delayed union 
 of fracture of the humerus of several weeks' duration 
 which seemed hopeless of union and in which the open 
 operation upon the fragment had been advised as the 
 only presumed remaining resource. 
 
 In the author's own practice, which was very ex- 
 tensive, he rarely had an instance of delayed union 
 and, according to his recollection, never an instance 
 of non-union in any variety of fracture. 
 
 In brief, the plaster-of-Paris splint, in its mechani- 
 cal, essential attribute embodies the greatest mechani- 
 cal resistance to forces tending to disturb the con- 
 tinuous practical immobility of the fragments in their 
 adjusted relation, as shown by the extension of that 
 attribute as a functioning variable, its superior ex- 
 cellence being shown by the large range of coarse 
 motion of the organism, the practical immobility of 
 the adjusted fragments being maintained. On the 
 other hand, in its non-essential, constant attribute, 
 that is, in its inseparable accidents or characteristics, 
 so far as its therapeutic influence is concerned, it is 
 the most deleterious of all extrinsic appliances that 
 have been reviewed. It is very restrictive of function 
 of the included tissue, giving to the term function its 
 broadest signification. 
 
 This restriction for a limited time of early treat- 
 ment is beneficial by quieting the muscles and thereby 
 indirectly assisting in the maintenance of immobility 
 
72 PEIXCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 of the fragments. The induced oedema also assists in 
 the tight packing of the splint thereby promoting its 
 mechanical efficiency. In its continued application, 
 however, by its restriction of the surgical relations of 
 the limb (its surgical functioning) by preventing in- 
 spection and palpation, it greatly diminishes the range 
 of choice of beneficial surgical measures otherwise 
 included in the categories of conditions constituting 
 the treatment of the injury. The distinctly bad 
 therapeutic influence of the splint upon all included 
 tissues, said injurious influence being cumulative and 
 proportioned to the duration of the application of the 
 splint is in strong contrast with the distinctly bene- 
 ficial influence of the contradictory in categories of 
 conditions, which enlarge the functioning of the 
 tissues, using the term functioning in its widest 
 signification. 
 
 It follows therefore that in the distributions of con- 
 ditions through the use of extrinsic apparel, to evoke 
 the largest responses from the organism the plaster- 
 of-Paris splint should be applied during the earlier 
 stages of treatment when the adjusted fragments 
 may be the more easily distributed in their immobility 
 and when the tissues are healthy. In the latter stages 
 of treatment when the fragments may be the more 
 easily held immobile, the plaster-of-Paris splint 
 should be discarded and for it should be substituted 
 some form of movable splint which, while continuing 
 equally well the operation of the essential factor of 
 maintained practical immobility at the same time al- 
 lows a larger response to be evoked from the func- 
 tioning tissues. 
 
 In the author's treatment of compound fractures 
 
PRINCIPLES OF TEEATMENT OF BROKEN LIMBS 73 
 
 in preantiseptic days in an infected hospital, the 
 plaster-of-Paris splint was gradually discarded by 
 him. Instead of the splint there were substituted 
 appliances which permitted an enlarged range of sur- 
 gical treatment. To reach and treat complications 
 of the septic wound, the window in the splint was at 
 first enlarged, then further enlarged, and finally the 
 obstructing envelope of the splint was discarded alto- 
 gether. To give extension to the essential factor 
 under such circumstances, special appliances were 
 devised, which in the author's hands yielded satis- 
 factory results. Some control was exerted over the 
 inunobility of adjusted fragments as shown by some, 
 though limited, range of coarse motion. The inju- 
 rious therapeutic influence of the splint was elimi- 
 nated and an extended surgical functioning range of 
 the tissues was secured. 
 
 Some of the appliances used were somewhat com- 
 plex in construction but quite simple and effective in 
 action. In their turn, efficient antiseptic measures 
 totally changed the distribution of conditions in 
 wound treatment, and allowed the substitution for 
 the complicated treatment of compound fractures of 
 a category of conditions closely allied to that used in 
 the treatment of simple fractures. This of course 
 resulted in its turn in a further extension of the opera- 
 tion of the essential factor as marked by an increase 
 in the range of coarse motion, the maintained practi- 
 cal immobility of the adjusted fragments being un- 
 disturbed by incident mechanical forces ; at the same 
 time the influence of the wound as a complicating 
 element was reduced to the vanishing point. 
 
74 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 In the instance of simple fracture of both femora 
 at the middle of their shafts, after the immovable 
 splints had been applied, the patient was anchored 
 in one position in bed from which he could not move 
 except when helped. He very soon became dis- 
 pirited and lost strength. The suspension appliance 
 shown in the photograph was at once devised. By its 
 means the patient's range of coarse motion was im- 
 mediately enlarged, with a consequent improvement 
 in morale and gain in strength. His increase in 
 weight kept the splint a snug fit and consequently 
 an efficient mechanical resistance to incident mechani- 
 cal forces. The splint was not once changed till it 
 was finally removed, when the fractures were found 
 united without deformity and of equal length. Such 
 a result is indeed even apparent from an inspection 
 of the photograph showing the limbs still encased in 
 the splints. 
 
 To generalize : — ^We have found that the measure- 
 ment of the essential attribute (maintained immo- 
 bility), under extension from a zero toward a maxi- 
 mum, comprehends variation in coarse motion of the 
 concerned organism. This variation extends from a 
 lessened degree caused by injury, through a range of 
 increased motion toward a maximum, which maxi- 
 mum is a proximate measuring test of the realization 
 of the criterion of excellence. These variations in 
 coarse motion, though classified as variations in spe- 
 cial functionings of the organism, may be generalized 
 as responses of given states of the organism to given 
 distributions of conditions constituting the phases of 
 treatment of the injuries. Likewise, the variations of 
 
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PRINCIPLES OF TREATMENT OF BROKEN LIMBS 75 
 
 the characteristics of treatment (the inseparable ac- 
 cidents) extend through a range from a zero to a 
 largest functioning, which functioning, however spe- 
 cialized in classfication, may be constituted and made 
 measurable as responses of the given states of the 
 organism to given distributions of conditions, all be- 
 ing in relation to, and measuraJble by, the criterion of 
 highest excellence constituted by the largest number 
 of responses. 
 
 It is thus found that both the essential attribute, 
 and the inseparable accidents (characteristics) of all 
 methods of treatment (exhausting the subject-matter 
 under study) may be generalized under the common 
 head of responses of the concerned organism to the 
 distributions of conditions to which it is exposed by 
 the proceedings of surgical art. 
 
 The measure of quality is necessarily quantitative 
 and in the last analysis is resolvable into and expres- 
 sible in terms of number. 
 
 It is gratifying to find that the conclusion, inde- 
 pendently reached through our induction, harmonizes 
 with the Spencerian definition of Life. 
 
 Spencer, in his "First Principles," says: "Divest- 
 ing the conception of all superfluities and reducing 
 it to its most abstract shape, we see that Life is de- 
 finable as the continuous adjustment of internal rela- 
 tions to external relations. And when we so define 
 it we discover that the physical and the psychical life 
 are equally comprehended by the definition." 
 
 Such continuous adjustments are expressed in re- 
 sponses of the organism and may be quantitatively 
 measured in terms of number. The individual life 
 
76 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 as a variable, measurable in terms of number, ob- 
 viously extends in variation from a zero, or vanishing 
 point, to a maximum number of responses. 
 
 The categories of distributions of conditions con- 
 stituting the treatment of injuries evoke a variable 
 number of responses, which variations in number ex- 
 tend from a zero to a maximum. In our ideal scheme 
 of values the criterion of highest excellence is con- 
 stituted by the maximum number of responses. 
 
 Practically, the surgeon is always engaged in 
 determining by observation, and defining the cate- 
 gories of conditions embraced in varying states of the 
 organism. His treatment consists in supplying to the 
 defined categories of conditions embraced in given 
 states of injury given categories of distributions of 
 conditions. The categories of responses evoked from 
 the organism, constituting the results of treatment, 
 are measurable by the connoted number of responses. 
 Their value is estimated in relation to a maximum 
 number of responses, constituting the practical reali- 
 zation of approach to the maximum number of re- 
 sponses constituting the ideal of supreme excellence. 
 It follows therefore in comparison of the value of 
 methods judged by their results, that that method of 
 treatment is better and to be preferred over another, 
 which in its result evokes the larger number of re- 
 sponses measured in the presence of the criterion of 
 highest value, the maximum number of responses. 
 
 The results of treatment in connoted responses* 
 called forth from the concerned organism by the cate- 
 gory of distribution of conditions to which it is ex- 
 posed, in their effects are immediate, cumulative and 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 77 
 
 remote, extending their influence to the social or- 
 ganism. 
 
 It will be observed that the criterion of value 
 though most general in expression includes classified 
 functions of the organism, modes of relation. 
 
 In the complex and variable subject-matter em- 
 braced in the province of surgery, the formation and 
 definition of distinct groups or categories is an im- 
 portant task. 
 
 These categories embrace states of the organism, 
 distributions of conditions constituting surgical treat- 
 ment of said states, and categories of responses con- 
 stituting the given results of treatment. 
 
 Refinements of observation, changes in the or- 
 ganism itself, the invention of new distributions of 
 conditions in treatment, lead to the creation of new 
 categories and their consequent definition. 
 
 The multiplication of instances in categories al- 
 ready constituted and defined, as an end in itself, is, 
 scientifically viewed, an unnecessary loading of the 
 record in confirmation of that which has already been 
 established. 
 
 The writer knew a surgeon who died unhappy be- 
 cause he had performed a certain operation only 
 ninety-nine times, failing to obtain and operate his 
 hundredth patient. And yet, all his operations added 
 nothing new to categories already known and defined, 
 extended no new embodied principle and after all, 
 only, as is too often the case, burdened the record to 
 no commensurate useful end. Indeed, the very 
 operation which he performed with so much skill and 
 pride was very properly superseded before his death 
 by another operation attaining the same object 
 
78 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 equally well, and with the advantage of expressing 
 much greater scope. 
 
 To sum up: A given fracture is a given definable 
 category of conditions of the state of the injured or- 
 ganism. A given treatment of the fracture is a given 
 definable category of distribution of conditions to 
 which the given injury is exposed. The result of 
 treatment is a given definable category of responses 
 evoked from the injured organism consequent upon 
 its exposure to the given category of distribution of 
 conditions constituting the treatment. The criterion 
 or measure of value of the results of treatment is the 
 largest number of evoked responses, in practical reali- 
 zation of approach to the conceived ideal of maximum 
 number of responses. 
 
 There may be difficulty in determining and defin- 
 ing the given categories but the method of determi- 
 ning values remains alticays the same and immutable, 
 unaffected by, and independent of, the dicta of per- 
 sonal authorities or the consensus of opinion. 
 
 Reduced to syllogistic form, that method of treat- 
 ment when compared with another is better and to be 
 preferred, that evokes the larger number of connoted 
 responses from the category of distribution of con- 
 ditions to which the injury is exposed, in practical 
 realization of approach to the ideal of supreme ex- 
 cellence, which is that of the largest number of re- 
 sponses. A certain method of treatment in its results 
 shows a larger number of responses in practical reali- 
 zation of approach to the ideal of maximum number 
 of responses when compared with others, and is there- 
 fore the better method and should, in obedience to 
 ethical requirements, be preferably adopted. 
 
SEPTIC SATURATION OF BELLEVUE 
 
 HOSPITAL IN THE SEVENTIES. 
 
 BATTLE AGAINST SEPSIS 
 
 The saturation of Bellevue Hospital, in the seven- 
 ties, with erysipelas infection is well illustrated by 
 the following example: On one occasion in entering 
 upon his term of service, the writer found in his ward 
 a patient suffering from a discharging sinus of the 
 brain caused by a pistol-shot wound inflicted six 
 weeks before (see Plate XX, Fig. A). The sinus 
 having definite walls was easily probed and the ball 
 touched near the centre of the brain. Small hair-pin 
 like retractors were made of wire. The brain was 
 slightly incised and the imbedded ball was plainly 
 seen in its position. It was seized with proper for- 
 ceps, but was felt to resist traction upon it very much 
 as a button sewn upon a coat. The ball was partly 
 encysted. It was wiped clean and a small flake of 
 lead was picked from it with forceps. Recognizing 
 that an attempt to remove the ball was fraught with 
 great danger and being under the obligation not to 
 perform any dangerous operation upon the patient, 
 manipulation was restricted to wiping the sinus clean 
 with the object of disinfecting and healing it. The 
 sinus healed kindly till only a spot of granulations 
 about the size of the thumb-nail remained. 
 
 79 
 
80 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 At a visit at this time to inspect the wound, the 
 corner of the covering antiseptic dressing was lifted 
 just enough to give a view of the wound. The gauze 
 stuck to the granulations and in lifting it a bleeding 
 of two or three drops was caused. Just at that mo- 
 ment a near-by door leading into the corridor and 
 stairway was opened permitting a strong inrush of 
 cold air. The door was instantly shut. This hap- 
 pened at the very instant the dressing was lifted and 
 sight caught of the wound. At the same moment the 
 gauze which had not been removed clear from the 
 head, but turned slightly back, was at once turned 
 down and bandaged again in position. The whole 
 incident occupied but a few seconds. The patient 
 was shortly afterward seized with a chill and affected 
 with erysipelas spreading from the wound. His head 
 swelled enormously, closing his eyes, etc. Fortu- 
 nately the erysipelas ran a favorable course without 
 suppuration. The patient recovered and was dis- 
 charged cured. 
 
 It was clear that the broken small spot of granula- 
 tions was infected during the brief exposure at the 
 time the blast of air came in through the opened door. 
 The writer hav'ing no case of erysipelas in his wards 
 was interested in tracing the source of infection. He 
 found the ward immediately below the one occupied 
 by his patient was being dismantled for fumigation, 
 on account of an outbreak of erysipelas which had 
 affected three or four patients, spreading from bed 
 to bed, adjoining. It was perfectly clear, therefore, 
 that the infection originating in the ward one flight 
 of stairs below, had passed into the corridor, lurked 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 81 
 
 upon the stairs, and entered the writer's ward upon 
 the blast of air when the door was opened. 
 
 The septic condition of the wards was so generally 
 known that it had become a matter of public noto- 
 riety. Patients dreaded to be carried into Bellevue 
 Hospital and with good reason. Their outlook for 
 recovery from serious wounds would have been far 
 better had they been operated upon in the open street 
 where they had been injured, and afterward cared for 
 there by the charity of the passers-by. The Hospital, 
 although provided with a staff of brilliant surgeons, 
 was a centre of danger. It was the only large hos- 
 pital that served the needs of a great and growing 
 city and was crowded with patients suffering from 
 open wounds. The writer never saw a healthy open 
 wound for the year and a half while he was interne 
 of Bellevue Hospital. The simplest as well as the 
 most serious wounds alike became infected, and pa- 
 tients in greatest proportion of instances died from 
 septicemia and pyaemia. The complications due to 
 sepsis were a great discouragement to operative pro- 
 cedures and as a consequence attention and skill were 
 concentrated and lavished upon bloodless operations. 
 The peculiarities of the practice of septic surgery 
 required great skill and trained judgment and stress 
 was very properly laid upon the education of the 
 hands, or as expressed in established phrase, the 
 ''t actus eruditus." 
 
 The great prevalence of sepsis early drew the 
 writer's attention to the invention of preventive meas- 
 ures against the dread disease. Thinking that per- 
 haps the poor nourishment provided by the Hospital 
 
82 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 was a factor of some importance, he organized a pri- 
 vate source of food supply for certain patients suffer- 
 ing from the most serious open wounds and primary 
 amputations. The better feeding had no perceptible 
 influence in diminishing the occurrence of septicaemia. 
 He next directed his attention to the overcrowded 
 condition of the wards with open wounds. Acting 
 upon this line of thought, he cleared one of the larg- 
 est wards of all patients having any open wound what- 
 soever. In such a ward, he placed a patient with a 
 primary amputation, the operation, of course, having 
 been most skilfully performed by an exceptionally 
 experienced surgeon. This patient was unremittingly 
 attended night and day by the best nurses, and pro- 
 vided with the best nourishment. In spite of all, he 
 developed septicemia and followed the fatal course 
 of his predecessors. 
 
 About this time, the writer was selected to take 
 charge of and reorganize "the Park Reception Hos- 
 pital." This was the first reception hospital that 
 was established in the city. It cared for all emer- 
 gency patients in the lower part of the City, below 
 Canal Street, and had been in operation between two 
 and three years. Although a great many patients 
 were transferred from the Reception Hospital to 
 Bellevue Hospital, yet its wards were crowded with 
 patients suffering from serious injuries. 
 
 The large number of deaths from septicaemia in 
 Bellevue Hospital was of such common knowledge 
 that the newspapers mooted the advisability of tear- 
 ing down that great Central Hospital and building 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 83 
 
 in its stead, at different places about the City, numer- 
 ous small hospitals. 
 
 A committee of the Medical Board of Bellevue 
 Hospital investigating the matter found that a 
 greater proportion of patients died from septicaemia 
 and pyaemia in the small Reception Hospital than in 
 Bellevue Hospital. Patients were dying in "The 
 Park Reception Hospital" from those complications 
 when the writer took charge. Experience in Bellevue 
 Hospital had taught the writer that skilful perform- 
 ance of operations, combined with nourishment with 
 the best food, the most careful nursing, together with 
 reducing the number of open wounds in a ward to a 
 single wound, all, had no perceptible influence in pre- 
 venting the disease. One factor remained and that 
 was the influence of the environing walls of the hospi- 
 tal wards themselves. In Bellevue Hospital the floors 
 had been washed and the bedding changed frequently 
 enough, but the walls of the wards had not been 
 washed within recollection. The writer reasoned that 
 the infected walls constituted the efficient causative 
 factor of which he was in search. Accordingly, in 
 assuming control of the Park Hospital in which, as 
 stated, patients at the time were dying from infec- 
 tion, he directed his attention to the walls of the 
 wards, in addition to other measures of cleanliness. 
 The hospital building was an old one, and there were 
 many cracks in the walls. Under the writer's own 
 supervision, the walls were thoroughly washed with 
 soap and water, the ceilings were whitewashed and 
 all cracks were injected with a 5 per cent, watery 
 solution of carbolic acid. And this was frequently 
 
84 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 and thoroughly done under supervision, as a matter 
 of routine. 
 
 The Hospital after that procedure was more 
 crowded with serious open wounds than ever before, 
 and yet, after the first two weeks, when the system 
 had been thoroughly brought into efficient operation, 
 no case of septiccemia or pycemia ever occurred during 
 the writer's charge of the hospital which was for a 
 peiiod of nearly two years. As a gratifying conse- 
 quence the death-rate of the Hospital was reduced 
 30 per cent., although retaining many operative cases 
 of a class that had hitherto been transferred to 
 Bellevue Hospital; all of which facts were made a 
 matter of official record. 
 
 On account of this successful administration of the 
 Park Hospital, especially in the matter of suppress- 
 ing the occurrence of septicaemia and pyaemia, the 
 writer was appointed to take charge, in addition, of 
 the Ninety-ninth Street Reception Hospital. This 
 latter Hospital cared for emergency patients in the 
 upper part of the City, above Fifty-ninth Street. It 
 was six miles distant from the Park Hospital, sit- 
 uated in a newer and fast gi'owing part of the City 
 where, at the time, many public improvements were 
 in progress. The record of the Ninety-ninth Street 
 Hospital when the writer assumed sole medical and 
 administrative charge, was similarly bad as regards 
 infection as was formerly the case in the Park Hos- 
 pital. From his experience in the Park Hospital 
 he anticipated no doubt that the same measures that 
 had been so conspicuously successful there would be 
 equally happy in their results when vigorously en- 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 85 
 
 forced in the Ninety-ninth Street Hospital. In this, 
 however, he was disappointed. It is true that the 
 occurrence of septicEemia was reduced in frequency, 
 nevertheless, it continued to occur, and the writer 
 recognized that his measures of elimination of that 
 infection, though strictly carried out, were only par- 
 tially successful. 
 
 While puzzling to discover the missing contribu- 
 tive factor causing failure of his efforts, one day as 
 he was turning the leaves of the record-book of the 
 very large Out-Patient Service connected with the 
 Hospital, he was struck with the great number of 
 patients that applied and were treated for some form 
 of malarial poisoning. Upon investigation he found 
 that at times a large number of workmen engaged 
 in digging the streets in the vicinity for the laying 
 of the great water-mains, were incapacitated and laid 
 off from work on account of malarial poisoning. 
 Further, every member of the House Staff living in 
 the Hospital had been at times affected during his 
 residence, and frequently members of the Staff were 
 incapacitated for duty on that account. He also 
 noticed that otherwise healthy patients, admitted to 
 the Hospital for injuries other than open wounds, 
 became affected with malarial poisoning while staying 
 in the wards. Added to this, he was called upon to 
 visit a patient living in a shack next to the Hospi- 
 tal whom he found dying, distinctly from malarial 
 poisoning. 
 
 The conclusion was irresistibly forced upon the 
 writer that the Hospital was situated in a zone of 
 intense malarial infection, and he reasoned that the 
 
86 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 depression caused by that poison was the missing 
 overlooked factor contributive to the causation of 
 septicaemia and pyaemia which was not present in the 
 Park Hospital. Accordingly, he gave orders that 
 every patient admitted into the Hospital suffering 
 from any open wound should immediately be brought 
 under the influence of quinine and that a mild de- 
 gree of cinchonism should be maintained during the 
 whole course of his wound treatment. This measure, 
 combined with those previously instituted, proved 
 sufficient to control, by prevention, the further oc- 
 currence of septicaemia and pyaemia. Not another in- 
 stance of the disease occurred thereafter, during the 
 writer's continued charge of the Hospital, for more 
 than a year. 
 
 The battle fought by the writer for the prevention 
 of septicaemia and pyaemia, which has been described 
 somewhat in detail, concerned the environment of the 
 patient, conditions remote from the wound. It re- 
 lated to what may be termed the first line of defense 
 of the wound. 
 
 In Belle vue Hospital, in preantiseptic days, for 
 various reasons, interesting in themselves, but which 
 in adequate consideration would extend this note too 
 far, very little attention was paid to this first line of 
 defense. The members of the Visiting Staff in im- 
 mediate authority over the wards were constantly 
 changing service and consequently there was no ad- 
 ministrative authority alive to its importance, con- 
 tinuously caring for this defense. In the progress 
 of years great attention has been given to this first 
 line of defense by improved hospital construction 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 87 
 
 and, equally important, in hospital organization and 
 management. As a consequence the Hospital which 
 was formerly a centre of infection and danger has 
 become a refuge of safety in its model construction 
 and intelligent sanitation. The first line of defense 
 concerns the care of environing conditions remote 
 from the wound. The second line of defense con- 
 cerns the proximate distribution of conditions of the 
 wound itself. 
 
 It is greatly to be desired that "antiseptic meas- 
 ures" comprehended in the second line of defense 
 should be standardized. 
 
 How often has the writer seen a surgeon employ 
 "antiseptic measures" which would have proven sadly 
 defective but for the perfection of the first line of 
 defense. Such a surgeon would have resented the 
 imputation that the complex conditions connoted by 
 his "antiseptic measures" were in any feature defec- 
 tive. Much might be written in amplification of this 
 point which is left to the reflection of the thoughtful 
 reader. 
 
 Broadly considered, the clinical experiences of the 
 writer with septicemia and pyemia on a considerable 
 scale in Bellevue, Park, and Ninety-ninth Street 
 Hospitals, seem to justify certain interesting deduc- 
 tions. 
 
 In Bellevue Hospital in preantiseptic days the in- 
 tensity of the incident cause of sepsis was fatal in a 
 large class of recent wounds. 
 
 In the Park Reception Hospital, equally infected 
 as Bellevue Hospital, the surgical and administra- 
 tive measures narrated, directed against the incident 
 
88 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 cause, so modified that variable as to eliminate the 
 septic wound complications. 
 
 In the Ninety-ninth Street Reception Hospital, 
 similarly infected, the same measures directed against 
 the incident cause that were so strikingly successful 
 in the Park Hospital were at first only partially suc- 
 cessful. When, however, with those only partially 
 successful measures were combined other measures 
 combating another incident cause (malarial poison- 
 ing) the results were as good as those obtained in 
 the Park Hospital. 
 
 It is highly improbable that the measures taken 
 against sepsis were operative to the extent of totally 
 excluding the incident cause, that they reduced the 
 number of germs to a zero. ISTevertheless, the varia- 
 ble incident cause was modified to that degree as to 
 be harmless. 
 
 The incident cause of sepsis was a variable; the 
 incident cause in combination with that of sepsis 
 (malarial poisoning) was also a variable. 
 
 The modifiable malarial influence was practically 
 eliminated or reduced to harmlessness by means of 
 quinine, thus placing the patients in the Ninety-ninth 
 Street Hospital in practically the same relation to 
 sepsis as those in the Park Hospital, insuring a like 
 consequent favorable result. 
 
 It cannot be held that quinine had a controlling 
 specific influence over the septic cause, for it should 
 be remarked that quinine had been tried in Bellevue 
 Hospital for that purpose, even by the writer, and 
 although enormous doses of the medicine had been 
 given, it had only shown a temporary influence over 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 89 
 
 the temperatures of the patients and no apparent in- 
 fluence over the fatal course of sepsis. 
 
 It is also interesting to note (see the N. Y. Medi- 
 cal Record, June 7, 1890) that in the presence of the 
 most virulent intensity of the septic cause the writer 
 under strict antiseptic precautions performed a num- 
 ber of operations of suturing simple fractures of the 
 patella by the open method in all stages and condi- 
 tions of the injury, without the formation of pus or 
 the occurrence of any septic complications whatso- 
 ever ; and that this was done and the results achieved 
 in the same wards where compound fractures of 
 the patella, before the introduction of antiseptic treat- 
 ment, were otherwise so generally fatal that the writer 
 regarded a prompt primary amputation at the lower 
 third of the thigh, the site of election, as affording 
 the best chance of saving the patient's life. 
 
THE OPEN OPERATIOX IX THE TREAT- 
 MENT OF SIMPLE FRACTURES CON- 
 SIDERED IX ITS LOGICAL RELATION 
 TO THE ASSERTIOX OF A XEGATIVE 
 
 It will be noted that the extrinsic splint regarded 
 as a part of a truss is most effective when it can be 
 secured in relation to a considerable extent of the 
 upper and lower fragments. The joints in close prox- 
 imity to the false points of motion, must of necessity 
 be included within the operation of the truss. It is 
 especially difficult to obtain a grip through the mass 
 of soft tissues, upon the upper fragment in fractures 
 near the hip- joint. In connection with particular 
 difficulties in defining categories it is to be noted that 
 radiography has placed within the hands of the sur- 
 geon a wonderful means of determining the exact 
 condition of the broken bones. As the difficulties of 
 accomplishing extrinsic control over adjustment and 
 immobilization of the fragments become extreme, the 
 motive for using intrinsic appliances gains in force. 
 
 In preantiseptic days, in the treatment of a com- 
 pound fracture of the leg with much mobility at the 
 site of fracture the author had discarded the immov- 
 able plaster-of-JParis apparel as too restrictive of 
 surgical treatment of the wound. The supports of 
 the limb sometimes did not have sufficient control 
 
 90 
 
PRINCIPLES or TREATMENT OF BROKEN LIMBS 91' 
 
 over the adjustment of the fragments. Occasionally 
 in such cases the fragments were held by small iron 
 wire staples. Into the superficial shell of each frag- 
 ment was drilled a small hole and then the staple was 
 lightly hammered into place. These staples had only 
 a feeble hold upon the fragments and worked loose 
 in three or four days. 
 
 To act more efficiently the author constructed a 
 bridge or truss which could be easily taken apart or 
 assembled. It was made of steel screws carefully 
 plated and a connecting member of soft iron that 
 could be easily bent as desired with tools always at 
 hand. First, in each fragment was drilled a hole 
 barely large enough to take the thread of the screw. 
 The hole went through the superficial shell of bone 
 down to the inner surface of the opposite side of the 
 shaft. The screws were then driven home, their ends 
 resting against the opposite inner surface of the 
 shaft, and were thus firmly implanted. Next, the 
 fragments were adjusted in position and the connec- 
 ting member consisting of the strip of soft iron which 
 was slotted near its ends was so bent that it could be 
 slid into position in the open slots in the bodies of the 
 screws when the fragments were adjusted. Then iron 
 wedges were pushed into the slots of the connecting 
 member filling the open spaces on each side of the 
 bodies of the screws. Finally, the detachable caps 
 or heads of the screws were screwed on, consolidating 
 the bridge or truss into a rigid whole. This bridge 
 or truss was more efficient than the common iron wire 
 staples, yet it worked loose in a few days and was 
 removed. The drilling did not seem to harm the 
 
92 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 bones. The drill-holes speedily filled with granu- 
 lations. 
 
 This contrivance, together with the rest of the com- 
 plicated and delicate constructions described, was dis- 
 carded to give place to the practice of antisepsis w^hich 
 placed the treatment of compound fractures and the 
 adaptation of extrinsic apparel in a category closely 
 approaching that of simple fractures. 
 
 It is well to impress upon the mind, that in the 
 formation of categories in which given incident con- 
 ditions embodied in treatment are the subject of 
 negative assertion, a single successful affirmative in- 
 stance in the given category is logically destructive 
 of the universality of distribution of the negative as- 
 sertion essential to the validity of argument. For 
 example, it may be said that in the category of re- 
 cent oblique simple fractures in the lower third of 
 the shaft of the femur with much shortening, the 
 open operation with intrinsic fastening of the bony 
 fragments is necessary, which is tantamount to as- 
 serting the denial that in the given category other 
 methods, perhaps embodied in extrinsic apparel, are 
 productive of equally good union of the bones in cor- 
 rect position. This negative assertion derives its 
 logical force from the universality of its distribution. 
 A single successful instance of treatment by extrinsic 
 support limits the universality of that distribution, 
 destroys the validity of the argument and leads to 
 the necessity for the creation and definition of new 
 categories. 
 
 The photographs (see Plate XVIII) show dif- 
 ferent views of a specimen of an oblique fracture at 
 
Cd. 
 
 'X 
 
 
 OCKt. <,y. .' .■£ ^M2I>C^' ^: -/■WBfiMr^snracii 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 93 
 
 the lower end of the shaft of the femur which has 
 not only an interesting history, but strikingly illus- 
 trates the meaning of what has been said regarding 
 an affirmative instance limiting the universality of 
 distribution of the negative proposition. 
 
 The patient from whom the bone was taken was 
 the first instance of fracture of the shaft of the femur 
 which was ever treated by the author. Shortly be- 
 fore admission to the Hospital the patient suffered 
 from a simple fracture of the shaft of the femur from 
 direct violence with considerable shortening of the 
 limb. There was little tendency to swelling of the 
 injured soft parts. The writer applied an immov- 
 able plaster-of-Paris splint immediately. The patient 
 was out of bed in a day or two, walking about on 
 crutches. He made an uneventful recovery. Upon 
 removal of the splint, only one having been applied, 
 the fragments were found united without shortening 
 or other deformity. In time the patient was dis- 
 charged, cured, from the Hospital. 
 
 Several weeks later he was admitted into a medical 
 ward of the same institution suffering from nephritis 
 from which he died. 
 
 The bone, through the many years it has been kept, 
 has suffered some disintegi'ation at its spongy ends 
 but without impairment of its value as a specimen 
 of united fracture without deformity treated in the 
 plaster-of-Paris splint. The osteophyte is, of course, 
 extraneous to the subject under consideration. It 
 will be observed that although the line of fracture 
 was oblique in the extreme, the union was in all re- 
 spects a perfect one. 
 
94 PEINCIPLES OF TREATMENT OF BROKEN LIMBS. 
 
 The union of the fragments in perfect adjustment 
 as regards deformity shown in this photograph of the 
 fracture at the lower third of the femur was achieved 
 before the discovery of radiography, when it was 
 therefore impossible to show the perfection of results 
 in life as by an exhibit of the bone itself. 
 
 So far as tests could be made by measurements 
 and otherwise, perfect results like that shown in the 
 author's instance were the common occurrence. This 
 is even well shown through the applied splints in the 
 photograph of the patient with fracture at the middle 
 of both thighs. 
 
 The results were often so perfect that the writer 
 himself has sometimes heard a celebrated authority, 
 averse to the method for personal reasons, declare in 
 examining some patients that he had' no evidence that 
 the thigh-bone had ever been broken. 
 
 The objection to the use of the immovable plaster- 
 of-Paris splint in treating simple fractures of the shaft 
 of the femur was not directed against the character 
 of the results achieved, which in expert hands were 
 conspicuously superior to those of other methods then 
 in use, but was against the necessity of using that 
 high degree of skill for its perfect construction only 
 possible at the hands of trained operators. 
 
 The use of the splint was therefore not primarily 
 a question of results but of skill. The important 
 question arises, should skill be cultivated to that de- 
 gree capable of attaining results of higher value, or, 
 should inferior results be accepted, that are within 
 the reach of a lower degree of skill and consequently 
 more generally obtainable. To avoid an easy appli- 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 95 
 
 cation of the reductio ad absurdum to the argument 
 for lowering the aini in accommodation to a lower 
 degree of skill, but one answer is possible. Clearly, 
 skill should be cultivated to the degree of obtaining 
 results of higher value. Such cultivation of skill be- 
 longs to the function of educators. Since practice 
 founded upon experience is a necessary qualification 
 in such education, it follows that some degree of 
 specialization will probably be necessary to furnish 
 the needed instances for experience. 
 
 It will be noted that some of the open operations 
 on fractures of long bones now somewhat in vogue 
 are performed to correct the results of initial faulty 
 treatment. For that purpose they are a valuable 
 resource. Such instances lack force in an argument 
 against the original procedures when properly per- 
 formed and speak loudly for the cultivation of skill 
 since proper measures of treatment carried out with 
 adequate skill in the first instance might have pro- 
 duced satisfactory results, thus doing away alto- 
 gether with the need of the corrective measures of the 
 open operation. 
 
 The argument for the general performance of the 
 open operation is not parallel to, or comparable in 
 cogency with, that of the open operation for suturing 
 simple fractures of the patella. In the latter class 
 of injuries the infolded fringe of tissue practically 
 always prevents contact of the bony surfaces in ap- 
 position, and the open operation is therefore neces- 
 sary to lift away the interposed tissue to insure bony 
 imion. In fractures of the long bones generally, in- 
 terposition of tissues sufficient to prevent union under 
 
96 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 proper methods of treatment is a rarity. The author 
 has never seen but one instance. In that injury, a 
 compound fracture of the leg, the loose, detached 
 transversely interposed fragment was easily removed. 
 The burden of proof rests upon the operating sur- 
 geon to show that such an interposition of tissue or 
 other adverse condition exists in the given instance 
 to constitute a bar to union or union without deform- 
 ity under the best prescribed conditions of treatment, 
 consequently creating the necessity of the open opera- 
 tion. While deprecating the procedure as a routine 
 measure the writer does not deny that exceptionally 
 such states of fracture may occur and consequently 
 that infrequently the open operation may be advis- 
 able as a primary procedure. 
 
 If there exist categories of conditions of the frac- 
 ture of the shaft of the femur either in location or 
 character of the fracture in which the non-operative 
 treatment would fail in producing like happy results 
 to the one shown in the writer's specimen, it is highly 
 important that such categories embracing the excep- 
 tions should be accurately defined. 
 
 In view of the large number of successful instances 
 in which union without shortening or other deformity 
 has been achieved by skilled surgeons throughout dif- 
 ferent regions of the shaft of the femur under a wide 
 range of conditions of fracture, and under different 
 procedures of treatment, the great difficulty in cre- 
 ating and defining categories of exceptions in which 
 the open operation is a necessity is evident. 
 
 It is always to be remembered that a single success- 
 ful exception in any such created category by limit- 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 97 
 
 ing the universality of distribution of the negative 
 proposition vitiates the logical force of the category in 
 substantiating the assertion of the negative, that is, 
 in asserting the denial of the sufficiency of some non- 
 operative method to attain the proposed good result. 
 
 The burden of proof in justifying their action 
 rests, of course, with those who would assert the nega- 
 tive. The force of such proof must be overwhelming 
 to justify as a routine method of treatment the con- 
 version of recent simple fractures into compound 
 fractures, when results equally good or superior may 
 be obtained without inflicting a serious superadded 
 and unnecessary wounding of the patient and expos- 
 ing him to the risk of infection, which, when it occurs 
 in fractures of the shaft of the femur is a serious 
 disaster. When suppuration has spread among the 
 muscular planes of the thigh the author is of the 
 opinion that amputation affords the most efficient 
 drainage. 
 
 The patient with simple fracture of both thighs 
 (see Plates X and XI) would have been in a pitiable 
 plight had he been treated by the unnecessary open 
 operation, wherein, according to one apostle of the 
 method, "The incision which is always long" is "from 
 eight to ten inches." It is further to be noted the 
 intrinsic means "must be considered only of value 
 merely to approximate the fragments and not at all 
 sufficient to hold them. For this purpose the whole 
 reliance must be placed upon the solid external plas- 
 ter case, most accurately and carefully applied. If 
 this does not succeed in absolutely immobilizing the 
 fragments, the operation may fail." 
 
98 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 In view of occasional fallacies it is to be noted that 
 a bad result consequent upon an error in judgment, 
 fault of skill, or from any cause, in the performance 
 of this operation, as in the case of all operations, does 
 not in itself constitute a basis for argument against 
 the value of the result obtained in the successfully- 
 performed operation. 
 
 The author quotes in full from a recent Hospital 
 Report omitting the confirming radiographs, the re- 
 port of a successful instance of non-operative treat- 
 ment of a simple subtrochanteric fracture of the 
 femur, as an instance limiting the universal distribu- 
 tion of the negative proposition and therefore de- 
 structive to the validity of the argument in favor of 
 the necessity of the open operation for the given 
 group of patients. 
 
 "Two weeks previous to admission this patient, a 
 lady forty-eight years of age, had sustained this in- 
 jury while on vacation in the country. When brought 
 to the city and admitted to hospital the . . . upper 
 fragment was flexed and abducted and the lower 
 fragment was drawn upward producing a shortening 
 of one and a quarter inches. 
 
 "The patient was somewhat stout in habit and of 
 highly nervous temperament. The difficulties to be 
 overcome in securing satisfactory reposition of the 
 fragments were appreciated. We were familiar with 
 the fact that in this class of fractures position and 
 traction are usually so inefficient in overcoming dis- 
 placement that such a fracture is recognized as one 
 in which exposure and plating are especially indi- 
 cated. We hesitated therefore to rely on position 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 99 
 
 and traction in this case, notwithstanding that in no 
 case of this kind previously under our care had we 
 failed to get a satisfactory result either as regards 
 function, deformity or length. 
 
 "But in this particular case, taking into account the 
 length of time since the injury had been sustained 
 and the peculiar physical and temperamental status 
 of the patient, we earnestly advised that the fracture 
 should be exposed and coaptation secured by plating. 
 The patient herself, however, would not accept this 
 proposition, but insisted that first a non-operative 
 treatment should be tried. This was therefore in- 
 stituted. A slight flexion was obtained by keeping 
 the leg on a sliding Volkmann's apparatus, which 
 also reduced to a minimum the friction resistance to 
 the full effect of the extension traction. Counter-ex- 
 tension was provided not only by elevating the foot 
 of the bed, but also by the use of a suitable perineal 
 band secured to the head-post of the bedstead. A 
 pelvic band held the pelvis to the side of the bed cor- 
 responding to the sound limb, so that by placing the 
 traction pulley at the foot of the bedstead, close to 
 the opposite post, a good angle of abduction was se- 
 cured. The perineal counter-extension band, the pel- 
 vic lateral band, the sliding leg support and abduct- 
 ing extension adhesive strips, kept taut by the weight 
 at their end, all formed a very excellent confining 
 harness that still was not intolerable, and, as the event 
 proved, was well borne by an unusually restless and 
 intolerant individual. This traction weight was rap- 
 idly increased up to twenty-five pounds. This was 
 well borne and within a few days the length of the 
 
100 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 injured limb was brought to the same measurement 
 as that of the sound one. Consolidation proceeded 
 in normal rapidity and at the end of ten weeks the 
 patient walked out of the hospital with the aid of 
 crutches. . . . 
 
 * 'Examination made four months later confirmed 
 the facts that the length of the two limbs was equal 
 and that no deformity was exhibited by the injured 
 thigh. 
 
 "We are reporting this case somewhat fully, not 
 with a view of in any way reflecting upon the value or 
 propriety of subjecting such injuries frequently to 
 exposure by incision and to plating, but as an ex- 
 ample of the possibility of securing excellent results 
 by more conservative methods whenever for good 
 reasons prudence dictates the avoidance of special 
 hazards which must always attend the more radical 
 and perhaps more eflicient operative methods." 
 
 The foregoing instance, which in its logical bearing 
 will repay the most thoughtful study, establishes by 
 strongest proof that for the specified patient the open 
 operation by incision and plating was not an opera- 
 tion of necessity. This conclusion is placed beyond 
 doubt by the statement of the surgeon himself. 
 
 The eminently able surgeons in charge of the pa- 
 tient, on account of the unusual length of time that 
 had elapsed between the time of the occurrence of the 
 injury and the date of the beginning of treatment, 
 together with peculiarities of temperament of the pa- 
 tient, were inclined to doubt that the specific instance 
 could be included in that category of which they af- 
 firmed "in no case of this kind previously under our 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 101 
 
 care had we failed to get a satisfactory result either 
 as regards function, deformity or length." The event 
 proved, however, that the patient was no exception, 
 belonging to a different category calling for other 
 conditions of treatment. 
 
 Admitting that the open operation by incision and 
 plating could have secured equally good union of 
 the fragments in correctly adjusted position as that 
 which was actually achieved by the non-operative 
 treatment, the impersonal proof of the comparative 
 value of the differing methods of treatment open to 
 choice remains to be established. 
 
 It is not enough to verify the facts comprehended 
 in given results, the comparative value of these re- 
 sults in their elements of dissimilarity must be proven. 
 This being accomplished, the conduct of the surgeon 
 in adopting his choice of methods is governed by 
 ethics, and is under the control of the social organism. 
 
TREATMENT OF SEPTIC WOUND COM- 
 PLICATIONS; COMPOUND FRACTURES 
 AND PRIMARY AMPUTATIONS 
 
 The practice of acute septic surgery is a delicate 
 branch of surgical art requiring trained judgment 
 and educated hands to promptly deal with the quick 
 changes in the tissues. 
 
 Septic patients stand the loss of blood badly; a 
 very small additional loss of blood being enough to 
 turn the scales fatally against them. 
 
 In the treatment of septic compound fractures and 
 amputations it is a great error, the author conceives, 
 to bandage absorbent dressings about the wound. 
 The disturbance of the inflamed septic tissues in the 
 act of changing dressings alone inflicts great injury. 
 Such tissues have very feeble resistance and do not 
 tolerate handling, not to speak of the dissemination 
 of the infective material. Such wounds should be left 
 undisturbed, at complete functional and ph5^sical rest. 
 
 The apparatus devised by the author for the treat- 
 ment of amputations of the thigh, the arm and fore- 
 arm, together with compound fractures in the upper 
 extremity, was very simple in its construction and 
 satisfactory in its action, and might be especially ser- 
 viceable in militai*y surgery. It is well shown in the 
 instance of the treatment of the amputation of the 
 
 102 
 
PLATE XII. 
 
 Recent Primary Amputation at the Thigh, Treated by Suspen- 
 sion on Frame. Duplicate clean frame shown at the right. 
 No dressings upon the wound. 
 
PLATE XIII. 
 
 Recent Primary Amputation at the Thigh. The clean support 
 has been substituted for soiled support. Strips of soiled 
 support are being removed. Wire of soiled frame has been 
 lifted away in removal. No dressings upon the wound. 
 
PRINCIPLES or TREATMENT OF BROKEN LIMBS 103 
 
 thigh. It consists of a steel wire about one-fourth 
 of an inch in diameter, bent to conform to the general 
 outline of the limb. The wire is given a spring out- 
 ward to keep the covering of the frame upon the 
 stretch. The branches of wire are tied the proper 
 distances apart. The skeleton wire frame is covered 
 by bandaging with one inch wide bandage. 
 
 To cover the frame with bandage, an assistant holds 
 the frame at the open end, keeping upon the stretch 
 the piece of bandage holding the branches of wire the 
 proper distance apart. The surgeon, beginning at the 
 closed end of the frame, ties the end of the bandage 
 to his left-hand wire. He carries the bandage to the 
 upper surface of the right hand wire, around which 
 he makes one and a half turns. In making the last 
 half turn the bandage is made to encroach upon one- 
 half of the width of the turn already made, thus tying 
 the bandage to the wire. From the under surface of 
 the right hand wire the bandage passes to the under 
 surface of the opposite or left hand wire, around which 
 one and a half turns are made, the last half turn in- 
 fringing upon or overlapping one-half the width of 
 the turn of the bandage already made, fastening the 
 bandage to the wire. From the upper surface of the 
 left hand wire the bandage is continued across the 
 frame to the upper surface of the right hand wire, 
 being applied about the wire slightly in advance of 
 the previous turn already made. 
 
 Some little degree of practice is required to make 
 the bandage covering of the frame of even tension, 
 and to tie the bandage firmly round each branch of 
 wire. When properly constructed, the covering 
 
104 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 bandage is so firmly secured to each wire that neigh- 
 boring slips may be cut, and the uncut adjoining slips 
 will still hold fast to the wire and support the tissues, 
 as shown in the illustrations. The covered frame is 
 tied at its ends to a bandage passed around the pa- 
 tient's body. The frame sustaining the limb is then 
 suspended from the apparatus already described by 
 lengths of wire picture-cord having hooks at each end, 
 all of which can be easily made by the surgeon, the 
 limb resting upon the support without any dressing 
 of the wound whatever. To prevent the skin sticking 
 to the frame the latter is smeared at the proper place 
 with some kind of simple ointment. An excess of pus 
 from the wound drains away between the narrow 
 strips of bandage covering the frame; this drainage 
 may be facilitated by snipping holes in the support 
 without impairing its integrity. To change the 
 treated wound to a clean frame, a duplicate frame 
 covered with bandage is slid beneath the soiled one 
 upon which the limb rests. The hooks are changed 
 from the upper to the lower frame; the covering of 
 bandage is cut all around near the wire of the soiled 
 frame beginning at the open end of the frame, thus 
 freeing the wire ; the cut slips of bandage of the upper 
 frame are then drawn down between corresponding 
 ones forming the covering of the fresh support, 
 pulled away and discarded. In the very amputation 
 of the thigh shown in the illustration a fresh new 
 frame supporting the thigh was substituted for the 
 soiled one without awakening the patient from sleep. 
 In the case of the leg where there is much change 
 in contour the support cannot be made in one piece 
 
PLATE XIV. 
 
 Recent Primary Amputation of tlie Forearm, Treated by Suspen- 
 sion, without Dressings upon the Wound. 
 
 Upper Figure. — Clean frame beneath soiled frame. 
 Middle Figure. — Wire of soiled frame removed. 
 Lower Figure. — Limb resting upon clean frame. 
 
PLATE XVI. 
 
 Upper Figure. — Compound Fraeture of the Leg, Treated in 
 a Fracturc-box'. 
 
 Lower Figure. — Same Com])ound Fracture of tlie Leg, 
 Treated in Suspension Apparatus with Sectional Supports. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 105 
 
 but must be divided into sections. Plate XV shows 
 a double amputation, a Syme and a Stephen Smith 
 side-flap amputation treated upon sectional supports. 
 
 Plate XVI, upper figure, shows a compound frac- 
 ture of the leg which is under treatment in a fracture- 
 box. Several incisions have been made to deal with 
 spreading suppuration. Obviously, had the limb 
 been treated in a plaster-of-Paris splint the splint 
 would have been restrictive of those surgical measures 
 demanded by the wound complications. In dressing 
 or changing into a clean fracture-box the limb was 
 necessarily disturbed in violation of one of the car- 
 dinal principles of treatment of septic wounds, which 
 demands that the limb be kept at physical rest, and, 
 if possible, not even handled. In the fracture-box the 
 lower fragment remains stationary, while the slight- 
 est motion of the patient disturbs the upper fragment. 
 
 Plate XVI, lower figure, shows the same limb in ap- 
 paratus which permits the freest surgical functioning 
 while the fragments, as shown by the outline of the 
 limb, are preserved in even better position than in 
 the fracture-box. The sectional supports are so con- 
 trived that any one or two of them may be tempora- 
 rily removed without impairing the efficiency of the 
 general support of the limb. No dressings are used 
 except a piece of lint spread with some simple oint- 
 ment to cover the granulating surfaces. The sectional 
 supports are of bandage carried by a single iron vrire 
 bent into such form that when the section supports 
 the limb there is no contact of the wire with the tis- 
 sues. The supports are adjustable by means of the 
 links of the chain catching into the hooks fastened to 
 
106 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 the steel frame. Provision is made for balancing the 
 limb and for its elevation or depression. 
 
 The construction shown in Plate XVII was a de- 
 velopment of that shown in Plate XVI, lower figure. 
 It was designed to exert a greater control over the 
 fragments. A base line was provided by the use of a 
 square brass bar which while strong enough to hold 
 the suspended limb yet could be bent by the surgeon 
 into desired form. To make the bar adjustable in 
 length for use upon different limbs it was cut in two, 
 and the two portions firmly held together by two 
 clamps (see Plate XVII, lower figure) . The bar was 
 drilled transversely throughout its length, making 
 holes about an inch apart. At first these holes were 
 made only large enough to receive snugly the small 
 hard brass wires carrying the sectional supports. It 
 was so constructed that when the sectional supports 
 were in position the friction alone developed by the 
 weight of the limb would hold immovable the wires 
 passed through the bar. 
 
 It was found desirable, however, on account of 
 wear to be able to key the wires in any given position. 
 This was done by drilling another hole of the same 
 size alongside and infringing upon the holes already 
 made through the bar. Consequently a small piece 
 of brass wire like that used in the sectional supports, 
 bent at a right angle and slightly tapered at one end, 
 could be pushed into the second hole keying the wire 
 fast that had been passed through the hole alongside. 
 By this means the carrying wire of the sectional sup- 
 port could be held in position with great accuracy of 
 adjustment. 
 
PLATE XVII. 
 
 Upper Figure. — Compound Fracture of the Leg. Treated 
 by Suspension and with Sectional Supports. Two supports and 
 part of a third have been removed and an abscess incised. 
 
 Lower Figure. — Excision of the Knee-joint. Treated bv 
 Suspension and with Sectional Supports. No wiring or nailing 
 of the bones. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 107 
 
 Two crossbars mounted upon the carrying wire 
 held the bandage constituting the sectional support. 
 A narrow bandage was easily fastened to the cross- 
 bars in the same manner that the bandage covered the 
 frames used to support the amputation of the thigh 
 (see Plate XVII, upper figure). Thus constructed 
 even a portion of the bandage of the sectional support 
 could be cut away and the remaining portion of the 
 bandage would hold fast (see Plate XVII, upper 
 figure). The bar constituting the base line was fast- 
 ened at one end to a band of simple webbing which 
 made one turn of a spica about the pelvis. The other 
 end of the bar was bandaged to the foot in the man- 
 ner shown, holding it so it would not shift from posi- 
 tion. Thus conditioned the injured limb while in ab- 
 solute rest was in an attitude for extended surgical 
 functioning. It was open to inspection, palpation 
 and surgical treatment. The suspension of the limb 
 was adjustable and the patient enjoyed a consider- 
 able range of motion without disturbing the immo- 
 bility of the adjusted fragments. 
 
 The advent of the antiseptic treatment of wounds 
 led the author to discard the use of the special ap- 
 paratus described. Through effective antisepsis 
 compound fractures were brought into a category 
 closely approaching simple fractures, and treated ac- 
 cordingly. 
 
 While the complex of conditions comprehended 
 under the term antiseptic measures may be easily for- 
 mulated, it is to be borne in mind that the practical ap- 
 plication of those measures, and full realization in 
 practice of antisepsis depend upon the surgeon him- 
 
108 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 self, a factor of the first importance, although of 
 great and incalculable variability. 
 
 It is almost amusing to note in surgical literature 
 how, sometimes, a surgeon, in excusing unfortunate 
 mishaps, has sought to limit the range of antiseptic 
 efficiency by naively "begging the question" in refer- 
 ence to his own employment of antiseptic measures. 
 
 It will be observed (Plates XII and XIV) that 
 the amputations of the thigh and forearm are placed 
 in a state of physical rest. The tissues are also so 
 conditioned as to be capable of an extended range 
 of surgical functioning and are not necessarily sub- 
 jected to any special therapeutic influence. 
 
 It is emphasized, in repetition, that the discarded 
 apparatus has been described not in any special ad- 
 vocacy of its use, but in exposition of the extension 
 of the principles which it embodied. 
 
 The author not using dressings upon wounds be- 
 came unaccustomed to expressions of pain on the 
 part of patients in the usual dressing of their com- 
 pound fractures and amputations and as a conse- 
 quence well recalls the following incident : 
 
 On a visit to a large surgical hospital the author 
 was invited by the distinguished and veteran surgeon 
 who had operated upon the patient to witness the 
 dressing of a recent primary amputation of the thigh 
 in which he took particular pride. 
 
 At the surgeon's approach the patient's face be- 
 came clouded with anxiety. The wound dressing 
 consisted in binding a quantity of loosely shaken, 
 fluffy oakum about the stump. After the removal of 
 the old dressing, which was sodden with decomposed 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 109 
 
 pus, an assistant industriously squeezed the stump 
 till the last drop of pus was expelled from the sinuses 
 communicating with the wound. The wound and 
 connecting sinuses were then thoroughly syringed 
 with a watery solution of carbolic acid, and finally 
 the new oakum dressing was bandaged to the stump. 
 In doing this, an assistant stood upon the bed astride 
 the patient, whom he lifted while the bandage was 
 being carried around the pelvis. At last, the patient 
 sank back exhausted and exclaimed: "For God's 
 sake, doctor, stop and let the wound have a chance 
 to heal!" 
 
 The observed procedures were justified by preva- 
 lent practice, and were carried out under the direc- 
 tion of the operating surgeon who did not seem to 
 realize that his patient, in the dressing of his wound, 
 lost as much energy in a higher form, as would have 
 followed a considerable blood-letting. According to 
 the author's usual procedure all that wasted energy 
 accompanied by manifestations of pain would have 
 been saved to the patient. 
 
SCOPE OR DEGREE OF EXTENSION 
 CONSIDERED IN REFERENCE TO 
 PRINCIPLES EMBODIED IN SURGI- 
 CAL PROCEDURES 
 
 In the comparison of methods of treatment the 
 consideration of scope or the degree of extension of 
 embodied principles is of great importance. 
 
 For example, in the case of the tin strips it has 
 been stated that the fixation of the bony fragments 
 in a given relation is achieved in a minimum time. 
 Increase of speed in immobilizing the fragments is 
 in itself an increase of scope. 
 
 Furthermore, the strips may be fastened in posi- 
 tion, thereby insuring the quick fixation of the bone 
 either by a dry, wet, plaster-of-Paris, starch, water- 
 glass or other kind of bandage that may be chosen 
 for the construction of the enveloping apparel. This 
 is an increased range of choice of material in the con- 
 struction of the permanent splint. 
 
 Increased scope is illustrated in the use of the 
 writer's crochet-drill in the suturing of simple frac- 
 tures of the patella by the open operation, the es- 
 sential element of the operation being the holding 
 of the fragments in the desired relation by suturing. 
 
 In usual drilling when the drill is withdrawn, tis- 
 sues are apt to slip over and obscure the drill hole, 
 making the passing of the suture very difficult. 
 
 no 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 111 
 
 Again, the fragments must 
 often be tilted or the joint flexed 
 to enable the operator to secure 
 the end of the suture as it merges 
 upon the under surface of the 
 bone at a definite point. In other 
 words, the efficiency of the ordi- 
 nary drill is restricted to a very 
 limited distribution of conditions. 
 
 By the author's method there is 
 no need of such tilting of the frag- 
 ments. They can be drilled and 
 the suture can be passed with facil- 
 ity in any position of the joint, 
 preferably, of course, in the posi- 
 tion of election, that is, when the 
 limb is extended, and without in- 
 terference with the cavity of the 
 joint. Again, according to the 
 usual method the drill hole is some- 
 times made unnecessarily large 
 and so cleared of tissues as to ex- 
 pose the bone to the risk of a slight 
 necrosis. According to the au- 
 thor's method the drill hole need 
 be no larger than to receive a 
 suture and the nutrition of the 
 bone need not be endangered. 
 
 The crochet drill designed by 
 the writer for use in suturing sim- 
 ple fractures of the patella is a 
 drill with a slightly enlarged flat 
 
 > 
 
 Fig. 5. — Hand Cro- 
 chet-drill and Fork. 
 Two-thirds of actual 
 size. End of drill, 
 b, actual size. 
 
112 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 head. In the head of the drill is cut a small notch 
 only large enough to receive a silk thread (see Fig. 
 5). The shank of the hand drill is of the same size 
 throughout, about one-sixteenth of an inch in diame- 
 ter, is spring tempered so that the pressure of the 
 hand constantly keeps the cutting edge of the head 
 of the drill at its work. The enlarged size of the head 
 of the drill converts the drill into a sort of probe and 
 the varying resistance of the tissues through which 
 it passes can therefore be differentiated. The head 
 
 Fig. 6. — Use of Fork in placing Loop of Silk in Notch of the 
 
 Crochet-drill. 
 
 of the drill having passed through a fragment, a loop 
 of silk is cast over it and caught in the notch either 
 by means of the tip of the finger or by the specially 
 designed fork shown in Fig. 6. The loop of silk is 
 then drawn through the drill hole by the withdrawal 
 of the drill, thus holding the path made by the drill- 
 ing. By means of the loop of silk any sort of 
 suture can be drawn into position. ( See Fig. 2. ) 
 
 The hand-power mechanism shown in Plate XIX 
 jv^as designed to shorten the time of drilling, and is 
 
PLATE XIX. 
 
 Hand-power INIecharism of Crochet Drill. At the right, the 
 drill-handle taken apart. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 113 
 
 especially useful when the bony fragments are hard. 
 The contrivance is an adaptation of the Archimedean 
 spiral which in action makes the same number of 
 positive and reverse turns, thus preventing the head 
 of the drill from picking up shreds of tissue and 
 fouling. The mechanism is very simple in construc- 
 tion and action. It is sectionalized and can be read- 
 ily assembled without accessory tools. It is, of course, 
 capable of being perfectly sterilized. In action the 
 assistant working the power stands on the opposite 
 side of the bed away from the operator and the field 
 of operation. He holds the body of the mechanism 
 by his left hand, firmly pressing the three legs against 
 his breast while he actuates the drill by working the 
 handle back and forth with his right hand. The drill 
 being governed by the flexible wrist motion of the 
 operator there is no need of making the shank of the 
 drill of spring temper. 
 
 Upon trial on several occasions the mechanism ful- 
 filled with perfect satisfaction the purposes for which 
 it was designed. It shortened the time of drilling the 
 patella fragments from several minutes to a minute 
 and a fraction. 
 
 To show the range in choice of suture materials 
 with the author's method, he once drilled two pieces 
 of soft pure rubber, each an inch thick and accurately 
 united them with a heavy silver wire and the finest 
 human hair. 
 
 The author's method of drilling, therefore, ex- 
 pressed a gain in scope, preserving its maximum 
 efficiency under widely varying distributions of con- 
 ditions. 
 
114 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 Fig. 7. — Drilling of Irregular Fracture of the Patella while the 
 Knee-joint is Extended. 
 
 Explanation of Figure 7. 
 
 In an actual case "The transverse fracture had taken a very 
 oblique direction through the thickness of the bone so that the 
 broken bony surface of the upper fragment widely overhung its 
 cartilaginous margin. In drilling the upper fragment, 1, deceived 
 by the obliquity of the fracture, the point of the drill was made 
 to emerge through the cancellous tissue some distance above the 
 bony cartilaginous junction. As the lower fragment could not be 
 readily exposed, the drill was passed directl}^ through the skin and 
 soft parts to the bone, 3, its point emerging through the under 
 surface of the cartilage. It was clear tliat when the fragments 
 would be wired together the upper fragment would be on a lower 
 plane than the loAver one and that tlie apposition would be quite 
 imperfect. The misdirection of the hole through the upper frag- 
 ment was corrected by drilling again, 2, directing the drill even a 
 little upward to insure exit of the point through the under sur- 
 face of the cartilage. By means of a properly constructed instru- 
 ment (the Fork, see Fig. 6) the silk loop was cast over the notch 
 in the end of the drill, which could be only reached by the tip 
 of the finger. One end of the wire was drawn through the upper 
 fragment and the other through the lower fragment and the skin. 
 The drill was again introduced alongside of the wire emerging 
 from the skin, 4, and passed superficially to the upper surface of 
 the fragment. By means of a loop of silk drawn along the track of 
 the drill, the wire was made to re-enter its opening of emergence 
 through the skin and was pulled into place." See original com- 
 munication by the author in the N. Y. Medical Record of June 7, 
 1890. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 115 
 
 The sharp pointed sickle-curved bistoury shown 
 in Fig. 8, was formerly known as an abscess knife, 
 its special use being for the opening of abscesses. 
 It will be observed from its curved shape, it cannot 
 be well aimed. The sharp point penetrating the 
 cavity of the abscess meets with increased resistance 
 as it is pushed onward through the tissues. 
 
 Fig. 8. — Ordinary Curved Bistoury, used for Opening Abscesses. 
 
 The abscess knife designed by the author, shown 
 in Fig. 9, being straight, can be well aimed to reach 
 a small collection of pus deeply situated. As it is 
 pressed onward the entrance of the end into the cav- 
 ity of the abscess can be readily noted because the 
 grasp upon the blade by the tissues becomes less as 
 
 X 
 
 ~# 
 
 Fig. 9. — ^Author's Design of Knife for Opening Abscesses. 
 
 it advances, since the cross section of the blade les- 
 sens in approaching the heel. The knife acts some- 
 what like a probe. Turned slightly upon its long 
 axis, the contents of the cavity ooze along the side 
 of the blade and disclose their nature, the blade act- 
 ing as an exploring needle. Turned quickly back 
 into its original position, thus keeping the cavity full 
 
116 PEINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 of contents, the end of the blade is pushed across the 
 cavity till it strikes the inner surface of the opposite 
 wall, and then while the point is held fixed in posi- 
 tion, the handle is swept upward, thereby cutting 
 open the cavity the desired extent. It has increased 
 range as an exploring needle and as a probe. It ex- 
 presses an increase in scope. 
 
 The handle of the scalpel may be considered from 
 the standpoint of scope. 
 
 When the author was a student, it was customary 
 for the surgeon to carry his own instruments, as 
 needed, from place to place. Even the great Belle- 
 vue Hospital at that time had such a poor supply 
 of instruments that it was usual for operators to 
 provide their own instruments at the great surgical 
 clmics. The knife-handles were made very thin in 
 order that a number of knives might conveniently 
 be packed in a small space in the surgeon's case. The 
 handles were given their particular form to suit the 
 instrument-maker and not from surgical reasons. 
 JNIany years ago the writer whittled the model of his 
 knife-handle into desirable shape. Such a handle 
 was thick and very nearly octagonal in shape. Since 
 those early days hospital equipment has undergone 
 a great change. The thin flat handle in development 
 has given place to one of thickness and octagonal in 
 shape. The thin handle restricts manipulation largely 
 to wrist motions. The latter design, while not ex- 
 cluding wrist motions, allows finger motions permit- 
 ting the rolling of the handle upon its long axis be- 
 tween the fingers — in other words affording a gain in 
 scope. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 117 
 
 The patient with brain injury who was the subject 
 of erysipelatous infection is shown in Plate XX, 
 Fig. A. 
 
 The six weeks' old brain sinus with resisting walls 
 was easily probed with an ordinary probe. With the 
 recently inflicted wound, however, conditions were 
 quite different, and a surgeon who thought of using 
 an ordinary probe according to old procedure might 
 well have been pardoned for refraining to attempt 
 thus to locate the bullet. 
 
 In further detailed exposition of the construction 
 of his probe and the principles of probing wounds 
 the author makes the following extract from his con- 
 tribution to the New York Medical Journal of 
 March 28, 1885, describing the successful extraction 
 of a pistol-ball from the brain by a counter-opening 
 in the skull. 
 
 "In probing a woimd it is essential that the end 
 of the exploring instrument shall be of such a size 
 as not easily itself to wound the tissues and make a 
 false passage. The end should therefore be large. 
 Not only does a large extremity to the probe save 
 the tissues from injury and diminish the chance of 
 making a false passage without the exercise of an 
 undue amount of force, but the large end, even when 
 it is deep beneath the surface of the body, is easily 
 discoverable by palpation or dissection. 
 
 "In probing a wound to learn its course, depth and 
 other features, we should be able to follow or infer 
 with exactness from the exposed portion of the in- 
 strument, the varying positions of its buried end. It 
 is further essential therefore that the end should hold 
 
118 PKINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 Fig. 10. 
 
 Author's Design 
 for a Probe. 
 
 Actual size, except 
 the length, which 
 is twelve inches. 
 
 a fixed relation to the shaft, or, in 
 other words, that the probe must 
 have suiRcient rigidity to retain a 
 given shape. This rigidity is requi- 
 site to the practice of another pro- 
 cedure to determine the location 
 of the exploring extremity, namely 
 conjoined manipulation through the 
 medium of the probe. The shaft of 
 the probe should not only be rigid 
 but should also have a considerable 
 bulk, that a large surface may be in 
 contact with the fingers and subject 
 to the informing touch. Finally, the 
 probe fulfilling these requirements 
 should be as light as possible in order 
 that the delicacy of touch should not 
 be lessened in the exertion to move 
 a heavy mass and that vibrations that 
 would otherwise be lost in the probe 
 itself may be communicated to the 
 hand. 
 
 "The probe combining these prop- 
 erties has the shape (sho^\Ti in Fig. 
 10) and is made of tempered alumi- 
 num. The large end will generally 
 pass along the sinuses connected 
 with a wound and from its size and 
 shape it is often possible to tell the 
 nature of the structures with which 
 it comes in contact. It is only ex- 
 ceptionally that the smaller end need 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 119 
 
 be used. In probing, to curve the instrument is to 
 complicate it and increase the chances of error in 
 interpreting the position of the exploring extremity. 
 
 "When the probe is curved near the exploring end, 
 the other end of the shaft should be bent in the same 
 plane in the opposite direction. 
 
 "In case the sinus is tortuous, rather than complicate 
 the exploring instrument I am in the habit of simpli- 
 fying the wound. Thus, in following such a sinus 
 
 Fig. II. — Method of Probing a Tortuous Sinus. 
 
 the end of the instrument after it has passed along 
 one curve (Fig. 11) should, if practicable, be brought 
 toward the surface and exposed by careful dissec- 
 tion. The first curve having been eliminated the re- 
 bent probe can be introduced through the new open- 
 ing at b, the commencement of the second curve bCj 
 and the latter explored." 
 
 In the illustrative instance described, the writer by 
 his probe followed the path of a pistol-ball antero- 
 
120 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 posteriorly through the whole length of the hemi- 
 sphere of the brain, made a counter-opening at the 
 indicated point on the opposite side of the head, in- 
 serted the probe in the new opening, followed the 
 ball on its deflected course and extracted it, saving 
 the patient, who lived for several years. (See New 
 York Medical Journal, March 28, 1885.) 
 
 It is proper to add that the correctness of the prin- 
 ciples involved and the capabilities of the probe as 
 an instrument of precision were further confirmed by 
 two other instances of brain injury, the only other 
 cases that came under the author's care, and until 
 now unpublished. 
 
 It is to be noted that the missiles in all instances 
 were located by means of the probe alone, no assist- 
 ance being derived from radiographs. A single error 
 in passing the probe would have made the operation 
 a failure. 
 
 In one patient the pistol-ball passed transversely 
 through the brain and rebounded from the inner sur- 
 face of the opposite wall of the skull for over an inch 
 toward the centre of the brain. The large end of 
 the probe was introduced through the opening of en- 
 trance. The skull was opened by trephining at the 
 indicated point on the opposite side of the head. The 
 probe being introduced through the new opening, the 
 rebounded ball was traced to its place of lodgment, 
 about one-third way toward the centre of the brain, 
 and felt on the side of the wall of its initial path 
 through the brain. The head was so placed that the 
 principal path of the ball was perpendicular to the 
 horizon. With the large end of the probe introduced 
 
PLATE XX. 
 
 A. Upper Figure. — Pistol-shot Wound of the Brain, Six 
 Weeks since Injury. The brain- wound had become a discharging 
 sinus with walls of some resistance. The ball, lodged near the 
 centre of the brain, was encysted. The sinus was followed by 
 an ordinary probe which could not have been done in the fresh 
 wound. 
 
 Lower Figure. — Shows the course of the probe to the con- 
 tact with the ball. 
 
 B. Upper Figure. — Straight Course Antero-posteriorly of a 
 Ball to the point of Contact on Inner Surface of the Opposite 
 Side of the Skull. Very troublesome hemorrhage of a branch of 
 the artery of the corpus callosum, shown in E, lower figure, was 
 stopped. The ball was then tracked with a large probe to its 
 point of contact with the opposite side of the skull. Judging 
 from the exposed portion of the straight probe the concealed end 
 of the probe was opened upon by a trephine at the indicated 
 point upon the opposite side of the head. The probe was en- 
 tered at the new opening and the deflected path of the ball was 
 followed till the ball was reached and removed. 
 
 Lower Figure. — Shows the course of the path of the ball 
 through the hemisphere. 
 
 C. Upper Figure. — Opening of Entrance of a Pistol-ball Be- 
 hind the Right Ear. 
 
 Lower Figure. — Shows the Course of the Ball, Inward, Up- 
 ward and Forward. Path of the ball explored by the large probe 
 and place of lodgment of the ball established by contact with 
 the probe. The author introduced his left index finger its full 
 depth, felt the ball and with uterine tenaculmn hooked the ball 
 against tip of the finger and removed it. 
 
 D. Upper Figure. — Point of Entrance of Pistol-ball. 
 
 Lower Figure. — Dotted Line Indicates Course of Ball Trans- 
 versely Across the Brain to Place of Contact with the Inner Wall 
 of the Opposite Side of the Skull. Skull opened at indicated 
 point by small trephine hole, probe introduced at new opening 
 and the rebounded ball traced to its place of lodgment half way 
 toward the centre of the brain. 
 
 E. Upper Figure. — Median Section of the Head showing 
 Falx Cerebri in Position and Point Probably Pierced by the Ball 
 in its Course Across the Head in Figure D. 
 
 Lower Figure. — The Inner Face of the Hemisphere After 
 the Falx was Removed. Branches of the artery of the corpus 
 caUosum may be seen. 
 
PRINCIPLES OF TREATMENT OF BROKEN LIMBS 121 
 
 into the opening of entrance the ball was gently urged 
 downward by the probe till it could be felt against 
 the tip of the finger watching at the counter opening, 
 and was then extracted (see Plate XX, Fig. D). 
 
 The head was replaced in normal position and 
 the probe reintroduced transversely into the brain. 
 When the large end was half way through the brain 
 its progress was checked by a soft but distinctly felt 
 resistance. Presently the brain was felt to move 
 slightly and the probe was then passed easily on- 
 ward through the head. To the smaller end of the 
 probe were attached five or six strands of small-sized 
 catgut, which were drawn through the brain to act 
 as a drain. 
 
 Upon careful after-study it was established that 
 the ball had passed through the falx cerebri (see 
 Plate XX, upper figure, E). Without doubt in 
 passing the probe transversely through the head the 
 large end was halted against the edge of the opening 
 through the falx, but upon the slight movement of 
 the brain that opening was centred. The patient 
 recovered and lived for more than five years. 
 
 In the third patient the pistol-ball entered behind 
 the upper portion of the right ear, pushing frag- 
 ments of bone before it. The patient displayed no 
 nervous symptoms to guide, and there was much dis- 
 cussion as to the course of the ball. The probe re- 
 vealed that it had passed inward, forward and up- 
 ward. It was so much flattened that it could not be 
 grasped with the bullet-forceps. The writer then 
 passed his left index finger its full length into the 
 brain and felt the ball at the tip end of the finger. 
 
122 PRINCIPLES OF TREATMENT OF BROKEN LIMBS 
 
 By sliding a delicate uterine tenaculum along the 
 finger he hooked the ball against the tip of the finger 
 and extracted it. Hemiplegia of the opposite side 
 set in immediately, but wholly cleared up in twenty- 
 four hours. The patient recovered and lived more 
 than two years (see Plate XX, Figure C). 
 
 No test for probing a wound in soft tissue could 
 have been severer than those imposed in these three 
 patients. It showed the extreme range of probing 
 through paths of wounds with delicate walls. 
 
 The educated touch, the "tactus eruditus/^ is an ex- 
 tension of scope in manipulation. No illustrative in- 
 stances are needed to emphasize its great importance. 
 
 In all fields, scope as a measure of value is acknowl- 
 edged. The smaller range in scope is always at the 
 mercy of the larger range. In final analysis all such 
 increases in scope are resolvable into increases in 
 responses. To pass from lesser to greater scope, 
 is progress; to pass from greater to lesser scope, is 
 regress. 
 
INDEX 
 
 Abscess-knife, author's design, 115. 
 
 Absolute immobility, unattainable with extrinsic splints, 54. 
 
 Absorbent dressings, discarded, 52 ; upon septic wounds, 102. 
 
 Adjustment of bony fragments, 9. 
 
 Affirmative instance destructive to negative assertion, 92. 
 
 Ambiguous term, 2; plaster-of-Paris splint as, 62. 
 
 Amputation of the thigh, treatment of, 103; dressing of, while asleep, 
 
 104. 
 Amputation of the thigh and forearm, in physical rest, 102; in extended 
 
 functioning, 108. 
 Antiseptic measures, effect upon, compound fractures, 53, 73; should be 
 
 standardized, 87; defective, 87. 
 
 Bandage, first layer of, 13; second layer of, 14. 
 
 Bandaging, part of soldier's training, 8; secundum artem, 11; practical 
 skill in, 12; traumatic gangrene from tight, 8; compression of 
 tissues, 13; tactus eruditus, 13; figure of eight reverses, 14; grad- 
 uated support of the circulation, 41. 
 
 "Begging the question," 3, 108. 
 
 Bellevue Hospital, septic saturation, 12, 52, 53, 79, 81, 82, 83, 84, 86, 
 116; medical board of, 83, 84, 86. 
 
 Bistoury, sickle-curved, 115. 
 
 Brain, probing of, 120. 
 
 Brain sinus, 79; resisting walls, 117. 
 
 Bridge or truss, construction of, 91. 
 
 Burden of proof, 96, 97. 
 
 Categories, creation and definition, 77; multiplication of instances in, 
 77; difficulty of determining and defining, 78; of exceptions of 
 non-operative treatment, 96; subject of negative assertion, 92. 
 
 Categories of responses, 76. 
 
 Clove-hitch, 33. 
 
 Coarse motion, range of, 55; normal may be exceeded, 56; affected by 
 suspension apparatus, 74. 
 
 Commissioners of Public Charities and Correction, 4. 
 
 Comparison of the value of methods of treatment, 76. 
 
 Compression of soft parts, 47. 
 
 Compound fractures, regarded as infected, 16; protective covering of, 16; 
 Lister's bandages for, 17; antiseptic gauze about the wound, 17; 
 sterile dressings, 17; plaster-of-Paris splint discarded in treatment 
 of, 72; eff'ect of antiseptic treatment on, 73; bridge or truss to 
 hold fragments, 91; treated in fracture-box, 105; treated upon 
 sectional supports, 105; without dressings upon wound, 105; in 
 category allied to simple fractures, 107; iron staples, 91. 
 
 Compound pulleys, 19, 23, 29, 38, 40. 
 
 123 
 
124s INDEX 
 
 Conjoined manipulation through medium of probe, 118, 
 
 Consensus of opinion, 58. 
 
 Constructive field of the mind, 58. 
 
 Counter-extension, 18, 20, 99. 
 
 Criterion of value, 1, 77, 78; of excellence, 76. 
 
 Crochet-drill, an example of increase of scope, 110; description of, 111; 
 
 notch in head of^ 112; as a probe, 112; hand-mechanism of, 113; 
 
 drilling and suturing of soft rubber, 113, 116. 
 
 Diagrammatic representation of truss, 5. 
 
 Disturbance of broken limb, 10. 
 
 Double amputation, Syme and Stephen Smith, 105. 
 
 Drainage in compound fractures, 16. 
 
 Drilling of irregidar fracture of the patella, 114. 
 
 Elastic suspension, 66. 
 
 Elective period of applying thigh splint, 24. 
 
 Empiricism, results of, 1 ; social organism in region of, 59. 
 
 Erysipelas, in Bellevue Hospital, 69, 80; affecting brain wound, 80; 
 
 cause of infection of brain wound, 80. 
 Essential attribute of treatment, 54; is a mechanical one, 55; measure 
 
 of its value, 55. 
 Essential and non-essential attributes, generalized, 58. 
 Essential factor, influence of methods of treatment upon, 62; as a 
 
 functioning variable, 62; extension of functioning, 64. 
 Extreme range of probing wounds with delicate walls, 122. 
 
 Fallacies, drawn from bad results, 98. 
 
 Falx cerebri, pistol-ball passed through, 121. 
 
 Fenestrse in plaster-of-Paris splint, 52. 
 
 Figure of eight reverses of bandage, 12. 
 
 First line of defense of wounds, 86. 
 
 Foot, immobilization at right angle with leg, 41. 
 
 Foot and leg, splint constructed upon, before making thigh splint, 41. 
 
 Fork, 111, 112, 114. 
 
 Fracture of both thighs, suspension apparatus, 46; increase of coarse 
 motion by suspension, 74; open operation, 97. 
 
 Fracture-box, restriction of surgical relations, 67 ; compound fracture of 
 the leg treated in, 105. 
 
 Fracture of the shaft of the femur, evolution of apparatus, 18; author's 
 apparatus, 20; perineal-bar, 21 ; time of setting, 22 ; long-existing 
 shortening, 23 ; splint exerts extension and counter-extension, 23 ; 
 elective time of applying splint, 24; measurement of shortening, 
 25; personal error in measuring, 25; protection of limb during 
 an£Esthesia, 26; covering limb with blanket protective, 27; covering 
 of the foot, 29; assistant controls fragments, 29; ground plan of 
 position of patient, 30 ; fixed points of extension and counter-exten- 
 sion, 30; duties of principal assistant, 31; leverage upon upper 
 fragment, 31; duties of anaesthetizer, 32; purpose of pelvic wire, 
 32; fixed point of extension, 32; review of steps of procedure, 34; 
 temporary extension, 35; details of construction of plaster-of-Paris 
 splint, 35 ; pelvic portion of splint, 36 ; reinforcement of splint, 36 ; 
 placing of tin strips in position, 37; full degree of extension, 38; 
 strengthening of splint, 39; finishing coat of splint, 40; removal 
 of clove-hitch, 40; places exposed to undue pressure, 41; freeing 
 
INDEX 125 
 
 patient from apparatus, 42; care of splint after it has set, 42; 
 care of tissues of perineum, 43; subjective realization of union of 
 fragments, 43; removal of splint, 44; shortening in limb after 
 treatment, 45; stiffness of joints, 45; non-union, 46; specimen 
 of, 93, 94. 
 
 Fracture of shaft of the femur, categories of, 96 ; sub-trochanteric frac- 
 ture of the femur, 98; logical bearing of result of treatment upon 
 assertion of a negative, 101. 
 
 Fracture of both bones of the leg, 4; in a woman, 60; analysis of con- 
 sequences, 61. 
 
 Fragments, speedy fixation of, 3; impossibility of holding immobile, 
 5, 6; initial fixation of, 11. 
 
 Frame, covering of, 103. 
 
 Function, signification not arbitrarily limited, 67. 
 
 Gangrene, traumatic, 17, 18. 
 
 Generalization, 74. 
 
 Guides for adjustment of fragments, 9. 
 
 Hamilton, Professor Frank H., 4, 
 Handle of scalpel from standpoint of scope, 116. 
 Hand-power mechanism for drilling patella, 112. 
 House Staff, 13, 60; Ninety-ninth Street Hospital, 85. 
 House surgeon, 19, 61. 
 
 Humerus, tin strips in fracture of, 18; dangers of immovable splint, 18; 
 traumatic gangrene, 18. 
 
 Impersonal proof of values, 58, 101. 
 
 Impersonal truth, 58. 
 
 Incident forces, modified by suspension apparatus, 65. 
 
 Inclusion of foot and ankle in thigh splint, 41. 
 
 Increased scope illustrated by crochet drill, 110. 
 
 Inseparable accidents or characteristics, 57, 66, 75. 
 
 Interposition of tissue in fractures, 95. 
 
 Intrinsic appliances, motive for use, 90. 
 
 Iron staples, used in compound fractures, 91. 
 
 Knife-handles, why made thin, 116; example of scope, 116. 
 
 Lister's bandages, 7, 17. 
 
 Logical expressions, use of, 2. 
 
 Loss of blood, in septic patients, 102. 
 
 Maintained immobility of fragments, 54; under extension, 74. 
 
 Malarial poison, causative factor of septicaemia, 86; quinine, 86, 
 
 Measure, of quality, 75; of value, 122. 
 
 Measurement of shortening of leg, 11. 
 
 Medical Board of Bellevue Hospital, 83. 
 
 Military practice, thigh setting apparatus, 20. 
 
 Military training, in bandaging, 8. 
 
 Methods of treatment, therapeutic influence, 57. 
 
 Missiles in the brain, located by probe alone, 120. 
 
 Negative assertion, 90, 92, 97, 98. 
 New York Medical Journal, 117, 120. 
 
126 INDEX 
 
 New York Medical Record, 89, 114. 
 
 Ninety-ninth Street Reception Hospital, 84; aepticsemia, 85; malarial 
 
 poison, 85, 88; out-patient service, 85. 
 Non-union of fractures, 71. 
 
 Oakum dressing, 109. 
 
 Objection to the plaster-of-Paria splint, 94. 
 
 Observation of facts, 2. 
 
 Obsolete procedures, 2. 
 
 (Edema, rendering splint eflFective, 44. 
 
 Open operation in treatment of simple fractures, 90, 95; as a routine 
 
 measure, 96; may be advisable, 96; not of necessity, 100. 
 Organization of phenomena, 58. 
 Osteophyte, 93. 
 Outline of limb, guide to setting fracture, reverses of bandage away 
 
 from, 12. 
 Overcrowded wards, 82. 
 
 Padding of Cotton, 10. 
 
 Park Hospital, 83, 84, 86, 88. 
 
 Pearson, Prof. Karl, 58. 
 
 Pelvic portion of plaster-of-Paris thigh splints, 36. 
 
 Perineal bar, 19, 20, 21, 31, 32, 46. 
 
 Permanent splint, material in construction of, 7. 
 
 Personal authority, 58. 
 
 Personal error in measuring, 25. 
 
 Phenomena, organization of, 58. 
 
 Pistol-ball in brain, 120, 121. 
 
 Plaster-of-Paris bandages, 11, 12. 
 
 Plaster-of-Paris splint, 5; truss in, 6; strengthening of, 15; finishing 
 construction of, 16; an ambiguous term, 62; connotes variety of 
 resistances, 63; resistance varies with recession of swelling, 63; 
 restrictive of functioning of tissues, 67; therapeutic influence, 68;' 
 deleterious influence over the union of the bony fragments, 69, 70; 
 essential and non-essential attributes, 71 ; beneficial influence in 
 early stages of application, 72; discarded in the treatment of 
 compound fractures, 72. 
 
 Plating fragments of bone, 99. 
 
 Pott's fracture, 4, 17. 
 
 Practical immobility distinguished from absolute immobility, 54; dis- 
 turbance of, 54; factor of safety in preserving, 54; niaintenance 
 of, 55. 
 
 Probe, construction of author's, 118; conjoined manipulation by means 
 of, 118. 
 
 Probing of wounds, principles, 117; of tortuous sinus, 119; of brain, 
 antero-posteriorly, 120; transversely, 120. 
 
 Progress, 122. 
 
 Protective covering material, 9, 10, 13, 28. 
 
 Quality, measure of, 75. 
 Quinine, 86, 88. 
 
 Recapitulation, regarding restriction of function, 68. 
 Reductio ad absurdum, 95. 
 
INDEX 127 
 
 Regress, 122. 
 
 Relative values, determination of, 2. 
 
 Responses, 75 ; varying, 57; comparative value of, 58, 67; expressive 
 
 of continuous adjustments of the organism, 75. 
 Restriction of functioning of tissues, fracture-box, side splints and plas- 
 
 ter-of-Paris splint, 67. 
 Results of treatment, in their effects, 76; in elements of dissimilarity, 
 101; arbitrary limitation of, 56; as effects, 56, 57. 
 
 Sayre, Prof. Lewis, A., 4. 
 
 Scope, 110; in speed of immobilization. 110; illustrated by crochet 
 drill, 110; illustrated by abscess-knife, 115; illustrated by handle 
 of scalpel, 116; illustrated by probe, 117, 118. 
 
 Second line of defense of wounds, 87. 
 
 Sectional supports, 105, 106, 107. 
 
 Scientific exactitude, 59. 
 
 Self-abnegation, acts of, 59. 
 
 Separable accidents, 59. 
 
 Sepsis, antiseptic measures competent to prevent, 53, 81, 82. 
 
 Sepsis, modification of incident cause, 88. 
 
 Septic patients, loss of blood, 102. 
 
 Septic Saturation of Bellevue Hospital in Early Seventies, 79. 
 
 Septicaemia, in Bellevue Hospital, 82; in Ninety-ninth Street Hospi- 
 tal, 86. 
 
 Shortening of broken femur, 25. 
 
 Side splints, 67. 
 
 Silver wire, 113. 
 
 Sinus of brain, 79. 
 
 Skill, 2, 12, 94, 98; errors of, 12. 
 
 Social organism, 59, 77, 101. 
 
 Soldiers, 7, 8. 
 
 Specimen of oblique fracture of the femur, 43. 
 
 Spencer's definition of life, 75. 
 
 Stephen Smith side flap amputation of the leg, 105. 
 
 Sterile dressings, 17. 
 
 Stiffness of joints, 45. 
 
 Sub-trochanteric fracture of the femur, 98. 
 
 Summing up, 78. 
 
 Surgeon, engaged in defining categories, 76. 
 
 Surgical functioning, 105, 108. 
 
 Suspension apparatus, fracture of both thighs, 46; principles embodied 
 in, 47; primitive, 48; Dr. Van Wagenen's, 48; author's, 48; ele- 
 vation of limb in, 51, 66; extension of function of essential factor, 
 64; evolution of, in Bellevue Hospital, 64; incident forces modified 
 by, 65; vertical position in, 66; from a single point, 66; infiuence 
 upon coarse motion, 74. 
 
 Suturing of recent simple fractures of the patella, 89. 
 
 Swelling. 10, 22, 24, 25, 63. 
 
 Syllogistic form, 78. 
 
 Syme's amputation at the ankle-joint, 105. 
 
 Tactus eruditus, 13, 81, 122. 
 Theoretical maximum of excellence, 57. 
 Therapeutic influence of plaster-of-Paris splint, 68. 
 Thigh, primary amputation of, 108. 
 
128 INDEX 
 
 Time element, 7. 
 
 Tin strips, immediately effective, 6; in civil practice, 7; in military 
 practice, 7; are the splint, 9; an example of scope, 116; dispense 
 with water and plaster-of-Paris, 8; details of construction, 8; use 
 in fractures of the leg, 14; uncontrolled, 38, 39. 
 
 Toes, tell-tale of the circulation, 16; covered by splint, 12, 42. 
 
 Tortuous sinus, probing of, 119. 
 
 Traumatic gangrene, 18. 
 
 Treatment of septic wound complications, compound fractures and pri- 
 mary amputations, 102. 
 
 Truss, surface member of, 4, 5; diagrammatic representation of, 6. 
 
 Values, attach to results, 2. 
 Vertical suspension, 66. 
 Visiting Staff of Bellevue Hospital, 3. 
 Visiting Surgeon, 60, 61, 86. 
 Volkmann's apparatus, 99. 
 
 Wasted energy, 109. 
 Wire frame, 103, 104. 
 World's Fair of 1873, 4. 
 Wound, first line of defense, 86. 
 
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