^rA^'T^H'IcVErllfSS; HX64056112 RD1 01 F84 1 91 8 Fractures j Trealmen RECAP m\^\o\ ,, ""F^S Columbia ®nibers(iij> in tte Citp of iBeto ^ovk ^cfjool of 3Bental anb 0ta\ ^urgerp J&eference Eibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/fracturestreatmeOOIeri FRACTURES FRACTURES TREATMENT OF FRACTURES FRACTURES OF THE LOWER JAW FRACTURES OF THE ORBIT BY AUTHORS R. LERICHE L. IMBERT PIERRE REAL FELIX LAGRANGE CH. FEVRJER EDITORS AND XRAKSLATORS F. F. BURGHARD J. F. COLYER HERBERT CHILD J. HERBERT PARSONS With Three Huxdred Thirty-eight Illustrations AND Eleven Plates D. APPLETON AND COMPANY NEW YORK AND LONDON 1918 Copyright, 1918, by D. Appleton and CompaDy Printed in the United States of America CONTENTS SECTION I TREATMENT OF FRACTURES BY R. Leriche PAGE Chapter I. General Considerations Upon Wounds of Joints, Their Gravity and Their Treat- ment 1 Gravity of Wounds of Joints ... 1 General Treatment of Wounds of the Synovial Membrane and of Compound Fractures into Joints 8 General Technique of Operations upon the Joints 18 r {Continued) General Survey of Present Methods for Obtaining Wound Asepsis . ...... 34 The Carrel-Dakin Method ... 37 Dakin Solution Without Boric Acid . • • • 40 Dakin Solution With Boric Acid . 41 Titration of the Solution (Lyle) . 42 Equipment 42 Employment of Hypochlorite So- \ lutions 45 Dichloramin-T in Oil Method . . 5^ vii viii CONTENTS PAGE "Javelle Water" in the Treat- ment of War Wounds 65 Hypochlorous Acid Preparations — Eusol and Eupad 67 Hypertonic Solutions (Lymphago- gic Agents) 71 Salt Pack Method of Wound Treatment 72 Magnesium Chloride ...... 74 Sugar Treatment of Wounds ... 75 Collargol 76 Bipp (Rutherford Morison's Meth- od) .. . 77 lodated Starch . 80 Flavine (Acri- and Pro-flavine) . . 80 Brilliant Green, Paste and Lotion 83 Methyl Violet 86 Magnesium Sulphate 86 Vincent's Powder 88 Sunlight and Ozone Treatment of Infected Wounds ....... 90 Acetozone . 93 Delbet's Pyoculture 94 Vaccine and Serum Treatment of Infected Wounds . ...... 95 Donaldson's Method (Introduc- tion of Living Anaerobes) .. . .100 Chapter IL Wounds and Fractures of the Shoulder 102 Anatomical Types and' Clinical Course 102 Primary Therapeutic Indications. 105 Operative Technique 112 Post-Operative Treatment . . . .117 CONTENTS ix PAGE Evacuation of Patients with Shoul- der Wounds 124 Treatment of Patients Seen Late or After Evacuation . . . . .125 Chapter III. Wounds and Fractures of the Elbow 129 Anatomical Types and Clinical Course 129 Primary Therapeutic Indications. 134 Operative Technique 149 After-Treatment 154 Evacuation of Patients with El- bow Wounds 160 Treatment of Patients Seen Late or After Evacuation 162 Chapter IV. Wounds and Fractures of the Wrist 170 Anatomical Types and Clinical Course 170 Primary Therapeutic Indications. 171 Operative Technique 175 Post-Operative Treatment .... 177 Evacuation of Patients with Wrist Wounds 180 Treatment of Patients Seen Late or After Evacuation 180 Chapter V. Wounds and Fractures of the Hip 184 Anatomical Types and Clinical Course 184 Primary Therapeutic Indications. 187 Operative Technique 190 X CONTENTS PAGE Post-Operative Treatment . . . . 193 Evacuation of Patients with Hip Wounds 197 Treatment of Patients Seen Late or After Evacuation 197 Chapter VI. Wounds and Fractures of the Knee 201 Anatomical Types and Clinical Course 201 Primary Therapeutic Indications, 206 Operative Technique ...... 216 Post-Operative Treatment . . . . 218 Evacuation of Patients with Knee Wounds 225 Treatment of Patients Seen Late or After Evacuation 225 Chapter VII. W^ounds and Fractures of the Ankle 234 Anatomical Types and Clinical Course 234 Primary Therapeutic Indications. 238 Operative Technique 245 Post-Operative Treatment .... 248 Evacuation of Patients with Ankle Wounds 25£ Treatment of Patients Seen Late or After Evacuation 25^ Chapter VIIL W^ounds and Fractures of the Anterior Tarsus and the Fore-Part of the Foot . . . 255 Anatomical Types and Clinical Course ^55 Primary Therapeutic Indications. 256 CONTENTS xi PAGE Operative Technique ....... 262 Post-Operative Treatment .... 266 Evacuation of Patients with. An- terior Tarsal Wounds 268 Treatment of Patients Seen Late or After Evacuation ...... 268 Chapter IX. Multiple Joint Wounos 272 Chapter X. A General Study of Shaft Frac- tures. . 277 Pathological iVnatomy of the Seat of a Fracture in Its Earliest Stage . . 280 Immediate Results of Fracture, and the Normal Course to Re- covery .... 292 Pathological Changes in a Frac- ture, 294 Chapter XI. General Principles in the Con- servativeTreatment of Frac- tures 313 Operative Disinfection of Open Fractures . 314 Initial Operative Disinfection of Fractures in the First Few Hours : Exploratory and Pro- phylactic Esquillectomy . . .315 Secondary Operative Disinfec- tion ^of Clinically Infected Fractures : Esquillectomy and Drainage : Total Subperios- teal Esquillectomy 328 General Indications for the Operation 331 xii CONTENTS PAGE Technique of Sub-periosteal Es- quillectomy 343 The Reduction of Gunshot Frac- tures 353 The Immobihsation of Fractures . 362 Chapter XII. Fractures of the Humerus . . . 385 Fracture of the Neck of the Hu- merus (Sub-epiphyseal Fracture) 385 Sub-deltoid Fracture 400 Fracture of the Middle of the Shaft 406 Supra-condylar Fracture of the Elbow. 433 Chapter XIII. Fractures of the Forearm . . . 439 Fractures of Both Bones of the Forearm 441 Fractures Just Below the Elbow Joint 441 Fractures of the Shafts .... 446 Fractures Just Above the Wrist . 460 Fractures of the Radius Alone . . 465 Fracture of the Shaft ..... 465 Fracture of the Lower Radial Epiphysis . 476 Fractures of the Ulna 484 Chapter XIV. Multiple Fractures of the Upper Limb 490 CHAi'TER XV. Fractures of the Femur .... 494 Sub-Trochanteric Fracture. . . . 494 Fractures of the Shaft; the So- called Fractures of the Thigh . 507 Supra-Condylar Fractures .... 547 CONTENTS xiii PAGE Chapter XVI. Fractures of the Leg 554 Fracture of Both Bones of the Leg . 554i Fracture of the Tibia 574 Fracture of the Fibula 577 ChapterXVII. Multiple Fractures of the Low- er Limb 581 SECTION II FRACTURE OF THE LOWER JAW BY L. Imbert and p. Real Chapter I. Introduction 585 Chapter II. Etiology . . 597 Chapter III. Pathological Anatomy 599 Incomplete Fracture 600 Complete Fracture 602 Large Loss of Bony Substance. Shattering 622 Large Loss of Substance of the Soft Parts 623 Anatomical Development .... 623 Chapter IV. Symptoms and Diagnosis .... 629 Recent Fracture ........ 633 OldFracture 640 Fracture of the Angle 641 Fracture of the Ramus ..... 642 The Use of Radiography in Man- dubular Fracture . 642 Closure of the Jaws 645 Clinical Development 649 Chapter V. Mechanical Treatment ..... 659 Elementary Principles 659 xiv CONTENTS PAGE The Immediate Treatment of Le- sions 662 Mechanical Treatment of Frac- tures . . 666 Treatment of Pseudo-Arthrosis . . 710 Treatment of Malocclusion . . . 727 Mechanico-Therapeutic Treat- ment of Myotonic Construction of the Maxillae. . . . . . . .730 Chapter VI. Surgical Treatment 734 Osteo-Synthesis 735 Operative Technique 736 Results of Osteo-Synthesis . . . 748 Bony and Cartilaginous Grafts. Actual Results . ....... 751 Chapter VII. Assessment of the Disablements Consequent Upon Fracture OF THE Mandible 763 Loss of Teeth, Complicated by Fracture of the Alveolar Border but Without Complete Fracture 765 Fractures 767 Closure of the Jaws . ...... 771 SECTION III FRACTURES OF THE ORBIT BY Felix Lagrange Chapter I. Historical 777 Chapter II. The Orbital Cavity 788 Conformation 788 CONTENTS XV PA.GE Resistance to Injury 794 Vulnerability of the Orbit .... 798 Chapter III. General Considerations upon the Atiology of Fractures of the Orbit 802 Fractures of the Orbit 802 Pathogenesis 807 Chapter IV. Fractures oy the Orbit with Preservation of the Eyeball. 813 The Laws Governing the Affec- tions of the Visual Apparatus in Injuries of the Orbit with Pres- ervation of the Orbit ..... 813 Pathology of the Visual Disorders 849 Description of the Visual Defects . 853 Symptoms and Diagnosis .... 934 Chapter V. Fractures of the Orbit with De- struction OF the Eyeball . . 938 Fractures Implicating the Neigh- bouring Cavities 946 Chapter VI. Treatment of Fractures of the Orbit and Their Complications 970 Superior Orbital Margin and Wall 971 Fractures of the Internal Margin and Wall .......... 973 Fractures of the Inferior Margin and Wall . 973 Fractures of the External JNIargin and Wall 974 Chapter VII. Treatment of Ocular Complica- tions 983 Sympathetic Ophthalmia . . . .983 xvi CONTENTS PAGE Traumatic Cataract 988 Retinal Detachment 990 Chapter VIII. Reparative Surgery of Orbital Fractures 993 Restoration of the Eyehds .... 993 Restoration of the Conjunctival Culs-de-sac 994 Repair of Damage to the Orbital Walls and in the Bone . . . .997 Conclusions 1015 List of Case Reports 1019 Index 1021 SECTION I TREATMENT OF FRACTURES THE TREATMENT OF FRACTURES PAET I FRACTURES INVOLVING JOINTS CHAPTER I GENERAL CONSIDERATIONS UPON WOUNDS OF JOINTS, THEIR GRAVITY AND THEIR TREAT- MENT I. Gravity of Wounds of Joints Wounds of the joints, which in civil practice have always had the reputation of being very serious, are among the most formidable injuries which the surgeon at the front is called upon to treat. It may be added with truth that they are perhaps those for which most can be done if he intervenes in time. Their gravity is due to three causes. (a) The projectile which strikes the patient carries with it some particles of clothing which it deposits in the joint whether it remains there itself or whether it passes out again. These particles carry various germs which there find conditions perfectly suited to their rapid development, since they are shut up in a closed cavity sheltered from everything which might hinder their growth. 2 THE TREATMENT OF FRACTURES (6) The damaged synovial membrane, which is highly absorbent, has numerous folds and recesses in which the virulence of the microbes increases the more rapidly because the recesses are shut off from the exterior, and hence the microbes are not amenable to exposure to the air, which is essential in the treatment of all septic wounds. (c) The synovial injury is almost always compHcated by a fracture of the articular surface. Doubtless pure synovial injuries are to be found, either with or without the presence of the missile. In the knee such a con- dition is not rare, but everywhere else, even in the shoulder, it is quite exceptional ; practically, a joint injury is almost synonymous with a fracture of the joint. Even in the knee bony injury is always to be expected and considerably aggravates the prognosis ; arthritis is then conjoined with osteomyelitis, for the fissures extending up into the shaft carry the infection for a long distance, and if the patient escapes severe early infection he is very likely to die of chronic septi- caemia. Only one type of joint wounds remains almost always uncomplicated by these formidable conditions : the bullet wounds with punctiform openings run a course similar to that of injuries not exposed to the air. A long-range bullet of high velocity only makes an almost imperceptible skin wound, meets the body point foremost, passing through the clothing without taking anything with it, and perforates the tissues without producing the great explosive damage which bullets fired at short range so often do. The wounds thus made generally remain aseptic. In all other cases there is nearly always grave joint sepsis which develops in one o^ the following three principal types : First Type of Joint Infection. — ^The sepsis spreads with frightful rapidity. In a few hours the temperature reaches 40° C. (104° F.), the general con- GENERAL CONSIDERATIONS 3 dition is bad ; the patient appears profoundly toxic. The joint is distended and very painful, and the whole limb is oedematous. Death ensues in three or four days from septicaemia, with or without gangrene ; secondary amputation or disarticulation rarely saves one-third, certainly not one-half of the patients. Second Type of Joint Infection. — ^One sees here the development of septic local phenomena of increas- ing gravity. The limb presents marked oedematous swelhng, the joint is swollen, hot, and very painful ; the least movement makes the patient cry out, and there are foul sloughs on the wound and a sero-purulent discharge oozes from the wound of entry, about which there is often localised gas crepitation. The tempera- ture oscillates markedly and the general condition is profoundly depressed. One operation after another may be performed, each too late. If the knee, the hip, or even the shoulder be the joint concerned, the mortality is high in spite of amputation ; the case runs its course in from eight to ten days. Third Type of Joint Infection. — ^Here the in- juries are limited. There is copious suppuration with purulent tracks communicating with the joint ; if nothing be done, a chronic septicaemia supervenes. In the case of the shoulder, the elbow, and the ankle, repeated incisions and the removal of bony fragments generally succeed in keeping the complications under and the patient slowly gets well with an ankylosed joint. In the case of the knee and the hip, amputation and death are frequent. Patients who have appar- ently recovered are liable to numerous risks, such as recurrent articular osteitis, bone abscesses, and per- sistent sinuses. This last cUnical type is the one seen almost exclu- sively at the base ; it and the bullet wounds with small openings comprise the forms of joint wounds most frequently seen by many, and that is why some sur- geons at the base hospitals have got it into their heads 4 THE TREATMENT OF FRACTURES that wounds of joints are not grave. No view could be falser or more dangerous, for it leads to the advocacy of treatment at the front which is inadequate for the severely wounded, and to the proscription of the really conservative methods as being too severe. It can never be too often repeated that it is a long way from the aid-post to the base hospital ; those who arrive at the latter with an articular fracture are only those who have been able to bear the journey ; the worst cases have been left behind at various stages along the route. To take account only of those who arrive at the base is to omit two-thirds of them at least. This is directly proved by statistics. In examining the figures of the wounded who were evacuated from the aid-posts of one division during the winter of 1914, I made a point of noting the different degrees of gravity of the wounds which I saw, and here are the results. Of 614 wounds of the upper Umbs, 457 were considered fit for immediate evacuation ; .157 called for immediate intervention. Of 601 wounds of the lower limbs, 451 were appar- ently shght, and 150 required operation on the spot. Thus, out of 1,215 wounds of hmbs, 908 were evacuated from the front and 307, or a quarter, did not leave the ambulances in the immediate battle area. The 908 who were considered fit to be evacuated during the first few hours after being wounded only quitted the anny zone the ev.ening of the next day, after a whole day's journey and after having passed through three successive surgical lines, where a great number of them were retained because their wounds had become aggravated or their pain had become worse. Those who reached a base hospital after a two or three days' journey were only slight cases in comparison with those who had been left behind en route. GENERAL CONSIDERATIONS 5 Among the 307 wounded who required immediate surgical intervention, there were obvious joint injuries in more than a third. It will thus be seen what reliance is to be placed upon the opinion of those at the base who think that they receive wounded straight from the front. Here are a few more figures : At the beginning of November my ambulance re- ceived in thirty hours 489 wounded comprising 251 injured limbs, of which 178 were caused by bullets and only 83 by shell-spUnters. Of 138 wounds of the upper limbs, 36 were detained (29 bullet wounds, 7, by shell-sphnters), and 102 were considered fit for "evacuation from the zone of the divisional ambulances (74 bullet wounds, 28 by shell- sphnters). Of 123 wounded in the lower hmbs, 79 were evacu- ated (58 bullet wounds, 21 by shell-sphnters) and 44 — more than one-third — ^were detained (27 bullet wounds, 17 by shell-splinters). Half of the wounded detained had evident joint injuries. On the night of December 24-25 we received 150 w^ounded. Aniong 43 having injuries of the upper limbs, 15 — i.e. 28 % — presented fractures of the shaft or articular ends, and were treated on the spot. Among 27 having injuries of the lower limbs, 13 — or almost 50 % — presented fractures of the shaft or articu- lar ends, and were not evacuated. These few figures enable one to understand how greatly mistaken is the calculation of those who judge the real gravity of joint fractures by what they see at the base. In dealing with war-surgery it is always necessary to be precise as to where the operation is performed when one talks of the nature of the surgical procedure, for there is a fundamental difference in the gravity of the wounds seen at a station situated half an hour's journey from the line of fire and those seen twenty-five miles behind ; and much more betv^een those received 6 THE TREATMENT OF FRACTURES by the divisional ambulance and those which arrive at a base hospital after two or three days of successive transfers. Since the conditions are not similar, treat- ment that would appear conservative at the base is not so at the front because it would be insufficient, while an operation that would be thought conservative at the front might appear too radical at the base. It is owing to their inability to draw this necessary distinction that some surgeons have proclaimed the failure of conservative surgery, while others, with a like conviction, have been able to recommend syste- matic abstention from operation and advise immobili- sation pure and simple, as was advocated in military surgery before the present war. For the surgeon at the front who has to sort out his patients without delay, articular fractures fall into three large groups : 1. Crushing of a Limb in the neighbourhood of a Joint. — Here there is a smashing-up of the bones and joint accompanied by extensive destruction of muscles and irreparable vasculo-nervous injuries, for which amputation or disarticulation is alone of any use. The best time to perform the operation is the only matter open to discussion in these cases. The injured arrive in a condition of extreme shock. None of them are evacuated from the front line ; unless there is an enormous number of cases, none are passed through to the 2nd Ambulance station, much less the clearing-station ; they do not get past the first surgical line {relai). Whatever be the treatment, whether by immediate or delayed amputation, the mortality is considerable. This might perhaps be diminished by performing transfusion of blood before operation, if this were possible, and it might well be tried. But to conditions such as these the name of joint- wounds is inapplicable, and to include them in the same category as those in which the joint injuries are GENERAL CONSIDERATIONS 7 more or less uncomplicated is to create confusion. It will not be done here. % Comminuted Articular Fractures with or without fissures radiating into the shaft, but with the main vessels and nerves intact. — tms is the group comprising wounds of medium severity which form the great majority of joint fractures. There are all degrees between the complete destruction of a joint on the one hand and the simple parietal fracture of an articular end on the other. The treatment of these will be discussed almost exclusively in this book. In the case of each articulation I shall consider the treatment of a joint wound without fracture, with or without the missile present. 3. Bullet Wounds of Joints with a Punctiform Skin Wound, with or without fracture. — ^These behave like simple fractures and are quite mild in character, provided that rigorous immobihsation is secured. They are really punctured wounds of the synovial membrane, simple trochar-like wounds of the bone with or without radiating fissures of the shaft, and they result from long-range bullet-wounds. In the case of the knee, a copious hsemarthrosis often requires one or more aspirations which it is well to make quite early. Otherwise prolonged immobihsa- tion alone suffices for cure, but it must be kept up for a long time and movement must only be commenced when all pain has completely disappeared. I have had 12 cases of this kind — 7 of the knee, 3 of the shoulder, and 2 of the elbow ; they wore a plaster casing for from three weeks to two months. They all recovered, with very satisfactory recovery of the functions of the joint. Briefly, these cases are of the mild type which before the war was considered the usual type of bullet wounds of joints. Their mildness is explained by the con- ditions under which the wound is made ; the bullet enters with its pointed end foremost, passes through 8 THE TREATMENT OF FRACTURES the clothing between its threads without carrying any with it. It traverses the skin, the muscles, and the synovial membrane without depositing in them any infected fragments of clothing, and the fracture, whatever be its type, whether erosion, cartilaginous abrasion, furrow, gutter, or bony perforation, is an aseptic fracture, and runs its course as such without infection. But no rule is absolute, and one can quite well understand that infection may occur in these joint wounds with tiny skin orifices. So these patients ought always to be very carefully supervised ; their tempera- tures should be taken regularly, the joint should be examined daily without necessarily removing the plaster each time. If after the first few days the primary fever caused by the haemarthrosis persists, if the temperature, after having fallen to normal, suddenly goes up, if the general condition is affected, or if theje is the least suspicion of infection, free' arthrotomy may become necessary. I have never had occasion to perform it under these circum- stances. All the foregoing remarks about joint injuries with punctiform skin wounds refer to the injuries made by bullets. In the case of quite a minute wound caused by a small spUnter of a shell or grenade, infective com- pHcations are to be feared. The wounds made under these circumstances resemble those in the second category above and will be considered with them. II. General Treatment of Wounds of the Synovial Membrane and of Compound Fractures into Joints Since the crushing of limbs in the neighbourhood of joints requires amputation, and bullet wounds ©f joints with very small skin wounds are amenable to simple immobilisation, there is only a single category of joint wounds in which the treatment is varied and GENERAL CONSIDERATIONS 9 open to discussion. It forms our second group and is a very large one. Before seeing what it is best to do for one of these cases it is well to define the principal types which can be identified by radiography. They are, in order of increasing anatomical gravity : [a) A wound of the synovial membrane, without a bony lesion but with the projectile free inside the joint ; this is rarely seen except in the knee, and is very exceptional elsewhere {e.g. the shoulder). (6) A wound of the synovial membrane with the projectile embedded in bone, that is to say with a fracture of the cancellous end of one bone. (c) A wound of the joint with a fracture of the com- pact layer of the epiphysis, that is, a fracture not interrupting its continuity. In these cases there are sometimes fissures and multiple jagged splinters. {d) An articular fracture properly so called, single or multiple ; here the bony lesions vary very much according to the epiphysis affected and the circum- stances governing the impact of the projectile. In the case of the upper end of the humerus there may be a simple separation of the head, or complete destruction of it, a frequent type ; at the elbow there is often a T-shaped fracture with irregular fissures, recalhng in certain points the fractures of civil practice ; the articular fragment is often lar^e, the shaft being pointed like the mouth-piece of a fiute. In the ulna, besides a transverse fracture of the olecranon, com- plete crushing of the bone into small fragments is met with. The same thing may occur in the head of the radius where large spHnters are rare. In the hip, crushing of the trochanter, with fissure through the neck, or separation of the head of the bone is frequent. In the knee, simple fracture of one condyle or a T-shaped fracture (figs. 2 and 4) of the femur may be found ; in the tibia, it is common to find extensive 10 THE TREATMENT OF FRACTURES crushing of the cancellous tissue with pulverisation of bone, but without large splinters or radiating fissures (fig. 3). Radiating fissured fractures are especially often met with in the lower extremity of the humerus, in the ulna, the hip, and the lower end of the femur. (e) Complete crushing of the articular end. This classification makes it clear that one standard method of treatment is not appUcable to all cases. But the fundamental principles of treatment remain irrefutable ; they are those which govern the entire treatment of war-wounds, that is to say, the necessity of a primary clearing operation, performed as early as possible, removing missiles, fragments of clothing and organic debris on its way to rapid decomposi- tion. There can be no question as to the absolute urgency of these preventive incisions, which are pro- phylactic against sepsis and are the basis of all con- servative surgery. This clearing out by incision ought to be complete, extend to all the injured parts, and leave nothing doubtful behind. In practice there are still differences of opinion upon the best way of carrying it out and the extent to which it should go. We have the choice of four methods — viz. arthro- tomy, removal of bony fragments from the joint (esquillectomy), resection, and amputation. These operations are in no way opposed to one another ; each has its indications, which are deter- mined by the extent and nature of the injury as deter- mined by radiography and by exploration. On the other hand, the indications vary according to the time that has elapsed since the infliction of the wound and according to its situation. A. Primary Operations (during the first twelve hours). — ^Theoretically we may say that to effect with certainty the necessary prophylaxis and to make sure of a definite orthopaedic result, it is necessary in the GENERAL CONSIDERATIONS 11 first twelve hours to extract the missile, to remove fragments from simple parietal frac^ares, to resect those fractures which interfere with the mechanics of the joint, and to amputate for conditions in which the damage is incompatible with the ultimate satisfac- tory functional restoration of the limb. In practice these are the rules which ought to be applied as soon as possible, certainly within twenty-four hours. {a) Missiles within the joint must he removed. — There are no doubt some which remain clini- cally aseptic, but they are quite the exceptions. As a rule, a sphnter of a shell or grenade, carrying with it debris of cloth- ing, is followed with certainty by a rapidly spreading acute arthritis. The infection intro- duced into a closed cavity is very formidable, and a fatal result often follows. In short, the presence of a missile in a joint is always dangerous. Its removal is quite the opposite. Simple opening-up of the wound is not sufficient to ehmi- nate all chance of sepsis ; drain- age certainly diminishes the immediate risk of its development, but unless the missile be removed, the degree of infection is only lessened and the patient remains a prey to slow septicaemia which is some- times fatal. (b) The area of a 'parietal fracture should he excised. — Every bone which is fissured or frayed at the edge and all crushed cancellous tissue ought to be treated Fig. 1. — Wound of the joint with parietal frac- ture not interrupting the continuity of the epiphy- sis and amenable to a limited esquillectomy after removal of the projectile. 12 THE TREATMENT OF FRACTURES by scooping out the bone and removing the bony splinters ; on the points of these, even after extraction of the missile, minute organic particles and threads of clothing material are held up, and the develop- ment of a focus of osteitis is a grave matter. This osteitis is the more dangerous as bony fissures often radiate from the point which was struck, and the Fig. 2. — Fracture of one condyle requir- ing, in view of future orthopaedy, resection of the knee-joint through the epiphy- ses. Fig. 3. — Fracture of one condyle of the tibia requiring, in view of future ortho- paedy, resection of the knee-joint through the epiphy- ses. Fig. 4. — T-shaped fracture of the lower end of the femur re- quiring typical resec- tion of the knee- joint. sepsis travels along these. As a result, infection of the bone marrow occurs which amputation alone is able to remedy. (c) A fracture that ivill permanently interfere with the functions of a joint should be treated by immediate re- section, chiefly because that operation in the very early GENERAL CONSIDERATIONS 13 period guards against infection ; and also because it provides for the future usefulness of the joint except in the case of the knee, where ankylosis ought to be systematically aimed at ; elsewhere it assures satis- factory if not entire, recovery of function, while at the knee it is the only measure that assures a position of the Umb which is fundamentally necessary to walking (figs. 2-4). But for this purpose resection must be as true to type as possible : it ought not to be merely a question, as it often is, of the mere level of the bone sections. The typical operation is that derived directly from the teaching of OlUer, and deals with the joint without sacrificing the tendons, carefully separates the perios- teal prolongation of the capsule without dividing Hgaments or tendons, and is followed by a most strict post-operative treatment. {(1) A fracture of the loioer Umb extending as far down the shaft as it does towards the epiphysis should be treated by amputation, because a cure is difficult to obtain by conservative methods and would be followed by a very bad functional result (fig. 5). In the upper limb amputation is to be avoided at any price short of extensive excision of bone, however little hope there is of preserving a useful hand. To these general statements we may add that : (a) Arthrotomy in the early stage ought to be only an exploratory procedure followed by extraction of the missile, which should be locahsed if possible. The best method of locaUsation would appear to be Hirtz's " compasses," when there is time to employ them ; if stress of work will not allow of this, the position of the projectile should be ascertained by radioscopy, marked on the surface, and the joint widely opened. If radioscopy is not available, an exploratory arthro- tomy should be performed so as to admit of removal. (6) Esquillectomy {removal of the fragments) will be added to arthrotomy whenever the bony lesion is 14 THE TREATMENT. OF FRACTURES confined to the surface of the bone. It should be done by a rugine followed by a curette. If the fracture is more extensive than at first appeared or than is indicated by radioscopy, if, for example, there be deep- seated cancellous crushing of one of the condyles of the femur, one would perform immediate resection; " esquil- lectomy " * is only of use in the small parietal fractures. They are, in my opinion, the only cases suited for this method. Many surgeons take a different line : arthrotomy with esquil- lectomy is with them the treat- ment of choice for almost all fractures into joints, because it appears to be the most conser- vative method. They contrast it with resection, which they say gives bad results and look upon as a mutilating operation. Ac- cording to their view, arthro- tomy is done to drain an area that esquillectomy has cleared out. Thus presented, the paral- lel is absurd ; each operation has a precise field of its own, which cannot be departed from without falsifying the results and the indications. In the early stages of these war-wounds arthrotomy ought not to be done to drain, but to explore, so that the surgical sterilisation of the wound may be ensured by the removal of foreign bodies ; if the missile in its passage has caused a partial fracture, a gutter or furrow on the articular end, if it has detached a frag- FiG. 5. — Fraeture of shaft and epiphysis ne- cessitating amputation. * The term " esquillectomy " will be used throughout this trans- lation instead of the more cumbrous term "removal of splinters of bone." — Ed. GENERAL CONSIDERATIONS 15 ment or splinters of bone, the removal of these also is indicated ; and the same is the case when the missile has embedded itself in the bone and has pro- duced in it a crush-fracture. But whenever there is definite solution of the continuity of an epiphysis, esquillectomy ought to give place to resection. One can doubtless recall some brilHant results from Hmited intra-articular esquillectomy in these complex cases, but these will always be exceptional results obtained under favourable circumstances : the method is dan- gerous, because patients in great numbers cannot all receive the strict supervision which is imperative for success ; besides, the final orthopaedic result of these partial operations is generally bad. (c) Subperiosteal resection is the method of choice for comminuted epiphysial fractures Hkely to unite badly, and for all those that interfere with the mechanics of the joint. If done early, it is the typical operation for the prophylactic clearing-out which anticipates all sepsis and ensures aseptic results. When done according to the subcapsular-periosteal method, it gives remarkable results. It is used more freely in some regions than in others ; at the shoulder it will sometimes be possible to do without it, subcartilagi- nous excision giving very favourable results. At the elbow, at the knee, at the ankle, and in the metatarsus it should, however, always be employed ; in these situations it is the ideal conservative operation. {d) Immediate amputation ought only to be chosen in exceptional cases, unless there is crushing of the bones with irreparable injury to the muscles, vessels, and nerves. In the upper hmb it ought never to be performed primarily whatever the extent of the injury, because subperiosteal resection and extensive esquillectomy always suffice to deal with even the greatest damage. In the lower limb it is performed sometimes after direct exploratory examination. 16 THE TREATMENT OF FRACTURES Whatever may be the state of the elbow or the shoulder, a normal Tiand with mobile fingers is always of more use than a hook on the forearm. In the lower limb, on the contrary, the conditions may be such that an artificial leg is much better than a con- siderably shortened leg or thigh. One can hardly define these conditions in words ; it is largely a ques- tion of degree. Three factors, however, dominate the decision : If the lesions of the soft parts are very extensive, if, in short, preservation of the limb appears too hazardous, immediate amputation should be done. If the bony lesions are too extensive for the func- tional power to be ultimately restored, one would amputate at once ; in practice, any injury may be considered as too extensive that would entail a short- ening of at least 4 inches. When there is a great influx of wounded, amputa- tion should be chosen unless the case appears very favourable for resection ; conservative surgery requires diligent post-operative supervision, much time and care. Without them it is dangerous and apt to lead to disappointing results. B. Secondary Operations (in the febrile period). — In these cases there is no longer any question of prac- tising prophylactic operations upon damaged areas threatened with imminent sepsis, but of ensuring drain- age and rapid disinfection of an already infected joint. The decision as to the operative measures best fitted for this purpose is guided by the question of the resist- ance of the individual patient ; the longer the time since the commencement of the sepsis, the more radical should the measures be, and the less the rehance that should be placed upon drainage without removal of bonfe. (1) Arthrotomy is suited to pure synovial injuries, to drain abscesses, and to remove if possible the foreign bodies causing the trouble. It is useful for joints GENERAL CONSIDERATIONS 17 with loose capsules and large synovial cavities. It only drains close-fitting joints like the elbow and the hip indifferently. It is only successful in cases of joint suppuration due to superficial osteitis that easily finds its way to the surface. It should be employed for the shoulder and the knee, elsewhere it is not worth while wasting time upon it ; the less so since the usual result of these suppurations is ankylosis, and it is therefore better to resect at once, especially where articular mobiHty is desirable, as for example in the elbow. (2) Resection is a method of drainage only in the close-fitting joints. In severe infections without fracture it performs marvels at the elbow, the wrist, the hip, the ankle, and the tarsal joints. Often useless at the shoulder, it is equally so at the knee, since it leaves no cavity for drainage. In simple suppurating arthritis of the knee, without injury to bone, if arthro- tomy with extraction of the missile does not lead to rapid improvement of the general and local phenomena, and if at the end of three or four days the condition is still critical, resection is useless and even dangerous. Perhaps excision of the synovial membrane might be of value : I do not recommend it since I have no expe- rience of it, and until we have more knowledge on the point we must resign ourselves to rapid amputation. It is quite a different matter when there is a fracture. The infection is then rather an osteomyelitis than an arthritis, and it is safer to resect at once, even at the knee, to get rid of the infection. Undoubtedly failures will/)ccur, but there will also be remarkable successes. My advice is to use it immediately for any joint unless the injury is parietal or extra-articular. (3) Immediate amputation is called for when the patient's general condition is profoundly lowered, when there are purulent sinuses everywhere, and when there are multiple infected wounds ; in short, when the patient obviously requires to be rid at once of the source of the infection. 18 THE TREATMENT OF FRACTURES Secondary amputation should be done, without too great loss of time, for injuries of the knee after the failure of arthrotomy or resection, the risk of the septicaemia being then only too apparent. In the case of the ankle and the upper limb an attempt to pre- serve the limb by resection can be persisted in much longer without danger. in. General Technique of Operations upon the Joints The operations which are performed on the joints, being essentially conservative, require great precision and much attention to detail from beginning to end. The different operative stages should be conservative, in order that the final result may be preservation. It is a fundamental precept, never to be forgotten, that whenever an attempt is made to obtain recovery of function, none of the elements of strength and mobihty in a joint must be sacrificed. This precept imposes two rules of technique which ought to be regarded as dogmatic. The exploratory incisions should not sacrifice any tendon, muscle, or muscular nerve-supply. The opening up of bony cavities ought to be done with the sharp rugine, ivhich not only separates the periosteum, but raises with it the capsular ligaments and tendinous insertions, thus leaving intact all the working apparatus of the joint. I place on record these two precepts of Olher's conservative surgery because many surgeons do not know them or have not understood the bearing of them, which will explain the want of functional success which is wrongly attributed to resection. These surgeons have regarded the preservation of the periosteum as the only point in Ollier's method, and since the osteo- genetic power of the periosteum is not always neces- sary, and as from this point of view it is possible at times to do without it, they have concluded that GENERAL CONSIDERATIONS 19 its separation is a useless complication, and have returned to their former extra-periosteal (parosteal) methods. This is an absolute misapprehension of the conser- vative method, as we shall see. 1. Physiological Incisions. — ^In 1885 OlHer wrote as follows : " The object is to preserve all the tissues, all the elements essential for the reconstitution of the bones and the joints, while causing the least possible damage to the peripheral organs. To attain this end we must do our operations by methods different from those in ordinary use. One should approach a joint in the same manner ias one approaches an artery, namely, through carefully planned incisions. There is no longer any call for rapidity in opening a joint : it should be approached by way of the muscular interspaces without injuring any structure not only important, but merely useful, and without sacrificing any of the requirements of a sound operation, such as room for the operator and space for the movement of his instruments." These intermuscular incisions are made only in certain well-defined anatomical situations when an arthrotomy or resection is in question. The incision appropriate for each joint, " the physiological incision,^' is given farther on ; it is the incision chosen with due consideration for the future physiological function of the joint. In war-wounds it may seem impracticable to follow these lines : one will often be tempted to utiHse the openings made by the missile. Whenever these are not gaping holes, however, it will be an advantage to approach the joint by the correct route and to utilise the track of the missile, after it has been duly cleaned up, as a route for draining, and not as a means of access. That is a question of dexterity and common sense which cannot be reduced to rules . If it is decided to utilise the existing wound, its walls ought to be 20 THE TREATMENT OF FRACTURES excised with a bistoury so as to transform it into a passage with clean sides without unduly sacrificing healthy muscular tissue. Muscles and tendons ought not to be divided transversely by joining the two openings of a sinus ; in the case of the shoulder particu- larly, division of the deltoid is disastrous. In a word, a joint ought always to be approached with a full regard to its future movements. 2. Preservation of the Capsulo-periosteal Sheath. — ^This ought to be preserved, for two, reasons : first, to retain the elements essential for regeneration of bone, which is the anatomical aim, so to speak ; second, to maintain intact the factors concerned in the stability and mobility of the joint, the physiological aim. (a) The whole thickness of the periosteum with its deep osteogenetic layer ought to be preserved because, thanks to its activity, the bony extremities are regen- erated. What happens after a resection ? At each end of the capsulo-periosteal sheath at its periosteal edge, the osteogenetic layer proHferates, thickens, and gives rise to masses of soft consistence and cartilaginous appearance, in which ossification occurs. Two masses of new bone result, which soon constitute new articular extremities between which a new joint is formed. (&) The capsular sheath ought to be preserved because one thus retains inside it a certain number of endothehal cells which favour the creation of a new synovial membrane, and outside it the necessary Hga- mento-tendinous continuity. Let us consider first the formation of a new synovial membrane. At the edge of the capsular portion where the syno- vial membrane exists, the serous layer thickens under the influence of traumatisin ; its endothehal layer sends out cellulo-vascular processes which meet one another GENERAL CONSIDERATIONS 21 and, blending together, form what will become later the articular cavity. If the wound does not suppurate, or only does so sUghtly, we have at hand all the elements necessary for that gliding motion which it is the object of gentle movement to promote during the early stages of the organisation of the wound. Little by little, under the influence of these movements, the endothelial lacunae enlarge, the partitions wear away and disappear, and finally a new synovial membrane is formed : that is the ideal plan of development. When, on the contrary, inflammation or operative measures have destroyed these synovial elements, it is much more difficult to form, by means of repeated gliding movements, a sort of hygroma, or an inter- osseous serous bursa, and this is always less perfect and less adapted to its purpose than is the true synovial membrane in the former case. After this explanation it is ' easy to understand why technique and post- operative care play an essential role in the final results of resection if we regard them from the point of view of restoration of function. It is for want of under- standing of this anatomico-physiological development of new joints that some surgeons only get bad results and therefore condemn resection. If the preservation of the synovial membrane and its regeneration play a large role in the post-operative formation of a new joint, it is the preservation of the whole tendino-Hgamentous capsule of the joint, and the retention of the muscular insertions in their normal relations to the capsulo-periosteal sheath, which causes the gradual development of the new joint towards the perfect physiological type. The capsulo-periosteal sheath placed in immediate contact with the bone acts at first like a guardian to the process of osteogenesis ; it limits the new formation of bone, restrains it, and maintains it in good position ; then at the proper time it models it under the action 22 THE TREATMENT OF FRACTURES of the muscles, which, having retained their insertions into the part of the capsule corresponding to the epiphysial tuberosities, remain in their normal position and contract as usual. By their normal action they press on the capsule and make their impress through it on the newly formed bone. In other positions they pull upon and mould the soft bone into shape. In short, their action, which is retained intact by the pre- servation of the capsular sheath, is constantly tending towards the production of a physiologically normal joint. The careful separation of the capsular sheath is even more indispensable when the injuries are so extensive that it might seem useless to take all this care. Here, the preservation of the tendinous inser- tions in the capsulo-periosteal sheath assures the func- tions of the muscles, permits the secondar}^ drawing together of the widely separated bones, and rearticu- lates them in some measure ; the capsule then acts as an elongated tendon, and it is by its means that one is able to obtain excellent functional results in many extensive resections. It is unnecessary to labour this point further. What are the necessary steps in practice to preserve these indispensable factors for recovery of function ? After the joint has been opened, as described, and the intermuscular intervals kept apart by retractors, it is necessary first to incise the capsule in the direction of its fibres, or the long axis of the limb. When that is done, the knife is abandoned for the nigine, which should be used throughout the rest of the operation. This rugine should be of a special pattern : for separating the periosteum and its sheath there is only one good one, that of OlHer, with a steel shaft ending in a flattened extremity, as sharp as a razor. This cutting edge is bevelled from its dorsal surface downwards towards the under edge which is kept in contact with the bone (fig. 6). GENERAL CON til DERATIONS 23 which Oilier i\ I A.J ill With this instranient, wiiiclj lias a solid handle, a way is made by degrees between the bone and the periosteum, and one is able to raise the periosteum and the capsule bit by bit, and to preserve intact a fibro-periosteal prolongation of the muscles and tendons. The name '' detaclie-tendon gave to this instru- ment indicates the r;::^^ ^ object in view. But !l. I i in order to attain it |.^^J M without accidents, ^^m |ij the rugine must be ^^f^ |||| used slowly and for- cibly, the right hand being guided by the left index finger ap- phed to tile right. With a little practice it is possible to de- nude the most ir- regular tuberosities so that finally the bone will be as fret as if it had been enucleated from its fibrous .sheath. This method is appHed to each fragment of bone whicli is more or less free. Every little fragment, however small, ought to be treated thus ; it should be grasped in forceps and its external surface carefully stripped. It is only in this way that the subperiosteal operation can be truly and typically carried out. A final detail will perhaps be useful : as one approaches the shaft, the separation of the periosteum becomes easier. Sometimes a careless movement causes the shaft to project through the separated sheath. This is an accident which is most likely to occur in resection of the elbow when the separation is being carried above the condyles of the humerus, espe- m Fig. G. — Ollier's rugiiies with cut- ting edge for the complete detachment of the deep layer of the periosteum, the ligaments, and tendinous insertions. 24 THE TREATMENT OF FRACTURES cially in secondary operations : it can be avoided by care. 3. Division of the Bone. — ^In resections it is often remarked that it is difficult to steer a correct course and remove enough bone to procure mobihty without removing too much to preserve a sufficiently firm joint. The best sections are those made through the epiphysial ends. It is much more frequently possible to do this than one would think. When these injuries are limited, there is sometimes difficulty in making the bone project sufficiently to divide it, and the surgeon may be tempted to prolong the denudation further towards the shaft : this is useless, and gives very little more room. The difficulty is caused by the periosteal-ligamentous adhesions, and should be overcome by again applying the rugine to each tuber- osity, and stripping off these structures transversely instead of axially. A chain saw, or Gigli's saw, can then be used, and the epiphysis divided at a suitable level. When the injury is more extensive and runs along the shaft, there is no need to conclude that the con- servative operation is doomed to fail to restore the function of the joint, and should be rejected. In the majority of these cases the fracture in the shaft runs parallel to the long axis of the bone ; a large fragment comprising the articular end and a part of the shaft is detached, but there is no actual solution of continuity of the shaft itself. The pointed end of the latter reaches down to the level of the broken epiphysis, and the saw has only to remove this sharp extremity. If the periosteum has been carefully preserved, bone formation will result, and a new epiphysis will be constituted. In a number of cases the epiphysis is only fractured on one side ; the broken fragment comprises a thin shell of the shaft which is of no importance ; enough of the articular end remains on the opposite side for GENERAL CONSIDERATIONS 25 a unilateral intra-epiphysial section to be made which is sufficient if the periosteum has been pre- served. When both epiphyses are destroyed [i.e. T-shaped fracture), it is customary to find fissures extending up the medullary canal of the shaft. Unless resection is performed, these parallel fissures constitute a very Fig. 7. — Fracture of the el- bow by shell-splinters. Total resection of the elbow- joint on the second day, in consequence of the fissured shaft of the ulna. Fig. 8. — The same case as fig. 7. Radiograph fifteen days after resection. great danger if the bone becomes infected, because it is thus that acute osteomyehtis arises. If, however, the intra -articular fragments are removed, and the wound is systematically cleaned, they frequently weld together and reconstitute the shaft (figs. 7-9). There is no need for anxiety in these cases : the bone section should be performed as if the fissures did not exist. If the fracture is clearly as much epiphysial as dia- physial, with its centre at the line of junction, it must 2o THE TREATMENT OF FRACTURES be realised that this injury often leads to amputation if resection is not performed at once. But the opera- tion ought to have for its object the preservation of a large portion of the lower fragment of the shaft, which is nearly always pos- sible. The articular end is removed and the Hmb carefully immobilised in p suitable position for five or •six weeks, so that bony union, which is accelerated by the operative measures, may occur in the fractured shaft. Then, but then only, attempts at movement may be made if mobility is de- sired. Thus, resection in certain cases is an operation true to type, in others it con- sists in removal of all the epiphysial fragments, sub- periosteally of course, fol- lowed by trimming with the saw. When the articular end of one hone only is affected, should resection he confined to that hone ? This is the usual proce- dure in certain situations ; hemi-resection of the upper end of the humerus is commonly called resection of the shoulder, and femoral hemi-resection resection of the hip. In mihtary surgery, the classical method is adhered to at the hip and shoulder if one bone only is injured, because it is sufficient to ensure good post- FiG. 9. — The same case as figs. 7 and 8. Radiograph at the end of two months. The wound was healed by the thirty-ninth day ; active flexion had then almost reached a right angle. At the end of a year the result is perfect : ac- tive flexion and extension are normal ; the patient can carry 1 5 kgs. with the arm raised ; pronation and supination are normal. GENERAL CONSIDERATIONS 27 operative results, and because the functional recovery is better when it is so done. But in other situations it is different. As a general rule, when mobihty is desired, it is better to put into contact two bony surfaces, which by friction will adapt themselves to one another, than to oppose bone to cartilage, in which case the adaptation will not be so good, since the unmouldable cartilage will remain as it is, the other surface having to do all the work of fashioning the joint. At the elbow this is very clear : no doubt some perfect results are obtained from hemi-resection, but more often the articular movement becomes checked at a certain stage ; in the lower hemi-resections of the elbow [i.e. of the bones of the forearm) the movement of active flexion beyond a right angle can only be effected after a sudden sHde over the anterior trochlear surface. In the superior hemi-resections {i.e. of the humerus) one never restores pronation and supination. At the elbow, then, it is better to do a total resection, unless the loss of substance in one of the two bones is too great. In the resections where ankylosis is aimed at, as at the knee, there is great advantage in bringing two bleeding bony surfaces into apposition. It is illogical to allow contact between bone and cartilage if one wishes to obtain firm bony union ; and be- sides, the removal of a thin slice of cartilage does not add greatly to the loss of substance. Thus, except at the hip and shoulder, a resection of both articular ends should be the rule. 4. Drainage. — ^The best method of draining a "joint which has not been resected is to insert drainage tubes into small openings in the capsule. It is better not to pass them in deep, and not to insert any transversely, aseptic though they be, across a serous membrane which does not tolerate them well. In the case of the pleura, this rule is well estabUshed ; in the case of the synovial membrane it holds equally well. 28 THE TREATMENT OF FRACTURES When the case is one of resection instead of an arthrotomy, the injuries being largely exposed, I do not as a rule put in drainage tubes, but insert tampons of aseptic gauze gently without force or pressure. Gauze is regarded as holding up the discharges, and many surgeons proscribe it for that reason. It is probable that they plug too forcibly, which makes it ineffective, or that they leave the dressings in place too long. These are questions of personal practice which are not absolute rules. The principal point is to leave the wound wide open without ' suturing it, as A. Poncet always advised in all surgical casualties. 5. Immobilisation.— Every joint that has under- gone injury or has been operated upon ought to be immobilised. In principle, the only good immobilisa- tion is that which fixes the joint above and that below, as A. Bonnet advised, and the reahsation of this ideal ought to be striven for. After resection, how- ever, it is not absolutely necessary everywhere ; thus in the case of the elbow it is useless to immobiUse the shoulder ; but as a general rule the principle holds. The best immobiUsing agent is the plaster casing. I think that at first this method should always be used (except at the elbow, where I often omit it). Metal splints ought only to be used if there is no time to make others. It is only later on that the wire spHnts or plaster-of-paris splints with windows are indicated. The former do not immobiUse as well as the plaster casings, the latter make it difficult to inspect the limb ; OlHer abandpned them twenty-five years ago. In spite of their present vogue they should only be used sparingly for joint injuries, and even then always only temporarily. 6. Dressings and Sunlight Therapy. — ^After primary resection performed early, the course of the wound is uniformly aseptic. Dressings can and ought to be done seldom ; the post-operative dressing may well remain unchanged for 8 to 15 days. In GENERAL CONSIDERATIONS 29 all cases one can and ought to dress the cases only occasionally unless sunlight treatment is possible. After secondary [intra- febrile) resections, it is often necessary to do the first dressing as early as the end of 2 to 4 days, but after this has been done it will be advantageous to disturb the wound as seldom as possible. I have seen intra-febrile operations for the removal of the astragalus healed in 60 days after 6 dressings, some secondary resections of the elbow in 39 and 45 days with 2 dressings between the 1st and 15th days, after which the necessity of move- ments called for greater frequency. The current fashion then is few dressings, and, I would like to add, not voluminous ones. There is a tendency to use too much wool, to bury under enormous layers a wound which wants to be aerated, a skin which is best exposed to the air and the sun. A custom which is very expensive and particularly bad is to envelop the limb in non-absorbent wool steriHsed or not. These bad practices ought to be abandoned. In general it is well to do the first dressing under ethyl-chloride anaesthesia ; one is able thus to remove the gauze and replace it without pain. After each dressing strict immobiUsation is renewed. If the cHmatic conditions allow of a sun bath, the procedure is different : insolation and a change of dressing will be the daily rule. In these circumstances a yery light dressing is employed. Those who have never practised hehotherapy can have no idea of the truly magical effect of the sun on surface wounds ; in a few minutes, under one's eyes, the bleeding surface is entirely modified. A sitting of a quarter of an hour suffices to get rid of the sloughs and after three or four sittings suppuration is at an end. This result is due to a regular flow which occurs from within outwards. If the sun is rather strong, at the end of five minutes on an average one sees the wound dotted with red spots ; at the end of seven minutes 30 THE TREATMENT OF FRACTURES a sort of pink serum exudes having the appearance of blood serum ; the flow is abundant enough for one easily to collect an appreciable quantity if one wishes. Then the wound becomes glazed ; it takes on a fine reddish tint, and if touched it bleeds. In short it gives the impression that some embryonic capillaries are formed on the spot in a few moments, and that the wound is vascularised as if by some intense reaction. At the end of some days the wound is considerably reduced in size ; cicatrisation progresses with wonder- ful rapidity, and healing is obtained more quickly than by any other method. But insolation has yet another advantage : under its action the muscles do not atrophy but they remain strong and vigorous. When it is desired to re-estabUsh movement in the joint the period of passive movements is much short- ened ; the power of active contraction is recovered in a few days. I have seen patients whose elbows have been resected move their forearms themselves fifteen days after operation. One patient at the end of forty days was able to lift Ij kilogrammes with arm extended, and then to raise it beyond a right angle. Heliotherapy is an expedient no one should overlook. 7. Mobilisation. — If one does not deliberately seek for ankylosis, whether after arthrotomy or resection, early movement is the condition necessary for the recovery of the functional power. But this ought not to be begun until the day after all pain has dis- appeared ; it should only be continued if the passive movements can be performed without any acute pain and without producing inflammation. There are no other rules than these. It should never be forgotten that absolute rest and immobility form the basis of all treatment of inflammation. By not obeying this law one runs counter to the end in view. On the other hand, if the period of immobihty is GENERAL CONSIDERATIONS 31 unnecessarily prolonged, the formation of bony anky- losis and finn ligamentous adhesions is favoured. It also induces a muscular atrophy that is often irre- mediable. It is not well, then, to prolong the period of joint-rest too far. But attempts at movement must be made very gently ; any undue force is paid for by inflammation which increases the tendency to ankylosis. In fine, if recovery of the normal function of a joint is sought for after an operation, one must avoid three dangers : too prolonged immobiUsation, too rapid mobiUsation, and forcible mobiUsation. Neglect of this is the explanation of many failures. MobiUsation, therefore, should be begun very gently but early, subject to the above reservations (no pain, no temperature, no secondary reaction), even if there is much loss of bone. In this case the muscles have got to take the place of ligaments in the new joint : it is essential to preserve them to the utmost. But in the intervals between the short trials of passive movement there must be complete im- mobility with the bones in contact. Care is necessary not to exceed the limit : so per- suaded does one become of the necessity of movements that one is apt to consider the patient who does not wish them to be performed as cowardly or hyper- sensitive. Either they are imposed upon him as a stern necessity, or they are done unexpectedly, which is the worst of methods. I have often witnessed the deplorable results of too much zeal. As Olher has written, " If dociUty on the part of the patient should be his greatest virtue, patience on the part of the surgeon is no less necessary. It is a mistake to hope to obtain in eight days what requires several months. It is not a matter of conquering resistance and of breaking down adhesions, but of favouring the recon- stitution of gliding movement and the regeneration of an interposed serous membrane. Time is indis- pensable for these things. Too violent or too pro- 32 THE TREATMENT OF FRACTURES longed exercise is capable of injuring the tissues which it is intended to make supple, and of inducing a plastic and adhesive process instead of creating a sHding joint." By adopting these precepts one is sure not to end either with ankylosis or with a fiail-joint. The latter, with its complete loss of power of active movement, is primarily due to complete muscular insufficiency and bad post-operative management. When a primary resection has been done, the muscles are vigorous and strong, nothing has atrophied them ; when they contract, they press the articular surfaces closely together ; they articulate the new joint and permit to it a play of movement of satisfactory ampHtude and precision, even if the resection has been very extensive. Doubtless in war-wounds one should not look for the ideal anatomical result of the resections performed in peace-time with their perfect restoration of the bony extremities in their normal position bound together by a marvellously regular ligamentous apparatus ; but the important point is to obtain a satisfactory physiological type. Only great patience is capable of producing this result with certainty. Speaking generally — ^I might almost say, speaking literally- mechanical therapy ought to be proscribed : it haS often led to disiaster, from not taking sufficient account of resistance and of pain ; it is too brutal, however gentle it may be, and tries to go too fast. Many resections of the elbow have ended in ankylosis because it has been imagined that a new joint could be pro- duced by a mechanical machine. 8. Later Appliances.— Some patients after re- covery from arthrotomy or resection derive advantage from wearing a simple supporting . apparatus for some months : for the elbow or the wrist a bracelet or gauntlet of leather, for the knee a laced spHnt, for the foot a boot with lateral supports. After resection of the knee a leather spHnt with rigid supports should GENERAL CONSIDERATIONS 33 be advised during the first year or two. After resection of the hip a raised boot is necessary, an orthopaedic apparatus useless. 9. Evacuation of Patients with Wounds of Joints. — ^As far as can be, wounds of the joints should be treated on the spot, moved as little as possible and evacuated as late as can be managed. In a war of position every joint wound, however small, ought to be operated upon immediately after the patient has been brought in, for it is only in this way that a small wound can be made to remain harmless. The patient's evacuation after operation should be carried out after complete immobilisation has been effected : the apparatus to be preferred is a plaster trough. But evacuation ought not to be ordered, save for military necessity, except for convalescents, that is for patients who have been free from fever for many days, who have no pain, and whose wounds are clinically aseptic. CHAPTER I (Continued) GENERAL SURVEY OF PRESENT METHODS FOR OBTAINING WOUND ASEPSIS The presentation of modern methods of treatment for infected wounds meets with difficulties at this particu- lar time. Opinions are still divided concerning" the value of certain new procedures, notably the Carrel- Dakin treatment by multiple irrigation of war wounds with a special antiseptic fluid ; a method which has won popular favor and has been accepted by the United St-ates Government for its military medical services. Prominent German war surgeons, such as V. Bruns and others, are equally convinced of its superiority, and on the basis of extensive experience with this treatment in the worst type of artillery and similar injuries are inclined to regard sodium hypochlorite as the turning- point in the treatment of infected war wounds and the hoped-for solution of the problem of chemical wound- disinfection. The status of the treatment of war wounds as it ex- isted at the' inception of the war eventuated in the speedy revelation of the inadequacy of the procedure then in use. The failure of antiseptics and asepsis as practised in tlie early days of the war has since been shown to be due, not to a fallacy of the fundamental principle, but to the Inadequacy and incompetence of the older technics and disinfectants to deal with the new tj'pe of artillery wounds and the intense contann'na- tion of the soil of the battle fields with a multiple of anaerobic germs. From the failure of the old grow the involution of modern methods of wound treatment. A conflict arose between the antiseptic or Listerian meth- ods, essentially represented by the Carrel-Dakin wound 34 GENERAL SURVEY 35 treatment, and the purel}'^ physiological method of Sir Almroth Wright and his school. The gradual im- provement of the antiseptic methods is represented by the evolution of the chlorine compounds, with the work of Dakin, Lonain Smith, Geo. Makins, J. E. Sweet, and others. The drawbacks of the hypochlorites, the hypochlorous acid preparations, and the hypertonic salt solutions led to the elaboration of Dichloramin-T and its substitutes, to the introduction of Flavine and Bipp, tfc) Delbet's method of hypoculture and his mag-, nesium chloride, to the use of Vincent's powder, Hey's brilliant green paste, and a number of other methods of wound treatment. Special mention must be made of the new Serotherapy introduced into wound treat- ment, notably in form of the polyvalent serum of Le- clorinche and Vallee, the merits of which are not yet sufficiently appreciated, for lack of familiarity with the results accomplished. The success of all modern methods of wound treat- ment is based upon the fundamental principle of com- plete mechanical or surgical sterilization, the excision of all dead or dying tissue, the extirpation of whole wounds and bullet-tracts, which admits of even imme- diate suture of war wounds in selected cases. It goes without saying that only the most highly skilled and experienced surgeons are qualified to carry out the primary closure of war wounds. Primary suture of wounds, as practised by prominent French pioneers in this field, after excision and during the period of con- tamination, in other words, prophylactic excision of the contaminated wound tissue, although not yet generally accepted, is practically the last word in war sui^gery. It is this greater attention to the niechanical or sur- gical sterilization of wounds which has made the strik- ing difference in the results obtained now and at the beginning of the war. The success which has lately attended the treatment of infected war wounds on the Western front, as contrasted with the acknowledged 36 THE TREATMENT OF FRACTURES failure of surgery in the first year of the war, is un- doubtedly due, not so much to any one of the numer- ous antiseptics now in vogue, but to the thoroughness with which the contaminated areas are extirpated sur- gically during the period of contamination, in the first teuv or twelve, at most fifteen hours, before actual in- fection has taken place. The extirpation of the dead or hopelessly damaged tissue, before the germs have had time to incubate, is the secret of success, and it is for this reason that nearly all methods of chemical sterilization yield good results. Future investigators may be expected to throw light on the individual char- acteristics of the infecting bacteria in war wounds, and the specificity of antiseptics employed for the con- trol of these infections, a line of study suggested in the Archives de Med. et de Pharm. Militaire of 1917. The disinfection of war wounds is the easier the earlier it is begun ; in other words, the closer the treatment follows the production of the wound. Surgical prophy- laxis of infection is the fundamental feature of the present treatment of war wounds, its progress, and success. The principles of modem methods of wound treat- ment diff*er so radically and intrinsically as hardly to admit a classification of therapeutic procedures now in use .under the heading of antiseptic, physiological, vaccine, and other methods. Any attempt at such grouping would necessarily be open to criticism, as not uncommonly these methods are combined or overlap. A diagnostic-therapeutic procedure such as Delbet's pyoculture method requires a place by itself, and this is also true to a certain extent for a few other curative suggestions which have been offered. Although some logical sequence has been aimed at in the arrangement, the different methods are described independently, and irrespectively of kindred, competitive, or opposite ideas on the management of infected wounds. It is not the object of this book to extol any of the curative GENERAL SURVEY 37 procedures which have been called forth in abundance by the wholesale slaughter on European battle fields, nor is it proposed to enter into a discussion of the value of these methods from the scientific viewpoint of surgical pathology. Without criticizing or grading the various methods, the fact is emphasized that all very recent methods of wound treatment are of necessity more or less experimental and under trial. The text aims at presenting in concise but intelligible form the modern methods of wound treatment now in use, so that they can be tried and tested by those interested in their practical utility. The aseptic effectiveness of the first wound dress- ings, as pointed out by Vincent, often governs the sur- gical prognosis. After the wound has been virtually made clean. and free from necrotic matter a successful course of repair and a favorable outcome are assisted and . ensured by the purposeful selection and proper utilization of the most advantageous chemical agent. An article is intended to help the reader not only in this choice, but also to provide him with sufficient grounds on which to base his own judgment as to the relative merits of modern methods of wound treatment. The Carrel-Dakin Method The novelty of the Carrel method of wound treat- ment consists in its providing a protracted and inti- mate contact between a relatively non-irritant antisep- tic agent and the infected wound surface. In pursu- ance of this object the same degree of concentration of the antiseptic solution must be constaintly maintained, and this necessitates a special technic for the constant renewal of Dakin's fluid, which is very unstable and easily decomposed. A preliminary requirement of this as well as all other modern methods of wound treatment is the earliest possible and scrupulously careful cleansing of the in- 38 THE TREATMENT OF FRACTURES fected wound, preferably within the first six hours, with free incisions, removal of all foreign bodies, and extirpation of all hopelessly damaged or dead tissues. This surgical cleansing of the wound is followed by the institution of the Carrel procedure, which has for its main object the sterilization of the wound by chem- ical means, and aims at accomplishing this purpose through a special mode of application of a "definite an- tiseptic solution, i.e., Dakin's fluid, claimed to be ap- proximately isotonic with blood serum. The early union of the wound margins by sutures or other means which this method renders practicable is the best proof of its efficiency in the treatment of infected war wounds. The results of the Carrel method in badly infected artillery and similar wounds are described as far sur- passing those obtained by other methods. The tem- perature drops to normal within 48 hours ; after a week's treatment, the appearance of the wound surfaces is very favora,ble; the entire duration of the treatment is considerably shortened in comparison with other methods. This wound disinfection guards against lymphangitis and lymphadinitis, as well as against os- teomyelitis in infected compound fractures ; amputations are rarely needed, in spite of the gravity of the cases, and deaths from sepsis are exceptional. The cicatrices following the junction of the disinfected and sterilized wound surfaces resemble operation scars rather than those obtained by the secondary suture of granulating wounds. This outcome constitutes a valuable auxiliary in the mechanical after-treatment of war wounds. A special committee appointed by the Director-Gen- eral of the British Array Medical Services for the pur- pose of investigating and reporting on the Carrel- Dakin treatment of wounds is of the opinion that this method of treatment, if carried out thoroughly, is full of promise, and believes that it will (1) diminish the dangers incidental to sepsis, including secondary hem- orrhage ; (2) hasten the patient's convalescence; (3) GENERAL SURVEY 39 lessen the liability to stiff joints and cicatrical deformi- ties ; (4) enable the patients to leave the hospital with better general health than they otherwise niiglit ; and that (5) when secondarj-^ operations become necessary these operations are more likel}' to be free from septic complications than when some other system of primary treatment has been adopted. (Brit. ]Med. Jrl., II, 1917. p. 597.) In conformity with these views, the Britisli Army Medical Department has arranged that the treat- ment can be continuously carried out not only in the Front and Base Hospitals but also in ambulance trains, hospital ships, and the hospitals in Great Britain. (Sir Anthony Bowlby.) The method takes its name from the tcchnic spe- cially devised by Alexis Carrel for bringing Dakin's fluid of sodium hypochlorite into contact witli tlie in- terior of infected wounds. Dakin's solution in a septic wound acts both as an antiseptic and as a cleansing agent or remover of dead tissue liable to serve as a nidus for microorganisms. Although it sliglitly irri- tates the skin, this disinfecting fluid does not injure liv- ing tissue, and it is described by Dr. Lyle as an ideal isotonic wound antiseptic of high bactericidal and low toxic or irritating quality. The solution possesses hemolytic properties and will dissolve recent bloodclots ; so that a good hemostasis is essential to guard against the dangers of secondary hemorrhage. In order to combine the strongest germicidal with the lowest irritating action, the solution must be of definite strength, namely, between 0.45 and 0.50 per cent. The fluid is deprived of its chlorin in an hour or less by the w^ound secretions, which render it inert. The many details of the! necessary technic require the atten- tion of a large, weJl-trained staff of doctors and nurses, so that the method is hardly applicable outside of a thoroughly equipped modern hospital. Several modifica- tions and simplified apparatus have been suggested and will receive consideration in the text. 40 THE TREATMENT OF FBACTURES Dakin's fluid is used in a solution of 0.5 per cent, strength, and is prepared according to two formulas, with and without the addition of boric acid. Practical experience with the two solutions apparently favors the boric acid free fluid. The following formulas for the preparation of the two fluids were given by Dr. Dakin. Dakin Solution Without Boric Acid "Neutral hypochlorite prepared without boric acid is best made according to the formula 'given by Dau- fresne, and at the present time is perhaps more gener- ally used than any of the other modifications. Two hundred grams of good bleaching powder are put in a 12-liter bottle with five liters of tap-water. The solu- tion is shaken vigorously and allowed to stand for at least six hours, unless a mechanical shaker is used, when half an hour's shaking will be found sufficient. In another vessel, 100 grams of dry sodium carbonate and 80 grams of sodium bicarbonate are dissolved in five liters of cold water and then added to the bleaching powder mixture. The whole is shaken vigorously for a few minutes, and the precipitate allowed to settle. At the end of half an hour the clear solution is siphoned out and then filtered through paper. The proportions given above for the carbonate and bicarbonate of soda are those given by Daufresne. It is our experi- ence, however, that with' most brands of American bleaching powder it is better td use 90 grams of each salt. This solution must invariably be tested for neu- trality by adding a pinch of solid phenolphthalein to a little of the solution. If the solution should react alkaline, one of three methods must be employed to correct it, otherv/ise skin irritation will surely result. "(a) Pass carbon dioxid gas into the solution until a sample shows no alkalinity when tested as described. This is perhaps the best method. "'(?)) A neutral hypochlorite may be secured by re- GENERAL SURVEY 41 diicing the proportion of carbonate of soda and Increas- ing- the bicarbonate. "(c) Boric acid may be added until neutrality Is secured. An advantage of the carbonate preparation Is that It possesses greater stability and can be kept for several weeks without much cfeterloratlon. On the. other hand, with varying qualities of bleaching powder, con- taining different amounts of free lime, it is more diffi- cult to adjust the proportions so as to obtain a neu- tral solution directly. Probably those having adequate laboratory facilities will prefer the carbonate-bicar- bonate solution, while the mixture containing boric acid is readily made under less favorable circumstances." Dakin Solution with Boric Acid "Neutral hypochlorite prepared with boric acid Is best made as follows : One hundred and forty grams of dry sodium carbonate (NaCO), or four hundred grams of the crystallized salt (washing soda) are dissolved in twelve liters of tap-water, and two hundred grams of chloride of lime (chlorinated lime) of good quality are added. The mixture is well shaken, and after half an hour the clear liquid Is' siphoned off from the pre- cipitate of calcium carbonate and filtered through a plug of cotton ; forty grams of boric acid are added to the clear filtrate, and the resulting solution is ready for use. A slight additional precipitate of calcium salts may slowly occur, but it is of no significance. The solution should not be kept longer than one week. The boric acid must not be added to the mixture before filtering, but afterward. The solution should be tested by adding some of It to a pinch of solid phenolphthal- ein. If a red color. Indicating free alkali, shouW de- velop, a little more boric acid must be added In order to remove It," No caustic alkali must exist In sodium hypochlorite solutions destined for surgical use. 42 THE TREATMENT OF FRACTURES A very simple and practical test for alkalinity is recommended by Dr. H. H; M. Lyle : Pour 20 c.c. of the solution into a glass, and drop on the surface of the liquid a few centigrams of powdered phenolphthalein. Agitate the fluid by giving the glass a circular motion, as if one were rinsing the glass. The liquid ought to remain colorless. A red tint more or less intense indicates the presence of a quantity of free alkali, or an incomplete carbonation due to faults of the technic. Titration of the Solution (Lyle) "Measure 10 c.c of the solution, add 20 c.c. of 1 :J0 iodin solution and 20 c.c. of acetic acid. Pour into this mixture a decinormal solution (2.48 per cent.) of sodium thiosulphate (hyposulphite) until decoloration. Let N equal the number of cubic centimeters of thiosul- phate employed. Then the quantity of sodium hypo- chlorite for 100 c.c. of the solution would be given by the equation : T — N X 0.03725. "Precautions : Never heat the solution. If, in case of an emergency, it is necessary to titrate the chlorinated lime, use only water, never with the solution of soda salts. ^'^Do not use old solutions. Hypochlorite solutions change quality in the light, more slowly in the dark, but will not keep indefinitely under any conditions. For practical purposes, sodium hypoclilorite, when properly kept in a dark place, docs not lose in strength as re- gards its effectiveness (the deterioration not exceeding 0.505 to 0.500 in three weeks)." Equipment (1) A sodium hypochlorite solution of 0.5 per cent, strength, prepared according to the technic described above. GENERAL SURVEY 43 (2) A glass receptacle holding from 500 to 1000 c.c. (3) Ordinary medium-sized rubber tubing, two yards. (4) A movable clamp for the regulation of the flow through the main distributing tube. Fig. la. — Glass Connection Tubes, Vision Tubes and Stop-cocks. (5) Rubber instillation tubes of assorted widths (average size No. 16 French) and about 25 cm. in length. The ends are tied, and a number of very small 44 THE TREATMENT OF FRACTURES holes are then punched out of the tubes ; these holes are no larger than 1 mm, or 1/25 of an inch in diam- eter. The internal diameter of the primary and second- Fig. 2a. — Carrel's Distributing Tubes. ary tubes is 7 mm. and that of the final distributing tubes is 4 mm. (6) Ordinary rubber drainage tubes, without per- forations, 25.35 cm. in length. (7) Glass tubes for connection and distribution. GENERAL SURVEY 45 (8) Cotton surrounded by gauze, for dressings of different sizes, (1) fitting well around the leg; (2) fit- ting well around the arm; (3) a small size. The thick- ness of these dressings is about 3 cm. ; they consist of a layer of absorbent cotton and a thicker layer of non- absorbent cotton. The dressing is held by straps of webbing, with adjustable buckles. (9) Sterilized gauze squares soaked in yellow vase- lin (petrolatum) serve for the protection of the skin. White vaselin must not be used. Employment of Hypochlorite Solutions (1) Preparation of the Wound. — The first sur- gical intervention — which should be as prompt, thor- ough, and aseptic as possible — comprises a routine me- chanical wound disinfection, with removal of all foreign bodies, fragments of projectiles, shreds of clothing, and so forth. The following rules have been laid down on the basis of practical experience: Paint the part with iodine tincture, and trim away the necrotic skin edges of the wound with a sharp knife. Lay the wound open, using clean instruments, and remove all that does not belong there or that may have been infected, giving special attention to all pouches and wound recesses, as possible lurking-places of a latent infection. Be gentle and conservative, sparing all non-infected tissues and all those reasonably safe from infection. Save all that can possibly be saved of comminuted bone-fragments. The patch taken by the projectile must be carefully resected and the exposed muscular surfaces be freed from adherent dirt and other contamination. Bone wounds require the same accurate mechanical cleaning as soft parts wounds. Finally, the wound must be carefully examined from the standpoint of a reliable hemostasis. Not only is it difficult to disinfect blood- infiltrated muscle tissues, but recently formed blood- 46 TEE TREATMENT OF FRACTURES clots are liable to be dissolved by hypochlorite solu- tions, involving the danger of secondary hemorrhage. The object of the hypochlorite technic is to keep the disinfecting liquid in constant contact with all the sur- faces of the wound. Counter-openings for dressings are only exceptionally applied, and when needed must not be placed at the most dependent point. (2) Introdltction of the Instillation Tubes. — The nature of the wound governs the placing of the tubes, which must be put so as to bring the disinfecting fluid into direct contact with every portion of the wound. The technic varies according to the super- ficial, penetrating, or perforating character of the lesion. {a) Surface Wounds, — These wounds are covered with a thin layer of gauze, on which lie the instillation tubes, in a number adapted to the needs of a given case. Rubber cufFs and sutures retain the tubes at the wound Fig. 3a. — Showing the mode in which the small distributing tubes are carried through the dressing to the various parts of the wound (Carrel and Dehelly). margins. A two-way flax tube is sometimes used. The placing of the tubes directly on the surface, without the intervening layer of gauze, would result in clogging GENERAL SURVEY 47 and blocking of the orifices by granulations. Access of the germicidal solution to all parts of the wound would be hindered by thick gauze layers stiffened with the secretions of the wound. {h) Penetrating Wounds. — One readily understands how a rubber tube without openings in its walls is passed down nearly to but without reaching the floor of a simple wound cavity, with the result that the dis- infecting liquid wells up from the bottom. The ragged walls of Avound cavities at the end of wide channels must be held up by means of a little gauze, so as to facilitate the universal spreading of the bactericide. Perforated tubes wrapped in toweling (see Fig. 2a) are used for penetrating wounds with a low dependent point of entrance (posterior surface of legs and arms, back, and buttocks), but non-perforated tubes may be employed, the essential point being the continued con- tact of the disinfecting agent with the wound. (c) Perforating Wounds. — Infection of such wounds is controlled by passing a perforated tube, tied at its end, from the lower to the higher wound. The dis- infecting liquid is distributed over the entire wound as it flows from the small openings in the tube and re- turns to the lower orifice along the wound channel. A hypochlorite bath of ten to fifteen minutes is the treatment for open amputation stumps and for periph- eral wounds of the extremities, to be repeated every two hours until the wound is sterilized. Cutaneous irri- tation with the soda hypochlorite is guarded against by smearing the skin with sterile yellow vaselin. Technicat. Precautions. — In order to secure suffi- cient penetration of the disinfecting fluid, it is impera- tive to guard against certain sources of error, as follows: (1) Slipping or dropping of one of the con- ducting tubes, (2) Blocking of one or more tubes by bloodclot. (3) Kinks and bends in imperfectly placed tubes. (4) Neglected wound recesses, not reached by any tube. 48 THE TREATMENT OF FRACTURES The irrigation apparatus is sometimes incorrectly installed, a common fault being that a drop-counting appliance is connected with a number of tubes ; here the Fig. 4a. — Showing Carrel method of irrigating wound with the Dakin Fluid. Note on the main distributing tube the pinch- cock below the reservoir. The wound is covered witt^ the dressing, which is fastened by safety-pins. The distributing tube is similarly held in place by being pinned to the plaster bast (Carrel and Dehelly modified). GENERAL SURVEY 49 fluid may flow down one tube to the exclusion of the others, in conformity with the laws of gravity. A very narrow main tube, or a very small inferior outlet of the reservoir, will reduce the flow, so that the bactericidal fluid does not pass along as many tubes as it should in order to disinfect the entire wound. Rules concerning the relative calibers of the several tubes and the installa- tion of the irrigation apparatus must be strictly fol- lowed. An insufficient delivery of disinfecting fluid is a more serious error than an excessive amount, which is trouble- some to the patient, but will not harm the wound itself, as will an inadequate supply of hypochlorite. This is indicated by the presence of unmodified secretions in the wound and an offensive odor of the pus. Fig. 5a. — Nurse using a pinch-cock and so instilling antiseptic liquid. 50 THE TREATMENT OF FRACTURES Pain is caused by excessive pressure of liquid in the wound, which is sometimes due to a very small incision retarding the back flow of the fluid between the walls of the wound and the conducting tube. Another easily remedied occasional cause of excessive pressure is the exaggerated elevation of the reservoir above the level of the bed. The Healing Wound. — Only sterilized instruments, never the gloved hands, are allowed to touch the wound or the dressings. Once in two hours, or twelve times in the twenty-four hours, the disinfecting fluid, usually to an amount of 10 c.c, and at a rate of flow of from five to twenty drops per minute, is passed into the wound. This is accomplished by releasing for a few seconds the pinch-cock which regulates the flow, and requires the attention of a nurse. The instillations are continued until sterility has been obtained, as shown by the routine bacteriological control. The instillation tubes are then replaced by a compress soaked in the hypochlorite solution. The progress of the wound and the condition of the irrigation apparatus are ascertained by frequent inspection, at least once daily. Bacteriologic Controt. of the Wound. — Deter- mining the number of bacteria on the wound surface is an integral item in the Dakin-Carrel method. The diminishing quantity of germs is the indicator of ad- vancing sterilization. The progress of the wound is ascertained by means of "smear specimens," which are easily interpreted by those having even an elementary knowledge of bacteriology. Cultures are less desirable for this particular purpose, the object being to find out what the wound actually contains rather than what growths might be obtained in the incubator. No smears can be prepared from a bleeding wound, as the blood will effectually conceal the bacteria. Technique. — A stiff platinum wire, mounted on a glass rod, serves for the removal of the specimen from the wound. The standard loop in use in bacteriological GENERAL SURVEY 51 laboratories answers the requirements. The material must be taken at the end of the two hours' interval be- tween treatments, and from the deeper regions most likely to be contaminated, such as jagged wound re- cesses, damaged bony surfaces, necrotic fascia, etc. The loop transfers the material to microscopic slides, witli identification labels. The slides are then taken to the laboratory, where they are fixed and stained. Fixation and staining of specimen. — Pass the slide, smear towards flame, three times through the flame of a Bunsen burner. Next, place it on a glass support and cover with a few drops of carbolized thiolin. Let the stain act for half a minute, then wash with water, and put aside to dry. Counting of Bacteria. — Place a drop of cedar oil on each slide, and count the number of germs in a micro- scopic field with a No. 12 immersion objective and a No. 3 eye piece. It is advisable to examine several fields, especially near the end of the treatment, before a wound is closed. Only a rough estimate of the num- ber of germs in a microscopic field is required, the ob- ject being to ascertain the progress of the treatment. The control is made every day, and the findings are noted on a chart. Absence of germs indicate a sterile wound, which may be closed by sutures. Not less than three successive sterile counts should be relied on. After the hypochlorite treatment is stopped, a steril- ized wound may be re-infected by way of the epithelial margins and the adjacent skin. To guard against this re-infection, it is recommended to wash the entire sur- roundings with neutral oleate of soda. The hypochlorite treatment sterilizes soft parts wounds in five to nine days, as a rule. Contused wounds with extensive tissue destruction need a more prolonged contact with the disinfecting fluid. From two to four Aveeks are required for the sterilization of fractures ; all bone sequestra must be removed. Germs persist the longest on the skin and bony surfaces. 52 THE TREATMENT OF FRACTURES Microorganisms without distinction of species are de- stroyed by hypochlorite; but although the free ana- tomical elements are equally affected, the defensive Fig. 6a. — Case 577. Wound of knee, 5th day phagocytosis, according to Carrel and Dehelly, is not disturbed in the deeper regions unreached by the so- lution. Closure of Wound. — A wound shown to be sterile by three successive bacteriological tests is ready for clos- ure ; usually after a week to nine daj^s, on the fifth day in favorable cases. Layer sutures are the preferred mode of closure. When the suture method is not ap- plicable, elastic adhesive straps are used to draw the wound edges together. The straps must be long enough to be passed around the entire circumference of the limb, guarding against too tight a compression by a circular bandage. Elastic traction is utilized to overcome an extensive loss of substance, which prevents the apposition of the wound margins. Strips of adhesive plaster about three inches in width and four inches longer than the wound are punched on one edge and shoc-liooks arc inserted at intervals of two cm. Two such strips arc attached to the skin parallel with and on each side of the wound. GENERAL SURVEY 53 Strong rubber laces are passed over opposite hooks, and by virtue of their elasticity progressively bring the wound margins •together. The hooks can also be in- Fig. 7a. — Case 577. Suture, 14th day serted into the hemmed edges of two canton flannel bands, slightly longer than the wound, and a trifle narrower than half the circumference of the limb. The woolly side of the flannel is placed on the skin, which has first been painted with resin varnish, or Heusner's glue, up to the edges of the wound. The rubber lacing is carried out as with the strips of