The Treatment of Certain 
Forma of Fracture. 
BY 
CHARLES PHELPS, M. A., M. D., 
Surgeon to Bellevue and St. Vincent'* Hoepitala, 
and Conaulting Surgeon to Gouverneur Hoipital. 
REPRINTED FROM 
Re Neto ¥orft fHeto'cal 
/or July 15, 1893. Reprinted from the New York Medical Journal 
for July 15, 1893. 
THE TREATMENT OF 
CERTAIN FORMS OF FRACTURE* 
By CHARLES PHELPS, M. A., M. D., 
SURGEON TO BELLEVUE AND ST. VINCENT'S HOSPITALS, 
AND CONSULTING SURGEON TO GOUVERNEUR HOSPITAL. 
The treatment of osseous fracture from rude beginnings 
has been eminently progressive and has gradually attained 
a perfection of methods and results remarkable even in the 
growth of modern surgery. In the management of many 
fractures it would seem that the possibilities of surgical art 
had been well-nigh exhausted, and this result has been so 
largely due to the contributive work of a great number of 
individuals, widely scattered in time and place and of varied 
degrees of professional prominence, that an unusual num- 
ber of persons have come to rightfully regard themselves 
as identified with this particular phase of surgical progress. 
This fact has rendered the subject one of exceptional 
universality of interest, and, together with its great practi- 
cal importance to every general practitioner, has been suffi- 
cient to give it standing in the deliberations of any medi- 
* Read before the Fifth District Branch of the New York State 
Medical Association, May 23, 1893. 
Copyright, 1893, by D. Appleton and Company, 2 
THE TREATMENT OF 
cal association not exclusively devoted to the advancement 
of special subjects. It is an application of the surgical art 
which, in the exigencies of our profession, even the physician 
most averse to surgical practice is occasionally compelled 
to make, and in which the results, when unfortunate, are 
patent, and become the subject of always severe, sometimes 
judicious, and occasionally judicial, comment. 
It is therefore pardonable, where professional pride and 
personal responsibility are both so deeply concerned, to 
traverse well-worn paths, for something always remains to 
the gleaner. It would be both useless and fatiguing to 
sketch, even in the most desultory manner, the treatment 
of fractures, either in general or in classes. Recent au- 
thors, Stephen Smith and others, have given it entirely ade- 
quate attention. There are, however, certain details and gen- 
eral considerations which, if scarcely demanding extended 
individual comment, may yet be naturally aggregated as a 
personal contribution to the subject. In this view some 
facts and observations here collated are worthy of notice 
either because of their importance or of their failure of gen- 
eral recognition. They touch the matter at somewhat distant 
points, but are related by laws of general acceptance and 
application. 
The simplest form of fracture is that of a long bone at 
some distance from a joint. Its treatment in accordance 
with the careful methods in vogue during recent years usu- 
ally affords almost perfect results. Angular deformity 
under ordinary circumstances, and when the accepted ap- 
pliances for coaptation, extension, and counter extension 
are employed, is hardly to be feared ; and since the advent 
of the aseptic era, when the resection and wiring of obdu- 
rate fragments became practicable, any considerable distor- 
tion is scarcely to be tolerated. Such, in this country at 
least, where mechanical skill is a common gift of Nature, CERTAINS FORMS OF FRACTURE. 
3 
has long been the happy outlook for those who are still un- 
fortunate enough to suffer this simplest of simple fractures. 
Up to a much later period abroad, however, eccentric re- 
sults were still sufficiently common. I well remember, 
when thirty years ago I first saw foreign museums of pa- 
thology, I marveled much at their richness in strange osse- 
ous deformities and distortions, but the wonder lessened 
when I subsequently saw and noted in the service of Vel- 
peau the indifference, carelessness, and neglect in treat- 
ment, and the distorted limbs which seemed to quite con- 
tent even the master in surgery. I doubt not bones in 
France have since come to unite in more aesthetic form, 
but I question whether even now results in this particular 
are comparable with what we are accustomed to see at 
home. 
There is another point of view from which the result of 
treatment has been less uniformly fortunate, and from 
which failure is quite too frequent. I refer to the oc- 
currence of non-union and of ligamentous union of the 
fragments. I shall not attempt to present a statistical ac- 
count of what may be termed this accident of treatment. I 
have encountered a considerable number of such cases dur- 
ing the past few years, though it has chanced that none of 
them were originally in my care. They have involved the 
humerus, radius, ulna, femur, fibula, and tibia, and the last 
mentioned has been most frequently in fault. The aetiology 
which is directly connected with treatment is well known, 
and the constitutional causes I have found to be more gen- 
erally operative in the larger bones. Thus in six instances 
involving the femur two were of syphilitic origin, one was 
from malnutrition, and the fourth apparently resulted from 
too frequent disturbance of the fragments at an early pe- 
riod, and to a subsequent cachectic general condition. In 
a very interesting case, however, in the practice of Dr. S. 4 
THE TREATMENT OF 
G. Cook, of New York, it was one of the metacarpal bones 
which suffered from constitutional cause. Union failed 
for ten weeks. The patient, who admitted former syphi- 
litic infection, but presented no symptoms, was then sub- 
jected to specific treatment, and union began in two weeks' 
time and was rapidly perfected. It is evident that when 
the cause is wholly or in part of constitutional origin a 
corresponding general treatment is of primary importance, 
but local fixation and the correction of local errors should 
follow hard upon it. If the fault be essentially local the 
primary treatment must of course be local, but must often 
be supplemented by assiduous attention to the improve- 
ment of the general health. 
I believe it can not be insisted upon too strenuously 
that possibility of imperfect union always exists. In a 
large proportion of such cases as have come under my ob- 
servation the danger could have been averted by sufficiently 
early recognition and adequately careful treatment. There 
are instances like that in Dr. Cook's experience in which 
the clew is lost by absence of specific symptoms, and others 
in which constitutional depravity is irremediable. There 
are also instances of local default in which prevision is of 
no avail. Compound fractures sometimes, and intracapsular 
fractures of the cervix femoris always, fail of union. I 
speak advisedly of the latter lesion and am mindful of the 
earnest controversy which it incited some years ago, and 
which was so vigorously maintained by Dr. James R. Wood 
and Dr. Willard Parker. No one maintained that union 
seemed even possible a priori, but Dr. Parker presented a 
single specimen in which he believed it had actually taken 
place. Dr. John G. Johnson, of Brooklyn, demonstrated 
its fallacious character in a discussion of the whole sub- 
ject, and no similar contention has since been made. 
The same anatomical conditions obtain in intracapsular CERTAIN FORMS OF FRACTURE. 
5 
fractures of the cervix humeri and the same result must 
follow. If full allowance be made for these exceptional 
instances it still remains that the major part of cases of 
non-union depend upon remediable causes and defects of 
treatment. I think it is further true that the error is usu- 
ally local. If firm, accurate, undeviating, and persistent 
coaptation be made, osseous union will seldom fail in un- 
complicated simple fractures. The present means at our 
disposal for securing and maintaining coaptation are so va- 
ried and so perfect and so readily permit relief from unduly 
prolonged and exhausting confinement, that the surgeon can 
rarely escape full responsibility for perfect restoration of the 
parts. If in fractures of the shaft of the humerus the el- 
bows were always properly supported, if in fractures of the 
shaft of the femur the fragments were always properly re- 
duced, if in all fractures after the application of proper re- 
tentive apparatus it were left without unnecessary disturb- 
ance, the opportunities for study in the field of ununited 
fractures would be seriously curtailed. I dissent strongly 
from the opinion that it is ever safe to intrust any fracture 
which is within reach of retentive apparatus to the sole pro- 
tection afforded by surrounding parts. It is not very long 
since I saw a case in which an unsuspected fracture of the 
upper fourth of the fibula had remained ununited for some 
months, and had led to a subacute arthritis of the knee. 
It united readily in the usual time after the application of 
a silicate-of soda bandage. No fracture could be better 
supported by thick muscular environment and no result 
could more distinctly illustrate the efficacy and necessity of 
surgical aid. 
I had not intended to discuss the causes of ununited 
and improperly united fracture, or measures for its avoid- 
ance, but rather to consider one or two of the operative 
methods for its repair. It is always well to regard any 6 
THE TREATMENT OF 
case of this nature as simply one of delayed union till 
after the lapse of a considerable time and the thorough test 
of absolute immobility, with systematic hygienic and nu- 
tritive regimen. Where union is entirely wanting, attrition 
of the fragments may also be of service. 
If operation is demanded, the choice lies between nu- 
merous procedures, two of which I have found to be effi- 
cient and deem to be simpler and safer than the others. 
These are (1) drilling, and (2) wiring and resection of the 
ends of the fragments, and of these the former seems to me, 
in suitable cases, the one to be preferred. It is certainly 
the easier of performance, can be indefinitely repeated, and 
in case of ultimate failure will not prejudice the resort to 
more serious operative measures.. The femur, of all bones, 
is perhaps least suited to its employment. In case by any 
chance purulent inflammation follows, it is liable to be dif- 
fused along the muscular planes and to involve loss of limb 
or even life itself. I have met with one such accident 
after drilling the femoral fragments, and though the patient 
escaped dire disaster and eventually obtained proper union 
without further operative interference, I fully realized the 
danger to which he had been subjected. I saw in my 
service as interne, before aseptic surgery was practiced, a 
case in which death did result from diffuse suppurative in- 
flammation of the deeper structures of the thigh after one 
of the other operations for the establishment of osseous 
union. The control of deep femoral suppuration is suffi- 
ciently difficult under favorable circumstances, but when 
the constitutional condition of the patient is impaired by 
long confinement, and perhaps by specific poison besides, 
and when it is induced by subcutaneous lesion, the diffi- 
culty may well become insuperable. I therefore favor an 
open operation in the thigh which permits early and thor- 
ough antisepsis and drainage should they be demanded. CERTAIN FORMS OF FRACTURE. 
7 
Again, in very many, and probably in the majority, of 
cases there is an overlapping of the femoral fragments, 
which not only increases the difficulty of firm union, but 
causes deformity and weakness of the limb. An operation 
is requisite in which more perfect coaptation and a higher 
grade of ossific inflammation is obtainable, and in which, 
at the same time, the strength of the limb can be increased 
by the relief of deformity. I depend upon the wiring pro- 
cess to fulfill these indications. The seat of fracture is, of 
necessity, freely exposed, and every opportunity afforded 
for asepsis and drainage. Coaptation can be accurately 
effected and reduction of the fragments, or resection, if re- 
quired, be made with proper care. 
I am unprepared to demonstrate statistically its com- 
parative safety or efficiency. Since the aseptic era, with 
which such comparison must begin, the whole number of 
recorded cases which have failed of osseous union and have 
been subjected to operation of any kind can not be large, 
and I am sure have not been tabulated. I have done this 
operation in two cases; in one, after resection of two 
inches and a half of bone, union became firm in thirty-three 
days and without the formation of pus; in the other, after 
a resection of one inch, union became firm in forty-five 
days after prolonged suppuration. In both the fracture 
had occurred in the middle third, six months previously 
in the first, and four months in the second. In the first 
case the subject was a girl of sixteen, suffering from the 
effects of syphilitic infection and dissipation; the second 
case was that of a man of twenty-nine, whose history was 
not clear. The method of operation presented nothing of 
special interest, and none of the delays and difficulties sug- 
gested by Treves were encountered. The question of 
safety is the general one of a simple wound originally un- 
contaminated and should hardly occasion anxiety. The 8 
THE TREATMENT OF 
certainty of cure, comparative and absolute, must be a mat- 
ter of estimate in the absence of any large number of cases 
in modern practice. If the patient's general condition 
warrants surgical interference of any kind, and always pre- 
supposing due skill and care on the part of the surgeon, 
success as well as safety should be reasonably assured. No 
other method has been devised in which the fragments can 
be so accurately secured, and under conditions so favorable 
to osseous production. If it results in failure, there is no 
reason to believe that the osteogenic process can be com- 
pelled by any other form of direct stimulation. 
The consideration of ununited fractures of the humerus 
follows the same lines and leads to the same conclusions. 
The anatomical situation is similar and suggests the same 
views of treatment and of probable results. If there is 
much angular deformity or overriding of the fragments, or 
if a false joint has been formed, resection and wiring are 
likely to be indispensable. If there is simple non-union 
from want of support to the elbow or from too frequent 
manipulation during the progress of the case, drilling may 
possibly be successful, but is still injudicious for the same 
reason that obtains in case of the femur. In the present 
very general survey of the subject of mal-unions, it suffices 
to indicate the points of relation in this regard between the 
two bones. 
In defective union of the smaller long bones of the ex- 
tremities, notably the radius, ulna, and tibia, the question 
of treatment presents itself under somewhat different con- 
ditions. The fracture is likely to have occurred in a much 
more accessible position, usually subcutaneously, and even 
when nearer the head of the bone it has less formidable 
muscular surroundings. There is consequently diminished 
danger from the diffusion of pus from an accidental suppu- 
ration. The radius and ulna, if not the tibia, are much CERTAIN FORMS OF FRACTURE. 
9 
smaller bones than the femur or humerus, and their osteo- 
genic property is proportionately easier to excite. It is 
also practicable to maintain absolute immobility without 
necessitating an irksome confinement of the patient, which 
is always detrimental to the general health, and indirectly 
prejudicial to the process of repair. It might therefore be 
expected that the simpler method of drilling would suffice 
in case of these bones, and in my experience the result has 
justified the expectation. I have several times resorted to 
it for one or both bones of the forearm, and always with 
success. I have used it in a much larger number of cases 
for the tibia, and, with the exception of those in which the 
patient has abandoned treatment, they have all been eventu- 
ally cured. The exact number I am unable to state, but I 
think from fifteen to twenty would be a conservative esti- 
mate. The fractures of the forearm have all been simple; 
those of the tibia, in three or four instances, were originally 
compound. In the latter a loss of substance, suppuration 
in the wound, or caries and necrosis of the fragments suf- 
ficiently account for lack of proper union. In all the radial 
and ulnar cases I have thought failure to result from origi- 
nal fault of apparatus or its too frequent disturbance in 
the course of treatment which has prevented absolute im- 
mobility, and I have no doubt the same error has been con- 
tributive in many of the tibial cases. I have had no reason 
to suppose that constitutional causes were operative in any 
of them or that the interposition of the softer tissues had 
played a part. The essential and determining cause of 
tibial default I believe to be found in deficient posterior 
support. I have certainly very generally observed it to be 
accompanied by a dropping backward of the lower frag- 
ment, which, as I infer, stands in relation of cause rather 
than of result, from the fact that when its prevention has 
been the subject of special care union has always been firm. 10 
THE TREATMENT OF 
It is not sufficient to apply a plaster or silicate-of-soda 
apparatus, or to rely solely upon lateral coaptation. Tn 
either case, with or'without the immovable appliance, a 
posterior supporting splint of some sort is requisite to 
safety. 
If operation has been finally determined, and drilling 
selected as the means, nothing can be easier than its execu- 
tion. It is well to use an anaesthetic, especially in primary 
operations, but it may be dispensed with on occasion. In 
private practice, where it is usually available, nitrous oxide 
is the preferable agent. I have not observed Brainard's 
advice to use the drill sparingly, but am accustomed to per- 
forate each fragment in every direction, upward and down- 
ward, without its withdrawal, and to insert it again, or 
even a third time if necessary, to reach every part of the 
bone within an inch or more of the line of fracture. I 
have not hesitated, with due caution, to wound the soft 
parts contiguous to the bone. If there is considerable 
haemorrhage, it is none the worse for the prospect of cure. 
The bone is often soft, but in cases of long standing 
it is more probably eburnated and its medullary cavity 
empty. It is scarcely necessary to say that every aseptic 
precaution should be employed with the same thoroughness 
as in a capital operation. The limb should be dressed 
aseptically, and, after superficial inflammation has subsided, 
should be put in plaster for four weeks. At the end of 
that period, if union is not satisfactorily firm, the drilling 
should be repeated and the limb again incased in plaster. 
I know no limit to repetition of operation but success. 
When union has become reasonably firm, it may be in- 
trusted to plaster for a longer period and the use of the 
limb permitted. The general health of the patient should 
receive the same attention as should be accorded in the 
treatment of recent fracture. If I have been more fortu- CERTAIN FORMS OF FRACTURES. 
11 
nate in my results than have other surgeons who have less 
confidence in this method, I attribute it entirely to my 
greater perseverance, or possibly in part and in some lesser 
degree to my habit of earlier interference. I know it has 
been thought wise to defer operation till after the lapse of 
many months. I am disposed to resort to the drill earlier- 
in two months even. I can not forget that the greater part 
of surgery is done in the service of the poor. It is their 
bones that are oftenest broken and that oftenest fail of 
solid union. If, then, time, which has to them an extraor- 
dinary value, can be saved by operation devoid of danger 
and fruitful of result, I am quite sure it should not be 
withheld in view of an otherwise possible recovery in the 
indefinite future. It is a luxury of dalliance beyond their 
means. If osseous union is delayed beyond two months 
it becomes improbable, and with the lapse of time the bone 
suffers changes which render the operative cure more diffi- 
cult and more tedious. For a double reason, therefore, I 
advocate comparatively early interference. 
I propose to very briefly abstract the history of three 
illustrative cases: 
Case I.-A young lady, thrown from her horse, frac- 
tured the right radius at the junction of the middle and lower 
thirds. At the end of two months, when I saw her first, 
union was still soft. She attributed the defective result, with 
apparent reason, to frequent removal of the dressings for pur- 
pose of examination. I drilled the fragments, and repeated the 
'operation twice at intervals of thirty days before union was 
satisfactorily firm. The bone was in some way refractured at 
the same point shortly afterward, and I again used the drill for 
the fourth time, and without delay. The result was perfect 
at the end of the usual period, and now, after five years, is 
without reproach. No anaesthetic was employed. 
Case II.-A young man of twenty-live years was entangled 
in a rapidly-running rope, and his right leg nearly severed in 12 
THE TREATMENT OF 
the lower third. Both bones were comminuted, and the limb 
held only by the integument and fascia of its posterior aspect. 
A fragment of the tibia was removed at the first dressing, and 
others after the necrotic process. The accident occurred on 
March 19, 1889, and the patient was originally in care of Dr. 
F. S. Dennis. The wound was not entirely healed till August. 
Union on the 2d of November was still fibrous, and resort was 
had to drilling, which was repeated on December 1st and Feb- 
ruary following, with the application of the plaster apparatus. 
Union became progressively firmer, and three weeks after the 
last operation he was allowed to walk with a brace fastened to 
the shoe. I have seen him within the present month, and his 
leg is absolutely solid, with an inch shortening and some limita- 
tion in extension of the ankle. 
Case III.-A locomotive engineer received injuries in a col- 
lision which necessitated amputation of the left leg below the 
knee, and occasioned a compound fracture of the right leg at 
the junction of the middle and lower thirds, resulting in fibrous 
union. He stated that his fractured leg was treated with vari- 
ous forms of apparatus, and that he was allowed to sit up at 
the end of six months, and three months later to walk with a 
crutch. The wound at the point of fracture was unimportant 
and readily healed. The tibia was drilled after fourteen months, 
at the time he came under my care, and plaster applied. Union 
became somewhat firmer, and the bone was again drilled at the 
end of thirty-eight days. In six weeks union was so firm that, 
after the reapplication of plaster and another drilling, he was 
allowed to go home into the country and to bear weight upon 
the leg in walking. The plaster soon broke away at the ankle, 
and he continued to walk upon the leg without any considera- 
ble support. Two months later union was found to be much 
weakened, and he was again drilled and put in plaster. In an- 
other two months union had again become firmer, and he was 
drilled for the fifth time and sent home in plaster, to return at 
the end of the summer, three months afterward. I have not 
seen him since, and have been unable to obtain any information 
as to his condition. CERTAIN FORMS OF FRACTURES. 
13 
The second case I regard as the most extraordinary in- 
stance I have ever seen of recovery without mutilation from 
a compound fracture, and the subsequent establishment of 
osseous union as scarcely less remarkable. 
These instances of fracture in which osseous union origi- 
nally failed for different reasons all teach the necessity of 
patience on the part of both surgeon and patient. The 
first and second were ultimately successful because the pa- 
tients realized the gravity of their condition, and were pos- 
sessed of sufficient intelligence and resolution to be guided 
by advice and to persevere to the end of treatment. In the 
third, a man of equal intelligence ignominiously deserted 
when the prospect of cure was entirely hopeful, and left 
the surgeon not only helpless, but ignorant even whether 
or not his object had been accomplished. It is this infirm- 
ity of purpose which makes not only such cases, but pri- 
mary fractures as well, often discouraging and always of 
uncertain issue. Any patient in hospital, or in private 
practice for that matter, is at any time quite likely to de- 
mand his discharge, in order to put himself in the care of 
an incompetent and irresponsible medical person, and to 
afford, perhaps, still another example of badly united frac- 
ture. The reference to causation in this accident would be 
most incomplete if attention were not emphatically directed 
to the patient's own frequent negligence, disobedience, and 
abrupt severance of professional relations. 
Fractures through the extremities of the shaft of long 
bones constitute a clinical class by themselves. The danger 
here is less a question of angular deformity or of imperfect 
union than of fibrous ankylosis. It is true that I have 
quoted a case of non-union of the fibula near the knee joint, 
and that the adduction of the lower fragment in fracture of 
the surgical neck of the humerus is only too constant and 
too mischievous to escape attention; but the ever-present 14 
THE TREATMENT OF 
menace-the one never to be avoided without early recog- 
nition and unremitting care-is the limitation of articular 
movement. The propinquity of the joint is a source of 
trouble and danger which I may assume to need no ex- 
plication. The necessity of judiciously early, patient, and 
prolonged passive motion is too thoroughly taught and 
understood to require even cursory mention. The use of 
massage, however, as practiced by the skilled masseur or 
masseuse, is an adjuvant in treatment of comparatively re- 
cent introduction and is worthy of at least passing consid- 
eration. It is not new to the profession, but as a definite 
means of accomplishing a specific object in surgical prac- 
tice it is even yet imperfectly appreciated. In connection 
with the passive movements exercised by the surgeon, well- 
directed massaging and manipulation of the parts may be 
made of the greatest importance. It renders passive move- 
ments less painful, curtails the period of secondary treat- 
ment, and gives increased assurance of ultimate freedom of 
motion; but to obtain its full advantage it should be in- 
trusted only to those who possess the requisite technical 
skill. 
There is a special fracture in the vicinage of a joint 
which I propose to consider with some particularity, be- 
cause it is in general so badly treated. This occurs at the 
lower end of the radius. In its more common form, known 
by the name of Colles, no fracture is more frequent; and, 
from the long continued weakness of the hand and wrist 
which it usually entails, none is more important. It is be- 
cause this secondary condition is unnecessary that I char- 
acterize the treatment of which it is the direct result as 
pre-eminently bad. My criticism applies solely to the 
splints habitually employed. The reduction of the frag- 
ments by extension, counter-extension, and manipulation, 
the subsequent lateral flexion of the hand to the ulnar side, CERTAIN FORMS OF FRACTURES. 
15 
and the use of anterior and posterior splints with the ulna 
and radius in parallel position, can not be questioned. It is 
the prolongation of these splints which is the source of 
evil. I believe long splints are generally recommended in 
the standard text-books of surgery, and I know from my 
observation of hospital internes that their use is taught in 
the medical schools of New York with perhaps a single ex- 
ception. It is insisted that immobilization of the wrist is 
essential to the stable fixation of the radial fragments. 
Actual experience shows this to be untrue, so that the pro- 
longed and even permanent disability which it causes is 
gratuitous. The splints should be made of thin deal, a 
little wider than the forearm, should extend from the 
elbow to the wrist, leaving both joints free, and should be 
secured by broad bands of adhesive plaster and, if neces- 
sary, by a roller bandage. At the elbow they should allow 
absolute freedom of motion at the convenience of the pa- 
tient. At the wrist they should accurately compress the 
extremities of the radius and ulna, just reaching to the 
margin of the joint without encroaching upon it. Al- 
though the wrist will be unimpeded in action and the hand 
mechanically unrestrained, the constraint of the forearm 
and the dependent position of the hand will maintain their 
absolute quiescence. The freedom of the joint from pres- 
sure or interference by apparatus insures its future integrity 
of action. 
If the retentive bands of adhesive plaster are applied in 
the manner recommended by Dr. J. W. S. Gouley, who first 
in this country used the short splints for radial fracture, no 
readjustment will be required except as the subsidence of 
swelling may demand. In this method the lower band is 
attached to the inner border of the ulna, carried over the 
dorsal aspect of the wrist, and then over the anterior splint. 
The upper band is attached to the anterior surface of the 16 
THE TREATMENT OF 
forearm below the elbow and carried over the posterior 
splint. Each band is made long enough to more than sur- 
round the limb. If the bands are simply wrapped around 
both splints, almost daily readjustment will be required for 
a week or more on account of the slipping of the appara- 
tus downward. In this event great care should be exer- 
cised to avoid disturbance of the fragments. 
Any splints which extend below and fix the wrist joint 
should be denominated long and the term short restricted 
to those which leave the joint free. Some confusion in 
nomenclature exists from failure to make this distinction 
upon an anatomical basis. Long splints have been made 
to extend to the metacarpo phalangeal articulations, or 
even to the finger tips. They have also been fashioned in 
pistol shape as a means of maintaining lateral flexion of 
the hand, and this point has been much exploited. The 
smallest experience with straight splints, long or short, 
demonstrates that the hand once made to assume the 
proper position will retain it without special care. 
The effect of long splints upon the future usefulness of 
the hand and wrist is so constantly observed as to scarcely 
admit of question even by the advocates of their use. 
Months or years often elapse before they are sufficiently 
restored to easily subserve the ordinary functions of life, 
and their finer movements, indispensable in certain occupa- 
tions, are often permanently impaired. It is objected that 
the short splints do not sufficiently hold the fragments after 
reduction to obviate the danger of deformity. Experience 
and observation must be the sole arbiters in this point of 
dispute. I have never once treated this fracture in any 
other way, and I have never failed to keep the fragments 
in as good position as I was able to obtain in reduction. 
No splint can do more. This result has been confirmed in 
the practice of other surgeons who hold similar views. I CERTAIN FORMS OF FRACTURE. 
17 
believe deformity will be really less with this method of 
treatment, since the bone is more open to inspection, and 
trifling derangements can be more readily corrected and 
with less disturbance of the apparatus. There is equal ad- 
vantage to be gained in the treatment of other fractures of 
the forearm by not extending the splints below the wrist. 
Fractures of the extremities of long bones implicating 
the joints are always unfortunate in result. The operative 
procedures which they demand are of great interest, and I 
regret that the limits of this paper do not permit their 
consideration. The conditions and methods of interference 
are of too great importance to justify the merely casual 
mention to which I should be restricted. 
The treatment of compound fractures is another subdi- 
vision of the general subject which is too extended for our 
present limitations of time and purpose. I am less reluctant 
to turn aside from its discussion since it is already prominent 
in the literature of aseptic surgery. It may be said to 
epitomize the methods and possibilities of asepsis as it is 
practiced at the present time. I can not refrain from con- 
trasting the results in compound fractures of thirty-five 
years ago and of to day. Then few escaped without loss 
of life or limb; now few lives or limbs are sacrificed. The 
occasional recoveries of unmutilated patients which I saw 
at that epoch were in Bellevue and were mainly attributable 
to the genius of Dr. James R. Wood, in whose service at 
the hospital I had the honor to be and whose friendship I 
shared with all young men in the profession with whom he 
came in personal relation. His professional sagacity was 
phenomenal, and, by the maintenance of open wounds, 
thorough drainage, and the most systematic attention to 
cleanliness which available means then permitted, he un- 
consciously anticipated without antiseptic agents the most 
important part of modern aseptic treatment. It may be of 18 
THE TREATMENT OF 
passing interest to mention that impure carbolic acid was 
in use in that hospital at that time, but as a stimulant, not 
as an aseptic, and upon ulcers and old granulating surfaces, 
and not upon recent wounds. 
The extraordinary collection of cases published a few 
years ago by Dr. F. S. Dennis admirably illustrates what is 
accomplished in the present aseptic care of this class of 
fractures. They probably underestimate than otherwise 
the chances of recovery. If those cases are excluded in 
which complications exist, as well as those in which some 
crushing violence has primarily destroyed or fatally im- 
paired the vitality of all the structures of the part, failure 
to preserve the integrity of the limb may be fairly termed 
exceptional. A possible danger to life, born of aseptic 
faith, exists in overconfidence of the surgeon and a conse- 
quent attempt to avoid mutilation where there is no rational 
ground for hope. As safety lies in primary amputation, 
rash conservatism incurs a mortal responsibility. There is 
no conceivable contingency in which a surgical decision 
requires a more delicate appreciation of all the features of 
a case, studied in the reflected light of past experience, 
nor in which it should follow a more critical survey of all 
the elements of the situation. It may even then ultimately 
depend in great degree upon a professional instinct, not 
ignorantly innate, but founded upon the unconscious impres- 
sions derived from a multitude of previous observations, 
which upon occasion takes precedence of all formulated 
rules. If under such circumstances it proves that life has 
been endangered in the vain effort to save a limb, the in- 
telligent and conscientious discretion which has been ex- 
ercised and the acknowledged fallibility of human judg- 
ment will afford full absolution from responsibility. There 
can be no similar condonation of the error which comes 
from technical ignorance and inexperience when wiser CERTAIN FORMS OF FRACTURE. 
19 
counsel can be had. Consultation costs nothing to the 
surgeon, and may profit much to the patient. 
It may happen in a primary amputation, and usually 
does occur in secondary cases when the condition has be- 
come so depreciated as to be unfitted to withstand the 
effects of shock, that rapidity of operation is literally of 
vital importance. It can be facilitated by perfection of 
preparation ; the assistants can be so familiarized with the 
operator's requirements, and his every possible want can 
be so exactly anticipated, that losses of time can be counted 
in seconds. I am accustomed to go further than this. The 
preservation of life is of paramount impoitance and the 
severance of the part which imperils it is the only pressing 
operative necessity. I therefore content myself with doing 
just this and no more. In such urgent cases I waste no 
time in forming flaps and have no hesitancy in cutting 
straight through the limb. If the patient lives, flaps may 
be fashioned or reamputation made at some more conven- 
ient season. I never employ an Esmarch bandage, and 
consequently have no occasion for a multitude of ligatures. 
There is no need for sutures or refinements of dressing. 
Three or four ligatures and a dash of hot water, a compress 
in the wound, some combination dressing, and a roller 
bandage over all, are matters of but a moment or two of 
time if preparation has been adequate. If the arterial 
trunk has been accurately compressed, if the anaesthetic 
employed has been nitrous oxide, or if ether or chloroform 
has not been carried beyond the necessary very moderate 
effect, shock will be reduced to its minimum. Cardiac 
and general stimulants can be hypodermically exhibited, 
hot-water bottles applied to the surface, and even hot-water 
encmata administered during the progress of an operation. 
It is the minutest attention to such details as these that 
makes the difference between life and death, and that has 20 
THE TREATMENT OF 
sometimes enabled me to save cases which seemed practi- 
cally hopeless. I should perhaps apologize for passing by 
the many serious questions connected with the treatment 
of compound fractures to linger over the steps of an ampu- 
tation. I have often observed, however, that things which 
are quite simple and obvious are most neglected and con- 
sequently least understood. I am not sure whether this 
provisional amputation has been heretofore recommended 
as a formal operation. 
There are two fractures-one of the vault of the cra- 
nium, the other of the patella-which, when simple, I usu- 
ally make compound. This I do in the first for purpose of 
examination as well as of treatment, and in the second for 
treatment solely. I am compelled to assume, perhaps erro- 
neously, that my views in regard to these fractures are 
known, for they have already appeared in print. 
In a recent paper upon injuries of the head I referred 
briefly to fractures of the vault. I recur to them now in 
order to emphasize some points in treatment which I con- 
sider of sufficient importance to admit of iteration. These, 
in form at least, may be axiomatically expressed. A sus- 
pected simple fracture should be exposed by an incision of 
the scalp for purpose of examination. If a simple linear 
fracture be discovered, and there be no symptoms point- 
ing to a complication, the wound may be closed. If with 
a linear fracture there be indications of meningeal haemor- 
rhage, or of lesion of the brain substance, or if there be an 
open fissure, trephination should be made for further ex- 
ploration. If the fracture be depressed, the bone should 
be elevated, even in the absence of complicating symptoms. 
The further incision of the dura, or invasion of the brain 
itself, concerns the management of complications and not 
the fracture per se, and is consequently foreign to our pur- 
pose. This series of rules, which I regard as aphorisms. CERTAIN FORMS OF FRACTURE. 
21 
are founded upon a belief in the necessity for the elevation 
of depressed bone under all circumstances-a necessity so 
urgent as to demand that the depression should be deter- 
mined or disproved by any requisite operative means. It 
has fortunately become possible to institute these explora- 
tive measures without danger to the patient. The validity 
of the proposition that depressed bone should always be 
at once discovered and elevated or removed would seem 
to have been made convincingly clear in the history of 
numberless cases in which it has been neglected. It is not 
an occasional but a frequent instance in which, after the 
lapse of years, epilepsy, abscess, or mania has followed a 
cranial fracture, and in which a simple depression unrelieved, 
a cyst, or a spiculum of bone penetrating the brain, has been 
found to be the cause of an irremediable disease. If the 
occurrence of immediate danger is to limit responsibility, 
the surgeon may well allow his patient to drift, while he 
watches from day to day for the manifestation of primary 
symptoms, and in their absence for some brief time regard 
the cure complete. It is not even possible in a majority of 
cases to repair the evil consequences of such neglect by 
later operation ; the remedy lies in prevention, not in cure. 
The epileptic habit, or the maniacal condition, once firmly 
established, the final removal of its cause is too often but 
an ineffectual resort. I have within the year removed an 
extensive area of depressed bone and a subjacent cyst in 
an adult, the result of an injury in childhood, without as yet 
any marked improvement in an epileptic condition. I offer 
no suggestion as to the method of primary operation. The 
employment of the elevator, rongeur, drill, chisel, or tre- 
phine is simply a matter of preference or convenience. The 
fact that a different view of practice is still maintained is 
simply an additional illustration of the vagaries of surgical 
opinion. 22 
THE TREATMENT OF 
In the paper to which I have already referred I ex- 
pressed an opinion that trephination is devoid of danger. 
I have feared lest I might have been understood in a broader 
sense than I intended. I am quite aware that this opera- 
tion, in cases of chronic organic disease of the brain, is 
sometimes followed by a fatal result. I have recently tre- 
phined in a case of paresis in which I am convinced that 
death was hastened by interference. I am equally certain 
that an explorative trephination in a late stage of cerebral 
traumatism has in two instances been similarly unfortunate, 
and it is scarcely more than a month ago that, in a New 
York hospital, death followed trephination for epilepsy. It 
would not be difficult to multiply examples. In cases of 
recent fracture or of suspected meningeal haemorrhage, to 
which I intended to confine my expression of opinion, I 
have no doubt of its entire safety. I have never seen any 
case in which there was the slightest reason to suspect that 
it had hastened or produced an untoward result. I do not 
hold the operation responsible for the effects of prolonged 
etherization, excessive haemorrhage, or septic poison. It is 
true that shock from ether and haemorrhage has proved 
fatal. If the brain has been crushed, the great venous 
sinuses wounded, or the larger meningeal arteries torn, 
much blood may be lost and considerable time occupied in 
the treatment of the wound ; but it is these conditions, and 
not the operation which they necessitate, which involve 
danger. In the simpler and doubtful cases-the ones in 
which exploration or operation has been deprecated-there 
can be no great difficulty in safely limiting anaesthesia, con- 
trolling haemorrhage, or counteracting the effects of shock. 
The further possibility of the occurrence of sepsis is not 
more a factor here than it is in operative wounds in gen- 
eral. If anything may be assumed absolutely, it is the cer- 
tainty with which surgical cleanliness may be assured where CERTAIN FORMS OF FRACTURE. 
23 
the making of the wound, as well as its cure, is under the 
control of the surgeon. I have seen cases of compound 
fracture, originally contaminated or foul from neglect, in 
which the suppurative process had invaded the brain or its 
membranes, but I have seen none in which an operation 
made to convert a simple into a compound fracture, or to 
open the cranial cavity, has given entrance to the pyogenic 
germs. 
If we consider, then, the serious morbid conditions which 
often follow a neglect to relieve the brain from bone pres- 
sure, and the absence of probable danger which it involves, 
there seems to be no good reason why fractures of the vault 
should not be subjected to as critical examination as other 
accessible injuries, or why practicable measures should not 
be taken to avert future complications. 
The second of the simple fractures which I habitually 
make compound is that of the patella. Three years ago, 
at the annual meeting of the Bellevue Hospital Alumni 
Association, I advocated wiring this fracture as the treat- 
ment to be almost invariably adopted, excepting scarcely 
more than those cases in which organic visceral disease ren- 
dered any operative interference inadmissible. My later 
experience has been for recent fractures entirely corrobora- 
tive of the statements made at that time. The essential 
contentions which I then made were : That the obstacle to 
union is usually the intervention of the anterior capsular 
fibers, which fall between the fragments and prevent osseous 
contact, even though close approximation be effected; that 
this obstacle can not often be removed by any measure 
short of opening the joint; that this method is without 
danger ; that its result is invariably osseous within less than 
half the time required for ligamentous union by other 
means ; that restoration of the function of the joint can be 
made perfect by sufficient care in after-treatment; and that, 24 
THE TREATMENT OF 
when the surgeon possesses ordinary operative skill, it is an 
operation not of choice but of obligation. I had at that 
time operated in forty-two recorded cases. I had never 
lost a life or limb, had never had a drop of pus in the joint, 
had never failed of osseous union, and had never but once 
had any ultimately serious limitation of joint movement. 
Since then I have continued to treat this fracture in the 
same way with the same results, and have had no occasion 
to change my views. At that time, only three years ago, 
the operation was regarded very much as was ovaiiotomy 
thirty years previously. No one quite ventured to call it 
unjustifiable, but almost every one looked at it askance, 
congratulated himself that he did not do it, and cheerfully 
awaited disaster to the occasional man who did. As a gen- 
tleman expressed it at a meeting of the Surgical Section 
of the Academy of Medicine, he treated fractures of the 
patella without operation, and could sleep undisturbed at 
night. In this brief interval I have noted with pleasure 
that an increasing number of surgeons are able to so treat 
this fracture as to gain the best results without the loss of 
rest which an uneasy conscience or lack of self-confidence 
seems to entail. 
It will be unnecessary to recapitulate the steps of opera- 
tion, which I have since modified in only one or two par- 
ticulars. I have discarded the use of strong antiseptic 
solutions. I began with a bichloride-of-mercury irrigation 
of 1 to 5,000. I afterward reduced its strength to 1 to 
10,000, with some misgivings as to its safety. I now use 
a solution of 1 to 20,000 in boiled water. I have no rea- 
son to doubt that boiled water by itself would be as suffi- 
cient here as in the larger serous cavity of the peritonaeum. 
I add the modicum of antiseptic salt as a perhaps unneces- 
sary precaution lest the joint cavity should suffer some 
casual contamination during operation. I find that by this CERTAIN FORMS OF FRACTURE. 
25 
avoidance of strong antiseptics the subsequent restoration 
of movement in the joint is much more easily accom- 
plished. 
I continue the use of a single articular drainage-tube 
merely to afford an exit for post-operative haemorrhage. 
I have long since ceased to fear the occurrence of purulent 
synovitis. I regard superficial suppuration, however, as 
quite possible whenever there has been much laceration 
of the soft parts; but if the deep sutures have been care- 
fully placed and superficial drainage provided, there is not 
the slightest danger that pus will enter the joint. 
In the second stage of treatment, after union has be- 
come sufficiently firm to render manipulation safe, the 
same advantage is to be derived from systematic massage 
that has been noted in fracture near the extremity of a long 
bone. There is the same necessity also, if it is to afford 
the greatest possible advantage, that it should be applied 
by a professional person who possesses technical skill and 
experience. Since I have discarded antiseptics of more than 
nominal strength, and have employed a masseur in cases 
where the joint is of more than usual rigidity or where it 
readily inflames by the use of passive motion, I have had 
much less trouble in restoring natural function. 
The proper treatment of recent fracture of the patella is, 
in my mind, quite clear and well determined, but what to 
do with the fracture which has existed for a longer time is 
often difficult to decide. It is such cases which are most 
likely to come from a distance for relief, and they are cer- 
tain to include all those most unfit for operation. The 
conditions which militate against success are mainly three- 
the contraction of the quadriceps extensor muscle, the 
atrophy of the lower fragment, and the shortening of the 
ligamentum patellae. The muscular contraction can be 
overcome by massage, and is consequently unimportant; 26 
THE TREATMENT OF 
the atrophy of the lower fragment is irremediable; but it is 
the shortening of the patellar ligament which renders many 
cases hopeless. Unless the fragments can be brought into 
at least partial contact, operation will be worse than use- 
less. The length of time which has elapsed is important, 
but not absolutely determinate. At the end of two years I 
have obtained entire contact without difficulty or prelimi- 
nary treatment. At the end of a few months even partial 
contact has been impracticable. Tn all cases the length of 
the quadriceps extensor should be restored, and the ligamen- 
tura patellae, if possible, elongated by preliminary manipu- 
lation. Contact may be deceptive from portions of ruptured 
ligament which remain attached to the bony fragments. 
Operation, therefore, should not be ventured unless the 
fragments can be so readily brought together as to enable 
some allowance to be made for this source of error. There 
may be a single exception made to the rule. If there be 
absolute non-union, so that the whole joint cavity be sub- 
cutaneously exposed, flexion as well as extension impaired, 
and the limb so weakened as to justly occasion fear of 
fracture of the opposite patella, it may be well to operate 
even if doubt exist as to the nature of contact, and even at 
the risk of an ankylosed knee. If no contact at all be 
had, protection of the joint cavity will be lost and trouble 
probably arise from some form of synovitis. Old fractures 
of the patella at best are as troublesome and unsatisfactory 
after operation as recent cases are tractable and perfect in 
result. 
There is an operation which has been recommended in 
place of wiring, and which has for its object approximation 
of the fragments by means of a subcutaneous suture. It 
is radically defective because it fails to secure osseous 
union. It does not provide for the removal of intervening 
capsular fibers, and has consequently no advantage over a CERTAIN FORMS OF FRACTURE. 
27 
plaster apparatus except in making approximation closer. 
It is quite as difficult to do as the radical open operation, 
and would seem to be quite as likely to be followed by 
superficial suppuration. 
The consideration which I have been able to give to the 
several fractures mentioned has been of necessity hasty and 
imperfect. 1 have already disclaimed any intent to make 
either a systematic or an exhaustive study of the general 
field in which they occur, and have sought only to emphasize 
some facts and observations which have impressed me with 
special force. I have spoken with some positiveness and 
insistence because my personal observation has led to posi- 
tive convictions, and because I know that exact truth al- 
ways loses by indirectness of expression. 
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