J\To. 2. 
BYS 
R. 0. COWLING, A.M.. 
Professor Principles and Practice 
of Surgery, University 
of Louisville. 
PRICE, TWENTY-FIVE CENTS. Aphorisms in Fracture 
BY 
RICHARD 0. COWLING, A.M., M.D., 
Professor Principles and Practice of Surgery, University 
of Louisville. 
LOUISVILLE, KY: 
John P. Morton & Company, Publishers. 
1881. COPYRIGHTED 
By John P. Morton & Company. 
1881. PREFACE. 
The greater portion of the following Aph- 
orisms were originally read before the Cen- 
tral Kentucky Medical Society at its meeting 
in Harrodsburg in 1877. Subsequently they 
were published in the Louisville Medical 
News. They met with considerable favor, 
having been copied by a number of medical 
journals, and were especially honored by the 
criticisms of several distinguished authori- 
ties in surgery. Some changes have been 
made in the present edition as a result of 
these criticisms, and with a thorough revis- 
ion of the old matter fifty-four new Aphorisms 
have been added. It will be found now 
that pretty nearly the entire field of fract- 
ures is covered in these few pages. APHORISMS IN FRACTURE. 
INTRODUCTORY. 
Fractures form perhaps the widest chapter 
of importance in surgery, and the experience 
gathered concerning them is corresponding- 
ly great. There are few members of the pro- 
fession who have not treated a number of 
broken bones. And yet with all these op- 
portunities for observation a singular differ- 
ence of opinion exists on fundamental points. 
The question of extension and counter-ex- 
tension is a vexed one. Mr. Flower, in 
his article in Holmes, describes a “crutch- 
splint ” with which to exert these forces in 
fracture of the arm, while on the other hand 
the necessity for such measures is denied by 
a large body of surgeons even in fracture of 
the thigh. Men are divided upon the sim- 
ple question of when to dress a fracture; 
upon what should apparently have long since 6 
Aphorisms in Fracture. 
been positive knowledge—the prognosis in 
this injury; and what has been written con- 
cerning the methods of dressing fracture 
would take many volumes to record. We 
have all felt the disadvantage of this, es- 
pecially in the early days of our practice— 
how our memory has been taxed with the 
multiplicity of apparatus, losing sight, in the 
midst of so much paraphernalia, of the fact 
that the principle of treating every fracture 
is the same. It will be a grand day for sur- 
gery when the lumber-room which contains 
its fracture-boxes and splints of various de- 
signs is destroyed. The simple necessities 
of our art could easily be restored. 
In the following Aphorisms it has been as 
much the aim of the author to ignore use- 
less matter as to indicate that which is valu- 
able. What is stated is upon the basis of no 
little clinical experience, obtained with all 
the anxiety incidental to fracture practice. 
He has tried to answer as briefly and as 
positively as he could such questions as 
were continually rising in his own mind and 
what must have occurred to others going 
along the same way. If the answers are Aphorisms in Fracture. 
7 
not as satisfactory to every one as they are 
to himself, he believes he has done service 
in indicating points where disagreement may 
arise. 
The doctrines enunciated are chiefly those 
of Mr. Erichsen, upon which the schools of 
Louisville are well agreed. “Simplicity with 
efficiency” is the motto of these teachings. 
Methods which may be pursued by the road- 
side with results as excellent as those ob- 
tained through hospital machinery are cer- 
tainly to be desired; and such, at any rate, 
are the claims of the plastic apparatus; and 
so, too, Persuasion, not Force—the theory 
which underlies this practice—has acted ad- 
mirably in many affairs in life, and is cer- 
tainly a comfortable doctrine to hold in the 
treatment of rebellious muscles. 
GENERAL APHORISMS. 
1. Fracture is the term applied to the 
breaking of bone or cartilage. 
2. The cause of fracture is external vio- 
lence, direct or indirect. Exceptionally it 
may occur from muscular contraction. 
3. Clinically the important division of 8 
Aphorisms in Fracture. 
fracture is into open and subcutaneous and 
into transverse and oblique. 
4. The signs of fracture are pain, swell- 
ing, loss of function, deformity, mobility, and 
crepitus. 
DIAGNOSIS. 
5. Pain and loss of function are symp- 
toms which may accompany any injury. 
They are of special importance in establish- 
ing the existence of impacted fracture, fract- 
ures of the outer third of the clavicle, in- 
tra-capsular fracture of the femoral neck, and 
fracture of the fibula. 
6. In establishing diagnosis swelling is 
the least important of the symptoms accom- 
panying fracture, as it is among the most im- 
portant in treatment. It does not necessarily 
occur, and when present obscures signs which 
are pathognomonic. 
7. Deformity frequently indicates at once 
the presence of fracture, and when present 
is particularly valuable in doing away with 
the necessity of painful and injurious meth- 
ods of diagnosis. This is especially true 
in intra-capsular fracture of the femoral 
neck.- Aphorisms in Fracture. 
9 
8. Mobility is absent in impacted fracture 
and green-stick fractures, and is obscured in 
Colies’ fracture, fracture of outer third of 
clavicle, of the fibula, and all fractures near 
the joints. 
9. In establishing the diagnosis of fracture 
crepitus is the most satisfactory sign; never- 
theless it is not always necessary or desirable 
to obtain it. It may not be had in impacted 
fracture, except to the injury of the patient. 
It is difficult to obtain in intra-capsular fract- 
ure of the femoral neck, fracture of outer 
third of clavicle, and of fibula. 
10. The sensation of crepitus in recent 
fracture is sut generis and unmistakable. 
When once detected, further attempts to 
elicit it should not be made. 
11. A great difficulty in the differentiation 
of fracture is from sprain, as well as from 
dislocation, which latter is apt to have its 
own positive signs. 
12. Whenever any doubt exists as to the 
diagnosis of fracture the examination should 
be conducted under an anesthetic. 
13. In making diagnosis of fracture, and 
especially in determining if proper reduc- Aphorisms in Fracture. 
10 
tion has been effected, it is all-important 
that comparison should be made between 
the injured and uninjured limbs. 
14. The direction of simple fracture may 
sometimes be made out in subcutaneous 
bones by manipulation; but when it is at all 
deep-seated, as in the thigh, it is to be de- 
termined more by general than local signs. 
Practically that fracture is transverse where 
the abutment is sufficient to prevent return 
of shortening after reduction has been ef- 
fected. 
15. In handling a fractured limb it should 
be grasped firmly. By so doing muscular 
spasm is best controlled. The seemingly- 
gentle way of lifting upon the hand is far 
more painful to the patient. 
16. Frequently in fracture cases more dam- 
age is done in the conveyance of the patient 
than by the original injury. Simple fracture 
may thereby be made compound; and in 
compound fracture life may drip away from 
a wound which is thought not to be bleed- 
ing. It will add greatly to the comfort of 
the patient if those who carry him will keep 
step. Aphorisms in Fracture. 
11 
i7- The prognosis in simple fracture is 
always favorable when the injury is confined 
to the shaft of the bone, even if there be 
comminution of the bone. 
18. In multiple fracture, when simple, the 
healing process is not retarded. 
19. In fracture involving a joint more or 
less stiffness is to be expected. 
20. The probabilities are that less damage 
is done in fracture from indirect than from 
direct violence. 
21. Fractures do best in the young—in ce- 
lerity, in certainty, and perfectness of cure. 
All things are here possible with youth. 
22. Old age is not a bar to the union of 
bone where the fracture is through the shaft. 
23. In all fractures with separation of frag- 
ments—acromion, humeral tuberosity, olec- 
ranon, patella, and femoral condyle — the 
prognosis for perfect cure is not good. 
24. With the improved methods of treat- 
ment the danger to life and limb in com- 
pound fracture has been reduced to such an 
extent that former laws for determining the 
question of amputation are to be recast. 
PROGNOSIS. Aphorisms in Fracture. 
12 
25. The elbow and hip are the bugbears 
of fractural surgery. 
26. Under the best-devised treatment of 
fracture conscientiously carried out bad re- 
sults may follow, and he who is swift to 
condemn a fellow practitioner for such is 
wanting as much in knowledge of his art as 
in charity. 
TREATMENT. 
27. The best time to dress a fracture is 
immediately after its occurrence. 
28. Temporary dressings are only to be 
used when the materials for permanent dress- 
ings are not to be obtained, or for the pur- 
pose of moving the patient. 
29. Under proper treatment immediately 
instituted swelling will probably be pre- 
vented, and if swelling be present it is best 
treated by proper fracture dressings. 
30. The indications for treatment of fract- 
ures are, first, reduction of the fragments of 
bone; second, their immobilization. 
31. The reduction of fracture is to be done 
without violence. The muscles being re- 
laxed, a gentle, steady pull is all that is 
necessary in fracture of the shaft. In fract- Aphorisms in Fracture. 
13 
ures near the wrist the fragments are' to be 
unlocked. 
32. While the deformity following fracture 
is chiefly due to the action of muscles, it is 
also greatly due to this, that the shape of the 
limb is restored. In reduction of fracture 
we unlock the fragments and bring down the 
lower one to a position where the coordina- 
tion of the muscles lands it in its proper place., 
33. In simultaneous dislocation and fract- 
ure the rule is to reduce the dislocation first. 
This is easier to recommend than to do, 
however, if fracture is near dislocated joint. 
34. The dressing of all fractures is best 
done under an anesthetic, which not only 
secures comfort to the patient, but by its 
influence over muscular spasm gives the best 
chance for perfect reposition of fragments. 
35. The fractured limb should be dressed 
in the position of ease—rectangular for the 
forearm and general fractures of the elbow; 
in the lower extremity, with the knee slightly 
flexed. In fracture of olecranon the arm 
should be as much flexed as possible not to 
separate the fragments. 
36. Perfect immobilization is only to be 14 
Aphorisms in Fracture. 
obtained when the joints contiguous to the 
fracture are secured ; and in fractures of the 
lower extremity there is no law more impor- 
tant than this. 
37. One of the commonest reasons for 
failure and disaster in the treatment of 
fracture arises from the fact that bone and 
muscle only are considered, and blood-ves- 
sels and nerves are left out of sight. 
38. Carved and manufactured splints gen- 
erally fit nobody, and are to be rejected as 
not only expensive but damaging. Deal- 
board, pasteboard, and the materials for 
the plastic apparatus form all the appliances 
needed by the surgeon. 
39. Bandages are made of cotton stuff or 
cheap flannel (preferable for the cotton in 
it) with the selvage edge torn off, and thor- 
oughly shrunk before use. 
40. Plastic material consists of cotton 
batting, oakum, bandages, plaster of paris, 
eggs and flour, starch, liquid glass, etc. 
41. The application of the roller bandage 
immediately to the skin, whether as a pro- 
tective or to prevent muscular spasm, has 
resulted in such disaster that it is one of the Aphorisms in Fracture. 
curiosities of surgery how it could be re- 
peated at this day. When cotton is placed 
over such a bandage it forms an absurdity 
scarcely credible in a man of ordinary sense. 
42. Evenness of pressure is only to be 
obtained by the proper lining of the splints 
or retaining-apparatus with cotton, or in 
the case of compound fracture with oakum. 
The method of padding splints or protect- 
ing limbs with folded lint, blanket, etc. is 
not only vastly inferior, but generally results 
in discomfort to the patient, from the close 
packing of the material. 
43. The cotton to be used is preferably 
that known as “batting.” “Wadding” is 
inferior. It is of prime importance to use 
the best batting whenever this can be ob- 
tained. This is smooth, easily separated 
into layers, and free from foreign sub- 
stances, which produce inequalities and ir- 
ritation. The layers should be unbroken. 
It is next to impossible to make an even 
dressing With the broken bits which the 
housewife so often offers to the surgeon. It 
should be freely used, especially over bony 
prominences. A fracture in the thigh of or- 16 
Aphorisms in Fracture. 
dinary dimensions will generally require a 
“pound roll.” It is to be smoothly and 
evenly applied. For convenience it may be 
held in situ while the rest of the dressing 
is applied by ordinary sewing-thread which 
does not constrict. 
44. Continued extension and counter-ex- 
tension are as a rule not necessary to prevent 
shortening in fractures. This is best done 
by removing the causes which lead to mus- 
cular spasm : first, by early and as a com- 
plete reposition of the fragments as possi- 
ble; second, by the smooth application of 
cotton batting to the limb; third, by the 
equal pressure of a bandage extending from 
the distal end of the limb to a point be- 
yond the joint above the fracture; fourth, 
by the accurate fitting of the splints or 
plastic material for support; fifth, by as 
little interference afterward as possible. 
45. Angular deformity is best overcome 
by the same measures as are used in longi- 
tudinal deformity. Compresses'are to be 
avoided as insufficient and unsurgical. 
46. Comfort is the sign that a fracture has 
been properly dressed. A certain amount of Aphorisms in Fracture. 
soreness may be left after any fracture, and 
with some temperaments pain maybe present 
even when the fracture is properly dressed; 
but the general law is that pain should 
speedily subside when the dressings are 
right. 
47. Wherever it is possible, after the dress- 
ing of a fracture, it should be seen again in 
a few hours, and the case should receive 
daily attention in its earlier stages. 
48. Frequent dressings of fractures for the 
purpose of examination are not only useless 
but hurtful. 
49. While meddlesome interference with 
the dressing of fracture is to be strenuously 
decried and great reliance is to be placed 
upon general signs, as comfort, absence of 
fever, etc., and upon the condition of fingers 
or toes, nevertheless it is prudent under sev- 
eral circumstances to make inspection of the 
limb with comparative frequency. This pre- 
caution refers especially to fractures in the 
aged, to compound fracture, and to fracture 
accompanied by deep bruise, though the 
skin may be unbroken. Under such cir- 
cumstances sloughs may be produced with- 18 
Ap/iorisms in Fracture. 
out warning and by the weight of the limb 
independent of any pressure of the bandage. 
•50. A common reason why accidents in the 
treatment of fracture go undetected is that 
inspection is limited to the front of the limb. 
51. The surgeon is to regard not only the 
welfare of his patient, but his own reputa- 
tion. To this end he ought to give fair 
warning as to possible ill results. As suits 
for malpractice have arisen oftener from 
fracture cases than any other kind, it will 
be remembered there is one thing which 
the law is slow to excuse—neglect. 
52. If there be a consultation between 
two physicians in a fracture case, and a dif- 
ference of opinion in regard to treatment 
arise, one should yield. Compromises in 
cases of this kind are apt to result badly, 
while fractures may do well under almost 
any reputable method properly pursued. 
53. If in a case of fracture a consultation 
is called of a surgeon by one who does not 
make special pretensions to the art, he should 
resign to him the conduct of the case, as on 
him will rest the responsibility of the out- 
come. In other words, he who “sets” the Aphorisms in Fracture. 
19 
fracture, not he who watches it, is charged 
with the result. 
54. Whenever a fracture occurs every phy- 
sician in the community within reach is usu- 
ally summoned. The doctor should there- 
fore be ready to treat such cases not only for 
the comfort of the patient, but for his own 
profit. 
55. The consolidation of fracture being a 
gradual process, the exact date of its occur- 
rence is not to be fixed without continued 
experiment, which would be disastrous to 
the patient. 
56. The date upon which retentive appa- 
ratus may be laid aside varies with (1) the 
age of the patient, (2) the nature, and (3) sit- 
uation of the fracture. 
In simple fractures of the adult: For the 
lower extremity, eight weeks; for the upper 
extremity, six weeks. 
During second decade of life: For the 
lower extremity, seven weeks; for the upper 
extremity, five weeks: 
From five to ten years: For the lower ex- 
tremity, six weeks; for the upper extremity, 
four weeks. 20 
Aphorisms in Fracture. 
Under five years: For lower extremity, five 
weeks; for upper extremity, three weeks. 
Fractures near the joint should be turned 
loose in the adult a week earlier; other ages 
in proportion. In compound fracture, if 
the wound heal readily, the date may be 
taken from this event as in simple fracture. 
If not, retentive apparatus is generally worn 
from twenty-five to fifty per cent longer af- 
ter compound than after simple fracture. 
In all cases the natural timidity of the pa- 
tient may be depended upon to restrain 
undue action for a number of days after 
apparatus is laid aside. 
57. It sometimes happens that from excess 
of timidity the patient refuses to use the limb 
long after the period for proper union has 
gone by, giving rise to suspicion of ununited 
fracture. The remedy is enforced exercise 
in proper gradation. 
58. In all cases of anchylosis occurring af- 
ter fracture where the joint is not directly in- 
volved—and in many where it is involved— 
the best method of treatment is by gentle 
measures—by tiring the muscles rather than 
by forcing them. Aphorisms in Fracture. 
21 
59- Rubbing with whisky and water is the 
best remedy for the itching which comes af- 
ter (and before) apparatus is removed. 
60. It is generally best to leave the flesh- 
wound of compound fracture unsealed. If 
small and clean-cut it will perhaps speedily 
close itself; if large and lacerated it will re- 
quire the best drainage it can get. Nothing 
but disaster can follow the closing of a deep, 
lacerated wound accompanying fracture. 
61. Not every fever which follows injury 
is surgical fever. Frequently in malarial 
districts after fracture there rises a fever of 
well-marked intermittent type thoroughly 
controllable by quinine. 
62. In an ordinary compound fracture it 
is not necessary, as a general thing, to cut 
a trap in the apparatus under a week or a 
fortnight. The thermometer in the axilla 
with appearance and sensation of patient 
are generally good indices of state of 
wound. 
63. Green-stick fracture, when the bend is 
excessive, should be straightened even at 
the risk of completing the fracture, which 
occurrence is not a matter of much conse- Aphorisms in Fracture. 
22 
quence. When the bend is slight the bone 
will assume its proper shape by natural 
processes. 
64. In the treatment of ununited fracture 
the simplest measures will often suffice. Re- 
tentive apparatus having been properly ap- 
plied, fresh air and food, with specific rem- 
edies in special diathesis, will generally do 
the rest. When local irritation is necessary 
the order of trial should be (1) rubbing 
ends of bone together; (2) subcutaneous 
scoring with tenotome; (3) drilling; (4) 
the seton; (5) pegs; (6) subcutaneous re- 
section. 
65. As all the dressings of fracture can 
be applied on the model, the young practi- 
tioner has ample opportunity to make him- 
self an adept in their application, without 
waiting for clinical experience. 
66. In view of the vast responsibility ac- 
companying the treatment of fracture the 
surgeon should demand for his services a 
fee commensurate with the ability of his pa- 
tient to pay, and also in adjusting the fee 
for fracture it should be done upon the basis 
of skill rather than labor. Aphorisms in Fracture. 
23 
FRACTURES OF THE FOREARM. 
67. In fracture of forearm the order of 
frequency is: i. Lower third of radius; 
2. Both bones; 3. Ulna; 4. Radius, upper 
third. 
68. There is but one mode of dressing 
necessary for all fractures of the forearm, 
whether these be of one bone or of both, 
and whatever be their situation. 
Method of Dressing. The pieces for dressing a 
fractured forearm consist, first, of cotton batting; sec- 
ond, of light wooden splints; third, of bandages. 
The splints should extend from the elbow to the 
tips of the fingers. They should be a trifle wider 
than the wrist, to prevent lateral pressure upon the 
bones and the obliteration of the interosseous space. 
They should not be much wider, else lateral displace- 
ment may occur. For convenience they may be 
shaped to the arm and hand. It will always be 
found more Convenient to envelop the arm with the 
cotton instead of padding the splints with the same; 
and where splints are padded with the cotton it is 
always better to fasten this material by a few turns of 
ordinary sewing-thread. The method of padding 
splints by securing the cotton with bandages inter- 
feres greatly with their plasticity and comfort. 
The bones having been put in apposition by gentle 
extension, and the splints secured to the palmar and 24 
Aphorisms in Fractu?-e. 
dorsal aspect of the arm by proper bandaging from 
tips of fingers to elbow, the arm is to be placed in a 
sling, with thumb pointing upward, in which posi- 
tion the bones are half way between supination and 
pronation, and the interosseous space is well pre- 
served. 
The dressing, when fitted for fracture of the fore- 
arm, is not to be removed, if comfort declares that it 
is properly doing its work, for a week or ten days, 
when the splints are to be shortened, so that they 
shall not reach beyond the roots of the fingers; and 
these are to be exercised frequently to prevent stiff- 
ness. . 
69. The Pistol splint does nothing toward 
preserving the interosseous space; and the 
interosseous pad, formerly considered neces- 
sary for this purpose, is very nearly obsolete, 
and should be entirely so. 
70. In the treatment of fractures of the 
lower end of the radius reduction is every 
thing. Pilcher’s method of first strongly 
bending the hand backward on the forearm, 
making extension while in this position, and 
then bringing it forward into flexion while 
the extensio*n is kept up, acts admirably, the 
fragments unlocking and the deformity dis- 
appearing as if by magic. It is the opinion 
of Dr. Pilcher that in most cases no reten- Aphorisms in Fracture. 
25 
tive apparatus beyond a bandage and a sling 
is required, confinement in splints favoring 
stiffness. It would seem, however, that after 
severe injury the support of these would be 
required to prevent soreness. 
71. The complicated dressings for Colles’ 
fracture of the radius are not called for, and 
such dressings as include a compress to cor- 
rect deformity are to be condemned as un- 
surgical, not only at the wrist but elsewhere. 
72. In Colies’ fracture, after union has 
taken place, there may remain some of its 
characteristic deformity. In the young this 
generally disappears under the play of the 
muscles, or sometimes in a bone recently 
united it may be remedied by actual com- 
pression. 
73. A common result following Colles’ 
fracture, and in fractures near the wrist in 
adults, more especially in the aged, is a se- 
vere and persistent neuralgia. Which is 
best treated by the hot-water douche. 
74. In fracture of both bones of the fore- 
arm, and frequently after fracture of one 
bone, there is after union a bowing of the 
forearm always toward the ulnar side. Some- 26 
Aphorisms in Fracture. 
% 
times this is chiefly apparent, often real. It 
will frequently disappear, even when excess- 
ive, under the play of the muscles, espe- 
cially in the young. But healing is never 
so perfect that the site of the injury can not 
be detected by manipulation. 
75. Stiffness of the tendons and of the 
wrist-joint are not confined to Colies’ fract- 
ure, but may occur with other fractures of 
the arm. Massage and passive motion will 
generally effect relief. 
76. Many physicians do not have clear 
ideas concerning the fit of a sling. It should 
be wide enough to reach from the elbow to 
the tips of the fingers and worn with the 
straight side to the hand and the angle to 
the elbow. 
FRACTURE OF FINGERS. 
77. In fracture of the fingers or any portion 
of the hand the retentive apparatus should 
include the forearm. 
78. In compound fracture of the fingers, 
the result of crush, the principal question is 
in regard to amputation. In connection with 
this the following points are to be consid- 
ered : First, The recuperative powers of the Aphorisms in Fracture. 
27 
hand are peculiarly great, and it is possible 
for a severe wound to heal. Second, Af- 
ter the wound has healed there is great dan- 
ger that the fingers may be useless from stiff 
joint. Third, It is better to err on the side 
of conservatism, as even when the healing 
results in useless fingers the proper point for 
amputation can then be best determined; 
and besides, the vast majority of people pre- 
fer stiff fingers to none at all. 
FRACTURES NEAR THE ELBOW. 
79. Every injury, save fractured olecranon, 
near the elbow-joint, whether it be fracture 
or dislocation, should be dressed with rec- 
tangular splints. 
Method of Dressing. The rectangular splints for 
the elbow are best made from pasteboard. The limb 
from the fingers to the shoulder is to be enveloped in 
cotton; the splints, moistened in water, are to be ap- 
plied laterally, molded and confined with bandage 
from hand to shoulder. 
Rectangular splints are called for in injuries near 
the elbow, as effecting in the best manner immobili- 
zation; and, secondly, should anchylosis result from 
the injury they preserve the arm in the best possible 
shape for its future usefulness. 28 
Aphorisms in Fracture. 
80. More or less stiffness of the elbow is 
to be expected in every fracture occurring 
near this joint. If the fracture be through 
either condyle such result can scarcely be 
avoided, as passive motion in such cases, 
when early instituted, tends to prevent 
union. Where the bone is broken above the 
condyles stiffness can frequently be pre- 
vented. 
81. It is probable that passive motion when 
instituted while the healing process is going 
on does more damage than good. The best 
measures against anchylosis are perfect re- 
position and rest. 
82. Where decided stiffness has persisted 
for some time after the union of fracture near 
the elbow, much can be done for its relief 
by passive motion and massage faithfully 
pursued. 
83. In fracture of the olecranon where 
there is no separation of the fragment, owing 
to the fact that the fibrous expansion of the 
triceps is unbroken, the arm may be dressed 
in an angular position. In fracture with sep- 
aration of the fragments it is necessary for 
their apposition that the arm be dressed in Aphorisms in Fracture. 
29 
an almost straight position, but the earliest 
possible moment should be seized to bring 
the arm back to an angular position, that 
anchylosis may not occur with the arm 
straight and its usefulness in so far destroyed. 
FRACTURES OF HUMERUS. 
84. Fractures of the humerus in the lower 
half are best treated by rectangular splints, 
as in fractures of the elbow. Fractures of 
the upper end require shoulder-cap, the 
spica, etc. 
Method of Dressing Fractures in Upper End of 
Humerus. Fractures of the upper end of the hume- 
rus, including fractures of the shaft, surgical and 
anatomical neck, are dressed, first, by enveloping 
the limb from hand to shoulder with cotton; second, 
by bandaging from the hand to upper arm; third, by 
fitting cap to shoulder, and over this carrying the 
spica bandage. The body of the patient acts as the 
inside splint, the hollow being filled with a folded 
towel, and the arm is secured to the side by addi- 
tional turns of the bandage, the forearm supported 
in sling. 
These fractures may be also dressed with plaster- 
of-paris apparatus. After four or five weeks splints 
may be laid aside and retention trusted to spica 
bandage alone. Aphorisms in Fracture. 
85. Stiff joint at the shoulder is not liable 
to occur in extra capsular fracture. 
FRACTURES OF CLAVICLE. 
86. Two methods of dressing a fractured 
clavicle are worthy of chief consideration. 
These are, first, for temporary purposes, an 
ordinary sling, lifting the forearm across the 
breast to an angle in which it is comfortable, 
with a band passing around the body, con- 
fining the arm closely to the side. For a 
permanent dressing Sayre’s method, by ad- 
hesive strips, is the most convenient and 
efficient, save in very warm weather, when 
the plaster “runs.” 
87. Whenever the clavicle is broken at 
its great convexity, and shows the character- 
istic deformity, perfect apposition is difficult 
to effect, or to maintain, and deformity will 
remain to a greater or less degree after union 
has taken place. It is more likely to be pre- 
vented by keeping the patient in a recum- 
bent posture, or by using means to fix the 
scapula. 
88. Fractures of the outer third of the 
clavicle are frequently overlooked by physi- Aphorisms in Fracture. 
cians, the injury being mistaken for a sprain. 
Displacement is not liable to occur in this 
situation, and crepitus is difficult to elicit. 
Wherever, after a fall or other injury, sharp 
pain is developed by pressure upon the outer 
third of the clavicle, fracture at this point is 
to be suspected. 
89. The axillary pad in Fox’s apparatus 
can not be worn with comfort, and is of very 
doubtful utility. 
FRACTURES OF THE RIBS. 
90. In fractures of the ribs the jack-towel, 
or better, the roller, is our chief reliance. 
Adhesive strips or collodion and gauze, over 
and around the seat of fracture, are gener- 
ally not practicable, and not always suffi- 
cient to conquer pain, which is the one thing 
we are to attack. 
FRACTURES OF THE JAW. 
91. In fractures of the jaw our chief re- 
liance is in Barton’s, Gibson’s, or the four- 
tail bandage, and soft food. Internal appa- 
ratus (inter-dental splints or tying the teeth 
together) practically amounts to little. 32 
Aphorisms in Fracture. 
FRACTURES OF THE NOSE. 
92. In fractures of the nose the main 
thing is early reposition of the fragments. 
Apparatus to keep the bones in place after- 
ward are principally theoretical. 
FRACTURES OF THE PELVIS. 
93. In fractures of the pelvis our chief 
reliance is in relaxation of the abdominal 
muscles, and control of these from spasm, 
from cough, etc. This is best done by the 
inclined plane, jack towel, broad bandage, 
and anodynes. 
FRACTURES OF THE LOWER EXTREMITIES. 
94. The proper dressing for every fract- 
ure of the lower extremity is the plastic 
apparatus. 
Method of making Plastic Apparatus. In all cases 
the cotton should come first; next, thread holding 
it in place till it can be secured evenly by band- 
ages; and on top of this the stiffening material. 
Plaster of Paris must be fresh, finely ground 
(dental plaster), and well rubbed into slazy band- 
ages made of quilt lining, not more than three yards 
long, these to be dipped in water and applied in 
two or more layers over limb. Aphorisms in Fracture. 
33 
Flour and Eggs. Whites to be well separated 
from fresh eggs, and thoroughly beaten to a 
froth; sifted flour to be stirred in to make a paste, 
which is to be rubbed into cotton bandages as 
they are carried over the limb, in three or four 
layers. 
Starch. Method of application the same, ex- 
cept it generally requires the addition of paste- 
board splints for proper stiffness. 
In view of the great advances made in plastic 
apparatus the “starch bandage” may be consid- 
ered obsolete, and only to be used when the better 
materials for stiffening are not to be had. 
95. The plastic apparatus in fractures of 
the lower extremity is not only the best of 
dressing, but most comfortable to patient 
and surgeon. 
96. Failure or disaster with the plastic ap- 
paratus in fractures of the lower extremity 
has been due generally to its improper appli- 
cation, or to causes which would have oper- 
ated had it not been used. 
97. The chief causes of failure with the 
plastic apparatus have been, first, the ab- 
sence of cotton as a foundation, or its scant 
or irregular application; second, unequal 
pressure of retaining bandages; third, im- 
proper material; fourth, neglect to secure 34 
Aphorisms in Fracture. 
the upper joint, especially a neglect of the 
spica in fracture of the thigh. 
98. Under the properly-applied plastic 
apparatus swelling is not liable to occur. 
99. In recent fracture, and above all in 
compound fracture, plaster of paris is to be 
preferred for the plastic apparatus. After 
union has taken place other materials may 
be used from consideration of lightness, etc. 
100. Plaster-of-paris bandages are gener- 
ally sufficiently firm for their purposes inside 
of thirty minutes; the flour-and-egg mixture 
within twelve hours, with manila paper some- 
what earlier; prepared chalk and gum, oxide 
of zinc and glue, and starch seldom harden 
under forty-eight to seventy hours. The 
“ setting ’ ’ of the plaster may be hastened 
by the addition of alum to the water in 
which the rollers are placed. 
101. In setting a fractured thigh it is good 
precaution to turn the lower fragment so that 
the foot may be placed a little “pigeon- 
toed.” The natural tendency to eversion 
will correct this; whereas if the foot start 
straight it is apt to come out “spraddled.” 
102. Particular care should be taken to Aphorisms in Fracture. 
35 
keep the foot at right angles during the ap- 
plication of the plastic apparatus. 
103. After the plastic apparatus has been 
applied it will be found that in a week or so 
later the limb has shrunk so that the hand 
may be interposed between it and the band- 
age. It is prudent to cut the bandage and 
refit it that displacement of the fragments 
may not occur; but it is to be remembered 
that in the shrinking of the muscles their 
contractility is also impaired and tendency 
to shortening is prevented. 
104. The “burning heel,” which is apt to 
come on soon after the application of any 
apparatus, is best remedied by shifting the 
position of the limb. It seldom requires a 
division of the plastic apparatus. 
105. While it is possible for a single plas- 
ter-of-paris dressing to carry a fracture 
through safely, it is better for the surgeon 
to renew it every three weeks, until a third 
apparatus is applied. This will give oppor- 
tunity for inspection at critical periods, will 
allow proper molding to the decreased size 
of limb, and will conserve to general clean- 
liness and best success. 36 
Aphorisms in Fracture. 
106. The plastic apparatus is to be cut and 
tied with loop bandages, when from force of 
circumstances the surgeon can not watch it, 
or for swelling or shrinking of limb. 
107. While it is possible for the patient to 
be moved immediately after the application 
of the plastic apparatus, and even for him 
to go on crutches, he is best in bed during 
the earlier stages of treatment. 
108. It is possible, but not probable, that 
fractures of the thigh may heal without 
shortening. 
109. In fractures of the thigh high up 
there is a tendency of the bone to bow out- 
ward. This may show itself for some time 
after the union of the bone. If not excess- 
ive it generally disappears under the play of 
the muscles. 
no. If extension and counter-extension 
should be demanded in fractures of the 
lower extremity, there are but two methods 
worthy of consideration—one by “Buck’s” 
weight and pulley, the other by Smith’s an- 
terior splint, or methods on the same prin- 
ciple. 
in. Extension and counter-extension prac- Aphorisms in Fracture. 
37 
ticed by means of the long splint, perineal 
bands, etc. are useless. If the force is ex- 
erted sufficiently to have any influence on 
the muscles, the perineal band becomes un- 
bearable. The apparatus speedily becomes 
disarranged, and requires constant profes- 
sional supervision. Whatever use the long 
splint may have, is in correcting in a minor 
degree angular deformity. 
112. It is most probable that those fractures 
of the thigh will heal without shortening, 
which occur in the young, toward the lower 
end of the shaft, which are dressed under 
an anesthetic early, by the plastic apparatus, 
well applied and carried above the pelvis; 
nevertheless fractures even of the upper third 
in stout adults do sometimes thus heal when 
dressed as above described. 
113. In considering the question of short- 
ening after fracture in the lower extremity it 
should be remembered that the lower limbs 
are not necessarily of the same length nor- 
mally. Practically no shortening has oc- 
curred when the gait is not affected. 
114. The measurement of a fractured limb 
immediately after its release from retentive 38 
Aphorisms in Fracture. 
apparatus does not indicate the ultimate 
condition of affairs. The chances are that 
several months later the limb will be a frac- 
tion shorter. 
115. Absolutely accurate measurement of 
the lower extremities is not to be made with- 
out special apparatus. Measurement from 
anterior spinous process of ilium to malleo- 
lus is untrustworthy. It is better to put one 
end of the tape at the umbilicus, and carry 
it in succession around either foot back to 
the point of departure. The difference in- 
dicated in this manner is twice the differ- 
ence between the lengths of the limbs. 
116. Shortening of the lower extremity 
under an inch can be concealed by obliq- 
uity of pelvis, or by an additional thickness 
or so of leather to the heel. 
117. It is possible for a serviceable limb 
to be preserved after fracture of the femoral 
neck, and this is most probable when there is 
least separation of the fragments. It is all 
important therefore that in establishing diag- 
nosis of the injury such methods as favor 
separation should not be employed. When 
the patient is past fifty, when the function of Aphorisms in Fracture. 
39 
the limb is gone, when there is deep-seated 
pain in the hip increased by efforts at lifting 
the limb, when the foot is everted, all the 
result of slight violence, the chances are in- 
finitely in favor of intra-capsular fracture of 
the femoral neck. 
118. Shortening of the limb in intra-cap- 
sular fracture of the femoral neck may be 
so slight at the beginning that it can not be 
positively detected by ordinary methods of 
measurement. 
119. Crepitus in intra-capsular fracture of 
the femoral neck is difficult to elicit under 
any circumstances. It may be prevented by 
impaction of the fragments, or by unbroken 
fibers of the capsular ligament holding them 
in place. Attempts to elicit crepitus by ro- 
tation and flexion are not only, as a general 
thing, unnecessary, but, by separating the 
fragments, may destroy the best chance the 
patient has for a serviceable limb. 
120. Granted a fracture in the neck of the 
thigh-bone; should doubt exist if it be intra- 
or extra-capsular the chances are greatly in 
favor of it being intra-capsular, as extra-cap- 
sular fracture has positive signs of its own. 40 
Aphorisms in Fracture. 
121. Dislocation of the head of the thigh- 
bone, along with fracture near the hip-joint, 
is among the rarest of surgical injuries. It 
may occur, however, and, as experience has 
proved, escape detection even by the most 
skillful surgeons. This arises from the fact 
that the signs of dislocation in the position 
of the foot, rigidity of limb, etc., are de- 
stroyed by the coexisting fracture. 
122. Fracture of the acetabulum with dis- 
placement of femur is to be distinguished 
from ordinary dislocation of the hip chiefly 
by the position of the foot, which may be 
turned by the surgeon inward or outward. 
Crepitus is generally wanting. 
123. Lameness is a necessary consequence 
upon fracture of the acetabulum with dis- 
placement of femur. 
124. Fracture of a condyle of the femur is 
exceedingly rare, and without care may 
be overlooked. The fragment is dragged 
downward by the gastrocnemius into the 
popliteal space, where it appears as a bony 
tumor, difficult to determine whether it be- 
longs to femur or tibia. The anterior por- 
tion of limb shows no deformity. Reduc- Aphorisms in Fracture. 
tion is made by forced flexion, in which 
position the limb must be dressed. 
125. It is probable in very many instances 
that the patella is broken by violent contrac- 
tion of the quadriceps, and that the person 
falls because the bone is broken, not the re- 
verse. 
126. In setting a fractured leg it is in prop- 
er axis when, sighting along the tibia, the 
great toe is on a line with the inner edge of 
the knee-cap. 
127. The cause of the obstinate displace- 
ment of the fragments in fracture of bones 
of the leg lies chiefly in the muscles. From 
the fact that the shin is subcutaneous and 
the general action of all the muscles is from 
before backward, without restraining set in 
front; the lower fragment is tilted, and will 
remain so until the muscles are properly re- 
laxed. 
128. Fracture of both bones of the leg is 
seldom cured without leaving some trace of 
the injury behind. 
129. Fracture of the fibula is generally 
noted by localized pain and loss of func- 
tion. At the lower end of the bone the line 42 
Aphorisms in Fracture. 
of fracture maybe sometimes made out; but 
in any situation, owing to the close connec- 
tions of the bone, crepitus is wanting. 
130. If doubt exists whether an injury near 
the ankle is fracture or sprain, treat for fract- 
ure. 
131. In fractures of tibia or fibula about 
ankle, stiffness of this joint for several 
months is generally inevitable. Use and 
massage form the after-treatment. FRACTURED FEMUR: 
DOES ITS LONGITUDE VARY WITH ITS LATITUDE? 
A number of lectures delivered by Prof. 
Frank Hamilton, during the winter past, on 
fractures of the long bones have been pub- 
lished from time to time in several of our 
contemporaries. They must, of course, have 
attracted considerable attention as coming 
from one whose name is so intimately con- 
nected with the literature of fractures in 
this country. We wish we could think that 
the republication of his views would be 
productive of as general good. We use 
advisedly the word republication, for those 
who read Prof. Hamilton’s last lectures must 
have been struck with the fact that in spite 
of slight symptoms he exhibited at one time 
of modifying the’views of his earlier life 
under the influence of changes made in the 
department of fractures, he returns wholly 44 
Aphorisms in Fracture. 
to his former opinions. Nay, more than 
that—as if to make amends for his ap- 
parent backsliding, he returns more deeply 
dyed than ever in the tenets of his ancient 
faith. 
The peculiarities of Prof. Hamilton’s ideas 
in regard to fractures may be stated to be 
the activity and multiplicity of the measures 
he deems necessary for their cure. We have 
neither space nor inclination to review here 
the details of his treatment of fractures in 
the several localities; but we do consider 
that the stand he has taken against the use 
of the plastic apparatus in the treatment of 
fractures of the femur ought not to pass un- 
challenged. Prof. Hamilton speaks with no 
uncertain sound against it. For two years 
he used it in alternate cases in practice, and 
he unqualifiedly condemns it. In his own 
hands, and in the hands of others, it was 
productive of shortened and crooked limbs, 
excoriations, discomfort, and heart-breaking 
woes innumerable; and he is happy to state 
that its reign in New York is fast drawing 
to a close. If extension was tried by the 
perineum, says Prof. Hamilton, there was Aphorisms in Fracture. 
45 
ulceration and slough; if the contour of the 
great muscle of the thigh was relied upon 
to give the necessary supports for this, the 
development of most thighs was not great 
enough to furnish the points; and in fract- 
ures of the femur in children, from the del- 
icacy of their skin, the abundance of fat, 
the tendency to excoriation from the urine 
saturating the dressing, the short, fat limbs, 
and the restlessness of the subject, the acme 
of the difficulty is reached. Indeed, says 
Prof. Hamilton, the difficulty attending the 
treatment of these cases is so great that sur- 
geons have generally dodged any separate 
consideration of it. “ The books do not say 
much about it; for their authors have found 
it, no doubt, a very disagreeable subject, and 
most of them do not make any distinction 
between fracture of the femur in the child 
and in the adult.” We may say, before leav- 
ing this part of the subject, that Prof. Ham- 
ilton still confines his patients with fractured 
femur in bed, with weight and pulley and 
splint and bandage for adults, and with the 
frame apparatus for children. 
Now it sounds very strange to ears in this 46 
Aphorisms in Fracture. 
latitude to hear these last words from a great 
surgical center like New York. Of course 
we would not think of putting individual 
experience against one who has the wards 
of such a great hospital at his command as 
has Prof. Hamilton; but surely the general 
experience in a city containing a hundred 
and forty thousand inhabitants, a long-estab- 
lished center of medical teaching, ought in 
thirteen years to have gathered something 
which can stand even against the greatest. 
It was about thirteen years ago that the 
plastic apparatus was first used in Louisville, 
to any very great extent at least, for fract- 
ures of the femur. We believe that it was 
principally by the example and teachings of 
Prof. D. W. Yandell that its use in this direc- 
tion was spread hereabout. Starched appara- 
tus had been previously used in fractures of 
the leg-bones, but the long splint and peri- 
neal band were still in vogue with the thigh. 
Prof. Yandell had, with other surgeons in 
the Confederate army, witnessed its good 
effects in fractures of the femur, and com- 
menced this practice of dressing such inju- 
ries in Louisville immediately after his return Aphorisms in Fracture. 
47 
from the war. The first dressings used were 
the old cumbrous starched bandage, with 
pasteboard splints to help stiffen them; 
usually requiring seventy-two hours to be- 
come dry. A few years later Mr. Tuffnell’s 
admirable paste of flour and whites of eggs 
was substituted, and is used to this day in a 
number of cases, especially after union has 
taken place. In 1870 Dr. Cowling intro- 
duced manila paper as a material to stiffen 
the apparatus. With the flour and eggs it 
dries in twelve hours or so, and makes one 
of the most beautiful of all models—smooth, 
tight, and durable. It is tedious to apply, 
however, and gave way, along with every 
other material, when, in 1871, the plaster-of- 
paris bandage came into use in Louisville. 
The plaster-of-pan's bandage has not only 
held its own since that year in this city, but 
has steadily grown in the confidence of the 
profession, and the field of its application has 
widened day by day. A long splint, a weight 
and pulley, an inclined plane, an anterior 
splint, a suspensory apparatus, are curiosities 
in this city. They were shown at the schools 
for a time among the appliances for treat- 48 
Aphorisms in Fracture. 
ment, exhibited later as vestiges of the past, 
but for five years they have slumbered undis- 
turbed with the fathers. 
The plastic apparatus is used for fractures 
of the foot-bones, of the leg-bones, of the 
patella and thigh-bone, in shaft and neck. 
(It constitutes, besides, the general treatment 
of joint-diseases, whether at ankle, knee, or 
hip.) It is put on as soon as it can be got 
on; it is disturbed as little as possible after 
it is on. Now with this general practice 
here, and with the practice of hundreds of 
practitioners in the South and West who 
have carried away from the schools of Louis- 
ville abiding faith in the method, it strikes 
us it is about time for us to witness or to 
hear from a number of those fearful results 
recorded by Prof. Hamilton if they follow in 
such numbers; and yet they do not appear. 
Of course perfect results are not obtained in 
every single instance, but positively ill re- 
sults are rare, and they can either be traced 
to the improper application of the apparatus 
or to causes which would have operated, no 
matter what treatment might have been sub- 
stituted. A stiff joint in fracture through Aphorisms in Fracture. 
49 
the joint, an excessively shortened leg in a 
compound and excessively oblique fracture, 
or a crooked limb when plain rules for the 
support of the upper fragment of the fract- 
ured bone have been neglected, has resulted 
in a very few instances; but tvhere one man 
has limped after the use of the plastic appa- 
ratus a hundred have walked without doing 
so, and crushed and mangled limbs in num- 
bers have not only escaped the knife, but 
have been almost perfectly restored. Have 
the limbs been shortened after thigh-fract- 
ure? Probably they have, as a rule a half 
inch or so; but the gait does not show it, 
and most careful measurement has demon- 
strated in some instances that even in fract- 
ure of the upper third of the femur in adults 
positively no shortening has occurred. 
Sorhe one may ask, how is the necessary 
extension kept up with the plastic appara- 
tus? It isn’t kept up at all—that idea was 
exploded here half a dozen years ago, when 
the last extending band was laid aside. The 
bones being put in apposition, the plastic 
apparatus removes the causes which produce 
the shortening by its incomparable fixation Aphorisms in Fracture. 
somewhat, but probably most by the sooth- 
ing influence of its equable warmth and 
gentle pressure, substituting, we imagine, 
persuasion for force. But the most curious 
thing about the use of the plastic apparatus 
in Louisville is, perhaps, that if it has any 
special field it is in the treatment of the 
fractured femur in children. On account 
of their tender skin, fat limbs, their ten- 
dency to irritation from discharges, their 
restlessness, etc., nothing so admirably suits 
them as the plaster-of-paris bandage. Ab- 
solutely free from pain after its application, 
causing often a doubt that fracture exists, 
playing with their toys in a few hours, easily 
handled and cleansed, out of bed in a day 
or so, crawling about, tumbling about, walk- 
ing about on their crutches if they are old 
enough to walk at all, and coming out of 
the bandages at the end of four or five weeks 
with sound and straight and unshortened 
limbs, with scarcely a redness thereon. 
How are we to explain these widely dif- 
ferent results in New York and Louisville? 
Is n’t it barely possible that we are not look- 
ing at the same shield at all—4hat the plastic Aphoris?ns in Fracture. 
apparatus of one place is not the plastic ap- 
paratus of the other? We do not know what 
method Prof. Hamilton used in his applica- 
tion of plaster of paris. We hope he did 
not—and in fact don’t believe he did—put 
the bandage next to the skin. That were 
a stone coffin indeed; and, if we remember 
rightly, he called it so. The method used 
here is not the Bavarian method, with the 
blanket and hinge. It may be a very good 
method; we know nothing about it prac- 
tically, but it is not desired here; for when 
one of our surgeons puts up the limb he 
puts it up to stay up, in sublime faith of 
its coming out all right in the end, or else 
that it will give evidence by the discomfort 
it occasions that something is going wrong 
which must be remedied. 
If Prof. Hamilton’s dressers adjusted the 
fractured femurs early, under an anesthetic; 
if they used smooth and ample layers of 
unbroken cotton batting next to the limb, 
buttock, and back; if they were ordinarily 
skillful bandagers, and confined the cotton 
equably and with moderate firmness with 
dry rollers; if they carried a spica over the 52 
Aphorisms in Fracture. 
hip even for fracture just above the knee; 
and to make sure that they did carry the 
spica above the hip they brought it six 
inches above the crest of the ilium; if on 
the base thus constructed they placed two 
or three layers of plaster bandages made of 
slazy muslin (cheese-cloth) not longer than 
three yards each, into which dry plaster 
(best dental) had been thoroughly rubbed, 
and the bandages thus prepared were dipped 
into water and wetted through before ap- 
plication; if these bandages were smoothly 
applied, and especially thoroughly applied 
over the spica, which can be done without 
encircling the abdomen; if they removed 
any redundancy about the perineum so that 
the bandage might not touch it, and looked 
well to the cotton in that locality, covering 
it with oil-silk if they cared to do so; if in 
the application of the plaster bandages the 
foot was kept, rigidly at a right angle, and 
the knee straight or slightly flexed; if the 
case was looked to twice during the first 
twenty-four hours, and half a dozen times 
during the subsequent six weeks; then, if 
affairs turned as badly as Prof. Hamilton has Aphorisms in Fracture. 
53 
said, we must believe that the New York 
thigh and the Kentucky thigh have been 
evolved from different progenitors. 
The fact is, we don’t know what to think 
about the matter. We can hardly believe 
that Prof. Hamilton doesn’t know how to 
apply the dressing, and it is hard to think 
that bone nature changes with latitudes, 
however strong our faith in the blue-grass 
beef and the Bourbon. We are bothered, 
too, by conflicting statements in regard to 
the matter. Prof. Hamilton says his col- 
leagues have pretty well abandoned the 
plastic dressings. He may think so, but 
one must go away from ljome to learn the 
news. Does not Prof. Van Buren still be- 
lieve in it? is it possible that Dr. Sayre has 
weakened in his faith concerning it? and is 
its stout defender, Dr. St. John, ready to re- 
tract what he has said about it? We imag- 
ine Prof. Hamilton has been misinformed. 
Philadelphia would of course rather give 
up her machine-shops than the bewildering 
mechanism of her fracture wards, but New 
York is more progressive. 
It would be foolish, of course, to declare 54 
Aphorisms in Fracture. 
that one method in the treatment of fract- 
ures gets all the good results, and other 
methods get all the bad ones. The fact is 
that under the best directed treatment by 
any method fracture cases will sometimes 
result badly; and he who is swift to con- 
demn a brother surgeon for this, lacks as 
much in intelligence as he does in charity. 
The surgeon is most apt to get good re- 
sults by the application of methods in which 
he has most facility. Early impressions are 
difficult to remove and skill in new methods 
hard to acquire; hence it is that we deem it 
important that the plastic method of dress- 
ing fractures of the lower extremities should 
be thoroughly put before every student at 
the outset of his career. 
We can not but think that the plastic 
dressings are among the greatest of the 
blessings of modern surgery, both to pa- 
tient and to surgeon. They fill the whole 
measure of the law. They heal as quickly 
as the nature of the case will admit, as 
safely as by any method yet devised, and 
pleasantly to a degree beyond the power of 
any other plan—past, present, and we may Aphorisms in Fracture. 
55 
safely say future — to achieve. And if our 
words in their defense have been many, they 
are not wasted if they do but inspire one 
wavering brother to test their merits.—Ed- 
itorial in Louisville Medical News, March 
16, 1878. CRITICISMS. 
Professor Louis Bauer’s Criticism. 
While emphatically indorsing every one of your 
propositions, I beg to suggest a few additions in 
behalf of completeness. 
In fundamental symptoms of fracture you might 
also have included deformity and undue mobility, 
which gives rise to that “ physiognomy about 
fractures” to which you refer in your second Aph- 
orism. 
To Aphorism 11 there might be profitably added, 
Except in fractures of the surgical neck of the 
scapula, which exhibit all the attributes of dis- 
location of the humerus into the axillary cavity. 
I am fully aware that some surgeons deny the 
occurrence of that fracture; but this is an error. 
It is very rare, I admit, and some surgeons may 
not meet it in a lifetime. That proves, however, 
nothing to the contrary. I myself have observed 
three cases, and a fourth one has just come under 
my notice in its ulterior results. 
One of our prominent city officials sustained a 
fall at the great fire of the Southern Hotel last 
year. His family attendant recognized a disloca- Aphorisms in Fracture. 
57 
tion of the humerus in the axilla, but wisely sent 
for a surgeon. Being absent, his alter ego came in 
his stead. The diagnosis was affirmed and the 
arm reduced. The surgeon in propria persona saw 
the patient subsequently several times and pro- 
nounced the case all right. 
After the patient had held the arm in a sling 
for some weeks and suffered considerable pain, 
he was permitted to dispense with the sling and 
to use occasionally his arm. Every attempt to 
bring it into play caused him pain so intense that 
he had to give it up. The pain followed the 
course of the brachial plexus, and was accompa- 
nied by numbness. 
This condition had lasted several months, when 
the patient submitted his case to my inspection. 
When completely undressed, I saw at once that 
the symmetry of his form had been lost, that the 
distance of the affected shoulder from the spine 
had been materially reduced, and that the con- 
vexity of the deltoid was flattened. The articula- 
tion was free and the motion impeded only by 
pain. This position may be found after fractures 
of the clavicle with overlapping of the fragments; 
but there was no trace of such injury. There is 
but one solution of the enigma, and that is fract- 
ure of the surgical neck of the scapula with dis- 
placement. Unfortunately the patient is rather 
corpulent, and therefore it is out of the question 
to disclose the exact place of union. But this 58 
Aphorisms in Fracture. 
much is clear, that a simple dislocation of the 
humerus promptly reduced can not lead to such 
consequences. There may be moderate atrophy 
of the muscles of the shoulder-joint; but neural- 
gic pain, numbness of the hand, nor material 
alteration of the symmetry are sequelre of dis- 
location. 
Aphorism No. 19 should be more positive. 
Aphorism 29. No swelling at all as emanating 
from the fracture. 
Aphorism 38. You might have included har- 
ness-leather as an excellent material for splints. I 
have used it exclusively for at least the last ten 
years, and it has always given satisfaction. Its 
advantages are manifold: (1) It molds itself to the 
form of the member when softened by warm water; 
(2) it is permeable, hence not heating; (3) the 
splints may be used again by the same process; 
(4) it is a material which the surgeon can find every 
where at moderate expense; (5) it dries quickly, 
and is then as hard as needed. I generally keep 
half a hide on hand, take it to the patient’s house, 
and cut the pieces out according to the previous 
measurements. The stoutest part of the hide I 
take for adults and the lower extremities, and the 
lesser for children and the superior extremities. 
Aphorism 39. I exclusively use the be'st flan- 
nel for bandages—never shifting and most elastic. 
The price may be an inconvenience, but most pa- 
tients are able to defray the expense in their own Aphorisms in Fracture. 
59 
behalf; and if I had to bear it I should consider 
myself compensated by saving time. 
I fully indorse all you have said in Aphorism 
45. The muscular theory, which underlies Buck’s 
treatment, is untenable. An article on this sub- 
ject will be published by me in one of the next 
numbers of the St. Louis Clinical Record. 
Emphatically of your opinion as expressed in 
Aphorism 47. 
According to the early commendation of Dr. 
Gehring—formerly of Denver, now of St. Louis 
—the immobilization of the thorax is the best 
auxiliary in almost all inflammatory affections of 
the respiratory organs, more especially in pleuritis. 
Might not a plaster jacket be preferable to the 
jack-towel in fractures of the ribs? 
In the treatment of fractures at the lower ex- 
tremities, especially of thigh, I prefer the double 
inclined plane to the straight position, as less irk- 
some ; but the chief reason of this plan is that the 
body is prevented from pushing the upper fragment 
over the lower, which, in my opinion, is the prin- 
cipal cause of the shortening so frequent in fract- 
ures of the thigh. 
This is all that sharp scrutiny of your Aphorisms 
could suggest, and this surely is of little weight 
when compared with the profound views you have 
advanced. 
Louis Bauer. 
St. Louis. 60 
Aphorisms in Fracture. 
I can indorse the Aphorisms almost without 
qualification. One I would like to add, a slight 
adaptation of Jackson’s great maxim, “Eternal 
vigilance is the price of success in treating fract- 
ures.” 
Aphorism 7. When swelling has already taken 
place very largely before the surgeon sees a severe 
injury of the hip, shoulder, or elbow, I think, and 
could quote a strong array of cases in support of 
the statement, that the diagnosis between fracture 
and luxation is not always easy. 
Aphorism 47. While I am willing to admit 
that is evidence that fractures are not 
properly dressed, I am sorry to say that I have seen 
very bad results in cases which had been comfort- 
able all the way through, in spite of angular de- 
formity, shortening, and rotary displacement of 
fragments. 
Aphorism 71. Without denying that the use 
of compresses is often injudicious and unsurgical, 
I shall be very loath to be debarred from employing 
them in many instances, temporarily at least. 
Aphorism 72. Do not think me presumptuous 
in saying that there ought not to be any deformity 
remaining after Colles’ fracture, seen early and 
properly treated. 
Aphorism 88. Let me suggest that one great 
reason of the deformity in fracture at the middle 
From Professor Packard. Aphorisms in Fracture. 
61 
of the clavicle is the drawing forward of the scap- 
ula by the serratus magnus, which must be over- 
come. 
Aphorism 95, ct seq. I should not be willing 
to risk treating fracture of the thigh without 
weight-extension for the first three weeks at least, 
except in very young children, and believe the 
soluble glass or silicate of soda to be the best 
plastic material. 
Aphorism 115. Pardon my saying that it seems 
to me that in skillful hands the measurement from 
the anterior iliac spine to the malleolus would be 
as the method you propose, and that in unskillful 
hands either would be likely to give erroneous 
results. 
Aphorism ill I think will meet with unques- 
tioning approval from all surgeons who are not 
hopelessly behind the times. 
About New York surgeons I do not, of course, 
know as much as about those of my own city, but 
I think their tendency, like ours, is to do away 
with complicated apparatus, and to aim at accom- 
plishing the great object of retaining the fragments 
in their normal relation by the simplest and most 
direct means. I therefore do not exactly under- 
stand the statement (No. 116, p. 132), that “Phila- 
delphia would, of course, rather give up her ma- 
chine-shops than the bewildering mechanism of 
her fracture wards.” 
In my own wards at the Episcopal Hospital 62 
Aphorisms in Fracture. 
there is certainly no bewildering mechanism, and 
I did not see any thing of the kind during the 
terms of service of my colleagues, or in our other 
hospitals. Possibly the person on whom such an 
impression was made was somewhat easily bewild- 
ered, and perhaps he had never seen so many cases 
together before. 
Pardon the freedom of these hasty criticisms, 
and permit me again to express my sense of the 
value of your Aphorisms. 
With much respect, very truly yours, 
John H. Packard. 
Philadelphia. 
Professor Van Buren on the Aphorisms. 
It is rare in my reading to find so little open 
to criticism where so much is put forth in the form 
of positive opinion tersely expressed. 
There’s one point in which I can not go with 
you. I am not willing to agree that in the treat- 
ment of fracture compresses are “unsurgical.” A 
saddle-shaped compress over an unruly upper frag- 
ment of a tibia, and the double compress in silver- 
fork fracture, to prevent recurrence of deformity 
after reduction, have served me well in too many 
cases to pass without acknowledgment. I think 
also that the treatment of this fracture by short 
splints not reaching beyond the radio-carpal joint is Aphorisms in Fracture. 
63 
a method of which the merit will be permanently 
recognized. I have used it almost exclusively for 
twenty-five years, having adopted it through a hint 
from a Danish surgeon—Fenger—about the time 
I first entered on duty as a surgeon of the New 
York Hospital, and have rarely failed in getting 
an excellent result. Owing to the impaction that 
usually masks crepitus in this fracture, it is too 
often mistaken for luxation, otherwise it would 
undoubtedly be recognized as the most frequent of 
all fractures, occurring as it does from the involun- 
tary thrusting forth of the hand to save the face in 
falling forward. I have refractured several limbs 
rendered useless by this mistake, and always with 
advantage. The impaction should always be bro- 
ken up, and the fragments accurately molded, and 
this usually under ether; then a thin compress 
of blanket on the dorsal and palmar aspects, to 
replace the thumb and finger, which retain the 
fragments reduced; then over these short splints 
with blanket pads, the whole retained by three 
strips of adhesive plaster two inches in width; no 
bandage. 
The rule of Boyer and Pott, to immobilize con- 
tiguous joints in applying apparatus for fracture, 
although a good one, has its exceptions—it some- 
times spoils a joint unnecessarily in the interest of 
a broken bone, by keeping the joint too quiet. I 
believe in the elder Warren’s recommendation—in 
fractures near joints always take off splints a week 64 
Aphorisms in Fracture. 
sooner. I have done this in treating silver-fork 
fractures, with a result in earlier use of the mem- 
ber, for which the laborer or mechanic is always 
grateful. 
Your “Aphorisms” recall a remark dropped by 
Erichsen when he visited us a year or two since: 
“You Americans enjoy a great advantage in not 
being tied down by traditions and respect for old 
authorities; you can get rid of ancient errors faster 
than we can.” 
Pardon my much speaking, and believe me, dear 
Dr. Cowling, yours very truly, 
Wm. H. Van Buren. 
New York. 
Dr. W. O. Roberts’s Criticism, 
I read your Aphorisms with considerable inter- 
est. Their practical character must make them 
popular with the profession. I was glad to see 
your emphatic indorsement of the plastic appara- 
tus. Its comfort to patient and surgeon alike has 
been proved so thoroughly that it seems strange 
it should need recommendation at this day. 
The importance of Aphorism 64, concerning 
the position of the foot at a right angle, I have 
just had opportunity of testing. A patient was ad- 
mitted to the hospital with anchylosis of the ankle- 
joint (after fracture of the tibia), and with his foot 
pointing in such an angle that his heel could not Aphorisms in Fracture. 
65 
touch the ground. The rectangular position would 
have obviated some of his difficulty, and probably 
all. At any rate I do not remember to have seen 
a case of serious anchylosis at the ankle where the 
position of the foot had been properly attended 
to where the tendo-Achilles was not at fault. It 
is a point frequently overlooked, as in the recum- 
bent posture the foot naturally bends forward, and 
it is only when the patient rises, and, in attempt- 
ing to walk upon his crutches, strikes his toes upon 
the floor, that the mischief is seen. Erichsen re- 
fers to the fact, you remember, that the continued 
pressure upon the ligaments, by the extension of 
the foot may result in more or less permanently de- 
ranging them. The rectangular position, after a 
few minutes, is well borne. 
In regard to deferring cutting the trap in com- 
pound fractures, I fully agree with you, provided 
oakum has been used over and to some distance 
above and below the wound. This easily becomes 
saturated and provides for drainage. In four cases 
of compound fracture which I treated during the 
past year, three were dressed with oakum and one 
with cotton. The trap was deferred in all. In 
the cases where the oakum was used the results 
were entirely favorable. The oakum was saturated 
throughout, but the wound was clean and closed 
readily. In the case where the cotton was used the 
cotton came out clean, not being soiled more than 
a few inches around the wound, but an abscess 66 
Aphorisms in Fracture. 
was formed and pointed on the opposite side of 
the limb. 
In fracture of the lower third of the leg I have 
not found it necessary to keep the knee confined 
longer than three weeks. 
Very truly yours, 
W. O. Roberts. 
Louisville. INDEX. 
APH. 
Acetabulum, diagnosis in fracture of, 120 
Acetabulum, prognosis in fracture of, 122 
Accidents in fracture cases, why not detected, . . . . 53 
Anchylosis, treatment of, 58 
Anesthetics in diagnosis of fracture, 12 
Anesthetics in dressing fracture, 34 
Attention necessary in fracture cases, 47 
Bandages, composition of, 39 
Bandages next to the skin, dangers of, 41 
Burning heel, how to remedy, 104 
Bauer, Prof., criticism of, page 56 
Cause of fracture, 2 
Carved splints useless, 38 
Clavicle, how to dress fractures of, 86 
Clavicle, prognosis in fracture of, 87 
Clavicle, diagnosis in fracture of, 88 
Clavicle, axillary pad, in fracture of, 89 
Colles’ fracture, reduction of, 70 
Colles’ fracture, complicated dressings in, 71 
Colles’ fracture, deformity in 72 
Colles’ fracture, neuralgia following, 73 
Comfort a sign of proper treatment 46 
Compound fracture, treatment of wound in 60 
Compound fracture, diagnosis of fever in, 61 
Compound fracture, prognosis in, . 24 
Compound fracture, exposure of wound in, 62 
Consolidation of bone a gradual process, 55 
Condyle of femur, fracture of, 124 
Conveyance of patients, dangers of, 16 
Crepitus as a sign of fracture, 9 
Crepitus not to De elicited unnecessarily, 10 
Cotton batting in dressings, 43 
Danger of bandage next to the skin, 41 
Definition of fracture, 1 
Deformity in fracture, 7 
Deformity in fracture, treatment of angular 45 
Deformity in fracture due to muscular action, .... 32 
Diagnosis, general( 4 to 16 
Diagnosis, comparison of limbs in, 13 68 
Aphorisms in Fracture. 
Diagnosis of direction in fracture, 14 
Dislocation with fracture, 33 
Division of fractures, 3 
Dressings, when to apply, 27 
Dressings, temporary, 28 
Dressings, frequent, to be avoided, 48 
Elbow, fractures near, how to dress, 79 
Elbow, fractures near, prognosis in, 80 
Elbow, fractures near, passive motion in, 81, 82 
Even pressure, how to make, 42 
Extension and counter-extension, 44 
Extension and counter-extension in fracture of thigh, no 
Extension and counter-extension by long splint, .... m 
Editorial from Louisville Medical News on fractured 
femur, page 43 
Fees in fracture, 66 
Fevers accompanying fractures, ....... 61 
Fibula, diagnosis in fracture of, 120 
Fibula, prognosis in fracture of, 130 
Fingers, how to dress fracture of, . . 77 
Fingers, amputation in fracture of, 78 
Forearm, order of fractures in, 67 
Forearm, dressing of fractures in, 68 
Forearm, pistol-splints, fractures in, ... . . . . . . . 69 
Forearm, interosseous pad, fractures in, ........ 69 
Forearm, deformity, fractures in, 74 
Fractures belong to surgeon, S3 
Green-stick fracture, 63 
Heel, burning, how to remedy, 104 
Humerus, how to dress fractures of, 84 
Humerus, prognosis in fractures of, 85 
Handling fractured limbs, 15 
Itching in fractures, treatment of, ... 59 
Inspection, when and how to make, . 49 
Interosseous pads, . •, . 69 
Immobilization, how obtained, 36 
Jaw, how to dress fracture of, 91 
Leg, cause of displacement in fracture of, 127 
Leg, prognosis in fracture of, 128 
Leg, position of foot in setting fracture of, 126 
Loss of function as a sign of fracture, ..... 1 - . . 5 
Lower extremities, how to dress fracture of, ....... 94 
Lower extremities not always same length, 103 
Lower extremities, method of measurement, ..... 115 
Lower extremities, shortening in, 116 Aphorisms in Fracture. 
69 
Mobility as a sign of fracture, 8 
Multiplicity of doctors in fracture cases, 54 
Neglect in treatment of fractures, dangers of, 51 
Nose, how to dress fractures of, 92 
Olecranon, dressing of fractures in, .... 1 93 
Padding for splints, 42 
Pain as a sign of fracture, 5 
Patella, cause of fracture in, 125 
Pelvis, how to dress fracture of, 93 
Pistol splints, 69 
Plaster of paris, when to be preferred, 99 
Plastic apparatus, material for, 40 
Plastic apparatus, how to make, 94 
Plastic apparatus, comfort of, 4 95 
Plastic apparatus, causes of failure with, 96, 97 
Plastic apparatus, prevention of swelling, 98 
Plastic apparatus, preference in material for, 99 
Plastic apparatus, time for hardening, 100 
Plastic apparatus, shrinking of limb in, 103 
Plastic apparatus, number necessary, 105 
Plastic apparatus, when to open, 106 
Plastic apparatus, when to put' on crutches, 107 
Position of limb in dressing fracture, 35 
Prognosis in simple fracture of shaft, 17 
Prognosis in multiple fractures of shaft, 18 
Prognosis in joint fracture, 19 
Prognosis in direct and indirect fracture, 20 
Prognosis in fracture of the young, 21 
Prognosis in fracture of the old, 22 
Prognosis in fracture with separation, 23 
Prognosis in compound fracture, 24 
Prognosis in elbow fracture, 25 
Prognosis in hip fracture, 25 
Packard, Prof., criticism of, page 60 
Reduction, how made . 31 
Reduction, influence of muscles in, 32 
Retentive apparatus, how long to wear 56 
Roberts, Dr. W. O., criticism of, page 64 
Signs of fracture, 4 
Slings, how to make, 76 
Shrinking of limb, 103 
Splints, 38 
Stiff wrist in forearm fractures, 75 
Sprain and fracture, 11 
Swelling as a sign of fracture, 6 Aphorisms in Fracture. 
70 
Swelling, how to prevent, 29 
Thigh, position of joint in setting fracture of, . . . 101, 102 
Thigh, shrinking of limb in fracture of, 103 
Thigh, prognosis in fracture of, 108 
Thigh, prognosis with plastic apparatus in fracture of, 112 
Thigh, deformity in fracture of, 109 
Thigh, extension in fracture of, no 
Thigh, long splints useless in fracture of, in 
Thigh, shortening in fracture of, 113 
Thigh, shortening may be progressive in fracture of, . 114 
Thigh, fracture of condyle of, 124 
Treatment, indications of, 30 
Treatment, causes of failure in, 37 
Treatment, compressions in', dangerous, 52 
Treatment, promptness necessary, 54 
Timidity delaying use of limb, 57 
Ununited fracture, treatment of, 64 
Van Buren, Prof., criticism of, page 62 
Warning to be given, 51