Preferable Methods of Fixa- 
tion in the Treatment of 
Simple and Compound Frac- 
tures of the Leg. 
BT 
N. A. POWELL, M.D., 
TORONTO. 
REPRINTED FROM 
*The Canada Canoet, 
February, 1889. Reprinted from the Canada Lancet, February, 1889. 
PREFERABLE METHODS OF FIXATION 
IN THE TREATMENT OF SIMPLE AND 
OF COMPOUND FRACTURES OF THE 
LEG.*' 
BY DR. N. A. POWELL, 
Lecturer on Surgical Appliances and Assistant Demon- 
strator of Anatomy, Trinity Medical College, Toronto. 
How to treat successfully a simple fracture of 
the leg is a mechanical problem which may be 
solved in numberless ways. Reduction secured 
and fixation maintained, consolidation almost uni- 
formly follows. No one plan of treatment is so 
much better than all others yet advanced as to be 
the one first thought of by a majority of surgeons 
anywhere. If I attempt to classify a number of 
the methods now in use, to contrast their relative 
merits and deficiencies and to collect for your in- 
spection a quantity of apparatus, it will not be 
because I have anything original or even new to 
present. Some, at least, of the appliances to which 
I shall call your attention are not heard of in 
practice here. There are those present who have 
had vastly more experience than myself in the 
use of certain other of the technical resources of 
•Read before the Toronto Medical Society. 2 
surgical art here presented, and from them I hope 
to elicit such a practical discussion as shall more 
than make up for the defects in my own presenta- 
tion of the subject. 
“Every surgeon,” wrote Bell in 1815, “ sets a 
broken limb as he writes his name, after a fashion 
of his own.” We get our creeds in our cradles and 
our routine ways of immobilizing fractures from the 
offices and schools in which our student days are 
spent. Once in the rut it is easier to jog along than 
to make an effort to reach higher ground. Yet it is 
chiefly by the labors of those discontented ones, 
who are constantly striving to improve the means 
we have and to devise more perfect ones, that we 
make progress. The wnfittest sometimes survives 
and the iconoclast is needed. To seek out and set 
in order the demerits of appliances which under 
the influence of certain great names have out- 
lived their usefulness, is to do the surgical world 
a service which might rank equal with the services 
of those who have genius for construction rather 
than destruction. 
I trust that both types are represented here to- 
night, and that the loose joints in this part of our 
surgical armour will be found and pierced, while 
at the same time we are strengthened by the free 
exchange of helpful suggestions. Young—that is 
very young—physicians are apt to have a special 
remedy for eacli disease or symptom, and to think 3 
they should have a special splint for each fracture. 
With ripening experience the tendency is to lessen 
the number of drugs used and to recognize that 
the essentials for fracture treatment are few 
and simple. An ample outfit, one with which 
many of us could get along very comfortably, need 
contain nothing ponderable beside thin basswood, 
mill-board, batting, bandages, cheese-cloth and 
plaster-of-Paris. The imponderable essentials are 
anatomical knowledge, the training of the hand, 
and what I once heard Mr. Erichsen call, “surgical 
horse-sense.” 
From my point of view it hardly seems 
that profitable discussion can be had regarding a 
choice of methods in the treatment of the later 
stages of simple fractures of the leg. There does 
not appear to be room for much divergence of 
opinion. The complete-encasement of the limb 
by plaster-of-Paris bandages is admitted to be the 
procedure which gives to both patient and surgeon 
the greatest degree of security and comfort. So 
well known has this method become that I shall 
refer to but a few points regarding it. It has 
seemed to me worth while to have the crinoline or 
cheese-cloth, from which the bandages are made, 
boiled in a solution of washing-soda and then in clear 
water. This makes it an absorbent gauze ; it will 
sink at once if thrown into water, and plaster will 
set in its meshes as well as on its surface. Plaster 4 
dressings made with it wear out like felt, instead 
of scaling off and cracking. If a web of cheese- 
cloth be rolled tightly on a wooden cylinder and 
this placed in a lathe, it can, as suggested by 
Martin, of Boston, be cut in a few moments into 
bandages of any desired width. The cutting is 
done by holding one corner of a broad chisel 
against the cylinder while it is in rapid motion. 
I have brought a roll so divided with me to show 
you; each section is fifty yards long by three 
inches wide. Cheese-cloth will not tear like 
thicker cotton, and life is too short to waste in 
cutting bandage material by hand. For crinoline, 
the bookbinder’s knife has been suggested, and this 
machine will smoothly and rapidly divide the cloth 
into strips. 
The earlier a plaster bandage is used the thicker 
should be, in my opinion, the layer of cotton under 
it. Batting makes the best padding while swel- 
ling exists and the patient is kept in bed. After 
all swelling has subsided and the patient is 
allowed to go around on crutches, padding by a 
single layer of old shrunk blanket has some 
advantages over that by batting or wadding. 
Abundant cotton padding allows the leg to tele- 
scope down into its case, while blanket padding 
will make the support more perfectly crustacean 
in type, and will correspondingly relieve the in- 
jured part of the skeleton from pressure when the 5 
patient is allowed to be up and about. Over the 
padding I always apply a firm dry flannel or cot- 
ton roller. It distributes the pressure evenly and 
lessens the risk of undue constriction. 
There is no analogy between a bandage so used 
and a “ primary roller,” that is, one used under 
splints, applied to a part only of the circumference 
of a limb. While so good a surgery as that by 
Agnew advises the primary roller, and we continue 
to meet with physicians who employ it, I feel 
justified in asking for an expression of opinion 
from those present regarding this dangerous relic 
of the dark ages. In applying the plaster bandage 
so as to cover in the heel, if each turn be carried 
over the instep, there will be such a thickening 
at this part that slight pressure from the hands of 
the assistant making extension, or a slight change 
in the angle at which the foot and leg are being 
held, will lead to the formation of a ridge on the 
inner surface to groove the tissue on which 
it presses. To avoid this it is better to go back 
and forth over the heel from one malleolus to the 
other, binding all down smoothly by two or three 
final turns carried over the instep. The more 
figures-of-eight we can put into a dressing of this 
kind the better will it be, and the more it is felted 
together and the air expelled from between its 
layers by rubbing with the hand the longer will it 
last. To strengthen it without increasing its bulk, 6 
the plan of interweaving two or more of the tin 
strips first advised by Dr. Fluhrer, is a good one. 
They should be cut from heavy tin plate, since 
common tin bends so easily as to be almost worth- 
less. A single long strip crossing the sole and 
passing up to the knee on each side, gives the 
best support when the fracture is in the lower 
fourth of the limb. The strips should be per- 
forated from each side and fixed to the limb by 
passing the bandage alternately over and under 
them. 
Returning now to the treatment of the earlier 
stages of simple fracture of the leg, we find scope 
for endless differences of opinion and practice. 
What should the ideal dressing for a broken leg be 
and do 1 In answer to this question, permit me 
to quote from an address delivered by Dr. Gay, 
before the Massachusetts Medical Society : “It 
must be simple, comfortable, cheap, readily ob- 
tained, easily applied and removed, and must 
allow a frequent inspection of the limb without 
disturbing the patient. It must be applicable to 
all cases, capable of correcting any and all de- 
formities and of retaining the fragments in their 
desired position for an indefinite length of time \ 
not liable to produce abrasions or other mischief, 
and once properly adjusted it should require little 
attention during the progress of the case.” Let 
us try by this standard some of the dressings in 7 
use here and elsewhere and note how far.they fall 
short of our ideal appliance. 
The support given may be by splints" which are 
rigid or plastic, single or multible. They may be 
applied to one or to more than one aspect of the 
limb or the encasement may be complete. 
A Rigid Single Splint. —The form known as 
Dupuytren’s is capable of meeting the indications 
in a small proportion of cases of Potts’ fracture. I 
should limit its employment to those instances in 
which we have to deal with marked and persistent 
outward displacement of the foot and but little back 
ward displacment. A chief object of its use being 
to draw outward the upper end of the lower 
fragment of the fibula, it passes my comprehen- 
sion why Erichsen and Stephen Smith should 
figure its application with a bandage directly over 
the break. Hamilton and Druitt show it cor- 
rectly. The wonder need not be great that 
students so often mis-apply this splint, when the 
teaching by illustration is in such marked contrast 
to the teaching in the text. The importance of 
keeping the lower bandage below the external 
malleolus, and of having the pad both firm and 
thick at a point just above the internal malleolus, 
are points long insisted upon but constantly need- 
ing to be emphasized. 
Mr. Bryant figures and advises the application 
of a single straight wooden splint with foot-piece, 8 
of either one of the bones of the leg. 
Excepting as a temporary expedient, to be re* 
placed as soon as possible by a more comfortable 
and efficient dressing, I am unable to endorse this 
plan. 
Under the direction of Dr. Levis, of Philadel- 
phia, a series of perforated and plated copper splints 
have been prepared and are largely sold in the U.S. 
Those for the leg are the least satisfactory in the 
entire set ; they are posterior gutters which are 
apt to fit imperfectly in spite of moulding by the 
hands. My chief objections to them are, that 
they do not surround the limb sufficiently to 
maintain the apposition of fragments, and that 
they do not keep the foot at a fixed angle with the 
leg. 1 show you samples of the various sizes sup- 
plied. A series of lateral splints of the same 
material would be very much better, and could be 
moulded without difficulty. 
Rigid Splints, in pairs.are usually applied later- 
ally. Thin straight boards here seem to me in- 
efficient means of support. They do not clasp the 
soft parts, and in spite of padding they are very 
apt to press hurtfully upon bony processes. The 
old and excellent plan of placing two thin boards 
at the opposite ends of a towel, rolling them in it 
toward the centre till a space is left between them 
corresponding to the width of the limb, placing 
the leg upon this web, stretched so as to form a 9 
posterior support, bringing up the sides and secur- 
ing them after building a bird’s nest of padding 
around each bony prominence, can be commended 
for temporary use. Folded newspapers do well 
for padding such splints. The toes can be kept 
from pointing by a strip of bandage passed around 
the ball of the foot and pinned to the splints upon 
each side. With such an apparel a patient can 
often be moved home without the disaster of hav- 
ing his simple fracture converted, on the way, 
into a compound one. I should be sorry, however, 
to have one of my own legs, if fractured, left for 
even a week or two in such a crude and uncom- 
fortable appliance. Once, in consultation, I saw a 
patient, who died from the effects of sloughing 
over one malleous, produced by pressure of just 
such a pair of splints. 
American surgical writers, as a rule, do not 
approve of carved wooden splints, while a goodly 
number of English surgeons endorse the kind 
known as Cline's. In America, Pratt’s or Day’s 
splints replace the English Cline model. Samples 
of each form are here presented. I must confess 
to an early prejudice against these splints derived 
from association with my old and greatly respected 
teacher, Frank H. Hamilton. With a consider- 
able assortment of these appliances to choose from 
and with no hesitation in cutting them in order to 
secure a tit, one may make them serve useful pur 10 
poses. On the other hand, if the physician thinks 
more of the splint than of the patient, he is better 
without the splint, or the patient is better with- 
out him. It must be admitted that a splint, even 
partly fitted, is better than straight board in the 
hands of a practitioner with whom the jack-knife 
is not an instrument of precision. 
Rigid Posterior and Lateral Supports.—Under 
this head I mention fracture boxes and the iron 
splint used with lateral supports, and known in 
England as Arnold’s or Neville’s. 
The common fracture box has always seemed to 
me to be a poor affair. When allowed to rest upon 
the bed it is especially objectionable. While it 
may be a safe and conservative practice to 
teach the average student to use it for the first 
week or ten days, until swelling has gone down, I 
should be sorry to have to use it very often myself. 
In the old days, when the manufacture of pus, 
by compound fracture, was considered to be a 
laudable industry, the bran box had more uses than 
at present. Where its use is indicated I think it 
well to have at hand the most improved form. 
The one I show you is more nearly like those 
figured in Wyeth’s Surgery or in Stimson’s work on 
Fractures, than any other, but seems to have some 
advantages over either of these. It was made 
from directions which I furnished, but for which I 
make no claim of originality. The idea of having 11 
sides to let down in sections was suggested by John 
Neil, nearly forty years ago. The sliding door by 
which the box may be adjusted to suit any length 
of leg is a real advantage. By means of Schede’s 
adhesive plaster sling for the heel, the application 
of which I show you, the suffering of the patient 
from pressure upon this part of his limb can be 
relieved, and the risk of having that surgical dis- 
grace, a bed sore over the os calcis, entirely obvi- 
ated. 
The iron back splint, with well fitted lateral 
supports, when suspended, is better than a box. 
It can be made by any blacksmith ; should be 
to inches wide, provided with cross pieces 
by which it can be swung, cut out at a point 
opposite the heel, bent at right-angles for the foot, 
and at an angle of 160° for the knee, and should 
be of metal sufficiently strong to support the weight 
of the limb without bending. 
This appliance meets the indications excellently 
well in the treatment of severe cases of fracture of 
both bones, with over lapping and over-riding of the 
fragments. It is not as well known here as it 
deserves to be, and so I show you a sample. 
Without a doubt the most important advance 
ever made in the treatment of simple fractures was 
the introduction of plastic material for splint 
making. As surgeons, we can well afford to toast 
the memory of that unknown benefactor of his 12 
race, who first padded a broken limb with moss 
and plastered it with clay. 
Of plastic splints now in use we may make two 
divisions. The first of these will include all those 
softened by heat, or otherwise, and moulded to a 
part upon which they become firm and unyielding. 
The second division will include materials liquid 
at the time of application but subsequently harden- 
ing. 
Gutta-percha is supplied in sheet form for splint 
making. I utter no malicious slander when I say 
that it is not eternal. With rubber goods gener- 
ally most of us find this out to our cost. It is no 
better than other plastic material in any respect, 
and not so good in some. It is non-porous, expen- 
sive and short-lived. On the other hand, it can be 
moulded so as to perfectly fit any part, and no force 
need be used in shaping it. 
Sole-leather, being inexpensive and easily ob- 
tained, is a favorite material with many. It should 
be slowly and perfectly softened in cool water, 
with or without acetic acid, and can then be 
adapted to the inequalities of a part almost as 
perfectly as gutta-percha. One who has time at his 
disposal, and who by practice has gained some skill 
in working with leather, can make capital side 
splints from it. If it be imperfectly softened, the 
attempt to make it fit down to the exact shape of 
a limb may be the cause of new' injury at the seat 13 
of fracture. Exceedingly bad splints are often the 
result of trying to economize time by using very 
hot water for the softening of leather. 
Felt, and similar poro plastic material, is supplied 
in sheets and in blocked forms. The English make 
is thicker and stronger than the American, and 
for the leg at least, the models adopted are decidedly 
the best. Softened by slightly moist heat, they are 
easily moulded and give sufficient support. I show 
you samples from leading manufacturers. These 
materials soon become soft and useless if dipped 
into hot water whenever a change of shape is re- 
quired. 
Kocker’s adaptable splint seems to be a good 
form of shellac-stiffened cloth. It is, as you see. 
rather light for use upon heavy limbs. 
Wire gauze has long been in use for splints. Its 
most distinguished advocate at present is Professor 
Jarvis S. Wight, of Brooklyn. He has been kind 
enough to send me samples of the best gauze for 
surgical uses. 
The lighter variety has inch meshes, is made 
of No. "20 iron wire, and is dipped into molten 
zinc, so that the wires are coated, and the points 
of intersection firmy soldered together. So made, 
the gauze is light, clean, cheap, strong and easily 
moulded to fit a part. 
Mill-board is often referred to as though it is the 
same thing as, or is interchangeable with, paste- 14 
board or straw-board. It is really a great deal 
better than either, and is at once excellent for all 
its proper uses, easily obtained and cheap. It 
may be used as rigid as { inch deal, or as plastic 
as felt or gutta-percha. I am in the habit of ad- 
vising students to stuff a long stocking with oakum 
and to use it as a model in making plaster dres- 
sings and in moulding mill-board In my hearing, 
many old practitioners have expressed surprise at 
the really excellent quality of the splints which 
were made by moistening the mill-board just suffi- 
ciently with hot water, moulding and bandaging it 
upon the model, and allowing it to dry in position. 
Additional strength and an elegant finish can be 
given to such splints by an outside coating of sili- 
cate of soda. 
Practice of this kind wastes no time, since, so 
far as fractures are concerned, it helps to make us 
independent of the instrument maker. 
In the second division, as starch dressings are 
practically obsolete, I shall consider only silicate 
of soda and plaster-of-Paris. The silicate I have 
used for a number of years. As it is not easily- 
obtained here, and may not be familiar to all 
present, I place a sample before you. From it 
light, clean, strong and elegant splints can be 
made, but it is sticky to handle, and dries so 
slowly as not to give security against displacement 
by the time the physician is ready to leave the 15 
patient. It has been charged with causing exten- 
sive sloughing when allowed to remain in contact 
with the skin. 
My personal experience with plaster-of-Paris, 
in the treatment of leg fractures, includes a series 
of thirty-eight consecutive cases, put up as soon 
as reduced, in one or other of the forms of splint 
presently to be described. I have never com- 
pletely encased the limb in plaster bandages dur- 
ing the first week of treatment. Tn no instance 
was it thought necessary to wait and see if swel- 
ling would come on or for it to subside, and no 
increase in its amount was ever noted after the 
dressing was applied. The amount of ensheath- 
ing callus thrown out in these cases was suprisingly 
less than that wrhich I have seen in cases treated 
by other methods. My three first cases were 
treated by the regular Bavarian splint, made by 
pouring plaster mud between two layers of flannel 
secured together down the back of the leg. Be- 
coming dissatisfied with the weight and clumsy 
look of this dressing, I substituted, as many 
others have done, layers of cloth soaked in plaster 
for the plaster alone. Later, the doubled piece of 
flannel was omitted and layers of gauze or blanket- 
ing, cut by the measure of the patient’s stocking 
and bandaged to the sides of the limb somewhat 
after the manner suggested by Mr. John Croft, 
became the favorite method. Finally I adopted. 16 
and have now used for four years, the plaster 
posterior splint, essentially, as it was perfected by 
HEEL.c 
KNEE 
Fig. 1. 
my friend, Dr. Kingman, and others in the Boston 
city hospital. No new principle is involved in 17 
the making of this splint. It is not the posterior 
splint described by Esmarch or by MacCormac. 
It is not the same thing as a plaster bandage with 
an inch-wide strip removed down its centre line 
in front. It differs from, and is better than either 
of these for the early treatment of simple fractures. 
I show you samples and photographs of the com- 
pleted splint, and will now demonstrate the 
method by which it is made. The materials re- 
quired are, cotton-wadding, cheese-cloth and plaster- 
of-Paris. I have lately been substituting scrim, 
a coarse and strong fabric, for the cheese cloth as 
a less number of layers will give equal strength. 
I have this material here and also a splint made 
from it. The leg is to be bandaged with the 
batting, which, for the purpose, is torn into strips 
four inches wide and applied as a roller. Using 
the sound leg as a model, to save the injured one 
from movement, a pattern is cut which shall 
cover in all of the leg excepting a space an inch 
wide along its anterior aspect. Deep slashes 
opposite the heel allow the part for the sole of the 
foot to be brought into a right-angle with that for 
the leg without forming clumsy folds at the ankle. 
From this pattern four or five layers of scrim or 
from six to nine of cheese-cloth are cut. Then 
with extension made and the foot properly held, 
the strips are to be saturated with a cream made 
by sifting—not stirring—plaster into warm water, 18 
smoothed one upon another, applied to the posterior 
aspect of the limb, interleaved by the slashes at 
Fm. 2. 
the ankle so as to hold the foot at right-angles 
with the leg, moulded to the part and then firmly 19 
bandaged to it with a cotton roller. He who is 
to be responsible for the result had better, as soon 
as this bandage is on, hold the limb in proper 
position till the plaster sets. To resign the duty 
into unskilled hands may mean either a deformity 
or the necessity for a new splint. 
No more skill and no better judgment is called 
for in the use of this method than is needed for 
successful treatment by any other. A little 
practice will make almost anyone familiar with its 
essential details, and the result of its use may 
often become, as I can testify, a subject for the 
mutual gratulation of surgeon and patient. 
This then is the dressing which I present to 
your notice as being more nearly the ideal one 
than any other yet proposed. Permit me to quote 
again from Dr. Gay : “ Properly applied, it is 
comfortable and efficient, it is self-retaining, it 
holds the fragments firmly in position, it allows 
the patient to be moved or to move himself with- 
out danger of disturbing the fracture, it permits 
the parts to be readily examined. Being opened 
throughout its entire length the bandage accom- 
dates itself to the swelling of the limb without 
danger of strangulation, it can be applied im- 
mediately after the accident, there being no 
negessity for waiting until the inflammatory stage 
has subsided. It can be removed and re-adjusted 
with ease and can be worn indefinitely.” 20 
Any and every means by which displacement of 
the fragments is likely to be prevented, may pro- 
b’u;. 3. 
perly be considered in discussing fixation. Position, 
suspension, extension and tenotomy become in this 21 
way possible factors in fixation. My own expeii 
ence has been limited to the treatment of cases 
with the leg in the straight position, or at an angle 
of not more than 160 with the thigh. Reasoning 
from the ease with which reduction can at times 
be effected when the leg is flexed to a right-angle 
with the thigh, as well as from the comfort given 
the patient before his fracture is set, by flexing the 
injured limb to relax the calf muscles and allowing 
it to rest upon its outer side, I am disposed to think 
favorably of this position continued throughout the 
stage of consolidation in certain cases. I will 
leave it for those who have had experience in this 
matter, to define the cases which are suitable for 
such treatment. Theoretically, only fractures in 
the lower part of the leg should be put up with the 
knee unsecured. 
Stanley Boyd, in his late and excellent revision 
of Druitt’s Surgery, makes the curiously inaccu- 
rate statement, that in the United States frac- 
tures of the leg are usually treated by Buck’s 
method—the American stirrup (meaning by these 
terms the weight and pulley extension), and 
that coaptation splints (Cline’s) are also used 
when the fracture is oblique. It would be in- 
teresting to know in wdiat small proportion of 
cases the members of this Society have used the 
weight and pulley for leg fractures, and in what 
still smaller proportion they succeeded in mak 22 
mg this form of extension honestly efficient in 
overcoming deformity. It has appeared to me to 
be so difficult to obtain a purchase on the parts 
below the fracture for our extending force, with- 
out running the risk of ligating the limb or mak- 
ing injurious pressure upon parts like the instep, 
unfitted to sustain it, that I have not even made 
trial of this expedient. And before doing so, I 
shall certainly make trial of one or other of the 
two forms of double inclined plane which are here 
presented—the Liston’s splint improved by Mc- 
Intyre, or the wooden apparatus manufactured by 
Pratt & Son, of Bennington, Vt. When displace- 
ment is prevented by keeping the limb at a certain 
fixed angle, these appliances may prove useful. 
Suspension.—I have seldom seen a broken leg 
doing so well without suspension, that it would 
not do better with it. One need not pay $20 or 
$30 for a Salter’s swing, when any ordinary black- 
smith, if shown how, can for $4 or $5, make one 
equally good. I show you one which is easily 
taken apart for convenience of carrying. This I 
have had in use for nearly ten years, and it has 
paid for itself many times over. 
A simpler and quite familiar frame is this, which 
resembles two small window sash hinged together 
along one side. Simplicity and portability can go 
even further than this, and I show you here a bar 
of wood, inches square by 2 feet long. Into 23 
the upper surface of this and near each end, a 
screw hook is fixed, by which it may be suspended 
over and parallel with the injured leg. Into its 
under surface three or four more screw hooks are 
fixed, and from them the leg is, by loops of bandage 
or otherwise, suspended. Dr. Walker, of Detroit, 
was the first, so far as 1 know, to describe the use 
of a bar like this. In practice, we often find 
that loops of bandage used for the suspension of 
limbs soon draw into ropes. Hamilton, to obviate 
this and to distribute the pressure along the limb, 
suggested the use of broad leather loops. As these 
are not always at hand, I have used instead starched 
linen cuffs, one cuff at the ankle and one below the 
knee, suspended by soft cord or bandage so as not 
to tear out the button-holes, will answer every 
purpose. In swinging a limb, it is good practice 
to have the knee slightly higher than the ankle. 
Motion at the point of fracture, muscular starting 
and pain from pressure on the heel, are almost if 
not entirely obviated by suspension, and yet I feel 
sure that no small number of limbs are kept lying 
upon the bed throughout the treatment. 
The discussion of tenotomy of the tendo-achilles 
I leave to others, as I have had no practical expe- 
rience with it. In very oblique fractures of the 
tibia, compound or threatening to become so, and 
in the Y-shaped fractures first and best described 
by Glosselin, this procedure may well commend 
itself to our consideration. 24 
Compound Fractures of the Leg. — Antiseptic 
surgery has revolutionized the treatment of this 
class of injuries and reduced the mortality of cases 
not demanding amputation, from over 30 %, to 
practically no mortality at all. Volkmann, in 
1876, startled the surgical world by reporting 75 
consecutive recoveries. Dennis, in 1886, records 
150 cases without a death due to septic causes. 
The very success we now attain brings to us new 
dangers. Men who formerly would have died now 
recover, and if not turned out models of manly 
symmetry, are very prone to listen to the sugges- 
tions of Ishmael and of Ananias, and to try and 
recover damages from those to whom they owe 
debts of gratitude for life prolonged. In selecting 
our methods of fixation for these cases, we should 
bear constantly in mind the fact that we may, 
within a few months, have to defend in the courts 
the procedures we adopt. 
He who studies to be fertile in helpful resources 
will not be tied to any routine practice. After 
testing a considerable number of plans, such as 
fenestrated and bracketed plaster splints, the bran 
box, etc., I have settled upon one method as being 
the best under all ordinary circumstances. The 
plan referred to is to make an anterior and a pos- 
terior splint, each of eight or ten layers of cheese- 
cloth and each extending from the toes to the mid- 
thigh. The anterior one only needs to be removed 25 
for the renewal of the antiseptic dressing over 
the wound. MacCormac gives outlines of good 
patterns for these splints, and I present for your 
inspection a complete pair. The plaster posterior 
splint, described as best for simple fractures, I 
have used in but a single case of compound frac- 
ture. It gave satisfactory support, but not as 
free access to the wound as would have been re- 
quired had the latter done badly from any cause. 
In conclusion, permit me to submit the following 
propositions for your discussion :— 
1. Plastic appliances are the best for the fixation 
of fractures of the leg in all their forms and at all 
stages of their treatment. Exception, certain cases 
of Potts’ fracture. 
2. For the early fixation of simple fractures, the 
plaster posterior splint is the best and safest appli- 
ance yet suggested. 
3. Next to it should rank side splints made from 
plaster - soaked blanket, or open-meshed cotton, 
bandaged on so as to be hinged along the back. 
4. In the later stages of all simple fractures of 
the leg, the complete encasement of the limb by 
plaster bandages is the preferable plan of treat- 
ment. 
5. In treating compound fractures of the leg, 
posterior and anterior splints made of plaster- 
soaked gauze, are ordinarily the best for fixation. 26 
Exceptionally fenestrated or bracketed plaster 
splints may meet the indications more perfectly. 
Without considerable practice in the use of plas- 
ter, the fracture box suspended may be safer, both 
for the patient at the time and for the surgeon 
subsequently. 
259 Sinicoe St.