Part 55

Another improvement made on the lower end of the external splint by Dr. James Hutchinson deserves also to be mentioned. It was found that in the original apparatus of Desault, the strap or roller L (plate 2) used for the purpose of extension, had a tendency to draw the foot too much outward. This fault Dr. Hutchinson very ingeniously remedied, by attaching to the lower part of the external splint, a little above the mortise, a small block extending inwardly, at a right angle with the splint, so far as to be on a line with the middle of the sole of the foot. Over the end of this block, in which a notch is cut to receive them, the ends of the strap L are carried, previously to their being secured to the external splint. By means of this expedient extension is made precisely in the direction of the limb, and the inconvenience of drawing the foot outward is completely obviated.

Thus improved by Drs. Physick and Hutchinson, the apparatus of Desault for oblique fractures of the os femoris, leaves, perhaps, scarcely a remaining desideratum on the subject.

ARTICLE III.

EXPLANATION OF THE THIRD PLATE.

This plate gives a full view of an apparatus for making permanent extension, in oblique fractures of the leg, when both bones are broken. This apparatus was first devised and constructed several years ago, by Dr. James Hutchinson, then a pupil in the Pennsylvania hospital, and is now in general use among the practitioners of Philadelphia.

Fig. 1. Represents the leg and foot, with the apparatus applied.

A. A common roller, passed several times round the leg a little below the knee, on which counter-extension is made.

B. A silk handkerchief folded, or a strong roller made of soft muslin, passed once round the leg, just above the ancle, from behind forward. C. The place where its two ends cross each other to pass down along each side of the foot, as seen at b, to D, where they are secured by a knot drawn but moderately tight. a a. The same ends continued to E where they are again secured by a firm knot over the cross piece F, which passes between the two strong splints G G, that run on each side of the leg from a little above the knee, to the distance of four or five inches beyond the sole of the foot. This is the bandage by which extension is made, as will be mentioned hereafter.

H. Two bits of strong tape, each about two feet long, placed in the longitudinal direction of the leg, and firmly secured by the roller A, which passes over their middle. Two such bits of tape, are thus applied on each side of the leg, and their four ends, passing through four holes in the upper end of each of the splints G G, are secured on their outsides by firm knots as represented at H.

Fig. 2. A view of one of the splints G G, separated from the leg.

a. The four holes in the upper end, through which the bits of tape H pass.

b. The mortise in the lower end, which receives the cross-piece F.

Fig. 3. A view of the cross-piece F, which must be firmly fixed in one of the splints G G, but moveable in the mortise of the other, so that the splints may be taken asunder at pleasure.

The following is the method of applying this apparatus.

While extension and counter-extension are made by two assistants, the surgeon placing the bits of tape H on each side of the leg, secures them firmly by the roller A applied round the limb, with a proper degree of tightness. He then applies the middle of the handkerchief or roller B on the tendo Achillis, brings its ends across each other, before the leg at C, and carrying them down along each side of the foot, secures them by a knot at D. Letting go the ends of the handkerchief B, he next places on each side of the leg the splints G G, connects them at the lower end by the cross-piece F and secures them at the upper end by the tapes H. He then resumes the ends of the handkerchief B, carries them downward as seen at a a and secures them by a firm knot at E round the cross-piece F.

From this view and explanation of the apparatus Fig. 1, I presume its construction, application, and mode of operation will be very easily understood. It is unnecessary therefore to add, that the extension and counter-extension made on the limb, will be directly proportioned to the degree of force with which the ends a a of the handkerchief B are drawn over the cross-piece F. As action and reaction, in this case, must, as in all others, be equal, the splints G G will be pushed upward by the ends of the handkerchief B with precisely the same force that is applied on these ends to draw the foot and lower fragments downward. Hence the counter-extension made above on the roller A will be exactly equal to the extension made below by the handkerchief B.

I ought to have observed, that it is necessary to defend the soft parts, both above and below, from the pressure of the extending and counter-extending straps, by means of soft compresses applied next to the skin. This is particularly necessary on the instep C where the ends of the handkerchief B cross each other. It requires some attention on the part of the surgeon to prevent this spot from being excoriated, especially if it be found necessary to make a forcible extension.

If the fracture be simple, a bandage of strips previously applied round the limb from the ancle to the knee is highly useful. It secures the fragments more effectually from lateral displacement, and prevents the swelling of the leg. A simple roller applied with a moderate degree of tightness round the foot, is also of service in preventing a swelling in that part, as well as in removing it if it has already occurred.

This apparatus is still more strikingly useful in compound fractures, on account of the facility with which it enables the surgeon to apply the necessary dressings. These can be renewed as often as may be requisite, without giving the patient the least pain, without discontinuing extension, or in any measure whatever deranging the fragments. The surgeon can also, in all cases, discover by a single glance of his eye, whether or not the fragments are in proper apposition. It is right to secure the whole apparatus by three bits of tape passed round it, similar to those tied round the leg in the apparatus for fractures of the thigh, as represented in plate 2.

I shall only add, that the surgeon must employ such bolsters and compresses as he may find necessary to support the limb, and protect it from undue pressure, and that he must be vigilant to prevent, by frequent examinations, the extending and counter-extending straps from becoming relaxed.

For a few further remarks on the subject of this apparatus, the reader is referred to a paper published by Dr. Hutchinson, in the second number of the Philadelphia Medical Museum.

FINIS.

Inconsistencies:

armpit/arm-pit condyl/condyle coracoid/corocoid coronoid/coronoide expence/expense fixt/fixed forearm/fore-arm/fore arm inconveniencies/inconveniences plane/plain Scultel/Scultet teres-major/teres major

Corrections:

aingly → singly appplication → application backwaad → backward Bruningaushen → Bruninghausen cataloginous → cartilaginous ciscumstance → circumstance considerasion → consideration constanly → constantly controuling → controlling cotemporaries → contemporaries croud → crowd decieve → deceive divison → division Engravd → Engraved examing → examining exextremities → extremities faciæ → fasciæ follow- → following imitatators → imitators make → makes matrass → mattress nect → neck of of → of passsive → passive percieve → perceive recieves → receives resourse → recourse the the → the to to → to whould → would 1303 → 1803 (date) 67 → 66 (para numbering error)