Practical Notes from Kilkenny County Infirmary. 101

.ART. VII.--Practical ~)tes from Kilkenny County Infirmary. By ZACg. JOHNSON, A.M., T.C.D., F.R.C.S.I.; Licentiate, King and Queen's College of Physicians, &c., &c.

ON T H E T R E A T M E N T O F F R A C T U R E S O F T H E F E ) I U R B Y A N E W

3 I I E T H O D A N D A P P A R A T U S .

THE treatment of fractures of the femur has always been a subject of great interest to the profession. Its importance is indicated by the amount of attention it has engrossed, the many treatises and monographs which have, from time to time appeared about it; the different plans of treatment proposed, and the various splints and apparatus which have been exhibited and recommended for its suc- cessful management ; and when it is considered that all of these have

"their merits, that many enjoy the impress of the highest authority, while each successive design proposes to obviate some defect or objec- tion in its predecessors, it might be thought that there was little room left for improvement, and none for originality.

The management of a fractured thigh is beset with difficulties known to every experienced and practical surgeon, and it cannot be said that any of the apparatus heretofore devised completely or satisfactorily fulfil the intentions of the inventors or the requirements of the practitioner. It will not, then, be considered presumptuous to bring under notice, in addition to the many in use, one which has been subjected to the test of hospital experience for many years, and has been found to possess advantages over its rivals, which the fbl- lowing description of its principle and construction will explain.

It is not proposed to enter here into a complete dissertation on the treatment of fractured thigh, and the various plans from time to time proposed and recommended by eminent surgical authorities, nor to examine into the respective merits of the inclined and extended positions. With the received opinions on these points it is presumed the readers of this article are already acquainted. The arguments of the late lamented Professor Houston, so lucidly propounded in his admirable little brochu~'e on the advantages of the extended position in treatment of fractures of the lower extremity, leave nothing to be said on this point. As a rule, then, the extended position is that now accepted as the best, when practi- cable. The cases are unusual which do not admit of it, though it may here be incidentally observed that there are two in which it is not available, and though these are rare, as they occasionally present

102 _Practical Notes from Kilkenny County Tnfirrnary.

themselves in actual practice, they should not be overlooked. The one is where the fracture occurs in the upper third of the femur, in which case the upper fragment may be tilted up, almost at a right angle, by the spasmodic action of the psoas and iliacus muscles. Here there is no resource but the inclined plane for some days, until the irritability of the muscles has been overcome, when the limb may be gradually brought down to the horizontal position, and the extended plan of treatment ultimately put in practice. The other where, with a knee anehylosed at an angle, the femur is broken;and here, obviously, the inclined plane alone is available throughout.

It is, however, with the extended position we have more imme- diately to do. It is for the more effective management of the limb in that position the apparatus about to be described w~ specially devised and subsequently tested, although it will be seen by-and- by, it is capable, on an emergency, of being adapted for use in the inclined position also.

The objections to Desault's long splint, with its oblique inguinal and ankle straps, its defective extensile powers, and tendency to excoriate the pcrin~eum and groin, are too well known to require further comment. The paramount objection, obviously, is the loss of power arising from the obliquity of the extending and counter- extending forces. The minor objections are several, such as the danger of excoriation of the groin and perin~eum above, and the ankle and instep below, interference with the use of the bed-pan, &c., &c. These objections all hold good, more or less, in the case of Liston's and Bulley's splints, which, although they present some advantages, retain many of the most serious defects of Desault's apparatus.

Our primary object in the management of a Fractured thigh is, that the extending and counter-extending forces should antagonize each other in a direct line, which line should be parallel to the long axis of the limb. On this principle depends the efficiency of all our expedients to counteract the inevitable tendency to shortening, caused by the contractions of the powerful femoral muscles. Here it is that Desault's plan fails, the obliquity of the antagonizing forces necessarily entailing great loss of power. Next in importance is the condition that the power should be constant and persistent, such as to weary and overcome the rebellious muscles, while our aim should be to accomplish this in such a way as shall be thoroughly efficient and at the same time in the least possible degree distressing

By DE. ZACH. JOH~rSON. 103

or inconvenient to the patient. With a view to devise means by which to keep up a direct extending and counter-extending power, various expedients have been proposed. For this purpose the weight and pulley was long since adopted and has had very gratify- ing success in the hands of many practical surgeons. I t has been frequently used with satisfaction in the Kilkenny County Infirmary by my colleague and myself. About the year 1852, I published, in the Dub. Med. Press, the details of a most remarkable case where a femur, shortened after a first fracture, was brought to its normal length by this treatment, when accidentally broken a second time, about a year or more afterwards; and Dr. Smith, of Donoughmore, has drawn attention to the fact that the weight and pulley was used to effect extension of the fractured thigh, so i~ar back as 1829, by Dr. Daniell, of Gcorgla, in America, and by Sir P. Crampton, in the Meath Hospital (Medical Press and Circular, 23rd June, 1869).

But the weight and pulley', however effective and admirable in its action, has its objections, as every practical surgeon must have found. The difficulty of effecting counter-extenslon, the tendency to drag the patient to the foot of the bed, intolerance on the part of the patient, generally speaking, (if the weight be sufficient to overcome the contractile power of the muscles), all present difficulties which stand much in the way of its universal or even general adoption. Besides it is awkward, unseemly, and inconvenient.

I t will be admitted that any apparatus which could embody all the advantages of the several systems now in use, at the same time that it got rid of their several disadvantages, would be a great boon to tim practical surgeon, as well as to the sufferer. With such intentions the apparatus about to be described has been constructed. It has been tested amply in actual practice, and the result has been to induce me to submit it to the experience and judgment of the profession.

Among the advantages claimed for the apparatus now proposed, is its simplicity ; although a modification of Desault's, Listen's, and Bulley's splints, combining the good points of each, with the addition of several innovations unknown to them, it is simple, easy of application, and, best of all, thoroughly effective. It does not excoriate, it can be so used as not even to incommode the patient, while it confers on the surgeon power, which no apparatus hitherto in use has realized.

The apparatus consists of a single long splint and l%ot-piece, each of which requires separate description.

104 Practical Notes from KiUeenny County Infirmary.

The long splint resembles Desault's inside splint, but differs from it in some very essential points. The most important of these is the method of effecting the counter-extension. Instead of the perin~eal strap, which is open to so many objections, the upper or perinmal extremity of the splint, which is slightly concave, is applied directly to the perinmum. It is softly padded on the extremity with caoutchouc, which again may be covered with chamois, silk, lint, or any other movable and non-irrit~ting material. The ramus of the pubis is here made the fulcrum, and it will be seen that, with the foot-piece used, the extending and counter-extending powers act" in directum." The pressure of the splint against the perinmum is borne, so far as past experience has gone, without complaint, and has great and obvious advantages over the perplexing and ineffective oblique inguinal strap of Desuult's spllnt.--(See Plate IV., Fig. 1.)

But, should any objection arise to using this fulcrum, a second one has been provided, the idea of which has been borrowed from Dr. Sayer's ingenious method of treating affections of the hip-joint and knee.

A short splint of strong sole leather or flexible material, about some twelve or fourteen inches long, is proylded with a stud or gig-apron button, which is firmly rivetted; this splint is to be attached to the outer side of the thigh and pelvis. This can be effectively done by means of oblique adhesive straps, of sufficient length and breadth, laid on in the manner proposed by Dr. Sayer in attaching his apparatus for extension of the hip and knee. The surface of the splint itself may be made adherent by a coating of starch, or soap plaister, and by these means a degree of fixity can be obtained more than sufficient for any practical purpose.--(See Plate IV., Fig. 1 c.)

In the upper end of the long splint may be seen a series of button- holes, capable of fitting on the stud in the short splint. By trans- ferring the long splint to the outer side of the thigh, the surgeon can now, if he wishes, make this stud the point of counter-extension, an arrangement which has been found perfectly effective, and which contributes immensely to the comfort of the patient.--(See Plate IV., Fig. 2.)

The fulcrum of counter-extension having been decided on, exten- sion is to be effccted by means of the foot-piece attached to the other end of the long splint, to the peculiar construction and advan- tages of which attention is now directed.

By rJerence to Plate IV:, Fig. 3, it may be seen that, by means of a ball and socket joint (b) at the back of the foot-piece, it is capable

PLAT~: IV . u LVI . ] [No. 20, p. 104.

Fig. 1 . - -Sp l in t applied on inner side of limb. ]-r of pubis the fulcrum of com~ter extension. Foot-piece paral lel to splint, a. Splint. b. The s tandard or ful- crum extension, c. The but ton by which counter-extension is effected, when spl in t is applied on outer side of limb.

Fig. 2 . - -Sp l in t t ransferred to outer uide of l imb. Fu lc rum of counter-extension now the bu t ton c, ac t ing throu~q~ whichever button-hole be~t suits the length of the limb. b. The padded end, which rests agains t ramus (,f pubis, when spl int is applied on inner side. In tids di~tgram the bed has been t i l ted up, so as to bring more into view.

Fig. 3 . - -Sepa ra t e view of foot-piece : - -a . The s tandard or fulcl=um of extension, ~h ieh admits of being fixed ei ther perpcmlicular or paral le l to ti le bed. b. The bai l and socket joints by means of which the foot-piece can observe any position wi th reference to the s tandard c~. c. The pinching screw of ttLe ba l l ~ud socket joint, which fixes the foot-piece immedia te ly in any required position, d. The t r ave r s ing bar, which rmls backwards and forwards th rongh the mort ice hole in a. e. The winged nut, which plays on the thread cut on the corners of the square bar d. f . The caoutchouc fl~u~ges, which, when compresst.d, draw the foot-piece towar,ls the ful- e r n n ] g .

By DR. ZACI:L JOHNSON. 105

Of an infinite variety of adaptations, while, by the use of a pinching screw (c) provided for the purpose, it can be firmly and immovably fixed in any required position. The ball is riveted on the end of a bar (d), which moves horizontally, backwards or forwards, through a mortice hole in the standard, or support (a), which is affixed to the long splint. On the other extremity of the horizontal bar a winged nut (e) plays, drawing the fbot-piece towards the standard, or support (a), with great power when required. Between the winged nut and the standard may be observed a series of caoutchouc rings or flanges (f), the use of which will be explained presently.--(See Plate IV., Fig. 3).

The advantages of this foot-piece are numerous and obvious. By attaching the foot to it any requisite position may be obtained, and then maintained by a turn of its pinching screw. This is of immense value in injuries of the leg and ankle. The motions of the ball and socket joint allow of any adaptation, and the pinching

�9 screw secures it. In fracture of the thigh it obviates eversiou of the foot. In fracture of the fibula it can evert the lower fragment.

I f we suppose the extending lacs to be attached to the limb, in whatever manner the surgeon may prefer, and the foot-plece brought into apposition with the sole of the foot, by sliding the horizontal bar through its standard (Plate IV., Fig. 3, a), the lacs are to be tied firmly at the back of the foot-piece, and now extension will be effected by screwing up the winged nut, which draws the foot-piece towards itself with irresistible force.

Thus two important objects are obtained--a steady, gradual force of great power, and one acting in a direct line with the axis of the limb.

I t will be observed, that by a simple revolution of the foot- piece on tile ball and socket joint the long splint may be applied indifferently to either the inner or outer side of the leg.

Having obtained a powerful extending force, acting "in dlrectum," it remained to render this force persistent and self-adapting, so as to combine, if possible, tile action of the weight and pulley with the advantages already gained.

This has been effected in the following manner : - When tension is applied by so screwing tile winged nut as to draw

downwards the foot-piece, the caoutchoucflanges, which lie between it and the standard (and to which attention has been already drawn), become compressed, and by their elasticity exercise a constant strain on the extending lacs, which can be modified by increasing or relaxing

I

106 _Practical Notes from Kilkenn S Count S Infirmary.

the pressure. Thus the antagonizing action of the muscles may be wearied out. The more they contract the greater the strain on the lacs, while the tension continues, in modified degree, in proportion as they yield and relax, and thus the action of the weight and pulley is emulated ; and if the attachments of either extending or counter- extending agents should yield or stlp, the resiliency of the caoutchouc will compensate for the derangement, and still kcep up an equable tension.

Such arc the paramount and essential features of the apparatus. Some points of detail remain to be noticed and explained.

The reason that the horizontal bar is square is, to ensure steadi- ness when it is desired to fix the foot in any peculiar attitude, by tightening the pinching screw of the ball and socket joint ; were it round, the foot-plece could revolve, when it was desirable to have it fixed and steady. The thread of the screw which the winged nut traverses is traced only on its corners, but will be found as unerring and effective as if the circle were complete.

The persistent tension of the weight and pulley might be simu- lated by elastic lacs, secured to the foot-plece, but with this great disadvantage, that when the lacs yielded the foot would be drawn away from the foot-piece, and would be free to take wrong positions. I t is of manifest importance to keep the foot in close apposition with the foot-piece by a slipper, bandage, or adhesive straps, so that when any peculiar position has been attained, deviation from it may be obviated. In order to ensure this it was necessary so to arrange the elastic force that, while it yielded to any extraordinary tension, the foot should not become in the least separated from the foot-piece, and its requisite attitude should be still perfectly maintained. This has been accomplished by interposing the elastic medium between the extending agent (the winged nut) and the fulcrum against which it works (the standard attached to the long splint). (Plate IV., Fig. 1, b.)

But as cases will occur which cannot be treated in the extended position, such as those previously alluded to, arrangements have been made so as to allow of converting this splint, on emergency, into u double inclined plane.

A large oval fenestrum may be noticed about the middle of the long splint. This allows of the splint being kept in close apposition with the thigh, so as to avoid encroaching on the scrotum or vulva, without pressing against, or hurting the knee, opposite to which this vacancy has been purposely constructed. I t will be also

By DR. Z.~cm J o ~ s o N . 107

observed that, at the centre of this oval the splint is hinged, so as to allow of its being doubled together on the outer side. This not only makes the entire more portable, but allows of its being converted, at any moment, into a double inclined plane, tile inclina- tion of which can be easily regulated by pillows or cushions. The foot-piece now revolves to a suitable position, perpendicular to tile plane of the leg-piece, instead of being parallel to it as beibre, while a second oval has been removed, to secure the heel from any contact or pressure. Thus, in case of emergency, a double inclined plane can be readily extemporised.

' When it is desired to keep the long splint straight, for the purposes of extension, the yielding of the hinge can be effectually prevented by inserting a pad of adequate thickness between the knee and the site of the hinge, which will prevent tile bending of the splint, whether it be on the inner or outer side of the thigh.

The revolving fbot-piece will be found of great advantage in other cases beside those where an extending power is required. In accidents and injuries of the leg and disease of the ankle, where it may be of importance to secure some special position of the foot, it will be found most useful. Here it is to be kept in apposition with the sole of the foot by means of a second pinching screw, whose office is to prevent the square bar from sliding in the standard, and so to keep the foot-piece permanently in contact with the foot, which now derives support from it. I f it be desired to effect any peculiar position of the foot, the ball and socket joint enables the foot-piece to be adjusted at any fraction of an angle, and the foot having been previously secured suitably by adhesive strapping, the entire may be fixed in the required posture by a turn of the pinching screw (Plate IV., Fig. 3, c) which controls the ball and socket joint.

This fbot-piece is equally useful for support or extension. It is applicable alike to long splint or inclined plane. I t was exhibited by me at the Surgical Society some twenty years ago, since which time it has been amply tested in hospital and private practice. I t has been found to possess great advantages in a variety of cases. Where some special position of the foot is required it can exercise either extension or support, as may be most desirable. In the case of fractured fibula it can fulfil the purposes of Dupuytren's splint. For the purpose of direct extension, it has proved more effective than any means hitherto proposed.

With respect to the best method of applying extension in the

108 Practical Notes from Kilkenny County l~rmary.

case of fractured thigh, it may not be amiss to say a few words. I t can be applied, as is so frequently done, above and close to the ankle, by means of the familiar clovehitch tie. Here it is apt to excoriate and cause pain by its pressure on the malleoli. A great advantage will be gained by attaching the extending agent near the knee; this may bc accomplished by broad adhesive straps, applied after the method followed by Dr. Sayer in his treatment of hip disease. By this means double points of attachmcnt may be effected by which a double advantage will accrue. Thus one attachment may be arranged above, the other just below the knee, and by using these alternately the patient obtains great relief. I t will be found that the irritability of the femoral muscles will be lessened by applying the extending power high up. When practicable, it is well to attach it above the knee, and relieve the ligaments of the knee from strain, but in any case it can be attached, with advan- tage, above the calf of the leg.

A decided advantage will also be obtained from the use of short secondary splints, embracing the femur alone. Of these, one in front and one on either side will be sufficient. They may be secured by broad straps and buckles, and their equable pressure tends to soothe the spasmodic irritability of the femoral muscles. Their use was much insisted on by the late Sir Philip Crampton, at the Meath Hospital, and they have been justly recommended by other eminent authorities.

When counter-extension is made against the ramus of the pubes, and the long splint applied to the inner side of the leg, it serves as the inner splint, while the leather splint, with stud affixed, is available as the outer one. The straps and buckles may now embrace all, and by including the long splint will keep it close to the thigh, and prevent any encroachment on the scrotum or vulva.

When counter-extenslon is effccted by the button on the outer side of thigh it will not be so convenient to include the long splint in the straps which confine the short Ones. The comfort enjoyed by the patient when this method of counter-extension is used is very great. I t can be best appreciated by applying extension on the inner side first, and then changing to the outer side. I t is fully as effective as any other method, and presents no interference what- ever with the use of the bed-pan ; thereby contributing materially to the convenience and comfort of the patient.

I t would not be right to conclude these observations without acknowledging my obligations to the ingenuity of Dr. Sayer,

On Tapping in Hepatic Ascites. By DR. M'Ca~A. 109

of the Bell Vue Hospital, New York, from whose method of affixing his apparatus for hip and knee disease I took the idea of attaching a fulcrum (Plate IV., Fig. 1, c) on the outer side of the thigh, a measure which conduces vastly to the comfort of the patient. The mode of applying counter-extension by broad adhesive straps, applied above and laterally, to the calf of the leg, and to which the name of " Paneoast's Stirrup" has since been given, was adopted by me previous to 1850, and referred to in my publication " On the Weight and Pulley," about that time.

I now submit this mode of treating disease and injury of the lower extremity with all deference to the judgment of an impartial profession.

ART. V I I I . - - O n Tappb~g in Hepatic A scites. By JOHN M'CREA, M.A., M.D., Senior Medical Officer to the Belfast Dispensary.

A DISCUSSION at the Medical Society of the College of Physicians some months ago directed attention to the diversity of opinion that exists on the value of tapping in hepatic ascites. Recent authors, also, appear to be divided in their views on this subjact. Murchison considers the operation a dernier ressort, while Habershon and Ward recommend early tapping.

The two following cases (besides presenting other interesting features) have this in common, that in both the operation was performed, and in both the results were favourable.

CASk I . - -A child, aged three years, was brought to the Belfast Dispensary On December 2, 1872. He was rachitic, and belonged to a very rachitic family. He had been sickly for the grcatel: part of the preceding summer, having lost appetite and become emaciated. When I saw him, the abdomen was distended with fluid ; the urine was scanty, and free from albumen; the bowels were regular. On the next day I drew off; by tapping, two quarts of fluid. The liver could now be palpated with facility. It was very nmch and uni- formly enlarged, firm, inelastic, smooth, and not tender. The edge was rounded and free from indentation. After the operation he was ordered a mixture containing iodide of potassium and sweet spirit of nitre guarded by a little carbonate of potash. This he took for three days without perceptible effect, and the fluid was again accu- mulating. I then prescribed for him eight grains of sal ammoniac