APPENDIX.

The following interesting paper, extracted from the Medical Repository, Hexad: ii. vol. i. p. 122 . . . 124, will give the reader a better idea, than he can receive from any other source, of Dr. Physick’s new and successful method of treating an old and obstinate fracture of the os humeri.

A Case of Fracture of the Os Humeri, in which the broken ends of the bone not uniting in the usual manner, a cure was effected by means of a seton. Communicated to Dr. Miller by Philip S. Physick, M. D.

“Isaac Patterson, a seaman, twenty-eight years of age, applied to me in May, 1802, in consequence of a fracture of his left arm, above the elbow joint, which had taken place several months before; but the ends of the bone not having united, rendered his arm nearly useless to him.

“The history he gave me was, that on the 11th of April, 1801, after having been at sea seven months, his arm was fractured by a heavy sea breaking over the ship. Nothing was done for his relief until next day, when the captain and mate bound it up, and applied splints over it. No swelling supervened, nor did he suffer any pain, Three weeks after this accident,he arrived at Alexandria, when the state of the arm was examined by a physician, who told him, that the ends of the bone were not in a proper situation. After making an extension, the splints and bandages were again applied. He remained in Alexandria four months, when, finding his arm no stronger, he left off all dressings, and went on board the New-York frigate as steward: in this capacity he remained near the Federal City six months, and by being under the necessity of using his arm as much as possible, he found the connexion between the ends of the bones became looser and looser, till, at length, the arm bent as easily as if a new joint had been formed at the place of the fracture. From the frigate he went to Baltimore, where an attempt was made by machinery to extend the arm, and keep the ends of the bone in apposition, by continuing the extension. Under this treatment he remained two months, but experiencing no benefit, he was advised to come to Philadelphia.

“On examining the arm, I found that the humerus had been fractured about two inches and a half above the elbow joint, and that the ends of the bone had passed each other, about an inch: the lower fragment, or that nearest the elbow, was situated over, and on the outside of the upper portion of the bone. The connexion that existed between the ends of the humerus was so flexible, as to allow of motion in every direction, and by forcible extension, the lower end might be pulled down considerably, but never so low as to be on a line with the end of the upper extremity. He was admitted into the Pennsylvania hospital, the latter end of May; but the weather becoming very hot,it was judged best to defer any operation that might be necessary, until the fall of the year. Unfortunately he then contracted a bilious fever, of which he was so ill, that his life was despaired of for some days. From this fever his recovery was so slow, that it was not thought proper to perform any operation until December. It still remained to decide, by what means a bony union of the humerus, might most probably be effected. In the year 1785, when a student, I had seen a case in our hospital, similar to this in every essential circumstance, in which an incision was made down to the extremities of the fractured bone, which were then sawed off, thereby putting the parts into the condition of a recent compound fracture. No benefit, however, was derived from this painful operation, and some months afterward the arm was amputated. This case had made a strong impression on my mind, and rendered me unwilling to perform a similar operation. I therefore proposed to some of the medical gentlemen of the hospital, who attended in consultation, that a seton-needle, armed with a skein of silk, should be passed through the arm, and between the fractured extremities of the bone, and that the seton should be left in this situation, until by exciting inflammation and suppuration, granulations should rise on the ends of the bone, which uniting and afterwards ossifying, would form the bony union that was wanting. This operation being agreed to, it was performed on the 18th of December, 1802, twenty months after the accident happened. Before passing the needle, I desired the assistants to make some extension of the arm, in orderthat the seton might be introduced as much as possible between the ends of the bone. Some lint and a pledget were applied to the orifices made by the seton-needle, and secured by a roller. The patient suffered very little pain from the operation. After a few days the inflammation (which was not greater than what is commonly excited by a similar operation through the flesh, in any other part) was succeeded by a moderate suppuration. The arm was now again extended, and splints applied. The dressings were renewed daily for twelve weeks, during which time no amendment was perceived; but soon afterwards the bending of the arm at the fracture was observed to be not so easy as it had been, and the patient complained of much more pain than usual whenever an attempt was made to bend it at that place. From this time, the formation of the new bony union went on rapidly, and, on the fourth of May, 1803, was so perfectly completed, that the patient could move his arm, in all directions, as well as before the accident happened. The seton was now removed, and the small sores occasioned by it, healed up entirely in a few days. On the 28th May, 1803, he was discharged from the hospital; perfectly well, and he has since repeatedly told me that his arm is as strong as it ever was.”

To the preceding paper it is unnecessary to add, that the mode of treatment there stated might be adopted in similar fractures of other bones, provided a seton-needle could be passed near to the ends of the fragments, without any risque of wounding blood-vessels, nerves, or other parts of importance. It isthus that solitary facts minutely detailed and well substantiated, oftentimes grow into principles of extensive application.

An account of Dr. Physick’s improvement of Desault’s apparatus for making permanent extension in oblique fractures of the os femoris.

Dr. Physick having observed that in the application of Desault’s apparatus, the patient was sometimes injured by the pressure of the strap or rollerg g(plate 2) which passes under the tuberosity of the ischium for the purpose of making counter-extension, devised the following method of remedying this inconvenience, in which he succeeded to his wishes.

He directed the upper end of the long external splint to be formed like the head of a crutch, and the splint itself to be lengthened so as to reach and bear against the axilla of the affected side, which must be well defended from pressure by a bolster of flannel or some other soft material. By this expedient the Dr. evidently formed two points of counter-extension, instead of one, as is the case in the apparatus of Desault. Between these two points, namely, the axilla and the perineum, the same quantity and force of pressure is, by Dr. Physick’s improvement,divided, which, in the original apparatus of Desault, is borne by theperineum alone. The risque of excoriation and injury to the patient, then, in the formercase, is to that which he runs in the latter, only as one to two, or nearly so. As it is no less the duty of the surgeon to prevent suffering than it is to remove deformity or to save life, Dr. Physick has certainly in this respect made an important step in the advancement of his profession.

But there is still another advantage derived from the lengthening of the external splint. In the original apparatus of Desault, the strapggintended for counter-extension, by passing no higher up than the spine of the ilium, runs too much across, and therefore acts too much on, the upper part of the thigh. By this it not only irritates the muscles of the part, and induces them to contract, but also tends to draw the upper fragment of the os femoris a little outward, and thus to render the thigh in some measure deformed. But, in the improvement of Dr. Physick, the strapggis secured in a mortise cut in the external splint, about midway between the spine of the ilium and the axilla. This strap, by being thus carried higher up on the body, does not run across the thigh at all. It consequently presses on and irritates the muscles much less, acts more in the direction of the os femoris, and has no tendency to draw the superior fragment outward.

Hence this improvement not only diminishes the patient’s sufferings, but gives him, perhaps, the best possible chance of having his limb preserved free from deformity.

Another improvement made on the lower end of the external splint by Dr. James Hutchinson deserves also to be mentioned. It was found that inthe 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.

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.

Plate 3.Hooker delt. Tanner, Sc.

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 atb, 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.

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 atb, 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 ata aand 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 endsa aof 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 handkerchiefB 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 arein 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 inplate 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.

Return totranscriber’s notesInconsistencies:armpit/arm-pitcondyl/condylecoracoid/corocoidcoronoid/coronoideexpence/expensefixt/fixedforearm/fore-arm/fore arminconveniencies/inconveniencesplane/plainScultel/Scultetteres-major/teres majorCorrections:aingly → singlyappplication → applicationbackwaad → backwardBruningaushen → Bruninghausencataloginous → cartilaginousciscumstance → circumstanceconsiderasion → considerationconstanly → constantlycontrouling → controllingcotemporaries → contemporariescroud → crowddecieve → deceivedivison → divisionexaming → examiningexextremities → extremitiesfaciæ → fasciæfollow → followingimitatators → imitatorsmake → makesmatrass → mattressnect → neckof of → ofpasssive → passivepercieve → perceiverecieves → receivesresourse → recoursethe the → theto to → towhould → would1303 → 1803 (date)67 → 66 (para numbering error)Return totranscriber’s notes

Return totranscriber’s notes

Inconsistencies:armpit/arm-pitcondyl/condylecoracoid/corocoidcoronoid/coronoideexpence/expensefixt/fixedforearm/fore-arm/fore arminconveniencies/inconveniencesplane/plainScultel/Scultetteres-major/teres major

Corrections:aingly → singlyappplication → applicationbackwaad → backwardBruningaushen → Bruninghausencataloginous → cartilaginousciscumstance → circumstanceconsiderasion → considerationconstanly → constantlycontrouling → controllingcotemporaries → contemporariescroud → crowddecieve → deceivedivison → divisionexaming → examiningexextremities → extremitiesfaciæ → fasciæfollow → followingimitatators → imitatorsmake → makesmatrass → mattressnect → neckof of → ofpasssive → passivepercieve → perceiverecieves → receivesresourse → recoursethe the → theto to → towhould → would1303 → 1803 (date)67 → 66 (para numbering error)

Return totranscriber’s notes

FOOTNOTES:1(Appareil.) I am fully sensible that the word Apparatus, does not, according to the common acceptation of the term, convey, in English, precisely the same ideas, that the word “appareil” does, in French; but it certainly approaches much nearer to it than any other term found in English works on surgery. It signifies a collection or assemblage of means, used for the attainment of a particular end; and this is, in substance, what Desault meant by the term “appareil.” His “appareil” (apparel) for a broken bone included splints, bandages, bolsters, and every thing else necessary for retaining the fractured ends in apposition. The English reader will naturally enough annex the same ideas to the word Apparatus, as used throughout the present work. I have, therefore, thought proper to adopt it, rather than to introduce a new or uncommon term, and am sure, that, for all practical purposes, it will be found sufficiently expressive of the meaning of the original. And I am much more solicitous to become instrumental in giving some aid to the surgeon in the practice of his profession, than to escape the censure of the fastidious critic.Trans.2That form of lever, where the weight to be raised or the resistance to be overcome, is at one end, the force at the other, and the fulcrum or prop between them. This form is well represented by the handle of a pump, where the piston is the weight or resistance, the hand of the drawer of water the force, and the iron pin, on which the handle works, the fulcrum or prop.Trans.3This paragraph is so obscure in the original, that a translation of it would be scarcely intelligible. Instead of a mere translation, therefore, I have given rather a comment on what I believe to be its true meaning.Trans.4That process or operation in which the surgeon uses his hands to effect the reduction and apposition of parts, which cannot be accomplished by extension and counter-extension alone. If a bone be broken into two or three pieces, mere extension and counter-extension will not bring all the fragments into their proper places, so as to restore the natural form of the part. In such cases, the surgeon uses his hands to aid the action of the extended muscles, and this is the process which our author denominatesconformation. The term occurs in many places in the course of the work.Trans.5I find in English books of anatomy no appropriate names for these two ligaments. I am therefore obliged to translate the French terms for them literally. The anatomist will have no difficulty in recollecting their situation.Trans.6I do not recollect any terms in English works of anatomy equivalent to these.Trans.7Compresses laid one upon another, of which the upper one is still the smallest, not in relation to thickness, but as far as regards length and breadth.Trans.8The rupture in the capsule that surrounds the joint.T.9Une pelotte.10For a very important improvement made by Dr. Physic in the treatment of an old fracture of the os humeri, and which may be applied also to similar fractures of other bones, see Article I. of the Appendix.Trans.11(* L’echelle, † la porte, ‡ le baton.) These pieces of machinery, though formerly in use, are now, I believe, in all parts of the world, laid aside. It would be superfluous, therefore, to consume time in describing either them, or their mode of operation.Trans.12In this form of lever, the power is applied between the fulcrum and the weight to be moved, or the resistance to be overcome.Trans.13(Bandage a bandalettes.) This is a most convenient form of bandage, in fractures of the upper or lower extremities. It is composed of strips of soft linen or muslin, from two to three inches wide, and of a length accommodated to the size of the limb, on which they are to be applied. These strips are not sewed together, but merely laid along side of each other, or rather spread in such a way that their adjoining edges may overlap a little. Being thus arranged, on the bed or mattress, where the patient is to lie, the broken limb is placed on them, when the surgeon, taking them, one by one, folds them round it, so as to form a very perfect and neat covering. The number of these strips must be regulated by the extent of the limb, or, at least, of that portion of the limb, which they are intended to cover.Trans.14(La fosse sous-scapulaire). I know of no English anatomical term for this. I therefore translate it literally. The same is true with respect to “fossa sous-epineuse,” translated here, fossa infra-spinata.Trans.15(De mouffle de Petit.)16That is, to draw, or otherwise force the head of the os humeri, with his hands, towards the glenoid cavity, while the assistants are making extension and counter-extension. In doing this, he must pull the head upwards, if it be lodged in the axilla, backward if it be under the upper part of the pectoralis major, &c. Desault, however, contends that this assistance from the surgeon is unnecessary, and that extension and counter-extension are alone sufficient to effect the reduction.Trans.17With the particular mechanism and mode of action of this bandage, I am unacquainted. Nor are these matters of much moment, as the bandage is, I believe, entirely out of use.Trans.18On this point Desault is certainly mistaken. Paste-board, when of a proper thickness and well applied, makes an excellent splint for fractures of the fore-arm. It moulds itself to the form of the arm, sits easy, and retains the fracture extremely well.Trans.19Not generally named in English works of anatomy.20Echancrure sigmoide.21That deep depression in the os humeri, which, in a natural state of the parts, receives the upper end of the olecranon process.Trans.22(La longueur, l’epaisseur, et la direction.) That is, the thigh may be shorter than natural, owing to the ends of the broken bone overlapping each other; it may have a protuberance on one side, in consequence of these ends being separated or displaced laterally; or the direction of the limb may be changed, by a bend or angle being produced in the bone at the place of the fracture.Trans.23A term of nearly the same import with “conformation.”Trans.24(Le lit d’Hippocrate.) As many of the machines mentioned here have probably never been seen in this country, and as there is, perhaps, scarcely one of them used, at present, in any country, I shall not consume the time of the reader by troubling him with descriptions of them.Trans.25(Drap-fanon.) This is a piece of linen or muslin (Desault appears to have used flannel, which is not however so good) spread under the broken limb, reaching in length from one end of it to the other, and wide enough to go about twice round it. It is to be folded at its edges several times round the internal and the long external splints, in order to retain them the better, and make them bear with more steadiness and advantage on the limb. The junk-cloth and these two splints, when properly applied, form a kind of soft elastic case, in which the limb rests. This case is of service in securing the bolsters in their places. The junk-cloth is the outside piece of the apparatus, except the bits of tape which go round and secure the whole. In arranging the different pieces, therefore, on the bed or mattress, where the patient is to lie, the surgeon places the tapes first, the junk-cloth next, the bandage of strips next, and so on, in an order the reverse of that in which he afterwards applies them on the limb.Trans.26Le Spica de l’aine.Trans.27(L’ecusson.) The literal meaning of this word is an escutcheon, or a coat of arms. But when used in surgical language, it signifies a retentive or strengthening plaster. Such I conceive its meaning to be in the present instance.Trans.28A motion or sweep describing the arch of a circle.Trans.29That which forms the superior boundary of the longitudinal fracture by which the condyls are separated from each other.Trans.30For an account of an improvement of the splint, represented in this plate, projected by Dr. Physick, and now used in the Pennsylvania hospital, see Article II. of the Appendix.Trans.31A case of luxation of the head of the os femoris in a forward direction, but differing in some respects from the above, occurred lately in the Pennsylvania hospital under the care of Dr. Physick. The doctor reduced this luxation in the amphitheatre, in the presence of his class, by a process which was also somewhat different from that adopted by Desault.In the case of Desault’s patient the luxated limb was shorter than the sound one: in that of Dr. Physick’s it was evidently longer. This was no doubt owing to the head of the os femoris having, in the former case, passed farther up towards the superior rim of the os pubis than it had in the latter. In both cases the protuberance formed by the head of the bone in the groin could be readily felt.For the purpose of making counter-extension, Desault passed a strap between the scrotum and the thigh of the sound side: Dr. Physick, for the same purpose, passed the strap between the scrotum and the affected thigh. He conceived that by this mode he could act with more effect on the pelvis, and more effectually prevent the acetabulum of the affected side from being drawn in any measure downward by the extending forces. It would seem, that by making counter-extension, in such a case, on the sound side, the pelvis is made to rotate, so to speak, on its own axis, in the direction in which the counter-extension is made. The necessary effect of this rotation must be, a slight descent of the acetabulum of the affected side. But to retain the acetabulum firmly up is the true and only end of counter-extension. Dr. Physick appears therefore to have availed himself of the greatest mechanical advantage of which the situation of the parts admitted.Again: Desault placed the strap on which extension was made just above the ancle: Dr. Physick placed the strap intended for the same purpose above the knee. His object in this was, to have the leg free and unincumbered, in order that he might be able to use the limb with more advantage, as a lever of the first kind, to assist in moving the head of the os femoris towards the acetabulum. The fulcrum of the lever into which the limb was thus converted, was a strap passed round the affected thigh a few inches below the groin, and drawn laterally with great force in a direction opposite to that in which the bone was displaced.In this case extension and counter-extension were made by means of powerful sets of pullies. Notwithstanding this, these forces were not alone sufficient to subdue the resistance of the muscles. The reduction was not completed till muscular contraction had been weakened, and the patient reduced almost to a state of syncope, by the loss of nearly two quarts of blood. This copious evacuation, co-operating with the fatigue which the muscles of the limb necessarily sustained, in consequence of the powerful extension to which they were for some time subjected by the action of the pullies, overcame all resistance and the head of the bone was finally replaced. To exhaust the energy of the resisting muscles by forcible and permanent extension, and to weaken the action of the system generally, by copious blood-letting, appear to be the two most effectual modes of ensuring success in the reduction of all obstinate cases of luxation.Another point of difference between these two cases of luxation remains yet to be mentioned. In Desault’s case the head of the os femoris was, as he tells us, displaced in a direction “upward and forward.” In Dr. Physick’s case, the direction of the displacement was downward and forward. This was proved beyond all doubt, by the circumstance of the affected limb being longer than the sound one.Trans.32I know not of any English term equivalent to this. T.33The roller or strip with holes in it, which is extended along the fore part of the limb, serving, in some measure, the purpose of a compress.Trans.34That is, without any assistance from the hands of the surgeon.Trans.35Analogous in its form and uses to that employed in fractures of the thigh. It may not be amiss, on this occasion to mention, that in the form of apparatus for oblique fractures of the leg, represented in the Appendix, plate III. no junk-cloth is necessary.Trans.36For a view and description of an excellent form of apparatus for oblique fractures of the leg, constructed on the principles of that here described, see article III. plate III. of the Appendix.Trans.37(Genouilliere.) I believe this was a piece of apparatus made of leather, somewhat similar to the top of a boot, and secured on the limb just above the knee.Trans.

1(Appareil.) I am fully sensible that the word Apparatus, does not, according to the common acceptation of the term, convey, in English, precisely the same ideas, that the word “appareil” does, in French; but it certainly approaches much nearer to it than any other term found in English works on surgery. It signifies a collection or assemblage of means, used for the attainment of a particular end; and this is, in substance, what Desault meant by the term “appareil.” His “appareil” (apparel) for a broken bone included splints, bandages, bolsters, and every thing else necessary for retaining the fractured ends in apposition. The English reader will naturally enough annex the same ideas to the word Apparatus, as used throughout the present work. I have, therefore, thought proper to adopt it, rather than to introduce a new or uncommon term, and am sure, that, for all practical purposes, it will be found sufficiently expressive of the meaning of the original. And I am much more solicitous to become instrumental in giving some aid to the surgeon in the practice of his profession, than to escape the censure of the fastidious critic.Trans.

2That form of lever, where the weight to be raised or the resistance to be overcome, is at one end, the force at the other, and the fulcrum or prop between them. This form is well represented by the handle of a pump, where the piston is the weight or resistance, the hand of the drawer of water the force, and the iron pin, on which the handle works, the fulcrum or prop.Trans.

3This paragraph is so obscure in the original, that a translation of it would be scarcely intelligible. Instead of a mere translation, therefore, I have given rather a comment on what I believe to be its true meaning.Trans.

4That process or operation in which the surgeon uses his hands to effect the reduction and apposition of parts, which cannot be accomplished by extension and counter-extension alone. If a bone be broken into two or three pieces, mere extension and counter-extension will not bring all the fragments into their proper places, so as to restore the natural form of the part. In such cases, the surgeon uses his hands to aid the action of the extended muscles, and this is the process which our author denominatesconformation. The term occurs in many places in the course of the work.Trans.

5I find in English books of anatomy no appropriate names for these two ligaments. I am therefore obliged to translate the French terms for them literally. The anatomist will have no difficulty in recollecting their situation.Trans.

6I do not recollect any terms in English works of anatomy equivalent to these.Trans.

7Compresses laid one upon another, of which the upper one is still the smallest, not in relation to thickness, but as far as regards length and breadth.Trans.

8The rupture in the capsule that surrounds the joint.T.

9Une pelotte.

10For a very important improvement made by Dr. Physic in the treatment of an old fracture of the os humeri, and which may be applied also to similar fractures of other bones, see Article I. of the Appendix.Trans.

11(* L’echelle, † la porte, ‡ le baton.) These pieces of machinery, though formerly in use, are now, I believe, in all parts of the world, laid aside. It would be superfluous, therefore, to consume time in describing either them, or their mode of operation.Trans.

12In this form of lever, the power is applied between the fulcrum and the weight to be moved, or the resistance to be overcome.Trans.

13(Bandage a bandalettes.) This is a most convenient form of bandage, in fractures of the upper or lower extremities. It is composed of strips of soft linen or muslin, from two to three inches wide, and of a length accommodated to the size of the limb, on which they are to be applied. These strips are not sewed together, but merely laid along side of each other, or rather spread in such a way that their adjoining edges may overlap a little. Being thus arranged, on the bed or mattress, where the patient is to lie, the broken limb is placed on them, when the surgeon, taking them, one by one, folds them round it, so as to form a very perfect and neat covering. The number of these strips must be regulated by the extent of the limb, or, at least, of that portion of the limb, which they are intended to cover.Trans.

14(La fosse sous-scapulaire). I know of no English anatomical term for this. I therefore translate it literally. The same is true with respect to “fossa sous-epineuse,” translated here, fossa infra-spinata.Trans.

15(De mouffle de Petit.)

16That is, to draw, or otherwise force the head of the os humeri, with his hands, towards the glenoid cavity, while the assistants are making extension and counter-extension. In doing this, he must pull the head upwards, if it be lodged in the axilla, backward if it be under the upper part of the pectoralis major, &c. Desault, however, contends that this assistance from the surgeon is unnecessary, and that extension and counter-extension are alone sufficient to effect the reduction.Trans.

17With the particular mechanism and mode of action of this bandage, I am unacquainted. Nor are these matters of much moment, as the bandage is, I believe, entirely out of use.Trans.

18On this point Desault is certainly mistaken. Paste-board, when of a proper thickness and well applied, makes an excellent splint for fractures of the fore-arm. It moulds itself to the form of the arm, sits easy, and retains the fracture extremely well.Trans.

19Not generally named in English works of anatomy.

20Echancrure sigmoide.

21That deep depression in the os humeri, which, in a natural state of the parts, receives the upper end of the olecranon process.Trans.

22(La longueur, l’epaisseur, et la direction.) That is, the thigh may be shorter than natural, owing to the ends of the broken bone overlapping each other; it may have a protuberance on one side, in consequence of these ends being separated or displaced laterally; or the direction of the limb may be changed, by a bend or angle being produced in the bone at the place of the fracture.Trans.

23A term of nearly the same import with “conformation.”Trans.

24(Le lit d’Hippocrate.) As many of the machines mentioned here have probably never been seen in this country, and as there is, perhaps, scarcely one of them used, at present, in any country, I shall not consume the time of the reader by troubling him with descriptions of them.Trans.

25(Drap-fanon.) This is a piece of linen or muslin (Desault appears to have used flannel, which is not however so good) spread under the broken limb, reaching in length from one end of it to the other, and wide enough to go about twice round it. It is to be folded at its edges several times round the internal and the long external splints, in order to retain them the better, and make them bear with more steadiness and advantage on the limb. The junk-cloth and these two splints, when properly applied, form a kind of soft elastic case, in which the limb rests. This case is of service in securing the bolsters in their places. The junk-cloth is the outside piece of the apparatus, except the bits of tape which go round and secure the whole. In arranging the different pieces, therefore, on the bed or mattress, where the patient is to lie, the surgeon places the tapes first, the junk-cloth next, the bandage of strips next, and so on, in an order the reverse of that in which he afterwards applies them on the limb.Trans.

26Le Spica de l’aine.Trans.

27(L’ecusson.) The literal meaning of this word is an escutcheon, or a coat of arms. But when used in surgical language, it signifies a retentive or strengthening plaster. Such I conceive its meaning to be in the present instance.Trans.

28A motion or sweep describing the arch of a circle.Trans.

29That which forms the superior boundary of the longitudinal fracture by which the condyls are separated from each other.Trans.

30For an account of an improvement of the splint, represented in this plate, projected by Dr. Physick, and now used in the Pennsylvania hospital, see Article II. of the Appendix.Trans.

31A case of luxation of the head of the os femoris in a forward direction, but differing in some respects from the above, occurred lately in the Pennsylvania hospital under the care of Dr. Physick. The doctor reduced this luxation in the amphitheatre, in the presence of his class, by a process which was also somewhat different from that adopted by Desault.In the case of Desault’s patient the luxated limb was shorter than the sound one: in that of Dr. Physick’s it was evidently longer. This was no doubt owing to the head of the os femoris having, in the former case, passed farther up towards the superior rim of the os pubis than it had in the latter. In both cases the protuberance formed by the head of the bone in the groin could be readily felt.For the purpose of making counter-extension, Desault passed a strap between the scrotum and the thigh of the sound side: Dr. Physick, for the same purpose, passed the strap between the scrotum and the affected thigh. He conceived that by this mode he could act with more effect on the pelvis, and more effectually prevent the acetabulum of the affected side from being drawn in any measure downward by the extending forces. It would seem, that by making counter-extension, in such a case, on the sound side, the pelvis is made to rotate, so to speak, on its own axis, in the direction in which the counter-extension is made. The necessary effect of this rotation must be, a slight descent of the acetabulum of the affected side. But to retain the acetabulum firmly up is the true and only end of counter-extension. Dr. Physick appears therefore to have availed himself of the greatest mechanical advantage of which the situation of the parts admitted.Again: Desault placed the strap on which extension was made just above the ancle: Dr. Physick placed the strap intended for the same purpose above the knee. His object in this was, to have the leg free and unincumbered, in order that he might be able to use the limb with more advantage, as a lever of the first kind, to assist in moving the head of the os femoris towards the acetabulum. The fulcrum of the lever into which the limb was thus converted, was a strap passed round the affected thigh a few inches below the groin, and drawn laterally with great force in a direction opposite to that in which the bone was displaced.In this case extension and counter-extension were made by means of powerful sets of pullies. Notwithstanding this, these forces were not alone sufficient to subdue the resistance of the muscles. The reduction was not completed till muscular contraction had been weakened, and the patient reduced almost to a state of syncope, by the loss of nearly two quarts of blood. This copious evacuation, co-operating with the fatigue which the muscles of the limb necessarily sustained, in consequence of the powerful extension to which they were for some time subjected by the action of the pullies, overcame all resistance and the head of the bone was finally replaced. To exhaust the energy of the resisting muscles by forcible and permanent extension, and to weaken the action of the system generally, by copious blood-letting, appear to be the two most effectual modes of ensuring success in the reduction of all obstinate cases of luxation.Another point of difference between these two cases of luxation remains yet to be mentioned. In Desault’s case the head of the os femoris was, as he tells us, displaced in a direction “upward and forward.” In Dr. Physick’s case, the direction of the displacement was downward and forward. This was proved beyond all doubt, by the circumstance of the affected limb being longer than the sound one.Trans.

In the case of Desault’s patient the luxated limb was shorter than the sound one: in that of Dr. Physick’s it was evidently longer. This was no doubt owing to the head of the os femoris having, in the former case, passed farther up towards the superior rim of the os pubis than it had in the latter. In both cases the protuberance formed by the head of the bone in the groin could be readily felt.

For the purpose of making counter-extension, Desault passed a strap between the scrotum and the thigh of the sound side: Dr. Physick, for the same purpose, passed the strap between the scrotum and the affected thigh. He conceived that by this mode he could act with more effect on the pelvis, and more effectually prevent the acetabulum of the affected side from being drawn in any measure downward by the extending forces. It would seem, that by making counter-extension, in such a case, on the sound side, the pelvis is made to rotate, so to speak, on its own axis, in the direction in which the counter-extension is made. The necessary effect of this rotation must be, a slight descent of the acetabulum of the affected side. But to retain the acetabulum firmly up is the true and only end of counter-extension. Dr. Physick appears therefore to have availed himself of the greatest mechanical advantage of which the situation of the parts admitted.

Again: Desault placed the strap on which extension was made just above the ancle: Dr. Physick placed the strap intended for the same purpose above the knee. His object in this was, to have the leg free and unincumbered, in order that he might be able to use the limb with more advantage, as a lever of the first kind, to assist in moving the head of the os femoris towards the acetabulum. The fulcrum of the lever into which the limb was thus converted, was a strap passed round the affected thigh a few inches below the groin, and drawn laterally with great force in a direction opposite to that in which the bone was displaced.

In this case extension and counter-extension were made by means of powerful sets of pullies. Notwithstanding this, these forces were not alone sufficient to subdue the resistance of the muscles. The reduction was not completed till muscular contraction had been weakened, and the patient reduced almost to a state of syncope, by the loss of nearly two quarts of blood. This copious evacuation, co-operating with the fatigue which the muscles of the limb necessarily sustained, in consequence of the powerful extension to which they were for some time subjected by the action of the pullies, overcame all resistance and the head of the bone was finally replaced. To exhaust the energy of the resisting muscles by forcible and permanent extension, and to weaken the action of the system generally, by copious blood-letting, appear to be the two most effectual modes of ensuring success in the reduction of all obstinate cases of luxation.

Another point of difference between these two cases of luxation remains yet to be mentioned. In Desault’s case the head of the os femoris was, as he tells us, displaced in a direction “upward and forward.” In Dr. Physick’s case, the direction of the displacement was downward and forward. This was proved beyond all doubt, by the circumstance of the affected limb being longer than the sound one.Trans.

32I know not of any English term equivalent to this. T.

33The roller or strip with holes in it, which is extended along the fore part of the limb, serving, in some measure, the purpose of a compress.Trans.

34That is, without any assistance from the hands of the surgeon.Trans.

35Analogous in its form and uses to that employed in fractures of the thigh. It may not be amiss, on this occasion to mention, that in the form of apparatus for oblique fractures of the leg, represented in the Appendix, plate III. no junk-cloth is necessary.Trans.

36For a view and description of an excellent form of apparatus for oblique fractures of the leg, constructed on the principles of that here described, see article III. plate III. of the Appendix.Trans.

37(Genouilliere.) I believe this was a piece of apparatus made of leather, somewhat similar to the top of a boot, and secured on the limb just above the knee.Trans.

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