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.
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2 That 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.
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3 This 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.
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4 That 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 denominates conformation. The term occurs in many places in the course of the work.
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5 I 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.
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6 I do not recollect any terms in English works of anatomy equivalent to these.
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7 Compresses 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.
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8 The rupture in the capsule that surrounds the joint.
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9 Une pelotte.

10 For 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.
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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.
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12 In this form of lever, the power is applied between the fulcrum and the weight to be moved, or the resistance to be overcome.
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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.
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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.
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15 (De mouffle de Petit.)

16 That 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.
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17 With 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.
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18 On 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.
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19 Not generally named in English works of anatomy.

20 Echancrure sigmoide.

21 That deep depression in the os humeri, which, in a natural state of the parts, receives the upper end of the olecranon process.
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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.
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23 A term of nearly the same import with “conformation.”
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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.
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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.
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26 Le Spica de l’aine.
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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.
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28 A motion or sweep describing the arch of a circle.
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29 That which forms the superior boundary of the longitudinal fracture by which the condyls are separated from each other.
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30 For 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.
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31 A 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.
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32 I know not of any English term equivalent to this. T.

33 The 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.
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34 That is, without any assistance from the hands of the surgeon.
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35 Analogous 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.
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36 For 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.
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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.
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