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           /
            LECTURES
                  ON
FRACTURES AND DISLOCATIONS,
EXPLAINING
NEW IVIODES OF TREATMENT, FOUNDED ON ANATOMY.
   PHYSIOLOGY, AND THE LAWS OF MECHANICS,
TOGETHER WITH
CONCISE INSTRUCTIONS
IN THE USE OF
THE  ADJUSTER
By GEORGE O.  JARVIS, M. D.
        STjjirtr isaition.



           BOSTON:
DAVID CLAPP, PRINTER..........184 WASHINGTON STREET.
              1847. 
\NEA
1311 
JARVIS'S   ADJUSTER
  By means of this instrument the surgeon  has at his command
an extending and counter-extending force, equal to that of twelve
men, all or any  part of which he can apply to any limb at plea-
sure, and yet the limb remain perfectly moveable and free from
manipulation.
ADVERTISEMENT.
      MESSRS.  H.  &  CJ.  KELLOGG,
              OF BIRMINGHAM, CONN.
  Would  respectfully  announce to the Medical Profession, to
ship-owners, and ship-masters, that  they have made arrangements
with GEORGE  0. JARVIS,  M. D., the inventor and proprietor
of the "Surgical  Adjuster," for the sole and exclusive manufac-
ture of that  instrument in the United States; and that  they are
also authorized to sell the same for  use,- either by themselves, or
by agents duly appointed for that purpose.   All orders, therefore,
for  the  instrument, addressed to  them as above,  will  receive
prompt attention.
  They take pleasure in here giving their assurances to those who
may wish to procure the instrument, that every part shall be made
of the best materials, and shall also be finished in a style worthy
of so important  an apparatus in surgery, and  as shall be  best
adapted to fulfil  the indications required.   In short, they would
state in few words that they do  not intend to allow an instru-
ment to leave their  establishment, which, at the time, shall be im-
perfect.   Thus by faithfulness and fair dealing, on their part, they
hope to  receive that encouragement from the profession,  and from
ship-owners, which the addition of an instrument so  important to
surgery, and so valuable to the world,  would lead them reasona-
bly to expect.
  It is, perhaps, unnecessary to mention, that this instrument has
received the unqualified approbation of the  most eminent surgeons
both of Europe and America, and that it has been used with com-
plete  success in  numerous cases  where all the  ordinary means,
and the most persevering  efforts to effect  reduction, had failed.
Should  this  their first  effort to benefit the profession be crowned
with success, they hope in due  time to present other important
surgical instruments of their manufacture,  for examination. 
 
ADDRESS.
  In presenting this instrument to the surgeon, I beg leave
to remark, that I  had long felt the  want of means  better
adapted to reduce dislocations, to adjust  fractures, and to
maintain coaptation ;—means more in accordance with sound
principles  of surgery, than any  which  had  hitherto been
presented to the profession.
  In dislocations (for example), the application of force by
pullies or by assistants, I found always and  of necessity to
operate from fixed points, over which the surgeon could have
no control, and in  consequence of which  those movements of
the limb, so necessary  to  render reduction easy, were so
restrained by the  means  employed, as  not only to prove
a material  hinderance,  but occasionally, I  had too much
reason to  believe, were actually the cause  of defeat,  and
perhaps of additional injury ; nor indeed did the principles
of science appear to me to be so applied as to do credit
to a learned profession ;  mere mechanical or physical force,
applied in a given line, being all that could  be relied upon
to effect the object.   In fact,  with  the  most  skilful,  this
was all that  was  available in  the use of those means ; so
that he who fearlessly pulled the  hardest, and  stuck  to his
case most perseveringly, regardless  of the pain he inflicted
on his patient, generally had the  reputation  of being " the
best bone-setter."  In short, this was almost the only  way
in which the skill of the  surgeon  could  be exercised, and
science employed  in the use of the means above indicated ;
and it is presumed, in consequence of those  means operat-
ing mechanically  just as  they do  in their not being con-
formed  to the principles of surgery, that so many cases
               1* 
6
ADDRESS.
have been  dismissed by the surgeon before reduction, and
the unfortunate patient  doomed  to perpetual lameness ;
becoming, in his hopeless state, an easy prey  to the design-
ing charlatan.
  To illustrate these views, let us suppose a  dislocation  of
the hip.  The head of the bone being thrown upwards, and
outwards, it would be driven as a consequence into the sur-
rounding soft parts, and by the oblique position of the neck,
to the shaft of the bone;  the head and neck would now act
like a hook thrown around  the muscular fibres, which lie
below them.   When force is applied from fixed points and
in a line with the shaft, that force will tend either to tear
through the  muscles around which  they are  thrown, or to
break the bone, and not to disengage the head from the sur-
rounding soft parts, while extension, and counter-extension,
are thus operating  on the limb: and any force applied poste-
riorly, would furnish but imperfect assistance to disengage the
head, since that head is always larger than its  neck, and  of
course,  must press more deeply into the muscular substance
beneath it.   From  this cause alone, it is believed, that the
femur has occasionally been broken in attempts at reduction.
   From the foregoing facts it must be apparent to  every
surgeon, that "all is not right"  here; while the  objec-
tion to the  use of force operating from fixed points  in reduc-
ing other dislocations, as in some cases of the shoulder, the
elbow &,c, are  equally  clear, as a moment's  reflection will
show, although the  same mechanical difficulties may not,
strictly, be involved in their reduction.
   In fractures, too, the principles on which the various me-
chanical contrivances  have hitherto been constructed  for
preserving coaptation, I  cannot but regard as essentially
defective.   In their management I have long held  position,
and extension and counter-extension, to be two distinct and
essential principles in surgery, of equal importance, or  nearly
so, of  which,  neither should give  place to the other.  In
 oblique fractures  of the  femur,  for  example,  immediately
 below the trochanter minor, attended with strong  muscular
 contractions of the limb, to disregard the action of the psoas 
ADDRESS.
7
magnus and iliacus internus muscles, in throwing the upper
portion of the fractured bone forwards, and that also of  the
short head of the biceps flexor cruris  and gastrocnemii, in
throwing the lower portion backwards (while there are none
whose direct action tends to prevent this deformity) ; under
such circumstances to adopt the straight position, for  the
sake of extension and counter-extension, would  be to sacri-
fice entirely the principle of position ; while it yet requires
a greater extending force  to restore the normal length of the
limb, in the straight position, than it would if those muscles
were first relaxed by adopting the bent position.
   On  the contrary, to adopt the bent position, which would
effectually relax those muscles, and would  also  incline  the
lower portion of bone into a normal line with the upper, and
 yet neglect to use extension and counter-extension ; in  turn
 would be to sacrifice the  principle of extension and coun-
 ter-extension for that of position, the ill  effects of which
 would probably be as strongly marked as in the former case,
 and both of which, it is conceived, the surgeon should, if
 possible, endeavor to avoid.
    Nor, indeed, can these  defects be  fully remedied by at-
 tempting  to combine the two principles  in  one apparatus.
 For example—the extending point being fixed  to the  foot,
 the counter-extending point being also fixed to the body at
 the perinaeum,  and these again operating from  the two ex-
 tremities of a double-inclined plane on which the limb  is to
 rest, it must  be  apparent, to  apply  force  to the two ex-
 tremities  of a  limb  thus situated, would tend, just in  pro-
 portion as the limb  is flexed, to throw the fractured por-
 tions of bone out of a normal line, by converting each  por-
 tion into a lever ; and that, too, by the very mode of apply-
 ing the force—the soft parts serving as their fulcra.  These
 remarks  and principles  apply  to other fractures  of the
 femur below the trochanter minor, and also to fractures of
 the leg, as much as they do to the one just named, and yet
 not perhaps with all the ill consequences so frequently at-
 tending, as a careful examination of the action of the various
 muscles of the extremities will plainly show. 
8
ADDRESS.
  To these defects in surgical  practice may be ascribed,
mainly,  the introduction of this instrument to  the  profes-
sion :  and in perfecting its arrangements, the following prin-
ciples were adopted in its construction.
  First.—Always to admit of  the same free motion of the
limb during the application of force, which  that limb pos-
sessed independently of the use of this instrument.
  Second.—To allow the surgeon to apply any amount of
force in the exact line of the shaft of the bone on which he
is to operate.
  Third.—To have that force  both gentle and  steady, ca-
pable of being applied  either rapidly or slowly, and retained
permanently on the limb, or relaxed  instantly,  as the sur-
geon shall choose, while it is  also, at all times, under his
entire control.
  Fourth.—To enable the surgeon to confine the points of
extension  and counter-extension within the limits  of any
given round bone.
  Fifth.—To enable the  surgeon to apply extension and
counter-extension in any position of the limb.
  In presenting  an instrument  to the profession by which
the foregoing  principles may be conveniently and  readily
applied, I conceive that many of the difficulties in reducing
dislocations, in adjusting fractures, and  in  maintaining co-
aptation, may  be obviated ; and I respectfully invite a tho-
rough investigation of its principles—a faithful trial  of  its
merits.   And  that its objects  may  be  clearly defined,  I
will distinctly  state, that  it is  intended  to reduce all dis-
locations,—to  adjust all fractures,—and to maintain coapta-
tion of all fractured bones,  where extension and counter-
extension are  requisite to accomplish either of  those ends.
  It may not be  out  of  place also  to  state, briefly, some
further advantages which this apparatus possesses over every
other means.
  1. Its whole force being entirely subject to the command
of the surgeon,  and applied by  his own hand; he is thus
enabled to regulate that power  at will, inasmuch as he is ca-
pable of feeling  the amount of power which he  uses. He is 
ADDRESS.
9
also enabled  to dispense with the services of assistants, the
aid of more than one  being never necessary, and generally
not even that.
   2.  It is  more  readily applied  than the  pullies, and in
places, moreover, where to apply  these, it  would  be  ex-
tremely difficult; it being just as  conveniently and suc-
cessfully used in the  bed-chamber,  or in the field, or  in a
ship,  or,  indeed, in  any other  place where the  person
injured can be approached, as in the best regulated hospital.
It is also compact and portable, and made of materials so
strong and durable, that it is not liable to get out of order.
   3.  In fractures at the neck of the thigh bone it allows the
patient to  lie on the side opposite the one injured.   This is
an advantage, which may not appear to many  at first sight,
but which  is nevertheless a great one, and which on reflection
will appear so obvious, that it will be accounted matter of no
small consideration  in the treatment  of those injuries.  On
this and other points, however, I would refer the reader to my
lectures delivered at the Royal Westminster Ophthalmic Hos-
pital, Charing Cross, London, and published in the March,
April and  May  Nos.  of the  London Lancet,  which are
here subjoined  for  the benefit of those  who may use the
instrument.
   I  have  thus endeavored to point out, briefly, some of the
more prominent objections—objections, I mean, to the prin-
ciples, which must not only now, but always in the nature
of things,  lie against the  use  of  the  means in common use
for treating both fractures and dislocations.   I  have  also
briefly, but plainly,  and I trust correctly, stated some of the
advantages to be obtained in  using the Adjuster in those in-
juries.  That I have not in the least magnified the defects of
the one, or over-rated the benefits of the other, I leave  it to
the man of experience—the practical surgeon, to decide.  I
now  cheerfully submit it to the profession in my own coun-
try, as I have already done to  very many of the most learned
in that profession in England, France and  Germany, whose
approval  it  has  received (most promptly  and cheerfully
bestowed), for their candid  investigation  of its principles. 
10
ADDRESS.
and their thorough trial of its merits, trusting it may prove in
their hands, as it has in the hands  of  all who have used it,
a blessing to mankind.
  I take this opportunity to state that I have made arrange-
ments with Mr. Henry Kellogg, of  Birmingham, Conn., for
the manufacture and supply of the Adjuster, and to him I
refer not  only members  of the  profession, but  also ship-
owners, and ship-masters, for  the  instrument, "against  a
time of need."  I am happy  in being able to  state, that
Mr. Kellogg is  not  only  every way qualified for the task,
but is worthy of their entire confidence,  not only as a manu-
facturer, but also as a man, and that he has associated with
him for the above purpose, Mr. George  Kellogg, A. M.,  a
scientific and practical mechanic of the first order.  Under
their management, the profession and all who are  interested
may be well assured that every part will be faithfully made,
and that all business  transactions  will be honorably  con-
ducted.
                      GEORGE  O.  JARVIS, M. D.
  Portland, Conn., July, 1846. 
      A COURSE OF FIVE LECTURES
                       ON

FRACTURES  AND DISLOCATIONS,
                    EXPLAINING
  NEW MODES OF TREATMENT, FOUNDED ON ANATOMY AND
       PHYSIOLOGY, AND THE LAWS OF MECHANICS.
         BY GEO. O. JARVIS, M.D., &c.  &c.
              Portland, Connecticut, United States.
Delivered at the Royal Westminster Ophthalmic Hospital, Charing Cross,
                London, November, 1815.
JHlustratefc b$ lEnfltabfnjjs.
                LECTURE  I.
Division of the Muscles of the Thigh into Classes.—
  Mechanical Action of those Muscles in Fractures of
  the Bone.—Usual Violation of the Laws of Mecha-
  nics in the Treatment of such Fractures.—Necessary
  Attention to fixed points in applying Force to reduce
  Luxations.
  The brief course of Lectures, of which the present
forms the first, will contain a summary of my  expe-
rience during twenty-six  years of professional labor,
the last five of which, have been spent in a situation
peculiarly favorable for the observation  of fractures
and dislocations, my attention having been particu-
larly turned to the subject, while designing, testing,
and perfecting, the apparatus which is now offered to
the notice of the profession for treating those injuries.
Numerous  opportunities  have occurred  to me  for 
12
FRACTURES AND DISLOCATIONS.
observation, at different hospitals in America, Lon-
don, and Paris; but it is not without feelings of due
respect to the opinions  and practices of others,  for
whom I entertain the highest regard, that  I attempt
to advance principles, and to  urge treatment,  which
is at variance  with  those  in  common  use.  Still it
appears to me that the cause of science demands  the
step  to  be taken.  Therefore  I comply  with  the
kindly expressed wish of those who have desired  me
to deliver  these  discourses under the  present roof,
trusting that  the views which  I advocate will  be
examined with care and candor,  while I  cheerfully
say, that whatever I recommend,  if it will not stand
the test of experience on the part of others, I wish it
to be rejected.  1 have  come to this country for  the
purpose of obtaining and communicating information
in matters of surgery.  During my sojourn in Europe,
I have visited  the whole of the Hospitals in Paris, as
well as those of London ;  and in  the course of two
months attendance at the former, I have  performed
operations in some of the wards, which were planned
wholly in accordance with  the principles which I  am
now about to  develop,  and happily  with  a success
which had not attended the efforts previously7 made in
the treatment of the  injuries  experienced.  Having
now completed the round of my observations in Eng-
land, I am about to retire to my  native country ;  the
delivery of the present  brief course being the only
object which has induced me to  defer until another
voyage of the Boston steamer, my departure from  this
metropolis, after having derived  \ery great pleasure
and advantage from my visit.
   In calling your attention to that branch of our pro-
fession which is to  form the  subject of our  present 
LECTURE I.
13
course,  I do so, under the firm conviction that much
of the practice of the present day is characterized by
a very unsettled mode of treating  fractures and  lux-
ations, and is  not consistent  with the laws  of  me-
chanics ; or, in other words, that those  laws are not
so applied  in practice, as always to be made conform-
able with sound and  well-settled principles in surgery.
To  show  this, therefore, will be  the object of the
present lecture, after which it is my intention to illus-
trate the  manner in which mechanical  proceedings
require to  be conducted, in order to make them accord
with those principles; and in doing so, I  must  once
more express  my obligations to the  surgeon of this
 Hospital,  Mr.  Guthrie,  and to the Committee of the
 Institution, for generously tendering to me the use of
 this Hall,  to meet you here assembled,  before finally
 quitting this  land of my Fathers,  for that  Western
 World where is my  home.
   1 shall call your attention, first, to some of the ef-
 fects which muscular contraction produces on a  frac-
 tuied bone, as the  result of the laws of mechanics ;
 and, to save time, 1 will confine my remarks to  frac-
 tures of the thigh, trusting that  if these be well un-
 derstood,  the comprehension of  them  will  be  quite
 sufficient  to enable  us  to apply  those principles to
 practice in other  fractures.
    It will  not be thought necessary,  I  trust, that  I
 should go into a particular anatomical description of
 the femur.  You are already too well acquainted with
 the convexity of  its shaft, its condyles, trochanters,
 oblique neck and round head, to need description of
 them.   Cut  respecting the myography of the thigh,
 although  you  may be well acquainted with that also,
 still I beg  you to allow me to direct your attention par-
             2 
 14       FRACTURES  AND DISLOCATIONS.

 ticularly to them as agents of mechanical action ; be-
 cause, on their attachments, their locality,  and the
 direction  of  their  fibres, must  depend  the  relative
 position which the  two portions of a  fractured  bone
 occupy :  and in order to make  my views on this sub-
ject plain, let us divide the muscles of the thigh into
 three classes.
   First, those which pass lengthwise over the femur,
 and yet are not attached to it at either extremity.
   Second, those whose fibres are attached to it at
 one end, while the  other is united  to the pelvis above.
   Third,  those whose  fibres  are attached  to the
 femur by  one extremity, while the other  descends, to
 be united to the .tibia or fibula below.
   I will call  your attention to each particular class.
 Of the first class, or those which pass over the femur,
 are the rectus femoris, the sartorius, the gracilis, the
 semi-tendinosus,  and  the  semi-membranosus,  the
 long head of the biceps flexor cruris ; and among these
 may also  be classed (from its mechanical action  on
 the limb when broken)  the  tensor vaginae  femoris.
 These seven, when the  bone is broken,  only tend to
 shorten the limb by approximating the two extremi-
 ties of the bone ; and in  a fracture of the  shaft of the
 bone, do not, in  any measure, operate directly to
 throw the fractured portions out of a  normal line.
 For such an effect as that,  we must look to  other
 agents than to the  muscles just named, because, it is
 a well-settled principle in surgery, not  less  than in
 physiology, that a  muscle acts  only in a right line be-
 tween the points of its attachments.
    Of the second class, or those having their attach-
 ments to the femur at one end, and to the pelvis at
 the  other,  are,  the  pyriformis,  the  superior and 
LECTURE I.
15
inferior gemellus, the internal and external obturators,
the three glutei (maximus, medius, and minimus), the
quadratus femoris, the three adductors (brevis, longtas,
and magnus), the psoas magnus, the iliacus internus,
and pectineus.   Of these, let it be remembered,  all
have their attachments to the femur, at, and above
the point  where the gluteus maximus is inserted* ex-
cepting the  adductor longus, and about two  thirds of
the adductor magnus, the fibres of this last descend-
ing quite  to the inner condyle.
   Of  the third class, or those diverging from the fe-
mur to the knee, there are  the  two vasti (externus
and internus); and between  them, on the anterior sur>
face of the bone, lies the crurseus, while on its poste-
rior surface are attached the two heads of the gastroc-
nemii, and the short head of the biceps flexor cruris.
Of these  let it also be remembered, that they have
the whole of their attachments to the femur, below
the insertion of the gluteus maximus, excepting a por-
tion of the  two vasti, and a portion,  also, of the cru-
raeus whose fibres are attached  the  entire length  of
the shaft  of the bone.   The fibres of these  muscles
diverge from the femur to the knee, as the fibres of
the second  class do from the femur to the pelvis.
   We will now examine some of the effects which
the mechanical action of this arrangement of muscles
is likely to  have in fractures of the femur:  for, be it
remembered,  that the bone which before served as a
connecting  link,  for the action of all the  muscles
(preserving, as it were, a just balance between them
all), now no longer serves as the  centre of  that har*-
monious  action; but a new centre, and a new com-
bination of actions, form around each broken portion,
as the result of this lesion of bone. 
 16       FRACTURES  AND DISLOCATIONS.

   To  illustrate our views, let us suppose  a fracture
 of  the  femur, between the  trochanter  minor  and
 the insertion of the gluteus maximus muscle, which,
 as you  are well aware, would be in the upper third
 of the bone.   Now what  is it which  generally at-
 tracts our attention in a fracture at this point?  It
 is,  the  distorted figure of  the  limb, the  peculiarly
 distinct angle  at  the  point  of injury, the  unusual
 convexity at the upper and  front part  of  the thigh.
 And why is this  the  form peculiar to this injury,
 excepting only those  cases where the  force applied
 to produce it,  has  evidently interfered  with  the  na-
 tural action of some of the  muscles?  Is it not from
 the balance  of power on the side of the psoas magnus,
 iliacus internus, and pectineus muscles, all of which
 have their attachments, as we have seen, to the upper
 portion  of bone, and  situated  to  act upon it ante-
 riorly?  I say, is it not from the  balance  of power
 which these possess, over those attached to the same
 portion posteriorly, which so casts  the upper portion
 forward, while the fractured end of the lower portion
 is also  carried  forward with  it, from its attachments
 to the two vasti and  cruraeus muscles;  the  gluteus
 maximus serving as a  fulcrum to the lower  portion in
 carrying the knee backwards, while the other extremi-
 ty is thrown forwards by the attachments just named
 and by the  force  which acts on the upper portion?
 From this cause, then, arises the angle which we al-
 ways see in  fractures  at this  point;  and  from  this
 cause, too, the inclination of the lower, always to sepa-
rate from the upper portion or rising end of the bone,
while it is only prevented to a much greater extent,
 as we may fairly presume, by its attachments anteriorly
 to the vasti and cruraeus muscles.  We  also  see, on 
LECTURE I.
17
the lower portion, a balance of muscular power on the
posterior side, always inclining it backwards, as that
on the upper always inclines that portion forwards;
this arising, obviously, from the more favorable posi-
tion which the two heads of the gastrocnemii, and the
short head of the biceps flexor cruris occupy, for acting
on this portion of the  bone, as compared with  their
antagonists, the two vasti and cruraeus muscles, now
that its shaft is severed. But more than this, that bal-
ance of muscular power must evidently be increased
in both, as we depart from that angle of the limb which
places the  fractured  portion nearest to a normal line.
We  here  see,  then,  the  mechanical  effect which
the muscles have on  a fracture of the  thigh at the
point indicated.   Let us  next examine whether, in
treating such fracture, the laws of  mechanics have not
been too often violated or neglected ; and for the sake
of brevity  and clearness, I will first state, that  there
are but two positions,  generally adopted by the sur-
geons of the present day, in the treatment of fractures
of the inferior extremities—viz., the straight and the
bent position of the limb, the patient lying on his back.
Nor, at the present day, are there but three distinct
and leading methods adopted  for the application of
mechanical principles to this department of surgery.
 Yet  there are a thousand ingenious   contrivances,
 through which these three  are applied.   I refer to the
 double-inclined plane, to the straight splint of Desault,
 and to a combination of these two.  All others which
 I have seen, are mere modifications of the one or the
 other of those which I have named, and do not, in any
 measure, escape the general principles on which their
 originals were based.  As  these are found to be right
 or wrong, so must the others be also.  And therefore
               2* 
18        FRACTURES  AND DISLOCATIONS.

a particular description of them would not be needed
—'even if our time would allow it.   You  will doubt-
less examine many of  them, if you have not already
done  so,  and decide for yourselves, whether I have
correctly stated the fact.
  Let us  then look at some of the effects which these
different positions have on  this fracture; and for  the
sake of rendering both more  clear,  we will  at  the
same time consider some of the mechanical effects of
the three  kinds of apparatus just alluded to.  With
regard to position, it  must be apparent, from what
has already  been  shown,  that to place the  limb in a
line with the body, inclines the fractured extremities
to separate,  to the utmost limit which  the vasti and
cruraeus muscles will allow, from their attachments to
the upper surface of the bone near the point of frac-
ture ;  and much in proportion  to the extent of lesion
between the muscle and the bone, will this tendency
be increased;  and in proportion as the muscular con-
tractions in  the limb are strong or weak, will the two
fractured ends be drawn asunder.  Any force, there-
fore, which  can  overcome  this separation,  must  be
more  than  equal to  all the  muscular contractions
which produce it; this force must be applied, too, ex-
terior to the limb.  Is  it  not plain, therefore, that we
must apply force  antero-posteriorly  to  overcome this
separation of  the fractured ends?  an application of
force which would be entirely uncalled for in a dif-
ferent position of the limb. Would it not require an
amount, too, which is not always quietly to be borne ?
And more than this,  should there be strong muscular
contractions in the limb, what would be the effect of
such an amount of  force as to preserve co-aptation,
on  the circulation of the  limb, especially if this arose 
LECTURE I.
19
in an  irritable  system, with  feeble constitution ?
Would  it not also require a greater amount of  ex-
tending and counter-extending force, to restore  the
normal length of the bone, than if it were first placed,
so as to relax the flexor muscles of the limb?  And
would  not the muscular tissue  be more likely to be
wounded and irritated by the fractured  extremities,
when the position is  such  as to render co-aptation
difficult, than in one  where it is rendered compara-
tively easy?  This is the position in which the straight
splint  of  Desault is  always to be applied, and in all
of its modified forms; and it is on account,  mainly,
of the  extension and counter-extension to  be  ob-
tained  by it, that it is employed—a principle, sound
in theory, and important in practice, when correctly
applied, but in this  instance, by the very mode in
which  it is obtained, another one, of equal or greater
importance, is entirely sacrificed—I mean, that posi-
tion which inclines the fractured portions nearest  to a
normal line, and most effectually relaxes the muscles
of the  limb.
  It is conceived to be a sound  rule in  this  depart-
ment of surgery,  so to apply force,  as that  the small-
est amount  capable of accomplishing the end, shall be
employed.  The reasons for this, it is believed, are too
plain and obvious to need comment.
   We  will now, however, consider the application of
the double inclined plane.   And  here I will observe,
that this apparatus seems to have been arranged, more
for the purpose of securing such a position as the  sur-
geon shall choose, than for any other object;  and, so
far as position is concerned, it answers such intention
quite well.  Here we can not only relax the muscles
which  pass over the thigh,  but we can also relax the 
20        FRACTURES  AND DISLOCATIONS.

gastrocnemii and short head of the biceps.   We can
also so flex the limb on it, as to incline the lower por-
tion of bone, nearest a normal line with the upper, and
can also make the nearest approach to co-aptation, of
which the two portions are capable, by the action of the
muscles.  Still,  unless the  weight of the body is suf-
ficient to  answer all the purposes of extension  and
counter-extension, we shall fail to preserve co-apta-
tion, although we  may  have once effected it.   And
here allow me to show the importance of extension
and counter-extension in this position of the limb, not
more for the purpose of co-aptation, than to counteract
the continual tendency of the fractured extremities to
separate.   Allow me to fix your attention for a mo-
ment  on the fibres of the cruraeus muscle, attached to
the whole length of the upper surface of the bone, and
also to the two vasti, attached in like  manner, on each
side of it,  and these  descending to the  knee,  to be
united at the patella.  What, I ask, would be the ef-
fect of traction,  applied in the exact  line  of the limb,
on the depressed end of the fracture,  through the me-
dium of these fibres of which we are speaking? Would
it not be,  to elevate the depressed portion, to a line
with the upper, and thus to perfect co-aptation ?  Most
certainly it would.   Here,  then, is where the double
inclined plane, with all its modifications,  is defective.
But some may say, perhaps, there are many appara-
tus in use, where extension  and counter-extension
may be applied with the double inclined  plane.  I
admit  it;  but not so (pardon  the assertion) as  that
the points of traction shall operate in the exact line
of the shaft of the bone.  And here lies the fault, as
I humbly  conceive, in the multitude of ingenious con-
trivances  for treating fractures.  They all  make the 
LECTURE I.
21
perinseum one point of traction, and the foot or the
leg the other.   It must be plain, therefore, that to act
on a limb, laid on the double inclined plane, with any
force from these points, the  force must be so applied,
as that more  of  it is  spent at right angles with the
bone, than is exerted in the  line of the limb, operat-
ing favorably to produce extension and  counter-ex-
tension ; and  furthermore,  all  that  is  thus spent,
there being sufficient to produce the necessary exten-
sion and counter-extension,  tends to throw the frac-
tured portions out of a normal  line.  We have an
amount, too, which, if rightly  applied, would be alto-
gether beyond the amount required for the object in
view.   And it is,  moreover,  applied in  a  manner,
which would not only  be likely  to  give  pain at the
knee, but, as the ligaments become elongated by con-
tinued extension, they would very likely deceive the
surgeon in  the length of the  limb.  We will not, how-
ever, extend our remarks on this point.
   I  proceed, however, to  consider, in the next place,
some of the effects of these laws, on a fracture between
the  insertion  of the gluteus maximus and the knee.
And what do we observe in this, that we did not in the
other case?  The chief difference which we notice, is
the greater mobility between the  upper  and lower
portions of  the thigh.  That peculiar angle and con-
vexity of the  thigh,  does not appear in this;  and al-
though there may be a greater deformity in the limb,
still that deformity is characterized by other marks of
derangement; as, for instance, the lower portion may
appear as if thrown off from the upper—or if an angle
appear, it may be either laterally or posteriorly; the
inferior portion, however, being always found to lie
at the back of the superior.   And, why  do we find 
22         FRACTURES  AND DISLOCATIONS.
this difference in two  fractures so near together, and
in the same bone?  Is not the chief cause of this dif-
ference the absence of an agent like that of  the glu-
teus maximus, in the  lower  portion, to serve  as a
fulcrum for those muscles which throw the fractured
end forwards, and the knee consequently backwards?
To me this appears plainly to be the cause.   In the
first case, the fracture is  more  thickly  covered  with
muscles than in this  one; the muscles  which attach
to the fractured  extremity of the  lower portion, and
are united to the pelvis,  also depart from  the  bone
nearer to a right angle, than in this.  Still, these could
not  make the differences which we see, while the
other might, and probably does.  With  reference  to
position, the same remarks which  we applied to the
first case, apply  to this also;  it cannot.be necessary,
therefore, to repeat them.  Our remarks, too, in re-
ference to  the  application  of mechanical  principles
through the various apparatus,  apply equally in this,
as in the other case;  nor will it be  necessary to re-
peat them.   We will, however,  call your attention
to but one more form of fracture, and that, a  fracture
at the neck of the thigh bone.  And to avoid all phy-
siological  questions which might  arise—since  it  is
only mechanical principles which  are to be applied to
surgery, that I am attempting to discuss—I will con-
fine my remarks to one  of those  supposable cases of
a fracture out of the capsular ligament.*
  * The author does not believe that a fracture of the neck of the bone, out
of the capsular ligament, can take place, except the whole neck be separated
from the trochanter and shaft of the bone.  Any other one, it is believed,
would be quite impossible, since the capsule envelopes the whole neck, as
a careful examination of the parts will plainly show. Nor, indeed, does he
believe in the great uncertainty (amounting very nearly to an impossibility)
of an osseous union taking place within the capsular ligament. He has at his
side, while writing this, a femur in which the head of the bone has been
separated from its neck, and yet it is manifest that as perfect an osseous 
LECTURE  I.
23
   In a fracture at the neck of the bone, what do we
observe ?  the limbs being at rest,  and  the  patient on
his back.'  What is the first thing which  attracts the
attention  of the  surgeon?   It  is,  that one limb  is
shorter by some two or three inches than  the one on
the  opposite side.  The foot is also turned outwards ;
and  perhaps the trochanter major  may also appear
somewhat prominent.   These are the chief marks of
difference which we notice, on looking atthe two limbs.
And now, why so  marked  a difference between  this
and the other two  cases?  A greater difference  in the
fracture  of  any  two limbs, could  not well appear ;
and it is the result merely  of a lesion at this part of
the bone, rather  than at another,  which marks all the
difference which we see.   Is  it not, that by this frac-
ture another and a different mechanical  effect  is  al-
lowed the muscles acting on the two portions of  bone?
Must we not, therefore, expect that a different  appli-
cation of mechanical means would be required, in  so
marked  a difference in  the limb,  to  overcome this
effect, and to restore it to its normal length and figure?
Most certainly we must.   In  this instance the  mus-
union has taken place between them, as can be shown in the middle of the
shaft of the bone—he has also seen other examples as plainly marked. More
than this, he can no more doubt that osseous union within the  capsule has
taken place under his own practice, than he can that definitive bone has ul-
timately united a fracture in the shaft; instances of this kind are too frequent
to admit the generally received opinion, that osseous union within the cap-
sule is never to be expected.  Surely without co-aptation and perfect rest we
may hardly hope for it.   The reasons are obvious: definitive bone appears to
be designed to unite together only broken surfaces,  under the most  perfect
rest, in°all cases where the bone is deprived of a provisional formation, as it
is in fractures within the capsular ligament of the hip-joint.
 But with these—co-aptation and perfect rest, maintained during the time
requisite for the  formation of definitive bone—we may expect an osseous
union, except where from the extreme age or impaired health of the  patient
such union would be unlikely to take place.  The author hopes to be able
hereafter to point out the causes which, in his judgment, have so generally
operated with the profession to prevent an osseous union at the neck ot the
thi"h bone.  At present he can only say he is  convinced that principles ot a
wrong pathology have generally prevailed with regard to them, and that it
will afford him pleasure to contribute his share in endeavors to correct them. 
24
FRACTURES AND DISLOCATIONS.
cles of the first and second class  only are  concerned
in producing the derangement in the line of the bone.
The lower portion, which now includes the whole of
the shaft and the  trochanters, is  thrown directly up-
wards, and the neck only is thrown  from a  normal
line, and is also shortened,  as  one of the necessary
effects of these mechanical laws, by the action of the
muscles attached  to the trochanter  major and  the
pelvis.  Now,  it  must, be  manifest, that  we can no
more  co-apt a fracture, at the neck of the bone, with-
out restoring  it to its normal length, than we can one
in the shaft, without giving that its due length; and
any apparatus, which fails to do this, fails  to fulfil all
the indications which  correct surgery requires in the
case.
   Allow me to call your attention, for a moment, to
a particular arrangement between the pelvis and  the
head of the bone,  for the purpose of calling your at-
tention to it at another time ; and  that  is, that  the
head of the bone serves as a pivot, on  which, at the
pelvis, turn all the movements of the body with  the
lower limbs, even the smallest motion which is made
between them gives motion at this point.  Now, from
what  has already  been  shown, I presume I shall  be
anticipated in my remarks,  in reference to position  ;
for it  must be apparent that the straight position, or
one nearly allied to it,  must be the  one which  the
mechanical effect  of which we have spoken requires,
that the means for restoring the normal length and
figure may be correctly applied to the limb; and here
the straight splint of Desault would seem  to be well
adapted.  But how must it be  with the neck?—
what, in that apparatus, is to restore  that to  its nor-
mal length?   Unfortunately, nothing;  but,  on  the 
LECTURE I.
25
contrary, much which is calculated to shorten it still
more.   We will  endeavor to show this  fact.   One
point of traction is to operate from the perinaeum,  by
a band passed upward and outward on the  anterior
and posterior sides of the pelvis, to be made fast near
the upper end of a broad splint, lying on the outside
of the limb ;  the  other point  of traction is to be at the
foot, and is secured to the other  end of the splint.
Now, is it not  plain, that just in  proportion as we
apply force, to approximate the foot to the lower end
of the splint, in order to lengthen the limb, a portion
of that  force must operate at the top of the splint, to
incline  it towards the perineum, that being the point
of resistance from the body,  which connects it with
the upper end of the  splint, by the means of the band,
and  which is out of the line of the two extreme points
to which force is applied?   And,  therefore, must not
the upper surface of the splint operate to  depress the
hip,  just in proportion to the angle at which the belt
is made to operate from the splint?  Hence,  if we
regard, as of the least importance, the length of the
neck or the wounding and irritating the  muscles, by
the fractured extremities, this application of the splint
cannot  be  right in surgery.   Indeed,  no one,  under
any  arrangement, which I have  seen, tends to give
length to the neck of the bone.  On this account, they
are all alike defective ; yet all do not actually depress
the hip, though they may, and most of them do, require
a position, unsuited to the condition of the limb; and
from two or more wrongs, it is often difficult to make
a selection.  We will not, however, detain you longer
on the  subject of fractures, but will proceed to exa-
mine into  some  of  the  modes in which  mechanical
principles are applied for reducing  luxations.
                 3 
26        FRACTURES AND DISLOCATIONS.

  In these, the first and great object which we gene-
rally have in view, is, to overcome any resistance
which the muscles, opposing reduction, may offer to it.
That  resistance is generally  from the power which
the muscles possess of approximating their points of
attachment, when the head of the bone is dislodged
from its articulating cavity.  To overcome this resist-
ance, extension and counter-extension have very gene-
rally and very necessarily been employed. There have,
however,  been various expedients resorted to, for ac-
complishing this  end, only two of which remain in
general use at the present  day.  These are physical
force, by means of assistants, and mechanical, by the
use of  pulleys; both alike are employed for the pur-
pose of making traction on the luxated  limb.   I  am
aware  that  the screw has also been employed, at
various  periods  of time  and in  many parts of the
world;  but the objections to it are so grave,  and so
numerous, that it has never been received into general
favor.  I may therefore leave that out of the account.
As it regards  the two methods remaining in use, their
effects,  mechanically,  on  the luxated limb,  are pre-
cisely the same ;  for I cannot conceive a  difference,
where a given amount of force is employed, whether
that force is applied through  the pullies, or through
assistants, provided both  are equally  steady  in  their
application, and the points of traction secured alike in
both.   What I would  be  understood to say, is, that
the  mechanical operation  of the two methods, on the
luxated limb, is, for all the purposes of reduction, the
same ;  one may command more power, and the other
may be more gentle in  its operation ; still on these
points I can  see  no difference  between  them, both
being, as they may be, of equal power; or one may be 
LECTURE I.
27
more steady in its operation, and the other more ready
of application; yet this does not affect the main prin-
ciple, that both act mechanically alike on the limb, so
that in  discussing the principles of the  one, we also
discuss those of the other.  And that to which I would*
first call your attention, is, that they both operate from
fixed points, over which the surgeon can have no con-
trol.  Thus, if the line of extension happens to be the
correct one, he does not desire it  changed;  but if it
happens to be incorrect, the force must first be relax-
ed  before he can change it.  It is the effect of being
thus  confined  to these fixed  points, which I wish to
consider.
   We will suppose a luxated femur,  the head of the
bone in the iliac fossa.  The  appearances of the limb,
we will not stop to notice.  You are too  familiar with
them, to  render it necessary.  One condition,  how-
ever, which frequently  exists, I beg leave to notice.
In consequence of the oblique position, which the head
and neck occupy to the shaft of the bone, any  force
applied to the head, from the other end  of the shaft,
and in a line with it, necessarily forces  that  head, in
some degree (while passing through muscle), to fol-
low the obliquity of the neck, and not the line of the
shaft, thus making an  oblique track from the cotyloid
cavity.
   Suppose we apply the pulleys to reduce this luxat-
ed femur: the head and neck being forced obliquely
into the muscular tissue, as not unfrequently happens:
we have  power, constantly and  steadily operating
fron  fixed points; and  before the direction of that
force can be changed,  we must relax it.   Would not
the head and neck, from their oblique position  to the
shaft (and especially, since the head is larger than 
 28        FRACTURES AND DISLOCATIONS.

 the neck), be likely to operate like a hook, around a
 portion of muscle which lies directly below them; and
 before they could be disengaged (the force operating
 in one line), be likely to tear through the muscle, or
, break the bone?  The case is not chimerical.  It has
 happened.   But suppose,  instead of the extending
 point being  fixed, as in the case of  the pulleys, it is
 left free and subject  to the command of the surgeon,
 while force is steadily and constantly applied, would
 not the surgeon be much more likely to disengage tire
 head, by giving free motion to the limb,  than he
 would by applying that force in one given line?  Here,
 then, 1 conceive, is another error in  the mode of ap-
 plying mechanical principles to surgery.
    I will  detain you  with but one more illustration.
 Suppose  the case where the head of the bone is dri-
 ven into  the soft parts, and  the neck is closely em-
 braced by them,—as, for  instance,  in some cases of
 the head of the os humeri,—we  must first disengage
 the head, before we can even hope to succeed in re-
 duction.   Suppose, also,  that we  apply the pulleys.
 Force is steadily and long continued, but, owing to the
 firmness with which the  neck is embraced, and the
 strength with which the  muscles contract, it is not
 relieved  from its confinement.  Is it not plain, there-
 fore, that should the  extending point now be subject to
 the will of the surgeon, to move at pleasure, while the
 force is yet constant and  steady, to give free motion
 to that limb, it would greatly aid him in reduction, and
 that, too, without increasing the power ? These are all
 ;grave questions, which it is the duty of every surgeon
 >to answer, satisfactorily, in his own mind.
    Thus I  have  endeavored to  point  out  clearly,
  wherein the laws of mechanics are violated, in this 
LECTURE I.                 29
every-day business of the surgeon; and in doing so, I
beg you to consider, that it has not been with joy,
but with sorrow, that I  have attempted it; for these
evils in practice pervade the entire civilized world,
and I can only  rejoice that,  peradventure, I may  be
the humble means of supplying the remedy.  It was
the conviction within me, of the existence of the evils
of which wre have been speaking,  that first prompted
me to make the attempt.
   At our next  meeting, I will call your attention to
the mechanical arrangement of the instrument, and
commence showing its application to the various lux-
ations and fractures.
3* 
30      FRACTURES AND DISLOCATIONS.
PLATE  I.



    Fig 1
n.
&
L,
 
(   31   )
        DESCRIPTION OF  THE  INSTRUMENT.

   Fig 1.   The  Adjuster:  A, the rack or extending bar.   B, the
shaft of the pinion and ratchet wheels.  C, the catch.   D, the
counter-extending bar, for  lengthening the Adjuster at pleasure.
E, a screw for securing the  counter-extending bar at any point,
   Fig. 2.   The Lever: the square socket in its end, is fitted to
receive the square end, or heel, of the shaft B.
   Fig. 3.   The  Side Lever: used in dislocations  of the hip, to
throw the head  of the bone outwards.   The fulcrum, F, is re-
ceived on that end of the Adjuster, at which is the extremity of
the counter-extending bar, D, the plate, G, pressing against the
inside of the thigh.
   Fig. 4.   The Thigh  Fork, with the roll or round pad, H, at-
tached to it: K,  the socket,  to receive the end of the counter-ex-
tending bar D.
   Fig. 5.  The Shoulder Fork, with  the roll, H, attached to it:
K, the socket, to receive the end of the counter-extending bar D.
   Fig. 6.   The Jointed Fork: L,  the two joints, in which the
two arms move, and which are adjusted by two screws, removable
at pleasure:  K, the socket,  into which the  end of the counter-
extending bar, D, is received.
   Fig. 7.  The Elboio Fork: K, its socket, for receiving the end
of the counter-extending bar  D.
   Fig. 8.  The  Pad: used in fractures of the  leg and thigh;
there are two of them. 
(  32   )
                LECTURE   II.
 Violation of the Laws of Mechanics in the Treatment
   of Fractures.—Adjuster,  and the  Principles  on
   ivhich it is based.—Its Application to the four Dis-
   locations of the Thigh.
   At our last Lecture, I endeavored  to show where-
 in mechanical principles, in attempting to apply them
 in the treatment of fractures and dislocations,  were
often violated or neglected.  It will now be my endea-
vor to show in what manner they are to be applied so
as to be conformed to the principles of surgery, in the
 treatment of these injuries.   In showing this, I am to
 avail myself of the use of the instrument, which I
 now  exhibit;  and that you may readily comprehend
 the various modes in  which it is applied,  and  the
 manner in  which it operates, allow me to explain its
 mechanical arrangement.   Let me  first,  however,
 lay down the indications which it is intended to fulfi 1
 which are—
   1. To establish a line of extension between  any
 two given  points of the body :
   2. To furnish an extending force, which is unlimit-
 ed in principle, yet easily calculated,  and  which is
perfectly subject to the will of the operator:
   3. To be able to combine, with the simple extend-
 ing force, a lever of the first or second order, accord-
 ing to the exigency of the case, so as to act transverse-
 ly to the line of extension, yet without in any way hir
 terfering with it, and subject, in like  manner, to the
 will of the operator :
   4. To fulfil all these indications,  without in any
 way interfering with the mobility of the limb: 
LECTURE II.
33
  5. To enable the operator to apply the force, whe-
ther direct or  transverse, either  rapidly or  slowly;
and to retain it on the limb during his pleasure.
  These indications, I conceive, may be fulfilled in
the following manner:—A brass  box  or case (fig. 1)
contains a  rack-bar A, and a pinion-wheel within the
case, the teeth of which match into those of the rack-
bar, the pinion wheel within being at one end of the
brass case.  The brass case is about  thirteen inches
long, and  is divided in the centre, lengthwise, so as
to form two ways, one  for the rack-bar, which is al-
ways the extending bar, and the  other for  the  coun-
ter-extending bar, D, which may be drawn out,  and
fastened by a small screw, E, at  any  desirable point.
On the surface of the brass case, and on  the  same
shaft with the pinion-wheel, is a ratchet-wheel, B,
with a catch,  C, corresponding  to the  teeth of the
ratchet-wheel; the shaft of these wheels terminating
in a square heel, or hub,  to which the lever (fig. 2)
is applied.   On the end of the counter-extending bar,
is received, according to the case to be  treated,  one
of these  four forks—the thigh fork (fig. 4), the shoul-
der fork (fig. 5), the jointed fork (fig. 6), or the el-
bow fork (fig. 7).  These are each  received on the
end of the counter-extending bar, by their  sockets,
K,  K, K, K, and each,  in its turn, according to the
case to he  treated, is used as the counter-extending
point of the instrument;  while the end of the rack-
bar, which  is turned at a right angle with  the  part
which  is received into the case, is always the extend-
ing point of the instrument.  There is also a side lever
(fig. 3), which is used to apply force  transversely, to
the line of extension ;  as in dislocations  of the  hip.
The socket F is slipped on the end of the brass case 
34        FRACTURES AND  DISLOCATIONS.
at D; and when the thigh fork (fig. 4) is received by
its socket K, on the end of the counter-extending bar
D, the plate G passes between  the thigh fork,  and
the roll H, hanging loosely between the arms of the
fork.   To these belong several belts, straps, &c,
which  are for taking hold of the limb,  securing the
instrument, &c. ; but as  you will readily understand
their use, in applying the instrument—and since the
requisite  instructions are always  furnished by  the
manufacturers, Mess. Weiss & Son, No. 62 Strand,
London—I will not take up your time by any further
description.    The several parts of the instrument
being  explained, let us now  apply it, as to the  four
dislocations of the femur generally  noticed by writers
on luxations—viz., upward and outward on the dor-
sum of the ilium,—backward into the ischiatic notch,
—forward and  a little upward on the pubes and under
Poupart's ligament,—and downward and inward  into
the foramen ovale.   If, in all these  positions of the
limb, we are able to apply the instrument so as to have
any required amount of power available, and in what-
ever direction  it may be needed,  and at  the same
time can leave the limb just as free for motion as it
was without the instrument attached to it, then have
we all the indications fulfilled which are required  of
any instrument.  And not only so, we can also apply
mechanical force to a dislocated femur, without the
extending point being fixed, as at our last lecture we
found  it must be, in using the pulleys, or with  assist-
ants, and against both of which methods we  found
weighty objections to lie.  Let us first apply it,  as
to a dislocation upward and outward ; the head of the
bone resting on the dorsum ilii.  We must begin by
placing the belt around the thigh, immediately above 
LECTURE II.
35
the knee, with a loop lying on each side of the limb,
and armed with strong cords.  The instrument being
arranged as already described,  with the thigh-fork
and  side  lever attached,  and the roll suspended be-
tween the arms of the fork, we  apply it to the inside
of the thigh, the roll pressing firmly  against  the peri-
nseum, observing, first,  to lay some soft substance,
such as wash-leather or  cotton flannel, between the
                   PLATE  II.
roll and the skin, to prevent friction  on the skin  by
the roll  when  we move the limb.  Tie the cords
closely around the foot of the rack, having previously
passed them through the loops, the  arms ol the fork
bavin- also been  passed one  on each  side of the
pelvist upward and outward to the top  of the ilium.
Let a strap, crossing the top of the ilium, pass around
each arm of the fork, having a buckle to it, and let it 
36       FRACTURES AND DISLOCATIONS.
 make fast  the  arms in  this position.  To press the
 instrument close to the inside  of the thigh,  let a
 thick bolster of cloth be laid under the strap cross-
 ing the ilium ;  tie a strap or handkerchief around the
 instrument and limb close to the knee ; apply  the
 lever and make  extension.  Do you  now  wish to
 move the limb, to disengage the head of the  bone
 from the gluteus minimus muscle, into which it has
 been driven, while all of the power which you have
 applied, is retained without  the  most  trifling  varia-
 tion?  You have the same liberty now to  move it,
 which you possessed before the instrument was ap-
 plied.   Do you wish to throw the head of the  bone
 from the dorsum of the  ilium, while  an assistant ro-
 tates the thigh  on its own axis ?  The side lever is at
 your command, nor does it in the least  affect the line
 of extension.   Do you wish to apply force rapidly ?
 Describe one circle with the hand at the end of the
 lever, and you  have near four inches  of extension.
 Do you wish to relax all power instantly?  Apply your
 finger and press the catch which  holds the  ratchet-
 wheel, and, quick as thought, the force  is gone.   Do
 you wish to relax it slowly ?  With one hand take hold
 of the lever, with the thumb of the other raise the catch
 from the ratchet-wheel,  and so long  as  the  hand is
obedient to the laws of voluntary motion, so long will
 the power  be  subject to the will of  the surgeon.
 Thus, we have  any amount of power which we de-
 sire ; it can be applied in the most gentle and steady
 manner, or  with the rapidity of voluntary motion.  It
 can be relaxed instantly, or slowly, and retained dur-
 ing the pleasure of the surgeon ;  nor can the unruly
 movements of the patient in the  least affect the line
of extension, or change  the  relative position  of the 
                   LECTURE  II.                 37

limb, while they are both entirely subject to the will
of the surgeon.
   Let us secondly apply the instrument as in the case
of dislocation into the ischiatic notch.   The  instru-
ment is applied in every respect as before,  except
that the arms of the fork stand more backward, and
the limb nearer to a right angle with the body, that
the  head of the  bone  may  be drawn  towards the
acetabulum.   Here we have occasion to use the side
lever early, to lift the head o( the bone from the sacro-
sciatic  notch, as the extending  force is applied, to
bring it forwards from  that deep impression, to the
acetabulum.   Here, too, we  have the  same  power,
the same liberty to move the  limb, during  extension,
the same facilities for applying or relaxing, either ra-
pidly or slowly, any amount of power which the sur-
geon shall choose to employ.
   Let  us in the third place apply the instrument, as
to a dislocation of the  head of the bone on the os pubis,
under Poupart's ligament.   Here we  shall have oc-
casion  to use a lever  of another order, that in which
the  body to be moved lies between  the  fulcium and
the  moving power, while we shall also have the ser-
vices of the same levers which we have already  used,
if we require them.  Now  let it be observed, that
the head of the bone  in its new position, is out of the
line of the upper third of the ilium, and  the inside of
the knee, some two or three inches.  It lies above  a
transverse line passing through both acetabula about
one inch.  Let us  apply the instrument  in the  same
manner that we did before, only  observing to  place a
bolster of cloth  under the strap  crossing  the ilium.
sufficiently thick to firmly press the instrument against
the  inside of the thigh.   It  may  here lie observed,
            4 
38        FRACTURES AND DISLOCATIONS.
                        i
that the greatest amount of force to reduce this dis-
location, is generally required to operate transversely
to the body, yet much will doubtless be required  to
restore the normal length of the limb.  Now suppose,
that while we are applying the  extending  force,  we
also gently, yet firmly, carry the instrument and limb
outward.   In such case the instrument itself becomes
a lever; the strap passed around the arms of the fork,
and crossing the dorsum of the ilium,  becomes the
fulcrum; the head of the bone, the body to be moved ;
and the surgeon gently applies his own force  to  the
end of the lever as the moving  power; while he at
the same time can apply the lever to the shaft of  the 
                   LECTURE II.                 39

pinion-wheel to make extension.   Should he require
the aid, also, of the side  lever, he could add to that
already applied, five times the amount.   It will here
be observed, that the very mode of applying  power
transversely, to incline the head of the bone  to the
acetabulum,  depends on  the freedom from that re-
straint, which the  pulleys uniformly impose.   Thus
have we sufficiently shown the application of the in-
strument to this dislocation.
   The fourth case  to which  your attention will now
be called, is to a  luxation of the hip, when the  head
of the bone is lodged  in  the foramen  ovale.   Here
we require  an  entire change in  the  application of
power, and of course, in the direction  of the instru-
ment.   For here the head of the bone lies below the
acetabulum, and  consequently, we require  force, in
the line of  the  limb, for no other purpose than to
allow the head of  the bone  to pass over the cotyloid
portion of the ischium.   But here, allow me to ob-
serve, that  in all the cases  which  I  have seen, the
rectus femoris and  the adductor muscles were remark-
ably tense.  Indeed, I can  hardly  conceive  how  it
could  be otherwise; there  being  no muscle whose
direct tendency  is, to  throw the  head of  the  bone
outward  to  its  normal position,  it is plain, that the
greatest amount  of force  is  required, in  a direction
transverse to the shaft of  the bone ; and that this force
 must be applied  on the inside  of  the thigh.   It will
readily  be perceived, therefore,  if we increase the
tension of the adductor muscles —it being transversely
 through these that we are to act on the head of the
 bone, by the force  applied — that force will with the
greatest difficulty reach that head, so as to be likely
 to move it  from  its present abnormal position:  espe- 
40       FRACTURES  AND DISLOCATIONS.

cially since, I doubt not,  it is often in those cases
that the head is driven through muscular tissue in its
passage to  the foramen.   It is  the  firmness  with
which the neck is embraced by the tissues around it,
when the  injury becomes  one  of long standing, which
frequently so resists our efforts at  reduction;  and to
increase the tension of the adductor muscles by ex-
tension, must increase the difficulty.  To apply force,
therefore, transversely, lelaxing  the rectus femoris
and adductor muscles to the utmost limit which  mav
be consistent with the condition of other muscles, and
to move the limb freely, would allow the head of the
bone to glide over that portion of the ischium, which
separates it from  the cotyloid cavity,  more  readily
than to apply  force in an opposite direction.   We
will therefore apply the instrument transversely; and
in doing so, let me observe, that here the force is
applied in the same manner as by  the pulleys, when
used for this luxation.  This may  readily be seen by
consulting the excellent work  on Practical  Surgery,
of Mr. Fergusson.  Nor does the power here applied,
possess any advantages over the same power applied
by the pulleys, in the case  under consideration, except
that in this, the power is not so likely to be disturbed
by the unruly movements of the patient.  Nor, indeed,
is the force so liable to vary during the operation.   In
all other respects, then, as far  as I  have yet been able
to discover, for reducing this luxation,  they may  be
regarded alike: yet, in  these respects, in a grave
luxation, those advantages are  many times of no small
importance.  In this dislocation, instead of using the
thigh  fork, we  remove it from the  instrument,  and
apply the elbow fork (fig. 7),  by its socket, K, to the
end, D, of the  counter-extending bar.  Apply a broad 
LECTURE  II.
41
belt, or strap, with a buckle at one  end, around  the
body so as to make the ilium  of the injured side the
resisting point, the instrument lying flat and crossing
the sacrum ; let the broad belt be buckled round the
fork,  over the  uninjured  side;  pass  another strap
round the upper part of the thigh of the injured limb,
and under the broad strap  at the groin; tie the strap
passing round the thigh to the foot  of the  rack-bar;
let both straps be tied to the instrument at the respec-
tive sides of the body, to prevent them from slipping
from the instrument;  let padding be laid between the
instrument and  the body, and between the straps and
the body; now, by the lever  we throw out the rack-
bar, and consequently the head of the bone, while we
are able to move the limb  in any direction.

  N0TE.—The two Plates, III. and  IV., which were not in the
London Lancet, are here introduced, to illustrate more perfectly
the application  of the instrument to this dislocation.  Plate III.
presents a front view—Plate IV. a back view of the patient, with
the instrument  and belts or straps applied.   It will be observed in
Plate IV., that a small strap is tied round the instrument and belt,
              4* 
42         FRACTURES  AND  DISLOCATIONS.
over the right hip  (the left being dislocated): this strap is passed
under the perinaeum, and brought around to the belt in front, and
there made fast.   Another strap is made fast to  the  instrument,
near the left hip, passed over the right shoulder, from thence car-
ried to the belt in front, near the left hip, and  made fast to it.
This is for the purpose of preventing the instrument from chang-
ing its  relative position, when force  is applied.   The strap may
be conveniently supplied by the use of handkerchiefs. 
(43)
               LECTURE  III.
Mode of correctly applying Mechanical Principles to
  Surgery.—Four principal Rules to be observed in
  the Treatment  of  Fractures.—Violation of  those
  Rules by all the ordinary means.—Fractures of the
  Thigh.
  I am  this evening to call your attention  again, to
those principles of surgery, which relate to  fractures,
particularly to fractures of the thigh.  In the  first
lecture, I endeavored to show the manner  in which
the laws of mechanics were violated or neglected in
treatment.  It will  be my object,  this evening, to
show in what manner  they may be applied, so as to
fulfil the indications required, or, in other  words, to
be conformed to  the principles of surgery.
  But,  before we proceed, allow me to lay  down four
principal rules, which I cannot but regard as essential
in the treatment  of all fractures.  They are the  fol-
lowing :—
   lst.—So place the limb, as that the fractured por-
tions  shall be inclined to a normal line of  that  bone,
the nearest that can be effected by the action of the
muscles.
  2nd.—So  apply extension  and counter-extension,
as that the  smallest amount, capable of preserving
coaptation, shall  be employed.
  3rd.—So apply force, as that the line of extension
shall operate  the nearest possible to  a perfectly nor-
mal line of the fractured bone.
  4th.—Let  the points  of  extension and counter-
extension be  confined within  the  limits of the  frac-
tured bone. 
44       FRACTURES AND  DISLOCATIONS.

   If, in our treatment, we  succeed in  applying  effi-
ciently these  four  rules in practice, it  is conceived
that we then have the laws of mechanics conformed
effectually to  the  principles of surgery, in the treat-
ment of fractures.   If not, we fail in our object.
We  will first see, however, whether these rules have
been correctly applied, by  the apparatus in general
use.   You recollect,  we showed that there were but
three, although there may be, and undoubtedly are, a
thousand modifications of these.
   From what appeared at our first lecture, it is mani-
fest, that in a  fracture of the thigh, between the tro-
chanter minor and the insertion of the gluteus-maxi-
mus muscle, and also, in one  between  the  insertion
of that muscle and the knee,  if we place  the limb
in a line with  the body, we violate our  first  rule, by
inclining the fractured extremities  further from each
other, instead of the reverse, as should be the case.
And this is the position which the splint of  Desault
always imposes.  It also violates the second  rule, by
requiring more force  to restore the normal length of
the limb, than is required when the flexor muscles are
relaxed.  The third rule it does not appear to violate.
The fourth  one, however, is  violated, the points of
extension, &c. not being confined within the limits of
the fractured bone.   Thus,  of the four rules, we  find
three of them entirely violated  by  the  splint of
Desault.
  We will now look at the double-inclined plane.   In
this, it is obvious that the first rule may be correctly
applied—viz.,  that of inclining the fractured  portions
nearest to a normal line, and relaxing the muscles of
the limb.   The second, third and fourth rules, how-
ever, are altogether neglected. 
LECTURE
HI.
45
  We will also look at the double-inclined plane, so
arranged as to produce extension and counter-exten-
sion, from the  extreme  points  of  the  limb.   With
this as with the last, the  first rule would, of course,
be correctly observed.   But how is it with the other
three ?   My remarks at the first lecture, pointed out
that the  second rule would be violated by there being
more force exerted at right angles with the bone, than
was employed in  the line of the limb.   Is  the third
rule any  better applied?   I endeavored  to show, that
the tendency of force, applied to the extremities of a
limb, laid on a double-inclined plane,  was,  to throw
the fractured extremities out of a normal line.  Hence,
if my  remarks on that  point  were in  any measure
correct, this rule  is also violated.  But let  us look at
the fourth rule.   Even this, too, is violated,  for the
points  of extension and counter-extension are not
within the limits  of the  fractured  bone.  Thus, im-
portant as are each of these rules (and it is believed
their importance  will not be denied by any surgeon),
we find but one of them applied by any one appara-
tus.  I therefore  ask once  more—is not that appara-
tus defective, which applies but one of these  rules in
the treatment  of  fractures?—which comes no nearer
answering  the intentions of the  surgeon?—which
violates, or neglects, so important a rule in surgery as
that of coaptation?
   It will not be claimed, I trust, that  I have here
been making rules, by which to try the  various me-
chanical  means.   These rules are true in nature, and
are  founded on the immutability of her  laws, and
hence  were always true; and the mere  circumstance
of  my having  given them a  definite form,  for  the 
46
FRACTURES AND DISLOCATIONS.
purpose of aiding our own frail intellect, does not, in
the least, touch the matter of their originality.
   But some will say, perhaps, it is  quite  impossible
to apply all these rules, and at once, in the treatment
of any fracture.
   During a recent visit to Paris, I was kindly invited
by Marechal de Calvi, a military surgeon, and a gen-
tleman of superior attainments in his profession,  to
visit the Val de Grace, a military hospital in  Paris.
At that visit he very kindly showed  me  through the
various wards  of that noble institution.   He took es-
pecial pains to show  me the  fractures which were
then in progress of treatment (for there were several,
both  of the leg and  of the thigh)  in  their various
stages.   And what, think you, was my surprise, when
I unexpectedly found, that precisely the same rules
which I have here laid down, as  necessary to be  ob-
served in the treatment of fractures, were  there cor-
rectly applied in practice.  Not, however, by adopting
the same means which I  employ, but those,  never-
theless, which faithfully applied  all those principles;
not so conveniently, nor  so happily perhaps, as might
be desired, but yet they were applied ;  and I had  a
good  opportunity to  judge,  too, of their  effects, as
compared, not only with  others, but with those in my
own practice.   I understood that they did not always,
and in every case,  employ their  apparatus, probably
from the inconveniences which attended its use ;  but
when the least difficulty  presented itself, in preserv-
ing coaptation, they invariably resorted to it; and the
cases  which I  saw, showed not only its efficiency, but
the truth of the principles which I  here  advocate.
Among all  the hospitals  which I  have  visited, I have
not seen elsewhere such good results. They answered 
LECTURE
III.
47
perfectly to the experience which I had had in apply-
ing those rules.   I will not stop to describe the appa-
ratus.  It was simple,  and constructed on sound prin-
ciples ;  but yet so inconvenient that it could  not well
be used, except in hospital practice; and then not al-
ways with the facility desired.   I  was told the  name
of the  inventor,  but  unfortunately do not  recollect
it.*   I  was also informed that he ranked at the head
of the  military surgeons.  I regret  having  lost his
name, the more from having had the  honor of a very
pleasant and  agreeable interview with him.   Whether
the inventor  of that apparatus designed to  fulfil the
same intentions which I  had in view, in the arrange-
ment of the one which you saw, I  know not; all that
I know about it, is, that  those rules  were there ap-
plied ;  and I saw the  results,  which  I have already
stated.
   We will, however,  apply the apparatus which you
have seen here;  and  you will then be able to judge,
whether those rules may all be adopted in fractures.
We will  apply it, as in the case of a fracture of the
thigh in the  shaft of the  bone.
   First place the pads (fig. 8) one on each side above
the  knee, immediately back of the  condyles ; then
around the limb  and pads, apply a  common  bandage,
loosely, to prevent the India-rubberf surface of the
belts from stimulating the skin;   next  apply a belt
 loosely, with a loop on each side of  the knee,  armed
 with tapes, the tapes to  cross the bulbous part of the
  *I am informed by my young friend Robert King Stone, M.D., of Wash-
 ington, D. C , who was present with me at Val de Grace, that the name of
 the inventor, whose apparatus pleased me so much, is M. Baudens, surgeon
 in chief, a man of great surgical talents and attainments.  He was chiet of
 the surgical staff in Africa.
  t Instead of India-rubber cloth, the inventor has of late preferred to use
 oiled silk, it being equally adhesive,  yet less stimulating to the skin, and
 therefore in most cases it is esteemed much better. 
48        FRACTURES  AND DISLOCATIONS.

pads.  Apply the instrument to the limb, as in a dis-
location of the  femur, except  that the  side  lever is
not to be attached to it.   Then lay the limb, and in-
strument attached, on the double-inclined plane, pre-
viously arranged with mats, or any thing  which will
make an  easy  surface on the plane, on which the
limb is to rest.   Over  the whole, lay  the eighteen-
tailed bandage, or tapes,  at suitable distances,  ready
for dressing, after the bone is adjusted.  All being
arranged in the manner just described, the  surgeon
will,  with one  hand, apply the lever  (fig. 2) to the
shaft of the pinion-wheel, while the other is laid over
the seat of injury.   Thus with one  hand he makes
gradual extension, while with the other he is able to
feel the progress which the bones make towards co-
aptation.   When properly adjusted, apply splints  on
each side of the thigh, letting the ends pass a  little
distance under the pads.   Let the space between the
inside  splint and the instrument be filled  up with
folds of cloth, so that the pressure may  be equal on
the inside of the thigh.  Apply the tapes or bandages
over the whole.   A bolster should also be laid under 
LECTURE III.
49
the bandage, between the instrument and  plane,  to
support the  former from bearing on the limb.  I will
here state the mode which I saw adopted at the Val
de Grace Hospital, from  which to fix the point  of
extension, which, in some cases, I think I should pre-
fer.   The dextrin bandage was applied, above, below,
and over the knee, with  tapes  or  a  piece of  roller
inclosed in the coils  of the bandage, so as  to be tied
to the extending point of the  apparatus.    Extension
could not, of course, be made  by it, until the dextrin
had become dry and hard.  Those on whom I saw it
applied, appeared to wear it with perfect ease.   The
same material was used,  for  fixing the  counter-ex-
tending point at the knee, and the extending point at
the foot, in  fractures of  the leg.  Thus, you see the
mode in which this instrument is applied on the dou-
ble-inclined plane, and you will therefore readily per-
ceive, it is conformed to the first rule  by the  limb
being placed on the inclined  plane.   It  is  also  con-
formed to the second, by being  so  applied, that the
smallest amount of  extension, necessary to preserve
coaptation, is employed.   It is conformed to the third,
because the line of extension is the  nearest possible
to a perfectly normal line of the fractured  bone.  It is,
finally, conformed to the fourth, the points  of  exten-
sion and counter-extension being confined within the
limits of the fractured  bone.   Thus  we  here see the
four rules, applied to practice, by this apparatus, and
at one time.
   I will now  call  your attention to a fracture at the
neck of the thigh bone.  But,  first, allow  me  to
suggest  another position, in  which  that fracture
may be treated ; and  for that purpose. I  beg your
attention  to that particular   arrangement   between
            5 
 50        FRACTURES AND  DISLOCATIONS.

 the head of the bone and the pelvis, to which I al-
 luded on the  first  evening's  lecture—viz.,  that  the
 head of the bone serves as  a pivot on which  turn all
 the movements of the body.   I  next wish  to  show
 you, that, in a fracture at the neck of the femur,  there
 will be less motion at the point  of fracture, and  be-
 tween the  fractured portions,  by  placing the  patient
 on the side  opposite the one  injured, than there would
 be, to place him on his back, as is usually done.   My
 reasons for it are the following.   A person, while  ly-
 ing on his  back, cannot  raise his shoulders, or turn
 them to either side even  but a trifle, without produc-
 ing motion at   the fractured point; and how much
 inclined patients are to do this, especially for the pur-
 pose of viewing objects around them, you are doubt-
 less all aware.   Indeed, the movements of the head,
 and the trifle of corresponding motion of the shoulders,
 seem almost involuntary.  Still, involuntary as those
 motions may be,  they all result  in  motion  at the
 point of  fracture;  and it is not my wonder, that  so
few fractures at the neck of the  bone result in  an
 osseous union, but rather, that so many  result in it;
 for motion,  the  great disturber of all osseous union, is
 constantly, yet involuntarily employed by the patient.
 On the other hand, by placing the patient on the unin-
 jured side,  the position subjects  him to greater im-
 pediments to motion of the shoulders, than when  he
 is on his back.   He  would  be unlikely  to raise his
 shoulders for any  object, especially if  he were  told
 not to do so, and yet he could  move his head   freely,
 without communicating motion to the shoulders.  His
 inclinations to turn to either side  would doubtless  be
 increased, although that could  be greatly restricted.
 Still, if the  limb were properly secured with the pel- 
LECTURE III.
51
vis, it would move with the body, without producing
motion  at  the site of fracture.  These are my rea-
sons for placing a patient, with a fractured neck of
the thigh bone, on the side, yet if it is not found to
answer (in the  hands of others) equally well  with
the position of the patient placed on his back, there
is nothing in  our  principles or treatment, in other
respects,  which  renders the position I have recom-
mended, essential.   We will, however, apply the in-
strument,  in the position  we have  been describing.
Indeed, it must be so applied in both ;  and it is only
for the  surgeon to select, according  to  the case to be
treated ;  the one on the side being especially adapted
to persons who  are  large  and fleshy, and  who can
with difficulty be confined  on the back.   We occa-
sionally meet  with  such patients.  I once had one ;
and I would have given any thing, to have been  able
to accommodate my patient, with  that position she
so much  desired, but it was before I  knew how to
accomplish it.  Extensive sloughing, after every thing
we could  do to prevent it, was  the consequence of
her  confinement ;  and  after suffering  beyond  my
power  of description, the  case  resulted  in  death.
During  the  whole  treatment, I was convinced, that
could  she have  been allowed  to be on her side — a
position which she had used for years  — without,  at
the  same time, provoking  greater pain by the frac-
tured ends of the bone piercing the  muscular  sub-
stance around them, she would have been compara-
tively easy;  but the last  evil, at  least  for a time,
seemed worse than  the  first.   Her  suffering  was
extreme, and she died at the end of about five weeks*

  * This was written when I was obliged to trust to my memory.  On refer-
ring to my notes of the case, I find that the patient lived seven weeks from
the time of receiving the injury.                          J- 
52
FRACTURES AND DISLOCATIONS.
from the time of receiving the injury.  But I will not
detain you, by stating any more cases.  For the one,
however, which  I have just related, should you  ever
have a case of the kind to treat,  I doubt not, you will
feel greatly obliged  for the account I have here given.
We will now apply  the instrument.
                 PLATE  VI.
   The surgeon should first be provided with two long
splints, one to reach from the perinaeum  to  the sole
of the patient's foot, the other from the top of the ilium
to the sole of the foot.  He should also be provided
with a square piece of cloth in which to roll the splints,
so as to make a trough, in which to lay the limb.   First,
apply a belt around the thigh above the knee,  mind-
ing first to protect the  skin by a common roller.  Let
a piece of tape, of about three feet in length, be tied
to each loop, on  each side of the knee.   Now  let the
limb be laid between the splints, rolled  in  the cloth
as described.   The counter-extending  bar, D, will
now be drawn out to its full length,  and made fast
by the screw, E  ; the thigh-fork (fig.  4) will  be  ap-
plied to it, with  the  roll, II, suspended  between its
arms; and the rack will be drawn out, sufficiently to
allow the  foot of it to cross the  sole of the patient's
foot.  Now apply the  instrument,  on  the external 
LECTURE III.
53
side of the inner splint, or, in other words,  on the
inside of the thigh and leg, and on the outer  surface
of the splint, the roll, H, pressing against  the  peri-
naeum, as in fractures in the shaft of the bone.   Draw
the tapes tensely, and tie them on each side of the
patient's foot, to the foot of the rack; apply the strap,
across the top of the ilium, and around  the arms of
the fork,  in  the  manner before described ;  place a
thick pad between it and the skin, and draw the strap
sufficiently tense over it, to give  full length to the
neck.   Tie  tapes around the whole, at convenient
points, to securely fix the  limb, splints, and instru-
ment, as one piece.   The instrument may be further
secured to the pelvis by passing a band once around
the pelvis, and, on its second turn, to pass it round the
end of the arm of the fork on its respective side, and
make it  fast to it.    Finally,  give the necessary ex-
tension to the limb.    I  will not detain you, to  point
out how the four  rules have been complied with in
the treatment of this fracture, for I trust you will be
able to discover it without assistance.
5* 
(  54   )
               LECTURE   IV
Fractures of the Leg.—The Dextrin Bandage used to
  fix the points of extension and counter-extension to
  the Limb.—Its abuse in Fractures.—Fractures  of
  the Patella.—Dislocations  of the Knee—of the
  Ankle.
  1 shall this evening endeavor to finish my remarks
on fractures, and also, on the  dislocations  of the in-
ferior extremities.   I will first call your attention  to
a fracture of the leg.  But, before I proceed, allow
me  to remark, that we find the same anatomical ar-
rangement for mechanical action—if I may be allowed
the expression—in the muscles of the leg, which we
found in the thigh.   Indeed, all the long  bones  have
the same general arrangement of muscles.  We  can-
not, however,  now stop to classify  them, nor, indeed,
will it be necessary; since your knowledge of  ana-
tomy will readily furnish  this very natural division.
First;—of muscles  passing over  the bone, and yet
are not attached to it at either  end ;—second, those
attached to it at one end, the other end being attached
at some point  above;—and third, those attached,  in
like manner, at one end,  while the other  descends,
and are attached below the bone.  There  are other
muscles  than   those  thus classified—for instance,
where two bones  lie parallel,  as in the bones of the
forearm.  Yet they do not materially affect this  divi-
sion ; nor do they in the least interfere with the prin-
ciples, to illustrate which, this division is now made.
It must be apparent, however, that much depends  on
this arrangement  of muscles with the bone, in placing
it in a favorable position for coaptation ;  and  by 
LECTURE IV.
55
giving attention to this, it will readily be  seen  what
position the bone should occupy, when fractured, to
preserve coaptation most readily.
  But,  let us proceed to apply the instrument,  as to
a fracture of the leg.   It is always to be  applied in
the same manner, let the surgeon adopt what position
of the limb he may; for, be it remembered, with this
instrument, the surgeon applies extension and counter-
extension, independently of position.  Position is one
thing, and extension and counter-extension another;
and they should ever be left  free and independent for
the surgeon to apply at his pleasure.  Both are  im-
portant principles in surgery.   The one should,  there-
fore, never be sacrificed for  the other; and  if right
methods are adopted,  such  sacrifice never becomes
necessary.
  Apply the bulbous part of the pads (fig. 8), one on
each side of the leg, below the head of the tibia ; and
around the pads and limb, a belt with a loop, on each
side of  the leg, the loops standing upward over the
bulbous part of the pad.   Arm the two loops with
tapes.   A belt  may now  also be applied to the ankle 
56       FRACTURES AND DISLOCATIONS.
with tapes in it.   But I much prefer a fracture-shoe
instead of a belt round the ankle, especially if  there
is  any inflammation or swelling of the  leg.  The
double-inclined plane, being arranged with a suitable
mat, bandages, &c, and the instrument  being pro-
perly arranged as to length; the arm of the jointed-
fork (fig. 6),  which will not be required for use, being
removed from the fork ; and  the  socket  K, of the
fork, being applied to the counter-extending bar D ;
let  the  tapes from the upper belt be tied to the arm
which remains in  the fork, immediately  above the
knee, and the foot of the rack be  made fast at the
sole of the patient's foot.  Lay the limb and instru-
ment, thus arranged, on the double-inclined plane;
make the necessary extension;  and apply the dress-
ing ; minding to place between  the instrument  and
the plane, and under the bandage, rolls of cloth  suffi-
ciently large, to support the instrument against the
middle of the leg.   Proper- splints should be applied
on each side of the leg ; and on the side at which the
instrument is placed,  the  splint should  be  placed
between the instrument and leg.   I am  inclined  to
think the dextrin bandage might, in some cases,  be
advantageously used with this instrument, as a splint.
Apply the bandage  with  the  limb nicely adjusted;
when dry, split the bandage lengthwise over the tibia,
and cut away a piece about an inch wide,  through its
whole length.  Then, over the whole, apply tapes,
at suitable distances.  I have never used the dextrin
in this form with the instrument,  but its operation
would be simple.   I think I cannot be  mistaken  in
the opinion I have formed of it.  Indeed, I  think  it
equally applicable in some fractures of the thigh.  Of
its  use, however, in some  of the  cases  in  which I 
                    LECTURE IV.                 57

have seen  it applied,  and especially  the manner in
which it was applied, I am obliged to remark that I
cannot, too strongly  deprecate both.  To leave a limb
enveloped for days in this unyielding casement, during
the inflammatory  stage of a fracture, is hazarding the
limb of the patient,  and the reputation of the surgeon,
beyond all bounds of prudence.  Nor, indeed, as  far
as I have seen, has  there been less deformity in the
limb,  resulting from its use,  than with the more com-
mon means; yet there has,  undoubtedly,  been less
trouble to  the  surgeon.  And  the practice of fre-
quently cutting it off and re-applying it, is, necessarily,
attended with evils of the worst  consequences ;  for
every time the dressing  is re-applied, coaptation, and
the fractured ends, must  be greatly disturbed.  When
provisional  callus  has formed around the fractured
ends of the bone, and yet the limb requires support,
I have not the same objections to this use of the dex-
trin bandage.   In such cases, indeed, I think it highly
useful, if properly applied.
   I will now call your  attention to a fracture of the
patella.   It is not usual, however, that any mechani-
cal means are required in  this injury, other, than to

  •Plate VIII., which was not in the English edition, is here added, the
better to illustrate the application of the instrument to fractures of the pa-
tella. 
58        FRACTURES AND DISLOCATIONS.

place the  limb  perfectly straight, and to elevate the
foot, so as to relax the rectus femoris and vasti mus-
cles.   Indeed, any  attempt to approximate the two
fractured  portions by an apparatus about the  knee,
generally  results in a greater separation of the frac-
tured portions,  than to leave the  limb as above de-
scribed.   Yet this is not always the case.  There are
instances in which it is desirable to overcome, in some
measure, the extreme contractility of the three muscles
above named.  This may  be done  in  the  following
manner:—Place  the bulbous part of one pad above
and against the upper fragment of bone, and around i*
and the limb, apply a belt with a loop  lying over the
bulb; pass the other belt around the limb  below the
lower  fragment, with a loop lying over the  broken
portion ; pass a tape through the loops  and tie  mode-
rately tight;  but through the upper loop, pass  a  loug
tape, an end of which is to pass down on each side of
the leg.   Apply the instrument, as in fractures  at the
neck  of the  thigh-bone, but  without  any splints or
bandages.  Let an end of the tape be tied  to  the
foot  of the rack, crossing the  sole of the patient's
foot, and on each side of  it.   Thus, by making  ex-
tension with the instrument, the upper  portion  is only
acted upon, and  may thus  be brought in contact with
the lower, without applying the least force  to the in-
ferior portion—a point much to be desired, if we must
needs have recourse  to mechanical means.
  I here  close  my  remarks on  fractures ;  and will
again call your attention to  dislocations.   This evening
particularly, to  dislocations  of the  knee and  ankle,
beginning with  the knee.
  The knee is subject to luxations every way, though
fortunately, they are not  frequent.  When they do 
LECTURE IV.
59
occur, the injury is apt to be so extensive, that am-
putation  is required ; yet, in general,  it is  in  those
cases where  reduction is most difficult, that the sur-
geon should  by all means in his power endeavor  to
save the limb.  It is not my business, however,  to
lecture  either  upon diagnosis  or pathology,—mine
merely relates to treatment.   1 will at once, therefore,
explain the method of reducing a luxation of the knee
by  this apparatus.  There  are two ways, and the
surgeon is to select that one which applies best  to
the kind of luxation which he has to reduce.
  First method.—Let a belt be applied immediately
above the knee, with a loop low over the patella;
another belt round the ankle, armed with strong cords,
the instrument being arranged as  in  fractures of the
leg.  Pass the arm of the jointed fork through the
loop above named, and tie the foot of the rack, cross-
ing  the sole of the patient's foot, to the lower belt.
Make extension and free motion if necessary.
  Second method.—Apply a large silk handkerchief,
by a clove-hitch, immediately  below the knee, the
knot lying on the  tibia in front;  put the  instrument
on the limb as in fractures of the thigh,  except that
the foot of the instrument is to be securely fixed  to
the limb by the silk handkerchief;  apply extension,
motion, &c.
  To reduce a dislocation of the  ankle, buckle a belt
round the leg, immediately below the knee, with one
loop in front, on the tibia,  and looking towards the
foot; another directly back of it, on the posterior side
of the leii.   Pass the two arms of  the jointed  fork
through the two loops above named ; insert the end
of the counter-extending bar, D, into  the socket of the
fork (fig. 6), and to make fast the extending point of 
60        FRACTURES AND  DISLOCATIONS.
the instrument to  the  foot, the following method
should be adopted :—Let the back of the limb, im-
mediately above the heel, rest on the middle of a large
                 PLATE  IX.
silk handkerchief in form of a roll, the foot of the
rack lying across the hollow  of  the  patient's  foot.
Bring the ends of the handkerchief down  on  each
side of the heel, and cross  them over the sole of the
patient's foot and the  foot of the rack ; carry them
forwards and cross them again on  the top of the foot;
pass each  end,  as  respectively  inclined,  under the
handkerchief lying on the side of  the heel;  bring the
ends forward again, to the top of the foot, and tie them
elosely and firmly down.
   In a dislocation where the foot is  thrown  either
outward or inward to a great extent, to prevent the
sole of the foot from being drawn  too suddenly under,
another handkerchief may be thrown around the top
of the foot and  tied to the foot of the rack.   This
will prevent the patient's  foot from turning, until the
surgeon thinks he may  have sufficiently extended the
foot, to admit the two points of the luxated bones to 
LECTURE IV.
61
pass each other.  He may then suddenly  loose the
last-named handkerchief, and all the force will  now
fall upon the handkerchief first applied, when the sur-
geon can manipulate the limb.
   I conceive it quite possible, that in some cases, an
additional instrument might be required, to make ex-
tension lengthwise of the foot, at the same time.   In
this case, or when the force is required between the
tarsal and  metatarsal bones, the jointed  fork  being
attached to the instrument, and the instrument placed
to the sole of the foot, let a strap  pass from arm  to
arm of the fork, in front of the leg, at the instep ; and
with a band applied round the metatarsal bones,  in
the  form of a clove-hitch, the knot lying on the under
side of the first metatarsal bone, attach the patient's
foot to the foot of the rack.  This is  the mode  in
which I reduced a dislocation of the metatarsal from
the  tarsal bones, at Hopital  Cochin, as reported  in
the  Gazette des Hopitaux, Oct. 2d, 1845.
6 
(62)
                LECTURE   V.
Dislocations of the Shoulder—of the Elbow—of the
   Thumb.
   I will, this evening, call your attention to disloca-
tions  of the superior extremities.   We will begin
with those of the shoulder; and, from the manner in
which this instrument operates, you will at once per-
ceive, that there is no necessity  of its having but one
mode of application for  luxations of this joint; the
line of  extension  being entirely under the control of
the surgeon, to  vary it  at his  will.  Whether the
head of the bone is under the tendon of the triceps,
in the axilla, or  under the  pectoralis  muscles,  it is
equally  subject to his direction;  and therefore  its one
mode of application is quite sufficient for every variety.
Let us now apply  the instrument, and describe  that
mode.
   Buckle a belt round the  arm,  immediately above
the elbow, with one loop  lying  on  the upper,  and
another on the under side of the arm.  Through these
loops, pass strong tapes or cords.  1 think it well  also,
in grave luxations, to cover  the whole hand and  arm
below the belt,  with a common roller, to prevent, in
some  measure,  the congested state of  the capillary
vessels.  It is always certain  to  attend  the applica-
tion of force from this point, in whatever way applied,
and it is frequently the  cause of the greatest  pain
which the patient has  to endure, during  reduction,
especially where the operation must be long continued.
Prepare the instrument  by buttoning tensely across
the top of the shoulder fork (fig. 5), the roll, H.   Ap-
ply the fork to  the counter-extending bar, D; place 
LECTURE V.
63
the roll in the axilla, and tie the tapes closely round
the foot of the rack.   I  would here recommend, in
difficult cases, to lay in the axilla,  between  the  roll
and the skin, folds  of  cloth sufficiently thick to pre-
vent the roll from pressing strongly on the tendons of
the latissimus dorsi and pectoralis major muscles, the
folded  cloth being placed between those tendons.
By doing this, the surgeon can, if  he chooses, make
the instrument operate precisely like the  heel in the
axilla; but much more steadily, and with much greater
force than he can  ordinarily  command.   Moreover,
the whole operation is immediately under his control.
The instrument being thus applied, buckle the strap
across the shoulder; or, as I  prefer,  pass the strap
which is used on the dorsum of the ilium, in fractures
at the neck of the thigh-bone,  around the roll on each
side of the shoulder, crossing the top of the scapula.
Draw  the  strap sufficiently tight to press  the roll
firmly against the under side of the shoulder, so that
the line of extension shall be from the centre of the
elbow, to near the centre of the glenoid cavity.
  This arrangement  completed,  apply the  hollow 
64        FRACTURES AND  DISLOCATIONS.

part of the strap (which accompanies each box of the
instrument for that purpose) to the point of the acro-
mion process; carry  the ends on each side, between
the fork and the roll, and around the body;  and let
it be drawn tight and buckled.   Thus, as you  see,
the instrument is now on the patient,  and ready for
the operation.   By the lever  you hold great power
in your hand, more than a prudent man  would  ever
think to use on  the  shoulder.  You will, however,
soon get so accustomed to its use, that you will know
very nearly the amount which you at any  time  may
use; indeed, by this instrument, with very little trou-
ble, you may tell to an ounce, at any time, the amount
of power which you have applied.
  I will not detain you longer with this luxation, but
will call your  attention to  one  of the elbow.  We
will suppose the case, where the  coronoid process of
the ulna is lodged in  the posterior fossae of the hume-
rus.  It is an  important point  in  this  dislocation,
when it presents difficulties, to be  able to flex the
arm, while extension and counter-extension are ope-
rating on the limb, without,  any abatement of force.
There are two ways  of applying the force of this in-
strument,  in this luxation.  Some surgeons have pre-
ferred the one, and some the other method.   As for
myself, I think them  both important, according to the
case to be treated; and if I had an exceedingly bad
case, and one which required my best efforts to reduce,
I should apply both modes at  the  same time, which
may be done very readily.  I will show and describe
them both.  The first one described, however, is the
one which I commonly use.
  Buckle  the belt having a close loop on it around
the arm, with  the  loop low  over the olecranon pro- 
LECTURE V.
65
cess.   Buckle the short belt around the wrist, with
a loop on  each side of the  hand armed with strong
tapes.   Insert the elbow fork (fig. 7)  into the close
loop, and the counter-extending bar, D, into its sock-
et K.  Tie  the tapes in the belt at the wrist, to the
foot of the rack, minding to  draw them closely round
the foot of  the  instrument.  With the  lever make
extension, &c.   [See Plate  XI.~\
   Second mode.—Buckle a belt around the arm, be-
low the shoulder, with a loop on the back, and another
on the front part of the arm, the loops looking towards
the elbow.   Pass  the two arms of the jointed  fork
through the two loops, the joint being on the  under
side of the arm.   On the fore-arm, and close to the
elbow, apply a silk handkerchief, in form of a roll, by
a clove-hitch, the knot resting  on the ulna, immedi-
ately  below the  olecranon process.  Insert the end
of the counter-extending bar, into the socket of the
fork ; and  tie the handkerchief closely around the
foot of the rack.   To securely  fix  the instrument to
             6* 
66       FRACTURES  AND  DISLOCATIONS.

the limb, let another  handkerchief be passed closely
round both, near the top of  the instrument, and tied.
With the lever make extension, &c.
   Thus you have the  two  methods explained; and
you  will readily see,  that they are both easy of ap-
plication, and  may be  applied at  the  same time, by
employing  two instruments.  The last mode would
bring the radius and ulna down, while the arm is in
a flex position; thus drawing the  coronoid  process
out from the fossa.   The first  would press the hu-
merus backward, while the fore-arm was being flexed
on the arm ; thus  bringing the coronoid process for-
ward of the trochleated surface of the humerus.
   There is but one more luxation to which I would
call your attention, trusting,  that if you understand
those already shown, you will  be able  to apply this
instrument  in  every case which  you  may  be  called
upon to  reduce.  The one of which I speak is of the
thumb ;  and although this is but a small member,  it
                PLATE  XII*
often makes a grave case for the surgeon.   Yet with
I his instrument I am quite  sure  you need  never be
 * Plat* XII. was not in the English edition, but is here introduced to show
Hie application ot the instrument to reduce a luxated thumb. 
LECTURE V.
67
defeated ;  and the same may be said of all the pha-
langes.
  The application of  the  instrument to reduce this
luxation is not so easily exemplified as in the other
cases which you have seen.   This proceeds, mainly,
from the want of that peculiar prominence, which the
luxated bone presents, projecting over the side of the
distal extremity of the bone from which it was dislo-
cated ;  since it is around this prominence of the lux-
ated bone,  that  the  force  is to  be applied.   The
thumb may  be dislocated,  either  backward  or for-
ward ; and whichever way the bone is displaced, the
force should be applied, against the upper extremity
of  the distal bone.   Suppose  the thumb displaced
backward — wet a bioad tape,  and apply it, smoothly
doubled, lengthwise,  by a clove-hitch, over the pro-
jected shoulder on the back of the thumb, letting the
knot rest on the inside.  Apply the jointed fork to the
instrument; and let the strap which  is used to cross
the dorsum of the ilium, be suspended from the arms
of  the fork, forming a loop, and hanging loosely down
between them.  Let the hand, between the thumb and
index-finger,  be  made to  rest  against  this  strap,
 the back of the hand resting on the brass case.  Then
 tie the tape which is attached  to the luxation, to the
 foot of the  rack ;  pass a handkerchief round the wrist
 and the instrument;  and tie it so as to confine them
 together.   With the lever make  extension;  and,
 while that  is made with one  hand, with  the other
 cast the luxated bone directly  backward towards the
 wrist.  When the extremity of the bone to which the
 tape is applied,  has  reached the  edge of the articu-
 lating surface from which it was displaced, bring the
 luxated bone forward again, and  the two articulating 
68        FRACTURES AND DISLOCATIONS.

surfaces will readily be restored to their normal posi-
tion.  When the thumb is luxated inward, apply the
tape to the prominent end on the inside — as it was
before applied to that on the back of the thumb. Let
the thumb also be cast inward, as it was before back-
ward.  In all other  respects the two operations are
alike.
  Thus I close my remarks on luxations ;  and it only
remains for me  to return you my sincere thanks for
the attention I have  received, while I have been at-
tempting to contribute a small amount to  the general
stock of surgical knowledge.  My desire has been to
do good,  by endeavoring to improve the practice of
that profession,  in which there should be felt but one
common  interest; and in conclusion, I have only to
ask  that what  I have said may be judged by  the
standard of truth. 
APPENDIX.
NOTICES OF THE ADJUSTER
        EXTRACT FROM THE (JAZETTE DES HOPITAUX.
 Notice of a new Apparatus  of Dr. Jar vis, for the  Reduction of
          Luxations and Fractures.  By Dr.  Stout.
   " Among the various means which surgeons employ for the re-
 duction of grave luxations, there is one not yet known in Europe,
 and which seems nevertheless to merit their acquaintance; we al-
 lude to an apparatus invented by Dr. Jarvis, to which he has given
 the name of surgical adjuster, and which he makes use of to reduce
 not only all luxations of limbs requiring mechanism, but also frac-
 tures  with displacement, and to coapt the latter in an efficacious
 manner when they present any difficulty.
   These three distinct applications of the same apparatus result
 from its simple  construction, which presents  nothing but what is
 conformable to the laws of mechanics applied to surgery, as the
 result of the effects produced by its application, and which are :—
   1st.   To establish a line of extension between any  two parts
 whatever of  the body, according to the exigency of the required
 case ; or as regards luxations only, to establish a straight line of
 extension, which shall operate in the normal line of the luxated
 bone.
   2nd.  To  furnish an extending force, illimitable but calculable,
 and perfectly subjected to the will of the operator.
  3rd.   To combine with the simple extending power, the power
 of a lever of the first or second order, according to the  operative
 procedure adopted by the surgeon.
  4th.   To be able to add a line of extension  at right  angles to
the preceding, without interrupting its action.
  5th.   To fulfil all these different indications without interfer- 
70
APPENDIX.
ing  with the  mobility of the dislocated  limb, and to permit the
operator to act according to his pleasure.
  6th.  To give the patient more liberty during a long treatment
than he would have had by any other known means.
  The  mechanism which produces these results is simple, and
merely  a happy application of  the pinion wheel and rack-bar to
surgery.  A brass case, thirteen inches long, one inch and a half
wide, and half an inch thick, incloses a pinion wheel which moves
a steel rack-bar, with teeth corresponding with the pinion wheel,
and  of the same length as the  case ; which rack-bar constitutes
the extending power.   A ratchet wheel, on the exterior of the
case, operating on the same shaft  with the pinion wheel within, is
held by a catch so as to  maintain,  at  any desired point, the ex-
tending force.  Upon the axis of these  two wheels is applied a
lever, of length sufficient to give the instrument the power of
twelve men.   The extending power occupies one side of the brass
case, the counter-extending power the other side, provided with a
mechanism which allows  of its elongation or contraction at plea-
sure, and according to the case to be treated.  The rack-bar is bent
at right angles at one extremity,  in order to make the line of ex-
tension  in the  axis of the limb, while  the  instrument is applied
parallel to its side.
  At the counter-extending point, are alternately applied, several
appendages  for  properly securing the instrument  to the parts
which form the point of resistance for the counter-extending force.
Thus for the thigh there is a long steel fork, between the branches
of which is suspended a cushioned roll.  When this fork is ap-
plied to the perineum, so that the cushioned roll rests upon the
great tuberosity of the ischium, one of its branches passes in front
of the pelvis, while the other lies back of it.  The fastenings which
unite the extremities of  the fork to the cushioned roll form  the
points of counter-extension.  Thus the points of traction are bound-
ed on one side by the extremities  of the fork, and on the other by
the foot of the rack-bar.
  Certain modifications of these appendages  for the securing of
the  limb, render the application of the instrument easy to all parts
of the body. But a description  of them and of the bands destined
to fix the apparatus, would surpass the limits of this notice ;  and
might besides  tend to cause an  opinion of there being some com-
plexity in the  instrument, which, in fact, does not exist.   We will
hereafter publish a detailed  description of the whole apparatus, 
SURGICAL ADJUSTER.
71
with the necessary cuts, and the  mode  of its application  in  all
cases.
  Surgeons have for so long a time been  in search of a means of
powerful extension and counter-extension, at the same time regu-
lar, subject to the will of the operator, and easy  of application,
that it is astonishing that the apparatus of Dr. Jarvis, which seems
to have almost reached perfection, should have been till now un-
discovered.   Indeed, by  the aid of this apparatus, the pulley  be-
comes in future useless; hereafter we are freed from the greater
part of the inconveniences which usually accompany the reduction
of a luxation.  The operation will be performed in a manner more
conformable with the dignity of the surgeon.   There will no
longer be a necessity for six or ten assistants; two are  sufficient,
or, if necessity require it, the surgeon alone may suffice.   With
regard to the place where the operation is  to be  performed;  the
bed of the patient, a table, or even the field  of battle, offer as great
 conveniences as the best furnished amphitheatre.   There will no
 longer be occasion to look around the patient  for fixed  points  for
 extension and counter-extension, which, in  the ordinary proceed-
 ings, call for so much of the  surgeon's attention.  The point of
 counter-extension, departing directly from the  centre of the motion
 of the instrument, is furnished by the apparatus  itself;  but it is
 not only in the removal of  the inconveniences which surround an
 attempt at reduction of a difficult case, that the greatest utility of
 this apparatus consists.  The operator will now have at his disposal
 an enormous power,  which the most vigorous  muscles can no
 longer resist, but which he will apply according to circumstances.
 He may increase it, diminish it, apply it  rapidly, or as slowly and
 mildly as he may wish, according to the resistance of the muscles,
 without danger of injuring them in any manner. In fatiguing
 them, there will no longer  be any fear of losing the degree of ex-
 tension already obtained.   The extension that has been gained,  is
 maintained as long as the operation requires  ; if it be diminished,
 it is readily increased to the same degree.  From the  foregoing,
 it is seen that with the new apparatus is  obtained a notable dimi-
 nution in the time required for the reduction  of difficult and pain-
 ful cases.
    Another advantage, not  less important, is the facility  this instru-
 ment gives to the surgeon, of acting  upon the mobility  of the dis-
 located limb, during the whole period of reduction, which remains
 free, in spite of the progress of  the extension, and the unvarying 
72
APPENDIX.
application of the apparatus ; and from the position of the fixed
points we have indicated, it is no longer possible  for the line of
extension to be deranged by the unruly movements of the patient.
Moreover, these movements themselves become less  violent, in
consequence  of the  mildness combined with the power, and the
invariable certainty of the action of the apparatus.
   The patient can also, in  his movements, carry  with him  the
instrument, without interfering with its action, or without causing
the axis of extension to deviate.   Dr. Jarvis has not  contented
himself with  these ameliorations only, important as they are ; he
has found, by the ingenious employment of a lever, the means of
applying at pleasure, a power which operates at right  angles to
the axis of extension ; this lever is arranged in such a manner as
to be  applied or removed without  affecting  the action of the  ex-
tending power in any case ; as for example, to throw out the head
of the femur from the pelvis, after the proper extension has been
made, and without interrupting in any wise the other parts of the
operation.  There are cases where, in the ordinary modes, reduc-
tion becomes  impossible without the aid of two pulleys,  which act
at right angles to each other; and then how many difficulties
unexpectedly arise ! how many unlooked-for obstacles ! how many
assistants are required! and, finally,  how often  a sudden move-
ment  of the patient may in an instant destroy the effect of a long
and tedious attempt.   The  side lever replaces the second pully
and remedies all these inconveniences.
   It will, perhaps, be objected that the greater portion of disloca-
tions  are reducible by other means ;  in fact, we may use others,
since  we  have not  at hand a methodical apparatus.   But, in
future, the surgeon will not be obliged to  put  himself in such
positions with respect to his patient, which  are  often so  unplea-
sant and ridiculous—as are  fully described in treatises on surgery.
By the aid of the surgical adjuster, we shall no longer  see  the
operator forced to put his foot in the axilla of the patient, in order
to reduce  a dislocation, or for his aid to pass a towel around  his
neck in order to make extension upon the  pelvis, steadying  and
pulling upon  it at the same  time  with  his  hands.   If there  be
some  cases which are very  simple, in which we  can do  without
this instrument, it is  not less  true  that as  soon as a dislocation
presents any difficulties, we regret not having at  our disposal  a
mechanical means which shall be powerful and  easy to manage,
to re-place the enormous efforts to which we find ourselves obliged 
SURGICAL  ADJUSTER.
73
to have recourse, and which too often give  rise to local lesions,
inflammation, and febrile re-action, which complicate through ill-
treatment, cases which were very simple in their origin.
   We have as yet spoken of the application of the surgical adjus-
ter to luxations alone : let us glance at its use in the treatment of
fractures.   Do we wish to treat a fracture with the double-inclined
plane which accompanies the apparatus, with a modification which
allows of its being shortened or lengthened at  will; the employ-
ment of this instrument gives the facility of adjusting  the limb in
the first place upon the inclined plane, then  the necessary reduc-
tion  is made, and the dressing applied with or without the appa-
ratus, but without communicating to the  patient any of those va-
rious motions which tend  to destroy or separate the parts brought
together, and increase the pain and the  re-action.  The  patient
thus treated with the apparatus as a fixture, is not bound  to pre-
serve always the same position; he can put himself more at his
own ease, and even change his position.  The parts remain always
maintained in their proper place, the instrument being disarranged
with difficulty.   Do we wish to dress the member in  a  straight
line, and continue the extension in order to guard against shorten-
ing ; the instrument having become a fixed apparatus is elongated
to equal the length of the leg, securing it against any consecutive
retraction,  at the same time that it permits the patient  to change
his position, and the surgeon to examine all the necessary dress-
ings  which may now  be  less  complicated and  less bulky than
before.
   The surgical  adjuster offers nothing in its application contrary
to the soundest principles  of surgery,  and admits of every variety
of dressing.  If it act with considerable, and, we  may say,  irre-
sistible  power, it is to the manner in which it is constructed that
it owes it, and to the facility with  which  its principal action may
be directed;  thus it may be confided, with the assistance of a short
instructive pamphlet, drawn up by Dr. Jarvis himself, to hands
little accustomed to its use.   Hence  in  America  it is found on
board of vessels fitted out for the whale fishery, and those bound
upon long voyages.   We  are however aware that in spite of the
ease with which this instrument may  be  applied, it does not dis-
pense with the surgical knowledge necessary  for  diagnosis and
the other parts of the treatment of luxations, or  fractures  with
displacement, on the part of those  who make use of it."
7 
74                      APPENDIX.
 EXTRACT FROM ARCHIVES GENERALES DE MEDECINE, AUG., 1846.
 " Description of the new  Apparatus of Dr. Jarvis, for the Re-
   duction of  Dislocations,  the  Adjustment of  Fractures,  and
   keeping them in their place.   With Plates."
   The author of the above article in the  (Paris) Archives Gene-
 rates  de  Medecine,  gives a very  fair  history  of Surgical In-
 struments invented to reduce luxations and fractures, from the
 days of Hippocrates to the present, and which he very justly di-
 vides into three periods, as follows,  viz.: 1st. From Hippocrates
 to the time of Ambrose Pare in 1582.   2nd. From the time of
 the great Pare, to that of J. L. Petit  in 1750.  3rd.  From the time
 of J. L. Petit to the present:  each  of which he  regards  as cha-
 racterized by improvements and circumstances peculiar to  itself,
 and which he clearly defines :  he  then proceeds  to say,  " We
 come finally  to speak of the lever acting by means of the rack and
 pinion.  The apparatus of Dr. Jarvis is constructed on this prin-
 ciple.   The assemblage of essential  qualities which this principle
 presents, renders it  more applicable to surgery than all of those of
 which we have spoken.   Force multiplied mechanically,  com-
 bined with gentleness and  precision, constitutes the whole of the
 requisite qualities, and  which are all found in the use of the rack
 and pinion."
                        APPRECIATION.
   After having given an  idea of the apparatus which preceded
 Dr. Jarvis's, it remains only to give  due prominence to the merits
 which give to his Adjuster the preference over all other machines.
 These advantages are the following.
   1. The universality of its application, whether to luxations or to
 fractures, the adjustment and coaptation of which offer difficulties
even in supporting  a limb  while the injured  person  is raised and
carried home, or finally as  an orthopedic apparatus.
  2. The facility of communicating motion of every sort to the
member subject to its action, without deranging or interrupting
that action.
  3. The harmony of its action, with such a position of a limb as
places  its muscles in repose.
  4. Its  application in every  place,  without the  necessity of
searching for fixed  points around the patient in order to establish
extension  and counter-extension.
  5. The possibility of modifying at will the force  employed, in
regard either to its  quantity or its velocity. 
SURGICAL  ADJUSTER.
75
   6. The facility of transportation—the  whole apparatus being
inclosed in a box, 15 inches long, 12 inches broad, and about 5
inches high.
   7. In difficult and painful reductions, the considerable diminu-
tion of  time, and the patient's enjoyment  of much greater liberty
during his treatment.
   By the aid, then, of this instrument, the Surgeon  possesses a
regular and powerful force, subject to his  will, and easy of appli-
cation.   He has at his disposal a power which the most vigorous
muscles can no longer resist, and which he will manage accord-
ing to circumstances.  He can augment or diminish, accelerate
or retard this power,  according to the resistance of the muscles,
without injuring them in any manner.  He will no longer fear to
lose, by fatiguing them, the degree of extension already obtained.
The extension he has gained is sustained as long as the operation
requires; whenever it shall be  judged proper to diminish it, it
can without difficulty be brought back to the same degree. Hence-
forth the pulleys become useless.  The operator, no longer obliged
to seek  around the  patient those  fixed points for extension and
counter-extension, which so much pre-occupy his attention in  the
ordinary methods, finds himself relieved from most of the embar-
rassments which accompany the reduction  of a  luxation.  The
point of counter-extension proceeding directly from the centre of
motion  in the instrument, is furnished by  the apparatus itself.
   As to the place where the operation  must be performed—the
patient's bed, any kind of table,  even the field of  battle itself,  af-
fords as convenient a position as the best furnished amphitheatre.
   Among the  advantages of this apparatus we cannot insist too
much upon that which it possesses, of leaving the surgeon free
during the whole continuance of any operation, to act with facility
on the mobility of the luxated limb.   Notwithstanding his appa-
ratus  is immovable,  and the  limb is  extended  to the uttermost,
nothing hinders  the operator from turning the limb round, or
changing its direction in every way.  It is no longer possible that
the line of extension should be deranged, either by the movements
caused by the surgeon, or  by the uncontrollable movements of the
patient.   Besides, the precision  in the action of so methodical an
apparatus renders all these inconveniences shorter and less   fa-
tiguing  for the operator, as well  as for the patient; at most,  the
patient in his agitation can only  carry his  instrument  away with
him, but will not interrupt its action, nor cause the axis of exten-
sion to deviate. 
76
APPENDIX.
EXTRACT FROM THE LONDON MEDICAL GAZETTE, MAY 23d, 1845.
Lectures delivered before the Royal College of Surgeons,  May,
   1845; by  Bransby B. Cooper, F.R.S., Professor of Surgery,
   fyc.
   The Professor next introduced to the notice of his audience an
instrument, invented  by Dr. Jarvis,  an American surgeon, for
reducing fractures and dislocations, and commented on  its use.
This instrument has been modestly denominated " the Adjuster "
by its ingenious inventor ;  a name which correctly enough points
out the ultimate effects produced by its application, but  conveys
no adequate idea of the enormous power and wonderful simplicity
of action which characterize this important invention; and Mr.
Cooper gave it  as his opinion, in unqualified terms, that the appa-
ratus must necessarily rise into the most general use.
Extract from the Proceedings of the Convention of the President
  and Fellows of the Connecticut Medical Society, held at Hart-
  ford, May Uth and 15th, 1845.
  Voted, That Doctors E. K. Hunt, Witter, W. Hooker, Fowler,
and Beckwith, be a Committee to  examine Dr. Jarvis's  Surgical
Adjuster, and report to this Convention.
  Report of the  Committee *n Dr. Jarvis's Surgical Adjuster,
was accepted, and the following Resolution recommended by them
was adopted:—
  Resolved, That in the opinion  of this Convention, the " Sur-
gical Adjuster " of Dr. Geo. O. Jarvis, for simplicity of design,
ease and efficiency in its operation and management, in the reduc-
tion of dislocations, and maintaining in coaptation oblique frac-
tures of the longer bones of the body,  has never been equalled—
successfully supplying a desideratum  which  has  long  been ad-
mitted to be wanting in  the  practice of surgery.   We  cordially
recommend it to the notice of all those engaged-in this difficult and
responsible department of our art. 
(77)
OPERATIONS  PERFORMED  BY  THE
                 ADJUSTER.
     FROM THE BOSTON MEDICAL AND SURGICAL JOURNAL.
Dislocation of the Humerus of five weeks' standing, reduced by
  means of Dr. Jarvis's Surgical Adjuster.   Reported by Robert
  King Stone, M.D.
  Clinique of Prof. J. F. May,  Columbian College,  Washington,
D.C., Nov. 21st, 1846.—Wm. Boothman, a3tat. 36,  an  English-
man, of exceedingly robust and muscular frame, presented himself
to-day, on account of a dislocation of the humerus,  the origin of
which,  he thus  describes.  About  six weeks since, he  suddenly
ceased his unfortunate habits of intemperance, and in consequence
had a slight attack of delirium tremens; while in this condition,
and crossing a street, he fell, striking the back of his right shoulder
against the curbstone.   He was not aware that any dislocation
had taken place, but supposed that the pain, great tumefaction and
discoloration which extended to the wrist, were merely the results
of a violent bruise.  It was but a few days before presenting him-
self, and after the tumefaction had subsided, that he  observed the
permanent immobility of the arm, and the deep depression under
the acromion.   Examination detected a  dislocation downwards
and forwards, with the head of the bone resting under the edge of
the  pectoralis minor, the elbow thrown backwards and very slight
mobility in its new position.  Much numbness of the  arm  had
existed since the accident, on account of  pressure on the axillary
plexus, and was still a subject of complaint.   It would be proper
to remark that the right clavicle  had been fractured in his youth.
and its bad coaptation produced deviation backwards and slightly
upwards of the acromion.  Careful examination satisfied Prof.
May, that although the head of the bone was but slightly movea-
ble,  no  danger was to be  apprehended from any complication of
the  axillary artery.
  Although previously preferring and exceedingly successful with
the  pulleys, Prof. May acceded to my wish to apply the apparatus
of Dr. Jarvis, in a case so capable of testing its powers.  Its ap-
plication was preceded by vs. Jxviij., and an ineffectual attempt
to nauseate with tart, antim. and ipecac.  Traction for a few mi-
nutes, in connection with the rotation so fully  permitted by  the
                7* 
78   .
APPENDIX.
 adjuster, seemed greatly to increase the mobility  of the  head of
 the bone, and the ratchet bar was left in this position for some time,
 in order to weary the muscles and act gently upon the adhesions.
 This alternate extension and rest was continued at proper inter-
 vals, when just before the moment at which reduction would have
 been perfectly practicable, the extending  bands,  which  had  not
 been previously well examined, all  gave  way, leaving  only the
 gain of greater mobility at the head of the bone.  As it was  im-
 possible to remedy the accident at that moment, Prof. May applied
 the sheets, &c,  in the ordinary method, assisted by Profs. Miller,
 Johnston and others,  but  without success.   Recourse was next
 had to the pulleys, which being gently and steadily applied for a
 long time, until  the man's endurance  was exhausted, were also
 laid aside.
  In questioning the patient as to the relative suffering during
 the three processes, he declared that the action of the adjuster was
 by far the least painful, and at the moment of snapping the extend-
 ing bands, he "felt the bone at  its socket,  and  that it slipped
 away."
  Nov. 23d.—Vs. 3 xx.   Tart,  antim.  and ipecac, with much
 better effect;  the man for the first time acknowledged  nausea.
 Having procured stout cords, we proceeded to the  reduction with
 Jarvis's adjuster.  The axilla was filled with a mass of cotton as
 usual, and the pad of the fork placed thereon.   It may be worthy
 of remark, that on this occasion, the perineal was  substituted  for
 the  axillary fork, on account of the man's great depth of thorax,
 as it was observed that on bringing the elbow forward, on Satur-
 day, its end impinged  upon the sternum, causing excessive  pain.
 The arm being flexed at the elbow, the  extending cords  were
 made fast and extension commenced.   At this stage of the opera-
tion, the vast  superiority of  Dr.  Jarvis's instrument  was mani-
fested, for whilst extension was made precisely in  the axis of dis-
location, Dr. May, with one hand in the axilla  and the  other
grasping the forearm,  had the most perfect command of the limb,
and could produce rotation at his pleasure.   When  satisfied that
 the  head of the bone had been brought low enough in the axilla,
 and sufficient mobility existed, a broad band was  passed under
the  neck of the  humerus and tied over the shoulders of the ope-
 rator.  The forearm was then resigned, and  with both hands  he
grasped the bone in the axilla, at the same  time throwing back his
 body, so that  the head of the humerus was forcibly lifted upwards 
SURGICAL  ADJUSTER.
79
and outwards.  Whilst this manoeuvre was performed, the elbow
was  rapidly  thrown  forwards at  "the word"  and "hard up"
against the ribs, and the extending bands  instantly relaxed.  As
a matter of course, the bone entered the glenoid cavity precisely
in the same manner as it left it.
   Although this case had resisted  the best efforts with the sheets
and pulleys, the reduction was effected in less than thirty minutes
with the adjuster.   Of  course a very slight depression remained
after the reduction, on account of the wasting of the deltoid, &c;
but when a pad was placed in the axilla and  Desault's apparatus
applied, the roundness of the shoulder was restored,  making but
a slight deduction  for the deformity from the  old fracture of the
clavicle.  This result is a source of  gratification to the operator
and those surgeons who witnessed it, as it   proved conclusively
the great power of the instrument, and that the manceuvre could
not have been thus performed with the aid of any other. I should
remark,  that  the method of commanding the head of the bone by
Prof. May, in connection with the instrument, was novel to my-
self, although I had the pleasure, a year ago, of seeing Dr. Jarvis
apply the adjuster in a similar case  at  the Military Hospital of
Val de Grace at Paris.
   In the application of this instrument, the proper rule for traction
seems to be,  to draw  down until the  patient feels it severely, and
then to rest a few  moments and rotate, waiting until the muscles
are so  wearied as to enable us,  when extension is resumed, to
make great progress at a moment when they are unable to  resist.
Extension and rest are thus to be alternated, until the  operator is
satisfied that the head of the bone is brought down parallel with
the plane of  the glenoid.   In this case there was no deviation in
extension from the axis of dislocation, and the head was made to
retrace  its path precisely;  then by lifting it forcibly, whilst at the
time of relaxing  the extension, the elbow was brought forwards
and close to the thorax, the bone was set free in a line outside of
the glenoid cavity.  When thus set  free, the muscles were made
available, and even the triceps and pectoralis assisted in the reduc-
tion.
   The patient is now perfectly well—only carrying his arm  in a
sling as a precautionary measure.
   Washington, D. C,  Dec. 20th,  1846. 
80
APPENDIX.
        EXTRACT FROM THE GAZETTE DES HOPITAUX.
         Luxation of the first Phalanx of the Thumb.
  Dr. Michon, surgeon of the Hospital Cochin, has had the kind-
ness to put at Dr. Jarvis's disposal, the two following cases:—
  First  Observation.—No 9,  Salle Cochin, M—, cook, fell in
the street, and throwing out his  hands to save himself,  received a
compound  luxation  of the thumb.  The accident occurred five
days ago.  During two days, various unsuccessful attempts were
made to reduce the luxation.   Extension was made  by means of
straps and  several men.  At  the  time of the operation the first
phalanx of the thumb was much swollen by erysipelatous inflam-
mation; a large wound was found on the inner side of the thumb,
near the dislocated  articulation.  The phalanx  was  dislocated
outwards, and carried obliquely upon the  second phalanx.   To
diminish the inflammation, leeches, poultices, and local baths of
warm water, had been employed.
  Operation.—The hand being placed upon the brass case, the
fore-arm rested in a jointed fork joined to the counter-extending
point.  A strap fixed to the two  branches of the fork, passing di-
rectly between  the  thumb and  the indicator.   A  sailor's knot
(made with a tape) attached  the first  phalanx to the  extending
point;  this tape  mounted very high upon the phalanx and com-
pressed the wound.   In consequence of the state  of  tumefaction,
it made every thing attached to it slip off easily, and, in fact, pro-
longed the  operation, the tape having slipped  once during the ex-
tension.
  The reduction was completed  in about fifteen minutes.
  Second Observation.—No 11, Salle Cochin, Legendre, carter,
has been confined to bed for twenty-two days* with a luxation of
the bones of the metatarsus upon the tarsus.  His horse fell upon
him.   Nothing has  been done.
  On the day of the operation,  the foot was  found to be swollen
with a sub-acute inflammation, and was painful when handled; the
internal edge of the foot presented a very concave line ; the head
of the first phalanx projected out, and a depression was felt behind
it.   The apophysis  of the last  phalanx very  projecting over the
external  edge of the foot; the foot shortened and  slightly twisted.
  Operation.—The instrument being applied upon the  sole of the
foot, was fixed by bands which were carried around the ankle and
* I understood the Interne, five weeks.—G. O. J. 
SURGICAL  ADJUSTER.
81
the heel to the counter-extending point;  with  other  bands the
foot was fastened above the inferior extremities of the bones of the
metatarsus, and they were fixed to the extending point.
   A stronger extension was here required than in the preceding
case, but at the end of fifteen minutes, and by the aid of a pretty
vigorous manipulation of the foot, the bones returned to their nor-
mal situation.
   During the operation, the patient, although he was a very timid
man, did not utter a cry.*
              FROM DR. SKILTON, OF TROY, N. Y.
Dr. G. 0. Jarvis.
   Dear Sir,—I have used the Adjuster to  reduce luxations  on
several occasions—once in a case of dislocation of the hip, on the
fifth day of the accident—five times in dislocations of the shoulder,
in one of which ineffectual attempts  had been made at reduction,
on the day of the accident, by others.  On the second day, however,
I reduced it with the adjuster.  In all these  cases the success was
perfect—highly satisfactory.   I have also used it in a case of dis-
location of the elbow, complicated with fracture of more than five
weeks standing.   In this case I was  happily able considerably to
increase the mobility of the joint, and  thus  to  give to the  little
patient the assurance of eventually recovering a fair  use of the
limb.
   I feel under deep obligations for this  improvement in surgery,
and I am bound to state that I find  the instrument, on  trial, to
operate on sound and correct surgical  principles, and to  afford
facilities to the surgeon, which, as I  believe, he can  find in  no
other apparatus  for  treating  the injuries for  which this one is
especially designed.                   Yours truly,
                           (Signed)     Avery  J.  Skilton.
   Troy, N. Y.,  Nov. 28th,  1S46.
         FROM DR. WRIGHT, OF WESTERN NEW YORK.
                    Akron, Erie Co., N. Y., Nov. 29th, 1846.
Dr. Jarvis.
  Mv Dear Sir,—I have had some practical experience with the
Surgical Adjuster, and I can cheerfully say that I think it one of
the greatest improvements in modern surgery.  I will refer to one
or two cases succinctly.

          * Nor did the man in the first operation.—G. O. J. 
82
APPENDIX.
  The first one to which I will refer  was a case of oblique frac-
ture of the femur, with shortening of the limb.   I  applied the in-
strument : the bones  were very readily brought into coaptation,
and with very little inconvenience to either patient or myself they
were there retained.   In five weeks, I had reunion  of the bone,
and a limb of full length.   This, I think, could hardly have been
possible with any of the old methods.
  In a dislocation of the elbow backwards, where  some attempts
at reduction had been previously made, by a neighboring  physi-
cian, I applied the adjuster, and with extraordinary ease, and even
comfort, to the patient, the parts were  restored.
  I have used the instrument in some other cases, and  always
with the happiest effects.   Indeed,  it has inspired me  with so
much confidence, that my faith  in it is almost unbounded  for ac-
complishing the  objects for which it is arranged, especially when
compared with all the other methods with which I am acquainted.
                  I am, with much esteem,
                           Yours, &c.
            (Signed)              Samuel  S. Wright, M.D.
               FROM THE ATTICA DEMOCRAT.
  " Surgical Adjuster," is the name of an instrument invented
by Dr. Jarvis, for the purpose of setting dislocated or  fractured
limbs.   How long it has been in use we  are  not informed,  but
we can speak from actual experience of its utility.  It was  our
misfortune to have our right shoulder dislocated by a fall from a
horse, on Saturday evening last.  Dr. A. P. Curtis happening to be
at hand, applied the instrument for the purpose of re-placing the
bone in its proper place.  Having seen and assisted in the setting
of many fractured and dislocated limbs, we were prepared to un-
dergo the usual amount of excruciating pain attendant upon the
old mode of procedure in such cases.  But before we were scarcely
aware of it—and without the least additional pain—the bone of
the arm was re-placed in its  socket—something of a  soreness
about the shoulder caused by the fall, only reminding us of the
accident.
   Dr. Curtis, the possessor of the instrument, has been at consi-
derable expense to procure it, and if those who are afflicted  like
us, knew its value, they would prefer to  be mended  up in this
mifd method, rather than  by the usual hauling  and pulling of
half a dozen men. 
(  83  )
TESTIMONIALS.
From the Adelphi Society, London, of which His Royal Highness, Prince Albert,
   is President, and who, in person, presented the Gold Medal, referred to below.
                  Society for the Encouragement of Arts, fyc.
                           Adelphi, May 23, 1845.
   Sir,—I have the pleasure to inform you that the Society have
voted you their gold Medal for your Surgical Adjuster,  and that
your card of admission is sent  herewith.
                         I am,  Sir, yours, &c.
                                Francis Whishaw, Secretary.
                 From Professor Mott, of New York.
                              New  York, December 4, 1843.
  I am acquainted with Dr. Jarvis's " Surgical Adjuster."  It is
a valuable present from a highly deserving and intellectual Phy-
sician to the Surgical Profession.  Its value to the  Surgeon can-
not be too highly prized in the treatment of fractures and disloca-
tions.   It ought to be  in the hands  of every practitioner, and
should make a part of the instruments in the possession of every
Surgeon in the Army and Navy.
                  (Signed)                Valentine Mott.
      From Mr. Stanley, Surgeon to St. Bartholomew's Hospital, London.
             Brook Street,  Grosvenor Square, June 16, 1845.
  My Dear Sir,—I beg to  assure  you that I  have, with  very
great pleasure, witnessed  the  application  of your apparatus for
the reduction of dislocations.  Many of the contrivances  it pre-
sents appear to me entirely new, and they are certainly most in-
genious.  I can readily believe that your apparatus may be suc-
cessful in the reduction of dislocations, when all other contrivances
have failed, and I am sure that the  public in all countries  owe
you a debt of gratitude for the pains you have bestowed on so im-
portant an object.
  Wishing you, most sincerely,  the fullest success for your la-
bors,         I remain, my dear Sir, yours very truly,
                                         Edward Stanley. 
84
appendix.
       From the late Dr. Forrey, Editor of the N. York Medical Journal.
                              New  York, November 4, 1845.
   I have examined with much interest and satisfaction the appa-
ratus calculated for all the purposes  of extension and  counter-
extension, invented by Dr. George  0. Jarvis, of Connecticut.   I
am free to say, that as regards reduction of dislocations, the ad-
justment of fractures, and the maintenance of the coaptation  of
the latter,  Dr.  Jarvis  has supplied a desideratum in  this mecha-
nical contrivance, and which in point of ingenuity and simplicity
is  perhaps unparalleled in the  whole  history of surgical instru-
ments.              (Signed) *             Samuel Forrey.
 From Dr. Hodgkiw, Author of Lectures on Morbid Anatomy of the Serous and Mu-
                      cous Membrane, London.
                            Brook Street, Grosvenor Square, )
                                      17, 11, 1845.          j
   My Dear Friend,—I greatly admire  thy Surgical Adjuster,
 which gives great command of power without increase of risk to
 the patient, but as I conceive with rather a diminution of danger,
 since the whole of the  force employed is under the same direc-
 tion.   I was particularly struck with the  general applicability of
 the Instrument,  which must be seen in operation to be duly  ap-
 preciated.                       Thine, sincerely,
   To Dr. Jarvis.                          Thomas Hodgkin.

                 From Professor Parker, of New York.
                         College of Physicians  and Surgeons, )
                            Neio York, December 4, 1843.    j
   I have examined with  care the apparatus  invented  by Dr.
 George O. Jarvis, for the treatment of fractures and dislocations,
 and concurring very fully in the favorable opinion of it which so
 many  distinguished surgeons  have  expressed,  I most heartily
recommend it to every practising surgeon.
                (Signed)       Willard Parker,  M.D.
                                              Prof. Surgery.

From Mr. FeRgusson, Surgeon to King's College Hospital, London, and author of
                    " Practical Surgery," &c. &c.
                               Dover Street, June 14, 1845.
  My Dear Sir,—I feel greatly obliged to you for the demonstra-
tions which you  have made of your instrument for reducing dislo- 
SURGICAL ADJUSTER.
85
cations and adjusting fractures, and regret that I have not had an
opportunity of trying its effects, so that I might give my testimony
in its favor from actual experience. I have no hesitation, however,
in stating my admiration of the apparatus, and that it appears  to
me, as the most  ingenious and powerful  ever devised  for such
cases.                     I am,  most faithfully, &c,
                                             W. Fergusson.
From Mr. Keate, Surgeon to St. George's Hospital, London, Sergeant Surgeon to
                           the Queen.
                       15 Albemarle Street, August 14, 1845.
  Dear Sir,—I have examined carefully the apparatus which you
have invented for reducing dislocations  and adjusting  fractures,
and  I have watched with great interest its application by you  to
these different objects.   It appears to me calculated to save much
trouble to the surgeon and much pain  to  the  patient, and  as a
proof of my favorable opinion of it, I purpose to  recommend one
to be purchased for use in St. George's  Hospital.
           I am, dear Sir, your very faithful servant,
                             Robert Keate,
               Sergt, Surgeon to the Queen, and Surgeon St. George's Hospital.
From Samuel Cooper, Esq., Author of '• First Lines on Surgery," " Dictionary of
                     Practical Surgery," &c &c.
                      Woburn Place, London, June 14, 1845.
   My Dear Sir,— Your apparatus for the reduction  of disloca-
tions and the treatment of fractures, exhibits a great deal of  me-
chanical ingenuity directed to the fulfilment of the indications in
particular cases with superior efficacy.  I consider the  invention
likely to prove exceedingly useful in old dislocations or displace-
ments of the head  of bones, where  the  ordinary means fail,  or
cannot be employed with safety.
                 I am, my dear Sir, yours always truly,
                                                 S.  Cooper.
From Mr. Quain, Professor of Anatomy, &c. at University College Hospital, Lon-
             don ; Author of a valuable work on Anatomy, &c.
                               Keppel Street, June 20, 1845.
  I have had an opportunity of examining the apparatus invented
by Dr. G. 0. Jarvis, for assisting in the adjustment of fractures
and the reduction of dislocations of the limbs, and I have seen
                  8 
86
APPENDIX.
the method of its application by its inventor.   My belief is,  that
the apparatus is calculated to give increased power to the surgeon,
as well as precision in applying the power, at the same time  that
it will  enable him to dispense with several of the assistants, which
are now  required in some forms of the injuries referred to.   For
these reasons I regard the contrivance as an excellent one, and,
as well as can be  judged without seeing it used in actual prac-
tice, I  am satisfied that it will afford important  assistance  to the
practitioner.  It will readily be inferred that, in  my opinion, Dr.
Jarvis  is  entitled to much credit for the persevering application of
his ability and mechanical skill in the construction of so useful
an instrument.                                     R. Quain.
                From Professor Mutter, of Philadelphia.
                           Philadelphia, November 29, 1843.
  I beg leave to offer my testimony in favor of an instrument of
Dr. Jarvis's invention, for the reduction and treatment of disloca-
tions and fractures.  It is unquestionably a most  ingenious and
excellent apparatus, and must prove highly useful in many cases
of accidents, for the relief of which it has been invented.
       (Signed)       Thomas D. Mutter, Prof.  Surgery, &c.
From Sir Benj. Brodie, Bart., V. P. R. S., Author of " Clinical Lectures on Surge-
          ry," " On the Urinary Organs," " On the Joints," &c. &e.
                             14 Saville  Row, June 13, 1845.
  I have examined the machine invented by Dr. Jarvis for the
reduction  of dislocations and adjustment of fractures.   The con-
struction of it appears to me to be highly ingenious, and as far as
I can form an opinion on the subject, without having seen it actu-
ally employed on the living person, it is likely that it  will  prove
very useful in severe cases in surgical practice.
                  (Signed)                    B. C Brodie. 
( 87 )
CONCISE  INSTRUCTIONS  IN  THE USE  OF
                 THE ADJUSTER.
   TO REDUCE A DISLOCATION OF THE  HIP.
                      [See Plate II]
  Buckle the long belt around the thigh immediately above the
knee, a loop lying on each side of the limb.  Let  each  loop be
armed with a strong cord.   Attach the roll, H, to  the thigh fork
(fig. 4), by the buttons on its arms; letting it pass  over  the end
of each arm so as to hang loosely down between them.   Slip the
fulcrum, F, of the  side lever (tig. 3) on to the brass case  at D,
making it fast at the point which will allow the stem of the plate,
G, to move freely  between the fork and the roll.  Insert the end,
D, of the counter-extending bar into the socket, K, of the fork;
the stem  of the side lever (fig- 3) passing between the roll and
the fork.   Apply the instrument thus arranged to the inside  ot
the thigh, the roll, H, pressing firmly againt the body,  the arms
of the fork (fig. 4) passing upward and outward, the one in front
of the hip, the other back of it, so that by the strap, No. 1, pass-
ing around each arm of the fork and crossing the body above the
hip, the instrument may be made to press firmly  against the in-
side of the thigh.  Let the strap be drawn tense and buckled; and
let a bolster be placed under the strap,  of sufficient thickness  to
enable the surgeon, by means of the strap, to press the instrument
firmly against the inside of the thigh.  Make the limb fast to the
other end of the instrument by  the cords drawn tight.  Tie  a
handkerchief around the instrument and limb, immediately above
the knee, so as  to confine them together.  Apply the lever-make
steady and gradual extension ; moving the limb freely, if need be
until the head of the bone is brought down to a transverse hm
with  the  socket.  Now, by means of the side lever let the surgeo:
throw the head of the bone outward; that an assistant may rotat.
 the thigh on its own axis, preparatory to the  head being agau
 received into its socket. 
88                      APPENDIX.
  Note.—In all cases when the thigh fork is  used, a  piece  of
wash  leather, cotton-flannel,  or  other  soft material, should be
placed between the roll and the skin, in its entire  length, to  pre-
vent friction.   This rule should be observed, equally in  fractures
as in dislocations,  for it is an important one in both.
  TO REDUCE A DISLOCATION OF  THE KNEE.
  Buckle  the  long belt around the limb, immediately above the
knee; with one loop lying low over the  knee-pan.   Buckle the
short belt around the ankle.  Take off that arm of the jointed fork
(fig. 6) which will not be required to be used; and pass the other
arm through the loop, over the knee-pan.   Attach the Adjuster
to the fork, and make fast the lower belt to the foot of the instru-
ment, by tapes passed through the loops.   Apply the lever, make
extension, free motion, &c.
 TO REDUCE  A DISLOCATION OF THE ANKLE.
                       [See Plate IX.]
   Buckle the long belt around  the  leg, immediately below  the
:knee.   Let one loop lie in front, and another directly back  of it,
on the posterior side of the leg; the loops being on the lower edge
of the belt and looking towards  the foot.  Pass the  two arms of
the jointed fork (fig. 6) through the two loops above named.  In-
sert the end of the counter-extending bar, D, into the socket,  K,
of the fork ; and to make fast the extending point of the instru-
ment to the limb, let the following method be adopted.   Let  the
back of the limb, immediately above the heel, rest on the middle
of a silk  handkerchief in the form of a roll.  Let the foot, A, of
the rack, cross the hollow of the  foot.  Bring the ends of the  hand-
kerchief down, on each side of the heel; and cross them over the
sole of the patient's foot; and foot, A, of the instrument.   Carry
them forward and cross them again on the top of the foot.  Pass
•each end as respectively inclined, under the handkerchief  lying
on the side of the heel.  Bring  the ends forward again to the top
of the foot;  and tie them closely and firmly down.  Apply  the
lever;  make extension ; and manipulate as  necessary,  to  effect
reduction. 
SURGICAL ADJUSTER.
89
TO REDUCE A DISLOCATION OF THE SHOULDER.
                       [See Plate X.]
  Buckle the short belt round the arm immediately above the el-
bow.  Pass the tapes through the loops ; one being placed on the
under and another on the upper side of the arm.  Button the roll
tensely across the top of the arms of the shoulder-fork (fig. 5).
Insert the end  of  the counter-extending bar, D,  into the socket,
K, of the fork.  Place the roll in the arm-pit, and tie the tapes,
drawn tensely, to the foot of the rack, A.   Buckle the hip  strap
across the shoulder, passing it around the roll, H, on each side of
the shoulder; minding to draw it sufficiently tight to press the
roll firmly against the under  side of the  arm.   To  prevent the
shoulder-blade from yielding to extension, apply the  hollow  part
of the acromion strap, to the point of the shoulder.   (Acromion
process.) Let each end pass between the fork and the roll, at their
respective sides : the long end passing round the body and under
the opposite arm to the short end.   Buckle  it  closely round the
body.   Apply the lever ; make extension;  use free motion  with
the arm, as necessary to favor reduction.
  TO REDUCE A DISLOCATION OF THE ELBOW.
                      [See Plate XI]
   Buckle the long belt with the loops standing  upwards,  round
the arm above the elbow ; and very low down: taking  care that
the close loop lies immediately on the point of the elbow. Buckle
the short belt round the wrist.  Insert the  elbow fork into the
close loop.   Attach the adjuster to it by inserting the counter-ex-
tending bar, D, into its socket, K.   Arm the loops on  the  front
and back of the hand with strong tapes; and tie them to the foot,
A, of the rack.   Apply the lever and make extension ; while free
motion is made with the limb.
 TO REDUCE A DISLOCATION OF THE THUMB.
                      [See Plate XII]
  Apply the jointed fork (fig. 6) to the instrument.  Pass the hip
strap over the arms of  the fork, the ends being buckled together
so as to form a loop hanging loosely between the arms of the fork.
                 8* 
90
APPENDIX.
Let the hand, between the* thumb and index finger, rest against the
middle of the strap; the back of the hand resting on the instrument.
Make the thumb fast to the foot, A,  of  the adjuster, by a clove
hitch with a broad tape, doubled.   Tie a handkerchief round the
wrist and instrument.   Make extension with the lever, and throw
the distal extremity  of the thumb directly backwards, and when
the two articulating surfaces are  sufficiently approximated, let  it
be again  brought forwards.
         FOR  FRACTURE OF  THE THIGH.
                       [See Plate V.]
  Place the pads (fig. 8), one on each side of the thigh, immedi-
ately above the knee.   Around the limb and pads, apply the long
belt, having two  of the loops armed with strong  tapes, cross the
bulbous part of the pads.   Apply the instrument to the limb as in
dislocations of the hip; except that the side lever  (fig. 3)  is not
to be attached to it.   Prepare the double-inclined plane for  receiv-
ing the limb and instrument upon it, by adapting  the length of
the  two parts of the plane to the length of the two portions of the
limb.   Give the  plane that angle which the limb is judged to re-
quire, and cover  it with mats, or anything that will make an  easy
surface, on which the limb is to rest.  Over  the whole, and on
the  appropriate part of the plane, lay tapes or an eighteen-tailed
bandage, ready for dressing the limb when adjusted.   On the
plane, thus prepared, lay the limb and instrument already attached.
By  the lever, make sufficient extension to set the bone ; now place
splints on each side of the  thigh, the inner splint being placed be-
tween the instrument and limb.  Let the lower end of each splint
pass a little distance under its pad.  Be careful to allow none of
the weight of the instrument to press on the  limb—this is  done
by placing a bolster between the instrument and the  plane.   Let
the space between the inner splint and the instrument be  filled
with folds of  cloth,  so that the splint shall press  equally and
gently on the whole length of the thigh.  Over  the  whole apply
the tapes or eighteen-tailed bandage.
  Note.—In all cases of fractures, when the belts are lined  with
India rubber cloth, the limb should be covered with  a cotton or
flannel bandage beneath the belts* to protect the skin from  the too
stimulating properties of the lining.  Where oiled silk is the lin- 
SURGICAL  ADJUSTER.
91
ing, such precaution is less essential.  Where the pads are used,
the belt should be but  loosely applied.   To apply it tightly would
be doing a wrong to the patient and the instrument.
     FOR  A  FRACTURE  OF THE  KNEE-PAN.
                      [See Plate VIII]
  Apply one of the pads above and against the upper fragment of
the fractured bone.   Around the pad and  limb,  buckle  a belt
with a loop crossing the bulb of the pad.  Buckle  the other belt
around the limb, immediately below and against the  lower frag-
ment, with a loop from the upper edge of the belt, crossing  the
fragment.   Pass a tape, about six feet long,  into the upper loop.
Let the tape cross the centre of the bulb in its passage to the foot.
Apply the instrument as in a fracture at the  neck of the  thigh
bone ; except that no splints or cloth are to be used.   Tie an end
of the tape, on each side of the patient's foot,  to the  foot  of  the
rack.  Make the necessary extension with the instrument, to co-
apt the  fractured bone, when the two  loops are gently brought to-
gether by  a  short piece of tape ; and then let them be tied.   Lay
the limb on  a perfect plane, and let the foot of it  be a little ele-
vated to gently elevate the limb.
TO  DRESS A FRACTURE AT THE NECK OF THE
                     THIGH  BONE.
The limb being in a straight position, and the patient resting on
               the side opposite the one injured.
                      [See Plate VI]
  Apply a belt, as in fractures of the thigh, but without the pads.
Let two straight splints 2\ inches broad, three eighths of an inch
thick, one of them the length of the limb on the inside, the other,
the length of it on the outside, to the top of the hip, be rolled in a
square piece of cotton cloth, so as to  form a  trough; in which
place the limb.   Run out the counter-extending bar of the instru-
ment to its full  length, and fasten it in that position by the screw,
E.   Run out the rack,  so that the foot, A, of the instrument shall
cross the sole of the patient's foot.  Apply the thigh fork (fig. 4)
as in  a dislocation of the hip.  Apply the instrument on the inside 
92
APPENDIX.
of the limb, and over the inside splint.   Make the limb fast to the
foot of the instrument by the tapes.  With the lever,  make  the
necessary extension of the limb, and of the neck of the bone, by
the strap crossing the body above the hip, and passed around both
arms of the fork.   Let a thick bolster be placed between the body
and the strap, sufficiently  thick to  give effect to the strap,  in
lengthening the neck of the bone.   Let tapes be tied around the
whole, at several convenient points, to secure the  perfect rest of
the limb.  Let the foot rest on  a pillow of sufficient height,  to
place the limb horizontally, and to admit the sound limb to move
freely under it.
  The surgeon  can adopt this position,  or the one with the patient
lying on his back, at pleasure.
         FOR A  FRACTURE OF  THE LEG.
                       [See Plate VII]
  Apply the pads, one on each side of the leg, immediately below
the knee, and the long belt around the limb and the pads; with a
loop on each side, standing upwards, and crossing the thick  part
of each pad.  Let the two loops be armed with tapes.  Apply the
short belt around the ankle, with the loops towards the foot, armed
on each side with tapes; or, in lieu of the belt, apply to the foot,
the wood-soled fracture shoe, and fasten it to the foot of the instru-
ment.  Remove that blade from the jointed fork, which will not
be required for use? and place the other blade  across the  thigh,
immediately above the knee.  To it, attach the upper belt, by its
tapes from either side.   Apply the instrument to the  fork as be-
fore.   Make fast the foot of the instrument to the lower belt, or
to the shoe, whichever may be used.   Place the limb, in a bent
position,  on the double-inclined plane, prepared with tapes or
bandages for dressing.   Apply extension, to set the bones.   Ap-
ply splints on each side  of the leg, and secure the whole by the
bandages or tapes previously arranged on the plane.
  Should there be much swelling and  inflammation  of the limb,
the fracture shoe is  greatly to be preferred.   There should, how-
ever, always be placed between the top of the  foot and the shoe,
some folded flannel and a thin piece of  sole leather, to prevent
any unequal pressure from the straps of the shoe.   The care with
which  the belts, fracture-shoe,  dextrine  bandage,  or any  other 
SURGICAL ADJUSTER.                93
means which may be adopted, and from which the points of exten-
sion and counter-extension are to act, should be applied to a limb,
in a  case  of fracture, so that the pressure may operate equally
over a large surface, and their bearings be made to  press  gently
and kindly on the limb, so as quietly to be borne by  the patient,
is a point in the treatment, which cannot  be  too strongly urged
upon the attention of the surgeon.  Without this duty being well
performed, the danger is,  that the necessary extension and  coun-
ter-extension will not be long endured by the patient, nor will its
benefits be secured to the surgeon.   This, then, should be a rule
in the treatment of all fractures.   To so apply the materials, what-
ever they may be, by ivhich the points of extension and counter-ex-
tension are attached to the limb,  that the necessary pressure, in
making extension, may be quietly borne by the patient.
   Great care having been taken  in the construction of the parts,
used for the above purpose, it is believed  that they may be  quiet-
ly maintained  by the patient, in every  case, where continued ex-
tension and counter-extension are requisite, if  correctly applied.
But,  should they be negligently, or carelessly used, the ease and
comfort of the patient would most surely be much disturbed ; and
the success of the surgeon would thus be rendered  extremely
doubtful.
   Let the foot of the plane be so  elevated, as that the leg shall lie
in a horizontal position ; the  thigh resting on the elevation of the
plane.
   By giving attention to the foregoing directions, so as to under-
stand them fully, it is believed that every surgeon will be  able to
apply the adjuster readily and correctly, in all cases where any
extending force is required, and with much greater ease and safe-
ty to the patient, than by employing any  of the ordinary means;
although the especial mode of its application may not, in all cases,
be here particularly described. 
 
 
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